@prefix edm: . @prefix dcterms: . @prefix dc: . @prefix skos: . edm:dataProvider "CONTENTdm"@en ; dcterms:isReferencedBy "http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642"@en ; dcterms:isPartOf "History of Nursing in Pacific Canada"@en ; dcterms:creator "Vancouver Medical Association"@en ; dc:date "1938-11"@en ; dcterms:issued "2015-01-30"@en, "1938-11"@en ; edm:aggregatedCHO "https://open.library.ubc.ca/collections/vma/items/1.0214657/source.json"@en ; dc:format "image/jpeg"@en ; skos:note """ The BULLETIN of the VANCOUVl#f" MEDICAL ASSOOSAllON ■Jl&iS Vol. XV. NOVEMBER, 1938 No. 2 With Which Is Incorporated Transactions of the Victoria Medical Society and the Vancouver General Hospital In This Issue: LETTER FROM THE B. C. CANCER FOUNDATION TUMOURS OF THE PITUITARY AND |PARAPITUITARY REGION J SURVEY OF EPILEPTICS BULKETTS (With Cascara and Bile Salts) . . FOR . . Chronic Habitual Constipation BULKETTS POSSESS ENORMOUS BULK PRODUCING PROPERTIES AND BEING PROCESSED WITH CASCARA AND BILE SALTS PRODUCE BULK WITH MOTILin|| WE WILL BE PLEASED TO PROVIDE ORIGINAL CONTAINERS FOR TRIAL ON REQUEST. Western Wholesale Drug (1928) Limited 456 BROADWAY WEST VANCOUVER - BRITISH COLUMBIA (Or at all Vancouver Drug Co. Stores) THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Db. J. H. MacDermot Dr. M. McC. Baird Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XV NOVEMBER, 1938 No. 2 OFFICERS 1938-1939 Dr. G. H. Clement Past President Dr. D. F. Busteed Hon. Secretary Dr. Lavell H. Leeson Dr. A. M. Agnew President Vice-President Dr. W. T. Lockhart Hon. Treasurer Additional Members of Executive: Dr. J. P. Bilodeau, Dr. J. W. Arbuckle. Dr. F. Brodie Dr. Neil McDougall TRUSTEES: Dr. J. A. Gillespie Historian: Dr. W. D. Keith Auditors: Messrs. Shaw, Salter & Plommer. SECTIONS Clinical Section Dr. W. W. Simpson Chairman Dr. F. Turnbull Secretary Eye, Ear, Nose and Throat Dr. S. G. Elliott Chairman Dr. W. M. Paton Secretary Pediatric Section Dr. G. A. Lamont Chairman Dr. J. R. Davies Secretary Cancer Section Dr. B. J. Harrison Chairman Dr. Roy Huggard ..Secretary STANDING COMMITTEES Library: Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland, Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davies. Publications: Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird. Summer School: Dr. J. R. Naden, Dr. A. C. Frost, Dr. A. B. Schinbein, Dr. A. Y. McNair, Dr. T. H. Lennie, Dr. Frank Turnbull. Credentials: Dr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J. Buller. V. 0. N. Advisory Board: Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell. Metropolitan Health Board Advisory Committee: Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller. Greater Vancouver Health League Representatives: Dr. W. W. Simpson, Dr. W. N. Paton. Representative to B. C. Medical Association: Dr. G. H. Clement. Sickness and Benevolent Fund: The President?—The Trustees. Protection Against Typhoid Typhoid and Typhoid-Paratyphoid Vaccines Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly in rural and unorganized areas. This is borne out by the fact that during the years 1931-1935 there were reported, in the Dominion, 12,073 cases and 1,616 deaths due to these infections. The preventive values of typhoid vaccine and typhoid- paratyphoid vaccine have been well established by military and civil experience. In order to ensure that these values be maximum, it is essential that the vaccines be prepared in accordance with the findings of recent laboratory studies concerning strains, cultural conditions and dosage. This essential is observed in production of the vaccines which are available from the Connaught Laboratories. Residents of areas where danger of typhoid exists and any one planning vacations or travel should have their attention directed to the protection afforded by vaccination. Information and prices relating to Typhoid Vaccine and to Typhoid-Paratyphoid Vaccine will be supplied gladly upon request. CONNAUGHT LABORATORIES UNIVERSITY OF ^TORONTO Toronto 5 Canada Depot for British Columbia Macdonald's Prescriptions Limited MEDICAL-DENTAL BUILDING, VANCOUVER, B. C VANCOUVER HEALTH DEPARTMENT STATISTICS, SEPTEMBER, 1938. Total Population—estimated 259,987 Japanese Population—estimated 8,685 Chinese Population—estimated 7,808 Hindu Population—estimated . 335 Rate per 1,000 Number Population Total Deaths 205 9.6 Japanese Deaths 3 4.2 Chinese Deaths ..•_ 8 12.5 Deaths—Residents only . . 175 8.2 BIRTH REGISTRATIONS— Male, 183; Female, 174 . 357 16.7 INFANTILE MORTALITY— Sept., 1938 Sept., 1937 Deaths under one year of age 9 9 Death rate—per 1,000 births 25.2 26.4 Stillbirths (not included in above) 9 9 CASES OF COMMUNICABLE DISEASES REPORTED IX THE CITY October 1st August, 1938 September, 1938 to 15th, 1938 Cases Deaths Cases Deaths Cases Deaths Scarlet Fever 14 0 20 0 3 0 Diphtheria 0 0 2 1 0 0 Chicken Pox 4 0 19 0 15 0 Measles 3 0 10 10 Rubella 0 0 0 0 0 0 Mumps 10 6 0 10 Whooping Cough 44 0 28 0 7 0 Typhoid Fever 10 10 2 0 Undulant Fever 0 0 0 0 0 0 Poliomyelitis 3 1. 10 0 0 Tuberculosis 37 9 36 17 15 Erysipelas 2 0 10 0 0 Ep. Cerebrospinal Meningitis 0 0 0 0 0 0 V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH, DIVISION OF VENEREAL DISEASE CONTROL. West North Hospitals and Vancouver Richmond Vancouver Vancouver private doctors Totals Syphilis 1 0 0 73 45 119 Gonorrhoea 0 0 1 100 39 140 BIOGLAN THE SCIENTIFIC HORMONE TREATMENT Descriptive Literature on Request. A Product of the Bioglan Laboratories, Hertford, England. Represented by STANLEY N. BAYNE 1432 MEDICAL-DENTAL BUILDING "Ask the Doctor Who Is Using It" Phone: SEYMOUR 4239 VANCOUVER, B. C. Page 25 EDITOR'S PAGE We have received a number of kind comments about the new Bulletin, and appreciate these greatly. The first number was in some ways not quite what we wanted, but we shall hope to iron out any lumpy places as we go along. Victoria contributes this month a paper read by Dr. H. H. Murphy, Director of the Department of Radiology at the Jubilee Hospital. Those of us who have heard Dr. Murphy speak will not be surprised to find this a most readable and suggestive paper, written currente calanto, in an easy style, yet full of valuable matter. The Bulletin is publishing shortly a Supplement containing the papers read at the Annual Meeting of the B. C. Medical Association in Victoria. Either jointly with this, or separately, the papers read at the Vancouver Medical Association Summer School will also be published. In another column we reproduce an editorial from a recent number of Collier's Magazine, entitled "R/ Hands Off." There is considerable food for thought in this, and it seems to us to state fairly and dispassionately what the man in the street is thinking, and may we add, is justified in thinking. While as a profession it is our right, nay more, our duty, to maintain a high standard of medical care, and resist any action calculated to impair or lower this, we must at the same time remember that we are facing conditions, not merely theories, and that in one way or another, sooner or later, and at the cost of a reasonable sacrifice on our part, a solution is going to be found, and must be found. The sacrifices we must make will be reasonable, only if we make them; if they are forced on us, we may not fare so well; and we are sure we speak for the best minds in our profession in this matter when we say that now, as always, we are quite willing and ready to make reasonable and fair concessions, in order to secure the greatest good for the greatest number. An important step was taken by the organised medical profession of British Columbia when, at its Annual Meeting in Victoria, changes in the Constitution and By-laws of the B. C. Medical Association were made, whereby this body became "The British Columbia Medical Association (Canadian Medical Association, British Columbia Division)." This made us into a division or branch of the national body, and is a definite move in the direction of national unity. This step has already been taken by most of the ten Provinces, and it is hoped that the remaining Provinces will, soon join the majority. We congratulate those who have worked hard and long for this consummation, which has crowned the efforts of many years. Perhaps Dr. J. S. McEachern of Alberta, that most staunch and loyal member of our profession, is the outstanding figure in this; in our own Province Dr. H. H. Milburn stands out perhaps as the man who has done most of the actual work for some time, though, of course, as he himself~would be the first to admit, he has had many loyal helpers. NEWS AND NOTES Dr. J. W. Arbuckle has left for Montreal, where he will meet Mrs. Arbuckle. He will probably be away for a month, going south before he returns. Dr. Schinbein has left for New York, where he will attend the meeting of the American College of Surgeons. We offer our congratulations to Dr. and Mrs. W. E. Harrison on the birth of a daughter, on September 27th. Dr. J. Whitbread and Dr. A. R. Anthony were elected to membership in the Vancouver Medical Association at the meeting held on October 2nd. Dr. Agnew has left with Mrs. Agnew for a month"s well-earned vacation in the South. Dr. and Mrs. Fred Sparling of Haney are being congratulated on the birth of a daughter last month. Page 26 Dr. A. Maxwell Evans has recently arrived in Vancouver to take charge of the Cancer Clinic which will open here on November 5 th. Dr. Evans was born in Vancouver and took his pre-medical course at the University of British Columbia. He graduated from McGill and later won a diploma in medical radiology and electrology from Cambridge University. He has lately come from England, where he was surgical registrar at Mt. Vernon Hospital for Cancer at Middlesex; resident medical officer at the Radium Institute, London, and assistant radiologist at Addenbrooke's Hospital, Cambridge. Dr. J. A. MacMillan and Dr. Frank Hebb, Vancouver physicians, will be part-time medical officers of the clinic. Dr. E. J. Ryan, Superintendent of the Provincial Mental Hospital, Essondale, is doing post-graduate study in New York. Dr. Alfred Warren, of the staff of the Provincial Mental Hospital, has left for London, where he will do post-graduate work. Dr. L. R. Williams of New Westminster has left for London to do post-graduate work. Dr. and Mrs. Bruce Cannon of New Westminster returned in August from a trip on the Continent, where Dr. Cannon was engaged in post-graduate study. During his absence his practice was attended by Dr. L. R. Williams. Dr. and Mrs. N. B. Hall of Campbell River will be in the East for two months, where Dr. Hall will be engaged in post-graduate study in Chicago and New York. Dr. Hall will stop off at the Mayo Clinic on the way back. Dr. F. H. Stringer of Rock Bay will carry on the practice for Dr. Hall during the latter's absence. A A A A Dr. R. B. Shaw of Nelson has returned from Montreal, where he was doing postgraduate work. Dr. E. S. Hoare of Trail has returned from a vacation in Edmonton. Dr. J. S. Kitching and Dr. R. A. Walton have joined the staff of the Metropolitan Health Committee. A A A A Dr. G. L. Sparks has opened an office at White Rock. GOLF At the Fall Golf Tournament, held at Shaughnessy Heights Golf Club on September 29th, the Division of Venereal Disease Control covered itself with glory. The Worthing- ton Cup was won this year by Dr. S. C. Peterson. Dr. Jack Wright won the Low Gross and Dr. S. A. McFetridge was Low Net in the Handicap 11-18 Class. The Ram's Horn Trophy was won by Dr. H. H. Pitts, who made the best Aggregate Low Net in the three games played for this trophy. Others winning were: Dr. W. T. Ewing, Low Net in the Handicap 1-11 Class; Dr. J. A. McLean, Low Net in the Handicap 19-23 Class; Dr. A. R. Anthony, Low Net in the Handicap 24 Class; The "Hidden Hole" contests—Drs. A. C. Frost and D. McLellan. Presentation of the permanent replicas of the MacDonald's "3, 4, 5, 6" Trophy were made to Dr. G. A. Davidson, who won it in 1937, and Dr. G. E. Seldon, who was the winner in 1938. Page 27 LIBRARY NOTES For the sake of new and incoming members of the Association (and some older ones), the Library Corrimittee would like to draw attention to the following regulations regarding the borrowing of books, and the' use of the Library generally. 1. All members using the library in the evenings are requested to sign the register. 2. All Journals must remain on the shelves for ONE MONTH after they are received. The "Received" date is stamped on the front cover. 3. All books and journals taken from the library must be signed for in the register at the door. *r *»• *r ^r At a recent meeting of the Library Committee it was decided that a list should be kept of books which have been suggested for purchase, but which it was thought should be held for further consideration. This list will be posted on the Bulletin Board in the Library, and any member of the Vancouver Medical Association is invited to make recommendation for or against the books in question. The 1938 Yearbook, which is an additional volume to the Encyclopaedia Britannica, has been ordered for the Library and will be here in about one week's time. The following books have been purchased recently from the Nicholson Fund: The Diary of a Surgeon in the Year 1751-52, by John Knyveton, who was, among other things, Surgeon's Mate, H.M.S. Lancaster. Das Denken in der Medizin (On Thought in Medicine), by Hermann Von Helmholtz. An address delivered August, 1877. The Horse and Buggy Doctor, by Arthur E. Hertzler. Chevalier Jackson, an Autobiography. Items from the Journals Progress in Nutrition, by Francis L. Burnett, M.D., Boston. Dr. Burnett reviews recent work done on Nutrition in general, and then in relationship to Pregnancy and the nourishment of children; Ophthalmia, and disorders of the eyes; Disorders of the Nerves; Scurvy, Ascorbic acid and Skin Diseases; Rickets, Dental decay and Arthritis; Goitre, Kidney disorders and Cancer. New England Journal of Medicine: Oct. 6, 1938, p. 524. Recent Advances m Knowledge of Vitamins, by H. K. Butt, Mayo Clinic. A brief review, mentioning only some of the work done, but containing recent information concerning some of the less well-known vitamins, their sources and uses. Proc. Mayo Clinic: Sept. 21, 1938, pi 601. Eye, Ear, Nose and Throat Symposium, ed. by /. N. Evans and L. W. Dean, Jr. Amer. J I. Surgery: October, 193 8. *■ A Monograph on Veins (De Venarum Ostiolis 1603, of Hieronymus Fabricius of Aqua- pendenta (1533-1619)), translated by K. J. Franklin, D.M., has been presented to the Library by Dr. D. E. H. Cleveland. «• The following books are on order and should be here very shortly: Grant—Method of Anatomy. 1938. De Lee—Obstetrics. New edition, 1938. Boyd, Wm.—Textbook of Pathology. New edition, 1938. Boyd, Wm.—Surgical Pathology. New edition, 1938. Piney and Wyard—Clinical Atlas of Blood Diseases. New edition, 193 8. Page 28 ancouver Medi cal ssociation VANCOUVER MEDICAL ASSOCIATION At the forthcoming regular meeting of the Vancouver Medical Association, the paper of the evening will be given by Dr. J. Ross Davidson on "Some Aspects of Contract Practice." The discussion will be led by Drs. A. C. Frost and A. J. MacLachlan. The Annual Dinner of the Association, which will be held on November 18 th at the Vancouver Hotel, promises to be bigger and better than ever. Dr. Clement, who is in charge of arrangements, says "Cocktails at 7 p.m." Dr. Jack Harrison is to have charge of the entertainment, and Dr. D. D. Freeze will be business manager. Put a red ring around this date on your calendar. At the Anniversary Dinner of the Association, held at the Georgia Hotel on October 2nd, about one hundred and twenty were present. Among these were men who had been members of the Association for many years. The Executive were particularly pleased to welcome Dr. W. B. MacKechnie, who came from Armstrong on purpose. Dr. F. X. McPhillips was another guest for the evening. The birthday cake, resplendent with forty candles, was cut by Drs. Riggs and Burnett. An interesting coincidence was brought to light when it was found that exactly forty years before these two doctors had shared offices here in Vancouver and had done many an operation together. Dr. Riggs spoke briefly concerning his remembrance of Vancouver in those days, and Dr. Burnett followed with a very witty little account of his early days in practice here. In proposing a toast to the Association, Dr. MacDermot spoke of the progress that had been made in medical practice in the past forty years; he felt that this was a suitable occasion to follow the counsel of the old Hebrew essayist, quoted by Kipling, in his essay beginning "Let us now praise famous men, and our fathers that begat us." He reminded us that the Vancouver Medical Association had^been a most potent factor in promoting unity and harmony amongst medical men, and that it had served not only the medical profession but the city at large, and concluded by asking all those present to rise and drink to the Vancouver Medical Association. Dr. W. D. Keith seconded the toast and took the opportunity to give a short account of some of the men who took a prominent part in forming the Association, many of whom gave generously of their time to matters of public welfare. Telegrams of congratulation on the 40th Anniversary of the Association were received from Medical District No. 3, and from Drs. Baird, Huggard and Thomas, who were on a lecture tour in the Interior, and from Dr. L. H. Leeson, President, who was unavoidably absent. The regular monthly scientific meeting of the Association followed the dinner, and after routine business was transacted Dr. Frank Turnbull gave a paper which is printed elsewhere in the Bulletin. Dr. Glen Campbell and Dr. B. J. Harrison contributed to the discussion of the paper, Dr. Harrison showing some excellent slides illustrating his remarks. The Association has recently purchased a very fine Projectoscope, which will show ordinary slides, micro-slides, film slides, and postcards, or pictures from books. A most generous donation to the Association has been made by Dr. T. F. Saunders in memory of the late Mrs. Saunders. Dr. Saunders has given the sum of $500.00, which is to be used, at his suggestion, as the nucleus of a Sickness and Benevolent Fund, the interest of which is to be added to the Sickness and Benevolent account which the Association uses at the discretion of the Trustees. Page 29 TUMOURS OF THE PITUITARY AND PARAPITUITARY REGION By Dr. Frank A. Turnbull. (Read before the Vancouver Medical Association, October 4, 193 8) [While this paper may have a fearsome title, it is really a very readable one, put in simple language. The author is to be congratulated on his technique in the arrangement of his subject. By classifying the main types of syndrome, and quoting cases to illustrate each of these, he has put in compact and usable form the information he wished to give. The enjoyment of the paper was, of course, greatly enhanced by the slides shown in the course of its delivery. We cannot reproduce these here, unfortunately, nor can we reproduce the discussion, so ably led by Dr. I. Glen Campbell and Dr. B. J. Harrison, but Dr. Turnbull has brought out clearly in his text the immense importance of careful perimetric examination of the eyes, and x-ray examination of the pituitary area, whenever any of these syndromes, with failing eyesight, appear.—Ed.] I feel honoured in being asked to read a paper on a neurosurgical subject at this meeting which commemorates the fortieth anniversary of the founding of the Vancouver Medical Association. Practically our whole knowledge of neurosurgery has developed during the intervening forty-year period. In no part of this special field can the march of time be better illustrated than in the progress which has been made in the diagnosis and treatment of tumours of the pituitary and parapituitary region. I shall attempt to portray in a. sketchy fashion something of the advance in our knowledge of the physiology of the pituitary gland, outline briefly the evolution of the modern surgical approach to this region of the skull, and, finally, describe several syndromes which result from tumours in this neighbourhood. Physiological Advances. Nature saw fit to enclose the central nervous system in a bony case lined by a tough, protecting membrane, and within this case she concealed a tiny organ which lies enveloped by an additional bony capsule like the nugget in the innermost of a series of Chinese boxes- No other structure in the body is so doubly protected, so centrally placed, so well hidden. Galen, the Greek physician who was the founder of experimental physiology, believed that the gland secreted was a mucous substance, pituita, which entered the nose. In the middle ages the great Vesalius expressed the same opinion. The complex region between the brain and the sella turcica remained a complete puzzle until Willis in the 17th century disentangled it to the extent of recognizing an arterial circle surrounding the pituitary stalk. By the end of the 18 th century someone had discovered that certain parts of the human body are useless relics of bygone ages, and as nothing was known about the pituitary gland it became conveniently accepted as a vestigial organ. Interest was not reawakened until near the close of the 19th century when several clinicians, notably Marie, described a condition, termed acromegaly, which was usually accompanied by a pituitary tumour. Moreover, pathological gigantism was soon recognized as a corresponding condition which differed merely in commencing earlier in life. Marie interpreted acromegaly in the presence of tumour as a state of glandular insufficiency. The truth was not established until Cushing (1908) showed that animals who survived for long after partial extirpation of the gland, exhibited a picture which was the reverse of acromegaly. In the year of the founding of this society, Schafer (1908) demonstrated that when extract of the posterior lobe of the pituitary gland was injected there resulted a rise of blood pressure. Within three years Babinski (1900) and Frolich (1901) had attributed adiposity and sexual infantilism to a disturbance of this area resulting from neoplasm. Far from being a vestigial organ, it was coming to be regarded as the very "mainspring of primitive existence.'* The pituitary body is now recognized as a combined neuro-epithelial organ. Its anterior portion, the epithelial lobe, represents the first of the endocrine organs to be differentiated in the embryo. Certain cells in this area have an affinity for acid dyes and are related to the function of growth. Others, which are best stained by basic dyes, have a positive influence on sexual activity. The remaining group of feebly staining cells have a purpose which has yet to be discovered. The posterior portion or neural lobe arises as a downward expansion of that part of the brain which deals with vegetative functions and instincts. In the adult human it sill remains connected with demonstrable neural fibres with cell stations in the Page 80 floor of the brain. Whether the posterior lobe produces various effects by virtue of dispersing one chemical substance or many is unknown. Certainly an extract of this lobe has a diversity of functions, serving not only to increase blood pressure, but also to contract the pregnant uterus, counteract polyuria, and, under certain circumstances, display galacta- gogue, antipyretic, pigmentary and sudorific effects. The metabolism of fat and also of water is controlled by cell-stations located at the point where the pituitary stalk joins the floor of the brain, so that these are not, strictly speaking, functions of the pituitary gland. Surgical Advances. This growth in physiological knowledge has been paralleled by equally noteworthy advances in the surgical treatment of pituitary tumours. Both fields of endeavour have seemed to stimulate and improve the other. Early experimenters found that access to the pituitary gland of an animal, for example a dog, was a simple matter of elevating the temporal lobe and approaching from the side. But in the human patient the temporal lobe was not so easily dislocated and such an approach was very hazardous. The earliest operations on record were undertaken by this route. It is likely that the pioneer members of this society were familiar with a report in the British Medical Journal of the first attempt to expose a pituitary tumour. This was undertaken in 1893 by Caton and Paul, acting on Victor Horsley's suggestion. The operation was never completed, as the patient died before the second stage was performed. Horsley himself is said to have consistently followed this route and by 1906 had done ten hypophyseal operations with two deaths. During the first two decades of this century, imaginative and daring surgeons proposed a variety o£ means of gaining access to the pituitary region. The gradual evolution of the modern operation may be illustrated by the experiences and changing points of view of two great American neurosurgeons, Harvey Cushing and Charles Frazier. With his first patients, in 1902, Cushing attempted the lateral subtemporal approach. In only one of six cases was he able to even partially extirpate the tumour. He then tried Eiselberg's operation, in which the entire nose was reflected to one side and everything in the upper third of the nose removed to provide a path to the sphenoid sinus and thence to the sella turcica. By 1912 Cushing had devised a modification of the less mutilating inferior nasal approach. He approached the floor of the nose from beneath the upper lip and gained access to its depths and the sphenoid sinus by means of a submucous resection of the nasal septum. This remained the operation of choice, and that which was most widely performed throughout the world, until 1926. It is obvious that by the trans-sphenoidal route one can remove only portions of a tumour within the sella turcica. The capsule of these growths within the sella, or tumours which lie above the sella, cannot be removed. With this in mind, and aided by greatly improved technical methods in neurosurgery, Frazier in 1925, after eleven years' experience with the trans-sphenoidal operation, returned to an intracranial operation. Instead of approaching from the side, he chose to approach from the front. It is interesting to recall that this transfrontal operation had been devised and described in detail by Krause in 1900. But, like the operation of Caton and Paul, it had not proved successful in thei hands of surgeons untrained in neurological surgery. Frazier gradually improved the operation which has come to be the accepted standard. By concealing the scalp incision behind the hair line and turning down flaps of the scalp and bone separately, it is now possible to perform the operation without deformity or visible scar. Through the use of the intracranial approach a large group of tumours about the pituitary gland and optic chiasm has come to be recognized. Seventeen different types might be enumerated. They vary in their pathological characteristics but are clinically similar in that they all cause visual disturbance. In the early reports of pituitary surgery interest was centred on improvements of the glandular symptoms, but it has become apparent that surgical results in this respect are not worth while. The chief concern at the present time is with the serious visual disturbances which may be caused by this variety of tumours. Immediately above the pituitary gland lie the optic nerves which are passing backwards from the orbits to the optic chiasm. All tumours in this neighborhood press on the optic nerves and eventually cause loss of vision. It is usually possible to recognize, prior to operation on one of these tumours, not only the exact location in relation to the sella turcica, but also its pathological nature. Being Page 81 forearmed in such a manner may mean the difference between surgical success and failure. Whether the tumour be an intrasellar chromophobe adenoma, or a parasellar meningioma, or suprasellar cyst, for example, is usually indicated by certain individual characteristics, which painstaking examination should elicit. For convenience of discussion the clinical aspects may be grouped into several syndromes. The conclusion of this paper will be taken up with a consideration of four of the more common of these syndromes. Syndrome of Skeletal Abnormality, Headaches, Optic Atrophy, and Enlarged Sella Turcica. These are the commonly known cases of acromegaly and of gigantism. They show excessive growth of the skeleton, particularly in the face and extremities, and overgrowth of the soft tissues. Case 1.—F. H., a youth, aged 20, referred by a school doctor, has been under our observation in the Out-Patients and In-Patients services of the Vancouver General Hospital since 193 5. At the age of 13 he began to suffer from severe headaches and he has been troubled with them periodically ever since. His adolescent growth was phenomenal. By the age of 18 he was 6 ft. 6 in. in height, with big hands and big feet. Since then he has grown another inch. X-ray plate of his skull shows a greatly enlarged sella turcica, which is definitely indicative of tumour. Repeated examinations of his field of vision have been negative. Deep x-ray therapy has been given periodically, with resultant lessening in the severity of his headaches. The tumour in this case is undoubtedly an adenoma comprised of acidophilic (growth factor) cells, arising in the anterior lobe of the pituitary gland. These tumours respond fairly well to x-ray therapy, but whether such treatment can always hold them within bounds is problematical. The important feature from a surgical standpoint is the degree of pressure on his optic nerves. It is certain that his optic nerves and their point of junction, the optic chiasm, must be riding upwards over the tumour and must be tightly stretched. Unless his vision fails, however, there is no indication for operation on this tumour. Vision may fail with alarming rapidity in these cases and thus bring about a situation which should be regarded as a neurosurgical emergency. It is important that he should always remain under medical observation. Syndrome of Failing Vision, Bilateral Optic Atrophy, Field of Vision Defect and Enlarged Sella Turcica. Case 2.—Mrs. C, aged 49, was admitted to the General Hospital under Dr. Colin Graham in August, 1937. One year before admission her vision began to fail. This disturbance of vision gradually progressed until she was unable to read even the largest newsprint. Neurological examination was entirely negative except for bilateral optic atrophy, diminished vision, and field of vision defects. With the left eye she was barely able to distinguish movement of her hands, and with the right eye could only count fingers at fifteen feet. Perimeter examination of the right eye, by Dr. Graham, showed vision remaining only in the left upper quadrant. X-ray showed an enlarged sella turcica, indicative of tumour. The situation as regards her vision was obviously critical. Operation was performed in two stages, approaching from the left side through a frontal bone flap, using the usual concealed scalp incision. The tumour was curetted out except for a very solid portion which was lodged beneath the optic chiasm. Following operation she was given deep x-ray therapy. Six weeks later examination showed that she could count fingers with the left eye and read 3 mm. print with the right eye. The visual field in her right eye was now comparatively full. She reported by letter in May, 1938, no appreciable change. The tumour in this case was a chromophobe adenoma, arising from the "inactive" cells of the anterior lobe of the pituitary gland. If her symptoms had occurred prior to the menopause she would have complained of amenorrhcea as a result of diminished activity of the basophilic (sex-factor) cells. Chromophobe adenomas respond to x-ray therapy and in certain instances surgery may not be indicated, or may be safely deferred until x-ray treatment has been given a trial. I believe that all of these cases which have a marked defect in the visual field should have operation in addition to x-ray therapy. Page 82 Syndrome of Headache, Failing Vision, Homolateral Optic Atrophy, Contralateral Choked Disc. Case 3.—Mrs. C. G., aged 33, Italian, mother of five children, referred by Dr. W. H. Lang, was admitted to Vancouver General Hospital from the Out-Patients Department in May, 1934. She had been subject to fits for three years. These occurred at least once a week, occasionally several times a day. They took the form of generalized convulsions with loss of consciousness. Occasionally after a fit she was unable to speak for several hours. For eighteen months prior to admission she had complained of a constant headache and gradual failure of vision. She also noted that her menstrual periods had become irregular and of shorter duration. Examination showed an obese, rather lethargic woman. The abnormal neurological findings were: (1) loss of sense of smell on the left side; (2) ability to read only 3 mm. print with both eyes; (3) optic atrophy on the left side with choked disc on the right side, and (4) slight lower right facial weakness. X-ray picture showed absence of the left anterior clinoid process. It was apparent that something which had caused erosion of the bony anterior margin of the sella turcica on the left side was also pressing directly on the left optic nerve, and indirectly through a rise in intracranial pressure causing choked disc on the right side. The relative amenorrhcea suggested pressure on the pituitary gland with a resultant lessening of function of the sex-factor cells. The anosmia and contralateral facial weakness indicated pressure aginst the brain just to the left of the sella turcica. At operation a medium sized meningioma attached to the floor of the skull at the inner end of the lesser wing of the sphenoid bone was disclosed. In order to deal with it adequately, a portion of the left frontal lobe of the brain was resected. The tumour was then removed except for its attachment to the floor of the skull. Recovery was uneventful. She has remained in good health and free of headaches during the subsequent four and a half years. Her fits are only fairly well controlled with phenobarbital, as she continues to have them at one to two months intervals. Lately her vision has commenced to fail in the left eye and I fear that she may be developing a recurrence of the tumour. Meningiomata, if well removed, offer a better prognosis than most brain tumours. This case illustrates that removal of a brain tumour will not always cure fits which have been caused by the tumour. She has been saved, nevertheless, from an incapacitated state approaching a fatality, and enabled to carry on her home duties. Syndrome of Headaches, Failing Vision, Bilateral Optic Atrophy, Field of Vision Defect, Normal Sella Turcica. Case 4.—Mr. H. F., a logger, aged 32, was admitted to the Vancouver General Hospital in January, 1936. He related that in February, 193 5, he began to suffer from severe frontal headaches. In July his vision began to blur, but the headaches became less severe. In September his vision began to fail rapidly and on this account he was forced to give up his work. During the month prior to admission he was always very drowsy. He had a somewhat acromegalic appearance, with heavy lower jaw and prominent supraorbital ridges. Neurological tests were entirely negative apart from examination of the optic nerves. There was no central vision in his right eye but some vision in his upper temporal field. Vision in left eye was 18/200. The field of this eye was restricted to a small area entirely in his nasal field. There was marked atrophy of both optic discs. The sella turcica appeared normal in x-ray plates. An operative approach was made from the left side and a yellowish transparent cyst was found projecting upwards between the optic nerves from beneath the chiasm. When the cyst was opened thin fluid poured out, and it collapsed so entirely that there did not appear to be a scrap of tissue large enough to remove for section. He recovered uneventfully, and one week after operation vision was 20/30 in the left eye and 4/200 in the right eye. There remained slight constriction of the right temporal field and blurring of central vision of the right eye. He left hospital on the twelfth day. Three weks after operation he was seen again, and stated, to my consternation, that vision had gradually failed during the third week until it was practically the same as before operation. Tests confirmed his statements. Operation was repeated the next day, by reopening his barely healed wound. The cyst had reformed and refilled with the same yellowish fluid. This time the whole top of the Page 88 cyst was torn off and as many fragments of the wall as were visible were teased out. After operation he was given a course of deep x-ray therapy. This time the post-operative improvement in vision was maintained. In the late Spring he resumed his former work in the woods. In January, 1937, re-check of his visual fields showed them to be full, and he could read small print with either eye. One and a half years later he returned and stated that three months previously he had again been forced to give up his work because of failing vision. He was now totally blind in the right eye. With the left eye he could read small print but he was completely blind in his temporal field. A third operation was performed, on this occasion approaching from the right side. The cyst had of course refilled, but this time its walls were thick and fibrous and its cavity could be seen extending backwards beneath and behind the optic chiasm. After operation he was given another course of x-ray therapy. At the last examination, on August 15 th, he had a complete field of vision in the left eye. In the right eye he had a central scotoma and could barely see to count fingers. Somewhat shaken, but full of courage, he has again returned to work. This was an epithelial lined cyst which arose from a remnant of the embryonic Pouch of Rathke. They are more commonly found in children and treatment of them is notoriously unsatisfactory. X-ray therapy in these cases probably does more for the feelings of the doctor and relatives that it does good for the patient. Of the combined treatment, surgical and roentgenological, at least it can be said in regard to this patient that his vision has been temporarily restored and his working years prolonged. Discussion. A greater number of syndromes could be described, but they would merely present minor variations of the four which have been discussed. An exact diagnosis of the nature, location, and extent of these tumours is only made after a painstaking study of all the ophthalmological, neurological and roentgenological findings. These illustrations which have been cited show how precisely these jigsaw bits of information may be fitted together to form a composite picture. My personal experience with these neoplasms in Vancouver during the past five years comprises nine cases, six of whom have been operated upon. The boy with gigantism, mentioned in this paper, and a lady of fifty with acromegaly, have not undergone operation, but both have been told that they must return regularly for tests of vision. I have recently examined an acromegalic man of thirty-two, who was operated upon by Dr. Cushing in 1930. At that time the patient was almost blind in the left eye and had a gross field of vision defect in the right eye. Dr. Cushing's operation was immediately successful in restoring vision and now, eight years later, vision is 15/15 in both eyes and the visual fields are normal. The story of three of our six operative cases has already been related. The only fatality in the group was a lady who was already blind in both eyes as a result of a huge pituitary adenoma, and on whom operation was undertaken because of intolerable headaches. Of the remaining two cases, one was a patient with a chromophobe pituitary adenoma, for whom operation and x-ray therapy have greatly improved vision but have not widened the visual fields to any extent. The last patient was found to have an unusual tumour of the optic nerve, about which a report will be made in the future. Conclusions. Success in the treatment of tumours of the pituitary and parapituitary region often depends on how early the diagnosis is made. They occur more frequently than is generally recognized. As the majority of these patients complain of failing eyesight before any other symptom, it is generally an ophthalmologist who is first consulted, and the members of this specialty consequently may have an opportunity of detecting such cases at an early stage. It cannot be overemphasized that few gross mistakes would be made if all cases of optic atrophy were subjected to roentgenological and perimetric examination. Either enlargement of the sella turcica or a defect of the field of vision would reveal the cause of the failing eyesight. Unfortunately, even when optic atrophy is recognized and adequately investigated, vision may be so impaired that removal of the offending tumour does not Page 8k restore function completely. It should be possible to recognize these neoplasms before optic atrophy occurs. To ensure early recognition, all cases of failure of vision for which no local ocular cause can be found should have a careful charting of the fields of vision with a perimeter and x-ray investigation of the sella turcica. REFERENCES Cairns, H.: A study of Intracranial Surgery. 1929, London, H. M. Stationery Office. Cushing, H.: The Pituitary Body. 1929, Lippincott, Philadelphia. Cushing, H.: Pituitary Body and Hypothalmus. 1932, Thomas. Heuer, G.—The Surgical Approach and the Treatment of Tumours and Other Lesions about the Optic Chiasm. Surg., Gyn. & Obst, 1931, 53: 489.9 Frazier, C.: Resection of Pituitary Adenomata. Surg., Gyn. & Obst., 1932, 54: 330. Frazier, C.: Lesions in and Adjacent to the Sella Surcica. Am. J. Surg., 1932,16:199. Frazier, C.: A Review Clinical and Pathological of Parahypophyseal Lesions. Surg., Gyn. & Obst., 1936, 62:1,158. BRITISH COLUMBIA MEDICAL ASSOCIATION ANNUAL GOLF TOURNAMENT | Dr. G. Elliot won the Mead Johnson Co. cup for Low Net at the Annual Tournament in Victoria this year. Other prize winners were: Low Gross, Dr. R. Scott Moncrieff; runner-up Low Gross, Dr. Colin Graham; Dr. Geo. Hall won the Low Gross for the first nine holes and Dr. E. L. McNiven for the Low Gross for the second nine holes; Dr. D. F. Murray, Dr. F. S. Parney, Dr. Geo. Wilson, Dr. A. T. Henry, Dr. J. H. MacDermot, Dr. F. C. Dunlap, Dr. W. T. Lockhart, Dr. W. M. G. Wilson, Dr. R. J. Nodwell, Dr. F. S. Hobbs, Dr. M. Baird. The Consolation Prize was won by Dr. R. A. Gilchrist. VANCOUVER MEDICAL ASSOCIATION Founded 1898 Incorporated 1906. GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m. CLINICAL MEETINGS will be held on the Third Tuesday of the month at 8 p.m. Place of meeting will appear on the Agenda. General meetings will conform to the following order: 8: 00 p.m.—Business as per Agenda. 9: 00 p.m.—Papers of the evening. 1938 October Programme of the 41st Annual Session 4th—GENERAL MEETING. Dr. Frank Turnbull: "Pituitary and Para-pituitary Tumours." October 18th—CLINICAL MEETING. November 1st—GENERAL MEETING. Dr. J. Ross Davidson : "Some Aspects of Contract Practice." November 15th—CLINICAL MEETING. December 6th—GENERAL MEETING. Dr. Kari/ Haig : "Diagnosis of Congenital Dislocation of the Hip, with treatment of those which are reducible." December 20th—CLINICAL MEETING. Page 85 British Columbia President— ~ Medical Association Dr. D. E. H. Cleveland, Vancouver. First Vice-President ! Dr. F. M. Auld, Nelson. Second Vice-President Secretary-Treasurer — Dr. E. Murray Blair, Vancouver. Dr. A. H. Spohn, Vancouver. In addition to the officers as set out above, the following were elected as Directors at the Annual Meeting held in Victoria September 15th to 17th, 1938: Directors at Large: Dr. P. A. C. Cousland, Victoria; Dr. Anson C. Frost, Vancouver; Dr. Stewart A. Wallace, Kamloops; Dr. Geo. T. Wilson, New Westminster; Dr. Wallace Wilson, Vancouver. Chairmen of Standing Committees, 1938-1939: Committee on Constitution and Bylaws, Dr. H. H. Milburn; Committee on Programme and Finance, Dr. G. F. Strong; Committee on Study of Cancer, Dr. Roy Huggard; Committee on Public Health, Dr. A. H. Spohn; Committee on Medical Education, Dr. D. M. Meekison; Committee on Study of Economics, Dr. W. A. Clarke, New Westminster; Committee on Maternal Welfare, Dr. W. S. Turnbull; Committee on Pharmacy, Dr. C. H. Vrooman; Committee on Credentials and Ethics, Dr. J. D. Moore, Chilliwack; Committee on Osier Memorial, Dr. T. C. Hilton, Port Alberni; Committee on Medical History, Dr. M. McC. Baird; Committee on Editorials, Dr. J. H. MacDermot. BRITISH COLUMBIA MEDICAL ASSOCIATION COMMITTEE ON PUBLIC HEALTH, 1938-1939 Dr. A. H. Spohn, Chairman; Dr. D. H. Williams, Secretary. Dr. D. E. H. Cleveland, ex-officio; Dr. M. W. Thomas, ex-officio. Dr. D. Berman, Dr. K. F. Brandon, Dr. C. E. Brown, Dr. D. A. Clark, Dr. J. S. Cull, Dr. J. R. Davies, Dr. Richard Felton, Dr. J. J. Gillis, Dr. L. Giovando, Dr. E. S. James, Dr. A. Y. McNair, Dr. G. O. Matthews, Dr. H. H. Milburn, Dr. Stewart Murray, Dr. E. K. Pinkerton, Dr. H. H. Planche, Dr. E. Therrien. The B. C. Medical Association, by appointment of its Committee on Public Health, has recognized its responsibility in giving consideration to and playing an active role in the solution of problems pertaining to public health in British Columbia. The scope of the problems confronting this committee is as broad as the field of preventive medicine. The increasing interest in public health on the part of our citizens is evidenced by the active participation of lay groups in these matters. It behooves the B. C. Medical Association, out of its knowledge and experience, to give voice and practical assistance to measures of preventive medicine which will result in increased health and happiness to the people of British Columbia. The Committee on Public Health asks that the members of the Association bring to its attention any problems in this field which may arise at any time in their community. They will receive consideration, and recommendations relative to their solution will be forwarded to the executive of the Association. The opening meeting of the Committee was held on Wednesday, October 19th, and the following Public Health problems were suggested as worthy of immediate attention:— 1. The compulsory pasteurization of raw milk; 2. The prevention of prenatal syphilis by routine seriodiagnostic tests and adequate treatment instituted early in every pregnancy; 3. The smoke nuisance in Vancouver. 4. Expectoration in public places. Page 36 THE BRITISH COLUMBIA CANCER FOUNDATION A letter from the Chairman of the Board of Directors ■ v Plllp f :| -1 I w THE BRITISH COLUMBIA CANCER FOUNDATION to THE MEDICAL PROFESSION OF BRITISH COLUMBIA I am very glad of the opportunity extended to me by the Editor of your Bulletin to say something regarding the present status of the British Columbia Cancer Foundation, and its plans and hopes for the future. Before doing so, however, there are one or two definite statements that I desire to make on behalf of myself and my fellow directors. The first one is this: The B. C. Cancer Foundation is an entirely independent organization. Due to the fact that we are without sufficient funds to set up a complete unit of our own, we are receiving, either by donation or by purchase, certain services from the Vancouver General Hospital, but we are in no way connected with or controlled by that, or any other institution. Further, our policy for the future is that we will continue to maintain that independence, for we believe that in that way we can best serve the interests of the cancer patients of this Province. The other statement is: The members of the Board of Directors, knowing something of the present state of knowledge concerning the cause and cure of cancer, realize that radium is but one of the weapons available in the great war against cancer. But it is a weapon that is of value in certain cases and under certain conditions, and as such we believe it should be made available to as many suitable cases as possible. With this statement, we think the medical profession will be in agreement, and we therefore ask for your help and co-operation. Now as to the Foundation itself: In April, 1938, the Foundation received a gift of $50,000 from an anonymous donor, on condition that some of the Foundation's radium be made available immediately to cancer sufferers in this Province. After careful consideration, the Foundation decided to use $30,000 of this gift to repay part of the loan, under which the 3J4 grammes were purchased in 1935, and thus to release one gramme of the radium for use in a clinic; $10,000 was set aside for the processing of this one gramme of radium, and the remaining $10,000 for the furnishing and equipment of a suitable building. The Vancouver General Hospital agreed to provide free of charge, for a period of one year, the former Internes' Building at 11th Avenue and Heather St., and also offered to contribute certain essential services. With the assistance of the anonymous gift, the contribution from the General Hospital, and other donations, principally from the Rotary Club and the Lions Gate Riding & Polo Club, the Foundation has been able to establish a clinic, to be known as The British Columbia Cancer Institute. This institute will be officially opened on November 5th. Until further financial resources were available, it was decided to restrict the activities of the Clinic to two fields: radium therapy and diagnosis. It has been agreed that the minimum regular staff for the Institute should include: 1 Radium Therapist (full time); 1 Radium Nurse; 1 Nurse; 2 Medical Officers (part time); 1 Stenographer-Secretary; 1 Orderly. It is hoped that with the assistance of your organization it will be possible to appoint an attending staff and an honorary consulting staff, to assist with the diagnostic work of the Clinic. Shortly you will receive, if you have not already done so, a letter from the Foundation telling you of this Clinic, and outlining certain regulations for the handling of patients. We know that the cancer population of the Province goes through the hands of the medical profession, and we desire to care for only those patients who are referred to us by the medical profession. We do not want patients coming to our doors of their own free will. At present, and for a long time to come, you can supply us with more cases than we can deal with in conformity with our regulations and facilities. The doctors throughout Page 81 the Province, and not the patients, should decide which are the suitable cases to be sent in, either for the clearing up of difficult points in diagnosis, or for active treatment. The opening of the Clinic will entail a certain amount of unavoidable publicity, but it is not the policy of the directors to publicize the work of the clinic in the lay press. We realize that any publicity concerning a form of treatment for cancer is apt to be misinterpreted by the people at large, and is extremely liable to raise unduly the hopes of cancer victims and their relatives. They then look for results which in so many cases cannot be obtained, and the end is sorrow and disappointment. At some future date we hope, with your assistance, to put forward, with all publicity possible, a campaign for funds to provide a fully equipped and modern institute, with adequate research and other facilities. At that time we hope to be able to tell of what we have done and of the need that we have been unable to meet because of lack of adequate resources. At the regular meeting of the Board of Directors of the Canadian Medical Association (B. C. Division) on November 9, we are inviting your directors to submit to us a panel of names, and from that panel we propose to appoint our Honourary and Active Medical Staffs. We look forward confidently to the co-operation of your directors in this matter. We intend to look to these two staffs, not only for active participation in the work of our Clinic, but also for advice and counsel in directing the policies of the work, so that in our field the greatest possible advance may be made towards bettering the lot of the cancer patient in this Province. In conclusion, may I take this opportunity of congratulating your branch of the Canadian Society for the Control of Cancer for the excellent work it is doing under the vigorous charmanship of Dr. Allan McNair. Its work, our work, all work aiming at the control of cancer, is indivisible, and worthy of the most cordial support of every layman and every doctor in British Columbia. W. H. Malkin, Chairman of the Board of Directors, British Columbia Cancer Foundation. QUESTIONS TO BE CONSIDERED PREVIOUS TO GOING APPRENTICE FOR AN APOTHECARY Requirements laid down in the time of Edward Jenner—not altered much today. Can you bear the thoughts of being obliged to get up out of your warm bed, in a cold winter's night, or rather morning, to make up medicines which your employer, just arrived from attending a labour, through frost and snow, prescribes for a lady just put to bed, or a patient taken suddenly or dangerously ill? Or, supposing that your master is not yet in sufficient business to keep a boy, to take out the medicines, can you make up your mind to think it no hardship to take them to the patient after you have made them up? Are you too fine a gentleman to think of contaminating your fingers by administering a clyster to a poor man, or a rich one, or a child dangerously ill, when no nurse can be found that knows anything of the matter? This is a part of your profession that is as necessary for you to know how to perform as it is to bleed or dress a wound; or are your olfactory nerves so delicate that you cannot avoid turning sick when dressing an old neglected ulcer; or when, in removing dressings, your nose is assailed with the effluvia from a carious bone? If you cannot bear these things, put surgery out of your head, and go and be apprenticed to a man milliner or perfumer. (Extract from Professional Anecdotes, edited by Dr. E. Jenner, 1802. (Father of Vaccination.) Page 88 [An interesting paper received lately, through the courtesy of Dr. H. M. Cassidy, Director of Social Welfare, is that of Dr. A. E. Larsen, Medical Advisor to the California State Relief Adrninistratioru We believe it will be of interest to our readers, especially in his conclusions as to the feasibility of giving a full medical service, paid for on a fee basis, to the indigent. He finds that the cost of this service would be about four times as great as when the service is given through a clinic. This is, however, a rather one-sided statement. The "clinic service" includes social service work, employability examinations, home care nursing, appliances, special diets, housekeeping service, etc. Presumably all those who do this work are paid, but they are not all medical men. For the medical work, certain physicians are paid on a salary basis for part-time work. This opens up a whole new line of thought. It will be noted that the physicians chosen to do this work get a very small remuneration, as standards go. This feature is in need of improvement. But it does afford to the young physician certain things. It gives him work to do, and pays him something for it; it gives him a start in the community; it keeps him in touch with clinical work, and gives him plenty of opportunity to become a better doctor. These are all things that are sadly lacking under our usual method of beginning practice. We have two loose ends: the doctor starting practice that needs work and pay therefor,, and the indigent who need medical care and cannot pay for it. The connecting link may very well be some system, perhaps inaugurated by the Government, which must ultimately meet the cost of medical care of the indigent somehow, along lines such as those suggested by Dr. Larsen. This may lead to a solution of that most obstructive problem, the medical care of the indigent on terms fair to the medical profession, and yet calculated to ensure adequate care to the indigent. It is worth our earnest consideration. There is no doubt that the ideal method from our point of view is payment for services rendered according to a schedule of fees, and this has been proved to be feasible, in Ontario, and, as far as a simplified system of office and home practice goes, in Vancouver, but the schedule is altogether too moveable to be satisfactory. While we may, for reasons adduced above, question Dr. Larsen's conclusion that a system of practice on a fee basis would cost four times as much as the clinic system—and while we may feel that if this is true it is probably because the doctor is so very much underpaid under the clinic system—we must yet consider whether perhaps the latter, as administered in the plan described by Dr. Larsen, may not have sufficient merit to make it worth trial, and sufficient opportunity for improvement and expansion in detail to suggest that along these lines we may eventually reach a satisfactory solution of some of our problems.—Ed.] CALIFORNIA STATE RELIEF ADMINISTRATION 180 Montgomery Street, San Francisco, California. Dr. H. M. Cassidy, August 26, 193 8. Director of Social Welfare, Parliament Building, Victoria, B. C. Dear Dr. Cassidy: I am sending you a copy of the paper which was read in Seattle, which is based on the observation of the operation of a panel system in Los Angeles and a clinic system in San Francisco Over a period of the past four years. It is difficult to compare the two completely and accurately because of the different nature of the services that are rendered. For instance, in Los Angeles County, under the panel system, there is an average of a little over one visit per case per month, whereas in Page 89 San Francisco the visits per case are nearer three. However, it is possible to take the services rendered by the clinic system in San Francisco and compute them in terms of what they would cost under a panel system. This is really the only way that they might be compared on a sound financial basis. We have done this for the San Francisco plan and found that to duplicate the services provided in the clinic system would cost approximately four times as much by the panel plan. There is another factor to be considered besides the question of cost which I think is equally important, and that is the social benefit derived from a central unit which understands the work of the welfare division. The clinic system is able to concentrate and standardize certain matters which are of interest to the welfare division. As you know, there are many accessories to medical service for an indigent person. We have to give considerable thought to medical reports to the case worker, to employability examinations, appliances, home care nursing, housekeeping service, special diets. All of these functions may be departmentalized within a clinic system with uniform standards and with proper thought of the conservation of funds, so that the maximum benefit to the patient as well as to the fund may be achieved. The clinic system is able to direct its attention to specific problems that may arise in the case load. As an instance of this, we are able to pay particular attention to the psychiatric phase of the relief client. Such work is not easily obtained with a panel system. We have found that the people willingly accept the clinic service, although we do allow them choice of their own physician if they so desire. In the latter instance we provide drugs and nursing supplies, but we do not compensate the physician. This phase of clinic service has been shown to be almost negligible, as less than 1 per cent of all the patients we have seen have had a family physician with ,whom they desire to continue medical care. I am in the process at the moment of writing a detailed analysis of the San Francisco clinic system and at some future date I shall be glad to send you a copy of this. Thanking you very much for your inquiry, I am, Sincerely yours, A. E. Larsen, M.D., Medical Advisor. MEDICAL RELIEF BY THE CLINIC AND PANEL SYSTEMS Albert E. Larsen, M.D. (Read before the conference of the American Public "Welfare Association in Seattle, June, 193 8.) The results of many excellent surveys have shown that (the medical problems of the indigent are greater than in any other population group. There are implications in these surveys that these medical needs are not being adequately met. The Federal Government in 1934 recognized this, but withdrew its support. Many states continued with their medical programs, but began to modify the original to meet local conditions. This caused the growth of a variety of medical plans. In California two plans have developed to care for the medical needs of the unemployed relief group: the clinic in San Francisco, and the panel in Los Angeles. I shall attempt to give a bri^f description of each. The panel system, as used in Los Angeles and the rest of the state, began with the co-operation of the state and local medical societies. They agreed upon a fee schedule and all licensed physicians in the community were invited to participate. A physician was appointed to direct their programme. To secure medical care, the prospective patient consults his case worker and is allowed to select his own physician. If there be no preference, cases are rotated among the panel. Forms necessary for social service and accounting purposes are sent to the physician for completion. This material returns to the local medical department, is certified as to correctness, and then forwarded to the central accounting office for payment and budget adjusting. The Central Medical Bureau originated in San Francisco in 1932 from the recommendation of a committee composed of the Director of Public Health, physicians who had been presidents of local or state medical societies and the president of the local medical (Italics in this copy are ours.—Ed. Page hO society, and interested lay persons representing the Community Chest and labor. With the policy determined, a physician was appointed to design and direct the programme: a home care service for the acutely ill, a clinic for chronics, and existing community services compensated on a visit basis. Physicians were offered part-time work on a salary basis for home care and the clinic for chronics. To secure medical care the patient is issued an identification card by the case aide and may then use the clinic facilities at any time while he is on relief. A master file of active cases in the Bureau checks eligibility. This file is identical with! the accounting files of local and state offices. Each patient has a medical chart, which is correlated with his social service record by name and number. This chart contains all information of medical and social interest and is used by all the departments within the clinic. Social service directs all inquiries of a medical nature to the clinic. Information is returned interpreted in lay terminology and in accord with the policies of the administration. The major part of the expense of the clinic is for personnel. A medical programme for the indigent must be considered from the point of view of the patient and the medical profession, social service and the administration. I shall discuss some of the advantages and disadvantages of the panel and clinic systems in relation to these points. The panel system meets with the approval of the medical profession because of presumed service on the physician-patient relationship. This is functioning very well in the rural areas, but its application to a metropolitan centre is questionable. A survey of the free choice experience has shown that in Los Angeles, though the clients were encouraged to choose their own physician, less than one per cent availed themselves of this privilege. Medical care is limited to the acute stage of a disease. Cbjronic conditions are referred to a clinic resource. Therefore, from the M.D.'s point of view, there cannot possibly be a successful continuity of treatment. The idea of a fee schedule was not always acceptable because of the danger of establishing a precedent on the value of physicians' services. (! Ed.) Most physicians object to the amount of paper work they have to complete. As many as nine forms may be referred to satisfy the social worker and the accountants. A few of these reasons may possibly account for the shrinkage in the size of the panel. In February, 193 5, in Los Angeles, 2,300 physicians out of 4,150 applied for panel service. There are now about 200 remaining. The average income of each for panel service is approximately $10 monthly. The clinic system does not imply the physician-patient relationship in the true sense of the word. However, patients are allowed to continue with their private physicians1 should they desire. Drugs and sickroom supplies are then provided for these patients by the clinic facilities. The profession was of an idea that clinic service would influence the patient to become clinic minded, but a survey showed that this was unjustified, as less than one per cent of patients had sought the services of a private physician in the year previous to registration. It was also shown that the people on relief rolls in the metropolitan area always had been accustomed to using clinics. Physicians for the Medical Bureau are selected from approved medical schools. Marriage, dependents, their economic need and residence are factors considered. They average $65.00 a month for nine hours' work a week. This has been a great help in aiding many young physicians to become established in the community. The same percentage of practising physicians is employed by the clinic as is on the Los Angeles panel. In the present-day structure of relief a physician's responsibility extends beyond the actual care of an illness. By reason of contact with a relief client, he actually becomes part of the social service personnel. The person whom he treats is living in an artificial environment. His existence has been made possible by legislation, in which there are many rules and regulations. These must be considered in relation to housing, special diets, housekeeping services, and employability. The quality of- medical service produced by the ^vsician is often dependent on adjusting these needs. It therefore becomes essential for xun physician to co-operate and work with the medical social workers and the case aide in Page Jfl use of limited funds. The size and diffusiveness of the panel system renders this phase of medical service difficult. The clinic is able to centralize all medical information and to train its personnel in these regulations. Therefore, a maximum of benefit to the client may be secured within the imposed limitations. It also provides the physician with a trained staff of special workers to follow their cases. The quality and efficacy of medical care is directly related to this effort. The third factor in medical relief is adrninistration. The panel requires a staff to control the extent of services, eligibility, and authorizations. It must maintain locally an accounting department to handle this detail. This overhead amounts to about 2 5 per cent (depending on the load) of the total medical expenditures. A percentage of this cost is duplicated in the central accounting office. Since the panel treats only the acute stage of a disease, it is caring for only one-fourth of the medical needs of the case load. The remainder are cared for in county clinics where the physician usually is not compensated for his services. It has not been possible to say what the cost for complete medical care would be, due to the lack of actual experience. Theoretically it may be computed // services provided in the clinics were extended to a panel system the cost would be approximately four times as great. The clinic in San Francisco has an overhead of about 10 per cent. It is practically self- sustaining, in that only a small part of its accounting necessities are duplicated in the state office. This releases a comparatively larger sum than the panel system affords to be devoted to pure medicalcare. Statistics show the average incidence of illness per month to be about 18 per cent and reveal the actual medical needs of the relief group. The cost per person on relief for complete medical and dental care varies1 inversely according to the load. In 1935, with a case load of 70,000, this cost was 2 5 cents per person a month; in 1936, with 20,000, the cost, was 50 cents a month. From available figures it is therefore possible to predict with accuracy the cost of providing medical care to any case load. There are also figures whereby it is possible to compute the number of physicians, nurses and clerical help necessary for a given case load. It is the policy of the Medical Bureau to vary its staff according to these changes. This is based on a basic standard established of the number of minutes per patient consistent with, good quality of medical care. In conclusion, the medical needs of unemployed relief clients are greater than those of any other population group. There is an economic and a public health, as well as the humanitarian challenge to meet. The quality of medical care given should equal the standards as practised throughout the nation. It should draw a minimum from the tax structure consistent with this service. The present theory of meeting medical needs supplements local resources, where physicians are usually not compensated. Should responsibility for medical care follow the source of funds, because of overburdened local resources or policy changes, new methods would have to be considered. From the foregoing it would seem that the panel system would be the method of choice in the rural areas. In metropolitan centres with populations of 100,000 concentrated within a radius of 10 miles, the clinic system as described could include adequate compensation to the medical profession and render efficient medical service to the patient, and social service, with simplified administration at a minimum cost for all home and ambulatory needs of the entire case load. R_HANDS OFF [Below is a copy of the article in Collier's Magazine referred to editorially.—Ed.] Copy of Editorial in Collier's Magazine, September 10th, 193 8. Of all the many activities of our government, the suggestion by the Department of Justice that the American Medical Association is fair game under the antitrust laws is quite the maddest. Not that we are taking the part of the doctors in their quarrels with some of the brain trusters in Washington. Our belief is that the doctors are well able to fend for themselves. Page 42 But the long attack of Assistant Attorney General Thurman Arnold on the doctors is just too extreme. The antitrust laws seem to be against anything except trusts. As Thurman Arnold himself said somewhat extravagantly in his book, The Folklore of Capitalism, "the actual result of the antitrust laws wast to promote the growth of great industrial corporations by deflecting the attack on them into purely moral and ceremonial channels." Yet years ago the Danbury Hatters' Union was prosecuted under the antitrust law. The Sherman Act had not done much toward breaking up trusts but it was a sixteen- inch gun where the hatmakers were concerned. The small Danbury union felt the full force of the governmental fury. Poor little men lost their homes and savings. The hatters were crushed. Or, at any rate, such was the general impression thirty years ago. Perhaps that conclusion was wrong. Maybe there is some connection between blind partisanship exhibited in the prosecution of a small local labor union under the antitrust law and the subsequent adoption of the frankly partisan Wagner Labor Act. Injustice breeds injustice and partisanship gives rise to more partisanship as in time the wheel of fortune turns. It is tragic to see important matters so mishandled. It is also too bad to see the bright young idealists at Washington getting slick in the application of statutes. It is possible to be just too smart. Arnold's scheme to fight an imaginary medical trust is much too cunning. Very plainly there is a medical problem with which the government sooner or later will have to deal. The problem is as simple—and as complicated—as poverty. The poor do not have enough, or good enough, medical service. The doctors and hospitals have provided much free service for those unable to pay. Most good doctors give generously of their time and skill to patients unable to pay. The generosity of doctors with the poor is proverbial. Still, better arrangements can be made. The most pressing needs exist among the vast number of families unable to pay for competent medical service but unwilling to accept charity. Different methods have been tried to meet their requirements. Corporations, voluntary co-operative associations and other organizations have been formed to provide medical service. The present controversy arose over the creation of a co-operative medical agency in one of the governmental bureaus at Washington. By paying a small sum monthly the government employee was given medical care for himself and family. Regular physicians opposed this scheme. Doctors who worked for the co-operative were not favored by the medical associations nor received by the hospitals. So the Department of Justice's Thurman Arnold decided that the medical associations could be brought to terms by using the antitrust laws against them. Maybe so. The Danbury hatters certainly took a beating. On the other hand, maybe the doctors are not quite so vulnerable. They at least can hire plenty of counsel to argue the point. Perhaps, also, in the struggle public opinion will support the doctors. They have many friends, and, as individuals, they have rendered valiant service. But it won't be wise for the doctors to get too technical or too self-satisfied. The Department of Justice would not be sticking its nose into the policies of medical associations if it were not persuaded of the public interest. Somebody, somehow, must devise a way of making good medical service available to the entire population under reasonable conditions. The doctors themselves would be wise to take the leadership in this effort. Many promising experiments are already being conducted. The mutual insurance plan of providing for hospital expenses is being widely adopted with the approval of both doctors and hospitals. Other ways of adapting the insurance principle to medical care are being tried and some doubtless will work. Meanwhile, the doctors will do well not to be too much annoyed at being denounced as a medical trust. The courts or Congress can take care of the farfetched accusation of a medical monopoly. Only the doctors themselves, however, have the information necessary to evolve a comprehensive policy under which the best possible medical care may be available to the largest number of people. If the doctors do their part, they will have little to fear from Washington or elsewhere. Page >,$ Vi ctoria Medical Society Officers, 1938-39. President Dr. P. A. C. Cousland Vice-President Dr. W. Allan Fraser Hon. Secretary Dr. W. H. Moore Hon. Treasurer Dr. C. A. Watson The Annual General Meeting of the Victoria Medical Society was held on October 3rd of this year. The chief business was the receiving of reports of committees for the previous year, and the election of officers. The Library, Indigent, Publications and Public Health Committees were all re-elected with the same personnel as last year. An Editorial Committee, to provide material from Victoria for the Bulletin of the Vancouver Medical Association, is to be appointed by the incoming Executive. RADIATION THERAPY By Dr. H. H. Murphy Director, Department of Radiology, Jubilee Hospital, Victoria, B. C. (Address given before the Victoria Medical Asciety on January 11, 193 8) Mr. President and Gentlemen: To address this society is a privilege which I appreciate, and I trust that a brief review of Radiation Therapy may prove of interest to each one of you: and if such a review is to prove of interest it must, I think, be conducted with a telescope rather than a microscope, so that you may be able to detect the broad underlying trends which we can follow from year to year or from decade to decade. In radiation therapy, as in most things, such underlying trends will come, I think, nearer to the truth than do the surface variations which are cast up from year to year. You will all remember that Professor Wilhelm Conrad Roentgen, Professor in the Institute of Physics in the University of Wurzburg in Bavaria, discovered the x-rays in November, 1895. You will also remember that when he made this momentous discovery,. Professor Roentgen was working with a Crooks tube excited by an induction coil; so that, obviously, Sir William Crooks produced x-rays but did not recognize them. It is of interest to us that the late Dr. Pepperdyne of Toronto—who, ass some of you know, died a martyr to science, losing first one arm and later the fingers of the other hand as a result of skin carcinomata developed through this early work, and later dying of metastases— worked with Sir William Crooks during this period before Professor Roentgen's discovery, and that we have working with us in Victoria one technician trained under him. As I look around this meeting I see many who, like myself, began medical training and practiced for some years before this "new ray" was sufficiently understood to be known outside the laboratories of the experimental physicists. I have just spoken of a "new kind of ray," and this was the title of Professor Roentgen's original paper announcing the discovery on December 28, 1895, before the Wurzburg Physical Society. The discovery was announced in England in the lay press on January 6th and in New York on January 9th. On January 10th the first scientific announcement was made in England through the medium of The Electrician and the good news was carried to the medical profession on January 11th in the issues of the Lancet and of the British Medical Association Journal. So, Mr. President, the time is singularly fitting for a review such as I contemplate this evening, as we are opportunely marking an anniversary. For this reason you will, I am sure, be interested in hearing the brief editorial from the Lancet announcing the discovery. I would here thank the Library Committee of this Society, as their work enabled me to find this here in Victoria. McGill students will be interested to know that this particular volume of the Lancet is from the library of the late Professor James Bell of Montreal. Page U "The Searchlight of Photography" "Everyone remembers what Mr. Samuel Weller said in reply to the question put by Sergeant Buzfuz: 'Have you a pair of eyes, Mr. Weller?' 'Yes, I have a pair of eyes,' replied Sam, 'and that's just it. If they wos a pair o' patent double million magnif yin' glass micro- -scopes of hextra power, p'raps I might be able to see through a flight of stairs or a deal door, but bein' only eyes my wision's limited.' In Sam Weller's day it is safe to assert that such an instrument was not available, and many will be sceptical even in these enlightened days as to whether it is possible to see or to bring to view an object situated behind a deal door. Yet this has been virtually accomplished, if we are to believe an announcement from Vienna this week. Thus it is reported that Professor Roentgen, the Professor of Physics at Wurzburg University, has discovered that a certain kind of light, while it will penetrate wood and the flesh of men and animals, will not penetrate bones and metals. The special kind of .light which appears to be endowed with this remarkable differentiating property is obtained by passing an electric spark through a vacuum tube. As far as we can gather, a photograph may be obtained of metals enclosed in wood or of the bones of a man's hand, by simply interposing these objects between the luminous vacuum tube and sensitized paper. If this be so, then, bones and metals being impervious to this light, a print will be produced which will represent the object in white, and the wooden or fleshy covering, as the case may be, as a sharp dark border in strong relief. Such results, we learn, have actually been obtained, both with metals enclosed in wooden boxes and with the bones of a living hand. In how many ways such a discovery might, if it be true, be turned to the highest account we cannot at this juncture pretend to say. For us, it much possess the greatest possible interest, even though it contain only the shadow of a promise of affording a means, to quote one instance, of finding the locality of a bullet embedded in the flesh without causing the pain necessarily inflicted by probing for its whereabouts. At any rate, whether these applications are practically impossible or not, we have evidently advanced since Mr. Samuel Weller's time, since it is announced that means have been found for bringing objects enclosed in wooden cases to view, and that, to all intents and purposes, amounts to 'seeing through a deal door'. . . ." While speaking of the various magazines which announced the discovery, we must not overlook Punch. In the issue of January 25, 1896, we find a so-called poem of five verses —I shall quote only one of these to you. "We do not want, like Dr. Swift, To take our flesh off, and to pose in Our bones, or show each little rift And joint for you to poke your nose in." The year 1896 saw the "new kind of ray" used in medicine both for diagnosis and treatment, and before the year was out the sad results of the, as yet, not understood dermatitis made themselves known. It is also interesting to note in passing that, in this same year, x-rays were used in industry, in the Carnegie steel works, to detect flaws in castings and weldings. It was thought that the x-rays were present in sunshine, and, as sunlight was then inown to be bactericidal, the first experimental work done with x-rays was to try and establish the discovery as a new bactericide, but this was soon abandoned. However, during 1896, malignant conditions of skin and breast were treated empirically by medical practitioners of various nationalities, and it is of geographical interest to us here to note that in this same year (1896) the first case of x-ray dermatitis with histological study of the affected skin was made by A. B. Kibbe, of Seattle. Soon the possibility of producing epilation was discovered, and this, rather than dermatitis, gave the clue to modern therapy. An Austrian named Leopold Freund heard of these epilating effects and decided to treat a large hairy nasvus. The nsevus, according to Freund's report, extended unilaterally from the neck down the posterior part of the thorax, and he treated it two hours a day for many days—so many, in fact, that one area received 42 hours of irradiation. He gave his type of coil (20 cm.) and distance (10 cm.) and was greatly pleased when epilation occurred on the seventh day. However, his enthusiasm was ■dampened a bit when, later, the child was admitted to hospital with albuminuria and evidence of toxicity from the extensive tissue ulceration, which later required several Page 45 excisions; but five years later he reported the case as healed, and only a lesion "the size of a guilder" remained. (Science of Radiology, pp. 214, 215.) This case had wide publicity, and physicians knew that they had now a potent, if as yet little understood, therapeutic agent. Freund had described his current as of an intensity that "permitted a hand to be photographed in one minute," and the first attempt at a dosimeter was when someone took a skeleton and mounted the hand on a block of wood and used this, rather than his own hand, for estimating dosage. This was to develop into the Ionization chamber, and the "R" unit of today, with all its exactness. By 1905 something was known of the value of filters and the problem of quality in radiation therapy. Marked improvement in equipment, such as the development of the interruptless transformer by Clyde Snook of Philadelphia (1906), and the Coolidge hot cathode tube by W. D. Coolidge (1913), placed in the hands of radiologists equipment of precision and accuracy, and the advancement from that time on was rapid. In 1920 L. Seitz and L. Wintz of Berlin announced the massive dose technique for treating malignancies that were deep seated—that is, administering as large a dose as possible in as short a time as possible—so to speak, a cancericidal sterilizing dose, and, as it was only shortly before that the idea of a massive dose of 606 held the field, it was not to be wondered at that this system, fundamentally wrong as it was, should have had such a general appeal. Everyone talked of a "lethal dose" or a "critical dose," and thought only of a direct depressant action on the tumour cell. This idea ia still widely held and no one yet has the final answer, but there are many observations that make us think a great deal today of an indirect action. In connection with this question of indirect action, I will read to you a short extract from a symposium from the annual Congress of the British Institute of Radiology on December 8, 1933, and I am quoting from the contribution of Dr. F. Hernaman-Johnson (The British Journal of Radiology, March, 1934, pp. 142-144): "I began to believe that the killing of all cancer cells at one time by the direct action of x-rays or radium was impossible. This belief saved me from any exaggerated hopes when the so-called Erlangen method was introduced more than a decade ago. The heavy 'lethal dose' seemed to me but my old friend the 'critical dose' under another name, and no more likely to be justified. Nevertheless, I still thought that direct depression of malignant cells played a large part in the disappearance of any tumour. "Steadily, however, my belief in the importance of direct action has diminished: it seems to me that during the past few years a large amount of evidence, both experimental and clinical, has been obtained which emphasizes the indirect factor. Experimentally, there is the work of Bainbridge and Murphy in America, and of Russ in this country, on the irradiation of tumour sites before implantation. Transplanted cancers do not take well on irradiated tumour sites. Murphy further states that when a tumour fails to grow under the above circumstances, the degenerating malignant cells pass through a series of phases identical with those which occur under treatment by x-rays in situ. "Modern research has provided us with no proof whatever of direct selective activity in hi vivo experiments. Let me quote again the cautious words of Dr. Finzi: 'After an irradiation which is not excessive, some change takes place, causing the growth cells to disappear and the healthy cells to remain'; and the more positive statement of Dr. Shaw: "X-rays act mainly as a stimulant to the healthy cells of the body.' At a recent cancer congress, slides were shown of a spontaneously regressing mouse cancer, and of one disappearing under the action of radium. Microscopically, there was no difference in the appearances. "Tissue culture experiments in vitro present great technical difficulties, and the results have the appearance of being conflicting; malignant cells are found to be sometimes more, sometimes less, sensitive to radiation than normal cells, according to varying conditions. "It is said by some that because certain forms of sarcoma almost 'melt away' under x-rays, that action must be direct on the cells. It does not follow. We have all seen large gummata rapidly disappear under the internal administration of potassium iodide—an action which is certainly not direct. "Direct action is also unlikely on a priori grounds, in view of the multiplicity of disorders in which x-rays are of service. It must surely be the names of the disorders which Page 46 are multiple rather than the disorders themselves, for it is inconceivable that nature should have, say, fifty different ways of responding to the same agent. We know, in fact, from pathological and biochemical studies that the means of defence which the body possesses,, though highly complex in themselves, do not, in fact, differ greatly whatever the morbific agents. Elimination, inflammatory reaction, phagocytosis and the mechanism of immunity in its widest sense almost exhaust the list. Nor can any remedy, apart from chemical antidotes, act except through these processes. Even so-called specific remedies like salvarsan and quinine have been shown to require the co-operation of the body tissues if they are to be successful. Now I do not think it will be claimed that x-rays are a specific remedy. Are we to suppose, then, that their action, whatever it is, is essentially different in two such apparently diverse cases as, for example, a fracture due to a secondary deposit in the upper end of the femur and an osteoarthritic hip joint? Precisely the same dosage may cause the healing of the cancerous lesion and the arrest, and to some extent the reversal, of the osteoarthritic process. "It is, I believe, taught that x-rays have a selective action on white blood cells, and that this accounts for their good effect in splenic leucaemia. I have tested the effect of the same dosage scheme on cases of leucaemia with the typical increase of leucocytes, low red cell count, and deficient haemoglobin, and on patients suffering from polycythaemia, showing an excess of reds. In the one case, the whites are, rapidly reduced and the red cells go up. In the other, the red cells are brought back to normal. In both, the patients are restored to a symptom-free condition. Yet the same dosage applied for some other purpose to a patient with a normal blood picture caused no change in the red or white cell count. Obviously, selective action on white cells does not explain the good effect of x-rays in leucaemia. All one can say is that in some way they assist the body to regain, for the time being, a proper balance, and it is quite probable that direct destruction of cancer cells, if and when it occurs, is, with regard to the process of healing, of secondary importance, or even of the nature of a mere epiphenomenon. "Let us take another line of argument. The effects of x-rays on the body are of the nature of electrical phenomena. Electricity in various forms has been found to be of use in rheumatism, exophthalmic goitre, many skin diseases, rodent ulcer, and, in fact, in a list of disorders similar to, though smaller than, that for which x-rays are employed. Rodent ulcer, which is truly malignant although it does not metastasize, may be caused to heal by galvanism—which you may call ionization if you wish—or by daily mild high- frequency sparking around its margins. These measures call into being our old friend inflammatory reaction. They stimulate healthy tissues. But can anyone with a microscope tell by examining the deeper layers of such a growth whether the therapeutic agent is electricity or x-rays? "I venture to suggest, in all humility, to the laboratory worker, that the limit of progress as regards study of malignant cells per se has been nearly reached. On the other hand, the reaction of the surrounding healthy tissues and of the body as a whole have not been fully investigated. Researches not confined solely to the study of radiation effects in cancer, but extending to their action in various non-malignant conditions, also comparative studies with regard to other remedies, might lead to fresh discoveries, or at least to a fuller understanding as to how x-rays and radium act." I have referred to the temporary popularity of the massive dosage system, but that was only a surface variation. As early as 1914, C. Regaud of Paris suggested that, in view of his studies on the effect of radiation on cells during the process of division, a more valuable plan would be to treat with comparatively small intensities over a very long period so as to irradiate cells during all phases of division when they seem most directly vulnerable. This idea was first applied to radium and later to roentgen ray therapy. With the increased knowledge that we now have on the question of the quality of radiation (wave length), this idea has been further developed by Professor Henri Coutard of Paris. At this point I would just mention his observations on "Periodicity": he found that under radiation therapy there was a normal cyclical response, and that, to a certain extent, the same rule held true of malignant conditions, and he tries to plan his treatment so as to deliver large doses during the period of maximal sensitivity. Page 47 This whole problem of cell sensitivity is the subject of an immense amount of research work at the moment, and, in passing, I would just ask you to remember the important work done by Dr. Maude Slye on the question of heredity amongst her mice—the relationship of heredity and malignancy is a very close one in the mouse—and she thinks that it is probably closely associated in the human race. I am sure that the mere mention of the possibility brings to your mind many families you have attended where the possibility seems to exist. While speaking of research work, during the last couple of years the combination of radiation therapy and the repeated elevation of tissue temperature by shortwave treatment seems to offer a better result. However, this is still just a laboratory procedure. In those cases where it is necessary to combine any surgical procedure with the treatment of malignant disease, I would remind you of a recent (Am. J. Rod., Sept., 1932) statement of Dr. James Ewing of New York, that he had seriously tried to estimate the number of cells that were present in a lymph node about 1.5 cm. in diameter in a case of cancer of the breast. To use an expression that the legal fraternity is fond of, he gave it as his "considered opinion" that there were a little over 8,000,000,000. Does this not call for the greatest possible care to determine that, when operative measures are taken, the case is suitable and can be dealt with satisfactorily. In this connection I would also remind you of those cases that we all see from time to time (I myself saw at least one during the past year) where the malignant cell is transplanted on the surgeon's knife. You will find a very important article on this subject in Surgery, Gynecology and Obstetrics for December, 1936.' The question of supervoltages is one that is much before the roentgenologist at the moment; by this I mean voltages above 200 K.V.P. Very interesting adventures in higher physics and therapy have been going on in many centres for some years without any definite findings as to the ultimate value of 400,000, 600,000 or a million volts. When I was in Chicago, the offices of the General Electric received a telegram from the works in Schenectady that a new 1,500,000-volt installation had just completed 120 hours of continuous operation without breakdown. The completion and release of this type of unit for therapy on an experimental basis will probably give us the answer in the next few years, as the wave-length from this unit is so close to that of radium that the element of error in measure could equal the difference. Now what does all this mean to the victim of cancer today? It means that all your malignancies fall into three categories: 1. The radiosensitive group—the embryonal growths and certain growths of uncertain origin, such as the leucaemias; 2. The resistant group—such as osteogenic sarcoma and the differential sarcoma such as fibro-, chondro- and myxosarcoma, and alimentary adenocarcinoma; 3. Tumours of intermediate sensitivity—squamous cell, transitional, basal cell, and breast carcinoma. Curative radiation treatment is one for the early and not for the late case, and if it is to be successful it must be given to the absolute limits of tolerance. There is no place for half-hearted treatment, or half-hearted reactions. Any permanent results that surgery had has have come through the development of radical surgery, and the same is true of radiation therapy. Palliative radiation therapy is, of course, quite a different story, and much smaller doses may relieve pain,,and occasionally we are more successful than we expect to be, but I wish to register very emphatically that I do not consider that radiation therapy should ever be given just "to do something." This can be accomplished in much simpler and less expensive ways, and without prejudicing the method when it is really showing some real successes. For the advanced case, the problem is still that of clinical medicine, with perhaps certain well-considered surgical procedures for the relief of pain, or mechanical difficulties such as obstruction. Here I would remind you of the dictum of Trudeau, that the (Continued on page 50) Page ',S We are happy to present herewith a short synoptic presentation of The Physician and Venereal Disease in British Columbia, by Dr. D. H. Williams, the Director of the Venereal Disease Control Department of the Provincial Board of Health. In the course of an address at Victoria, given at the B. C. Medical Association meeting, Dr. Williams offered, with evident sincerity, that the fullest help and co-operation by his department would be available to any practising physician at all times. This is excellent, and we cordially thank Dr. Williams. But this entails a definite response on our part. If the people of British Columbia are to obtain the best in preventive and curative treatment from the medical profession, they can only do so if there is a true, honest interchange between these two branches. The preventive side cannot do it all: nor can the curative side. Dr. Williams referred, courteously but unmistakably, to some of the duties that devolve on the practising physician. These are: 1. Diagnosis—Use of the Kahn test; a chronically suspicious habit of mind: a constant keeping in mind of the possibility of syphilis. 2. Adequate reporting of cases. 3. Use of consultative services provided by the Government, which proposes to send out regularly information for the physician's use. A travelling consultant is now employed, and consulting teams will some day be available. 4. Adequate treatment—continued for a sufficiently long time to ensure cure. For treatment purposes drugs will be supplied by the V. D. Control Department. 5. Painless methods of treatment, especially in intravenous therapy, as this has a distinct bearing on the attitude and co-operativeness of the patient. 6. Lumbar puncture regularly. Of 300 cases of syphilis done in Vancouver, 46% showed neurosyphilis. And other details. Dr. Williams has kindly agreed to furnish us with several short papers similar to this, and we heartily applaud his action in this regard.—Ed. THE PHYSICIAN AND VENEREAL DISEASE CONTROL IN BRITISH COLUMBIA Contributed by Dr. Donald H. Williams, Director, Venereal Disease Control. The Problem—A challenge to the physician and the Division of V. D. Control. 1. It is the major problem in the field of communicable disease. 2. It ranks with cardiovasculo-renal disease and cancer as a major cause of morbidity and mortality in the second half of life. 3. It renders many sterile, and spells disaster to the products of many conceptions. 4. The economic loss to employee and employer is great. 5. The social consequences to the individual, the home and society, expressed in loss of happiness and undue burden on the innocent, cannot be overemphasized. Page 49 The Solution—Close co-operation between the physician and the Division of Venereal Control is essential. 1. Diagnosis—Depends upon a high threshold of suspicion for venereal disease. The diagnostic services of the Division of V. D. Control are available to the physician. (a) History; (b) Physical examination; (c) Laboratory tests—facilities provided by the Division of Laboratories, Provincial Board of Health: i. Blood serodiagnostic test—Kahn; ii. Spinal fluid examination—Kahn and cell count most important; iii. Smears for gonococcus. 2. Treatment—The function of the Division of V. D. Control is to make treatment readily available to all and to facilitate the physician in its administration. (a) Consultative Service: i. Outline of treatment prepared by consultants of the Division of V. D. control upon request from physician for any patient; ii. Distribution of practical therapeutic information to all physicians—to be prepared and distributed shortly by the Division of V. D. Control. (b) Medication—Available upon request at Central Office, Division of V. D. Control, 2700 Laurel Street, Vancouver: i. Arsenicals—Neoarsphenamine, Tryparsamide, Bismarsen,; ii. Heavy metals—Bismuth salicylate, Bismuth potassium tartrate, Mercury succinimide; iii. Sulphanilimide; iv. Silver proteinate; v. Miscellaneous—Potassium iodide, Potassium permanganate, Amniotin suppositories, Malaria parasite, etc. (c) Clinics of Division of V. D. Control—The provision of diagnostic, therapeutic and educational services which are available to the physician. 3. Public Health Responsibility rests on the shoulders of the physician, health officer and the Division of V. D. Control: (a) REPORT ALL V. D. INFECTIONS; (b) Trace the source and contacts of every venereal infection; (c) Encourage premarital examination and blood Kahn; (d) Take a routine Kahn early in every pregnancy; (e) Utilize the services of the Local Health Officer in preventive aspects. RADIATION THERAPY (Continued from page 48) function of medicine is "to cure sometimes, to relieve often, but to comfort and support always," and coupled with this I would add an epigram of Harrington Sainsbury: "When Death would come as a friend, let us not compel him to hostility since he must prevail." Page 50 ancouver enera Hospita pathological conferences In view of the great variety of pathological material passing through the Laboratories of the Vancouver General Hospital it was felt that some use should be made of this material by presenting it in some fashion to the profession at large., Finally chiefly due to the efforts of Drs. A. B. Schinbein and G. F. Strong, it was decided to hold weekly pathological conferences. Accordingly, on January 26th, 1938, the first conference was held. Through the co-operation of Dr. A. K. Haywood, a projectoscopic lantern for gross -specimens was purchased and several alterations made in the Chemistry Building, such as the hanging of dark curtains to better facilitate the use of the projectoscopic machine. Since that time, weekly conferences have been held each Wednesday, from 12 to 1 p.m., and three cases from the preceding week's autopsies presented along with a resume of the history and pathological findings on the other cases for that week. It has been the aim to present cases of general interest, as much as possible, and also at times rather unusual cases. These conferences are open to the profession in general, and while they are in a sense an experimental endeavour, we are anxious to receive any suggestion which will make them more interesting or generally beneficial to all concerned. Dr. Donald Munroe has very kindly acted as registrar and has been of paramount assistance in synopsizing histories and organizing the material for presentation. We are extremely anxious to make these weekly conferences as interesting as possible and it is only by the attendance that we can judge whether or not this endeavour is meeting with success. The final meeting for the summer was held on Wednesday, June 29th; the meetings were resumed this fall, being held each Wednesday at 12 noon in the Chemistry Building. CLINICAL CASE Chinese, aged 60; admitted with severe epigastric pain, normal temperature, and a Tiistory of loss of weight, with the pain being present for one month—worse after meals. Epigastrium rigid on admission. Sippy diet and morphia were given for the pain, which gradually lessened with bed rest, and he was discharged in 20 days feeling well. Investigation at that time: (a) K.U.B. plate—no stones; (b) Barium series—no filling defect, ulceration or obstruction. (c) Barium enema—normal. (d) E.K.G.—some evidence of coronary sclerosis. (e) W.B.C.—on admission, 15,000. Differential Dignosis on this admission was perforated peptic ulcer, coronary occlusion and ca. of the liver. Patient admitted one week after discharge with severe intractable pain in the epigastrium. Maximum tenderness over gall bladder area. Epigastrium rigid, pain only slightly relieved by morphia grs. %. A few crepitations and soft friction rub were heard over the left lower lobe in the anterior axillary line. Surgeons saw the patient and advised medical treatment in view of chest findings. Differential diagnosis was now: (1) Ruptured peptic ulcer; (2) perforated ulcer on previous admission, patient now having subphrenic abscess with overlying basilar pneumonia; (3) primary lobar pneumonia, lower right lobe, with referred symptoms to epigastrium. Signs of pneumonia increased, and x-ray showed density at the right base. With sinapisms, cardiac stimulants and oxygen tent, the pneumonia cleared. Six days after admission patient began to fibrillate and became dyspnoeic. On slowing the heart with digitalis, "when the normal rhythm was resumed the patient developed a right hemiplegia, following which the chest signs again increased. The patient this time developed basilar pneumonia J*age 51 on both sides. This again cleared on treatment; patient's breathing became easier and he again became quite rational. On the twelfth day after admission patient again collapsed with severe pain in the epigastrium. Shortly after this friction rub was heard 1 inch inside the apex in the precordium. The patient died in 6 hours. Autopsy Explanation.—On the first admission patient had a coronary occlusion, with the development of a thrombus at the site of the infarct in the wall of the right ventricle. The severe pain on the second admission was due to a piece of the thrombus forming a pulmonary embolus, pneumonia developing on top of the lung infarct. When patient's heart was slowed with digitalis, after having been fibrillating for two days, a piece of thrombus from the left auricle lodged in the brain, causing his right hemiplegia. With the diminished movement of the right chest hypostatic pneumonia developed, signs of which cleared with treatment. Following this the patient developed a second caronary occlusion, this time apparently the descending branch of the left coronary, as a friction rub was heard anteriorly. The patient died of myocardial failure. A SURVEY OF EPILEPTICS FROM OUTPATIENT DEPT. Dr. S. E. C. Turvey : Dr. F. Turnbull. Dr. Turnbull: "Dr. Turvey and I have recently conducted a survey of epileptics in the Outpatient Neurological Clinic. We have been able to procure the records of 61 cases treated in the past four years by ourselves. During the last two years the work has been done almost solely by Dr. Turvey. Regarding the type of investigation of cases of epilepsy, the records kept in the Outpatient Neurological Department are probably more complete than those in any other department, and if the survey has done nothing else it has at least served to indicate where we might improve our records. It seems as though, if our Outpatient records are to serve any purpose at all, legible diaries must be kept. "There were approximately 70 cases during this four-year period. It is a very small group considering the size of Vancouver. About one in 250 is subject to convulsive seizures, so that there must be well over one thousand cases in Vancouver. Of these, possibly two-thirds would fall into the Outpatient category. These patients do not come to the Outpatient Department for two reasons: (a) they may be unaware that there is a clinic for epilepsy, and (b) the doctors do not consider it worth while for the patient to attend the clinic. "There is a high percentage of mental deficiency in the patients who come to the clinic. On the other hand, in private practice the percentage of mental deficincy is low and the epileptic seizures are mild. A large percentage (over two-thirds) of the patients are over 21. However, not more than 20% of epilepsy starts after 20. It merely happens that we get cases late in the disease. "Regarding the case history, it is surprising to note the number of cases where the physicians have insisted that the disease was not epilepsy: this only amounts to delaying proper treatment. "An x-ray/of the skull was taken in 45 cases and should have been taken in all. One showed calcification which pointed to a brain tumour. Encephalography was done on only eight of these cases and four showed abnormal findings. This unfortunately means four days' stay in hospital and some patients have to wait months for admission. We should have a better system of admissions. Blood Kahn was found to be positive in only two cases. Most of the syphilitic cases are treated by their own physicians and are not sent to the Outpatient Department. Of the 61 cases, a satisfactory diagnosis as to the exact cause of the disease was arrived at in only 15 cases (25%). In a further 12 there was obvious mental deficiency, indicating that the brain was congenitally below normal. Regarding the diagnosis of "birth injury," we were very canny about making that diagnosis because of the possible reflections on the profession. There was not sufficient justification to consider arteriosclerosis as the cause of the fits. The brain cyst case was the most interesting case in the group—this child had a congenital hemiplegia. The examination included an encephalogram which showed the cyst to be taking up most of one lobe. There was one case of encephalitis made on the basis of the encephalogram. If more encephalograms were made, Page 52 more patients of this type would be found. Following an infection the patient develops severe headaches, and following this there is the development of fits. There was one case of encephalitis associated with measles." Dr. Turvey: "Most of these patients only come to Outpatients after they have had epilepsy for a long time—months or even years. Not one patient had had adequate treatment before coming to the Clinic. Not one case was controlled. "When the patient comes to the Clinic the history is taken from the patient, and if a relative or friend accompanies him it is explained what they must watch for in each subsequent fit. It usually takes about three visits before you have all the data you want. The patient is asked how he feels after the attack, i.e., headache, weakness, etc. The physical examination must be painstaking. One case came in with a field defect in one eye, which pointed to a brain tumour. This man eventually died from a brain tumour—he had to wait three a"nd a half months for admission to hospital although his slip was marked urgent. Young and new cases are given x-rays and lumbar punctures. The old cases are not done— this is a gross error. A lumbar puncture was done on one of these latter today and a positive Kahn found. Usually the patient is started on phenobarbitol, not because it is better than bromides but bromide starts a rash. Tablets are much more easily dispensed and handled by the patient. Grains 1 l/z once a day—if necessary up to six times a day—are given. It is put up until they are so drowsy that they can hardly carry on. This is combined with bromides and the patient is continued on this combined therapy for six to nine months. "Treatment.—Bromides, 5; phenobarb., 34; both, 22; brom. rash, 8. "Results of treatment.—Cured, 1 year, 10; improved, 33—total, 43. "Age group.—0 to 10, 6; 10 to 20, 8; 20 to 30, 21; over 30, 26—total, 61. "Two died from brain tumour. Some cases contiriued to have fits on both phenobarbital and bromide. These patients were put to bed for three months in a quiet room and kept half doped. In all three cases of this type the patient was free of fits in the three months period, but on going around the house again had a recurrence of fits. This brings us to the question—how long should treatment be continued? Three years. If you finally get free of attacks after two years the cause may still be there. One boy was free of fits for three years and five months. The treatment was stopped and he has had twelve fits." Dr. Lowrey: "What are your experiences regarding the use of phenobarb. and bromides in the treatment of petit mal and grand mal? A doctor in the East says that phenobarb. should be used for petit and bromides for grand mal, and that very little effect is obtained when they are used vice-versa." Dr. Davidson: "Regarding the complications, I should like to ask about the x-ray of the skull. How many had positive findings? In doing mental work (mental deficiency with epilepsy) probably the deficiency is there, or probably, as Dr. Turnbull has said, there was a congenital defect in the beginning. One young girl was completely free of seizures, and then a brain tumour flared up. She had no seizures when on bromides." Another doctor asked how much ideopathic epilepsy is hereditary, and Dr. Palmer replied that ideopathic epilepsy usually occurs in a patient with a family tendency to migraine. Regarding the bromide rash, Dr. Hunt remarked that luminol will give a rash too. Dr. Turnbull: "There were only two cases of petit mal. Experience shows that phenobarb. is more effectual in petit mal. However, a man in the States got excellent results with bromides and used hardly any phenobarb. You can detect patients who will develop a bromide rash. Phenobarb is much more convenient to handle. Regarding Dr. Davidson's question re x-ray of the skull, the percentage was very low. Yet in those cases where the x-ray did show something the information was of paramount value; one was a brain tumour. Regarding luminol rash, we did see it sometimes, but not nearly as frequently as bromide rash. We have had to change some patients back to bromides because of the rash. It is very rare." Page 58 Dr. Turvey: "In private practice I have had only three cases out of a series of forty rhich were run on a ketogenic diet alone. They were given no drug. It is a very expensive iet and it is very hard to get people on it, especially children. It is not very reliable. In tie matter of migraine being associated with epilepsy, I do not think there is any association etween the two. In the Eastern States they do report allergic epilepsy." * Regarding the question of hereditary epilepsy, Dr. Davidson was of the opinion that : is a matter of the individual and not of the stock. Dr. Coburn asked whether in-breeding tad anything to do with it and Dr. Davidson said that he did not think so. III.—TWO CASES OF DISEASE OF THE LIVER. Dr. F. N. Robertson, Dr. A. W. Bagnall. Dr. Bagnall was unfortunately unable to be present. The cases were presented by Dr. ^hristopherson. A) Toxic hepatitis. This patient was admitted on August 22nd, with the chief complaints of nausea and vomiting for two lays, pain in the right lower chest. He had had diarrhoea for two or three-day periods in the last two months. Jp till two weeks ago this man was employed in a cannery. Since then he dissipated his earnings on alcoholic leverages—a bottle of gin a day—and at the time of admission to hospital had developed quite a marked remor. In the last week he had developed a cold with cough and pain in the right lower chest. The nausea md vomiting had become worse in the last two days. His family and personal histories were negative. He has 10 history of syphilis or GC. Physical examination showed a well developed, well nourished adult male with i high colour to his cheeks and a very definite tremor. He was quite rational. Head and neck were negative ixcept for a head cold. The chest showed slight diminution of breath sounds and diminished motion in the right lower chest with distant breath sounds and a distant to-and-fro rub was heard. There was no evidence >f any moisture. Abdomen: The abdomen moves freely. It was resistant over the whole right abdomen with tenderness in the lower right quadrant with some rebound pain. No masses were felt in the right upper quadrant. The liver was palpable 4 inches below the costal margin and quite tender. Reflexes hypoactive; rectal negative. A diagnosis of toxic hepatitis was made. On discharge on September 14th the liver had decreased in size to one finger breadth below the costal margin. The patient was re-admitted on October 17th with the chief complaints of nausea and vomiting and pain in the abdomen developing throughout the past week. This time the patient had been drinking loganberry wine, which resulted in the gradual onset of the above symptoms. Examination on admission showed the liver to be down again four finger breadths and quite tender. Laboratory findings—Kahn and urinalyses negative. Icteric index 5. On the first admission the Brandenberg was negative. On the second admission the icteric index was 13; N.P.N. 93; creatin 9.3. On October 26th—N.P.N. 53; creatin 2.5; blood urea .4; W.B.C. 10,100; eos. 4; monos. 2;; polys 48; lymphs 47. (B) Gumma of the liver or luetic cirrhosis. This patient was admtited in March of this year for a pleurisy with effusion which was tapped and subsequently found to be of tuberculous origin. On routine examination he was found to have a positive blood Kahn and enlarged liver to four finger breadths below the costal margin. This liver condition was considered to be of luetic origin. He was started on adequate treatment of pot. iodide and bismuth, with subsequent good results. While in hospital in March and April he had six injections of .13 gms. of bismuth. He was discharged on May 29th and appeared at the Government Clinic. He has since had the following injections of metallic bismuth: six l/z ccs, four % ccs> six 1 cc- Today his general condition has improved a great deal, showing a gain in weight, and he has been able to resume his occupation. The liver is now one finger breadth below the costal margin. The improvement in his general condition is not considered due to the antiluetic treatment but to the clearing up of the tuberculous lesion. The diagnosis made in this case is gumma of the liver or luetic cirrhosis. Laboratory findings are all within normal limits. (A) Dr. Robertson remarked that this was the beginning of hepatic sclerosis. Because of the high N.P.N., he said, you can rule out infective processes in this man. In reply to Dr. Hodgins' question about the infective idea, Dr. Robertson said that the leucocytes would certainly behave that way. It is a curious thing, he said, that in both it was preceded by an alcoholic bout— "I would take it that the alcohol was the cause." Dr. Harrison: "Because he had an infection, alcohol would do this?" Dr. Robertson: "Yes." (B) Dr. Harrison remarked that it is quite interesting to contrast these two cases of diseases of the liver, regarding which there is such a great amount of detail. Dr. Hodgins said that the patient had improved markedly and is now apparently well. Regarding the treatment, Dr. Hodgins asked whether the bismuth should be stopped now, and enquired as to the proper time and amount—presupposing the diagnosis is correct. Page 54 NEWS AND NOTES Dr. W. T. Kergin of Prince Rupert returned from Eastern United States and Canada. Dr. L. W. Kergin of Prince Rupert leaves for a visit to Eastern Canada and hopes to take in the Interstate Post-Graduate Assembly at Philadelphia. Dr. W. Leonard of Trail has returned from a week in the Happy Hunting Ground around Vernon. Dr. M. E. Krause of Trail is taking a well-earned holiday for a couple of weeks. Work is progressing rapidly on the new hospital wing and nurses' home in Rossland. It will be completed this winter or in the early spring, and will be one of the best-equipped and finest buildings in the Province. * Our correspondent, Dr. J. S. Daly of Trail, noticed in Spokane over the Thanksgiving week-end the familiar faces of Doctors W. Leonard, M. E. Krause, J. M. Crawford and H. R. Christie. He also called on Dr. Dave Harten, who asked to be kindly remembered to all the doctors of the Province. Our genial friend Dr. W. Laishley of Nelson, in his Silver Bullet, ran into and terminated the life of a fine buck. The impact smashed his grill and fender, but the doctor states that the steaks were delicious. However, it does seem to us an expensive, though no doubt very novel, way of hunting. GENEROSITY AND BENEVOLENCE (From Professional Anecdotes, edited by Edward Jenner.) A surgeon, in bleeding a lady of quality, had the misfortune to prick an artery; the result of which was the death of the patient. In making her will, she had the generosity to leave the surgeon, who was extremely affected, as may well be supposed, a life-annuity of eight hundred livres, as much for the purpose, said the will, of consoling him, as to oblige him never again to bleed anybody so long as he lived. There is a similar instance almost to the above in the Journal Encyclopedique of the 15th of January, 1773: A Polish Princess having experienced the same misfortune, two days before her death, she caused the following to be inserted in her will: "Convinced of the injury that my unfortunate accident will occasion to the unhappy surgeon who is the cause of my death, I bequeath to) him a life-annuity of two hundred ducats, secured by my estate, and forgive his mistake from my heart. I wish that this may indemnify him for the discredit which my sorrowful catastrophe will bring upon him." One sighs for such patients and such a forgiving spirit. The "follies of 1938" would hardly, in these days of litigation and liability insurance, meet' with such lenient and generous treatment.—Ed. Page 55 MEMBERS of THE GUILD of PRESCRIPTION OPTICIANS of AMERICA Always Maintain the Ethical Principles of the Medical Profession Guilder aft Opticians 430 Birks Bid?. Phone Sey. 9000 Vancouver, Canada. ADEQUATE IRON |1 for HYPOCHROMIC ANEMIA Excellent hemoglobin response results in most cases from the daily dose of three Hematinic Flastules Plain. This provides 15 grains of ferrous iron. Small dosagfe, easy assimilation and toleration favor the use of Hematinic Flastules for hypochromic anemia, he- cause they produce maximal results, at low cost, without discomfort or inconvenience to the patient. Hematinic Flastules provide ferrous iron and the vitamin B complex of concentrated yeast, in soluble gelatin capsules. They are issued in two types—in bottles of fifty—Hematinic Flastules Plain and Hematinic Flastules with Liver Concentrate. JOHN WYETH & BROTHER, Inc. WALKERVILLE, ONTARIO I For Complete BINDING THE BULLETIN A phone call will bring immediate attention. Sey. 6606 Roy Wrigley Printing and Publishing Co. Ltd. 300 West Pender St. Vancouver, B. C. A PRESCRIPTION SERVICE . . . Conducted in accord with the ethics of the Medical Profession and maintained to the standard suggested by our slogan: Pharmaceutical Excellence AACG! 6 0rmo LIMITED ^-^ FORT STREET (opp. Times) Phone Garden 1196 VICTORIA, B. C. SCIENTIFICALLY MINDED vC- V ^ EXPRESSES the attitude of the Medical Profession on the ever important question of milk. Now universally accepted, pasteurization, as a protective agency in controlling the ravages of disease, contributes much to a better public health. Milk f°r CONSTANT vigilance is the price of cleanliness and safety in the preparation of milk. We guard continually to see that our products deserve the confidence placed in us, and fully recognize our moral responsibility to the mothers of Vancouver. \\\\t \\\\ >** I%i IMITED ^ '£for J€RS€Y QUALITY MILK CREAM BUTTERMILK Ooctors— YOUR || PRESCRIPTION AND RECOMMENDATION Is Our Guide Always-- OUR 2 MECHANICAL and SCIENTIFIC ORTHOPAEDIC \\ EQUIPMENT Is At Your Service Avail Yourselves of our experience in last making to aid correction in Miiior Foot Ailments. PHONE Pierre Paris FOOT CLINIC Sey. 3778 51 W. Hastings The Purified ACTIVE PRINCIPLE OF SANDALWOOD OIL £,«««« ECONOMICAL Dosage Form Doctor, why use ordinary sandalwood oil when you can just as easily administer the active principle of the oil with the irritating and therapeutically inert matter removed—and at a cost to your patients of only a very few pennies more? You can do this by prescribing1 the new, economical 50-centigram capsules of ARHEOL (ASTIER) now obtainable in bottles of 12, 24 and 100 capsules at $1.00, $1.75 and $6.00 a bottle respectively. ARHEOL is the purified active principle jof sandalwood oil. It is a uniform, standardized product with which prompt and dependable results may be expected. Undesirable sequelae often associated with sandalwood therapy are either absent or reduced to a negligible degree. A3-BVMA Dr. P. Astier Laboratories 36-48 Caledonia Rd., Toronto. Please send me a sample of ARHEOL (Astier) in the new economical dosage form. Street. City Prov. Dr. P. ASTIER LABORATORIES 36-48 Caledonia Road, Toronto A PHYSIOLOGlffONlf Kara ...6 »o ax0—. PATIENT ^a GLYCOLIXIR derives its beneficial, tonic properties from Blyco- coll, simplest of all amino acids, ■which combines positive "muscle - sparing action" with biochemic detoxification. Glycocoll increases the Phospho-creatine content of muscular tissue and thereby heightens the economy and energy of muscular tone and contraction. Systemically, glycocoll unites or conjugates chemically with a variety of aromatic and phenolic compounds. With benzoic acid it forms physiologically inert hippuric acid. Toxic Cholic acid is converted into innocuous glycocholic acid, a normal constituent of bile. These two major actions—detoxification and muscle-sparing properties—are both physiologically and biochemically demonstrable. Coincident "with these specific biochemic actions is improved appetite, a higher level of general health and vigor, and, as a corollary, an increase in the forces naturally resistant to disease as they occur or exist in the well person. Glycolixir—modern in concept,, therapeutically assayable, is proposed for the management of age- old, stubborn, refractory conditions—non-specific asthenia, weight loss, easy fatigability, anorexia, and nervousness, in short—the "tired" patient. SUPPLIED IN TWO HIGHLY PALATABLE DOSAGE FORMS Elixir—One tablespoonful presents 1.85 Gm. glycocoll in a specially blended base of fine wine. Average adult dose: three tablespoonfuls daily. Tablets—The tablets present 1.0 Gm. glycocoll each. They are pleasantly flavored and distinctively colored. Also useful where the alcohol in the elixir may be undesirable. Average adult dose: two tablets, t.i.d. For literature address—Professional Service Department 36 CALEDONIA ROAD, TORONTO. E-RiSqtjibb&Sons of Canada, Ltd. MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858 £a*y