CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
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STCKAGE IIE* _OOB_A££ r THE BULLETIN VOLUME XXXI. OCTOBER, 1954 VANCOUVER MEDICAL ASSOCIATION AND OFFICIAL PUBLICATION OF British Columbia Division - Canadian Medical Association In This Issue: OFFICIAL PROCEEDINGS OF THE ANNUAL GENERAL MEETING AND THE GENERAL ASSEMBLY - CANADIAN MEDICAL ASSOCIATION - B.C. DIVISION SEPTEMBER 24, 25, 1954 - PRINCE CHARLES HOTEL - PENTICTON, B.C. ECOND JOHN MAWER PEARSON MEMORIAL LECTURE-THE PATTERN OF PERNICIOUS ANEMIA - BY S. C. DYKE, M.D., F.R.C.P. _ u L AT 10 N COMPOUND F FOR PROMPT ANTI-INFLAMMATORY ANTIPRURITIC ACTION rWWk *t ' _ w#-#J jp_f **_* X- '__^X*' I* _»l •«■ • ' ■ *» I* K_ JJw JiydroCortone ^*^ (HYDROCORTISONE MERCK) HYDROCORTONE* Topical Ointment and Emulsifying Ointment provide quick and effective relief for the patient suffering from atopic or contact dermatitis. Use of dermatologic HYDROCORTONE will reduce the inflammation and pruritus. Successful response will often be obtained in conditions refractory to other therapeutic measures. If secondary infection has already supervened, HYDROCORTONE Ointment with Neomycin can often be used to advantage. Descriptive literature on these three products is available upon request. JiydroCorbme THE ORIGINAL BRAND OF COMPOUND F ♦HYDROCORTONE is the registered trade-mark of Merck & Co. Limited for its brand of hydrocortisone. M E MERCK 1C1 K MERCK & CO. Limited Manufacturing Chemists MONTREAL • TORONTO • VANCOUVER • VALLEYFIELD HOSPITAL CLINICS VANCOUVER GENERAL HOSPITAL Regular Weekly Fixtures in the Lecture Hall Monday, 8:00 a.m.—Orthopaedic Clinic. Monday, 12:15 p.m.—Surgical Clinic. Tuesday, 8:30 a.m.—Ophthalmology Clinic (Health Centre for Children) Tuesday, 9:00 a.m.—Obstetrics and Gynaecology Conference. Wednesday, 9:00 a.m.—Clinicopathological Conference. Thursday, 9:00 a.m.—Medical Clinic. 12:00 noon—Clinicopathological Conference on Newborns. Friday, 9:00 a.m.—Paediatric Clinic. Saturday, 9:00 a.m.—Neurosurgery Clinic. ST. PAUL'S HOSPITAL Regular Weekly Fixtures 2nd Monday of each month—2 p.m Tumour Clinic Tuesday—9-10 a.m fe- Paediatric Conference Wednesday—9-10 a.m ^Mm • .—Medical Clinic Wednesday—11-12 a.m jjj . Obstetrics and Gynaecology Clinic Alternate Wednesdays—12 noon Orthopaedic Clinic Alternate Thursdays—11 a.m. —Pathological Conference (Specimens and Discussion) Friday—8 a.m Clinico-Pathological Conference (Alternating with Surgery) Alternate Fridays-8 a.m Surgical Conference Friday—9 a.m Dr. Appleby's Surgery Clinic Friday— 11 a.m Interesting Films Shown in X-ray Department SHAUGHNESSY HOSPITAL Regular Weekly Fixtures Wednesday, 11:30 a.m.-General Medicine. Friday, 9:00 a.m.-Chest Conference. Wednesday, 1:00 p.m.-Pathology. Friday, 12 noon-Surgery. BRITISH COLUMBIA CANCER INSTITUTE 2656 Heather Street Vancouver 9, B.C. SCHEDULE OF CLINICS-1954 MONDAY-9:00 a.m.-10:00 a.m.-Nose and Throat Clinic. TUESDAY-9:00 a.m.-10:00 a.m.-Clinical Meeting. 10:30-12:00 noon—Lymphoma Clinic. THURSDAY—11:00 a.m.-12:00 noon-Gynaecological Clinic. DAILY-1L45 a.m.-12:45 p.m.-Therapy Conference. Page 3 GREATER VANCOUVER PUBLIC HEALTH Metropolitan Health Committee Dr. Stewart Murray, M.D., Senior Medical Health Officer Vancouver, B.C. FLUORIDATION By fluoridation is meant the supplementing of a deficient natural concentration of fluorine in a communal water supply. Observations regarding the importance of fluorine and its relationship to denial health have been going on since it was first reported in 1892 by Sir James Creighton Brown. About 1916 interest regarding the place of fluorine was shown by Black and McKay concerning the presence of mottling of the enamel of teeth. This same effect was observed in the Maldon area of Essex and reported by Ainsworth in 1928. Eventually studies revealed conclusively that abnormally high amounts of fluoride were associated with motding. Later observations showed that when fluorine was present in approximately 1 p.p.m. a lower rate of caries incidence prevailed than when fluorides were absent. Subsequent studies have shown that communal waters with a low fluoride content will have, with the addition of fluorides, the same effect as waters which have a natural fluoride content. It has been further observed that babies, children, and adults who have lived in areas where the water has a natural fluoride content of at least 1 p.p.m. have a lower diseased, missing, or filled (D.M.F.) rate than where fluoride is absent. With the thought that the artificial correction of a fluoride deficient water would have the same effect as the natural, programs were introduced in Brantford, Ontario, Grand Rapids, Michigan, and Newburgh, New York. Over the years since 1945 the results have shown a decrease in the prevalence of dental caries to the extent of approximately 65% in the age group 6 to 8 years and decreasing values above this age group in children who have had the benefit of what one might term a "fluoride washing" of their teeth, but whose teeth were already fully developed when the procss was introduced. The above studies have shown no deleterious effect either on the children or adults, and studies of vital statistics by the U.S. Public Health Service on special disease groups, such as cancer, arteriosclerosis and others have indicated that there is no detrimental effect from the addition or presence of fluorides in the quantities mentioned. The studies in Brantford associated with comparative studies in Stratford, whose water has a natural fluoride content, along with similar studies in Sarnia, whose water has little or no fluorine content, have revealed no evidence of either a dental or a medical nature which would contraindicate fluoridation of a public water supply to the levels recommended, that is, approximately 1 p.p.m. This expression of opinion regarding the absence of untoward effects from fluoridation is confirmed by the medical staff of the Brantford General Hospital. A similar statement was made in an official joint pronouncement issued by the Canadian Dental Association and the Canadian Medical Association in January, 1953. Official approval of fluoridation by the Canadian Medical Association was made in June, 1954. Estimates of the cost in the Greater Vancouver area by the Commissioner and staff of the Greater Vancouver Water Board show the cost to be approximately 19c per capita per year. This, by contrast, would buy very litde in the way of dental service. In summary, in fluoridation there is available a method that considerably reduces the incidence of dental caries, which studies indicate, extends at least into middle life. It does not diminish the need for adequate diet, mouth hygiene, and dental inspection at proper intervals. It has no deleterious effects medically or dentally, and would Page 4 appear to be economically feasible. In 1953 some 842 communities with a population of 15,900,000 were using fluoridated water in the United States, and in Canada 8 water systems with a population of 192,000 have fluoridation in effect. Baltimore, Maryland, with a population of approximately 1,200,000 is the largest city with fluoridation in operation at present. The Senior Medical Health Officer for the Greater Vancouver Metropolitan Health Committee recommended the adoption of fluoridation in 1951 and has reiterated this stand in 1954. Submitted to Vancouver Medical Bulletin October, 1954. To LOWER Blood Pressure ALLEVIATE the Symptoms HYPOTENSYL Each HYPOTENSYL-PHENO HYPOTENSYL s.c. tablet contains: Eacr i s.c. tablet contains: Viscum Album Extract 75 mg. Hepatic Extract 100 mg. Viscum Album Extract 75 mq Pancreatic Extract 50 mg. Rutin 10 mg. Hepatic Extract 100 mg Vitamin C 15 mg. Phenobarbital 14 grain Pancreatic Extract 50 mg POSOLOGY 3 to 6 tablets daily preferably V_ hour before meals. ANGLO-FRENCH DRUG CO. LTD., Montreal FRED BARDAL tredenid f_fUD) Adventure Tours BE AN ARMCHAIR GLOBE TROTTER - Travel the World with top explorer—Photographers in person showing their own motion pictures in radiant color. World Adventure Tours will take you to Europe, the Americas, sunny Switzerland, the Alps, fascinating Norway, historic England and Scotland. Far north to the Arctic, and to magic Mexico. NEXT EVENT FAR NORTH withAdmiraiMacMman NOVEMBER 10, 8:30 P.M., GEORGIA AUDITORIUM All tickets reserved — $1.95, $1.60; Students $1.00 (incl. tax) On Sale -MODERN MUSIC - 536 Seymour Street, TAtlow 3622 Coming Events —j England and Scotland, February 7; Mexico, March 23; Switzerland, April 6; A Norwegian's Norway, April 27 Page 5 ■ C CONNAUGHT J - —FOR PROLONGED ACT/ON— * CORTICOTROPHIN (acth) with PROTAMINE and ZINC Corticotrophin with Protamine and Zinc, for prolonged action and in a form convenient for use, is prepared as a milky suspension aqueous medium and is ready for use after shaking. In clinical investigations, two injections per day have been found to replace adequately four daily injections of regular Corticotrophin (ACTH). In some cases even greater prolongation of effect may be experienced. Corticotrophin with Protamine and Zinc is prepared with ingredients whose properties are of established value in parenteral administration. The Connaught Medical Research Laboratories now provide Corticotrophin (ACTH) in three forms—a dried powder, a sterile solution, and a suspension with prolonged-action properties. HOW SUPPLIED Dry Powder —10 International Units per Vial —25 International Units per Vial Sterile Solution —10-cc. vial (20 I.U. per cc.) Prolonged-acting Suspension —10-cc. vial (40 I.U. per cc.) CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto, Canada Established in 1914 for Public Service through Medical Research and the development of Products for Prevention or Treatment of Disease. DEPOT FOR BRITISH COLUMBIA MACDQNALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER 1, B.C. Page 6 The Annual Meeting of the B.C. Division of the Canadian Medical Association at Penticton is over now — and it was a great success. The Okanagan Medical Society, which was in charge of arrangements, deserves our sincerest congratulations and thanks. They were marvellous hosts, and everyone who was there evidendy had a very good time. The weather was good and Penticton is a lovely place to have such a meeting.. The attendance, too, was very good, over a hundred and twenty-five members having registered—and we must all agree that the decision to hold the Annual Meeting away from the larger centres for once, was a wise one, and thoroughly justified by the result. And the organization of the meeting by the Head Office was beyond praise. The Proceedings of the meetings of both the Board of Directors and the Assembly are reproduced in this issue — and are well worth reading. One cannot but be impressed by the immense amount of hard work, by the various Committees, that has been done. All the reports are good, and will repay study. One or two impressed us especially. We cannot enlarge on all of them, but would like to refer to one in particular — that of the Committee on Public Relations — the discussion was full of interest. The realization by the medical profession of the importance of public relations is really a fairly recent thing in many ways. Of course, we have talked of public relations for many years — but it is only recently that we have awakened to the fact that our relations with the public require a great deal of study on our part, and that they are of most vital importance to both ourselves and the public — perhaps especially to ourselves. In the old days, when the practice of medicine was individualized, when it was merely a matter of an individual doctor and an individual patient, there was very litde public relations to be considered, and it was difficult to work up much interest in it. But today things are very different. The great growth of collective medicine, if one can put it that way — the multiplicity of prepaid plans, the Workmen's Compensation Board, the B.C.H.I.S., and other similar group considerations, have, almost overnight, imposed on us a great many responsibilities. We have to deal with the public now, not as individual doctors, but as a professional group — and this has introduced entirely new factors into the scene. It means many things: and first, it means that the group, that is, the medical profession as a whole, has got to be responsible for its individual members. It cannot escape this responsibility. It must lay down basic principles of group practice — it must set up standards of fairness and equity and generosity, and it must see to it that all its members live up to these standards. Otherwise, we cannot have good public relations — the type that alone we want and must have. And one could see how deeply conscious the leaders of the profession are that this is so. It was the basis of all they said — all their arguments and suggestions. They realise, as all of us must at bottom, that the fundamental thing in all public relations is sincerity and complete honesty. There is, we have seen somewhere, a maxim in law "who comes into a court, seeking equity, must himself have clean hands:" and this is true for us, too. And this imposes a responsibility on each one of us — each member of the medical profession — for the group is the sum of the members, and the chain is only as strong as the weakest link. We medical men, through long tradition and history, tend to be highly individualistic — to travel as lone wolves. But that is no longer possible, in this day of altered relations between us and the public. Each one of us Page 7 must consider his responsibility to his profession, and through his profession to the public at large. Each one of us must be willing to concede something of his own individual ideas, for the good of the whole. In the words of Kipling "the game is more than the players of the game, and the ship is more than the crew." We are not single doctors any more — we are a team, and must work as a team, and with the team spirit. Our relations with each other are at the very root of our public relations — which cannot ever be good, until and unless our inter-professional relations are good, and based on the qualities referred to above — sincerity, honesty and generosity. After all, these are the marks of the mature mind — and the converse qualities, greed, dishonesty and selfishness are the marks of immaturity of mind. Other things come to our memory, of the meeting — the discussions on Economics and so on — all most simulating and encouraging, all shewing how much is yet to be done. We are passing through a rather critical time — we are by no means secure on all our fronts — but courage and good will, a sincere willingness to give and take, and an honest intention to do the fair and right thing, we shall come through safely, all in good time. And we have a goodly leadership to guide us. THE SECOND JOHN MAWER PEARSON MEMORIAL \ LECTURE H | f. Introduction by Dr. Murray Blair Mr. President — Fellow members: Our meeting this evening may he said to serve a dual purpose. We are here to welcome a distinguished, visitor and we' are here to do honour to a distinguished member of our Association. Because this is the John Mawer Pearson Memorial Lecture, and because many of you will not recall Dr. Pearson in person — it was suggested by your Executive that something might be said to apprise you of the nature of the late Dr. Pearson, and the reason that his memory is being perpetuated by the Association through the medium of this lecture. Dr. Pearson came to Vancouver to practise in the Spring of 1897, after graduating from Trinity College, Toronto in that year. He was twenty-eight years old. The city had a population of some 20,000 and there were fourteen doctors practising here when he arrived. The young doctor became aware immediately of the need for a closer association and exchange of ideas with his confreres, and so in 1898 he wrote a letter to each doctor suggesting a general meeting in an office on the northeast corner of Homer and Hastings. There, it was decided that an Association be formed, and the first President was Dr. D. H. Wilson (Uncle of Dr. Wallace Wilson) with Dr. John Mawer Pearson as Secretary-Treasurer and guiding spirit. Dr. Pearson was Secretary Stephen. Dr. Pearson was Chairman of the Library Committee for many years. In 1906 a Committee was formed by the Association to look into the formation of a Library and the members of that Committee were Dr. Pearson and Dr. William Stephen. Dr. Pearson was Chairman of the Library Committee for many years. In 1919 Dr. Pearson was appointed Chairman of a Committee to look into the possibility of establishing a Summer School and the first sessions were held in August 1921. He was Chairman of the Summer School Committee for two years. Dr. Pearson presented the second Osier Lecture in 1922. In 1924 the first Bulletin of the Vancouver Medical Association was published with Dr. Pearson as Editor. He held this office until his death. Dr. Pearson retired from active practice in 1932 and died in 1935 — loved and revered by all who knew him. His contributions to organized medicine in this City Page 8 and Province are perhaps second to none. This Association, its Library, and its Bulletin are in themselves monuments to his memory. Dr. Sidney Dyke, our speaker tonight, is of particular interest to the members of this Association, because although an Englishman by birth he is or was a British Columbian by adoption. During the early years of this century, Sidney Dyke came to British Columbia and lived with his family on a farm at Haney. He went to school in New Westminster and later joined the staff of a New Westminster newspaper. When the family moved to Vancouver in 1905, our speaker joined the staff of the Vancouver Daily Province. In 1906 he went to Toronto University graduating with honours from that school in 1909. He returned to Vancouver and again joined the staff of the Province. Later he became a teacher in a Vancouver High School and then in 1910 was chosen Rhodes Scholar from this Province. He went to Oxford in 1910 and there took subjects which would assist in the subsequent study of medicine. He graduated from Oxford in 1913 and continued his medical studies in London. In August 1914 he joined the Army but was able to get leave to graduate in medicine in 1915. Dr. Dyke's interest has always been directed toward Clinical Pathology, and early in his career he showed an amazing aptitude for organization, particularly in that field. Through organization he has been able to do a great deal for Pathology generally and for its place in the hospital and University curricula. His last organization was that of the International Society of Clinical Pathology, which he brought into being in 1946. He has been President from its inception until a short time ago, when he was made its Honorary President. The first Congress was held in London in 1951 and the second in Washington, D.C. early in September, which is the principal reason for Dr. Dyke's presence on this Continent. It was our good fortune that after the Congress he decided to return to the scenes of his youth in British Columbia. It is his first visit since he left forty-four years ago. His subject tonight is "Pernicious Anaemia." It is a pleasure indeed to present your John Mawer Pearson Memorial Lecturer — Dr. Sydney Campbell Dyke. THE PATTERN OF PERNICIOUS ANEMIA: LANDMARKS AND PERSONALITIES jj by S. C. DYKE, f.r.c.p. The unfolding of the pattern of pernicious anaemia as we now see it offers a striking example of the manner of advance in medical knowledge; my endeavour is to place before you the steps in its development and to call to your mind some of those personalities whose efforts have made is possible for this generation to treat with certainty and accuracy a condition the diagnosis of which thirty years ago meant sentence of death without hope of reprieve. I owe to Dr. Robb-Smith the information that the term "anaemia" makes its first appearance in medical literature in the 17 th Century as descriptive of cachectic states attributed to poverty of blood. It remained for a Scotsman clearly to recognize the existence of anaemia as a disease in itself, and to state the problem of its solution in an answerable form. James Scarth Combe (1796-1883) was born in Leith in 1796; he obtained his degree of Doctor of Medicine in the University of Edinburgh in 1815. He was writing his examinations when he heard the guns from the Casde speaking in salute to celebrate the victory of Waterloo. It is a pertinent comment on the difference between his days and ours that Combe later said that he was bitterly disappointed because he realised that the voice of the guns was announcing the end of his cherished hope of becoming an army surgeon. After several years in India Combe setded in general practice in Leith; in 1823 he became a Fellow of the Royal College of Page 9 Surgeons of Edinburgh and in 1847 moved to the Metropolis of the North. He acted as examiner in surgery to the Royal College of Surgeons of Edinburgh and became its President in 1851. Throughout his long life he was engaged in a busy general practice with a leaning towards surgery. He published only four papers. The one of these which concerns us is "The History of a case of Anaemia" describing the last days and exitus in 1821 of the unfortunate Alexander Haynes, c? j ~ * "the servant of a corn merchant where his duties are neither laborious nor unhealthy. \ Combe made a careful post mortem examination and was impressed by "the nearly bloodless state of every viscus and structure in the body with the exception of the spleen." But the importance of Combe's paper lies in that in reporting the case he posed the question of aetiology. 'This condition of 'Anaemia'", he asked, "is it a morbid state sui generis or is the defect of the red circulating mass a . . . circumstance denoting some peculiar change in the assimilatory powers?" The first serious attempt to answer Combe's questions did not come for over a quarter of a century; its author was Thomas Addison. Thomas Addison was born at Lonb Benton near Newcasde-upon-Tyne about 1793. His parents came from Cumberland, where his family had been yeoman farmers since the 17th Century. He attended the village school and thence went to the Newcasde Grammar School; there he became so fluent in Latin that when a medical student in Edinburgh he took his lecture notes in that language. There is, however, no evidence that he took any particular pleasure in the classics. Addison moved to London in 1817 and was at first attached to the Lock Hospital. A few years later he entered Guy's Hospital as a student, and in 1824 was appointed Assistant Physician. In -1837 he was appointed full physician and became associated with Bright in the Chair of Medicine. Addison had litde interest in the therapeutics of his time; he was essentially an observer of facts, and like all the great physicians of his own, and I suppose of all time, he was assiduous in following such of his patients as afforded him the opportunity, to the post mortem table. Among his patients were a number suffering from various cachectic states labelled with the diagnosis of "anaemia." In 1849 Dr. Addison, under the tide of "Anaemia—Disease of the Suprarenal Capsules" described to the London Medical and Chirugical Society a series of such cases. In three "inspection of the body after death revealed a diseased condition of the suprarenal capsules." These were evidendy not examples of pernicious anaemia but of the condition which now bears Addison's name. Of the unspecified number of patients who did not come to the autopsy table some probably suffered from pernicious anaemia; some did not, as for instance the man "below the middle period of life who was looked upon as past all hope" but "who slowly but steadily recovered under the free use of brandy, but with the singular result of the hair on one side of his head becoming permanendy grey." In his classical monograph on "The Constitutional and Local Effects of Disease of the Suprarenal Capsules" (1855) Addison does not stress the anaemia. The first impetus to the study of pernicious anaemia came from Switzerland and was given by Anton Biermer (1827-1892). Biermer studied medicine at Wurzburg where he came under the teaching of the great Virchow. He was called to the Chair of Medicine at Zurich in 1865. His contributions to medical literature were not extensive; in 1872 he communicated to a meeting of the Swiss Association of Physicians certain observations on fifteen cases of anaemia. His observations later appeared in a report of the meeting in the Correspondenz Blatt fur Schweize Artze under the tide of a 'Form von progressiver pernicioser Anamie." Biermer gives few details of his cases and some of them certainly represented anaemias of types other than what later came to be called "pernicious." Biermer's contribution was to provide a tide and to restate the problem set by Scarth Combe. It is said that having recognized the disease and its inevitable progress Biermer had to watch his wife, to whom he was devotedly attached, die from it. Page 10 Unlike the paper of Scarth Combe that of Biermer attracted wide attention. In 1874 the Medical Times and Gazette accepted progressive anaemia as a disease sui generis and remarked that no case had so far been observed in Great Britain. It thereby started a controversy as to priority and nomenclature that was to rage for a quarter of a century. The last echoes of the conflict were only just dying away in my own time as a medical student. Up to this stage no scrap of evidence of any structural change underlying the anaemia had come "to light; the first real advance towards the understanding of its pathology was made in 1876 by the great Julius Cohnheim. Cohnheim held the chairs of Pathology at Kiel, Breslau and finally at Leipzic where he did the major part of his work. We all know that Cohnhein laid the foundation of our present knowledge of inflammation. His contribtuion to our understanding of pernicious anaemia tends to be forgotten. Following up the suggestion by Bizozzero that the bone marrow is the seat of blood formation, Cohnheim,. in 1876, observed the marrow in cases of Biermer's progressive pernicious anaemia; he first made the observation now so familiar of its deep red colour and further reported that under the microscope it resembled foetal marrow. He concluded that pernicious anaemia is a disease of the blood-forming organs, thus in part answering the question posed half a century earlier by Scarth Combe. Scarth Combe had suggested a "failure of the assimilatory powers" as the cause of anaemia. This proposition was forcibly restated by that redoubtable figure of American medicine, Dr. Austin Flint. Born at Petersham, Mass. in 1812 in the third generation of a medical family, Flint was founder of the Medical Colloge at Buffalo and occupied the chairs of Medicine successively at the Rush Medical College, Chicago Buffalo, Louisville, and New Orleans. In 1860 he came to rest in New York as physician to the Belle Vue Hospital. I am indebted to Dr. W. B. Casde for pointing out to me that in 1860 in a clinical lecture on anaemia Flint referring to the form which Addison had distinguished as "idiopathic", wrote, "I suspect that in these cases there exists degenerative disease of the glandular tubuli of the stomach ... I shall be ready to claim the merit of this idea when the difficult and laborious researches of someone else have shown it to be correct." That "someone else" was to be Dr. Samuel Fenwick of Newcasde-upon-Tyne. Like Addison, Dr. Samuel Fenwick was a Northumbrian; he came of a long line of distinguished ancestors, stemming from a certain de Fenwyke appointed custodian of the Border by William the Conqueror. It is seldom that we have the opportunity of studving the armorial bearings of our colleagues; through the kindness of Professor W. E. Hume of Newcasde-upon-Tyne I am happy to be able to present to you that of the Fenwick family. |§ Fenwick entered the Royal Infirmary, Newcastle-upon-Tyne as an apprentice at the age of 14- at the age of 21 he became a Fellow of the Royal College of Surgeons of England and later an M.D. of St. Andrew's. For some years he was m genera nractice in North Shields; at the same time he was acting as Lecturer in Pathological Anatomy at the Medical School of the University of Durham then as now situated at Newcasde. Later he entered upon consulting practice in Newcastle In 1862 like Addison he left the North for London; in 1868 he joined the staff of the London HoS as Assistant Physician, become Physician in 1879, retired in 1896, and died in 1902. He was the second consulting practitioner to establish himselr in Harley Stre6In 1877 Fenwick writing on "Atrophy of the Stomach" remarked "Everyone who has been engaged for some years in the practice of the profession must have met with cais of slow progressive anaemia unaccompanied by emaciation, occurring m persons of middle age! unaffected by treatment, terminating in death, in which it has been impossible to find any sufficient cause to account for the bloodlessness. impossible w y ^ ^^ ^ ^^^^ t0 use the words 0f Scarth Combe, had come to be regarded as a likely cause of anaemia. Probably it was this opinion that Page 11 led Fenwick to make a careful examination of the stomach of two patients dying under his care. lip The description of Fenwick's two cases leaves no doubt that both patients were suffering from pernicious anaemia. The lantern slide shows the gastric mucosa in case 2, that of an army surgeon aged 50 who "had served in different climates without having suffered from ill health." I would ask you to compare this with the illustrations a biopsy specimen of the gastric mucosa from a case of subacute combined degeneration of the cord without marked anaemia published by Doig and his coworkers; the similarity is at once apparent. Although in Fenwick's own time his observation attracted little attention in this country, on the continent it did not go unmarked and in 1879 was confirmed by the great Nothnagel. The means of investigating the chemistry of the gastric secretion during life were now becoming available, and in 1886 Cohn and Mehring drew attention to absence of free HCI. from the gastric juice in all cases of Biermer's progressive pernicious anaemia investigated by themselves. Again it was long before the full significance of this observation was to be recognised. Meanwhile the nervous manifestations were attracting attention. In 1887 Lichtheim first described the characteristic degeneration of the posterior and lateral columns; they were first illustrated by. Minnich in 1892 who rightly concluded that ethnervous changes are not direcdy due to the anaemia but that both derive from a common cause. Two years later Bowman (1894) working at the National Hospital, London, for the first time confirmed the findings in Great Britain. I use Bowman's illustration in "Brain" to mark this stage in the revelation of the pattern. Until about this time the techniques now readily at our disposal for the examination of the blood and blood-forming organs had in large measure been lacking. They now started to come into general use. In 1877 Gowers had arranged with Hawksley's for the manufacture of a haemocytometer "on the principle devised a quarter of a century ago by Vierordt." One of the first to use it for the study of pernicious anaemia was Stephen Mackenzie, (1844-1909) one of the outstanding medical figures of Victorian England. Mackenzie's father was in general practice near London; he was killed in a carriage accident when young Mackenzie was only 7 years old. Mackenzie entered the London Hospital in 1866. He served the Hospital- as House Officer, Registrar, Lecturer in Pathology, Physician to the Skin Department and later as full Physician. He was knighted in 1903. Mackenzie's paper on "Idiopathic, Essential or Progressive Pernicious Anaemia" (1878) was a major contribution to the natural history, of the disease. Some of his cases may appear somewhat doubtful, as for instance that of the boy who developed anaemia "after being attacked by a sheep" and of the peculiarly distressing case of the young lady "who accidentally poisoned her father", but Mackenzie noted and carefully described all the clinical and pathological features now familiar to us, including the high colour index, the anisocytosis and the "deep violet colour of the bone marrow." Mackenzie was no theoretician; he dealt with observed facts but he expressed his agreement with "Cohnheim, Osier and some others" in regarding "the nucleated and dwarf corpuscles" found in the blood as due to arrest of their development and quotes with approval the description of Osier of the abnormal red cells as "deformed, unfinished and sent before their time into the peripheral blood." Nothing was to be added to Mackenzie's description of the clinical features and morbid anatomy of the disease for many years to come; but its haematological study was now to make a rapid advance. This advance was made possible by the introduction into histological technique of the aniline dyes; this we owe to that amazing man Paul Ehrlich (1865-1915) whose figure along with that of Pasteur towers over the whole field of modern medicine. Ehrlich came of a Jewish family settled for generations in Silesia where his father was the host of the Inn of the Wreath of Rue at Strehlen. Practically from the Page 12 *ffe cradle the young Paul displayed an interest in Biology and Chemistry; at the age of eight he was having cough drops made up to his own prescription by the village chemist. Like Addison he was a fluent Latinist; in fact his biographer, Martha Marquardt remarks that to the end of his life he wrote Latin better than German. Ehrlich entered the University of Breslan where later he worked under Cohnheim. He completed his medical studies at Leipzig where for his Doctor's thesis he presented a dissertation on the Theory and Practice of Histological Staining. This thesis consisted entirely of new and original matter; it was to govern histological technique for half a century. Under the influence of Cohnheim and Heidenhain he applied himself first to the study of the blood and the bloodforming organs by Farbenanalyse, the application of the aniline dyes to the tissues. By this means he differentiated the classes of the granulocytes of the blood and established their classification as we now know it. Further he identified the megaloblast both in the marrow and the peripheral blood and established its. relationship to the foetal erythroblast. With A. Lazarus he brought together the results of his researches on the blood in "Die Anamie" (1898). Here it is stated that "das Blut in pernicioser Anaemie ein megaloblastiches ist." (sic) In the marrow Ehrlich and Lazarus describe the proliferation of the megaloblasts which they attributed to a "degeneration." They made the truly prophetic remark, to remain unconfirmed for over a quarter of a century, that "das Knochenmark unter chemischen Einflussen Stent." Later Ehrlich concentrated all his efforts on the search for the "therapeutia magna sterilisans" which to most of his contemporaries appeared like the quest for the astrologer's stone; in oblique reference to Dr. Faustus he was nicknamed "Dr. Phantasterei." To these researches however we owe much of our present knowledge of immunity, "606" with all its subsequent offspring and the foundation of modern chemotherapy, a term invented by Ehrlich himself. Ehrlich always worked with the simplest apparatus, and once remarked that he could have made all his discoveries in a barn; to a younger colleague he oudined the principles on which he worked as "much experimenting — the absolute minimum of hypotheses — no guess work — few publications." I now introduce to you the figure of William Hunter (1861-1927), physician to Charing Cross Hospital and Fellow of the Royal Society of Edinburgh. I do so because towards the close of the last and in the beginning of the present century it was impossible in Great Britain to speak of pernicious anaemia without reference to that then distinguished ornament of British Medicine. Hunter was educated at Edinburgh University and Cambridge. The principles on which Hunter worker were not those of Erhlich. He experimented little, hypothesised freely and published extensively. In 1888 he published his first paper on pernicious anaemia and thereafter wrote widely on the subject, his efforts culminating in a series of papers published in the Lancet in 1903. He concluded that pernicious anaemia is "a specific infectious disease" and proposed to rename it "specific haemolytic anaemia." He embodied the results of his cogitations in schematic form. Hunter's views were almost universally accepted in Great Britain. Such importance as now attaches to the work of Hunter lies in its influence upon Dr., later Sir Arthur Hurst (1879-1944), like Addison, Physician to Guy's Hospital. Hurst was primarily a clinician and his contribution to the formation of the pattern of pernicious anaemia was his firm insistence in linking together the anaemia, the degenerative cord lesions and the achylia as essential features of the disease; he pointed out that in subacute combined degeneration of the cord, even in the absence of marked anaemia, the red cells show the typical size distribution then recendy demonstrated by Price-Jones as characteristic of pernicious anaemia. Unlike his predecessor Addison, Hurst was very ready to theorise and was far from scorning therapeutics. He accepted Hunter's views on the infective nature of the condition and implicated the haemolytic streptococcus; his therapy concentrated upon rendering Page 13 that organism uncomfortable by the free use of hydrochloric acid, and the eradication of "focal sepsis." It was the work of Cecil Price-Jones (1863-1943) which made it possible for Hurst with certainty to bring the cord lesions into" the pattern of the disease. Unassuming and modest Price-Jones was one of the most likeable of men. He was a keen musician, and in the minds of his many surviving friends is associated with a cello about as large as himself. He was in general practice for a few years, but left it to attach himself to Professor A. E. Boycott at Guy's, and to devote himself to the study of the blood. He early became convinced of the importance of the accurate measurement of the red cells; in 1933 appeared his classical monograph of only 82 pages on "Red Blood Cell Diameters". In this he supplied the final proof that in pernicious anaemia, in spite of the anisocytosis there is an overall macrocytosis and furthermore demonstrated by means of the "Price-Jones curve" that the distribution of the red cells according to size in characteristic of that condition. The work of Price-Jones supplied overwhelming evidence that pernicious anaemia is due not to blood destruction as proclaimed by Hunter but to faulty blood production as suggested by Cohnheim over half a century earlier and confirmed by Ehrlich. The final proof of the correctness of their view was supplied by F. W. Peabody in the year of his death, 1927. Peabody was born at Cambridge, Mass. in 1881. He took his degree of Doctor of Medicine in 1907 and thereafter studied widely in Europe; including Russia in his travels. At the Johns Hopkins Medical School he served both as Fellow in Pathology and as Assistant Physician. He was strongly impressed by the need to bring medicine into touch with its fundamental sciences; his appointment to the staff of the Peter Bent Brigham Hospital then newly opened as the Medical Clinic of the Harvard Medical School, gave him the opportunity of putting his views into practice. In 1921 he was appointed Professor of Medicine in Harvard University and Director of the Thorndike Memorial Laboratory. Peabody was equally at home in the wards, the laboratory and the dead house, but to him the care of the patient came before all other considerations; "the secret of the care of the patient", he wrote, "is caring for the patient"; with this always in mind he made, before his untimely death at the age of only 45, a great contribution to medicine based entirely on the study of the patient. Peabody's paper on "The Pathology of the Bone Marrow in Pernicious Anaemia" was published after his death; he preferred his observations by the remark that "in order to understand the pathology of this disease . . . more attention must be paid to the bone-marrow". Following Zadek he removed by tibial trephine samples of bone marrow from the living patient and triumphantly confirmed Ehrlich's observation that in pernicious anaemia it is of foetal type. He concluded that "the anaemia ... results from the failure of the megaloblasts to differentiate towards mature erythrocytes". Although this had been suggested by Ehrlich, Osier and others this appears to be the first definite statement that the anaemia is due to failure in maturation of the red cells. We arejiow upon the eve of the demonstration of the proof of Ehrlich's surmise that haemopoiesis is under "Chemische Einflusse". The next movement in the development of the pattern was truly astounding — the more so that it came from an entirely unexpected quarter, — the field of nutritional studies. It was made by the late Professor G*. R. Minot (1885-1950) and his co-workers at the Huntington Memorial and Peter Bent Brigham Hospitals, Boston. Minet was impressed by the fact that many of the patients suffering from pernicious anaemia in the Boston Hospitals came from the surrounding rural districts where their diet consisted largely of "dairy produce, sugar and muscle meats". To Minot it appeared that this diet might be deficient in certain essential amino- acids; to pursue this research he joined with himself Dr. W. Parry Murphy (1892- ). In 1926 they contributed certain "observations on patients with pernicious anaemia partaking of the special diet", in which liver with other "offal" figured largely, to the American Association of Physicians. They cautiously remarked that Page 14 "the dietetic treatment of pernicious anaemia may be of more importance than hitherto generally recognized". That a diet of liver was highly effective in maintaining blood regeneration in the face of a uniformly sustained experimentally produced anaemia had already been shown by Professor George Hoyt Whipple in his studies in blood regeneration and haemoglobin production at the University of California. It was not immediately evident that the observations of Whipple and those of Minot actually bore no relationship whatsoever to each other, but the curative effect of liver in pernicious anaemia was now widely recognized; it had become clear that by eating sufficient liver sufferers from this hitherto incurable disease might be maintained in a state of normal health. By universal accord this ranked as a major advance in medicine, and the Nobel Prize in Physiology and Medicine was in 1934 awarded joindy.to Professors Minot and Whipple and Dr. Murphy. But it remained for a biochemist to demonstrate what was becoming abundandy clear, that the action of liver in pernicious anaemia is not merely a matter of correcting a faulty diet. The late Professor E. J. Cohn betook himself to the search for the principle in liver responsible for such miraculous results in the treatment of pernicious anaemia. Professor Cohn held the honorary degree of Doctor of Medicine or of Science in at least five universities. In 1928 he was Assistant Professor of Physiological Chemistry in Harvard Medical School and shordy to become Associate Professor. In that year along with Dr. Minot and others he published his literally epoch-making observations on "The Nature of the Material in Liver Effective in Pernicious Anaemia". In prefacing his observations Professor Cohn permitted himself the luxury of making a generalisation. "Advances in practice, resulting upon observation and experience often precede exact knowledge of the underlying reactions and mechanisms of natural phenomena". Having paid this tribute to the discoverers of the advance in practice Professor Cohn proceeded to move the problem into the field of biochemistry. Conn's original method of extraction has undergone many refinements, but it was his work which laid the foundation of the treatment of pernicious anaemia by the parenteral route. By reason of its enormous economy this treatment soon came to replace oral treatment. It was fortunate that his discovery came when it did; many thousands of patients for whom during the Second World War it would have been impossible to find sufficient liver for oral use were kept alive and well by parenteral injections of the anti-anaemia principle. And now the long forgotten observation of Fenwick again comes into the picture. It was Fenwick's observation that had led the continental workers to the analysis of the gastric juice in pernicious anaemia and the establishment of the achylia as a universal feature. It was with this achylia in mind that Dr. W. B. Casde set himself to investigate the role of the gastric juice in pernicious anaemia and in so doing established the framework for the development of the pattern up to the present time, in 1928 Dr. Casde, then Instructor in Medicine to Harvard Medical School and Associate Physician to the Thorndike Memorial Laboratory of the Boston City Hospital, presented to the 20th Annual Meeting of the American Society for Clinical Investigation certain "Observations on the Etiological Relationship of Achylia Gas- trica to Pernicious Anaemia". He reported that "the stomach contents of a normal man recovered one hour after a meal of 300g. of rare hamburg steak" when ingested by a sufferer from pernicious anaemia would produce a remission. He cautiously suggested that "the secretions of the normal gastric mucous membrane alone or through their action on food protein can produce some substance capable of benefiting certain cases of pernicious anaemia". WBm i • ••• j At the Thorndike Memorial Laboratory Casde and his co-workers initiated research on the hypothesis "that the significant defect in the patient with pernicious anaemia is an inability to carry out some essential step in gastric digestion". Page 15 Minot had many years earlier noted the rise in the reticulocytes of the blood in active blood regeneration and Castle early recognized the value of the "reticulocyte crisis" as an index to the response to treatment of pernicious anaemia by liver. It must have been a thrilling experience for Castle and his team to watch the rise of reticulocytes occurring in the blood of a patient in relapse of pernicious anaemia, after the oral ingestion of the product of digestion of the "rare hamburg steak". After searching investigation of every possible fallacy Casde and his co-workers announced that "Addisonian pernicious anaemia stands revealed as ... a disease dependent for its production upon the . . . defective gastric juice of the patient". His conclusion, which still holds, was that the anti-pernicious anaemia principle consists of two factors — an "intrinsic" present in normal gastric juice and an "extrinsic" present in beef muscle. The hunt was now up for the identification of the two factors. And now a change becomes apparent in the agency behind the development of the pattern. Until then it had been in the hands of workers concerned wholly with the advancement of medical knowledge. Now major advance is to come from the laboratories of the great commercial pharmaceutical firms. As a worker for one of these firms has somewhat drily remarked, "these are industrial concerns" and it is understandable that "publication of methods has been delayed". Attention was first directed towards the intrinsic factor in 1929 by Dr. A. El wood Sharpe of the Department of Experimental Medicine of the firm of Parke Davis & Co., and Drs. C. C. Sturgis and R. Isaac with assistance from the same firm early showed that pernicious anaemia could be treated satisfactorily by the oral use of preparations of dried hog's mucosa. Later Dr. C. C. Ungley of Newcastle-on-Tyne, of whom we shall hear more later, was able to demonstrate that, in full agreement with Castle's hypothesis, the hog's mucosa is only active in the presence of a source of the extrinsic factor. In Fenwick's old medical school Dr. Ungley had already initiated a course of research which still continues and, as will later be seen, has triumphantly vindicated both the accuracy of Fenwick's observations of 1877, and Casde's hypothesis. The search for the extrinsic factor was at first directed solely towards liver as a source. Methods of extraction of liver were continually refined until by 1946 Emery and Hurran working in the Glaxo laboratories had managed to prepare an extract giving maximal activity in a dose of only 1.0 mg. At the time it seemed that this must represent the extrinsic factor in a practical pure form. We now know that it cannot have been present to an extent of more than 1.0%. During all this time it was becoming increasingly evident that pernicious anaemia was by no means the only form of anaemia associated with macrocytosis and megalo- •blastosis; and now new and startling facts were coming to light mainly as the result of the work of American nutritionalists and veterinarians. These had isolated from spinach, yeast and liver concentrates a substance necessary for the normal growth and feathering of chickens and for the prevention of anaemia in monkeys. It was found also to be essential for the growth of certain lactobacilli and the use of these organisms was introduced as a means of testing for the presence or absence of the substance. Its chemical formula when determined proved to be pteroylglutamic acid, closely related to santhopterin present in nature as the yellow pigment in the wings of butterflies. It was finally synthesized by the Lederle group of workers and placed on the market as Folic Acid. The appearance of Folic Acid in the field of haematology was a sensational affair. It proved itself capable of producing haematological remission not only in pernicious anaemia but also in many other forms of macrocytic and megaloblastic anaemia not responsive to the anti-anaemic principle of liver. It looked for a time as if Folic Acid might come to replace liver extract in the treatment of all forms of macrocytic anaemia, pernicious anaemia included, but it was not long before it became evident that the remission produced in pernicious anaemia by Folic Acid was (Please turn to page 54) Page 16 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION PROCEEDINGS OF THE ANNUAL GENERAL MEETING September 25, 1954 AND THE GENERAL ASSEMBLY September 24, 1954 Prince Charles Hotel, Penticton, B.C. PROCEEDINGS of the 1954 ANNUAL MEETING Canadian Medical Association — B.C. Division September 25th — 9:30 a.m. Prince Charles Hotel, Penticton, B.C. 1. CALL TO ORDER-Chairman, Dr. R. G. Large, President. 2. FINANCIAL STATEMENT AND APPOINTMENT OF AUDITOR- Dr. J. A. Sinclair, Honorary Secretary-Treasurer. Due to the change last year of the ending of the financial year from August 31 to December 31 to coincide with the payment of dues on a calendar year basis, the financial statement presented is for the four months ending December 31, 1953. The Statement of Financial Position and Statement of operations for four months are as follows: We have examined the books and accounts of the Canadian Medical Association, B.C. Division for the four months ended 31st December 1953 and have obtained all the information and explanations we have required. We have prepared and append hereto the following statements, namely:— 1. Statement of Financial Position as at 31st December 1953. 2. Statement of Operations for the four months ended 31st December 1953. 3. Statement of Receipts and Disbursements — Annual Meeting Fund for the same period. 4. Statement of Founders Fund Receipts for the four months. In our opinion the accompanying statements are properly drawn up so as to exhibit a true and correct view of the Association's affairs as at 31st December 1953 and of the results of its operations for the four months ended that date, according to the best of our information, the explanations given to us and as shown by the books of the Association. Reported by Buttar & Chiene, Chartered Accountants. Appendix No. 1 STATEMENT OF FINANCIAL POSITION As at 31st December, 1953 CURRENT ASSETS Cash: On hand - Petty Cash I $ 15.00 In Current Bank Account: General Funds __$ 1,775.65 Less — Canadian Medical Association — Unremitted Dues 110.00 • " " $ 1,665.65 ';|| Convention Funds 353.52 2,019.17 In Savings Bank Account 626.58 Page 18 Bonds - $10,000.00 - Provincial Government - 3%% Bonds — at cost _ _ 9 45000 (Market Value - $9,400.00) $ 12,110.75 FOUNDERS FUND ASSETS Cash in Savings Bank Account I $ 803.01 Investment in $15,500.00-4% Provincial Hydro Electric Power Commission Bonds—at cost 15,463.75 (Market Value - $15,370.00) FIXED ASSETS-at cost Office Furniture and Fixtures I I _$ 3,409.62 Less — Accumulated Depreciation 374.80 TOTAL ASSETS REPRESENTED BY Surplus Account: Balance at 31st August 1953 $ 29,256.18 Less—Net Loss for four months— per Appendix No. 2 14,110.61 Balance at 31st December 1953 $ 15,145.57 Founders Fund: Balance at 31st August 1953 $ 15,979.49 Add—Receipts for four months— per Appendix No. 4 287.27 16,226.76 -$ 31,412.33 This is the Statement of Financial Position referred to in our report of even date. Buttar & Chiene, Chartered Accountants. Appendix No. 2 STATEMENT OF OPERATIONS For the Four Months Ended 31st December, 1953 RECEIPTS Membership Fees j ._$ 1,035.00 Interest on Savings Bank Account and Bonds Canadian Medical Association: Dues Collected' $ Less—Remitted $440.00 and Balance Payable $110.00 DISBURSEMENTS Travelling Expenses: Executive Secretary—District Meetings, etc $ Automobile Expenses President to C.M.A. Convention Board of Directors District Tour Vancouver Medical Association Bulletin News Letter and Schedules of Fees Audit Fees Committee Expenses—Other than Travelling: Public Relations . . $ 663740 Salaried Doctors and Contract Practice Committee 1,500.00 Economics Committee _ 1.00 President's Chain of Office Expenses : _ Administrative and General Expenses: Salary—Executive Secretary $ 3,833.36 Salaries-Office Staff | 2,154.00 Postage, Telephone and Telegraph 305.92 Office Rent i 520.00 Office Supplies and Expenses 637.64 Unemployment Insurance 24.08 Medical Services Association 6.52 Bank Charges and Exchange:. 2.55 Depreciation on Furniture and Fixtures 1— 200.00 151.06 250.00 2,164.40 6.18 7,484.07 113.65 11,384.90 LOSS FROM OPERATIONS $ 10,312.93 Add Excess of Disbursements over Receipts- Annual Meeting Fund—Appendix No. 3 3,797.68 NET LOSS FOR PERIOD.: . $ 14,110.61 Appendix No. 3 STATEMENT OF RECEIPTS AND DISBURSEMENTS— ANNUAL MEETING FUND For the Four Months Ended 31st December, 1953 RECEIPTS " Tickets Sales j $ 3,775.15 Exhibitors Rentals and Donationus 525.00 $ 4,300.15 DISBURSEMENTS Preliminary and Incidentals . $ 342.94 Printing and Stationery .__ 547.61 Entertainment and Hotel Expenses 6,915.71 Speakers 18.41 Secretarial Honoraria and Expenses 167.35 Hobby Show Expense is&fs 105.81 8,097.83 EXCESS OF DISBURSEMENTS OVER RECEIPTS- Carried to Appendix No. 2 $ 3,797.68 Appendix No. 4 STATEMENT OF FOUNDERS FUND RECEIPTS For the Four Months Ended 31st December, 1953 PAYMENTS FROM FOUNDERS $ 30.00 INTEREST ON SAVINGS BANK ACCOUNT j 7.27 Page 20 INTEREST ON BONDS 250.00 CARRIED TO APPENDIX No. I $ 287.27 Also reproduced here is a combined statement of operations for the first half of 1954. This is not an auditor's statement but its preparation is auditor controlled. FINANCIAL STATEMENT — 1954 January 1st, 1954 — June 30th, 1954 RECEIPTS: 1st Quarter Membership Dues _„ 29,325.00 C.M.A. Conv. Suspense Acc't C.M.A. Refund See's. Conf jl—— B.C. Gov. Employee's MSA — Ref. Comm Interest on Bonds 570.00 From C.M.A. - for Conv.Jl 549.23 2nd Quarter 4,275.00 760.76 235.00 21.00 DISBURSEMENTS: Travelling Expenses: $ 30,444.23 $ 5,573.01 1st Quarter District Tour $ 264.65 Board of Dir I __ 85.00 Ex. Sec 331.50 Auto Expenses 137.11 Committee Expenses: Economics Committee 334.35 Public Relations Comm 806.65 Reference Committee 186.00 Board of Directors Vancouver Medical Ass'n. Bulletin 150.00 Administrative and General Expenses: Salarv-Ex. Sec _.__ 2,875.00 Salaries-Office Staff 1,371.30 Postage Telephone & Telegraph Office Rent Jl Office Supplies Unemployment Insurance M.S.A. 111 Bank Charges g| Over Remittance—C.M.A. Legal & Audit Fees Past Pres. Chain of Office Over Remittance—C.M.A. 238.39 79.25 390.00 460.82 17.68 4.89 36.00 100.00 2nd Quarter $ 128.80 248.00 28.90 68.12 71.75 1,566.51 21.75 150.00 2,979.17 1,605.00 496.25 96.23 520.00 1,277.08 18.72 4.89 4.42 100.00 8.70 30.00 $ 7,868.61 $ 9,324.29 Excess of Receipts over Disbursements $ 22,575.62 Excess of Disbursements over Receipts CASH BALANCE 1st Quarter Cash in Bank as at January 1st, 1954: General Account $ 1,775.65 Savings Account 626.58 Founder's Fund _ 803.01 $ 3,751.28 March 31st, 1954 Annual Meeting Account 353.52 353.52 C.M.A. Trust Bank Account 1,899.23 'l||§§f $ 3,558.76 • $ 26,134.38 Add—Increase in Funds for the period 22,575.62 Deduct—Decrease 3,751.10 $ 26,134.38 $ 22,383.10 Cash in Bank as at March 31st, 1954: June 30th, 1954 General Account 21,882.04 7,288.75 Savings Account 626.58 10,707.83 Founder's Fund Acount 1,373.01 1,373.01 Annual Meeting Account-.. 353.52 353.52 C.M.A. Conv. Trust Bank Acct. 1,899.23 2,659.99 26,134.38 22,383.10 Moved, seconded and carried: "That this reported be adopted." Moved, seconded and carried: 'Wg "That Buttar & Chiene be appointed our auditors for the coming year." 3. AMENDMENTS TO THE CONSTITUTION AND BY-LAWS- Dr. H. Carson Graham. Moved, seconded and agreed: That the present By-law VII, Section 10, be renumbered as By-law VII, Section 11. Moved, seconded and agreed: That a new By-law VII, Section 10, entitled "Committee on Public Relations" be adopted, as follows: 1. The Committee shall consist of 6 or more members. 2. The Committee shall be responsible to the Board of Directors and shall seek its approval concerning publication of policy on all major issues. 3. The duties of the Committee shall be: (a) to study and formulate public relations policy on all aspects of all matters affecting the relationship of the Medical Profession and the public; (b) to keep the members of the Association informed on all policies of the Association; (c) to use any media of communication to the public approved by the Board of Directors; (d) when considered necessary, to arrange public statements by a member of the Board of Directors, in the event of adverse criticism from whatever source; (e) on the authority of its chairman, to make public statements on matters affecting the health of the people; (f) to act as liaison committee with all allied professions in matters of common interest. 4. REPORT OF THE CHAIRMAN OF THE GENERAL ASSEMBLY- Dr. Gordon C. Johnston. In reporting the activities of the Assembly, no attempt will be made to discuss the multitude of lesser problems that have been dealt with. Furthermore, most of yo utook part in or were observers of the session which took place yesterday. As one who has observed the activities of the Assembly since its beginning, one cannot help but note its dignity, its high standard of debate, and the statesman-like level of its sense of responsibility. An observer is bound to feel pride in the achievements of the members of this profession and anticipate greater things for the future. Page 22 Of unusual note has been the accomplishments of the committee under the chairmanship of Dr. Sparling in developing in one year a prepaid health insurance organization which is now in operation. The future of this plan remains obscure, but it nevertheless is a remarkable achievement in insurance and a political answer to those people who demand national non-contributory health insurance at once. Dr. Sparling and his committee deserve the highest praise from the profession. Ever since the reorganization of this Association, economics has occupied much of the Assembly's time and thought. Great advances have been made and much remains which requires setdement. There is still much healthy disagreement between interested groups. Nor can we expect unanimity in the conduct of a problem which affects each one of us so intimately. Nevertheless, one has the feeling that we will always be able to conduct our internal economic affairs to the satisfaction of the vast majority of our members. Furthermore, one has no doubt that we will be able to continue to conduct our external financial affairs with the individual and the employer in a satisfactory manner. This will be especially true as long as the national economy remains healthy. The increasing participation of employed doctors in our Assembly is a matter of great satisfaction and of importance to everyone concerned. The number of doctors working for a salary is increasing and will continue to increase. They represent a strong section of our profession. More and more, those man who are employed and those who are engaged in private enterprise are beginning, through our Assembly, to recognize the problems of each other and their overall community of interest. The two groups are interdependent and can only succeed by close cooperation and mutual support. The problem which continues to plague your representatives is their failure to make satisfactory contact with government. On the Federal level we have the problem of payment for the care of merchant seamen working in our own coastal waters and the unsatisfactory D.V.A. schedule of fees. The remoteness and seeming indifference of the national authority and the necessarily indirect approach we find necessary, adds gready to the difficulties. More frustrating still is our failure to achieve reasonable liaison with the Provincial Government. Apparendy legislators do not welcome our opinions on matters of state. Information regarding proposed health legislation is usually withheld until it is a 'fait accompli'. Should the Government continue to withhold its confidence and refuse to accept our help and advice, our only alternative is to use our influence with the public. In short, we can, if we wish, present our views regarding pertinent matters by means of the press, radio and public forums. Over the years we have built up this organization and developed our public relations with such an eventuality in mind. At the present time our Association is strong and our public relations have reached an all time high. Are we going to use the mechanisms we have developed to support our principles in public? This question involves not only the immediate interests of the profession but the welfare and freedom of the whole community. Progress has been made after yesterday's meeting. The question seems to be:— Should we openly support our principles or remain silent and inoffensive? Should we respond to the stimulus of expanding bureaucracy or quiedy watch our privileges disappear? Are we to enter the lists openly at political level or be content to adapt ourselves to a series of departmental directives? Should we take our place as leaders in the community or leave this to lesser men? Should we stand out openly for freedom, justice and dignity or be content to forever adapt and appease? Some time we will have to make this decision and I recommend it for your consideration. Page 23 5. PRESIDENT'S REPORT-Dr. R. G. Large. As retiring president it is my duty to present to you a report on my year in office. Owing to the condensed form of our Annual Meeting this year, my position this morning is rather anomalous. Last night, the Chain of Office passed to my successor, so I find myself in the position of being retired while in the act of retiring. Because of the same condensed program, our time this morning is definitely limited, and I shall refrain from making a lengthy address. Most of you have already heard the report of the year's work at the General Assembly, and I would only refer to one or two important developments. Last year, Dr. Ganshorn dealt at length with the development of prepaid medical care in this province, and the part played by organized medicine in that development. This year marks another milestone along the road to eventual universal coverage with the inauguration of M.S.I. This new prepaid medical plan is our baby and is meant to be the answer to the need for assistance to the self-employed individual and the small industrial groups. While still in its infancy, we believe it will evntually expand and develop until it may well be a complete and satisfactory alternative to state Health Insurance. It can only fulfil this function if it receives the wholehearted support of every member of the medical profession in this province. During the year I have had the privilege of visiting most of the District Associations throughout the Province and in all cases I had the support of the Secretary, Dr. Ferguson. We also had as travelling companions a medical officer of the Workmen's Compensation Board who shared with us the responsibility for the program at these meetings. Dr. Stanley accompanied us as the representative of the General Practitioner's Section to. meetings at Penticton, New Denver and Fernie; and Dr. Roger Wilson to Prince George and Prince Rupert. I also visited the Victoria Medical Society and Dr. Turnbull very kindly substituted for me in the visit to the Upper Island meeting. We were very hospitably received at all these meetings, and I concur with my predecessor in stressing the importance of continuing them from year to year. They serve to foster a feeling of intimacy between the practising doctor and his elected representative, but, more important, they enable the Officers of the Association to become familiar with the varied conditions of practice throughout the Province and to hear at first hand the peculiar problems of each District. The past year we tried the experiment of holding a joint meeting with an officer of the Workmen's Compensation Board. Without any intent of criticism, I would strongly recommend that the practice be not continued. Both organizations have sufficient important business to transact to monopolise a full meeting; and in these joint meetings it is almost impossible to see that each organization has adequate time at its disposal. Because of travelling time involved, it has been impossibl for me to give the detailed attention to the duties of this office that their importance demands. If they have been discharged with satisfaction to you, it is largely due to the loyal support I have had from the Secretary, Dr. Gordon Ferguson, and the willingness of the President-Elect, Dr. Frank Turnbull, to accept many of the responsibilities which should have been mine. To both of these gendemen I wish to acknowledge my indebtedness and express my deep appreciation. I would also be remiss were I to overlook the efforts of the other members of the Board of Directors, particularly those who headed up committees. In particular Dr. Bagnall, whose committee did such excellent work in Public Relations, and Dr. Lehmann, whose Committee on Economics had to deal with the thorny problems of medical finance. To both these men and their committees I proffer my thanks for a job well done. This has been a year of unusual and rewarding experience for me and in laying aside the gavel of authority I thank you sincerely for the oportunity I have had of meeting and serving tha Profession of our province. Page 24 6. PRESIDENT OF C.M.A.-Dr. G. F. Strong. The President spoke extemporaneously to the meeting. The occasion of an Annual Meeting of a Division seems the proper time to become aware of the problems that present themselves to the profession as a whole. As you know, I have just returned from a visit to the four Adantic provinces and I was struck by the similarity and the differences of the problems. One cannot but have a feeling of pride for the accomplishments of the B.C. Division since our recent reorganization. Great credit for the reorganization goes to your newly eletced President, Dr. Frank Turnbull, but not alone; there are the other men who helped him, to whom we should render thanks. I noticed a difference in approach to our problems here to the approach that I saw in some of the other provinces. It is most gratifying to know that we are gradually coming to have a statesmanlike approach to the problems. By and large we are moving toward setdement of our differences all the time. It is proper at this time to point to the efficiency of our Executive Secretary. The excellence of this meeting is shown by the fact that he has had committee reports available in order that the discussion of our problems may proceed in an orderly fashion. I want to pay tribute to the very excellent job Victor Johnston is doing in the establishment of the College of General Practice of Canada. A chapter is being set up in each of the provinces. Again, it is a happy arrangement that the Canadian Medical Association is sponsoring this. I hope that time will not bring about a separation of the Royal College of Canada and the C.M.A. The C.M.A. was instrumental in bringing about the establishment of the Royal College of Canada. One sometimes feels that some of the Fellows of the Royal College look down on the C.M.A. as unnecessary. We should all recognize the need for these organizations in their various spheres. There was need for some organization which would improve the standards of specialists and that has been brought about by the Royal College by Fellowship and Certification examinations. Raising of the standards of general practitioners is going to be accomplished by the College of General Practice. There should be no separation or breaking up of the unity of the medical profession. Neither the Royal College or the College of General Practice should go off on a tangent from the main body of the C.M.A. We know that the C.M.A. consists of a federation of ten divisions. It is said that a chain is only as strong as its weakest link. This is not entirely true as regards a federation which may derive its strength from its strongest link. I think it is true to say that Ontario in Central Canada and B.C. in the West are leading the way and the West as a whole is setting a high standard which is pretty well recognized. The subject of rehabilitation is really close to my heart, and I am convinced that it is a most important problem facing the medical profession today. The increased effectiveness of medicine and public health have led to increased longevity and wellbeing that now makes rehabilitation measures essential. The whole program is being held up by a lack of trained personnel. . Economics is a vital subject in all parts of the Domiinon. Each Province approaches the problem in different aspects. Here, prepaid plans occupy much more of our thinking and our work. One thing that was disturbing is the difference in the approach to the registration and licensure of doctors, particularly displaced doctors. Page 25 7. INSTALLATION OF NEW OFFICERS. Dr. J. A. Ganshorn, after some introductory remarks, introduced each of the Officers for the coming year, and handed the gavel of authority to the new President. Dr. F. A. Turnbull, President. Dr. Eric W. Boak, President-Elect. Dr. R. A. Palmer, Honorary Secretary-Treasurer. Dr. Gordon C. Johnston, Chairman of the General Assembly. 8. NEW BUSINESS. A formal motion of appreciation to Dr. Plecash, the Chairman of the Committee in charge of arrangements for the Convention in Penticton, and to the members of his committee and the ladies committee was expressed. It was also moved, seconded and agreed: THAT this Division ask our Board of Directors to consider very seriously the policy of electing our representative to the Executive of the C.M.A. for a minimum of three years and that the motion include our chairmen of important committees. The meeting adjourned to be followed by the Annual Meeting of the College of Physicians and Surgeons. 3729 Kingsway Opposite Simpsons-Sears Available Immediately MEDICAL OFFICE SPACE Call BOB ORR — CHerry 9119 PHYSIO-THERAPY Registered Physio-Therapist and Massuese. Specializing in Bed Side, treatments. For appointment, please call KErrisdale 0316. Mrs. Anne Cottingham 2265 41st Ave. West Page 26 PROCEEDINGS of the GENERAL ASSEMBLY Canadian Medical Association — B.C. Division 24th SEPTEMBER, 1954 - 9:00 A.M. PRINCE CHARLES HOTEL, PENTICTON, B.C. | CALL TO ORDER jf ft- The meeting was called to order by Dr. Gordon C. Johnston, Chairman. Seventy-eight members were present. 2. TREASURER'S REPORT-Dr. J. A. Sinclair. A report prepared by the auditors, Buttar & Chiene, for the period ending December 31, 1953, and two quarterly statements to June 30, 1954, were presented. Himeographed copies of the quarterly statements were in the hands of all members. The Treasurer _ report was adopted. The Financial Statement is published in the Proceedings of the Annual Meeting in this Bulletin. C.M.A. CONVENTION FINANCIAL REPORT-Dr. F. A. Turnbull RECEIPTS: J|. |§ C.M.A., B.C. Division-To Fund i $ 1,350.00 —To information Sub Committee C.M.A. Receipts from tickets sold Returned from Inforamtion Sub Committee Returned from Ladies Committee Refund re: Liquor _ TOTAL $ DISBURSEMENTS: Ladies Committee $ 58.81 General Accounts for Meeting 1,846.61 Tuesday Dinner 2,441.39 Wednesday Reception and Dance 463.88 Thursday Cruise . 6,451.09 -$ Advance to Ladies Committee Advance to Information Sub Committee Excess of Receipts over Disbursements and Credit Balance of Convention Trust Fund Account RECONCILIATION: Advance by C.M.A., B.C. Division $ 1,500.00 Less Credit Balance 1 .'. 694.30 Net Cost of Convention to C.M.A., B.C. Division $ 805.70 Moved, seconded and carried — That this report be adopted. (The Annual Meeting of the College of Physicians and Surgeons authorized the Council to pay $500 to the Division to help defray these costs. This wae gratefully received). 3. REPORT OF GROUP INSURANCE GROUP LIFE INSURANCE PLAN It The following is a summary of the experience developed during the first year of the above policy i.e. over the twelve months' period 1st July 1953- 30th June, 1954: Total Premiums paid $ 50,879.81 Total Claims paid _$ 40,072.00 78.8% Dividend allowed 631.84 1.2% Insurance Company retention 10,175.96 20.0% $ 50,879.81 , 100.0% $ 50,879.81 You will recall that when the Group was initiated, it was assumed that for the first two or three years the claims experience might prove to be somewhat higher than that normally anticipated. A normal claims experience could be expected to be somewhere around 55% - 60% of premiums, and it is reasonable to assume that this group will eventually settle down near those figures — provided a satisfactory level of participation is maintained, i.e. at least 75% of eligible members. Up to the present time, however, the flow of enrollments from new eligible members appears to have been far from satisfactory. Due to the latitude which must apply to the eligibility requirements for Ordinary Members who are interns or postgraduate students, and the fact that the plan has only been in force one year, it is difficult to ascertain precisely the percentage of participation by new eligible members. Nevertheless, a study of the data which you supplied for the period March 1953 to August 1954 concerning newly registered doctors, new members of the Association and new participants in the Group Life Insurance Plan, would seem to indicate that participation in the Group Life Plan bv new eligible members is running at less than 50%. If this rate of enrollment by new members is allowed to continue over the years ahead the total number participating in the plan will either shrink or, at best, remain static; and, as a corollary of this, the plan will tend to develop a concentration of substandard risks with a consequent mounting of the claims experience. It is recommended that consideration be given to means whereby the support of new and eligible members can be more actively enlisted. Apart from the problem of enrolling new members, the first year's experience has conformed quite well with our original expectations, and it is indeed gratifying that at the conclusion of the first policy year it has been possible for the Insurance Company to allow a 1.2% dicidend. m MARSH & McLENNAN. Page 28 THE STANDARD LIFE ASSURANCE COMPANY C.M.A., B.C. Div. Group Life Assurance Plan Review July 1, 1953 - July 1, 1954 TERMINATIONS CLAIMS Effective Date Number Joining Plan Non- Payment Premium Terminated Membership CMA BC Div Est. perm't residence outside B.C. Att'd Age 70 nearest birthday Disability Death Number Insured Premium 1 July 53 1 Julv 54 573 612 7 0 2 0 0 4 573 599 4271.35 4598.45 ACCIDENT & SICKNESS GROUP POLICY We are pleased once again to report on the Disability Group. A most important factor for the welfare of the Group is the maintenance of membership participation, because the higher the membership, the greater the possibility of a good record which enables us to obtain increased benefits for the Group. On August 2nd, 1953, members totalled 420 and on August 2nd, 1954, the total was 450. A net gain of 30 accrued from 50 new members less 20 lapses. This is healthy, as the Group total has risen adequately as compared to the overall membership picture. We were delighted commencing February 2, 1954 to announce further additional protection without added premium cost. The endorsement and an explanation were forwarded to every Group member detailing: (1) Broader sickness coverage (2) Addition of elective benefits under accident (3) Waiver of premium clause. Both an announcement and an endorsement are enclosed. We have not lessened our efforts to obtain superior protection for the Group, and we have now completed arrangements to announce very very shortly a much broader Aircraft Clause, which will cover all flying accidents with very few limitations. There will be no additional premium for this. Mercy flights, which are of particular importance to the medical profession, will be covered. May we thank you, your staff and the membership for 'the assistance and cooperation available to us always. It has been our pleasure to be of service to you. m PARSONS, BROWN LIMITED. 4. EXECUTIVE REPORT-Dr. R. G. Large. Mr. Chairman, I have the honor to present the report of the Executive Committee and the Board of Directors. During the year, the Directors have met the four times required by the Constitution and the Executive Committee has had five meetings. In reviewing the work accomplished, I find that in almost every case it has been a continuation of effort to solve problems dealt with in last year's report. Some of them are still with us and will continue to plague Boards of Directors for years to come. Some of the matters dealt with are entirely economic in nature and you will receive a full report on them from the Chairman of the Economic Committee, so I shall merely refer to them here for the record. I. The Fee Schedule was reviewed and minor adjustments made, most important of which was the addition of an item of $5.00 for an office examination. 2 SAM S.-negotiation with Government was successful in raising the per capitapayment to $20.00 for this year. Your Board of Directors was not particularly happy with this amount as it is far short of the 90% of the minimum fee schedule which is our avowed objective, but it seemed to be the best which could be accomplished this year. A further group of individuals now come under the scheme in the implementation of the Disabled Persons Assistance Act, but discussions with Page 29 the Government indicate that, in fact, most of these people are already covered and the new arrangement will not be burdensome to the scheme. Since the per capita fee is only agreed upon from year to year, and will come up for negotiation in the Spring of 1955, your Board of Directors would like some expression of opinion from the Assembly as to what figure should be the ultimate goal of future negotiations. A motion will be introduced at the conclusion of my report. 3. M.S.I.—This new prepaid medical service has now come into operation and will be fully reported on by Dr. Sparling, its President. 4. In connection with the operation of the prepaid plans, we have had the usual number of problems. The solution arrived at last year of declaring certain doctors as non-participating has been discredited through an adverse legal opinion and we are still in the position of having no disciplinary methods available to enforce our decisions. We must rely on education and the force of public opinion, in this case medical, for the effective implementation of the regulations as interpreted by your mediation and reference committees. 5. The problem of the allocation and payment of the surgical fee when two or more doctors are concerned in the care of the patient, is still unsetded. During the year a joint committee of the General Practitioner Section and the Surgical Section met under the Chairmanship of Dr. D. S. Munroe and, to date, they have not been able to come up with a solution. They have, however, reached agreement on certain phases of the question and the economic committee will present the findings in detail. The Directors have a definite proposal to make in this regard. In addition to these predominantly economic questions, we have had to consider the following: 1. The Formulary. You will remember that last year your Chairman reported the acceptance of a Formulary which was drawn up by our Pharmacy Committee and accepted by the Government as the list of drugs available in the care of S.A.M.S. cases. It was the opinion of your Directors that this publication should be made available to all doctors in the Province by the Government, but the Government would not agree. Sinqe the cost of publication had been borne by the Pharmaceutical Society, we suggested to that Body that they should distribute the volume with a bill and leave it to the individual doctor to decide if he would accept and pay for it. Unfortunately, certain misunderstandings arose which resulted in some acrimonious correspondence. These misunderstandings have now been cleared up and the new Formulary seems to be fulfilling its intended function. Two points, however, should be made clear. First, the policy of the Government of dispensing certain drugs from its own central dispensary was entirely the Government's own idea. We were not . consulted and felt we should confine our protests to the medical aspects of the ruling, in particular as it concerns delay in the supplying of these drugs. Secondly, the decision of which drugs shall be allowed in the treatment of individual cases, is made by your own Pharmacy Committee, not by the Government. While the requests are routed through the office of the Director of Medical Services, any adverse decision can only be rendered by our own members of the committee. 2. Relations with Hospitals. A lack of contact with the Hospital Association and also with the Government in its operation of hospitals under B.C.H.I.S. has given your Board of Directors some concern. It was felt also, that we should be studying the various problems of hospital accommodation and services, and to this end, a committee has been set up under the chairmanship of Dr. Frank Turnbull. In cooperation with the College of Physicians and Surgeons, contact has been made with Government, and we can hope to be consulted in the future in major decisions regarding hospital services. In fact, Government has agreed to the setting up of a Medical Advisory Committee. We are concerned, however, over the present policy of Government in the freezing of hospital services, and this will be the subject of a resolution to be presented to you later. Page 30 Finally, the question of financing future annual meetings was considered. It was the opinion of your Board that the time had come for the Association to stand on its own feet and pay its own way. It was therefor decided to take no responsibility in future for the supplying of space for exhibitors and to accept no fees from surgical and drug houses toward the cost of the Convention. This decision would have necessitated the charging of a registration fee, a practice which is almost universal in the holding of conventions. At the Board of Directors meeting yesterday, a letter was read from the Exhibitors Association protesting our decision, and after some discussion the original motion was rescinded and the whole matter referred to the General Assembly for discussion. The Board of Directors felt that they would like some expression as to the value placed on exhibits by the membership before laying down a final ruling. In closing this report, I should like to mention the happy spirit of cooperation which has existed between your Association and the Council of the College. While this is only as it should be, it nevertheless represents a conscious effort on the part of the members of both bodies to approach common problems with sympathy and a spirit of conciliation, and this changed atmosphere is gready appreciated by your executive. R. G. Large, M.D., Chairman. This report was adopted. Re: S.A.M.S. Mover, seconded and carried: THAT the Board of Directors be instructed to continue to press for the ultimate goal of 90% in negotiations with Government. RE: COMMERCIAL EXHIBITORS Mover, seconded and carried: THAT in future annual conventions dependence shall not be placed on the Exhibitors Association for financial support but the cost of the convention shall be met by a registration fee. Further, this policy shall not be construed as preventing cooperation with the Exhibitors Association in the supplying of exhibits. 5. C.M.A. REPRESENTATIVE REPORT-Dr. J. A. Ganshorn. It has been my privilege to represent the B.C. Division on the Executive Committee of the C.M.A. since June 1953. As a duty I now report on the important problems which the Executive and General Assembly have faced and the actions taken. I must first remark on the very successful annual meeting of C.M.A. held in Vancouver in June 1954. 1600 doctors and 500 wives registered. This is the largest meeting of C.M.A. excepting the last Montreal and Toronto meetings. This bespeaks the great credit due Dr. Strong and the committees and persons who worked so hard to make the meeting such an outstanding success. The next annual meeting will be held in Toronto as a Joint Meeting of B.M.A., C.M.A., O.M.A. The scientific sessions will be held from June 20-25th inclusive. General Council of C.M_\. will meet the preceding Friday and Saturday, June 17th and 18th, and the British Commonwealth Medical Conference will be held* June 14th, 15th and 16th. Four meetings of the Executive Committee were held during the year. Dr. Strong, as President Elect, and myself attended all of thse meetings. The membership fee of C.M.A. has been $20 for two years now. Membership did not fall off nearly as much as some had anticipated. Membership in C.M.A. in Page 31 this Division has increased and now stands at 1094. With this membership, B.C. is the second largest Division in the C.M.A. C.M.A. offices are to be consolidated in Toronto and the General Assembly instructed that the offices shall be in a property owned and controlled by the C.M.A. The College of General Practice of Canada has come into being and we saw its impressive inaugural meeting here in June. This has come into being with the blessing of the C.M.A. and through the efforts of the Section of General Practice of the C.M.A. The C.M.A. Journal will be published twice a month beginning January 1955. Dr. S. S. B. Gilder was appointed co-editor of the Journal and began his duties April 1954. He served three years on the Editorial Staff of the British Medical Journal and following this did secretarial and editorial duties with the World Health Organization. He speaks both French and English. Dr. H. E. MacDermot will retire as Editor of the Journal in June 1955. Dr. T. C. Roudey retired as General Secretary of the C.M.A. June 1954 and became President Elect of B.M.A. and C.M.A. He is continuing as Managing Editor of the Journal. Dr. A. D. Kelly became the new General Secretary. Dr. A. F. W. Peart was appointed Assistant Secretary. The past year has been very successful financially. Assets were increased by $100,000. Some excess revenue has been planned because of an anticipated deficit in the operation of the Journal in the next two or three years when it is printed semi-monthly. However, certain expenses which had been anticipated in the past year did not materialize; neither the new editor or assistant secretary were avaiable as early as had been expected. A section of "Physicians in Public Service" on a national level was formed this year. This followed the forming of the first such section in our own Division one year earlier. This step has much significance. There has been a need for unity between that portion of our profession in private practice and that portion in public services. This is a move which will help gready to make our profession one. C.M.A. continues its support of T.C.M.P. $4,000 is budgeted for the T.C.M.P. again this year. Dr. Roy Richardson was again appointed as C.M.A.'s representative on the Commission of T.C.M.P. Re: T.C.M.P. (Trans Canada Medical Plans) It has opened an office in Toronto and has appointed Mr. Howard Shillington from Saskatoon Medical Service Plan as its Executive Director. Several accomplishments should be noted: || Trans Canada now has member plans operating in all provinces, including Newfoundland. Through its efforts, an inter-plan transfer agreement is in operation and sub- ecribers can go from one province to another without losing seniority or benefits. • It is working hard and hoping to soon have a "national policy" to sell Federal employers which will allow their employees in different provinces to have coverage in the plan in operation in the province in which they live. There is some evidence that Quebec is being stimulated to get a service plan. Something has happened in the past year which I think is most significant; something which will make us all feel that the C.M.A. is endeavouring to do a job which it should do. For the first time each provincial representative or chairman in Public Relations met together in a two-day conference in Toronto at C.M.A. expense. In addition and at the same time, each provincial secretary attended a two-day conference in Toronto. The provincial chairmen of the Economics Committees also met twice during the year for two-day conferences. These conferences help every division. They stimulate the tardy divisions; they assist the divisions who alone could not Page 32 afford to do some of the pioneering that other divisions can do. It. is the C.M.A.'s job to put itself in the position where it can advise and assist in economics, public relations and many other matters. In Public Relations the C.M.A. will spend up to $25,000 this next year. Last year it was $10,000. Our own budget in B.C. is $4,000. The General Assembly indicated that it felt in public relations pretty much as we feel here — that doctors must assume responsibility in public relations. It cannot be delegated to layman hired to do the job. That our top public relations men must be the officers of our Association and, the executive secretary. The C.M.A. executive are authorized to hire full-time help for public relations and will be most anxious to get a doctor (bilingual, if possible). We can expect more help on a federal level with our public relations in the future. The part-time consultative services of a public relations firm is being retained. Hospital Accreditation. In 1952 the American College of Surgeons ceased the Accreditation of Hospitals in Canada and the U.S. Canadians have not deemed it financially possible to do the accreditation of hospitals themselves. The job has been taken over by the Joint Commission on Accreditation of Hospitals, which is Canadian and American, and by a Canadian Commission on Hospital Accreditation. The C.M.A. is spending over $15,000 a year as its contribution to the job. Dr. Kirk Lyons, chairman of the special committee on Hospital Accreditation, was proud to present a report which indicated definite progress and not just hope. The Canadian commission have this year put two men in the field — Dr. Karl Hollis (English speaking) and Dr. J. J. Laurier (French speaking). There are the equivalent of 2l/2 field representatives working in Canada from the Joint Commission. In B.C. only 28.7% of 94 hospitals over 25 beds have been surveyed. This indicates much work to be done. You will realize that this task requires considerable money. The C.M.A. collects $20,000 annually from its members in B.C. and spends $15,000 on accreditation of hospitals in Canada. C.M.A. has a special committee working on the revision of the basis of approval of hospitals for interne graining. There had been no change since 1931. There has been so much more concern about specialist training since 1931. There is need to reassess the basis of approval of hospitals as there must be concern too for training of General Practitioners as well as specialists. C.M.A. has set up a Standing Committee on Rehabilitation and recommends that a similar committee be set up in each Division. Federal grants are available to each province for rehabilitation and very little of it is being used. In B.C. only $8,000 of an available $40,000 was used in the last year. The amount available doubles this year. The Committee on Rehabilitation of the C.M.A. recommended that the funds now available be used to set up rehabilitation demonstration units in teaching hospitals and other comparable establishments; these units to consist of rehabilitation, treatment and evaluation teams. We are fortunate in B.C. to have already set up certain rehabilitation facilities. In spite of considerable effort, the D.V.A. schedule of fees has not been revised. Efforts to have the schedule increased will be continued and it was considered by the General Assembly to work out one federal schedule of fees. This schedule could then be applied to the different departmnts of the Federal Government making payments to doctors — i.e. D.V.A., Indians and Sick Mariners' Fund. Liaison Committee of C.M.A. with the Canadian Association of French speaking doctors continues to function. C.M.A. accepts that the medical profession as a whole are represented in Canada by the two associations, the C.M.A. and Le Assoc, des Medecins du Langue Francaise du Canada. This is not the time to try and get all French doctors into C.M.A. Cooperation and the best attempt at unity can be gained through this liaison committee. Page 33 The payments under the Sick Mariners' Fund were investigated and it was determined that it would be unreasonable to expect an increase in payments here because of the international nature of the Fund and the inability of certain impoverished countries to pay more into the Fund. However, it was established that men on government and coastal fishing boats who were now covered under the scheme should really not be included and instructions have been given to have them removed from coverage under this scheme and if possible brought under a scheme which allows reasonable remuneration for medical services. There was contact with the Minister but no attempt this year to gain relief from income tax for professional people. The Minister of Finance indicated he was not willing to amend the income tax act at this session. The basis argument against the proposal was that the Dept. of Finance was not yet convinced that they could administer a tax deductible system for the individual taxpayer. Efforts to obtain relief will be continued this year in conjunction, as before, with other professional bodies. 6. To name representatives. (a) Representative to C.M.A. Executive, June 1955. Elected by Acclamation. THAT Dr. F. A. Turnbull be nominated to be our representative to C.M.A. (b) Nomination to M.S.A. Board of Directors. rt|| Elected by Acclamation. THAT Dr. J. F. Tysoe be our nomination to the M.S.A. Board of Directors. 7. Report of Nominating Committee. The Nominating Committee met for breakfast and presented the following nominations for 1954-55. President-Elect : Dr. Eric Boak Chairman, General Assembly Dr. Gordon C. Johnston Honorary Secretary-Treasurer Dr. R. A. Palmer Members of the Finance Committee Dr. W. E. McElmoyle Dr. G. O. Matthews, Dr. W. R. Brewster Place of meeting for 1955. It is recommended that the 1955 meeting be held in Vancouver. The Chairman called for further nominations for each office separately. There being no further nominations, the report of the Nominating Committee was adopted and the officers named declared elected. 8. Committee Reports. Committee on Constitution and By-Laws The proposed changes were accepted by the Assembly and passed to the Annual Meeting for ratification. They are published in the Proceedings of the Annual Meeting. COMMITTEE ON MEDICAL EDUCATION This committee was composed of one member—the chairman. At the beginning other members were contacted to serve but it was not necessary to call on them—the duties hardly being enough for one. One year ago a letter was sent to the secretary of each medical society in the province offering to obtain speakers on any subject of interest to them for their regular meetings. Only the Upper Island Medical Society responded to this particular letter. Dr. Gordon Ferguson, Dr. John Elliot and the chairman made that trip in April. However, speakers were obtained for three other meetings. Dr. Gordon Ferguson and Dr. Roger Wilson visited Prince George and Prince Rupert in January, while Dr. Ferguson, Dr. Frank Turnbull and Dr. Kay Belton visited the Upper Island earlier last Fall. I believe that these meetings were successful and the effort appreci- Page 34 ated. It was surprising to find so few of the groups interested in such a program, which is available at practically no expense to the different societies. The possibility of helping the University place fourth year medical students with practitioners throughout the province was investigated but in this Dean Weaver had already obtained the cooperation of the General Practitioners own Society. The Medical Faculty is so well established at this time that all this committee could do was to offer service, not perform any. A preliminary meeting preparing for a meeting of the Committee on Medical Education of the C.M.A. under Dean Weaver was attended. The possibility of establishing a School of Physiotherapy at the University is at present being investigated. The duties of this committee were extremely light this year. One would hope that more advantage will be taken of the facilities offered in the coming year. Charles G. Campbell, M.D. Chairman. COMMITTEE ON PUBLIC HEALTH We beg to submit herewith the annual report of the Committee on Public Health, Canadian Medical Association—B.C. Division, for the year 1953-1954. Your committee continued to act in an advisory capacity in matters related to the field of Public Health. Only two problems were referred to the Committee for action, namely: (1) At the request of Dr. G. G. Ferguson, Executive Secretary of the Division, the committee prepared for publication a paper designed to stimulate the sense of responsibility among medical men when asked to give certificates for the purpose of obtaining Motor-Vehicle Licenses. (2) Again, at the request of Dr. G. G. Ferguson, Executive Secretary of the Division, your committee explored possibilities of setting up a committee to investigate the frequency of use and method of supply of the Koch treatment for Cancer in British Columbia. In this connection it was decided that a committee composed of representatives from the B.C. Cancer Institute, Veterinary Medicine, Departments of Pharmacology and Pathology at U.B.C, Agriculture, Div. of T.B. Control, Federal Food and Drugs Division, would be activated for this purpose at an early date. Your committee noted with satisfaction the unqualified endorsation by the Canadian Medical Association at the meeting in Vancouver in June, 1954, of the principle of fluoridation of communal water supplies for the prevention of dental caries. James M. Mather, M.D. Chairman. COMMITTEE ON PUBLIC RELATIONS During the past year the activities of this Committee have been rather extensive, most of the existing media for communicating the views of the profession having been utilized. The following is a review of the year's activities: 1. RADIO: H The radio programme broadcast from Vancouver over CJOR has been the most cosdy feature of this Committee. Earlier in the year the same policy as in the previous year was followed and one programme was presented weekly, on Thursday night. While there was no doubt of the good calibre of the material presented on these evening programmes, there was some uncertainty as to whether we were reaching enough people. By adding a second weekly programme directed at the-housewives, it was felt that a much larger total audience would be achieved. In the spring of 1954, a second programme was added Friday morning after Dorwin Baird's "Man in Page 35 the House" — because it was essentially a revision of previous evening programmes, and at a less expensive time of day, this addition was much less costly. Comments: 1. At least as much favourable comment has been received about the housewives' programme as about the more expensive evening programme. However, because highly controversial topics have been avoided, there has been little comment on these programmes from the public. 2. Although the Committee feels that it is most desirable to reach all parts of the Province, and although the availability of prepared scripts has been called to the attention of all District Societies, there has been litde call for these. 3. Although it is almost impossible to assess the size of the radio audience, the use of radio has provided experience that may be of great value in the future. Moreover, we have been fortunate in incidentally securing the services, and advice, of Dorwin Baird. He has acted as a non-medical "sounding board", as well as a consultant in regard to public opinion. It is the opinion of the Committee that even if regular radio broadcasts are greatly reduced, or even discontinued in the metropolitan area, the services of Mr. Baird should be retained in an advisory capacity. 4. It is suggested, for the coming year at least, that much less money be spent in metropolitan broadcasts — and that a considerable proportion of Public Relation funds be allocated to develop local facilities in smaller centres. THE PRESS: Each Saturday, the Daily Colonist in Victoria, and the Daily Province in Vancouver have published a B.C. Division Medical column, written by one of our members. This column has been published without editing by the newspapers, and without cost to the Association. District Societies have been notified that these prepared columns are available for their use in local newspapers, but, as with radio, there has been very litde call for them. Comments: 1. While the quality of the material submitted has been excellent, there has been greater and greater difficulty in obtaining material so that, for the summer months of 1954 it was necessary to abandon these columns. Such breaks in continuity do not appeal to our friends in the press, because "meeting a deadline" to them is almost a religious obligation. The Committee is sorry that such a break in continuity was not avoidable but it should be understood also that many of the columns already published were written by Committee members, when columns seriously-promised by others in the profession failed to materialize. 2. With the plethora of syndicated medical columnists from the U.S., it seems hardly worthwhile for a few members of the Association to be called on to write on behalf of all their colleagues in B.C., if most of their colleagues are not sufficiently interested to help. If these columns are worth publishing they should be attuned particularly to B.C. problems. 3. Each column published carries the crest of the C.M.A., B.C. Division— and this thoroughly worthwhile repetition of goodwill is entirely without cost to us. It is regretted that there is so much difficulty in maintaining this service. Much consideration has been given as to whether each column should be signed by its author. Since some have raised strenuous objections to doing this, the decision was made to apply the "all-or-none-law" — either all columns are signed, or none. To date, not one has been signed — but due recognition of the author might encourage more enthusiasm for the project. 4. It is no easier to assess the reader-audience of the newspaper columns than it is to know how many listen to the radio broadcasts. Nevertheless, we know that relations with the Press have been greatly improved by this contact with press per- Page 36 sonnel, and that even rival newspapers now recognize the value of good liaison with our profession. 5. Following the lead of the metropolitan newspapers, weekly papers have made advances for our co-operation. Our co-operation would have been prompdy offered except for the fact that we were expected to pay full advertising rates for any material submitted. To do what was suggested by the weekly nwspapers would have cost more than the entire annual budget of the Division for all its activities. This matter was therefore left in abeyance. III. PUBLIC MEDICAL FORUMS: Two Forums were held in Vancouver in the spring of 1953 to see how they were received. The audiences were larger than expected, and both the degree and accuracy of newspaper coverage were excellent. Beginning in September 1953, therefore, a series of Forums were given almost at monthly intervals, finishing with the final one in June 1954, that was held in conjunction with the Annual Meeting of the C.M.A. in Vancouver. More recendy, a similar programme was inaugurated in Victoria and met with an excellent response. In some respects such Public Forums have considerable advantage over other media of approach in public relations. There is a tangible way of assessing the audience by counting the number of people in attendance. Moreover, the considered medical viewpoints presented are published verbatim and at full length, without editing, in the next day's edition of the sponsoring newspaper. This ensures that reliable information vis made available to large numbers of people to be read at their leisure. This is in contra-distinction to the radio programmes in which the size of the audience is at present more or less an accident — this could only be remedied by a very elaborate programme of advertising, which would be too expensive for us to carry out. Moreover, there is no way of assessing with any accuracy the number of people who actually listen. Whenever possible a mimeographed copy of the script has been supplied to radio listeners who request this, but no attempt has been made to collect the information given in reprint form because it would be too cosdy. However, the Daily Province requested permission to publish the Forums in booklet form and approval for this was given by the Board of Directors of the C.M.A., B.C. Division. This is to appear very soon, at no expense to our Association. Certain specifications have been laid down by the Board of Directors for this booklet so that no undue prominence will be given to any of the participants in the Forums. Their names are listed on the frontispiece and do not appear again throughout the text. It is our opinion that the Public Forums have therefore done more to improve the relations of the medical profession within their community than any other of the Committee's activities. Nevertheless we consider it important that no chance should be taken of overdoing them. Comments: 1. The Public Forums, like the weekly columns, have strengthened the bond of understanding between the medical profession and the Fourth Estate — through the frequent discussions and the profession's co-operation in providing satisfactory programmes. 2. There is danger of the public tiring of Forums, and due consideration should be given to "doling them out" in lesser quantity than seems at present to be desired by the Press and Public. 3. There has been very litde professional criticism of the use of the speakers' photographs and names in connection with the Forums, and there seems litde doubt that this departure has helped gready to draw large crowds to the Forums. Also, it has given rise to the feeling that "at long last", the medical profession is-becoming less starchy and more understanding. Page 37 4. It is strongly advocated that, as the use of Forums extends to less-metropolitan, smaller communities, these Forums continue to be advertised as activities of the B.C. Division and not be sponsored purely by a local medical society. It is our opinion that they should remain, as in Vancouver and Victoria, illustrative of the exemplary behaviour of the C.M.A. (as a profession). IV. TELEVISION: Investigations have been made to assess the potentialities of T.V. for our public relations. To date, experience in this Province is too small for us to feel justified in making any recommendations. There is little doubt that it is the most difficult medium in which to guarantee a successful appearance before the public, and it will be necessary to decide if enough of our members have the necessary T.V. talent, before deciding on any commitments. "Dry-runs" — i.e. dress-rehearsals that do not go on the air, are being arranged for this fall. Much further exploration should be done before firm decisions about T.V. programmes are made. V. RECOMMENDATION FOR CONSTITUTION OF NEXT COMMITTEE It is felt that the work of this Committee would be facilitated, and improved, by improving the liaison with the various regional medical societies. Suggested methods of achieving this are: (a) That the Public Relations Committee be constituted somewhat differently than in the past. To date, the members of this Committee have been chosen largely from the Vancouver area with one member from Victoria In future it is suggested that at least one member be nominated from the Upper Island, New Westminster, and North Vancouver regions to a nucleus committee. The remaining regional medical societies should have some representation also, but it is felt that this could be done by means of a regional correspondent who would be responsible for Public Relation activities. Such a corresponding member of the committee would have minutes of the regular meetings of the nucleus committee forwarded to him, and could be responsible for instigating radio programmes, newspaper columns, or Public Forums locally as approved by the local medical society. (b) That the corresponding members meet with the nucleus committee at least twice yearly for purposes of full co-ordination, and that the out-of-pocket expenses of the corresponding members be defrayed by the Division, for these two meetings. VI. PUBLIC RELATIONS, AS REGARDS INDIVIDUAL PRACTITIONERS OF MEDICINE N B.C. Your Committee finds it necessary to report confidentially that at present the biggest deterrent to good public relations seems to stem from certain practices of a small minority of the profession — Viz: 1. The "padding" of accounts rendered to insurance companies, and pre-paid medical-care plans. 2. Unnecessary surgical procedures, major and minor. 3. The tendency of some practitioners to forget the Hippocratic oath, and behave in an unprofessional manner — perhaps this is best exemplified by the doctor who demands payment in advance of rendering the service. 4. The unwillingness of some physicians to agree to consultation. If, after such refusal, the patient later finds relief through other channels, which he usually seeks, the initial refusal appears to harm the whole profession quite as much as it does the original doctor. 5. While it is realized that "extra-billing" may be a very necessary curb on the over-indulgence of patients subscribing to a pre-paid scheme, certain abuses have cropped up, in the case of a few of our members, that amount almost to banditry. It is realized that only a very few are responsible but the feeling of outrage at their evil practices spreads from mouth-to-mouth to many of our patients. It is therefore sug- Page 38 gested that a critical review be made of the circumstances under which extra-billing is considered ethical. As a corollary, it may be necessary to suggest to the College those circumstances under which extra-billing should be considered unethical, and even wanton and, therefore punishable. On the other hand, it is realized that many who justifiably could "extra-bill" have refrained from doing so because they do not wish to be included as sheep among the goats, 6. There are quite a few other matters that from time to time diminish the respect given to our profession, but most of them are held to a minimum by the activities of the C.M.A. and the College of Physicians & Surgeons. SUMMARY OF REPORT OF PUBLIC RELATIONS COMMITTEE 1. Rather extensive activities have been reported in the following fields: Radio, newspaper columns, and Public Forums. 2. As a result of this experience in the past year the following suggestions are made for consideration: (a) The cost of radio coverage in the metropolitan area be reduced and perhaps more extensively pressed throughout the rst of the Province. (b) Newspaper columns in Vancouver and Victoria be continued and extended to other parts of the Province. This will require much better co-operation of the whole profession. (c) Public Forums as a C.M.A. activity should be continued but not pushed to the point of saturating public demand. 3. Decision to utilize television should be made only after further careful study. 4. Recommendation for constitution of next Committee. 5. No matter how much effort is expended on public relations by various councils and committees of the C.M.A., good public relations depend on the total behaviour of all doctors in B.C. Much of the adverse comment on the profession arises because some individual doctors, not infrequendy, and even persistently, forget their duty to maintain the good name of our profession. Moved, seconded and carried. THAT the Public Relations Committee report be adopted and that authority be given for the recommendations contained therein to be carried out. Moved, seconded and carried. THAT a letter be sent to the publishers of the Vancouver Province and the Victoria Colonist expressing the thanks of the B.C. Medical Association for their hearty cooperation in publishing the weekly columns and Forums. COMMITTEE ON ARTHRITIS AND RHEUMATISM This committee continues to be active, having met four times during the past year. As in the past, it acts in a dual capacity, functioning also as an Advisory Committee for the Canadian Arthritis and Rheumatism Society. The extensive investigation as to the best method for the use of Cortisone in the treatment of rheumatoid arthritis has been completed and published. Funds for this purpose were supplied by the Canadian Arthritis and Rheumatism Society. Other research which was under way is still being pursued, namely, the role of Cortisone in the treatment of rheumatic fever and studies of the blood steroids in various rheumatic I diseases. Both these projects are of a long term nature but valuable information will be obtained from them in the future. Those projects have been financed by the Canadian Arthritis and Rheumatism Society and more recendy, by the National Research Council. The committee continues to supervise trials of new remedies appearing on the market and reports have been made from time to time on their efficiency and toxicity. Page 39 A travelling consultant service was inaugurated in September, 1953. This service is under the supervision of this committee but financed by the Canadian Arthritis and Rheumatism Society. On the whole, there appears to have been very good acceptance of it by the medical profession and it is planned to continue this service for the coming year. Largely through the efforts of the committee, arrangements were concluded whereby the Provincial Welfare Department will provide Cortisone for Social Assistance cases with rheumatoid arthritis. The Canadian Arthritis and Rheumatism Society have been asked to act as a screening and distributing agent. In cooperation with other agencies, the committee has continued to agitate for the establishment of a Physiotherapy School at the University of British Columbia. The shortage of registered physiotherapists is acute and it is felt that this is detrimental to the medical care of the community at large. It was our recommendation that the Association continue to press for the early establishment of such a school. The committee again would like to emphasize the need for special beds, both for the study of rheumatic diseases and the instruction of undergraduate and postgraduate students. It is felt that many of the advances in the knowledge of rheumatic diseases will come from improved instruction at a medical school of teaching hospital level. With its relationship with the Canadian Arthritis and Rheumatism Society, the committee continues to advise that its policy should be to augment the facilities" available for the family physician to treat his patients with rheumatic disease. This policy has been followed out and the relationship between the Society and the profession continues to be good. F. W. B. Hurlburt, Chairman. R. Lamont-Havers, Secretary. COMMITTEE ON ETHICS It so happened that the Nucleus Committee on Ethics of the Canadian Medical Association was working in Vancouver during the past year, under the Chairmanship of Dr. Wallace Wilson. The members of this Committee were Doctors Wallace Wilson; Ethlyn Trapp, Secretary; R. B. Kerr, Vice-chairman; Murray Baird, E. M. Blair, T. H. Lennie, J. H. MacDermot, and Rocke Robertson. Since it appeared redundant to have two committees on ethics working in the same locality, it was agreed that Dr. Wallace Wilson's Nucleus Committee, with the undersigned as Chairman, should be considered the Committee on Ethics of the B.C. Division, and should so report. One of the main objectives of the Committee was to attempt to evolve a common Code of Ethics for the Royal College of Physicians and Surgeons of Canada and the Canadian Medical Association, which differed particularly in the Section on Commissions. For this reason, Doctors Rocke Robertson and Murray Baird were authorized by the Council of the R.C.P & S. to represent them. The Committee met on numerous occasions and considered chiefly the subjects listed below: 1. Commissions. 2. Communications to the laity on medical subjects. 3. Group Practice and Ethics. 4. The Relationship of Medical Practitioners and Chiropodists. 5. The Relationship of Medical Practitioners to Insurance carriers and other organizations receiving reports regarding patients. 6. Partnership with non-medical persons, such as pharmacists and optometrists. The report of your Committee has already been published in the Canadian Medical Association Journal, Volume 71, No. 3, Page 220, dated September, 1954, Paoe 40 and with certain alterations has been accepted by the General Council of the Canadian Medical Association. Your Committee's report on the following subjects was adopted unchanged by the General Council: 1. Communications to the laity on medical subjects. 2. Group Practice and Ethics. 3. Partnership with non-medical persons. In the case of the controversial subjects, "Commissions", the report was adopted with a change in paragraph 6 dealing with Commissions on the Sale of Commodities. The changes in the Code of Ethics which were adopted are attached to this report as Appendices A, B and C. The Council referred back to the Committee for further study the complicated question of reporting on patients to insurance carriers and other organization, such as employers. Your Committee were of the opinion that not only ethical but legal as follows: THAT having carefully reviewed the documentary evidence submitted by the Canadian Association of Chiropodists, showing the courses of training prescribed for those wishing to become chiropodists; their pre-academic standards of education; their training in the basic sciences and clinical subjects; their rules of ethics, and their work in hospital clinics, together with other details. The Nucleus Committee recommends to the Council: That Chiropody, as prescribed by those men and women who conform to the educational standards of training equal to those set down and approved by the Canadian Association of Chiropodists, be recognized as a profession ancillary to the Medical professions and that it be regarded as in every way ethical and proper for medical men to consult with, or be consulted by or to refer patients to, or to have patients referred by chiropodists as defined; and to associate with them professionally. This recommendation was referred back by Council for further study. Your Committee feels that it does not require to study this subject further, and recommends to the General Assembly that the above resolution be adopted as far as the Canadian Medical Association, British Columiba Division is concerned. Your Committee has no information as yet to whether or not the published changes in the Code of Ethics have been communicated officially to the Royal College of Physicians and Surgeons. Murray Baird Chairman. Moved, seconded and carried. THAT the C.M.A.-B.C. Division accepts the recommendation of this Committee on Ethics regarding the recognition of Chiropodists. COMMITTEE ON HOSPITALS I would like to stress the importance of the newly organized Committee on Hospitals. Your chairman of this committee is ex officio a member of the B.C. Hospitals Association. It would be gready to our advantage if the hospitals could form an all-inclusive Hospital Association. A delegation of the Board of Directors visited the Minister on August 31 regarding B.C.H.I.S. Our most important project was to establish with the Minister that there has been no clear-cut official liaison with the Medical Association and B.C.H.I.S. On the part of the Government there have been confused lines of communication. We were accompanied to Victoria by the President of Council and we clearly established at that time the existing situation. There is no doubt in the minds of the Goverment now what we want and we have heard that they will establish a Medical Advisory Committee to the B.C.H.I.S. Page 41 Moved, seconded and carried. THAT this meeting approve the action of the Executive Committee in protesting to the Government about the "B.C.H.I.S. Freeze-up" policy, WHEREAS the doctors of B.C. are fully aware of the greatly increased cost of present-day hospital care. We realize that without any controls, costs would become unbalanced in relation to the total provincial economy. Nevertheless we consider that the publicly announced intention of B.C.H.I.S. to "freeze" hospital budgets at a stated level—e.g. the 1952 figure, is detrimental to good hospital and medical care. Hospitals are service institutions. They are not hotels for the sick. The freeze-up policy disregards in a blunt, unrealistic manner the year by year improvement in the standard of hospital care. These advances entail an inevitable increase of costs for certain hospitals each year. The slogan of "economy with efficiency" is not in the public interest unless "efficiency" includes acceptance of year by year advance in standards. The "Freeze-up" policy invites subterfuge because B.C.H.I.S. has not yet sterilized hospital initiative. Ways will be found by conscientious hospital administrators and directors to circumvent any order that halts progress. Spokesmen of B.C.H.I.S. have recendy adopted the attitude toward certain larger hospitals that if the budget is increased for one hospital it must of necessity be increased for all. Perhaps it should be increased for all. Nothing will be gained by insistence on a mediocre level. In B.C. a certain centralization of-special hospital facilities is necessary. Costs of operation will always be graded in relation to the proportion of more-than-average-cost service which central or stragetically situated hospitals will supply for not only the local community, but also for whole districts, and in a few instances, for the whole province. THEREFORE BE IT RESOLVED that the C.M.A.-B.C. Division request the government of B.C. to review the B.C.H.I.S. Freeze-up policy, and substitute a broader more considered policy. THAT the C.M.A.-B.C. Division request the government to make a clear public statement of policy in this regard. Moved, seconded and carried. THAT since only the medical profession has the scientific knowledge to be the proper guardian of the health of the people, our opinion on the dangers to the public health of the "Freeze-up" of B.C. hospital services be given to the press by the Public Relations Committee. And also, THAT the satisfaction of this group be expressed for the step that government has made in setting up a Medical Advisory Board for the B.C.H.I.S. This is a step in the right direction and it is hoped that the C.M.A.-B.C. Division will in future be consulted on similar major problems concerning the health of the people before decisions are made by government. COMMITTEE ON MEMBERSHIP Ordinary Members—C.M.A. and B.C. Division. Paid 1,090 Unpaid 17 Total %__ 1,107 Ordinary Members—B.C. Division only Paid jj 90 Unpaid 4 Total ___ 94 Post Graduate Members Paid . 16 Unpaid 2 Total - 18 Page 42 Retired Members M 8 Senior Life Members 8 Honorary Members 0 Total in good standing U 1,212 Total delinquent Grand total 1,235 Contributors to Founder's Fund—255 23 COMMITTEE ON PHARMACY The committee consisted of Dr. B. Shallard, Chairman; Drs. S. L. Ward (secretary), D. M. Whitelaw, C. C. Covernton, C. Treffry and H. Weaver. This committee has met on October 24, 1953; February 27, 1954; May 13, 1954 and June 5, 1954. The following is a resume of transactions on the respective dates. October 24, 1953. At this meeting the problem of the B.C. Pharmaceutical Association in the distribution of the new Formulary was dealt with. Whereas the Pharmaceutical Association had extended a considerable sum on publishing the Formularly and whereas the Government declined to reimburse them, it was recommended by this committee that the cost be borne as formerly by the individual physicians. It was further recommended that further delay be avoided by distributing the copies by November 1, 1953. February 27, 1954. The matters discussed were various complaints as follows: 1. From certain drug manufacturers that their proprietary preparations were not named in the Formulary. 2. From the B.C. Pharmaceutical Association that the Provincial Government Central Pharmacy was competing with their members. 3. From the B.C. Pharmaceutical Association concerning the non-acceptance of the Formulary issue by over 200 doctors. 4. From the B.C. Pharmaceutical Association suggesting revision of the Formulary. As regards items 1 to 3, no action was recommended. As the Formulary had just been distributed, item 4 was deferred. May 13, 1954. The business was chiefly concerning complications between the Penticton Medical Society, the B.C. Pharmaceutical and others occasioned by the former misdirecting their communications. The complaint re specific drug preparations was further considered. It was decided that die names appearing in the Formulary were expedient because they wer clear and well known to all. June 5, 1954. On this occasion the committee met with Mr. Faryon, a nominee of the B.C. Pharmaceutical Association. No new issues would appear to have been raised between Mr. Faryon and this committee and the former expressed his satisfaction with the committee's attitude on the various matters discussed. As regards revision of the Formulary to include new drugs, it was agreed that this should be done in the reasonably near future and that the method proposed was the issuing of loose leaves to be inserted in the present Formulary, the cost of this to be borne by the B.C. Pharmaceutical Association. Throughout the year the special committee of three (Pharmacy Committee and Government medical nominee) have met on innumerable occasions in an advisory capacity for the purpose of ruling on requests from individual doctors for special drugs. Bruce Shallard, M.D., Chairman. 9. Reports from Sections Reports were received from the following Sections. Anaesthesia Obstetrics and Gynaecology Eye, Ear, Nose and Throat Orthopaedics Page 43 Dermatology Internal Medicine General Practice Neurology and Psychiatry Pathology Paediatrics Physicians in Public Service Radiology COMMITTEE ON ECONOMICS Criticism has been directed against the Economic Committee that the members sitting on the committee are not representative. In practice, the Economics Committee are appointed by the Board of Directors. The committee is an advisory committee only — any decisions made by the committee are presented to the Board of Directors for activation. Final decisions are made by your elected representatives on the Board of Directors. In the ever changing sphere of medical economics, it is to be expected that your committee on Economics has been active throughout the past year. The committee has included Drs. Russell Palmer, Ross Davidson, John Ganshorn, together with the following new members, Drs. W. H. Sutherland, Hamish Mcintosh, D. M. King, A. F. Hardyment, all of Vancouver, and Dr. H. J. Alexander of Vernon and Dr. D. M. Whitley of of Victoria. A considerable time was spent on isolated problems, the details of which I am sure, will not interest this body. As in the past, various sub-committees have been established to deal with recurring subjects and it is my impression that the major work in the realm of economics has actually been carried out by these sub-committees, all of which have had additional members appointed from the membership at large. With regard to the sub-committee on Tariff, this committee consisted of Dr. H. J. Alexander as chahman and Drs. H. I. Williams, Roger Wilson, Peter Spohn and N. J. Blair. No major review fo the fee schedule was considered necessary this year in view of the revision in 1953, copies of which were distributed to the membership in April of 1954. The most significant innovation in this schedule of fees is the new item of $5.00 for a first visit. This fee was not introduced to replace either the existing $3.00 fee or the $7.00 fee, which is payment for a complete history, physical examination and certain laboratory tests. It was felt that often the work done at the first entailed less work than can reasonably be allowed at the $7.00 fee but does entail more than a $3.00 fee. It is hoped that the new $5.00 fee will in part overcome some of the criticisms of the policy of specialist services payment by the prepaid plans only in referred cases. Insofar as the new schedule of fees was the result of last year's sub-committee efforts sub-committee efforts, the sub-committee this year has confined its activities to considering new items and interpreting a few of the existing items more specifically. Dr. A. W. Wallace has been chairman of the Reference Committee in the past year. Unfortunately Dr. Wallace is not able to report in person, but I will read his report as it is important that this body and the profession generally know the problems of this committee and the public relations invblved. Dr. L. S. Chipperfield has been chairman of the S.A.M.S. Sub-committee in the past year. The affairs of the S.A.M.S. have been very efficiently managed by Dr. Henry Scott and his staff, and the sub-committee has consequently had fewer problems to cope with this year. Of major interest insofar as the S.A.M.S. is concerned is the data accumulated during the past year with regard to those surgical fees in which the attending doctor rendered service and was paid on a fee-for-service basis. This data will not be reported upon now but will be available during discussion on the subject of division of surgical fees later in the day. Dr. Scott has the report of the functional activities of S.A.M.S. during the past year, and will, I hope be prepared to present them now. Much time and thought has been expended by the Health Planning Conferences of which Dr. Russell Palmer has continued to be chairman. The year's activities have Page 44 been confined to studies of the potential impact on private practice o fthe latest Federal Health Grants announced in 1953, dealing with extension of laboratory services and rehabilitation. In studying the former, we have been helped by representatives of the Sections most vitally interested and by the Provincial Department of Health. To date no real extension of services has been provided under these Grants in B.C., but it is our understanding that no new services will be introduced by the Department of Health without further discussions with our representatives. One year ago the report of the Economics Committee included with considerable satisfaction the findings of the study of the costs of obtaining training in medicine. This study was published under the tide of "A Report on Medical Salaries", and was considered to be Part 1 of an overall statistical study of medical costs. The second phase to determine the costs of medical practice has again been undertaken by Dr. Ross Davidson, but the actual work has been delayed pending a decision by the Canadian Medical Association Executive as to whether that body will undertake part of the costs of the study. The Canadian Medical Association is interested in the study, but is asking some very pertinent questions from each division. At the last meeting of the Assembly the problems of extra billing were considered and the Executive was instructed to study teh effects of the policy and if it could not be shown that the policy of extra billing was accomplishing its purpose, namely to check the cost of increasing unreferred specialist care, then the policy of extra billing should be stopped. Your committee undertook such a study in January 1954, and reviewed statistical data provided by the M.S.A. At that time we recommended to the Executive that no change in policy be undertaken. At that time the committee received and studied a brief from the Section of Internal Medicine, recommending the abolition of extra billing. It is felt by the committee that at this meeting a decision re extra billing must be established in finality. The major economic development of this year has been the establishment of the Medical Services Incorporated. This development was not made by the Prepaid Plans Sub-committee, but was the work of a specific committee appointed for the special function of developing such a plan. Dr. J. F. Sparling will report in detail the developments of the new plan. The Economics Committee has watched critically the development of this plan. The chairman has attended two meetings of the Central Canadian Medical Association Committee of Economics in Toronto during the past year. Subjects of national importance were considered, among these being a new D.V.A. schedule of fees, problems of the Indian Affairs Department and the Sick Mariners' Fund. An attempt is being made to evolve a single and simplified form for health and accident insurance forms. Consideration was also given to reviewing the statement of policy with regard to health insurance and it was felt that no essential changes in policy have occurred since the last policy in Saskatoon in 1949. P. O. Lehmann, M.D., Chairman. SUB-COMMITTEE ON PREPAID PLANS Two main subject, were referred to the Sub-committee on Prepaid Plans. I. Lowering of the age limit of infants to cover newborn. The committee met to discuss ways and means and interviewed representatives from the Sections of Paediatrics, .General Practice and Obstetrics. The following were the committee's recommendations. 1. That infants should be covered from birth. 2. Prematurity — It was agreed that it represents a morbid condition and should be paid for on a fee for service basis if the baby has to stay in hospital longer than usual. Payment should be made to Specialist or General Practitioner. Not every premature will necessarily be considered a problem case. Page 45 3. Management of problem baby. This is usually a feeding problem. If the baby is referred, then it should be accepted and paid on a Consultation basis. 4. Circumcision should be covered. 5. Baby should not be covered for routine well baby care. 6. Congenital defects should be covered. II. M.S.A. coverage for U.B.C. students. The suggested program submitted for consideration did not meet the approval of the committee and our recommendations were: 1. That it must be complete coverage. 2. Full year coverage would be more economically sound than 8 month coverage. 3. There must be free choice of doctor. W. H. Sutherland, M.D., Chairman. REFERENCE COMMITTEE REPORT The Reference Committee is set up to pass opinions on disputed accounts in Pre-paid Plans. The cases may be referred to the committee by the physician, the prepaid plan or the patient, or the prepaid plan acting for the patient. Cases which have been seen may roughly be divided into eight categories. 1. Unusual cases in which the physician and the approved plan are both asking for guidance. 2. Cases in which the physician protests the assessment of his account by the approved plan. These cases must be examined each on its own merits before a decision can be made. In some cases the committee felt that the physician was actually underpaid. In others it was felt that the physician was overcharging. In some it was felt that the fault lay in the physician not setting down the facts in contentious cases. 3. Cases in which the approved plans before payment protest the charges made by a physician and ask for opinions as to a legitimate charge. 4. Cases in which two or more doctors are necessarily involved in a single case. It is often very difficult to pass judgment regarding what has been necessary care by these physicians. Only by a complete history can a decision be arrived at. 5. Cases in which there is an apparent attempt by a physician to repeatedly charge more than the minimum schedule of fees. The approved plans have in some instances sent a record of a number of these cases pertaining to one physician. A protest as to payment received by the physician usually accompanies these. In some instances a protest is also received from the patient, who has received an extra bill about which he had not been previously advised. 6. Cases in which the approved plans have felt that there has been excessive and unnecessary investigation. In these cases a history is necessary before any decision can be given. 7. Cases of extra billing. In cases of this type the approved plans may ask their obligation regarding the fee. 8. Cases in which there is a set fee for a specific procedure. Rarely during the past year we have been asked regarding the apportionment of a set fee for a specific procedure when two or more physicians were involved. We have been unable to give any decision in these cases. We felt that it could only be decided by the physicians concerned. During the past year nine meetings were held in which 94 cases were considered in detail. Roughly, half of these were referred by the approved plans and the other half by the physicians. Only one case was referred directly by a patient. There were Page 46 61 doctors represented in these 94 cases. It, however, should be noted that a few doctors were involved in several cases. One group of 20 cases involved only 4 doctors. In the rare instances in which the decision of the Reference Committee has been questioned, the problem was referred to the Executive Committee. In concluding this report, the Reference Committee respectfully make the following suggestions. In the matter of extra billing to patients covered by approved plans that a continued educational campaign be carried on advising physicians of the proper procedure if they must extra bill. That there be a clarification of the meaning of a referred case in contra-distinc- tion to a case passed for treatment. That in potentially contentious cases physicians be advised to send a reasonable explanation with their account. Respectfully submitted, A. W. Wallace, M.D. Chairman. SOCIAL ASSISTANCE MEDICAL SERVICE Social Assistance Medical Service functions as a Sub-Committee of the Committee of Economics. The following are the Members of the Board of Directors of Social Assistance Medical Services: Dr. L. S. Chipperfield, Chairman Dr. A. F. Hardyment, Vice-Chair. Dr. S. Marinker Dr. K. O. Fleming Dr. T. Bridge Dr. H. Scott, Medical Director Dr. H. Black, Asst. Medical Director Dr. W. Simpson, Asst. Medical Director The function of this Board is to direct the internal operation of S.A.M.S. The Administration of Social Assistance Medical Service consists of myself as Medical Director — two Assisting Medical Directors, all on a salaried part-time basis and a full-time Business Manager and staff of eight. I wish to convey on behalf of the Board of Directors certain points of interest in relation to this schemes activities during the fiscal year April 1st, 1953, to March 31st, 1954. During this period the number of recipients covered under S.A.M.S. increased to 66,573, an increase of 3,716. The amount received from the Government: $1,218,486.76, an increase of $28,243.46. The total administration cost $48,263.14, or 3.9%, an increase of $2,383.96, or .1%. The total accounts received as billed $2,402,243.61, an increase of $261,203.04. The total accounts received as assessed $2,133,281.66, an increase of $256,261.11. The total accounts as paid $1,128,919.17, an increase of $ 1,130.18. The average percentage paid '. 53.5, a decrease of 6.5. Number of accounts submitted \ 129,110, an increase of 13,110. Number of Doctors participating by account number 969, an increase of 72. (This represents approximately 1,100 individually.) The per capita grant from the Government was $18.50. There has been an increase in the per capita this year effective April 1st, 1954, to $20.00. We feel that this increase, if based on our previous years experience, will approximate 60% of the minimum schedule. Hospital Out-Patient Services. Our per capita grant of .50c appears adequate to cover this service. We have received the fullest co-operation in our daily dealings with the Provincial Department of Health and Welfare. In our response to adopting a speedier method of expediting medical cards to recipients and changes in enrolment which Page 47 affect some 6,000 changes in our- files per quarter, the Department is, through their approximately twenty-eight offices throughout the Province, endeavoring to co-operate with us to have these changes in our office in order to honor your accounts prompdy. No Extra Billing in S.A.M.S. There appears to be some confusion in the minds of certain members of the Profession on the question of extra billing and two recent cases have come to our attention where the Doctors have extra billed for the balance of their accounts. Our agreement with the Government specifically states that there shall shall be no extra charge to the recipient when the service is rendered under S.A.M.S. In other words, once having accepted a case who presents his proper mdical identity card, the Doctor renders his account to S.A.M.S. for payment and agrees to "accept in full payment of his fee such sum as those administering S.A.M.S. shall fix and pay". Patterns of Practice and Taxing Accounts. We are at times criticized and accused of slashing accounts. Our figures show that there is a difference of 12% between the accounts rendered and accounts as assessed. The greater part of this is made up by rigidly taxing prolonged hospital care of chronic cases. This chiefly applies to chronic cases who remain in hospital for prolonged periods and the Doctor bills for daily visits. We continue to have a small percntage of Doctors whose accounts appear excessive in comparison with their respective colleagues. Rigid taxing alone of these particular accounts does not appear to be an adequate solution to this problem. We have recendy submitted a more comprehensive report on our first five years of operations to be published in the Gazette. pHi H. SCOTT. Moved, seconded and carried, THAT the matter of the contribution by the medical profession to the costs of medical care to the S.A.M.S. group be made known to the public of this province. Extra Billing. Moved, seconded and carried, THAT the terms of service of prepaid plans regarding extra billing as in force at present should be continued and a further study made of statistics. CHAIRMAN AND MEMBERS OF GENERAL ASSEMBLY The Board of Directors of the B.C. Division, C.M.A. appointed a Committee last fall to study ways and means to form another Society to provide prepaid medical care for the citizens of B.C. who do not qualify for M-S-A. This Committee reported early this spring to your Board of Directors making specific recommendations: A. That a Society be formed to be known as Medical Services Incorporated. B. That the Society sell prepaid medical care on a service type contract. C. That memebrs of the Society be Physicians and Surgeons of B.C. registered with the College of Physicians and Surgeons and who have signed M-ST Membership Cards. In addition there be lay members appointed by the B,C. Division, C.M.A., from time to time, to sit on the Board of Directors of M-S-I. D. That the Board of Directors of M-S-I be elected by the members of the Society on an electoral district basis from the whole Province. Following this report your Board of Directors of the B.C. Division, C.M.A. appointed 7 doctors and 2 lay members to act as the first Board of Directors of M-S-I. A Constitution, Rules and Regulations and By-laws were prepared and an application made to the Superintendent of Insurance at Victoria for a charter to operate a Society to sell prepaid medical care service contracts. This charter has been granted. Page 48 With your kind indulgence I would like to review the type of medical care contracts now being sold by M-S-I. First let it be clearly understood that M-S-I is now and will continue to be in closest harmony with M-S-A. As evidence of this close harmony M-S-A is at the present time giving M-S-I office space and administration on a cost basis. This has given M-S-I trained and efficient administration from the very beginning. In addition to this, M-S-I has been fortunate in obtaining as our Executive Director, H. W. Jones, who has been for many years Assistant Executive Director of M-S-A. It is extremely gratifying to the Board of Directors of M-S-I to be able to report the business administration of the Society to be in such capable hands. At the present time 3 types of contracts are being sold by M-ST: (1) A Group Contract to Small Firms of from 3 to 9 members. This contract will give complete medical coverage exactly the same as M-S-A gives to firms of 10 or more members. (2) A Group Contract to Employees of Large Firms of 10 or more employees where for some reason or other the Employer is unable to participate in the contract. This is a partial care contract and will provide "in hospital medical care only". (3) An Individual Contract which will be available to members of M-S-A on leaving the employ of firms with M-S-A coverage; and also to individuals moving to B.C. who have membership in an approved plan with their own Province. This individual contract will be a partial care contract providing "in hospital medical care only". There has been a good deal of discussion among the Profession about the partial Contract which limits medical service in hospital care only. May I assure you that the Board of Directors of M-S-I has done much soul searching on this question. The first and paramount desire of the Directors of M-S-I is to allow every citizen of B.C. the opportunity to buy complete medical care on a prepay basis. However, this paramount wish has always to be tempered by the realization that since we all insist that only the best medical care be provided then the rates charged the prospective buyer must be high enough to meet all costs. There is the rub! The people of this Province have to a certain extent been spoiled by M-S-A in that they were contributing out of their own pay cheque only Vz the cost of their medical care. In other words, they have been conditioned to obtained family medical care for approximately $4.00 a month. It was the considered opinion of the Directors of M-S-I that these people would not be prepared to pay $10.00 a month, $4.00 doubled plus 25 percent extra cost of handling individual accounts. If the majority of these people are not prepared to pay $10.00 for medical care which they have been receiving for $4.00 then you are able to sell only to those who feel certain they will need medical care and you are immediately obtaining adverse risks. In other words, until the individuals in B.C. are educated to expect to pay and are willing in sufficient numbers to pay for complete medical coverage then any attempt to sell such coverage would mean sale only to very, poor risks and could lead M-S-I to financial ruin. The effort to offset this by raising the premium rate would thereby only increase the percent of adverse risks sold. Another problem which is receiving the attention of the Board of Directors of M-ST is the providing of an Individual Contract which will be available to anyone on application. It is our hope that we will be able to. offer such a contract some time in the next six months. Please, however, be it understood quite clearly that individual coverage is the most difficult type of prepaid medical care to offer on a wide basis and yet to remain financially sound. We at this time are unable to give any details as to the type of individual contract that will be sold by M-S-I. On September 1st, 1954, M-S-I started signing contracts. By September 7th, the date of our last Board Meeting, some 20 small companies had been signed. In conclusion, I would like to draw attention to the unanimity of the profession on the matter of offering to the public the opportunity to purchase prepaid medical W% Page 49 care. Over 1,125 Physicians had signed M-ST cards by September 1st, the day M-ST went into business. I am proud of the medical profession. Regardless of our individual personal feelings, we are as a group in effect saying "If the people of this Province want prepaid medical care then we as doctors are prepared to offer such type of care", insisting always that the high standards of medical practice must and shall be maintained. All of which is respectfully submitted on behalf of the Board of Directors of M-S-I. THE AFTERNOON DEBATE METHOD OF PAYMENT BY PREPAID PLANS WHEN TWO DOCTORS ARE INVOLVED IN AN UNCOMPLICATED SURGICAL CASE This problem has been before the members of the Association for some years and during the General Assembly held in Vancouver, Septembr, 1953, the Executive laid the problem before the meeting. During the year, in order to obtain some experience in administering the problem, the S.A.M.S. was given permission to pay the two doctors involved for the work done. The surgical fee was not divided in any way and the second physician was paid for actual calls rendered. The Assembly, then, in September 1953, by motion following debate, approved the action of the Executive in authorizing the S.A.M.S. to pay two or more doctors in one case, with particular reference to surgical problems. This above resolution supporting the action of the Executive was qualified by the following resolution: "THAT the motion just passed is understood by this Assembly to be an experiment and that therefore the terms of the resolution be limited to an experiment and reported at the next Assembly." This debate held in Penticton on this subject is, then, by direction of the previous Assembly and a continuation of the same subject. During the year a committee was established under the chairmanship of Dr. D. S. Munroe and included three representatives each from the Section of General Practice and the Section of General Surgery. This committee endeavoured to find that ground which was common and that ground which was unacceptable to either one or the other. After a very serious attempt to resolve difficulties, a report was drawn up which was presented to this Assembly. The report is reproduced herewith and it must be remembered that this is merely a statement of fact and all the items noted are not necessarily accepted by the whole profession. This report was received as a basis of discussion and for information to know what had been done about the problem during the previous year. As you read it, please bear this in mind. REPORT OF JOINT COMMITTEE OF SURGERY AND GENERAL PRACTICE This committee was formed in the spring of 1954 and consisted of the following members: Dr. L. S. Chipperfield Dr. L. B. Fratkin Dr. E. C. McCoy Dr. Simon Marinker Dr. Frank B. Thomson Dr. J. F. Tysoe Dr. D. S. Munroe (Chairman) Dr. Victor Hertzman sat in at the last meeting as a representative of the B.C. Society of Internal Medicine. Page 50 The purpose of the Committee was "to find a formula for payment of services rendered when two or more doctors are involved in one uncomplicated surgical case". Four meetings of the Committee were held in Vancouver — at these the basic problem presented to the Committee was thoroughly discussed in its numerous ramifications. The Committee members were able to agree on certain phases of the problem but were unable to agree on others. The representatives of both the Surgical Section and the General Practitioners stated their cases on the points of difference and both made suggestions for a compromise. 1. Points of Agreement. (a) The services of two doctors in any case results in better care to the patient than from one alone. (b) Both should be paid for services actually rendered. (c) Each participating doctor should independendy render his account for services rendered. (d) The Fee Schedule and its interpretation by officials of pre-paid schemes should not be set up in such a way as to give a practitioner any incentive to select one the referring doctor participates in the post-operative care. specialist over another. (e) Any alteration of the Fee Schedule should not considerably raise the cost of medical care to the public. (f) In referred cases only, the immediate pre-operative care of elective cases should commence one day before the operation. In emergency cases, the immediate pre-operative care should commence at the time of operation. The fee for all previous care in referred cases should be paid to the referring doctor on a fee for service basis. |||l (g) Simple referral of the patient to a specialist should not entide the referring doctor to remuneration other than such fees due for other services rendered. (h) Prepaid schemes should fully honour the account for pre-operative care, assistant service and post-operative work done by the referring doctor. The failure in the past to so honour accounts when rendered in accordance with existing fee schedules has, on occasion, led to considerable resentment and often friction between the referring doctor and the surgeon. (i) Ghost surgery is wholly reprehensible. II. Points of Disagreement. Members of the Committe were unable to agree on the basic problem of the payment of the fee for the actual operation and the post-operative care in referred cases. III. The basic argument of the Surgical representatives on the problem of the fee for the actual operation and the post-operative care in referred cases. (a) There should be one fee paid to the Surgeon Specialist whether the case is referred or not and this fee should be indivisible rgardless of the extent to which the referring doctor participates in the post-operative care. (b) Certainly the Surgeon Specialist should not have to accept a lesser fee in a referred case than paid to a non-specialist for the care of a similar non-referred case. (c) While assistance of the referring doctor during the post-operative period is welcomed by the surgeon and is to the advantage of the patient, in no way does it decrease the responsibility or work of the surgeon during that time. This extra service is to the patient and not on behalf of the surgeon. The surgeon's fee should therefore not be reduced. (d) The fee of a Surgical Specialist should not be reduced at any time in referred cases for the following additional reasons. Page 51 (1) Division of the surgical fee results in patients being referred for the economic benefit of the referring doctor. ^p (2) Division of the surgical fee can be used as an unfair and unethical means of obtaining referred work. (3) Division of the surgical fee may result in the surgeon neglecting his responsibility during the post-operative period. The surgeon who accepts his post-operative responsibility should not be placed in an officially disadvantageous economic position by any fee schedule. (e) The referring doctor should be paid for his pre-operative work, the assistant's fee where applicable and for services rendered in the post-operative period. (f) The cost of such an indivisible surgical fee for the operative procedure and the post-operative care will be more to the prepaid scheme in referred cases. This is fully justified because of the better service rendered to the patient by two doctors. IV. The basic argument of the General Practitioner Representatives on the problem of the fee for the actual operation and the post-operative care. (a) The cost. The cost of an indivisible surgical fee in referred cases where the referring doctor is paid for his services will be appreciably more to the prepaid scheme or to the patient. It should not cost the prepaid scheme or the patient appreciably more when the patient is referred to the Surgeon Specialist as compared with the situation when he goes directly to the specialist. (b) The principle. The patient should be encouraged to call the General Practitioner first. He will not do this if by so doing the cost of specialist care is greater than if he went direcdy to the specialist. (c) The work done. The fee paid to the Surgeon Specialist for the actual operation and the post-operative care in referred cases should be reduced below the usual level for the following additional reasons: (1) The referring doctor does part of the work and under some circumstances, geographical or otherwise, he may do most or even all of the work in the post-operative period. (2) The Surgical Specialist therefore may have less work to do and in certain circumstances, geographical or otherwise, he may take litde or even no part in the post-operative care of the patient. V. The suggestion of the Surgical Representatives as to the means to avoid or reduce the extra cost of the indivisible surgical fee in referred cases. The tariff for surgical procedures in all cases should be reduced by an amount sufficient to cover the added cost which would result should this be a significant increase. P|f This suggestion was not acceptable to the General Practitioners representatives on the Committee. VI. The suggestion of the General Practitioners representatives. In referred surgical cases where the referring doctor participates in the postoperative care, the fee paid to the Surgeon should be less than the basic fee by an amount to be determined (e.g. — 10-20% of the basic surgical fee). This amount should be paid to the referring doctor. In non-referred cases, the fee paid to the surgeon should be more than the basic fee for the procedure done by an amount to be determined (e.g. — 10-20%). This suggestion was not acceptable to the surgical representatives on the Committee. All of which is respectfully submitted. D. S. Munroe, M.D., &|f| Chairman. Page 52 0R Since the action by the S.A.M.S. was to be considered an experiment, the statistics from their work had been sought. This information was received in the Association office and considered by the Committee on Economics. It obviously takes some time to start a policy in the S.A.M.S. when the accounts are rendered quarterly. It means that when a policy starts, three months usually go by before accounts come in and then there is the period necessary for processing. The result was that the only quarter that had any seemingly reliable figures was the last quarter. These, however, would be hardly extensive enough or long enough experience to make it wise to be used as a guide in establishing a very permanent and important policy. The Economics Committee recommended to the Board of Directors that this policy in S.A.M.S. be continued and studied for another year and the Board advanced this recommendation to the Assembly as their considered opinion in respect to that one aspect of the work. The Board of Directors, after noting the report of the Joint Committee, made this recommendation and made it before the Assembly. THAT this matter be reviewed by a special commission who will render a report to a special meeting of the General Assembly to be called in January, 1955. The main debate, however, resolved around a resolution put forward by a representative of the Section of Surgery, as follows. pH THAT all approved prepaid plans be asked by the Canadian Medical Association, B.C. Division, to adopt for a trial period of one year the plan of payment for surgical procedures that has been used by the S.A.M.S. during the past nine months. The debate lasted for between two and three hours and many members of the Assembly spoke to the subject. It is neither possible nor wise to quote in this report statements made by individual participants in the debate, but in general, they revolved around all the points that were so carefully oudined in the report of Dr. Munroe's committee. The chairman kept excellent order and allowed the speakers to express themselves freely and in no way attempted to limit debate. The time came when the members of the Assembly themselves called for the question. The motion introduced by Dr. Robertson was defeated by a vote of 24 to 19. Th two resolutions, then, that were passed to the Assembly as recommendations from the Board of Directors and which have been published above were presented to the Assembly and passed unanimously. The meeting adjourned at 5:30 p.m. after acknowledging their gratitude to the applejuice men and to the local committee in Penticton for such excellent arrangements. ft ESTABLISHED PRACTICE |§ Unusual opportunity for eye, ear, nose and throat specialist seeking to locate in Vancouver, British Columbia. Immediate establishment in large, busy, lucrative practice, due to death of principal. Applicant should have certification or Fellowship in Royal College of Physicians and Surgeons in Canada. Please communicate by letter or telegram with * st. _^r. Ljrimmeti 502 ROYAL TRUST BUILDING 626 W. Pender Street, Vancouver, British Columbia Page 53 THE PATTERN OF PERNICIOUS ANAEMIA: (Continued from page 16) spurious and transient, that relapse soon occurred and further that it did nothing to correct and might even accelerate the advance of the nervous manifestations. The pursuit of the extrinsic factor by the great commercial houses continued unabated, though for the reasons already mentioned litde was heard of it until in 1948 there was announced simultaneously in England and America the preparation from concentrates of liver of certain red crystals which appeared to represent the extrinsic factor in pure form. The discovery was made simultaneously by E. Lester Smith and L. F. J. Parker working in the Glaxo Laboratories in this country, and in America by a team of five headed by E. L. Rickes working in the Merck Laboratories. It is significant of the new secretive atmosphere in Medical Research that Lester Smith and Rickes, with their respective teams, should have made their discoveries in isolation from and entirely independently of each other. The name Vitamin B.12 was proposed by Rickes and his co-workers for the red crystals. The chemical formula of Vitamin B.12 was soon determined and provided a surprise when it was found that each molecule contained one atom of Cobalt and a grouping of Cyanide. It was christened Cyanocobalamin. It soon became evident that Vitamin B.12 could do all that the most refined preparation of liver can do in pernicious anaemia and in far smaller dosage. Up to this stage liver had been the sole source of Vitamin B.12 and many tons of liver were required for the preparation of a few mgs. of the Vitamin. And now there came a surprising development again from an entirely unexpected direction. Professor Mary Shorb of the Department of Poultry Husbandry of the University of Minnesota had already demonstrated in 1947 that the concentration of the factor in liver extracts essential for the growth of lactobacillus lactis Dorneri is "in linear relationship to the potency of the extracts for effecting remissions of symptoms in pernicious anaemia". The Merck group of workers headed by Rickes set themselves to investigate the potentialities of other substances showing growth producing activity for LLD. It was soon found that many micro-organisms produce Vitamin B.12 in their metabolism and in 1948 they reported that among these was the streptomyces griseus grown on an immense scale for the preparation of Streptomycin. At a bound what had previously been a waste produce became invaluable as a source of Vitamin B.12. Like the liver extracts Vitamin B.12 was found to be many thousand times more effective when given parenterally than by the oral route. Berk with Castle and other first showed that orally it was rendered far more active if first treated with normal gastric juice or some other source of the "intrinsic" factor. Many workers have contributed to this subject; outstanding among them in Dr. C. C. Ungley. Thanks to the work of Dr. Ungley and others it became evident that Vitamin B.12 is indeed the extrinsic factor of Casde, but it also became evident that for effective oral administration Vitamin B.12 must be given along with a source of Castle's intrinsic factor. Work on the intrinsic factor had up to this stage been hampered by lack of any means of assay comparable to the reticulocyte response in pernicious anaemia to Vitamin B.12. In 1952 the work of Heines, Welch and their associates provided such a means of assay. They prepared a Vitamin B.12 tagged with the radioactive cobalt isotope Co60, and found that when this was given orally to patients with pernicious anaemia in a dose of 0.5 uy the faecal excretion over five or six days was never less than 70%; in normal subjects the excretion was never more than*40%. The oral administration of intrinsic factor in the form of normal gastric juice or of a fraction precipitated from an extract of hog gastric mucosa, along with the Vitamin B.12, to patients with pernicious anaemia reduced the faecal excretion of the Vitamin B.12 to within normal limits. At Newcastle-upon-Tyne Dr. A. L. Latner working in association with Dr. Ungiey had been diligent in the pursuit of the intrinsic factor. Medical students Page 54 have provided unnumbered gallons of gastric juice, and from this material Dr. Latner and his team, by means of a highly refined electro-phoretic technique, succeeded in March of this year in identifying the intrinsic factor as a mucoprotein with a molecular weight of between 15 and 20,000. What influence the identification of the intrinsic factor may have on the treatment of pernicious anaemia remains to be seen; it would appear that, however it may be done, its role is simply to convey the extrinsic factor through the walls of the alimentary tract. As Casde has said (1953): pernicious anaemia "would not develop if the patient could effect daily the transfer of a millionth of a gramme of Vitamin B.12 the distance of a small portion of a millimetre across the intestinal mucosa and into the blood stream. This he is unable to do, principally on account of the failure of his stomach to secrete into its lumen some essential but still-unknown substance". Dr. Latner and his co-workers appear to have identified this substance, and in so doing to have rounded off the observation of Fenwick of nearly 80 years ago. It is peculiarly happy that this research should have been crowned with success in Fenwick's old Medical School of Newcasde-upon-Tyne. As the pattern now stands it would appear that the extrinsic factor, cynacobala- min or Vitamin B.12 forms one of a complicated system of coenzymes necessary for the formation of deoxyribonucleic acid; the function of the intrinsic factor is simply to guide the extrinsic factor into the blood stream. Deoxyribonucleic acid is an essential constituent of the nuclei of all cells of the body. This year Rush and Rheault have demonstrated in cells obtained by gastric lavage from patients suffering from pernicious anaemia certain morphological abnormalities; squamous cells in particular are far larger than normal and show peculiarities of nuclear pattern comparable to those of the megaloblasts. There seems good reason to believe that the disturbance of deoxyribonucleic acid metabolism in pernicious anaemia affects all cells of the body but shows itself most markedly in the haemopoietic system because in this cell multiplication is more rapid than in any other. Further work in this direction may throw light upon the neurological manifestations of the disease. The question originally posed by Scarth Combe now seems to have received its answer. Pernicious anaemia is indeed a "disease sui generis". I am privileged in being able to speak on the pattern of the disease at a time when so large a portion of it has become evident. Much remains to be done but even as it now stands I believe pernicious anaemia to offer an example unique in medicine of the conquest of an hitherto inevitably fatal disorder. Many have contributed to the weaving of the pattern. I hope I may have been successful in bringing some of them and their labours to your minds. + + + THE FACULTY OF MEDICINE J| THE UNIVERSITY OF BRITISH COLUMBIA SEMINARS IN EXPERIMENTAL MEDICINE Schedule for 1954 The Seminars will be held in Lecture Room B-2 by the Cairn, U.B.C. Campus, on Thursdays from 5:00 to 6:00 p.m. November 18—Toxaemia of pregnancy Dr. F. E. Bryans, Dr. D. Claman November 25—Studies in renal function in patients with uncomplicated mitral stenosis Dr. R. A. Palmer December 2—Calcium and phosphorus homeostasis Dr. D. H. Copp December 9—Recent work on nucleotide co-enzymes Dr. H. G. Khorana December 16—Studies on foetal-maternal iso-immunization due to the ABO blood group system Dr. G. C. Robinson Page 55 WORKMEN'S COMPENSATION BOARD October 7th, 1954 To the Members, College of Physicians and Surgeons of British Columbia. Dear Fellow Members: At times during the past year and a half, I have wondered if I have been succeeding in doing anything in my attempt to improve the Public Relations between the Members of the College and the Workmen's Compensation Board and particularly with the medical staff of the Board. A good many times I am sure I would feel as if we were getting somewhere if I received more complaints from the doctors or more suggestions as to what we might do to improve the over-all situation. The problem which comes closest to our hearts is the question of the money we receive for the work we do. I wish it was possible to indicate to you in some way the increased costs of medical attention as they have occurred in the past ten years. When one reviews the statistics of the number of accidents, the length of time loss, the medical costs per case over the past ten years, one notices in a very dramatic manner the decrease in the average time loss and the very marked increase in the cost per case. It is noted the total number of cases in the past ten years has not varied in a very large percentage either way. We are noticing a very rapid increase in the costs of minor injuries and these in the great majority of instances, seem very much out of proportion to the severity of the injuries. We are making every possible effort to pay the doctors adequately for the work they do but it is our responsibility to the employers to see that they are not charged more than they can reasonably be expected to pay to give the injured workman the best possible care. There is another problem that is being repeatedly encountered and I think more frequendy encountered in relation to form 11A, and that is the final report account. It is often necessary at this time to send repeated requests to doctors for their accounts as we often have to delay paying the accounts until all accounts are on file so that they can be adequately adjudicated. Files have been recently seen in which 8, 10 or 12 letters, follow-up cards and notices have been sent requesting the accounts and they still have not been received. I have recently made a suggestion, that after two letters have been sent and two follow-up cards, and a period of four to six weeks goes by and no reply has been received of any kind, that we should simply pay the accounts on file and outlaw any accounts which may come in afterwards. This may sound like a very radical procedure and it may in some instances, be very unfair, but it would only be unfair to the one doctor who has delayed sending in his accounts and would allow payments of the other accounts which were on file and in most cases these may be accounts from several doctors including consultants, specialists, anesthesiologists and the like. I am not sure that the Commissioners and our Solicitor would approve of the foregoing suggestion but to date I have been unable to find any way either by requesting, begging, threatening or any other means by which we could succeed in getting the reports. Just one more problem for this month and this is in relation to the emergency forms sent in particularly by the General Hospital, the form Ml5. A great deal of difficulty is encountered in receiving forms which have been adequately filled out by the attending doctors. In a good many cases we know the attending doctors have seen the workman but the forms are incompletely filled out and definitely unsigned. In a great many.cases this lack of completion of the forms has seriously jeopardized the claim in relation to the workman and has caused a great deal of inconveniences. I repeat our desire to cooperate with you to the extreme and request that you send your complaints to me personally, I don't care how many come as long as we can be helpful. Page 56 I could go on and write several pages on the problems of costs, the adjudication of accounts and similar things but I will leave that part for now. We are having a problem in relation to patients who are sent to our Clinic and this applies very largely to the specialists who are sending workmen for treatment. It is very important when workmen are being sent to the Clinic, that special instructions be sent if any special type of treatment is desired. Several times previously I have made suggestions in relation to consultation reports. Again I would ask the consultants to please submit their consultation reports under their own letterhead without sending a form 8 and to please not send the consultations on a form 8. The form 8 is simply the surgeon's first report and under every circumstance there should be a workman's first report, an employer's first report and one surgeon's first report on each file. The consultation reports should come under the letterhead and cooperation of the consultants in this manner would be very much appreciated by the entire Board. I remain, Sincerely yours, J. R. NADEN, M.D, Chief Medical Officer. PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D, D.P.H., Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D, Director, Mental Health Services, Province of British Columbia aa NATIONAL HEALTH GRANTS PROGRAM AS IT AFFECTS THE PRACTISING PHYSICIAN The program of National Health Grants was inaugurated in Canada in 1948. The purpose of the Federal program was not only to make possible important improvements and extensions in provincial and local government health programs, but also to supplement and support what was being done by the health professions and voluntary agencies. In other words the Federal measure was intended to reinforce health advances already well under way in Canada and to sustain and add to their momentum. The National Health program makes federal grants available to the provinces under certain conditions to strengthen and extend Canada's public health services and at the same time to clear the way for the establishment of a comprehensive nationwide pattern of provincial health insurance systems. This health measure, the most important ever sponsored by the Federal Government, has the following broad purposes: (a) To help the provinces survey their own health programs^ and future needs; (b) To help them overcome serious shortages in hospital accommodation; (c) To raise the level of training of health workers, to open employment to many more such workers and to encourage health research. (d) To improve public health facilities in rural and urban Canada; (e) To intensify efforts to combat mental illness, rheumatism and arthritis, tuberculosis, cancer, venereal disease and crippling conditions in children; (f) To lay sound foundations for health insurance. A few major changes have taken place since the grants were first made available. In 1951 provision was made for assistance under the Hospital Construction Grant Page 57 towards the cost of construction of nurses' residences, combined laboratories and community health centres; in 1954 construction of training facilities for hospitals and health personnel also came within the scope of this grant. Additional grants became available in 1953 for Laboratory and Radiological Services, Medical Rehabilitation and Child and Maternal Health. The Health Survey Grant has been discontinued as the purpose of this grant was to provide for a survey of existing services and facilities and this has now been completed. The National Health Grants are now well established and accepted as providing valuable assistance in the development of health services. Total expenditures in British Columbia for the six years ending March 31, 1954 were $11,234,693. Of this amount $3,812,820 or 33 per cent was expended on hospital construction; $20,104 on the health survey, and $57,208 on public health research. The remainder, $7,344,561 or 65 per cent was expended directly on the improvement and extension of services, including professional training. Because of the stimulus and support provided by the National Health program the provincial and local governments have substantially increased their expenditures on health. The grants were designed primarily to improve public health. With the exception of the Hospital Construction Grant, the major expenditures have therefore been on those services generally accepted as public health, such as tuberculosis control, mental health and local health services. However, due to "public health" being given the broader interpretation of the "health of the people", it has been possible to give assistance in the field of clinical medicine within the limitations of other provisions in specific grants. Examples of this type of assistance which are of particular interest to the practicing physician are as follows;. To improve the care of premature infants, 63 standard incubators have been supplied to 32 general hospitals; seven incubators of the Isolette type to five hospitals; and seven resuscitators have been supplied to six general hospitals. Biopsy examinations performed up to March 15, 1954 were 51,562. As the hospitals providing this service, which is free to the patient, are reimbursed at the rate of $2.00 for each examination, over $1.00,000 has been expended for this service during the past four years. There have been 18,118 examinations performed by the cytology laboratory in the three years ended December 31, 1953. The total cost of this laboratory, as well as the biopsy service, is charged to the Cancer Control Grant, and as this is a matching grant Provincial funds constitute one-half of the amount expended. Free chest x-rays are now available at the request of the private physician in all areas of the province, either through the 42 miniature x-ray units supplied to general hospitals or through payments to other hospitals for each large film taken. During the year 1953 there were 68,198 miniature films and 9,642 large films taken on hospital admissions and 31,785 miniature films taken on outpatients referred to the hospital through the local health services. Diagnostic and treatment facilities have been improved in various general hospitals by the provision of the following types of equipment — diagnostic and therapeutic x-ray units, apart fro mchest x-ray units, electro-stimulator, electroencephalographs, shock therapy apparatus, tissue processing machines, Beckman ultraviolet and fluorescent accessories, Beckman flame and photomultiplier attachments, spectoscope and other laboratory equipment. Standards of hospital care have been improved through postgraduate training provided to date to 23 nurses on the staff of seven general hospitals and to 12 general hospital administrators. Assistance towards short term postgraduate training has been given to six members of the Faculty of Medicine, University of British Columbia, and to five practicing physicians who are on the part time staff of the Provincial Health Branch. Page 58 n ewA an d Iloted T}r. W. F. Baldwin is now practising in Vancouver. Dr. John R. Moore has recendy come from Montreal to practise general surgery in Vancouver. Dr. R. DeVito is now practising in Trail. Dr. W. R. Goran is now practising in Vancouver. Eh. T. Gray is now practising in Vancouver. Eh. L. Komar, formerly of Kemano is now studying orthopedics in Philadelphia. Eh. Morris Levine is now practising in Vancouver. Eh. W. M. McCallum has moved from Main Street in Vancouver to the downtown area. Eh. C. /. McKenzie is now director of the Peace River Health Unit at Dawson Creek. Eh. Leonard Maher is now with the Avery Clinic in Quesnel. Eh. Michael Penn is now practising in Victoria with Dr. P. M. Wolfe. Dr. R. G. Ross is now practising in Prince George, B.C. Dr. W. E. French is now certified in general surgery. Eh. Rudolph C. Anderson has taken over Dr. R. M. famieson's practice in Victoria, B.C. Dr. Henry Dunne, formerly of the Vancouver General Hospital, is now practising in New Westminster. At the Annual Meeting of the Victoria Medical Society held on October 5 th, 1954, the following officers were elected for the year 1954-55: President, Dr. G. H. Grant; Vice-President, Dr. S. Marinker; Honorary Secretary, Dr. James W. Anderson, Honorary Treasurer, Dr. W. A. Trenholme. Dr. D. A. Hewitt has left Victoria for San Francisco where he is doing postgraduate work at the University. Dr. ]. E. Dalton of Victoria is doing postgraduate work at the Columbia Medical Centre in New York City. Eh. C. J. Mackenzie has left Victoria for Northern B.C. Eh. Gordon Harris is now in Whitehorse. BIRTHS To Dr. and Mrs. Hugh S. Ford, a son. To Dr. and Mrs. E. A. Boxall of Vancouver, a son. MEDICAL ADMINISTRATORS From time to time experienced doctors are required for administration in medical care plans, e.g. Director of Medical Services, Medical Advisor, etc. It is possible that M.S.I, will soon need a medical director. The medical plans, before appointing a medical director, seek the advice of the Association concerning suitability. Indeed they often approach the Association for names of interested doctors from whom they can choose. If you are interested in medical administration,- either part time or whole time, it would be appreciated if you would communicate with the C.M.A.-B.C. Division, c/o Executive Secretary, 1807 West 10th Ave., Vancouver 9, B.C. Replies will be treated confidentially if requested. Page 59 POTENCY ASSURED in new FOR CHILDREN • • | Potency of vitamins in Pediavite is assured because they are dispersed in a dry, dextrose base. In addition, Vitamins A & D have been given a special stabilization process. Pediavite is a palatable, vitamin preparation which dissolves readily in the child's formula, in a glass of milk or orange juice, or spread on cereal or other food. Contains per level teaspoonful: Vitamin A 5000 I.U. Vitamin D j p 1000 I.U. Thiamin Mononitrate 1.2 mg. Riboflavin ., 2.0 mg. Niacinamide 7.5 mg. Vitamin B12 3.0 meg. Ascorbic Acid 60.0 mg. Dextrose 2.7 Gm. Suggested Dosage: One level teaspoonful daily. Package: 3 oz. jar (30 day treatment) f*»iPbXi> B Write for sample to 525 Logan Ave., Toronto Lv2Ay_/_S Available by U ... at all pharmacies w* )w# *^Jtuit£ewortfl ^L^imited ■W1 PHARMACEUTICALS TORONTO CANADA Page 60 GREATER VANCOUVER PUBLIC HEALTH Metropolitan Health Committee Dr. Stewart Murray, M.D., Senior Medical Health Officer Vancouver, B.C. Population (Est.) Vancouver 390,325 Burnaby Municipality \ _. 61,000 North Vancouver City 16,000 North Vancouver District Municipality 16,000 West Vancouver Municipality 14,250 Richmond 19,186 University Area 3,800 District Lot 172 ___ I 1,469 522,030 ¥• * * * H TETANUS ANTITOXIN OR TOXOID? S When a child is treated for a dirty wound, should he have toxoid or antitoxin or both? Experience in World War II demonstrated conclusively the value and effectiveness of immunization with tetanus toxoid. As a result, tetanus toxoid has been included in the triple antigen—Diphtheria-Pertussis-Tetanus, for the past six years and also in the T.A.B.T. vaccine. Over 22,000 children in Metropolitan Vancouver received a series of inoculations or reinforcing doses which included tetanus toxoid, in 1953 and over the past five years the total has been 56,000. To this must be added many treated by private practitioners. This means, therefore, that a large proportion of our pre-school children have been so immunized. How effective is this immunity? A study reported in the Bulletin of the Johns Hopkins Hospital (94:204, 1954), and referred to in an editorial of the C.M.A.J. September, 1954, indicates that immunity, especially after a booster dose, is high and effective for several years; also that a small booster dose, even after an interval of five to ten years has a quick and almost dramatic effect on the antitoxin level. The editorial concludes "It would seem, therefore, that practitioners could maintain a satisfactory level of immunity in veterans by giving a booster dose of tetanus toxoid at five-year intervals, or even, in the majority, at ten-year intervals. It is also recommended that such persons treated for injuries in civilian practice should receive tetanus toxoid alone as prophylaxis, and that as part of a campaign to increase the incidence of immune members in the population, everyone given antitoxin should simultaneously receive toxoid at a different site." Some will disagree about giving these "simultaneously", but in general this is good advice, and the figures above would indicate that the same recommendation will be increasingly applicable to the young children in our midst. SUMMARY OF VITAL STATISTICS — 1953 Vancouver Burnaby N. Shore Richmond Totals Births—by residence 7776 1706 1370 569 11421 Birth rate 19.9 28.0 29.4 29.7 21.9 Deaths—by residence' 4252 544 429 137 5362 Death rate 10.9 8.9 9.2 7.1 10.3 Infant deaths 184 37 25 20 266 Rate 23.7 21.7 18.2 35.1 23.3 Stillbirths 83 22 19 9 133 Rate 10.7 12.9 13.9 15.8 11.6 PLEASE NOTE—Health Unit No. 3 is now removed from the City Hall and it at 1530 West 8th Avenue. Page 79 -C CON NAUGHT > __^S^^ Official Names only are usei ^^^^^^^^^^^ i%v .*& \N j_Cl /^v.£ t_> co**N lCto9 ■©H* \0 5 v-,wm iiO BwP** cc- CC _* >*cn ^BO* >t OR«S lof Conoj r*»>f" fcP* Hi *\»* YC< O- C^° R\0* SOV^ \_f» ,oo<» ?ot WV° ,derttv»c use 30 *c- _eV« ica\W COH<^l t_ ;o\c*v Rt* >»c>* \> Ao*>) lO»*S en_ CflO ,o»<» \jo«»< _&_______ i **« *ROC___~» vm a ■»«, PRO **" _o.ooo - >W«* _©W _f»S_I MO*"* _._ iI___i_.;_;„.^^-._____;^-_ i „ - ^ ____„ „^___.__^___- T has been the policy of the Connaught Medical Research Laboratories to use only recognized official names for products, e.g. Epinephrine, Liver Extract Injectable, Penicillin G Procaine, etc. Physicians have only to add the word Qonnaualtt in writing prescriptions to be assured of receiving the products of the Laboratories. CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto, Canada Established in 1914 for Public Service through Medical Research and .the development of Products for Prevention or Treatment of Disease. DEPOT FOR BRITISH COLUMBIA MACDDNALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER 1, B.C. Page 80, or A aae Some two or three years ago, we remember very vividly, a special committee of the Vancouver Community Chest was appointed by the President of that organization Dr. Wallace Wilson of this city, to study the drug problem — drug traffic, drug addiction, and drug control, and bring in a report. This they did, and an excellent report it was. Among its recommendations ,one stood out particularly. This was that clinics should be set up, at which addicts could obtain doses of their particular drug, enough to satisfy their craving, while other steps, preventive and curative, might be taken. Full consideration was given to these necessary steps. Merely to recommend clinics which would provide drugs would be sheer folly, unless a programme of prevention and treatment and rehabilitation were combined with it. But the Report contained this programme as well. At first sight, it might seem that the provision of drugs for addicts was rather a shocking suggestion, merely a sort of appeasement, and a continuation of the evil practice of addiction. But the authors of the Report had good sense and good reason and some experience in other centres to back up their suggestions. We all know that the drug habit is in the first place largely initiated, and in the second place fostered, by the vile work of drug-sellers and "pushers", who wring enormous profits out of the degradation of their victims, most of whom are first introduced to the habit by these same travesties of mankind. There is so much money in drugs that, as with liquor during prohibition days, a certain section of society does all in its power to keep the traffic going, and the only way, it would seem, to cut away the props from under these people, is to remove the need for addicts to go to them; and this alone is a most cogent justification for the plan suggested. It would seem very likely, too, that the constant supply of new addicts would be gready lessened in this way. Moreover, it brings the addict within reach of our personal attention — we have a chance to get his confidence, to try to cure and rehabilitate him. At present, about the only way of getting in contact with him (or her) is through the jails and police courts. We all know the terriffic toll in robberies that is taken by the drug traffic, under the present system — to obtain their drug at the high prices demanded, the only method open to the addict to get money, is robbery, from stores, and other places. This is another argument for any method which will reduce the price of drugs. But Ottawa, which has the last word in the control of narcotics, and quite j righdy so, rejected this suggestion absolutely, and refused to consider it. We remem- I ber, at the time this Report came out, a conversation we had with one of the men who was most active in putting forward this suggestion of public clinics. He told us that he foresaw that in a few years Vancouver would be the centre of the drug traffic, and that the police problems presented by this traffic would become almost unsoluble, unless something were done along the lines of durg clinics. Well, he was right, and we in British Columbia, and especially in Vancouver, are right in the midst of it. Robberies, constant arrests of addicts, murders, are our daily fare. We note that the City Council and other organizations are coming round to the consideration and approval of this plan, suggested some years ago. Dr. G. F. Stevenson, appointed by the Federal Government to make a survey of the whole matter, has expressed himself as in favour of it, and other leaders in the academic and scientific and legal world are also in accord. It is not a case of saying "we told you so." Perhaps we had to learn the hard way. In any case we are learning by a very hard way — and it is to be hoped that Page ill some plan will soon be worked out which will be realistic and simple and effective. We still believe, as we said of the suggestions in the Report when it came out, that these suggestions fulfil the above requirements — and we hope they will soon be put into effect. They are not absolutely ideal — of course not — but they do offer hope that at some reasonably early date we may solve this hideous problem — and may blot out this appalling traffic which is making of Vancouver a den of iniquity— a resort of criminals, and the abode of lawlessness. I Library Hours: Monday to Friday. 1JP»|. 9:00 a.m. to 9:00 p.m. Saturday _ 9:00 a.m. to LOO p.m. Recent Accessions: Surgical Infections by Pulaski. C. C. Thomas. 1954. The Power of Poison, by J. Glaister. Christopher Johnson. 1953. Surgical Infections, by Pulaski. C. C. Thomas. 1954. Broadmoor: A History of Criminal Lunacy and Its Problems, by Ralph Partridge. Chatto & Windus. 1953. Perspectives in Neuropsychiatry. Essays presented to Prof. Golla on his seventieth birthday. Le Gros Clark et al. H. K. Lewis. 1954. Historical Review of British Obstetrics and Gynecology 1800-1950. Edited by Munro Kerr et al. Livingstone. 1954. Oestrogens and Neoplasia by Harold Burrows & Eric Horning. Blackwell. 1952. Anoxia of the Newborn Infant, edited by Cross, Lelong and Smith. Blackell. 1953. Surgery of Trauma, edited by J. Warner Bowers. Lippincott. 1953. The English Pioneers of Anesthesia, by J. J. Cartwright. John Wright & Sons. 1952. Modern Trends in Dermatology, by R. M. B. McKenna. Butterworth. 1954. New Journal: Members may be interested to learn that publication of the American Journal of Syphilis, Gonorrhoea and Venereal Diseases will cease on completion of the current volume. A new publication is to take its place under the title "Journal of Chronic Diseases" and a subscription to this journal has already been entered by the Library. Page 82 ancouver Medical Association OFFICERS— 1954-55 President. | Dr. J. Howard Black Vice-President _Dr. F. S. Hobbs Honorary Treasurer Dr. R. A. Gilchrist Honorary Secretary Dr. G. E. Langley Editor_. 1 Dr. J. H. MacDermot The following doctors were elected to Active Membership in the Vancouver Medical Association at the General Meeting held in the Tuberculosis Institute Auditorium on Tuesday, November 9th, 1954: DR. PETER BELL-IRVING Born in Vancouver, B.C.—Graduated from the University of Toronto in 1946— post-graduate study in the United States, commenced general practice in Vancouver in 1953. DR. JOHN WILLIAM DENNIS Born on March 29th, 1923 in Winnipeg, Manitoba. Graduated from the University of Manitoba in 1945. Special one and one-half years in the post-graduate study of Internal Medicine at St. Boniface Hospital, Winnipeg—later went to McGill University, where he obtained his diploma in Anaesthesia in 1953. Was licensed and commenced practice in Vancouver in July, 1953 (Anaesthesiology). Dr. Dennis is married and has one child. His hobbies and particular interests include golfing and gardening. DR. M. ALBERT MENZIES Born in Vancouver. June 24th, 1921 (the son of Dr. A. M. Menzies). Graduated from Queen's University, Kingston, Ontario, in 1945. His post-graduate study includes one year rotating interneship; one year internal medicine; one year pathology and three years psychiatry. Received his certification as a Specialist in Psychiatry in 1952 and is now a member of the Metropolitan Health Committee, Division of Mental Hygiene. Dr. Menzies is a golf enthusiast—is married and has a two-year-old daughter. DR. L. MIRABEL Born in Warsaw, Poland, on August 10th, 1917. Graduated from the University of Edinburgh in 1947. - Had five years of post-graduate training and one year of research work with the Medical Research Council of Great Britain. He came to Vancouver and started to practise in August, 1953 (Internal Medicine). He is married and has one child, and is a skiing enthusiast. DR. JOHN S. MONTEITH Born on December 16th, 1912, in Belcarres, Saskatchewan. Graduated from the University of Manitoba in 1943; licensed in British Columbia in 1946 and commenced practice in December, 1950. DR. GORDON HARRY SHEPHERD Born in Calgary, Alberta, September 2nd, 1921. Graduated from the University of Alberta in 1951. Studied general surgery at Shaughnessy Hospital for one year and has been in general practice here since July of last year. Dr. Shepherd is particularly interested in oil painting and his outdoor activities include skiing and camping. He is married and has one child. Page 83 DR. HERMAN J. van NORDEN Born in Amsterdam, Holland, in 1920. Graduated from the University of Amsterdam in 1947 and before coming to Canada was a ship's surgeon. He is now engaged in general practice in Vancouver. His hobbies and particular interests outside the medical profession include chess, bridge, music and travelling. His wife is Dr. Jacoba van Norden. ft DR. ROBERT GEORGE WILSON . Dr. Wilson was born in Vancouver on January 14th, 1922, and graduated from McGill University in 1951. His post-graduate studies include time spent at the Royal Victoria Hospital, Montreal, and the Shaughnessy Hospital in Vancouver. He commenced general practice in Vancouver last year and some of his spare time is used up in his work with the Reserve Army. Dr. Wilson is married and has three children. DR. FRANK DOUGLAS WILSON Born in Vancouver on February 19th, 1923. Studied medicine at the University of Toronto and graduated in 1947. Took post-graduate training in surgery in Adanta, Georgia, from 1949 to 1950 and Orthopaedics in Memphis, Tennessee from 1950 to 1953, after which he came back to Vancouver and opened a practice in Orthopaedic Surgery. Dr. Wilson's favorite sport is skiing and his hobby is stamp collecting. He is married. THE FACULTY OF MEDICINE, THE UNIVERSITY OF j§' :^J; BRITISH COLUMBIA /|| . SEMINARS IN EXPERIMENTAL MEDICINE Schedule for 1954-55. The Seminars will be held in Lecture Room B-2 on Thursdays from 5:00 to 6:00 p.m. December 9—Recent work on nucleotide co-enzymes Dr. H. G. Khorana December 16—Studies on foetal-material iso-immunization due to the ABO blood group system Dr. G. C. Robinson January 14—Calcium and phosphorus homeostasis J Dr. D. H. Copp January 21—Mode of action of streptomycin Dr. W. J. Polglase January 28—A synaptological survey of the human brain: (a) in normals | Dr. J. R. Smythies (b) in lobotomized mental cases Dr. W. C. Gibson ***** Preliminary Notice: Western Canadian Anaesthetists' Society meeting will be held in Regina, Saskatchewan, early in 1955. Every effort will be made to hold this simultaneously with the Western Surgical Meeting. Doctors interested in Anaesthesia who have papers they would like to present, please write Dr. J. E. McCutcheon, P.O. Box 34, Regina, Saskatchewan. Papers at the meeting will be printed in "The Canadian Anaesthetists' Society's Journal". Yours very truly, L. V. Jackson, Sec'y. T. V. Drake, M.D., Secretary, Sask. Section. Page 84 PRESENT CONCEPT ON THE PHYSIOLOGY AND THERAPY OF PULMONARY EMPHYSEMA By Dr. K. K. Pump. Pulmonary emphysema has been known for over 250 years. The first one to describe the anatomical condition was Floyer of Litchfield, who spoke of the disease as "flatulent asthma". (19698. Laennec (1) gave a fairly accurate description of the gross appearance of the emphysematous lung post mortem in his treatise of 1934. He expressed the opinion that asthma is due to emphysema, a belief which is not supported today. Concerning its cause, he stated: "This, next to hypertrophy, is the most simple of all the organic lesions of the lungs, since it consists simply in the dilatation of the air cells". However, he also noticed that there existed some obstruction to the passage of air from these vesicles and believed that this is particularly so if the existing cause of the emphysema is the "dry catarrh". Although its cause appeared to be simple in those days it has not been possible to ascertain the reason for the dilatation and rupture of the alveolar sacs up to the present day. It has also not been possible to determine and to understand fully the far-reaching effects this malady has on bodily functions as a whole. Since the advent of respiratory function tests in the second decade of the twentieth century (2) the physiological changes occurring in emphysema began to be better understood. Studying the lung volumes (3-7 all investigators agreed that the residual volume* in emphysema is always increased and that the ratio of residual volume to the total capacity** is always above normal, usually between 35% and 80%. The vital capacity is diminished and the dimnuition is primarily due to a marked decrease of the reserve volume*** (8). These findings explained to some extent the appearance of the chest of such a patient namely, the high inspiratory position of the ribs and clavicles and the deep supraclavicular fossae. However, many patients were found to have a high residual volume and a high ratio of residual volume to total capacity and yet not exhibit the "barrel chest". It was also found that the spirographs of emphysematous patients revealed an irregular pattern of breathing, a slow respiratory rate and an increased minute volume.x Christie further noticed that when an emphysematous patient took a deep breath and was then asked to breathe normally again the patient did not return to the functional residuaal capacity* in one breath as a normal does but did it in twelve or more breaths (Fig. 1). On the spirograph it produces a peculiar pattern, frequendy called the Christie Effect (2, 8). Diaphragmatic excursion and rib movement was found to be diminished (9). Because of the increased minute ventilation in emphysematous patients the early investigators believed that the alveoli are even better ventilated in emphysema than they are in the normal individual, an opinion which was soon proven to be erroneous. ^ ^ i The suspicion that the elastic tissue of the parenchyma of the lung is deficient in cases of emphysema received further support from the studies of Christie, Meakins and Mcintosh (8, 10, 11). It was shown that in well developed emphysema the intrapleural pressure at the end of inspiration and during expiration fluctuates around that of the atmosphere, whereas in the normal it always remains negative. These facts appeared to substantiate the belief that the elastic recoil of the lung in emphy- * Residual volume is the volume of air which remains in the lungs after a maximal expiration. - |f|| ** Total capacity is the sum of the residual volume and the vital capacity. . *** Reserve volume is the largest volume of. air that can be expired after a normal expiration, x Minute volume is the volume of air breathed per minute. * Functional residual capacity is the volume of air left in the lungs after a normal expiration. Page 85 EMPHYSEMA. MR RSS. Fig. 1. Spirograph of a male patient with severe pulmonary emphysema. Upstroke = Inspiration, downstroke = Expiration. A.=Demonstration of a Christie Effect. Following an inspiratory vital capacity the patient returns to the functional residual capacity in approximately ten breaths instead of the normal one or two. . B.=On performing a maximum breathing capacity test the patient cannot exhale] as easily as inhale and therefore the functional residual capacity is markedly increased. C.=Demonstration of an inspiratory vital capacity. sema is deficient and the lung can therefore not collapse and bring about expiration unless positive pressure is applied. In other words, expiration in these patients is no longer a passive act. Inspiration, on the other hand, proceeds as long as the intrapleural pressure is negative, as the elastic recoil offers no resistance to the expansion of the parenchyma. Obstruction, commonly present in the bronchioles, also contributes to the necessity of a positive intrapleural pressure during expiration. It would seem, therefore, that inspiration in emphysema is performed with ease, as the lungs expand readily owing to the absence of the hindering influence of the elastic recoil. The bronchiolar obstruction is also lessened as the negative pressure acting on the bronchiolar walls dilates them. However, expiration is made considerably more difficult. The absence of the elastic recoil requires a positive force to collapse the lung and the positive pressure pressing on the walls of the bronchioles tends to constrict them. Thus a vicious cycle is introduced. It would seem that this theory explained by the residual volume had a tendency to increase. The positive pressure present during expiration has another deleterious effect, namely, it hinders the ascent of the diaphragm. As the residual air increases and the chest cage assumes more and more of an inspiratory position the diaphragm becomes stretched and thinned. This thin leaf is thus readily prevented from ascension during expiration by the positive intrapleural pressure (8). The flattened domes of the diaphragm are a common sight in far advanced emphysema. (Figs. 2 and 3.) Page 86 X-ray of adult male suffering from Pulmonary emphysema. Note the flattened^ diaphragm. Lateral chest X-ray of adult male, suffering from Pulmonary emphysema. The diaphragm is flattened antero-posteriorly. The ribs are markedly elevated, giving appearance of a "barrel chest". Even though this theory of the intrapleural pressure by Christie appears to explain many factors adequately it has not been universally accepted. It is argued that there is no such thing as an intrapleural space nor pressure. Both of these factors are created by the introduction of a needle and with it a small amount of air. In well established emphysema when the chest cage is fixed in the inspiratory position and rib movement is markedly reduced, inspiration depends a great deal on the diaphragm. This organ, however, functions at a disadvantage as it has been stretched and thinned. Its tremendous efforts soon lead to fatigue and the muscular Jeaf becomes a relaxed partition between chest and abdominal cavity and its movements are governed by the intrapleural pressure. Thus the positive pressure during expiration will force the diaphragm down and the negative pressure during inspiration, suck it up. Thus a paradoxical movement of the diaphragm may be observed. The latter, however, is very rare, as the patient seldom survives to this stage. As mentioned earlier the respiratory rate in established emphysema is slow. Expiration is prolonged and laborious, requiring the aid of the accessory expiratory muscles. It has been explained as being due to the deficient elastic recoil and the obstruction present in the smaller respiratory passages. However, these factors alone do not explain it fully, since the degree of hypercapnia and hypoxia present in these patients would stimulate the respiratory centre to such a degree as to overcome these obstacles. Hering and Breuer in 1867 (12, 13) found that distending a lung invariably brought about an expiration, even though the immediately preceding respiratory movement was an expiration. Further work by Lumsden, Adrian and Pitts (14-17) established that distention of alveoli stimulated vagal receptor organs in the lung parenchyma which in turn stimulated the expiratory centre and inhibited the inspiratory centre. Hering and Breuer found that by producing a partial tracheal stenosis in an animal and then distending - the lungs by inflation, the expiratory Page 87- movement which followed would be considerably prolonged. Leaving the partial tracheal stenosis intact the animal continued to breathe at a slower than usual rate. Removing the stenosis suddenly the animal would assume immediately a rapid rate, which would persist for a short time after which a normal rate would return. The same phenomenon has been observed in children with diphtheritic membrane obstruction, where the slow, wheezing respiratory rate was changed to a very rapid rate when the membrane was removed. In emphysema one can assume that the marked distention of the alveoli stimulates the vagal receptors unduly, bringing about a marked stimulation of the expiratory centre and considerable inhibition of the inspiratory centre. If alveolar sacs of a normal individual were suddenly distended to the degree seen in advanced emphysema the expiratory centre would be stimulated to such a dgree that the patient would be induced to cough, thus bringing about a sudden deflation of the alveoli, expelling a large volume of residual air, enriched with CO2 and thereby establishing again a normal gaseous relationship. It is believed that in emphysema the threshold of the vagal receptor organs has been raised, and the expiratory centre is not stimulated to the same degree. Recent work in this connection seems to support this hypothesis. If the main bronchus of one lung in a normal individual is suddenly blocked at the end of a normal expiration the remaining lung will immediately increase its inspiratory effort, decrease the expiratory effort and increase the respiratory rate. This occurs because the alveoli in the blocked lung are deflated, and remain so as long as the bronchus is blocked and thus the vagal receptors from this lung do not inhibit the inspiratory centre. The inspiratory centre being more powerful than the expiratory centre brings, about an increased inspiratory effort, shortened expiratory phase and therefore an increased respiratory rate. Blocking a main bronchus in a patient suffering from emphysema does not cause this to occur. Even though the blocking is again done at the end of a normal expiration the alveoli are still so distended as to exert some inhibition on the inspiratory centre, and the patient continues to breathe in almost the same fashion as prior to the block (18). The slow respiratory rate can therefore be considered to be due to a powerful inhibition of the inspiratory centre and stimulation of the expiratory centre, which in turn is due to the large residual volume, bringing about distention of the alveolar sacs. The disturbed mechanics of respiration occasioned by the deficiency of elastic recoil and the bronchiolar obstruction undoubtedly plays also a part. The condition described so far would not be serious or handicap the patient if it did not affect the respiratory gas exchange, the cardiovascular system and ultimately the acid-base balance of the humoral media. These are not affected as long as the patient is able to overcome the detrimental effects of the emphysema by the use of compensatory mechanisms. Only when these mechanisms fail does the patient become aware of respiratory difficulties. One of the first things to occur as the residual volume increases is an increase in the content of CO2 and a decrease in O2 in the alveolar air, which is due to a diminution of the effective alveolar ventilation. In a normal the CO2 partial pressure in the alveolar air is 38-40 mm Hg. In emphysema it may rise to 80-100 mm Hg. This naturally means that the arterial blood has asimilarly high CO2 tension and the venous blood an even higher one. Since the alveolar ventilation is sub-normal the O2 tension becomes much lower than in the normal. If the arterial blood returns to the tissues with such a tension of CO2 it means that the tissues contain at all times a large volume of CO2. Conversely, since the arterial blood returns to the tissues not fully oxygenated a state of hypoxia of the tissues may be present (19). This state of hypercapnia and hypoxia may be partially remedied if the cardiac output and the minute ventilation are increased. Normally the blood medium does not carry such large volumes of C02 and in order to do it, it must increase its CO2 combining power. This is achieved by Page 88 releasing Na in. the plasma previously bound to CI, for combination with HCO3 to form NaHC03. To establish Donnan equilibrium shift of the chloride ions from the plasma into the cells occurs. In a well established emphysema low plasma chloride and an elevated CO2 combining power are often seen. Even though the flood carries large amounts of HCO3 the Buffer systems of the blood maintain the pH at its normal level. A change in the pH will occur after the various compensatory mechanisms have broken down and whenever this occurs the prognosis is, indeed, very unfavorable. Since the arterial blood has a much higher C02 tension and therefore a higher H+ concentration than normal (19), the respiratory centre is continuously stimulated to greater exertion. A sense of dyspnea is therefore present of which the patient complains. The reasons why the patient does not breathe faster and eliminate the excess of CO2 have been cited above. In patients with severe emphysema the arterial O2 saturation may be as low as 53% (19) and a state of anoxia of the tissues is present. The nervous centres, such as the respiratory centre, are very sensitive to a depression of the normal O2 tension and in time this deficiency, it is believed, reduces the sensitivity of the respiratory centre to the H+ concentration in the blood. Thus in advanced cases an insensitivity to CO2 excess is present but sensitivity to anoxia remains normal. Anoxia stimulates the respiratory centre via the chemoreceptors of the aortic and carotid bodies. The administration of high O2 concentration in emphysema may have a toxic effect because the O2 raises the arterial O2 saturation markedly and thereby depresses-respiration even though carbonic acidosis develops and the blood pH falls as a consequence. This state has been called "Oxygen poisoning", but is actually a CO2 narcosis. If such a patient is given O2 only intermittendy by mask and for only brief periods coma may be avoided. As the emphysematous state of the lungs develops and progresses the cardiovascular system is adversely affected. The disadvantages under which the heart has to work become greater as the emphysematous state becomes worse and ultimately may lead to cardiac failure. In mild emphysema where only minimal arterial blood anoxia exists the cardiac output at rest is normal. If the emphysema is severe enough to cause an arterial blood O2 saturation of less than 90% definite changes are present in the circulation even at rest. In addition to a slight elevation of the resting cardiac output, an increase in the total blood volume and the hematocrit there is a moderate pulmonary artery hypertension. r®H It has been shown that acute anoxia induces pulmonary hypertension without simultaneously causing more than a small increase in blood flow. This action is probably the result of a local vasoconstriction of the pulmonary arteries or arterioles and does not involve ganglionic reflexes (19, 20, 21). The anatomic lesions may also contribute by reducing the expansibility of the vascular bed. The presence of anoxia in emphysema initiates and perpetuates a vicious cycle of physiologic abnormalties. The sequelae of arterial or arteriolar constriction due to the chronic anoxia are polycythemia, hypervolemia and increased cardiac output. Increasing anoxia and hypervolemia are danger signals as hypervolemia exists for some time before the onset of failure. Venous pressure may be elevated in some instances, apart from right sided failure and is attributed to the raised intrapleural pressure. The enzyme carbonic anhydrase present within the red blood cell hastens the solution and evolution of C02 enormously. Altschule and Lewis (21) found that the blood carbonic anhydrase activity in cases of severe emphysema with polycythemia was increased. Recendy an anti-carbonic anhydrase agent (Diamox) has been introduced and is used in the treatment of congestive failure. Page 89 The use of the anti-carbonic anhydrase inhibitor (Diamox) in congestive failure due to emphysema has been shown to interfere with the release of CO2 from the pulmonary blood (22) to reduce the serum bicarbonate and produce a fall in the arterial pH (23). This would therefore indicate that the use of this agent is contraindicated in congestive failure due to pulmonary emphysema as it causes a retention of CO2 and thus brings about a state of acidosis. Treatment. As no cure is available for this ailment up to the present time treatment is aimed at amelioration of the condition. The treatment varies depending on the severity of the emphysema and the type of complications which may be present. The patient with mild emphysema usually does not seek medical aid unless a complicating bronchitis supervenes. A bronchitis, no matter how mild, has the effect of increasing the obstruction in the respiratory passages, increasing the residual air and may thus induce a certain degree of anoxia. The use of antibiotics, the liberal use of bronchodilators to reduce obstruction and secretions and limitation of exercise for the duration of the infection are indicated. Precautions should be taken to reduce the number of bronchial infections. In moderately severe emphysema where respiratory distress is evident especially after slight exertion prophylactic therapy may be undertaken to improve respiration. This again consists of broncho-dilators and restriction of exercise. If fluoroscopy reveals a flattened, fatigued diaphragm an abdominal belt or pneumoperitoneum may be tried. Both of these measures frequendy fail to relieve th patient from his distress. One of the reasons for failure may be that the patient's diaphragmatic function has not been correcdy assessed. It may still have fairly normal movement and the intrapleural pressure may not be much higher than in the normal. The use of an abdominal belt or the institution of a pneumoperitoneum in such a case raises the intraperitoneal pressure unduly, making the patient uncomfortable by restricting rather than helping diaphragmatic movement. A second reason is a lack of proper adjustment of the belt or the pressure of the pneumoperitoneum. The amount of air injected has to be carefully regulated so as to find the optimum intraperitoneal pressure. The danger signals of impending right heart failure should be carefully watched in these patients. Polycythemia, hypervolemia and especially arterial blood unsatur- ation should be assessed. The patient with far advanced emphysema and with unmistakable signs of right heart failure has to be treated first of all for heart failure. Phlebotomies, to reduce the hypervolemia and polycythemia, usually give the patient marked relief. Digitalization should be tried, although the pulmonary hypertension caused by emphysema is usually not relieved (19) if the left ventricle functions normally. Cournand has observed some improvement in the pulmonary hypertension due to chronic pulmonary disease if left heart failure coexisted. Intermittent oxygen, given under close observation, relieves the anoxia and thereby may ameliorate the pulmonary hypertension. Anti-carbonic anhydrase (Diamox) would appear to be a dangerous drug to use. It is advisable to reduce the congestion by using other diuretics. These patients should not have pneumoperitoneum or an abdominal belt until the right heart failure has been corrected. Lately several forms of breathing apparatus have been devised to help the patient with.emphysema. One of these is the Bennett pressure breathing apparatus. Using this apparatus the oxygen and the .vapor of the bronchodilator (e.g. neosyne- phrine) are inhaled under pressure. 1 It would appear that the beneficial effects derived from the use of this apparatus are, to a large degree, due to the concomitant use of the. bronchodilator. Without the use of the latter the condition could easily be aggravated as it would bring about an increase in the residual volume. .*§ij Page 90 ' ISisiiJl Cherniask (26) has advocated exsufflation therapy. This treatment requires that the patient is in a respirator. At certain intervals high positive pressure is applied which causes the patient to exhale a large volume of air. In this fashion the elimination of the C02 is increased and the oxygen tension of the alveolar air is raised. Patients subjected to this therapy show marked improvement. It is evident, however, that the improvement is only temporary. If exsufflation is applied too vigorously rupture of an emphysematous bleb may occur and a pneumothorax will result. A pneumothorax is dangerous in emphysema and requires immediate treatment. Cherniack does not report the occurrence of this complication in his series. Some selected cases benefit from surgery. The occasional patient has bullae which are so large that they compress the remaining functioning of lung parenchyma, causing a severe respiratory insufficiency. If these bullae are removed the patient experiences considerable relief. Some patients suffer recurrent spontaneous pneu- mothoraces. They can sometimes be helped by instilling a mild irritating fluid into the intrapleural space which produces pleural adhesions and thereby reduces the number of attacks. Bibliography. 1. Laennec, R. T. H. A Treatise on the Diseases of the Chest and on Mediate Auscultation. 4th Edition, 1934. London, English Translation. 2. Staehelin, R., Schuetze, A. Spirographische Untersuchungen an Gesunden, Emphysematikern and Asthmatikern. Ztschr. Klin. Med. 75: 14, 1912. 3. Knipping, H. W.; Lewis, W-; Moncrieff, A. Ueber dieDyspnoe Beitr. Klinik TbK. 79: 1, 1931. 4. Christie, R. V. The lung volume and its subdivisions. 1. Methods of measurements, J. Clin, Investigation, 11: 1099, 1932. 5. Hurtado, A.; Kaltreider, N. L. Studies of total pulmonary capacity and its subdivisions. VII. Observations during the acute respiratory distress of bronchial asthma and following the administration of epinephrine. J. Clin. Investigation, 13: 1053, 1934. 6. Lageder, K. Untersuchungen ueber den Einfluss inhalierten Adrenalins auf die Lungenventilation beim Asthma bronchiale und ueber dessen Allgemeinwirkung. Beitr. Klin. TbK. 83, 605, 1933. 7. Anthony, A. J. Die Bestimmung der Residualluft. Beitr. 'Klin. TbK. 83: 502, 1933. 8. Christie, R. V. The elastic properties of the emphysematous lung and their clinical significance. $&= J. Clin. Investigation, 13: 295, 1934. 9. Hurtado, A.; Boiler, Ch. Studies of total pulmonary capacity and its subdivisions. V. Normal values in female subjects. J. Clin. Investigation, 13: 1027, 1934. 10. Christie, R. V.; Meakins, J. C. The intrapleural pressure in Congestive heart failure and its Clinical Significance. 11. Christie, R. V.; Mcintosh, C. A. The measurement of the intrapleural pressure in man and its significance. J. Clin. Investigation, 13: 279, 1934. 11. Christie, R. V., Mcintosh, C. A. The measurement of the intrapleural pressure in man and its significance. J. Clin. Investigation, • 13: 279, 1934. 12. Breuer, J. Die Selbststeuerung der Athmung durch den Nerven Vagus. Sitz. der Akad. Wiss., Wien, Abt. 2, 58: 909, 1868. 13. Hering, E. Die Selbststeuerung der Athmung durch den Nerven Vagus. Sitz. der Akad. "Wiss., Wlen., 14. Lumsden, Th. Observations on the Respiratory Centres in the Cat. J. Physiol. 57: 153, 1922. 15. Adrian, E. D. Afferent impulses in the vagus and their effect on respiration. J. Physiol., 79: 332, 1933. 16. Pitts, R. F. The function of components of the respiratory complex J. Neurophysiol., 5: 403, 1942. 17. Pitts, R. F. The differentiation of respiratory centres. Am. J. Physiol., 134: 192, 1941. 18. Pump, K. K. The effect on respiration of the occlusion of a bronchus in man during broncho- spirometry. J. Clin. Investigation 33: 611, 1954. 19. Harvey, R. M., Ferrer, M.I., Richards, D. W., Cournand, A/Influence of chronic pulmonary disease on the heart and circulation. Am. J. Med 10: 719, 1951. 20. Siebens, A. A., Smith, R. E., Storey, C F. Acute hypoxia upon pulmonary vessels. 21. Aviado, D. M., Ling, J. S. L., Quimby, C W., Schmidt, C. F. Additional role of reflex pulmonary vasoconstriction during Anoxia. Federation Proceedings 13: 4, 1954. 22. Donald, K. W., Christie, R. V. The respiratory response to carbon dioxide and anoxia in emphysema. Clin. Sc. 8: 33, 1949. |||| Page 91 23. Altschule, M. D. Physiology in Diseases of the Heart and Lungs. Harvard University Press. Cambridge, Mass. 1954. ffipl 24. Shepard, R. H., Donoso, H., Killick, E. M., Cherniack, R. M., Johns, C. J., Riley, R. L. Interference with release of C09 from pulmonary capillary blood after inhibition of carbonic anhydrase Federation Proceedings 13: 135, 1954. 25. Galdston, M., Hunter, M., Nadell, J., Weiss, I. Effect of Diamox; in patients with advanced and mild pulmonary emphysema. Federation Proceedings, 13: 52, 1954. 26. Cherniack, R. M. The effect of mechanical exsufflation on respiratory gas exchange in chronic pulmonary emphysema. J. Clin. Investigation 32: 1192, 1953. FIFTH ANNUAL MEDICAL BALL The Medical Undergraduate Society of the University of British Columbia is happy to announce that plans are well advanced for the Fifth Annual Medical Ball, to be held on Thursday, March 17, 1955, in the Hotel Vancouver Ballroom. The Society hopes that the success of previous years will encourage their many friends in the Medical Profession to lend again their splendid support, so that the Bursaries established from the preceding Medical Balls can be maintained. POSITION VACANT Part time Clinical Director required for The Alcoholism Foundation of British Columbia. To be responsible for the establishment and direction of Out-Patient medical services in Vancouver for the treatment of Alcoholism. Experience in the field not essential but a thorough interest in the problem necessary. Certification by the R.C. of P. & S., in either Internal Medicine or Psychiatry a requirement. Position available at once. Balance of medical staff to be recruited and the assistance of Clinical Director required in recruitment. Salary $4000 per annum for part time appointment. Appliations should be submitted to the Executive Director, The Alcoholism Foundation of B.C., 2670 Laurel Street, Vancouver 9, B.C. Competition closes two weeks after publication of this notice. Page 92 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. Vancouver Victoria OFFICERS 1954-1955 President—Dr. F. A. Turnbull i President-Elect—Dr. E. W. Boak Immediate Past President—Dr. R. G. Large Prince Rupert Chairman of General Assembly—Dr. G. C. Johnston j Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer ! Vancouver Executive Secretary—Dr. G. G. Ferguson \ Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bonnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F. Sparling Dr. P. M. McLean Kootenay Dr. S. C. Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall • Dr. P. O. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C. Poole Dr. N. J. Blair Constitution and By-laws_ Finance Chairmen of Standing Committees Dr. Carson Graham, North Vancouver Dr. R. A. Palmer, Vancouver Legislation IDr. E. W. Boak, Victoria Medical Economics _^ Dr. P. O. Lehmann, Vancouver Medical Education .. >' ; Dr. M. M. Weaver, Vancouver Nominations : Dr. F. A. Turnbull, Vancouver Programme & Arrangements ! Public Health ! Dr. G. R. F. Elliott, Vancouver Public Relations _& Dr. A. W. Bagnall, Vancouver Archives Arthritis and Rheumatism- Cancer Civil Defence Ethics Hospitals Industrial Medicine Maternal Welfare Membership Nutrition Chairmen of Special Committees Dr. J. H. MacDermot, Vancouver Dr. J. A. Traynor, Vancouver Dr. Roger Wilson, Vancouver Dr. John Sturdy, Vancouver Dr. Wallace Wilson, Vancouver Dr. G. C. Johnston, Vancouver Dr. G. B. Helem, Port Alberni Dr. A. M. Agnew, Vancouver Dr. N. J. Blair, Vancouver Pharmacy Rehabilitation Dr. J. F. McCreary, Vancouver Dr. B. T. Shallard, Vancouver Dr. W. J. Thompson HOSPITALS TODAY Dr. Gordon C. Johnston, Chairman of the General Assembly Mr. Chairman, Reverend Sisters, Ladies and Gendemen: In less than a decade revolutionary changes have occurred in the utilization, adiniiiistration and financing of hospitals in this Province. Almost over night one has seen rather inoffensive, quiedy run community institutions become over-crowded, unionized, multi-million dollar business and the centre of political controversy. My profession, for which I speak, in attempting to adapt itself to the rapid technical advances and convulsive social changes following the Second World War, has only recendy begun to consider the implications presented by this new state of affairs and its inevitable effect on the patent. Most noticeable probably is the wide gap between those concerned with hospital administration on the one hand'and those involved in the direct care of the patient on the other. This schism varies a great deal in the various hospitals, between fairly close liaison to no communication at all. At times it would appear that both groups may have forgotten that the basic purpose of a hospital is to care for the sick. It is easy to understand that the administration, involved as it is with a multitude of Page 93 problems related to logistics, employment, finance, etc., may be unaware of the effect their policies may have on the patient. Likewise the medical staff, concerned as it is with clinical and technical matters and relieved of monetary responsibility, may be intolerant of the restrictions imposed by hospital economy. It seems apparent that'almost any decision made by a hospital board will affect-the patient to some extent at least. It is equally apparent that the doctors are the ones best able to anticipate or interpret the effect that a given change of policy will have on the care of the patient. If, then, we are to achieve the highest standard of hospital care, it is essential that the closest possible co-operation must exist between the hospital board and their medical staff. One would think that the minimum liaison should consist of a medical representative on the hospital board. Not only would the patient benefit by the unified action of the hospital board and the medical staff, but negotiations between hospitals and government would be simplified and strengthened. At present, delegations from the medical profession, proceeing to Victoria on matters of hospital policy, may be referred back to hospital boards, who are not allowed to act because of restrictive government regulations. Certainly very little can be achieved as long as this dichotomy exists. The picture is further both simplified and complicated by a very important third party. This is the Provincial Government or its hospital commission euphemistically described as B.C.H.I.S. in which the "I" is silent. This third party simplifies matters in so far as it provides the necessary funds for hospitals, but it complicates the administration in that it may indicate Jiow these monies may or may not be spent. This powerful body, completely detached and remote from the intimate routine of hospital activities, may make policies which profoundly affect the welfare of the patient. At the present time hospital costs are frozen and, as a result, hospital initiative-is completely arrested. Such an inflexible and unrealistic policy has the effect of sterilizing the normal development of hospital services. In this respect it should be realized that neither the physical size of a hospital or the numbers of beds which it contains necessarily indicate the character of service it may render to the sick. The quality of treatment is more closely related to the facilities it provides for diagnosis and research treatment, and to the encouragement for progress which it gives to its staff. It is palpably apparent that large metropolitan hospitals which are provincial in scope cannot be classified with small community hospitals. The former, having a highly organized medical and ancillary staff, must be allowed to explore and lead in new methods of patient care. The patient must not be denied the fruits of scientific discoveries. Indeed, such a policy may be cheaper in the long run. For example, new techniques in the last few years have eliminated the need for some of our tuberculosis beds. New forms of treatment have practically eliminated pneumonias from hospital admissions, etc. One is aware that unrestricted expenditure on health can easily ruin the national economy. However, if costs must be reduced, discrimination must be made between the essential and less important aspects of the problem. We must find a way to reduce expenditure without curtailing the care of the serious, urgent and catastrophic cases. Unfortunately any reduction of service, essential or otherwise, has a political connotation and for this reason is hard to accomplish. If we fail to achieve reasonable modification of the present blanket "freeze-up" policy, it is inevitable that the standard of hospital service in this Province will fall far behind that in other parts of the continent. In closing, Mr. Chairman, I would therefore like to suggest that all of us who are concerned with hospital policy should at all times consider what effect our actions might have on the care of the patient. Page 94 I would suggest further that close liaison between hospital administration and medical boards is essential, if we are to maintain the highest standard of patient care. And finally, if we are to successfully influence government policy in respect to hospitals, the British Columbia Hospital Association and the British Columbia Medical Association must together decide on a course of action and give it their unified support. In these conclusions, Sir, I have the support of the Directors of the B.C. Medical Association. DR. ROGER A. GMMMETT It was with deep regret we heard of the death of Dr. Grimmett, who had practised in Vancouver for several years — as an ear, nose and throat specialist. Dr. Grimmett was a member of the Attending Staff of St. Paul- Hospital, and was most highly regarded by all his colleagues, there and elsewhere. For many months he carried on under the shadow of a coronary condition which he knew to be present, but which he defied, till he had to give in and enter the hospital as a patient. He fought his enemy bravely, but the batde went against him, and he died suddenly. To his family we extend our sincerest condolences and sympathy. ***** DR. G. CAMPBELL In the death of Dr. Campbell, Director of the X-ray Department of St. Paul's, the medical profession of Vancouver lost a good friend and colleague, an dthe Hospital lost a most skilful and competent radiologist. His death was very sudden, occurring as he had just finished giving a report at an executive meeting of the Medical Board of St. Paul's, and as he died, a knock came at the door announcing the death of another member of the Staff, Dr. Roger Grimmett. Dr. Campbell was an all-round man — he had many interests beside his vocation of radiologist, at which he excelled in any case. He was very fond of art in any form, and was an accomplished Greek scholar. He had a charming gende manner, and was always keenly inteersted in seeing that those who came to his X-ray department, either as doctors or as patients, got the best he had to give them. He will be gready missed by all of us. To his wife and family, we offer our sincerest sympathy in their loss. ***** DR. GEO. A. LAMONT Dr. Lamont had a long and distinguished career, both as a paediatrician practising this specialty in Vancouver for many years, and as a medical officer in the Forces. He served in both the Great Wars, and had a great deal to do with the medical department of the C.O.T.C. at the University of British Columbia. Dr. Lamont was a very keen man at his job, and had a great deal to do with the advances in paediatric service which have been so notable at St. Paul's Hospital, where he was on the paediatric staff for many years. He was at one time Chairman of the Medical Board of the Hospital. He leaves a wife and family — Mrs. Lamont is well known as an ardent worker in hospital affairs. We extend to her and her family our sincere sympathy. Page 95 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H., f; M Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D., Director, Mental Health Services, Province of British Columbia A NEW LIGHT ON MORTALITY STATISTICS A new measure of the force of mortality from specified causes has recendy been evolved which is creating considerable interest in medical and public health circles. The usual measure of total mortality from each cause is either the crude death rate or the standardized death rate. These rates merely reflect the cost of mortality in terms of total lives lost. However, neither of the above measures takes into account the age at which the death occurred and yet it is well recognized that some diseases take their toll earlier in life than others. Few people would deny that a death in infancy is a much more serious loss than one in old age. It is, therefore, valuable to know not only the number of deaths resulting from certain causes, but also the number of years of life lost. By application of actuarial methods it has been shown that today the average expectation of life is approaching seventy years. Hence, any death under that age can be considered premature to the extent of the number of unexpended years of life under seventy. Computations have been made to obtain this measure of mortality for specified causes of death in terms of "Life-Years Lost Under Age Seventy". . The following table, based on the 1953 mortality statistics of this Province, shows the percentage of total deaths due to seven major cause groups and also the percentage of life-years lost from these same causes. Deaths under one year have been excluded from the specific causes listed in order to show infant mortality as a separate group. ^PERCENTAGE OF TOTAL MORTALITY CONTRIBUTED BY SPECIFIED CAUSES, BRITISH COLUMBIA, 1953. % of Total Cause (1) % of Total Deaths Life Years Lost Cardiovascular-renal __ 51.0 17.0 Cancer 15.9 9.9. Accidents 7.6 15.6 Infant Mortality _ 6.8 38.7 Bronchitis, Influenza and Pneumonia 3.4 2.5 Tuberculosis 1.2 1.6 Other Infective and Parasitic Diseases.- 0.5 1.8 All Other Causes Jf 13.6 12.9 All Causes 100.0 100.0 It can be seen from the foregoing table that in terms of deaths alone the usual order of magnitude prevailed, namely, cardiovascular-renal disease, cancer and accidental death. In contrast, the picture given when the same groups of causes are measured in terms of life-years lost under seventy is radically different. Infant Mortality, as a group, became the most serious .factor in extinguishing potential years of life, with cardiovascular-renal Page 96 causes in second place, followed by accidents, cancer, respiratory diseases, other infective and parasitic diseases, and tuberculosis. Infant mortality was responsible for almost as great a loss of life-years under age seventy as the entire group of cardiovascular-renal diseases, accidents and cancer combined, even though these three causes accounted numerically for almost three-quarters of all deaths and infant mortality only seven per cent. These figures heavily underline the serious wastage of life which is still taking place due to deaths in infancy, in spite of the great improvements that have already been made in the last two decades in reducing infant mortality. Likewise, cancer deaths, which occurred at twice, the frequency of accidental deaths, were responsible for only two-thirds of the number of life-years lost to accidents. While it is not suggested that the force of mortality should be measured only in terms of lifeyears lost, it is evident that this concept is an imporant one in bringing into truer perspective the severity of the various causes of death. It is a concept which should have particular significance to the medical and public health professions whose ultimate aim is not to prevent deaths, but to prevent untimely or premature deaths. CO All causes except "Infant Mortality" exclude deaths under one year. STAFF NOTES Dr. Alan Davidson, Mr. F. Matheson and Mr. C. B. Watson attended the Sixth Annual Mental Hospitals Institute, October 18-21, in Minneapolis held under the auspices of the American Psychiatric Association. The Mental Hospitals Institute is designed to discuss major administrative problems in Mental Hospitals dealing with patient care and institutional management. Special sessions were devoted to the use of volunteers in mental hospitals and the place of religion in mental hospitals. An annual highlight of the Institute is the academic lecture which this year was delivered by Dr. Lauren H. Smith, Superintendent of the Hospital for Nervous and Mental Diseases, Philadelphia. This topic was "Critique of Somatic Therapy". The program also included visits to nearby mental hospitals and clinics and preview screening of new mental health films. Page 97 Eh. W. E. Baldwin is now practicing obstetrics in South Burnaby. Eh. W. J. Thompson is now practicing orthopaedics in Vancouver. Eh. D. S. Pattison has begun a specialty practice in Vancouver in obstetrics. Eh. Joan Eord is now doing general practice in South Burnaby. jyr. L. Komar has left Kemano and is now in Philadelphia. Eh. C. A. McLean is now practising in the Vancouver Block. Dr, J. R. Moore is now in the Broadway medical district in Vancouver. Eh. Agnes Weston is now with the South Burnaby Health Unit. Dr. Stanley Avren of Victoria is now studying internal medicine in Ann Arbor, Michigan. Dr. L. K. Poyntz has received his certification in Radiology and is now in Zeballos, B.C. "r V *r v Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. BIRTHS and Mrs. John Schinbein of Vancouver, a son. and Mrs. Cyril Pow of Vancouver, a son. and Mrs. J. L. McMillan of Vancouver, a son. and Mrs. E. A. Boxall of Vancouver, a son. and Mrs. R. D. Nash of Vancouver, a daughter, and Mrs. Eric Robertson of Vancouver, a daughter. and Mrs. J. A. McCaffrey, a daughter. DR. JAMES E. SPANKIE Very few men now practising in Vancouver will have known Dr. Spankie, who graduated 1from Queen's University in 1891, sixty-three years ago, and came to Vancouver in 1909. In the interim he practised in the interior of B.C. — first at Banff, and later at Greenwood. He was an excellent general practitioner, and had a large practice here. Dr. Spankie was very much liked and respected by his follew medical men. He had a warm and friendly geniality, and the esteem in which he was held was shown by the bestowal of a life membership in the B.C. College of Physicians and Surgeons in 1950. He had many interests outside medicine, notably in the breeding of rare species of pigeons and poultry, of which he had a large collection. He was a director of the P.N. Exhibition for some time. He was a Mason, and a member of Melrose Lodge in Vancouver. . One more of the old guard has "crept silently to rest." We who knew him will miss him. His wife and son survive him and we extend to them our sympathy in their loss. Page 98 "MEDIC" PROGRAM Approved by the Public Relations Committee of the Canadian Medical Association TITLE OF FILM My Very Good Friend, Albert Wild Intruder Red Christmas I Climb the Stairs Death Rides a Wagon When Comes the Autumn Vagrant Heart, Vagrant Cup MEDICAL SUBJECTS COVERED Difficulty in hearing. Delicate surgery— hearing restored. Cancer of the Breast Hospital accident ward Heart—Closing of the ventricular valve because of scar tissue Cholera in the Pioneer West (Old Time) Old Age Story of Alcoholism DATE OF BROADCAST Time (10:00 p.m.) 8 Dec. FOR RENT THE GREYHOUSE — 1812 W. BROADWAY Lately Occupied by Dr. G. A. Lamont Accommodation for Two or More Doctors Parking Space in Rear For Information, Call D. B. Pollock Phone: CHerry 9219 (9 to 3) DExter 2945-F (Eves.) ■ m m m m m >:*»:*;« m WEST VANCOUVER FOR RENT One Medical Suite — Enquiries Invited COLUMBIA INVESTMENTS LTD. |f |j Marine Dr. and 17th Tel.: West 2198 - 2673 FOR SALE One Microscope, One Set Baby Scales In Good Condition Reasonable Price For Information Please Telephone New Westminster 20 CEdar 3840 V INVESTORS Syndicate You will find the ideal answer to your savings and investment problems through Investors Syndicate and its affiliate Company, Investors Mutual — Canada's fastest growing mutual fund. ^rni/edtord ^undicate of L^anada. oLtd. ^rnve&tord rr/utuat of L^anada oLtd. NEVILLE ASTLEY 2u* »«_,_. 313-— 744 West Hastings Street — Vancouver Telephone MArine 5283 FRED G.HITCHENS 3__*_ % 3220 Wetherby Road, Victoria, B.C. Telephone Garden—9556 anaqt' Each ENTERIC coated tablet contains: Sodium Salicylate 3 grains Potassium Salicylate ! 1/7 grain Calcium Salicylate 1/12 grain Para-Aminobenzoic Acid 2V_ grains Strontium Iodide 1 V_ grain Vitamin C 20 mg. Safer, more effective, better tolerated salicylate therapy in ARTHRITIS and RHEUMATISM DOSAGE Two tablets every two hours, between meals, with half glats of water, 6 times daily. Issued: Bottles of 100, 500 and 1,000 e.c. tablets. ANGLO-FRENCH DRUG CO. LTD., Montreal 18 Page 100 GREATER VANCOUVER PUBLIC HEALTH Metropolitan Health Committee Dr. Stewart Murray, M.D., Senior Medical Health Officer Vancouver, B.C. VIRAL HEPATITIS In the brief period of five years, hepatitis has become a serious challenge to health in this area. The incidence of reported infectious hepatitis in British Columbia has increased from 10 cases in 1949 to 789 cases in 1953. The City of Vancouver had 305 cases reported in 1953 with 6 deaths. Infectious and serum hepatitis are almost identical diseases clinically. Infectious hepatitis has an incubation period of 2 to 6 weeks and occurs in the form of sporadic cases or epidemics. Serum hepatitis is associated with a syndrome that develops 1 to 6 months after an opportunity for parenteral entry of the hepatotropic virus. Both are common diseases, world wide in distribution, affecting both sexes and all races. The mortality rate is variable. The actual incidence is greater than that reported because of the frequent lack of recognition of the non-icteric cases which may account for as many as 70% of the actual infections, particularly in young children. The disease appears in two stages, a pre-icteric and an icteric phase. The signs and symptoms include anorexia, nausea, vomiting, abdominal distress, hepatic enlargement and jaundice which may last for variable periods. No specific diagnostic tests are available. The numerous liver function tests merely indicate the degree of liver damage. The basic principles of treatment are, restricted physical activity and a high calorie, high protein, high carbohydrate and moderate fat diet.1 The Committee on Viral Hepatitis of the World Health Organization calls the attention of the medical profession to the dangers of transmitting hepatitis by transfusion of plasma and whole blood and also by the use of certain blood derivatives, and advises that plasma, particularly large pool plasma, should not be used unless the advantages gained by its transfusion out-weigh the risk of transmitting the disease.2 Blood carriers of the virus, among the donor population, range between 1 to 5%. Normal human Gamma Globulin is effective as a specific prophylactic if given after exposure, and up to six days before the onset of symptoms, in a dosage of 0.02 cc. per Kg. General Measures — The oral-intestinal route is recognized as the mode of spread. Measures should be taken to prevent the contamination of food, water and milk supplies. Personal cleanliness merits close attention. The virus is resistant to agents such as alcohol, ether and zephiran, so special care should therefore be taken in the sterilization of all instruments which have been used for the collection of blood.3 Chlorination of water should be preceded by setting and filtration. 1. Treatment—Neefe A.J.M., March, 1954. 2. W.H.O. Technical Report Series No. 62, March, 1953. 3. Warren, W. R.—U.S. Armed Forces Med. J., 1953. FIFTH ANNUAL MEDICAL BALL The Medical Undergraduate Society of the University of British Columbia is happy to announce that plans are well advanced for the Fifth Annual Medical Ball, to be held on Thursday, March 17, 1955, in the Hotel Vancouver Ballroom. The Society hopes that the success of previous years will encourage their many friends in the Medical Profession to lend again their splendid support, so that the Bursaries established from the preceding Medical Balls can be maintained. Page 121 <CONNAUGHT> iN PERNICIOUS ANAEMIA LIVER EXTRACT INJECTABLE Liver Extract Injectable provides a thoroughly dependable form of treatment. The preparation of highly purified extracts of liver has been a subject of research studies in laboratories and clinics of the University of Toronto for more than 20 years. An objective of these studies has been to retain in the extract the anti-anaemia factors of beef liver and to eliminate therefrom other material which might be reaction-producing and which is not necessary for remission of the disease. The success of the studies is evidenced by the fact that a dose of Liver Extract Injectable "Connaught", suitable for intramuscular administration once in each three-week period, contains less than seventy milligrams of organic solid. Liver Extract Injectable, 20 micrograms of Vitamin B„ per cc, derived solely from beef liver and tested clinically and by biological assay, is available from the Laboratories in 5-cc. and 10-cc. vials. CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto, Canada Established in 1914 for Public Service through Medical Research and the development of Products for Prevention or Treatment of Disease. DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER 1, B.C. Page 122 A new year is upon us again, and the Bulletin extends to all its readers wherever they may be, the most sincere wishes for happiness and prosperity in 1955. We have many more readers than we ever had — some 2300 copies of this Journal are printed monthly — and they go, literally, all over the world. The great increase, of course, is accounted for by the rapidly growing medical population of this province — every member of whom receives the Bulletin. We have frequently been deeply touched by letters that we receive from time to time, from all sorts of people, showing their interest in the Journal, and their appreciation of its efforts. These make our work so well worth while, and our resolution for 1955 is to try to make the Bulletin ever more useful and valuable to all our readers. In this we are gready helped by the B.C. Division of the Canadian Medical Association, which makes use of the Bulletin as its organ of communication with all medical men of the province, whether members or not of the Division. The Public Health Department of the Province, too, contributes monthly to our columns, and its contributions are, we know, of great value and interest to all. So with the Library of the Vancouver Medical Association. And lasdy, but only lasdy in point of order, we are grateful to those who contribute papers from time to time, many of them representing original and highly valuable work in medicine. And so again, to all of you, a Happy New Year. In last month's issue of the Bulletin, we referred editorially to the question of narcotic control — and the steps that should be taken to lessen the evils of narcotic addiction: using as our text the report and recommendations of the committee appointed by the Community Chest some year and a half or two years ago, to study this matter. Unfortunately we referred to Dr. G. H. Stevenson, who is conducting a complete and comprehensive study of the narcotics problem — and stated that he had been quoted as being in favour of legal sale of narcotics to addicts, in clinics set up for that purpose. We see now that it would have been the right and wise thing to have asked Dr. Stevenson about this, before ascribing to him opinions that we thought he held. Our only excuse is that he was quoted quite frequendy in the current press, and we certainly gathered that he was in favour of this method. But he is not, and we hasten to tender to him our sincere apologies for putting him in a rather awkward position — a position which is no fault of his at all. Dr. Stevenson is a very important person in this whole affair and his opinions and conclusions will carry great weight — and while we most certainly did not intend to, we have carelessly, to say the least, done him an injustice. Dr. Stevenson wrote to us, far more kindly, we fear, than we deserve — and we feel that his letter, which we gladly subjoin, will explain his stand in the matter much more clearly than we can do. He has very generously offered to prepare an article on the matter, which we shall hope to publish in the next month or two. Meantime, we hasten to assure our readers that Dr. Stevenson is in no way responsible for the incorrect references made to him in the editorial. Page 123 Dr. J. H. MacDermot, December 22, 1954. Editor, Bulletin. Dear Dr. MacDermot: Your very interesting editorial in the November issue of the Bulletin, on the matter of narcotic clinics, indicates that I had expressed myself as in favor of this policy. I am very much concerned about this statement. I have naturally been giving a great deal of attention to the advisability of legal sale of narcotics along with the many other related problems, but at no time have I expressed an opinion favourable to legal sale. There are very attractive arguments in favor of legal sale, but there are also very good arguments against legal sale. The more one studies this matter and all the aspects of it, and attempts to evaluate the arguments for and against legal sale, the more doubtful it becomes that this is a policy to be advocated. I shall not take the time here to put forth an evaluation of these arguments, but shall be pleased to do so for the information of the medical profession of this province if you should like me to do so. I would request, however, that as soon as possible this letter be published in the Bulletin to clarify my position in this matter. With kindest regards, I am, KT . , 1 Yours very sincerely, G. H. STEVENSON, M.D., Director, Narcotic Addiction Survey. ^ I --1 - >J_ Library Hours: Monday to Fridey 9:00 a.m. to 9:00 p.m. Saturday - - 9:00 a.m. to 1:00 p.m. Recent Accessions: Text-Book of Ophthalmology—Injuries—by Sir Stewart Duke-Elder. Vol. 6, 1954. William H. Welch and the Rose of Modern Medicine by Donald Fleming. 1954. Medical Biographies: The Ailments of Thirty-three Famous Persons by Philip Marshall Dale. 1952. The Scalpel of Scodand Yard: The Life of Sir Bernard Spilsbury by D. Gordon Browne. 1952. Society and its Criminals by Paul Reiwald. 1950. Narcotics and Narcotic Addiction by Maurer and Vogel. 1954. Operative Gynecology by R. Te Linde. 2nd edition. 1953. Hypertensive Disorders of Pregnancy by Ernest W. Page. 1953. Hypertension and Nephritis by Arthur M. Fishberg. 5th edition. 1954. The Care of Children—Problems of Infancy and Childhood by Josiah Macy Jr. Foundation. Seventh Conference New York 1953. Copyright 1954. Lectures on General Pathology. Edited by Sir Howard Florey. 1954. Human Embryology by Bradley Patton. 2nd edition. 1953. Clinical Endocrinology by Karl E. Paschkis et al. 1954. Mitchell-Nelson Text-book of Pediatrics. 6th edition. 1954. Page 124 FIFTY-SIX YEARS OF MEDICINE — A RETROSPECT By DR. DYER The following is the first part of a paper by Eh. H. Dyer of North Vancouver — an old friend of ours. Dr. Dyer has been in practice over fifty years, a great deal of it in North Vancouver, where he is the Coroner: and in addition to a supreme competence in his medical work, he has the delightful quality of humour, which on several occasions has made listening to him a matter of keen enjoyment. The Bulletin published in 1924, an address given before the Vancouver Medical Association which is a masterpiece of witty, tongue-in-the-cheek writing. We were very much delighted when Dr. Dyer gave us his permission to publish these reminiscences of his, and they are well worth reading. To th older men among us, some of whom can remember back to the Boer War, there is a nostalgic note in these memories. To the younger men who may read this, a glimpse of what to them are the Dark Ages of the late nineteenth and early twentieth century, may be of interest, as showing the beginning of modern medicine and surgery.—(ed.) Having started to record some of my memories of 56 years of practice and knowing that the majority of those who may read this are only acquainted with medicine and surgery as practiced in the last 25 years, I have concentrated on the first 25 years as being a comparatively safe period to deal with before an up-to-date, modern hospital staff. In August 1898 I walked out of the Exam. Hall into the Strand, a qualified man with the Conjoint degree of London, after a very uneventful five years hospital career at St. Mary's Hospital. My only distinction was that of having won five pounds, this being the Dermatology Prize, with which went the useful post of clinical assistant to Sir Malcolm Morris in the skin department for six months. However, I did not get the full benefit of this appointment because I was afflicted with a very obvious and virulent type of Acne Indurata which resisted all his efforts at treatment and my own endurance of them for the first six weeks of our partnership, after which we mutually tolerated the sight of each other twice a week for the remaining four and a half months. But I saw much syphilis, and also the experiments made with Koch's original tubercular vaccine on numerous Lupus Vulgaris cases. After the injections a few showed very temporary improvement, but all showed, finally, rapid spread of the skin lesions followed in some cases by general tuberculosis and death. Having qualified I went as assistant to a partnership in Luton for two months where I was in the unfortunate position of trying to serve two masters and so "holding to the one and despising the other." The latter was the town health officer and in charge of the Isolation hospital where a small boy lay dying of laryngeal diphtheria. On my asking him why he did not give antitoxin and do tracheotomy he countered by asking me who was going to pay for the antitoxin, and if tracheotomy was done who was going to pay for two special nurses? Public Health administration has definitely improved since then. Having left Luton I spent a pleasant month at a London Fever Convalescent Hospital where, a severe outbreak of diphtheria having occurred, an extra doctor was required. The present Lord Horder was the senior assistant and he taught me the essential differences between the true and the pseudo-diphtheria bacilli as seen in a fresh smear from the throat-. In January 1899, I went as junior surgeon to the Guest Hospital, Dudley, a hospital for the emergencies of a coal and iron industrial area. There was much crude but effective surgery done here; I can only remember one acute appendix operation which recovered, but can remember no other cases which died with symptoms suggestive of appendix trouble. Most operations were done quickly. An old Page 125 man of 81 was brought to hospital about 11:00 a.m. with dysuria and retention. Having passed a metal catheter and hit a large stone I phoned one of the doctors who drove back from his home, about two miles away and told me to anaesthetize the man which I did after giving him a hasty pubic shave. He then made a cut in the belly, opened the bladder and scooped out a large, hard and craggy stone, put in a large supra-pubic drainage tube and drove home to his lunch. The old man soon recovered from the chloroform and had a good lunch, followed by a rapid healing of the wound. After six months I left and, full of the spirit of adventure, soon sailed for West Africa where a railway was being built from Lagos into Nigeria. My stay on the West Coast was very brief. After fourteen days duty in the camp I got malaria with hyperpyrexia and, the senior doctor being away, received no attention till he returned. Consciousness returned to me as I lay in a bath with a native pouring cold water over me and the doctor sitting by the side of my bed, smoking his pipe. My temperature had been 107.6 Fahr. when first treated and so after three days of alternate high fever and cold baths I was carried down to the harbour and put on a ship for England. Early in 1900 after two or three weeks as House Surgeon at the West London Hospital I took over the appointment of House Physician at Great Ormond Street Children's Hospital from a friend who was leaving for the war in South Africa. This appointment was for six months and I then had another three weeks as Medical Superintendent. This time at G. O. S. was thoroughly enjoyed by me and I picked up as much information as possible, but not enough, I found later, to make my opinion of any value to anyone except myself for the next fifty years. However I learned to recognize the look of a very sick child and, nearly as important, to recognize when a child was not ill enough to require unnecessary drastic treatment either at home or in hospital. The ability to do this with some confidence has enabled me to carry on a "solo practice" with a minimum of anxiety. Two wards of thirty beds, and one of twenty, each in charge of an honorary physician who made rounds twice a week were my responsibility. A Medical Superintendent supervised the working of the whole hospital, both medical and surgical, between the visits of the medical staff. Dr. D. B. Lees the senior physician, was an original thinker both in diagnosis and treatment. He had definite lines of treatment which he pushed to the limits of safety but his results were rather better and certainly more dramatic than those of the other two of the visiting staff who followed more orthodox and less vigorous lines of treatment. Dr. Lees always had several cases of pericarditis, endocarditis, chorea, pleurisy.or other manifestation of rheumatism in his ward and very often some type of pneumonia. He was an expert in the physical examination of the chest with his .fingers. By percussion he could map out small areas of dulness caused by very early pneumonia or the multiple small areas of broncho-pneumonia many hours before the stethescope could detect any sign except, perhaps, a diminution of breath sounds. These areas, marked out on the chest wall with indelible blue pencil, were almost always confirmed later by more obvious signs of consolidation, or later by postmortem findings. By the same method he demonstrated the progressive dilatation of the right heart in pneumonia and capillary bronchitis, and in the 'obstruction to the circulation caused by mitral disease. He showed also the extension of the cardiac dulness to the left caused by the early toxic effect on the left ventricle of the rheumatic poison. He marked out with blue pencil the daily enlargement of the heart in severe or fatal cases. Also he or his house-physician showed the diminution of right heart engorgement after treatment by free bleeding with leeches, and the gradual recovery of tone by the left ventricle following large doses of salicylates. The right and left boundaries of the heart, so defined, were marked daily in blue pencil on the front of the chest. Page 126 These markings were recorded daily on strong tracing paper, compared daily and kept as a record for future reference. In fatal cases the last chest marking was applied to the chest with the two nipple tracings as guide at the start of the autopsy. Long needles were then thrust vertical to the chest wall along the outer edge of the blue pencil tracing. When the front of the chest wall was carefully removed along this line the right and left boundaries of the heart were found to conform very accurately with those marked out by percussion prior to death. For children of all ages suffering from pneumonia Lees applied ice-bags to the dull areas in the lungs. This required careful nursing with the constant watching for cold extremities and the taking of temperatures, the bags being taken off at 99F. and replaced at 100F. In addition to this bleeding by leeches was done if the right heart showed signs of dilatation. The child with a rheumatic heart received the same line of treatment. Ice over the praecordium in all cases and bleeding if increased dullness to the right indicated right heart dilatation. Enormous doses of Sod. Bicarb, and Sod. Salicylate were given, up to 200 grs. a day to a child of six years. These doses were also given to all cases of chorea with heart involvement. These procedures were not followed in every detail by others, being considered too heroic. In 1900 Poynton and Paine were doing much research work to confirm their theory that a specific microbic infection was .the cause of rheumatic fever and chorea. Their methods seemed to me very convincing, though they did not then receive the credit which may yet be theirs. As soon as possible after the death of a rheumatic child or a chorea case with heart sign of involvement the body was moved to the post-mortem room and Dr. Poynton notified. Deaths from other causes in the hospital were used as controls. Before the body had lost much heat they sterilised the skin and then exposed the heart and pleural surfaces with hot irons. They then collected fluid from the pericardial sac, blood from the heart cavities, scrapings from the valves and from brain meninges. These or their resultant cultures were injected into rabbits. The symptoms of joint pains with swelling of joints and sometimes paralysis or spasmodic movements of one or more limbs developed. At autopsy the same pathological changes were seen in the valves of the heart, joint surfaces, etc., in the human subjects. The same type of Streptococcus was found in the cultures and in the lesions of the injected rabbits as in the human "originals". No pus formation occurred at the sites of inoculations nor in any of the resulting arthritic, pleuritic or heart lesions in any of these animals; this emphasized the effectiveness of the aseptic technique employed and also one of the distinctive features of the rheumatic streptococcus, namely not to produce pus but to cause plastic inflammation when present in pure culture. Dr. Harold Stockton in the Vancouver Medical Bulletin of June — 1949, announced the fact that the Alpha-Haemolytic Streptococcus is the exciting cause of Rheumatism in all its varieties. Salicylates are still valuable in relieving the painful symptoms of rheumatic fever. New treatments by Sulfa, antibiotics, A.CT.H. and cortisone may now hope to be more successful in prevention and treatment but are still on trial. After leaving G. O. S. I then went to one of the London Fever Hospitals for ne weeks where I learned a method of doing tracheotomy in the dark if necessary. The South African War was my next venture, landing at Capetown on December 29, 1900. Typhoid was. rampant in the hospitals, both at Kroonstad and Bloemfontein where military medicine was to be ssen at its worst. Men with typhoid lay in marquees with baths on wheels full of cold water into which they were lowered again and again whether feeling hot or cold, conscious or unconscious, rational or delirious, if their temperatures were above a certain height. On a box at the side of each bed was a mug, from which at regular intervals they were compelled to drink two ounces of chlorine water to kill the typhoid bacilli active in the Page 127 V intestines (Transactions of New York Med. Society 1892 page 203-293, also year 1899 page 272). Diluted tinned milk was the only nourishment allowed, with increasing doses of brandy as the probability of death appeared more imminent. Many survived but the death rate was more than 20%. After two weeks I was attached to the Cameron Highlanders as their M.O. and with them I spent perhaps the best days of my life. We trekked through the Eastern Transvaal in alternate blazing sunshine and drenching thunderstorms. Taking part in a kind of guerilla warfare proved rather an abrupt change from living as a pampered interne in a children's hospital. There were no tents nor bedding for any of us, with long weary marches for the men but a horse for myself. For some days half the regiment were enduring hours of agony due to galled heels resulting from an issue of new boots just before starting the trek. There was not much fighting for the infantry except at Lake Chrissie where we were attacked just before dawn in a dense fog by 2500 Boers. After three months the Camerons went to rest in Pretoria and I was transferred to another regiment. The next five months were not so good, as the CO. had no use for me and life became rather difficult.. However, everything comes to an end, and I was moved to a field hospital at Potjetstroom and later to Klerkdorp. This was one of the first wars to have X-Rays tried out in military surgery. As far as I know there was only one X-Ray machine in use with the forces in South Africa and that was with the Duchess of Westminster's Yeomanry hospital at Pretoria, under semi-military and semi-civilian administration. Early in 1902 I returned to England in a 4000 ton ship with invalids. Soon after leaving Capetown a man who was invalided home with deafness and R. ear discharge began to have fever and severe headaches. He became more deaf and after repeated pressure over the right mastoid admitted to some pain over it. I urged operation and my fellow civil surgeon backed me up but the old P.M.O. demurred. Finally, on the day we crossed the equator I opened the mastoid, scraped away much bone but found no pus. Having exposed the lateral sinus and found nothing I closed up in haste, regardless of the remark of the anaesthetising civil surgeon that "in Glasgow they never turned back without finding the pus". The man's fever continued high, he became more dopey and in a few days spots began to appear with the usual distended belly and enlarged spleen of typhoid. In spite of treatment he was recovering when we reached England. After a few weeks in England I sailed for Capetown which was reached a few days after peace had been declared. After four months in charge of the officers' hospital at Wynberg I left the Army and started an office practice in a native compound for a few weeks. Tiring of this I went to "locum" staying on as assistant to a doctor at Clanwilliam, a litde Dutch village 96 miles from the railway. There was much typhoid to be treated in the village and farms round with the nursing to be done by myself or shown to them, with the help of the very young or very old and the usual Kaffir or Hottentot woman servant. After three and a half months the Cape Health Officer sent me to Port Elizabeth where a small outbreak of plague was in progress. Having had my injection of Haffkine's prophylactic I took charge of the sick and their contacts in the Lazaretto, and also did the autopsies on the bodies of all found dead in the town and also on the dead rats found in the warehouses and elsewhere. A native assisted me in the postmortem work, but one died after a short time and his successor a few weeks later. It was interesting to observe in the small number of cases treated (about 135) how the biblical account of the plague of emerods described in the 1st Book of Samuel, Chap. V and VI was confirmed by the course of the disease. Those with buboes showed a fair proportion of recoveries, but those with pneumonia and litde or no bubonic swelling all died. The Philistines evidently recognized the leading part Page 128 that rats and mice played in the pestilence when they sent golden mice as a peace offering when they sent back the ark to the Israelites in a hurry. Plague having died down smallpox developed, and all, white and coloured, were vaccinated. After about two weeks one of the native washerwomen developed smallpox but, when at her worst, confessed that she had scratched her own arm with a needle while standing among those waiting to be done and then had shown me her arm as already vaccinated. Also I saw a young girl, the beauty of the city, brought into hospital with a few scattered spots, go out with one eye lost and hopelessly disfigured. These were two striking lessons in the dangers of avoiding vaccination. After six months of this place I felt the urge for England and returned home in October 1903. My memory is rather vague about this time but in Jan. 1904 I went as resident M.O. to the Bristol Women and Children Hospital of six women's and eighty children's beds. After living for three months in a building with so many nurses, sick women and children, I resigned and setded down to work for the Edinburgh Fellowship. My chosen special subject was Gynaecology, for the reason that I had found at Bristol that my knowledge of women's pelvic disabilities was almost nil and also because it seemed to be the easiest one to learn. In the closing stages of my practising career it seems only fair to my professional brethren to give an explanation of how I ever managed to get my F.R.C.S. Ed. The only-reason was an extraordinary run of good luck in my oral exam. At the first table one of the three examiners at once began to disagree with my answers. This was Sir Patrick Heron Watson, president of the Council, a truculent type of man, unpopular with his colleagues. Finally he pushed a skull over to me and cross- examined me as to skull fractures and head injuries. Every answer I gave was treated with derision or doubt, and at last, to my suggestion that it might have been caused by a long range bullet wound he gave a sniff and said " well he must have been an unusually thick-headed sort of man". By this time I considered that all was lost and I might as well retaliate so I snapped at him "well he probably was; as he was a Scotsman in the Cameron Highlanders". The other two examiners burst out laughing and Watson handed me over to them for the rest of the interview. Next I was taken to a cot where lay a small boy, about five years old, with an anxious expression on his face, who watched me with movements of his eyes only as we approached. "Just examine him and tell me what is the matter with him when I come back" said the examiner. I looked at the child with apprehension, for I could see that he was terrified, and after a few words, having felt his neck and cervical glands, made no attempt at a thorough examination. The surgeon soon came back and said "well what is the matter with him, you have not made a very thorough examination". To which my reply was that I thought the boy had cervical caries and that it was not safe to move him about much. To my relief the surgeon replied "that is just what he has got — two men have been ploughed for telling him to sit up and see how much he could move his head round." By now I was feeling a little better and was led into the women's ward. Here I was left behind some screens and told to investigate the pelvic troubles of a very good looking young woman. Having examined her with great care I could find very little the matter but felt that I must have missed something obvious. As no one appeared I began to talk to her and hoped that her worst troubles were over and and that she would soon be better. At this she laughed and said "I am alright. I came in for my third miscarriage and have been kept in an extra day for the exams. Why man there is nothing to it. Tomorrow morning I am going out and shall be having a dish of tea at my home in the afternoon." I thanked her suitably and the examiner returned almost at once and enquired what were my findings. I gave him the physical signs to be expected after an early abortion and advised no further treatment. Early in the evening my name was posted among those having passed the exam and I left Edinburgh by the first train out to the south in a state of only moderate jubilation. Page 129 Soon after I returned to South Africa full of confidence and optimism and went as assistant to a doctor at Calitzdrop. It was in a lovely valley with Mimosa, Oleander, and Arum lilies in bloom, on the banks of a small and winding river with ostriches in full plumage among it all. The doctor had just bought a Panhard motor car and drove furiously over the roads with all the horse traffic and mule wagons stampeding over the veldt as the new invention rattled past them. I had two very good white horses to ride or drive and was sorry to leave the place, but a financial slump had hit South Africa and I felt that my talents would never be suitably rewarded there. It takes a life time to make some of us realize that those who "stay with it" during a depression will get all the plums when the reaction comes along. Early in 1905 I left Capetown for New Zealand and after five weeks stav with an aid friend of mv student days left for San Francisco and then on to Victoria and North Vancouver in May 1905. After nineteen months in North Vancouver waiting for the town to grow, and a few weeks after telephones and streetcars had been installed I went on to Vernon in December 1905. Here there was a bitter feud between two doctors and I backed the wrong one who had a weakness for morphia. In August of 1907, somewhat subdued, I left for England with the idea of settling down there, but after wasting some three or four months there, some of it in the O.P. of G.O.S. the "wander lust" got me again and brought me back to Canada early in 1908. About eight months were spent in Vancouver posing as a children's specialist, but seeing none except when assisting the health officer in dealing with infectious diseases. These included an outbreak of very mild smallpox known in South Africa as "Emmaas" and welcomed by them as a protection against the real smallpox. The characteristic feature was that it started with the onset of severe illness and high fever followed by apparent recovery with the appearance of a rash at first typical of chicken pox, the watery vesicles of which gradually hardened into the typical nodules and then pustules of small pox. My time, however, was not so completely wasted as in many of my ventures since 1898, as I got engaged returned to North Vancouver to get married in June 1909. One doctor was on trial in the criminal court and the other was preparing to leave and specialize in Vancouver. Almost at once two other doctors arrived in partnership and two others arrived soon after who worked harmoniously with me till the war of 1914. There was a real estate boom on, money was in fair supply and living cheap. I held down the school inspector job and made a comfortable living. Then the slump came in 1913 and we all became poverty stricken and the First Great War started in 1914. In February 1915 I left for England with my wife and two boys, aged three years and four months respectively, where I joined the R.A.M.C. About sixteen months of my time was spent in France, mostly with regiments and the Field Ambulance, and I then went back to England in December 1916. At home I was in charge of a large training camp near London and later of two small hospitals, in neither of which was there much clinical experience to be had. Returning to Canada at the end of 1918, after a brief but unsatisfactory spell at Chemainus I again returned to North Vancouver where there was at least my own home to live in, for houses were almost as scarce then as they have been after the recent war. I did not intend to stay in North Vancouver but resentment at my survival and re-appearance were so obvious with some people including some of my best patients, while others were so loyal in returning to me and helping me that I decided to stay on in a spirit of unusual obstinacy which carried me through two very lean years for myself and family. During these years the "total prohibition" regulations were in force. The medical profession as usual was put "on the spot". To give prescriptions ad lib. was an easy way to make money and friends, to refuse them caused permanent hostility. Ultimately it worked out to my advantage. A local doctor who was notorious as an easy prescriber wrote a prescription for two bottles of whiskey for a man who was so Page 130 drunk that he staggered down the office stairs and crossing the road fell under a streetcar. At the inquest the doctor, who was also the coroner, had to face his own prescription, which had been clutched in the hand of the deceased at the time of his death. This was too much for public opinion and he was relieved of the appointment and it was given to me, being a returned man. The work of coroner has been of great interest to me but looking back two very early inquests badly bungled, and two more handled the same way in recent years, have reduced to a minimum my opinion of myself as coroner. My appointment as medical school inspector was not returned to me till three years after my return to North Vancouver as there had been no bargain nor written agreement to that effect. After my re-appointment the annual issue of Iodine tablets was introduced for any children who wished to have them. This was done following Dr. W. D. Keith's work on thyroid defects and sterility among the livestock of the Pemberton Valley farming district due to shortage of Iodine. North Vancouver had probably the first school in B.C. to adopt this preventive treatment against Goitre. In a very few years the prevalence of goitre in the High School had become very much less than prior to their issue as a ration if requested by the parents. A beginning had been made to deal with the visual defects of destitute children by Dr. Graham Eliot when the present health unit took over all the school medical work in the early thirties. There is litde more to recall of the first 25 years of my "qualified years" which could be of any possible interest to any one of you. At the end of 52 years of mixed practice in various parts of the world one has much to regret and little to feel satisfied with. In the various recurring problems to solve and decisions to make — financial, ethical, professional, moral and legal, which all must meet with, it is only possible to do what appears to be most right or least wrong at the time and under the conditions prevailing. Having done that one can look back with a minimum of remorse when the end result of it all seems to have shown that the decision was the worst possible. One redeeming feature of the last few years of a rapidly shrinking practice is that these difficult problems seem to arise less frequendy than in the early years. May I disclose to you one fact emphasized to me by a very successful and ethical practitioner soon after I qualified. He told me that after more than 35 years of a large practice in a town of 60,000 people he was amazed to find how few of the patients of the early years and their families had stayed with him from one generation to another. He was such an able man that his warning has helped me to watch many of my former patients and their families go off to younger and more up-to-date practitioners as their finances improved, without any feeling of surprise or extreme hostility toward them. From our student days we probably all look on each new discovery and line of treatment as of final and permanent value. Even I can look back on such wonders now discarded. Arbuthnot Lane used to do a wonderful operation for cleft palate in infancy. Surgeons used to come from all parts of the world to see him do it but after a few years it was discredited and discarded, to be seen fifty years later in Vancouver as something new. The same surgeon used to remove large intestine from caecum to sigmoid as a cure for chronic constipation. Many of these patients lived, including one lady of the Royal Family. For several years after this success well-to-do constipated females competed to have their mobile abdominal septic tanks removed by Lane. Again surgeons crowded to watch him but the final results were uncertain and more simple methods were devised to deal with costive bowels. Ballance drew a crowd for some years to watch him do mastoid operations and line the cavity in the bone with gold foil. The craze lasted about five years, which was certainly five years too long. For the medical treatment of most of the acute diseases we used Calomel, Pot. Iodide and Salicylates and thought we did much good for at least our patients said that they felt better and came back for more. (To be continued.) Page 131 MANAGEMENT OF CARDIAC ARRYTHMIAS |§D. S. MUNROE, M.D. ' Vancouver, B.C. Cardiac arrythmias are very common and their presence may or may not be of great importance. They may be the cause of an acute medical, life-threatening emergency — or they may be an insignificant clinical finding. J|| l PREMATURE BEATS OR EXTRA SYSTOLES These are the commonest and least important of the cardiac arrythmias. Nevertheless they are the commonest cause of cardiac neurosis and therefore of importance. They may occur in four general situations. (1) When the patient is on digitalis therapy — the appearance of premature beats suggests the possibility of digitalis overdose. (2) Following myocardial infarction — the appearance of frequent extra systoles demands prophylactic quinidine or pronestyl therapy to prevent other more important or even serious arrythmias. |||p (3) In other types of heart disease and in the absence of digitalis therapy, premature beats are of little importance although they may cause anxiety to the patient. (4) In the absence of organic heart disease — premature beats are frequently the reason a patient seeks medical advice. The diagnosis that premature beats are the cause of the patient's symptoms may be very easy or very difficult. The symptom may be described by the patient in the following terms — "my heart stops" — or "my heart stops and turns over in my chest" — or "my heart goes up in my throat." This sensation may be followed by jumping up in bed, hyperventilation which may be readily confused with cardiac asthma, tachycardia and a state of near panic. The diagnosis is therefore important and often must be made on the history alone. Premature beats may be handled along the following lines: (a) Exclude organic heart disease. (b) Reassure the patient — this may have to be repeated frequently and forcefully. (c) Eliminate if possible any psychogenic precipitating factors — or explain their relation to the occurrence of extra systoles. Remember that the commonest cause of systoles is tension. (d) Stop tea, coffee, tobacco and alcohol. (e) Mild sedation. (f) Specific drug therapy is not frequently required but if so, use quinidine gr. 3-6 qid or pronestyl 250-500 mgm. bid to qid in the case of ventricular extra systoles. If these fail, digitalis may be beneficial. Finally, do not tell patients of premature beats if they are not aware of them— iatrogenic heart "disease" is hard to cure. -& it it it One of the common and important problems with which we are faced is the diagnosis and management of a person with tachycardia, especially if sudden in onset. The first requirement of the clinician in such circumstances is to decide whether the ventricular rate is regular or irregular. If it is regular, the diagnosis will fall into one of the following groups: (1) Sinus Tachycardia. (2) Atrial (Auricular) Flutter. (3) Paroxysmal Tachycardia. (a) Atrial (Auricular) (b) AV Nodal (c) Ventricular Page 132 t|§ If the apex rate is irregular, only two things need be considered. (1) Sinus tachycardia with frequent premature beats. -(2) Auricular fibrillation. (There are other uncommon and clinically unimportant arrythmias, such as the Wenckebach phenomenon and other variations in AV conduction, which are not a matter of practical importance.) All of these are important, but it should be pointed out that with the exception of paroxysmal ventricular tachycardia every one of these can occur in the absence of organic heart disease. It is unwise to diagnose organic heart disease, let alone give a bad prognosis, on the basis of an arrythmia alone. The arrythmia should be treated and when it is controlled or corrected, the situation should be re-evaluated for an accurate diagnosis and prognosis. The majority of the arrythmias can be corrected or controlled, but on the other hand, rare cases of nearly every one of these arrythmias can be neither corrected nor controlled. This applies particularly to auricular flutter. THE ARRYTHMIAS WITH A REGULAR VENTRICULAR RATE There is unfortunately no absolute bedside method of differentiating the various entities in this group, but attention to the following points may be of value. (O The age of the patient — the only common regular arrythmia in the young and middle aged is paroxysmal auricular tachycardia. (2) The history of previous attacks — recurrent tachycardia over many years strongly favours the diagnosis of auricular tachycardia — even though the attacks may have been very infrequent. (3) The presence of antecedent heart disease — the presence of prior angina or myocardial infarction favours the diagnosis of auricular flutter or ventricular tachycardia. (4) Cardiac Pain. If the tachycardia is preceded by cardiac pain, the diagnosis is more likely to be flutter or ventricular tachycardia. If, on the other hand, cardiac pain follows the onset of the arrythmia, the pain is probably due to coronary insfficiency which can occur in any arrythmia. (5) Examination of the pulsations in the neck veins. If the venous pulse in the neck is twice as fast as the ventricular rate, the diagnosis is atrial flutter. In all other regular tachycardias, the venous pulse in the neck has the .same rate as the ventricles. It is however often difficult to be sure of the count of venous pulsations. (6) Carotid sinus massage. This has no effect on ventricular tachycardia, may "cure" the attack of auricular tachycardia and may temporarily alleviate the attack of atrial flutter. The absence of effect from carotid sinus massage is, however, of no diagnostic value. All of these points are unreliable and the only absolute method of making the diagnosis is by the electrocardiogram. A regular pulse of 140 or more is the one absolute indication for an emergency electrocardiogram, if the apparatus is available. Precise diagnosis is of the utmost importance because of differing therapy in the different types of arrythmia. The treatment of these arrythmias can be best approached by considering them individually but general supportive measures may be necessary in all of them. These include oxygen, sedation, reassurance, morphia and agents to elevate the blood pressure when it is unduly depressed (neosynephrin or noreinephrine). §| |f SINUS TACHYCARDIA " || This term is a source of some confusion among students and interns. It implies a normal cardiac rhythm in which the impulse arises in the normal pace-maker and is conducted normally to the various chambers of the heart. The cause of sinus Page 133 F tachycardia is almost always extracardiac in origin as, for example, in such conditions as pneumonia, septicaemia, shock and etc. Its treatment is the treatment of the cause — no specific cardiac therapy is indicated or necessary unless of course cardiac failure develops. PAROXYSMAL TACHYCARDIA (.1) Atrial (Auricular) This is the commonest type and it is not usually associated with organic heart disease. Prevention of Attacks Stop or reduce stimulants such as tea, coffee, tobacco and alcohol. Remove foci of infection. Small divided doses of sedatives. Quinidine is indicated if the attacks are of sufficient frequency to warrant continuous drug administration. The dose is grains 3 to 6 bid to qid. Digitalis therapy may be effective where quinidine has failed. Treatment of an Attack What the patient can do. (i) Change of posture. (ii) Various methods of Vagal stimulation such as pressure on the eyeballs, induction of vomiting, carotid sinus massage and the Valsalva manoeuvre, (iii) Quinidine grains 3-6, q 1-2 H for several doses.. What further can be done. (i) Digitalization. In the opinion of many, rapid digitalization by the intravenous route is the treatment of choice. This of course cannot be used if the patient has already been digitalized. The following preparations may be used: Digitoxin—0.6 mgm intravenously and repeat in 2-4 hours. Digoxin—0.5T.0 mgm intravenously and repeat 0.5 mgm in 2-4 hours. Lanatoside C (cedilanid) 0.8 mgm intravenously and repeat 0.4 to 0.8 mgm in 4 hours. (ii) Quinidine Gluconate may be used intramuscularily in cases who are unable to take oral medication and who have already been on digitalis. The dose of quinidine gluconate is 0.4 gm q2H until sinus rhythm ensues or a maximum of 4 or 5 doses is given. (iii) Drugs which act by sudden elevation of the blood pressure and consequent stimulation of the vagus through the carotid sinus. They are especially useful in cases complicated by vascular collapse but are not without risk and should not be used in the first instance. These drugs include neo- synephrine and vasoxyl (Methozamine Hydrochloride). (iv) Others—These include prostigmin and pronestyl. Mecholyl is recommended only where all others fail. (2) AV Nodal Tachycardia. This is rare and is nearly always due to digitalis overdose. The treatment is to stop the digitalis and treat as for atrial tachycardia. (3) Ventricular Tachycardia. This is relatively uncommon and it is always associated with organic heart disease, usually of serious grade. It occurs most frequently as a complication of myocardial infarction. The attack can be stopped only by the use of quinidine or pronestyl. Opinion at the present time is divided as to which of these should be used first. (i) Pronestyl Oral—500 -1000 mgm. and repeat q2H until the attack is over or until symptoms of toxicitv ensue (hypotension, nause, vomiting). Intravenously—slowly to a maximum dose of 1000 mgm. over a period of Page 134 20 - 30 minutes—stop when conversion of the rhythm occurs. A continuous electrocardiographic tracing should be taken to ensure that the change to normal rhythm is recognized. Frequent blood pressure readings should be taken because of the hypotensive effect of the drug. Neosynephrine may be used to control hypotension. Intramuscularily—250-750 mgm. and repeat in two hours if necessary. Electrocardiographic tracing is necessary before repeating each dose of the drug. (ii) Quinidine 0.2-0.4 gm. (gr. 3 to 6), orally q2h for 6 doses. If this fails, allow a rest period of 6-8 hours unless the situation is immediately urgent and then give the same dose every hour for 6 doses. Quinidine Gluconate intramuscularly is an alternative mode of therapy. Quinidine intravenously should be used only after all other methods of therapy have failed. ATRIAL (AURICULAR) FLUTTER. Digitalis is the treatment of choice in most instances. These cases require large doses of the drug and any preparation of it can be used. Unless the situation is immediately urgent, oral therapy is preferred. Digitalis folia, digitoxin or digoxin may be used orally while the latter two may be used intravenously. The patient is fully digitalized and slighdy more than the daily maintenance dose of the digitalis preparation is continued until one or more of three events occurs. (i) Signs of toxicity. (ii) Sinus rhythm. (iii) Auricular fibrillation develops. The drug.is then stopped. If sinus rhythm does not ensue, quinidine therapy may be added as described for the conversion of auricular fibrillation. A small percentage of cases of auricular flutter however are refractory to all forms of treatment. £- -fr * if ATRIAL (AURICULAR) FIBRILLATION. This abnormality of rhythm may be treated with digitalis or quinidine or both. The immediate treatment Quinidine may be the first choice in an effort to convert the abnormal rhythm to normal under the following circumstances. (i) In absence of impending or actual heart failure, (ii) In absence of considerable cardiac enlargement, (iii) In absence of important valvular heart disease—e.g. mitral stenosis, (iv) In recurrent paroxysmal auricular fibrillation. All other cases (the majority) should be treated with digitalis in the first instance. If in doubt, digitalis should be used. This will control the rate and subsequent leisurely thought may be given to the question of attempting to convert «_e rhythm to normal if conversion does not occur spontaneously. Conversion of fixed auricular fibrillation may be attempted by the use of quinidine in the following circumstances. (i) Where there is no evidence of organic heart disease, (ii) In thyrotoxic cases where the arrythmia persists after the thyrotoxicosis is controlled, (iii) Where there is a relatively minor grade of organic heart disease and the arrythmia is of recent onset. Page 135 (iv) In far advanced heart disease, it may be impossible to correct heart failure in the presence of the arrythmia. A trial with quinidine may result in conversion of the rhythm and add materially in the establishment of compensation. There is a wide difference of opinion regarding the use of quinidine in the - conversion of auricular fibrillation under other circumstances. All cases selected for trial should be in hospital and should be maintained on anticoagulant therapy (herapin or dicumarol in effective doses). The dosage schedule of quinidine for this purpose is as follows: First day—grains 3 test dose. Then grain 3 q2h until toxicity appears or until 5 or 6 doses are given. Second and Third days—grains 6 q2-3h until toxicity appears or until 5 or 6 doses are given. Some increase the two-hourly dose to grains 9 or even grains 12 on subsequent days but the wisdom of these larger doses may be questioned. WORKMEN'S COMPENSATION BOARD December 14th, 1954. To the Members of the College of Physicians and Surgeons of British Columbia. Dear Fellow Members: A few weeks ago I had a telephone call from a specialist in Vancouver complaining about the action of the Board in a specific case. The problem was discussed at some length on the telephone and I asked the doctor if he had been reading the letters which had been published in the Vancouver Medical Association Bulletin in an endeavour to bring certain problems to the attention of the profession and asking the Members' cooperation so that we would be able to handle claims more rapidly and more efficiently at the Head Office of the Board. The doctor's immediate reply to my query was that he did not have time to read the Vancouver Medical Bulletin. I find it extremely difficult to develop or devise some meansof communication between our Board and the profession unless the members are willing to cooperate with us when we are attempting to bring some of our problems to your attention which we think, when corrected, will be to our mutual benefit and of particular benefit to the workman for whose care we are responsible. We have repeatedly asked in our letters that consultation reports be sent in under the doctor's personal letterhead and NOT by a form 8 or a form 11. When the consultation report comes by personal letterhead, it is not necessary to accompany the letter with a copy of a form 8. The form 8 is simply a surgeon's first report and should only be used as a surgeon's first report and not as a consultation form, or to accompany a consultation report, nor should it be used in an attempt to re-open a claim. In a workman's file there are three important forms: The employer's form 7, the workman's form 6 and the surgeon's first report form 8. It is upon receipt of these three forms that a claim is set up and these are the triumvirate which form the basis upon which the claim is established. Further forms of these numbers on the same claim are simply redundant. We would again ask your cooperation in reference to second and third copies of forms as are sometimes submitted. Page 136 I am making another plea with reference to the progress reports, form 11. We do have at the Board a number of people who are simply wizards in the interpretation of doctors' writing and signatures, but there are other members of the staff, including myself, who find it almost impossible to make out certain doctors' writing or their signatures and consequently it is extremely difficult to make out what information is being portrayed for the benefit of the workman. If there is not room on a form 11 for all the information you wish to send, it would be much appreciated if you would dictate the information to your secretary and have her type it so it could be interpreted by all the members of our staff who become involved in the handling of the case. We see a great many form lis in which the doctor has started writing in longhand at the top of the page and has continued from section to section with the same longhand written on top of the printing and in some cases, around some question which has been previously answered. In the end there is a maze and a jumble of completely undecipherable hieroglyphics which cannot be interpreted. When the writing cannot be read, the report is of no value in the handling of the claim of the workman and most often, something important as far as the doctor and the workman, has not been portrayed on the form. A few days ago a file of a workman in an interior town with a new progress report was brought to my attention. I could not make out the writing, nor could I make out the signature, but one of the clerical staff had printed in pencil below the doctor's signature, her interpretation of the doctor's name. It had been possible to interpret the name of the town but the signature was completely undecipherable. I was quite sure that the pencilled interpretation was incorrect because I recalled the transfer of the doctor's whose name was printed, to a different town some year or more ago. On looking up the College of Physicians and Surgeons Directory, I found the name of the doctor whose writing we were trying to decipher, and even knowing the correct name, I had a great deal of difficulty interpreting it from the writing. I well know, from my experience at the Board of a little over two years, that one of the factors which comes closest to your heart is in relation to the form 11 A's and your account. I have made a number of requests by my monthly letters asking that one page of the form 11A be used fo reach year of the care fo the workman. I have in front of me at this time an account of a workman who was injured on Vancouver Island on October 24th, 1952. On October 21st 1954 we received an account on a single form 11 A. There are no entries as far as I can determine from October 24th 1952 until June 3rd 1953. The entries are mixed up on the same sheet, as office and Hospital visits for the remainder of 1953 and into 1954, some of the dates are overlapping so that there are office visits marked in the same month for 1954 as the patient was in the Hospital in 1953. We are most anxious to be able to adjudicate all claims as rapidly as possible. We are also anxious to pay your accounts as quickly as possible, but when it is necessary for three or four people to have to look at a signature or to attempt to decipher an account or to interpret a progress report, it is time consuming, causes unnecessary delay and I must say, often necessitates the claim being put aside for later review when there is adequate time to work.out what may be a cross between a crossword puzzle and scrabble. We sincerely ask your cooperation. Very kindest of personal regards and the best wishes for the New year, I remain, Sincerely yours, • J. R. Naden, M.D., ll Chief Medical Officer. Page 137 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull Vancouver President-Elect—Dr. E. W. Boak I Victoria Immediate Past President—Dr. R. G. Large Prince Rupert Chairman of General Assembly—Dr. G. C. Johnston Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer Vancouver Executive Secretary—Dr. G. G. Ferguson Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria New Westminster Vancouver Dr. J. F. Tysoe Dr. J. F. Sparling Dr. A. W. Bagnall Dr. F. H. Bonnell Dr. P. M. McLean Dr. P. 0. Lehmann Nanaimo Kootenay £• **"" Wj|»n Dr. G. B. Helem Dr. S. C. Robinson jj; & ft Stantoj,^ Prince Rupert and Cariboo Yale Dr. J. C. Poole Dr. J. G. MacArthur Dr. H. I. Campbell-Brown Dr. N. J. Blair Chairmen of Standing Committees Constitution and By-laws I Dr. Carson Graham, North Vancouver Finance * j Dr. R. A. Palmer, Vancouver Legislation j Dr. E. W. Boak, Victoria Medical Economics : Dr. P. 0. Lehmann, Vancouver Medical Education : Dr. M. M. Weaver, Vancouver Nominations j ! 1 Dr. F. A. Turnbull, Vancouver Programme & Arrangements Public Health j i Dr. G. R. F. Elliott, Vancouver Public Relations Dr. A. W. Bagnall, Vancouver Chairmen of Special Committees Archives Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism Dr. J. A. Traynor, Vancouver Cancer j i Dr. Roger Wilson, Vancouver Civil Defence Dr. John Sturdy, Vancouver Ethics Dr. Wallace Wilson, Vancouver Hospitals . 1 Dr. G. C Johnston, Vancouver Industrial Medicine Dr. G. B. Helem, Port Alberni Maternal Welfare 1 Dr. A. M. Agnew, Vancouver Membership Dr. N. J. Blair, Vancouver Nutrition Dr. J. F. McCreary, Vancouver Pharmacy Dr. B. T. Shallard, Vancouver Rehabilitation Dr. W. J. Thompson In this first written message to the doctors of British Columbia, I wish to express again my appreciation of the honor that has been extended to me by my election to the office of President. During the course of the coming year I plan to bring to your attention, by brief memoranda in this Bulletin, certain general problems of the medical profession. These notes will not be a recital of our troubles, but an expression of some thoughts about policy, as viewed from this office. The matters that I have in mind are: 1. The effectiveness or otherwise of our present organization; 2. The relationship of doctors and hospitals; 3. Public relations; 4. The relationship of doctors in practice, and the Association, to the Medical School. When one looks at the medical profession objectively it is obvious that we are a very heterogeneous group — dissimilar in racial origins, somatic body types, personalities, and in the daily pattern of our lives. The bond that holds us together, and distinguishes our profession, is less tangible but very real. It is apparent particularly in medical students, who are just stepping across the threshold of medicine. This is the strong feeling of altruism, or desire to serve one's fellow man, that is the chief asset, and most important attribute, of the medical man's way of life. Our affairs, individual and corporate, will remain most safely and securely oriented, if they continue to be guided by that high desire. Frank Turnbull. Page 138 Fellow Members of the Medical Profession in British Columbia: For years, I have searched for a good definition of the word "Profession" and I have failed to find a good answer. Such authoritative works as the "Encyclopaedia Britannica" omit consideration of the subject — and probably for this good reason: The term "profession" is just as elastic as the majority of its members care to make it. We doctors, or at least the majority of us, would define the term "profession" in words that would mean, in part, a skilled trade, and, in its other part, something of a religion. Devotion to duty, bevond what could be expected of the normal person in the business world, is what Dr. Turnbull means when he speaks of "altruism". I am sure that this is what we all had in mind when, on graduation, we subscribed to the Oath of Hippocrates. Some of did it formally, others informally — but, unfortunately, others did it with tongue in cheek. At present, practitioners of medicine have been forced into the rather unenviable position of accepting the schizophrenic role of a professional businessman. On the one hand, there are the economic forces of income tax, the need to provide for one's wife and family: and on the other hand, there is the need to give service for those in need without regard to their ability to pay. Therefore, we must have a very clear idea of what we mean when we refer to "our medical profession". Each doctor must show, in his dealings with each of his patients that although he may be forced by circumstances to carry on a business, he is at the same time doing so according to the medical needs of the patient — and without regard to their ability to compensate him as adequately as he might wish. Also, in these days of rapid advances in medical science, failure to keep abreast of the times is hardly worthy of members of our profession — but this does not excuse those undesirable efforts of a minority to get ahead of our times by employing new, and unproven, forms of treatment simply because they are advocated by the frenzied few (who may be financially, and unprofessionally, interested). In summary, and as Chairman of your Committee on Public Relations, I should like to point out that the actions of some of the members of our profession in British Columbia are not always above reproach. Not a few complaints are received by your Association, both of an economic, and of an ethical nature. These are investigated carefully by the appropriate committees and occasionally, these complaints appear to be justified. We read in our newspapers of charges of manslaughter, or blackmail, being laid against an individual doctor. Whether these charges are true or false, they do the profession no good — and they make some of us wonder whether a Public Relations Committee is worthwhile. Nevertheless, most medical men wish to practise their art without fear of criticism. With this in mind, and with the support of the Executive of the C.M.A. (B.C. Division) your Public Relations Committee has established a sub-committee whose terms of reference are to bring to the attention of the profession those situations that stimulate the patient to quarrel with his doctor. Some physicians may have the happy faculty of "satisfying all customers". Most of the rest of us have Na few dissatisfied patients — but some of us do not realize when our actions are antagonizing patients — and a few do not seem to care. Since good "doctor-patient relationship" is the basic connotation of our definition of the word "profession", the C.M.A. (B.C. Division) herewith introduces its new sub-committee — Public Relations Within The Profession — and its two Co-Chairman, Dr. R. A. Stanley and Dr. Palmer McLean; both are members of the Board of Directors. A. W. BAGNALL, M.D. Chairman, Public Relations Committee, C.M.A. (B.C. Division). Page 139 DOCTOR PATIENT RELATIONSHIP We quite appreciate that we shall encounter snags, and that there will be differences of opinion, as we discuss with Doctors how we might better handle our patients. There can be no harm, and there might be some good in trying. Frequendy one hears criticism of the patient's actions: "The patient should know better, he should not do that sort of thing." However, this is the doctor's problem, not the patient's, and as one reads these relatively random thoughts, we trust that one will keep in mind that our theme is, "What can the DOCTOR do about it?" As Dr. Turnbull has said, each doctor has strong feelings of altruism. Over the centuries medicine has been a very personal thing. The patient has for the most part had only one doctor. The doctor's feelings of altruism were readily felt and understood without conscious attempts at expression. Everyone in the community knew of the night that Dr. Smith rode twenty miles in the blizzard to treat Mrs. Jones. The community accepted Dr. Smith and all that he represented as altruistic. In the past few years, however, with increased numbers, increasingly complicated living, and more distant personal relationships, the doctor's feelings of altruism might not be so apparent. Specialization has introduced teamwork. Each member of-the team, concerned with his detail, is apt to neglect to express his altruism in terms understandable to his patient. The patient is apt to come to think his doctor is a machine for hire, and not an altruistic human trying to help. It is time, we think, for us to take stock, to try to analyze this trend and see what we can do about it. It will be the task of this column to delve into the ways in which the present day doctor might better express his altruism in terms that his patient can understand. It will remind us of the things that we ought to do, and of the things that we ought not to do, if we subscribe to the assumption of our Board of Directors that our public relations should be improved. To be convincing in this attempt at expression, we must have respect for and the respect of our colleagues. Few single items will so undermine the confidence of the public as public criticism of one another. If we find acts of a colleague indefensible, it is our responsibility to either come to understand his point of view, or help him to understand and act on ours. To this end are our medical associations; with their committees, such as the mediations committee of B.C.M.A. and the disciplinary powers of the College of Physicians and Surgeons. These are our instruments. If they do not accomplish our purpose, it is our duty, yours and mine, to so mould them that they will. Out patient will, in some degree, hold us responsible for the adjuncts to treatment that we utilize; hospitals, from why there is a shortage of beds, to the dust under the table; medicine, whether or not they work, and what they cost; the ambulance, and why it did not arrive when it was supposed to, the medical school, and why students' instruction; the Metropolitan Health, the Victorian Order of Nurses, the Red Cross, Government Health Agencies. Granted that over most of these things we have no actual control, it will help our cause greatly, and our confidence in ourselves, if we can feel that we, through individual and association effort, are doing something to help remedy the source of reasonable complaint. Our Association with its numerous committees is constantly at work with these responsibilities. If each of us would make himself so much a part of these efforts that he would automatically be prepared to be enthusiastic about the effort, then unconsciously would he impart to his patients confidence in the atruism of our profession. Let this be general background. In subsequent articles we will proceed to more detailed discussion of things that the individual doctor might do in his day by day meetings with his patients, things that will improve our public relations. The cue undoubtedly lies in the Golden Rule; Treat him as you would have him treat you. Sub-Committee on Doctor-Patient Relationship Palmer M. McLean. Robt. A. Stanley. Page 140 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H. Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia TELEPHONE NUMBER CHANGES EFFECTIVE JANUARY 9, 1955 Assistant Provincial Health Officer, 1670 Laurel St i EXpress 2451 Division of Venereal Disease Control, 2700 Laurel St ____ EXpress 2451 Division of Tuberculosis Control, 2647 Willow St EMerald 3282 (Willow Chest Centre) Division of Vital Statistics, 2670 Laurel St Dickens 1636 (Statisticians) Crippled Children's Registry, 2670 Laurel St Dickens 1636 CURRENT PLANNING IN REHABILITATION FOR BRITISH COLUMBIA On September 16, 1954 the Honourable E. C. Martin, Minister of Health and Welfare in British Columbia announced that Mr. C. E. Bradbury had been appointed Provincial Rehabilitation Co-ordinator. Prior to assuming his new duties Mr. Bradbury had several years of valuable experience in the rehabilitation field. From 1947 to 1949 he was Rehabilitation Director for the B.C. Tuberculosis Society and from 1949 until his recent appointment he was the Rehabilitation Officer in the Division of T.B. Control. Mr. Bradbury's headquarters for an interim period will be in the Health Branch Offices in the Legislative Buildings in Victoria, where he will be directly responsible to the Deputy Minister of Health. Mr. Bradbury's appointment reflects the growing concern of all segments of our population for those among us who are handicapped by a physical or mental disability. The idea of rehabilitation is not new, although prior to about 1915 the word was rarely used or understood. There is recorded evidence that in the Third Century, the Roman Emperor, Marcus Aurelius Probus attempted to rehabilitate the battle injured veterans of that day by granting them tracts of land on which they could engage in farming pursuits and so maintain themselves. As available land ran out less fortunate veterans clamoured for what they conceived to be their rights, and the Emperor temporarily solved the problem by putting into effect a public works programme of road construction and drainage operations. The group employed on the programme became dissatisfied when they saw some of their old comrades-in-arms comfortably established on farms and probably felt that the coarse manual labour in which they were employed was beneath the dignity of a soldier of Rome. Eventually, their discontent reached such a pitch that they rebelled and assassinated the Emperor. Through the intervening years most rehabilitation plans have been initiated for the benefit of veterans and have attempted, quite properly, to reward veterans for services given to their country and to help them become self-sustaining citizens. History tells us that a woman, Queen Elizabeth I, was the first in comparatively recent times to perceive the responsibility of the state to the war-injured and it was she who instigated the first Pensions Act. However, until very recendy litde or nothing has been done in any part of the world for disabled civilians. World War I gave the first impetus to the discovery and practice of modern techniques of rehabilitation. Subsequent to 1918, many rehabilitation programmes were began and in some cases disabled civilians were invited and Page 141 encouraged to participate, although it must be admitted that in the late 1920's and 30's most of the programmes were allowed to languish and die. During World War II when labour was in short supply in Canada, everyone not in the service was needed to further the war effort at home. Employers searched far afield for labour and there resulted increased employment of the disabled in industry. Studies of their production record showed that many of the disabled, who heretofore had been considered merely as recipients of charity, were making a distinguished contribution when they received proper medical treatment and were trained to develop their latent work skills. At the same time the Department of Pensions and National Health (later the Department of Veterans Affairs) was energetically determined to develop a comprehensive rehabilitation plan for those disabled by war injuries. The able performance of the disabled in industry during the war, coupled with the impressive results of the scientific programme initiated for handicapped veterans, led to a resurgence of public interest. As a result of public concern, the Federal Ministers of Labor, National Health and Welfare, and the Minister of Veterans Affairs convened a National Conference on the Rehabilitation of the Physically Handicapped in Toronto in February 1951. From the proceedings of this conference came two important recommendations: (1) That a National Committee be formed to advise the Federal Government on matters pertaining to rehabilitation. (2) That a National Co-ordinator of Rehabilitation be appointed. The Government in Ottawa acted on the first of the two recommendations when, after consultation with the Provinces and with private health and welfare agencies, the National Advisory Committee on the Rehabilitation of Disabled Persons was appointed by Order-in-Council late in 1951. The Committee comprises a repre- sensative from each of the Federal Government departments concerned, an official representative from each of the Provinces; (B.C. is represented by Dr. G. F. Amyot, Deputy Minister of Health); six representatives of the medical profession; four representatives of organized employers; six representatives of the national voluntary agencies concerned with disabled persons; and four representing Canadian universities. The Committee held its first meeting in February 1952 and subsequendy the second of the two recomemndations was implemented in June 1952, when Mr. Ian Campbell was appointed National Co-ordinator of Civilian Rehabilitation, attached to the Federal Department of Labour. Further recommendations from the committee resulted in the responsible Ministers announcing that assistance to the provinces to develop a provincial plan of rehabilitation would become available. The National Minister of Health and Welfare extended the National Health Health Grants to include a supplemental Medical Rehabilitation Grant to cover service not already covered by existing Health Grants. It can be utilized to: * (a) Provide for the costs of training rehabilitation personnel such as doctors, psychiatrists, nurses, speech therapists, brace makers, rehabilitation officers, etc. when the training projects are related to an approved programme. (b) Purchase rehabilitation equipment which is designed to reduce disability such as electro-therapy equipment, remedial gymnastic equipment. Included could be a variety of medical aids essential in a rehabilitation programme. (When the grant is to be used for either of the above two purposes, the funds used will be considered an outright grant. The province will be reimbursed on a 100% basis and no matching principle is involved.) (c) Expand existing rehabilitation services by assisting in the employment of professional personnel for hospitals and rehabilitation centres. The grant could also be used to aid in case-finding, and in providing prostheses and Page 142 for other purposes necessary to establish a well balanced rehabilitation programme. (When used for these purposes, the matching principle would apply and the province would be reimbursed for 50% of its expenditures. In British Columbia the Medical Rehabilitation Grant is administered by the Department of Health.) It also has been announced by the Federal Minister of Labor that an addition to the Vocational Training Agreement authorized by the Vocational Training Coordination Act of 1942 has been made and will be known as "Schedule R" and can be used for the following purposes: (a) Therapeutic Training. This includes any form of training or instruction prescribed by medical authority to restore or develop physical or mental function necessary for occupational employment. (b) Exploratory or Prevocational Training. This type of training may be given for its therapeutic value, but is usually intended to discover interests and aptitudes, and to help the trainee determine the type of employment or specific occupation in which he (or she) would like to be engaged. Such courses usually are taught by competent trade instructors or persons specifically trained in industrial arts. (c) Academic Training. Many disabled persons lack the necessary background of academic .training to qualify for admission to suitable vocational courses in schools and training centres. In some cases, specially organized academic courses may be necessary as preliminary training. (d) Related Instruction. Provision is made in all vocational courses for specialized instruction in subjects such as mathematics, science and drawing when they are direcdy related to the operations and skills of the trade being learned. (e) Trade Training. This consists of instruction and practice in the skills and operations of a trade. The most effective training is given by an instructor who is not only a skilled craftsman but is also a trained teacher. (f) Technical Training. The term is usually applied to instruction and training given in senior years of pre-university course leading to engineering in any of its phases or to courses intended to prepare adults for employment in technical occupations such as electronics, graphic arts, design, photography, laboratory techniques, etc. (g) Professional Training. Includes all forms of organized training for the professions whether given in universities, colleges, institutions, hospitals, or offices and industrial organizations. Although the foregoing indicates the wide scope of the training grant, which in British Columbia is administered by the Department of Education, certain requirements and provisions must be fulfilled. Of interest to the medical profession is the proviso that all training programmes under this schedule must be medically approved. It is stipulated also that insofar as is possible, the existing facilities for training must be used and that the training should be such that it fits the trainee for gainful employment. The aim of a rehabilitation programme is to "restore the disabled to the fullest physical, mental, social and economic usefulness of which they are capable." In following this concept, it has been accepted that the team approach is essential and for many years rehabilitation teams have operated with notable success in various isolated programmes. If the team approach is necessary and succeeds in isolated programmes, it was felt that it was equally necessary on a national and provincial level. The Federal Department of Labor therefore made another grant available, through the Co-ordinator of Rehabilitation Agreement, by which each province can share up to $15,000 per annum on a matching basis to pay salaries and expenses of Page 143 a provincial rehabilitation co-ordinator and to cover certain expenses of a rehabilitation programme not otherwise covered. It is the duty of the Provincial Co-ordinator to assist in securing the cooperation and active participation of the other departments of the Provincial Government the services of which contribute to a rehabilitation plan. He also is charged with the responsibility of co-ordinating the work of those agencies, public and private, which aid in the rehabilitation process and to stimulate the interest of labour, management and other groups and individuals in the community. It is perhaps appropriate at this point that mention should be made of the private agencies and community organizations which have worked toward comprehensive programmes for their clients. An outstanding example is the Western Society for Rehabilitation in Vancouver which, in its relatively short existence, has gained an enviable international reputation in the rehabilitation field. Most competent authorities insist that it is the medical profession which must i accept the primary responsibility for initiating the rehabilitation process and practitioners, to the best of their ability, have accepted their responsibility. They have assisted their patients to return to normal pursuits as a result of medical and surgical treatment, and to many, rehabilitation has been synonomous with "cure". However, it is the severely disabled who have presented the most baffling problem, because with this group, medical and surgical treatment alone will not suffice. The wider concept of rehabilitation has developed to meet the needs of the severely disabled persons in our population. The term "rehabilitation" has become a broad term including all the services necessary to make a handicapped person employable and runs the whole gamut of surgical and medical treatment, social services, vocational counselling, education, academic and vocational training, and placement. Representatives of the various disciplines contribute to the planning, which must be comprehensive and co-ordinated to be successful, and are members of the rehabilitation team. As the practitioner accepts the primary responsibility for the rehabilitation of the individual, the Health Branch has logically accepted the responsibility of the co-ordinating function in the larger area. In British Columbia it is felt that it is the Health Branch that should accept the responsibility for initiating a programme of rehabilitation for the handicapped and assist in making it possible for the practitioner in the community to offer a more complete service to his severely disabled patients. However, the planning and administration of a provincial rehabilitation service requires the active participation of other departments of government. The Health Branch is grateful for the assistance which has been offered by the Welfare Branch, the Departments of Education and Labor, and the Provincial Secretary's Department. An Inter-departmental Committee has been formed comprising the Deputy Ministers of the inteersted departments which, in effect, will be the "rehabilitation team" at the administrative level. Most of the handicapped wish no more than an opportunity to compete on an equal basis with other people in the community. Providing them with this opportunity is consistent with our humanitarian ideals and demonstrates our belief in their worth as citizens. Also important is the fact that we cannot afford the expensive luxury of maintaining those non-productive people in our community who could, with adequate service, become productive. A rehabilitation service is more than economically sound; it is economically necessary. EXCELLENT LOCATION FOR GENERAL PRACTITIONER j§ OBSTETRICIAN OR INTERNIST § J§ Directly across from Simpson's Sears in Burnaby. 800 square feet— 2nd floor. TELEPHONE: DExter 7056 Page 144 Eh. George L. McKinnon has begun a practice in obstetrics in Vancouver and is associated with Dr. Harold Caple. Dr. A. T. Wiens is now in private radiology practice in Vancouver. Eh. John D. Rajan is practising opthalmology in Vancouver now. Eh. Warren Bell is now studying in Jackson, Mississippi. Eh. George Darby is now doing private practice in Vancouver. Dr. James D. Nelson is now doing post-graduate work in Paisley, Scodand. Dr. Margaret Hardie and Dr. R. E. Beck were married in Vancouver in December. BIRTHS To Eh. and Mrs. J. R, Sidall, of Vancouver, a daughter. Safer, more effective, belter tolerated salicylate therapy in ARTHRITIS and RHEUMATISM Each ENTERIC coated tablet contains: I DOSAGE _ Two tablets every two hours, between Sodium Salicylate = 3 grains meals, with half glass of water, Potassium Salicylate 1/7 grain 6 times dailv- Calcium Salicylate 1/12 grain • Para-Aminobenzoic Acid 2V_ grains ^ Issued: Strontium Iodide V_ grain Bottles of 100, 500 and 1,000 e.c. Vitamin C 20 mg. tablets. ANGLO-FRENCH DRUG CO. LTD., Montreal 18 ifCcumt ^Irasattt Chap-T I FUNERAL SERVICE Kingsway at llth Ave. — Telephone EMerald 2161 Vancouver 10, B.C. fl&t. Peasant "mnbertaking Co. Xtb. Page 145 PROFESSIONAL PHARMACEUTICAL m SERVICE _P«C H_9 ^*»s»j Hg m w_ _w m ^ Ihacdoi tt% !* _» ** r**t EUMI-l-D icriplions Medical-Dental Building ::*i;r« _ 4141 ^Tree y^itu o&elii iveru an 7? d ^jrree [-Provincial J-^odL aae r Page 146 We are publishing in this issue the programme of the Scientific Session of the Section of General Practice of the B.C. Division of the Canadian Medical Association. As will be seen in the programme, a meeting of the College of General Practice of Canada, B.C. Chapter, will be held on Thursday morning, March 17th. This is the first meeting of this body, which was finally brought into being in 1954. The programme will speak for itself—and is an excellent one; the setting of the meeting is ideal. Harrison Hot Springs Hotel is close enough to all centres to be easily reached—it is in a beautiful setting, there are all sorts of attractions, golf, swimming, riding, dancing and so on—and it is hoped that a great many men will bring their ladies with them; the latter can be sure of a good time. Quite apart from the social side of this gathering, it is an important event in the medical life of the province. The General Practitioners' Section of the C.M.A. has made great strides in the past three years. Its policy is to improve and con- standy raise the standards of general practice in Canada. With this in view, it has as a condition of membership a sincere and honest effort on the part of each member to keep thoroughly up to date by regular post-graduate work and the observance of the highest principles of his profession. This cannot but be of great benefit, not only to himself but to the community at large. The last meeting in 1954 had an attendance of 148. There is no reason why this should not be doubled or better. Everybody should have received through the mail a copy of the programme and a registration card. You are asked to fill out the latter promptly and mail it to Dr. A. G. Vey, 745 Gates Street, Victoria, B.C. If you have not received this—write him at once and it will be forwarded to you promptly. We rejoice to see that the Vancouver Medical Association is holding its summer school this year in June. Last year it was suspended, as the Canadian Medical Association held its annual convention in Vancouver—but it will be back this year. We are printing the announcement of it in this number of the Bulletin, and it will be evident that this is going to be an outstanding programme. Further announcements will follow. t5t •& if SAM KINNISTON — An Appreciation We read recendy with great interest, mingled with definite regret, of the retirement of Mr. Kinniston from the quarantine department of the Metropolitan I lealth Department, of which he was Chief Quarantine Officer and Inspector. The accumulating years of service (forty-two of them) have reached a point with this faithful guardian of Vancouver's health where he has to retire—and we shall all be sorry to see him go. "Sam" Kinniston has been one of those not-too-common souls who makes his vocation his hobby and his chief interest in life. He possesses, too, qualities of heart and mind which have made him a particularly valuable man in his department; kindliness, a keen human sympathy, and a never-failing devotion to duty.. .Every man in general practice in Vancouver knows him, and his cheerful voice over the telephone, and readiness at all times to help, have been a great comfort to us all. In die hundreds of calls he received each year he was always adequate, prompt to Page 165 answer, prompt to carry out his duty, and withal unfailingly courteous and cheery. He always tried to make things as easy as he could for the unfortunate victims of quarantine. His record goes back to the days when in one year Vancouver (a relatively small town then) had 1100 cases of diphtheria—when smallpox frequendy visited us, when scarlet fever, was a deadly plague. Mr. Kinniston was always ready, day or night, and apparendy enjoyed it all. Fortunately for him, he has always been immune to infectious ailments—and never, he says, has had anything worse than a head cold. We all wish him, in his retirement, a long and happy life. Vancouver Medical Association OFFICERS — 1954-55 President | Dr. J. Howard Black Vice-President Dr. F. S. Hobbs Honorary Treasurer, - j Dr. R. A. Gilchrist Honorary Secretary Dr. G. E. Langley Editor Dr. J. H. MacDermot PRELIMINARY ANNOUNCEMENT VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL STANLEY PARK PAVILION, VANCOUVER, B.C. JUNE 6th to 10th INCLUSIVE, 1955 Speakers: Dr. Ian Aird—Professor of Surgery, University of London, England. Dr. N. S. Assali—Associate Professor of Obstetrics and Gynaecology, University of California, Los Angeles. Eh. Kenneth Evelyn—Director of the British Columbia Medical Research Institute, Vancouver. Dr. Donald H. Williams—Clinical Associate Professor of Medicine (Dermatology), University of British Columbia, Vancouver. ** Watch for list of other speakers and subject material. SPECIAL NOTICE TO VANCOUVER DOCTORS We would like to draw your attention to the fact that a considerable number of trained office receptionists, registered nurses, medical stenographers and laboratory technicians, etc., apply at the office of the Vancouver Medical Association for positions in offices of city doctors. Some of these applicants require full-time employment, while, others are looking for part-time or relief work only. It is our practice to keep these applications on file and available for the convenience of doctors requiring office help. For this information telephone Mrs. Dewest, Secretary, BAyview 4158. Page 166 Scientific Session of Section of General Practice BRITISH COLUMBIA DIVISION—CANADIAN MEDICAL ASSOCIATION MARCH 17-^-18—19 S 1 PROGRAM CHAIRMAN: DR. VINCENT SMITH Iguest speakers ' ■ Lennox G. Bell, M.D. (University of Manitoba, 1928), M.R.C.P. (London), F.R.C.P. (Can.), F.A.C.P. Dean of Medicine, Professor and Chairman Department of Medicine, University of Manitoba, Physician in Chief, Winnipeg General Hospital. Arthur B. Nash, M.D.C.M. (McGill University 1926), F.A.C.S., F.R.C.O.G., F.R.C.S. (Can.). Consultant in Obstetrics and Gynecology, Royal Jubilee Hospital, Victoria, B.C. H. Rocke Robertson, M.D.C.M. (McGill University, 1936), F.A.C.S.,F.R.C.S. (Edin.), F.R.C.S. (Can.). Professor and head of Department of Surgery, University of British Columbia. Director of Surgery, Shaughnessy Hospital. Maurice D. Young, M.D. (Cambridge University, England, 1938), M.R.C.S., L.R.C.P., M.R.C.P., F.R.C.P. (Can.). Assistant Professor, Department of Pediatrics, University of British Columbia; Consultant in Pediatrics, Vancouver General Hospital and North Vancouver General Hospital. ■ft- it it it PROGRAM THURSDAY, MARCH 17th 10:00 a.m.—Meeting of the College of General Practice of Canada, British Columbia Chapter. This is the first meeting of the College in B.C., and it should be of interest to everyone. The Convention begins with an afternoon session 2:00 p.m.—Dr. L. G. Bell. "Bronchial Asthma" 2:45 p.m.—Dr. Rocke Robertson "Management of Varicose Veins and Complications Thereof" 3:45 p.m.—Dr. /yi. D. Young "Pyrexia of Unknown Origin" 4:45 p.m.—Dr. A. B. Nash Functional Uterine Bleeding" FRIDAY, MARCH 18th 9:00 a.m.—Dr. Rocke Robertson "Investigation and Treatment of Minor Surgical Lesions of the Anus and Rectum" 9:45 a.m.—Dr. A. B. Nash % "Ante-Natal Care with Reference to the Common Complications" 10:45 a.m.—Dr. L. G. Bell "Management of Acute and Chronic Renal Failure" 11:45 a.m.—Dr. M. D. Young "Significance of Cardiac Murmurs Found at Incidental Examination" AFTERNOON SESSION |pf Social Program IB Page 167 SATURDAY, MARCH 19th 9:00 a.m.—Dr. L. G. Bell "Practical Endocrine Therapy" 9:45 a.m.—Dr. Rocke Robertson "Remarks on Surgery of the Hand" 10:45 a.m.—Dr. M. D. Young "Diagnosis of Acute Rheumatic Fever and Status of Cortisone" 11:45 a.m.—Dr. A. B. Nash j f| . "The Functional Causes of Gynecological Symptoms" AFTERNOON SESSION 1:00 p.m.—Luncheon Guest Speaker: Dr. Rocke Robertson 2:30 p.m.—Business Meeting 8:00 p.m.—Dinner . Guest Speaker: Dr. L. G. Bell REGISTRATION and ACCOMMODATION Reduced Rates have been procured. A special program for the ladies. Transportation supplied from Agassiz, if requested. For confirmation of reservations, please complete registration card and return without delay, not later than February 15th, 1955. Dr. A. G. VEY 745 Yates Street, Victoria, B.C. + + + COMING DR. IAN AIRD — Prof, of Surgery, Univ. of London VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL JUNE 6th to 10th — 195 5 FOR SALE Verticle Fluoroscopy in Excellent Condition, No Reasonable Offer Refused. Phone PA. 9844. Page 168 AFTER 56 YEARS OF VERY MIXED PRACTICE THE AFTERMATH In venturing to bring a paper like this before a gathering of medical men in a city boasting a Medical School and University I only do so in the same spirit that possessed Rudyard Kipling when he wrote his "prelude" to "The Islanders"— "No doubt but ye are the people—your throne is above the King's. Who so speaks in your presence must say acceptable things. Bowing the head in worship, bending the knee in fear — Bring the word well smoothen — such as a king should hear." These conclusions have been arrived at slowly, as doubts have arisen as to the ultimate results on the human race of the marvellous and apparently beneficial discoveries of science during these years. It has seemed to me to be becoming more obvious, that unknowingly during these years Medical Science has been and still is endeavouring to oppose or neutralize many of the laws of nature, which have in ages past controlled the progress and ensured the survival of the human race. The paradox before us is that the curse laid on mankind for eating of the tree of knowledge apparendy still holds good. With the increasing attainment of knowledge, which can alleviate pain and misery of each individual, it has become imperative for humane reasons to use this knowledge, even though its use may ultimately lead to moral and physical degeneration of the nations possessing it in the highest degree; in other words, the most highly civilized. Let me refer to an article read by Dr. R. Hutchison at the C.M.A. Winnipeg meeting (Journal Vol. 24-1931), "The Pursuit of Health". It was a criticism of the efforts then being made by the people of this continent to obtain perfect health and keep healthy. The article could well be read by all the adult population of this locality today. Periodic medical examinations, diet, fads, accurate vitamin ingestion, various anti-disease campaigns, organized as being essential to achieve the objective of perfect health, all come under his ridicule. It can be partly summed up by stating that he considers health as a condition equally of mind and body. It can only be present when we are unconscious of it. Directly we start out to seek health or, feeling well, try to feel better, that is enough to cause perfect health of mind and body to be no longer present. A nation "health conscious" is suffering from an "anxiety neurosis" as the direct result of intensive health propaganda. The success of this campaign is estimated by the number of neurotics flocking to the hospitals and medical clinics for assurance of safety. Very few medical men are capable of giving such a guarantee in the early stages of a disease; but, to quote Dr. Batten, "The doctor usually hedges for his own safety as well as that of the patient and sends him to a technician." The patient may get a report that all is well temporarily but to come again in three or six months' time. During this wait he or she is alerted against all sorts of insidious diseases not included in the guarantee, by a constant barrage of health pamphlets, magazine articles and radio broadcasts. The reaction of civilized man and woman to the sudden impact of knowledge reverses that of Adam and Eve when they learn more than was good for them. Genesis tells that "they were afraid, and hid themselves in the garden" and hastily made clothes for themselves. Modern mankind, thoroughly panicked by too much knowledge, take refuge in the medical clinics of a large city and proceed to take off most of their clothes. Dr. Batten in Sir Henry Bashford's book, "Doctors in Shirtsleeves", finishes an article on "Too Much Prevention" as follows: "If our whole concern is with death and gross organic disease and if the citizens'" expectation of life at birth is an accurate indication of the country's health, well and good. But if it is Health we are after and if the index of a country's health is rather the desire and ability of its citizens to Page 169 V lead vigorous, useful, happy and courageous lives — die when they may — then, I believe, we should think twice before we imbue the community with this idea of a doctor's function. Successive generations have their own problems to solve." "What to do with our boys" was that of the large families in the latter half of the 19th Century. Contraceptive equipment and technique perfected by the combined skill of the medical man and the manufacturer have reduced young life to a minimum and thus solved this problem. In any future struggle for national survival Medical Science must be held responsible for any shortage of young men and women available for the defence of their country. The prolongation of life by every known public health regulation and social security for the fit and unfit from the cradle to the grave even to the transfusion of young blood into old bodies at the near approach of death has created the new problem of "what to do with our grandparents" for the present and coming generations. The Progress of Medicine in the 10 Years Before 1900 and Since That Date. By the end of the last century Medicine, which had lagged behind the sensational progress of Surgery, was beginning to evolve achievements of its own. The X-Ray, first described in 1895, has probably had the most important influence on the practice of both Medicine and Surgery since the discovery of the circulation of the blood. It did not, however, come into much use till after 1900 and then only in the biggest hospitals of the big cities. Between 1890 and 1910 a series of curative steps in Medicine were introduced and perfected which have saved lives and reduced sickness among millions and have rendered large areas .of the world safe for the habitation of all races. Among these were Diphtheria-antitoxin, Typhoid, Plague, Cholera and Yellow Fever vaccines and also the identification of the Anopheles mosquito as the carrier of the malarial parasite. To have lived during these years and, like every medical man, taken a small share in the early use of some was the privilege of my generation. Even now I remember the thrill of watching under the high power of a microscope the mobile typhoid bacilli rallying in clumps against the blood serum of a positive typhoid suspect. To have seen an army in South Africa crippled by typhoid, and fourteen years later to have seen a much larger army, having been rendered immune, free from the same disease, was an impressive experience. But with all this progress, with its reduction of disease and suffering, the end results are not proving entirely beneficial either to the public or to the medical profession in their use of them. The increase of knowledge was so rapid and so extensive that it became impossible for one man's brain to comprehend it all and so the practice of "specialism" came into being. Certain medical men concentrated their efforts on learning all that was known or could be discovered about special organs of the body or special types of disease. This practice proved so popular and lucrative that many have chosen it and avoided the toil of G.P. work. The result has been to establish a privileged class who have acquired a temporary prestige not justified by the teaching and line of action advocated by many of them. They function in the batde of life against disease and death as the Medical Staff of the base establishments of a nation at war — the P.M.O.'s, the A.D.M.S. and such like. Their line of action in dealing with the G.P.'s who are the regimental M.O.'s of civil life is not always helpful. The coaching of all ranks actively engaged in the struggle for existence to be constandy on the alert for any sign of illness, even if they feel well and fit for duty, and to report i "sick without a cause" every few months in case they are sick without knowing it, does not help in the struggle for survival of an army or nation. As we consider all the achievements of the past hundred years they have all appeared to be of enormous benefit to each individual and also to mankind. Almost everyone lauds the progress of medical science, especially the members of the medical profession themselves. But it is possible that some, perhaps many of these achievements may not prove entirely beneficial to the future of all mankind and least of all Page 170 to the favoured nations now enjoying them. It is to point out that some of these methods, once considered essential to sound treatment, are now discarded as useless or dangerous, while others are already under suspicion, that I venture to comment on some of the more recent and other still popular methods of modern therapeutics. There are other results of progress whose influence is already beginning to menace the headlong progress of civilization with vague problems threatening its ultimate decay. Among these latter are birth control among the higher social and wealthier people in civilized nations and the preservation of the mentally and physically unfit among all grades of the social scale. These breed others and so carry on the same defective stock. The success of our efforts to prolong life beyond the "allotted span of 70 years" has become an economic problem. The reduction of mortality achieved by Hygiene through the control of plague, pestilence and famine among the crowded areas of the earth threatens to become an aggravation of the dangerous condition already existing of food shortage and land hunger. Already the virile hungry millions of Asia are beginning to recover their land from the more civilized nations of Europe. Varying Lines of Treatment popular Since 1898 — Some Helpful — Some Harmless and Some Harmful. p%. Before 1900 and for a few years after selective surgical cases were prepared for operation by at least two or three days' stay in hospital, undergoing a course of starvation, purgation and colonic irrigation. This in spite of the obvious fact that many accident cases, brought in drunk or recendy fed, recovered from severe and prolonged emergency operations much quicker and with less nausea and distress than most of those who had received some days' preparatory treatment in hospital. It was a long time before the routine was replaced by the present system of forced fluids and liberal carbohydrate diet. Vaccines and antitoxins were used with success in many infections. Hydrotherapy was popular, the use of hot or cold packs being the usual treatment for noisy and delirious patients. Persistent vomiting, whether functional or organic, was dealt with by the administration of nutrient enemas by nurses. It was an acquired art requiring almost as much skill and more patience than an intravenous injection of saline and glucose. The X-Ray Treatment of the Thymus in Infancy. Already this.procedure as a means of shrinking the thymus and so preventing sudden death in infancy is obsolete. Even as a diagnostic proof of enlargement of the thymus has proved unreliable, and has only shown that the X-Ray shadow of a thymus may vary gready at different hours of the same day. Infants whose thymus glands had been passed as normal either before or after treatment with X-Rays are found dead in their cots a few days later, and show at autopsy a large thymus generally with petechiae showing and most often some acute and early infection of some internal organ of the body present. In Nelson's Pediatrics 1950 Ed., the theory and practice of. empirical X-Ray examinations and treatments of the infant's thymus are pronounced obsolete. What part the thymus gland plays in the mental and physical development of the child is unknown. It is therefore uncertain how much good, if any, has been accomplished by the procedure, and also how much harm, if any, has been caused by the same procedure. The long period of time, about 20 years, during which this process was so popular that it was looked on as almost essential for the well-being of the baby, is difficult to understand. An editorial in the American Journal of Surgery by Dr. G. S. Fahrni in the April, 1954, issue on the "surgical management of Goitre, yesterday and todav", refers to the use of X-Rays as follows: "Enthusiasm for this form of radio- J * - - J therapy for even the hyperplastic type of goitre has been tempered by warnings of the Page 171 V uncertainties of its ultimate result', on other vital functions perhaps remote from the thyroid. The uncertainties as to the effects of such radiations on growth, sex and fertility are some of the questions which will not be fully answered for another two or three decades at least." It is satisfactory to know that the enthusiasm for treating the sensitive tissue of babies' Thymi is also waning with the uncertainty as to the ultimate result of X-Ray radiation on a gland of unknown function. Retrolental Fibroplasia. The revival of a moribund premature infant in an up-to-date heated and oxygenated incubator has been considered by the public as one of the great triumphs of the modern "Pedia-Obstetric Combine". Dr. Alvarez, however, definitely queries the success of this appliance when he describes "a new and horrible disease" unrecognized before 1942. This phenomenon of prgressive blindness is found chiefly among premature babies and almost exclusively from hospitals where oxygen can be run continuously into the incubator. This same disease is described in the British Journal of Ophthalmology of last month by three prominent doctors of the London Institute of Ophthalmology. They describe how this eye disorder was induced in premature laboratory rats by subjecting them to the same oxygen treatment in incubators and it s now believed to be the main cause of blindness in babies. These doctors state that he disease was unknown before 1943 when it was first noticed in the U.S. The lagedy of these sickly babies being preserved for a life of blindness makes one wonder /vhether even scientific knowledge always escapes from the curse of Eve. No doubt with more experience the danger to the baby's sight will be lessened considerably. But also let it be remembered that, in the past, premature babies have survived under the most primitive conditions of cold climate, poor housing, difficult heating with very poor ventilation before the oxygenated incubator had been thought of. It must be very doubtful if the hurried transfer of a baby from a room, where an even heat can be maintained by contact with the mother's body or the use of blankets and hot bottles, to a city hospital by 'plane and ambulance, is always in the best interest of the premature baby, especially if the mother does not accompany her child. A phenomenal wave of popularity following the successes in their use of two new types of treatment for different disease have marked the last 10 years or more of medicine and surgery. The use of Penicillin and the many antibiotics of various breeds have proved examples of that increase of knowledge which has already shown certain unforeseen sequelae suggesting that their use will be much restricted in the next few years. Many breeds of antibiotics seem to have some special danger, unless used with much more caution than was ever necessary in the use of drug remedies of previous generations. It is now known that after a short or prolonged use of one or more of these antibiotics complications may arise more dangerous than the condition for which they had been administered. Allergy is probably the most common and dangerous. Already I have seen the autopsies of two such fatal cases of oedema of the larynx. Permanent deafness from damage to the auditory nerve has occurred. Following the use of certain types of the remedy for some illness, destruction of the beneficial bacteria of the intestine may occur and so allow the pathogenic breeds to multiply unchecked and so originate an intractable fatal diarrhoea or a persistent attack of Pruritus' Ani. Sometimes pathogenic bacilli possess or develop immunity to one or many types of antibiotics, and much time may be lost before this fact is recognized, and other proven remedies neglected till too late for their successful use. Particularly has the extensive use of antibiotics been condemned as the treatment of infants and young children for trivial disorders, thus causing their future use in some future serious illness to be contra- indicated, owing to the allergy established at some previous illness of which there is no record. Routine pre-operative and pre-natal prophylactic treatment are discouraged because of the risk of unfavourable reactions appearing when most unfavourable to the patient's comfort or well-being. Page 172 The Use of A.C.T.H. and Cortisone for Rheumatic Affections. Personal knowledge of the use and abuse of these remedies being nil, the .report of Great Britain's Medical Research Council to Parliament in 1954 is therefore quoted in small part: "Constant medical supervision is necessary because dangerous complications with unexpected and perhaps uncontrollable rapidity" may arise. The most serious dangers listed by the experts are: High blood pressure, heart failure, perforation of peptic ulcer, mental disturbances and the touching off of hidden T.B. Even a normal dose to bring relief from pains in the joints could cause "coarsening" of the appearance, an increase in weight and the growing of superfluous hair. Surely most women would consider a remedy with such dreadful possibilities as a greater risk to happiness than constant pain or partial disability. In May of 1953 the same Research Council reported that after trials there was "surprisingly litde" to choose between Cortisone and Aspirin in the treatment of 61 arthritic cases. In quoting the disappointing and dangerous results sometimes resulting from these lines of treatment there is no wish to belitde the strenuous efforts and great ability which led to their discovery and application. It is desired only to point out how often, after a varying period of time, some unexpected results follow their use which render their further use no longer beneficial and often actually dangerous. The Transfusion of Blood. This is such a wonderful life-saver that it is impossible for me to criticize it as such. The introduction of any latent disease from the blood pool or bank does not seem to be considered a very real danger by those best qualified to judge. Under present conditions of peace and plenty all is well except that an unanswerable precedent for the revival of cannibalism has been established. In a starving beleaguered city it will be unreasonable to expect hungry fighting men to suffer and die for want of protein food when they can get their nourishment orally as cooked rump steaks or other joints from their dead enemies preferably, while the citizens, useless for its defence, are getting their nourishment intravenously from the uncooked blood of their civilian friends if under treatment in a hospital with a solvent "blood bank". It is difficult to deny the fact that to sustain human life by using any constituent of the human body, whether fluid or solid, as a source of nourishment, is a lapse back to barbarism, the more crude in civilized man because he prefers to take his portion raw instead of well-cooked as in a cannibals' feast. The need for an ample supply of human blood for transfusion in future wars and disasters is obvious, unless this line of treatment also gets out of fashion. Even now it is uncertain how long the supply can be maintained to meet the demand. Some donors are being bled too frequendy and, although it is claimed to be a harmless or beneficial procedure by the blood bank organizers, yet the donating of blood by the medical profession personally is not very popular. If blood transfusion facilities are to become a permanent part of our national and civil defence schemes we might as well recognize that donors will have to be obtained by conscription and start typing the population. Then, like jurymen, they can be summoned to attend the blood clinics as required and supply the necessary type of blood to replenish the stock in cold storage. Venereal Control and Progress in Psychiatry. Two prominent American specialists in very different branches of Medicine seem also to fear the end results of the recent phenomnal increase of knowledge. They fear lest all the present benefits to the individual now may not be outweighed in the future by the demoralization of mankind. John H. Stokes, M.D., Professor of Syphilology of Pennsylvania University and V.D. consultant to the U.S. Army, in an article in the Vancouver Medical Bulletin (Jan. 1950) entided "The Practitioner and the Antibiotic Age of Venereal Control" sums up some of the consequences which he foresees from the amazing success of the Page 173 V.D. campaign organized by himself even though not yet as satisfactory as he hoped. I quote a few sentences from the last section, "The Problem of Promiscuity": "And were Venereal Disease wiped out — it is now clear that the accomplishment of this would have heavy costs in the social, moral and material life of Man- it is a reasonable question whether by eliminating these diseases we are not bringing mankind to its fall instead of to its fulfillment. If the physician debases the spirit of man by the methods he employs to save his body he is indeed the Devil's servant." Apparendy Dr. Stokes foresees a Utopia of "Free Love" unchecked by any inhibitions of fear. The appearance of unexpected and unpleasant symptoms in spite of careful prophylaxis as instructed in Government V.D. Clinics would be dealt with effectively and free of charge at these same clinics. With no social stigma, no financial burden and little pain to be endured as the result of sexual indiscretions, he fears that no nation could possibly survive the round of gaieties resulting from such ideal conditions. Dr. Alexander Maclean of the neurological section of the Mayo Clinic and adviser to the U.S. Navy, read an article called "No Appreciable Disease" at the Winnipeg Medical School opening on July 18, 1946. It is difficult to extract the essence of this article without something of importance being omitted. He starts as follows: "The psychiatric problem which this war has brought to a focal point will soon be brought to the public in a manner which cannot be denied nor dismissed. Prior to the evolution of psychiatry a man was judged by his actions in battle which were either courageous, neutral, or cowardly. In fact there were simply courageous men and cowardly men in peace and war." He implies that Psychiatry has proved a serious hindrance to the successful carrying on of a war, by providing a theoretical excuse for anyone who either cannot, or is afraid to, or refuses to face death or extreme hardship. To quote him again: "Psychiatric terminology has been perverted to such uses in the field of Ethics that man can be neither cowardly nor weak and so can never be either courageous or enduring." The crux of the matter is that Psychiatry, having delved deeply into the mystery of the human mind and with the Jcnowledge thus acquired, has seen fit to discard the previously accepted standards by which men were judged as useful to the armed forces of their country in time of war. This has resulted in great loss of manpower by invalidism under the head of "No Appreciable Disease". In sterner times with no knowledge of modern Psychiatry but with the controlling factors of duty and discipline, the fear of the last and terrible remedy, a "firing party", gready reduced the frequency of this difficult problem of modern armies. Dr. Maclean is distressed and anxious about the tremendous issues involved in the management of these problem cases. He obviously fears that the new line of action in dealing wMi them, founded on modern Psychiatry, may be fraught with disastrous consequences to the morale of the army and navy and the safety of the nation. Modern Psychology appears to as often complicate as simplify the course of justice in criminal trials. No matter how obvious the guilt or how heinous the "crime, conscientious psychiatrists of equal reputation can almost always be found on the defence side to declare the accused mentally unfit and not responsible for his actions, and for the prosecution to declare him mentally sound and fully responsible for his actions. We probably all have deep respect for the profound study and investigation into the realms of thought by psychologists and the benefits accruing to individuals and their families. Yet, in the search after justice, the problem of making the penalty fit the crime may prove as difficult and unsatisfactory as in the past eras of "Trial by Combat" or by various superstitious ceremonies. But in the mysterious realms of Neurology and Psychology are found the most encouraging progress in the relief of human disabilities, mental and physical. With Page 174 increasing effectiveness Epilepsy, in all its varied forms, is being controlled and almost eliminated as a potent cause of danger and distress to both the patient and his friends. Barbiturates, especially Dilantin, and in selected cases, Brain Surgery, seem to have accomplished so much for so many that Epilepsy may be considered to have been brought almost under control with no drawbacks to the continued use of the present methods of treatment yet apparent. But even this long-sought ability to release a family from its hereditary spectre may be negatived by the passage of time and the changing conditions of life. Epileptics, controlled by Dilantin almost from birth, will marry and beget children unconscious of family history of their parents and grandparents. In them fits may make their first appearance at some time of personal or national emergency. In either the present or future generation's lifetime, the inability to manufacture Dilantin, etc., or distribute it may result in individuals holding key positions proving themselves unable to be relied on for their own or their companions' safety in peace or war. Progress in Child Welfare. In 1900 the wards of the children's hospital were crowded, as usual, at the end of summer with diarrhoea and vomiting cases. Litde had been done to differentiate excessive sugar fermentation and ptomaine poisoning as the cause of enteritis. Subcutaneous and sometimes intraperitoneal injections of normal saline were being freely used and very many different kinds of fluid diets. London was very backward in acknowledging the existence of such a specialty as Pediatrics. The very word was unknown to me while at G.O.S. Dr. Still was the only physician in all England to limit his practice to the care of sick children at that time. In 1918, while going round the wards with Dr. Still at G.O.S., he told us that he still treated congenital syphilis with mercury inunctions and Iodides, as he considered the injection of Bismuth or arsenical compounds into the veins of infants and young children to be too difficult and dangerous. A year later while going round the Toronto Children's Hospital we were shown infants who were being treated for scurvy and rickets by the intravenous injection of alkalized orange juice through a needle piercing the ant. fontanelle. This method had been devised to replace the successful but too simple method of getting the infant to swallow from a spoon or bottle. Both hospitals had to change their ways, the former to conform to the dictates of scientific progress, the latter to conform to the dictates of common sense. In the centenary celebration book of G.O.S. published in 1952 is this commentary: "Sir Frederick Still must always stand out as the first of our physicians to confine his work to children only — to become what is now styled a pediatrician. It is interesting to note that in his later days he expressed regret that he had set the fashion of pediatric specialism at G.O.S., foreseeing what he felt would be its limitations. There are not a few now who would venture to agree with him." Perhaps he had begun to realize that his successors already were tending to concentrate too much on the weaklings and abnormal infants with the resultant danger of an increasing number of poor stock recovering to ultimately reproduce themselves. Also that with the encouragement of the Obstetricians, who were not interested in the well-being of the baby, the Pediatricians had already begun to instil into the minds of all parents who could afford it, that it was better to have one or two children developed to perfection under the supervision of a real child expert than to have a batch of children dragged up under the care of their mother and any doctor available in an emergency. Repeated changes in the diet of infants announced as essential to the health or even the survival of the child have been tried and discarded. Many diseases have been controlled and others, previously little known, have become prevalent. The average bodily health and physique of the young has improved. Improvement in their mental health and moral standards cannot be so confidently claimed. Page. 175 Even allowing for the increase of population, the ever-increasing need of homes and hospitals for mentally defective children, the increase in juvenile delinquency and "teen age" criminals is a cause for anxiety rather than satisfaction. Education in childhood is designed to instil a state of mind best suited to meet the inevitable problems and anxieties of life. With the alarming increase of mental disorders in young and old, the study of cancer in our schools seems an uncertain way of achieving this desirable state of mind. The giving of prizes to those between the ages of 12 and 16 who have acquired the most complete knowledge of the disease and can best describe it, seems a rather effective way of starting off a group of apprehensive hypochondriacs on their life's journey. Renewal of Hope for the Future. Dr. Carroll in his book, "Man the Unknown", after prophesying the impending fall of our civilization for nearly 300 pages of almost unbroken gloom, finishes with a ray of hope: "For the first time in the history of humanity a crumbling civilization is capable of discerning the causes of its own decay. For the first time it has at its disposal the gigantic strength of Science. Will we utilize this strength and this power? It is our only hope of escaping the fate common to all the great civilizations of the past. Our destiny is in our hands. On the new road we must now go forward." Some of us feel that the fact that we hold in our hands the gigantic strength of Science does not necessarily give us complete control of our own destiny. Meanwhile we can only continue to do our best as our predecessors have done to the best of their ability. The surgeons in the middle of the last century thought that there was nothing left to learn. When Lister, who had been assistant to Syme, then considered the greatest of British surgeons, asked him for the hand of his daughter, Syme replied to him that "it was too bad that Lister should be going into Surgery just at that time when the outlook for any progress in it seemed quite dark. A man could not hope to make a great name for himself because he could only do what others had done before him as surgery was at its Apogee." A few years later Lister had revolutionized surgery. Along the same line Osier quotes as follows: "Let no man be so foolish as to think he has exhausted any subject for his generation. Virchow was not happy when he saw the young men pour into the old bottle of cellular pathology the new wine of bacteriology. Lister could never understand how aseptic surgery arose out of his work. Ehrlich could not recognize his epoch-making views on immunity when his generation had finished with them. It was Hegel who said that progress was a series of negatives, the denial today of what was accepted yesterday, the contradiction by each generation of some part at least of the philosophy of the last." Finally—Whether we have done well or badly in this batde of life with its uncer- tain and disproportionate rewards and penalties for similar actions, we shall all hope to be among those judged as having been "good workmen" in the opening verse of Kipling's poem L'envoi: "When Earth's last picture is painted and the tubes are twisted and dried, When the oldest colours have faded and the youngest critic has died, We shall rest and faith we shall need it — lie down for an aeon or two, Till the Master of all good workmen shall set us to work anew." "OSLER DINNER AND LECTURE" The Annual Osier Dinner of the Vancouver Medical Association will be held on Tuesday, March 1st, 1955, in the Banquet Room of the Hotel Vancouver. Dr. Donald H. Williams will deliver the Osier Lecture and has chosen as his subject "The Maimonidean Code". The 1955 Prince of Good Fellows Degrees will be awarded during the evening. Page 176 ARGUMENTS FOR AND AGAINST THE LEGAL SALE OF NARCOTICS || S| By G. H. STEVENSON, M.D. Drug addiction has been an increasing problem in British Columbia in recent years and a cause of concern to the general public, the merchants, the police, the courts, the provincial government and the medical profession. In spite of very diligent efforts on the part of the police and the courts, the number of addicts in the province appears to be on the increase and there is obviously a large illegal traffic in narcotic drugs to supply their demand. It is estimated that there are 5,000 addicts in Canada, nearly 2,000 of whom are located in British Columbia. Convictions in British Columbia under the Opium and Narcotic Drug Act amounted to 265 in 1953, and were 66 percent of all such convictions in the entire country. Ontario, with 3^_ times the population of British Columbia, had only 99 convictions in 1953 (and only 70 in 1952). The reasons for the unduly large proportion of addiction in British Columbia are complicated and need not be gone into fully in this paper. However, it should be noted that more than 70 percent of British Columbia's addicts began their addiction in this province (almost all of them in Vancouver) and there now exists in Vancouver an increasing colony of addicts who have what appears to be a dependable black market supply of their drug addiction—heroin. Most of the men of this colony support themselves by illegal means—shop-lifting, theft, breaking and entering, and by selling ' narcotics periodically, whereas the women, who constitute one-quarter to one-third of the total number, support themselves largely by prostitution and by assisting the men in criminal activities. There are some addicts who hold regular employment for varying lengths of time and most addicts have had periodic employment. However, it is obvious that such a large group of relatively unemployed and delinquent people must cost the citizens a large annual sum of money in stolen goods, police and court prosecutions and maintenance in prison. It might be mentioned at this point that some people believe there is a large body of non-delinquent addicts in the community, who are presumed to work steadily and to be otherwise well-adjusted persons. The writer has not been able to find heroin or morphine users in this category. There doubdess are a few such persons, chiefly in the medical and related professions, but anyone who has had professional relationships with such persons realizes their erratic undependability and the hazard they are to their patients when under narcotic influence. There are also non-delinquent persons addicted to the barbiturates and pethidine (demerol), who secure their supplies on medical prescription. These substances are highly addictive and physicians need to I be aware of these dangerous features in prescribing them. As addictions, they can be more damaging to the unfortunate user of them, than the more common drugs of addiction — alcohol, morphine, heroin. The failure of the police to prevent a steady flow of illicit narcotic drugs to the addicts and the failure of prison sentences to cure them (most addicts return to narcotics soon after leaving prison), coupled with the steadily increasing numbers of addicts in British Columbia, have led the public to seek some other solution to what has so far been an insoluble problem. The methods proposed by the Committee of Addiction of the Vancouver Community Chest and Council1, in their report of July, 1952, supported in December, 1952, by a brief to the Federal Government were mainly (1) amendments to the Opium and Narcotic Drug Act to make a distinction between traffickers and users, (2) the setting up of treatment and rehabilitation facilities for addicts who want to be cured, and (3) the establishment of "narcotic clinics" where registered addicts might legally receive narcotic drugs in "minimum required dosages". At this point it might be stated that the Federal Government has increased the penalties for illegal trafficking in narcotic drugs2. A request has also been made re- cendy to the British Columbia Government by the Vancouver Community Chest for Page 177 the authorization of payment to hospitals for withdrawal treatment of addicts and for the seating up of rehabilitation facilities. No action, however, has been taken by the Federal Government to permit the establishment of "narcotic clinics" where addicts might obtain drugs legally. What are the arguments for the establishment of such clinics ? The Chest's Committee Report states some of them: "3. The Federal Government should be urged to modify the Opium and Narcotic Drug Act to permit the provinces to establish narcotic clinics where registered narcotic users could receive their minimum required dosages of drug. "The establishment of this register of narcotic addicts would maintain a constant check-up on the number of addicts by any community. It would also protect the life of the addict and support him as a useful member of society. The assistance would hasten his rehabilitation, or at least reduce the amount of his addiction since many of the stresses of the addict's life would be reduced. "This action would within a reasonable time eliminate the illegal drug trade. The decision to modify the Opium and Narcotic Drug Act in this waw would be most violently opposed by those who profit from drug trafficking, and one should expect opposition and interference from such criminals. Nevertheless, no addict will willingly strive for $20 to $50 per day through criminal activities, if unadulterated drugs could be obtained for a few cents at a government-operated clinic. The operation of such clinics would not entail any reduction in the vigilance of law-enforcement agencies." Addicts themselves enlarge on or add to these arguments as follows: 1. If drugs were legally available, the cost of drugs would be nominal and the addict could easily support a modest habit from his wages. 2. He would not be in constant conflict with the police nor would he be sent to gaol. 3. Absence of police arrests and gaol sentences would enable him to work steadily, advance in his work and maintain himself and his family in respectability. 4. Employers are reluctant to employ anyone with a record of gaol sentences, especially addicts, a situation which legal sale would obviate. 5. If he could buy his drugs legally, he would not have to pay the exorbitant prices demanded on the black market (the only market now available) and which, to pay, he has to secure money illegally, as the average habit of four or five capsules a day costs him at present at least $15 a day and up to double that amount. 6. Lengthy gaol sentences interrupt work and family life and force the addict into a continuous life of crime. 7. The addict states that he is less of a danger with heroin in him than he or other people are with alcohol in their circulation. He contends that with heroin he only wants to be quiet and relaxed, whereas the alcohol user is apt to be aggressive, quarrelsome and dangerous. 8. If drugs were legal they would lose their glamor and adolescents would not be^ attracted to them as they are now. Some addicts claim, too, that having learned to like narcotics, they resent the legal prohibition and are all the more determined to get them, in much the same way as in the days of alcohol prohibition, when many people thought it smart to outwit the police, patronize the bootleggers and generally show their defiance of the alcohol prohibition law. These arguments sound attractive. Nearly every addict quotes them and believes in them. Many people believe that legal sale is the answer to them. Books and articles favoring legal sale have been published3-4. The Chest's recommendations were supported by quite a number of groups, as well as certain newspapers, some newspapers, some members of parliament and of the provincial legislature. Support Page 178 of the plan of legal sale rests on the apparent reasonableness of these arguments, the increasing number of addicts in British Columbia, the increase in crime which is attributed to addicts, and the failure of the police to prevent a large black market in Vancouver. A part of the support may be due to the belief that narcotics may not be as harmful as is commonly believed. There are those, too, who, holding such a belief, consider it only fair and right that a person who prefers morphine or heroin-to alcohol has as much right to them legally as he has to alcohol legally. It should, of course, be stated that this recommendation of the Chest's committee was not a de novo recommendation. Legal sale in various forms has been known and practiced in various countries for many years, even centuries. The best known example of extensive legal use of narcotics (in this case, opium) is China5-6-7-8-9-10, where over 200 years opium smoking was openly indulged in. True, from time to time, Imperial edicts were issued forbidding the smoking of opium, but these were never seriously enforced, and by the treaty of 1858 between China and England, opium was legally imported into China for smoking, and continued to be legally used until well into the 20th Century. It might be mentioned at this point that the actual deleterious effects of narcotic drugs, on the individual user as well as on society generally, are also a matter of controversy. That the Chinese government should repeatedly try to stop opium smoking by its nationals implies that the government must have come to the conclusion that opium smoking was a bad thing. They believed it exerted a deteriorating influence on the users and that it conduced to national poverty and social degradation. Suffice it to say here that the habitual use of narcotics has unfavorable effects on both the individual and society, but that these effects have been largely over-stated by the opponents of the use of narcotics. Compared with a very commonly used narcotic, alcohol, the deleterious effects of the opium derivatives may be qualitatively and quantitatively less than those of alcohol. In their habit forming propensities, however, and in the narrow margin of safety between social use and addiction, the opium group is more hazardous than alcohol, but in all other respects, alcohol may be the more dangerous of the two. Beg! This uncertainty concerning the actual deleterious effects of the opium group is responsible for the two extreme points of view held in Canada at the present time. The Opiu mand Narcotic Drug Act has been framed with the concept that narcotics are highly dangerous, that society has to be protected against them, and that persons who illegally secure narcotics, even minute amounts, must be punished severely, a minimum compulsory gaol sentence of six months being mandatory, with maximum sentences up to seven years for illegal possession of drugs, and up to 14 years for trafficking. On the other hand, people who favor legal sale of narcotics have presumably come to the opinion that narcotics use per se is not too serious a matter, to either the individual or society, and that people who prefer heroin to alcohol should have the legal right to the drug of their preference, under properly and legally supervised conditions. In this connection, it might be noted that many careful observers in China were of the opinion that opium for the Oriental was much the same as alcohol to the Occidental, that either could be abused, but that the majority of both races used their favorite drug in moderation without unfavorable consequences. Reverting to previous experiences with legal sale of narcotics, it might be noted that the United States had no national law prohibiting narcotics until early in the present century (the Harrison Act was passed in 191411), and the use of drugs was completely legal (except for local ordinances) all during the 19th Century. Whatever drug addicts there were in the eastern United States during much of that time had become so largely through medical treatment of physical disorders, whereas on the west coast, drug addiction was largely confined to Chinese, who had been admitted to the country as a labor corps, and who had brought their opium smoking tendencies with them. They were permitted to import all the opium they wanted to use, with Page 179 only a customs tax on it. Opium smoking spread in the 1860's and 1870's to the west coast underworld, and drug addiction as an acquired habit was quickly adopted by them12. The reasons for the very severe legal penalties adopted in the early part of the present century are not clar, but fear and horror of drug addiction appear to have been partially responsible, as well as the belief that the use of narcotics not only branded the user as a worthless and vicious person, but also was responsible for causing much crime. The remarkable difference of opinion in the U.S.A. as to the actual deleterious effects of narcotics was shown by the setting up of "narcotic clinics" in many cities of the United States about the year 193913. Much the same reasoning was given then, as now, that legal sale of narcotics to registered users would reduce crime, would enable the user to get his favorite drug at reasonable cost and would allow him to work regularly, and that illegal sale of drugs would be abolished. These "clinics" functioned until about 1923 and were finally all abolished, the results having been unsatisfactory. It is only fair to state that there were some people who felt the experiment had not been tried long enough and that the results were not invariably unfavourable. In those "clinics", too, the addict was given a supply of drugs to take with him, to be self- administered when desired, a situation which led to abuses, and might not be a part of the thinking for the "narcotic clincs" as envisaged by the Vancouver Chest's Committee. The chief defects of these earlier narcotic "clinics" might be listed as follows: 1. "Clinics" brought criminals and drug addicts from areas where no "clinics" were available, increasing the number of idle, delinquent and prostitute classes in the cities where there were "clinics". 2. No attempt was made to cure addicts. The "clinics" were merely dispensaries for issuing drugs. Because of the peculiar need for increasing the dose of the opium products to get a pleasurable effect, addicts were constandy demanding larger and larger amounts. There could be no "basic minimum dosage" which would satisfy the addict. 3. The illegal drug traffic continued to flourish. Addicts who wanted more drug than the "clinic" would allow, patronized the illegal trafficker. 4. As the addict group were not generally employed, crime continued to supply addicts with additional money for their added drug supply. 5. Prostitution flourished openly in the areas where "clinics" were located as most, women addicts, then as now, were prostitutes and supported themselves in this way. 6. Addicts would register their non-addicted wives and friends as addicts in order to get the supplies which would be issued to them. 7. Addicts would move from "clinic" to "clinic", or fr*om town to town, where "clinics" were located, hoping to increase their drug allotments. It will be noted that the word "clinic" is used in quotation marks in these comments. This word ought to have some medical or treatment connotation, but as used in the "clinic" experiment in the United States it had no such meaning. True, these so-called clinics were operated under medical supervision but no attempt was made to treat the addict for his addiction. They were, in fact, nothing more than legal oudets for the sale of narcotics to addicts. It is likewise difficult to see how the "clinics" advocated for Canada could be anything different. One might as well call a beer parlor or a liquor store by the name of "alcohol clinic". Another nation which is commonly quoted as proof of the workability of legal sale is Great Britain. Addicts frequently ask, "Why can't we have the.same system they have in England?" The implication is that addicts can get their drug requirements in England legally (and without cost through the National Health Scheme) and that they can be employed regularly and avoid the hazard of arrestand imprisonment. Page 180 What is the English "system"? In the first place it needs to be remembered that Britain has never had a drug addiction problem of comparable size with that of Canada or the United States, reporting to the U.N. Commission on Narcotics only about 300 recognized addicts in a population of 45 million. It has never had a large influx of opium-using Chinese, as have Canada and the United States. Britain has an underworld, but narcotics have never become common among its members, and are virtually unknown in the prison population of Britain, as contrasted with the prison population of Canada, where 15 percent or more of prisoners in British Columbia are or have been drug addicts. British authorities have never allowed narcotics to get a foothold on the people, other than those who became, medically addicted by physicians as a part of their treatment for physical diseases. For example, in 19th Century England, opium was freely administered for tuberculosis and not a few people became chronic drug users as a result. Also in the 19th Century, a few literary people became self-addicted, usually claiming physical reasons for starting, and De Quincey's "Confessions of an English Opium Eater"14 is a good study of a member of this group. The point to be emphasized is that there is no real parallel between the drug addiction problem as between Britain and Canada, and there need be no similarity in the methods of handling their respective problems. But it is important to understand the English "system" for the additional reason that some advocates of legal sale of narcotics do not favor the "narcotic clinic" idea but favor legal sale through physicians. One of the most earnest advocates of legal sale in British Columbia invariably emphasizes and recommends what he calls the British "medical, treatment" method. He would have addicts get their required supplies through physicians who would be authorized to supply prescriptions for them. That is, of course, a serious debasing of the concept of "medical treatment", as it is the duty of physicians to treat patients in the hope of ameliorating or curing the pathological condition. To ask physicians to be dispensers of narcotic drugs is to ask them to take on the function of the "beverage room" or liquor store. That this plan has earnest advocates is due not only to their belief in its efficacy and to their belief in the non-injurious effects of the usual opium group, but also because these persons realize that the "narcotic clinics" plan advocated by the Chest's Committee on Addiction would present tremendous difficulties of operation. Where would such "clinics" be located? Would every town be required to have one? Would they be open 24 hours a day? Who would pay for their upkeep? Would they be in every province? If a person lacked funds to pay for his drug would he be given it without charge? Would the addicts have to be given the drug in the "clinic" if self, or would he be allowed to take drugs to his home for self-administration? Even if Parliament approved such a plan, it would probably be the responsibility of each province to implement it or to decline to implement it, and what would happen if British Columbia alone implemented it and set up "clinics" in the larger centres? Would drug addicts come to British Columbia from all other provinces not having such "clinics"? If an addict wanted cocaine, could he get it from the "clinics"?. If an addict moved from Vancouver to a small town in the interior, how would he get his drugs in this new location? Would the proposed register of addicts be closed when all current addicts were registered, or would it be opened periodically to include new addicts who had become illegally addicted in the interval? Moreover, if legal sale were approved for Canada, would this mean that ex-addicts, having completed their sentences in gaols and penitentiaries, would be permitted to resume their addiction legally through "narcotic clinics" or by physicians' prescriptions? Why should ex-addicts be encouraged to resume their addiction? The alternate proposal of making the medical profession the official dispensers of drugs would do away with all these problems just enumerated, because physicians are located in all parts of all the provinces. In other words, drug oudets would be already established in the physicians' offices, if physicians were authorized or required to Page 181 supply narcotics to addicts. Is it conceivable that the medical profession would consent to become a legal oudet for narcotics to addicts, merely to perpetuate their addiction? The only proper relationship of the physician to the addict is that of helping the addict to overcome his addiction. Physicians are entided to treat addicts, but treatment can rarely be expected to be successful by the ambulatory method or by office practice. Hospital facilities with security provisions, skilled nursing, constant medical supervision and treatment are all essential, followed by an adequate rehabilitation program. To return to the English "system", it should be stated at once that England does not encourage, or even permit, the administration of narcotics to addicts for the purpose of addiction only. There must be sound medical reasons for a physician to administer narcotics to a patient, or to issue a prescription for them. If prescriptions are issued, they are treated the same as any other prescription and are filled by the druggist without direct charge to the patient under the provisions of the National Health Scheme. Nevertheless, it is true that under certain circumstances drug addicts can receive regular supplies of narcotics on medical prescription. No register is kept (as is recommended by the Chest's Committee), but each physician treating an addict must report the addict by name to the Home Office, and the physician is obligated to do his best to cure the addict of his addiction. If narcotics are to be administered over a considerable time, the physician is expected to have a second physician consult with him on this matter. If he learns that the addict patient is getting additional narcotics from another physician as well, he is expected to discontinue treatment and report the circum- sances to the Home Office. These regulations are related to the "Dangerous Drugs Act"15, under which act narcotics are controlled. Under this act a "Memorandum as to Duties of Doctors and Dentists"16 has been prepared which instructs such persons on their responsibilities in prescribing narcotics to addicts. The following quotations are from this "Memorandum": p. 4. "The continued supply of drugs to a patient, either directly or by prescription, solely for the gratification of addiction, is not regarded as a medical need'." p. 8—sec. 28. "A doctor who obtains, attempts to obtain, or who administers or supplies them (i.e. narcotics) otherwise than for the purposes of bona fide medical treatment commits an offence against this act. The abuse of this authorization in order to obtain drugs for the gratification of addiction is an example." p. 10—sec. 51. "Morphine or heroin may properly be administered to addicts in the following circumstances, namely: (a) Where patients are under treatment by the gradual withdrawal method with a view to a cure. (b) Where it has been demonstrated, after a pronlonged attempt at cure, that the use of the drug cannot be safely discontinued entirely, on account of the severity of the withdrawal symptoms produced. (c) Where it has been similarly demonstrated that the patient, while capable of leading a useful and relatively normal life when a certain minimum dose is regularly administered becomes incapable of this when the drug is entirely discontinued. p. 10—sec. 52. "Precautions in the Treatment of Addicts by the Gradual Withdrawal method. 'In these cases the primary object is the cure of the addiction if practicable. The best hope of cure ... in a suitable institution or nursing home... (or) the practitioner... attempt to cure his condition by steady, judicious reduction of the dose.' p. 10—sec. 54. "Precautions in Treatment of apparently incurable cases (these, cases under (b) and (c) of sec. 51 above). 'In all such cases the main object must be to keep the supply of the drug within the limits of what is stricdy necessary. The practitioner must therefore see the patient sufficiently often to maintain such observation of his condition as is necessary for justifying the treatment.'' Page 182 It will be seen from the foregoing that the English method of dealing with drug addiction can by no means be equated with "legal sale" or "narcotic clinics". Moreover, it must be realized that the rarity of drug addicts in England is coupled with a traditional belief, not substantiated by actual experience, that some addicts cannot be cured because of their suffering while on withdrawal treatment and that some may need narcotics in order to work. With our vast experience on this continent, we realize that English concern with such possible hazards and difficulties is completely unwarranted. Withdrawal treatment can be performed in a few days in practically every case and without undue suffering on the part of the patient. Moreover, every addict can work better after he has discontinued the use of narcotics and has had a reasonable convalescence than he was able to do while he was addicted. When one sees the way addicts improve in weight and in their general health following discontinuance of narcotics, and how much better they are able to work, one realizes the lack of need for such over-cautious handling of addicts as is the custom in England. Even if Parliament were willing to amend the Opium and Narcotic Drug Act to permit legal sale, it would have to forego its obligations in the United Nations pacts to which Canada is a signatory, and in which Canada and the other signatories are pledged to fight drug addiction. This has been well set out in a paper by Mr. R. S. S. Wilson17, published in the Vancouver newspapers in reply to the Chest's Committee's report. It has also been noted in a paper by Mr. G. W. Cunningham18, U.S. Deputy Commissioner of Narcotics. True, there is no reason why a nation might not adhere to its United Nation commitments and still try out new methods of managing its addiction problem, but the method proposed appears to be in contradiction to Canada's international commitments. There is very grave doubt that permitting addicts to receive drugs legally would actually result in good employment results or any sizeable diminution in crime. The "narcotic clinic" experiment in the United States gave no support to these theories. Moreover, detailed studies of the employment and delinquency records of British Columbia addicts indicate that these poor records are not the result of narcotic use, but largely preceded their use of narcotics. More than 70 per cent had unsatisfactory work records before they started on drugs and an even larger group had been delinquent before starting on drugs. Certainly the continued use of narcotics under present circumstances does tend to increase still further the addict's unsatisfactory social adjustments, but it should be made clear that basically their unemployment and crime records are not caused by drugs but preceded their drug use. There is no reason to think that by allowing addicts to be chronically under the influence of narcotics, they will improve their capacity for work or change their lifetime habits of delinquency. It is also worth noting that 75 per cent of the group were heavy users of alcohol before starting narcotics, and had not infrequently been in trouble because of alcoholic excesses. This data on the occupational history, delinquency records and alcohol use of drug addicts both before and after starting narcotics is very important because it indicates that drug addiction is not an unfortunate habit acquired innocendy, but is part of a general personality disorder. There is no reason to think that simply curing the addict of his addiction, or on the other hand, supplying him with all the drugs he wants at minimum prices, will solve his problem. In both cases there is the underlying personality distortion and antisocial tendencies which have to be recognized and dealt with. Supplying the addict with free or low-cost narcotics cannot be expected to change him into a mature, socially well-adjusted citizen. Whatever chance there is of helping him will have a better likelihood of success if he is first freed from narcotic domination. The next argument for legal sale is that it would eliminate smuggling and the illegal traffic generally. This surmise sounds as if it might be theoretically correct except for the fact that legal sale, under whatever form, never has defeated the Page 183 illegal traffic. Legal sale in China and other Asiatic countries went parallel with illegal sale. In China, as indicated time and again in books dealing with the opium problem there (4, 5, 6, 7, 8, 9, 10) the illicit traffic was always functioning successfully in spite of severe penalties at times, and even when drugs could be purchased through legal channels. In Hong Kong, where opium was sold by the Government to addicts, only 800 applied for legal opium as compared with 68,000 addicts who obtained drugs from illicit sources. (Quoted from Narcotic Clinics in the United States.) The same circumstances prevailed in the United States when opium and other narcotics were legally available. In a one-year period in the 1920's when these clinics were in operation, the volume of illicit peddling of narcotics reached the point where 71.151 ounces of narcotic drugs were seized in the domestic illicit traffic—or more than 14 times as much as was seized in 1952. (Quoted from Narcotic Clinics in the United States.) Theoretically, the addict would get his rationed supply from the "narcotic clinic", but it is one of the certain facts about heroin use that larger and larger doses are required, because of the peculiar mechanism of "tolerance." To get the desired effect the dose has to be steadily increased. Unless the "clinic" is to sell the addict as much narcotic as he requests, he must go to illegal sources for the amounts he wants. The legal outlet becomes a sure source for only his minimum purchases. The illegal traffickers will still supply the excess he wants at prices which would still involve the addict in crime to secure money for its purchase. Moreover, the addict would still have difficulty maintaining good employment because employers know that the average addict is, to say the least, an unstable personality. If an employer has to choose between a person taking drugs (legally or otherwise) and a non-user of equal ability, he would choose the non-user. True, the employer might never know that the addict was such but it is difficult to keep a matter of this sort a secret. The legally addicted addict would still be an addict, and would still consider himself discriminated against if he lost his position or was unable to secure remunerative employment, and, as at present, might readily revert to crime and heavier drug purchases from the illegal market. The argument that the heroin user is less intoxicated and less of a menace than the person under the influence of alcohol is a sound one. It is vitiated, at least in part, by the fact that the user of alcohol seldom is under the influence of alcohol while at work,- reserving his evenings and week-ends for drinking. But the heroin user has to take several "fixes" a day, which means that he is chronically under narcotic influence, sleepy, indolent, careless and lacking in energy, or he is having distressing abstinence symptoms which again interfere with, his work and require him to interrupt his work to re-intoxicate himself. The argument that if drugs were legal they would lose their glamor and would not appeal to adolescents is very questionable. Legal sale of alcoholic beverages has not made them unattractive to our adolescents. There is no reason to think that teh predisposed persons who become today's addicts, and who become so in adolescence or early adulthood, would not have become drug users if narcotics had been legally procurable. Supportive evidence for this assertion is that 75% of this series of narcotic addicts had already become heavy users of alcohol (which is also, of course, a narcotic), even though alcohol was legally available. If morphine was available through legal sale there would undoubtedly be an increase in the number of people who would want to use it. It should be admitted that there is nothing essentially evil or criminal in the taking of a chemical substance which tends to relieve stress and strain (19, 20). Tobacco has some such effect in times of tension or as a relief from ordinary stresses. Alcohol has still more of an effect in promoting relaxation. Both of these Page 184 chemical substances can be used legally with no loss of social prestige if used within reasonable limits. The opium derivatives are also sedatives and relaxants and are preferred by some people over alcohol. To label such persons as criminals and to sentence them to prison merely for having in their possession minute amounts of these chemical substances can be regarded as very severe treatment of them. And there is no doubt that prison sentences often tend to make the prisoner resentful and hostile. They cause him to lose his employment and break up his home, and may be determining influences in leading an otherwise non-criminal person into a lifetime of crime and prison sentences. The drug addict has a real grievance, but it should not be assumed that legal sale of narcotics is the answer. And legal sale of the narcotics, alcohol, does not in itself justify the legal sale of another narcotic, morphine, even though the effects were no more than the effects of alcohol. While most people can and do use alcohol moderately, it should be realized that the world pays a tremendously high price in money spent, accidents induced in part by alcohol, physical disease caused by alcohol and homes broken by addition to this alcoholic drug. But because most of us demand the right to use it in moderation, we accept ethprice. Canada has approximately 5,000 narcotic addicts. It has more than 100,000 alcohol addicts, and a great many more who are periodic hazards to themselves or to others through over-indulgence. Do we want a similar problem through narcotics to that caused by alcohol? While it needs to be appreciated that the 5,000 narcotic addicts are what they are largely through personality defects, inherited or acquired by unfortunate conditioning in childhood, nevertheless, merely because these 5,000 people (or most of them) demand legal sale of narcotics is not a sufficient reason for granting that request. They should be helped not only to be relieved of their drug addiction but their other anti-social propensities as well. With few exceptions they have been anti-social from an early age and have not accepted the responsibilities which the average citizen is required to accept and conform to. It is obvious that there is no ready or easy answer to the addiction problem. As most addicts have had unfortunate home and parental influences during childhood, constant efforts should be made to improve the home life of our children. The immediate needs are for still more vigorous efforts by the police to combat the illegal traffic in narcotics. This problem is extremely difficult for a variety of reasons but should not be insoluble if enough planning and effort goes into it. In wartime, solutions were found to more difficult problems. Another urgent need is for treatment facilities. Most addicts desire at times to be rid of their addiction, but the curious fact remains that with the largest addiction problem in Canada, British Columbia has steadfastly refused to provide treatment facilities. There is hpoe that this situation will be rectified and the medical profession is urged to support such plans. Most addicts are not without good intelligence and some attractive personality characteristics. If these assets can be salvaged, not only will the numbers of addicts be decreased but there will also be the likelihood of reducing the number of young people who might otherwise become addicted, as addiction usually spreads by contact between addicts and predisposed young people. The attempt has been made in this paper to present as comprehensibly as limited space permits, the arguments for and against the legal sale of narcotics, with certain historical and critical comments. Although these arguments have been presented as objectively as possible, for the information of the medical practitioners of the province, it will nevertheless be obvious that the writer has been brought to the conclusion that the proposal for legal sale of narcotics, if adopted, would not not only fail to solve the addiction problems but would actually make them more serious than they are at present. BIBLIOGRAPHY (1) Drug Addiction in Canada: The Problem and Its Solution. Community Chest and Council of Greater Vancouver. Committee on Narcotics. Page 185 (2) The Opium and Narcotic Drug Act, Canada, 1929 ,with Amendments to 1954, Queen's Printer, Ottawa. Opiate Addiction, Alfred Lindesmith, The Principia Press, Evanston, 111. 1946(?) Make Dope Legal. Alden Stevens, Harpers Magazine, November, 1952. Survey of Opium Smoking Conditions in the Far East, H. L. May, Foreign Policy Association, 1927. Japan and the Opium Menace, F. T. Merrill, Foreign Policy Association, 1942. Drugging a Nation, Samuel Merwin, Fleming H. Revell, 1908. Senate Report No. 6, U.S. Official Documents 1905—Report of Committee, appointed by the Philippine Commission to.investigate the use of opium (in Far East). The Trail of Opium, Margaret Goldsmith, London, Robt. Hale, Ltd., 1939. The War Against Opium, International Anti-Opium Association, Tientsin Press, 1922. The Harrison Act (U.S.A.), U.S. Government Printing Office, Washington, D.C. Opium Smoking in America and China, H. H. Kane, G. P. Putnam's Sons, N.Y., 1882.. Narcotic Clinics in the United States, U.S.A. Govt. Printing Office, Washington, D.C, 1953. Confessions of an English Opium Eater, Thomas de Quincey, J. J. Little & Ives Co., N.Y. 1932. Dangerous Drugs Act and Regulations, United Kingdom. Memorandum as to Duties of Doctors and Dentists (re dangerous drugs), H. M. Stationery Office, London, Eng., 1948. (17) Drug Clinic Plan Opposed in Canada, R. S. S. Wilson (included as an Annex in reference (13), Narcotic Clinics in the United States. (18) Shall the United States Adopt a New National Policy of Toleration and Maintenance of Narcotic Drug Addiction?? G. H. Cunningham (not yet published publicly). Flight from Reality, Norman Taylor, Duell, Sloane & Pearce, N.Y., 1949. The Doors of Perception, Aldous Huxley, Clarke, Irwin & Co., Toronto, 1954. Kbumtwcv in atom Sj^mtepifmis tttrluutttg (E&ptaut ifattnmtier'ja Ifmjaij* in tly, jtertftr (Errant unb tit, _fauratiatt $ _iattu_ This book by James Stirrat Marshall and Carrie Marshall is a factual record of Captain Vancouver's famous voyage from 1791 to 1795, and associated subjects. Seventeen pages of old and modern charts are reproduced to assist the reader in following this exciting adventure through the 240 pages of an exquisitely printed and bound book. AVAILABLE NOW AT LEADING BOOKSELLERS If your bookseller does not have it he can obtain copies from TALEX PRINTING SERVICE, 820 RICHARDS ST.,VANCOUVER 2, B.C. Page 186 PUBLIC HEALTH AND MENTAL HEALTH NEWS H G. F. AMYOT, M.D., D.P.H. Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia FIELD TRIALS OF POLIOMYELITIS VACCINE IN BRITISH COLUMBIA In previous issues of this Bulletin (August, 1953, and June, 1954), there has been discussed the various approaches explored in an attempt to secure the control of epidemic poliomyelitis. In the first of these articles it was pointed out that we have failed to secure control of this troublesome infection largely because there are no effective measures of active immunization with which to attempt protection of susceptible individuals and also because we lack specific chemotherapeutic or antibiotic agents with which to attack the causative virus. There can be litde doubt that the development of a suitable therapeutic agent for poliomyelitis would be a great boon to mankind, but we have no reason to believe such a development alone would be the answer to the control of epidemic poliomyelitis. Important in this connection is the epidemiological consideration that in poliomyelitis there is a high proportion of subclinical to clinical cases, so that treatment of the clinical cases alone would leave untouched the problem of the subclinical cases, who would continue to acquire and disseminate the infection. The development of a suitable immunizing agent, which could be used to confer protection on all susceptibiles, is clearly the only effective and practical method of attempting to control this disease. However, such a new immunizing agent must possess certain attributes before it can be utilized first on an experimental and then on a routine basis. More specifically, such a product must be safe, available in quantity, easily administered, and capable of producing durable immunity. Attempts to produce a vaccine suitable for human beings were begun many years ago—indeed, a vaccine of this type was produced as far back as 1930, but had to be abandoned as unsafe for administration to human subjects. Basic research, however, has continued over the years until now; a quarter of a century later, we appear to be upon the threshold of our ultimate goal. During these years we have learned much—how to obtain the virus in quantity and free of neuro-allergenic substances by tissue culture; how to attenuate or inactivate the virus by various biologic _nd chernical methods; and how to prolong the immune response obtained by administration in the form of a mineral oil emulsion. These are the principles underlying the vaccine developed by Dr. Jonas E. Salk, Research Professor of Bacteriology at the University of Pittsburgh, for the Salk vaccine as presently prepared is a trivalent virus vaccine prepared by tissue culture and with the virus killed by exposure to formalin. The safety of the new vaccine has been assessed by three independent series of tests carried out by the manufacturer, Dr. Salk's Laboratory, and the Biological Standards Division of the National Institutes of Health—the U.S. Public Health Service branch which licenses and controls the manufacture of all biological preparations in the United States. In addition, in extensive field trials carried on in the United States, Salk has reported that in about half a million children inoculated, such injections caused no untoward effects. The production of the new vaccine in quantity does not appear to offer any very great difficulties with the technical knowledge presendy available. The Connaught Laboratories in this country have been engaged in preparing a large Page 187 part of the culture fluids for polio virsuses used by U.S. manufacturers of the Salk vaccine and are now in a position to produce the vaccine itself for use here. Administration of the new vaccine is relatively simple—three 1 cc. doses are given subcutaneously or intramuscularly, the interval between the first two injections being one week, with the third injection given four weeks later. With regard to the immunity produced, Salk has reported that those vaccinated have developed significant titres of antibody against all three serologic types of Virus. Although litde is known at present regarding the duration of the immunity conferred, careful follow-up studies are presendy being conducted on those who have received the vaccine and some indication of the answer to this problem may be obtained when the results of the evaluation studies being carried on under the direction of Dr. Thomas Francis, Professor of Epidemiology at the University of Michigan, become available in April of this year. The final answer to this question is, of course, only likely to be available after a lapse of some years of field experience with the vaccine. The fact that the Salk vaccine has already satisfied many of the criteria required \ of a new immunizing agent, together with the promising, if presently limited, results available on its antigenic properties, appear sufficient to warrant the participation of British Columbia along with the other Canadian provinces in field trials of the new product. Arrangements for these trials are now well underway with the vaccine being manufactured by the Connaught Laboratories from funds provided by the Federal and Provincial governments who have contracted to buy the entire production for a limited period even if the vaccine does not come up to anticipated expectancies as regards duration of protection conferred. It will, of course, be necessary for the ; new vaccine to pass Canadian standards for biological products prior to its distribution among the various provinces on a population basis. It is estimated that British ; Columbia will receive approximately 42,000 unit courses. The immunization program will be carried out by local health services and no charge will be made either for the vaccine itself or its administration. It is planned to immunize those whom experience shows to have the highest attack rates for j poliomyelitis, i.e., the 5 and 6 year olds, who can be conveniendy reached through local health services. By attempting to immunize all Grade I school children, irrespective of age, and those entering school in September of 1955 (pre-school round-up group) throughout the Province, it should be possible to obtain maximum protection among these age groups. Since there are approximately 48,000 children involved, the supplies of vaccine available should be sufficient to permit of an 85% acceptance rate among those children in the eligible age-groups. In this connection it is of some interest to observe the wide range of acceptance rates which have obtained in areas where the vaccine has been made available to date. For the United States as a whole last year, the acceptance rate was 60%. Acceptance rates in Canada in 1954 varied from 63% in Manitoba to 93% in Nova Scotia. Since it is obviously desirable to obtain as high an acceptance rate as possible, a widespread educational campaign to obtain the co-operation of parents will have to be initiated at an early date. Further, since this vaccination procedure is still purely experimental, it will be necessary for all eligible children to obtain parental consent. It is hoped to get the vaccination program underway as soon as possible, the timing being dependent on two things: (1) the date upon which supplies of vaccine become available and (2) the necessity for ensuring protection during the ensuing epidemic season. Present expectation is that supplies of vaccine will be delivered to British Columbia probably in early April, which means that the vaccination program will have to be well advanced within a month thereafter, since experience over the years shows that the season incidence of poliomyelitis in British Columbia ordinarily starts to rise around May-June of the year and can be expected to reach a peak sometime in August or September. It is not unreasonable to anticipate that these field trials in the various provinces will afford valuable information regarding the protection offered by the new vaccine Page 188 and, if the results are satisfactory, will pave the way for the general use of the new product. Even if the results in the United States are disappointing or inconclusive, the Federal and Provincial Departments of Health will be in a position to modify or discontinue their plans while their commitment for supplies of the new vaccine will be at a minimum. It is hoped, however, that the people of British Columbia will understand that it is not practical or wise tp prepare vaccine for general use until its value has been fully established. There can be litde doubt that private physicians will, in the course of the new few months, have many enquiries on the subject to polio vaccination directed at them by their patients. Only by a clear understanding of the principles governing the use of the new product can they answer such questions mtelligendy and conclusively and, perhaps even more, encourage the participation of their patients and the public as a whole in- this new venture of preventive medicine. n ewd cut d I/oted Dr. James Kingston is now in pediatric practice in Vancouver. Dr. Ernest Holland is now practising in Princeton. Ih. Walter Hughes is now in Tulsequah. Eh. A. M. Inglis is now associated with Dr. F. P. Patterson in orthopedics in Vancouver. Dr. A.' K. Jacobsen is now practising in New Westminster. Eh. A. W. Lawler is now in T.B. Control in Victoria. Dr. J. R. Siddall is now practising in Burnaby. The following doctors have received their specialty certificates: /. S. D. Burnes, surgery; S. W. Civkin, E.N.T.; J. B. Costello, obstetrics; Henry G. Ehinn, pediatrics; E. E. McCoy, pediatrics; P. L. Masonville, E.N.T.; L. Mirabel, medicine; James Sandilands, medicine; Abraham Satanove, dermatology; Frank D. Wilson, orthopedics. Dr. W. A. Trenholme of Victoria has returned from a holiday in the South Pacific. The Victoria Medical Society held its Annual Dinner on December 3rd. Out- of-town guests included Dr. J. Howard Black, Vancouver; Dr. J. S. Goodbrand of Duncan, and Dr. Alan B. Hall, Nanaimo. Eh. F. G. Stuart has joined the Radiology staff at St. Joseph's Hospital, Victoria. BIRTHS Born to Eh. and Mrs. G. F. Houston of Victoria, a son. FIFTH ANNUAL MEDICAL BALL The Medical Undergraduate Society of the University of British Columbia is happy to announce that plans are well advanced for the Fifth Annual Medical Ball, to be held on Thursday, March 17, 1955, in the Hotel Vancouver Ballroom. The Society hopes that the success of previous years will encourage their many friends in the Medical Profession to lend again their splendid support, so that the Bursaries established from the preceding Medical Balls can be maintained. Page 189 COUGH « "^_&S$il_5^ < iM MMi J _■_. Ilil £> _V_v MM #••1: tt responds to treatment with PINOCODEINE // O Each fluid ounce contains: Pinus strobus 32 gr. (2.1 G.) Prunus virginiana ■. . 32 gr. (2.1 ||G.) Sanguinaria canadensis 4 gr. (0.25 G.) Populus balsamifera. 2 gr. (0.12 G.) Chloroformum 1 min. (0.6 cc.) Codeinae phosphas 1 gr. (65 mg.) (2) Narcotic prescription required. DOSAGE: One or two drams every 4 hours. Packaged in 16 fluid ounce bottles. _tao__t MONTREAL CANADA Page 190 A short while ago we received a cutting from a very good friend of ours, Dr. William Gibson, whose sphere of activity includes a wide sweep, from the University of British Columbia, via the Electro Encephalographic laboratory of St. Paul's, to the Crease Clinic. This cutting was a report of a speech made by an eminent American man of medicine in which he bewailed certain processes of degeneration which he finds in the modern medical profession, as compared with the profession of his day, say thirty or forty years ago. He laments the loss of devotion to the ideals of medicine, the change of emphasis from personal interest to the group methods of practice, mass thinking and so on. In fact, he views with considerable alarm the present-day trends of medicine. We suppose this sort of thing has always gone on — the older generation of practitioners of our art has always tended to deplore the doings of the younger generation—and to look back to the good old days when they were young and in the thick of the fight themselves—and, of course, this does not apply to medicine alone —one hears it in comments on modern art, modern music, modern literature, and so on. We just don't agree with the speaker, however; and we cannot but feel that this attribute is a sign that he is beginning to feel, and to show, his age. There are various signs of "growing old": all the way from Browning, who in his famous stanza "What Is Age?" gives as his criterion "When we shun labour, then only we grow old" down to the bun test. In this one offers a bun to the individual to be tested, an hour before the next meal. If he accepts it, he is still young, no matter what his chronological age. There are other signs of course- not to speak of the mere physical signs of age, which we can all recognise. But we are speaking now, not of somatic age, which we cannot avoid or postpone—but of spiritual or mental age—and we need not always allow this to overtake us too soon. One of the most characteristic signs of senescence in this regard is this tendency to live in the past, ignore or condemn the present, and misjudge or fail to accept the future. The Latins had a phrase for the man who does this, "laudator temporis acti"; the man who praises the time gone by and cannot see anything but inevitable disaster if the present generation does not change its ways (back to his ways, of course). Such a man has entered on the final stages of his life, whether these last one or thirty years—he is static, and mentally he has ceased to live—if life means growth, and sensitiveness to change, as we feel that it does. The truth is that each generation has its own problems, which it must work out in its own way: and it always does this. Those of us who are older, who have to some extent withdrawn from the struggle, had, in our day, to meet our problems and solve them, and we did not get a great deal of help from our seniors—nor can we do much for those who follow us, unless and until our advice is asked. A quotation from Kipling is appropriate here—it comes from "Kim": "We who go down to the burning-ghats clutch at the hands of those coming up from the River of Life with full water-jars." That does not help the burdened water-carrier. Those of us who are growing old have certain lessons, too, that we must learn. One is to accept the fact—that takes most of the sting out of it. Another is that the greatest help we can give, very often, is merely to avoid interference—to withhold advice which nobody is seeking—and to remember what we felt like ourselves in days gone by. Of course, the younger generation will make mistakes—so did we—and will learn from them as we hope we did. Meantime, speaking for ourselves, and from our own perhaps limited point of view, we have no feeling of alarm or anxiety. Page 211 We think the present active core of medicine is very sound and well able to grow and function for itself. We look at them individually and collectively, and they look very good; with as high ideals as our own, with as much sincerity and honesty of purpose—fitting their abilities to their own peculiar needs, the needs of medicine as it is today—and we wish them all the luck in the world. Of course, the idea occasionally occurs to us, that we could do it much better—but that is probably because, after all, we're not so young any more. And so we feel grateful to Dr. Bill Gibson, who started all this—and who takes such a keen interest in so many things, from Osier onwards. That, after all, is the sign of perpetual youth: to keep interested in everything; never to lose our sense of curiosity, of wonder, and of hope. jl * * * We have received many inquiries as to who wrote "Eifty Years the Aftermath." The name of Eh. H. Dyer, the author, was inadvertently omitted. I !_> ii Library Hours: Monday to Friday . 9:00 a.m. to 9:00 p.m. Saturday - ■ 9:00 a.m. to 1:00 p.m. Recent Accessions Anderson's Pathology edited by W. A. D. Anderson. 2nd edition. C. V. Mosby. 1953. Cardiography by William Evans. Butterworth. 1954. Jl|| The Specialties in General Practice by Russell L. Cecil. W. B. Saunders. 1954. Surgical Forum: 39th Clinical Conference of the American College of Surgeons. W. B. Saunders. 1954. Atlas of Operative Technics — Anus, Rectum and Colon by Harry E. Bacon. C. V. Mosby. 1954. Pregnancy Wastage by E. T. Engle, Ryerson Press, 1954. The Second Forty Years by Edward J. Stieglitz. Lippincott. 1953. Symtoms of Visceral Diseases by Francis Pottenger. C. V. Mosby. 1953. Diseases of Women by R. J. Crossen. 10th edition. C. V. Mosby. 1953. Chronic Iliac Pain in Women by H. B. Atlee. C. C. Thomas. 1954. Adas of Exfoliative Cytology by G. W. Papanicolaou. Harvard University Press. 1954. Mayo Clinic Diet Manual by the Committee on Dietetics of the Mayo Clinic. 2nd edition. W. B. Saunders. 1954. Sympathetic Control of Human Blood Vessels by H. Barcroft and H. J. C. Swan. Edward Arnold. 1953. Biochemistry of Genetics by J. B. S. Haldane. Allen & Unwin. 1954. History of the Second World War — Surgery. Edited by Sir Z. Cope. H.M.S.O. 1954. Page 212 AMERICAN COLLEGE OF SURGEONS SECTIONAL MEETING The Fort Garry Hotel Winnipeg, Man. APRIL 25-26, 1955 ALL SURGEONS ARE WELCOME TO ATTEND Non-Fellows — $5.00 Registration. Fellows, Members of the Junior Candidate Group, Internes and residents— NO FEE. Programme will consist of panels, papers and symposia dealing with gastric surgery, plasma substitutes, ureteral transplants, surgical lesions of the pancreas, biliary tract surgery, surgical diseases of the spleen, trauma, and cancer. In addition to the excellent local talent the roster of visiting speakers will include: Earl A. Connolly, Omaha; Richard L. Varco and W. Robert Schmidt, of Minneapolis; J. C. Evans, Rochester, Minnesota; Stanley O. Hoerr, Cleveland; Thomas S. Wilson, Edmonton; Walter C. MacKenzie, Edmonton; R. A. Mustard, Toronto; and Clayton H. Crosby, Regina. PRELIMINARY ANNOUNCEMENT VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL STANLEY PARK PAVILION, VANCOUVER, B.C. JUNE 6th to 10th INCLUSIVE, 1955 «F Speakers: Dr. Ian Aird—Professor of. Surgery, University of London, England. Dr. N. S. Assali—Associate Professor of Obstetrics and Gynaecology, University of California, Los Angeles. Eh. Kenneth Evelyn—Director of the British Columbia Medical Research Institute, Vancouver. Eh. Donald H. WUliams—Clinical Associate Professor of Medicine (Dermatology), University of British Columbia, Vancouver. ** Watch for list of other speakers and subject material. OFFICE SPACE Office space for rent on 6th Street across from Woodwards, New Westm linster. Fu lly fu rnished. $85.00 a month. Phone N.W. 745 Page 213 PULMONARY EMBOLISM By A. K. MATHISEN, M.D. The relatively frequent occurrence in hospital practice of pulmonary embolism as a complication of medical diseases, and a feeling that a number of the deaths caused by this condition was preventable, prompted this survey of patient who had died of pulmonary embolism or in which it had been a definite contributory cause. It was intended to determine, if at all possible, what factors played a part in the development of the thrombosis and embolus and if anything could be learned from this study to reduce the incidence. The cases surveyed were those found in the autopsy records of the Vancouver General Hospital. The three-year period 1951 to 1953 was chosen. Anticoagulants were freely used during this period and the trend to their decreased utilization had not started. During this time there were 3,588 autopsies, which was 70 percent of the total deaths in the hospital. Of these, 155 suffered from pulmonary emboli which was either a direct cause or a contributory cause to their death. This was approximately 4.3 percent, a litde higher than the 3 percent reported in other series of autopsy patients. There were 43 cases suffering from cancer with metastases. Forty-six patients had relatively long established congestive failure and of these three had myxoedema heart disease and 12 suffered from cor pulmonale. Twenty patients had cerebrovascular accidents. There were 20 patients with myocardial infarction, 12 patients with fractured hip; seven had a thrombophlebitis with repeated pulmonary emboli, and there were seven cases of post-operative pulmonary emboli. The great majority of these patients were in the older age group- sixth, seventh or eighth decade — although the youngest was only four months of age. In the 43 patients suffering from cancer with metastases, the pulmonary embolism played a useful role in terminating a fatal illness and preventing further suffering. The origin of the cancer did not seem to play much of a part in the development or predisposition to embolism. Cancer of the lung, gastro-intestinal tract and pelvis were represented in approximately the same proportion as the incidence in which they occur in a general hospital. There were no patients with leukemia in this group. It is doubtful whether preventive therapy would have been justified in any of the patients seen, but if effective therapy for cancers is developed pulmonary embolism as a cause of early death in this group must be considered and prevented. At the present time emboli seem to have taken the place of pneumonias before the antibiotics. In long-standing congestive failure it is perhaps to be expected that pulmonary emboli will eventually develop and this was the largest group, consisting of 46 patients. Most of these had had adequate treatment but did not have the capacity of responding and again the emboli served a useful purpose. It is felt, however, that some patients with congestive failure should be treated a bit more vigorously and the patients should not only be digitalized, as most of these patients were, but also diuretics should have been used. In this group there were a few who had not had the advantage of mercurials. More vigorous therapy might have allowed a litde more activity and perhaps have delayed the production of these emboli. There were three who suffered from myxoedema heart disease which seems a higher percentage than would have been expected. The further slowing of the blood stream as a result of the low metabolism probably predisposed them to thrombosis. There were also 12 patients with cor pulmonale and resulting polycythemia and again this seems a higher incidence than should have been expected in this group. Correction of polycythemia often aids in the treatment of a right failure which results from cor pulmonale and would have decreased the tendency to thrombosis. In the group of 20 with cerebrovascular accident some prophylactic measure would be desirable. From studying the protocol it was felt that considerable recovery might have been expected in a number of patients if their lives had not been shortened by an embolus. Anticoagulants are said to .be contraindicated in cerebrovascular accidents but after the first week I wonder if it would not have been possible to start Page 214 anticoagulants when a definite diagnosis of cerebral thrombosis had been made.. Anticoagulant therapy could then have been continued until the patient could demonstrate whether a capacity for recovery existed and perhaps a number could have been saved in this group. The presence of congestive failure should be carefully treated as in several of these patients there was also some occult ventricular failure present. In the 20 patients suffering from myocardial infarction not one patient had been given proper anticoagulant therapy. One had been treated adequately for two weeks and then it had been discontinued and he died in the fourth week from a pulmonary embolus. Another patient had been treated for one week and he died on the fifth week of hospitalization. Although the average age in this group was 72, there were a considerable number who might have recovered if the pulmonary emboli had not terminated their life, and in only about one-quarter of these auricular or mural thrombi were present which could be incriminated. In a great majority the source of the pulmonary emboli were from a thrombophlebitis of the leg. In this group there were a number of what is called small infarcts which were considered too mild for anticoagulant therapy. There were also several who had early failure and dyspnoea and a few in congestive failure in which the infarct was missed, and this was the reason for not using anticoagulant therapy. It would be difficult to reconcile this group with the present tendency to deplore the routine use of anticoagulant therapy in myocardial infarction. Perhaps the advocates of early activity will say that they are kept too long in bed. However, this was not the case as in the group where the infarct was missed the period of bed rest was only from two to three weeks and a number of them had been at home on merely restricted activity and were admitted only because of their pulmonary embolus. They were thus unintentionally on the therapy as recommended by Russek3 and Levine. It is not felt that the chair treatment would have altered the outcome either in this group. During a period of heavy air raids on London, when the older people with a certain amount of lower limb stasis had to sit in deck chairs in shelters, there was a considerable increase in the incidence of pulmonary emboli which decreased as soon as provision of sleeping bunks became more general and the number of deaths from pulmonary emboli was gready diminished4. There were 12 patients with fractured hips who died from emboli. These were all in an older age group but perhaps a certain amount of prophylactic therapy might have prevented a few of these deaths as the great majority of these patients had been relatively active until they suffered their fracture. Subsequent immobilization resulted in the thrombophlebitis. Perhaps careful attention to the treatment of occult failure and prophylactic anticoagulants is indicated in all elderly patients with fractured hips until the period of mobilization is obtained. In the next group, which contained seven patients with thrombophlebitis, repeated pulmonary emboli and subsequent death, I feel that the therapy might have altered the outcome in the great majority of these cases. Repeated pulmonary emboli occurred and the diagnosis was made in the great majority. Three of them were given adequate dicumarol therapy which did not prevent death. In all of these I feel that death could have been prevented by ligation of the inferior vena cava. So far I have seen seven patients, four of whom had staphylococcic septicemia with repeated emboli who have had the inferior vena cava ligated, with survival of the patients and very few residual complications. Adequate dicumarolization is not a guarantee that the patient will not die from repeated emboli. If after a trial for a short period pulmonary emboli are still occurring, the vena cava should be ligated. It is not as radical a procedure as is generally thought and is worth more general application in a group of patients such as these. There were only seven patients with definite post-operative pulmonary complications which seems a relatively low incidence. As has already been well recognized in the past, age and presence of stasis of any kind seem to be the predisposing factors to the occurence of thrombosis and emboli. In a great number of these patients, prevention might have been considered as meddle- Page 215 some therapy but in a number of these preventive therapy would have been definitely indicated and would have both delayed and prevented a fatal outcome. In treating elderly patients the frequent occurrence of emboli with its disastrous consequences must be constantly kept m mind when therapy of any kind is undertaken. If the -patient has a capacity for responding and if he is to be allowed to demonstrate this capacity to respond to therapy, measures must be undertaken to prevent thrombosis in all patients until the hopelessness of their original condition has been adequately proven. Certainly elderly patients with infarction, regardless of severity, must be treated with anticoagulants until some better prophylactic measure is developed. The figures would also suggest that ligation of the inferior vena cava deserves a wider application, particularly in the younger group with thrombophlebitis and repeated pulmonary emboli. Series have been reported from Paris and Buenos Aires5 where patients in congestive failure have had the inferior vena cava ligated with what they felt were beneficial results. It is possible that most of the benefit they observed is merely in the prevention of pulmonary emboli. The typical clinical picture of demonstrable phlebitis, sudden occurrence of pain in the chest, followed by haemoptysis, was present in less than one-fifth of the patients. Most were diagnosed as pneumonias, or myocardial infarction, or were missed in the gradual deterioration of the patient which the embolus itself actually caused but was ascribed to the primary condition present. The diagnosis is therefore difficult and to reduce the death rate we must depend on prevention rather than diagnosis once embolism has occurred. Fortunately in the group where specific therapy would have been most useful the typical clinical picture was present. In conclusion, I feel that the results from this brief survey indicate that thrombosis and pulmonary embolism are an important cause of death and in many cases are preventable. (1) Collins, D.C; "Pulmonary Embolism." American Journal of Surgery, 33:210-219:1936. (2) Wolff, Louis; "Pulmonary Embolism." Circulation VI: Nov. 1952. (3) Russek, H. I., Zohnman, B. L., Doerner, A. A., Russek, A.S., and White, L. G. "Indication for Dicumeral in Acute Myocardial Infarction." Circulation 5, 707-711, 1952. (4) Coope, Robert; "Diseases "of the Chest", E. and S. Livingstone, 1945. (5) Pedro Cassio and Isidro Perianes; J.A.M.A. 140; 772-774; July 2, 1949. The Faculty of Medicine, University of British Columbia The Simmons and McBride Lecture for 1955 RECENT PROGRESS IN STRESS RESEARCH Professor Hans Selye Director, Institute of Experimental Medicine and Surgery University of Montreal U. B. C. Wesbrook Building Friday, March 25,1955 at 8:15 p.m. FOR SALE Vertical Fluoroscope in Excellent Condition, No Reasonable Offer Refused. Phone PA. 9844. Page 216 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. .Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull : '. Vancouver President-Elect—Dr. E. W. Boak Victoria Immediate Past President—Dr. R. G. Large Prince Rupert Chairman of General Assembly—Dr. G. C. Johnston I Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer f Vancouver Executive Secretary—Dr. G. G. Ferguson Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bonnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. Mac Arthur New Westminster Dr. J. F. Sparling Dr. P. M. McLean Kootenay Dr. S. C. Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall Dr. P. O. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C. Poole Dr. N. J. Blair Chairmen of Standing Committees Constitution and By-laws Dr. Carson Graham, North Vancouver Finance : Dr. R. A. Palmer, Vancouver Legislation__ Dr. E. W. Boak, Victoria Medical Economics : Dr. P. O. Lehmann, Vancouver Medical Education Dr. M. M. Weaver, Vancouver Nominations Dr. F. A. Turnbull, Vancouver Programme & Arrangements ___ Public Health | I Dr. G. R. F. Elliott, Vancouver Public Relations Dr. A. W. Bagnall, Vancouver Chairmen of Special Committees Archives .Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism ■. Dr. J. A. Traynor, Vancouver Cancer Dr. Roger Wilson, Vancouver Civil Defence Dr. John Sturdy, Vancouver Ethics 1 Dr. Wallace Wilson, Vancouver Hospitals I Dr. G. C. Johnston, Vancouver Industrial Medicine Dr. G. B. Helem, Port AJberni Maternal Welfare _ Dr. A. M. Agnew, Vancouver Membership „.Dr. N. J. Blair, Vancouver Nutrition j Dr. J. F. McCreary, Vancouver Pharmacy Dr. B. T. Shallard, Vancouver Rehabilitation Dr. W. J. Thompson I TOWARD AN EFFECTIVE MEDICAL ORGANIZATION By FRANK TURNBULL* "J| Abridged from Speech to Victoria Medical Society February 1, 1955 Introduction. Periodic health examinations are just as important for organizations as for individuals. Three years have passed since the C.M.A.-B.C. Division was reorganized. At the teen-agers say, "how are we doing?" How can we assess its present standard |of health or efficiency? One might take a poll of our members and record their enthusiasm, indifference, or condemnation. Or one could have efficiency experts make time-motion studies on our office staff, and aptitude tests on our officers. These are laboratory methods, and our medical training would warn us to be skeptical of [the results. We are on more certain ground if we look direcdy at the patient. So tonight I would like to make some observations about the C.M.A.-B. C. Division in action. The organization and operation of a Provincial Medical Association is analogous |to the set-up of the federal or provincial governments. This government analogy is 'President, C.M.A. — B.C. Division. Page 217 h usually satisfactory, but does not always fit because sometimes an Association acts like a corporation. Let me illustrate. The General Assembly, which is made up of eighty to one hundred members, is a sort of Parliament. Its chief purpose is to decide about matters of policy. About half of the members of Assembly are elected, on a proportionate regional basis. The rest are ex-presidents, committee chairmen, chairmen of sections, etc. The common denominator is representation. No one is a member of the Assembly because of his individual views. He is there because he represents, or in the case of ex-presidents, has represented, the views of a group. The Boardi of Directors, a group of twenty-four, is comprised of our officers and the principalj delegates. They interpret policy and conduct the business of the Association. This] group functions much more like the Board of a large corporation than the cabinetj of a government. The principal reason for the difference is that our Directors do: not act full time. If the analogy of government was designed to include our full) time staff, it would spotlight a single, hard working deputy minister, our executive-! secretary. In brief, we have a General Assembly that acts like a Parliament, a Board of Directors who act like the Board of a Business Corporation, and an execu-j tive-secretary who might well be called our Deputy Minister. Organizations, like individuals, may succeed in their purpose, or fail, or bei mediocre, or anything in between. We are interested in what makes them succeed. Two principal problems must be adequately managed if an organizations in to bei effective. These are the Delegation of Authority and Communications. Delegation of Authority. . A great deal of the authority that one delivers or accepts in daily life is unconsciously bestowed and unthinkingly received. We all move through a maze of finely balanced lines of authority. The C.M.A.-B.C. Division is an association thatj has been devised to function for the betterment of the medical profession. It is interesting to consider what authority we have delegated, to whom we have delegated authority, and how far we can go in specifically defining authority. The questions] are legion. In this Association, as in any democratic organization, positions do not neces-j sarily create authority. The authority usually comes up to the leader from his group, whether he be the chairman of a small committee, or the President. If the group; does not continue to support the leader, he may still act, but his authority is in question. If the doctors of B. C wanted to give any individual, or group, complete authority to act on their behalf, they would have to form a union. The price of absolute authority for the leader, would be the sacrifice of liberty by the doctors. When crises impend, as in 1936, when an ill-considered Health Insurance Act was passed by the legislature of this Province, doctors come together and are prepared to sacrifice; some individual liberties of action and speech, so that one strong voice can speak for all. In ordinary times the need for a union-type of organization is frequendy expressed by doctors who are proponents of a special viewpoint. But the doctors as a whole are too heterogeneous in their activities and in their interests, to accept this.| I think that some thoughful men in our Association should consider the practical! problems of forming a union or medical guild (which is a more polite term for the] same). It could not be created in the present atmosphere. Our culture conditions us to "democratic" procedures. We try to apply thej principles but are apt to be saddened, or perplexed, or irritated, when we find thatj "democracy" has some faults. Democracy seems to invite the balancing of group in terest against group interest. We experience that in our medical societies. The onlyj issues that can obtain agreement by overwhelming majority are threats of action that appears likely to seriously lower the standards of medical care or the welfare) of doctors. It would be pleasant, though rather dull, if we could decide our policies by universal agreement among ourselves. That is unrealistic. We will always have minority groups. Indeed, we would be badly off without them. The C.M.A.-B.C Division will continue in good health only as long as we admit that in many argu- Page 218 ments there is more than one defensible position. Problems seem to work out better when one takes a full account of the less popular views. Decisions about policy are clearly the responsibility of the General Assembly. The Assembly cannot meet day after day, like Parliament, so it cannot debate every controversy that members wish to have aired. In practice, the Directors choose one or two matters for policy decision at each meeting of the Assembly. The Directors are too large a group to be an effective executive team. But meeting for a whole I day, four times a year, as they* do, enables them to look over the field of Association activities, note the trends, and keep the Executive Committee on the rails. The directors sanction actions of the Executive. Alongside the Executive is the full-time [ Executive-Secretary and his staff, without whom the whole system would collapse, 'and upon whom the Association relies for a large share of its stability. The "delegation of authority" is an important aspect of Association activities. With different personalities and changing points of view, the emphasis will shift from year to year. At some other time, and from another President, you may hear another interpretation of the functions of our Assembly and Directors. To future boards of Directors I commend a periodic study of the delegation of authority. Communications. Information about Association affairs requires the best two-way system that can be devised—to and from the doctors, the public, and government. It is the duty of the Directors to keep in touch with government. Our Public Relations Committee, and more importandy every individual doctor in practice, determines our communication with the Public. Communications to and from the doctors is a special matter. Doctors receive bushels of notices, pamphlets and booklets from many sources, notably drug firms. We understand the reasons why most of this trivia is consiged to the wastebasket. Somehow we must ensure that messages from the Association are sal- jvaged. Every doctor requires a special file for preserving memoranda about Associa- jtion business. A much greater problem than this straightforward matter of day-to-day working information, is communications from a semantic viewpoint. This viewpoint entails a consideration of the difficulties that we experience in communicating between ourselves, as individuals or groups, because of the obstruction of language habits and unconscious attitudes. There are plenty of good books on this subject and they would interest every doctor. Attend any medical meeting when economics or government are discussed, if you desire to witness examples of all the pitfalls that the semanticists describe. Most of the arguments that we hear at those meetings are between individuals who have not agreed on a definition of the subject that they are debating. When definitions are preferred they usually contain so many abstract terms that the definer himself appears to be confused. There is rarely an insistent demand for an "operational" | definition. We are apt to experience such an emotion effect from the introduction of certain words or subjects that rational thinking is upset for a time. It is very easy to outline these faults when you have suffered them all yourself. At least half of verbal communication consists of listening. When one sits j around a committee table it might be expected that the proportion of listeners was increased by three or four or ten or whatever the number might be beyond one. But that does not often happen. Sometimes it appears that no one is listening. They are all too busy preparing their own litde speech. To quote Jimmy Durante "everyone wants to get into the act." In medical association work we do too much talking, and not enough listening. That is no plea for indiscriminate listening to every bit of cloakroom gossip. It means selective listening. I would like to cite one example of intelligent, selective, sympathetic listening that represents a genuine accomplishment in our Association this year. It is the work of the Commission that was appointed by the Directors last Fall to study a special problem, and report to the Gen- Page 219 eral Assembly. They were asked to consider the proper method of payments by Prepaid Schemes, when more than one doctor is involved in the care of an uncomplicated surgical case. Their report will be debated by the General Assembly later this week. In due time you will all hear the story. Whether or not the Assembly approves their conclusions, I have litde doubt that there will be a great general satisfaction with the manner in which the Commission of three.doctors accomplished their mission. The most salutary feature of their work was that they took time, and listened. There were no blocks in their lines of communication. When a medical society faces a difficult decision about a contentious subject some of the methods of the Quakers might be used to advantage. The Society of Friends is primarily a religious organization. They have world-wide humanitarian interests as well as local community responsibilities. Many of these interests require difficult decisions of policy and management. It is said that no other group of modern men or women have developed methods of group agreement as effective as the Quakers. They aim to settle problems so that they will stay settled. That entails meetings of small groups, participation by all members, and attentive listening. There is no dominating chairman. The only officer is the Clerk who summarizes 'the sense of the meeting." If agreement is not unanimous, a decision is postponed, and further information is sought in the meanwhile. With these methods hopeless deadlocks tend to disappear in time and be replaced by some entirely new plan that was not evident at the beginning. This is inter-communication on a high level. It would be foolish to suggest that all of these methods could be regularly employed by the C.M.A.-B.C. Division, but they do provide an excellent example. Medical organization has plenty of other interesting facets. Before I am tempted to assume a dilettante role I will stop and leave these other matters for elaboration by my successors in office. I hope that what I have said will indicate to the younger member of our Association something of the interest that may be found in medical organization. In time and with good will, we will learn to act more effectively as a community of doctors. REFERENCES 1. Tead, Ordway, "The Art of Administration," New York, McGraw-Hill Book Co., 1951, 223 pp. 2. Chase, Stuart, "Roads to Agreement," New York, Harper Bros., 1951, 250 pp. 3. Tayakawa, S. E., "Language in Thout and Action," New York, Harcourt, 1949. ii * it it DOCTOR-PATIENT RELATIONSHIPS Following up our plan to make suggestions that may help Doctor-Patient Relationships, this month we will take our cue from a statement in the December issue of the Bulletin by the Chairman of our Public Relations Committee: "Not a few complaints are received by your Association, both of an economic and an ethical nature . . . Occasionally these complaints appear to be justified." Seldom will people officially register complaint. For the most part they will silendy endure, or in their own small circle discuss them, some with malice, some with bitterness and many just in a friendly spirit of warning their neighbour not to be similarly taken in. For every complaint offically registered, many, many others spread through gossip. It is to our advantage to keep the cause for complaint to a minimum, to avoid doing things that annoy patients. A review of the files of our Mediation Committee makes it clear that the most common cause for complaint lies in charging what would appear to be out of proportion for services apparendy rendered. Sometimes this is in effect true. Sometimes it is a misunderstanding on the part of the patient as to the value of the service. In either case it is the doctors responsibility to remove the cause for complaint. Occasionally the overcharge is the result of delegating responsibility for assessing the fee to a secretary. In a service as personal and variable as medicine, Page 220 the doctor himself must assess each fee if misunderstandings are to be reduced to a minimum. The most frequent complaint to our Mediation Committee is some variation of "He only saw me for a minute, he charged me ten dollars." As individuals we should either explain the fee if it is correct, or correct it. Let me briefly recount for you four stories; (1) and (2) from the files of the Mediation Committee; (3) from another doctor as told to him by a patient; (4). from a friend, as gossip. (1) A boy was injured and taken to a hospital. His family doctor could not be immediately contacted. A second doctor was called. During his preliminary examination of a fracture of arm the family doctor arrived. At the request of the patient's parents, he took over. The second doctor sent a bill for $25. Our Mediation Committee recommended that a more appropriate charge would be $15.00. (2) A patient attended a doctor's office for some five prenatal visits and received some medications. During her third month of pregnancy, she moved to another town. She received a bill for these original five visits of some $78.00. She had originally been told that the total charge would be $125. Our Mediation Committee strongly recommended a readjustment downwards. C3) A widow working in a laundry visited her doctor re menorrhagia menopausal. Following completion of treatment she received a bill for $403, itemized as follows: curettage $100, hysterectomy $250, sundries $53. *||| (4) An eighty-year-old lady in lengthy terminal illness was admitted to hospital for nursing care and general supervision some fifty days prior to death. For medical care for this fifty-day period her school teacher daughter states that she paid some $485. Such stories receive wide circulation, growing in proportions as they are retold. Created by thoughtless individuals, they reflect on our whole profession. There are too, too many of them. They suggest their own remedy. The task of writing a column such as this is difficult. Comment and suggestions from members of our Association will be most welcome. Space permitting, signed comments may be published. Please indicate whether or not your signature is to be used. Public Relations Committee, Sub-Committee on Doctor-Patient Relationships. -fc it ir it SPECIAL MEETING OF THE GENERAL ASSEMBLY |& Hotel Vancouver, February 5, 195 5 1. The Financial Report. Now that the fiscal year of the Association has been adjusted to conform to the membership year, that is January 1 to December 31, a complete year's operations can be shown in the auditor's statement. The opportunity of presenting this very recent report to the General Assembly was taken by the Treasurer, who after presenting it, had it approved by the Assembly. The financial statment follows in detail. Pace 221 -Appendix No. 1 CANADIAN MEDICAL ASSOCIATION, B. C. DIVISION STATEMENT OF FINANCIAL POSITION As at 31st December, 1954 CURRENT ASSETS Cash: On hand—Petty Cash . - $ 15.00 In General Bank Account Savings Bank Account i $ 8,999.52 Less—Current Bank Account Overdraft 1,283.98 7,715.54 Overpayment to Canadian Medical Association 20.00 Bonds—$10,000.00 Provincial Government— 3*,% Bonds—at cost 9,450.00 (Market Value—$10,000.00) NOTE—These Bonds held by bank as collateral security on loan to Medical Services Incorporated. $17,200.54 FOUNDERS' FUND ASSETS Cash in Savings Bank Account I . $ 2,064.13 Investment in $15,500.00 — 4% Provincial Hydro Electric Power Commission Bonds—at cost 15,463.75 (Market Value—$16,260.00) 17,527.88 FIXED ASSETS—at cost Office Furniture and Fixtures $ 3,987.45 Less—Accumulated Depreciation . 773.55. 3,213.90 $37,942.32 TOTAL ASSETS REPRESENTED BY: Surplus Account: Balance at 31st December, 1953 $15,145.57 Add—Surplus on operations for year—per Appendix No. 2 5,268.87 Balance at 31st December, 1954 _ j $20,414.44 Founders' Fund: Balance at 31st December, 1953 | $16,266.76 Add—Receipts for year—per Appendix No. 3 : 1,261.12 Balance at 31st December, 1954 .____ $17,527.88 $37,942.32 This is the Statement of Financial Position referred to in our report of even dated. (Signed) BUTTAR _* CHIENE, Chartered Accounts. Vancouver, B.C. 21st January, 1955. STATEMENT OF OPERATIONS For the year ended 31st December, 1954 Appendix No. 2 RECEIPTS Membership Fees Sales of Reports on Medical Salaries Interest on Savings Bank Account on Bonds Canadian Medical Association: Dues Collected plus overpayment of $20.00 Less—Remitted Page 222 $3 5,780.00 773.70 372.94 $20,693.00 . 20,693.00 $36,926.64 DISBURSEMENTS Travelling Expenses: Executive Secretary: District Meetings, etc. 5 $ 280.24 Automobile Expenses ." ! 503.30 Secretaries' Conference, CM.A. 1 $ 783.54 Board of Directors 5 567.30 District Tour ; 686.45 Vancouver Medical Association Bulletin Audit Fees i '. Committee Expense Public Relations Reference Committee Economics Committee 2,188.30 600.00 100.00 _$ 2,662.78 260.00 606.15 President's Chain of Office Expense Administrative and General Expenses: Salary—Executive Secretary $11,854.19 • Salaries—Office Staff j 5,051.30 Postage, Telephone and Telegraph 1,402.29 Office Rent 1,560.00 Office Supplies and Expenses .- . 3,839.07 Unemployment Insurance 65.26 Medical Services Association 6.52 Bank Charges and Exchange ! -. 46.20 3,528.93 Annual Meeting Expenses Net C.M.A. Convention Expense Depreciation on Furniture and Fixtures 23,824.83 478.29 507.22 398.75 31,657.77 SURPLUS ON OPERATIONS FOR YEAR $ 5,268.87 Appendix No. 3 CANADIAN MEDICAL ASSOCIATION, B.C. DIVISION STATEMENT OF FOUNDERS' FUND RECEIPTS For the year ended 31st December, 1954. Payment from Founders $ 630.00 Interest on Savings Bank Account 11.12 Interest on Bonds 620.00 Total Receipts for year—carried to Appendix 1 $ 1,261.12 2. Report of the Special Commission to study the method of payment in prepaid medical care for two doctors attending an uncomplicated surgical case. The report was presented to the Assembly by Dr. Murray Blair. After considerable debate the following motion was passed: THAT the listed surgeons fee remain undivided in all cases whether referred or not referred, and that the referring doctor receive adequate compensation for his preoperative work, his assistance at the operation and his work in the post-operative phase, regardless.of whether the case is complicated or uncomplicated, in keeping with the principles outlined in the report of the Special Commission. All the argument that preceded the vote on this motion has been transcribed on the dictaphone and it will be some days before the transcription has been reduced to writing and edited. The pertinent parts of these arguments will be laid before the general membership at an early date. 3. A brief was presented to the Assembly which was debated in the following motion. THAT all prepaid plans be requested to make payments to Internists according to the schedule of fees of the C.M.A.-B.C. | Division as published April 1, 1954, for both referred and non-referred cases. Page 223 Again the debate was transcribed. It will be abbreviated and reported to the general membership as soon as possible. This resolution was carried by the Assembly. There was also a similar one on behalf of the Paediatricians. It is now the task of the Board of Directors to negotiate with the Prepaid Plans on the basis of this medical policy. It is desired to remind all members of the Association that before any major change in policy can be effective, it must be.worked out and notified to subscribers of Prepaid Plans, as well as to doctors. It is important for all doctors to realize that the above motion will require a basic change in the M.S.A. contract now in existence between M.S.A. and their subscribers. The present contract reads that M.S.A. will contract for services on behalf of their subscribers on the basis of general practitioner care and specialist when referred. This resolution is asking them to change the contract to imply that it is not necessary to be referred. When the Board of Directors have successfully negotiated this change, everyone will be informed of the date upon which it will become effective. The transcript of this aspect of the Assembly meeting will be summarized for the general membership as soon as possible. WORKMEN'S COMPENSATION BOARD To the Members of the College of Physicians Februarv 8th, 1955. and Surgeons of British Columbia. Dear Fellow Members: It seems as though we are constandy having problems arise in relation to workmen, payment of time loss and the continuation of disability. Problems with reference to doctors are continuing. I have previously indicated in my letters, the fact that some doctors do not read the correspondence which is written in an attempt to improve their cooperation. During the past month it is my impression that a greater number of doctors have been reading our comments and have 'phoned expressing interest, asking questions and indicating to us certain matters of which they had not been previously aware. It might be of interest to comment on the number. This has been brought quite forcibly to my attention by the Medical Aid Department in that they are noting increasing numbers of doctors' accounts on form HA's being submitted with the visits for each year marked on individual and separate copies of the form. This is very much appreciated by everyone and is going to materially shorten the length of time required to review the accounts and may cause a definite increase in the speed at which accounts are paid. I must warn you that this will not necessarily be so, but it is certianly a step in the right direction. A problem has just presented with reference to a patient being brought in from out-of-town to Vancouver, for examination and an opinion by a specialist. As I carefully review the file I find that the specialist has given an opinion with reference to the diagnosis which is no different to an opinion which I had previously expressed on the lady's file but unfortunately the specialist has not expressed an opinion as to the treatment or the possible relationship of the reputed accident to the disability. It was some days following the examination before the report was received by the Board and we made an attempt to find out if the lady had returned home and to date have been unsuccessful in our enquiry. In this type of case it would be advisable to have the patient referred to the Head Office of the Board prior to going home, for disposal. This may be in respect to the finalizing of the claim, may be in respect to the suggestions as to treatment, or may be with reference to the estimation of a PPD award. Some problems have been arising in respect to the administration of stock drugs from a doctor's office supply, such as hydrocortone or novocain or novocain and Page 224 serapin. In some cases, months after the administration of the drugs, we have been receiving accounts from the drug store for replacement of these drugs. The drugs can be used or ordered and be paid for by two methods: 1. A prescription may be given to the drug store on the workman's specific claim and that drug used for the workman or 2. The drug may be used from the doctor's office stock and then when the 11A is submitted, the account for the drug should indicate the quantities used as well as the dates given. The dates given should have previously been indicated on the progress reports, and on the 11A simply reiterating this information with the quantities given so that we will have some means of checking the accounts. We do not wish to act in a peculiar way or appear to be very trivial in such matters, but when one sees many hundreds and into the thousands, of accounts from month to month, it is necessary that these be checked so that we are sure we are spending the employer's fund judiciously. We have been having some difficulty with reference to carelessness in the submission of accounts and the listing of office and hospital visits in the submission of accounts. We would ask your office particularly to be certain that the days that are listed are the correct ones, also that no more visits are charged for than have.been made, so we will not be charged for services which have not been rendered. Recendy a case came to my attention in which it eventually transpired that visits for the workman's wife and infant had been recorded on the compensation file instead of being reported on the M.S.A. card in the doctor's office. It is hoped that radical measures will not have to be taken when such discrepancies occur, but, if they per- sistendy develop, it will be necessary for the Board to take some rather drastic action, which I feel certain will not be in the best interests of medical publicity or public relations. We are still having some difficulty in reference to elective operative procedures, and elective consultations, being held without Board approval. This problem has been discussed very fully, and a definite rule has been set down indicating that unless permission is granted for such consultation, (and the onus in respect to this problem rests upon the referring doctor as well as the consultant) the consultation fee will not be paid. Unfortunately we find this is the only means by which the problem and the discrepancies can be corrected. One of the most vexatious problems arising almost daily is with reference to x-rays for fractures of the ribs. Under item J 38 of the Schedule of Fees, it is indicated that x-rays of the chest for ribs can only be taken with Board permission. Whenever you request permission for ri*» x-rays, please indicate the necessity. It is quite certain that x-rays cannot be taken to confirm the diagnosis, and that alone. If you suggest inter-thoracic damage, that is, a complicated fracture, or other specific information, we will be very glad to give permission for the necessary x-rays, but not otherwise. Similarly permission for intravenous pyelograms and for gastro-intestinal x-rays must be obtained from the Board, and then can be granted only when definite indications, related to the claim, are shown. The necessity for more careful scrutiny of accounts has been in part, precipitated by numerous complaints from employers due to the very great increase in the costs of medical aid. We will still very much appreciate having you write us or 'phone us about the handling of Workmen's Compensation Board cases, either with reference to the care of the workman or to the account. We will do our utmost to explain or correct any discrepancies which you may feel have occurred. Again with the very kindest of personal regards from the entire Staff, I remain, Sincerely yours, J. R. NADEN, M.D., Chief Medical Officer. Page 225 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H. Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia THE PROBLEM CHILD The 1953 Annual Report of the Crippled Children's Registry demonstrated the fact that we have a large number of handicapped children in the province who are a real problem to the medical profession. The lay public is inclined to think of a crippled child in terms of splints, crutches and bandages. It is, therefore, of interest to note that out of nearly three thousand children on the Registry at the end of 1953 only 18% were orthopedic cases and 82% were handicapped in other ways. For instance, the mentally handicapped child is the largest group, followed closely by the deaf or hard of hearing, defective sight and cerebral palsy. However, congenital malformation of the heart, rheumatic circulatory disorders as well as harelip and cleft palate represent a considerable group. In following up these handicapped children the Registry has been greatly helped by the fact that the newest registration form asks the question "Do you wish this case registered for statistical purposes only" and if this is answered in the affirmative such a case is placed on the inactive list and therefore no follow up through the public health nurse is undertaken. Some practitioners are under the misapprehension that by registering their cases, the children's parents will be written to and inquiries made as to the child's condition. This is very definitely not so. If the case is not registered for statistical purposes only the Registry's inquiries are all directed to the Family Physician or Local Health Services. THE ALCOHOLISM FOUNDATION OF BRITISH COLUMBIA The Medical, Social and Psychological problems created through man's excessive use of beverage alcohol have plagued mankind for many centuries and what is possibly more significant, these problems have largely defied solution because of one simple fact—the alcohol addict rarely, if ever, stopped drinking. Historically, the problems concerning the alcohol addict have been dealt with largely on an emotional level; those who favoured the use of alcoholic beverages and those who did not favour their use, each side holding tenaciously to their particular view. This dogmatic and many times irrational approach helped very litde in finding solutions to the problem, arguments flew back and forth, finally culminating in "The Great American Experiment." During all this furore, the alcohol addict continued to drink. With the end of prohibition in the United States, a new approach to alcohol and its problems emerged. The whole galaxy of problems arising from the use of beverage alcohol was subjected to scientific analysis, and a start was made to study the problems stripped of emotionalism. As the facts began to emerge, many old taboos disappeared, and many time-honoured truths disintegrated. As study progressed, a new, unique organization made its appearance — Alcoholics Anonymous. At fiirst A. A. was thought to be "just another organization of fanatics," but as the^ movement gained momentum, one significant point became clear, membership in Alcoholics Anonymous kept an alcoholic sober not just for a day, but for as long as the alcoholic maintained his contact with the organization. Here then was a method, a successful method of treating the alcoholic. Page 226 As a result of recent scientific evaluation, the concept of alcoholism as an illness has become clear, and it has been possible to differentiate between the alcohol addict and those who merely use alcohol to excess. As the nature of alcoholism was better understood and the record of success of A.A. subjected to analysis, it became evident that the principles so learned could be applied in a professional setting, and there developed at Yale University, New Haven, Connecticut, in 1945, the first Yale Plan Out-Patient Clinic. From this beginning, multi-disciplined Out-Patient Clinics have been developed across Canada and the United States. The National Committee for Education on Alcoholism, together with Yale University, have spark-plugged this movement and a desperate need for such treatment centres has been responsible for the rapid development of treatment programs on a local and provincial level. Many things have been responsible for the development of an alcoholism program in British Columbia. The increasing problem of impaired driving, the rise and success of Alcoholics Anonymous, a growing public awareness that something should be done and could be done, and finally, the recommendations of the Stevens Liquor Inquiry Commission in 1952. As a culmination of the community efforts to establish a program for British Columbia, the Alcoholism Foundation of British Columbia was incorporated as a Society in November, 1953. The Foundation sought and received the support of the Provincial Government and began the task of organizing and developing a program on a four-point plan of Treatment, Rehabilitation, Research and Education. At this writing, the first Out-Patient Clinic for alcoholics is nearing completion at 1690 West Broadway, Vancouver, B. C. This Clinic will provide a specialized centre for the treatment of alcoholism in its medical, social and psychological aspects. All clinical policies and procedures will be under the direction of Dr. B. B. Moscovich, recendy appointed part-time Clinical Director. So that an adequate liaison may be maintained with the medical profession in the province, a medical advisory committee has been established with the following members: Dr. Iser Steiman, Chairman, representing the Vancouver Medical Association; Dr. George Davidson, representing the Faculty of Medicine, University of B.C.; Dr. H. Gundry, representing the Metropolitan Health Services; Dr. Elmer Jones, representing the B. C. Division of Canadian Medical Assoc'n; The Foundation recognizes that the first line of defense in the batde against alcoholism lies with the medical profession in the province, for it is evident that in many cases an alcoholic can best be treated in his home setting. The Foundation will provide a centre for specialized treatment and study but more important, from the point of view of the Doctor in private practice, it will provide a consultative service for anyone who wishes to present a case for consideration. No one organization or individual can hope to accomplish a great deal in the alleviation and prevention of alcoholism, for it is only through team work that this many-sided medical, social and psychological illness can be attacked. The Executive Director and the Clinical Director welcome your enquiries and your assistance in their efforts to reduce the many implications of alcoholism. . For further information please phone or write to: The Alcoholism Foundation of B. C, 1690 West Broadway, Vancouver 9, B.C. BA. 4977. Page 227 FLUORIDATION FACTS The Bulletin is glad to publish the following notes supplied by the Vancouver and District Dental Society. Medical men will find these facts of value in answering questions put to them by their patients and others. Ed. Joint Canadian Dental Association—Canadian Medical Association Statement on Fluoridation—February, 1953. Since 1945 many communities have artifically raised the fluoride content of their water supplies to about one part per million. This in the level at which optimal dental benefits may be expected and at which no detrimental effects have been demonstrated. It has been found that children residing in communities where the water supply was brought in 1945 to 1 p.p.m. of fluoride have considerably less decay in theSl teeth than children whose whater supply is practically free of fluoride. Over 20,000,000 persons in 1,015 U.S. communities now drink fluoridated water. Fluoridation and Mortality—Journal of the Canadian Dental Association— August, 1954. New study re-affirms safety of fluoridation: The May issue of U.S. Public Health Reports contains the report of a study of the mortality experience of 32 pairs of fluoride and non-fluoride cities. The total population considered in the study was 892,625 persons in fluoride cities and 1,295,000 in non-fluoride cities. A city with 0.70 p.p.m. or more in its water supply was considered a fluoride city and a city with 0.25 p.p.m. or less in its water supply was classified as a non-fluoride city. This report presents an analysis of mortality from all causes and from five selected causes — heart disease, cancer, intracranial lesions, nephritis and cirrhosis of the liver — in 64 cities in 16 States, and compares rates in those cities in which water analysis show the fluoride content to be 0.25 p.p.m. or less with those cities where the fluoride content is 0.70 p.p.m. or more. These data show no statistically significant difference between the mortality rates of fluoride and non-fluoride cities for all causes or for heart diseaser cancer, intracranial lesions, nephritis, or cirrhosis of the liver. American Commission on Chronic Illness Favors Fluoridation— Fluoridation News—September, 1954. Published by Department of Health and Welfare of British Columbia. The commission on Chronic Illness at its meeting March 18 adopted a statement which urged American communities to fluoridate their drinking water. This action followed a study made by the Commission in which it reviewed and evaluated available evidence on the advantages and the alleged dangers of fluoridation. "Extensive research into the toxicology of fluorine compounds," said the Commission statement, "has revealed no evidence that the continued consumption of drinking water containing fluorides at a level of about 1 p.p.m. is in any way harmful to the health of adults or those suffering from chronic illness of any kind." The committee of scientists which made the Commission's study was headed by Dr. Kenneth W. Maxcy, Professor of Epidemiology, John Hopkins University School of Hygiene and Public Health. Report on Congressional Committee Investigating Fluoridation The safety and effectiveness of fluoridation were documented before a Congressional committee recendy. On May 25, 26 and 27, 1954 hearings on the Wier bill (NR 2341), which seeks to ban fluoridation throughout the United States, were conducted at Washington, D.C, by the Interstate and Foreign Commerce Committee. Page 228 Witnesses opposing the bill and supporting fluoridation included representative of the National Committee against Fluoridation, the Massachusets' Women's Political Club and the Christian Science Church. Fluoridation proponents included: Dr. J. W. Knutson, Chief Dental Officer, U.S. Public Health Service; Dr. N. C. Leone, Chief Medical Investigations, National Institute of Dental Research; Dr. Francis F. Heyroth, Assistant Director and Associate Professor of Industrial Toxicology, Kettering Institute of the College of Medicine, University of Cincinnati; Dr. J. D. Porterfield, Ohio State Health Commissioner, Dr. W. D. Armstrong, Professor and Head of the Department of Physiological Chemistry, University of Minnesota Medical School and Mr. David Ault, a director of the American Waterworks Association. Subsequendy, as reported in the Journal of the American Dental Association, September, 1954, the committee took no action whatever on the Wier bill other than to have the testimony printed and made public. Fluoridation in Brantford, Ontario. Fluoridation began in Brantford, Ontario in 1945. Surveys show that after eight years of fluoridation there has Jbeen a 53.7 percent reduction in the numbers of decayed-missing-filled teeth of children studied. Recendy the Brant County Board of Health adopted a statement which said that it "viewed with gratification the marked improvement in dental health of Brantford school children." Health League of Canada Endorses Fluoridation: Health League of Canada, Digest of Opinions on Floriduation, Toronto, June, 1954. Last June the League endorsed "without qualification, the fluoridation of communal water supplies in quantities recommended by official departments of health." The League arrived at this conclusion after studying replies received from a questionnaire requesting an opinion on the merits of fluoridation, which it sent last Spring to the heads of preventive medical departments of 92 Universities in Canada and the United States. Of the 76 medical authorities that replied, 69 "expressed themselves more or less emphatically in favour of fluoridation as a means of preventing dental caries without doing harm to the human organism, six claimed incomplete familiarity with the subject and declined to express an opinion, and one expressed a desire for caution and further study but was not opposed to fluoridation." ANNOUNCEMENT The Faculty of Medicine, University of British Columbia The First Annual Canadian Arthritis and Rheumatism Society Lecture on the Rheumatic Diseases "THE CHRONIC RHEUMATOID CRIPPLE: TOTAL REHABILITATION" Dr. E. W. Lowman Associate Professor, Clinical Physical Medicine and Rehabilitation New York University College of Medicine U. B. C. Wesbrook Biulding Tuesday, March 22, 1955 at 8:15 p.m. Page 229 'ewd an d f/oted Dr. Laura I. Coleman is currently employed by the Department of Psychiatry, University of Toronto in the capacity of Research Assistant. Eh. D. A. Hewitt is now taking post-graduate training at the University of California. Dr. E. G. Marhowski is now associate resident in orthopaedic surgery at Vancouver General Hospital. Dr. A. W. Massey is at the Montreal General Hospital in the Department of Radiology for a two and a half year period. Dr. A. W. Mooney formerly of Vanderhtfof, B. C, is now doing post-graduate work at the University Hospital, Edmonton. Dr. Roy Rowsell, is Assistant Resident in the Department of Hedicine, Sunny- brook Hospital. Dr. Wm. C. Stewart is a Voluntary Fellow in Surgical Department of the Lahey Clinic, Boston. His fellowship started January 3, 1955 and is scheduled to run for one year. Dr. W. G. Whittaker is in his first year of a four year training programme in Obstetrics and Gynaecology at the University of Toronto. Dr. M. H. Wong is now at Children's Memorial Hospital, Montreal. Dr. Wm. S. Wood is assistant resident in dermatology and syphilology at the University Hospital in New York. Eh. Murray R. Kliman has opened an office for practice of pediatric and general surgery in Vancouver. Dr. R. H. Lawler is now doing work in psychiatry at the Cincinnati General Hospital. Dr. E. L. Smith has passed his American Boards in Ophthalmology and received his Canadian certification. Eh. Howard A. Smith is now associated in urology with Dr. John McCaffrey in Vancouver. Eh. Philippe L. Maisonville has received his specialty certificate in Ophthalmology. Dr. Nathan Shklov, formerly of Vernon, B. C, has joined the staff of the Kapiolani Maternity and Gynaecological Hospital in Honolulu, Hawaii. OFFICE SPACE Excellent location for Medical man on Dunbar, will arrange space to suit tenant. Immediate occupancy. For information phone ALma 2252-Y. Page 230 PRECEPTORSHIPS A programme of preceptorship training for graduates of the Faculty of Medicine, University of British Columbia is being arranged through the cooperation of The Section of General Practice, B. C. Division of the C. M. A. This was inaugurated in May, 1954, and is on a voluntary basis. The Class will graduate in mid-May and preceptorship appointments will normally occupy two weeks to one month between graduation and the beginning of internships. A list of physicians who would welcome service as preceptors is being assembled and interested physicians are invited to contact Dr. J. L. Coltart, 2812, West 16th Avenue, Vancouver 8, B.C. Phone BA. 3154. FIFTH ANNUAL MEDICAL BALL The Medical Undergraduate Society of the University of British Columbia is happy to announce that plans are well advanced for the Fifth Annual Medical Ball, to be held on Thursday, March 10, 1955, in the Hotel Vancouver Ballroom. The Society hopes that the success of previous years will encourage their many friends in the Medical Profession to lend again their splendid support, so that the Bursaries established from the preceding Medical Balls can be maintained. POSITION WANTED University of British Columbia graduate, L.M.C.C., married, 31 years old, general rotating internship one year. Desires opportunity to do General Practice either as assistant or partner. British Columbia preferred. Apply "The Bulletin", 675 Davie Street, Vancouver 2, B.C. or Telephone: MArine 7729 LIPO-GERITAINE (LIQUID) has the same general indications as Geritaine but contains more particularly lipotropic substances, added in larger amounts, in order to produce a preparation with more specific action. Thus, when an immediate and complete lipotropic medication is desired, LIPO-GERITAINE is entirely satisfactory iii all cases. The liquid preparation also has the advantage of being more easily administered to elderly people and to those who do dislike swallowing capsules. Its formula contains basic constituents, both in respect to quality and quantity, corresponding to the most recent findings in the field of geriatrics. Each cc. contains: BETAINE _ Choline FORMULA Liver Extract (Fraction 1) _ Vitamin Bl2 (amorphous). Methionine -200 mg. . 15 mg. - 1J mg. . 1 meg. . 10 mg. INDICATIONS Coronary and aortic atherosclerosis, nephrosclerosis, chronic alcoholism, high blood cholesterol, hypertension, diabetes, hepatitis and the organic decline which accompanies old age and undernutrition. PRESENTATION Bottles of 12 ounces. ANGLO-FRENCH DRUG CO. LTD., Montreal 18 Page 231 PHYSIO-THERAPY Registered physio-therapist age 33, desires position in doctors7 clinic or hospital. Recommended by doctors at Courtenay, where for seven years he has had seven years private practice, also W.C.B. and D.V.A. cases. J. C. D. Priestman Qualicum Beach, B.C. Telephone: Qual. 3193 Managed and Distributed] by Investors Syndicate of Canada Ltd. Representatives from coosr-to-cooft M ...Mil INVESTORS Mutual J of Canada Limited H-DOfflCE-WiWIPK; I^S^______^____?LaTIB 3__^_M_^_^1___3___3___S Jm When you become a shareholder of Investors Mutual your investment is spread over more than 100 widely diversified and carefully chosen securities. You receive all the benefits of experienced managership^ ready marketability, quarterly reinvestment of dividends and many other advantages. ^rnueitori ^undicale of Canada oLtd. *?rnue&tor5 rrfutuai of L^anada cJLtd. NEVILLE ASTLEY JZw*/ flU^ 313 — 744 West Hastings Street — Vancouver Telephone MArine 5283 FRED G.HITCHENS 2W % anaq »r 3220 Wetherby Road. Victoria, B.C. Telephone Garden—9556 itttmmi pirasant (Eljaprl FUNERAL SERVICE Kingsway at llth Ave. — Telephone EMerald 2161 Vancouver 10, B.C. fl&t. pleasant XDlnbertahfno Co. Xto. Page 232 A letter received from an individual who signs himself "Inactive," wants to know "why the Bulletin publishes such trivia and veiled threats from the Workmen's Compensation Board," and later remarks that the "arrogant methods" (of the Board, we presume) are leading to "deterioration of previous cordial relations." It is difficult to answer an anonymous letter—but this one has brought up some points that we rather welcome the opportunity to deal with. In the first place, we do not agree with the definition given by "Inactive" of the letters we have received from the W.C.B., or rather the Chief Medical Officer of the W.C.B., as "trivia," or as "veiled threats." They are we feel, an important contribution. They are unfailingly couched in friendly and courteous language and we do not detect any threats in them, in the ordinary sense of the word. Warnings, yes, and some of these warnings would appear to be thoroughly justified. These letters give good advice, as to our relations with the Board; as to the right way of making out reports and so on. We think that sometimes men seem to forget just what the Workmen's Compensation Board is—what it has to do; and what our part in its operation is. The Board is a semi-judical body, with very considerable powers: It has not only the right to demand certain things of us—but the power to do so—and when we accept cases under the Workmen's Compensation Board, we are bound by statute to do certain things. Our responsibility does not end with good treatment of the case. Our reports are essential, both to the Board and to the workman—and the Board can insist on their being correct, and sufficiently detailed and explanatory—only so can the Board give a fair deal to the workman. Most men, we think, know these facts, and act accordingly—but some men do not do their full duty in these regards—and that is why Dr. Naden has been writing these letters. It seems to us, that instead of resenting them, we should be grateful for them. The Board can, if it wishes, enforce its demands—and if men fail to live up to the regulations of the Board, are guilty of carelessness, and even occasionally of worse, the Board has disciplinary powers. Through the years, the Board has hesitated to use these powers—and we owe it a debt of gratitude for consideration and patience —but the powers are there and members of our profession have come, from time to time, within the purview of these disciplinary powers. Dr. Naden and his staff have their duty to do—they cannot merely stand between us and the Board. And it is because of his desire to help to maintain good relations that he has been doing all in his power to make things clear. As to the Bulletin's relation to this. The Bulletin is anxious to be a medium of inforamtion to the whole profession. Thus it publishes the transactions and so on of the B.C. Division of the Canadian Medical Association, articles and news on Public Health and so on. And it is glad to be the medium for all such bodies, including the Workmen's Compensation Board. We feel that frankness and frank speaking, while occasionally somewhat of a shock, will eventually result, not in worsening of relations between the Board and ourselves, but of improving them. Our correspondent feels, too, that "the B.C. Medical Association should be consulted in any change of professional policies." We admit this fully—but there is no change here that we can see, merely an elucidation and emphasis on a policy that has always existed. In any case, the B.C. Division would use the Bulletin to bring it to the attention of the profession. Page 251 ancouver Medical Association OFFICERS — 1954-55 President Dr. J. Howard Black Vice-President 1 Dr. F. S. Hobbs Honorary Treasurer Dr. R. A. Gilchrist Honorary Secretary Dr. G. E. Langley Editor. f Dr. J. FL MacDermot PRELIMINARY ANNOUNCEMENT VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL STANLEY PARK PAVILION, VANCOUVER, B.C. JUNE 6th to 10th INCLUSIVE—1955 SPEAKERS AND SUBJECTS DR. IAN AIRD—Professor of Surgery, University of London, England. • 1. The management of the Pancreas in Upper Abdominal Surgery. 2. The management of certain puzzling varieties of Obstructive Jaundice. 3. The Palliation of Advanced Malignant Disease. 4. Current Research Problems in the Department of Surgery at Hammersmith- Hospital. 5. The Problem of Conjoined Twins. DR. N. S. ASSALI—Associate Professor of Obstetrics and Gynaecology, University of California, Los Angeles. 1. Pathologic Physiology of Toxemia and of Essential Hypertension. 2. Hemodynamic action of Vasodepressor Drugs. 3. Management of Toxemia of Pregnancy (Illustrated with colored sound film depicting incidence, classification, pathology and physiology in animate^ form and showing individual patients treated). 4. Mode of action of Diuretic Agents. 5. Causes of Maternal Death in a General Hospital. DR. DONALD H. WILLIAMS-Clinical Associate Professor of Medicine (Dermatology) University of British Columbia, Vancouver. 1. Chronic Skin Disorders of the Legs. 2. "Dollars and Sense" of Skin Therapy. 3. "Tension Eczema"—Neurodermatitis. 4. Common Skin Disorders of Children. DR. KENNETH EVELYN-Director of the British Columbia Medical Research Institute, Vancouver. 1. The Course and Prognosis of Essential Hypertension. 2. The Treatment of Essential Hypertension. ** Watch for list of other speakers and subject material. Page 252 Library Hours: Monday to Friday 4__. __9:00 a.m. to 9:00 p.m. Saturday 1 9:00 a.m. to 1:00 p.m. Recent Accessions: The Kidney. Ciba Foundation Symposium. Churchill. 1954. Peripheral Circulation in Man. Ciba Foundation. Churchill. 1954. Fluid Balance in Surgical Practice by L. P. LeQuesne. Lloyd Luke. 1954. A Manual for Psychiatric Case Study by Karl A. Menninger. Grune or Stratton. 1952. Nobel Prize Winners in Medicine and Physiology by Lloyd G. Stevenson. Schuman. 1953. The Bible in Modern Medicine, by'A. Rendle Short. Paternoster Press. 1953. Insanity, Art and Culture by Francis Reitman. John Wright. 1954. The History of Medicine in Oxford; by Maurice Davidson. Blackwell Press. 1954. The Hidden Causes of Disease, by Antonio Benivieni, trans, by Chas. Singer. C. C. Thomas. 1954. Technic of Psychotherapy, by L. R. Wolberg. Grune & Stratton. 1954. Tumours of Lymphoid Tissue, by George Lumb. Macmillan. 1954. Wine as Food and Medicine by Salvatore P. Lucia. Blakiston. 1954. Stuttering, by D. A. Barbara. Julian Press. 1954. Orthopaedic Surgery by Walter Mercer. 4th edition. Arnold. 1950. Neck Dissections by James E. Brown & F. McDowell. Ryerson Press. 1954. The Diagnosis and Treatment of Convulsive Disorders in Children by Samuel Livingstone. Ryerson Press. 1954. Lectures on the Thyroid by J. H. Means. Cumberlege. 1954. The Pathology of Trauma edited by Alan R. Moritz. 2nd edition. Lea & Febiger. 1954. •Book Review. BOOK REVIEW Pediatric Gynecology by Goodrich C. Schauffler, M.D. Pediatric gynecological examinations are done very rarely by the average practis-, ing gynecologist. The book represents a very wide experience in this field by Dr. Schauffler of Pordand, Oregon. The first chapter presents very clearly the embryology and normal anatomy of an infant's and a child's pelvic organs. Important points in history taking and technique of special examinations are discussed. The diagnosis and treatment of conditions of the external genitalia and vagina are largely a discussion of pruritus and vaginal discharge which are considered generally to be gonococcal in origin. Treatment with penicillin and estrogens is discussed. The importance of remembering that foreign bodies are occasionally the cause of vaginal discharge is stressed. The chapter dealing with disorders of adolescence is especially good with discussions of normal and abnormal development of breasts. The onset of menstruation Page 253 was well dealt with and the proper importance of variations in the normal considered. Three chapters were devoted to a comprehensive review of general surgical, urological and proctological considerations including a section on the chemotherapy of urinary infections. This book will be useful to pediatricians, gynecologists, and general practitioners, who probably most commonly see these disorders. Dr. Schauffler's unusual amount of experience in this field allows him to speak with authority on a subject about which so little seems to be taught. W. F. BIE. + + + Vancouver, B.C., February 23, 1955. Vancouver Medical Association, 1807 West 10th Avenue, Vancouver, B.C. Gendemen: It has recendy been agreed between the R.C.A.F. and Department of Health of British Columbia that; when such a position exists, request for R.C.A.F. transportation shall be made through the local Medical Health Officer. Where no Medical Health Officer is established request will continue to be received at the 12 Air Defence Group Rescue Co-ordination Centre, telephone CEdar 9111, Local 132. An extract of the regulation governing R.C.A.F. Transportation of patient is as below. Emergency Evacuation of Personnel It is not R.C.A.F. policy to operate an air ambulance service. Mercy flights for evacuation of those seriously ill or injured are normally to be conducted only at the request of other government services or departments and then only in areas where no sufficiently rapid alternate form of transportation is available, no commercial air operator is equipped or willing to handle the flight, and no adequate medical care is available. The fact that those requiring emergency transportation are unable or unwilling to pay charges levied by commercial firms cannot be allowed to influence general R.C.A.F. policy. Requests for emergency flights where adequate alternate means of transportation are available are to be refused with an explanation of R.C.A.F. policy if necessary, and that applicant referred to a commercial operator. Where a request has been made and accepted the patient should be kept under cover awaiting arrival of the aircraft and not held in the open at the airport. Yours truly, I. H. BARCLAY, Wing Commander for Group Commander, 12 Air Defence Group, 4050 West 4th Avenue, Vancouver, B.C. " 1 ft_P * ■-' * VANCOUVER MEDICAL GOLF ASSOCIATION |. H GOLF TOURNAMENTS flH|. The first three tournaments have been scheduled as follows: April 14th—Shaughnessy Golf Club g Golf and Dinner May 12th—Fraser View Golf Course Golf and Dinner June 9th-Quilchena Golf Club Ltd . Golf In conjunction with the Vancouver Summer School, golf only, followed by dinner and dance in the "Thunderbird" Room — Capilano Suspension Bridge, North Vancouver. Page 254 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull . %. Vancouver President-Elect—Dr. E. W. Boak . Victoria Immediate Past President—Dr. R. G. Large | Prince Rupert Chairman of General Assembly—Dr. G. C. Johnston 1 Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer ; Vancouver Executive Secretary—-Dr. G. G. Ferguson 1 : ft^H^ Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bonnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F. Sparling Dr. P. M. McLean Kootenay Dr. S. C. Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall Dr. P. O. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C. Poole Dr. N. J. Blair Constitution and By-laws. Chairmen of Standing Committees . , Dr. Carson Graham, North Vancouver Finance i \ Dr. R. A. Palmer, Vancouver Legislation Dr. E. W. Boak, Victoria Medical Economics Dr. P. O. Lehmann, Vancouver Medical Education '. ■ Dr. M. M. Weaver, Vancouver Nominations Dr. F. A. Turnbull, Vancouver Programme & Arrangements E , Public Health 3 Dr- G- R- F- Elliott, Vancouver Public Relations Dr. A. W. Bagnall, Vancouver Chairmen of Special Committees Archives ! ! Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism Dr. J. A. Traynor, Vancouver Cancer '. Dr. Roger Wilson, Vancouver Civil Defence ,,., ... j Dr. John Sturdy, Vancouver Ethics . Dr. Wallace Wilson, Vancouver Hospitals jfei Dr. G. C. Johnston, Vancouver Industrial Medicine j Dr. G. B. Helem, Port Alberni Maternal Welfare— Dr. A. M. Agnew, Vancouver Membership Dr. N. J. Blair, Vancouver Nutrition Dr. J. F. McCreary, Vancouver Pharmacy Dr. B. T. Shallard, Vancouver Rehabilitation .—___ __ Dr. W. J. Thompson REPORT OF SPECIAL COMMISSION ON REFERRED, UNCOMPLICATED SURGICAL CASES || (This is the Report referred to in the last issue of the Bulletin:) jp| I. This Commission was established by the Board of Directors of the Canadian Medical Association—B.C. Division in October, 1954. The problem referred to the Commission was to advise on the method of payment to be used when two or more doctors are involved in one referred uncomplicated surgical case. II. The establishment of the Commission was advertised to the profession throughout the province through the medium of the British Columbia Medical Gazette dated October 1954. As a result of this, numerous submissions were made to your Commission by representatives of various groups within the profession and by individuals. Many meetings of the Commission were held in both Vancouver and Victoria during the months of November and December 1954. On all sides we have met with only the finest courtesy and a genuine desire to help in the solution of a most vexatious problem. The variety of opinions expressed to us was great and not all the opinions suggested any change—in fact, in some areas it was felt by surgeons and general practitioners alike that the discontinuance of the one-third- Page 255 two-thirds plan of division of the surgical fee was, to say the least, unfortunate. The only unanimous opinion that we received throughout the whole of the sittings of the Commission was that "the problem must be solved." §|S| IIIJiMinimum schedules of fees are very old in Canadian medicine. They have been used by organized medicine in Canada for over fifty years and have been considered to be literally a minimum scale. They have always been very flexible. These schedules have established a basic fee only—a floor. The general idea has been to keep organized medicine up to a respectable standard in regard to its charges to the public. About eighteen years ago prepaid medical plans were introduced and having been organized by the profession, the plans accepted the minimum scale of fees of the profession as their scale of fees. This was considered to be, and is still considered to be, a very satisfactory arrangement. As time has passed an essential difference has, however, developed—namely, that our minimum standard has become their maximum standard. Our flexible scale has become a fixed scale of fees in their hands. It must be emphasized, however, that in our opinion any schedule of fees is and must remain the responsibility of the profession. It is further our opinion that this fixity of the schedule of fees is the chief irritant between the prepaid plans and the profession. It is the opinion of your Commissioners that the vast majority of practitioners in this province, and indeed in Canada, endorse voluntary prepaid plans as a pattern of practice. It is our opinion that it is our duty to foster and encourage their growth within the bounds of ethical medical practice. We believe prepaid plans are the answer of the profession to the alternative of state medicine. We remember the Saskatoon manifesto—Trans Canada Medical Plans came into being only yesterday. IV. The fee for services rendered by the referring doctor in the pre-operative period is already covered on a fee for service basis. The only comment that we wish to make in connection with the pre-operative phase is that referring to item 0081 of the minimum schedule of fees (1954). We believe that this item covering emergency bedside and other continuous attendance has been overlooked in the past, not only by the referring doctor but also by the prepaid plans. It is our opinion that this item should receive the emphasis and interpretation that it deserves. V. The fee for service rendered by the referring doctor in the operative periods (surgical assistant's fee) is also covered in the present minimum schedule of fees. VI. The problem of the Commission therefore resolves itself into payment for post-operative care. The Commission is unanimous on the following points about post-operative care. 1. It is our opinion that the services of two doctors in any one case results in- better care to the patient than that from one doctor alone. Furthermore, we are convinced that while the surgeon has prime responsibility for the surgical care in the post-operative period, the referring doctor also has an important role to play. This role should be designated as "the non-surgical aspects of post-operative care." It includes not only many medical or nonsurgical services to the patient, but also many non-medical services to both the patient and his family. It is a watching brief. This watching brief calls into play all the knowledge of the referring doctor concerning the patient— his family background, his idiocyncrasies both physical and mental, his responses to trauma, physical, mental or surgical, and his anticipation of complications. All these services are, we believe, professional services to or on behalf of the patient and are worthy of compensation. It follows therefore, that not only the surgeon but also the referring doctor should be paid for his services when they are actually rendered. 2. Any surgical procedure on a child under the age of two should be considered complicated. Payment to the referring doctor for his post-operative service^ Page 256 should be based on this fact. This problem, therefore, does not come within the terms of reference of this Commission. VII. The fee of the surgeon. It does not fall ,within the terms of reference of this Commission to pass any opinion on the absolute amount of the surgical fee for any procedure. We feel, however, that surgical fees in general might well be reviewed. It does come within our scope (and indeed it is our prime purpose) to express our opinion and to make a recommendation on the vexatious problem to the surgeon by a referring doctor who is going to participate in all phases of the proceedings. We have heard numerous arguments, forcefully expressed, on both sides of this question. These arguments have been previously detailed in the report of the Joint Committee of Surgery and General Practice 1954 to which reference is made. Much thought has been given to these arguments by us. It is our opinion that from these arguments and from the arguments that have been presented to us by many people during our sittings, the following have priority. 1. The responsibility of the surgeon is exactly the same whether or not the case is referred. 2. It is unfair and unrealistic to expect a specialist in surgery to receive less than a non-specialist in surgery for the performance of any major surgical procedure. 3. We are fully aware of the findings of organized medicine in the United States in regard to the division of the surgical fee under prepaid schemes. We are also aware that these findings are at variance with those of organized medicine in Canada. The majority opinion of the Commission is that the division of a surgical fee by whatever means and by whatever source lies beyond the bounds of the ethical practice of medicine in Canada. VIII. The fee of the referring doctor. 1. For years the referring doctor in addition to compensation for his pre-operative work on the patient has been paid for his assistance in the operating theatre. It is our opinion that the assistance of the referring doctor is required beyond the event in the operating theatre. This should include, in our opinion, not only assistance to the surgeon in the operating theatre but also assistance to the surgeon in the post-operative phase and/or the non-surgical aspects of post-operative care. 2. In those cases in which the referring doctor does not assist at the operation, it is our opinion that he should be paid for the non-surgical aspects of the post-operative care, provided, of course, that such services are rendered. IX. The added cost of any scheme wherein the referring doctor is paid for all of his services in an uncomplicated surgical case has been a source of much concern to us. We have endeavoured by various means to get an estimate of this added cost. Numerous factors enter into this and nearly all of these factors are variable. Medical Services Association has been unable to give any solid estimate of the increased cost. The figures which have been presented by the Social Assistance Medical Service on their recent trial in which the referring doctor is paid on a fee for service basis are, we feel, inadquate for several reasons. These reasons include the fact that the S.A.M.S. cases are largely of a different age group, that their figures do not separate complicated from uncomplicated surgical cases, and that many members of the profession have not been aware of the new basis of payment to the referring doctor by S.A.M.S. We have been likewise unable to get any accurate estimate of the cost of referred uncomplicated surgical cases in relation to the total cost of surgical care. It varies decidedly in different parts of the province. Although we are unable to state any Page 257 exact figure as to the cost of such cases, we nevertheless are of the opinion that referred uncomplicated surgical care is not a major factor in the total cost of surgical care. Conclusions. Based on the aforementioned facts and opinions your Commission makes the following recommendations with regard to the uncomplicated referred surgical case. I. The surgical fee shall remain undivided in all cases whether referred or not referred. This fee shall include the pre-operative phase, the operative phase and the post-operative phase. II. The referring doctor shall be paid a fee for his assistance to the surgeon in the operating room. III. The referring doctor shall be paid a fee for his services rendered in the postoperative phase. This fee shall be known as the fee for the non-surgical aspects of post-operative care. This fee shall be computed on a fee for service basis. IV. Item 7019 in the minimum schedule of fees as published April 1, 1954, shall remain unchanged. The out-of-town case remains a problem. Too many principles and facets present themselves to recount them all here. Suffice it to say that here your Commission has reluctandy agreed to disagree (perhaps a healthy sign. It is felt that all problems must have a solution and we suggest only that in view of some increase in the assistant's fee at operation and the introduction of a post-operative fee as already laid down that the out-of-town referred uncomplicated case be treated exacdy as a local case. Ipf Our findings are not revolutionary. We believe they live up to the definition and meaning of our fee schedule. We believe they live up to the dictates of good medicine. We believe that the comparative fixity of fees suggested herein will permit the prepaid plans to grow and flourish even as organized medicine has decreed. All of which is respectfully submitted. E. MURRAY BLAIR, Chairman DONALD S. MUNROE FRED H. BONNELL Acknowledgment. We would be remiss if we did not express our thanks to the large number of people who appeared before us. These doctors have given most unstintingly of their time and opinions and each has contributed in some way to the conclusions which we have expressed. We are especially indebted to Dr. Gordon Ferguson, Executive Secretary of the Canadian Medical Association — B.C. Division and to Mrs. Dorothy Coulter. FOR SALE Ear, Nose and Throat instruments. Fully catalogued and relatively complete assortment of surgical and clinical instruments required for the specialty are for sale as one group or in part. May be seen in the Operating Room section of the Royal Jubilee Hospital in Victoria, B.C. Apply to Miss Jamieson, R.N., Operating Room Supervisor or to Owner, Dr. W. E. Baker, D.V.A. office of the P.M.E., Calgary, Alta. Page 258 THE PROBLEM OF PRONENESS TO ACCIDENTS By DR. S. C. TURVEY, Vancouver There is an idea prevalent in medical and lay circles that certain individuals are inherendy prone to have accidents. However, as there is no universally accepted description of such individuals, the proposition warrants review and analysis. There is a living significance of words, which gives a clue to their relations and life history, to be a guide in selecting and averaging them into a system. Thus the word "accident" may imply either that a phenomenon of life has no causal connection with the pre-existing facts or conditions, or only that the causal conditions are not yet discovered. If the first definition be implied, then it stands in contradiction to the fundamental assumption of all science, namely, that every event has a cause; if the second, then it is merely admission of present ignorance, but even so, this is the proper implication for the inquiring mind. In neither case does it give any explanation of the phenomenon; but by frequent repetition of the word we get into the habit of thinking that it is an explanation. W_en Greenwood and Woods (1) in 1919 formulated the concept of "accident-proneness", later elaborated by Greenwood and Yule (2) and Newbold (3), that a minority of the people is responsible for the majority of accidents, they were thought to have found a new and unique hypothesis, of which many people had been vaguely aware in terms of "Jimson always is having accidents." Only lately have doubts arisen, but it is significant and worthy of emphasis, that these doubts apply to the subsequent claims of enthusiastic and uncritical researchers, for the authors' original work remains as the only thorough approach to the analysis of the statistics of accidents, and even more astounding, remains as an almost complete summary of existing knowledge of accident-proneness. They carefully limited the basic assumptions, rigidly oudined the method of deduction, and gave warning of the complexity of the problem, though all but a very few have airily disregarded their precepts. As almost everyone has assumed accident-proneness to be a fact, I shall begin the discussion with a cautiouslwarning — few facts are known concerning it, it is not a theory, but it is a useful working hypothesis, still lacking both definition and statistical proof. It has great potential value as a concept, which, with calm and reasoning minds, and if used by skilled researchers to obtain facts for the foundation of a theory, can reduce the incidence of accidents. "Not the fact avails, but the use you make of it" — Emerson's apophthegm is peculiarly applicable to the current controversy between "fact-applying" statisticians and "fact-collecting" clinicians. The clinicians generally tend to ignore the difficulty that the two significant words of the hypothesis were originally tentative terms, used of necessity to describe processes that were as yet inexplicable. But these tentative terms, by repetition and consequent familiarity, have tended more and more to become accepted as explanations of phenomena rather than tentative descriptions. Hence their tendency to obscure or conceal without explaining the problem. The word "proneness" merely names an essential factor in the hypothesis, without explaining it. An explanation would involve some knowledge of the origin and significance of this trait or quality, but, from judicious reading of the numerous papers on the subject, I believe an unbiassed opinion would admit there is no accepted description of this characteristic. No biological characteristics have been found to be connected invariably with this special susceptibility, in spite of numerous claims to the contrary. A few of these should be examined. Thus, Flanders Dunbar (4) states that 80% of a group of people who had one serious accident tended to have others, and showed special characteristics. This astounding statement would jolt the faith of the most credulous, but, she continues, this 80% had unusually good health records, were seldom off work, and Page 259 suffered very little from colds and indigestion. They were not dull or clumsy, but quick-minded, given to immediate action, and inarticulate about their feelings. Com- ' monly they were happy-go-lucky, impulsive, and apt to divorce and marry easily. Not \ one of these claims is warranted by statistics. All are impressions. However, she did not think "accident-proneness" to be necessarily a fixed quality. Alexander (5) writes: "The accident-prone individual is an impetuous person . who converts immediately into action his momentary impulses, without deliberation and planning. He harbours a deeply ingrained resentment against persons in authority. At the same time he has a strict conscience, which makes him feel guilty for this rebellion. In the unconsciously provoked accident, he expresses his resentment and revenge, at the same time atoning for his rebellion by his injury." This kind of sophistry was once used by psychoanalysts to explain epilepsy, which was also called an unconsciously intended accident on the part of certain personality types. Adler (6) found 60% of workers who had repeated accidents to be bitter, and to have a resentful attitude toward their parents and educators, blaming them for later un- happiness — "people take their pasts with them to their jobs." Few of us who treat the injured could corroborate these sweeping remarks. The suggestion that accidents are caused by deep-seated psychological conflicts, rather than by physiological or environmental conditions, has three major objections: (1) As psychoanalysis, or even full psychiatric care is impractical of application to all who are accident-prone, it invokes the defeatist solution of discharging or transferring the worker (2) It is a "dead-end" hypothesis, indicating as it does the futility of further research and effort, and (3) the evidence for such an hypothesis is so glib and flimsy that it justly invokes the scorn of statisticians and researchers. The attempt is made to transfer the entire matter from the real world of persons and things, into the disembodied space of an individual's mind. And why could not an employer plead that the accident was due to this workman's "rebellion" and "resentment" (subconscious, of course) rather than to a complex of contributory causes, and thus evade paying Compensation? Other clinicians have variously stressed the importance of fatigue, reaction time, diet, perceptual and motor failure, anxiety states, debilitating illnesses, dissatisfaction with, or lack of interest in job; others blame the so-called somatotonic personality, the type that is athletic and vigorous, has a muscular body, loves power, adventure and risks; tends to be impulsive and unthinking rather than deliberative or inhibited, and is energetic and assertive. Vernon (7) wrote: "The accident-proneness of various individuals is not a fixed quality, but is liable to be affected by any and every change in their bodily condition; by external changes of environment as well as by internal changes of physical and mental health." Thus, he postulates, proneness is a variable attribute which anyone may have at some time in his life, but he later confuses the picture by stating that accident-liability, a different state, depends on: (a) An inherent accident-proneness; (b) Variations in health, age, experience, fatigue, etc.; (c) The risks in the environmental condition. To further confuse us, Farmer and Chambers (8) state: "The fact that one of the factors connected with accident liability has been found to be a peculiarity of the individual, allows us to differentiate between "accident-proneness" and "accident- liability". "Accident-proneness" is a narrower term than "accident-liability", and means a personal idiocyncrasy predisposing the individual to a relatively high accident rate. "Accident-liability" includes all the factors determining accident rate; accident- proneness refers only to those that are personal. Such splitting of the hair is suspect, and adds nothing to the understanding of proneness. Page 260 Thus the clinicians: The opinion of the statisticians has been stated succincdy by Arbous and Kerrich (9). This is an unusual article in medical literature, for it is not only accurate and well written, but is a model of intellectual integrity and clarity, quite impatient of fuzzy thinking and writing. They show the basic fallacy of any argument based on the distribution of accidents in a single period of observation, and emphasizes the vital importance of determining whether accident-proneness is a variable or an invariable trait, and whether it is a general or a specific factor — "there is no point in attempting to devise means of measuring or assessing or predicting an unstable phenomenon." The popular view, that the accident-prone individual has many accidents at home, at work, on highways, and at play, lacks any proof, though this is the crux of the matter, and is vital for the prediction and prevention of accidents. In their words, "our existing knowledge is of a mathematical and statistical nature. There is a regrettable tendency of psychologists to forget conveniendy or unconsciously, the assumptions underlying all mathematical and statistical "proofs", and similarly to forget 'the fact that it is never possible in any science to prove a hypothesis'." The result has been confusion. They found very litde consistency in the records of individuals from period to period, so most of the studies are of litde value, and, as statistics, "fail lamentably"; all attempts at refinement of tests for accident-proneness have yielded only inconclusive results. What is an accident? It is the occurrence of the unplanned or unpredicted event. Scant attention has been paid in most studies to the definition of what should be considered an accident. Arbous and Kerrich define it: "In a chain of events, each of which is planned or controlled, there occurs an unplanned event, which being the result of some non-adjustive act on the part of the individual (variously caused), maj or may not result in injury." The injury is the result of this unplanned event and does not itself constitute the accident. "From this it follows that our statistical population of events is the sum total of all unplanned incidents in the given environmental circumstances, and in the given population of individuals. These will exclude all events attributable to mechanical or impersonal causes." It does not include the accident to "A" by a brick dropped by "B", nor to the motorist stung by a bee. "By definition, all the following must be regarded as constituting our population of accidents: (1) All errors or slips or "near accidents" which result in no injury; (2) All accidents producing minor injuries; (3) All unplanned events resulting in major or lost time injuries which incapacitate. (4) All unplanned events resulting in death." (The accident-frequency rate, as defined by'the American Standards Association, which is followed by the National Safety Council in compiling its records, refers only to the number of lost time accidents per million man hours worked.) The fallacy of excluding near-accidents or minor injuries is analogous to trying to judge the odds on rolls of the dice by the size of the stakes, yet in most researches only the major injuries and deaths are studied. This is not the study of accidents. Arbous and Kerrich separate two liabilities of the individual, first, to have an accident in a given environment and second, to sustaining an injury in a given environment, and state; "no techniques have been yet devised to disentangle the skeins of this intricate and confused pattern" and "to try to simplify it by sub-dividing it into personal causes and environmental causes leads us nowhere". And as noted before, the original paper of Greenwood and Woods was unique in its warning that, "individual susceptibility shelters a modey host of motives and factors which will be very difficult indeed to separate and measure." Why the wide differences in viewpoints of clinicians, psychologists and statisticians? They are not different jobs, rather dealing with different but inseparable aspects of the same job. The statician depends on the clinicianTor the accuracy of his Page 261 data, but he is not using statistics for their own sake, rather in order that the conclusions which he draws from them may be applied in practise by the administrator, the general practitioner and the consultant. The relationship between the statistician and clinician is thus a symbiosis. Statistics are used to investigate group tendencies, emphasizing isolated aspects of the individual personality; the clinician studies the total personality to analyse every factor that could possibly cause a proneness to accidents in any environment — mental, emotional, physical, sociological. There are no fixed equations of human behaviour. Arbous and Kerrich think "surely the essence of accident causation is the rather intricate inter-relationship which exists between the individual and the environment — full comprehension of these inter-relationships, and their statement in universal 'laws" will possibly only be achieved when we have evolved statistical techniques which will facilitate three and perhaps four dimensional thinking in these matters. Existing methods of analysis make the problem too simple — too dependent on the direct cause — and — effect relationships." I think this is a reasonable summary of our knowledge of accident-proneness. Its occurrence is like that of alcoholism, insofar as there are no known criteria of personality for predicting it in the individual, but a certain percentage will be present in any group of individuals. Accidents are problems of human adjustment. The proneness is not necessarily a permanent characteristic. Wolff (10) quotes some surprising figures. Thus statistics of the Metropolitan Life Insurance Company for a two and a half year period show that 2% of employees are responsible for 30% of the accidents, and in some industries, 15% of the employees are causing almost 100% of the accidents. Increased production in nearly every industry is accompanied by a decrease in the accident rate; and the rate drops con- standy with age. The rate is higher in those workers who are shifted from job to job than those who do the same job over a long period. It has been noted that some of the best workers, especially in the skilled group, are found to be accident-prone, probably due to temporary factors such as worry. However, all these observations are based on "single period" records, and constitute impressions, not facts. The criteria for adequate statistical investigation are well known: (a) Constant conditions of exposure to accidents; (b) Sufficient number of accidents of all types; (c) Sufficient number of people doing identical work for an adequate period of time (three years minimum). (d) Reporting of all accidents of a homogeneous population. Schulzinger (11) tried to approximate these conditions in his report on 35,000 accidents over a period of 20 years; 27,000 industrial accidents; 8,000 non-industrial. He concluded: 1. The tendency to have accidents passes with age (decreases after 21). 2. Most accidents are due to the increased liability to accidents of youth. 3. Men are more liable than women (2 to 1). 4. Most accidents (74%) are due to relatively infrequent solitary experiences of large numbers of individuals (86%). This remained constant for the; twenty year period. 5. Those who suffer injuries year after year, over a period of three years (3.5%) account for a relatively small percentage of all the accidents (0.5%). 6. Irresponsible or mal-adjusted individuals are significandy more liable to accidents. Thus, "the relatively small percentage of the population that contributes a disproportionate number of accidents is essentially a shifting group, with new persons con- standy falling in and out of the group." Advance in age, learning, physical and psychological adaptation takes people out of the group. "Almost any normal individual Page 262 under emotional strain or conflict may become temporarily accident-prone, and suffer a series of accidents." It should be noted that Henrich (12) in analysing half a million accidents, demonstrated a fixed relationship between accidents with injury and accidents without injury (in a unit group of 330 similar accidents, there were 300 with no injuries, 29 minor injuries, and 1 major injury). This fixed relationship was confirmed by experience during the war. It should not be presumed that it is impossible to spot the person who is apt to have accidents in one particular period of time, and at one task, particularly in complicated or skilled operations. The Air Force did it with their pilots, bus companies [Viteles (13)] have done it with their drivers. But the battery of physical and psychological tests is formidable, the process is tedious and lengthy, and is feasible only when an expensive aeroplane or bus is involved, as well as the liability of many lives. The expense would prohibit the application to all labourers. What course to prevent accidents is now practical? Neither mass education or termination of employment is the answer. The important factors to be stressed are: 1. Systematic instruction in avoiding faulty habits, 2. Close observation of the details of an operation; 3. Study of the individual — medical treatment, encouragement, discipline, and possibly study of the circumstances of the home, and an estimation of his personality by a trained personnel worker. 4. Constant review of the relationship between supervisor of foreman and worker. Really, the foreman is the key man in preventing accidents. It is he who must believe that the man, and not the job, is responsible for accidents, and he must be taught the value of the correct psychological approach, of sustained interest in his workers, and of encouragement. Thus, it is largely an educational program of both foreman and worker. All that the word "morale" implies is involved. 5. Special attention must be paid to minor accidents, to those who suffer repeated accidents, and to those who visit the sick bay frequendy. 6. For the very small percentage who continue to have injuries there are three choices: (a) An absolutely fool-proof job; (b) A psychiatrist; (c) Termination of employment. It has been shown frequendy that individuals will respond to new and sustained interest taken in them by management. Their problems can be discussed with them; they can be taught new lights about safety in new terms. The newer social skills have not been given adequate opportunity to demonstrate their useful role in reducing the individual's liability to an accident. "To depend primarily upon detection and removals, or psychoanalysis of particular personality configurations, is neither warranted nor wise in the light of the incomplete state of our present knowledge of accident-prone behaviour patterns (9)." Such personal reactions as carelessness, apathy, inattention, fatigue, disinterest, fear, worry, nervous tension, faulty judgment, impulsiveness and inexperience are more important and usually are amenable to treatment. Give the worker pride in his work, obtain his willing co-operation in health and safety measures, as well as a sense of identification with the foremen, safety engineers and his fellow workers. For the future, the hope is in research in occupational health. This is now regarded as a special branch of medicine, requiring special training of a very high order, both undergraduate and post-graduate. England is now contemplating a nation wide industrial service as part of the national medical care. Heretofore, both the training of medical and nursing personnel, and the facilities for research, have been inadequate. Consultants must be more closely linked with the industrial physician, Page 263 and consultants in industrial medicine should be trained. The British Medical Association has suggested five types of training: 1. Industrial consultants; 2. Whole time industrial doctors; 3. Part-time practitioners, engaged in industry, as well as 4. Industrial nurses, and 5. The education of laymen, personnel managers, medical auxiliaries, social service workers. It is doubtful if employers should be expected to subsidize such a service entirely. Industrial health and efficiency is a national asset and if the employer allowed the workman to attend for advice and treatment during working hours, he would be making a good contribution. Safety boards and evaluation centres for use by industry generally would be invaluable. An adequate and practical psychological test is a real need. The medical, engineering and sociological approaches to the worker's health have progressed further than the psychological. Psychologists are currendy investigating mathematics and computers, by which they hope to develop equations showing the foibles of both men and machines as they function in tandem. "Machines tend to gum up human behavior, and vice-versa." Perhaps it will be necessary to discover techniques involving multi-dimensional thinking to solve the psychological problem. Certainly more work in biostatistics must be done to demonstrate relationships between accidents and social factors. The aphorism, "Statistics may prove anything, even the truth" (Moynihan), is meant to indicate an inherent vice in statistics, not to impute corruption to their compiler. SUMMARY Accidents may be attributable to a disturbed personality, an impaired physiology, or a hazardous environment. There is a need for more systematic instruction designed to eliminate faulty habits. Continued emphasis is necessary on education for safety, correction of physical and emotional impairments, and control of environmental hazards. The concept of accident-proneness as a phenomenon of the group is valuable if considered as a shifting sequence of phenomena in any one individual, not necessarily as an immutable and inherent characteristic. As a theory, it is only valuable as a policy to stimulate and direct experiment, and to connect or co-ordinate apparently diverse phenomena. It calls for a skeptical approach to all arguments divorced from actual observation or experimentation. Whatever one's belief may be, at present there seems to be no way of knowing or conceiving the central trait of accident-proneness in a definite way. The whole hypothesis can be conceived only in a general way, and the phraseology in which it is set out cannot legitimately be more definite than the conception in the mind. REFERENCES 1. Greenwood and Woods—Rep. Indust. Health Res. Board (Lord) 1919, 4. 2. Greenwood and Yule—J. Roy. Stat. Soc. 1920, 83, 255. 3. Newbold—Rep. Indust. Hlth. Res. Board (Lord) 1926, 34. 4. Dunbar, F.—War Medicine, 1943, 4, 1. 5. Alexander, F.—Pub. Health Rep. 64: 359 (March 25) 1949. 6. Adler, Alexander—The Psychiatry of Repeated Accidents in Industry, Am. J. Psych., 98, 99, July 1941. 7. Vernon, H. M.—Accidents and Their Prevention, Camb. Univ. Press 1936. 8. Farmer, E. and Chambers, E. G.—Psych. Studies of Ihdiv. Difference in Accident Rates—I. H. R. B. Report No. 55, 1929. 9. Arbous, A. G. and Kerrich, J. E.—The Phenomenon of Accident Proneness, Biometrics, 1951, 7, 340. 10. Wolff, E.—Accident Proneness, A Serious Industrial Problem, Indust. Med. and Surg. 19: 9 (Sept.) 1950. 11. Schulzinger, M. S.—Indust. Med. and Surg. 23, 4, September 1954. X2. Henrich, H. W.—The Foundation of a Major Injury, Travellers' Standard, 1929. 13. Viteles—Indust. Psych., W. W. Marten Inc., N.Y. 1932. Page 264 INCOME TAX INFORMATION March, 1955 Individuals whose income — (a) is derived from carrying on a business or profession (other than farming); (b) is derived from investments; or (c) is more than 25% derived from sources other than salary or wages, are required to pay their estimated tax by quarterly instalments during such year. Each payment must be sent in with Instalment Remittance Form T.7-B Individuals. Any balance of tax is payable with interest with the T. 1 General return which is due to be filed on or before April 30 of the succeeding year. Doctors who pay salaries or wages to their own employees and assistants must deduct therefrom such amounts of tax as are prescribed in Tables obtainable from District Income Tax Offices. Amounts so deducted in a month must be sent to the local District Income Tax Office not later than the 15th day of the following month, accompanied by a T.D.7A Remittance Form. The following timetable indicates the returns required. A. Doctors NOT receiving salaries amounting to three-quarters of income: Date Due Forms to be Used March 31 T.7-B Individuals. April 30 T.l—General. (Note: Only doctors deriving their full professional income from salaries may use Form T.l Short). June 30 T.7-B Individuals. September 30 T.7-B Individuals. December 31 T.7-B Individuals. B. Doctors receiving salaries amounting to three-quarters or more of income: Date Due Forms to be Used April 30 - T.l—General. (Note: Doctors deriving their full professional, income from salaries may use Form T.l Short.) Whenever status is changed* — T.D.I. *With respect to new employer, marital status, dependents. C. Doctors who pay salaries to their own employees: Date Due Forms to be Used 15th of each month_T.D.7A. 28th of February—-_T.4 Summary and Supplementary. DOMINION INCOME TAX RETURNS BY MEMBERS OF THE MEDICAL PROFESSION As a matter of guidance to the medical profession and to bring about a greater uniformity in the data to be furnished to the Taxation Division of the Department of National Revenue in the annual Income Tax Returns to be filed, the following matters are set out: INCOME 1. There should be maintained. by the doctor an accurate record of income received, both as fees from his profession and by way of investment income. The record should be clear and capable of being readily checked against the return filed. It may be maintained on cards or in books kept for the purpose. §f EXPENSES 2. Under the heading of expenses the following accounts should be maintained and records supported by vouchers kept available for checking purposes: (a) Medical, surgical and like supplies; (b) Office help, nurse, maid and bookkeeper; laundry and malpractice insurance Page 265 premiums. (It is to be noted that the Income Tax Act does not allow as a deduction a salary paid by a husband to a wife or vice versa. Such amount, if paid, is to be added back to the income); (c) Telephone expenses; (d) Assistants' fees; the names and addresses of the assistants to whom fees are paid should be furnished. This information is to be given each year on Income Tax form known as Form T.4, obtainable from your District Income Tax Office; (e) Rentals paid; the name and address of the owner (preferably) or agent of the rented premises should be furnished [see (i)]; (f) Postage and stationery; Xg) Depreciation; a description of the treatment of depreciation may be found on page four of the Income Tax Return Form T.l General under the Part XI Method. The method of computing depreciation for tax purposes is the same as that used last year and you should have no difficulty if you have a copy of last year's return available. Simply carry forward the balance remaining in each class after deducting last year's allowance. Add to this figure the cost of any new equipment purchased and deduct the proceeds from any disposal of property in each class. The rate you wish to use not exceeding the maximum rate (see below) is applied to this new balance for each class to obtain the depreciation you may claim this year. The maximum rates for the classes of equipment most used by doctor follow: ^•;; Maxium Capital Item Annual Medical equipment Class Depreciation (a) Instruments costing over $50 each and medical apparatus of every type 8 20% (b) Instruments under $50 each __JI__ 12 100% Office furnitute and equipment 8 20% Motor car _|j| 10 30% Building (Residence used both as dwelling and office) S£ 3 5% Where a doctor practises from a house which he owns and resides in, the allowance may be claimed as above on a portion of the cost of the residence, excluding land. For example if the residence were a brick building costing $12,000, and one-third of the space were used for the office, the doctor would use $4,000 as the business portion of the cost and apply the building rate of 5% to detrmine the maximum depreciation allowable in the first year. For further information on the subject you may refer to the Regulations or you may consult your District Income Tax Office. (h) Automobile expense; (one car). This account will include cost of license, oil, gasoline, grease, insurance, garage charges and repairs; The capital cost allowance is restricted to the car used in professional practice and does not apply to cars for personal use. Only that portion of the total automobile expense incurred in earning the income from the practice may be claimed as an expense and therefore the total expense must be reduced by the portion applicable to your personal use. The mileage rate permitted in years prior to 1950 may no longer be used to estimate the automobile expenses. (i) Proportional expenses of doctors practising from their residence: (a) owned by the doctor: where a doctor practises from a house which he owns and as well resides in, a proportionate allowance of house expenses will be given for the study, laboratory, office and waiting room space, on the basis that this space bears to the total space of the residence. The charges cover taxes, Page 266 light, heat, insurance, repairs, capital cost allowance, and interest on mortgage (name and address of mortgagee to be stated); (b) rented by the doctor: only the rent and other expenses borne by the doctor such as heat and light will be apportioned inasmuch as the owner takes care of other expenses. The doctor should be prepared to demonstrate, if called upon to do so,'that his apportionment of any particular item is in accordance with the facts relative to that item. (j) Sundry expenses (not otherwise classified); The expenses charged to this account should be capable of analysis and supported by records. Claims for donations paid to charitable organizations will be allowed up to 10% of the net income upon submission of receipts to your Income Tax Office. This is provided for in the Act. The annual dues paid to governing bodies under which authority to practise is issued and membership association fees, to be recorded on the return, will be admitted as a charge. Initiation fees and the cost of attending postgraduate courses will not be allowed. (k) Carrying charges: the charges for interest paid on money borrowed against securities pledged as collateral security may only be charged against the income from investments and not against professional income. (i) Business tax will be allowed as an expense, but Dominion, Provincial or Municipal Income tax will not be allowed. II CONVENTION EXPENSES* "Effective January 1, 1948, the reasonable expenses incurred by members of the .medical profession in attending the following Medical Conventions will be admitted for Income Tax purposes against income from professional fees: 1. One Convention per year of the Canadian Medical Association. 2. One Convention per year of either a Provincial Medical Association or a Provincial Division of the Canadian Medical Association. 3. One Convention per year of a Medical Society or Association of Specialists in Canada or the United States of America. The expenses to be allowed must be reasonable and must be properly substantiated; e.g., the taxpayer should show (1) dates of the Convention; (2) the number of days present, with proof of claim supported by a certificate of attendance issued by the organization sponsoring the meetings; (3) the expenses incurred, segregating between (a) transportation expenses, (b) meals and (c) hotel expenses, for which vouchers should be obtained and kept available for inspection. None of the above expenses will be allowed against income received by way of salary since such deductions are expressly disallowed by statute." * As the deduction of these expenses has recently been challenged by the Income Tax Appeal Board, the question of convention expenses is now under review. The memorandum quoted above applies to the taxation year 1954. Its future application depends on the outcome of an appeal which is at present before the Exchequer Court of Canada. fPROFESSIONAL MEN UNDER SALARY CONTRACT The employees' annual contribution to an approved Pension Plan and alimony payments may be deducted from salary income. Amendments to the Income Tax Act, introduced in 1951 and made retroactive to the beginning of the calendar year 1951, provide for the deduction of certain expenses from salary income. The allowable expenses include travelling expenses, annual professional membership dues, office rent, salary to an assistant or substitute and supplies consumed direcdy in the performance of the duties of employment. Page 267 The annual registration fee of the Provincial medical licensing authority would be allowable if paid by the doctor himself. Certain conditions are attached to the allowance of the expenses and without trying to recite the exact provisions of the law the main points are: (a) That the expenses must have been incurred in the performance of the duties of the office or employment. (b) That the employee is required, under the contract of employment, to pay the expenses. (c) To claim travelling expenses the employee must be ordinarily required to carry on the duties of his employment away from his employer's place of business. Travelling between the doctor's home and his office is not included. Where the travelling expenses are allowable under these provisions, depreciation may be claimed on the automobile used for this purpose but no other claim for depreciation may be made. INCOME FROM A PARTNERSHIP Additional expenses incurred by a partner, but not charged to the partnership, may be claimed as a deduction from the partner's share of income. However, the partner must be in a position to substantiate these expenses, to show why they were not charged directly to the partnership and that they were necessarily laid out to earn the partnership income. DOCTOR'S RECEPTIONIST Available immediately. Has one and a half years training V.G.H. School of Nursing. Capable typist. Experience in meeting public. Miss Joan Tamboline Ladner, B.C. Phone: Ladner118-R MEDICAL OFFICES Property address—6194 Fraser Avenue, Next door to Canadian Bank of Commerce. East side of Fraser Avenue, Second floor of new building. Attractive modern design. Will be available for Lease Rental. Approximately 1600 square feet of office accommodation, built to suit Lessee. For information apply to FRANK H. YEOMANS, c/o BLANE FULLERTON & WHITE LTD. 517 Hamilton Street — PA. 8121. Page 268 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H. Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia CARE OF THE PREMATURE Since the introduction of the National Health Grants programme some 70 standard incubators have been supplied to 36 hospitals in this province using National Health Grants funds for purchase of same. The majority of these incubators have been of the Armstrong type and this choice has been as a result of discussions with leading paediatricians in the city of Vancouver. Recendy the Committee of the Fetus and the Newborn of the B.C. Division of the Canadian Medical Association has prepared pertinent information which is applicable to the use of the Armstrong type of incubator and this information is being circulated to all hospitals in this province for their guidance. The recommendations of the Committee on the Fetus and the Newborn of the B.C. Division of the Canadian Medical Association are as follows: "Recent developments in the study of the cause of retrolental fibroplasia indicate that an oversupply of oxygen to premature babies may be a major factor in the production of this abormality. It has seemed useful to measure the levels of oxygen under different circumstances in the Armstrong incubators which are in use in British Columbia. It appears that surprisingly high and apparendy dangerous levels of oxygen intake are achieved in these incubators unless precautions are taken. This is particularly true if the vents in the top and the bottom of the incubator are closed. (1) Vents at the bottom of the incubator closed. (2) Vents at the top of the incubator open at least half their breadth. (3) Never more than 2 litres of oxygen flow per minute. Although intakes approximating the danger level can occur even under these circumstances, the usual oxygen concentration varies between 25% and 42% in different incubators at different times. Closing the upper vents or increasing the flow to 3 litres will cause the concentrations to rise to levels of 70% or more. In the light of present knowledge, such levels would be most dangerous if continued for periods of more than an hour or two. It should be emphasized that a premature infant who is cyanosed should be provided with a sufficient concentration of oxygen to relieve the cyanosis. When cyanosis is present, high concentrations of oxygen apparendy do no harm since there is interference with gaseous exchange. However, as soon as the cyanosis is relieved a continuing effort should be made to reduce the rate of flow, since unnecessarily high levels of oxygen for more than an hour or two may possibly be dangerous." MEDICAL EXAMINATIONS FOR DISABLED ^PERSONS' ALLOWANCES On January 1st, 1955 there became effective an act to provide allowances for disabled persons. The act enabled the Government of Canada to enter into agreement with each of the provinces for the administration of this measure. Costs are being Page 269 shared equally by the Government of Canada and the provinces entering into the agreement. In British Columbia payment of allowances to disabled persons qualified to receive them will commence on April 1st of this year. Payment of allowances will be administered by the Disabled Persons' Allowances Board of the Welfare Branch, Provincial Department of Health and Welfare, with offices at 411 Dusmuir Street, Vancouver. Applications from persons resident in the province are now being accepted. Each application will be reviewed to establish that the applicant is entitled to an allowance. In brief, an applicant to qualify must be 18 years old, must have been a resident in Canada for the last 10 years, and be presently residing in British Columbia, must be financially unable to meet his own needs, and finally, must be permanendy and totally disabled. Qualifications regarding age, residence and financial state will be determined by the Disabled Persons' Allowances Board. To establish the medical condition of the applicant as to being totally and permanendy disabled, the Board has appointed a Medical Advisory Committee which will study each application from the standpoint of medical findings. In British Columbia this Committee will be comprised of an orthopaedic surgeon, Dr. F. C. Preston, Vancouver, B.C., an internist, Dr. John A. Leroux, Vancouver, B.C., and a medical social worker, Miss Aileen Mann of the Department of Health arid Welfare, Vancouver, B.C. Dr. Preston will represent the Department of National Health and Welfare and Dr. Leroux the Provincial Department of Health and Welfare. Miss Mann will advise the medical members on matters pertaining to social conditions of applicants but will not enter the final decision on medical qualification for allowances. Each applicant will be required to undergo a medical examination by his physician. The findings of this examination are to be recorded on a Medical Report which has been prepared specifically for this purpose as required by the regulations covering the allowances. Upon receipt of this medical report the committee will study the findings and advise the Board whether or not the applicant qualifies as to medical disability. The committee will be unable to make a decision on any application not accompanied by a completed medical report. In those instances where the committee feels unable to provide a sound opinion based solely on the information supplied in the medical report, it may write to the physician asking for further specific information or it may recommend that further examination be carried out with particular reference to special procedures, as for example psychiatric assessment of a doubtful mental disability or consultation on a cardiac problem. The committee must make its decision on as sound a medical basis as possible, and to do this it will depend on the exactness of the information provided by medical practitioners, with the aim that those who are entided to allowances will receive them, and, vice versa, that those not qualified are not accepted. The act enabling of such allowances very carefully defines what shall comprise total disability and the committee will decide each case within the limits of the definition. The following is the defiinition in the Regulations under the Act: "(2) For the purpose of the Act and these regulations, a person shall be deemed to be totally and permanendy disabled only when (a) the person is suffering from a major physiological, anatomical, psychological impairment, verified by objective medical findings; (b) the impairment is likely to continue without substantial improvement during the lifetime of the person and is one to which the concept of cure cannot be applied; and (c) as a result of such impairment, the person is severely limited in activities pertaining to self-care and normal living, such as being (i) bedridden or chairfast (ii) unable to leave home without being accompanied by another person, Page 270 (iii) normally in need of care and supervision for one or more of such self-care activities as dressing, body hygiene or eating, (iv) unable to perform such routine activities as climbing a short stairway or walking a limited distance on a level surface, or (v) certified by a qualified physician to be under medical instructions to forbear from activities of the kind mentioned in subparagraph (iv). (3) Notwithstanding subsection (2), a person shall be deemed not to be totally and permanendy disabled where, in respect of that person a favourable rehabilitation prognosis is obtained, or approved therapeutic measures are recommended, by provincial authority, and the requisite rehabilitation services or therapeutic measures are available." The medical report which physicians are asked to complete appears at first glance to be lengthy. However it is pointed out that the entry of relevant positive findings only is required which will make the completion a much briefer task. Physicians are not being asked to express their opinion as to whether the applicant is totally disabled. The committee will carry that responsibility and the patient may be so advised. The applicant is responsible to make his own arrangements with his physician for the payment of the fee for the examination and completion of the medical report. ||| Finally, the possibility of bringing such means of rehabilitation as are available in British Columbia to the aid of all applicants will be kept in mind. The medical committee in particular will assess each application from this standpoint drawing promising cases to the attention of those who may be in a position to do something definite in this field. FLUORIDATION FACTS (Continued) Prominent Child Specialist Endorses Fluoridation Many of those who oppose fluoridation of water supplies to prevent dental caries are of the same group who have also opposed pasteurization of milk and the use of toxoid to prevent diphtheria, according to Dr. Alan Brown, Emeritus Professor of Pediatrics, University of Toronto. "I have yet to notice any letter opposing fluoridation written by any person who has the semblance of a right to be called an authority. Too many of those who write letters to the newspapers show a lamentable ignorance of chemistry in their arguments. To state that public health authorities propose to put rat poison in the water is merely an indication of ignorance of the fundamentals of chemistry and physiology and provides an excellent example of the substitution of vituperation for logic. Many of the normal constituents of the human body, of which fluorine is one, would be poisonous if given in excessive amounts. This is true, for example, of iodine and chlorine. Iodized salt and chlorinated water are now accepted as normal means for preventing certain diseases. The fluoridation procedure has been endorsed without qualifications by numerous scientific bodies in North America. Natural fluoridation has, undoubtedly, caused a reduced rate of caries in nearly 4,000,000 people who have been drinking fluoridated water supplies all their lives. As a result of this observation, over 14,000,000 people are now drinking water to which fluorine has been artificially added in various cities in Canada and the United States. There is not the slightest evidence which would indicate that fluoridation of water in the proper proportions is other than a boon to the children of this and other countries." Page 271 Addition of Sodium Fluoride to. Community Water Supplies A Perfectly Safe Procedure Fluorides in relatively large doses are highly toxic. The lethal dose for man is approximately 4,000 milligrams. Acute symptoms may be caused by more than 250 milligrams. The high dosages necessary for acute fluoride poisoning could not be obtained as a result of acidental or deliberate over-fluoridation of water supplies. In order to obtain acute toxic effects it would be necessary, for example, to dump over eight tons of sodium fluoride into the Brantford, Ontario, water supply in one day. The amount actually used in the Brantford supply is about 140 pounds in one day, based on a 5,000,000 gallon consumption. At a controlled level of 1.0 parts per million, to suffer even minor ills, a person would need to drink 300 gallons of water in one day, a possibility that may safely be considered rather remote. PHYSICIANS' ART SALON The Physicians' Art Salon Committee invites any Canadian physician or medical undergraduate to enter his work in the 1955 Salon to be held in Toronto's Royal York Hotel from June 20-24. This will mark the 11th year for this popular art and photographic feature of the annual C.M.A. Convention. It is sponsored by Frank W. Horner Limited, Montreal. Conditions of Entry. The Salon structure will undergo few changes. As in previous years, entries will be accepted in three sections. 1. Fine Art. 2. Monochrome Photography. 3. Colour Photgraphy. The Fine Art section is further subdivided into Traditional, Contemporary, and Portrait categories. There is no restriction on medium, — oil, tempera, gouache, water colour, charcoal, pencil, or dry brush is acceptable in each. However, each exhibitor is limited to three entries in Fine Art and Colour Transparencies, but in Monochrome Photography four prints are permitted. And any exhibitor may enter up to the limit in one or more sections. There is no charge — all costs, including transportation of entries to and from Toronto, will be borne by Horner. Judging and Awards. All acceptable entries will be displayed prominendy in the Salon and then judged for awards by a competent jury to be selected by the Art Salon Committee. To obtain entry form. Any physician or medical undergraduate interested in subnutting work may obtain an entry form with details by writing the sponsor at P.O. Box 959, Montreal. A short note or post card will do. The entry form contains complete instructions on how to prepare and ship your entries. Art Salon Calendar. A novel feature of the Salon, the Physicians' Art Salon Calendar, will again be prepared by Frank W. Horner Limited. The Calendar reproduces award-winning work in full colour and is distributed to all physicians in Canada, with the compliments of the Company. Page 272 feet Dr. Stanley Avren of Victoria is now in Michigan studying allergic diseases. Dr. John R. Moore is now practising surgery in Vancouver. Eh. W. K. Massey is now in Radiology at the Montreal General Hospital. Dr. R. E. Marshall is now practising in Mission City. Retired from active practice are Eh. R. J. Elvin and Dr. W. A. Wilson of Vancouver, and Dr. H. R. Ross of Cloverdale, B.C. Dr. J. Morrow is practising in Duncan. Eh. J. M. McKellar is now in Esquimalt. Dr. Dodd Q. Chu is consulting in internal medicine in Vancouver. Eh. W. J. Johnston, executive director of the College of General Practice of Canada announced last month that 800 members have now received membership certificates. Dr. L. G. Wood has been appointed to the Board of Editors of the Journal of Urology, Baltimore, Maryland. Dr. Wood is Chairman of the Editorial Committee (for five years) with the Western Section of the American Urology Association. Doctor Cameron S. Allen has recendy received a signal honour. In 1948, a program of Exchange Fellowships was arranged between the British, American and Canadian Orthopaedic Surgeons whereby a selected group was to be chosen in alternate years from Britain and America to travel. In 1948, 15 Britishers came to North America and were entertained by the American and Canadian Orthopaedic Surgeons and travelled to various Clinics. This year, a group of four Americans and one Canadian are going to Britain as guests of the British Orthopaedic Association. The candidates are selected by the American and Canadian Orthopaedic Surgeons from applications by any Orthopaedic Surgeon under the age of 40 years. Doctor Allen's appointment is a high honour for himself, the Medical Faculty, and for Orthopaedic Surgery in British Columbia. BIRTHS To Dr. and Mrs. Michael Turko of Vancouver a son. To Dr. and Mrs. Walter Dunn of New Westminster a son. To Dr. and Mrs. Donald Oakley of Prince Rupert a son. To Dr. and Mrs. Baird of Vancouver a son.. ff|* To Dr. and Mrs. George Darby of Vancouver a son. OFFICES AVAILABLE Suitable for three doctors, large waiting room. Five examining rooms. Children's specialist preferred. Excellent location. Close to residential area. Fully modern. 741 Columbia Street For Information Apply S. F. MARK Phone: N.W. 280 New Westminster Page 273 i • o* f|:tt|' tcrease d protection y Go\den Wne^J o_H* M\LK 1___5*| vacu\>m 7.857o Ruttetlcose-ond^^ Protein V-a ^A |lSp SOU°S A.00% 6.85 9.75 A.40 ^2250% AAA 1VM ' A 800 \ntema^on^flwd oX. _____^_______ Cotones P* *» Page 274 PROFESSIONAL PHARMACEUTICAL SERVICE wsm .x___-i _.'.v Itlacdoi •|u|ui" Medical-Dent al Building PH-TED; Va___.i::i:?T__ icriglions 4141 •_//_« L^'^ rJUetiveru and ^rree /-Provincial f-^o&k aqe r Page 293 GREATER VANCOUVER PUBLIC HEALTH Metropolitan Health Committee Stewart Murray, M.D., Senior Medical Health Officer Vancouver, B.C. SPEECH DIFFICULTIES This month, many physicians who read this Bulletin will be visited by parents seeking advice about their child's apparent speech difficulty. The problems will range from simple "baby talk" through stuttering, to severe organic defects, and in some instances, assistance will be desired from outside agencies. "Baby talk" though viewed as a problem by parents, does not always need speech therapy despite the parents' request for such help. This does not imply that there is no problem in such cases. The greatest problem may not be the child, but the parents' attitude, for they, without realizing that the child is immature for his age, fear that the speech pattern will persist indefinitely. In most cases, the pattern of substituting consonant sounds for one another does not persist because the child in the learning process will outgrow it and learn the conventional usage as he becomes more mature. The physician's role therefore, is to help reassure parents of these "baby talk" children that the child will develop normal speech. One good method of helping the parents to be reassured is to provide them with the opportunity for talking out their anxieties, thus aiding them in accepting the concept that their child is somewhat younger than his chronological age. His "baby talk" is only the most noticeable symptom of this immaturity. Stuttering is a more serious disorder which may tax the ingenuity of medical, O J O J educational and speech therapists alike. Here the prognosis depends largely on the ability of the parents to reduce anxiety and tensions and to modify their attitudes early in its course so that the condition does not become relatively fixed and cause self-consciousness. When this stage is reached his anxiety increases; his original hesitations and repetitions become more pronounced, become incorporated into his personality and are very resistant to therapy. It is important that careful study be made to establish the etiological factor of the speech defect because, where it seems probable that there is an emotional basis to the child's difficulty, it is important that treatment be directed towards the emotional problem before any speech therapy is considered. Agencies such as Child' Guidance Clinics and the Mental Hygiene Division of the Metropolitan Health Committee and the Health Centre for Children are possible sources of help with this type of problem. These services can either provide treatment or direct the doctor to where such treatment can be obtained. These same agencies, as well as other medical services are available for the evaluation of speech handicapped children whose speech is affected by organic malformations. In cases where organic speech difficulties, such as cleft palate, arise, early evaluation and treatment at the suitable age are important. Here "speech therapy" in the narrow sense will be indicated after the usual surgical procedures. COMMUNICABLE DISEASES FOR 1954 Partial List Diphtheria 3 B. Dysentery 305 Infectious Jaundice 173 Measles - 2470 Men. Meningitis ___■ 14 Page 294 (1953 in brackets) (3) Poliomyelitis 58 (172) Salmonella pl06 (309) Scarlet .Fever 495 (1196) Typhoid Fever 3 (16) Whooping Cough 290 (207) (44) (662) (3) (169) Re: "Canadian Mother & Child" etc. We have recendy been informed that it is no longer the policy of the National Health and Welfare Department to make free distribution of the following publications: "Canadian Mother and Child" "The Dental Health Manual" "Up the Years from One to Six" "The Backward Child" These are now available at 25c each from the Queen's Printers, Ottawa, Ontario. A Package Transportation Plan (DESIGNED SPECIALLY BY DUECK) | (FOR THE MEDICAL PROFESSION) 1. An All-lnclllSive Monthly Billing (Including Insurance) 2. Predetermined Fixed Costing (includes Everything) 3. Brand-New Models of Your Choice (Constantly Maintained) DllECK MOTORS LEASE and SERVICE LTD. MR. JACK SCOBLE, Representative - CEdar 4111 Snrtor. rest qttfetlg f-^rescrioe k& -^igooI (barbiturate compound) Does away with: * Accidental intoxication * Suicide * Dreaded habituation * Hang-over Insures beneficial and restful sleep COMPOSITION Sodium Secobarbital N.N.R., 100 mg. (iy2 9rs.) Pentylenetetrazol U.S.P., 300 mg. Also Sodium Secobarbital N.N.R., 50 mg. [?/A gr.) Pentylenetetrazol U.S.P., 150 mg. Samp'e and literature available ANGLO-FRENCH DRUG CO. LTD., Montreal 18 DOSAGE: average dose: one capsule Page 295 { CONNAUGHT> The Work of Connaught Medical Research Laboratories in POLIOMYELITIS Research in poliomyelitis has been conducted in the Connaught Medical Research Laboratories for a number of years as part of a comprehensive program of investigations in diseases of man and animals. The fundamental contribution made by Enders and his colleagues in 1949 in cultivating poliomyelitis viruses in monkey kidney tissue made possible the preparation of a vaccine from these cultures by Salk in 1952. Research in the Laboratories contributed to the preparation of poliomyelitis vaccine. Medium #199 devised by Morgan, Morton and Parker for work in tissue culture was employed in the cultivation of poliomyelitis viruses, and methods for large-scale production of virus cultures were also developed. Practical use was made of these developments in the preparation of large quantities of cultures employed in making the vaccine. Last spring, The National Foundation for Infantile Paralysis, Inc., New York, planned and conducted a large-scale trial of the Salk vaccine in the United States. The Connaught Medical Research Laboratories supplied a large part of the culture fluids which were required for the preparation of the vaccine. Financial support for this was given by the National Foundation. In addition, the Foundation and the Government of Canada, through the National Health Grants, supported other studies in the Laboratories relating to poliomyelitis. Following the nation-wide trial of the Salk vaccine in the United States last spring, the Federal and Provincial Departments of Health in Canada arranged with the Laboratories for the preparation of sufficient vaccine for 500,000 persons for use commencing April, 1955, for the purpose of providing a trial in Canada. The safety of the vaccine has been already established, but no claims are being made, as yet, of its efficacy. The report of the results obtained in trials in the United States is expected to be made early in April on behalf of The National Foundation for Infantile Paralysis, Inc., by Dr. Thomas Francis, Jr., who is conducting a thorough study of the records of the 650,000 children who participated in the trial. The vaccine will not be commercially available until it is licensed by the Department of National Health and Welfare, Ottawa. CONNAUGHT MEDICAL University of Toronto RESEARCH LABORATORIES Toronto, Canada Established in 1914 for Public Service through Medical Research and the development of Products for Prevention or Treatment of Disease. DEPOT FOR BRITISH COLUMBIA MACDDNALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER 1v B.C. Page 296 As one travels south on Heather Street, from Broadway to Thirty-Third x^venue, one passes four hospitals, the smallest of which is known as Grace Hospital —but only in size and in the number of its beds may the word "small" be applied to it. Grace Hospital is more than merely a hospital where babies are born, and sick patients are treated. It is an emblem—a monument to the work of one of the most selfless and beneficial organisations in the world—the Salvation Army. Many years ago, sixty-eight to be exact, the Salvation Army began operations in Vancouver—the year after Vancouver was born. Its work then, as now, was to give help, material and spiritual, wherever it was needed—and it has never failed to give this help to all who apply. In 1893 it established a "hostel" or home for unmarried mothers, on 8th Avenue near Alder St., and a few of us, who practised here at the turn of the century, remember well looking after some of these unfortunates, who owed so much in aid and encouragement to the Salvation Army. The building still stands, and is known as the Maywood Home, and is still doing its magnificent work. In 1927, Grace Hospital was built, and has been an outstanding maternity hospital ever since. Mr. Blake Wilson and Frank Parsons were among the first presidents of its Board of Management. Today, Shaughnessy Hospital uses Grace Hospital for the obstetrical Gynaecological training of its internes—and many of our ablest obstetricians and gynaecologists are proud to serve on its staff. Another main activity of the Salvation Army, and one of its most important is the "Harbour Light Building" at 56 Powell Street in Vancouver. Here help, in the shape of shelter, food and clothing, is given yearly to thousands upon thousands of men and women—ranging from those who are merely down on their luck, to skid-road derelicts, drug addicts, and all the human wastage of a big city. Not "wastage" to the Army—which, through its personal work and encouragement, has found for many of these poor people a new approach to life, and a solution of its problems. Last year, 78,846 people passed through the portals of this "Harbour Light" house, and none was refused all the help that could be given. There are, too, their Rehabilitation and Industrial Centre, their Centres in Grandview and South Vancouver, their Dunsmuir House, and many, many other activities. But all these places are bursting at the seams. When Grace Hospital was built, Vancouver's population was 168,366. Today it is about 400,000. Grace Hospital has room for 75 adults—in 1928 it had 747 patients, in 1954, 3,590, its bed occupancy is 95 to 106%. We are particularly interested in Grace Hospital, as a profession. We know the excellence of the work that is done there, the high standard of nursing and hospital care that prevails and the kindliness and warm humanity of the staff. We know, too, that this staff is laboring under great handicaps. The case rooms are inconveniendy placed—the wards and nurseries are overcrowded—there is great need of expansion and rearrangement. And we as practising physicians have a personal interest in the Army's plans to bring these plans about. All its other institutions need to be enlarged, to be financed adequately—and at an early date, the Salvation Army plans a campaign to do all these things, to enlarge Grace Hospital, to enlarge its rehabilitation centres, and so on. We are beset these days with appeals from every quarter for money, for Children's Hospitals, for TB hospital, for Cancer funds and so on: and often it is difficult to Page 297. decide which of all these worthy causes is the most worthy of what support we can give. But high on the list, very high, comes this appeal from the Salvation Army, that wonderful organisation which has no prejudices, no sectarian attachments, no political angles or aspirations—to whom the only important question is "does this person need help?" And whose only solution is to give that help: without preaching, without reproaches, without exception, and without any limit. Wherever there is human misery and want, there is the Salvation Army worker—cheerful and helpful, and daunted by nothing—and never abandoning hope—the motto of Dante's Inferno "Abandon hope, all ye who enter here" means less than nothing to the Salvation Army. We are quite sure that even in the deepest, most hopeless recesses of hell itself, we should be sure to find the familiar uniform of this great Army, giving a cup of water, and a cheery word, in the face of all the pitchforks and bonfires. So we take great pleasure in bringing to our readers in this province, this most notable and most benevolent project of the Salvation Army, as well worthy of your attention, and of your generosity and help. (The actual date of this campaign has not yet been decided. It will be announced later). t . I Library Hours: Monday through Friday 9:00 a.m. to 9:00 p.m. Saturday 9:00 a.m. to 1:00 p.m. MISSING LIBRARY BOOKS I I /1|> 3 Members are asked to make a careful check of their libraries to see if any of the following books or journals are in their possession: Menders of the Maimed by Sir Arthur Keith. 1919. New and Non-official Remedies 1952: Council on Pharmacy and Chemistry. American Medical Association. New England Journal of Medicine v. 249, No. 13 & 14, 1953. v. 251, No. 20, 1954. British Medical Bulletin v. 7-8, 1950-1951. For the convenience of other members requiring these books, the library is anxious to regain possession of them as soon as possible! Recent Accessions: Comroes Arthritis and Allied Conditions 5th ed. Edited by J. S. Hollander Lea & Febiger, 1953. The Living Brain by W. Grey Walter. Norton. 1953. Unipolar Lead Electrocardiography and Vectorcardiography by Goldberger. Lea & Febiger. 3rd ed. 1953. The Roots of Crime. Edited by Sir Norwood East. Butterworth. 1954. * Book Review Page 298 VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL Stanley Park Pavilion, Vancouver, B. C. June 6th to 10th (Inclusive) Speakers: Dr. Ian Aird—Professor of Surgery, University of London, England. Dr. N. S. Assali—Associate Professor of Obstetrics and Gynaecology, University of California, Los Angeles. Dr. Kenneth Evelyn—Director of the British Columbia Medical Research Institute, Vancouver. Dr. Horace L. Hodes—Director of the Department of Paediatrics, Mount Sinai Hospital, New York. Dr. D. M. Whitelaw—Associate Professor of Medicine, University of British Columbia. Dr. Donald H. Williams—Clinical Associate Professor of Medicine (Dermatology)—University of British Columbia. Programme MONDAY, JUNE 6th 9:00 a.m.-REGISTRATION. 9:30 a.m.—Dr. N. S. Assali: "Pathologic physiology of toxemia and of essential hypertension." 10:15 a.m.—Dr. Kenneth Evelyn: "The Course and Prognosis of Essential Hypertension." 11:00 a.m.—Dr. Ian Aird: "Current research problems in the Department of Surgery at Hammersmith Hospital." 12:30 p.m.-LUNCHEON-Stanley Park Pavilion. Speaker: The Honourable Mr. Robert W. Bonner, Attorney-General. 2.30 p.m.-MEDICAL CLINIC-VANCOUVER GENERAL HOSPITAL- Conducted by Dr. D. M. Whitelaw. 8:15 p.m.—Dr. D. H. Williams: "Common Skin Disorders of Children." 9:00 p.m.—Dr. Horace L. Hodes: "Treatment of Severe Forms of Poliomyelitis." TUESDAY, JUNE 7th 9:00 a.m.—Dr. D. H. Williams:Chronic Skin Disorders of the Legs." 9:45 a.m.—Dr. D. M. Whitelaw: "The Natural History of Rheumatic Heart Disease." 10:30 a.m.—Dr. N. S. Assali: "Hemodynamic action of Vasodepressor Drugs." 11:15 a.m.—Dr. Ian Aird: "The Management of certain puzzling varieties of Obstructive Jaundice." 2:00 p.rri.-SURGICAL CLINIC-ST. PAUL'S HOSPITAL-Conducted by Dr. Ian Aird. Page 299 8:00 p.m.—Dr. Horace L. Hodes: "The Etiology of Infantile Diarrhea." 8:45 p.m.-ROUND TABLE CONFERENCE (Gynaecological) "OVARIAN TUMORS"-Dr. N. S. Assali, Dr. F. E. Bryans, Dr. Maxwell Evans, Dr. John Sturdy, Dr. F. S. Hobbs, Moderator. WEDNESDAY, JUNE 8th 9:00 a.m.—Dr. Horace L. Hodes: "The Present Day Status of the Rabies Problem." 9:45 a.m.—Dr. N. S. Assali: Management of toxemia of pregnancy (Illustrated with colored sound film depicting incidence, classification, pathology and physiology in animated form and showing individual patients treated). 10:30 a.m.—Dr. D. M. Whitelaw: "Abnormal Bleeding Tendencies." 11:15 a.m.—Dr. Ian Aird: "The palliation of advanced Malignant Disease." (Free afternoon). 8:00 p.m.—Dr. Kenneth Evelyn: "The treatment of Essential Hypertension." 8:45 p.m.-ROUND TABLE CONFERENCE (Medical) "MYOCARDIAL INFARCTION"-Dr. D. M. Whitelaw, Dr. Kenneth Evelyn, Dr. M. M. Baird, Dr. G. F. Strong and Dr. R. B. Kerr, Moderator. THURSDAY, JUNE 9th 9:00 a.m.—Dr. N. S. Assali: "Mode of Action of Diuretic Agents." 9:45 a.m.—Dr. D. H. Williams: "Dollars and Sense" of Skin Therapy. 10:30 a.m.—Dr. Horace L. Hodes: "Idiopathic Myocarditis." 11:15 a.m.—Dr. Ian Aird: "The Management of the Pancreas in Upper Abdominal Surgery." 2:00 p.m.-GOLF AT QUILCHENA GOLF COURSE. 7:00 p.m.-DINNER AND DANCE-THUNDERBIRD ROOM, CAPILANO SUSPENSION BRIDGE (North Vancouver). (Cocktails at 7, Dinner at 8 and Dancing from 9 'til 1). FRIDAY, JUNE 10th 9:30 a.m.—Dr. D. H. Williams: "Tension Eczema"—Neurodermatitis. 10:15 a.m.—Dr. N. S. Assali: "Causes of Maternal Death in a General Hospital." 11:00 a.m.—Dr. Ian Aird: "The problem of Conjoined Twins." 2:00 p.m.-ROUND TABLE CONFERENCE (Paediatric) "ANTIBIOTICS IN PAEDIATRICS"-Dr. Horace L. Hodes, Dr. G. O. Matthews, Dr. W. H. Cockcroft and Dr. Reginald Wilson, Moderator. 8:00 p.m.-ROUND TABLE CONFERENCE (Surgical) "THYROID - INCLUDING HYPERTHYROIDISM, NODULAR GOITRE AND CARCINOMA"-Dr. Ian Aird, Dr. H. K. Fidler, Dr. H. W. Mcintosh and Dr. Rocke Robertson, Moderator. %■ %■ }(. For advance Registration and Information write:— Dr. E. A. Jones, Secretary Summer School Committee, 1807 West Tenth Avenue, Vancouver 9, B.C. Registration fee $10.00 Students and Internes Free. Page 300 Vancouver Medical Association OFFICERS — 1954-55 Presidents | Dr. J. Howard Black Vice-President II Dr. F. S. Hobbs Honorary Treasurer. Dr. R. A. Gilchrist Honorary Secretary Dr. G. E. Langley Editor. Dr. J. H. MacDermot ANNUAL REPORT — TRUSTEES OF THE VANCOUVER MEDICAL ASSOCIATION 1954-55 The various funds of the Association are in a healthy condition. During the year your Trustees have purchased two $1,000 Canada Savings bonds and four $500 bonds, making a total of $4,000 invested and placed in the General savings fund. The securities held in the Safety Deposit Box at the Royal Bank of Canada are as follows: General Savings Fund. $12,500.00 Historical and Ultra Scientific Fund || 3,000.00 John Mawer Pearson Lecture Fund '38$^. 4,550.00 TOTAL Respectfully submitted -.— $20,050.00 MURRAY BLAIR, M.D. Trustee. ii ir it ANNUAL REPORT OF THE LIBRARY COMMITTEE OF THE VANCOUVER MEDICAL ASSOCIATION 1954-1955 Mr. President and Members: I have the honour to present the report of vour Library Committee for the years 1954-1955. The members of your Committee have been Doctors Moffatt, Gould, Bie, Gibson, Young and myself. I would like at this time to express my thanks to all members for their cooperation and support during the past year. A change of staff occurred in the library in August of last year. Miss Keays resigned from the library to be married and has since left for Europe. Her position has been adequately filled by Miss Sigrid Hahn as Assistant Librarian. Mrs. Helene Marchfelder, the Librarian, and Miss Hahn continue to render excellent and capable service. Library expenses have decreased by slightly more than $100.00 when compared with those of the previous year. This is apparent in the accompanying financial report. The difference is due to the decrease to the amount expended for salaries and on office supplies. It has also been possible to acquire a greater number of books for the amount allotted for their purchase, owing to the fact that Canadian and American publications have been bought at a 10% discount from the U.B.C. Book Store. However, to some extent this gain has been.offset by the 2% increase in the S.S. and M.A. tax which came into effect in 1954. The Committee wishes to acknowledge generous gifts of value, and in some cases rare books: our gratitude is extended to Doctors J. R. Farish, A. F. Hardyment, R. McGregor, J. D. F. Alexander and P. Lehman. Our thanks are also due to the Page 301 following members and organizations who have continued their gifts of journal subscriptions: Doctors D. E. H. Cleveland, W. B. Burnett, Doctors Turnbull, Dickey, Sloan, McCurrach and Norton, Doctor J. Dick, Doctor John A. MacDougall, the General Practitioners' Association of Greater Vancouver and the section of Neurology and Psychiatry of the Vancouver Medical Association. The volume of work performed by the library remains essentially the same as that of the previous year, with the exception of an increase in use of the library by Associate Members which has almost doubled the number of volumes handled through the library's postal services. An innovation for the Library Notes published in the Vancouver Medical Association Bulletin has been proposed. This is to consist of a few paragraphs on a subject of general interest, accompanied by a bibliography of recommended reading — the synopsis to be prepared each month by a member who has special interest in the topic presented. It is hoped in this way to keep members currendy informed of interesting material readily available in the library. The above report is respectfully submitted. R. J. COWAN, M.D, Chairman, Library Committee. LIBRARY EXPENDITURE AND STATISTICS, 1954-55 BOOKS ADDED TO LIBRARY: 100 New Books $ 3 Books purchased from the Nicholson Collection 4 Books purchased from the Historical and Ultra-Scientific Fund ; MEDICAL JOURNALS: 85 Journals subscribed to at a cost of : $ 1 Journal subscribed to from Historical and Ultra-Scientific Fund 3 5 Journals received as gifts 49 Journals received in exahange for Bulletin 'BINDING: 116 Volumes bound at a cost of 1 $ Boxes for unbound journals 1 _ 3 Volumes bound from Historical and Ultra-Scientifiic Fund ■. DUES TO LIBRARY ASSOCIATIONS: Medical Library Associations $ Canadian Library Association ; . S.S. 5 % sales tax on books and journals & $ Rent : 952.45 8.65 18.75 967.63 7.50 Salaries St ationery Telephone Audit Fee Miscellaneous (Insurance, Petty Cash, Postage, Laundry, etc.) Books and Journals Loaned 2,802 Borrowed by Mail ., 150 Borrowed by Messenger . 8 Returned by Messenger 3 packages 594.25 69.00 8.90 35.00 5.00 82.80 4,320.00 4,321.96 70.44 208.11 75.00 318.98* 2,952 INTERLIBRARY LOANS Books out 1 337 Books in . 70 VISITS TO LIBRARY Members . 1,964 Others ' 671 During Evening Hours (8 months) Members Others Bibliographies Prepared Microfilms Requested ; ■ Photostats Requested 496 143 397 7 6 Page 302 ANNUAL REPORT — PUBLICATIONS COMMITTEE OF THE VANCOUVER MEDICAL ASSOCIATION, 1954-55 Your Committee has held monthly meetings for the past year, with the exception of February, 1955, when several of the members were away. We have as an attached member of the Committee, a representative of the B.C. Division's Public Relations Committee — Dr. R. A. Stanley, who followed Dr. W. W. Simpson, the representative last year. We gready value their presence with us and they have been most helpful. The Bulletin's circulation continues to grow—the last printing (February 1955) was 2322, an increase of 116 over the number given as the total circulation (2216) at the beginning of the year. The following breakdown of this circulation on the basis of 2216 will be of some interest- Practising Physicians & Surgeons in B.C. 1 . -|i" 1714 Practising Physicians & Surgeons in other Provinces T 174 Practising Physicians & Surgeons on Post Graduate Courses in U.S.A. .. 57 Practising Physicians & Surgeons on Post Graduate Courses in England'__? 17 1962 Plf! — Medical Libraries in Canada : 46 Medical Libraries in U.S.A. . 51 Medical Libraries in Foreign countries ___ 14 111 Hospitals in Canada _ 32 Hospitals in U.S.A. ._.._ 24 Hospitals in Foreign countries . 7 63 Advertisers Copies 80 80 Total Circulation 2216 (Circulation February/55 2322) As I have stated before, the Bulletin does a lot of travelling: to many libraries and hospitals in the U.S.A. and to libraries in other parts of the world—all the way from India to South America, via Great Britain, where we have several exchanges. The Bulletin, in addition to medical papers and articles, news and notes, etc., has certain sections regularly filled by the B.C. Division of the Canadian Medical Association, by the Provincial Department of Public Health and so on. The Workmen's Compensation Board has also made use of our columns to transmit messages and information to the profession. The Metropolitan Health Department uses the Bulletin as a medium for details of public health. The large hospitals too, keep us informed of their Clinics and meetings. This is, we feel, a most important function of our Journal, and we intend to continue along these lines and develop them as fully as we can. It makes the Bulletin of greater value to every member of the profession, who is kept constantly in touch with the economics of the profession, and with public health developments in a way not possible by any other single means. We would impress upon all medical men in the Province the fact that all these agencies have information to give which is of value to them personally. There have been no major changes in the setup of the Bulletin—and at the moment none are contemplated—though we have in mind certain possibilities which may lead to further developments. It is a pleasure to acknowledge the hard work and loyal service which the members of die Committee have unfailingly given. Also, to pay tribute once more to the keenness and constant assistance given by our publisher, Mr. W. E. G. Page 303 Macdonald. In a journal such as ours, deadlines are hard to keep to, though we try— and any other journal would be, we are sure, more exacting along this line—but he is always able to cram in one more item that simply must find room, and he makes our task much easier and more pleasant. Our Secretary too, Mrs. Dewest, is always ready to do anything she is asked, and does it, one need hardly say, excellently well. All of which is respectfully submitted- J. H. MacDermot, M.D., Editor. _■ ■fr -fr it INTERIM REPORT OF THE SUMMER SCHOOL COMMITTEE VANCOUVER MEDICAL ASSOCIATION Mr. President and Fellow Members: Following is a short report on activities concerning the Summer School program which will be held in the Stanley Park Pavilion from June 6th to June 10th, inclusive. To date these speakers have consented to participate— Dr. Ian Aird—Professor of Surgery, University of London. Dr. N. S. Assali—Associate Professor of Obstetrics and Gynaecology, University of California. Dr. Kenneth Evelyn—Director of the British Columbia Medical Research Institute. Dr. Horace L. Hodes—Director of the Department of Paediatrics, Mt. Sinai Hospital, New York. Dr. D. M. Whitelaw—Associate Professor, Department of Medicine, University of British Columbia. Dr. Donald H. Williams—Clinical Associate Professor of Medicine (Dermatology), University of British Columbia. We have not yet received a complete list of topics, but these will be published in program form in the very near future. These speakers are giving lectures in their various fields which we feel will be most interesting to all members. Several round table discussion and clinics are also being arranged. Regarding the' meeting place—the Committee considered that a change from previous Summer Schools was in order. First of all the services at the Stanley Park Pavilion are much more reasonable than those at the Vancouver Hotel and parking space is adequate for all who wish to attend. Lunches are served there each day and we have secured the use of the dining room for the opening day luncheon. The Attorney-General, Mr. Robert Bonner, will address this gathering on a subject of current interest. Thursday afternoon as is usual, all lectures, etc., are cancelled and and the time is given up to Golf arranged by the Golf Committee at Quilchena. Thursday evening a Dinner Dance in the "Thunderbird Room," Capilano Suspension Bridge will be held under the auspices of the Summer School—arranged and convened by Dr. W. G. Evans and his assistants. We trust that the program as outlined will be satisfactory to the membership and that we can expect a good registration to support this undertaking. Respectfully submitted—Maxwell Frost, M.D., Chairman. Page 304 1954-55 ANNUAL REPORT OF THE MEDICAL ECONOMICS COMMITTEE The Medical Economics Committee held one meeting during the year. Although this Committee has no important function at the present time, we feel that it may well be needed in the future. E. A. Jones, M.D., Chairman Medical Economics Committee Vancouver Medical Association. -fr ii ii it EYE, EAR, NOSE AND THROAT SECTION Mr. Chairman, we beg to submit herewith the Annual Report of the E.E.N.T. Section of the Vancouver Medical Association for the year 1954-55. During this year nine monthly dinner meetings were held with an average attendance of 28 members. We were pleased to have a number of Colleagues from Victoria, Bellingham and Seatde attend several of our meetings. Outstanding guest speakers included Dr. Ida Mann, Australia; James Doggart M.D., London, England; Dr. Edward Tremble, Montreal; Dean George Curtis (Law) and Drs. Rocke Robertson and A. McKenzie, of the University of B.C. Following the Clinical Meeting at Shaughnessy Hospital, papers will be presented by Eve and E.N.T. Residents. Preceded by a Golf Tournament, the Annual Meeting winds up an active and successful year. It is expected that the Treasurer's report will show a reasonable surplus. We regret to report the loss last October of Dr. Roger Grimmett. During the year, the Section acquired five new members. Respectfully submitted, DR. A. J. STEWART, Secretary-Treasurer. E.E.N.T. Section of the Vancouver Medical Association. it ii ii REPORT ON THE ACTIVITIES OF THE SECTION OF NEUROLOGY AND PSYCHIATRY, 1954-1955 Regular monthly meetings of the Section were held throughout the Fall and Winter. There will be two more at which time members of the Section will be guests at Hollywood Sanitarium and the final one at which time election of officers will take place at the Crease Clinic. Most interesting clinical programs oudining case studies, research and areas for further research were presented by members of the Section during meetings at the Academy of Medicine, U.B.C, Shaughnessy Hospital, and the Vancouver General Hospital. Members of the Section were most cooperative in assisting their colleagues in the preparation of briefs, one concerning the sexual psychopath which was under the investigation of a Royal Commission and one concerning psychiatric practice and the fee schedule presented to the Economics Committee. I The section will continue to donate the Journal of Nervous and Mental Diseases to the Vancouver Medical Library. J. R. Wilson, M.D. Secretary-Treasurer, Section of Neurology and Psychiatry, Vancouver Medical Association. Page 305 A REPORT ON THE ORTHOPAEDIC SECTION OF THE VANCOUVER MEDICAL ASSOCIATION FOR 1954 Dinner Meetings were held on January 11th, March 1st, April 5th and November 1st. All Meetings were well attended. The first three Meetings were largely concerned with arrangements for the Clinical Day for the Canadian Orthopaedic Meeting at Shaughnessy Hospital. A number of papers were read. At the last Meeting the Officers for 1955 were elected:— CHAIRMAN: Dr. J. W. Sparkes. SECRETARY: Dr. F. C. Preston. Respectfully submitted, JOHN W. SPARKES, M.D., S Chairman of the Orthopaedic Section of the Vancouver Medical Association. it ii ii ii ANNUAL REPORT OF THE PAEDIATRIC SECTION OF THE VANCOUVER MEDICAL ASSOCIATION, 1954-55 One meeting of the Paediatric Section was held during the year. This was addressed by Dr. Margaret Mullinger and Dr. John W. Whitelaw who discussed their recent visits to Paediatric Centres in the United States. E. S. James, M.D., Chairman. ii ii ii REPORT OF THE SECTION OF RADIOLOGY The membership of this section has gradually increased and now numbers more than forty-five. The meetings are held monthly in conjunction with those of the British Columbia Radiological Society and are business and scientific in nature. As with other sections, much time has been spent over problems of economics. In this respect great concern is felt over the continued and growing threat by government to consider all radiology as a hospital or public health service rather than the practise of a medical specialty. It is a pleasure to report that the President Elect of the Canadian Association, of Radiologists is Dr. Andrew Turnbull and that the next annual meeting is to be held in Vancouver in January, 1956. Respectfully submitted, H. BROOKE, M.D., President, Section of Radiology. ii ii ii ii REPORT OF THE V.O.N. ADVISORY COMMITTEE There has been no occasion for a meeting of the V.O.N. Advisory Committee during the last year. The Chairman of the Advisory Committee has attended the meetings of the Board of the V.O.N, as often as possible. Respectfully submitted, D. M. WHITELAW, M.D., Chairman, V.O.N. Advisory Committee to the V.M.A. Page 306 REPORT OF THE REPRESENTATIVE TO THE GREATER VANCOUVER HEALTH LEAGUE The Greater Vancouver Health League has done a great many worth while things since it was founded in 1930. I wish to report another year of progress. Among the subjects for this year's discussions have been: — 1. Parent Education Division Activities. 2. Interprofessional Education Division Activities. 3. Food and Nutrition Activities. 4. Industrial Health. 5. General Projects such as an annual visual aids institute. New Projects to be taken up in the near future are:— 1. A Nursing Home Study. 2. A Study of the Needs in Chronic Illnesses. 3. A Study of the Needs of Lay Persons Coping with Nursing the Chronically 111 at Home. 4. A Study of Dental Services. This organization is to be commended for their activities and should receive the support of aU the doctors of the city. All of which is respectfully submitted. I move the adoption of this report. H H. HOBBS, Representative of the Vancouver Medical Association. ii ii REPORT OF THE REPRESENTATIVE TO THE HEALTH COMMITTEE OF THE BOARD OF TRADE The chairman of this committee for the past year has been Dr. F. L. Skinner. He and his executive have done an excellent job and are to be highly commended for their interest and hard work. Some of the subjects covered at the meetings were drug addiction, rehabilitation of the blind, health insurance, etc. This committee has been holding luncheon meetings and it has been suggested that dinner or evening meetings would provide a better attendance, with this I agree. All of which is respectfully submitted and I move the adoption of this report. f| H. HOBBS. + |f* " |§§: CARE OF THE PREMATURE In order to achieve a safe flow of oxygen—35% or less—the following requirements must be met. (1) Vents at the bottom of the incubators closed. (2) Vents at the top of the incubator open to at least half of their breadth. (3) Never more than two litres of oxygen flow per minute. Port of the above paragraph was omitted from the Public Health Section in the article CARE OF THE PREMATURE. Page 307 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D, D.P.H. M Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia VERNON HOME CARE PROGRAM Two and one half years ago, a pilot study was begun at Vernon to determine the number of hospital beds that could be released through early discharge of patients to convalescence under a program of home care. A joint undertaking of Vernon's Jubilee Hospital and the North Okanagan Health Unit, the plan is in essence an extension of hospital care to the home, as admission to the service can be effected only by the attending physician. In all cases, patientsjreceive either nursing care or housekeeping service, or both, at a nominal cost. During the first twenty-nine months of operation, the program resulted in a saving to both the community and government of almost $1000 per month. The total number of hospital days saved as a result of the home care program amounted to 3,236, or an average of 14.2 days per patient. The economic saving is demonstrated by the fact that whereas the per diem program cost was $1.71 for the twenty-nine month period, the hospital per diem rate would have been over $10.00. A comparison between the first eight months of 1953 and 1954 reveals a gradual expansion in both scope and extent of service. An increase of 15% in the number of patients using the service was noted for January - August, 1954, as compared with the same period in 1953. Further, it would appear that in 1954 a more acute type of nursing care was required, as indicated to some degree by the more numerous and more closely spaced nursing visits. To exemplify, from January to August 1953, each patient on nursing care required an average of one visit every 2.6 days for a total of 5.6 visits. On the other hand, during the same period in 1954 each patient was visited every 2.3 days for a total of 6.6 visits. To date, the success of the Vernon Home Care Program has resulted in a- pronounced economic saving to the community by obviating the necessity for constructing additional hospital space for beds. Moreover, the service has reduced the load on the facilities of the Jubilee Hospital to the extent of 4.3 beds in 1953, and 5.2 beds in 1954. PATIENT COVERAGE, OCTOBER, 1952—AUGUST, 1954 Nursing care only . 172 House Keeping service only 31 Nursing care and housekeeper service 24 227 (76%) (14%) (10%) (100%) HOSPITAL DAYS SAVED, OCTOBER, 1952—AUGUST, 1954 Nursing care only 2,491 Housekeeper service only 384 Nursing care and housekeeper service 361 Total days saved . 3,236 (14.5 per patient) (12.4 per patient) (15.0 per patient) (14.2 per patient) Page 308 PROPHYLAXIS OF OPHTHALMIA NEONATORUM The following is a statement recently published by the Committtee on the Fetus and Newborn Infant of the American Academy of Pediatrics as a result of a conference held in New York City on January 19 and 20, 1955: "There have been many inquiries concerning the advisability of substituting various antibiotics for 1% silver nitrate in the prophylaxis of ophthalmia neonatorum. In this regard, the following facts seem pertinent: A. No evidence exists of damage to the eyes following the use of 1% silver nitrate. B. Non-specific conjunctivitis occurs in a significant percentage of newborns whether or not any medication has been instilled into the eyes. C. Various antibiotics have been demonstrated to be of value in the prevention of ophthalmia neonatorum. However, the exact procedures associated with their most efficient use for all hospitals in all parts of the country are not as yet known. The Committee on the Fetus and Newborn Infant of the American Academy of Pediatrics believes that current data do not justify the advisability of substituting antibiotics for 1% silver nitrate in the prevention of gonorrheal ophthalmia. Further evaluation requires studies of: (1) The comparative effectiveness of different prophylactic measures against against gonorrheal ophthalmia in population groups where the incidence of gonorrhea is high. (2) The incidence and pathogenesis of non-gonorrheal conjunctivitis associated with various methods of prophylaxis and with no prophylaxis." The third annual scientific session of the section of General Practice was held in Harrison in March and attracted 200 doctors from B.C. and Washington for three days. Dr. Lennox Bell, dean of medicine of the University of Manitoba, spoke on asthma, renal failure and practical endocrine therapy. He was also dinner speaker on the final day of the convention and gave amusing highlights on the early days of the department of medicine at his college. Dr. Arthur Nash of Victoria gave excellent papers on uterine bleeding, functional gynaecology complaints and antenatal care. He also addressed the wives of the medical men on the topic of equanimity. Dr. Rocke Robertson, professor of surgery at UBC discussed varicose veins, rectal ailments and hand surgery. Dr. Robertson also gave an enthusiastic account of the preceptorship program initiated last year whereby final year students spent a month with family doctors before graduating. With some chagrin he reported that the students claimed they got more out of that month than out of any other month in their academic year. The program will be enlarged this year. Dr. Maurice Young, assistant professor of pediatrics at the UBC, spoke on cardiac murmurs, fevers and rheumatic fever. Complete papers will be published in later editions of the Bulletin. Page 309 Business of the College of General Practice of Canada was conducted under the chairmanship of Dr. Harold Mooney of Courtenay. Convention committee consisted of Drs. V. W. Smith, J. F. Tysoe, A. G. Vey, V. G. Stuart, R. A. Gale, J. B. Anderson and A. M. Steel of Victoria Dr. J. E. Fenn of Vancouver is now studying obstetrics in Toronto. Eh. R. G. Hines is now practising at Norman Wells in the Arctic. Eh. R. C. Hitchen is now in California. Dr. W. O. McDaniel is now practising in West Summerland. Eh. Argyle McMurchy is now practising at Ceepeecee, B.C. Eh. Tim McCoy has just returned from the American Academy of General Practice Convention in Los Angeles. He represented the College of General Practice of Canada, and reports that a rapidly increasing number of American hospitals have established sections of General Practice on the attending staffs. Dr. John H. Dixon has received his specialty qualification in surgery and Dr. J. G. Gillis his in medicine. Eh. C. R. Neve has begun a practice in Kimberley. Eh. D. M. King of Vancouver has been elected president of the B.C. division of the College of General Practice of Canada and Dr. Bert Wallace of Vancouver is chairman of the 1956 scientific session of the section of general practice of the B.C. Medical Association. Eh. Mark Roach is now practising in Haney. Eh. J. M. Shaw is now in Kimberley. Eh. Bruce Shallard and Eh. Gustav Schilder of Vancouver attended the American Academy of General Practice Convention in Los Angeles recently. Eh. A. J. Cook is now practising in Fort St. John. Dr. Lloyd O'Neil is now studying E.N.T. in Illinois. Dr. F. Mirhady of Vancouver has received his certification in pediatrics and is practising on Lulu Island with Drs. Turner and Robertson. At the International Congress of Medical Women held in Italy, September 1954, honorary membership in the Medical Women's International Association was conferred upon Eh. Ethlyn Trapp for signal service to the profession. Dr. Trapp is one of only two Canadian medical women to receive this honour. Births To Dr. and Mrs. R. W. Dunn of New Westminster, a daughter. K. C. Boyce of Vancouver, a son. /. E. McDonagh of Vancouver, a daughter. DOCTORS OFFICE 33RD AND MACKENZIE Immediate occupancy, fully furnished and newly equipped office. Complete examining room and separate laboratory unit plus consulting room and waiting room. The examining room complete with examining table and instruments. Former tenant deceased. Excellent location. Contact W. C. Graham Office, EMerald 6767 — Home, KErrisdale 3017-Y Page 310 We should like, first, to congratulate the Executive of the Vancouver Medical Association on the admirable programme they arranged for the Annual Meeting on May 3rd, and the changes they made in this programme. It was the first Annual Meeting for many years that everyone thoroughly enjoyed, and the large turnout was a sign that the change was welcomed. lifj It was an excellent programme, and most timely. We owe a real debt of gratitude to the speakers, who gave us, in most friendly and generous abundance, so much good advice, and so many helpful suggestions. Medical men, as a group, need this advice perhaps more than any other group of men earning their living; their work makes it difficult to be strict men of business — and success as a doctor does not by any means imply financial or business ability. In fact, if one studies the "sucker" lists, the truth is quite the contrary. So all of us, we think, gained a great deal from these gentlemen, who gave so freely of their time and knowledge to help us. Their advice on investments, on insurance, on wills, on estate-building should be of inestimable value to us all. We are hoping to publish at least part of the programme later. The keen interest of the large audience was shown by the numerous questions put to the speakers at the end of the programme. If time had allowed, there would it was quite obvious, have been twice as many questions asked. But our able moderator, Dr. C. E. G. Gould (or should we say "interlocutor"?) kept a tight hand on the timing of the programme, which he handled in excellent manner; it is to be hoped that this forum, or some variation of it, will be repeated on some future occasion. One of the speakers, Mr. Brissenden, who represented the legal profession, made a remark that impressed us deeply. He reminded us of a fact that we too often forget or fail to realize; that we live constantly under the "rule of law" and that there is a specific law or Act of Parliament to govern practically every action of our daily life. This opens up the whole question of our relation, as a profession, to the law; and our legal responsibilities as physicians. A couple of months ago, the writer of this, in company with Dr. Lynn Ginn, Registrar of the College of Physicians and Surgeons, had the privilege of attending, on behalf of the Council, the t5h Annual Congress on Medical Licenssure and Education, in Chicago. This Congress is made up of representatives of all the licensing bodies in the U.S.A., representatives of the main medical schools of that country, the American Medical Association and others. Amongst other delightful articles of fare provided by this Congress, was a session on the Legal Aspects of Medical Practice — on the legal relations of physicians and patients, on malpractice and so on. Several of the speakers were lawyers, and top lawyers at that, and the meeting the other night reminded us very strongly of what one of these speakers said — namely, that the physician in practice is daily in contact (or conflict), in one way or another, with dozens of statutes and regulations, many of which he is very largely ignorant. We are surrounded by laws which affect us in our daily practice, Workmen's Compensation Acts, Narcotic Drug Acts, Industrial Acts, Coroner's Acts are a few — we are responsible for notification of infectious diseases, of cancer, of epilepsy, (and soon it is probable we shall have to notify such disabling conditions as coronary diseases, to traffic authorities) — and so on, and so on. We were so much impressed by this programme and especially this part of the programme, that we secured copies of these addresses. Through the kindness and courtesy of the American Medical Association as shown through Dr. George F. Lull, the general manager and secretary of the A.M.A., we have received permission to publish these copyrighted articles — and we propose to do so from time to time. Later in this issue will be found the first one. The article on Malpractice will appear later — probably in instalments. Page 329 VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL Stanley Park Pavilion, Vancouver, B. C. June 6th to 10th (Inclusive) Speakers: Dr. N. S. Assali—Associate Professor of Obstetrics and Gynaecology, University of California, Los Angeles. Dr. Kenneth Evelyn—Director of the British Columbia Medical Research Institute, Vancouver. Dr. Horace L. Hodes—Director of the Department of Paediatrics, Mount Sinai Hospital, New York. Dr. D. M. Whitelaw—Associate Professor of Medicine, University of British Columbia. Dr. Donald H. Williams—Clinical Associate Professor of Medicine (Dermatology)—University of British Columbia. Programme MONDAY, JUNE 6th 9:00 a.m.-REGISTRATION. ||, || 9:30 a.m.—Dr. N. S. Assali: "Pathologic physiology of toxemia and of essential hypertension." 10:15 a.m.—Dr. Kenneth Evelyn: "The Course and Prognosis of Essential Hypertension." 11:00 a.m.—Surgical Subject and Speaker to be announced. 12:30 p.m.-LUNCHEON-Stanley Park Pavilion. Speaker: The Honourable Mr. Robert W. Bonner, Attorney-General. 2:30 p.m.-MEDICAL CLINIC-VANCOUVER GENERAL HOSPITAL- Conducted by Dr. D. M. Whitelaw. 8:15 p.m.—Dr. D. H. Williams: "Common Skin Disorders of Children." 9:00 p.m.—Dr. Horace L. Hodes: "Treatment of Severe Forms of Poliomyelitis." TUESDAY, JUNE 7th 9:00 a.m.—Dr. D. H. Williams:Chronic Skin Disorders of the Legs." 9:45 a.m.—Dr. D. M. Whitelaw: "The Natural History of Rheumatic Heart Disease." 10:30 a.m.—Dr. N. S. Assali: "Hemodynamic action of Vasodepressor Drugs." 11:15 a.m.—Speaker and Surgical Subject to be announced. 2:00 p.m.-SURGICAL CLINIC-ST. PAUL'S HOSPITAL ft ~ 8:00 p.m.—Dr. Horace L. Hodes: "The Etiology of Infantile Diarrhea." 8:45 p.m.-ROUND TABLE CONFERENCE (Gynaecological) "OVARIAN TUMORS"-Dr. N. S. Assali, Dr. F. E. Bryans, Dr. Maxwell Evans, Dr. John Sturdy, Dr. F. S. Hobbs, Moderator. Page 330 WEDNESDAY, JUNE 8th 9:00 a.m.—Dr. Horace L. Hodes: "The Present Day Status of the Rabies Problem." 9:45 a.m.—Dr. N. S. Assali: Management of toxemia of pregnancy (Illustrated with colored sound film depicting incidence, classification, pathology and physiology in animated form and showing individual patients treated). 10:30 a.m.—Dr. D. M. Whitelaw: "Abnormal Bleeding Tendencies." 11:15 a.m.—Surgical Subject and Speaker to be announced. 8:00 p.m.—Dr. Kenneth Evelyn: "The treatment of Essential Hypertension." 8:45 p.m.-ROUND TABLE CONFERENCE (Medical) "MYOCARDIAL INFARCTION"-Dr. D. M. Whitelaw, Dr. Kenneth Evelyn, Dr. M. M. Baird, Dr. G. F. Strong and Dr. R. B. Kerr, Moderator. THURSDAY, JUNE 9th 9:00 a.m.—Dr. N. S. Assali: "Mode of Action of Diuretic Agents." 9:45 a.m.—Dr. D. H. Williams: "Dollars and Sense" of Skin Therapy. 10:30 a.m.—Dr. Horace L. Hodes: "Idiopathic Myocarditis." 11:15 a.m.—Surgical Subject and Speaker to be announced. 2:00 p.m.-GOLF AT QUILCHENA GOLF COURSE. 7:00 p.m.-DINNER AND DANCE-THUNDERBIRD ROOM, CAPILANO SUSPENSION BRIDGE (North Vancouver). (Cocktails at 7, Dinner at 8 and Dancing from 9 'til 1). FRIDAY, JUNE 10th 9:30 a.m.—Dr. D. H. Williams: "Tension Eczema"—Neurodermatitis. 10:15 a.m.—Dr. N. S. Assali: "Causes of Maternal Death in a General Hospital." 11:00 a.m.—Surgical Subject and Speaker to be announced. 2:00 p.m.-ROUND TABLE CONFERENCE (Paediatric) "ANTIBIOTICS IN PAEDIATRICS"-Dr. Horace L. Hodes, Dr. G. O. Matthews, Dr. W. H. Cockcroft and Dr. Reginald Wilson, Moderator. 8:00 p.m.-ROUND TABLE CONFERENCE (Surgical) "THYROID - INCLUDING HYPERTHYROIDISM, NODULAR GOITRE AND CARCINOMA"- Dr. H. K. Fidler, Dr. H. W. Mcintosh, Dr. L. H. Appleby and Dr. Rocke Robertson, Moderator. We are sorry to announce that due to circumstances beyond his control, Professor Ian Aaird of London, England, who was previously scheduled to appear as a guest speaker at the Summer School, has been forced to cancel his arrangements to come to Canada. At date of going to press the name of the alternate speaker on Surgical subjects is not available. * For advance Registration and Information write:— Dr. E. A. Jones, Secretary Summer School Committee, 1807 West Tenth Avenue, Vancouver 9, B.C. Registration fee $10.00 Students and Internes Free. Page 331 Vancouver Medical Association OFFICERS — 1954-55 President Dr. F. S. Hobbs Vice-President *S_|__ Dr. G. E. Langley Honorary Treasurer | -. Dr. Paul Jackson Honorary Secretary Dr. A. F. Hardyment Editor Dr. J. H. MacDermot ANNUAL MEETING 1955 PRESIDENT'S REPORT J It is my duty now to present to you the Annual President's Report covering brieflly the activities of this Association during the past year. Having reviewed the committee reports it would appear that this has been a good year for the Vancouver Medical Association. ^B The scientific portion of our monthly meetings has continued on a high level with guest speaker participants from Canada, the British Isles and the United States. The Annual Dinner Meeting this year, under the direction of Dr. Eric Webb, again proved to be most successful and speaks well for the diversified talents of some of our members. 'The Osier Dinner Meeting will be remembered for the outstanding lecture delivered by Dr. D. H. Williams and the confering of P.G.F. degrees on Dr. W. J. Dorrance and Dr. R. P. Kinsman. The average attendance at meetings this year has increased and our total membership continues high, with only slight increase over total membership of a year ago. I regret to announce the death of several of our members during the past year. Dr. J. D. Whitbread I May 1954 Dr. J. G. McKay (Life Member) . May 1954 Dr. G. H. Worthington (Life Member) | May 1954 Dr. F. Day-Smith „_lglllll§lL June 1954 Dr. Ernest A. Campbell August 1954 Dr. Roger S. Grimmett .;_1|^_^^^_^-- October 1954 Dr. C. G. Campbell I fjjBit October 1954 Dr. G. A. Lamont jj S 1 November 1954 Dr. Neil McNeil (Life Member) yJJl|: November 1954 Dr. G. M. Foster (Privileged Member) 1 December 1954 Dr. F. J. Buller !||l|JL__April 23, 1955 I would ask you now to rise for a moment's silence in memory of these deceased members. The Committee reports published indicate that progressive activity continues in the affairs of this Association. The Treasurer will report a marginal profit on the: budget. The Library Committee reports the volume of work in the library, remains constant over last year, with increase in utilization by associate members. The publication of our journal derives increasing coverage with prospects of further interesting developments, thanks to Dr. MacDermot and his hard working editorial board. We are indebted to the Post Graduate Education Committee, who have been responsible for setting up the telephone service under the Doctor's Wives Club and for the new innovation of the Shaughnessy Hospital Meetings. The Vancouver Medical Association continues to have representation on and liaison with other organizations, including the Vancouver Board of Trade, Community Chest, Alcoholic Foundation, Vancouver Greater Health League, University of British Columbia and others, all of which substantiates its need and value in the community. Page 332 We are indebted to the Doctors' Wives Club for their telephone service offered and so well done. Again we express our thanks for the use of this auditorium and to Dr. Bain for the privileges offered during the year at Shaughnessy Hospitpl. I am pleased to have this opportunity of thanking the executive, all committees, the Library staff and especially Mrs. Helen Dewest for her loyalty and efficient manner as office secretary of this Association. J. HOWARD BLACK, M.D. ANNUAL REPORT OF THE HONORARY TREASURER — FISCAL YEAR 1954-55 Mr. President and Fellow Members: I have the honour to present the financial report of your Association for the fiscal year 1954-55. The books have been duly audited by Mr. R. H. N. Whiting, Chartered Accountant under the date of March 31st, and in accordance with the; Association's usual practice, interest accrued on investments, insurance premiums unexpired and members' unpaid dues have not been included in the accounts submitted. The charge to Income and Expenditure account for depreciation has amounted to $2,715.19 and has been calculated in accordance with the practice established in previous years, namely five percent of book value in the case of furniture, seven and! one-half percent in the case of library, fifteen percent in the case of projectorscopej and ten percent in the case of furnishings for the present offices. RECEIPTS Income from members' annual dues . 23i||§___ Interest received: Bank savings account _____!__ $ Bonds '. > . : m Revenue from Association Bulletin , TOTAL RECEIPTS 7.50 302.00 $ 17,964.75 309.50 1,100.00 $ 19,374.25 EXPENDITURES Salaries i . \ I _$ 7,3 69.06 Rent ___. \ \ '. - ■'., 4,800.00 Other expenses (Including Stationery, Postage, Telephone, Dinners prfe for visiting speakers, etc.) *M 2,963.35 Depreciation: Library - 1,697.%7 Equipment , — 1,017.3 2 TOTAL EXPENSES Excess of Income over Expenditure I 1_. The actual amount spent on books, journals and bindings for the Library came to $2,866.68. $ 15,132.41 2,715.19 $ 17,847.60 $ 1,526.65 ASSETS General: Cash on hand and balances at bank Bonds at cost 1 1- Library - less depreciation—,_ 1 Furniture and equipment - less depreciation 1,600.54 12,305.33 21,087.27 10,150.92 $ 45,144.06 Page 333 Investments (Special Funds) Historical and Ultra Scientific: Bank savings account 196.16 Bonds at cost 2,948.13 Owing by general fund -16 John Mawer Pearson Lecture Fund: Bank savings account 723.42 Bonds at cost \— 4,490.00 3,144.45 5,213.42 TOTAL ASSETS $ 53,501.93 You will notice that although our income shows a slight increase over last year ($584.89) expenses have increased proportionately, and that it will be only through maintaining and enlarging the present membership that we can look forward to a continued solvent Association. Respectfully submitted— R. A. GILCHRIST, M.D., Honorary Treasurer. & I 11 _ Library Summer Hours: Monday through Friday. 9:00 a.m. to 5:00 p.m. Saturday 9:00 a.m. to 1:00 p.m. FROM JENNER TO SALK At a time in our history when one of the major scourges of "high standard of) living" countries is about to be brought under control by vaccination, it is worth reviewing the origin of Jenner's wonderful concept. Edward Jenner, the third son of the Vicar of Berkeley, Gloucestershire, was born in 1749, exacdy one hundred years before Osier. At the age of eight he was "put under the preparatory regimen for inoculation"—a practice well established in Europe, Africa, and, thanks to Reverend Thomas Hatcher and Reverend Cotton Mather, in North America. Jenner was unlikely to forget his youthful ordeal or six weeks of bleeding, purging and starving which were required prior to inoculation (variolation) —using the human virus. When Jenner was nineteen years old and apprenticed to a physician near Bristol, he listened long enough to a patient's complaint to learn a great truth—that humans who had suffered from the relatively mild cowpox were unlikely to contract small-pox. Jenner took this concept to London with him while completing his medical studies at St. George's Hospital.* He lived at John Hunter's house and received encouragement from his mentor, when most of London turned a deaf or an intolerant Page 334 ear. To complicate things still further Captain Cook urged Jenner to join him on one of his great voyages of discovery. However, Jenner was keener on returning home to Gloucesterehire to prove his theory of cowpox vaccination than on sailing up the Pacific to enjoy the "stinking fogges" off the mouth of the Fraser River! Although Jenner never graced our local shores, his "Inquiry" (1798) and facsimiles of two of his interesting letters have come to rest in that most delightful of all medical libraries, the Vancouver Medical Association Library. (I speak not only of the reading rooms, but also of the Library's collection). The facsimile, given to the Library by Dr. A. B. Schinbein in 1949, is of the famous letter from John Hunter in 1775 in which he asked Jenner, "But why think, why not try the experiment?" The second facsimile letter, given to us by George Kidd, was written from Cheltenham in 1807, to Sir Richard Phillips, publisher of the "Monthly Magazine," Jenner refers to the investigation being made into vaccination both by the College of Physicians and the House of Commons. He says: "This inquiry will lay all those troublesome ghosts which have so long haunted the Metropolis with their ox-faces and dismal hootings against vaccination. However, 'tis all for the best You may depend upon it the new investigation will prove the touchstone of the vaccine discovery." Those who have seen poliomyelitis in all its heart-breaking forms can echo Jenner's statement. It is to be hoped that the continuing investigation of the value of the Salk vaccine will in time "prove the touchstone of the vaccine discovery." Bibliography: Rhodes, Andrew James and van Rooyen, C.E. "Textbook of Virology" Thomas Nelson, 1949. Rivers, Thomas Milton (editor) "Viral and Rickettsial Diseases of Man." Lippincott. 1948. Hodgetts, Charles. A. "Vaccination". Toronto Legislative Association. 1908. (2nd revised edition). Drewett, F. Dawtrey "The Life of Edward Jenner", Longman Green, 1933. Jenner, Edward "An Inquiry into the Causes and Effect of the Variolae Vaccinae" London, 1798. Copy published by R. Lier, Milan, 1923. U.S. Senate Document No. 822 "Yellow Fever." A Compilation of Various Publications: Results of Work of Major Walter Reed, Medical Corps, U.S. Army and the Yellow Fever Commission. Washington, 1911. Pearson, George, "Observations on the Effects of Variolous Infection on Pregnant Women" London. 1794. B.M.J. Editorial: "One Hundred Years Ago" 1913 :ii, Pp 30-1. Love, J., Shaul, J.F., Margileth, Andrew and Martelle, Robert "The Status of Immunization in 1954" Medical Clinics of North America, Sept. 1954 pp 1493-1534. Armitage, P. "Sequential Tests in Prophylactic and Therapeutic Trails" Q.Jl.Med. July 1954. v.23 pp 255-74. Sabin, Albert B., "Current Status of Research on Vaccination against Poliomyelitis", Jl. Michigan St. Med. Soc v.53, pp 985-, 1954. Laurance, Bernard, "Cowpox in Man" Lancet: i, 764-766 April 9th, 1955. * The Library's rare book collection includes an autographed copy of Doctor George Pearson's "Observations on the Effects of Variolous Infection on Pregnant Women", which was published in 1794. Besides being Jenner's contemporary, Pearson was also on the staff of St. George's Hospital, London. It is not unlikely that his publication of this document gave rise to some of the "dismal hootings" which so disturbed Jenner; the "effects" of inoculation with human small-pox vaccine were hardly calculated to inspire confidence in this procedure. W. C. GIBSON, M.D. OFFICE SPACE Excellent location for Medical man on Dunbar, will arrange space to suit tenant. Immediate occupancy. For information phone ALma 2252-Y. Page 335 BOOK REVIEW PROBLEMS OF INFANCY AND CHILDHOOD Transactions of the Seventh Conference, March 23 and 24, 1953. New York, N.Y. Edited by Milton J. E. Senn, M.D. Sponsored by the Josiah Macy Jr. Foundation, New York, N.Y. The introduction to the five conferences is rather enlightening. The officers who guide the policy of the Foundation feel that scientific advance is being delayed by misunderstanding. This misunderstanding is because J there is considerable obstruction to communication and mutual understanding across the disciplines and specialties .... there are psychological as well as semantic factors contributing to the difficulty of communication; people even in arguments with one another, are too much inclined to make statements at, rather than communicate with, others." The five papers are each about a different approach to the problem of understanding the child and his environment. The pattern in each conference is the same. One individual starts off by describing a phase of children's work which he has studied. Then follows the larger part which is a discussion of this presentation by other members of the group. 1. Truisms in Child Rearing. No amount of rules or mechanized thinking or mechanical aids are of value in rearing children. For the full development of the child's personality we must have the supporting influence of a loving parent or parent) substitute. Every child is an individual. If people who have the responsibility of rearing children thought of them as individuals there would be less tendency and less need of mechanized methods. 2. Some Pathological Ptocesses Engendered by Early Mother-Child Separation. During the first six months of life the infant becomes firmly attached to the mother. This attachment is very strongly motivated for the next two to three years, after which it begins to wane. Since future relationships with other persons seem to grow out of this early one, the form it takes is crucial. Wm This presentation and discussion is based on a movie of a well adjusted thirty month old child who spends eight days in hospital for the surgical repair of anj umbilical hernia. This discussion is a very vital one for doctors and hospital personnel who deal with hospitalized children. !i|| 3. Clinical Observations On the Emotional Life of Children in the Communal Settlements in Israel. The opening speaker in this discussion is a psychiatrist who spent four years in Israel. He gives a vivid description of the physical and emotional development of the pioneers of the Kibbutzim or Israel. It is a discussion that does not lend itself to abstraction. It should be read to be appreciated. It throws new light on the mystery of human development. 4. Observations of Individual Tendencies in the Second Year of Life. This discussion highlights how little we know about the development of the individual child. There) is some knowledge about groups from which we have developed vague generalizations. We tend to apply this knowledge to the understanding of the development of the individual. There is some validity in this, but its shortcomings are brought to light when the behaviour of an individual child is studied. This discussion is based on several observations in the two year old period of one child, ft is suggested by some of the speakers that they may be able to better predict the behaviour of children with some accuracy, when they have accumulated enough data. 5. Report of the Sub-Committee on Rooming-In. Most babies are delivered in hospitals on this continent. The mother and baby are separated in the delivery room. They meet only at feeding times. These episodes are usually scheduled and are) therefore hurried affairs. The mother and baby have very litde time to become Page 336 acquainted while in hospital. In several hospitals in the East this is being changed. The mother and infant remain in the same room. The mother takes over a large share of looking after her baby and gets to know it better. This report and the ensuing discussion is based on the experience of some of the people who helped start this rooming-in movement. Rooming-in is making some headway but is still meeting with a great deal of opposition. Incorporated in- the discussion are some very interesting observations about obstetrics in Britain. The speakers in these five conferences are all well qualified to speak in their individual fields. The editor is trained as a pediatrician and psychiatrist. He has brought together out of the five conferences, five interesting and informative discussions. They make pleasant and easy reading. Material of this type does not lend itself to abstraction. Each discussion is like a play. The stage is set and to really understand what happens one has to hear what each speaker says. Moreover it is important to hear what is said in its context. The book is well worth reading by those interested in child development. Harry Baker. CONGRATULATIONS Announcement appeared recently in the Press, about the election of Dr. G. F. Strong of Vancouver to the Presidency of the American College of Physicians for the coming year. This is a very signal honour, and we are sure that every member of the profession in B.C. will congratulate Dr. Strong on this very well-deserved recognition of his ability and worth. Congratulations are due, too, to Dr. H. A. Debrisay of Vancouver, who at the same meeting in Philadelphia, was elected to the Board of Governors of the American College of Physicians. We feel like congratulating the College, too on the acquisition of two such men; they evidently know good men when they see them. OFFICE SPACE FOR RENT Available in June. New building at 2768 Kingsway at Earles Road. 900 square feet. Opposite New Canada Dry Building. Suitable for one or more doctors. For further information call: "ft w- CUTLER Cutler Drugs, 2756 Kingsway DExrer 3384 Page 337 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull M Vancouver President-Elect—Dr. E. W. Boak Victoria Immediate Past President—Dr. R. G. Large _Prince Rupert Chairman of General Assembly—Dr. G. C Johnston .Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer Vancouver Executive Secretary—Dr. G. G. Ferguson . Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bonnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F: Sparling Dr. P. M. McLean Kootenay Dr. S. C Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall Dr. P. O. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C Poole Dr. N. J. Blair Chairmen of Standing Committees Constitution and By-laws Dr. Carson Graham, North Vancouver Finance j ! Dr. R. A. Palmer, Vancouver Legislation f j Dr. E. W. Boak, Victoria Medical Economics Dr. P. O. Lehmann, Vancouver Medical Education , -;|||»jgL Dr. M. M. Weaver, Vancouver Nominations.—— j Dr. F. A. Turnbull, Vancouver Programme & Arrangements . Public Health Dr. G. R. F. Elliott, Vancouver Public Relations 3s_ J^f Dr. A. W. Bagnall, Vancouver Chairmen of Special Committees Archives Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism : . | Dr. J. A. Traynor, Vancouver Cancer . 1 Dr. Roger Wilson, Vancouver Civil Defence— ^p Dr. John Sturdy, Vancouver Ethics _____ Dr. Wallace Wilson, Vancouver Hospitals. i _ Dr. G. C Johnston, Vaiqfcouver Industrial Medicine Dr. G. B. Helem, Port Alberni Maternal Welfare 1—Dr. A. M. Agnew, Vancouver Membership __ Dr. N. J. Blair, Vancouver Nutrition _ _Dr. J. F. McCreary, Vancouver Pharmacy . Dr. B. T. Shallard, Vancouver Rehabilitation Dr. W. J. Thompson Your Public Relations Committee, or any other committee, must keep its objectives constantly in mind. General objectives are not too difficult. Specific interim objectives, however, and the necessary steps towards their attainment leave much room for debate. In this light the following article, prepared by A. D. Kelly, M.B., General Secretary, Canadian Medical Association, is highly recommended for your reading. A. W. BAGNALL, Chairman, Public Relations Committee, C.M.A., B.C. Division. DEEDS NOT WORDS H A. D. Kelly, M.B. I am deeply conscious of the honour of opening the Second Conference on Public Relations of the Ontario Medical Association. I recall that the corresponding address of the first Conference one year ago was presented by Mr. Hugh Brenneman, Director of Public Relations of the Michigan State Medical Society. On that occasion he addressed us with the assurance and authority of a professional talking to amateurs and I can only infer that my selection on this occasion is due to a growing realization Page 338 that the improvement of the relations of the medical profession lies primarily in our own hands. This leads me at once to state that I believe it to be a fundamental fact that our stature in the eyes of our fellow citizens is direcdy related to our performance individually and collectivelv and only secondarily to what we sav about ourselves. I have been bold enough to entitle these remarks "Deeds not Words" and what I have to say will be one man's attempt to elaborate and apply this theme. The medical profession, in common with all other groups, acquires a relationship with the public whether it wants it or not, whether it works at it or ignores it. In the aggregate, it is probable that we attain that status in the minds of our fellow citizens to which our actions entitle us. It is almost obligatory at this point in any discussion of medical public relations, to contrast sharply the excellent relationships enjoyed by the good doctor with his particular public and the less favourable public attitude to the profession as a whole. I would not violate the tradition and I freely admit that there is a large element of truth in this hackneyed observation. We are, however, not unique in this respect, because the same phenomenon is evident in the case of the public attitude towards the legal profession, towards organized labour, towards our financial institutions and even towards the Church and the clergy. It appears to be true that when the attention of a member of the public is transferred from what he knows by personal observation and contact to what he observes or suspects by the less intimate sources of information available to groups in our society, that a deterioration takes place in his esteem. How much of this is due to the anti-social behaviour of the small proportion of the component parts of any group? In my opinion a great deal, since the elimination or control of the shyster lawyer, the labour racketeer, the avaricious trader, the worldly clergyman and the mercenary medical tradesman would immeasurably increase the prestige of the groups concerned. As one of the most socially useful of the professions, medicine has set a high standard for itself, a standard which the public has accepted and any failure to live up to it on the part of individual practitioners is damaging to the reputation of all of us. Stated less pedantically, good medical behaviour is not news but bad medical behaviour is likely to be so magnified that it impairs or cancels out the merits of the majority. Shakespeare has expressed the same idea in a different context. "The evil which men do lives after them, The good is oft interred with their bones." To return to my theme, I would suggest to you that solid performance is the basis upon which our good reputation depends and that this reputation is not to be measured in terms of newspaper lineage, radio time or other devices of publicity, whether their content be favourable or otherwise. This is the froth on the beer and almost as evanescent. The substantial portion of the brew is the respect which we merit by the aggregate of our conscientious service to the public, rendered to patients, one at a time. I would not have you infer that I under-estimate the value of the techniques of publicity because I subscribe to the view that the essence of better public relations is "To be good and to tell the public how good you are." The point I am trying to make is that the gloss of words and claim will not avail if the performance of the profession conveys a different impression to our fellow citizens. This leads us to one of the most difficult exercises, that of self-criticism. We are aided by what we believe to be the areas in which public misunderstanding exists. In examining these areas, many of us are apt to conclude that the public's attitude toward us is wrong or unfair, based on erroneous information or on a twisted interpretation of the facts. In certain instances, this may be so, but the important point for us all to recognize is this; true or false, right or wrong, rational or otherwise, public attitudes are factual, they exist, and to change them requires remedial action on our part. Such remedial action requires us to seek out and recognize our own shortcomings and to change our ways if any part of the fault lies with us. Let me give you an extreme example of a public attitude which I have heard Page 339 expressed in the following terms: "The doctors are making too much money, they are all driving Cadillacs and they don't care for me or my problems any more." We are inclined to react to such a viewpoint by condemning it out of hand as erroneous, wrong-headed and completely unfair. We can justify to ourselves our current prosperity on the basis of our long investment of time and money in training, our long hours of work, our limited years of earning, our substantial contribution to the public welfare in un-remunerative attendance on the needy, our fees when compared with the plumber and the television repairman, our high taxes and our high cost of practice, our usefulness to the community as compared with certain equally prosperous occupations and a dozen other points which you and I have heard raised in staff room sessions. If we leave it at that we are, in my opinion, not adopting an intelligent attitude towards a specific problem in public relations which is decidedly unfavourable to us. Instead, we should ask ourselves "Is it true?" and like so many general statements of this type, we will conclude that it may be partly true or true in certain instances. The next question might be "Why did such a viewpoint arise?" We think of such factors as published figures of income tax payments, showing doctors to be high in the list of occupations; we think of the extraordinarily high fees habitually charged by certain of our colleagues; we think of the misunderstandings we have encountered in relation to the extra billing of insured patients; we recall the evidences of affluence exhibited by a proportion of our confreres and we remember the stories we have heard of the difficulties encountered by patients in obtaining medical services in an emergency. Then we should ask ourselves "What can we do to change the opinion of people who talk about us in this way?" We consider the possibility of urging doctors to discuss with patients the financial aspects of their relationships before charges are incurred, to explain hospital charges, nurses' fees and the cost of medication. We examine our own relationship to insured patients and support the efforts of the insuring agencies to curb the abuses perpetrated by certain doctors. We carefully weigh the consequences of upward revisions of official fee schedules in terms of public reaction as well as their relationship to gross professional income. We reassess the work of our mediation committees and consider whether they can be used further to curtail overcharging of patients. We consider our obligation to participate in such professional activities as call answering services and similar devices designed to assure the public of medical care. You will observe that up to this point I have suggested certain avenues of thought and action which apply to the medical profession itself. They all lie in the direction of self-appraisal and remedial action. I believe that it is only after we have instituted corrective procedures that we should go to the public with the story of the medical labourer being worthy of his hire and the factors which affect medical charges and medical incomes. In this and in many other instances, deeds should take precedence over words in our effort to improve our relations with the public. It is recognized by all that the increasing costs of health care have given rise to demands on the part of our patients, the public, for a means of helping them to finance the necessary ouday for doctors, nurses, hospital, drugs, special diagnostic procedures and all of the services which modern medicine has to offer. Such demands have taken the form of movements to promote tax-supported medical services under government auspices, and many examples of this approach are evident in this country and throughout the world. A superficial appraisal of the value of good public relations would be to argue that if we can influence the public to our way of thinking it may be possible to forestall the entry of Government into this field. This reasoning appears to be based on two assumptions: (a) that a friendly feeling towards doctors and hospitals will persuade patients to abandon what may be represented to them as a financial advantage and (b) that the demand for health insurance is evidence of an antipathy towards medical services as they exist. I do not believe that either of these assumptions can be substantiated by the experience which is at our disposal and indeed it may be argued that the demand is accentuated by a widespread appreciation of what we have to offer and a desire to attain it more abundandy. Page 340 Be that as it may, I would call to your attention that a major step in attaining better public relations was taken when we recognized the demand jwhich I have mentioned and established under our own auspices the plans of voluntary prepaid medical care which now operated in every Canadian province. The establishment of such plans was evidence of enlightened medical leadership in providing an acceptable alternative to medical care provided by Governments. Whether the expansion of these plans will answer the needs of the Canadian people is still to be demonstrated,, but their very existence is a shining example of a positive approach by our profession to a public need and a happy contrast to the resistance and obstructionism of which we are sometimes accused. Despite the fact that our own plans were launched by the composite action of the professional bodies concerned and despite the fact that their success is vital to the profession's goals, their operation is still made difficult and their existence threatened by the actions of certain individuals within our ranks. The changes in the economics of medical practice have arrived so gradually that certain doctors are unaware of their extent and appear to be surprised and even irritated that an increasing proportion of their practice is composed of persons covered by insurance in one of its many forms. They regret the familiar, comfortable ways of private practice, uncomplicated by the presence of a third party holding the purse strings and adapt themselves with bad grace to the new regime. These are the doctors who lose no opportunity to criticize our plans, often in the presence of patients who are subscribers, who refuse to recognize that we have as a profession entered into contracts with well-disposed people who have paid money in advance for service and who treat such supporters of our plans as second class citizens. These are the doctors who need to be educated to the point that they recognize that old ways are being superseded in the hope that they will learn to work in harmony with the conditions of today and tomorrow. There are many other things that might be said about the obligations of doctors to the plans and the obligations of the plans to their originators and to the public. No plan is perfect and no plan will precisely reproduce the delightful but imaginary picture of the days when doctors practised without controls, forms or returns, and when all patients were in the upper income brackets and paid high fees accordingly. In this important area where the profession is attempting under its own auspices to answer an obvious public need, lip-service is not enough and the whole-hearted support of all the doctors is required to avoid an impairment in our public relations where it can be most damaging. There are certain other professional activities designed to improve our standing in the eyes of the public where deeds, not words, are required to make them more effective instruments. I refer to the establishment and operation of Mediation Committees. Perhaps no more powerful force has been devised to clear up misunderstandings, correct injustices and adjust complaints than the establishment of these medical courts of appeal. By their very nature they operate at the source of much of our trouble, the disgrunded patient, and when functioning properly and prompdy they not only adjust specific grievances but do much to improve our reputation for fair dealing. It is not enough to set up a shadow organization and keep its existence a secret. The personnel of a Mediation Committee should be doctors of unquestioned integrity and considerable courage. They should be seized with the importance of their functions and willing to discharge their duties without delay. The power of moral suasion is their main disciplinary weapon, and frank explanation the procedure most frequendy used. The results of the proper operation of the mediation machinery are immediate and salutary. The dissatisfied patient is converted into a satisfied one, the conscientious doctor is protected from malicious gossip and the erring member of the profession is made aware that his actions are observed by his colleagues. We have in this province the necessary organization, and with the full support of the units of Page 341 organized medicine, mediation can become one of our most useful instruments to improve our relations with the public. Ample evidence is at hand that the public is avid for information about medicine and doctors. One can scarcely pick up a newspaper or magazine, listen to radio or scan the television programs without encountering items which demonstrate this| public interest in our work. Much of this material is laudatory, some of it is critical, but all of it demonstrates that medicine, health and the behaviour of doctors are topics which excite a remarkably widespread interest. We appear to be going through a period of modification of our traditional attitude of resistance to publicity, since we recognize this interest in our affairs to be genuine and one which affords us another opportunity to present our views to the public. Coupled with this, we are becoming conscious of an obligation to assist in public information and education by providing authentic material in an understandable form. The organizations of our profession in Canada have undertaken to contribute to public enlightenment by the publication of signed health articles, by the promotion of Health Forums and by the production of radio programs, individually or in series. The medium of television has as yet been used more sparingly, mainly by the appearance of individuals on programs as the opportunity arises and in one instance by the endorsement of a program originating in the United States, for viewing in Canada. The support of such activities requires the help of a number of individual members of the profession as authors and participants in the various projects which may be grouped under the classification of Health Education. I would like to pay a tribute of gratitude to the doctors who have rendered such valuable service and to bespeak the assistance of other members of the profession who will undoubtedly be approached as the activities in this field are increased. In many instances, their participation has been forthcoming at the expense of some struggle with their instinct to avoid personal publicity. They have taken part at the official request of their Association or Society and they deserve the thanks of their colleagues both for their deeds and their words. It is difficult to assess the usefulness of these educational efforts but we gain the impression that the dissemination of health information has been valuable, particularly to patients arid their relatives who are adjusting themselves to the specific disability under discussion. Perhaps their most helpful by-product is to convey the impression that doctors are sincerely interested in the individual patient and his problems or as one report expresses it, "the feeling that at long last the medical profession is becoming less starchy and more understanding." We in the medical profession are the heirs of a noble tradition and our heritage is based on a sincere interest in human welfare. What our forefathers lacked in science they made up in the art of medicine which is essentially composed of interest, kindness and understanding. The advance made in scientific medicine in the last half century have greatly increased our usefulness but they have to a great extent overshadowed those human qualities which endeared the doctor to his patient. They have not, however, replaced them and one of our tasks is to recapture that affection and respect which we attribute to our professional predecessors. Our problem is not as unique as we are inclined to believe, and in this connection I would quote the words of Dr. Robert Boal, President of the Illinois State Medical Society, delivered in 1882: "The amenities of professional intercourse, and the obligations of medical men toward each other and the public, were perhaps better observed in 1850 than now. Then the doctor, next to the minister, was the trusted friend and counselor of every family to whom he ministered. He shared their joys, soothed their sorrows, and every passing year added to and cemented the attachment and affection between them. Now the doctor is regarded more in the light of a tradesman or mechanic, and is employed from the same consideration that a grocer, tailor or shoemaker is. The strong ties of gratitude and affection have almost ceased to exist. Relationship is now placed upon a mere commercial basis, and for this the profession is more to blame than the public." Page 342 Those views might have been uttered in 1955 by one of our leaders in organized medicine. They illustrate the fact that the same problems are with us and that each generation must contribute its share to their solution, by demonstrating again that our claims for the respect of our fellow citizens are justified by our performance. I am confident that our merits so far outweigh our deficiencies that both our deeds and our words will contribute to the good name of our profession. The current custodians of the task can go forward with courage and confidence, avoiding complacency and ready to reassess our attitudes and performance, not just as a means of putting ourselves in a better light before the public, but so that we can learn better how to serve the public. ]£&£ THE EMERGENCY CALL As Dr. Kelly says: "The important things are 'Deeds' not words." * One of the most potent factors influencing our public relations for good or bad is our response to the emergency call. Graceful acceptance or the supplying of a useful alternative is so easy, yet we are forever hearing of situations in which one of us would appear to have been almost deliberately uncooperative. Three such incidents, under current discussion, come to mind. In the first case a woman's attending doctor was called urgently on a Sunday evening. The doctor refused to go and offered no alternative. With considerable difficulty, a more cooperative doctor was contacted. On his arrival, however, the patient was dead. Whether or not early medical attention would have saved her life, the circulation of this story has done a great deal to interfere with our public relations in that community. The second is again a Sunday call. This time Sunday morning, for the regularly attending doctor to the deathbed of his patient. This time the doctor responded adequately to the call and everything seemed in order until the family received the bill. As officially recorded with our Association, for some reason the charge for this visit was fifteen dollars, far in excess of previous charges to the same patient. The family could not understand why this should be so and their faith in their doctor was shaken. The third is of the doctor who answered his phone in the middle of the night and in very impolite terms, offering no alternative, informed the patient that he limited his practice to other illnesses and did not accept emergency calls. In each instance it would have been so easy to have been at least polite and above all helpful. Those of us known in the community as graduates in medicine are best equipped to give advice in the emergency situation. Sometimes, for various reasons, we cannot respond by going to the patient. If we are unprepared to accept the call by any circumstances: limitation of practice, retirement, holiday, illness, or merely immediate social engagement, it is still, surely, our responsibility to the public and to our confreres to provide an alternative. In lieu of other arrangement, it is so easy to refer to the emergency section on the first page of the telephone book under the heading DOCTOR. And, if we do accept the call, much better that we do it gratefully. Sub Committee on Doctor-Patient Relationships. Committee on Public Relations, C.M.A.-B.C. Division. WANTED! General Practitioner for Group in North Vancouver. For appointment. Phone — YOrk 1424. Page 343 PUBLIC HEALTH AND MENTAL HEALTH NEWS U G. F. AMYOT, M.D., D.P.H. |j Deputy Minister of Health, Province of British Columbia I A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia PSYCHIATRIC EMERGENCIES Psychiatric emergencies can be among the most dramatic in medicine. In general there are three types of emergencies: 1. Those in which death or violence is a potential hazard. 2. Those in which the patient's discomfort makes him seek immediate Care. 3. Those in which acute maladjustments treated properly and immediately can prevent the development of more serious mental illness. The first group are the most dramatic and require the earliest attention possible. The psychiatric emergencies of this group alone will be dealt with here. They include the acute psychotic reactions of psychogenic origin, the acute psychotic reactions or organic origin, and the panic reaction to disaster. A. The Acute Psychotic Reactions of Psychogenic Origin In this group are included the depressive, manic, schizophrenic, and post-partum reactions. 1. Depressive Reaction—Patients showing depressive syptoms with danger of suicide are often seen by the physician in general practice. The early symptoms of depression such as anorexia, preoccupation with bowel function, loss of libido, lack of energy, and early morning insomnia require attention. Frequendy depressive illness will present itself with little in the way of the frank mood change that we are accustomed to associate with depression. Where overt ideas of self-depreciation and guilt plus an obviously depressed mood occur, there is> usually no difficulty in making a diagnosis and the patient is referred to psychiatric care. Potential suicides do escape recognition however, when the early symptoms of depression, such as those noted above, are not recognized as such. Patients showing agitation along with depressed mood are among the most likely to suicide. Even more dangerous is the person who has been profoundly depressed and is beginning to emerge from this state. At the depth of the depression, suicide is often beyond the patient's capacity to act but during the early phases of recovery from a retarded depression, suicide is much more likely to occur. Any patient presenting the above symptoms requires hospitalization both for treatment and avoidance of suicide. A psychiatric ward or a psychiatric hospital is preferable. Where none is available, around-the-clock supervision in a general hospital should be carried out. Treatment will vary with the degree of depression but in general includes control of environment to simple levels so that no major decisions are required of the patient, symptomatic treatment such as tube feedings where eating is a problem, adequate sedation, drugs such as methedrine, psychotherapy where indicated, and finally electro-convulsive therapy if the depression is profound. 2. Manic Reaction—Patients suffering from a manic psychosis also require hospitalization. The dangers to be encountered with these patients are again self- destruction but more likely difficulty arising from faulty business investments and sudden acts of belligerency on their part. These acts are the direct result of the typical manic symptoms which include self-assertiveness, euphoria, exhibitionism, over-activity, and in general over enthusiastic living. Manic patients show extreme emotional lability often swinging from tremendous enthusiasm to depression or rage, particularly when any frustration or inhibition is placed in their way. Treatment Page 344 involves hospitalization to prevent both injury to self and others and reduce the likelihood-of faulty business investments. Great tact is needed in hospitalizing these patients because their total lack of insight associated- with great feeling of well-being, makes hospitalization appear ridiculous to them. Underneath this lies the extreme irritability and belligerency of the patient when attempts are made to control him. Firmness in management is necessary but it should be extended with sympathy and tolerance. An excellent way to placate a manic patient is to get him to write his memoirs. He will consume reams of paper in the process and will be much less of a hospital nuisance. Other general measures should include sedation. Methods employed by the specialist include deep and prolonged narcosis or electric shock. 3 Schizophrenic Reaction—An acute schizophrenic reaction becomes an emergency at times, since these patients often have little or no self-control to combat the sudden explosion of fear and hate. Hallucinations may order the patient to suicidal or homicidal activity. The florid schizophrenic illness with its delusions, hallucinations and gross thought disorder is not difficult to recognize. More incipient forms of this illness which manifest themselves in subder ways require careful observation. The doctor should suspect the possibility of a schizophrenic illness in people who are able to handle without emotional distress situations which would upset normal individuals. He should also question the mental status of patients in whom intense excitement or tension is set off by relatively simple stimuli which would not bother normal people. With the acute schizophrenic reaction, hospitalization in a psychiatric hospital is necessary. The specific steps of therapy include insulin treatment, electro. shock, psychotherapy. These however, fall into the province of the psychiatrist. 4. Post-partum Reaction—This illness may be either depressive or schizophrenic in nature. It may appear suddenly in a young woman who has had a normal delivery and a healthy baby. One should be on the oudook for early symptoms such as insomnia, restlessness, preoccupation, and refusal to eat occuring four to seven days post-partum. The schizophrenic type of post-partum psychosis manifests symptoms similar to the schizophrenic reaction but usually carries a better prognosis. Treatment of the post-partum psychosis will vary depending on whether the process is a depressive or a schizophrenic one. Referral to psychiatric care is essential. B. The Acute .Psychotic Reactions of Organic Origin For convenience, these can be divided into both acute and chronic illnesses. The acute reaction includes the delirium. This may be the direct result of medical management of a physical illness, or may be caused by alcoholism, excessive sedation, or some other toxic agent. Nocturnal apprehension and confusion are symptoms that may progress to vivid hallucinations and delusions. Management in general consists of removal from the toxic agent, adequate foods and vitamin therapy, and sedatioii with drugs such as paraldehyde. It must be emphasized that these patients are frightened and should be subjected to a minimum of stimulation. Lights should be kept on at night and a familiar confident person in attendance is most helpful as reassurance and repeated emphasis on reality is vital to these patients. Restraints will be fought against and it is preferable to use side rails or a low bed. Chronic organic psychosis may occasionally become an emergency. Progressive arteriosclerotic cerebral changes may go unrecognized for a time because of the patient's ability to compensate partially for his deficit. Sudden changes in their environment, however, may precipitate an acute process requiring immediate attention. A careful history obtained from competent observers in the patient's family will often give evidence of some gradual impairment in memory, judgment and decreased ability in comprehension and calculation. Other symptoms of early brain damage are anxiety, irritability and emotional lability. These signs precede the acute break over a fairly lengthy period of time. Attention to the precipitating event be it physical illness, emotional loss, or financial reverses is required. Page 345 C. The Panic Reaction to Disaster A general regression in human behavior may occur during catastrophes such as fire, flood and war. To control the ensuing panic, immediate first aid measures may be necessary. Meerloo describes two main patterns in panic, the first is generalized paralysis; these people do not talk or move. The second is regression; these people throw tantrums, cry and wander aimlessly about. They have the emotional capacity oa| a small child and their behavior is a request for fatherly strength and understanding. People suffering from panic reactions should be placed in a quiet zone. Sedatives and narcotics should be avoided. Hot coffee, food and cigarettes are often more effective than drugs. Sleep should be induced as soon as possible. FLUORIDATION FACTS Vancouver and District Dental Society - April, 1955 During the past several months we have presented in these bulletins evidence for the safety and desirability of community water fluoridation. Statistical survey and scientific research have established beyond a doubt that fluoridation is the only answer to the problem of bettering the dental health of Canadians. The greatest advances in public health are those which seek to prevent rather than cure disease, and fluoridation has been widely hailed as one of the most important public health measures of this century. No public health measure — including vaccination, chlorination of water and pasteurization of milk — has been so thoroughly tested or unanimously approved within modern memory. Virtually every reputable medical and dental group in Canada, the United States and Britain has endorsed the measure, and there are in the United States at this moment ever twenty millions drinking artificially flouridated water, and three and a half millions living in areas where the water supply is naturally fluoridated. There have never been any ill effects. At this time when community fluoridation for Vancouver and district is due to be considered shortly, we wish to state again our reasons for supporting this great measure. Detailed evidence for all these statements has been presented month by month in "Fluoridation Facts", and can be found in medical, dental and public health journals throughout the country. II One part per million of fluoride, whether naturally occurring or added, will lower the decay rate in children's teeth by 60%, and this partial immunity will extend into adulthood. 2. There have never been any ill effects demonstrated from drinking fluoridated water of the recommended strength. 3. There is no danger of any harm coming to those suffering from chronic diseases. (Based on a study of mortality in fluoride and non-fluoride areas involving over 2,000,000 persons in 64 communities). In fact fluoridation is recommended by the Commission on Chronic Illness in the United States, so as $o prevent future chronic sufferers from the additional misery of decayed and ill lost teeth. 4. The cost on a per capita basis is trivial, a few cents a year. 5. To be effective, safe, and to reach all segments of the population, fluoridation must be carried out on a community basis subject to continual rigid checking and testing by public health, medical and dental personnel. We earnestly urge that those charged with the responsibility of deciding in this; matter will be guided by the advice of the medical, dental and public health professions based on hundreds of completed studies, rather than the cries of the anti-fluorida- tionists. This latter group falls into various categories. Some of them have something Page 346 ab sell for a profit — ideas, literature or foods and nostrums which they believe will prevent decay. Others are people who are also opposed to vaccination, pasteurization and the chlorination of water. Some are out-and-out "crackpots". It is true that a very few scientists are reluctant as yet, but these are greatly outnumbered by their colleagues who give unqualified endorsement. Certain religious groups and others oppose on the grounds that fluoridation is compulsory medication. However, fluoridation is not medication, since by definition, medication seeks to cure disease while fluoridation is a partial preventive. POSTCHOLECYSTECTOMY SYNDROME Peter E. Rees-Davies, F.R.C.S. (Eng.), F.R.C.S. (C), F.A.C.S., F.I.C.S. What is the Post-Cholecystectomy Syndrome? It is a collection of symptoms in which cholecystectomy occurs as an unfortunate incident Perhaps in the interests of diagnostic accuracy, a more anticipatory attitude could be cultivated by considering the term "pre-cholecystectomy syndrome". Not uncommonly a diagnosis of chronic cholecystitis is made in a patient of the fat, fair and forty vintage with vague dyspepsia and flatulence; the gall bladder is removed and found by the pathologist to show little evidence of disease. The patient continues to complain, of the same symptoms, sometimes more pronounced, as before operation. There is nausea, a general distaste for food, especially fatty food, dyspepsia accompanied by flatulence, sometimes relieved by the eructation of gas. There is steady pain in the right upper quadrant of the abdomen, sometimes described as a feeling of distension, sometimes colicky, penetrating through to the scapula and requiring drugs for relief. It is now well established that those who suffer most are those whose gall bladders showed the least signs of disease. In other words, those most afflicted are those who had normal gall bladders removed. One is reminded of Lord Moynihan's cynical aphorism in the troubled days of gastroenterostomy, "Gastro-enterostomy, a disease",—that may be transposed with a vengeance to—"Normal Cholecystectomy, a disease". Sufferers from this syndrome may conveniently be considered under three headings-. I. Incorrect Preoperative Diagnosis: 2. Incomplete or improper surgery and complication therefrom. 3. Malfunction of the Biliary Tract. 1. Incorrect Preoperative Diagnosis: Analysis of most large series of cholecystectomies shows, in the presence of gall stones, about 85% satisfactory results, while 15% continue to have symptoms. In patients with clinical biliary tract disease but normal cholecystogram, some 60% respond well to cholecystectomy and 40% continue to have severe symptoms. When discussing these figures with a well-known surgeon not unknown to some of you, he made the following observation, "When you have been removing gall bladders as long as I, and have had them come to belch at you across this desk for the past thirty years, you will be able to form your opinion of cholecystectomy"! It must be remembered that there are manv conditions which may simulate cholecystitis and many of these patients may coincidentally have gall stones. Post mortem examinations reveal 40-50% of women over 50 have gall stones, most of whom were symptomless during life. Mayo Clinic in a series of 612 routine post morterhs revealed 66% had biliary tract disease of which only 8% had been diagnosed during life. It is obvious therefore that the mere presence of gall stones is not presumptive evidence of active symptomatic disease. Indifferent results following cholecystectomy have reached sufficient proportions to merit a very careful assessment before removing the gall bladder, the more so Page 347 because some of these patients are going to be made worse by the operation. Of the many problems which may be benefitted by joint consultation of surgeon and internist, gall bladder must he one of the most prominent. After detailed history and complete examination; blood analysis, cholecystogram and upper G.I. tract X-ray should be routine. In many instances the internist will wish to carry out liver function tests in suspected chronic liver disease and electrocardiography to exclude cardiac conditions which not uncommonly accompany and resemble gall bladder disease. In obscure cases, therapeutic drug tests and duodenal aspiration of bile for analysis are useful ancillary measures. It is not intended to list all the possible conditions which may be mistaken for cholecystitis. The more obvious of these will be excluded by examination and relevant investigation. There are some which bear mentioning. Chronic Pancreatitis: This condition is intimately related to biliary disease and may remain to give symptoms after treatment of the biliary condition. Lancereaux in 1899 first suggested that acute pancreatitis might be due to stone in the common duct and Opie demonstrated that injection of bile into the pancreatic duct is followed by pancreatic necrosis. For this effect, the bile salts alone are responsible but if the injected bile is infected, the resultant pancreatitis is fulminant. Opie further reported a clinical case of pancreatitis in which a gall bladder blocked the common duodenal exit of the bile and pancreatic ducts permitted regurgitation from the former into the latter. This is such a rare finding, Vi of 1% according to Archibald, that reflex spasm of the sphincter of Oddi, the result of Cholecystitis or some other irritation, is a much more likely explanation. Pancreatitis is a sufficiently common complication of biliary disease, 2.6%, to warrant careful exploration at the time of surgery. The common union of bile and pancreatic ducts is present in 15% of normal subjects and present in 70% of those with pancreatitis. If one is fortunate enough to find a stone, it is removed but a more common cause is dyskinesia of the sphincter and when present should be neutralized. Recently, I had a case of bilateral chronic recurrent parotitis, where both glands would periodically swell, become painful, and saliva secretion ceased. The openings of Stenson's ducts were quite invisible. Under anaesthesia, these were found but would not admit a probe. They were incised and stitched open to the cheek mucosa and the condition has gradually subsided. The pancreas is histologically similar to the parotid and it is not unreasonable to suppose that a hypertonic sphincter of Oddi would give rise to similar congestion and distension. A preliminary account of sphincteroplasty in 5 cases of relapsing pancreatitis was recently reported from the Los Angeles County Hospital with favourable results to date. This falls in line with the general principle of maintaining drainage of a secreting organ and should be kept in mind in all cases of chronic pancreatitis. Recently I was asked to see a woman who had had cholecystectomy and transplantation of her common bile duct for recurrent pancreatitis. Her symptoms continued and the internist felt that further exploration was justified. At operation there was free drainage between the common bile duct and the first part of the duodenum. The pancreas, appeared normal. The second part of the duodenum was opened and after some searching the sphincter of Oddi was found. It would not admit a probe and had to be incised. A portion was excised and a ureteric catheter passed along the pancreatic duct, Urakon was injected and a normal duct outline seen. Microscopy showed the portion of sphincter to be markedly fibrosed. It is now twelve months since operation, and the patient has been free of symptoms. Chronic Liver Disease: Page 348 May be responsible for symptoms similar to cholecystitis. Some authorities maintain that cholecystitis and gall stones are but the complications of liver disease and their surgical treatment has no bearing on the original lesion. While it is logical to accept, on physiological grounds, that dyspepsia follows liver disease, it does not explain the colicky pain which we know accompanies distention of the ducts. Assuming that the internist saves his alcoholic friends from the surgeon's clutches, let us consider the aftermath of cholecystitis and cholelithiasis on the liver. Can the post-cholecystectomy symptoms be due to changes already brought about in the liver from biliary disease before removal of the gall bladder. It would seem that this is only likely to occur if there is obstruction, partial or recurrent, from stone in the common duct. Under these conditions hydrohepatosis develops. The liver is discoloured becoming brown or yellow with indistinct markings and granular in appearance. Microscopically, the bile channels are congested and even .ruptured, bile thrombi may be present and central lobular degeneration occurs. In the presence of infection varying degrees of ascending cholangitis are remarked. Other forms of liver atrophy and cirrhosis are described but cirrhosis and gall stones occur sufficiendy often to be present independendy: It seems doubtful if this explanation can be employed in uncomplicated cholelithiasis. Neurogenic Disease: Air-swallowing, pylorospasm, duodenal ileus, neurasthenia, migraine, are all conditions which must be kept in mind. II Incomplete or Improper Surgery and Complications therefrom: Here we are on surer ground and can separate fact from fancy. There are certain ^organic errors which cause symptoms to persist. Missed stone in the biliary ducts is the commonest surgical error and has led Lahey Clinic surgeons to explore the bile ducts in chronic cholecystitis in nearly 50% of their cases. They have found unsuspected stones in 17%. There are few surgeons who have not at one time had to return for a missed stone, and this humbling experience tends towards a greater inclination to explore. The indications for exploration are well known: 1. History of Jaundice. 2. Small stones in the gall bladder. 3. Chronic pancreatitis. 4. Non-calculous gall bladder with symptoms of cholecystitis. 5. Where palpation of the common bile duct is incomplete. 6. Any visible abnormality of the duct. It is well to begin by exploring upwards into the hepatic ducts to flush the occasional small stone which may otherwise be missed in this site. Attention is then directed downwards towards the duodenum, the likeliest hiding place being the ampulla of Vater. If difficulty is encountered in actually passing the probe through the sphincter, it is not uncommonly due to the irritating presence of a small stone causing sphincter contraction. Access can often be made easier by mobilizing the lateral aspect of the duodenum together with the head of the pancreas. A cholangio- gram taken on the operating table is an additional safeguard. It is respectiully suggested that the next step is to examine the sphincter of Oddi to ensure that this small important structure is functioning. More will be said about this later. > Cystic Duct Stump: For many years surgeons have been aware of the so-called re-formed gall bladder. In recent years, this phenomenon has received prominence in the literature. Mayo Clinic reported 40 cases which were treated surgically. Results varied according to the indications for the previous cholecystectomy. Where the indications were doubtful, results for the second operation failed. The condition probably arises from fear of ligating the common duct at its junction with the cystic duct. Page 349 If there is doubt of this relationship, a probe can be passed through the cystic duct to determine the exact position of the common bile duct. If a large portion of cystic duct is left, it becomes a diverticulum and is subject to the complications thereof, viz., stasis, inflammation and stone formation. The condition is now well substantiated and can be avoided by ligation of the cystic duct close to the common duct. Neuroma Formation: Examination of the neuro-anatomy has shown there is a rich plexus of autonomic nerve fibres derived from the coeliac plexus surrounding the duct system. Neuromata, likened to the neuromata of an amputation stump, have been found. This has led to the view that pain impulses may rise at this site and cause symptoms identical-with those of biliary disease. Recently, the stripping of nerve fibres from the cystic duct and cystic artery has been advocated. This would seem to require a meticulous dissection often under rather weighty conditions, which might tax even the most painstaking of neurosurgeons. Stricture of the Common Bile Duct: There is no structure in the body which commands greater respect from the abdominal surgeon than the narrow, unilateral, often anomalous common bile duct. Maingot states "about 30% of the patients who have sustained injuries of the bile ducts during cholecystectomy die of the immediate consequences of such an injury, another 30% succomb from the operative interference necessary for its repair and although 40% make good immediate recoveries after such interference, they are liable to recurrence of biliary disease, especially obstruction with suppurative cholangitis which eventually proves fatal." In addition to this unfortunately too well-known catastrophe, there is the patient whose structure is incomplete and gives rise to recurring post-cholecystectomy symptoms without clinical jaundice. Until the onset of jaundice, the presence of stricture is often over-looked but the early changes of biliary cirrhosis and ascending cholangitis may be taking place. Patients who present with late stricture will usually give a history of recurring pain and dyspepsia. There are probably many whose strictures are not diagnosed until jaundice occurs but are suffering from the effects of biliary obstruction. Removal of Functional Gall Bladder: This will be dealt with later but it must be mentioned under the heading of improper surgery. There is no doubt that the worst post-cholecystectomy sufferers are those whose gall bladders are proved to be normal by the pathologist. A surgeon may find himself in the position of operating on a patient with typical gall bladder symptoms in whom there is no gross evidence of disease. He may: 1. Remove the gall bladder and explore the bile ducts. 2. Find some other lesion, not uncommonly the appendix. 3. Close the abdomen and hope the patient is from out of town. While every effort should be made to exclude disease of the biliary system, it is equally important not to remove the gall bladder unless it is diseased. Its removal will interrupt the reflex functioning of the whole system, the bile ducts become dilated to accommodate the bile secreted by the liver and the sphincter of Oddi is relaxed for a time but later becomes hypertonic and may equal or exceed the secretory pressure of the liver cells and thus interfere with their activity. When this state has been reached, it is difficult in the extreme for both patient and doctor. There is no initiator in the reflex arc of gall bladder contraction-sphincter relaxation. The sphincter, which is not a true sphincter but a thickening of duodenal muscle, reverts to its normal state of muscular tone. This can only be overcome by a great rise of biliary pressure which is accompanied by colicky pain and incomplete digestion of food. It is at this stage that the patient often presents for specialist advice. Page 350 Research into the previous reasons for cholecystectomy usually reveal these to be inadequate. The problem here is not related to cholelithiasis or cholecystitis. Almost certainly there is malfunction of the sphincter of Oddi, probably present to some degree before operation and responsible for symptoms at that time. Normal Physiology of Biliary System: The gall bladder is a thin-walled structure with maximum capacity of about 50 cc. bile. During a normal 24 hour day, the liver secretes between 500 and 1000 cc. bile at a pressure up to 30 cms. When pressure in the bile ducts rises to about 7 cms., bile passes into the gall bladder. The secretion of bile continues so that more and more enters the gall bladder which, in order to accommodate the volume, has to expand or concentrate the bile. Heister in 1728 first noted that gall bladder bile was more viscid than hepatic bile. We now know there is resorption of isotonic saline through the Mucosa allowing a 6 to 10 times concentration of bile. During periods of digestion, the sphincter of Oddi partially relaxes and yields to a pressure of about 10 cms. At the same time, the gall bladder contracts, raising pressure in the ducts to about 20 cms. and bile is discharged into the duodenum. If the bile ducts are obstructed, pressure in them may rise above 30 cms. at which point bile is resorbed into the blood stream. This mechanism is activated by neurogenic and chemical J CD stimulation. Physiologists have shown that moderate stimulation of the vagus contracts the gall bladder and relaxes the sphincter. The presence of food, especially fat in the intestine liberates a substance, cholecystokinin, which produces contraction of the gall bladder. III. Malfunction of Biliary Tract: It is in this field that greatest promise lies. Why should this mechanism which is powered by the usual double system of control, neurogenic and chemical, become disorganized? We now know that Hirschprung's mega-colon is due to neurogenic imbalance from atrophy of the ganglia of the myenteric plexuses. This explanation is now considered in achalasia of the cardia and duodenal ileus. It would explain very neady a disturbance of the biliary reflex. It is known that if the sphincter of Oddi is cut, the gall bladder becomes flaccid and ceases to function. It is also known that if a normal gall bladder is removed, there is at first relaxation of the sphincter of Oddi followed by hypertonicity. It would seem that the impulse which initiates gall bladder contraction and synchronous relaxation of the sphincter must originate in the gall bladder and, if it is removed, the impulse is negated. Under these conditions, there is distension of the bile ducts and back pressure on the liver. Could this be a primary achalasia giving rise to stasis, later to stones and cholecystitis? In which case, cholecystectomy would be treating the effect, not the cause. In other words, which came first, the chicken or the egg? It is possible that local infection could give rise to inflamation and "odditis", setting in motion the above train of events. Perhaps this explains the clinical cholecystitis which occurs without stone, further evidence towards the pre-choleCystec- tomy syndrome which is later complicated by stone formation. The more one thinks about biliary disorders the more inclined one is to look for a physiological cause. There has never been an adequate explanation of how infection reaches the gall bladder. Of the several well known theories, the only one which is at all tenable is that organisms have passed in the portal blood to the liver and have been excreted in the bile. In chronic cholecystitis, the bile is usually sterile and it is well known that gall stones may form in the absence of any infection. Could not hypertonicity of the sphincter so alter pressures that re-absorption is interfered with and cholesterol, normally held in solution by the bile acids, is thrown out and reposited? It is a generally accepted principle that where drainage is interfered with, crystalloids are precipitated out of solution and calculi form. Page 351 Ivy has carried out experiments in which he has produced a resistance at the sphincter of 80 cms. bile pressure, giving rise to typical symptoms of biliary pairi. This he considers is the explanation of gall stone colic without gall stones. McGowan measured pressures in common bile ducts in which "T" tubes had been inserted. A normal flow of opaque substance was seen to pass through into the duodenum. Morphine was given and a pressure of about 16 cms. of water was measured. This was accompanied by upper right quadrant pain and colic radiating through to the scapula. Inhalation of Amyl Nitrate immediately relieved the spasm and allowed the opaque solution to pass through. The pain was relieved, only to return in about 15 minutes, as the relaxing effect of Amyl Nitrate wore off. This5 probably is the explanation of those patients who are free of pain when their common ducts are drained with a "T" tube but whose pain recurs on removal of the tube. Unless the tube passes through the sphincter and permanently dilates it, this form of treatment would seem to be a waste of time. What deductions can be made from our study of this common disability and how can the present day knowledge of physiology be applied? First and foremost a more exacting standard of diagnosis must be sought. Every effort must be made to exclude the many conditions which are aften lumped together under the nondescript heading of Chronic Cholecystitis. Use of the term Pre-Cholecystectomy syndrome is suggested as a prophylactic measure and to cultivate an atmosphere of awareness. Patients who have had their gall bladders removed and continue to have symptoms, must be completely re-examined. The first thing to re-assess is the indication for the previous cholecystectomy! If this was adequate, it is more likely that some organic cause for the persistence of symptoms will be found. If, on the other hand, it was inadequate, and the pathologist's report shows little abnormality in the gall bladder, then it is more likely to be a biliary dyskinesia. Every effort must be made to exclude any organic cause because here lies a golden opportunity for success. Good results have followed recovery of missed stones ancfc correction of the cystic duct stump. At operation a careful search is made, through an adequate incision, of the entire abdominal cavity. Special attention is directed to hiatal hernia, peptic ulcers which can often be missed in patients subjected to previous upper abdominal surgery, aneurysms of nearby vessels, malignant disease which has manifested itself since previous operation, etc. Finally, careful re-examination of the biliary apparatus is made. The duct system is thoroughly explored and no stone is left unturned. The site of the old cystic duct is examined for signs of inflamation or stone. Obstruction at the sphincter of Oddi is especially sought. Prior to operation, dyskinesia should be tested for. Morphine Gr. 1/6 is injected and will usually produce right upper quadrant pain penetrating through to the scapula. Amyl Nitrate is then inhaled and the pain relieved only to return in 15-20 minutes when its effect wears off. If this test is positive, it is strong evidence in favour of dyskinesia and requires that the sphincter be examined. For precise diagnosis of dyskinesia, biliary pressure may be measured and a cholangiogram taken at operation. In practice, the passage of a deBakey dilator will reveal characteristic resistance at the sphincter. For these patients sphincterotomy is advised. The second part of the duodenum is opened, the sphincter exposed and a portion excised establishing free access between duct and duodenum. There is a further group of patients made up of those whose symptoms do not merit surgical exploration and those who will not submit to further surgery. These can be managed on a medical regime. Common sense diet restrictions are imposed. A low fat diet is often more satisfactory than one excluding fat entirely. A cholagogue, such as Decholin combined with atropine frequently ameliorates symptoms. Small doses of Nitroglycerine, preferably using a delayed action tablet, will keep the biliary pressure low and promote free flow of bile into the duodenum this helping Page 352 to reduce the colicky pain often so troublesome. Non-surgical drainage duodenum by instilling 25% Magnesium Sulphate via duodenal tube to relaxation of the sphincter and contraction of the gall bladder, is advocated European physicians. In addition some suitable pursuit to distract the psyche misfortune is not out of place. Finally, after all these measures have been taken, there will remain who continues to suffer. Here will be an opportunity for the physician to his philosophical faculties and explain to the lady, that, some are fat, some and some have post-cholecystectomy syndrome. of the produce by some from its" a group indulge are thin (iDitttuarg The passing of Doctor Frederick James Buller marks the loss of one who was a good man, a good citizen, and a good physician, and there are many to mourn his death who have known him in one or more of these capacities. ||| Dr. Buller was born in Ossian, Iowa, in 1867, and received his early education in Ontario. He graduated in medicine from the University of Toronto in 1905 and it is a matter of keen regret that he will miss the celebration of his fiftieth year in practice, which he had planned to attend with the survivors of his graduating class in Toronto in June of this year, when the British Medical Association and the Canadian Medical Association will be meeting in that City. He came to Vancouver in 1908 and began his practice at Central Park, where he was the only physician for some years, and acquired a very large practice. Vancouver at that time, was still a pioneer city to a great extent, and Central Park was a long, long way from the "main stem." Travel was difficult, and distances gready magnified by bad roads — but Doctor Fred Buller was always available, and became gready beloved by the people of the district. Buller Street — not far from Boundary — was, we believe, named after him. Later he moved into offices in the downtown area of Vancouver. Fred Buller was always ready to pull his weight and he did a great deal of work for his profession. A long list of honours and tributes, show the esteem in which he was held. He became President of the Vancouver Medical Association in 1923 and was for many years a Trustee of that body. He was a member of the staff of the Vancouver General Hospital and held a Life Membership in that institution. He was an Honorary member of the College of Physicians and Surgeons of British Columbia and the affection of his fellows was shown by the conferral of the "Prince of Good Fellows Degree" on him by the members of the Vancouver Medical Association —the highest personal honour that is theirs to bestow. His work was along the lines of Internal Medicine, and he brought to it a wide knowledge and keen interest. He was an excellent clinician. Personally, he was a charming man to know. Quiet and somewhat reserved, he had a warm personality, and his kindness and generosity will long be remembered by many who were his patients for many years. He took a very keen interest in his church and was a member of St. John's Church (Shaughnessy) at the time of his death. ||p£ He was above all things, devoted to his family. He leaves, besides his wife, two sons and a daughter. The sympathy of all his friends, and they were legion, goes out to those he has left behind him. Page 353 'ews an d I loted Dr. Alec Boggie and Dr. Bud Sovereign of the Vancouver General Hospital will commence practising in Vernon this summer. Dr. B. Berger is now practising Ophthalmology in Vancouver. Dr. W. J. Buschlen is now practising in Port Moody. Dr. James Baird is now in Port Coquitlam after training this year at Shaughnessy Hospital. Eh. V. A. Ewert is now in the American Air Force. Dr. H. S. Gross is now practising in New Westminster. Eh. Ian Kent is now studying Psychiatry in Montreal. Dr. James Sandilands is now on the Workmen's Compensation Board in Vancouver. Dr. Eric L. Smith of Vancouver has received his Specialist Certification in Ophthalmology. Dr. G. B. Scott is now in association with Dr. P. Margetts at Kitimat. Eh. G. Marion is now certified in Pediatrics after post graduate study in France and is living in Ottawa. The Annual Memorial Oration of the Victoria Medical Society was held on May 6th at which Dr. J. W. Lennox and Eh. T. Miller were guest speakers. Out-of- town visitors were: Dr. J. S. Goodbrand and Sir Philip Livingston of Duncan. Eh. Cyril Robertson, formerly of Osoyoos, is now an assistant medical director of the M.S.A. in Vancouver. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. Born to Dr. BIRTHS and Mrs. Kenneth A. Campbell of Vancouver, a girl. and Mrs. G. P. Skelhorne of Vancouver, a son. and Mrs. E. D. Herberts of Vancouver, a daughter. and Mrs. E. Pritchett of Vancouver, a son. and Mrs. I. Klassen of Chilliwack, a son. and Mrs. A. E. Trites of Vancouver, a daughter. and Mrs. Ken Campbell of Vancouver, a son. and Mrs. W. McEwan of Vancouver, a son. and Mrs. W. Osier of Vancouver, a son. and Mrs. W. Manning of Vancouver, a daughter. and Mrp. Hugh MacDonald, a son. and Mrs. W. A. Folk, a daughter. and Mrs. M. Roach, a daughter. ESTABLISHED GENERAL PRACTICE IN VANCOUVER FOR SALE OR RENT Owner specializing. Phone: TAtlow 7718 or CEdar 7626 Page 354 We are publishing in this issue a notice of a three-day Post-graduate Course to be held in St. Paul's Hospital in October next; and will remind our readers of this from time to time. The actual programme will be published later. We have seen the tentative programme, and can assure everyone it is excellent. The course is designed for general practitioners, and will be highlighted by the presence, as Visiting Lecturer, of Dr. Martin M. Hoffman of Montreal, Assistant Professor of Medicine, McGill University and also Director of Medicine at the Jewish Hospital, Montreal. This is a new departure for St. Paul's and we congratulate the Medical Staff most sincerely on their enterprise in undertaking it. We all know what a tremendous success the Refresher Courses periodically offered by the Vancouver General Hospital have been — and have often wondered why St. Paul's, with its excellent staff, its vast stores of clinical material, and its up-to-date equipment in laboratories, lecture rooms and the like, has not done the same thing. Of course, the General Hospital has the advantages of being a completely equipped teaching hospital, with a considerably larger staff — and a course of this nature will be a much bigger undertaking proportionately for the staff of St. Paul's. But both in personnel and in equipment, the latter hospital has everything needed to provide as good a post-graduate course as any hospital can offer, and once they have started, we may hope to have other courses later. We are glad to see this for other reasons: St. Paul's Hospital has, we feel, been hiding its light under a bushel for too long. In its pathological department, for instance, special provision has been made for teaching, and the work of this department is of an exceptionally high order. Its X-ray department, too — its surgical department, are admirably designed for use in such work as this. In paediatrics, St. Paul's Hospital rates very high indeed — and the work that the staff of this Hospital has done, more especially in premature infants, is outstanding. Its air ambulance service, installed some years ago, has done most excellent work. In the forthcoming course, great emphasis is being laid on surgery, and here the Hospital has a great deal to offer. Its new operating suites, opened this month, will be fully equipped and ready — and will be especially convenient for teaching purposes. Medicine, too, will form a major part of the course, and here Dr. Hoffman will give several addresses, and lead discussions. And last, but by no means least, obstetrics will receive due attention. In fact, from the general practitioner's point of view, there is a great feast of good things to look forward to. In introducing this teaching course, St. Paul's is fulfilling one of the main duties of a hospital, that of teaching. Of course, it has done a good deal of teaching; it is part of the system of the University of British Columbia's medical school; it has monthly meetings of its staff, where a great many excellent papers are given — and so on: but this is a further step. We remember seeing, some years ago, in Dr. McEachern's book on Hospital Management, a list of five duties that a modern hospital must fulfil, to be completely adequate. One was, of course, the care of the sick and injured of a community (incidentally, this came rather surprisingly, at the end of the list), one was the training of nurses, of internes and so on — but either first, or second, came the teaching of doctors in practice — post-graduate work, in fact; and there is nothing more important. The General Practitioners' Section of the Canadian Medical Association, B.C. Division, will rejoice that yet another opportunity will be available for the man in general practice; and we are sure that its big sister, the Vancouver General, will applaud and endorse this new undertaking, and welcome this extension of teaching of medicine. Page 381 ancouver Medical Association OFFICERS — 1954-55 President | Dr. F. S. Hobbs Vice-President Dr. G. E. Langley Honorary Treasurer Dr. Paul Jackson Honorary Secretary Dr. A. F. Hardyment Editor . Dr. J. H. MacDermot MEMBERS ELECTED TO VMA DR. B. J. GAEBER—elected at the General meeting held on February 1st. Born in Austria-March 26th, 1899. Received his training in medicine at the University of Vienna where he graduated iri 1923. Postgraduate study in Vienna from 1923 until 1928. Came to Canada and practised for a time in Regina. Received his certification in Psychiatry December 1st, 1952. Came to Vancouver for a visit in the summer of 1953 and was so impressed by Vancouver's beautiful scenery, temperate climate and friendly people that he decided to settle here and obtained his licence to practise on December 16th, 1953. (Specialty ii Psychiatry). His particular interest outside his work are Music, Bridge and Fishing. He is married and has one son. DR. PHILIPPE ST. LOUIS MAISONVILLE-elected at the General meeting held on Dec 7th, 1954. Born in Toronto, June, 1921. Graduated from the University of Toronto in 1946. Post graduate study in Ophthalmology at Wayne University and Detroit Receiving Hospital from 1951 to 1953. I Received the Degree of Master of Science in Ophthalmology at Wayne University in 1953. Practised from 1947 to 1950 in the Yukon Territory and Alaska. Obtained his certification in Ophthalmology in 1954. His practice is now limited to Ophthalmology. His hobby is photography. He is married and has two children. The following members were elected to Active Membership on TUESDAY, APRIL 5th, 1955: DR. RICHARD E. BECK- M Born on June 8th, 1923 in Vancouver, B.C. Graduated from Queen's University in 1947. Postgraduate Study—3 years—Vancouver General Hospital. 2 years—Royal Victoria Hospital, Montreal. 1 year—Fellow in the Department of Medicine, University of B.C. Page 382 Fellow of the Royal College of Physicians (Canada) November 1953. Is now engaged in the practice of Internal Medicine — (Commenced in February last year). His favorite sports are fishing and golf. Was married last year to Dr. Jean M. Hardie (also a member of trie V.M.A.). DR. H. W. BROOKE- Born in Ardath, Saskatchewan on May 14th, 1913. Is a graduate of McGill University (1939). Postgraduate Study—Internal Medicine and Radiology. Degrees— 1948 Diploma Diagnostic Radiology, American Board of Radiology. 1949 Certification in Radiology, R.C.P.S. (Canada). Practised Radiology for a time in Ottawa, Ontario but his wife decided that they should come to Vancouver and besides he thought he would like the climate here better. His hobbies are "woodworking", "photography" and "sports cars." He is married and has five children. DR. W. J. COULDWELL- j| Born in British Columbia—December 20th, 1924. Graduated from McGill University—June, 1950. 3 years internship—rotating, surgery, orthopaedic. General Practice since July 1953. Favorite sports—hunting and fishing. Married and has two daughters. DR. VICTOR SAMUELS- M Born in Edmonton, Alberta—February, 1923. Graduated from the University of Alberta—Class of 48. Degrees: L.M.C.C. 1949—Certified in Specialty of Paediatrics 1953. Commenced the practice of Paediatrics in Vancouver in January 1954 after practising for a time in Calgary, Alberta. His main hobbies and interests outside medicine are his "home and family." He is married and has two children. - DR. A. T. W1ENS- " Jj || Dr. Wiens was born in Plum Coulee, Manitoba and he graduated in medicine from the University of Manitoba in 1935. Igp His postgraduate study was carried on at St. Paul's Hospital in 1951 and at the Vancouver General Hospital in 1952 and 1953. He obtained his certification in Diagnostic Radiology in 1954. Before he started practice in Vancouver he spent some years in Fort William, Ontario, doing general practice. His greatest sporting interest is in Golf. He is married and has one child. Page 383 Library Hours (Summer) Monday to Friday 9:00 a.m. to 5:00 p.m. Saturday 9:00 a.m. to 1:00 p.m. Recent Accessions: Diagnosis and Treatment of the Infertile Female by Fred A. Simmons. C. C. Thomas. 1954. Diagnosis and Treatment of Acute Phase of Poliomyelitis edited by Albert G. Bower. Williams and Wilkins. 1954. Treatment of Respiratory Emergencies Including Bulbar Poliomyelitis, by T. C. Galloway. W. B. Saunders. 1953. Surgery of the Adrenal Glands by William W. Scot. W. B. Saunders. 1954. Pharmacology in Medicine: A Collaborative Textbook by V. A. Drill. McGraw Hill. 1954. Textbook of Operative Surgery by Eric Farquharson. Macmillan. 1954. A copy of the book "Osier and Other Papers," by W. S. Thayer, Baltimore 1931, has been added to the library's collection of Osleriana. 'The Roots of Crime," by Sir Norwood East. Current Therapy by Howard F. Conn. McAinsh & Co. 1955. Advances in Internal Medicine, Vo. 6. Edited by William Dock. Year Book 1954. Modern Discoveries in Medical Psychology by Allen Clifford Macmillan 1954. ii ii ii BOOK REVIEW The Roots of Crime Sir Norwood East. 1954. This book was conceived by a physician who had years of experience in the medical service of prisons and "did so much to promote humane and moderate appreciation of the psychological aspects of crime." He writes the first chapter, on the Legal and Medical Advances in Criminology. It is not often that a physician writes in such polished and urbane prose, ranging the philosophical, legal and medical fields so effortlessly. His elucidation of cognitive and conative mental features, the definitions of health and disease, and the reasons why he thinks crime is not a disease, are excellent. He ends with a fine summary of the medical advances in treatment of the offender, but obviously thinks the hope for the future lies in improving the home conditions of the juvenile before they become offenders. "If one fact can be accepted as established in the field of criminology, it is the overwhelming influence of unsatisfactory home conditions in the formation of delinquency and that not only among juveniles." Page 384 Dr. Curran, the senior psychiatrist to St. George's Hospital writes on "A Psychiatric Approach to the Offender." As writers in psychiatry go, he writes clearly in language that the average physician can understand. His clinical summaries of the common psychiatric syndromes are accurate and concise. The oudine of the mental deficiency and intelligence tests is excellent. His advice to doctors giving evidence in court should be read by all of us. "It should be appreciated how unsatisfactory it is for the reputation of psychiatry that under the present system solicitors for the defense can, and some do, importune psychiatrists until they find one who is able to give evidence of the kind they want." And "It would be absurd to pretend that psychiatric evidence should be called to assist the court except in a very small minority of cases." Under the tide, "A Clinical Contribution" Doctor Peter Scott, psychiatrist of Maudsley Hospital, writes one of the best descriptions of the delinquent boy, the Spiv in England, the Hoodlum or Hood of the American adolescent gangs. "It seems very unlikely that the spiv, or wide boy, is a product of our time; the market places of most civilizations would probably provide a comparable sample." They are the insecure problem children, are essentially transitional. "The majority emerge as reasonably adjusted married men, perhaps with a tendency to be better versed in their rights than in their duties." Every general practitioner who advises parents should read this chapter and most psychiatrists would find it rewarding. His remarks on "The Psychiatrist and the Criminal Court" are also excellent. Doctor Mackwood, psychotherapist at H.M. Prison, Wormwood Scrubs, explains the methods of psychiatric treatment, and is chiefly of interest to psychiatrists and prison doctors. He has a good section on sexual offenders. Mr. W. Clifford, probation officer, has written a thoughtful article on "The Role of Probation in the Treatment of Offenders." Most if not all of us should read this or some such article, because as Mr. Clifford writes: "Probation is established as a definite social force and the probation officer's role has both prophylactic and constructive significance in the community. In a sense it represents something new in the history of man—a willingness of society to accept responsibility for and with its criminals." It is a surprise to read of the sociological advances and implications in probation as practised for offenders. The last article, on 'The Magistrate and the Psychiatrist" by Mr. Frank J. Powell, Metropolitan Police Magistrate of Clerkenwell, is a scholarly work, written with humor, insight and restraint. He can be blunt: "The term "black-out" is a vulgarism which has no psychiatric significance and is popularly used by malingerers"; and, "Ill-advised evidence in criminal trials, confident assertions regarding the value of nebulous theories which are unconfirmed and matters of dispute, and loose meanings attached to technical terms, impede progress in the psychiatric approach and treatment of crime." Most psychiatrists would agree with his judgment, "A convincing case for the special efficacy of prolonged psychotherapy, as opposed to other and simpler procedures, has not yet been made out except for a quite small group of offenders." He thinks, "every human being has an inherent and latent predisposition to assert the ego to the detriment of others: that the act of assertion is called into being by some personal, or environmental factor commonly called temptation; and that when this takes place the resulting conduct may range from anything which is a breach of good manners to the commission of a grave criminal offense." This is an unusual book, both for its excellent writing, its understandability, and its wealth of sociological knowledge. It is a book that not only lawyers and psychiatrists should read, b_t also all physicians and social workers. DR. S. E. C. TURVEY. Page 385 LIST OF MEDICO-LEGAL BOOKS IN LIBRARY of the VANCOUVER MEDICAL ASSOCIATION , Taylor's Principles and Practice of Medical Jurisprudence by Sidney Smith and W. G. H. Cook. 10th edition. Churchill. 1948. Pathology of Trauma by A. Richards Moritz. 2nd edition. Lea & Febiger. 1954. Medical Jurisprudence and Toxicologv by John Glaister, 9th edition. Livingstone. 1950. Society and Its Criminals by Paul Reiwald, translated by T. E. James. International University Press. 1950. Forensic Psychiatry by Henry A. Davidson. Ronald Press. 1952. Modern Trends in Forensic Medicine by Keith Simpson. Butterworth. 1953. Bernard Spilsbury—His Life and Cases by D. G. Browne and E. V. Tullett. Harrap. 1954. Mental Deficiency by Tredgold. 8th edition. Balliere, Tyndall & Cox. 1952. Law and Practice of Medicine by Kenneth George Gray. Ryerson. 1947. Legal Medicine and Toxicology by Gonzales, Vance and Halpern. Appleton-Century. 1940. The Medical Man and the Witch in the Middle Ages by Gregory Zilboorg. John Hopkins. 1935. Poisons and Poisoners by C. J. S. Thompson. Shaylor. 1931. Forensic Psychiatry by Norwood East. Churchill. 1927. Crime and Insanity by W. C. Sullivan. Arnold. 1924. Criminal Responsibility by Charles Mercier. Oxford. 1905. The Mask of Sanity by Hervey Milton Cleckley. C. V. Mosby. 3rd edition. 1950. Psychopathia Sexualis by von Krafft-Ebing, translated by Craddock from 7th German edition. Davis. 1892. The Psychiatrist and The Law by Winfred Overholser. Harcourt, Brace & Co. 1953. LECTURE BY RENOWNED BRITISH BACTERIOLOGIST \ JULY 5th, 1955- ' -|Bp:. § Dr. Robert Cruickshank, Professor of Bacteriology at the Wright-Fleming Institute of Microbiology, St. Mary's Hospital Medical School in London, England, will be a visitor to Vancouver from July 4th to July 6th. He has been an outstanding worker in clinical bacteriology and we are privileged to have him as our guest. He will address a public medical meeting in the Willow Chest Auditorium on Thursday, July 5th at 8:00 p.m., his subject being "Hospital Cross Infection," a subject of great current interest. It is trusted that a good turnout of medical practitioners will occur. DESIRABLE OFFICE SPACE Bright, clean, attractive. On West Broadway, vicinity of Academy of Medicine. Share waiting room and business office with physician. Available July 1st, 1955. Enquire CEdar 4188. Page 386 THE PHYSICIAN AND THE LAW* By GEORGE E. HALL, J.D. ** || The following article on "The Physician and the Law" is a copyright publication of the American Medical Association, Law Department—and is published with the permission of Eh. George Lull, Manager and General Secretary of the A.M.A. -ED. Our purpose this morning is to convince you, a group of leaders in the field of medical education, that certain improvements should be made in the medical school curriculum. If these improvements merely involved eliminating some courses, so that faculty and student body would have things a litde easier, you would probably shout "Amen" and adopt the suggestion happily. But unfortunately, 1 am not on this panel for the purpose of urging such a delightful idea. I am not unmindful of the way in which the medical school curriculum has.become stuffed almost to the bursting point. Educators, and this is not limited to medical educators, tend to become special pleaders and to urge that their own special field of interest deserves a greater emphasis if students are to be graduated as adequately educated persons. There is still one group of special pleaders to be heard from in the medical field. Dr. Regan has already indicated a few of the areas in which a physician should receive some indoctrination during his training period. In the time allotted me, I would like to point out a few more and possibly amplify upon some he has already mentioned. (1) All of the states now have enacted workmen's compensation laws and most have enacted occupational disease laws. These injured workmen either are not aware of the requirements of these laws or fail to comply with them. Reports of examinations and of treatment given must be filed in the prescribed form and within the prescribed time. Failure to follow the rules may result not only in the loss of a fee, which is bad enough, but may also result in the loss of compensation to the injured party and his dependents. A medical school cannot teach its students the detailed requirements of each state's compensation law. We would not urge that. A student should, however, be made aware of the existence of such laws before he starts to practise, so that his patients, perhaps the first one who walks in his office, will not be prejudiced by their choice of physician. Furthermore, a young physician who sees his future path leading him into the field of industrial medicine generally should have some concept of the obligations which an industrial medical department owes to both management and labor. Does the usual relationship of physician and patient arise? What should be done about referrals to the family physician and what is the legal, as well as ethical, relationship to the family physician? What are the legal obligations of reporting to management and to the employee matters of serious importance to the health of the worker? A recent Tennessee case resulted in a thirty thousand dollar judgment against a company because its medical department had not advised a worker that he had tuberculosis so that he would have been influenced to seek private medical care early enough to do him some good. The company had been subjecting the worker to periodic health examinations for a j number of years and apparendy the court felt it should have passed along to the worker the results of such examinations. What should the industrial physician know about privileged communications? What information can properly be revealed to management without jeopardizing the confidential nature of the physician-patient ! relationship and the patient's right of privacy? (2) The laws of many states and the ordinances of some of the larger cities require physicians to report various wounds and diseases to certain governmental Read before Congress on Medical Education and Licensure, February 7, 1955, Chicago Illinois. ** Staff Associate, Law Department, American Medical Association. \ Page 387 agencies. Gunshot and stabbing wounds must often be reported to the office of the local prosecuting attorney. Contagious diseases must be reported to state or local health authorities. Epilepsy and similar diseases must be reported to commissioners of motor vehicles. Blindness and deafness must be reported to health and sometimes school officials. Here again the future physician must be told to be on the alert for these public health matters. (3) I can well imagine that your schools already inculcate in your students^ the clinical importance and value of maintaining not merely adequate, but excellent, hospital and office records. This activity is no doubt stressed as being a necessity to the proper treatment, present and future, of a patient's condition. Above and beyond any advantage the patient may gain by having his physician maintain good records is the definite advantage which accrues to the physician himself. When a physician is haled into court to answer to a charge of negligence in the treatment of a patient, nothing so delights the physician's lawyer as a complete, clearly stated record telling what the physician diagnosed and how he treated the patient. Nothing need be left to guess work in preparing a defense. In addition to being helpful to the physician and his lawyer, his records may be helpful to the judge and jury. In every state, these records may be used to refresh the recollection of the physician before he testifies. (4) The Harrison Narcotic Act and narcotic laws of the individual states place upon physicians obligations which should be explained to them before they are thrown into the rigors of a busy daily practice. They should be given some insight into the sly and clever way in which addicts will attempt to secure narcotics from the unwary physician. They will simulate illness and substantiate it with a plausible story. They will decide to suffer from some particular disease, read everything about that disease that they can get hold of, learn every symptom, and know precisely when to flinch with pain during the physician's examination. Two quotations from the recent book entitled "The Traffic in Narcotics" by Anslinger and Tompkins will serve to illustrate this point more completely. Mr. Anslinger, you know, is the U.S. Commissioner of Narcotics. The first quotation is this: "Some addicts go to almost unbelievable lengths to carry out their deceptions. One had been operated upon years ago for a kidney ailment. In his efforts to obtain narcotics from a physician he would claim severe pain from a kidney stone. Whenever the physician insisted upon taking an X-ray, the addict would conceal in his hand an ordinary small stone. After being prepared for the X-ray, he would then secrete the stone in a pocket of the scar tissue on his back, in the exact position of a kidney stone, thus disclosing a stone in the X-ray. On his last attempt the stone fell out and was retrieved by the technician, resulting in his prosecution and conviction to a term of a year and a day for obtaining narcotics by fraud. Some inflict wounds on themselves to simulate post-operative scars. Others use some material which will produce a real coughing fit." The second quotation describes another actual case: "The old man was sitting on a park bench staring into space. Dirty, disheveled, unshaven, and worse yet, broke. His main concern was tonight's lodging. Just then he noticed a rather attractive young lady approaching and much to his surprise, as she drew abreast of him, she spoke. Would he like to earn five dollars? It was very easy and it would not take long. Ten minutes later the two of them were sitting in a doctor's office. Poor father was suffering severe pains from cancer of the rectum, and a prescription for morphine was necessary. And since it was so difficult for him to get to the doctor, would it be all right if the young lady simply picked up the prescriptions in the future. Assured it was, they departed. "A year later the doctor encountered the young lady on the street. 'How Page 388 is your Dad these days?' 'Still in great pain' was the response. 'Well you better bring him in and let me look him over next week.' said the doctor. 'This presented quite a quandary for the young lady for she had not the slighteest idea of the whereabouts of her alleged father. But she needed drugs badly. Down town she went, searched around, hired another old bum, visited the doctor, who after a short chat, issued another prescription and continued to issue them as previously. And he might be issuing them today if our young lady drug addict had not beep arrested for forging a prescription in another city. The doctor was a mighty surprised individual when Federal agents unveiled the whole story for him." (5) In former days it was not at all uncommon for a physician to act as sort of a go-between in many adoption cases. The unwed mother client often encouraged the physician to find a good home for the baby. The physician's friends who were^ anxious to adopt a child would ask him to let them know if a suitable opportunity arose. In 99 cases out of 100, these informal, friendly arrangements were undoubtedly satisfactory. Unfortunately, the one bad apple spoiled the barrel. Baby farms and other terrible practices were uncovered. The result has been a change in the law in a number of states so that babies can only be adopted through approved welfare institutions. (6) When a physician finally receives his license it is not too unlikely that he will associate himself with an established practitioner or a group of established practitioners for a while before he has acquired enough courage and capital to strike out for himself. Before he does so he should be told of the basic obligations and privileges which will be thrust upon him, and should be told of the basic obligations and privileges which his employer or employers must assume. If he steps right into a partnership he should know of his liability for the negligence of his partners. Whether a partner or merely an employee, he should be aware of his responsibility for the negligence of office nurses and technicians. Whether a partner or merely an employee, he should know about the requirements of the restrictive covenant and its validity in the eyes of the law. He should know these things so that he will be in a position to determine his course of conduct from all points of view and not just from the point of view of the financial reward that is being offered. (7) During the years, the Law Department of the American Medical Association and its predecessor, the Bureau of Legal Medicine, have received many letters and phone calls from physicians, not all of them recent graduates either, who were almost terrified because they w^re going to have to be a witness in the trial of a lawsuit. They didn't realize that a subpoena is a court order, not just a suggestion that they could accept or reject as they wished. They thought they would have to spend hours and hours of wasted time just sitting around the court house. They feared that the attorney for the other party would be able to make a complete fool of them on cross examination. They thought they would get into trouble by being forced to reveal what they considered to be confidential- information. They thought they would have to exhibit the fruits of their training and experience without being compensated for it. It would not take much time, and even if it did it would be time well spent, to explain to medical students the way law suits are started and what the purpose and effect of a subpoena is. Understanding of the task of the lawyer and of the problems he is facing would ease the student's mind and enable him to see why some delay is necessary, why cross-examination is necessary and why the physician himself is a very necessary part of the administration of justice. He could be told that a well prepared and honest and wide awake expert witness need never be afraid of any lawyer's examination because he knows so much more about the subject of his testimony than the lawyer can possibly know. He could be told about privileged communications and he could be assured that he would not subject himself to suit if he Page 389 is directed by the court to answer a particular question. He could be told that in most jurisdictions he would be justified in arranging for a fee for his services as a witness, so long as payment thereof was not contingent upon the success of the side for which he testifies. ff|| (8) Two other trouble spots for physicians should be briefly mentioned. The first is a subject which recent publicity throughout the country is skyrocketing into considerable prominence. It is artificial insemination. A superior court here in Chicago, on last December 13, rendered a decision to the effect that children resulting from artificial insemination using a donor other than the husband are illegitimate and that such procedure is contrary to public policy and good morals and constitutes adultery on the part of the mother, when done with or without the husband's consent. Although this decision is binding only in Cook County, Illinois, unless sustained by a higher court, it has been hailed as somewhat of a bombshell because there have been so few prior cases on the subject. The problem is not a new one. It has been discussed by the Law Department, and its predecessor the Bureau of Legal Medicine, on a number of occasions. There does seem to be some evidence, however, that the procedure is being resorted to more and more frequendy. This means that a greater number of physicians will be more frequently questioned about its medical, and also its legal and ethical, aspects. And this means that students should be given some of the answers so that they can best serve their patients. It is not the purpose of this panel to provide a complete course in legal medicine—but only to urge the need for such a course. Perhaps the mere stating of a few questions will serve to emphasize that need. For example, is the procedure unlawful? What is the physician's responsibility in selecting a donor? What is the physician's responsibility if the resulting offspring is abnormal? Is the physician performing the act accessory to a crime? If the physiciaaS|f who performs the insemination also delivers the baby, and if a donor other than the husband has been used, how should the physician execute the birth certificate? Is the child legitimate? What, if any, written consent should the physician preserve in his files? May the procedure be used in the absence of proof of therapeutic necessity? These are but a few of the questions which have already been raised by lawyers and doctors. Moralists will raise many more. Few of these questions can yet be definitely answered. It is begging the issue, however, to give a green light to the use of the procedure merely because no present laws prohibit such use. (9) The other problem to be specifically mentioned is eugenic sterilizatiorii Physicians should know the law of their state so far as permissive sterilization of the insane or feeble-minded is concerned. That will not be difficult to ascertain. They should also be cautioned about the potential dangers involved when a patient brings this kind of a story into their office. "Say doc, I'd like to ask you something. We've already got seven kids. You know—you delivered them. I guess I still owe you for the last two. I don't have much of a job. We can't afford any more — not even the ones we've got. I hear there's some kind of an operation you can perform on me or my wife to keep us from having any more." This particular case is fictitious, of course, but from discussions around the country-there are plenty of real ones just like it. What should the doctor do? Here, as with artificial insemination, it is too simple an answer merely to say that the procedure may be performed because there is no law specifically prohibiting it. Your students should be told that they are treading on dangerous legal ground when they perform this operation, or any other operation so closely allied with the future civilization as the propagation of children, without being convened of its therapeutic necessity. There are many more phases of legal medicine which I would like to discuss with you. I would like to try to convince you, if you aren't already convinced, how important it is to the physician and his patient and the public that the physician be at least aware of the medicolegal aspects of chemical tests for intoxication, abortions, commitment and treatment of mental cases, medical practice acts, quarantine and Page 390 vital statistics laws and many others. Before I close, though, I would like to tell you of a recent meeting I attended down in Knoxville, Tennessee. For about fifteen years, the School of Law of the University of Tennesee has sponsored an annual institute on some phase of law as a part of its postgraduate education program. This year, they called it a medico-legal institute and its purpose was to educate practising lawyers in the art of presenting medical testimony in the trial of personal injury cases. The physicians of the Knoxville Academy of Medicine gave generously of their time and talents in discussing problems of anatomy, neurology, trauma, x-rays, use of anatomical models and charts, etc. At the final session, four physicians acted as expert witnesses and permitted themselves to be subjected to direct and cross- examination under simulated court room conditions. From the point of view of the lawyers present, and they were from all parts of the state because that week was also Homecoming at the University, it was, I am sure, a very successful institute. The Knoxville doctors turned out to be excellent teachers. The thing about this institute— and similar ones are being held throughout the country with increasing frequency ^ the thing about this institute that should give us pause is this: everything that the lawyers learn to help them in presenting a more convincing personal injury or industrial accident case (and thus enable them to obtain for their client a more ade- qute award—as they express it) will also enable them to present a more convincing case of malpractice against the very physicians who were teaching them. You probably have all heard the story about the difference between the lawyer and the surgeon. When the lawyer finishes a trial he says to himself, "Now what have I left out that might have helped my client?" When a surgeon finishes an operation he says to himself, "Now what have I left in that might hurt my patient?" The point I wish to make is this. The law schools are doing their best to teach lawyers how to utilize to their advantage everything that medicine, and science in general, has to offer to them. Medical schools can do no less; Physicians must be taught what the law has in store for them, both the pros and the cons of it. In the March, 1953, Journal of Medical Education, page 57, there appeared a discussion of the Objectives of Undergraduate Medical Education. Five aims are stated and aim A includes this: 'To help the students acquire requisite knowledge of the social and cultural settings in which medical education and practice are carried on." The graduates of your schools and the licentiates of your boards, if they are to properly fill the position in society for which they are trained technically must also be given an adequate background in legal medicine. The Physician and the Law—neither can exist without the other in the daily struggle for success. OFFICE SPACE AVAILABLE New offices in fast growing district with a new forty-five bed hospital. Building newly remodelled. The partitioning and decorating will be left to the discretion of the new occupant. Living accommodation over the offices finished in wall to wall covering. Adequate parking facilities. Phone: T. BLEAKLEY, White Rock 3361 Page 391 More and more, the medical profession is realizing the necessity for measures of rehabilitation for those who are suffering, or have suffered, acute illness. Such men as the President of the Canadian Medical Association, Dr. G. F. Strong, in his travels through Canada, constantly lay emphasis on the need for this, and as we all know, he himself has been very active in this matter. But the average medical man is faced with this difficulty—he has no idea, very often, of where to apply for rehabilitation therapy. The Community Chest and Council of Greater Vancouver (Division for Guidance of Handicapped), has been making a study of this question, and has prepared a report, which we feel should be not only of great interest to all our readers, but also of value in helping them with their problems. We are indebted to Dr. J. L. Gayton of the Metropolitan Health Department for letting us have this report, and are publishing it below. We would specially emphasize one statement made in this report.. To be successful, rehabilitation must begin at the level of treatment of the acute phase of illness or injury" This is all too often overlooked^— ED, COMMUNITY CHEST AND COUNCIL OF GREATER VANCOUVER SOCIAL PLANNING SECTION DIVISION FOR GUIDANCE OF HANDICAPPED REHABILITATION SERVICES Rehabilitation has bee defined as "the restoration of the handicapped to the fullest physical, mental, social, economic and vocational usefulness of which they are capable." It means taking the handicapped person as and where he is and issisting him to make the best possible adjustment. A comprehensive rehabilitation program will either restore the sick or injured person to full health and activity or will allow him to use to the full his remaining powers. In either instance, rehabilitation is vitally necessary, not only for the well-being of the patient himself, but also for the good of the community as a whole. PRESENT FACILITIES A. Medical Care 1. General Hospitals — The main purpose of a general hospital is to provide care for the acutely ill or injured patient. Patients who have passed the acute phase of their illnesses must often be held in the general hospitals because there is no hospital to which they may be sent for convalescence, and patients may be admitted to general hospitals or held in general hospitals when they might be cared for quite adequately in nursing homes if enough beds of this type were available. Bedside nursing care is available in the community through the Victorian Order of Nurses. Thus, the primary purpose of a general hospital, viz, care of the acutely ill or injured, is being hampered by the lack of facilities for the further care of patients who have passed the phase of treatment for the acute condition. To be successful, rehabilitation must begin at the level of the treatment of the acute phase of illness or injury. Thus, rehabilitation must start at the general hospitals. 2. Special Hospitals — There are, within this community, a number of hospitals serving special groups, certain segments of the population, or caring for certain diseases. (a) Department of Veterans' Affairs — Shaughnessy Hospital, with its associated services, provides for the entitled veteran not only care in acute illness and injury, but also domiciliary care, convalescent care, and probably the best developed rehabilitation program in the entire area. Page 392 (b) Tuberculosis Control Hospitals — It has been recognized that rehabilitation of the tuberculous patient after sanatorium care is a vital factor in the control of that disease. Therefore, a programme of rehabilitation has been established and is being expanded. (c) Children's Facilities — Hospital care for acute illness in children is provided by a number of hospitals. The facilities for chronic and convalescent care are of interest. The Children's Hospital in Vancouver provides acute paediatric care, orthopaedic care and also convalescent care for patients from other hospitals. There are a number of institutions available for the care of the child with specific handicaps; the Preventorium for childhood tuberculosis, the School for the Deaf and Blind, etc. An effort to co-ordinate facilities for the care of children has been made. A registry for crippling diseases of children has been developed. The purpose of the registry is to guide the child and the parent to the best source of treatment. It is a method for assessing the problem in the province and for co-ordinating treatment and rehabilitation facilities. (d) "Convalescent" Hospitals — Supposedly, Glen, Grandview and Heather Street Annex, provide about 250 beds for the care of convalescent patients. Actually, it is only custodial care that is available in these units and the physical facilities are such that a rehabilitation program would be out of the question. (e) Hospitals for Incurable and Chronic Diseases — Marpole and Alco Infirmaries and Mount St. Mary's provide approximately 300 beds for this type of patients but their actual function is that of institutional care. At Marpole, with limited physical facilities, an interesting program of recreational therapy has been developed, but there is no true real rehabilitation at any of these centres. l|f§ 3. Other Community Health Facilities (a) Nursing Homes — There are many privately operated nursing homes in the, community. They are very expensive, over-crowded, and the services provided are inadequate for a rehabilitation program. . (b) Boarding Homes — There are many boarding homes in the community and they are very valuable to the person who cannot care for himself. The handicapped individual, however, requires certain specialized facilities and only a few boarding homes have been geared to provide these extra necessities, (c) Home Nursing Services (a) Public Health Nursing — This service is rendered by the Metropolitan Health where, under medical supervision, the public health nurse has varied activities related to rehabilitation. The nurses serve as co-ordina- tors in referring the patients to the member agencies which may be of help. (b) Bedside Nursing Care (i) The Victorian Order of Nurses provides a visiting nurse service rendering bedside care to all closses of patients in the community, (ii) Male Treatment Services — This service, available on a private patient basis, has recently been started. It deals primarily with genito-urinary, colostomy, and general male bedside care, (iii) Canadian Arthritis and Rheumatism Society (B.C. Division) provides a home nursing service to its patients limited primarily to taking of blood specimens, giving of injections, making of splints, applying traction apparatus and carrying out simple nursing orthopaedic duties. Page 393 (d) Physical Therapy Facilities — Most of the general and specialized hospitals have physical therapy departments. The Workmen's Compensation Board maintains a physical department. There are a number of privately operated physical therapy units in the community. The Canadian Arthritis and Rheumatism Society operates a mobile physical therapy unit for its patients throughout most of the province. (e) Occupational Therapy Facilities — With the exception of special groups, the occupational inadequate. No facilities are available on a private basikli (f) Rehabilitation Facilities (a) Western Society for Rehabilitation provides a well-developed program of physical, social and vocational rehabilitation for the orthopaedically disabled. The activities of the Canadian Arthritis and Rheumatism Society and the Cerebral Palsy Association are closely co-ordinated with the Western Society. (b) Workmen's Compensation Board provides all hospital and medical services to injured workmen. Rehabilitation services include physiotherapy, vocational counselling and guidance, job placement and training to those injured workmen who, as a result of their disabilities, may not return to their former occupations. (c) Assessment and Rehabilitation Unit, Department of Veterans' Affairs — A most successful rehabilitation effort on behalf of a special segment of the population, i.e. the entitled veteran, is provided. B. Vocational and Academic Training 1. Academic Training The Provincial Department of Education has a correspondence course unit which supplies free of charge correspondence courses for all "home-bound" persons desiring secondary education. Home-teaching facilities are available for children who cannot attend regular classes, through the Vancouver School Board. The teachers give instruction in courses up to Grade IX. Persons wishing to take advantage of the service must submit a request, through their family doctor, to the Metropolitan Health Committee which studies the applications and notifies the School Board office of those eligible. Children hospitalized receive academic training while in hospital from teachers provided by the Vancouver School Board. After discharge a report goes from the hospital to the school the child will attend. Teaching facilities are available at the School for the Deaf and Blind through the Provincial Department of Education. Children suffiering from cerebral palsy and having slight handicaps are prepared for attendance at regular public schools. The Vancouver School Board provides a teacher at the Western Society. Western Society has obtained the service of a spcialist in logopaedics and classes in speech therapy are given. 2. Vocational Training In 1952, the Vocational Training Co-ordination Act was passed and administered by the Federal Department of Labour through its vocational branch. Under the Act, various projects of training are carried on by means of agreements between the federal government and the provinces. Schedule "M" of the Act is being used to provide vocational training for certain handicapped unemployed persons. This training is given in vocational classes now operated in the city, and provision has also .been made whereby training on-the-job agreements may be entered into with individual companies. Page 394 Recendy, another agreement has been entered into under the Vocational Training Co-ordination Act. This agreement, Schedule "R", sets forth what are deemed to be the essential requirements and conditions of a special schedule for the training of severely disabled persons. Funds available for the operation of this new schedule are on a 50-50 matching basis between the federal and provincial governments. C. Recreational Training Recreational training is at present available to persons in such organizations as the Department of Veterans' Affairs, the Workmen's Compensation Board, the Western Rehabilitation Centre, the Children's Hospital, etc. D. Job Placement Some special groups who have rehabilitation programs and can meet the requirements of industry with fully retrained individuals make their placement primarily through personal contact with the employers. The National Employment Service maintains a division for special placements. In 1951, under considerable" pressure, a National Conference on the Rehabilitation of Physically Handicapped was called. The conference made recommendations, set up a National Advisory Committee, appointed a Federal Rehabilitation Coordinator supported by a central office in Ottawa in order to develop a rehabilitation plan. This committee made recommendations to the government and government grants are the outcome of these recommendations. The Rehabilitation Services Grant The Federal Government demonstrated its interest in the field of rehabilitation in 1953 by appropriating, through the new health grants, certain funds which would aid the province in the development of provincial rehabilitation programs. The purpose of this new grant is to fill in the gaps in the existing program! — to hedp develop suitable services for disabled persons not already provided for by government or voluntary agencies. Funds available under this grant may be used for three main purposes. 1. For the training of professional rehabilitation workers; 2. For medical rehabilitation equipment; 3. For rehabilitation health services. The Disabled Persons Act Allowances for disabled persons became effective in our province at the first of April 1955. The application forms are available at the Old Age Assistance office or at any branch of the Provincial Social Welfare Department. The means test is similar to that for the old age assistance and for the blind assistance. The total allowable income is $720 a year for a single person and $1200 a year for a married person. The pension is payable for those 18 years old and up. Persons must have resided in Canada for ten years. The disabled person has to be permanently disabled and totally disabled, as differentiated from unemployable, and if the person is capable of curative treatment or rehabilitation they are not eligible. The co-ordination agreement, which is provided as a special item in the Department of Labour assessment, provides for agreements with the provinces whereby the federal government would share in the cost, on a 50-50 basis, of establishing provincial co-ordination of rehabilitation services. Mr. C. E. Bradbury has been appointed Co-ordinator for the Province of British Columbia. In 1952 the Vancouver Council for Guidance of Handicapped, which had been active since 1946, became the Division for Guidance of Handicapped of the Community Chest and Council of Greater Vancouver. The purpose of this Division is to plan, to co-ordinate and develop rehabilitation programs and services within the community and to work in liaison with provincial and federal authorities. The Division has assumed the responsibility for surveying the present available rehabilita- Page 395 tion facilities, analyzing their deficiencies, and have made recommendations for a comprehensive and co-ordinated program for the Province of British Columbia in a Brief, "Recommendations for a Comprehensive Rehabilitation Program for the Physically Handicapped in the, Province of British Columbia." The Division provides consultative services to community groups concerned with all aspects of rehabilitation for. the physically handicapped. Through the medium of this year's program the Division is studying various community resources in rehabilitation. Study has been made of various community facilities for sheltered workshops and a Brief outlining the findings and recommendations of this committee will be presented shortly. THE HEALTH OF COLLEGE STUDENTS By FRANK HEBB, M.D., Physician and Deputy Director University Health Service and Hospital During classical times, the relationship of Health and Education was generally recognized. Both the Greeks and the Romans were of the opinion that physical fitness played as important a role in the education of the young as did the more conventional academic studies. However, with the fall of Greco-Roman civilization, this concept was entirely forgotten. For centuries — indeed, until modern times, the body was neglected while the educational efforts were focused on the intellect and the spirit — "The flesh was mortified and the spirit extolled" — so that one pictures the typical college man of the middle ages as an anaemic, frail and be* spectacled individual. Today, there is hope against a fading ignorance that marked the neglected physical and emotional welfare of the student of bygone days. One need not, therefore, emphasize the importance of health in a rounded educational programme, nor stress the indivisibility of education in its triple responsibility toward the body, the mind and the soul. Fortunately a great many university administrators, especially in recent years, have recognized their responsibility for teaching and providing health service to young people. This practical philosophy of health, had its beginning one hundred years ago at Amherst College, when President Stearns influenced the trustees to approve the addition of a new department to deal with the protection, preservation and promotion of the health of the students. In 1859, Dr. Edward Hitchcock was appointed as the first American College Physician and the medical care of special groups of people became a chapter in the history of medicine. Dr. Norman S. Moore, Clinical Director, Cornell University Infirmary and Clinic, refers to the college age as having an unique pattern of illness, just as characteristic in signs and symptoms as the medical disorders of other age groups. "College students," as one specialist put it, "belong to the 'not quite group' — not quite children and not quite adults." They have outgrown the paediatrician, yefc they react to ordinary infections just as young children do. They are trying desperately to grow up; yet their problems are not fully understood by the average general practitioner who- handles adult illnesses. The special care of this group, in their uneasy passage over the swaying bridge from late adolescence to maturity, has been called by one writer — the practise of Hebeatrics — after Hebe, the Goddess of Youth and growing maturity. First of all the Attitude of the College Physician: The majority of young people entering college are separated for the first time from home guidance in matters of health and from the valued medical counsel of a known and respected family physician. They do not have a free choice of physician, except within the limits Page 396 of the respective staffs. The student now carries his medical problems to a stranger. Regardless of professional honesty, medical astuteness, personal like or dislike, the physician must prove himself to be what some students may suspect he is not.*f He must show unusual interest in their slightest complaints and explain in great detail why this — and why not that. He must remember that, he is, at best, only a part time physician for but a brief period in the students' lives. Confidence is soon gained when close co-operation between the student's own doctor and the health physician is evidenced, or by acting as a medical agent of the family and the partner of the family physician. Above all, the college physician is a specialist on a campus team. There should be close co-ordination of counselling relationships between him, administrative counsellors and other faculty members, — and finally, the campus physician's task is a pleasant one — working amongst young, impressionable and interesting students from many parts of the world — living in a stimulating college atmosphere and at the same time, practising under all but ideal conditions. Turning now to the actual Care on the Campus: The primary function of a university health service is to serve the students. When the full responsibility of this service has been met, the personal health problems of the faculty, employees and their families should be considered, especially when the campus is a considerable distance from available medical service. Further, the health service should give first aid and emergency treatment to anyone on the campus whether student, faculty, employee or visitor. In the short space available one can only deal with certain facets of student health. On entering university, the physical examination should be more than a consideration of the usual clinical features. One would suggest a more leisurely interview and the determination of points of refinement in connection with problems of health, happiness and social adjustment. Lack of health care and education in these younger years is evidenced by physical defects, emotional and social maladjustments and health ignorance which individuals bring to university. With this entrance physical examination, the physician has an extraordinary opportunity to identify, diagnose and care for early manifestations of disease. He may contribute gready to the reduction of emotional maladjustment — he can be of much service in helping to reduce the number of students who fail because of their emotional problems. Along with physical and mental observations, the physician aids in screening students for professional schools, social service studies, athletics and physical education. Apart from a variety of accidents and physical defects, the commonest diseases found in this age group are: Acute upper respiratory affections, with not infrequent complications, infectious mononucleosis, skin diseases, measles, mumps, chickenpox, acute gastro-enteritis, acute appendicitis, anxiety states, psychosomatic and frank psychiatric problems. The student requires hospitalization more frequendy than others in the same age group since most of them are living away from home; the dormitory or rooming-house is a poor substitute for home care when acute illness occurs. Many university health services include surgical consultants, dermatologists and psychiatrists, who may be called upon to visit the health service or hospital once or twice a week. The special role played by the health service nurses cannot be overemphasized. Both doctor and nurse must function within the framework of the whole or total educational process and an infinite amount of patience is necessary. The nurse should never be the handmaiden of the doctor but an important member of the health team and an integral part of the campus. With anxiety states, students face a wide variety of problems. Most cases, acute and chronic, involve psychosomatic conditions, prepsychotic episodes or states, difficulties in sex and family relationships and social or scholastic difficulties of an emotional nature. How prevalent is mental distress? It is impossible to answer this; for, except by an objective and dramatic action, like abandoning an examination, assaulting a professor or committing suicide, the student only registers his distress if he comes and tells you. He may go to a friend, a professor or even a doctor outside. Page 397 Their unhappiness then, is statistically non-existent. Thus the importance of a student's pre-entrance history, which may indicate instability, along with the careful observation during the physical examination referred to above. It is estimated that about ten percent of the students who start at university do not finish the course. Most of these failures occur at the end of the first or second year; a small number repeatedly fail their final examinations. Since everyone who comes to university has presumably shown adequate intellectual ability in the entrance, examinations, it seems more than probable that distress, as one meets it clinically, is a major element in this failure. For the university physician, the severe cases,* paradoxically enough, are fairly easy to manage. Treatment, primarily, is for the qualified psychiatrist and it almost always involves interruption of studies and admission to hospital, on or off the campus. It is the adjustment problems, serious or mild, that call for long and patient management by the university physician. These are numerically the greatest. Some of the causes of distress are found in the unsure, the homesick, the victims of fancied injustice, the products of divorce and parental anxiety, those forced into college against their will and capacity because of family tradition, those who fear exposure to candid thought as they fear death — and one need not mention the time of oral and written examinations when anxiety, which may have so much power for good, becomes evil. Health Education: The health service participates in health instruction in many universities. Hygiene teaching, for example, is often most successfully carried by the medical staff members of the health service whose elinical interest has been supplemented by the realization of health informational needs of students. One of the most important tasks in health education is to teach the students to appreciate and secure medical attention when ill. Something surely can be done to overcome student ignorance and superstitions; they can be fortified against charlatans or quacks and inferior medical attentions. In the realm of hygiene, the most serious limitations in the teaching programme are due to inadequate training of teachers and other special groups, to problems of course content — placement of courses in the college curriculum and the tendency to stress the negative rather than the positive aspects of health. Health education should include basic courses in personal and community health, family health and mental health and special courses on the health problems of specific occupations for which students are preparing themselves. The addition of these courses seems to be an important and long overdue engagement in the batde of the curriculum in some universities. Research: There are responsibilities and opportunities for research by health services. Contributions can be made to the general increase in knowledge of individual health and group health characteristics in a selective environment, for example, the interrelations between the physical, mental and functional characteristics of individuals and groups within a specific living framework — the appraisal and prediction of the effect of college life on subsequent health fitness, occupational success and happiness — evaluation of the effectiveness of health service, public health protection, health education, physical education and counselling on the student group both individually and socially — evaluation of diagnostic and therapeutic procedures used by the health service in controlled and easily observable groups. Lasdy, university health services have come a long way and are fully conscious of how far they have to go. They have one major job to do — not to grow up, which they have done already — but to grow older. References: 1. Malleson, Nicolas, M.B., M.R.C.P., "The Distressed Student"—The Lancet, April 17, 1954: 824-5. 2. Moore, Norman S., M.D., "Student Medicine"—Health News: New York State Department of Health, volume 30, June 1953, No. 6. 3. Diehl, Harold S., M.D., and Shepard, Charles E., M.D., "A report to the American Youth Commission, American Council of Education, Washington, D.C, 1939. 4. Proceedings of the American College Health Association Bulletin—Volume 33: 1953. Page 398 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull I Vancouver President-Elect—Dr. E. W. Boak__ Victoria Immediate Past President—Dr. R. G. Large I | Prince Rupert Chairman of General Assembly—Dr. G. C Johnston _ -Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer_ jsji Vancouver Executive Secretary—Dr. G. G. Ferguson j ppi k Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bonnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F. Sparling Dr. P. M. McLean Kootenay Dr. S. C Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall Dr. P. 0. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C. Poole Dr. N. J. Blair Chairmen of Standing Committees Constitution and By-laws Dr. Carson Graham, North Vancouver Finance ..___=_: Dr. R. A. Palmer, Vancouver Legislation Dr. E. W. Boak, Victoria Medical Economics Dr. P. O. Lehmann, Vancouver Medical Education Dr. M. M. Weaver, Vancouver Nominations <$■ Dr. F. A. Turnbull, Vancouver Programme & Arrangements - Dr. W. M. G. Wilson, Vancouver Public Health Dr. G. R. F. Elliott, Vancouver Public Relations I Dr. A. W. Bagnall, Vancouver Chairmen of Special Committees Archives Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism ^ Dr. J. A. Traynor, Vancouver Cancer - £§£ Dr. Roger Wilson, Vancouver Civil Defence _fe_ Dr. John Sturdy, Vancouver Ethics _ Dr. Wallace Wilson, Vancouver Hospitals Dr. G. C Johnston, Vancouver industrial Medicine ; Dr. G. B. Helem', Port Alberni Maternal Welfare Dr. A. M. Agnew, Vancouver Membership 1 : Dr. N. J. Blair, Vancouver Nutrition =■ Dr. J. F. McCreary, Vancouver Pharmacy ".~rfc Dr. B. T. Shallard, Vancouver Rehabilitation Dr. W. J. Thompson Each Saturday the C.M.A.-B.C. Division Public Relations Committee contributes to a column in both the Vancouver Province and the Victoria Colonist. The subjects are educational and informative with a view to better understanding between the public and our profession. The following article, written by the Executive Secretary, is republished herewith so that all doctors will know what information has been passed to the public on this question of disputed accounts. Probably the most frequent cause of misunderstanding between doctor and patient is over an account for services rendered. As a better understanding of the financial implication of medical service is reached between patient and doctor, the number of problem cases are becoming less and less. This article is written to help all to understand the problem, its sources and methods of resolution. In a chatty column in the Winnipeg Tribune recently, the results of a public poll in the State of Minnesota were recorded. This had to do with the opinions of the people of that State toward their doctors. The following points were noted: "Two-thirds of the people consider doctors' fees reasonable. "More than four out of five are satisfied that doctors take a personal interest in their patients and their troubles. Most of them are confident that if they called a doctor to make a home visit, he'd come. Page 399 "87 percent believe doctors are better trained nowadays than they've ever been." It was also noted that by and large, little difficulty of any kind arose where the patient had the advantage of a personal medical advisor. Call him 'family doctor' if you like. He might be a general practitioner or a specialist. Certainly, each family needs to have "their doctor" to whom they can turn for medical advice in any time of need. Lack of a personal family physician, then, is the first cause of difficulty. What should you do then about an account you have received from your doctor which is not understood or which you feel is not correct? The first thing to. do is to speak to the doctor who did the work and and have him explain the account. Some accounts may be itemized for you, to show you the different factors that go* into its makeup. If the explanation seems sound and your difficulty is in the realm of particular personal circumstances, then the doctor will welcome the interview in order that he might understand your problems in the matter. It can very easily be understood now that there is no difficulty in a discussion of this kind when your doctor acts as your trusted family advisor. But sometimes this first step fails to resolve the difficulty. The account may then be paid but a feeling of ill will remains. Or the account may be ignored, and after a time the doctor will move to force collection. This also is unfortunate but the courts do have an interest in these matters. It is their responsibility to be certain that a service has been requested and rendered and that the account follows the usual custom. It is to relieve people of as much of this trouble as possible that the Medical Association has interested itself in this problem and has arranged within the Association to receive instances where patient and doctor have been unable to resolve the difficulty. The committee in British Columbia is called the Mediation Committee of the British Columbia Medical Association. It is somewhat similar to committees that have been established in other provinces and in some states of the United States of America and sometimes called a 'Grievance Committee'. We do not particularly like the name Grievance Committee in this province and prefer to use the title 'Mediation Committee'. r|l The work done by a doctor is of a service character and cannot be measured easily by units such as might occur with merchandise. Charges for this service, however, fall into a pattern and are based on the type of consultation, visit in hospital, home or office, or procedure such as an operation. There is a great variation in the capacity for work and ability of individual doctors and there is a great variation in the kinds of disorders for which they are consulted. Thus, the method of charging by visit or consultation is not always absolute and the personal feature of each doctor-patient contact sometimes enters into the account for services rendered. For this reason, the short request to the Association, such as 'I think I am being overcharged, what is the account that I should have received?' is not a question that can be answered fairly without some investigation.^Indeed, a thoughtless answer to indicate 'yes' or 'no' might prejudice the first step in the resolution of a difficulty, which is discussion between patient and doctor themselves. The Mediation Committee is brought into play when a patient sends the account to the Association with a letter oudining the circumstances of the service rendered as he saw it, and a request to have the matter looked into. It must be clearly understood that the commitee will find it necessary to enquire from the doctor concerning the service rendered, as he saw it. The committee, as experienced practitioners, will be able to review the matter and offer a solution. It must also be recalled that accounts that are protested oh their first receipt would seem to the committee to be more legitimate protests than those which arrive two or three years old, after the doctor has taken some steps to collect. Most doctors welcome the opportunity of knowing about their patients' problems and endeavouring to arrive at a mutually satisfactory solution. Most doctors today also appreciate the opportunity to discuss their accounts, especially Page 400 before heavy commitments are made. In this way the patient will know what is involved and will be able to make plans accordingly. No reference has been made in this discussion to that other type of patient- doctor problem which involves questions of careless or negligent work. These fall into the province of the governing body of the medical profession. This body is known as the College of Physicians and Surgeons of British Columbia. The offices of both the Medical Association and the College of Physicians and Surgeons are maintained in the Academy of Medicine Building in Vancouver. it ii it ■& The Hobby Show of the Canadian Medical Association B.C. Division There will be another Hobby Show during the Annual Meeting of the British Columbia Division, which is being held in the Hotel Vancouver October 4-7. All doctors who have hobbies to exhibit are kindly requested to do so. Although there were excellent displays in past years, many physicians were too reticent to display their work. Any hobby whatsoever is very welcome, whether they be paintings, etchings, photography, color slides, woodwork, metal work, model building, etc. Those physicians from. out of town are requested to send their work to the Vancouver Hotel by Monday, October 3, in care of the Chairman of the Hobby Show. Those in the city please bring them to the Bell Captain of the Hotel on the same date. They are to be collected the following Friday night or Saturday morning. The out of town exhibits will be returned by post. It would gready facilitate matters if those intending to send exhibits would let the Chairman know as soon as possible so that adequate space can be arranged. A. C. GARDNER FROST, Chairman, Hobby Show. Jk nnouncemen t ST. PAUL'S HOSPITAL STAFF Presents a three-day course in — * SURGERY $■ OBSTETRICS ^ MEDICINE ^ PAEDIATRICS for general practitioners Visiiing Lecturer: Dr. MARTIN M. HOFFMAN of Montreal OCTOBER 27th, 28th, 29th, 1955 Page 401 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H. Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia THE BASIC IMMUNIZATION PROGRAM J|p|: OF THE HEALTH BRANCH In the field of immunization, as in so many other medical fields, research has been pursued actively over the past few years. As a result, there have been numerous papers on the subject in the literature and it has been difficult for the practising health officer, public health nurse or physician to keep abreast of these newer advances and sift out those of established value which should be incorporated in our present activities. It is the purpose of the present paper to attempt such a comprehensive review of the medical literature with the object of integrating the newer thinking and procedures into our immunization program. At the present time, there is a wide variety of communicable diseases against* which active and /or passive immunization procedures may be considered effective, and a question which often arises is that of deciding against which of these diseases a basic immunization program shall be developed. Speaking in broad terms, the basic terms, the basic program should be restricted to those diseases: (1) which are or: were prevalent in this country; (2) which are serious to the patient in terms of complications, sequelae or death, and (3) against which there is an immunizing agent of established value. So far as Canadian experience is concerned, three infections — diphtheria, pertussis and smallpox stand high on- the list of those diseases satisfying all three of the criteria listed (Table A). Reported Cases of Diphtheria, Pertussis and Smallpox, Canada* 1924 - 1954 Av. Source Diphtheria Pertussis Smallpox Year Cases Deaths Cases Deaths Cases Deaths 1924-28 8,152 1,020 6,781 978 2,327 26 1929-33 5,850 600 11,627 715 910 7 1934-38 2,584 311 17,426 720 58 3 1939-43 2,771 266 18,393 516 49 — 1944-48 2,198 207 9,931 285 1 — 1949 806 84 7,961 213 j — — 1950 421 52 12,182 306 — — 1951 253 37 8,889 202 — — 1952 190 26 8,520 142 — — 1953 132 15 9,387 134 — — 1954 208 + 11,600 + — + ce: Summary of Notifiable Diseases, 1924- 52, Reference Paper No. 45, D.B.S. Annual Report of Notifiable . Diseases, 1953 and 1954, D.B.S * Exclusive of Y ukon and N.W.T. -j- Figure not yet avai table. Diphtheria was, and still is, prevalent in Canada but whereas for the five-year period 1924-28 there were on the average over 8,000 cases per year, in 1954 only 208 cases were reported. With this sharp reduction in the incidence of diphtheria, there has been a corresponding fall in the number of carriers and a diminishing rate of casual exposures in the community, two factors which formerly operated to maintain Page 402 the immunity of the general population against this disease. With the low carrier rates presently prevailing, the stimulus necessary to keep our population immunized against diphtheria must be provided artifically, and as early in the life of the individual as possible. Pertussis, likewise, is a severe and prevalent disease to which most new-born infants are susceptible. It is estimated that approximately 10 percent of all cases and 64 percent of all deaths from pertussis in the United States occur in infants (Dauer, 1943) so that this age-group should receive early protection. Smallpox has not been seen in Canada for a number of years now but with the painful lessons learned from past experience and from the recent experiences of other areas, e.g., Seatde-King County 1946; New York City, 1947, we can hazard no risk in permitting our population to become susceptible. Tetanus, against which protective immunization can be readily carried out in conjunction with that against diphtheria and pertussis (see "multiple antigen preparations") is also included in our basic immunization program. Although a rather uncommon infection, it is a serious disease for the patient when it does occur, while tetanus toxoid provides one of the most effective immunizing agents yet developed. 'Tetanus is one of the diseases which can and ought to be abolished. It is well- known that, thanks to active immunization of servicemen, the U.S. Army Medical Services had to deal with only 12 cases of tetanus out of over 2,700,000 hospital admissions for wounds and injuries in World War II. Of these men only 4 had been properly immunized and of the latter only 1 died." (Edit., Canad. M.A.J., 71: 287, 1954). In summary, therefore, the basic immunization program of the Health Branch aims at conferring protection at the earliest possible age and on each and every child, against four infections — diphtheria, pertussis, smallpox and tetanus. This aim is accomplished by means of a primary series of injections given in infancy, followed at intervals by booster or recall injections to maintain immunity at high level. There remains only the questions as to when, and how these immunizations should be accomplished. The remainder of this paper will be devoted to a consideration of these questions. Remembering, however, that on occasion individuals may require protection by active or passive immunization for the prevention or treatment of other infections, there will follow in later editions of the Bulletin a listing of diseases against which it is possible to confer protection by these procedures. Age for Immunization In determining the elective age for immunization a number of considerations are involved:— (1) It is well known that babies up to a few months old are immune to certain prevalent infections, e.g., measles. This resistance is dependent upon the presence of antibodies transmitted through the permeable placenta from the mother. Such passive immunity of infants lasts longer than the 2-4 weeks*usual in adults, e.g., against measles it lasts for periods up to 4 months. (2) As the child gets older and especially when this passive immunity is lost, the child is both susceptible to these infections and also at increased risk, e.g., from siblings, playmates, school-mates and adults. (3) It is desirable, therefore, to confer immunity (by artificial methods) against these infections, at the time when, or shortly before, this maternally- transmitted immunity is lost. Important in this connection is the fact that certain studies have demonstrated that many infants in the first few weeks of life do not respond too well to antigenic injections. Thus McKhann and Kapnick (1938) have shown that very young children develop diphtheria antitoxin more slowly than older children, and the production of antibodies Page 403 after typhoid vaccination is also less marked in these vounger babies (Halber et al, 1929). (4) Two limiting factors appear to be involved in this relatively poor immune response of young infants—(a) the mesenchymal tissue concerned with antibody production must have reached a stage of biological maturity (the advent of which is genetically determined) in which it can respond to antigenic stimuli, before active immunization can be effective; and/of (b) there is interference by maternally-transmitted antibody with the babies' response to the injected antigen (Peterson and Christie, 1951), (Osborne et al, 1952). (5) It would appear, however, that the limiting factors mentioned previously are of academic interest rather than of any practical importance in determining the elective age for immunization, for the following reasons:—(a) Obviously the baby is immune while carrying maternal antibody, and (b) the delayed type of immune response found when very young children are immunized is compensated for by the fact that their antitoxin levels rise sharply when a single booster dose is given between 9 and 18 months. Again, recent work on combined vaccines has shown that such a combination exerts a more pronounced antigenic stimulus in young babies (Bell, 1948); (Fleming et al, 1948). (6) From a practical point of view, therefore, consideration (2) outlined above is the most important in determining the elective age for immunization. The fact that pertussis is still a severe and prevalent infection to which* most new-born infants are susceptible points to the need for early protection against this disease at least. Although various immunization schedules have been proposed, the recommendations of the Committee on Immunization and Therapeutic Procedures for Infectious Diseases of the American Academy of Paediatrics may be regarded as authoritative. They recommend three monthly doses of slow-absorbing alum- containing DPT (see "multiple antigen preparations") starting at the age of three months and with the first booster dose one year after completion of the primary series. Report No. 61 of the World Health Organization, on Diphtheria and Pertussis Vaccine, concurs in this opinion. Mutiple Antigen Preparations Within the past few years, there has been a tendency towards the production of multiple antigen preparations which gready simplify the routine immunization program. As early as 1939, Ramon demonstrated the compatibility of mixed antigens while more recendy it has been shown that such combinations exert a more pronounced antigenic stimulus, particularly in young babies (Bell, 1948; Fleming et al, 1948). The Committee on Immunization and Therapeutic Procedures for Infectious Diseases of the American Academy of Paediatrics recommends use of multiple antigen mixtures and cites the following advantages:—(1) the more prolonged antitoxic immunity produced by precipitated or absorbed mixtures, (2) their much greater effectiveness as immunizers against pertussis in early infancy, and (3) their less likelihood of producing systemic reactions because of the lower protein content and the slower absorption." One might also add—(4) reduction in the number of injections required. In connection with the above, it should be pointed out that while precipitated toxoids are widely used in other countries, it has always been the custom in Canada to use ordinary formal toxoids (so-called 'fluid' toxoids). There is some evidence to show that mixed antigens, when alum-precipitated are more apt to give rise to local reactions, to some sterile abscesses, and to other undesirable complications. In Page 404 addition, evidence from the United Kingdom and Australia rather tends to "incriminate the tissue damage caused by alum-precipitated antigens which are usually given intramuscularly as the factor responsible for post-inoculation poliomyelitis. (Grant, 1953), (Peach and Rhodes, 1954). The following are the antigen mixtures commonly used in Canada: — (1) Diphtheria toxoid and pertussis vaccine (DP). (2) Diphtheria toxoid, pertussis vaccine and tetanus toxoid (DPT). (3) Diphtheria toxoid and tetanus toxoid (DT). (4) Typhoid—paratyphoid vaccine (TAB). (5) Typhoid—paratyphoid vaccine and tetanus toxoid (TABT). (6) Typhoid—paratyphoid vaccine with tetanus and diphtheria toxoids (TABTD). Boosters No immunizing procedure confers permanent protection so that in every instance booster or recall injections are required to maintain immunity at high level. Thus it has been demonstrated that once a person has had a satisfactory primary immniza- tion against diphtheria satisfactory antitoxin levels will persist for 3-4 years. Moreover, once the person has been so immunized, it is never necessary to repeat the initial series again since very small amounts of antigen are sufficient for restimulation. Even the small amount of antigen used in a Schick test control (about 1/1500) of the amount contained in a 1 cc. dose of toxoid) may convert a positive Schick test to a negative one. Therefore, in children immunized in infancy, it would seem proper to give 0-1 cc. of diphtheria toxoid (in combination with tetanus toxoid) at intervals in order to maintain antitoxin levels. A fairly high degree of protection against pertussis exists for 3-4 years following primary immunization (Kendrick et al, 1946) and periodic boosters are recommended to maintain immunity during the preschool years at least. Children of school age (6 and over) generally do not require routine boosters of pertussis vaccine since frequent contact with the organism generally supplies sufficient stimulus for maintenance of immunity. Again, in the previously immunized, the disease will probably be mild and the mortality from whooping cough in older children is small. Further, the reactions caused by pertussis vaccine in older children may detract from the 'diphtheria immunization program. Protection against tetanus is much more reliable than that against diphtheria orpertussis for it has been shown that severe personnel actively immunized against tetanus maintain protective titres for an appreciable number of years. In these individuals, a booster dose of toxoid will produce a rapid rise in antitoxin titre within a few days. It would appear that a satisfactory immunity can be maintained by giving a booster dose of tetanus toxoid at approximately 5 year intervals. In the event of injury and if more than five years have elapsed since the last routine booster injection, it is recommended that a minimum of 1,500 units tetanus antitoxin be given. Page 405 For a modern treatment ♦ ♦ ♦ The modern concepts of vaginal physiology have led us to develop an objective and rational treatment for several pathological conditions which have so far resisted the most varied not to say the most illogical types of therapy. INDICATIONS Vaginitis (trichomonas, monilia, and mixed flora. Pruritus and leucorrhoea. ISSUED Vaginal suppositories: Box of 12 Cream: Tube of 3 ounces with applicator. COMPOSITION Sodium Propionate ; 20% Propionic Acid j 1 % Diiodohydroxyquinoline 7.5% Effective acid pH ANGLO-FRENCH DRUG CO. LTD., Montreal 18 CAMPBELL & SMITH LTD. 820 Richards Street Vancouver 2, B.C. TAtlow 7364 cLjTSjatujs, iJ^zintinq Page 406 Sometime ago, the Bulletin published a delightful memoir, if one may call it that, of the life and practice of Dr. Dyer of North Vancouver — in two halves, which fitted together make a complete retrospect of "Fifty years of Medical Practice." This journal received literally scores of enquiries about this history—largely because through inadvertence, Dr. Dyers name was omitted at the head of the second part. But the large number of enquiries showed the intense interest that was taken by a very large number of readers — and the interest was all favourable, and we feel, well deserved. We owe a debt of gratitude to Dr. Dyer for his vivid picture of a very vital fifty years in the history of medicine. As one looks back, and a few of us can, over the past fifty years of medical practice, we find ourselves wondering what history will record as the greatest achievement of medicine in that time; for there have been many great achievements in fifty years. There are of course, the great advances in surgery — far outrunning all that has gone before — and yet, without two discoveries made in the years 1850-1900, antisepsis and anaesthesia, these would have been impossible, with them all things have been made possible, and the end is not yet. With all due deference to surgery, this is not, we think, the crowning achievement. Well, there is internal medicine, insulin, liver, antibiotics, cardiac study — how many millions of lives have not these things saved, both in the past, and in the future? But all of these things are based on the work of the great pathologists and physiologists and chemists and bacteriologists of the last part of the last century. So it is not medicine. These same limitations apply to paediatrics, to all the other specialties. We once heard an eminent paediatrician, Cushing of Montreal, say that in his opinion the greatest advance in medicine in the yast fifty years was the improvement in infant feeding, which has converted a dreadfully high infant mortality into one which is almost unsurpassbly low. One remembers the old proverb "there is nothing like leather." Of course, there are other directions in which growth has been almost unbelievable. One of which we think is the modern laboratory. Consider our almost complete lack of laboratory aids fifty years ago — and compare with that dark age the modern laboratory, both Public Health and Hospital. Think of the work being done every day as a matter of course on biochemistry, on fluid balances, electrolyte balance — in burns, in many other conditions. Think of the enormous gain to the community of the public health laboratories, the way in which they safeguard us all. One could go on indefinitely, with neurosurgery, with psychiatry, with the enormous growth in research. But if we had to prophesy, we think we would give the palm to those men who have brought us back to a realization of the fact that soul and body are one and indivisible, at least as far as medical men are concerned; the men who more and more, as the days go by, have seen clearly, and are bringing us to see, the great truths of psychosomatic medicine — the fact that, barring accidents and infections, the great bulk, perhaps the greatest part by far, of the ills that beset mankind, are disease, not only of the body, often not mainly of the body, but of the whole man, his mind, his body and his spirit. They are the products of stress, of fear, of insecurity — we call them arteriosclerosis and neurodermatitis and coronary disease, and duodenal ulcer, and neurosis, and senility - but not all the drugs in all the pharmacopaeias will ever cure them; and we have laboured long and in vain along that line. But the men of vision, the Selyes and the others, have put their finger on the latch of the door, and are gradually pulling it open for us, to see the Page 425 truth within. And when we have mastered this problem, we shall have paved the way for a new phrase "Life begins at 100." But, to do this, we medical men must learn a new therapy — and for us, it is going to be not an easy one to learn. We have to cease looking at illness as merely a bodily matter, a defect or an injury or a strain of the bodily structure — we have to look at the spirit — the personality of the man or woman who comes to us, bruised and beaten by life; and demanding our help. What success the old "family doctor" had was largely due to the fact that often unknowingly he did just this — he gave courage and sympathy and spiritual help, where often this was all he had to give — but his work bore fruit. And with all our advances in the science and art of medicine, we have come back by a long and roundabout road, to a realization, backed by logic and reason and scientific research that the medicine of the future has got to be a much bigger thing than it has ever been, since it has got to take all of mankind for its study. The poet Pope saw this many years ago. "The proper study of mankind is man." This, we feel, is the great achievement of our time — since it opens the way to great new possibilities in the treatment of disease, the lengthening of life, and, greatest of all, the betterment of life — happier and more healthy living. Monday to Friday -||__ 9:00 a.m. to 5:00 p.m. Saturday l M- It 9:00 a.m. to 1:00 p.m. RECENT ACCESSIONS: Morals and Medicine by Joseph Fletcher. Princeton University. 1954. The Liver and Its Diseases by H. P. Himsworth. 2nd edition. Harvard University Press. 1950. Surgery of the Elbow by Frederick M. Smith. C. C. Thomas. 1954. Myocardial Infarction by Irving S. Wright, Charles D. Marple and Dorothy Fahs Beck. Grune & Stratton. 1954. Public Relations in Medical Practice by James E. Bryan. Williams & Wilkins. 1954. The History of Medicine by Charles Greene Cumston. Kegan Paul. 1926 Leg Ulcers—Their Causes and Treatment by S. T. Anning. Churchill. 1954. Clinical Measurement of Uterine Forces in Pregnancy and Labour by Reynolds, Harris and Kaiser. Blackwell. 1955. Childbirth Without Fear by Grantly D. Read. 3rd edition. Blackwell. 1955. OF INTEREST TO ORTHOPODS Jt The long awaited second volume of Sir Reginald Watson—Jones' 4th edition of "Fractures and Joint Injuries" has now been received in the library where it is available on loan to all members. Page 426 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull '. _■„ Vancouver President-Elect—Dr. E. W. Boak 11| __?_____£;: 1 Victoria Immediate Past President—Dr. R. G. Large Prince Rupert Chairman of General Assembly—Dr. G. C Johnston 1 __ Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer /: \_|-f"'" —-—- \ Vancouver Executive Secretary—Dr. G. G. Ferguson 1^ Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bonnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F. Sparling Dr. P. M. McLean Kootenay . Dr. S. C Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall Dr. P. O. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C Poole Dr. N. J. Blair Chairmen of Standing Committees Constitution and By-laws Dr. Carson Graham, North Vancouver Finance i Dr. R. A. Palmer, Vancouver Legislation Dr. E. W. Boak, Victoria Medical Economics Dr. P. O. Lehmann, Vancouver Medical Education _Dr. M. M. Weaver, Vancouver Nominations Dr. F. A. Turnbull, Vancouver Programme & Arrangements * Dr. W. M. G. Wilson, Vancouver Public Health j Dr. G. R. F. Elliott, Vancouver Public Relations-iSs, Dr. A. W.- Bagnall, Vancouver Chairmen of Special Committees Archives -. j - Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism |—1 Dr. J. A. Traynor, Vancouver Cancer i - „ Dr. Roger Wilson, Vancouver Civil Defence____ Dr. John Sturdy, Vancouver Ethics § Dr. Wallace Wilson, Vancouver Hospitals - Dr. G. C. Johnston, Vancouver Industrial Medicine Dr. G. B. Helem, Port Alberni Maternal Welfare -Dr. A. M. Agnew, Vancouver Membership ! Dr. N. J. Blair, Vancouver Nutrition Dr. J. F. McCreary, Vancouver Pharmacy - -Dr. B. T. Shallard, Vancouver Rehabilitation Dr. W. J. Thompson The Annual Convention, Hotel Vancouver, October 4-7 inclusive, 195 5. The plans for the Convention have been proceeding apace and the programme can now be viewed with reasonable certainty. You will find the four-day programme published in greater detail in the centre of this Bulletin. The policy has been established to set a Registration Fee for our Convention. This year it. is set at the nominal figure of Two Dollars ($2.00). The General Assembly will meet in Salon A, all day Tuesday, October 4, under the chairmanship of Dr. Gordon Johnston. The Assembly will be preceded by a breakfast meeting of the Nominating Committee. Scientific Session. There will be three full mornings of scientific papers and two afternoons taken up with round tables. A great deal of thought has been given to the subject matter of these round tables and you will be pleased with the discussion The morning papers are in many instances being presented by our own members, but there will be two papers each by three visiting speakers, Dr. Howard Odel from the Medical Department, Mayo Clinic, Rochester; Dr. Robert Mustard, a surgeon from Toronto, and D(r. Douglas G. Cameron, an internist from Montreal. In addition to these scientific papers, we have asked Dr. T. C. Routley, the President of the Page 427 C.M.A., to occupy one space on Friday in presenting to us the details of the World Medical Association. This is an invitation extended to Dr. Roudey by our President, since Dr. Turnbull feels that every member should be fully aware of the part the World Medical Association plays on our behalf in contradistinction to the much more publicized World Health Organization, which is an organization of governments. Hobby Show. Dr. Gardner Frost is once more setting up an excellent Hobby Show and his invitation is repeated elsewhere in the Bulletin for your guidance in submitting your exhibits. Entertainment. Thursday afternoon has been set aside as a time for relaxation and for those who do not golf, arrangements are being made to go for a yacht trip or fishing or both, if you wish. After the afternoon in the fresh air, you may look forward to a relaxing time at an informal supper dance in the HMCS Discovery. There will be only one stated luncheon and it is for members only. "The Association Luncheon"—Wednesday noon. The guest speaker will be Dr. T. C. Roudey, the President of the C.M.A., who will give his Presidential address. Ask for your ticket when you register on Tuesday or Wednesday. There will be no charge. The Annual Dinner will be held in the Hotel Vancouver on Friday night, October 7. While this is our one formal affair, it must be made clear to our newer members that if they do not have a dinner jacket they are most welcome in any event. The guest speaker will be Dr. Peter Larkin, eminent Chairman of the International Commission on Fisheries. His subject will be very informative and interesting to us in British Columbia where we live so close to that primary industry. Tickets for the dance at HMCS Discovery and the Annual Dinner at the hotel will be on sale at the registration desk. . Evening meetings. Arrangements are being made to find space for the seve_d sections of the Association to hold their meetings on Monday evening. You will have the information about this meeting directly from your section. On Tuesday evening there will be the Annual Meeting of the College of Physicians and Surgeons. On Wednesday evening there will be the Annual Meeting of the Canadian Medical Association, B.C. Division, immediately followed by the first Annual Meeting of the Medical Services Incorporated of B.C. This M.S.I, meeting will be the first opportunity for the Board of Directors to report to its members and will see the newly elected Board of Directors launched in their new task. The Thursday evening informal dance at HMCS Discovery has already been mentioned and the Convention will close with the formal dinner on Friday. The ladies have been working hard to make certain the visiting wives of members are adequately entertained and there is a message to the ladies published in this Bulletin. To The Ladies Wives accompanying their husbands to the meeting of the Canadian Medical Association — B.C. Division in October at Vancouver are assured a full programme of entertainment. The ladies' committee, with Mrs. Frank Turnbull as chairman, is looking forward to welcoming you and making your visit a really enjoyable one. Registration will take place at Hotel Vancouver on Wednesday morning, October 5, from 9 to 11:30. The same day a reception and coffee party will be given at Point Grey Golf Club from 12 to 2 p.m., where registration will be continued. Thursday, October 6, out of town ladies have been invited to tea at the home of Mrs. G. F. Strong from 3 to 5 p.m. That evening an informal buffet dinner dance will be held at HMCS Discovery beginning at 7 o'clock. Friday evening, October 7, a dinner will be held in the Banquet Room, Hotel Vancouver. Dress is formal, but you will be welcome in any event. Page 428 When the doctors receive their programmes early in September there will be j included a brighdy colored card especially for the wives. Be sure and ask your husband for this card which concerns the programme of event for the ladies. You [will be asked to mark the functions you wish to attend and return the card to the address on the reverse side. For the full three days of the meeting there will be hostesses to advise you about >olf, shopping, baby sitting, tours, etc. October isn't so very far away. Start planning now! Mrs. Donald S. Munroe Publicity Chairman. The Hobby Show of the Canadian Medical Association B.C. Division There will be another Hobby Show during the Annual Meeting of the British [Columbia Division, which is being held in the Hotel Vancouver October 4-7. All doctors who have hobbies to exhibit are kindly requested to do so. Although there were excellent displays in past years, many physicians were too reticent to [display their work. Any hobby whatsoever is very welcome, whether they be paintings, etchings, photography, color slides, woodwork, metal work, model building, etc. Those physicians from out of town are requested to send their work to the [Vancouver Hotel by Monday, October 3, in care of the Chairman of the Hobby Show. Those in the city please bring them to the Bell Captain of the Hotel on the same date. They are to be collected the following Friday night or Saturday morning. The out of town exhibits will be returned by post. It would gready facilitate matters if those intending to send exhibits would let the Chairman know as soon as possible so that adequate space can be arranged. A. C. GARDNER FROST, Chairman, Hobby Show. FOR SALE X-Ray, Heavy Duty Table, General Electric 200 M.A. - Model No. 39, Serial No. 201674, with Head, Tubes, 2 Fluoroscopic Screens and 2 cones, less transformer and control unit. Changer, Cassette, Floor Mounted Type, Horizontal Picker Style No. 1453. CROWN EQUIPMENT CO. LTD., 1011 Bleury St., Montreal 1, Que. ESTABLISHED GENERAL PRACTICE IN VANCOUVER FOR SALE OR RENT Owner specializing. Phone: TAtlow 7718 or CEdar 7626 Page 429 (9 Z H ui in Z < in O _2 > UI - _ CQ C_ z_ O A- H < U O ui 1/1 < u 2 n 10 c c_ « g 3 ° _?— _2 c _, rj -rf _ 1 «^bo v__ _> E ° O (A fli _ C £< § i"_l |_£ o» . _ c c en •™ K flj (0 Q.— C © OiH E z . d ooo ooo •• • • •• CO 0> CO < 2 < z ca O U o H < a <u > o CO 1/5 3 -c _£ I 4- >- K _j < _ • It* ° s ra E 'ro _£ U (/i QJ u ro CD £ 4— ro O a E o U c - c OJ 4— ro Q. _£ <" | 5S I OJ o._ 0) TJ o TJ ro 4— '/> g 4— ro "u o co c/i < _ U ro - roTJ a ._ q/ ro JEc/) <A co i; - OJ oj »_ £_ ZQ ro ;r w ro. , ._ ^ P-£ 3 — *- _0 £Q O - _ _ ^^ -co J2 . o 3 _Q Qi •_ JC _ 3 -!► *" £Z o >--e __ O i: *rt " © "B C_JS ■.«/> Z> oQ ltbO HO |Z __ :_ _ £ _ _5: o __ _3 OJ c o _£__ 6__ o 5 O) — OJ 3 O _•_. ro _: I ro c ro -> to OJ CTJ -o ~_ _ "2 ro oj ro C_ ^ oj O _ - T *- 3 ro o (/) 4- 2* .2. 4- _ i- CO OJ Si — O *" c_ ._ en r _ OJ o > OJ _l £ ro u U c o v> l_ ro jC m U 3 O o Q 4- c OJ __ E OJ CD OJ CO ro to c OJ ro ti __Q Z<Q _j Qoo _tb H _c < * ui _ u o Z -° Q £ UJ u x to O u ro ro OJ > o .is co « _^ < o a. 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U ro Eg CQ _ lo ro 1. ro u ro c £ OJ -Q E OJ 5 CO 1. 3 CO CO ro > "ro sz U (/> _0 I/) III O O z fi_ ui H OJ c £ £ g CO > Q (J CQ ro ^■ 3 s m < u O) CO ._ £ o o {J CQ t/l z o Co uo ui i/> Z z 111 > Q OJ > o i_ (J cu (A £ £ Q Q CO* +- O OJ 5 3 co_L £ >- P ro OJ £ O OJ J_ CJ £ 3 >s _0J 4- 3 O Qi U I-' ro _) oj °9 O I- U .2 ■ST< _q •- I _ro X X I ro o o 4- oj _. _;,/ _B 2 _?* i « OJ c_ ro |5 <_ ro to 5-5 co co ro 3 o o VQ £ u o3^ 0J K " S 4-TJ _ TS OJ 3 to OJ u <<JCL E i o o en o | ro u% m _ro OJ 4— _: j i TJ £ 3 O i_ CO ro .. £ £ -o !5 S-C £ - Q- ._ "O E ro ^ >.-C E _ £ t ° of of ^ Q L L k' L QQQQ _ E OJ o £ g to > b U CQ < u CO :_ CO CO £ £ OJ OJ OJ OJ 5 2 "ro "5 3 3 £ £ £ £ < < Page 430 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H., SSi Deputy Minister of Health, Province of British Columbia. A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia RECOMMENDED ROUTINE IMMUNIZATION ll PROCEDURE SMALLPOX IMMUNIZING AGENT' :§ lpl| ' Smallpox vaccine use I ■ 'm Routinely in infancy (preferably at about six months of age) Indicated also for (a) residence in, or travel to, endemic areas (b) exposure to smallpox (c) epidemic, present or threatened (d) occupational exposure ADMINISTRATION (1) cleanse skin with acetone or ether and allow to dry |1§ (2) vaccinate by single scratch or multiple pressure technique (3) dressings should not be applied (4) in eases of doubt or failure (especially in infants) revaccinate in one month's time (5) in repeated failure, vaccinate in a distant site to circumvent possible local immunity (Steigman) CONTRAINDICATIONS (a) eczema in patient or siblings (danger of local or generalized autoinoculation) (b) septic skin or eye conditions (danger of local or generalized autoinoculation) (c) fiist trimester of pregnancy (? effect on foetus during organo-genesis) REVACCINATE (1) routinely every 5 years (2) when indications present (see above) NOTE: Smallpox vaccine should be kept refrigerated at all times and potency should be checked by ensuring that from each unexpired batch, a certain number of typical "takes" are being obtained. D1FHTHERIA IMMUNIZING AGENT Diphtheria toxoid. Should be administered as triple antigen (DPT-diphtheria and tetanus toxoids with pertussis vaccine) for primary series in infants and preschool children. Combined diphtheria and tetanus toxoids may be used for immunization of adults (see below) and as a booster dose for children over six, who have received DPT as a primary series. Page 431 USE Routinely as DPT in infancy (preferably commencing at three months of age) Indicated also (a) residence in, or travel to, endemic areas (b) if previously immunized, and exposed to diphtheria (booster) (c) if previously immunized, in presence of an epidemic (booster) (d) occupational exposure ADMINISTRATION Primary series in infants and pre-school children: use triple antigen (DPT)* four injections subcutaneously 0.5 cc, 1 cc, 1 cc, and 1 cc, with an interval of 1 month between first, second and third doses, and an interval of 3-6 months between third and fourth doses. Booster dose—up to 6 years of age, give DPT 1 cc, subcutaneously. Thereafter use combined diphtheria-tetanus toxoids as indicated below. Primary series for older children {Age: -\-6) and Adults who have not been previously immunized or for whom records of previous immunization are lacking:— In this connection it is important to remember that older children and adults even although they have not had the benefit of primary immunization in infancy may react severely to diphtheria protein because of previous sensitization by natural or artificial contact with C. diphtheriae or its products. In order to ascertain the immune status of any such individual and to avoid reactions, Schick and Schick control (or reaction) tests should preferably be carried out in children between the ages of 6 and 10 years and always done in children over the age of 10 before deciding the appropriate course of action. fj|p Schick Test Schick Control or Reaction Test Indication Pos. Neg.f Immune—further Immunization unnecessary. Reactor—immunize only with specially diluted diphtheria toxoid prepared for "reactors"^ and give tetanus toxoid separately. Immunize with combined diphtheria-tetanus' toxoid 4 doses subcut., 0.1 cc, 0.25 cc, 0,5 cc, 1 cc, with an interval of 1 mo., between first, second and third injections and 3-6 months between 3rd and 4th doses.:}: Booster dose—under 10 years, o.5 cc, over 10 years, 0.1 cc, every 5 years. The Connaught Laboratories recommend that when an interruption occurs in the DPT series and the interval between the first and second doses is longer than six months, the whole series should be repeated. When the interval between the second and third doses is longer than twelve months, the whole series should be repeated. NOTE: * Pos. Reaction—Erythema more than l/z inch diameter, or induration fNeg. Reaction—Erythema less than l/z inch diameter and no induration in both cases, appearing within 48 hours. ^Severe reaction to any injection of the series is a contra-indication to further immunization. PERTUSSIS IMMUNIZING AGENT Pertussis vaccine. Should be administered as triple antigen (DPT) for primary series in infants and pre-school children. USE t Routinely as DPT in infancy (preferably commencing at three weeks of age). Page 432 ADMINISTRATION Primary series: in infants and preschool children—use triple antigen (DPT), 4 injections subcutaneously, 0.5 cc, 1 cc, 1 cc, 1 cc, with in interval of 1 month betwen first, second and third doses, and an interval of 3-6 months between third and fourth doses. Booster dose—up to 6 years of age, give DPT 1 cc, subcutaneously. Pertussis vaccine is usually discontinued in children of school age. CONTRA-INDICATIONS ' " . - j| (a) Fever or other evidence of acute illness (b) Cerebral damage, e.g., cerebal palsy (c) Familial or personal history of convulsions or epilepsy (d) Severe reaction or convulsion following first injection TETANUS IMMUNIZING AGENT Tetanus Toxoid. Should be administered as triple antigen (DPT) for primary series in infants and pre-school children. Combined diphtheria and tetanus toxoids may be. used fori mmunization of adults and as a booster dose for children over six who have received DPT as a primary series. USE I Routinely as DPT in infancy (preferably commencing at three months of age) Indicated also (a) occupational exposure (b) as a booster at time of injury where patient is known to have been previously immunized against tetanus. This protection is unreliable if more than five years have elapsed since the last dose of tetanus toxoid was administered, and under such circumstances a prophylactic injection of Tetanus Antitoxin (minimum dose 1,500 units), should be given. ADMINISTRATION Primary Series: in infants and pre-school children—Use triple antigen (DPT), 4 injections subcutaneously 0.5 cc, 1 cc, lcc, and lcc, with an interval of 1 month between first, second, and third doses, and an interval of 3-6 months between third and fourth doses. Booster dose lcc subcutaneously, to age six. Primary Series in Older Children and Adults: Use tetanus toxoid alone—three doses of 1 cc. subcutaneously with an interval of 3-6 weeks between doses. Booster dose lcc, subcutaneously should be given 5-yearly or at time of injury. Alternatively, combined diphtheria and tetanus toxoids may be used (see Diphtheria). ii ii ii TEMPORARY CLOSURE OF CYTOLOGY DIAGNOSIS LABORATORY AT THE BRITISH COLUMBIA CANCER INSTITUTE J§ In order to provide a vacation period for the technicians and clerical staff of the Cytology Laboratory, it will be necessary to close this laboratory for a period of three weeks. The very large volume of work precludes the staggering of holidays throughout the summer months and maintain service with a short staff. The laboratory will be closed from August 12 to September 6th. The co-operation of the medical profession throughout the province will be gready appreciated. Routine screening specimens should .be postponed until a later date. Essential diagnostic speciments will be received upon re-opening of the laboratory but there will be a delay in reporting upon them. Page 433 Advance Notice of Move Provincial Health Branch, Vancouver Canadian Red Cross Blood Transfusion Service The new Provincial Health Building at 828 West Tenth Avenue, Vancouver 9, is to be occupied during the month of August. Tentative moving dates are as follows: August 1— Assistant Provincial Health Officer Division of Venereal Disease Control Crippled Children's Registry August 6-7— Division of Laboratories Births, Deaths and Marriages Office (Division of Vital Statistics) August 13-14 Red Cross Blood Transfusion Service As the new building adjoins the Provincial Division of Tuberculosis Control, all offices of the Provincial Health Branch in Vancouver will now be located in one area. mm The Canadian Red Cross Blood Transfusion Service is moving from its present location at 28th Avenue and Laurel Street, Vancouver. It is hoped that the move may be made without any inconvenience to physicians, particularly from the Division of Laboratories. Further information will be given in the August Bulletin. Phone Number effective August 1st — Dickens 2331. Specialist Recognition: The following have received certification from The Royal" College of Physicians and Surgeons of Canada and have been added to the Specialist List: Dr. Gordon Fred Clark—Anaesthesia „ 1954 Dr. Patrick N. J. Kenny—Anaesthesia 1954 j Dr. Lois Dorothy Crawford—Anaesthesia \ 1954 j Dr. Geo. Edward Sleath—Anaesthesia : . . 1954 : Dr. Henry Barss Dimock—Internal Medicine . ^ 1954 Dr. Arthur Wm. Lawler—Internal Medicine . 1954 '• Dr. Robert Halliday—Psychiatry 19541 Dr. Ian McDougall Kerr—Psychiatry 1954 i Dr. Gordon H. Stephenson—Psychiatry 1954 i Dr. Edward Geo. Cook—Paediatrics : • 1954 Dr. Fereidoun Mirhady—Paediatrics . i 1954 1 Dr. Alex Clyde Knkerton—Physical Medicine I 1954 Dr. Glen McKenzie Crawford—Therapeutic Radiology ! ..1954 < Dr. Ralph Edward Fisher—General Surgery : 1954 \ Dr. Benjamin Goodman—General Surgery -1954 i Dr. William Graham—General Surgery 1954 \ Dr. John Charles Sullivan—General Surgery \ 1954 | Dr. Charles Hubert Borsman—Obstetrics and Gynaecology 1954 ' Dr. Russell Quentin Colley—Ophthalmology . ; 1954 Dr. Denys Kensington Ford, F.R.C.P. (C)—Internal Medicine 1954 1 Dr. John Albion Leroux, F.R.C.P.(C)—Internal Medicine [ 1954 1 Dr. Jone Chang, F.R.CP.(C)—Anaesthesia I \ 1954 Dr. Thomas W. H. Lamont, F.R.CS.(C)—General Surgery. 1954 Dr. Wm. George Trapp, F.R.C.S. (C)—General Surgery 1954 Dr. John Angus Boyd, F.R.CS.(C)—Obstetrics & Gynaecology 1954 Dr. Clarence Edward Cook, F.Ff.CS. (C)—Orthopaedic Surgery I 1954 Dr. Verne Wm. Pepper, F.R.C.S.(C)—Obstetrics & Gynaecology 1 1954 Dr. Emery France Word, F.R.CS.(C)—Urology . 1954 Page 434 EMPLOYEE PHYSICAL VALUES § By L. A. PATTERSON, M.D. Physical Examinations of Industrial Employees Personnel Department heads might well emulate the exactitude of purchasing departments. From so doing the employee and industry would benefit. Shocking exhibitions of ineptitude present themselves for pre-employment examinations. Personnel officials are apt to employ decrepit, maladjusted and sick workers who, as misfits, are a curse to their fellow workers and a danger, expensive in production and most unhappy in themselves. Detailed discussion of the doctor's efforts for Personnel must include: — (a) Union Policy and co-operation. (b) Definite health specifications (c) Job Placement (d) Remedial Programme (e) Rehabilitation and Placement Programme (f) Education A Public Health Official enjoins us all to forever keep in mind that the success of Medical Personnel Selection demands constant attention to the formula that the applicant's best interests and future must be the primary concern. Expansion of any project and weight of experience confirm this view. The Doctor who is employed and functions with any hint of bias defeats Personnel, the applicant and himself. On the other hand, acceptance of the applicant in a doctor-patient relationship benefits industry, the Union, the applicant and the doctor. The applicant fears his medical; The Company concerns itself with what the Union thinks; the Union can fear the Doctor who examines with a bias. Fear is dispelled by facts and experience in selction. The ambition to sell every man on a selection project gives a reward commensurate with the real effort expanded on his behalf by the examiner. Union policy favours selection. We quote from a letter received from The Club and Cabaret and Construction Camp, Culinary and Service Employees' Union:— March 25th, 1955 "Widi regard to the method and necessity for medical examinations for all applicants for employment with the various Construction Firms, who do their own catering, or for such Catering Companies as may do that part of the business for the Construction Firms, Club, Cabaret, Camp Construction and Service Employee's Union, Local 740, would like to convey to you their appreciation and satisfaction gained by such an examination. We know of course that all the Employing Companies approve of this procedure, since they primarily were the instigators of said examinations being inaugurated. We can assure you, that we as a group are in full accord with the Companies in this matter and where as a result of an examination the Doctor rejects an applicant for employment, the nature of said examination naturally being confidential, die Union recognizes his decision and endeavours to ensure that the reject is not dispatched to any other employment until a further examination has been held and the applicant cleared. We find that the men themselves also appreciate the fact that being isolated as they may possibly be and in places where medical assistance or medical treatments are held to a minimum, it is a matter of great concern to them that they should be in good health before leaving for their jobs. Naturally, all concerned, Employers, Employee and Union, have to work together to ensure that all other persons are safeguarded from any contagious or communicable diseases. Page 435 We, therefore, wish to be put on record as supporting this movement of medical examinations one hundred percent, and hope that in the very near future, it will be one of the necessities for employment, not only in all phases of Catering work, but in other Industries as well. WM May we congratulate you on the work you have done in this regard to this date. Sincerely yours, President." Four Salmonella carriers have been found. Sickness producing boils has been treated. Tuberculosis is found. One case of acute scarlet fever was on his way to camp as a flunkey. From the standpoint of contagion alone, the Union officials seek to protect the average member from the carelessness of the probable sick applicant. We are assured that proper placement, control of obesity, and high blood pressure, early detection of cancer, management of diabetes, detection of infection and other assets of the scheme all contribute to the present high degree of Union co-operation and forward thinking. Definite Health Specifications are a prerequisite. Some applicants have been surprised and some chagrined at a programme demanding a complete physical. A personable character swore when he was told to get his pants off for a physical. He had never been subjected to this ritual before. He had been examined medically for his cooking job on previous occasions and never below the waist. The doctor insisted, only to discover about forty "luscious" boils on his legs which could have produced violent intestinal infection in the whole camp when spread through this cook. A rather well-muscled mine boss cursed the Doctor because he had to strip. He was only forty-two years old and had never been sick. Rectal examination in his case revealed a malignant condition the size of a walnut. His life was spared because specifications called for the rectal examination of ten thousand applicants to find a cancer in six. We agree that Personnel must insist on specifications for medical examinations. Labor is expensive. It is more expensive than machines which Purchasing rigidly appraises. In setting exacting standards of Physical Examination, Personnel will triumph in acquisition of well, non-dangerous, happy employee producers. Constant study must go on and revision of requirements for individual jobs. Hiring and firing as well as hit and miss will sometimes get a man in the right niche. Experience shows that the doctor can help by classifying a man's limitations and assets. We must admit that we doctors miss the boat on sex deviates, some addicts, some psychopaths and some medical disabilities such as epilepsy, but our averages get better every year as evidence on individual industrial employees accumulates. Once again, Personnel, the Union and the doctor must set specifications for examination. The examination must be thorough and placement treated as an individual problem. How is the health of the cook, miner, logger, banker or clerk? This study is not analytical or complaintive about our applicant as a group but emphatic in its interest in the individual. Can the consumptive get treatment:5 How do you manage a case of trench mouth? Is syphilis a bar to food handling? We are assured that the best of medical care is available for the reject. We are also assured that the Employer will get the sick applicant back to work when he is well. The Examiner's policy has been to refer the man to his own doctor with a detailed report. Insistence on recovery before employment is helpful. The applicant's financial incapacity is not any great problem. Hospital out-patients Departments have never failed us. The Tuberculosis Division has been very co-operative. The Division of Venereal Disease Control has extended itself beyond reasonable requirements. Provincial Laboratory has been extremely efficient. We have yet to see a patient lack Page 436 medical care when it is required. Remedial problems are no concern now and probably we shall never have difficulty in this field. Social Service and Assistance have been co-operative in the management of the unemployable. Some nightmare is created by the out-of-Province ineligible, but this is being worked on. It is folly to forget the "reject". If he doesn't fit one place, he must be employed in another. It is equal folly to seek to place the unemployable. Remarkably, a miner with syphilis, diabetes and tuberculosis insisted on his right to employment. His only rehabilitation or hope was immediate hospitalization. He was finally sold on the idea and today is back at work. One could argue that the examiner's duty ceases with assessment. This man and his fellow rejects are often "broke." They possess no knowledge of medicine, they know nothing about Social Service. Our experience suggests the necessity of handling their every problem. The reject from specific employment may be employable in selected work or in other placement. The diabetic should not work in an isolated community and away from medical care. The asthmatic should be in a central community. The ulcer and hernia case may work if near a doctor. The whole programme of Industrial Employee Selection can break down if these men and women are not looked after. The Employer, the Union and other Employment Agencies help. The Special Placement Division of the National Employment Service is a particularly useful and cooperative body of experts. The Doctor can find for these patients a niche in which they will be happy and productive. Again, it can be argued that the Examiner has fulfilled his duty by telling the diabetic to go to his family doctor and that he is a reject. Our experience is that the whole scheme can fail on such demarcation in Professional Service. Can a doctor benefit by direct group contact with these men? The layman will leave his T.V. set to hear about cancer and tuberculosis. He will listen to stories about diabetes and heart disease. Moreover he is interested in ways of preserving his health and his life. He also likes to know that the salad maker doesn't have salmonella and that the baker isn't mixing carbuncle germs in the cream puffs. We have a responsibility in the education of the employee. Will a programme of physical examinations lower Workmen's Compensation Board assessment? Will the Unions notice our overall better health incidence? The co-operation of all interested groups in future study will come as fast as we engender it by perfection in doctor's methods of study in this field. In conclusion:— (a) Pre-Employment Assessment of the Individual worker is a complex but rewarding assignment. (b) All Organizations responsible for the worker argue that the scheme is advantageous. (c) There is plenty of room for study and improvement. MODERN OFFICES AVAILABLE In busy suburban district of Vancouver. Three room suite adjoining large waiting room. Central to growing residential area. For further particulars write or phone Publisher, 675 Davie Street, Vancouver, MArine 7729 Page 437 MALPRACTICE AND THE PHYSICIAN Report of the Committee on Medicolegal Problems, American Medical Association, prepared by Louis J. Regan, M.D., LL.B. Reproduced by permission of Dr. George Lull, Manager and General Secretary A.M.A. The incidence of malpractice claims increased tenfold during the decade between 1930 and 1940. In some localities, malpractice claims have become so frequent that any patient with a less than perfect end result is a potential malpractice claimant. If this alarming situation were evidence that the medical profession was becoming increasingly inefficient, then the solution would of course be obvious. But the blunt truth is that the majority of all malpractice suits filed are without merit; more than half of them involve physicians who are above the median of their respective groups in skill, experience, and professional standing. The search for a solution to this problem demands an understanding of what actually constitutes malpractice, an analysis of the causes of malpractice claims, and a universal knowledge among physicians as to the positive steps which may be taken to decrease both the relatively few justified claims and the preponderandy greater number of unjustified claims. Any Physician May Be Sued For Malpractice The bringing of a malpractice action does not even suggest that the claim has merit; for any patient may bring such an action against any physician who has attended him professionally. Nevertheless, the practitioner who is the target of the accusation is damaged by the mere filing of the action. Accordingly, it is necessary that every physician understand what constitutes malpractice under the law. What Constitutes Malpractice Under The Law? The law requires that a physician who undertakes to diagnose or to treat a patient must possess the skill and exercise the care commonly possessed and exercised by other reputable physicians in the locality. If he holds himself out as a specialist, he must meet the standards of practice of the specialist in the designated field of practice. These legal interpretations of his duty are not changed if the professional services are rendered gratuitously. It follows, then, that no malpractice charge is justifiable unless the physician's service to the patient does not meet the requirements of good medical practice; unless in the diagnosis or treatment of his patient, the physician omits to do something he should do or does something he should not do in terms of accepted standards of practice. The standard of practice is always determined by what other reputable physicians in the community, or in similar communities, would or would not do in the care of similar cases. This definition of standards needs further clarification; for medicine is not an exact science, and not all patients who are given medical treatment get well. Many are left with some disability or deformity. There are few conditions in which there is available a sole, specific, universally utilized remedy or procedure. There is frequendy a great latitude for honest difference of opinion, and often the attending physician must exercise his best judgment in deciding which of the several methods to adopt. In certain circumstances, the physician's acts or omissions may be so unseemly and shocking as to be generally recognized as reprehensible and supportive of legal liability. On the other hand, complications or untoward and unexpected results are not uncommon, and the mere fact that a patient is not cured or does not progress favorably does not suggest culpable ignorance or negligence on the part of the medical attendant. Under Law, What Skill And Care Has The Patient The Right To Expect? In the absence of evidence to the contrary, the law presumes that a physician has exercised the ordinary skill and care required of him in treating his patient. He is justified if his conduct of the case would be approved by even a respectable minority of his confreres in the same locality. He may make a mistake in diagnosis or be guilty of an error of judgment; he may use medicines or methods of treatment different from those which some of his colleagues would have used; he may obtain a bad Page 438 result instead of a satisfactory one; but no one of these things is sufficient to fasten upon him the charge of malpractice. Actionable malpractice consists in doing something that should not be done or in omitting to do something that should be done. Malpractice Suits Lessen Public's Confidence in Medical Profession It is of primary importance, of course, that every physician familiarize himself with the legal interpretation of what does and what does not constitute malpractice. But that is only the first part of the control of the malpractice contagion; for experience has taught us that the most meticulous attention to the dictates of good medical practice is not sufficient to ward off unjust claims, and that no physician, regardless of his excellence, is.immune. The misunderstanding, indeed the ill will, which has been engendered by the great number of unjust malpractice suits has tended to break down the public's confidence in the medical profession. This situation has important and far-reaching implications for both the public and the medical profession; for the public interest is adversely affected when the physician in caring for his patient is forced to give thought, time, and energy to safeguarding himself against the possibility of an unjust malpractice claim. The public should be informed of the facts of this problem, for in the long run it is the public—in the persons of individual patients—whose well-being is being jeopardized. There is no relationship outside the family which is so personal and intimate as that of physician and patient, no relationship in which the character, integrity, and conscience of one party are so important to the well being of the other. The overwhelming majority of physicians faithfully and unselfishly meet the demands and obligations of their calling; and the majority of patients do not unjustly file malpractice suits. The acts of the ignorant, the greedy, the callous few—among either patients or physicians- must not be permitted to destroy the merited esteem in which the profession as a whole is held. How Much Shall The Physician Tell His Patient? As a basic step in improving the situation, the physician must realize that at all times he is obligated to act with the utmost good faith toward his patient. Thus, if he knows that he can not accomplish a cure or that the treatment adopted will probably be of no benefit, he is in duty bound to advise his patient of these facts. It is extremely doubtful that a physician has a therapeutic privilege to withhold a specific diagnosis from a patient who is sick with serious or fatal illness. To the contrary, the confidential relationship requires in ordinary circumstances that the physician make a frank and full disclosure of all the pertinent facts to any adult and mentally competent patient. Such completely open handling of a case would do much to improve the physician-patient relationship and to remove the possibility of unjust malpractice actions. However, there are other unavoidable and even psychological factors in the practice of medicine which must also be considered carefully in this respect. Factors That Promote Malpractice Suits If physicians were always able to obtain perfect results there would be, of course, no malpractice actions. But deaths, untoward and unexpected results, continu- .^ig disabilities, and complications occur and will continue to occur. Whether or not the uncured patient brings an action is often determined by his feeling toward the physician. Patients who have a feeling of friendly trust for the physician and who believe that everything possible has been done for them are not so likely to sue for malpractice—even when bad results ensue. Malpractice suits more often arise if the patient is resentful of some fancied or actual affront, if he belives that he has not been sufficiendy closely attended, or— above all—if some third person raises a doubt in his mind as to the propriety of the treatment. In regard to this last point, it would be sheer folly to assume that the "third person" is always—or even most often— a layman who is uninformed about the facts of the case. Regrettably, many of these people are physicians who are also uninformed about the details and facts but who Page 439 precipitate unjustifiable suits by criticising directly or by implication the work of physicians who have cared for particular cases. Another potential danger to the physician-patient relationship arises from the physician's lack of attention to certain elements of patient psychology as factors in malpractice causation. Although the patient is sick or injured when he comes to his physician, he nevertheless visualizes himself as he was prior to becoming sick—with his body structures intact. Thus, unless the physician understands this viewpoint and prepares the patient properly, the patient with a fracture, for example, is likely to compare the final result with the part prior to injury, not with the injured member, as presented to the physician. As another example of patient psychology, the average patient is not disposed to understand an error in diagnosis or the failure to make an early diagnosis. Or again, the unwarned patient is not happy with the surface tissue changes which are sometimes associated with deep x-ray therapy. An analysis of malpractice claims reveals the significant fact that they arise almost invariably out of the first course of treatment. In other words, it is rare indeed that an old patient instigates a suit against his physician. It is obvious, then, that from the very first contact—indeed, especially with the very first contact—the physician should do everything within his power to develop an honest, frank, and psychologically sound relationship with his patient. How Physicians May Safeguard Themselves Against Malpractice Suits The foregoing discussion has analyzed what malpractice is and what can be done in the physician's conduct to avoid real malpractice or to forestall the filing of an unjust claim. But it would be completely unrealistic to assume that any course of conduct on the part of the physician would prevent his being unjustly sued for malpractice. Good medical practice in itself is not enough; the physician must be able to defend his actions by proof of what he has done. He must not only know his legal duty to his patient, but he must fulfil it. He must know and take advantage of every measure to protect himself against the unjustified claim of malpractice. Under present circumstances, it is absolutely foolhardy for any physician to be ignorant of or careless of malpractice prophylaxis. He must take positive actions carefully based upon his legal responsibilities and liabilities. To begin with, a physician is not legally obligated to undertake the care of any patient. But from the time he assumes the responsibility until he is discharged or withdraws from the case, he must give—or be sure that there is given—the care and treatment required by the condition of the patient. Before a physician may, without legal liability, withdraw from a case he must give reasonable notice of his intention and allow the patient reasonable opportunity to fill his place. By notice or special contract, the physician may limit the service he is to render. He may agree to treat the patient only at a certain place, or for a limited time, or for certain conditions. On the other hand, he may increase his obligation by expressly agreeing or warranting that he will effect a particular result; in this circumstance, he will be liable on his contract or warranty if he fails to fulfil the agreement. A physician is not an insurer of results; he makes himself one by his special promise. Many malpractice actions are brought as the result of some unwise statement made by the attending physician, or his partner, assistant, or office nurse, to the patient or to a friend of the patient. Care should be taken to avoid making any remark constituting an "admission" of fault, or one which may be construed as such. It is understandable that such remarks have been made under emotional stress or when exercising "hindsight" in the face of an unsatisfactory result even when good practice has been followed throughout. A single careless statement might create liability for damages where actually no liability exists. The effect of such a remark when reported to a jury is incalculable and almost impossible to counteract. Further, an admission on the part of the defendant may free the plaintiff from the necessity of offering medical expert testimony. Page 440 Expert Testimony And Res Ipsa Loquitur Generally, the proof of a physician's negligence must be established by the testimony of medical expert witnesses. The application of the doctrine of res ipsa loquitur1 in a case gives rise to an inference of negligence on the part of the defendant, and relieves the plaintiff of the necessity of proving the alleged malpractice by the testimony of experts. It places on the defendant the burden of making explanation, if he can, to offset the inference of negligence; and by the majority rule a question is created for the jury, regardless of any and all evidence presented by the defendant. The doctrine of res ipsa loquitur has been held applicable in the field of malpractice chiefly in cases which involve (1) slipping instruments, (2) sponges left in the tissues, (3) burns from heating modalities, (4) roentgen radiation injuries, generally limited to cases wherein the roentgen ray is being used diagnostically, (5) infection through the use of an unsterilized needle or instrument, and (6) injury to a portion of an anesthetized patient's body outside the field of treatment or operation. A Good Case Record Is A Valuable Safeguard The importance of good medical case records, as a factor in malpractice prophylaxis can not be overestimated. A good medical case record should contain a history 2 of the case and a physical examination of the patient, together with reports of all indicated laboratory studies. These data constitute the foundation of the medical record and will generally serve as the basis for at least a working diagnosis. If diagnosis is not possible, consultation is desirable. Consultation reports must be in writing. Thereafter, a good record will reflect (by means of progress notes) a sequential history of the case, its course, complications, and sequelae and, thus, the justification for further or changed investigation and treatment. Such a record will contain a statement of all treatment rendered in the case. Copies of special forms and of reports used or made in a particular case are also a part of a good record. It is desirable that an attending physician ask himself from time to time what he would wish to have in the record of the case under treatment in the event he should later be called upon to justify in court his conduct of the case. If a patient discontinues treatment before he should or fails to follow instructions, the record should show it. A good method is to file a carbon copy of the letter sent to the patient advising him against the unwise course. 3 Unwarranted Professional Criticisms Promote Malpractice Suits The precipitating cause of a majority of all malpractice actions is found in the unwise comments or criticism of physicians with regard to treatment given to patients by other physicians. Commonly it is criticism by a succeeding physician of the work of his predecessor. Various authorities have estimated that 50 to 80 per cent of all the suits for malpractice would be eliminated if such destructive criticism could be stopped. It is profitless to attempt to determine why physicians are so prone to criticise destructively and unethically, but the results of it are deplorable. Legitimate criticism rests only on full knowledge of the facts as gathered from all parties; from the physician who treated the patient, as well as from the patient. Other Preventive Precautions The importance of tact can hardly be overemphasized. It should be manifest especially in the handling of the patient and the patient's family; in the avoidance 1. Res ipsa loqiUtur (literally the thing speaks for itself) is a doctrine of the general law of negligence. It is held applicable whenever one person is injured by an instrumentality entirely in the control of another person, the use of which does not ordinarily result in injury if the person in control exercises due care. 2. It is important to indicate the source of the medical history (from the patient, member of family, etc.) 3. There is a legal presumption that a letter mailed has been received by the addressee; but there is no presumption that a letter has been mailed. Page 441 of fees (considering the provisions of the statute of limitations); in the avoidance of overoptimistic prognoses and especially of any promise constituting a guarantee of a particular result; in the avoidance of betrayal of privileged communications; in the avoidance of making any statement constituting (or which might be construed as) an "admission" of fault or negligence; in the avoidance of any reference to malpractice insurance protection; and in the securing of legal advice before making any statement in regard to a malpractice claim or suit. Liability For Acts of Others In addition to being responsible for his own acts and omissions, a physician encounters, in his everyday practice, instances in which he may also be responsible for the negligent acts and omissions of others. Thus, he is responsible for the acts of his assistants and employees, for their negligence occurring during the course of their employment. Where doctors practice as partners, each partner is liable not only for his own acts and those of his partner, but for the negligent acts of any agent or employee of the partnership. When two independent practitioners are caring for a patient, each is liable not only for his own acts but for doing nothing about the negligent acts of the other which he has observed or which in the exercise of ordinary diligence he should have observed. Mm The attending physician is generally not liable for the negligence of an interne, a nurse, or other hospital employee. He is, however, responsible for the acts of the hospital personnel in so far as they are carried out under his immediate supervision and control. Thus, the operating surgeon and not the hospital is held liable for any negligence of operating room attendants during the performance of surgery. Consent For Operations, Treatment And Autopsies Consent for operation must always be secured. Any adult in a clear state of mind may authorize operation upon himself. Oral consent might be considered sufficient; but because of the difficulty in proving that it was given, the physician should invariably require a witnessed consent in writing. If the patient is a minor (that is, a person under the age of twenty-one) consent is to be obtained from parent or guardian.4 If the individual is mentally incompetent, the consent of the one who stands in the position of guardian is required. When an operation is made compulsory by law (such as vaccination or sterilization5) the law furnishes the consent. If an operation is unlawful, consent to the performance thereof does not absolve the surgeon from liability. In an emergency which demands immediate action for the preservation of the life or health of a patient and in which it is not practicable to obtain his consent or the consent of any one authorized to speak for him, it fs the duty of the attending physician to perform without consent such operation as good surgical practice demands.6 If sterility is likely to result from the surgery which is contemplated, explanation of that probability should be made and a signed authorization obtained from both spouses. It should be borne in mind that it is hazardous to sterilize any person exceQ£ upon a positive medical indication. Further, there should be no promise or guarantee that the patient will be sterilized as the result of the procedure undertaken. The individual physician must secure consent to perform a postmortem examination. This, too, should be in writing7 and sufficiently comprehensive to allow the 4. Statutory exception: In California a female of the age of 18 or more who is or has been married is an adult for the purpose of this consent. 5. Under Eugenic Sterilization Statutes. 6. 48 C J. 1131; Jackovach v. Yocum (Iowa), 237 N. W. 444. 7. In California, and several other states, it is criminally illegal for any person to perform an autopsy without having first obtained the written authorization of the coroner or other authorized public officer or of the person who has the right of disposition of the body. Page 442 removal and taking away of tissue if such is to be done. The trend of the cases in recent years indicates that it is extremely unwise to pursue a course of treatment in itself hazardous or capable of producing harmful effect without securing a written statement from the patient, or from someone legally responsible for the patient—a statement which clearly expresses understanding of and consent to the special treatment. Failure To Use Recognized Diagnostic Aids There are a large number of malpractice actions in the law reports which may be classified under the general heading of "Insufficient Treatment Cases." In every field of medical practice there are cases illustrating "insufficient care": the failure to make a blood count, a Wassermann, a pregnancy test, a culture, a smear, a urinalysis, a stool examination, an x-ray, original or follownip; failure to make a complete diagnosis or overlooking a reasonably determinable condition; failure to utilize an indicated prophylactic measure (diphtheria, tetanus, etc.); the failure to give instructions, to follow up the original treatment or operation, to institute measures to protect contacts, etc., etc. Failure to use the x-ray at all, or failure to make sufficient use of the x-ray, has been the chief allegation in many malpractice actions. Whenever a fracture is present which was not diagnosed and no x-rays were taken, the conduct of the attending physician is likely to be condemned as not coming within the standard of good practice.s Whenever a bad result, deformity or limitation of motion occurs, the defense is immeasurably strengthened by the possession of a series of x-rays taken at intervals during the progress of the case. Whenever a patient refuses to have an x-ray made, the physician should fortify himself with the strongest written evidence. X-rav records, as well as the entire case record, should be carefully preserved beyond the time during which a malpractice action may be brought. The statute of limitations provides the period of time after which specified actions may not be brought. The time provided varies gready in the several states. A physician should wisely inform himself of the situation in his own state. Obligations To Patients To summarize, the physician who would understand his legal obligations, responsibilities, and duties to his patient, must constantly bear in mind the following fundamental obligations: 1. The physician must possess the degree of skill commonly possessed by other reputable practitioners in the same field of practice. 2. He must exercise the degree of care, diligence, and judgment commonly and ordinarily exercised by other reputable members of his profession in similar circumstances. 3. He must keep abreast of progress and follow good practice, common practice, in diagnosis and treatment; he must experiment. 4. He must not neglect or abandon his patient; he must proceed diligently, without unnecessary delay. 5. He must give his patient sufficient attention and must utilize the indicated diagnostic aids. 6. He must find or anticipate any condition reasonably determinable or reasonably likely to develop. 7. He must obtain legal consent to operate and to perform an autopsy. 8. "The failure to make use of x-ray as an aid to diagnqfsis in cases of fracture amounts to a failure to use that degree of care and diligence ordinarily used by physicians of good standing in the community and the court, in absence of expert testimony, may take judicial notice of such fact." Agnew v. City of Los Angeles (Cal.), 218 Pac. (2d) 66. Page 443 8. He must give proper instructions (that is, instructions consistent with the standard of practice) for the care of the patient in his absence, and for the protection of those coming in contact with the patient. 9. He must fulfill the terms of a special contract if he makes one. The foregoing directions for reducing and avoiding the instigation of malpractice suits will not, of course, guarantee that a physician will not be sued unjusdy; for already malpractice may be regarded as a contagious disease of the social body. There are several major reasons for this.condition, but two are paramount: (1) the winning of a suit inevitably encourages the filing of others as patients become increasingly "suit conscious"; and (2) such suits are difficult to defend, and the knowledge of how best to conduct such a defense is not sufficiently wide-spread. The inter-relationship of these two points will be obvious; for each successful defense of an unjust suit will serve as a discouragement to the filing of others. But the second of these causes of high malpractice incidence—the difficulty of conducting a defense—is dangerously enlarged by many physicians themselves. Large numbers of medical men are naive enough to believe that their patients would never file such suits and that no precautions need be taken; and yet such precautions are the only assurance of the best possible defense in the event of a suit. The most vulnerable physicians are those who know that they are maintaining at least an average standard of practice and who are therefore (and blindly) assuming that they will not be sued. This discussion is concerned with unjust claims; no doctor who is actually guilty of malpractice should be allowed to go free of penalty. Meritorious claims should be settled out of court—preferably before a suit has been filed. Prompt Attention Should Be Given To Claims Anodier too frequent hindrance to an adequate defense is delay in the investigation of claims; such delay is highly disadvantageous to the preparation of a defense. As a final word of warning that the physician may need every available precaution; one must consider the condition under which most cases are heard. They are tried before juries made up of lay persons, and it is a truism that no one can say what a jury will do. This is particularly true of malpractice cases, for certainly lay jurors can not be expected to understand complex medical facts. How does a jury arrive at a decision when two expert witnesses testify that the defendant's conduct of the case did not meet the required standard, and two others declare that what the defendant did was consistent with the usual and ordinary practice in the community? To physicians who have had litde or no experience with the law and to lawyers who have litde or no medical knowledge, the problem of adequately defending the unjust malpractice case seems insurmountable. And it is true that far too many such cases have been lost simply through poor defense. This is an aspect of the problem which needs a great deal more attention, particularly in areas which have become virtual "hot beds" of non-meritorious malpractice claims. At all times and to all physicians, there should be available expert advice on problems relating to the physician-patient relationship. 9 Whenever a threat is made against a physician, _ carefully prepared procedure should be put into effect. Unjustified claims should be contested as thoroughly as possible. In such cases, it is sheer folly to compromise, on the theory that a slight settlement would be less expensive than the cost of defense. Such a course simply serves as an encouragement to others whose claims are not justified. This shortsighted view is largely responsible for the rapid increase in the number of malpractice claims in some sections of the country. If cases based upon unjust or absurd claims are permitted to receive even a slight profitable return, there will be an incentive to bring more of them. 9. Regan, L. J.: Doctor and Patient and the Law, St. Louis, The C. V. Mosby Company, 1949, chap. 20. Page 444 Be Slow To Compromise It is a great temptation to a doctor to rid himself of a nuisance claim by making a small settlement. The unfavorable publicity, the loss of time, and the mental and emotional strain involved in defending a malpractice suit may lead the physician to compromise. But, as is so often true, the easiest way out of a situation is seldom the best. For the sake of both himself and his colleagues, the doctor should make a detennined opposition to an unjustified claim. A List of "Commandments" in Malpractice Prevention In the final analysis, it is the physician himself who is responsible for the continuing existence of the vicious malpractice situation. The physician has generally been satisfied to pay his professional liability insurance premiums and thereafter to sit back complacendy, doing nothing until he becomes a target for a malpractice claim. He must be brought to realize that his money payment is only part of his insurance premium; a much more important part is his contribution of time, of study, and of putting into effect all possible measures to safeguard himself and his colleagues. Prevention is the best defense against malpractice. Listed below are the 23 malpractice prophylaxis "commandments": 1. The physician should care for every patient with scrupulous attention to the requirements of good medical practice. 2. The physician must know his legal duty to the patient. 3. The physician must avoid destructive and unethical criticism of the work of other physicians. 4. The physician should keep "ideal" medical records in every case: records that would be presentable when offered in court; records that clearly show what was done and when it was done; records that clearly indicate that nothing was neglected and that the care given met fully the standard demanded by the law. If any patient discontinues treatment before he should, or fails to follow instructions, the record should show it; a good method is to file a carbon copy of the letter which advises the patient against the unwise course. 5. The physician should be careful to avoid making any statement which constitutes or which might be construed as an admission of fault on his part. Such an admission, which is usable against the physician, might be made to a third party as well as to the patient at any time before the trial. Such an admission may be made by an agent or employee of the physician during the course and within the scope of the employment. It is important to instruct employees to make no statements. 6. The physician should exercise tact as well as professional ability in handling his patients. A proper professional manner and a sound attitude should be maintained at all times toward both the patient and the patient's family. The attentive physician may early sense some unsatisfactory and disturbing under-current which, by the institution of protective measures, may be prevented from developing into something much more unpleasant. Thus, if the patient is not doing well, consultation may be suggested; if the patient is dissatisfied or complaining, of if the family's attitude indicates dissotisfaction, consultation should be demanded. The use of a consultant affords, in any case, great protection against a malpractice claim. 7. The physician should refrain from overoptimistic prognoses and should avoid promising too much to the patient. 8. The physician should advise his patients of any intended absence from practice and should recommend, or make available, a qualified substitute. 9. The physician should unfailingly secure written consent for operation and for autopsy. Page 445 10. The physician should carefully supervise assistants and employees and take great care in the delegation of duties to them. 11. The physician should have some knowledge of the statute of limitations and of its significance. 12. In his selection of patients the physician should limit himself to such fields as are well within his qualifications. He should keep abreast of progress in the medical profession. 13. The physician should keep inviolate all confidential communications. 14. The physician should frequently check the condition of his equipment and make use of every available safety installation. Mm 15. In the treatment of the patient the physician must not experiment. 16. The physician must be careful to render sufficient care to his patient in general instructions, frequency of visits, clinical and roentgen ray laboratory investigations and the like. Moreover, every precaution should be instituted for the protection of those caring for the patient and of all other contacts. 17. The patient must not be abandoned. The physician-patient relation can be terminated without liability only in certain ways and under certain conditions. 18. The physician should never reveal that he carries professional liability insurance. Except on the recommendation of his legal adviser, he should never write a letter or make any statement with reference to a malpractice claim. Immediately on being advised of even the possibility of suit, he should consult with his attorney. 19. The physician should arrive at an understanding in the matter, of fees. Misunderstanding in this matter, particularly when the question of excessive fees arises, contributes an avoidable element of risk. 20. The physician should secure legal advice if he is called to attend a coroner's inquest as a witness in a case in which he has been in professional attendance. 21. The physician should realize that because of the possibility of error in transmission, it is dangerous to telephone a prescription. 22. The physician should realize that it is hazardous to sterilize any patient except when a medical indication exists. 23. Except in actual emergency, the physician should not examine a female patient unless a third person is present. There is no more serious or destructive charge than that of undue familiarity; and the only way to avoid claims of this sort seems to be to have some one else present during all examinations. Conclusions There must be recognition of malpractice as a problem; that the conditions created by it are harmful to the physician and injurious to the public; and that action must be taken to correct it. The public should be informed as to (1) what constitutes malpractice, (2) how really few cases of actual malpractice occur, and (3) the major degree of responsibility which the individual has in the maintenance of his own health. Physicians must learn what they may do to safeguard themselves, and must put into effect every possible precaution against an unjust malpractice accusation. OFFICE SPACE Excellent location for Medical man on Dunbar, will arrange space to suit tenant. Immediate occupancy. For information phone ALma 2252-Y. Illll Page 446 Eh. ]. R. Boyd, former resident at the Vancouver General Hospital, is now in specialty practice in Vancouver. Dr. Kenneth Davidson is practising dermatology in Vancouver. Dr. Philip Margetts, formerly of Kitimat, is finishing his graduate surgical training at the Vancouver General Hospital. Eh. Glen Ankeman is now in urology at the Vancouver General Hospital. Eh. George Scott of Duncan is practising at Kitimat. Eh. A. Knudson is now practising in Ladner. Dr. John Poole is studying pathology at the Vancouver General and Dr. Clarence Wilson is in pediatrics there. Eh. Hugh Pontifex and Dr. J. Martin have begun a joint practice in Burnaby. Eh. E. N. C. McAmmond of Vancouver has just returned from Europe where •he spoke to the Royal Society of Medicine in London on the subject of Diverticulitis, on May 17th. At the Twentieth Anniversary of the International College of Surgeons in Geneva on May 27th he spoke on the subject of Pneumatosis Cystoides Intestinalis. g||| Dr. Ben Berger is practising ophthalmology in Vancouver. Eh. J. J. Adrian is in general practice in Vancouver. Dr. Michael Selwood is practising in Penticton. Dr. Dave Peterson is practising in Princeton. Dr. Jack Hamilton is practising in Dawson Creek. Dr. Charles Carpenter has gone to continue his studies in Kingston General Hospital. Eh. A. Schmike is now in Newton, B.C. Dr. Joseph Witmore is continuing post graduate training in Shaughnessy Shaughnessy Hospital. Dr. G. K. Heyden is now in Chemainus. Dr. Roy White returned from the Mayo Clinic and is going into practice with Dr. /.' Ganshorn. Eh. R. G. Hasselback is practising in association with Dr. G. F. Strong in Vancouver. Dr. G. H. Blair is in association with Dr. W. M. Toone of N. Vancouver Dr. A. R. Yarrow is practising in Vancouver with Dr. M. Morrison. Dr. N. M. Thornton is now at the Crease Clinic. Eh. ). H. Woods and Dr. J. Olivier are now practising together in Lilooet, B.C. Eh. L. H. Appleby is in practice in Nanaimo. Eh. Peter ]. Banks is in practice in Victoria. Eh. T. M. Brand is in Kemano. Eh. C. B. Holmes is in Kelowna. Dr. P. W. Jaron is practising in Prince George. Eh. J. C. Kovach is practising in Port Coquidam. Dr. H. H. Smythe now maintains offices in both Castlegar and Nelson. Page 447 Dr. L. T. Maxwell is now taking post graduate surgery in the Vancouver General Hospital. Dr. Charles F. Ballam has opened General Practice in Oak Bay, Victoria. Dr. Donald R. Hodgins is associated with Drs. Patterson & Hunt in Victoria. Dr. Charles H. Borsman of Victoria has received certification from the Royal College of Physicians and Surgeons in Obstetrics & Gynaecology. If BIRTHS Born to Eh. and Mrs. M. Earle of Vancouver, a son. Born to Dr. and Mrss H. Mcintosh of Vancouver, a son. Born to Dr. and Mrs. ]. T. Sandy of Vancouver, a son. THE BOIL... VANISHES • No criscross incision • No irksome dressing When you treat boils orally with . No needless torture No permanent scar Chemically pure metallic tin and tin oxide As a TAENIAFUGE 10 tablets, 3 times daily before I meals, for three days if needed. Also efficacious for | Styes, Carbuncles and staphylococcal abcesses. Posology: | 4 to 8 tablets daily, taken any time. ANGLO-FRENCH DRUG CO. LTD., Montreal 18 A PackagejTransportation Plan (DESIGNED SPECIALLY BY DUECK) (FOR THE MEDICAL PROFESSION) 1. An All-inclusive Monthly Billing (including insurance) 2. Predetermined Fixed Costing (includes Everything) 3. Brand-New Models of Your Choice (Constantly Maintained) A Service Used Extensively by the Medical Profession DUECK MOTORS LEASE and SERVICE LTD. MR. JACK SCOBLE, Representative - CEdar4111 Page 448 The practice of medicine has changed enormously in a great many ways in the past fifty years, and in none, perhaps, more than in what we call "public relations". One looks back sometimes almost with a feeling of nostalgic regret, to the days when we were all individualists, and did pretty much as we pleased: when there were no forms to fill out, no workmen's compensation records, no prepaid plans, no group practice, very few specialists, and when income tax was very low, if not entirely nonexistent. There are many compensations, no doubt, in modern life — but all the same, things were simpler then. But, to translate the Latin phrase, "times change, and we change with them". Today we are hedged around with endless requirements imposed upon us by increasing contact, as a group or a profession, with the public. No longer do we practise our profession as individuals dealing with individuals. In much of our work we have to do with a third party — the Workmen's Compensation Board, for example, or the M.S.A., or any one of a dozen organizations who have assumed rights and responsibilities, and with whom we have constandy to deal. Much of this is due to alterations in the social structure, which is becoming more and more socialised, where groups deal with groups more and more. We do not regret this at all — we feel that a great deal of good has come out of it all, for us as well as for the public at large. It has removed a great many injustices and has introduced a good many amenities into our way of life — and it will undoubtedly increase. But it has made us, as a group, very much more conscious of our relations to the public as an organised body, and not as individual physicians, and it has developed many problems which we have to study and solve. It has immensely increased organization amongst us, and has also impressed upon us the fact that we have responsibilities as well as privileges; it has brought into prominence certain dangers which come from an increasing realization of this fact by the public. In the last issue of the Bulletin we published an article on malpractice, which we believe every medical man would do well to read; for his own sake, and in his own defence. In Canada, perhaps, at least so far, the danger of malpractice suits is not as great as it is in some other countries — but reading this article, one sees what a really serious menace lies in the gradually increasing tendency towards charges of malpractice brought against doctors. We heard much of this in a discussion in Chicago this spring, and this article in question was prepared for the American Medical Association by an authority on the subject — and the A.M.A. generously allowed us to publish it, Perhaps one great reason why we in Canada have had relatively so little trouble in this regard, is that we have an organization, the Canadian Medical Protective Association, which has done a tremendous job in educating our members, and in teaching them how to avoid occasions for suit, and how to meet them when they arise. Elsewhere in this issue, we are publishing a note by Dr. Lynn Gunn, Registrar of the College of Physicians & Surgeons, in connection with the Annual Meeting of that body in October. This is a meeting which we should all attend in any case, but this year particularly it will be profitable — because the guest speaker will be Dr. T. L. Fisher, a member of the Executive of the Canadian Protective Association. Dr. Fisher will deal with the legal aspects of medical practice, factors involved in malpractice suits, etc. and will answer questions. We believe that this will be of great value. No medical man, no matter how skilled, no matter how careful, is immune in this regard. We need much more than to be "harmless as doves" — we need the "wisdom of the serpent" as well. The experiences of medical men in the United Page 467 States, and even in our own country, to a lesser degree, shows this, and the worst and most disastrous error which we can commit, is when we think we can protect ourselves, without legal help, either direcdy sought, or provided by such organizations as the Canadian Medical Protective Association. We are very fortunate to have this opportunity. ; t I Library Summer Hours: Monday to Friday B 9:00 a.m.to 5:00 p.m. Saturday - 9:00 a.m. to 1:00 p.m. Recent Accessions: Midwifery by Ten Teachers, edited by F. W. Roques. Edward Arnold. 1955. Geriatric Medicine, edited by J. Stieglitz. Pittman Medical Publications 1954. The Doors of Perception by Aldous Huxley. Chatto & Windus. 1954. Varicose Veins by R. Rowden Foote. Butterworth. 1954. Medical Mycology by Emma Sadeler Moss and Albert I. McQuown. Balliere, Tindall & Cox. 1953. Conquest of Plague by L. Fabian Hirst. Oxford University Press. 1953. Diseases of the Nervous System by F. M. R. Walshe. 8th edition. Lippincott. 1955. Recent Advances in Endocrinology by P. M. F. Bishop. 7th edition. Churchill 1954. New Worlds and Old by Charles Singer. Heinemann. 1951. Ancient Therapeutic Arts by W. Brockbank. Heinemann. 1954. Principles of Internal Medicine by T. R. Harrison. 2nd edition. Blakiston. 1954. Disorders of the Blood by Sir Lionel Whitby and C. S. C. Britton. 7th edition. Grune & Stratton. 1953. CHOLANGIOGRAPHY Postoperative or residual stone in the common bile duct is a common and serious surgical problem. In at least 10% of all common duct explorations one or more stones are overlooked, bile duct is approximately 10%. Postoperative cholangiography through the T tube has proven a useful diagnostic technique and demonstrates residual stone very frequently. Recently intravenous cholangiography using cholografin has been found to demonstrate the common bile duct and residual stones in a high percentage of cases, particularly in the absence of the gall bladder, jaundice, or poor liver function. During the past few years many surgeons have become interested in operative cholangiography as an adjunct to common duct exploration. "Diagnostic" operative cholangiography carried out through a tube tied in the cystic duct enables the surgeon to decide as to the need for common duct exploration when this is not clearly indicated by clinical and operative findings. "Control" operative cholangiography by injection through the T tube after common duct exploration and before the abdomen is closed, demonstrates the adequacy or otherwise of the common duct exploration. The need for further exploration, at times augmented by duodenostomy and retrograde exploration of the common duct, is clearly demonstrated when there are residual stones or obstruction from any cause. Page 468 BIBLIOGRAPHY 1. Behrend, A. and Steppacher, L. G. The Hazard of Retained Common Dust Stones. Am. Jl. Surg. 87: 520, 1954. 2. Hicken, M. R, Hunt, H. B., and Best, R. R. Cholangiography. Ann. Surg. 103: 210, 1936. 3. Best, R. R. Cholangiographic Demonstration of the Remaining Common Duct Stone and its Non- Operative Management. Surg., Gyn. & Obst. 66'. 1040, 1938. 4. Clark, C. W., Jr. Operative Cholangiography, Survey of Present Day Opinion. Am. Jl. Surg. 88: 599, 1954. 5. Cotte. Refer to ref. 14 (French). 6. Gabriel, B. B. Proof of Potency of a Common Bile Duct. Lancet, i: 1014, 1930. 7. Glenn, F. Common Duct Exploration for Stone. Surg., Gyn. & Obst. 95: 431, 1952. 8. Glenn, F., Evans, J., Hill, Malcolm and McClenahan, John. Intravenous Cholangiography. Ann. Surg. 140: 600, 1954. 9. Gray, H. K. and Sharpe, W.S. Beliary Dyskinesia: The Role played by a Remnant of the Cystic Duct. Proc. Mayo Clinic, 19: 164, 1944. 10. Hardy, J. D. Duodenotomy for Common Duct Stone. Surg., Gyn. & Obst. 94: 251, 1952. 11. Hicken, M. F. Reference to Clark, C W. See Ref. 4. 12. McBerney, C. Removal of Biliary Calculi from the Common Duct by the Duodenal Route. Ann. Surg. 28: 481, 1898. 13. Howard, M.A. Experiences with Cholangiography during Surgery. Am. Jl. Surg. 88: 56, 1954. 14. Mehn, W. H. Operating Room Cholangiography. Surg. Clinics North America, Feb. 1954, p. 151. 15. Xixter, C. G., Hermanson, L. and Seyel, A. L. Operative Cholangiography. Ann. Surg. 134: 346, 1951. 16. Pribram, B. O. C The Method for Dissolution of Common Duct Stones remaining after Operation. Surgery, 22: 806, 1947. 17. Thornton, J. K. Observations on Additional Cases illustrating Hepatic Surgery. Lancet, 1: 763, 1891. ANNUAL MEETING of the College of Physicians and Surgeons of British Columbia Tuesday, October 4th, 1955 - 8:00 p.m. HOTEL VANCOUVER, SALON A This meeting is being held in conjunction with the Annual Convention of the C.M.A., B.C. Division, to facilitate the attendance of out of town members. In addition to the regular business of the Meeting, our Council have been most fortunate in securing an outstanding Canadian speaker in the person of Dr. T. L. Fisher, who, in addition to serving on the Executive of the Canadian Medical Protective Association is Chief of Department of Medicine Ottawa Civic Hospital and Assistant Professor in Medicine at Queen's University. Dr. Fisher's address will cover factors involved in malpractice suits, the duties and responsibilities of doctors, and common errors which could result in medico-legal action. This will be followed by a question period. As has become the pleasant custom at these meetings, Honorary Life Memberships will be presented to four members of the College. As the Guest Speaker is giving an address on a matter of general interest and vital concern to the entire Profession, it is anticipated there will be a large attendance. LYNN GUNN, Registrar. Page 469 UROLOGICAL ASPECTS OF STRESS INCONTINENCE IN THE FEMALE^ " jf; H" S E. FRANCE WORD " M J| B.S., M.D., F.R.C.S. (CANADA), F.A.C.S., F.I.C.S, In this age of ultra-speculation in medical practice the occasional problem is encountered which interdigitates between the specialties and is often kicked around from one group to another with no single group willing to assume the over-all responsibility. The subject under consideration is said to fall in this category. The problem of stress incontinence in the female is seen by the general practitioner, the gynaecologist, the general surgeon and the urologist. I will not argue into which slot this problem should be stuffed, but will consider the problem and its various ramifications from my own point of view. Involuntary loss of urine under conditions of stress and strain is one of the most perplexing problems, not to mention the social embarrassment it causes which the female has to face. These unfortunate people are naturally ill-at-ease, and often hesitate to confide in their closest friends. They accept their plight as one of the unfavourable visitations of the gods. As Balzac once said, "Le Dieu represent le progres." Fortunately for these unhappy individuals progress has been made to the point where most of these patients can be relieved of this distressing situation. Although urinary incontinence is a very common ailment among women, there are many types and degrees of lack of urinary control. Partial Incontinence Due to:—1. Stress Incontinence caused by weakness of the sphincter mechanisms. 2. Urgency incontinence. 3. Overflow incontinence. 4. Stranguria from cystitis, etc. 5. Small uretero-vaginal fistula. 6. Vesico-vaginal fistula. 7. Congenital lesions (ectopia). 8. Lesions of the Central Nervous System. Complete Urinary Incontinence 1. Large vesico-caginal fistula. 2. Bilateral uretero-vaginal fistula. 3. Congenital lesions, e.g. exstrophy of the bladder, absence of vesical sphincter. 4. Lesions of the Central Nervous System. A great many of these types of urinary incontinence can be found in both sexes. Some of these, such as exstrophy of the bladder, are more common in the male than in the female. Many of the causes of incontinence listed here are treated at great length in the various gynaeological texts and will not be considered in this paper, but what we are interested in is Stress Incontinence in the female, and this may be defined as, "The Involuntary escape of small quantities of urine on straining, sneezing, coughing or increasing the intraabdominal pressure." The degree of incontinence varies with each individual patient. It may amount to only a few drops of urine and be present only at infrequent intervals, or, on the contrary, it may be very troublesome, both because of the amount of urine that escapes and the constancy of the condition. It is very important that stress incontinence be differentiated from incomplete incontinence that accompanies irritative lesions such as chronic cystitis, vaginitis, urethritis and ureteritis. In the stress incon- J ' CD ' tinent patient there is no significant frequency and no pain on voiding. However, when the desire to void appears, they cannot postpone urination without the scape of a small quantity of urine. Page 470 Long ago the importance of careful study of the upper urinary tract, especially of the ureters, in all cases of obstinance incontinence was stressed. Both of these conditions, that is, stress incontinence and incontinence due to irritating lesions, CD * are very common and are often associated with each other. Hence, a careful urological history and examination are always indicated because the treatment is entirely different. If the person with typical stress incontinence also has urgency due to urinary infection, the operative treatment for stress incontinence would probably be unsatisfactory unless the irritation was cleared up first. In a like manner, if the urinary organs are restored to a healthy condition before operation, the urinary control j may be so improved that operative treatment for stress incontinence may be unnecessary. I would like to point out here, however, that a fair percentage of cases with j cystoceles and smaller or greater amounts or residual urine will have developed cystitis I due to this infected residual urine, and would be completely relieved of their i symptoms once the anatomical defect is corrected, no longer requiring the aid of : medical treatment. Stress incontinence may recur at any age, although it is typically a disorder of j the obese, middle-aged parous woman. It must be recognized that the sphinctet j mechanism in the female is not as effective as in the male. Minor degrees of stress I incontinence are not uncommon even in virgins. It may occur in the absence of ! childbirth, injury, cystocele, or prolapse of the uterus or bladder. On the contrary there are many cases of cystocele and complete prolapse of the entire uterus, upper /agina, bladder and rectum in which urinary control is perfect. We have also seen jorae unfortunate cases in which a well-performed and satisfactory operation for prolapse was followed by stress incontinence which was not present before the operation. Hence the factors which produced stress incontinence are inconstant and difficult to evaluate. This uncertainty has a definite bearing on the prognosis and type of treatment, so in order to approach this problem it is first necessary to have a basic knowledge of the anatomy and physiology involved and of the pathological deviations from the normal. I feel it is practical for the surgeon dealing with this problem to consider the female urethra as traversing the pelvic floor and its component parts just as the testicle in the male traverses the inguinal canal. Unlike the indirect inguinal hernia following upon the heels of the testicle and being always congenital in origin, the relaxation of the urethra and bladder supports which so frequendy follows the stretching of the birth canal at delivery or from atrophy at menopause is usually an acquired type of hernia more like the direct type of inguinal hernia in the male. The pelvic floor anatomically is arranged in three layers. The urethra traverses three muscular layers, the levator ani, the deep transverse perinei, and the bulbo-cavernosus. The strongest layer is the levator ani stretching from the symphysis pubis along the white line to the ischium and is divided into three parts; the pubo-coccygeus, the ilio-coccygeus, and the ischio-coccygeus. These muscles with their supporting fascia constitute the pelvic diaphragm. Of these, the pubo-coccygeus is closely allied with the physiology of micturition. Enlargement of the genital hiatus, like enlargement of the inguinal canal, allows the organs to present to the outside. The second layer of the pelvic floor is the uro-genital diaphragm which forms the middle wall of the pelvic floor and stretches from the rami of the ischium on either side and covers the genital hiatus. This layer in the female is pierced by the urethra and vagina. This layer is composed of a musculo- connective tissue plate. The apex of this plate is directed toward the symphysis, stretching laterally to the public rami. The deep transverse perineus muscle is enclosed in this plate as well as the sphincter muscle of the urethra. The third layer of the pelvic floor is the sphincter layer, the external sphincter of the rectum, the bulbo-cavernosus (or constrictor cunei) which serves as the constrictor of the vagina. All of these three layers of muscle have a direct relationship to the genital hiatus. They are somatic in origin and are all supplied by the pudendal Page 471 nerve. The sphincters of the bladder and urethra are composed of two separate sets of muscles, having different origins and nerve supplies. The sphincter of the urethra is somatic, taking its origin from the deep transverse perineus and is supplied by the pudendal voluntary nerve. This muscle is referred to as the rhabdo-sphincter. This rhabdo-sphincter is a part of the urogenital diaphragm which has been pierced by the urethra and vagina. The striated fibres of this muscle surround the urethra and vagina. The sphincter vesicae internus is composed of smooth muscle. This musculature is referred to as the lisso sphincter. This muscle is fashioned at the bladder neck like two horse-shoes facing away from each other. The limbs of this horseshoe arrangement hold the neck of the bladder as if in a vice. This sphincter is composed of smooth muscle and is supplied by the autonomic nerves. This double loop of muscle acts as a pressing mechanism forcing the walls of the vesical orifice together except during the act of urination. In addition to this sphincter muscle the carvernous nets which surround the base of the urethra also act as constrictor mechanisms. As the bladder fills it takes the shape of a ball; as the bladder is emptied the activity of the circular vesical musculature makes it assume the shape of an egg. Two things happen during the mechanism of voiding: — 1. The fibres surrounding the neck of the bladder, the lisso-sphincter loops, are relaxed. 2. The vesical orifice moves toward the pelvic floor, which in turn relaxes the vesical neck by virtue of the pubo-vesical ligament holding back the anterior wall of the vesical orifice. In other words, the vesical orifice is pulled apart. This relaxation of the bladder neck likewise allows the cavernous sinus to empty. When voiding is completed, the pubo-coccygeus contracts, elevating the base of the bladder which in turn causes contraction of the lisso-sphincter and congestion of the cavernous sinus. This mechanism is enhanced by continued filling of the bladder. The sphincter muscle, or compressor urethrae, which is circular in the resting stage or stage of continence, takes an oblique position when the pelvic floor and the base of the bladder is lowered, such as in the act of voiding, thus allowing the escape of urine. Incontinence will be present in direct proportion to the amount of oblique distortion of the true sphincter, and will be permanent if the true sphincter is unable to retain its normal circular contour. The two chief factors which distort the sphincter are: — 1. Para-urethral adhesions. 2. Relaxation of the bladder neck supports, causing sagging of the bladder neck. Requirements for the restoration of continence are to restore completely the relaxation of the muscles of micturition by putting the internal meatus of the urethra as far back in the pelvis as possible; restore the contracting power of the levator ani, the transverse perineus and the bulbo-cavernosus muscles; finally to restore as much as possible the damage inflicted on the trigone and adjacent bladder wall and anterior vaginal wall. Cystoscopic and panendoscopic examination of these patients shows no apparent lesion of the compressor urethrae muscles in over 30%. When these patients are asked to contract the perineum under vision, the bladder neck does not rise jn a normal manner. 15% to 20% of these patients with accompanying large cystoceles have varying amounts of residual urine. 80% of •these with residual urine show some signs of trabeculation of the bladder. Recurrent infection is common in this group. With the Braun-Berger convex sheath undue relaxation of the base of the bladder can be demonstrated. Cystometer recordings are usually within normal limits in the absence of nerve lesions or in the rare exception where large amounts of residual urine have been present over long periods of time. It is now thought that man utilizes a group of striated, somatically nervated muscles in which he initiates the reflexes of micturition. These important muscles Page 472 re the diaphragm, the accessory muscles of respiration, and the pubo-coccygeal bortion of the levator ani. The act of urination is brought about as follows:— Voluntary micurition begins with a slight increase of intra-abdominal pressure which |s brought about by fixation of the diaphragm at the end of a brief inspiration and ;ontraction of the abdominal muscles. 'The contraction of these muscles is associated vith relaxation of the muscles of the pelvic floor. It is the pubo-coccygeal muscle of the pelvic floor which is particularly concerned with this process. As a result of this ncreased intra-abdominal pressure and the relaxation of the pubo-coccygeus, the pladder neck is pushed downward. It is this downward push on the bladder neck vhich initiates the stimulus of the para-sympathetic part of the autonomic nervous ystem which causes the detrusor muscle of the bladder to contract and thus precipitates the reflex of micturition through the reciprocal opening of the internal sphincter pd of the proximal urethra. Involuntary inhibition of the urinary stream is carried mt, not by the mere contraction of the external sphincter muscle as we were origin- Uly taught, but by the contraction of the entire levator ani muscle. This contraction )f the levator ani muscle elevates the bladder base, which has originally been depressed py relaxation of the pubo-coccygeus. This elevation causes the external sphincter to [nap shut. It changes from the oblique to its circular contour and the urinary stream k thus prompdy shut off; first at the internal sphincter, not at the external sphincter. fThis concept of the physiology of micturition emphasises the importance of the normal function of the levator ani and its component, the pubo-coccygeus. These jnuscles are the primary means by which man exercises voluntary control over hi_ urinary stream. When the function of these muscles is abolished it becomes impos- [ible for man to start or stop micturition at will. Without the use of the voluntary mechanism, micturition becomes dependent entirely on the response of the detrusor knd to other stimuli other than somatically nervated muscles. fhe Mechanisms of Stress Incontinence: Litde progress was really made until 1948 at which time Read and Millan levised a cystogram technique of the study of urinary incontinence in the female. p 1949 Muellner portrayed the dynamic events of micturition and the specific esions of stress incontinence. The precise pathology of stress incontinence becomes ipparent when the findings in the normal nullipara and in the continent multipara kre compared with observations in women with stress incontinence. Using a technique of filling the bladder through a 16 French Foley Bag catheter pith a contrast medium consisting of a 5% solution of Sodium Iodide, the bladder is piled to a capacity of 200 to 250 cc. of this mixture. X-Rays are taken while at [est, coughing or steaming. Muellner found that in the normal nullipara while fecumbent the bladder had a smooth oudine and its base was located just above me symphysis pubis. This position of the bladder was maintained when the patient [tood up. On coughing, the bladder base did not yield, but the impulse from the pcreased intra-abdominal pressure was disseminated along the dome and sides of he bladder revealing the excellence of the bladder supports. When the normal nullipara was asked to void, the bladder base descended sharply so that the position pf the internal urethral meatus became the most dependent portion of the bladder pd assumed a pointed appearance. It is here that the internal sphincter opens dightly and permits a small amount of the contrast medium to enter the proximal urethra. As contraction of the detrusorvesicae follows, uninterrupted micturition psues. Once micturition is started the bladder base returns to a position slightly ower than that of its resting phase. If the patient is asked to stop or inhibit the urinary stream the bladder base rises quickly to a level slightly lower than it had assumed before micturition. In the continent multipara the events are similar except the bladder is somewhat larger and flabbier and the base affords a little more yield. After having studied this problem now for several years, I feel that it is Extremely important to make cystoscopic observations on each and every case of tuspected stress incontinence. The X-Rays are relatively simple and can be done in Page 473 the office with a 100 milliampere machine, and at the same time as the cystoscopic examination is being carried out, the actual relaxation of the bladder base can be determined. In women with stress incontinence, while recumbent the bladder shape is very much like that of the continent multipara. If the patient coughs while lying in this position the bladder base makes a considerable excursion downward. The incontinent patient in a standing position and straining shows the bladder neck to descend and become the most dependent portion of the bladder. The bladder base assumes a pointed appearance characteristic of the bladder that is poised fforj micturition. It is this abnormal descent and forward position which causes relaxation of the vesical sphincter, resulting in stress incontinence. In my own observation on these cases of stress incontinence, cystoscopic, examination shows a sagging of the trigone with relaxation of the bladder neck, taking on a funnel-like appearance not unlike that seen in some cases of cord bladder. When the patient is asked to tighten the perineum with the cystoscope in place there is a failure of proper elevation of the bladder neck. Panendoscopic examination may or may not show weakness of the depressor urethra muscle. Diagnosis of Stress Incontinence The diagnosis of stress incontinence in the female is made by the following observations and tests:— 1. History—A careful history should be taken on every female patient. The date of origin of the stress incontinence; is it constant or intermittent. 2. Physical Examination—In addition to a routine physical examination, consider the possibility of congential anomalous lesions of the nervous system such as cord bladder, intrinsic lesion of the bladder neck, extrinsic causes, such as tumour of the cervix, fistula .or socalled false stress incontinence, which is in reality an extreme degree of urgency and frequency of micturition. 3. Urinalysis—This is a most important point in the diagnosis. In addition to routine chemical examination, microscopic studies should be done by the physician himself on a fresh specimen of urine. Cultures should be routinely carried out and the patient should always be checked for residual urine. It must be remembered that a woman can have overflow incontinence the same as the male patient; and lesions such as urethritis, cystitis and ureteritis must be ruled out. 4. Cystoscopic Examination—This is probably the most valuable single means of reaching the proper diagnosis; not only can ureteritis, cystitis and urethritis be ruled out, but tumours, foreign bodies, abnormal anatomical developments can accurately be observed by having the patient strain, relax, cough, etc. with the cystoscope or panendoscope in place. Sagging of the bladder neck can also be observed. The relaxation of the bladder neck and its relationship to the symphysis can be determined. 5. Radiograms—li these are done properly, they are a very valuable means of diagnosis and it must be remembered much of the original research depended on the interpretation of the anatomical relations recorded by X-Rays. 6. The Urethral Elevation Test—In the United States this test is called the Marchetti Test. This is also an office procedure consisting of making a wheal of novacaine on the anterior vaginal wall at a point between the ureteral orifices. This point can be accurately determined by a cystoscopic examination.J|An Allis tack is then used to grasp the mucous membranes of the anterior vaginal wall and push upward toward the umbilicous while the patient coughs, strains or tries to intitiate the act of urination. If continence results from this elevation test, then a repair, giving a permanent elevation of the bladder neck should bring about excellent results. Page 474 I The Treatment of Stress Incontinence in the Female: It is probably advantageous to divide treatment into three phases:—1. Prophylactic [Treatment. 2. Non-Operative Treatment. 3. Operative. 1. Prophylactic Treatment—Consists of ante-partum care; intra-partum care, that is, at the time of delivery; and post-partum treatment. I will not go into the intricacies of this form of treatment as these are dealt with in any standard gynaecological text book. 2. Non-Operative Treatment—Consists in first making an adequate diagnosis with the elimination of infection nerve lesions, fistulas, etc. Non-operative treatment also consists of dilating the urethra to break up any adhesions. The perineometer is considered by some to be a very useful adjunct in the management of these cases in that it trains the patient to use the proper muscles for control of the urinary stream. Many mild cases of so-called stress incontinence are actually not stress incontinence. These patients respond very nicely to dilatation of the urethra and the instillation of Sdver Nitrate Solution 1/1000 into the bladder, and in the use of medicated urethral suppositories. Cases that respond to this type of treatment are not usually true stress incontinence cases, but they clinically present themselves I as such. 3. Operative Treatment—No one method seems to be superior for all types of cases. Each case presents specific problems. The various types of operations may be grouped into the following categories: (a) Pelvic Repair and Plication of the Bladder Neck from below—this is simply Ian anterior and posterior colporrhaphy with plication and elevation of the bladder [neck incorporated into the vaginal repair. (b) The use of transplanted muscles or fascia from- below. The sartorious j muscle has been used on many occasions with varying results. (c) The supra-pubic approach for means of elevation of the bladder neck. The various types of sling operations are included in this group. (d) Simply lengthening of the urethra from above, that is, freeing the urethra of all of its adhesions and lengthening it. In reality this procedure allows the bladder neck to rise. Although this operation has been hailed by some as being an excellent procedure, there is no one group of cases large enough and of sufficient duration to be properly evaluated at this time. In view of the fact that by far the majority of stress incontinence cases that we see follow child-birth it seems rational to suppose that a careful pelvic repair with elecation and plication of the bladder neck from below would be the operation^ of choice in a large majority and that the most satisfactory results should follow this type of procedure. This procedure is simply an anatomical repair of the herniation of the pelvic organs through the pelvic diaphrogin. It is not unlike the repair of any other hernia. Results of Treatment |p| The results of our study here are based on some 97 cases. Some of these cases date back over a period of 15 years. The majority of these, however, have been done \ in the last 7 years. In this group there have been four cases that we have considered complete failures. Two of these eventually required uretero-intestinal transplants. Nine of the cases have shown varying degrees of improvement. Over 80% of the cases have shown satisfactory to excellent results, and would probably recommend I the operation to their friends. I would like to stress, however, that these cases should be followed over a long period of time. The immediate results may appear to be brilliant but in a year or so I the patient may present herself to the office complaining once again of stress incontinence. One should not become too immediately discouraged if the patient presents Page 475 herself stating that she has again lost control of her urine, because many of these cases will not actually have stress incontinence but will have urgency due to a low- grade urethritis trigonitis. Simply dilating the urethra and instillation of Silver Nitrate Solution into the bladder and the use of urethral suppositories will often give them a miraculous cure. Summary and Conclusions For those who are seriously interested in this problem, and this problem does from time to time involve by far the majority of our profession I would like to outline our procedure of handling these cases. Being in a position of doing no maternity work these cases zre\ mostly all referred cases either by doctors who are fed up listening to their complaints and having them come into the office with wet clothing or by other patients who have been operated on for stress incontinence and have felt that they have benefited. When we first see these cases we are usually completely unfamiliar with the social and mental background of the patient or the past history of events. We therefore start with a careful history. This is followed by a complete physical examination and urinalysis with a catheterized specimen of urine. The patient is also checked for residual urine. Following this part of the precedure, if we feel that the patient probably falls into the category of stress incontinence, they are then prepared for the following procedures: (A) A cystoscopic and Panendoscopic examination. At this time renal secretion tests are carried out, usually using indigo carmine intravenously. (B) Following this procedure, cystograms are made in a lateral position using a lead marker on a 16-French Foley Bag catheter and the patient is X-rayed in resting and straining positions. (C) Following this procedure with the catheter still in place the cystometer is attached to the catheter and the bladder pressures are recorded. After having carried out the various procedures in the order listed above, one will not drift far astray in any particular case and a fairly accurate diagnosis can be reached. It is only after carrying out the above procedures that I feel we are entitled to advise a patient as to whether or not she would be likely to benefit from surgery. Although a few of our results have been appalling and we have had to resort to uretero-intestinal anastomosis, in the last few years after having carefully studied the detailed anatomy, physiology and pathology involved, the results have become increasingly better. I would like to again repeat that this is a problem with which most of us are faced with from time to time. It is a problem which must not be taken lightly as the entire personality of the patient can be distorted if she is handled in an improper manner and poor final results are obtained. I also feel that a definite routine must be established for these patients if an accurate diagnosis is hoped to be arrived at and good results obtained. Although this requires a great deal of effort on the part of the surgeon, these efforts are soon~forgotten when one of these poor despondent women presents herself for her first post-operative check and has a radiant beam of pleased delight because she can now cough, laugh, dance and carry on in a normal manner without fear of dampening her lingerie. SPECIALIST DESIRES LOCATION Eye, Ear, Nose and Throat man, age 39. Desirous of locating in B.C. Prefer association or purchase of established practice. For further information call the Publisher, MArine 7729. Page 476 The Bulletin is glad to publish the following very brief summary of the work being done by the Family Service Agency of Greater Vancouver, an agency of the Community Chest. The Bulletin feels that the medical profession does not know enough about this work — and does not make the use of it that it should. Only some 5% of this agency's calls come from doctors. Those of us who have taken advantage of this agency's casework can testify to the invaluable help it can give. Editor. SPECIALIZING IN THE FAMILY by KAY BELANGER (Former caseworker and now member of the Board of Directors of the Family Service Agency of Greater Vancouver) The family physician treats a family's medical problems; a famfly service agency treats its social and personal problems. And while the family physician and the family caseworker have, necessarily, different viewpoints, different skills and techniques, their goal, basically, is the same, to produce health in the families under their care. Health, in this broad sense, is more than a bodily state; it is, hopefully, a state of effective physical, emotional and social functioning. This combination of conditions is like the chicken and the egg. Nobody knows which, in the beginning, came first. A man tries to handle a job that's too big for him—he gets an ulcer; or because he has an ulcer his job becomes more than he can manage. A mother gets T.B. but treatment isn't effective because she's so tense with worry about her children that she can't relax; or, conversely, she's so overwhelmed by personal problems that her physical condition has deteriorated to the point where she's prey to the first germ that comes along. Families are complicated things, even more complicated than the individuals who make them up. Whenever something happens to upset a family—physical or mental illness, unemployment, a marital disturbance, behaviour problems in the children, each member of the family is affected in one way or another. In the main, people do not have problems simply as individuals; they have problems as members of families. When they are ill they are not only sick individuals but sick members of families. The family physician knows this well; the knowledge he has of the relationship within the families he cares for helps him to gear his treatment to their needs with understanding and effectiveness. He is in a position to know that a small boy's resdessness in sleep coincides with a move to a frightening new environment; he is [well aware that Mrs. Smith always gets a low-back pain whenever her husband is unemployed. Family caseworkers have regretted, at times, the present day division of responsibility between the specialist and the family physician with its accompanying loss of close contact with the patient in his family group, at the same time applauding the miraculous advances in medical knowledge that have made specialization necessary. However, it is beginning to seem that the family physician is not only refilling his old role but is finding himself a new one, that of a specialist among specialists. More and more families are seeking out a physician who can fill their needs as a group. Families don't mind being placed in medical categories so long as they can return to home base when the need for the services of specialists is over. And home base is the family physician. Alone, no matter how competent he is, he cannot give to his families the benefit of all the new knowledge and techniques in medicine; he must know when to call upon the services of specialists. But in most cases he remains the family physician. No one else has the intimate knowledge of the family's history of illness, or their reactions to illness. He is the family specialist. Family service agencies, too, have seen a necessary change in function. For many years after the inception of the first agency of its kind in 1877, only the poor Page 477 could bring their problems to a family agency. If you were self-supporting you were supposed to be able to look after yourself. If you were rich you could afford, presumably, to hide your problems in the closet like the proverbial skeleton. The whole thing, of course, was about as sensible as if one were to say that only the poor get sick. For many years family caseworkers gave money, clothing, food, but gradually the realization dawned on us that many of those we tried to help were still unable to manage under their own steam. Then we began to hunt around for other methods of helping—still only the poor, of course. We searched busily for jobs, housing, medical care, glasses, false teeth, second-hand bicycles, betterment courses. And we still found that people went on being miserable, couldn't hold the jobs that were found for them, weren't responding to the medical care given to them. No matter how much was given to some families it was never enough; others could not use what was offered. And so, after many years of study, experiment and research in ways of helping, we came at last to the realization that there were factors inside people — inadequacies, maladjustments, uncertainties — that kept them from effectively using the help offered. Out of this realization came the practice of professional casework as we know it today. When the disastrous depression of the thirties made it imperative that public departments be set up to spend tax money for the financial maintenance of huge numbers of destitute families, family service agencies were at last set free to develop skills and special techniques to deal with these inner needs in troubled families. Schools of social work were set up to impart the body of knowledge and skills compiled over the many years of practice and careful research. And so a new profession was born — a healing profession — one dedicated to the healing of social and personal ills. It is now considered that two years of post-graduate training in a recognized school of social work is a minimum requirement for a competent caseworker. Along with tbe necessary theoretical training goes field work in a functioning social agency. This field work might be compared to a short interneship. In helping people to come to grips with their problems, the caseworker's main tool is his relationship with the people whom he or she helps. This is a familiar word to the family physician and he uses the physician-patient relationship in all his dealings with his patients, often unconsciously, but nevertheless as a part of treatment. The best physicians know instinctively that the patient and the way he feels come first, the germs second. In casework the relationship is used consciously and for a definite purpose, but it still must have its basis in a genuine, mature liking for people. Without this liking and concern for people and a pervasive sensitivity to their needs a caseworker would be about as effective and as curative as a surgeon trying to operate with a pair of rusty garden shears. Within this relationship the client finds first that the caseworker is to be trusted. All information given is confidential; weaknesses are not scorned but accepted; strengths are encouraged. The client finds out that in spite of what the world has done to him or what he may have done to himself, he has worth; that he counts for something, that there is hope for a solution to his problem. This coming to grips with a problem is a slow business, requiring much patient skill on the part of the caseworker and as much effort as the client can be helped to muster. Since the days when we finally had to admit that new teeth or a course in barbering weren't going to help a dependent man into solid employment, we've come to the firm conclusion that it is only the things a man, with skilled help, can do for himself, that count and last. Just as it is in the last analysis the patient, with the physician's skilful help, who cures himself. It may take only one or it may take a number of interviews before even a diagnosis of a problem can be made. Then one or two interviews may be enough Page 478 to give a client real and lasting help. Sometimes many interviews over a long period of time are needed. Sometimes people have such insurmountable problems that no help is possible except encouragement and the knowledge that they can share at least part of their burden with the caseworker. Sometimes people cannot see, or prefer not to see that they themselves are largely responsible for their own difficulties; sometimes they are unwilling or even unable to make the effort necessary to change their situation. Then, of course, little help is possible. Briefly and broadly grouped, here are some of the problems dealt with at the Family Service Agency of Greater Vancouver1 — difficulties in marriage, problems in handling children, personality maladjustments (except where referral to a psychiatrist is indicated), individual troubles and family tensions arising out of physical illness, care of children in their own homes through the Supervised Home- maker service,2 problems in budgeting the family income.3 The services of the Family Service Agency are available to the people of Greater Vancouver (including Burnaby), West Vancouver and North Vancouver. In other areas of B.C.—except Victoria which has a family service agency—problems in the above categories would be handled by the family service divisions of the various Provincial Government Social Welfare Branches. The Family Service Agency is entirely supported by Community Chest funds. There are eighteen professional caseworkers on the staff and a clerical staff of eight. Confidential records are kept on each family for purposes of diagnosis, treatment and research. Fees are charged on a sliding scale according to the family's ability or wish to pay, but whether fees are paid or not the service is the same. The first step in referring a patient for the kind of family counselling available at the Family Service Agency is to telephone. If a service is indicated, much valuable information can be secured from the physician which will help to make the service quicker and more effective. If the situation is not one for the Agency, the physician will be informed of other appropriate sources of help, and the patient will be saved steps and a needless repetition of his story. Each caseworker must know the available sources of help in the community and which of these sources is directly fitted to help each individual with his particular problem. Just as the family physician must sometimes enlist the help of specialists for /sick patients so must the family caseworker know when to seek the assistance of specialists for people in trouble. This assistance may need to come from doctors, lawyers, nurses, ministers, psychiatrists, vocational counsellers, or other health and welfore agencies. The main concern of the Family Service Agency is to strengthen the family and help it to function effectively. And in these tense days, the family needs all the help it can get. 1. Formerly the Family Welfare Bureau of Greater Vancouver. 2. This Service is at present limited to families where the mother's illness is temporary and where the income does not enable the family to make its own plan. While the Service is designed to meet short term needs, service for a longer period is occasionally arranged. For chronic illnesses or other situations involving special needs, service will be considered on a temporary basis to give opportunity for more adequate plans for the future. 3. Families in need of financial help because of the wage-earner's illness of unemployment are referred to the appropriate public assistance agency. Pace 479 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull Vancouver President-Elect—Dr. E. W. Boak i 1pl_ Victoria Immediate Past President—Dr. R. G. Large . Prince Rupert Chairman of General Assembly—Dr. G. C. Johnston Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer Vancouver Executive Secretary—Dr. G. G. Ferguson '-. Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bonnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F. Sparling Dr. P. M. McLean Kootenay Dr. S. C. Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall Dr. P. O. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C. Poole Dr. N. J. Blair Chairmen of Standing Committees Constitution and By-laws 1 Dr. Carson Graham, North Vancouver Finance Dr. R. A. Palmer, Vancouver Legislation ;|§_ Dr. E. W. Boak, Victoria Medical Economics Dr. P. O. Lehmann, Vancouver Medical Education Dr. M. M. Weaver, Vancouver Nominations : Dr. F. A. Turnbull, Vancouver Programme & Arrangements Dr. W. M. G. Wilson, Vancouver Public Health . Dr. G. R. F. Elliott, Vancouver Public Relations Dr. A. W. Bagnall, Vancouver Chairmen of Special Committees Archives ~- Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism Dr. J. A. Traynor, Vancouver Cancer I Dr. Roger Wilson, Vancouver Civil Defence _ Dr. John Sturdy, Vancouver Ethics ? . i Dr. Wallace Wilson, Vancouver Hospitals -_ Dr. G. C Johnston, Vancouver Industrial Medicine . Dr. G. B. Helem, Port Alberni Maternal Welfare : Dr. A. M. Agnew, Vancouver Membership^- Dr. N. J. Blair, Vancouver Nutrition ._.. Dr. J. F. McCreary, Vancouver Pharmacy .. Dr. B. T. Shallard, Vancouver Rehabilitation $Sm Dr. W. J. Thompson CONVENTION NOTES To the Ladies! The Ladies' Committee, Canadian Medical Association, B.C. Division, is hoping that many of the wives will be accompanying their husbands to the meeting to be held in Vancouver from October 5 to October 7. A full programme of entertainment is being planned in your honour, and for the three days there will be hostesses to advise you about golf, shopping, baby-sitting, tours, or anything else to make your visit a comfortable and enjoyable one. ||f| Doctors throughout the province should receive their programmes the first week in September, and attached will be a pink card. Ask your husband for this card, which concerns the programme of events for the ladies; mark the functions you wish to attend, and return the card to the address on the reverse side. Mrs. Frank Turnbull, chairman, will be assisted by the following convenors of committees: Mrs. Peter Lehmann, secretary-treasurer; Mrs. George Elliott and Mrs. Russell Palmer, registration; Mrs. John Ganshorn and Mrs. Gordon Johnston, hospitality; Mrs. Bill Wilson and Mrs. Frank Olacke, entertainment; Mrs. George Davidson, golf and transportation; and Mrs. Donald Munroe and Mrs. Leigh Hunt, publicity. Pa-re 480 Registration wil 1 take place at Hotel Vancouver on Wednesday morning, October 5, from 9 to 11:30. The same day a reception and coffee party will be given at Point Grey Golf Club from 12 to 2 p.m., with registration continued. Thursday, October 6, out-of-town ladies have been invited to tea at the home of Mrs. G. F. Strong from 3 to 5 p.m. That evening an informal buffet dinner-dance will be held at H.M.C.S. Discovery, beginning at 7 o'clock. Friday evening, October 7, a dinner- dance will be held in Hotel Vancouver banquet room. This is a formal function, but you will be welcome if you do not have your formal clothes with you. The ladies' committee is looking forward to your visit and to welcoming you on the morning of Wednesday, October 5. MRS. DONALD MUNROE, Publicity Chairman. ii ii ii ii DOCTOR-PATIENT RELATIONSHIP J| H It is a great tribute to our profession that there are few registered complaints related to our handling of illness. In general the public accepts the doctor and his efforts at diagnosis and treatment without question. Our patient comes to us in trust and confidence. He believes that his doctor is the best doctor in town. It must be so. We can order expensive diagnostic tests to no avail. We can prescribe costly medicines that do not help. We can carry out morbidity producing surgical procedures without benefit. We can remove his tonsils, his appendix, his gall bladder and other things without relieving the symptoms that brought him to us. Occasionally he will carry his problem on to another doctor. Should the second doctor know a more successful treatment, the patient seldom complains that the original doctor should have known this treatment. For the most part he assumes that we all do our best, and that is all that he asks of us. This places on us a tremendous responsibility. The responsibility to warrant this confidence. Occasionally we hear rumours that would suggest that we have failed. Occasion ally the patient does assume that the original doctor should have utilized the more successful treatment. He found that it was wise to shop. Next time he will shop earlier. We criticize the shopping patient. In efforts is he not, often, protesting failure on our part? He shops because he has lost confidence in the individual among us. He consults irregulars because he has lost confidence in us as a group. Is not the multi- scarred abdomen a reminder of our failure at proper diagnosis and treatment? We can rationalize our mistakes by applying the old medical adage "Show me a patient with multiple abdominal scars and I will show you a neurotic." But rationalization does not excuse. The apprehensive patient does not give us extra privilege. Certain individual doctors would appear to have their names attached to these laboratory requisitions, expensive experimental prescriptions and surgical scars, much more frequentlv than other doctors. Though there is litde official protest, each one of us has in his office, not infrequendy, a patient who tells a story of previous treatment or recommended treatment, that in spite of maximum allowance for two points of view, suggests that the former doctor was either woefully ignorant, extremely careless, or deliberately taking advantage of a situation. The patient is aware, that is why he has sought further advice. He spreads his lack of confidence to family and friends so that they in turn begin to question and ultimately to shop. The acts of the individual create the reputation of the group. It would appear worthwhile for each of us occasionally to review our practices and assess as to whether or not we are contributing to this lack of confidence that creates _be shopping patient. Committee on Public Relations, Sub-committee on Doctor-Patient Relationship. Page 481 SOME REMARKS ABOUT THE SOCIALIZATION OF It MEDICAL SERVICES jf f§ by Dr. Frank Turnbull * The expansion of socialized medical services is not a new feature of our life in Canada. It is merely rolling faster. Canadian doctors have been party to its development for several decades — sometimes by active participation in Government- sponsored schemes, more often by passive acceptance. The leading example of active participation in a Government scheme is the Department of Veterans' Affairs Medical Service. This service is largely dependent for its operation and success on the services of part-time specialists. Passive acceptance has usually involved schemes that introduce Government care for specific diseases. We look back now and wonder how the doctors of the twenties greeted the proposed public care of their tuberculous patients. It represented a financial loss for some of them. A few did protest. The majority of doctors considered that it was a common sense public health decision and adjusted their practice to the new look. Consider how we have accepted the gradual development of public care for poliomyelitic patients in the past few years. It is obvious that the interests of individual doctors can be overlooked, or submerged, by measures that are designed to improve general medical care. Little by little the free economy of medical practice at the turn of the century has become the semi-public economy of medical practice today. This metamorphosis has paralleled a lot of other changes in our culture, notably the increasing concern of Government about social welfare. To what extent has the voice of Medicine affected the trend? Have we followed up our policy of non-participation in politics by providing constructive advice to all members of Parliament, about the good effects and the bad effects of all this change upon the quality of general medical care? Have we been remiss in our policy of informing the public-at-large about clinical matters %M maintaining aloof silence about the way in which medical services can be best provided? There was a time when the doctors of this Province spoke out and were heard. This occurred in 1936, when a Health Insurance Act was passed by the Provincial Legislature. The doctors objected to the inadequacies of the Act, and refused to cooperate. That was a dramatic stand, but it has left us poorly oriented ever since. We keep waiting for another beach-head to defend. It would be more practical to recognize that the socialization of medical services is a process that is going on all around us, and has been proceeding thus for thirty years, and more. Otherwise, we will fail, as an organized profession, to provide an effective voice when it is needed. Our Association must continue to study with care every sincere proposal for the improvement of medical services, and give considered advice to community leaders and politicians while decisions are in the making. Spokesmen for the doctors need to state the doctors' viewpoint in simple language. Principles that are windy, or ambiguous, or out of date should be thrown out. What the medical profession says must be understood by the man-on-the-street. When we try to define elusive abstract concepts like "Health Insurance" and "State Medicine". the practical politicians smile, and play havoc with our trite definitions behind the scenes. We accepted Hospital Insurance in B.C. when it burst upon us. After all, it was "insurance" and had we not been beating the drums for the "prepayment principle"! Somehow we were lulled into accepting the term "universal" in place of the offensive word "compulsory". After two years, by simple amendment of the Act, the insurance collections were abandoned, and the Hospital service was made a public charge. The "I" in B.C.H.I.S. became silent. Then we woke up. But it was too late. There was no prior discussion by the Government of this reversal of a principle, with either the Medical Association or the Hospitals Association. Neither group had established any real liaison with the Government. *President, C.M.A. — B.C. Division. Page 482 The replacement of voluntary medical services by Government-sponsored and Government-directed services, or the socialization of medical services, or call it what you may, is the stoutest plank in every political platform today. We can hold our heads and mourn dismally for the halcyon old days, or muddle along as passengers, or we can accept the fact that it is our job to be constantly aware of the changing pattern of community medical welfare and be ready to play a responsible role. ■6 ii ii CANADIAN MEDICAL ASSOCIATION — B.C. DIVISION RETURNING OFFICERS' REPORT ELECTION 4 AUGUST, 1955 If I declare the following to be elected in order of preference: DISTRICT NO. 1 VICTORIA Delegate Ballot— Edmison, Henry M. Reid, Andrew N. Trottier, A. E. Nominating Committee Ballot— Ptak, L. L. Tysoe, John F. Anderson, James W. DISTRICT NO. 2 NANAIMO Delegate Ballot— Lunam, James B. Nominating Committee—By Acclamation Baldwin, J. H. Pitts, W. C. DISTRICT NO. 3 VANCOUVER Delegate Ballot— Whitelaw, Jack W. Lehmann, Peter Wilson, Roger Austin, W. Eric Osier, Thomas R. Hurlburt, Fred W. B. Palmer, Russell A. McCoy, E. C. (Tim) Farish, James R. Graves, Horace B. Nominating Committee Ballot— Robertson, Ross Charlton, William J. Wallace, Albert W. Sarjeant, Thomas R. Robertson, C. Eric Certified True Copy G. G. Ferguson, M.D., Executive Secretary. DISTRICT NO. 4 PRINCE RUPERT & CARIBOO Delegates—By Acclamation Large, Alfred W. Nominating Committee—By Acclamation Railing, Antony DISTRICT NO. 5 NEW WESTMINSTER Delegate Ballot— Sparling, J. Fred Watson, Harry Norman McClure, W. G. Nominating Committee—By Acclamation Cannon, H. E. Graham, John E. Harper, R. R. DISTRICT NO. 6 YALE Delegate Ballot— Holmes, Charles Brian Nominating Committee Anderson, Walter F. - Gibson. John J. -By Acclamation DISTRICT NO. 7 KOOTENAY Delegate Ballot— Williams, K. J. Carpenter, John C. Nominating Committee Ballot— Callback, Gordon R. M. Haszard, John Francis G. O. Matthews, M.D., Returning Officer. PHYSICIAN DESIRES POSITION M.A., M.D., D.P.H., L.M.C.C, age 51, in excellent health with wide general medical experience. Administrative; Industrial medicine; clinical pathology; with clinic group or other organization. All replies answered. State requirements. DR. Wm. L. COOPER 908 Westholme Ave., Los Angeles 24, California Page 483 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H., J Deputy Minister of fiealth, Province of British Columbia A. M. GEE, M.D. Director, Mental Health Services, Province of British Columbia COMPLETION OF MOVE The new Provincial Health Building at 828 West 10th Avenue, Vancouver 9, B.C., is now occupied and houses the following Provincial Health Branch offices: Assistant Provincial Health Officer, Health Branch Office. Division of Laboratories. Division of Venereal Disease Control. Births, Deaths and Marriages (Division of Vital Statistics). Crippled Children's Registry. The telephone number of the above offices located in the Provincial Health Building is Dickens 2331. Please also note that the telephone number of the Division of Tuberculosis Control, 2647 Willow Street, has been changed to Dickens 2331. CANADIAN RED CROSS BLOOD TRANSFUSION SERVICE-B.C DEPOT The Canadian Red Cross Blood Transfusion Service is now located on the third floor of the Provincial Health Building, 828 West 10th Avenue, Dickens 2331. This Service was previously located at 28th Avenue and Laurel Street. it K -ft iSpS * RECOMMENDED IMMUNIZATION PROCEDURES Immune Serum Globulin (commonly called gamma globulin) an antibody concentrate prepared by the fractionation of human plasma, has heretofore been issued by the Health Branch, Department of Health and Welfare exclusively for the prophylaxis of poliomyelitis. Over recent months there have been less urgent demands for this product, which, coupled with improved supplies makes possible the extension of its use for the protection of contacts to certain other infections as indicated below. it ii it POLIOMYELITIS IMMUNIZING AGENTS Field studies are underway in Canada at the present time in order to evaluate the effectiveness of the Salk Vaccine for active immunization. Immune Serum Globulin (Human) is available for passive protection against poliomyelitis. Because of the limited supplies available, it is not considered practical to attempt any widespread immunization program, such as has been carried on in certain trial epidemic^ areas in the United States. Prophylaxis with immune serum globulin is restricted to household contacts who have presumably been exposed to the virus and who have been shown by epidemiological study to be at greater risk than the general population. USE OF IMMUNE SERUM GLOBULIN Not routinely. Indicated if it can be given within 3 days of diagnosis of index case (paralytic or non-paralytic) in family for— (a) Household contacts, from birth to age 30. (b) Household contacts who are pregnant, irrespective of age. Page 484 ADMINISTRATION 0.14cc. per lb. body weight injected intramuscularly in divided doses if necessary. NOTE: Immune Serum Globulin— (1) Should be given to eligible contacts as soon as possible after diagnosis of index case in family. (2) Should not be given to contacts who have received the Salk Vaccine on an experimental basis. it ft ii jl MEASLES IMMUNIZING AGENT Immune Serum Globulin (Human) is available for the prevention or modification of measles. While complete prevention may be necessary or desirable in very young children or those in impaired health, it is usually preferable to attempt modification of the disease only, since this procedure will minimize the illness and hazards of measles, but not interfere with the development of naturally aquired immunity. USE filot routinely. Indicated (a) Exposed children, four years of age or under. (b) Exposed children and adults with intercurrent illness or chronic disease. (c) Outbreaks in children's institutions. ADMINISTRATION |t (a) for prevention 0.1 cc. per pound body body weight injected intramuscularly within five days of exposure to the disease, i.e., within five days of the onset of preemptive symptoms in the infecting child. (b) for modification 0.02 cc. per pound body weight injected intramuscularly within five days of exposure to the disease, i.e., within five days of the onset of preemptive symptoms in the infecting child. NOTE: At the present time the Health Branch, Department of Health and Welfare is still issuing anti-measles serum for the prevention and modification of measles. As it would appear that immune serum globulin has decided advantages over serum for theprophylaxis of this infection, the Health Branch proposes as soon as more adequate supplies of the former become available to discontinue the issue of anti- measles serum. USE OF IMMUNE SERUM GLOBULIN flgf| JT Ipfj Routinely: for all contacts in relatively closed groups, i.e. follow—one or more cases in institutional, classroom, camp, military or isolated community groups. Indicated: also for Contacts with intercurrent illness or chronic disease. ADMINISTRATION m gl f| |||| 0.01 cc. per lb. body weight, injected intramuscularly. Page 485 C.A.R.S. The following article has been prepared by the Medical Advisory Board of the B.C. Division of the Canadian Arthritis and Rheumatism Society. It follows naturally the article published in the June number on Rehabilitation and Public Health Services, under the aegis of the Community Chest, and will be of service to men in practice as showing the work that the CARS is equipped and willing to do (Ed. Note). The Canadian Arthritis and Rheumatism Society, B.C. Division, offers the following services to physicians for the treatment of their patients with any of the' arthritic or rheumatism diseases: PHYSIOTHERAPY: Canadian Arthritis and Rheumatism Society physiotherapists who will give treatments either in the home or in a treatment centre, are stationed in 28 B.C. centres and give service in the surrounding areas. Travelling Consultant Service: With the approval of the local medical society, a travelling consultant service is offered periodically to any area outside of the Lower Fraser Valley and Greater Vancouver. These clinics, primarily designed for patients who cannot obtain a consultant's opinion through the usual channels, are held at the request of local physicians. Drugs: Cortisone, hydrocortisone for local injection and gold are supplied to physicians for those of their patients who would be unable to obtain these drugs otherwise. C.A.R.S. Medical Centre: Suitable cases from any part of the province may be admitted when beds are available to the C.A.R.S. Medical Centre in Vancouver as resident patients for a period of three months or more for an intensive rehabilitation programme including physiotherapy, ccupational therapy, case work and medical consultant service. Occupational Therapy: In the Greater Vancouver area, C.A.R.S. has three occupational therapists concentrating on improvement in self-care and function of the patient. Patients are treated both in the home and at the C.A.R.S. Medical Centre, at 900 West Twenty-seventh. Nursing Service: In the Greater Vancouver area, a nursing service for the administration of gold, venesection and application of casts is available. Social Case Work: In the Greater Vancouver area, two social case workers are available, both for home-bound and for ambulatory cases. These services are available only upon the requisition of a physician. They are meant to aid the doctor in obtaining an effective programme in the treatment of his patients with arthritis and the other rheumatic diseases. Further information may be obtained from the Medical Director, C.A.R.S., B.C. Division, 900 West 27th Avenue, Vancouver 9, B.C. C.A.R.S. Physiotherapist services are available in the following centres: Abbotsford, including Sumas, Matsqui and Aldergrove; Burnaby; Chilliwack, including Lillooet, Lytton, Yale, Hope, Sardis, Rosedale; Courtenav, including Comox, Cumberland, Campbell River, Powell River. Page 486 Cranbrook, including Creston, Invermere, Kimberley, Fernie; Kamloops, in- eluding Chase, Ashcroft, Merritt; Kelowna, including Westbank, Peachland, Okanagan Mission, Winfield. Langley, Surrey, and Delta municipalities. Mission, including Haney, Hammond, Ruskin, Pitt Meadows, Albion, Deroche; Nanaimo, including Ladysmith; Nelson, including Nakusp, Edgewood, Proctor, Kaslo; New Westminster, including Coquitlam, Port Moody, loco. North Vancouver, including West Vancouver, Deep Cove, Whytecliff, Horseshoe Bay; Penticton, including Naramata, Summerland, Oliver, Osoyoos, Cawston, jKeremeos, Okanagan Falls. Port Alberni, including Alberni, Parksville, Qualicum; Prince George, including jQuesnel, Vanderhoof; Trail, including Casdegar, Rossland, Fmitvale, Grand Forks; [Vernon, including Enderby, Armstrong, Falkland, Revelstoke, Salmon Arm, Lumby. Vancouver, including Richmond; Victoria, including Sydney, Saanich, Cowichan, I Esquimalt. AN EXPANDED EXTRACELLULAR FLUID VOLUME fit §: 1 N EPILEPSY - CASE REPORT JOHN KOVACH, M.D., BRUCE HEINZEN, M.D., MARGIE PIFER SECOND SURGICAL (CORNELL) DIVISION, BELLEVUE HOSPITAL NEW YORK, N.Y. While studying the extracellular fluid volume change in a large series of cases following surgery, we found that when the extracellular fluid volume rose, it did so on the first or second postoperative day or not all.1 To our surprise, subject J. T. who was admitted to Bellevue Hospital in January of 1953 for a small skin graft to his hand, had an increase in extracellular fluid volume of 3487 mis. or 5.2% of total body weight on his third postoperative day (see table). This subject's normal body weight was 66 Kg. The change in EC.F. volume represents mainly a shift of intracellular water to the "extracellular space" since his total body weight increased by only 700 grams. On his ninth postoperative day his body weight was 300 grams below his normal weight whereas his extracellular fluid volume had increased by 4100 mis. or 6.6% of total body weight. This late extracellular fluid increase is distinctly abnormal and could not be explained on the basis of his surgery, since this surgery was of relatively low stress, and one could not expect much activation of the hypothalamocortical mechanism such as we found in procedures of greater magnitude. This patient developed a series of grand mal seizures on his third post-operative day which continued off and on until his tenth day. This coincided with the period of the elevation of extracellular fluid volume. From that time until his twentieth day he felt well, had no seizures and his extracellular fluid returned to normal. On his twenty-first postoperative day his extracellular fluid volume again increased 4,200 mis. or 6.7% of body weight when he again had grand mal seizures. By his twenty-third day his seizures had stopped and he was discharged feeling perfectly well. His extracellular fluid volume at this time returned to normal. All determinations were carried out using our single injection inulin technique.2 DISCUSSION This demonstrated to us strikingly the occurrence of grand mal seizures coincident with an increase in extracellular fluid volume. An increase in extracellular fluid volume has been found in postoperative complications manifested by convulsions but no change has been reported in epileptics.3 Page 487 In view of the finding that this subject's total body weight did not vary much at any time from 66 Ggs., one can conclude that there was no increase in total body water, and the real phenomenon was a shift of water from the intracellular to the extracellular space with grand mal seizures and a shift back again during the free intervals. There is an increase in extracellular fluid volume coincident with grand mal seizures with a concomitant decrease in intracellular water and no increase in total body water. Subject—J.T. Bellevue Hospital TABLE Days Post- ■op Body Weight (Kgms) ECFV Increase Increase ECFV % body wt. Epileptic Seizures 0-2 66 NONE NONE NONE 3-10 66.7-65.7 3487-4100 5.2-6.6 Grand Mal 11-20 No Change NONE NONE No Seizures 21 67.0 4200 6.7 Grand Mal 22-23 NONE NONE No Seizures REFERENCES I Kovach, J., M.D., Heinzen, B., M.D. and Pifer, M.: Extracellular Fluid Response to Surgery Journal, International College of Surgeons, Feb. 1955 2. Heinzen, B., M.D., Kovach, J., M.D. and Pifer, M: Extracellular Fluid Volume in Surgical Patients. Surg., Gyn. & Obs., Vol. 96, No. 3, March 1953. 3. Zimmerman, B., and Wagensteen, O.H.: Water Intoxication in Surgical Patients. Surg., 31:654, 1952. SEVENTH ANNUAL SYMPOSIUM on HEART DISEASE WASHINGTON STATE HEART ASSOCIATION and WASHINGTON STATE DEPARTMENT OF HEALTH University of Washington Medical School Auditorium SEPTEMBER 30th and OCTOBER 1st, 1955 For the seventh year the Washington State Heart Association and the Washington State Department of Health joins hands to bring the physicians of the Northwest some of the latest developments in the Field of Cardiovascular Disease. Once again we have secured outstanding authorities in their respective fiel_s: Doctor Howard Sprague of Boston, Massachusetts; Doctor Charles Kossman of New York City, New York; and Doctor Jesse Edwards of the Mayo Clinic, Rochester, Minnesota. The theme of the Symposium will be "Myocardial Infarction" and "Pericarditis." The speakers will conduct panel sessions and discuss questions from the audience, as well as present their scheduled papers. This Symposium is the equivalent of nine hours of formal post graduate training for members of the Academy of General Practice. Details of the program will be forthcoming. There will be no registration fee. Page 438 'eu/6 an d I loted in the Dr. John H. Dickinson is now associated with Dr. C. Mellis Mail practice of Obstetrics and Gynoecology in Victoria. Dr. Dickinson is a graduate of the University of Toronto Medical School, 1949, and has just completed six years of post graduate study in Obstetrics and Gynaecology. In the course of his training he was on the House staff of the Toronto General Hospital, Wellesley Hospital and Toronto East General Hospital. Dr. Dickinson has his Certification in the specialty of Obstetrics arid Gynaecology from the Royal College of Physicians and Surgeons of Canada. In the July issue of The Bulletin it was stated that Dr. L. H. T. Appleby was practising in Nanaimo, this was in error. Dr. Appleby is with the Avery Clinic at Quesnel, B.C. HYPOTENSYL-SERP is as the name implies a combination of HYPOTENSYL of Anglo-French and an alkaloid of Rauwolfia, Reserpine. (FORMULA Viscum Album Extract i 75 mg. Liver Extract lOOmg. Pancreas Extract y _^ 50 mg. Reserpine (pure crystallized alkaloid of Rauwolfia) ^0.2mg. INDICATIONS Essential and associated hypertension. PRESENTATION: Bottles of 50 and 500 tablets. DOSAGE: 1 to 3 tablets daily. ANGLO-FRENCH DRUG CO. LTD., Montreal 18 iHnmtt pirnsant (Eljaprl FUNERAL SERVICE Kingsway at llth Ave. — Telephone EMerald 2161 Vancouver 10, B.C. flDt. flMeasant XHnbettaRina Co. Xtb. Page 489 Thepnosi eimAm^al way §foprescribe f< v w Ostogen-A with C // Vitamins m A and C /& A '^"~V/ i fep; M Aqueous vehicle enhances absorption and utilization • Mixes readily with milk or other liquids • Pleasant flavour — accepted by all children Each 5 DROP DAILY DOSE [0.25 cc.) contains: Vitamin D 1,000 Int. Units Vitamin A (palmitate) 2,000 Int. Units Vitamin C 30 mg. Available in bottles of 8, 15. and 30 cc, with calibrated dropper at a cost of 2V_ to 3 cents per day. Dose for dose, this"'<§£bddT vitamin preparation costs the patient less. t&>\ v 77 GWOd&t ekcvite* & §viooat&&>. MONTREAL CANADA Page 490 In the last issue of the Bulletin, Dr. Frank Turnbull, President of the B.C. Division, has written a very provocative and even disturbing article—about the socialization of medical services. To quote two sentences, "litde by litde the free economy of medical practice at the turn of the century has become the semi-public economy of medical practice to-day" And again "Have we been remiss in our Policy of informing the public-at-large about clinical matters, by maintaining aloof silence about the way in which medical services can be provided?" We couldn't agree more. Looking back over the past thirty years, we see the question of Health Insurance being brought up again and again. The example of Great Britain and other countries stimulate interest here, and the proponents of "free" medicine have never given up hope that some day, somehow, the Canadian medical profession will be dragooned into some scheme, conceived by laymen, and enforced and manipulated by bureaucracy. Dr. Turnbull refers to the activities of 1936, and the Health Insurance Act passed in that. year. There are three features about that Act that are most important—and that we should, bear in mind, and from which we may profit. The first was that the Government of the day, without consultation with the responsible medical bodies of the day, worked out a Health Insurance plan largely based on the British plan—and having done this, called us in to discuss it. It was a feeble, inadequate plan—the acceptance of which by the medical profession would have made us into helpless serfs of the government. For two long, mortal years, we met them and made suggestions, and put forward our views. At the end of the two years, we had made literally no progress. None of our arguments were heeded—none of our suggestions accepted—and the Government, tiring at last, of this cat and mouse business, summoned us to a last meeting, when they told us, in so many words, that the time for fun and games was over, and now they had passed the Act, appointed a Health Insurance Commission, and we had got to accept the Act, and t work under it. Well, as we all know, we declined utterly to do so—and this is our second point— I that the whole of the medical profession of B.C. acting as a unit, stood firmly together, j and refused to work under the Act. This is not the first nor the second time that we I have found this. Whenever we have acted as a single, united body, we have been able i to secure adequate consideration of our views. We shall never succeed in anything, I unless we adhere to this principle—we shall not fail, if we do so adhere. The third point is this. All the publicity in this affair was provided by the opposition to us. The failure of the Act was blamed, not as it should have been, on the fact that the Act was unfair, unrighteous and unworkable, but on the greedy, j grasping medical profession, which wanted everything, and would concede nothing. To this day, the public believes that it is our fault that the Health Insurance failed. 1 If they knew the facts, if they had been told the truth, they would realize that they have to thank us for averting a rotten system of medical practice, under conditions I which could only have led to general dissatisfaction. And now, in the C.M.A. meeting at Toronto, men come from Great Britain, and the press is full of their tributes to the great success of the British Health Insurance plan. Frankly, we don't believe them—but that side gets full publicity: And the whole subject is once more a live issue—and conferences are to be held on I the establishment of Health Insurance, between the premiers of the provinces, later the in vear. Page 505- With this we can have no quarrel. We have said again and again, that we will not resist or refuse rearrangement of our medical structure along, rightly-drawn lines of Health Insurance—But we must do certain things. First, we must insist on taking our full share in these discussions, and must provide leadership along the purely medical lines of the discussion. We should make it clear that we will not accept any plan in the making of which we have had no share. Secondly, in some way we must take the public into our confidence—why shouldn't we do this? What have we to fear? We tell them clinical truths, as Dr. Turnbull says, why should we not give them the truth in other matters? In public forums if necessary or by other means. Thirdly, and fourthly, and fifthly, etc.—We must be united in this matter. We must speak as a single medical profession, not as surgeons and internists and general practitioners, and laboratory men. We could take a leaf out of the book of the Australian medical profession, which did stand together, and resisted unfair pressure, and brought into being a scheme which is perhaps a long way from perfection, but yet is infinitely better than the British scheme. We are sure that all these things are getting the fullest consideration of our leaders in the B.C. division and elsewhere. But we must let them know that we are behind them to a man. We are facing a crisis, and we con only face it by clearing the decks of selfishness, timidity and disunity. We must be fair to the other side, even generous. On our honesty of purpose, integrity, and unity depends a successful issue. We are responsible, in this, not only for our own prosperity and safety, but for the better health of the public, and the provision for them of the highest and best standards of medical care that we can devise; and they must be given an opportunity to realize our sincerity in this matter. And, "It is later than we think." Library Hours: Monday to Friday ill 9:00 a.m. to 9:00 p.m. Saturday It 9:00 a.m. to 1:00 p.m. Recent Accessions: Newer Concepts of the Causes and Treatment of Diabetes Mellitus: New York Diabetes Association. 1954. The Psychiatrist and the Law by Winifred Overholser. Harcourt Brace. 1953. Kinnier Wilson's Neurology edited by A. Ninian Bruce. 2nd edition. 3 volumes. Butterworths. 1954. Selected Writings of Florence Nightingale, compiled by Lucy Ridgely Seymer. Macmillan Co. 1955. Galen of Pergamon by George Sarton. University of Kansas Press. 1954. The History and Conquest of Common Diseases by Walter R. Bett. University of Oklahoma Press. 1954. Forgotten Leaders in Modern Medicine by B. Kisch. American Philosophical Society. 1954. Page 506 Man in a Cold Environment by Alan C. Burton and Otto G. Edholm. Macmillan 1954. A Synopsis of Childhood Diseases by John Rendle Short. Williams & Wilkins. 1954. Porphyrins—their Biological and Chemical Importance by A. Vanotti, Hilger & Watts. 1954. The New Steroids The literature on meticorten and meticortalone is already extensive and your library contains many of the original papers on the subject. A few of these papers are listed below because it is felt that they add most to our knowledge of this important subject in the shortest time. Many of us may feel' that we have little enough time to read even the commercial hand-outs on the subject, but it is our sincere belief that to read even one of the original articles in full will lead to a fuller understanding of the importance of these wonderful new compounds. Meticorten may well replace cortisone in the future, providing its cost can be reduced. At the moment, the expense of the drug is almost prohibitive. Chemically, meticorten has a very weak action on the electrolytes, and thereby the necessity of restricting the patients intake of sodium is obviated. In addition, meticorten has a strong anti-inflammatory action estimated at four times as great as that of cortisone. John Dick, M.B. Bibliography Dordick, Jack R. and Gluck, Edward J.: Preliminary Clinical Trials with Prednisone (Meticorten) in Rheumatic Diseases, J.A.M.A. 158:166 (May 21st) 1955. Arbesman, Carl E. and Ehrenreich, Robert J.: Meticorten and 9 Fluorohydrocor- tisone in the Treatment of Allergic Disorders, The Journal of Allergy 26:189, May 1955. Skaggs, Joseph T., Bernstein, Jerome and Cooke, Robert A.: Metacortandracin in Chronic Asthma, ibid p. 189 May 1955. Schwartz, Emmanuel: Metacortandracin (Prednisone) in Bronchial Asthma, ibid p. 206. May 1955. Herzog, H. L. et al.: New Antiarthritic Steroids, Communication, Science 121:176, 1955. Bunim, J. J.; Pechet, M. M., and Bollet, A. J.: Studies on Metacortandralone and Metacortandracin in Rheumatoid Arthritis, J.A.M.A. 157:311 Jan. 22) 1955. King, J. H. and Weimer, John R.: Prednisone (Meticorten) and Prednisolone (Meticortelone) in Ophthalmology, Arch. Ophthalmology 54:46 July 1955. POSITION VACANT FULLTIME general physician required for the Out-Patient Clinic of The Alcoholism Foundation of British Columbia. Under the direction of the Clinical Director to carry out medical treatments for alcoholism. Experience in the field not essential but a thorough interest in the problem necessary. Position available October 1, 1955. Salary $6672 per annum. Applications should be submitted to the Executive Director, The Alcoholism Foundation of B.C., 1690 West Broadway, Vancouver 9, B.C. Competition closes 2 weeks after publication of this notice. Page 507 PNEUMATOSIS CYSTOIDES INTESTINALIS DR. E. N. C. McAMMOND This paper was delivered by Dr. McAmmond at the International College of Surgeons' Congress in Geneva, in May of this year — and we are very fortunate to have it. (Ed.) Rarity in itself is no excuse for reporting of cases, but the fact that the rare so often becomes the commonplace when knowledge of its existence becomes widespread is good reason for reporting another case of gas cysts of the intestine. Pneumatosis cystoides intestinalis is not mentioned in manv standard textbooks of pathology. However, Professor R. A. Willis of Leeds (I.) states: "This is a rare condition characterized by the development of multiple gas-containing cysts in the subserous tissues of the intestine, in particular the ileum, especially along its mesenteric border. The cysts occur in clusters at first sessile, later pedunculated. The gas is under pressure and its main component is nitrogen. The cyst walls are thin and usually show no reactive changes, but sometimes they are thickened and contain lymphocytes, macrophages and foreign-body giant cells. The cysts cause no symptoms and are discovered only incidentally at operation for other conditions." Kaufman and Reiman (2.) in their "Pathology for Student and Practitioner" refer to the conditions as "Air Bubble Mesentery" or "Intestinal Emphysema" and state that the "Course is benign, for the gas absorbs". These text-book statements are not entirely true, for the cysts do cause symptoms, they can be present anywhere from the stomach to the rectum, they are not just subserous but frequently submucous as well and the course is not necessarily benign, for deaths have been reported as a result of their presence. Historically, John Hunter (1728-93) of England is stated to have made a reference to the condition, but the first adequate account was given by Bang in 1876. (3.), when he discovered the condition in a female who had died of volvulus of the colon. Leopold G. Koss of New York in 1952 made an extensive analysis of world medical literature. There have been some 260 cases reported and only about 60 of these were found in the Americas, and of these 60, 45 occurred in children and 15 in adults. The condition is three and a half times commoner in males than in- females and in adults is most commonly found in the third, fourth and fifth decades of life. PATHOLOGY: Grossly gas cysts have been found in the stomach, fourth part of the duedenum, jejunum, ileum, right half of the colon, left half of the colon and the rectum; however i the areas most commonly involved lie somewhere between the beginning of the ileum j and the mid-portion of the transverse colon. The mesenteries, gallbladder, falciform \ ligament and even the retroperitoneal tissues have been the sites of these cysts. In the bowel wall the cysts may be located in any plane. In infants they are found more commonly in the submucous layer, whereas in adults they are more i frequently located in the subserosa; also when found above the mid-transverse colon they are frequently subserosal whereas below this zone their existence is usually submucosal. The cysts vary in size from minute blebs to large filbert nuts and appear on reddish bases, discrete or in clusters. They contain gas which is odorless, does not burn (4.) and contains neither oxygen nor carbon diaxide and rarely a litde clear limpid fluid. Above the mid-transverce colon the condition is usually associated with i pyloric stenosis and ulceration of .the stomach or duodenum, whereas it appears to be primary when occurring in the left half of the large bowel. ETIOLOGY: No really logical explanation has as yet been promulgated but there are several theories. (5.) 1. Finney suggested a neoplastic theory but histopathological evidence is entirely lacking. Page 508 2. The bacterial theory is unacceptable, for even in the presence of persistent pneumoperitoneum, peritonitis is not found and on culture the cysts are commonly found to be sterile. 3. Nutritional deficiency: There is a striking similarity between the cysts found in pigs fed on a diet of polished rice and the cysts found in humans. (6.) The feeding of unpolished rice and yeast prevented the development of the disease. In humans there is a high incidence of pyloric stenosis and many of the cases are described as being malnourished and underweight; it is quite possible that nutritional deficiency is a factor in the production of these cysts.. It is postulated that some chemical deficiency permits the formation of gas within the lymphatics or again it may permit the absorption of gas from the bowel lumen into the lymphatics because of increased permeability of the mucosa. 4. Mechanical factors: It is etiologicafly difficult to believe that the gas does not come from the gastrointestinal tract lumen. Stiennon (7.) has taken into consideration various clinical findings including the high incidence of pyloric obstruction, the presence of "skip" areas, the predilection for the mesenteric border and has made a reasonable case for the passage of gas under pressure from mucosal ulceration into the root of the mesentery and so into the subserosa and and submucosa, following the route of the blood vessels. An explanation of the cysts occurring on the left side of the colon, when the condition is not associated with pyloric obstruction is not evident. CLINICAL AND X-RAY DIAGNOSIS: J|" - Pre-operative and pre-mortem diagnosis of pneumatosis intestinalis has been extremely rarely accomplished. Usually the presenting symptoms are those of the associated disease, for example the peptic ulcer or pyloric obstruction. Symptoms of intestinal obstruction have occurred from volvulus, band formation, encroachment into the lumen or pressure from without. In left-sided lesions constipation and occasionally diarrhoea may result, with the passage of bright red blood. Roentgenologic findings are variegated, but are such as to direct the examiner to the proper diagnosis, provided the possibility is kept in mind. The cysts may show themselves as multiple areas of foam-like translucency scattered along the distribution of the bowel. The gas may be revealed as linear stripes along the bowel margin, or as circles within circles when the end of the loop is visualized. Persistent pneumoperitoneum is exceedingly suggestive when other causes, such as perforated ulcer or recent Rubin's test, have been ruled out. Chilaiditi's sign, the interposition of a loop of bowel between the liver and the diaphragm, serves to put one on guard (8.) (The presence of the gas cysts causes the loop of small bowel to float upward to a position above the liver.) The barium enema may show constant and persistent translucent shadows encroaching on the lumen of the bowel. REPORT OF CASE: (Mrs. A. C. B., St. Paul's Hospital) Mrs. A. C. B., a 44 year old female has been in and out of various hospitals for the past seven years with a variety of indefinite abdominal complaints. Numerous gastric series and barium enemas have been taken but all have been reported to be within normal limits. History of present illness: During the past two years the patient's vague abdominal complaints have become more definite and she has had recurrent bouts of lower crampy abdominal pain with tenderness along the left side of the abdomen. Until a year ago the patient suffered from constipation but during the past year she has had recurrent bouts of diarrhoea, lasting for six weeks at a time and having seven to fifteen bowel movements a day. The bowel movements have been accompanied by the passage of a good deal of Page 509 flatus and considerable mucus but only on rare occasions has she seen the streaking of bright red blood which she believes to come from haemorrhoids which are known to be present. There has been no nausea or vomiting and appetite has been good. Past illnesses which may be significant include the following: 1929 - Caesarean section 1930 - Appendectomy 1931 - Tonsillectomy 1935 - Right mastoidectomy 1931 - Cholecystectomy Physical Examination Patient is obviously overweight. Her height is 5' 2" and weight is 176 lbs. A right mastoidectomy scar is present but ear, nose and throat reveal no other 1 abnormality. Thyroid gland was normal to palpation. Thoracic examination showed ■■ heart to be normal and chest clear. Abdominal examination revealed the presence of i a lower mid-line scar, a right grid-iron scar and an upper right paramedian scar. The sigmoid and descending colon could be palpated and were quite tender. Genitalia were normal. Tendon reflexes were equal and active. Laboratory Investigations Hb. 83%; White blood count - 8,650 with polymorphs 60%, lymphocytes 33%, monocytes 5%, eosinophiles 2%; NPN 39 mg %; CO 2 combining power 34 > m.e.q.; chlorides 109 m.e.q.; sodium 142 m.e.q.; potasium 4.8 ime.q.; Kahn was : negative. A half dozen specimens of stool on a meat-free diet showed a persistendy positive test for occult blood. BMR was minus 6. Examination of urine within normal limits. Barium enema performed on February 28th, 1955 recorded that following j the injection of barium, numerous filling defects were noted in the sigmoid and descending colon but owing to the fact that considerable faecal material was evident the exact significance of these filling defects was not determined and a sigmoidoscope examination was suggested. Consultation was sought by the physician at this point and for the first time a proctologic exam was performed, under general anaesthesia. The findings were quite startling. Minor haemorrhoids were present but at four inches aksense of slight induration which had been palpated at the tip of the finger only, proved to be a polyp, approximately three cms. in diameter and on a wide base. The polyp itself was covered with numerous reddish purple translucent cysts. From this distance of four inches upwards to as far as the scope could be inserted, namely ten inches, dozens of small cyst-like bodies protruded into the lumen and ranged in size from 2 mm. to about 2 cms. in diameter. On visual examination the differential diagnosis rested between lymphangiomatosis and pneumatosis cystoides intestinalis. Biopsy speciments were removed by means of the Frankfeldt snare from the sessile polyp described above. (It was observed that when the biopsy, snare specimens were removed, that there was a popping sound and the cysts contained no actual fluid. One cystic cavity was so deep that fear was at first felt that the bowel might have been perforated.) PATHOLOGY REPORT: ' |f GROSS DESCRIPTION:— Two portions of what is evidendy rectal mucosa, one measuring 2.5x2x1 cm. and the other one slightly smaller. Mucosal aspect appears smooth but in the submucosal tissues are several moderately thick-walled cystic structures. This might possibly be a difuse lymphangiomatous process. ||§ MICROSCOPIC DESCRIPTION:- Numerous sections were taken through out the material received and they show in each instance a relatively intact mucosa. It does show however, some apparent interstitial inflammatory cell infiltration and in one area a moderate fibrosis. Situated in the submocosa and subserosa are numerous cystic structures lined by fibrinous material and compressed-appearing endothelium and these have apparently been evacuated of content, or contained air Page 510 In the periphery of these structures there is a foreign body granulomatous reaction of rather unusual type and consisting for the most part of giant cells with very litde epithelioid or lymphocytic reaction. The giant cells contain a very abundant cytoplasm and very few nuclei. The cytoplasm in each instance is slightly basophilic. The gross and microscopic appearance of these structures is in keeping with the diagnosis of pneumatosis cystoides intestinalis. The slides show a very remarkable resemblance to a similar case, but involving the small bowel, operated upon in this hospital two years ago. There is no suggestion of any malignancy nor specificity of inflammatory process. DIAGNOSIS:— Pneumatosis Cystoides Intestinalis. Three weeks were allowed to pass in order to permit adequate healing of the biopsy area and a barium enema was again repeated after a very careful and thorough cleansing of the bowel. The final roentgenologic report is as follows: An antero-posterior film of the abdomen shows numerous foam-like loculated, translucent areas in the descending and sigmoid colon. Barium was instilled into the bowel and passed without difficulty around to the caecum. Again numerous filling defects were noted in the sigmoid and descending colon. In summary the films show three characteristics: 1. An area of transrucency along the lateral edges of the barium filled bowel. 2. The presence of numerous foam-like cystic translucent areas. 3. The presence of circular shadows within circular shadows. These three features make the diagnosis of Pneumatosis Cystoides Intestinalis very likely. The second sigmoidoscopy was performed under anaesthesia three weeks following the biopsy. We were surprised to find that the polyp previously found had completely disappeared. However, from six inches to as high as the scope could be inserted again were found numerous cysts of all sizes. Some of them pale white in color, many of them a blue translucent tinge. Several ectochrome pictures were taken through the sigmoidoscope. Approximately 30 of the cysts were destroyed by means of the bowel cautery. Each time cysts were fulgurated there was a sharp popping noise, such as is made by breaking of a small balloon. The sound was not that typically found from small explosions of gas so commonly heard during electrodesiccation. The patiient's symptoms of lower abdominal pain and diarrhoea have been improved and she is now having one to two bowel movements a day instead of 10 and 15 as previously. Should the severe abdominal cramps and diarrhoea recur, the condition will probably necessitate a left hemi-colectomy with an anastomosis of the transverse colon to the rectum. COMMENT M Pneumatosis Cystoides Intestinalis is an exceedingly rare condition and rarer still on the left side of the abdomen. This must be one of the first occasions on which the pathological entity has actually been visualized through the sigmoidoscope and almost certainly the first time that the condition has been photographed through the instrument. It was interesting to secure the X-rays which had been taken in 1952 and again in 1954 and to find that the typical picture of Pneumatosis Intestinalis could be easily identified, now that the criteria for its recognition are being established by the roentgenologists. Again the importance of always performing a sigmoidoscopy prior to the investigation of the colon by barium enema is emphasized; if there is an indication for barium enema, there is doubly an indication for sigmoidoscopy. te|| Page 511 SUMMARY: 1. Condition of Pneumatosis Cystoides Intestinalis is still a comparatively rare one, but is becoming commoner now that the criteria necessary for diagnosis have been established. 2. Above the mid-transverse colon the condition is frequently associated with pyloric obstruction, whereas below the mid-transverse colon, the condition is usually primary. 3. A case is presented in which the diagnosis was made by sigmoidoscopy and snare biopsy; the condition having been thus recognized it was possible to review X-rays and identify the lesion on films taken three years previously. 4. The cause of the condition is not known but it is believed that gas enters the bowel wall through some area of ulceration. 5. In the present case, the diarrhoea has been considerably improved since the fulguration of about 30 of the cysts. 6. The standard text-books should include Pneumatosis Cystoides Intestinalis since it is becoming increasingly common now that the criteria for its recognition have been established. The cysts do cause symptoms, they can be present anywhere from the stomach to the rectum (1st and 2nd parts of the duodenum excepted), they are not just subserous but submucous as well and they have resulted in death. 7. The importance of always using the sigmoidoscope before ordering a bariujp|: enema is again emphasized. BIBLIOGRAPHY — PNEUMATOSIS CYSTOIDES INTESTINALIS "The Principles of Pathology". 1. Willis, R. A., D.Sc, M.D. F.R.C.P., Professor of Pathology, University of Leeds, 1950. 2. Kaufman and Reimann 3. Bang, B. L. F. (1876). 4. Boyd, Wm. 5. Evelth, D. F. and Biester. 6. Biester, H. E., Eveleth, D. F., and Yamashiro, Y. 7. Stiennon, O. A. 8. Koss, L. A. 9. Kukral, Albert J.; Plank, J. R. Denst, John. "Pathology for Student and Practitioner" (P. Blakiston, Son and Co., Philadelphia). Nord Med. Ark. 8:18, 1. "Surgical Pathology" W. B. Saunders and Co. 6th Edition. American Journal Hyg. 1938 27:364. J. Am. Vet. Med. Ass. 41:7, 4, 1936. Am. J. Dis. Chil. 81:65, 1951. Archives of Pathology, 53:523, 1952. Annals of Surgery 141:109. NOTICE TO BOWLERS A Medical League is being formed and Doctors wishing to take part should phone CEdar 5211 for complete information. The League will be confined to Medical Men, and it is expected to function on Thursdays. Special instructions will be provided to beginners, and for those who wish to improve their Bowling. Page 512 SOME FUNCTIONAL CAUSES OF GYNECOLOGICAL ! SYMPTOMS DR. A. B. NASH Victoria, B.C. Eh. Nash has been kind enough to give us three papers he read before the Annual Meeting of the General Practitioners Section of the B.C. Division, C.M.A. when it was held at Harrison Hot Springs. While these papers were primarily for general practitioners, we feel that everyone will agree that they are very timely, and full of meat. The other two papers will be published in future issues. Ed. Sir Clifford Albutt, the great English clinician, said, in speaking many years 3go of the visceral neuroses: "A neuralgic woman seems thus to be peculiarly unfortunate. However bitter and repeated may be her visceral neuralgias, she is told either chat she is hysterical or that it is all uterus. In the first place she is comparatively fortunate, for she is only slighted; in the second case she is entangled in the net of the gynecologist, who finds that her uterus, like her nose, is a litde to one side, or again, like that organ, is running a litde, or it is as flabby as her biceps, so that the unhappy viscus is impaled upon a stem, or perched upon a prop, or is painted with carbolic acid every week in the year, except during the long vacation when the gynecologist is grouse-shooting, or salmon-catching, or leading the fashion in the upper Engadine. Her mind, thus fastened to a more or less nasty mystery, becomes newly apprehensive and physically introspective and the morbid chains are riveted more strongly than ever. Arraign the uterus, and you pin in the woman the arrow bf hypochondria, it may be for life." In the light of our present day knowledge of gynecology and of psychosomatic taedicine, these were words of great wisdom. More recently a wise and experienced Canadian gynecologist, Adee (1), Epitomized the modern viewpoint of the psychosomatically oriented in the statement: 'A woman with a large ovarian cyst may be treated as a mere case, but one with chronic iliac pain is better studied as a personality." It would be misleading and inaccurate to create the impression that a large jpreponderance of gynecological symptoms are direcdy attributable to psychic and pnotional factors. In order, therefore, to obviate the possibility of such misunderstanding of the ensuing discussion, I wish here to emphasize that in probably no more than one- third of patients with gynecological complaints, ate the symptoms attributable entirely to psychic causes. That, however, does not necessarily imply that in all other Enstances are gynecological symptoms due only to organic disease. Between these two extremes there exists a further group of patients in whom an organic lesion seems insufficient to be totally responsible for the severity of the symptoms and in whom, probably, symptoms are enhanced and aggravated by [emotional factors. And again there are other individuals in whom it is most difficult, pf not sometimes impossible, to discriminate between the respective effects of psychic factors and demonstrable somatic disease in the production of symptoms. There is a growing body of authoritative opinion to the effect that adequate investigation of the gynecological patient demands, as well as a careful medical pistory, functional enquiry, careful physical examination and the employment of laboratory diagnostic aids, a painstaking appraisal of the patient's personality and pattern of reaction to stress. This latter requirement demands the establishment of the patient's confidence and the expenditure of considerable amounts of time and patience. The "Personality" which we must attempt to evaluate, is defined by Groger (2) as a dynamic process—a functioning unit resulting from the integrating influence of physiologic, psychologic and sociocultural forces. Page 513 The scope of the enquiry required for an attempted personality appraisal is to some extent indicated by Diddle (3) and associates when they speak of "the sensitive, gynecological patient suffering from emotional immaturity, fears, desires, repressions, obsessions hates, and affections and subject to sexual distresses, domestic unhappiness,! financial worry, overwork and the other trials and tribulations of every-day living." Unless one is prepared then to enquire carefully into these considerations andi unless he is willing to be a patient and sympathetic "good listener", he is unlikely to attain a high degree of accuracy in gynecological diagnosis. It follows, also, that he will have a relatively high incidence of failure in attempting to relieve gynecological symptoms by the employment of methods directed only to the correction of organic, lesions. Thus Lock and Sluder (4) point out that there is a large group of patients with: symptoms of far greater severity than can be accounted for by the organic changes which are observed. They say: "It is our purpose to relieve these patients of theirI complaints. Frequendy operative treatment is required. Excellent results are obtained j if the lesion corrected by operation was the whole cause for the patient's illness. On! the other hand, an unnecessary operation may be performed for moderate pelvici disease if the emotional factor in the patient's symptoms is not appreciated." The fact that the physician takes cognizance of the emotional accompanimentsi of disease, according to Braceland (5), does not mean that he will pay less attention! to the somatic aspects of the problem. It is not, he says, a question of "either-or"; it is a question of "how much of each is involved." "To elicit the history of a patient from the psychosomatic point of view, the doctor is not constrained to change the scheme of his approach. He needs only to broaden it to see that patient as a person who is ill and not simply as a container! of a diseased process or organs." With respect to the psychosomatic aspects of pain, Cooper and Braceland express, themselves as follows: "Just as there is a serious danger in neglecting a physical; examination in a presumably functional state, one cannot afford to omit a consideration of psychic factors contributing to the pain induced by a bona fide organic lesion. The physician who fails to avail himself of the emotional currents which are operative in the patient who complains of pain, deprives himself of one of the most valuable diagnostic and prognostic aids in the whole picture." These authors point out that most patients with a psychosomatic basis for painj have been found to be dependent, with a low frustration tolerance, automatic! manifestations, poor adaptive ability and stereotyped somatic reactions to frustration. They expend energy in muscular, visceral or vascular activity rather than in interpersonal relationships. In emotionally immature persons, nervous tension results im a prolonged state of readiness for action, which can be satisfied only by being discharged in terms of somatic function. As a result, the unresolved tension gives rise to physiologic expressions which are perpetuated by emotional problems. These authors also emphasize that the emotional conflicts which are excluded! from consciousness for any one of a number of reasons, are the ones most likely to cause symptoms and to be expressed as psychosomatic illnesses. The most common and the most important gynecological symptom resultihg fromj functional causes is that of pain. This, of course, is usually lower abdominal andj pelvic pain. The abdominal pain may be suprapubic in location or may be on onej or other side, more often being on the right, though it may be bilateral. It is usually? aching and/or bearing-down in character and is seldom severe. It may radiate into! the thighs. As a rule it is more or less constant and is aggravated premenstrually and byi standing and fatigue. Significandy it may be post- coi tally aggravated, a point to which later reference j will be made. Especially premenstrually, there may be an associated sacral backache. There may also be an associated, thick, yellowish-white vaginal discharge. As a rule,j the pain bears no apparent relationship to the alimentary or urinary functions. Page 514 \ Superficial observation of the patient will suggest that she is tense and anxious and if she does not complain of fatigue she will readily admit to its presence. More often than not enquiry into this patient's childhood will reveal conflict and hostility with her mother, resulting in a father fixation and a subsequent personality development indicating reluctance to accept a feminine role. She may have been the "tomboy" type with an unusually developed interest in and enthusiasm for competitive sports and other athletic activities. She will probably give a history of dysmenorrhoea, and if married will almost certainly admit some lack of sexual responsiveness, having never, perhaps, experienced a satisfactory orgasm. Appraisal of her personality will suggest that she is of the hysterical type. On the other hand, such an appraisal may lead to the conclusion that she has I the obsessive-compulsive type of personality; particularly is this likely to be so if she lis unduly exacting in her demands upon herself in discharging her domestic and household responsibilities, when, if she does exhibit such perfectionistic characteristics, [she is likely to have experienced a good deal of frustration. This latter type will also j concede fatigue and will probably have previously experienced a normal sexual response, the capacity for which she now. seems to have lost—another source of frustration. If in addition to these considerations, regardless of personality type, this individual is the mother of two or more young children, with a limited household income and no domestic help, further enquiry will probably prove fruitful in that it will confirm that she has not had what could properly be termed a holiday since the birth of her first child and that she enjoys little or no recreation or opportunity to relax. This not uncommon victim of circumstances will probably admit premenstrual tension and irritability, the latter being responsible for a sense of shame and guilt, giving rise to anxiety concerning her relationships with her family at these times. Occasionally this patient will complain of a scant, dark, viscid intermittent vaginal discharge of several days duration, prior to the onset of the menstrual flow. She will prabably also suffer from typical tension headaches and perhaps soreness and aching in various groups of muscles, particularly the trapezius and shoulder girdle muscles, and she feels tired and stiff on awakening in the mornings. Unhappily the history will, in these circumstances, frequendy include the performance of one or more pelvic operations with only temporary relief of the symptoms. In fact, in my personal experience, I have frequendy been appalled at the extent of the surgical mayhem to which some of these patients have been subjected. All too often the story goes like this: the first operation was perhaps an appendectomy and reference to the pathological report, if it is available, will disclose no evidence of there having been any pathologic process. Either at the same time as the appendectomy, but frequendy at a separate sitting, the uterus has been suspended by one means or another, at which time also one or other ovary, usually the right, having contained "cysts", was removed or mutilated by the excision of these benign physiological components of a normal ovary. Following each of these operations, be it noted, the patient experienced relief from or improvement in her symptoms, the reasons for which I will refer to later. After their gradual recurrence, however, and following the laps of a decent interval, the patient has, in desperation, agreed to the performance of still another laparotomy for the relief of "adhesions", which are by now held responsible for the causation of the same symptoms that were to be relieved by the preceding operations which themselves produced these now offensive "adhesions". The fact that the adhesions will immediately reform, and be joined by new ones is disregarded. This sequence of events is so simple and obvious that one wonders sometimes if these patients, failing to recognize the explanation, are characteristically as stupid as the doctor who performed the operations. Page 515 In one of my patients, in whom this series of events had occurred, and who had /had, in addition, her gall-bladder removed, a curettage performed because of dysmenorrhoea had disclosed the presence of a few small endometrial polypi, by reason of which it was recommended that the performance of hysterectomy would be the final solution to her difficulties. This patient finally experienced some natural doubt and sought another opinion. I would like to emphasize that she has a hysterical personality with many deep-seated emotional conflicts and fears. I claim no personal credit for the fact that she benefited very considerably from treatment at the hands of a competent psychiatrist. Undoubtedly, had this therapy been applied several years earlier, the results would have been superior and the patient would have saved considerable money and would have been spared much unnecessary and avoidable suffering. It is interesting to note, as indicated previously, that these patients, as a rule, experience a temporary relief of their symptoms following the performance of the surgical operations to which I have made reference. The reasons for such temporary relief are, I believe, not difficult to identify. First the patient, having no insight into her problems, is overjoyed to learn that there is, in the opinion of the doctor in whom she has reposed her confidence, a specific cause for her symptoms, not of a serious nature, and amenable to the so-called definitive treatment which has been recommended to her. She eagerly acquiesces in the proposed surgery and, being tired and overburdened, she, in all probability, secredy looks forward to the indulgence of a litde luxury in the shape of bed-rest and attention, to say nothing of an escape from her more or less intolerable daily burdens. The only price she personally has to pay for these attractive considerations is that of submission to anaesthesia, the disagreeable features of which may nowadays be justifiably minimized, and the experience of some pain and discomfort for some 36 to 48 hours. Simultaneously therewith, let it be remembered, that this tired, frustrated and puzzled individual is escaping, while in hospital, a more fundamental difficulty, in that she will not have to submit to her husband's more or less unwelcome sexual insistence while recuperating. Furthermore, she leaves hospital and returns home the object of sympathy and high regard. Some of her relatives and friends, even she herself, may incline to hold her husband responsible in greater or less degree for her present predicament. Thus she is armed, for the time being, with a suitable defence against household drudgery and unwelcome, frustrating and disturbing sexual attention. Temporarily she has resolved her difficulties in a limited degree and it requires no great amount of rationalization on her part to be convinced that she is cured. This conviction alone has a profoundly reassuring effect upon her emotions. For the time being only, this patient's anxieties have been allayed. Kroger (7) has pointed out that the female genital tract is extremely susceptible to the physiologic expression of hidden conflicts. It would appear reasonable to assume that such patients as those just now described might well harbour hidden conflicts and that the development of symptoms referable to the genital tract in these individuals is not too difficult to understand. l|^ A useful question at this juncture would be, "Why did this patient's doctor, in the first instance, fail to recognize the true basis of his patient's symptoms and why did he choose the course which was followed?" Though this physician was undoubtedly mistaken he was probably sincere in his belief that he was doing what was best for his patient. Having been trained to seek and identify an organic lesion.to explain the cause of pain, and not having been oriented in the psychosomatic approach, he committed the natural sin of omission in failing to enquire into his patient's emotional problems and personality and in failing to recognize that this might be pain of functional origin. He then became guilty of a sin of commission in attaching undue significance to physical findings Page 516 that were not truly pathologic in nature; whereas the causative condition involved the patient's whole personality. Perhaps, also, this doctor may have subconsciously avoided a diagnosis of functional pain because of ignorance pertaining to its meaning and the methods required to establish such a diagnosis. He may perhaps have suspected this possibility and rejected it in the realization of his inability to treat pain of this origin. So too, he may have felt that such a diagnosis would suggest to his patient that, because he could "find nothing wrong with her", she must be "neurotic" and that he might in consequence lose that patient. I feel sure that these explanations apply frequently. With some reluctance, I also suggest that this busy doctor may have been unable to afford the time to listen, even though he may have suspected functional factors. It is appropriate at this time to emphasize that all pain is real, whether it is of functional or organic origin. Thus these patients must be made to understand that the reality of their pain is conceded and fully appreciated regardless of the fact that it may have no organic basis. The mechanism of what we have been discussing is explained by Kolb (8) in the following manner: "When the individual is confronted with some conflict between the inner drives and his personal and cultural standards, which he is unable to resolve realistically, he may adopt (regress to) some form of childish or infantile behaviour which, in his fantasies, gave him satisfaction in the past. The primary symptoms of the neurosis thus represent the re-appearance of such immature behaviour patterns. Painful symptoms in any portion of the body may occur as a regressive phenomenon in the face of such a neurotic conflict. A painful experience in childhood may have been rewarded by tenderness and solicitude. Such conditioning to pain may determine that later in life this child will regress when frustrated and obtain, by complaining of pain, the solicitude he desires from others, including his physician's, in order to allay his anxiety." "The over-conscientious person, brought up to repress hateful emotions, may complain of pain when confronted by hostile emotions, directed toward some close associate, which he dare not indulge. The guilty response for hostile feelings towards others, if extreme and persistent and aroused in a person with a rigid perfectionistic character, is often associated with other symptoms which are recognizable as expressive of an obsessive and compulsive neurosis or of a depression." Kolb further emphasizes that it is necessary to determine the type of emotional disturbance and he points out that many failures in the treatment of chronic painful conditions associated with emotional disturbances are due to a failure to evaluate correcdy the personality disturbance and factors underlying the illness. Taylor (9) (10) has described a syndrome which he designates as "Pelvic Congestion", and Duncan and Taylor (11) have studied the psychosomatic aspects of this syndrome, the symptomology of which is essentially the same as that already described. The characteristic physical findings, it is emphasized by Taylor, appear slight in relation to the severity of the subjective complaints and, in fact, they may easily pass undetected by the inexperienced or if they are not sought. Even when identified they may be difficult to evaluate. The outstanding physical sign on pelvic examination is tenderness—tenderness of the cervix on movement, tenderness of the uterus and of the ovaries on slight compression and, above all, marked bilateral and posterior parametria! tenderness. The cervix and uterus may both be appreciably enlarged and hypertrophied and there is frequendy hypersecretion from the endocervix. The ovaries are perhaps enlarged and "cystic." These authors, in their -very admirable investigations, have produced very convincing evidence that this syndrome has a vascular basis of congestion and they point out that vascular change in the pelvic organs is produced physiologically by vasomotor impulses received over the pelvic sympathetic and parasympathetic systems. Page 517 Thus, they deduce, that pelvic congestion is, in one sense at least, a "psychosomatic" disorder, even though they concede that other factors may be contributory. Because this syndrome has a vascular congestive basis, it is not too difficult to appreciate the common and characteristic post-coital aggravation of the symptoms in subjects whose sexual response and gratification is absent or inadequate. In view of the prevailing frigidity in these patients and, because of dyspareunia and subsequent aggravation of pain, it is understandable that they should frequently seek to avoid coitus. In support of their psychosomatic concept of this condition, Duncan and Taylor point to the frequency of associated extragenital psychosomatic manifestations, an observation that any of us may easily confirm. These authors have objectively demonstrated the existence of a relationship^ between emotional states and pelvic circulation and thus point to the probable etiologic role of life stress and emotions in the production of this syndrome. The patients whom they have studied with such meticulous care have exhibited inability to function as women, either sexually or maternally. They have been emotionally immature and, significandy, there was usually a lack of satisfactory relationship with the mother. Nearly all, they found, were psychologically ill. They stress, however, that decision as to whether the pain is the result of congestion or whether congestion and pain are parallel results of concomitant vascular and nervous system reactions, must await further study. In drawing the foregoing considerations to your attention, it is my hope to stimulate your genuine interest and enthusiasm in the inclusion of an evaluation of their personalities and a willingness to spend the time to listen to a recitation of emotional problems as important components in the total investigation of our patients with gynecological complaints. Thus, I earnesdy believe, may we improve and enhance our admittedly restricted ability to relieve human suffering in additional phases of its many complex ramifications. In closing, I would like to quote the opinions of two authors who have written extensively on this subject Rome (12 states: "There are many patients seen in the practice of medicine whose disabilities are reflective of minor maladjustments. The opportunity to "Talk it over" with a sympathetic listener is all that is needed to help them re-establish compensation." Finally, Diddle (13):— "One is frequently tempted to forego a detailed analysis into social influences of an illness, because it is usually time-consuming" and "The most satisfactory treatment of women with functional disease appears to be a frank, kind discussion of the illness in terms understood by the patient, to whom the use of unnecessary surgery or medication suggests "true" or somatic disease. REFERENCES (1). Atlee, H. B. Charles C. Thomas, Springfield, 111. (2). Kroger, William Si Obstet. & Gynec. 3:3:504. May 1954. (3). Diddle, A. W., O'Connor, K. A., Winebrenner, John D. Obstet. & Gynec. 1:2:197 Feb. 1953. (4). Lock, Frank R. and Sluder, Harold M. Amer. Jour. Obstet & Gynec. 60:5:1121 Nov. 195v.. (5). Braceland, Francis J. Medical Clinics of North America. Vol. 34:4 July 1950. (6). Cooper, Irving S. and Braceland, Francis J. Medical Clinics of .North America. Vol. 34:4 July 1950. sMM (7). Kroger, William S. Obstet. & Gynec. 3:5:504 May 1954. (8). Kolb, Laurence C. Journal, Lancet. 72:2:50 Feb. 1952. Page 518 (9). Taylor, Howard C, Jr. Amer. Jour. Obstet. & Gynec. 57:211,637,654 1949. (10). Taylor, Howard C, Jr. Amer. Jour. Obstet. & Gynec. 67:6,1177 June 1954. (11). Duncan, Charles H. and Taylor, Howard C, Jr. Americ. Jour. Obstet & Gynec. 64:1,1 July 1952. (12). Rome, Howard P. Diseases of the Nervous System. 10:9 October 1948. (13). Diddle, A. W. Obstet. & Gynec. 2:4,3 53 October 1953. THE POLIOMYELITIS PAVILION On June 28th, the Poliomyelitis Pavilion at the Pearson Tuberculosis Hospital in Vancouver was officially opened by the Honourable Eric Martin, Minister of Health and Welfare. The 55-bed single-storey Pavilion, the only one of its type in British Columbia, was built and equipped at a cost of approximately $447,000. It is specially designed for the cafe of post-poliomyelitis patients in the convalescent stages as well as patients requiring long-term care. If the care of polio patients can be thought of as usually being divided into three stages i:e., the acute stage, the convalescent stage and the rehabilitative stage, then the role of the Polio Pavilion can be termed as serving patients in the second, or convalescent stage. Prior to the opening of the new building, authorities concerned with the care and treatment of polio patients in the acute stage of the disease were faced with a serious shortage of space and facilities in the Infectious Diseases Hospital of the Vancouver General Hospital, where patients in both the acute stage and the convalescent stage were being cared for. This shortage of space has been gready relieved by transferring the convalescent and long-term care patients to the Pavilion. The new building has many special features. It has its own electrical power, supplied by a turbo-generator in the main powerhouse. In the event of possible failure of this source, an automatic switch-over is made to regular city power, so that the vital respirators can continue functioning. Two nursing stations are advantageously located so that patients in the male and female lung ward and the paralytic ward are in full view at all times. Any patient can operate a signal to call for assistance. Another feature is the outside asphalt-covered "respirator park," equipped with electrical oudets, so that if evacuation of the building were necessary, the respirators could be wheeled outside and "plugged-in" to the power supply in a very few moments. The Pavilion contains its own small operating suite. In the physiotherapy room, a Hubbard tank and other types of apparatus are in constant use by the physiotherapists. Occupational therapy classes and a library are also available to the patients. Meals for the patients are prepared in the kitchens of the adjoining Pearson Ifuberculosis Hospital and are transferred to the Pavilion in special electrically-heated wagons pulled by an electric "jeep." There is also a smaller kitchen located in the Pavilion. The front entrance is designed with a high truck-ramp for easier unloading of the large tank-type or "iron-lung" respirators, since this is the manner in which many patients arrive at the hospital. For administrative purposes the Pavilion will be considered part of the Pearson Tuberculosis Hospital. Dr. C. Mclver is the Medical Director. Page 519 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave. Vancouver 9, B.C. OFFICERS 1954-1955 President—Dr. F. A. Turnbull ! Vancouver President-Elect—Dr. E. W. Boak . Victoria Immediate Past President—Dr. R. G. Large Prince Rupert Chairman of General Assembly—Dr. G. C Johnston . Vancouver Hon. Secretary-Treasurer—Dr. R. A. Palmer : . Vancouver Executive Secretary—Dr. G. G. Ferguson .' Vancouver PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. F. H. Bpnnell Nanaimo Dr. G. B. Helem Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F. Sparling Dr. P. M. McLean Kootenay Dr. S. C Robinson Yale Dr. H. I. Campbell-Brown Vancouver Dr. A. W. Bagnall Dr. P. O. Lehmann Dr. Roger Wilson Dr. R. A. Stanley Dr. W. H. Sutherland Dr. J. C Poole Dr. N. J. Blair Chairmen of Standing Committees Constitution and By-laws Dr. Carson Graham, North Vancouver Finance — 1| Dr. R. A. Palmer, Vancouver Legislation Dr. E. W. Boak, Victoria Medical Economics Dr. P. O. Lehmann, Vancouver Medical Education _ : Dr. M. M. Weaver, Vancouver Nominations ! Dr. F. A. Turnbull, Vancouver Programme & Arrangements Dr. W. M. G. Wilson, Vancouver. Public Health Dr; G. R. F. Elliott, Vancouver Public Relations Dr. A. W. Bagnall, Vancouver Chairmen of Special Committees Archives . Dr. J. H. MacDermot, Vancouver Arthritis and Rheumatism Dr. J. A. Traynor, Vancouver Cancer Dr. Roger Wilson, Vancouver Civil Defence , __. Dr. John Sturdy, Vancouver Ethics Dr. Wallace Wilson, Vancouver Hospitals : Dr. G. C Johnston, Vancouver Industrial Medicine Dr. G. B. Helem, Port Alberni. Maternal Welfare .. . Dr. A. M. Agnew, Vancouver Membership 1 Dr. N. J. Blair, Vancouver Nutrition Dr. J. F. McCreary, Vancouver Pharmacy _ Dr. B. T. Shallard, Vancouver Rehabilitation Dr. W. J. Thompson Convention, Hotel Vancouver, October 4-7 Arrangements are now complete for the Convention and you will all have received a copy of the programme. The scientific lectures and round table discussions will prove to be of high order and the speakers have been well chosen. The entertainment has now been completely arranged and everything is ready for some happy occasions together. Your attention is drawn to two addresses to be given by Dr. T. C. Roudey, President of the C.M.A. Dr. Roudey's first address will be at the Annual Association Luncheon on Wednesday, October 5, at 12:45, in the Banquet Room. On this occasion, the President will speak about matters which concern the Canadian Medical Association and therefore, yourselves, as members. On Friday morning at 11:45, Dr. Roudey will be speaking in Salon A on the subject of the World Medical Association. This is a specific request from our President, Dr. Turnbull, in order that the members in British Columbia might have a very clear conception of the differences between the World Health Organization and the World Medical Association. Briefly, the difference compares to the Department of Health of the Govrnment of British Columbia and the British Columbia Medical Association. Page 520 Dr. Roudey's experience in the organization and development of both these bodies will form the basis of very important information to all doctors. The Annual Dinner of the Association which will close the Convention will be held on Friday evening. The guest speaker on this occasion is Dr. Peter Larkin, Ph.D., the Chairman of the International Commission on Fisheries. Dr. Larkin is an outstanding scientist and a capable Chairman of the Commission. Whether or not he chooses to tell us about his work, or the fish population in our Pacific waters or some other timely subject which interests him, will remain to be seen. In any event, you will be assured of a most pleasant evening together, good dining and an excellent address. Registration begins on Tuesday morning, October 4, and the registration table Will be manned all during the Convention, with the exception of Thursday afternoon. ii ii ii - A New Venture in Insurance Many members, it is not known in what distribution, will have received a letter "from the British Pacific Insurance Company, drawing to their attention a new plan. This is called "New Community Health Services Plan." Your Board of Directors wish you to be advised of certain factors which involve this communication. There are many insurance companies, both large and small, which for years have sold sickness and accident insurance as a business venture. The British Pacific Insurance Company is devising a plan which tends to define benefits on a service basis rather than a straight indemnity. In other words, the benefits are computed more according to service requested and less to a stated sum responsibility. It will gftecome apparent to you in reading the letter that this is an insurance policy offering a system of prepayment somewhat comparable to the M.S.A. and other prepaid plans. The letter implies there has been insurance company—doctor cooperation and it beseeches your individual cooperation in the future, while offering to pay your accounts at a 10% discount. Your Directors wish you to realize' that there has been no communication between the British Pacific Insurance Company and the C.M.A.-B.C. Division at any time and that the letter you have received and the offer to pro rate your accounts is purely unilateral action on the part of the Insurance Company. It seems then, important to remind you that there are a few plans, non-profit, direcdy managed by the participants themselves and actively assisted by the profession. These are the approved prepaid medical care plans. The essential difference between these approved plans on th one hand, and the insurance companies, both large and small, on the other hand, is the question of profit. In the approved plans, monies are received, administered, and completely used in the distribution of benefits for the subscribers. Some surpluses are retained to assure the stability of the plan, but the surplus money specifically belongs to the subscriber. In the insurance companies, any surplus belongs to the shareholders. The approved plans work closely with our Medical Association and we grant to them a 10% administrative discount from our minimum schedule of fees. In granting this discount, certain important privileges accrue to the profession. One is that members send their accounts direcdy to the plan and in cases where agreement is not possible on the assessment, the Association will act as mediator through the Reference Committee. The Association has earned the right to enquire from any plan concerning the specific relationship it might adopt to any of its members and retains the right to discuss medical policy. It is recognized that the 10% administrative discount accrues to the benefit of the subscriber who pays the premium. This situation does not develop in the instance of insurance companies and die Association has no right to question an assessed account, does not have the Page 521 privilege of discussing medical policy, and has no assurance that the 10% discount requested accrues to the benefit of the subscriber, but rather feels it becomes part o£ the dividend paid by the company to its owners. There have been many insurance companies operating over the years and all members will have had experience with them. No doubt with some it has been your policy, on behalf of your patient, to complete the form and send it to the insurance company direct, and no doubt with others it has been your policy to deal entirely with your patient and let your patient deal with the insurance company, through which he alone has a contract. Since this letter from the British Pacific Insurance Company has requested your individual cooperation somewhat after the same fashion as with the approved prepaid plans, of which M.S.A. is the largest, the Directors of your Association feel you should be fully aware of the facts detailed above. G. G.. FERGUSON, M.D. TWO OFFICES AVAILABLE FOR DOCTORS Conveniently located near the centre of Chilliwack in a new business block which already is occupied by doctors, optometrist, and a dispensary. Both offices are self contained and the four rooms in each covers approximately six hundred square feet. For information apply BOYD'S LIMITED, BOX 180, CHILLIWACK, B.C. Phone 3411 DR. W. A. DOBSON Obiit August 1st, 1955 Dr. "Bill" Dobson's death marks the passing of a very interesting and able man. He has been for many years, one of the leading psychiatrists of the province, and had attained a very high reputation, especially in court work. Bill Dobson began his career as a psychiatrist shortly after the end of World War I. He was almost a pioneer in this specialty in Vancouver — as most of the psychiatric work at that time was done by New Westminster physicians, who had been associated with the Provincial Mental Hospital. But Dr. Dobson's ability and interest in his work soon put him in the front line as a specialist in mental diseases, and he was busy, both in private practice, and on the staff of Shaughnessy Military Hospital. Latterly, he had not been very well, and had had to curtail his activities, but he established himself as a leader in his chosen specialty. Personally, Dr. Dobson was rather quiet in manner and reserved — but he had underneath this a friendly kindliness and willingness to be of help which endeared him to all those who came in contact with him; and it was a pleasure to meet him, professionally or otherwise. He will be greatly missed bv his manv friends. Page 522 DR. J. BOYD STORY Obiit Sept. 11, 1955 Aet. 57. Boyd Story will be missed in more than one area of the life of his community. He was a medical man, and an ornament to his profession — this was his vocation. His avocation was sport, and he was an active participant in many forms of sport. He was a football player, a tennis star at his University of Manitoba, and belonged to the Vancouver Curling Club. He was a past- president of the Vancouver Rugby Union. Dr. Story was born in Wawanesa, Manitoba — but came to Vancouver as a boy, went to high school here, and then returned to Manitoba University as a medical student, graduating in 1923. After some 14 years of practice in Shaunavon, Saskatchewan, he came back to Vancouver to settle, and practised here till his death. He died in the full spate of practice, and to his active energetic spirit this would be the ideal end. Boyd was a general favourite — friendly and always willing to hold up his end. He was an active member of the Vancouver Medical Association and whenever dinner tickets or any other tickets were to be sold or any other jobs were to be done, he was always in the forefront. He had a large practice, and worked hard at it. To his many patients and friends his death was a severe blow. We shall all miss his genial personality. To his wife and relatives we extend our sincerest sympathy in their loss. DR. JOHN NAY §S| ' Obiit Sept. 8th, 1955 The death of Dr. John Nay has taken from us a man who has left a mark on the profession of British Columbia, and a memory of kindliness, generosity and integrity. He had coundess friends amongst the profession, and one could not imagine him having any enemies.* As Chief Medical Officer of the Workmen's Compensation Board, a position he filled for many years, he won the respect and admiration of all of us, through his fairness and appreciation of our difficulties — and he was a most efficient Chief Medical Officer. In private life, he was a charming man to have for a friend; with a warm, friendly personality. John Nay was born in Portage la Prairie in 1883, and took his medical degree at Manitoba University. He practised in Emerson, Man. for some years, then moved to Trail. In 1922, following the resignation of Dr. Geo. Hall, Chief Medical Officer of the Workmen's Compensation Board, he was asked to take the position —and held it for many years. Ill health overtook him some two years ago, and forced his retirement — to be succeeded by Dr. John R. Naden. His loss was very keenlv felt by the Board, and by all the medical men of the province. He is survived by his wife, and family, and to them we tender our mosfi sincere sympathy. Page 523 n ewA an d f/oted Dr. George Speakman is now practising ophthalmololgy in Vancouver. Eh. Alan Inglis is now in orthopedics in Vancouver. Dr. John C. Mitchell has begun a practice in dermatology in Vancouver. E)r. Norman Hirt is now in association in psychiatry in Vancouver with Eh. B. J. Gaerber. Eh. A. S. Arneil is practising in Prince Rupert. Dr.V. A. Ewert is now in the U.S. Air Force. Eh. F. C. Lansdall is in Kitimat. Dr. R. H. McNaughton is doing post-graduate work in Cleveland. Eh. C. H. Moore is now practising in Victoria. Dr. C. R. Rally is studying in Montreal. Eh. W. M. Tait is now in association in radiology in Vancouver with Dr. Hugh Brooke. Dr. Kenneth Greer is practising in Britannia Beach with Dr. ]. H. Lindsay. Eh. E. D. McDade is now in Osoyoos. Dr. R. M. D'Amico is assisting Dr. M. K. Weare of Smithers. Eh. Melville Shaw is practising internal medicine in Vancouver Dr. ).}. Adrian is doing general practice in the Vancouver Broadway district. Eh. Madeline Chung has begun a practice in downtown Vancouver. Dr. R. Fraser is now at the Miller Bay Hospital, Prince Rupert. Dr. Oscar Karabanow is practising in Weyburn, Saskatchewan. Eh. ]. C. Kovach is now practising in Port Coquitlam. Eh. G. G. Lott is now practising in Port Alberni. Eh. J. M. McKellar is doing general practice in Prince George. Eh. James McLean is in association with Eh. J. W. Whitelaw in Vancouver. Eh. Peter Marioni is now practising in Nanaimo. Dr. D. E. Yates is taking the practise of Eh. A. C. Tanner in WTiitehorse for one year. Dr. J. W. Ibbott is now in practice in Vancouver. Dr. A. C. Schmok is practising in Newton with Dr. M. Verbrugge. Eh. Johan Bakker is at Pioneer Mines with Dr. W. Lipsett. Eh. G. F. Hicks is now at Terrace with Dr. J. B. Dukelow. Dr. A. H. Pontifex is now practising in Burnaby. Eh. John Dickenson is practising obstetrics in Victoria with Dr. C. H. Mair. Eh. Chris Moore, who has spent 3 years at the Mayo Clinic Foundation in Opthalmology, is now back in Victoria. Dr. Wr. A. McElmoyle of Victoria has returned from a trip to Europe. Dr. S. S. Avren completed one year in allergy and internal medicine at the University of Washington Hospital and has now resumed practice in Victoria. Mr. Lloyd G. McKenzie, Barrister, addressed a meeting of the Victoria Medical Society on "Legal Aspects of Medical Practice" last month. BIRTHS Born to Eh. and Mrs. D. H. Taylor-Lee of Victoria, a daughter. Born to Eh. and Mrs. Neil Stewart of Victoria, a son. Born to Eh. and Mrs. Vere Stuart of Victoria, a daughter. To Doctor and Mrs. W. D. McCauley of Duncan, a son. Page 524 INDEX TO BULLETIN VANCOUVER MEDICAL ASSOCIATION VOLUME 31, 1954 - 1955 ALCOHOLISM FOUNDATION OF BRITISH COLUMBIA—The B BAGNALL, A. W.—Letter from, Chairman Public Relations Committee.. BELLANGER, KAY—Specializing in the Family a BLAIR, MURRAY—The Second John Mawer Pearson Memorial Lecture Introduction. •. .-f?§_ —— BLOOD TRANSFUSION SERVICE)—Canadian Red Cross BOOK REVIEWS: Pediatric Gynecology—Goodrich C. Schauffler Problems of Infancy and Childhood—M. J. E. Senn (Ed.) ..._... The Roots of Crime—Sir Norwood East , 226 139 477 434 253 336 384 CANADIAN MEDICAL ASSOCIATION, B.C. DIVISION 17, 93, 138, 167, 338, 399, A New Venture in Insurance—G. G. Ferguson '.. Annual Meeting 1954 Proceedings Amendments to the Constitution and By-Daws '. _sfs_ ~-. Congratulations to Dr. Strong „ Deeds not Words—A. D. Kelly I ---%- - Doctor Patient Relationship \ 140, 220, Emergency Call—Sub-Committee on Doctor-Patient Relationship General Assembly Proceedings.... . , Hospitals Today—Gordon C. Johnston Letter from Dr. A. W. Bagnall, Chairman, Public Relations Com Referred Uncomplicated Surgical Cases—Report of Special Commission on Scientific Session of General Practice .-. Specialization of Medical Services—F. Turnbull Toward an Effective Medical Organization—F. Turnbull ~ % l&ANADIAN RED CROSS—Blood Transfusion Service -CARDIAC ARRYTHMIAS, MANAGEMENT OF—D. S. Munroe g_A.R.S _*fi__fc_ _§l i TODLLEGE STUDENTS—THE HEALTH OF—Frank Hebb COMMUNITY CHEST—Rehabilitation Services ; 1 DISABLED PERSONS ALLOWANCES—Medical Examinations For DOCTOR-PATIENT RELATIONSHIP 140, 220 DYKE, S.C.—The Pattern of Pernicious Anemia: Landmarks and Personalities (Pearson Memorial Lecture) 269 481 EDITOR'S PAGE . 7, 81, 123, 165, 211, 251, 297, 329, 381, 425, 467, 505 EMPLOYEE PHYSICAL VALUES—L. A. Patterson 435 EXTRACELLULAR FLUID VOLUME IN EPILEPSY—AN EXPANDED—John Kovach, B. Heinzman & M. Pifer 487 F FLUORIDATION —_ \ 4 FLUORIDATION FACTS _..'. 228, 271, 346 GENERAL PRACTICE, SCIENTIFIC SESSION OF SECTION—Program. GIBSON, W. C.—From Jenner to Salk GYNECOLOGICAL SYMPTOMS—Some Functional Causes Of—A. B. Nash. 167 334 513 HALL, GEORGE E.—The Physician and the Law HEALTH GRANTS, NATIONAL PROGRAM AS IT AFFECTS THE PRACTISING PHYSICIAN ,. HEBB, FRANK—The Health of College Students HEPATITIS, VIRAL HOSPITALS TODAY— Gordon C. Johnston I IMMUNIZATION—The Basic Program of the Health Branch _ INCOME TAX INFORMATION 387 402 265 JOHNSTON, GORDON C.—Hospitals Today. KELLY, A. D.—Deeds Not Words... KINNISTON, SAM—An Appreciation. K 93 338 165 LIBRARY NOTES 82, 124, 212, 253, 298, 334, 384, 426, From Jenner to Salk—W. C. Gibson Cholangiography—F. B. Thomson M MALPRACTICE AND THE PHYSICIAN—Louis J. Regan E - MATHISEN, A. K.—Pulmonary Embolism ip_ 469 334 468 438 214 Page 525 McAMMOND, E. N. C.—Pneumatosis Cystoides Intestinalis 508 MEDICAL ADMINISTRATORS _«_ 59 MEDICINE, FIFTY-SIX YEARS OF—A RETROSPECT—Dr. Dyer Pts. I & II 125, 169 MORTALITY STATISTICS—A New Light On , : 1 96 MUNROE, D. S.—Management of Cardiac Arrythmias 132 MURRAY, STEWART—Greater Vancouver Public Health 294 N AGAINST THE LEGAL SALE OF— 177 NARCOTICS, ARGUMENTS FOR AND Stevenson, G. H ." NASH, A. B.—Some Functional Causes of Gynecological Symptoms 513 NATIONAL HEALTH GRANTS PROGRAM AS IT AFFECTS THE PRACTISING Physician :„_ 57 NEWS AND NOTES —- 59, 98, 145, 189, 230, 273, 309, 354, 447, 489 OBITUARIES: ° Buller, Frederick James 353- Campbell, Clarence G 1 95 Dobson, W. A 522 Grimmet, Roger A .... 95 Lamont, George A .||||||g; 95 Nay, John „ ......:—...,^_..„ 523 Story, J. Boyd : 523^ OPHTHALMIA NEONATORUM—Prophylaxis of 1 309 PATTERSON, L. A.—Employee Physical Values PEARSON MEMORIAL LECTURE]—The Second John Mawer—Introduction by Dr. Murray Blair PERNICIOUS ANEMIA—The Pattern of, Landmarks and Personalities— Dr. S. C. Dyke 3j PHYSICIAN'S ART SALON PHYSICIAN AND THE LAW—George E. Hall PNEUMATOSIS CYSTOIDES INTESTINALIS—E. N. C. McAmmond POLIOMYELITIS VACCINE, FIELD TRAILS OF, IN BRITISH COLUMBIA POST-CHOLECYSTECTOMY SYNDROME—Peter E. Rees-Davies PRACTICE, AFTER 56 YEARS OF VERY MIXED—THE AFTERMATH—Dr. Dyer PREMATURE—Care of the &Jj PROBLEM CHILD—The .. PRONENESS TO ACCIDENTS—THE PROBLEM OF—Dr. S. C. Turvey PROPHYLAXIS OF OPHTHALMIA NEONATORUM i PSYCHIATRIC EMERGENCIES PUBLIC HEALTH—Greater Vancouver Metropolitan Health Committee - 4, 79, 121, 187, 294, 308, 387, PUBLIC HEALTH AND MENTAL HEALTH NEWS _.......... 57, 96, 141, 187, 226, 269, 308, 344, 402, PULMONARY EMBOLISM—Dr. A. K. Mathisen PULMONARY EMPHYSEMA, PRESEHSTT CONCEPT ON THE PHYSIOLOGY AND THERAPY—K. K. Pump PUMP, K. K.—Present Concept on the Physiology and Therapy Pulmonary Emphysema.... 435 9 272 387 508 187 347 169 269 22'6 259 309 344 484 431 214 85 85 REES-DAVIES, PETER E.—Post-Cholecystectomy Syndrome REFERRED UNCOMPLICATED SURGICAL CASES—Report of Special Commission. REGAN, LOUIS J.—Malpractice and the Physician . REHABILITATION SERVICES—Community Chest....'. REHABILITATION FOR BRITISH COLUMBIA—Current Planning ....... 347 2_Bj 438 392 141 SMALLPOX—Recommended Routine Immunization Procedure 431 SPEECH DIFFICULTIES 294 SPECIALIZING IN THE FAMILY—Kay Belanger 477 STANLEY,- ROBERT—Doctor-Patient Relationship '. ,_' 140 STATISTICS, A NEW LIGHT ON MORTALITY 96 STEVENSON, G. H.—Arguments for and against the legal sale of Narcotics 177 T TETANUS ANTITOXIN OR TOXOID? 79 TURNBULL, FRANK—Toward and Effective Medical Organization 217 TURNBULL, FRANK—The Socialization of Medical Services 482 TURVEY, S. C—The Problem of Proneness to Accidents 259 U UNIVERSITY OF BRITISH COLUMBIA—Faculty of Medicine Seminars 84 UROLOGICAL ASPECTS OF STRESS INCONTINENCE IN THE FEMALE— E. F. Word „ .. 47$ VANCOUVER MEDICAL ASSOCIATION 83, 166, 213, 252, 299, 330 Annual Report 301 New Members....... 83, 382 President's Report _"___" 301 VACCINE, FIELD TRIALS OF POLIOMYELITIS IN BRITISH COLUMBIA 187 VERNON HOME CARE PROGRAM 308 VIRAL HEPATITIS 10p WORD, E. F.- WORKMEN'S Page 526 W —Urological Aspects of Stress Incontinence in the COMPENSATION BOARD Female ;:__ 470 MJg 56, 136, 224
Periodicals
W1 .VA625
English
Vancouver : University of British Columbia Library
Vancouver, B.C. : McBeath Spedding Limited
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Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: October, 1954
Text