History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1942 Vancouver Medical Association Mar 2, 1942

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 5»
The BULLE
of the
VANCOUVER
MllDICAL ASSOCIATION
Vol. xvni
FEBRUARY,rt5>42
With Which Is Incorporated
Transactions of the ■
Victoria Medical Society
the
Vancouver General Hospital
and
St. Paul's Hospital
In This Issue:
NEWS AND NOTES §|jjj||§ -^^S^g^y    ^^^^^^^B
METHODS FOR THE PROTECTION OF SPINAL FLUID^^^^^K
LUPUS ERYTHEMATOSUS, LOCALIZED AND DISSEMINATED	
GRANULAR (NON-PURULENT) URETHRITIS IN WOMENjg|||
A STUDY OF THE ACCURACY OF FLUOROSCOPY OF THE LUNGS
A SIMPLE TEST FOR CANCER—4>fo. N. J^SH^BMW'IWBWWpiffBI
C.M.A. AND B.C.M.MANNUAL MEETING
JASPER — JUNE 15-19, 1942
NO SURVIVAL WITHOUT VICTORY! BUY VICTORY BONDS.
No. 5
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ANALGESIC
ANTIPYRETIC
SEDATIVE
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• Physicians who demand
effectiveness above all else,
know they can fully rely upon
E.B.S. preparations. And the
therapeutive effectiveness of
Shuttleworth preparations
keeps pace With medical
progress.
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GRAIN
Codeine
Phos.
GRAlfij!
Codeine
Pho^r
ODOPHEN
mHRHSffi^1 «^n g f h s
Being analgesic, antipyretic and sedative, Codophen E.B.S
offers symptomatic relief in muscular rheumatic pain, neuritis,
neuralgia, migraine and similar conditions, including certain
post-operative pains. Its usefulness to the physician is enhanced by its adaptability ... it is made in two strengths.
These are perfectly differentiated because each is distinctively
colored. Then for the sake of patients who may take longer
than usual to swallow tablets, Codophen tablets are pleasantly
and adequately flavoured with orange. To refresh your
memory, descriptions of the two strengths follow:
CT. No. 260 CODOPHEN, E.B.S.
With H grain, Codeine. Indicated
in those conditions where a mild
analgesic and sedative is required.
Tablets are a pale orange color and
each contains:—
Ebsal E.B.S.Ski.   .  ^ .   . 3 grs.
{.Acetylsalicylic Acid)
Phenacetine fiyiWM^^&MiM. 2 grs.
Caffeine Citrate |||pBJ|§|llj§|i 14.gr.
Codeine Phosphate    "x%jggi|i:* i£gr.
In bottles of 100, 500 and 1,000 tablets.
CT. No. 260A CODOPHEN
STRONGER E.B.S.
With H grain Codeine. Indicated
where a stronger analgesic and sedative is required. Tablets are a deep
orange color and each contains:—
Ebsal E.B.S. ^l@lf|§ W^^e8 gr-
(Acetylsalicylic Acid)
Phenacetine 'fiMrS^WfSi^^•   2 grs.
Caffeine Citrate 35J^?£%2-§i|   H 8T.
Codeine Phosphate    ^EBb.    J| gr.
In bottles of 100, 500 and 1,000 tablets.
CT. No. 248 CODASAL E.B.S.
This is available with M gr. or H gr. codeine
phosphate. All Codasal E.B.S. tablets are
pleasantly and adequately flavoured with
cinnamon. Codasal No. 248 contains:—■-
Ebsal E.B.&.M^J^^if^M.   W£M   5 grs.
mSl; {Acetylsalicylic Acid)
Codeine Phosphate '^S^^§^^^> V* £r.
Tablets are pale cinnamon tint, put up in
bottles of 100,500, and 1,000.
CT. No. 248A CODASAL STRONGER E.B.S.
Each tablet contains:
Ebsal E.B.S^^^^^^^m:i%^^.   5 grs.
(Acetylsalicylic Acid)
Codeine Phosphate   pjE^^B^B^SE    H gr.
Tablets are dark cinnamon color, put up in
bottles of 100, 500, and 1,000.
THE E. IL SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS ■H
THE    VANCOUVER    MEDICAL    ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDermot
De. G. A. Davidson Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
' J * *
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Vol. XVni.
FEBRUARY, 1942
No. 5
OFFICERS, 1941-1942
Db. C. McDiabmid Db. J. R. Neelson Db. D. F. Busteed
President Vice-President Past President
Db. W. T. Lockhart Db. A. E. Tbites
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Db. Gobdon Burke, Db. Fbank Turnbull
TRUSTEES
Db. F. Bbodie Db. J. A. Gillespie Db. W. L. Pedlow
Auditors: Messes. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Db. Ross Davidson Chairman Db. D. A. Steele ^.Secretary
Eye, Ear, Nose and Throat
Db. A. R. Anthony Chairman Db. C. E. Davies Secretary
Pcediatrie Section
Db. G. O. Matthews Chairman Db. J. H. B. Gbant Secretary
STANDING COMMITTEES
Library:
Db. F. J. Buller, Db. D. E. H. Cleveland, Db. J. R. Davies,
Db. A. Bagnall, Db. A. B. Manson, Dr. B. J. Habbison
Publications:
Db. J. H. MacDermot, Db. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. H. H. Caple, Db. J. E. Habbison, Db. H. H. Hatfield,
Db. Howabd Spohn, Db. W. L. Graham, Db. J. C. Thomas
Credentials:
Db. A. W. Hunter, Db. W. L. Pedlow, Db. A. T. Henby
V.O.N. Advisory Board:
Db. W. C. Walsh, Dr. R.~E. McKechnie II., Dr. L. W. McNutt.
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont.
Greater Vancouver Health League Representatives:
Dr. R. A. Wilson, Dr. Wallace Coburn.
Representative to B. C. Medical Association: Dr. D. F. Busteed.
Sickness and Benevolent Fund: The President—The Trustees.
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THIS IS WHAT S-M-A IS . .
THIS IS HOW IT IS
PREPARED
• ♦.••••■•••■
THIS IS THE WAY IT IS FED
THIS IS THE ONLY
SUPPLEMENT REQUIRED,
AND
THIS (in a nutshell) i«
the Easy, Economical Way used by an
ever-increasing number of physicians
to insure excellent, nutritional results.
A scientifically prepared formula fori
infants, deprived of breast milk.
.'!• Empty one tightly 2. Add enough warm.- 3. Cap bottle and shake
packed measuring cup previously boiled water into solution. Feed at
of S-M-A Powder into, to make one ounce. body temperature. I
bottle.
The quantity and number of feedings in 24 hours should be
the same as thai taken by the normal breast-fed infant.
Hi^ouWNCe juice
S.M.A.-BIOCHEMICAL DIVISION
John Wyeth & Brother (Canada) Limited
Walkerville, Ontario
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MEASLES
Modification
»«
Prevention
In 1939 there were 197 deaths from measles in Canada.
More than 95 per cent of these were in the age-group 0-5
years.
Human serum prepared from the blood of healthy adults
so as to involve a pooling from a large number of persons
may be used effectively either for modification or prevention
of measles. Modification is often preferable in that it reduces
to a minimum the illness and hazards associated with measles,
but does not interfere with the acquiring of the active and
lasting immunity which is conferred by an attack of the
disease. On the other hand, complete prevention of an attack
of measles is frequently desirable, and can be accomplished
provided that an ample quantity of serum is administered
within five days of exposure to the disease.
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For use in modification or prevention of measles, pooled
human serum is available from the Connaught Laboratories in
a concentrated form. While the recommended dose of this
pooled and concentrated human serum for purposes of prevention is ordinarily 10 cc, the most usual dose is for
purposes of modification and amounts to 5 cc. The serum is
therefore supplied in 5-cc. vials. Prices and information
relating to it will be supplied gladly upon request.
CONNAUGHT LABORATORIES
UNIVERSITY   OF   TORONTO
Toronto
Canadi
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C.
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IN PREGNANCY
SUGGESTED
FOR TREATMENT OF THREATENED
OR HABITUAL ABORTION DUE TO
ViTAJVUNE DiftlENCyl
tf^m
FOR INCREASED
CALCIUM REOiREMENTS
# Each capsule contains 50 milligrams of mixed tocopherols,
equivalent in vitamin E activity
to 30 milligrams of a-tocopherol.
Tocopherex contains vitamin E
derived from vegetable oils by
molecular distillation, in a form
more concentrated, more stable
and more economical than wheat
germ oil.
For experimental use in prevention of habitual abortion (when
due to Vitamin E Deficiency): 1 to
3 capsules daily for 8J^ months.
In threatened abortion: 5 capsules
within 24 hours, possibly continued
for 1 or 2 weeks and 1 to 3 capsules
daily thereafter.
Tocopherex capsules are supplied
in bottles of 25 and 100.
# Each capsule of Viophate—D
contains 4.5 grains Dicalcium
Phosphate, 3 grains Calcium Gluconate and 330 units of Vitamin
D. The capsules are tasteless, and
contain no sugar or flavouring.
Where wafers are preferred, Vio-
phate—D  Tablets  are  available,
pleasantly flavoured with winter-
green.
One tablet is equivalent to two
capsules.
How supplied:
Capsules—Bottles-of 100 and
1,000.
Tablets —Boxes of 51 and 250.
For literature, write 36 Caledonia Road, Toronto
 1
E-R:Sqjjibb&.Sons of Canada. Ltd.
MANUFACTURING   CHEMISTS  TO  THE   MEDICAL   PROFESSION   SINCE   185ft VANCOUVER  HEALTH  DEPARTMENT
STATISTICS—DECEMBER, 1941
Total Population—estimated   272,352
Japanese Population—estimated 8,769
Chinese Population—estimated 8,558
Hindu Population—estimated 360
Rate per 1,000
Number
Total Deaths :  282
Japanese deaths  5
Chinese deaths  13
Deaths—residents only  247
BIRTH REGISTRATIONS:
Male, 224; Female, 207_
431
INFANTILE MORTALITY: Dec., 1941
Deaths under one year of age        9
Death rate—per 1,000 births 20.9
Stillbirths (not included in above) 14
Population
12.2
6.7
17.9
10.7
10.7
Dec., 1940
16
36.7
9
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
November, 1941
Cases   Deaths
December, 1941
Cases   Deaths
Scarlet Fever 18 0 22          0 24
Diphtheria (Carrier) : 0 0 0           0 1
Chicken Pox 266 0 135           0 141
Measles -      7 0 16           0 20
Rubella 5 0 11           0 10
Mumps 53 0 60           0 163
Whooping Cough —t    22 0 24           0 14
Typhoid Carrier , 0 0 10 0
Typhoid Fever 0 0 2           0 1
Undulant Fever 0 0 0           0 0
Poliomvelitis 0 0 2           0 0
Tuberculosis 29 14 26         18 13
Erysipelas 2 0 5           0 0
Meningococcus Meningitis 2 0 2           0 '2
Influenza Meningitis 0 0 0           0 1
Flexner Dysentery 2 0 10 0
V. D. CASES REPORTED TO PROVINCIAL BOARD,OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
West North
Burnaby   Vancr.  Richmond   Vancr.
Vane.   Hospitals &
Clinic  Private Drs.  Totals
Syphilis 0
Gonorrhoea 0
1
0
0
1
0
2
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A DYNAMIC MENTAL AND PHYSICAL TONIC
INDICATED IN THESE DAYS OF STRESS
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BIOGLAN "A
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C.
Page 132
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10-
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£&
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• For Chest Colds, Bronchitis, Tracheobronchitis,
and other affections of the respiratory tract —
Antiphlogistine is an ideal adjuvant to internal
treatment. Its medication and sedative warmth
are an aid in bringing about symptomatic relief.
There are no systemic reactions when using Antiphlogistine; it may be used with chemotherapy.
Made in Canada
THE DENVER CHEMICAL MANUFACTURING COMPANY
153 Lagauchetiere St. W.       .... Montreal 12«\
VANCOUVER MEDICAL ASSOCIATION
Founded 1898    ::    Incorporated 1906
Programme of the Forty-fourth Annual Session
(Winter Session)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Papers of the evening.
1942
January   6—GENERAL MEETING.
Dr. F. N. Robertson: "A Simple Test for Caricer."
January 20—CLINICAL MEETING.
February   3—GENERAL MEETING.
Dr. J. H. MacDermot: "Epi-Sacro-Iliac Lipomata—A small cause of
much trouble."
February 17—CLINICAL MEETING.
March 3—GENERAL MEETING
Osier Lecture—Dr. D. E. H. Cleveland.
March 17—CLINICAL MEETING.
April   7—GENERAL MEETING.
Dr. L. H. Appleby: "The Use of Snake Venom in Medicine."
April 21—CLINICAL MEETING.
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Just
barley
hops
yeast
water
AN ANALYSIS OF GUINNESS STOUT 100 cc.
Total solids
5.87 gm.
\
Etbyl alcohol  (7.9%   by volume) 6.25 g*
Total carbohydrates 3.86 gm.
Reducing  sugars   as  glucose 0.66 gm.
Protein None
Total   nitrogen 0.10 gm.
Ash 0.28 gm.
Phosphorus 38.50 mg.
Calcium 7.00 mg.
Iron 0.072 mg.
Copper 0.049 mg.
Fuel   value 61 cal.
Vitamin   BI 6 Int. Units
Vitamin G 33   Sherman  Bourquin  Units
GUINNESS
Analysis is only a partial indication of the attributes of Guinness Stout. The
physical equilibrium of colloidal properties is important, and the well-nigh
perfect balance  between  the alcohol  and  the  malt  and  hops constituents.
LITERALLY   thousands   of   physicians   in   Great
Britain have testified to the value of Guinness
as  a  tonic  during  convalescence.
...  as   a   stimulating   and    appetizing    food   for
older people.
... in the treatment of insomnia, to obviate
the depressing after-effects 'which most hypnotics
produce.
All the natural goodness is retained in Guinness
for,   unlike   other   stouts   and   porters,   Guinness   is
unfiltered and unpasteurized. The active yeast
'which thus remains is a source of Vitamin B and G.
Guinness has been brewed in Dublin since 1759,
and is the largest selling malt beverage in the
'world. It is matured over a year in oak vats and
bottle. Foreign Extra Guinness is obtainable through
all legal outlets. Write for convenient 3"x5" file
card giving complete analysis and indications to
Representative, A. Guinness, Son & Co., Limited,
501   Fifth   Avenue,   N.Y.C.
A. GUINNESS, SON & CO., LIMITED
DUBLIN and LONDON
S314
Page 133
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AYERST, McKENNA & HARRISON LIMITED • Biological and Pharmaceutical Chemists • MONTREAL, CANAE
HELP   WIN   THE  WAR     •     BUY  WAR   SAVINGS   CERTIFICATES     •     PRESCRIBE   CANADIAN-MADE   PRODUCT toi/l
•■>; :i
*! During the past week or two, medical men have been receiving a circular letter from
the North Pacific Health & Accident Association of Vancouver, urging them to support
the application that this Company has made to the Executive of the B. C. Medical Association, to have their medical scheme recognized on the same basis as the schemes
Operated by the B. C. Telephone, B. C. Electric, Vancouver School Teachers, Medical
Services Association, etc.
fWe think that the Executive of the B.C.M.A. did exactly the right thing in declining
to recognise this company in this way. In the first place, their coverage is not comparable with that given by the organisations mentioned. For it to be comparable, they
would have to charge their members more than do these organisations, since they must
employ and pay agents, and there is not the same selection.
Next, we have no adequate knowledge of the reliability of this company. In this
connection we refer our readers to our extract from the Toronto Saturday Night (Insurance Dept.) published in the Bulletin in December last.
In the third place, there is no need for this organisation. The B. C. Medical profession has set on foot the Medical Services Association, which is doing excellent work,
covering its members adequately, paying our bills promptly, and doing all this at a
minimum of cost and overhead. There is no sense in multiplying organizations, and we
should support the M.S.A. even if the North Pacific gave a comparable service, which
it does not.
We are still not convinced that there is not a third-party profit in this. At the least,
a number of agents and salesmen are making money out of it, and this comes out of
the pockets of the "members."
We urge all medical men to disregard this appeal. Read and re-read the remarks of
the Committee on Economics, Bulletin, January, 1942, pp. 116-7—this concise and
clear statement answers all our questions in this regard.
,^\,
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'51
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In the last issue of the Bulletin, we took occasion to criticise the attitude, as we
saw it, assumed by the Canadian Medical Protective Association with regard to the collection by doctors of money due to them. Dr. Fisher, the Secretary of the C.M.P.A.,
has written us giving his side of the matter—and we gladly give his letter space in our
columns.
A great deal of what Dr. Fisher says is true, and we have not the least desire to put
difficulties in the way of the C.M.P.A., which has done, as we said, excellent work for
medical men. We agree, of course, with the idea that at times discretion is the better
part of valour—and we recognise the fact that the duty of the C.M.P.A. is, as far as
possible, to "prevent unnecessary legal action" when possible. All that Dr. Fisher says
is true about the additional cost, the difficulty of recovery, etc. Undoubtedly each case
must be dealt with on its own merits, and the advice and experience of the C.M.P.A.
will be of inestimable value to its members. Other things being equal, if a stay of proceedings of two or three months will make collection easier and safer, this would be the
common-sense course.  All this is obvious.
But this does not answer our objections to the letter written by Dr. Fisher to Dr.
Ainley, nor to the fact that the policy of the C.M.P.A. comes perilously close to submission to blackmail. In one case, the C.M.P.A. did advise reduction of an account when
a suit was threatened. Again, they say that when a member will not take their advice
about delay, they will leave him to his own devices, and will not defend him.
This is still the crux of the situation. What a doctor needs is adequate protection.
The fee paid to the C.M.P.A. evidently does not afford adequate protection, and the
only way it can be of value is by avoiding trouble.
Page 134
GET INTO THE FIGHT!    BUY VICTORY BONDS. I i Ml
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Our attitude as a profession towards fees is still rather too apologetic, and there i
no reason why it should be. We do work, and earn money. The debtor should pay, anc
if he doesn't pay in reasonable time, the account should be collected, while it is stil
collectable. Any collector will tell you that a year is a very long time to wait, anc
makes collection very difficult. Then why wait? Simply because otherwise, the debtoi
secures the services of a lawyer, who threatens blackmail. It is, as we said, poltroonerji
and weakness to submit to this, when we are entirely within our rights.
Insurance, adequate insurance that is, will protect us against this—and the best thinj
any doctor can do is have adequate insurance. The mere fact that he has it, is sufficient
in 99% of cases to avert these vexatious actions and the best way for him to handle the
situation is to inform the debtor, or his lawyer, that they can take their case to hii
insurance company. The C.M.P.A., conscious of financial weakness, advises its members
not to tell the debtor that he has such insurance.   We regard this as a mistake.
The Canadian Medical Protective Association is not an insurance company: but its
functions are those of a medical defence union. We have long thought that the medical
profession could very well develop a strong insurance organisation within itself, charging;
adequate fees, and protecting its members properly and adequately. This would mean,
the collection of a larger fee, of course—but this fee would still be less than that charged
by regular insurance companies which have to pay agents' commissions and other charges
We present this suggestion to the C.M.P.A. for their consideration.
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Dr. G. F. Amyot, Provincial Health Office, has stated publicly that the success off
the venereal disease programme in British Columbia during recent years has been due inl
no small degree to the acitve participation and fine co-operation of all the doctors in]
the province.
The Division of Venereal Disease Control is now embarking upon a provincial-wide*
programme in a vigorous effort to rid this province of prenatal syphilis. The responsi-j
bility for its success rests upon the Physicians, Health Departments and the women of
the province. The greatest burden, however, falls upon the doctors; they take the blood
tests. The aim of the programme is to have every pregnant woman go to her doctor
before the fifth month of every pregnancy for a complete examination, including always
a blood Kahn. If, when syphilis is discovered, weekly treatments are begun at once,
prenatal syphiHs can be stamped out in a single generation.
In order to educate the general public along these lines special pamphlets have been j
prepared which deal very simply with the question of prenatal syphilis.   These are being j
distributed through women's organizations, nurses, teachers, etc., throughout the whole
province until every person will have seen or heard something about prenatal syphilis.
(In this regard the Division has obtained the strong, enthusiastic support of the National
Council of Women.)
A special "Prevent Prenatal Syphilis Week" will be held in the first week of February and is being featured with proclamations by several of the city Mayors, endorsement by His Honour the Lieutenant-Governor, a radio address by Dr. Amyot, Provincial
Health Officer, a special letter to the profession from Dr. Hilton, Chairman of the Committee on Maternal Welface, and lectures by members of the Venereal Disease Control
staff.
By these means the barrier will be broken down, Kahns will become routine, and
prenatal syphilis will disappear, and with it one of the greatest public health problems
of our time.   Let us give it our full support.
As our readers know, the card on which the doctor in attendance reports a birth
asks "Was a blood test (for syphilis)  taken before the fifth month?"
We can readily see why this is asked—since treatment to be truly of value must
begin before the fifth month. Unfortunately, we do not always see our patients before
the fifth month—yet take a blood test. We feel that this should be worded differently.
For example, "Was a blood test for syphilis taken during pregnancy?" "Was it positive
or negative?"
Page 13 5
itiMti IM.
This is the information the department wants to have—and the question as asked at
present does not get this information. If necessary other questions could be asked as
to treatment.
We make this suggestion, as some of us have found the present question unsatisfactory, difficult to answer.
We are sure the medical profession of British Columbia will be, to a man, behind the
efforts of the Venereal Disease Control Department of the Provincial Board of Health.
jDr. Amyot's letters to nurses, doctors, women's groups, etc., are models of terseness
and clarity.
».
v4, ' J
NEWS    AND    NOTES
Dr. H. H. Murphy, Director of the Radiological Department of the Royal Jubilee
Hospital, and Dr. K. A. Bibby, Director of the Radiological Department of St. Joseph's
Hospital, attended the convention of the American Radiological Society which was held
in San Francisco during December.
Dr. H. E. Ridewood of Victoria has recently returned from a rather extended trip
to Montreal and other Eastern cities. Rumour has it that while in Quebec he has become
adept at the art of skiing.
Our congratulations are due Dr. and Mrs. T. W. A. Gray of Victoria on the birth
of a son on December 14th.
Dr . and Mrs. Herman Robertson of Victoria spent the Christmas holidays at Harrison Hot Springs.
Among the Victoria doctors who have recently joined the R.C.A.M.C. (Active
Force) are: Stuart Kenning, Lloyd Bassett, Norman C. Cook, Jack McKinnon, Douglas
B. Roxburgh, O. C. Lucas and Lumir Ptak.
'S
The hospitals in Victoria are organized and ready for any emergencies that might
I arise from enemy attack.
Lieutenants T. Dalrymple, W. S. Huckvale, R. A. Palmer and G. L. Watson are at
an Eastern centre taking special training.
hi
Congratulations are extended to Dr. and Mrs. R. A. Stanley on the birth of a son,
January 14th.
Dr. Grant Lawrence is attending the Eleventh Midwinter Post-Graduate Clinical
Courses in Ophthalmology and Oto-laryngology in Los Angeles.
Flight-Lieut. W. R. Brewster, formerly of Vancouver and New Westminster, is in
charge of a hospital near McLeod.
► *i
Lieut.-Col. W. E. M. Mitchell, formerly of Victoria, when last heard from was at
Malta.
Dr. R. D. Nasmyth, who has been associated with Dr. D. P. Hanington of Ladysmith
for some time, has returned to Victoria.
FOIL FREEDOM'S FOES.   BUY VICTORY BONDS.
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Dr. R. W. Garner of Port Alberni has been enjoying a brief holiday and visitedj
Seattle and Vancouver.
Dr. and Mrs. G. McL. Wilson have taken up residence in Revelstoke. Dr. Wilson
is associated with Dr. Hamer in practice there.
Dr. C. G. Morrison visited in Vancouver at Christmas, and was married on Decern-1
ber 26th to Miss D. P. Farnsworth, R.N. They will make their home in Trail, where]
Dr. Morrison is associated with the C. S. Williams Clinic.
Dr. and Mrs. E. S. Hoare of Trail are receiving congratulations on the birth of a
daughter.
Dr. and Mrs. D. J. M. Crawford of Trail spent the holidays in Medicine Hat, where!
Dr. Crawford was convalescing from a recent operation.
Dr. H. F. Tyreman of Nakusp has had a vacation in Vancouver. During his absence i
Dr. W. B. Clarke and Dr. H. Cantor relieved him.
Dr. H. Cantor is now Flying Officer with the Medical Services of the R.C.A.F.
Dr. W. B. Clarke has taken up practice at Blubber Bay, where the late Dr. A. A.
Sutherland had been for some time.
Lieut. W. H. White, late of Penticton, is in the R.C.A.M.C. and serving at Esquimalt Military Hospital.
Dr. Reba Willits, now associated with the Metropolitan Health Board in Vancouver,
spent Christmas at her former home in Kelowna.
Flight-Lieut. A. S. Underhill spent Christmas at his home in Kelowna.
Dr. P. L. Straith of Courtenay called at the office when in Vancouver recently.
The sympathy of the profession is extended to Dr. W. G. Saunders, Health Officer
of North Vancouver, in the loss of his father, who died in Victoria .on December 26th.
Doctors in North and West Vancouver are organized into teams for duty at the
Hospital in case of unusual demands, leaving one doctor in each district free to look
after A.R.P. and F.A. Stations, and to act as clearing agents for hospital cases.
Dr. H. L. Burris of Kamloops has been on holiday in Vancouver and called in at
the office.
Dr. B. J. Hallowes of Port Re/\frew called in at the office.
We had a very interesting letter from Major Roy Huggard, who is somewhere in
Britain, and for the time being is serving as S.M.O. at headquarters of a large Canadian
Training Centre.
He has seen Colonel La veil Leeson, who is A.D.M.S. of the 3rd Canadian Division,
and speaks in the highest terms of the services of this popular officer.
He has also seen Capt. C. H. Gundry, who is doing a very exxcellent piece of work
in the development of "intelligence tests," grading types for training in various branches,
all of which is very important.
Page 137 Capt. A. R. J. Boyd, formerly with the Metropolitan Health Board, is doing that
type of work with a Hygiene Unit and doing it very well.
Roy thought our members would be interested to know that both Capt. Gundry and
Capt. Boyd were doing their own type of work and making an excellent contribution.
Major W. L. Boulter is in a similar position to Major Huggard, in another area, and
doing well.
Capt. Jack Wright is reported to be doing very fine work among the troops in
Britain.
*g;
Dr. Paul Phillips of Princeton called at the office when in Vancouver recently.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY
Surgical Clinics of North America, Symposium on Military Surgery, and 3-year Cumulative Index, December, 1941.
Cunningham's Text-book of Anatomy, 7th ed., 1937, edited by J. C. Brash and E. B.
Jamieson.
The Principles and Practice of Ophthalmic Surgery, 2nd ed., 1941, by Edmund B.
Spaeth.
Diabetes Mellitus, 1941, by Wirtschafter and Korenberg. (Gift of Mr. Morton Stone,
Prescott and Company, Cleveland, Ohio.)
Plain Words Abount Venereal Disease, 1941, by Surgeon-General Thomas Parran and
Asst. Surgeon-General R. A. Vonderlehr, U. S. Public Health Service. (Gift of
Division of Venereal Disease, Provincial Board of Health.)
Transactions of the American Association for the Study of Goitre, 1941.
BOOK REVIEW
DIABETES MELLITUS, Wirtschafter and Korenberg, 186 pp., $2.50.  The Williams &
Wilkins Company, Baltimore, Md., 1942.
The chief author is associated with Cleveland Hospital and the Medical School, but
not with the Crile Clinic. The book is not a text-book and does not pretend to guide
the practitioner in the details of diets and handling of the diabetic, unless it be acidosis
or coma. The publishers speak about the authors pointing out the dangers of rule of
thumb procedures "but make the physician independent of them." This latter they
attempt to do by building up his groundwork of medical history, chemistry, pathology
and endocrinology, etc., of diabetes. It is a fairly complete review of the recent literature from many more than less distinguished authorities, with summary of salient data
brought out, though not always proved. The authors leave the reader to draw his own
conclusions, which in many cases he can only do by following up the many references
in a very complete bibliography.
The book is one to stimulate the reader and enlarge his understanding of an interesting, complicated and sometimes contradictory subject.
A. W. B.
MISSING
From library shelves, Emergency Surgery, 3rd ed., Hamilton Bailey
-please return.
Page 138
AVENGE HONG KONG!   BUY VICTORY BONDS. Ga, id ti> r*.(
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British  Columbia  Medical   Association
(CANADIAN MEDICAL ASSOCIATION, BRITISH COLUMBIA DIVISION)
President Dr. C. H. Hankinson, Prince Rupert
First Vice-President j Dr. A. H. Spohn, Vancouver
Second Vice-President  Dr. P. A. C. Cousland, Victoria
Honorary Secretary-Treasurer Dr. A. Y. McNair, Vancouver
Immediate Past President Dr. Murray Blair, Vancouver
Executive Secretary * Dr. M. "W. Thomas, Vancouver
2.
3.
4.
5.
6.
7.
8.
9.
COMMITTEE ON MATERNAL WELFARE
The above Committee wishes to impress upon the medical profession in B. C. who do
maternity work, the importance of filling out and returning to the Department of
Public Health for recording, the new Maternal Record Cards to be issued shortly. They
have been simplified and can mostly be answered by a V hi tne space provided.
They will serve to remind you to:
1.   See your patients regularly.
Take Kahn and Hb. tests.
Give Vitamin D during, and Vitamin K towards the end of pregnancy.
Give iron, calcium, and iodine when necessary.
Note an abnormal increase in weight.
Note an excessive rise in blood pressure.
Note onset of albuminuria.
Note onset of toxaemia.
Note onset of haemorrhage and possible placenta praevia.
From 2 you will be able to detect prenatal syphilis and take steps to cure it by proper
treatment.
Nos. 5 and 6 will give you the first signs of an approaching toxaemia and a chance
to eliminate it. The routine examinations will show any abnormality in the condition of
the mother, and a chance to correct it before it has time to produce harm.
From rectal examinations after the seventh month and from the position of the fcetal
hear, information can be obtained on:
(a) Relative size of fcetal head and pelvis..
(b) Presentation.
(c) Engagement of the head. |||||
An adequate post-natal examination should also be done.
The Maternal and Neo-Natal Death part of the record, if not wanted, can be torn
off, but if a death occurs it should be fully filled out, as a study of these is to be made
to try and find methods to eliminate those that are preventable.
But the most important factor that will reduce these deaths to a minimum is ADEQUATE PRENATAL CARE.
A registered pharmacist was charged in the Toronto Police Court with three violations of the Opium and Narcotic Drug Act, and was given the minimum fine of
$200.00 on each charge with costs.
The first two charges were for supplying preparations containing a narcotic, without
first obtaining a properly signed order from a physician.
Please note that neglect to comply with the regulations may not only involve the
pharmacist, but that the doctor is also liable to prosecution.
Page 139 DR. W. A. McTAVISH
OBIIT JAN. 7th.
"Will" McTavish, as he was known to many of us, was one of the old-
timers in Vancouver, medically speaking: he and his brother, F. C. McTavish,
who died some years ago, were practising here at the beginning of the century.
In later years, after the loss of his wife, Will more or less relinquished practice
in the city of Vancouver, and at the time of his death was on the staff of the
Columbia Coast Mission.
A quiet, rather shy man, Will McTavish was of a very friendly disposition,
and those who knew him were very fond of him. He was very devoted to his
wife, the more so perhaps because their marriage was childless, and one feels
that after her death he had somehow lost interest in things—but he died in
harness, and so, as the old writer says, "made a good ending."
DR. A. A. SUTHERLAND
OBIIT JAN. 3rd.
In the recent death of Dr. A. A. Sutherland at the age of 77, British Columbia has lost one of its oldest practitioners. Dr. Sutherland graduated from
Trinity in 1891, and has practised continuously since. After some years' practice in Ontario, he came to Cloverdale in 1895, and remained there till 1922,
when he came to Vancouver. Later, as he felt the need of a less strenuous life,
he went to live at Blubber Bay on Texada Island.
Dr. Sutherland lived a long and useful life, and was lucky to be in full
possession of his faculties and on active duty till his death.
1 w.
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THE CANADIAN MEDICAL PROTECTIVE ASSOCIATION
THE CANADIAN MEDICAL PROTECTIVE ASSOCIATION
Suite 401, 180 Metcalfe Street,
Ottawa, Canada.
January 9, 1942
The Editor,
The Bulletin of the Vancouver Medical Association,
203 Medical-Dental Building,
Vancouver, B. C.
Sir:
One of our members sent us an editorial which appeared in the December issue of
the Bulletin of the Vancouver Medical Association in which there is a forceful
comment on the policy of this Association. There are several aspects of the problem
which need consideration before any conclusion such as that drawn by the editorial
can be reached.
Page 140
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The C.M.P.A. is not an insurance company. It is a mutual defence union. That is,
the Association is simply an incorporated body made up of members who have organized
so that there may be a common fund from which each man may draw when, under
certain circumstances, financial assistance is desirable. The Council of the Association
has always felt, and still feels, that this point is of great importance with reference to
matters such as those brought up by Dr. Ainley. The Council considers that its duty
to the members should include more than their defence when they get into trouble. It
should include as one of its important services the prevention of unnecessary legal action
against doctors. There are several reasons why this function of the Association is
important. One is that there is always some publicity attached to a medico-legal suit
and even when such a case is defended successfully the publicity may be annoying if not
harmful. Another reason is that very seldom can the costs of an action be recovered
even when such an action is dismissed with costs against the plaintiff. The Association
does not object to spending whatever may be necessary to provide its members with the
best legal assistance available, but it does object to expenditures for preventable cases if
the suits can be avoided without loss to the members. The Association feels that once
an action against a member has been instituted this action should be defended as strenuously as possible, but if such actions or counteractions can be avoided without injury
to members these members have received better service than if they were allowed or
encouraged to become involved unnecessarily.
The Statute of Limitations of the Medical Act of British Columbia reads in part
as follows:
"No duly registered member of the College shall be liable in any action for
negligence or malpractice by reason of professional services requested or rendered
unless the action be commenced within one year from the date when the matter
complained of the professional services terminated. . . ."
A similar Statute forms part of the Medical Act of every Province in the Dominion with
the exception of the Province of Quebec where the prescriptive time differs. The
Statutes were not inserted by the Provincial Legislatures at the behest of doctors. It
has been judged wise since 1625 that actions of some kinds should be prescribed by time
limit so that frivolous and annoying actions could not be started years after the event
complained of. One type of action which, to a large extent, is prevented by the Statute
is the type described by Dr. Ainley, that is, where a patient, to avoid paying a just
account, threatens he will contest a suit for collection by a counter-suit for malpractice
or negligence. To refrain from collection of an account until it can be collected without
fear of annoyance and wasted time, that is, to take advantage of a provision of the law
designed for just this purpose, would seem, and does seem to the Association, the prudent
and the wise course. Nor does such delay mean that a doctor should submit to blackmail, or that he should reduce a just account because of the threat of a malpractice
action. It means simply that when threats have been made action to collect the account
will be delayed—not stopped—until such action can be taken in the most effective way.
Such delay will cause an occasional account to be lost. But the average account lost
in this way can be measured in tens of dollars whereas defence costs in suits or counter-
suits for malpractice or negligence invariably cost hundreds of dollars and commonly
thousands of dollars. This truth is emphasized by the fact that the majority of patients
who take this means to avoid paying medical accounts are patients who cannot afford
the costs of court action, so that even when judgment awarding costs to the defendant
doctor is obtained these costs cannot be collected. In 1941, of the cases it defended,
the Association collected costs from one only.
The Association feels that if its members, as individuals, were faced with a choice of
collecting an account at any given time, at a cost to them many times greater than the
account itself, or of waiting a year,, and being able to collect it with no expense other
than the cost of collection, they would decide invariably to wait. Therefore the Association feels that in no way is it asking of its members more than they as prudent indi-
Page 141 >i;
viduals would expect of themselves. As th eeditorial says, such a delay is unnecessary if
the case be a just one, and the Courts of Canada are competent to decide fairly the issues
of such cases. But this again in no way alters the fact that to proceed as the editorial
suggests would, in many cases, make a bad situation worse.
The C.M.P.A. must not allow itself to be used as a collection agency. It came into
being in response to a specific need, to provide a means whereby individual doctors need
not be ruined defending themselves against charges of malpractice or negligence. If the
Association encouraged its members to take action to collect accounts at a time when
needless counter-actions would result it would be wasting very necessary funds.
We draw your attention to the fact, Sir, that your statement "but to solemnly make
it a matter of policy to do this in all cases under twelve months" is inaccurate. In the
Annual report to which you refer the Association advised doctors to wait always in the
case of patients who may be dissatisfied, and said that this "might, with benefit" be
extended. In the letter to Dr. Ainley the wording was of similar meaning "that if by
collecting accounts precipitately they cause unnecessary suits." In this context the
meaning of "unnecessary" is fairly obvious.
Yours very truly,
T. L. FISHER, M.D., Secretary-Treasurer.
CANADIAN MEDICAL ASSOCIATION
ANNUAL MEETING — JUNE, 1942
JASPER, ALBERTA
Every medical man in British Columbia is urged to begin now to plan for this
meeting.
Of course we cannot all go—but a great many of us can go that perhaps think they
cannot.    So think it over carefully.
;
The place is unique. Probably never in the history of C.M.A. conventions has a
more beautiful site been chosen. Our Alberta brothers are entering wholeheartedly into
the matter of arrangements, and we are assured of a week that will linger long in our
more happy memories.
The programme will be more fully announced later—but we can say now that it
has a great deal for everybody.
Remember, the British Columbia Medical Association is a division of the Canadian
Medical. So this is our meeting. Matters of Medical Economics are receiving especial
attention at this meeting.
We regret that a fuller statement on this matter by Dr. M. W. Thomas has been
squeezed out by space considerations. Next month the Bulletin will carry more, dealing with travel schedules, meetings, etc.
Page 142
REMEMBER HONG KONG!    BUY VICTORY BONDS.
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"METHODS FOR THE PROTECTION OF SPINAL FLUID"
By Carl Lange, M.D., Albany, N.Y.
American Journal of Syphilis, Gonorrhoea and Venereal Diseases, Vol. 23, p. 638, 1939.
Abstracted by S. E. C. Turvey, M.D.
Standardization of the diagnostic examination of spinal fluid lags spectacularly behind
other laboratory determinations and every single one of its points is today controversial.
The critical selection of an adequate group of examinations depends chiefly on the
knowledge of the diagnostic significance and the correlation of the different groups, and
this again on using an optimal technique. There is even lacking a standardization of
collection, transportation, and preservation of spinal fluids. There are no data to show
how far a specimen may deteriorate during transportation, or how much the results of
the tests are affected. The laboratory should know how much fluid was collected, by
what route and on what date. The main factor in avoiding bacterial contamination is
speed in doing the puncture,, especially avoiding unnecessary procedures. The potentially
deleterious effect of even slight blood contamination is strongly underrated and this is
appreciated if it is remembered that the blood plasma contains three hundred times more
protein than normal spinal fluid, whole blood contains six thousand times more white
cells, syphiHtic blood serum may yield marked complement-fixation reaction in dilutions
up to 1:1,000, and finally in bacteriaemia blood may infect a previously sterile subarachnoidal fluid. These facts indicate the importance of avoiding blood contamination.
Centrifuging to remove the blood is valueless and every blood-contaminated specimen
is unsatisfactory and the test must be considered as a distinct failure. A trained operator
should have no more than one per cent bloody taps.
At present, the only dependable standard method for demonstrating fibrinogen in
the spinal fluid is based on its spontaneous coagulation. About 1,000 cells per cubic
millimeter, either red or white, elicit a readily perceptible turbidity. High dilutions of
haemoglobin exhibit a yellow colour, and the usual benzidine test is not sufficiently sensitive for detecting highly diluted haemoglobin in spinal fluids still recognizable by its
colour. After forty-eight hours, haemolysis begins and an essential haemorrhage of this
age is recognized by the yellow colour. A yellow colour of the spinal fluid may be due
to (1) dissolved haemoglobin, (2) bilirubin, (3) strong admixture of blood plasma.
Froin's syndrome "coagulation plus xanthochromia" indicates the subarachnoid bloc and
the blood plasma indicates only clotted fibrin. Other tests are usually valueless after this
syndrome has been demonstrated—thus, the Kahn test is even contraindicated because
of the wide-open communication between blood and spinal fluid. A weblike fibrin clot
with a marked increase of white cells is highly indicative of tuberculous meningitis. In
purulent meningitis the qualitative sugar test performed with a three-times diluted
Fehling's solution may be useful as a bedside test, both for therapeutic and prognostic
suggestions, as a decrease indicates bacteria that cause purulent meningitis.
Polymorphonuclear leucocytes and fibrin provide a sufficiently practical demonstration of increased permeability of the blood vessels. The comparative distribution of
crystalloids in blood and spinal fluid is not practical in diagnosis.
The gold reaction belongs simply to the protein examinations, providing quantitative
and qualitative data about the proteins which cannot be obtained in any other way. The
volue of this test should be based upon syndromes (multiple sclerosis, general paresis)
and not upon single tests (paretic gold curve). The gold test is of value in (1) exclusion diagnosis, (2) detection of the slightest degree of syphilitic inflammation, (3) the
discrimination of paresis.  This test is elicited by the admixture of products of secondary
Page 143 parenchymatous destruction with the products of syphilitic inflammation and is a nonspecific test but of the highest diagnostic value.
Technique of Tests
I. Cell Count: Fuchs-Rosenthal's chamber using Unna's polychrome methylene
blue for staining; a ripened solution of one gramme of methylene blue and one gramme
of potassium carbonate, dissolved in 100 c.c. of freshly redistilled water. The solution
of red cells by the admixture of acetic acid to the stain is highly inadvisable because it
prevents the possibility of roughly estimating the amount of potential blood contamination or of recognizing a slight one at all.
The stain is drawn up to the 0.5 mark and spinal fluid to the 11.0 mark of a pipette
used for the counting of white blood cells. For this purpose a few drops of spinal fluid,
after thorough shaking, are poured into a watch glass, the pipette is filled from this
portion, and the residue discarded.
By dividing the number of cells counted in the whole chamber by three and considering the dilution by the dye, the number of cells per cubic millimeter is obtained.
Normal counts are J4 to 1 per cubic millimeter.
The mononuclear cells may be present due to normal permeability of vessels or to
local histogenetic reaction or to a haematogenous origin (particularly if mixed with polymorphonuclears and fibrin). The polymorphonuclear leucocyte is never encountered in
spinal fluids under conditions of normal permeability as they are of exclusively haematogenous origin and their presence in the spinal fluid demonstrates definitely some gap in
the barrier. Their presence is the simplest means to demonstrate increased permeability.
The highest degree of increased permeability is demonstrated by the presence of fibrin.
The qualitative cell examination is performed by centrifuging the spinal fluid for
twenty minutes, pouring off the supernatant fluid, and transferring the entire sediment
within a ring drawn with a wax pencil on a glass slide. Dry in an incubator at 56°
Centigrade and stain with Giemsa's or Wright's stain.
There is no connection between any certain type of cell and any particular etiology.
For practical purposes, it suffices to discriminate only three cell types: (1) erythrocytes,
mononuclear, and (3) polymorphonuclear leuuocytes.
II. Protein Examinations'. The only dependable technique for accurate determination of total protein in spinal fluids is the micro-Kjeldahl method, but it is not practical.
By its standard, all other tests based on turbidity of precipitated proteins are inaccurate,
and the maximum percentage of error is even above thirty percent. The turbidity varies
with the variation in the albumen-globulin ratio, as globulin yields a higher turbidity
than albumen. The author states there is no satisfactory and accurate, practical test but
suggests the quantitative modification of Heller's ring test as an unsatisfactory compromise. The normal protein content of the spinal fluid is twenty to thirty niilligrammes
percent.
A normal protein content excludes any inflammatory disease of the meninges. At
present there is no method of detennining the protein fractions in the spinal fluid. The
so-called globulin tests are obsolete. Also, an absolute globulin increase running parallel
with an absolute increase of total protein and having no diagnostic significance, is quite
different from a relative globulin increase. Furthermore, the globulin tests are not even
specific for globulin.
The gold reaction attempts to give some restricted information about protein fractions and concentrations; it must be remembered that the temporary employment of
colloidal gold as a reagent is absolutely incidental. The author describes the technique
of the quantitative and qualitative gold reactions. The results of these tests must be
correlated with other tests in the spinal fluid as well as clinical data and anamnesis.
The gold reaction has no value as an isolated consideration, and this fact is too rarely
recognized.
HI. Serologic Examinations'. The technique of serologic tests in the spinal fluid
is the same as that used for blood serum.   They are rendered highly inaccurate by even
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Page 144
BUY VICTORY BONDS. minute admixtures of blood or plasma, and in conditions like tuberculous meningitis
where there is greatly increased permeability, a positive Wasserman reaction of the spinal
fluid may not mean neurosyphilis at all, but only leakage of the positive plasma of a
latent blood syphilis. In paresis where an increased permeability is also encountered, the
isolated complement-fixation test is unable to exclude a hematogenous origin of the
reagin; additional tests demonstrate the probability that the reagins are chiefly of local
origin. The problem of "local significance," that is, local meaning with regard to the
central nervous system, is greatly underrated. This permeability is estimated by the
presence of polymorphonuclear leucocytes without erythrocytes, and the presence of
coagulated fibrin.
IV. Quantitative Chemical Determination of Permeability: The chemical methods
for the determination of permeability are based on the distribution of sugar and chlorides
in spinal fluid and blood. An isolated performance of both substances in the spinal fluid,
as frequently performed, is unsatisfactory; both the spinal fluid and blood should be
examined simultaneously and before breakfast.
However, every inflammatory (not mechanical) increase of permeability may be
recognized practically by polymorphonuclear leucocytes, and the highest degree of permeability, either inflammatory or mechanical, is demonstrated by the appearance of
fibrin.  These chemical tests are of little if any practical use.
The average ratio of the sugar concentration in the spinal fluid to that in the blood
is about 0.6; the average chloride ratio is about 1.2. The sugar concentration is the
more satisfactory test or permeability. The analysis of the spinal fluid for other crystalloids, such as urea, is valueless.
LUPUS ERYTHEMATOSUS, LOCALIZED AND
DISSEMINATED
From the Deparitnent of Pathology, Vancouver General Hospital.
By Dr. R. D. G. McNeeley, Senior Interne.
Lupus erythematosus is a systemic disease characterized by cutaneous manifestations,
which may be either localized or disseminated widely in the body. O'Leary has classified
it as follows:
1. Localized or chronic discoid.
2. Disseminated varieties:
A. Generalized discoid or chronic disseminate.
B. Subacute disseminate.
C. Acute disseminate.
3. Conditions related to lupus erythematosus: \\*^
A. Senear Usher Syndrome.
B. Libman-Sacks Syndrome.
However, in many cases transitions from the localized forms to the acute disseminated type occur. Hamilton Montgomery1 reports ten of thirty cases of acute disseminated lupus erythematosus which began as the localized type. It is generally conceded
that usually one must recognize the cutaneous manifestations in order to diagnose the
disease.
Chronic discoid lupus erythematosus is an eruption of flattish red papules, usually
confined to the face, ears, scalp and lower lip. The eruption progresses slowly at the
edges, with an elevated erythematous, slightly indurated border on which one finds dry
adherent scales attached to keratotic plugs which dip into sweat glands or hair follicles,
leaving in the centre an atrophic clearing. On the face it usually progresses to a characteristic "butterfly" distribution on the cheeks, with a bridge extending over the nose.
In the chronic disseminated forms the lesions are the same but may occur anywhere
on the body, especially on the upper part of the chest and on the arms and hands.
Page 145 Systemic symptoms and signs are mild. In the subacute and acute forms, the systemic
manifestations predominate. It may even be a fulminating infection with the only
cutaneous involvement a permanent "blush." In the Senear-Usher Syndrome there are
lesions on the face resembling those of lupus erythematosus and on the body, lesions
resembling those of pemphigus foliaceus and seborrhoeic dermatitis. The Libman-Sacks
Syndrome combines a verrucous non-bacterial endocarditis with a clinical lupus erythematosus. These two syndromes are now considered to belong in the same group as
lupus erythematosus.
Disseminated lupus erythematosus is a wasting febrile systemic disease which may
appear in its subacute forms with fatigue, exhaustion, low-grade fever, hematological
and renal changes, and pains in the joints not unlike rheumatic fever or rheumatoid
arthritis. The cutaneous manifestations may not appear until late. Remissions occur or
it may progress to an acute form in which prostration is extreme, stupor and delirium
appear, the temperature is high and the cutaneous eruptions appear at the same time.
The acute form may appear spontaneously and as it is almost always fatal within a few
weeks or months, it is often difficult to diagnose. Only two cases of this disease have
been in the Vancouver General Hospital in the past ten years, so it is either rare or has
not been recognized.
The etiology is unknown. Although the name suggests a tuberculous origin, there is
no proven evidence that such is the case. A response to an infection conditioned by a
previous tuberculous allergy, has been suggested. Some writers suggest a cutaneous sensitization to abnormal products of the reticulo-endothelial system, or a sensitization to
metabolites, as urea, tyrosine, etc., while Ludy and Carson3 found haematoporphyrinuria
with lead in the skin and concluded the lead acted as a catalyst to the action of ultraviolet light. Other writers claim a virus and still others a streptococcal cause. All these
are hypotheses or guesses.
The blood culture is negative in the great majority of cases and the histo-pathology
suggests a toxic rather than an infectious agent. O'Leary believes that the disorder is
due to a toxaemia1 of unknown etiology, occurring in asthenic woman between twenty
and forty years of age. In twenty-three cases, twenty-two were female with eighteen of
these between the ages of twenty and forty years, the youngest being seven and the
oldest forty-five4.
The following chart4 shows the relative frequency of symptoms in twenty-three
cases:
Butterfly facial lesion 22
Erythema :  22
Mouth Lesions __  14
Purpura or petechiae . 11
Fundus lesions      9
Palpable spleen 4
Arthritis  . 17
Serous membranes 17
Pericarditis  and  pleuritis 10
Pericarditis only 2
Pleuritis only 5
Haemoglobin, 38% to 75% 20 out of 20
Red Blood Cells, 2 to 3.8 mm 12 out of 13
Leucopenia, 4 to 6 m 9 out of 23
Thrombopenia, 70 to 190 m.  9 out of 12
Albuminuria 23
Micro hematuria 19
Azotemia, moderate 7
Azotemia, marked : 2
Hypertension,  moderate 3
Coarse verrucous endocarditis, non-rheumatic_ 13
Libman-Sacks  type 5
Non-rheumatic verrucae j     8
No endocarditis 9
Unknown   (heart lost) 1
Aschoff bodies myocarditis (22 cases) 0
The general symptoms are as follows: Fever is constant but of an irregular type. In
the terminal stages, it rises continuously and frequently becomes "swinging" in character.
With the fever there is tachycardia and a gallop rhythm or soft systolic murmur may
develop. The electrocardiogram usually shows a low voltage. Terminal myocardial
failure may occur. At autopsy there is often an endocarditis involving all valvular
surfaces and the mural endocardium with non-bacterial vegetations5 (Libman-Sacks syndrome1). As is common in toxic conditions, there is a loss of weight, some degree of
prostration, with an increase in the sedimentation rate even to 100 mm. in an hour.
Another indication of the toxicity of this disease is the finding of a falsely positive result
of serological tests for syphilis (found in 17% of thirty cases at the Mayo Clinic).
Page 146
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The changes in the skin are important and the more acute the stage, the less does itj
resemble the lesion of the localized type. Here, areas of indefinite superficial erythema!
begin on the face, neck or upper thorax, coalesce and become well demarcated. Oedemai
of eyes and face is often marked. The eruption is bright reddish-violet, with a cyanotic I
tinge in the active areas. Indurated plaques, such as described previously, are not com-J
mon with involution; residual pigmentation much like Addison's disease may be left. I
In the mouth, ulcers with an erythematous border may occur—in this series, in fourteen!
cases.
The  synovial  membranes  were  affected  in  seventeen  of  the  twenty-three   cases.
Synovial effusions are common.   Recurrntly painful muscles and joints occur, affecting
one or two regions at a time, and then disappearing in a few hours or days, even before I
other manifestations have appeared.   The joints may become painful and swollen, with 1
local redness and heat.   This condition may migrate from joint to joint, simulating \
rheumatic fever, while residual swelling of the joints between attacks may simulate
subacute infectious arthritis.   Though treatment with rest and salicylates may relieve
the symptoms, they will not affect the fever.
The process affects the serous membranes (in seventeen of twenty-three cases), and
serous pericarditis, pleuritis and peritonitis may occur, more commonly together. Pneumonia may be a terminal event. It is wise to scrutinize every obscure case of pleural
effffusion or ascites for other diagnostic features of disseminated lupus erythematosus.
The toxic process involves the liver, spleen and lymph nodes. In the liver it causes cloudy
swelling, acute congestion, and occasional enlargement. In the spleen we may find an
acute splenitis or acute congestion but rarely is it palpable. The lymph glands are often
enlarged. Depression of the bone marrow is common and of extreme diagnostic importance. A leucocyte count of less than 4000 per centimetre with many immature leucocytes and swelling of spleen and lymph nodes may make a puzzling haematological problem. This persists throughout the fever, unless secondary infection takes place. The red
blood cell count shows an anaemia, usually hypochromic in type. Platelets are depressed,
at times to 40,000, and thus petechiae and purpura may develop, confusing the picture.
The kidneys are affected with changes not unlike those in eclampsia, ulcerative colitis
and peritonitis or other "toxic" processes. This is shown clinically by albuminuria,
cylinduria, and haematuria, which parallel the severity of the cutaneous symptoms. There
is unusually good renal function until the end stages when the blood urea rises. In
four of fifteen cases at the Mayo Clinic, uraemia was the terminal state6.
The process may affect the retinal vessels and "flame-type" perivascular haemorrhages
or fluffy exudates are seen. Rarely the gastro-intestinal tract may be involved with
abdominal pains, diarrhoea and other symptoms which may simulate typhoid fever.
Case I: Miss C. S., white female, aged thirty-one, admitted to the Vancouver General
Hospital August 15, 1941. Three months before admission, she developed fleeting and
varying rheumatic pains in the knee joints. She also noticed hot and cold spells and
chills. All the joints, including the lumbar region, were affected from time to time.
There was swelling of feet and ankles only. She noticed a purplish rash on her legs,
face and arms about this time. A few weeks before admission, she developed shortness
of breath, palpitation, sweats, insomnia, anorexia and occipital headache. She had lost
at least ten pounds in the past three months.
There was no history of rheumatic fever. She had had jaundice at sixteen years of
age; pleurisy and an appendectomy in 1935; menorrhagia in 1936 and 1937; shingles in
1931; and a bad attack of influenza in 1940. She stated she had an attack of "rheumatism" (?) in 1940 but no fever or chills.   The family history was negative.
Examination revealed a flushed female, temperature 102.4°, pulse 13 0, respirations
22. She showed a reddish to purplish, irregular rash, occupying an area four to six inches
in diameter, on the right side of her face, on the upper part of the sternum, and on
the medial aspect of both knees, three inches in diameter. This rash was smooth, not
raised, and not itchy. Examination of the head and neck was negative. The respiratory
system was negative.   The cardio-vascular system showed a pulse of 130, with a blood
Page 147 pressure of 128/60. The heart was somewhat enlarged to the left. The second sound
at the apex was somewhat diminished and there was an aortic systolic murmur. Examination of the abdomen was negative to palpation except that the liver was palpable at
the costal margin in the right midclavicular line. No glands were palpable. All joints,
except the ankle and wrist joints, were very tender on pressure and there was slight
pain on movement but no crepitation or swelling. Neurological examination was negative. The red cell count was 3,3 80,000, haemoglobin 62%, white cell count 4,900, with
56% polymorphonuclear cells, 36% lymphocytes, staff cells. Urinalysis showed albumin
plus 1, white blood cells plus 1, red blood cells plus 1, and granular casts plus 1. Blood
culture showed no growth. Kahn test was negative. The sedimentation rate was 6/150.
A provisional diagnosis of rheumatic fever, erythema multiforme or aortic insufficiency
was made and she was given salicylates. Although the joint pains became somewhat
less, her temperature continued from 103° to 101° with the peaks at four o'clock in the
afternoon. She was sent to a nursing home, still taking salicylates. Her temperature
continued and on the fifth day she developed an unproductive cough with pain in the
right chest. She was brought back to hospital on the fourteenth day, with a temperature of 103°.
The physical examination was the same as previously, except that the rash was on
the temporal region of the face only and there were many rales at the bases of both
lungs. The red cell count was 4,080,000, the haemoglobin 65%, white cell count 3,500
60% polymorphonuclears, 17% lymphocytes, 8% disintegrating cells and 15% staff
cells. Urinalysis of a catheter specimen showed albumin plus 2, white blood cells plus 2,
red blood cells plus 1 and granular casts plus 2. Electrocardiogram showed a rate of
110, with very low potential. Radiograph of the thorax showed diffuse bronchopneumonia.
A diagnosis of acute disseminated lupus erythematosus was made. However, she died
on the second day of re-admission.
At autopsy, the pleural cavities showed a slight increase in fluid arid the lungs showed
a pneumonic process in the bases. Microscopically, there was a pleurisy and bronchopneumonia. The pericardial cavity contained a considerable excess of fluid with large
adhesions binding the heart to the pericardium. The heart was not involved. The liver
was somewhat enlarged and there was fatty degeneration and cellular disintegration
about the central veins. The spleen was enlarged and there was congestion of the sinuses
with arteriolar thickening. The kidneys grossly were not extraordinary and microscopically showed avascularity of the glomeruli. Some of the small arterioles showed a
peculiar necrosis of the walls together with an increased thickening. There was much
cloudy swelling of the collecting tubules with red blood cells and casts in their lumen.
Summary: Disseminated - lupus erythematosus. Bronchopneumonia. Pleurisy with
adhesions. Fibrinous pericarditis. Fatty degeneration of liver. Degeneration of collecting tubules of the kidney with avascularity of the glomeruli. Splenic enarteritis.
Case II: Miss L. M., white, female, aged eighteen years. She was in good health until
five months before admission (April, 1940) when she noticed weakness and pain on
movement in both wrists, worse in mornings. There was no swelling. In several weeks,
stiffness of fingers developed with swelling of the proximal phalanges. Two months later
her knees became so stiff that walking was difficult, and later her feet became tender in
the ball and heel.
Three months later (July, 1940)^the lateral aspects of her upper arms peeled, leaving reddened tender areas, and in a few weeks there were smaller discrete lesions on her
forearms. She became tired, feverish, weak, and went to bed, where she remained until
admission to hospital on September 22, 1940 (ten months after the onset of illness).
Two weeks before admission, she developed sharp epigastric pain, radiating through to
the back, made worse on deep inspiration, and a cough with yellowish sputum.
There was no history of rheumatic fever or any previous illness. Exarnination was
found negative except for multiple slightly elevated roughened areas, not tender, about
Page 148
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".< one-half inch in diameter, on arms, trunk and legs, covered with a fine silvery scale.
The condition was typical of lupus erythematosus.
She showed an intermittent fever from 102° in the evening to 100° in the morning.
The pulse rate was 120 per minute. The red cell count was 3,100,000, haemoglobin
58%, colour index 0.93, white cell count 2,500 and 4,400, polymorphonuclears 68%,
lymphocytes 27%, monocytes 4% . The sedimentation rate was 105/129. Two blood
cultures were negative. Paratyphoid agglutinations were negative. Three Kahn tests
were doubtful.  Radiograph of the chest was negative.
She was discharged with a diagnosis of acute disseminated lupus erythematosus fourteen days later.   She died six months after discharge from hospital.
In both cases, the articular symptoins developed before any other symptoms. In the
second case, it was three months before the rash. One would think naturally of rheumatic fever as a diagnosis. The fact that the first case was put on salicylates with no
reduction in the temperature, as well as the low white blood count, was suggestive of a
non-rheumatic condition. In both cases, there were rashes, urinary changes, negative
blood cultures and pulmonary symptoms.
The treatment of a disease, of which the cause is unknown and which gives such a
varied picture, is a difficult and disappointing problem. In the acute type, the mortality
is 100% and in the subacute type 50% over a five-year period. In the chronic stages
various intravenous preparations of gold are useful. These show cure in 30% and improvement in 30% in the chronic discoid types, but care must be taken as this drug
has a tendency to disseminate the disease. Intramuscular injections of bismuth are used.
Local treatments used in the chronic stage vary from calamine lotion in the superficial
types to fulguration in the deep indurated forms. The usual hackneyed advice about
rest, high vitamin diets, and removal of foci of infection is usually given. However, one
factor must be emphasized: avoidance of exposure to light, and especially sunlight, is
imperative, as light disseminates the disease. Quinine bisulphate given orally has been
shown to decrease sensitivity to light.
In the disseminated forms, especially the acute type, therapy is usually futile. Thus
the importance of diagnosis so as to void burdening the patient with the cost of useless
treatment. Sulphonamides have not been of value because of their tendency to sensitize
the patient to light. X-radiation to the bland-bearing areas may increase the life expectancy in the more subacute types1. King and Hamilton have shown promising
results in eight cases by the use of liver extract intramuscularly, biweekly.7.
Summary: A brief review is given of the baffling syndrome known as lupus erythematosus.  Two cases are reported.   Therapy is discussed.
I would like to thank Dr. F. N. Robertson and Dr. G. L. Hodgins for their permission to include the case reports of their patients.
REFERENCES:
Kierland, Proceedings of the Stall Meetings of the Mayo Clinic, 15:675-688, 1940.
Gockerman, W. H.: Lupus Erythematosus as a Systemic Disease.   J. A.M. A., 80:542-547, 1933.
Ludy, J. B., and Carson, E. F.: Lupus Erythematosus.   Arch Dermat. (3 Syph., 37:403-416, 193 8.
Baehr, G., Klemperer, P., and Schifrin, A.: Jour. A. Am. Physicians, 50:139-155, 1935.
Rose, E., and Pillsbury, D. M.: Acute Disseminated Lupus Erythematosus.   Ann. Int. Med.,  12:951-
963,  1939.
Stickney, J. M., and Keith, N. M.: Renal Involvement in Disseminated Ltfpus Erythematosus.   Arch.
Int. Med., 66:643-660, 1940.
King, H., and Hamilton, C. M.: Use of Liver Extract in the Treatment of Lupus  Erythematosus
South. Med. Jour., 34:394, 1941.
Page 149 t
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GRANULAR (NON-PURULENT) URETHRITIS IN WOMEN
Earle R. Hall, M.D.
(Read before Osier Society Meeting, February, 1941.)
This condition may also be designated "non-specific urethritis," which denotes an
inflammatory condition of the urethra caused by neither the gonococcus, the tubercle
bacillus, nor the spirochaeta pallida.
In spite of its frequent occurrence, and although many believe it to be the most
common urinary ailment of women, there was not, until the past few years, a great deal
concerning it to be found in the literature. In a recent book on "Urology in Women,"
it is barely mentioned. The clinical association of a clear urine with urinary symptoms
has been discussed more in the foreign literature than in either the English or the American. Various names have been applied to it, each name reflecting the opinion of its
author regarding the source of the symptoms. The earlier names given in precystoscopic
days were: "irritable bladder," "neuralgia of the bladder," "cystospasm," etc. Later
names are: "trigonitis," "cystitis colli," "cystalgia," and "granular urethritis."
I wish to discuss this condition under the following headings: (1) Occurrence; (2)
Symptomatology;  (3)  Diagnosis; (4) Etiology and pathology;  (5) Treatment.
In considering the first three headings, we may form definite views from clinical
observation. In the case of etiology and pathology, however, conjecture and theory play
a big part, for, on account of the benign nature of the condition, pathological specimens
are rarely obtained.
Occurrence: Granular urethritis is an exceedingly common ailment, and, until the
symptoms become severe, it is often neglected by the patients themselves. It is also
much neglected by the medical profession in general. Too often the physician, when
consulted, labels the patient a neurasthenic, or says she has an "acid condition," or calls
it "cystitis" and treats it by oral medication or bladder irrigations, sometimes with
partial relief of symptoms, of tener with none. Many women consider a- certain amount
of frequency merely one of the usual concomitants of life, especially during or following
the active sexual and child-bearing period. In many instances, pregnancy seems to
accustom women to frequency. • This condition is found at all ages after puberty,
though most frequently in the middle years of life.
Symptomatology: The two most common symptoms are frequency and dysuria. Frequency is the chief symptom and often the only one. Many patients state that it is
more troublesome in the morning than during the rest of the day. Nocturia may, in
many cases, be absent altogether, and, if present, is never so marked a feature as the
day frequency. Dysuria consists of burning pain on urination, and usually immediately
precedes or follows the act, though it may accompany it. Occasionally it is present
without any frequency. Other common symptoms are urgency; a sense of fulness or
incomplete emptying of the bladder; suprapubic pressure; and haematuria. I have found
that when urgency is present, it is usually so intense as to amount to incontinence. The
patient may complain of having no- control, but this is due to extreme urgency, rather
than to the existence of a true incontinence. Haematuria, when present, is usually terminal, consisting of a few drops, and often accompanied by sharp pain. A number of
cases may notice the passage of a few pin-point clots from time to time. Gross haematuria is not commonly present, though it may rarely occur. I had a case, during the
past year, in which haematuria was present on two occasions, the urine and blood being
■well mixed, and the latter in large quantity. This patient admitted frequency and slight
urgency for several years previously, but until the onset of haematuria, did not think
HELP FINISH THE JAPS.   BUY VICTORY BONDS.
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In granular urethritis the urine is usually clear, and, microscopically, very often
negative. Occasionally, one may find blood cells present, and in my experience, when
cellular elements do occur, it is usually a few R.B.C.'s rather than pus cells. Pyuria in
its true sense is apparently a negative finding.
Many patients show periods of recession of symptoms, having intervals during which
they have no urinary complaints. With return of the symptom complex, it is usually
accompanied by increased severity. The majority of my cases, when questioned regarding the influence of menstruation, admitted that the symptoms were accentuated at
that period.
In addition to frequency and other urinary symptoms, one will occasionally find a
patient complaining of aching pain in one or both lower abdominal quadrants. This at
times may appear to radiate to the rectum, where it is often present during the act of
micturition, persisting for a short time following. Some writers report referred pain to
the back, hips, thighs, and along the course of the ureters.
Diagnosis: In a large number of cases, the diagnosis can be made from the history
and use of a catheter. In the presence of the symptoms mentioned, if the catheterized
specimen contains no pus or blood, or if only an occasional cell is found per low power
field, the symptoms are nearly always of urethral origin. The urethra is almost always
unduly sensitive to the passage of the catheter. It is often thickened, as determined by
vaginal palpation, and its calibre often found to be narrowed. When the urine is cultured, it appears to be the general experience that, while half the specimens show no
growth, the organisms most commonly found are a non-haemolytic streptococcus, a
stapyhlococcus, or a colon bacillus. Herrold advocates stanning the sediment from a
centrifuged specimen, and believes this method more reliable than culture.
Differential diagnosis from other conditions is usually not difficult. The presence of
a purulent discharge, or its expression by milking the urethra through the vagina, identifies purulent urethritis. Absence of Skene's glands or suburethral abscess may give some- ■
what similar symptoms, but pus can be expressed, and the swelling can be appreciated
by vaginal palpation. Urethral caruncle is not usually difficult to recognize, nor are
other lesions of the vestibule which may cause urinary symptoms. Urethral stricture
can be recognized by the use of bulbed bougies or sounds. In any of the cases complaining of nocturia one must think of interstitial cystitis or existence of the so-called
"elusive" or "Hunner ulcer." In this condition there is a typical history, the patient
complaining of extreme frequency and urgency day and night. There is always localized
pain when the bladder is distended; the capacity of the bladder is greatly reduced, and
usually, if the bladder be distended to the point of pain, there will be bleeding. As
stated, in interstitial cystitis there is invariably nocturia present, for the pain of distention wakens the patient. Other conditions to be considered are vesical calculus;
ureteral calculus; ureteral stricture; early tuberculosis; late tuberculosis with a healed,
contracted bladder; outside pressure on the bladder; polyuria due to diabetes or nephritis;
and the overflow of retention, either post-operative or due to cord bladder.
Though inspection, palpation, and catheterization are often sufficient to give the
diagnosis, cysto-urethroscopy will usually be necessary for treatment or to confirm the
diagnosis. The normal mucous membrane of the posterior urethra appears pinkish red,
is smooth and glistening and thrown into longitudinal folds. In the mildest form of
urethral inflammation, there is reddening and congestion only, involving chiefly the
posterior portion of the urethra. In more severe cases, the smooth glistening appearance
is replaced by a rough granular appearance, from which the condition takes its name.
The folds of mucosa are fewer and thicker, apparently due to oedema. Most cases show
some degree of definite polypoid growths or mucous cysts about the bladder orifice and
posterior urethra. If the polyps are a pronounced feature, the posterior urethra may
appear paler than normal. This polypoid type seems to be more severe, and is certainly
more resistant to treatment.
Page 151 This inflammatory process of the bladder neck has various appearances—sometimes
like a honeycomb, sometimes like little yellow vesicles, sometimes like oedema, and sometimes like small polyps.
Pathology and Etiology: Pathological study is difficult, for specimens are rarely
^obtained since the condition does not kill its victims. Maeda reported "By comparison
of male and female bladders which I have made from autopsy material during five years,
a clear preponderance of chronic cystitis in women became evident. These facts indicate
that the shortness and relative width of the female urethra produce a certain disposition
for the entrance of bacteria into the bladder from the vestibule, which is normally rich
in micro-organisms."
Folsom not only studied autopsy material, but obtained biopsies from the bladder
neck in some of his cases, and demonstrated the presence of gland-like structures at the
base of the polypoid or papillary masses found there.  He lays great emphasis on infec-
^tion of these alveoli or glands.
It seems reasonable to believe that the primary affection in most cases if a congestion
of the urethra, particularly the upper urethra, which causes oedema and proliferation of
the sub-mucosa, and interferes with the nutrition of the mucosa. This inflammatory
reaction spreads to the trigone, which is so closely related to the upper urethra and is
exposed to many of the same influences. It is possible that this congestive inflammation
is sufficient to account for symptoms in some instances, but in a large proportion infection can be demonstrated. This infection is secondary, and may be caused by direct
invasion from below—from vagina and rectum by continuity—or from infection of
the urinary tract above, such as an earlier pyelitis and associated cystitis. Bacteria may
invade the urethra through the blood stream or lymphatics. It may occur as a metastasis
from distant foci of infection. Distant foci, such as teeth and tonsils, were emphasized
by Hunner many years ago. Urethritis may follow respiratory infections, and I have
recently observed a case having onset of symptoms following influenza.
Treatment: The local inflammation is treated by dilatation of the urethra. This
should be a gradual dilatation, and can be carried out by ordinary male sounds, or a
short or straight anterior Kollman dilator. This procedure massages the mucous membrane, milks the alveoli, stretches the submucous tissues, and counteracts the periurethral
fibrosis. In many instances the symptoms disappear with no other treatment. I have
often had a patient remark about a definite improvement following examination with
the endoscope. Apparently the dilation produced by the instrument was sufficient to
cause amelioration of symptoms. Following urethral dilatation, various strengths of
silver nitrate are used by many as a local application.
Some cases may appear resistant to this treatment, and they are usually found to
have large polypoid cysts attached to the first portion of the urethra. This type will
do better following fulguration of these masses. A few writers advocate extensive figuration of nearly all cases, but my experience has shown that, in the absence of very
large papillary masses, progressive dilatation, with the use of silver nitrate, will produce
good results.
It is well to instruct the patient to render the urine as non-irritating as possible, and
in this respect to eliminate certain articles of diet, such as raw fruits (except oranges
and lemons), and to omit fried foods, fatty dishes, pastry, raw tomatoes, onions, radishes, vinegar and spices. Tea and coffee in some instances appear to irritate, and alcohol
nearly always produces irritation. It is well to advise a very liberal water intake, and
enough soda bicarbonate to alkalinize the urine.
The permanent relief of congestion is a matter of consideration, and constipation
should be combatted; haemorrhoids treated; and pelvic and vaginal inflammations or
■abnormalities remedied. Finally, the often present distant foci of infection should be
considered and eradicated.
In conclusion I think it should be pointed out that recurrences are not uncommon
and may occur after an interval of several months. It is a good practice, I think, to
give an occasional prophylactic treatment. Most patients, however, will soon return at
the first reappearance of symptoms, especially following months of complete freedom
from their previous urinary distress.
Page 152
NOT AN HOUR TO LOSE.   BUY VICTORY BONDS. A STUDY OF THE ACCURACY OF FLUOROSCOPY
OF THE LUNGS
By Lieut. R. A. Palmer, R.C.A.M.C.
(Presented at the Meeting of the Osier Society of Vancouver, B.C., April 30th, 1941.)
The clinician is using the fluoroscope more frequently as an ordinary instrument for
examination of the heart, lungs and other thoracic contents and it is of importance to
have a clear knowledge of its value and its limitations.
For many years its use has been generally conceded to be an accurate means of
studying the shadows produced by the heart and aorta, mediastinal structures and diaphragm, with particular reference to the movement of these structures. In the control
of artificial pneumothorax therapy it has long been an invaluable aid.
In the other hand, in the examination of the lungs, especially in the detection of
early pathological change, in past years it has been found inferior in accuracy to the
single X-ray film1' 2> 3' 4 and usually it has been recommended for use only as an adjunct
to the X-ray film. The general opinion in the past has been that the X-ray film offers
a clearer definition of the thoracic shadows and is a permanent record, while the fluoroscope permitted an examination from many directions as well as observations on the
effects of respiratory and cardiovascular movements. However, the modern fluoroscope
with the Patterson "B" screen produces an image with a clarity surprisingly superior to
that of the older instruments and in recent years published experiences 5' 6> 7 suggest that
the fluoroscope can be highly accurate in the detection of early pathological changes in
the lungs.
In a careful study of over 1000 cases with duplicate X-ray film and fluoroscopic
examination Israel and Hetherington7 found that of all the cases reported negative by
fluoroscope only 0.6% had clinically significant lesions. They concluded that in the
hands of examiners with reasonable experience in the use of the fluoroscope, but not
necessarily X-ray or chest specialists, very few lung lesions of clinical significance need
be missed. Stiehm6 reported experiences in which significant infiltrations hidden by
superimposed bony structures were missed by the single X-ray film, but detected by the
fluoroscope. Bloch7 states "It was with apprehension that we began our group examinations by using fluoroscopy, supplemented by roentgenograms in all cases of definite and
suspected findings. This technique was dictated to us by economy. However, from
surveys in which over 20,000 persons were examined by our group, we have become
convinced that fluoroscopy is a wholly satisfactory method, and therefore are willing to
retain it regardless of whatever funds may be available. There is good reason to believe
that very few of even small parenchymal infiltrations are overlooked by an experienced
examiner who is well trained in fluoroscopic technique, in roentgen diagnosis and in
pulmonary pathology."
The present paper is written to report the experience with 335 persons, receiving in
each case on the same day examination by the ordinary physical method; by fluoroscopy
of the chest, and by a single X-ray film of the chest. The study was done at the Vancouver Unit, Tuberculosis Division of the Provincial Board of Health, during the summer of 1940, and the cases were the consecutiv, unselected persons appearing at the
morning clinics for the routine chest examinations. {The fluoroscopic examinations were
all done by one observer, the writer of this report, who took especial care in the accommodation of his eyes before starting each day. In each case the findings were dictated
at the time to an assistant and each description attempted to state as clearly as possible
any positive findings. Each subject received a single film of the chest at 6 feet which
was read later by other members of the Chest Clinic staff. Finally a physical examination was made by a third examiner. No comparison of the results was attempted till
the conclusion of the study, when the findings by each method were given independently
to the stenograpic staff for assembly of the verbatim description and diagnosis in each
case.)
When these observations were completed the cases were then classified according to
the radiographic evidence into three main groups—as shewn on the table. The "Essen-
Page 153 daily Normal Group" includes cases with "increased markings" and minor scattered
calcification. The "Doubtful Group" consisted of cases with some suspicious findings
by one or other of the radiographic methods, but not definite enough to justify a diagnosis. The "Significant Disease Group" included only those cases with a clear description of some positive finding in the lung fields by one or other of the methods, and this,
group was further subdivided as shewn.
The table shows that the two radiographic methods employed were in agreement in
all except 5 cases (1 in the "Essentially Normal," 1 in the "Minimal Tuberculosis," 3
in the "Doubtful Group"). In the "Essentially Normal" case and the "Minimal" case
the fluoroscopic examination was clearly in error as shewn by a review of the findings,
though obviously the mistake in the former instance is not as important as in the latter-
In the 3 "Doubtful" cases the fluoroscopy report was negative in 1 case, the X-ray film
negative in 2 cases, the remainder of the cases yielding essentially similar descriptions ta
both methods of radiography. Several cases of obesity were included in the "Essentially
Normal Group," and while no errors were recorded with these cases the fluoroscopic
definition was certainly not as clear as in the cases of average build.
Discussion :
1. Fluoroscopy.—This study suggests that, with reasonable care and experience, the-
fluoroscopic examination of the lungs is highly accurate in the detection of clinically
significant disease. In the "Essentially Normal Group" the error of 1 case in 270 is less;
than 0.4%. This is much less than was expected and is obviously not a serious factor
from a clinical standpoint. In the groups with advanced disease (Far Advanced Tuberculosis, Moderately Advanced Tuberculosis, Miscellaneous), as expected there was no
error. The "Minimal Group" provided the real test for fluoroscopic accuracy and it is.
unfortunate that the group was not a larger one. The error was 1 case in 25 (or 4%
if the group were large enough to express a percentage). This is a more serious error,,
clinically, and though not a large one, it must be recognised.
2. Physical Examination.—As expected, this was highly inaccurate in the detection.
of early Pulmonary Tuberculosis (missing two-thirds of the "Minimal Group"), which
conforms to the common experience8, 9. In the more advanced disease the results were
better, though still rather poor. However, the value of physical examination in the-
investigation of chest disease is demonstrated in Group No. 1 wherein 31 cases of disease such as bronchitis, early bronchiectasis, asthma, dry pleurisy, were discovered in the-
presence of perfectly normal looking X-ray films and fluoroscopic findings.
Conclusions:
This study supports the recently published opinions that carefully done fluoroscopy,.
using Patterson "B" screen, is a reasonably accurate method of radiograpic examination,
of the lungs, and one that should be useful clinically. The accuracy of the method
approaches closely to but does not quite equal the apparent accuracy of a carefully interpreted single X-ray film. It is indicated that physical examination is a necessary part
of the exarnination of the lungs, but is not useful in the detection of early Pulmonary
Tuberculosis.
My thanks are due to Dr. W. H. Hatfield and the late Dr. P. W. Barker who
arranged the work of the clinic to facilitate this study.
Not
Reported
2.
SUMMARY OF FINDINGS IN PHYSICAL EXAMINATION, FLUOROSCOPIC, AND
SINGLE X-RAY FILM OF THE CHEST, 335 CASES.
Negative      Positive
Findings       Findings
Essentially "normal" group:
Fluoroscopic . —| :       269 1
Single   X-ray   film . 270
Physical   examination 239 31
Doubtful group:
Fluoroscopic 3,-
Single   X-ray   film 4*
Ph
vsical   examination
5*
4*
3
Total
270 cases;
8 cases.
Page 154-
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St 3.     Significant Disease  Group  57 easel
(i)  Far Advanced Tuberculosis  (9)
Fluoroscopic   ■ 9
Single X-ray film  9
Physical examination  '.  15 3
(ii) Moderately Advanced Tuberculosis  (8)
Fluoroscopic 8
Single X-ray film 8
Physical examination  2 6
(iii) Mimimal Tuberculosis  (25)
Fluoroscopic !  1               24
Single  X-ray film  25
Physical examination :  16                 8                 1
(iv) Miscellaneous^  (15)
Fluoroscopic 15
Single  X-ray  film '  15
Physical examination 7 8
335 cases!
* Though not clearly apparent by these figures the fluoroscope and single X-ray film were in agreement j
in 3 "positive" findings and 2 "negative"-findings, differing in 3 of the cases.
■f The Miscellaneous group consisted of cases of malignancy, lung "fibrosis," pleural effusion, lung abscess,]
childhood parenchymal disease, bronchiectasis.
REFERENCES
1. Edward, H. R.: Mass survey methods of case finding.   Am. Rev. Tuberc. Supp., 41:33-38, 1940.
2. Boynton, R. E., Diehl, H. S., and Shepard, C.E.: The relative value of fluoroscopic, roentgenographic
and physical examinations in a tuberculosis case-finding program in university students. Am.
Rev. Tuberc, 27:71-80, 193 3.
3. Sante, L. R.: The Chest, Paul B. Hoeber, Inc., 1930.
4. Hetherington, H. A., and Flahiff, E. W.: Fluoroscopy in tuberculosis case-finding. Am. Rev. Tuberc,
27:71-80, 1933.
5. Israel, H. L., and Hetherington, H. W.: Accuracy of fluoroscopy in detection of pulmonary tuberculosis.  Am. J. M. Sc, 201:224-232, 1941.
6. Stiehm, R. H.: Fluoroscopy of lungs; method for diagnosis of early tuberculosis. Journal-Lancet,
59:122-125, 1939.
7. Bloch, Robert G.: Case-finding in tubercjulosis.   Am. Rev. Tuberc, 43:213-223, 1941.
8. Amberson, J. B., Jr.: Case finding methods for diagnosis of tuberculosis. J. A.M. A., 107:256-258,
1936.
9. Chadwick, H. D.: Early detection of pulmonary tuberculosis. New Enland J. Med., 208:1143-1136,
1933.
TkNe*
NO. 7
Page 155 A SIMPLE TEST FOR CANCER
Read before the Vancouver Medical Association January 6, 1942.
By Dr. F. N. Robertson
Vancouver.
[The paper by Dr. F. N. Robertson which we publish herewith is, we feel, one of the
most significant and important papers we have ever had the privilege to print in the
Bulletin. It represents a well-tried and thoroughly checked series of experiments along
a definite line, and has already proved itself of very great value in a great many cases.
A recent example is very significant: a man of late middle age, complaining of symptoms
such as loss of weight, difficulty with bowels, etc.—is thoroughly examined and X-rayed
by most competent men who, surgeons, radiologists and internists, all agree that the
diagnosis is carcinoma of the colon, at its hepatic flexure, and that only colectomy will
serve. A preliminary Robertson test for cancer is negative. Laparatomy shews a band
of adhesions holding down a loop of the colon and providing partial obstruction. This
dramatic confirmation of the test is being repeated daily in many cases. We congratulate Dr. Robertson on his excellent manner of presentation in this case.—Ed.]
Mr. Chairman, Ladies and Gentlemen:
When our President asked me to give a paper on this subject and to give the result
of my findings, I greatly appreciated the honour, and the interest shown in this test,
which as yet lacks the authority of medical recognition. Naturally, until this recognition
is earned, I am very diffident, first about being dogmatic, and secondly because the work
is not yet complete. However, I am very willing to reveal the facts and findings as
truthfully and fully as I can give them. This is difficult because until all the pathological reports are received on these cases there is insufficient proof of the correctness of
the test, and I cannot very well hasten these poor unfortunates' departure from this
world, just to complete my files.
I hope, therefore, that you will accept this paper as being as complete a report as it
is possible to give under the circumstances and that it may succeed in making you
cognizant of everything I have learned about the subject.
In the war against cancer it has been argued over and over again that the most essential thing is early diagnosis. Doctors have been warned to be always on the lookout for
the earliest signs. The laity have been urged to report to their doctors the moment any
unusual sign or symptom appears. They have also been urged to present themselves
for periodic examinations. However, in a large percentage of cases we are not able to
tell when a cancer is a cancer, especially in the early stages. Even a lump on the Up,
the skin or the breast, which can be seen and can be handled, will often puzzle the most
expert.  How then are we to meet the demand for early diagnosis?
Possibly with time we could become more and more expert in diagnosis, but before
we do, there will be many cancers which will have gone on developing and which should
have been removed much earlier. Even granted we do develop our abilities to such a
degree that we can make an early diagnosis, shall we able to import that skill to others
or will they have to develop their own ability? To me, the answer to early diagnosis is
a simple test, a test which does not require a laboratory, nor expensive equipment nor
trained technicians, but an inexpensive one which anyone can do, even at the patient's
home.
Fuch1 found that washed fibrin-from a cancerous patient is digested by serum taken
from a non-cancerous patient, and vice-versa, serum from a cancerous patient digests
fibrin from a non-cancerous patient. He claims about 90% accuracy, although admitting that the test is very unreliable in oesophageal tumours and that syphilis and tuberculosis will give the same reaction and must be ruled out before the test is valid. The
test is strictly a laboratory procedure requiring much time, care and accuracy. The
growth must be over six months old and in an active stage. No operation, radium or
X-ray treatments should have been used for at least a month previously.
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Bendien2 found certain flocculation appeared in blood from a cancer patient different from normal blood, on the addition of vanadic acid. This test required the use of
a spectroscope and has been proved to be valueless. Cronin Lewis introduced a modification of the test called "Three Phase Test." It consists of the quantitative comparison
of the amount of flocculation produced in a given specimen of serum, which had been
treated with a standard solution of vanadic acid, and the amount of flocculation obtained
with the same standard, after the serum had been subjected to ether extraction (phase
C) and also to heat inactivation at 56°C. for half an hour (phase B). If the increase
of flocculation produced in phase C (as compared with the flocculation in the original
untreated serum) was greater than the decrease of flocculation in phase B, then active
malignancy was present. In other words, C — A -f- A — B if greater than unity,
meant cancer.   He claimed 75% accuracies.
Price, another observer, stated that in 427 specimens of blood there was agreement
between serum results and clinical findings in only 55%. H therefore concludes "that
the association of active malignancy with positive serum resuijts, is a matter of chance.
The test is of no value whatever, for either diagnosis, control or prognosis of cancer.
It is entirely unreliable."
Mann and Walker3 proved that precipitin anti-serum could be made from protein
■of carcinomatous tissue and that proteins are specific for carcinoma of various organs.
Pfeiffer4 found that blood from a cancer patient added to a solution of cupric
chloride, produced a definite arrangement in the crystals on evaporation. This method
has been improved by Gruner and seems to be accurate, but it is time consuming and
requires skill as well as laboratory equipment.
Lumsden5 proved the presence of antibodies. Moppett6 has improved and modified
his test. Moppett uses a glass slide with two depressions connected by a narrow channel.
TSJormal blood is placed in one depression, dissolved in various solutions. Blood from a
cancer patient, dissolved in the same solution, is placed in the other depression. In the
channel is placed a small piece of crushed mouse tumour. The whole thing is covered
with a cover slip and waxed. Cells from the tumour begin to migrate and their drift
is observed after 2 and 24 hours and should be photographed. A positive test consists
in a drift or migration of the tumour cells away from the test blood. This is supposed
to be on account of antibodies, a chemotaxis.
From these examples you will see the character of the different methods tried as a
test for cancer. They are all elaborate, difficult to perform, and require a laboratory and
trained technicians. Whereas the test I shall give you is not expensive, needs no laboratory nor trained technician, and can be done in about twenty minutes.
All this submitted evidence and more not mentioned, such as Link's test', Ruffo's
test8, Gruskin's test9 and Klein's test10, prove that the blood of a cancerous patient
contains abnormal substances. If these abnormalities are in the blood, is it too much
stretching of the imagination to believe that the urine should also contain unusual
substances?
The test to be described is a reaction between the patient's blood and his own urine
and results in the formation of a clot on the bottom of the dish, which clings and is
difficult to wash off.
Other observers must have felt that urine contained abnormalities, for Erlasser and
Wallace published a paper, claiming to be able to diagnose the presence of cancer by
injecting urine into pregnant rabbits. If the urine was obtained from a cancer patient,
the rabbit would abort in about five days. Aron11 found that an alcoholic extract of
urine from a cancer patient, injected into rabbits for two or three days, caused the
spongiocytes of the fasciculated zone of the adrenal cortex to lose their lipoid granulations.
Gereb13 describes an "Activator Reaction." The test requires the addition of a
measured quantity of starch and plant distase to 2 cc. of fresh, fasting morning urine.
A control is set up using water instead of urine. The mixture is shaken and heated to
36° C. for 10 minutes, after which 50th, normal iodine solution is added.   The control
Tage 157
"'m gfc
specimens and the negative specimens assume a blue colour, while the characteristic
proof of the presence of an activator is the appearance of various red shades.
Knowing by experience that I shall be showered with questions as to why I ever put
blood into urine, I shall take the opportunity to explain now. For many years I felt
sure that urine from a cancer patient must contain substances difffferent from noncancerous urines. All kinds of chemicals and reagents were tried but without attaining
any results. The spectroscope revealed nothing, nor did microscopic examinations across
a beam of light. The only thing found was a change in the surface tension of urine,
but this was not reliable. However, when washing out a syringe which had contained
blood from a cancer patient, a drop of blood fell on the surface of some water and acted
strangely. My own blood did not act so. A brownish stain had remained on the surface
of the water with the cancer blood. It immediately occurred to me, "What would
happen if this blood were placed in the urine from a cancer patient?" After many trials
and in various ways, a technique was gradually evolved.
The technique as now used is to place one or two drachms of lime water in a kidney
basin and to this add two or more ounces of urine from a cancer patient and mix them
well. The urine should be concentrated and for this reason the early morning urine is
used. With an ordinary syringe and needle 5 cc. of the patient's blood is drawn and
immediately the needle is placed against the bottom of the dish, near one end and pointing
to that end. The blood is then forcibly expelled against the bottom of the dish and
towards the near end of the dish. In this way the blood lies against the bottom of one
end of the dish, under the urine. The dish is now left to stand about five minutes and
the blood will probably travel along the whole length of the basin. No wgently raise one
end of the dish and see if there is any clotting of the blood. Slight clotting on the
bottom should be encouraged by not moving the dish too much. If the blood wants to
clot en masse or form a jelly-like clot or a tough skin, then the dish should be raised
more frequently and thus discourage the clotting. At the end of twenty minutes a
positive test will show clots on the bottom of the dish from the size of stipples up to
the size of a dime. Rather violent shaking of the dish will not dislodge them. Pour out
the blood and urine and the clots will still cling. Place cold water in the dish and swish
is about. If the clots still cling after several washings it is positive. Sometimes the clots
have actually to be wiped off to remove them. The action of normal blood in normal
urine will not result in this clinging clot. True, the blood may not lake, but rather form
cloths, but these clots will not adhere to the basin.
The presence of craks and chips in the enamel makes no difference, as I have never
seen a clot clinging to the roughened surface.
If the urine is very dirty, it should be filtered. Gross blood in the urine makes the
test useless. Also the least trace of any of the sulphonamides will give a positive reaction.
Lime water is Jiot essential in most cases and was not used in the earlier work. However, it was found that the time for clot forming was reduced from forty-five minutes
to twenty minutes and a number of false negatives were avoided by using lime water.
False positives have occurred where sulphonamides were being used, where there was
a severe or extensive dermatitis, in Hodgkins disease, and in some leukaemias. The test
is not reliable in sarcoma and it does not indicate in what organ the cancer may be. That
is, the patient may die from a haemorrhage from a gastric ulcer but cancer may be found
in some other organ.
On microscopic examination of the clots, they seem to be formed first by a deposit
of fibrin on the dish with blood corpuscles adhering to the surface of the fibrin. In other
words, it is not the blood that is coagulated but the fibrin. This is similar to the action
of renning on milk, where the casein is coagulated, and suggests that the substance might
be an enzyme like rennin.
This substance, whatever it is, can be extracted from the urine by ether. Ether and
urine are shaken together and then allowed to stand, when the ether will separate and
rise to the top. The ether extract is drawn off and allowed to evaporate. The urine
which formerly gave a positive reaction will now give a negative reaction.   Whereas, if
Page 158
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\,:S'$)m the residue, after evaporation, be dissolved in normal urine or even in normal saline
solution, it will give a positive reaction with cancerous blood. This extract can be kept
for some time with a preservative and should be used in cases where there is gross blood
in the urine. The extract is rendered more active by warming to 75° C. but it is killed
by boiling for five minutes. In this it also resembles an enzyme.
Fresh washings from a hog's stomach, containing rennin, will give a positive reaction
with blood from a cancerous patient, though not so strongly positive as urine.
These findings suggest that the substance contained in urine from a cancer patient
is an enzyme, resembling rennin.
In July, 1940, I published a short article describing the technique in use at that
time and the results found, but no record of cases had been kept as it was all experimental work. Following this the test was used on a numbr of cases and the results were
reported to the Staff of the Vancouver General Hospital in March, 194112. One hundred and thirty-three cases were reported. These tests were on 63 non-cancerous patients,
45 cancerous patients, 17 supposed cancerous patients by clinical or by X-ray diagnosis,
and all these 17 proved negative by test and final findings and 2 post-operative cases
proved to be negative. There were 7 false positive tests or 5.26%. Two of these were
due to errors in technique, two had Hodgkin's disease, one had thrombocytopoenic purpura and many transfusions, one has been lost sight of and not so proved, and one had
an extensive dermatitis.
There were 3 false positives or 2.26%. Two were technical errors and 1 was lymphosarcoma.   This gives 92.48% .accuracy for the test.
The Medical Staff of the hospital was impressed with the percentage of accuracy
and by the value of the test in the aforementioned 17 tests. They felt that the work
should be given a more extensive trial, and in order to speed it up and also to do away
with any bias of opinion on my part, they decided to provide me with a technician.
The technician has carried on all the tests since that time without any knowledge on
her part as to why the test was being done.
In June of this year an Interim Report on the work done was read to the Medical
Staff of the Hospital and upon their request a committee was appointed to oversee and
direct the technician's work. This committee consisted of Dr. B. J. Harrison, head of
the Radiological Department; Dr. G. E. Seldon, Chief of the Surgical Staff; Dr. D. E. H.
Cleveland, Chief of Dermatology, and myself.
The first decision by the committee was to find out if other diseases wherein there
was much destruction to the tissue would give a positive cancer test.
The technician was instructed to test 100 tubercular patients and this report will
appear with the others.
A number of the tests were repeated for three reasons:—
First: Some reports were doubtful.
Second: There was not enough clinical evidence to agree with the report.
Third: The test was positive and repeated after operation to see if the test had
become negative.
In speaking of the post-operative negative reports, we find that if the growth has
apparently been totally removed, the test will become negative in from one to two weeks.
In cases treated by radium or X-ray the reversal of the test is not rapid, but gradual, so
that a positive test may still be present when there appears nothing clinically.
As stated before, the test is not specific and gives no information as to what organ
is involved in the growth. It does seem to be remarkably sensitive in some instances.
Just how early a positive reaction will show I do not know, but I have seen a growth on
the lip no larger than a pin head which gave a positive reaction and after X-ray treatment became negative. Hence I suspect that some of the cases fisted as false positives
may really have an early cancer hidden away in some tissue that may not even be discovered at autopsy. And for this reason I would not have a test done on myself, nor
do I advise anyone to make one on himself, unless there are some definite symptoms to
Page 159 warrant it being done. It would be permissible to test a patient in a routine way but
the result of the test should be withheld from the patient until symptoms arise, in order
to prevent undue suspense and worry, maybe for months.
The statistics about to be given are based on the findings of seven different observers
upon 938 patients with 1197 tests done upon them. Unfortunately some of the cases
have to be eliminated from this report as they had no autopsy, no pathological report nor
follow-up to enable a final diagnosis to be made as to the correctness of the test. There
were also cases who were taking some form of sulphonamide and these should never have
been referred for the test, for, as has been said before, they give false positive tests.
There are also cases of Hodgkin's disease and cases of dermatitis, both of which give false
positive results, and after subtracting this number from the list, there still remain
812 cases.
The first work done on these tests was by myself and the early findings will be given
first and the statistics broken down more thoroughly than in the others as the information is more complete.
Table 1. There were 172 tests upon 138 patients. Of these 70 were males and 68
females. There were 50 positive tests agreeing with the final findings and 70 negative
tests agreeing with the final findings, giving an accuracy of 86.9%.
The positive tests occurred by ages as follows:—
Table 2.
Males Females
20 - 29   0 20-29  1
30-39  !  0 30-39   3
40-49  1 40-49  6
50 - 59  5 50-59  5
60 - 69  14 60 - 69   9
70 - 79  i  3 70-79  3
27
This table shows that the test is not the result of any sex-hormone, nor is it due to age,
as some cases were below the "cancer age."
Table 3.    The negative tests occurred
Males
10 - 19  4
20 - 29  5
30-39   1
40-49  ;  3
50 - 59  5
60 - 69  13
70 - 79   2
80 - 89  =  2
by aees as follows:—
Females
10- 19
3
20 -29
10
30 - 39
10
40 -49
2
50 - 59
1
60-69
70-79
80-89
2
■5
35
35
Here again is shown that age does not affect the test as there are numerous negative
tests in the
cancer age.
Table 4.    Malignancy was found in the following organs:
Stomach   	
Pancreas   	
Cervix   and   uterus	
Bowel   	
Thyroid   	
Prostate   	
Neck   	
Pelvis   	
Lung	
Vulva  and vagina-
Ovary 	
Skin   	
Breast   	
Kidney   	
Sigmoid and rectum 7
Table 5.    False positive tests were found in 3 cases:
The first in a woman who miscarried a few hours later.
In another series a false positive was found in a ruptured ectopic pregnancy. .This
may be due to breaking down of embryonic tissue and may simulate the breaking down
of cancerous tissue.
Page 160
BE A LENDTHRIFT!    BUY VICTORY BONDS.
■ t The second case was thrombocytopoenic purpura.   He had received many transfusions, but-there is no explanation for the failure of this test.
The third also presents no explanation.
Table 6.    False negatives occurred twice.
The first had a curettage and early malignancy was found in the scrapings. A test
done after this operation was negative but repeated later was positive. The patient
developed cancer of the body of the uterus.
The second was an early epithelioma on the finger and gave a negative test at first.
Later the test became positive. The growth was treated by X-ray and cured.
The results of these tests, therefore, were correct, positive and negative, in 120 cases
out of 138 cases or 86.9%.
Table 7. The next tests are those done by my technician, under the supervision of
the above named committee. Her first assignment was to test 100 tubercular patients.
Actually 107 cases were tested with 120 tests as 5 were taking some form of sulphonamide
and 2 had a severe dermatitis, so an extra 7 were done to make an even 100 cases, where
no excuse could be made for there being a false positive. These cases consisted of 32
females and 75 males. There were 6 false positives. These six cases were given a physical
examination by the interns and no suspicion of cancer was found, so we must consider
these tests as failures.  Therefore the 100 tests give an accuracy of 94%.
Table 8. The main work done by the technician was on 558 cases with 743 tests.
Certain of these cases must be eliminated, however, for the sake of accuracy. Sixty-four
had no autopsy or were not finally diagnosed, 41 were taking a sulphonamide, 4 had
Hodgkin's disease, 2 had sarcoma, 2 had gross blood in the urine. These should never
have been tested. This leaves 445 cases. These cases were patients in the General Hospital or referred for the test by the British Columbia Cancer Institute, the X-ray department or by private individual doctors.
Malignancy was found 297 times and non-malignancy 97 times, or a total agreement
with the final diagnosis of 394 or 88.5%. These were fairly evenly divided between,
males and females, varying in ages from the first to the eighth decade in both positives
and negatives.
Table 9.    False positives were 44 and false negatives were 7.
False positives gave 39 failures for which there is no explanation.
Two cases, a male and a female, had leukaemia. Is it possible that leukaemia is really
a cancerous condition?
Two had pernicious anaemia, a male and a female.
One had ruptured ectopic pregnancy, where there is destruction of embryonic tissue.
The false negatives consist of seven failures, for which there is no explanation.
Table 10. The next observer is Dr. H. W. Riggs. He reports 29 cases with 44
tests, 6 males and 23 females. The number is not large, but he found 6 positive tests,
verified by pathological report, and 36 negative tests which also proved correct. In the
29 cases he had only two false positives or an accuracy of 93.1%.
The most interesting point about his observations was the number of re-checks after
operation. Some cases were re-checked three or four times and all have consistently
given negative reports.
Table 11. St. Paul's Hospital has done a few' tests upon request of the attending
physicians. They have not searched out cases for testing, and the only reason that their
list of cases is not larger is because they have not been requested to do more.
Their report consists of 41 tests tried on 30 patients. Of these, five were not yet
diagnosed, one had no autopsy and three were taking sulphanilamide. That leaves 21
cases, 10 males and 11 females. The tests agreed with the final findings in 18 of these
cases, 9 positives and 9 negatives.  This gives an accuracy of 85.7%.
Table 12. The next observer is Dr. P. A. Jones, now of the United States Army.
He reports 44 tests, nearly all upon cases of influenza. One of the cancer tests referred
to in the earlier part of this paper, was found useless where there was influenza.
Page 161 i%
Dr. Jones tested 19 of these cases, by the original method of using a control and four
basins. Eighteen of these cases gave negative reports. The remaining one had a very
small plapable mass in the prostate gland and upon this evidence and that of the test,
was operated upon, against the judgment of the surgeon. However, the pathological
report was early carcinoma with no involvement of the glands.
His next case was a woman who had had a radical breast operation for cancer in
May, 1936. She now had a digestive disturbance and loss of weight so cancer of the
stomach was suspected. Both a cancer test and a gastro-intestinal series were negative
in February, 1941. She was found to have a hypoglycaemia and has recovered and is in
good health now.
The next case was a gastric carcinoma by X-ray and clinical findings. The test was
positive and later an autopsy confirmed the diagnosis.   All the controls were negative.
He had one false positive test. It was faintly positive and the X-ray showed a marked
scarring of the pyloric end of the stomach. He also had syphiHs as revealed by blood
tests and recovered his health on anti-syphilitic treatment. So this case must be considered as a false positive.
The percentage of accuracy in this series is therefore 97.7%.
Table 13. The sixth observer was Dr. E. White. He reports 15 tests; of these 7
were negative, 7 were positive, and 1 false positive. This given an accuracy of 93.3%.
One case is of particular interest. It was diagnosed as cancer of prostate with metastases
to the fiver or cancer of the head of the pancreas. The test was negative, and at
autopsy no cancer was found.   Cause of death pernicious anaemia.
Table 14. The last observer is Dr. Hardesty, Pathologist of McMillan Hospital,
Charleston, W. Va. The number of cases tried by him is limited, consisting of 17 cases
with 18 tests. Four of these cases were sarcoma, and as these have been eliminated from
the other records, the same must be done again. This leaves only 13 cases. Of these
sarcomatous cases two gave positive tests, one doubtful and one negative, which again
bears out the previous statement that the test is not reliable with sarcoma. Of the 13
cases, 9 were positive tests, 3 were negative, and there was 1 false negative. There was,
then, an agreement with the final findings in 12 of the 13 cases or an accuracy of 92.3%.
Now that the statistics have been told you it might be as well to condense all those
findings into a comprehensible total.
Table 15. No. of Reported
Observer Tests Cases Cases Accuracy
Robertson  172 138 138 86.9%
T. B. Cases  120 107 107 94.0%
General Hospital  743 445 558 88.5%
Riggs    |  44 29 29 93.1%
St.   Paul's I  41 21 30 85.7%
Jones  44 44 44 97.7%
White      15 15 15 93.3%
McMillan   Hospital  18 13 17 92.3%
1197 812 938
The lowest accuracy was 85.7%.  The average accuracy was 91.4%.
Considerable criticism has resulted from the wording of some of the reports. The
words "Doubtful and Weakly Positive" seem to have aroused much discussion. Just why
this is so is hard to understand. Examinations by X-ray are frequently repeated when
the report is not definite or the filnl not satisfactory. A report on a Kahn if doubtful
immediately calls for a repetition of" the test. Or if pus is found in a specimen of urine
from a female, a catheter specimen is asked for. Why then not have a repeat done in
this test?
Possibly, too, the fault is not all to be blamed on the test. Earlier it was pointed out
that a concentrated specimen of urine was required. Supposing such a specimen was not
obtained, it is easily seen why the test was "doubtful" or "weakly positive." It would
be very easy to keep the patient off all fluids after his evening meal until the next morning and then have the test repeated.   Again, it was pointed out that the sulphonamides
Page 162
PUT YOUR DOLLARS IN BATTLE DRESS.   BUY VICTORY BONDS.
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would give a positive reaction. If all this drug was not excreted, it could easily give a
faintly positive reaction or even a doubtful one. These points have been overlooked by
many men, requesting a test, and the writer pleads guilty himself. This has not happened just now and then but dozens of times.
So in the event you receive a report marked "Doubtful" or "Weakly positive," please
don't blame the test, nor yet the technician, but make sure there is a concentrated specimen of urine and that the patient has not been taking a sulphonamide recently, then
request the test to be repeated.
Regarding criticism, it is a little previous. Some of you have apparently accepted
it as a tried and proved test and seemingly had more faith in it than I myself. The test
was meant to be originally tried in the General Hospital only on cancer patients to see
if the blood clotted and would cling in all cases. However, a large proportion of cases =
referred for this test were for the purpose of diagnosis. The physicians did not know
whether it were a cancer or not and expected the test to decide the question. Other
doctors have even said that a test was not needed as they were sure of their diagnosis.
This was not the original intention and yet the test has proved correct in a great many
cases.
The test should be done and considered in view of the clinical findings and therefore
not abused.
Many of these cases could be reported in detail but time will not allow, and it would
be better if, in the discussion to follow, any of you who had experience with the test
would mention their cases, rather than for me to do so. Of cases unknown to any of
you might be mentioned a boy with a mole on his cheek. This was considered innocent
but the test was positive and the pathological report was "Melanotic." After operation
the tests became negative. Cases of intestinal obstruction, considered due to malignancy,,
gave negative tests, and were operated upon, proved non-malignant and saved. Others
again, considered as innocent but giving a positive test, were proved malignant at operation and as a result the patient was given a new lease on fife.
Here then is the history, the findings of this test and some of its weaknesses. It is
not yet presented to you as a thoroughly tried and reliable procedure, but only as some
interesting findings which may lead to a great aid in the early diagnosis of cancer and
a tremendous weapon in the war against it. The technique is very crude and will be
greatly improved as time goes on, and with each improvement the accuracy will increase.
But even as it stands it should be a very useful procedure to use as confirmatory evidence
in diagnosis. Also the finding of a negative reaction after operation or treatment for a
cancer must be very comforting knowledge even if it is toa early to rely upon it as a
sure sign that a complete cure has been secured.
In closing, I wish to thank all those who have so kindly assisted me. They are too
numerous to mention, but I wish to particularly thank the General Hospital,: the Staff,
the Committee, whose advice and guidance has been so essential; the British Columbia
Cancer Institute; Miss Gerow, the technician, who has done so many of the tests and
experimental work; and last but not least the many men who have referred cases or
allowed tests to be made on their cases.
Summary. The necessity of some test in order to diagnose cancer in the early stages
was shown. A number of tests which have been advanced but which are too expensive
and technical for common use were described. A simple inexpensive test was described
with its history and evolution. Weaknesses and places where the test is useless were
pointed out. A possible explanation of the cause of the reaction was suggested and a
method for the extraction of some unknown substance from the urine of cancerous
patients has been carried out. Statistics, based on the examination of 938 cases, with
1197 tsts by seven different observers, were given, showing an average accuracy of
91.4%.
BIBLIOGRAPHY.
1. Archives of Surgery, 41:370, July-Dec, 1940.
2. B. M. J., 551: March 18, 1939.
Page 163 3. Am. Jour, of Cancer, 39:360.
4. C. M. A. J., 43:99, Aug.,  1940.
5. Med. Jour, of Australia, 681: May 26,  1934.
6. Med. Jour, of Australia, 227: Feb.  11, 1939.
7. Chirurg., 6:632, Sept. 15, 1934.
8. Am. Jour, of Cancer, 22:363, Oct., 1934.
9. Med. World, 53:164, Mar., 193 5.
10. Jour. Am. Med. Assn., 107:1315, Oct., 1936.
11. Presse Med., 42:833, May 23, 1934.
12. Bull. V. M. A., 17:155, Mar., 1941.
13. Abst. A. J. of Cancer, 21:127, May,  1934.
*».
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Page 164 OESTROFORM
In Nervous States
The principal use of Oestroform, the natural cestrogenic hormone, is in the relief of menopausal symptoms; it acts in a
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Less commonly realised is the fact that some degree of ovarian
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symptoms that are a source of distress to the patient. The
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loss of sexual desire. Oestroform will be found of great value in
the treatment of these cases.
Stocks of Oestroform are held by leading druggists throughout
the Dominion, and full particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse Toronto 2 Ont.
-Oes/Can/422

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