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The Vancouver Medical Association Bulletin: December, 1940 Vancouver Medical Association 1940

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 TheiBULLETIN
of the
VANCOUVER
MEDICAL ASSOCIATION
Vol. XVII
DECEMBER, 1940
No. 3-
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
§St Paul's Hospital
In This Issue:
Pag*
NEWS AND NOTES M -.J^f^ j| ||| —jl ^M    60
MEDICAL ECONOMICS |pK' ----Jfc | 1 - -j|»----    64
THE OBSTRUCTING PROSTATE.. j|| „_________ | —-—     67
BENZOL POISONING ~_ - -II—- | H    73
HYPERVENTILATION SYNDROME—Dr. George H. Anderson^ |.    75
CLINICAL APPLICATION OF VITAMIN B COMPLEX—Dr. J. G. Reid-    78
MY OLD MAN ON DOCTORS—Damon Runyon_____ _||L A 8 3
THE ANTI-GRAVITY JACKET—Dr. Gerald L. Burke. S fft$4 .if
^CftEOBROiV^^
.. \immtsm,
As an adjuvant to internal medication
Prolonged heat
Non-irritating
No Systemic Reactions
Sample on Request
THE DENVER CHEMICAL MFG. COMPANY
-153 Lagauchetiere St. W;, Montreal
Made tot Canada 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:
De. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVII.
DECEMBER,  1940
No.  3
OFFICERS, 1940-1941
Dr. D: F. Busteed Dr. W. M. Paton Dr. A. M. Agnew
President Vice-President Past President
Dr. W. T. Lockhart Dr. R. A. Palmer
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. C. McDiarmid, Dr. L. W. McNutt.
TRUSTEES
Dr. P. Brodie Dr. J. A. Gillespie Dr. F. W. Lees
Auditors: Messrs. Plommer, .Whiting & Co.
S- SECTIONS
Clinical Section
Dr. Karl Haig Chairman Dr. Ross Davidson Secretary
Eye, Ear, Nose and Throat
Dr. J. A. McLean Chairman Dr. A. R. Anthony Secretary
Pediatric Section
Dr. R. P. Kinsman Chairman Dr. G. O. Matthews Secretary
STANDING COMMITTEES
Library:
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. W. A. Bagnall, Dr. T. H. Lennie, Dr. J. E. Walker.
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. H. H. Caple, Dr. W. W. Simpson, Dr. Karl Haig, Dr. J. E. Harrison,
I Dr. H. H. Hatfield, Dr. Howard Spohn.
Credentials:
Dr. A. W. Hunter, Dr. W. T. Ewing, Dr. A. E. Trites.
V. O. N. Advisory Board:
Dr. E. Riggs, Dr. W. C. Walsh, Dr. R. E. McKechnie II.
Metropolitan Health Board Advisory Committee:
Dr. H. Spohn, Dr. F. J. Buller, Dr. W. T. Ewing.
Greater Vancouver Health League Representatives:
Dr. G. O. Matthews, Dr. M. W. Simpson.
Representative to B. C. Medical Association: Dr. A. M. Agnew.
Sickness and Benevolent Fund: The President—The Trustees. HYPOBYN
E.B.S.
Each fluid ounce contains:
Calcium Hypophosphite
 12 grs.
Sodium Hypophosphite
 8 grs.
Iron Hypophosphite 2 grs.
Manganese Hypophosphite
 1 gr.
Potassium Hypophosphite
 . 1 gr.
Quinine Hypophosphite
 H, gr.
Strychnine    Hypophosphite
 1/16 gr.
With
Vitamin A—4900 int. units
Vitamin D— 800 int. units
Malt 25%
An excellent reconstructive
and nutritive tonic.
Dose—One-half to two fluid
drachms.
CCT. No. 466
MINEROVITE
E.B.S.
Each tablet contains:
1500 international units of
Vitamin A
60 international units of
Vitamin Bi
35 micrograms Vitamin
Ba
200 international units of
Vitamin C
400 international units of
Vitamin D
20 units VitaminK
5 mgm. Nicotinic Acid
and Vitamin E, combined
with salts of the following
mineral elements: Iron,
manganese, copper, calcium and phosphorus.
Dose—Three or four tablets daily.
CT. No. 501
NEUROVIT
E.B.S.
Each tablet contains:
100 international units
of Vitamin Bi
3 mg. Nicotinic
Acid
0.1 mg. Riboflavin
Vitamin B i is the antineuritic vitamin. Nicotinic Acid is a preventive
and corrective of subclinical pellagra, and
Riboflavin is essential to
carbohydrate metabolism
and muscle tonicity.
Dose—One tablet three
times a day.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA
OUR
P T I O N VANCOUVER     HEALTH     DEPARTMENT
STATISTICS—OCTOBER, 1940
Total population—estimated .  269,454
Japanese population—estimated   9,094
Chinese population—estimated   8,467
Hindu population—estimated   339
Rate per 1,000
Number       Population
Total deaths  . 3    253 11.1
Japanese deaths        4 5.0
Chinese deaths        7 9.8
Deaths—residents only .-   218 9.6
BIRTH REGISTRATIONS:
Male, 257; Female, 203.
460
Deaths under one year of age.
Death rate—per 1,000 births...
Stillbirths (not included in above)
Oct., 1940
6
13.0
8
20.1
Oct., 1939
11
29.9
9
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
September, 1940
Cases   Deaths
October, 1940
Cases   Deaths
Scarlet Fever	
Diphtheria 	
Chicken Pox 	
Measles 	
Rubella 	
Mumps   ~. .	
Whooping Cough 1	
Typhoid Fever 	
Undulant Fever   	
Poliomyelitis 	
Tuberculosis    -	
Erysipelas   	
Meningococcus Meningitis
Paratyphoid Fever	
Nov. 1-15,1940
Cases   Deaths
4
0
22
40
1
6
5
1
0
0
34
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
15
0
46
73
8
9
9
0
0
0
29
2
1
2
0
0
0
0
0
0
0
0
0
0
0
0
0
12
0
24
106
7
7
3
0
0
0
6
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
Burnaby
Syphilis     0
Gonorrhoea I   0
West North Vane. Hospitals &
Vancr. Richmond Vancr. Clinic Private Drs. Totals
0 2               0               28               17 47
1 0               0               68               17 86
BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
"Bioglan products differ in that they are derived from original material."
A Product of the Bioglan Laboratories, Hertford, England.
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STANLEY   N.   BAYNE
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Descriptive Literature on Request
Vancouver, B. C
Page 57 If, ttt
II
'<*
I
Biolotficcd a+td fiia^i^qe44^kSi 0mMiiii
MONTREAL
PRESCRIBE CANADIAN MADE PRODUCTS
HELP WIN THE WAR
CANADA
BUY WAR SAVINGS CERTIFICATES
*"::
■■*« VANCOUVER MEDICAL ASSOCIATION
Founded 1898 . • . Incorporated 1906
GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at
8:00 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.—Paper of the evening.
Programme of the 43rd Annual Session (Fall Session)
1940
October 1—GENERAL MEETING.
Dr. Hamish Mcintosh: "Some commonplace variations in the spine.**
October 15—CLINICAL MEETING.
November 5—GENERAL MEETING.
Dr. E. R. Hall: "The obstructing prostate—Recognition and treatment."
November 19—CLINICAL MEETING.
December 3—GENERAL MEETING.
Dr. Stewart Murray: "A Review of Four Years of Public Health Under the
Metropolitan Health Committee.**
December 17—CLINICAL MEETING.
CANADIAN    MEDICAL    ASSOCIATION
19411 MEMBERSHIP^!      1941
FEE OF $8.00 INCLUDES JOURNAL OF C.M.A.
TO BE PAID THROUGH THE OFFICE OF THE REGISTRAR
College Dues for 1941 $ 15.00
C. M. A. Membership, 1941     8.00
This will make your cheque total for 1941 $23.00
New Members are reminded that prompt response will assure receipt
of the January number of the Journal.
THE JOURNAL SPEAKS FOR CANADIAN MEDICINE
THE C.M.A. MEMBERSHIP FEE INCLUDES THE JOURNAL.
FOR R€NT
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The
Ii
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Pyridoxine
Filtrate Factors
0?.P. factor)
036)
Vitamin B4
Riboflavin
Thiamine Hydrochloride
Factor W
(B2)
(Bl)
AH available in Squibb Vitamin B Complex Syrup.
If the diet is deficient in vitamin Bl it is logical to assume that
it may be deficient also in many of the other factors of the B
Complex. Clinical studies have shown that the particular
vitamin deficiency which produces the most outstanding symptom shown by a patient usually results from a diet poor in
more than one factor,
Squibb Vitamin B Complex is so rich that 1 teaspoonful contains
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Vitamin B Complex deficiency, especially anorexia, gastrointestinal hypotonicity, restricted growth in infants and children,
pregnancy and lactation, and neuritis and polyneuritis due to
such deficiency,
Squibb Vitamin B Complex Syrup may be taken plain or mixed
with beverages. Dosage for prophylaxis: infants, 3^ tsp.;
children, 1-2 tsp.; adults 2-4 tsp. For therapy, at discretion of
physician. Supplied in 3-, 6-, and 12-oz. bottles.
Also available—Squibb Vitamin B Complex Capsules. Each
capsule contains not less than 333 I.U. of Vitamin Bl, 500
gammas of Riboflavin, 125 gammas of B6, 14 J.L. units of the
filtrate factor, 5 milligrams of nicotinic acid and other factors
of the complex derived from a special strain of yeast. In bottles
oi 25 and 250.
For information write
36 Caledonia Road. Toronto.
ERiSqtjibb &.Sons of Canada.Ltd.
MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE    1858 THE   EDITOR'S   PAGE
As we enter the last month of this momentous year of our Lord, 1940, a year which
has seen compressed into it more history, more heroism, more villainy, more human suffering, and more proof of the sublimity of the human spirit, than probably any single
year in history, we have been thinking of the future, as far as one can do so in this dark
and confused present. We believe that it is high time we did so. It is true that our
hands are full to overflowing with our immediate tasks, imposed on us by the war—
but it is not too soon to begin to plan, if we can do so, for the time after the war is
over, and we have to pick up the pieces, and fashion the world anew. When the end
of the war comes, and reconstruction begins, the medical profession is going to be profoundly affected. It is going to be, or can be, a major participant in the vast undertaking of restoring order and peace, and in the inevitably painful process of rebirth
which society must undergo.
The medical profession, the most democratic of professions, should surely be able to
take a leading part in this work: but it can only do so if it has, in advance, thought out
what part it is going to play, and how it is going to do it. We should be preparing ourselves to face certain inescapable facts, some of which will be pretty grim, and may well
be quite serious if we do not face them.
There is going to be, one can hardly doubt it, a profound alteration in our economic
and social set-up. Everyone will be called upon to make sacrifices beyond anything we
have ever been asked to face before—and it is quite on the cards that the changes
required will be so great as to constitute a complete revolution in our ways of living,
and our methods of practice. When the time comes, are we going to be found, as we
so often have been, complacently unprepared? A community in distress, hopelessly
beset by economic problems which seem well-nigh incapable of solution, is not going to
be in a mood to accept reaction and what it may regard as selfish individualism: and
we should be preparing ourselves now, to meet and help to solve the frightful problems,
economic, medical and social, which are bound to arise in the more or less near future.
We cannot delimit or define these problems now—but we can be thinking about them,
discussing them, preparing our minds for them, and doing what we can to organise ourselves to meet them and help in their solution. Otherwise, we shall be simply swept
aside by the rush of necessity and urgency, and we shall be likely to suffer a great deal
in the process. We are prepared, of course, and willing, to take our full share of the
burden of loss and sacrifice that is inevitably to be borne—but we should guard our
heritage, too, for only a strong, well-organised medical profession, in these complex days,
can be of service to the community, which will need'our help more than ever in the
dark days to come. All this is perhaps rather vague—but is perhaps none the less timely.
There is a danger, and the danger will increase as the emergency increases, that we may
be used as a scapegoat, and our back be laden with a burden that is not ours. Only if
we ourselves have a carefully thought out, constructive plan to offer, can we help to
mitigate and enlighten in some degree, the confusion and darkness that are bound to
come: only so can we do our full share in reconstruction, and only so can we preserve
our own integrity, and ensure our continued well-being.
*
The Bulletin has been asked to bring to the attention of its readers the request of
the Kinsmen Boys' Club of Vancouver, for old magazines that are suitable for boys'
reading, for which they have no further use. These are much appreciated by the boys,
and the Kinsmen's Club, which is sponsoring this excellent enterprise, would be very
grateful for any help given in this direction.
Page 58
r.\
i '4-1
Magazines particularly welcome, and most eagerly sought after, are such journals
as Popular Science, Popular Mechanics, and others which, like these, make a special appeal
to the boy reader.
A telephone message to the Library (MArine 4622) will bring a collector for these
magazines: and the Bulletin urges an early response.
BOOK REVIEW
EXPECTANT MOTHERHOOD: Nicholson J. Eastman.
170 pp.   $1.65.  Little, Brown: Boston, 1940.
This small volume on pregnancy and labour by the Professor of Obstetrics in Johns
Hopkins University may be confidently recommended to maternity patients. While the
book has been written for the expectant mother, it could be read with profit by physicians since many of the details mentioned concerning the hygiene of pregnancy are not
ordinarily found in standard medical text books. Doctor Eastman has a facile style,
making this little work very readable, and in addition a few well chosen illustrations
have been inserted. This volume will go far to supplement the usual instructions given
to patients and represents the best in accepted principles of modern prenatal care. In
Canada it may be obtained through McClelland and Stewart, Toronto.        —A. E. T.
m.t
WALTER SCOTT TURNBULL
Obut November, 1940
The medical profession of Vancouver received a great shock in the death of
Dr. Walter Turnbull of this city. There can hardly have-been a more popular,
more genuinely liked, man in Vancouver: his geniality, warmth of heart, unfailing kindliness, had endeared him for the space of a generation to the doctors
and public of Vancouver. To everyone that knew him, he was immediately
"Walter," and to those he served, he was a tower of strength and an unfailing
source of help and counsel.
Walter Turnbull began practice in Vancouver about thirty years ago and
had always been one of the busiest and most sought-after men in general practice, for which his personality especially fitted him. Some fifteen or sixteen
years ago, he had a severe illness, which made it unwise for him to continue the
heavy strain of an exceedingly busy general practice—accordingly, he limited
his work to obstetrics and gynaecology—and soon became just about as busy
as ever, especially as he was head of the Obstetrical and Gynaecological division
of the Staff of the Vancouver General Hospital for some years. Grace Hospital,
too, of which he was Chief of Staff for many years, owes a great deal of its
efficiency and excellent functioning to the wisdom and counsel of Dr. Turn-
bull. He filled, one after the other, most of the offices in the B. C. and Vancouver Medical Associations, and gave the most loyal service, and from a deep
fund of wisdom and practical common sense, gave freely to the counsels of
these bodies: he belonged also to the North Pacific Surgical Association, a
meeting of which he was to have attended at the time he died.
Perhaps we shall miss, more than anything, the whimsical wit and humour
that always lighted up his face, and made a meeting with him a cheery and
happy thing. He always enjoyed life, and saw the bright side of things—
latterly, he had not been well, and had had some distress of body—but his
courage and sanity never failed him. We are glad that he was well and active
to the last, that he died in harness, and that he had little or no suffering at the
last. To his family, in their great loss, we would extend our sincerest condolences and deepest sympathy.
Page 59 •
NEWS    AND    NOTES
Dr. Ethlyn Trapp, Dr. B. J. Harrison and Dr. C. W. Prowd attended the Annual
Convention of the American Radiological Society held in Cleveland.
Dr. and Mrs. Ian A. Balmer are receiving congratulations on the birth on November
11th of a daughter.
Congratulations are extended to Dr. and Mrs. H. G. Baker on the birth on November
25 th of a daughter.
Dr. F. E. Saunders of Vancouver was a recent visitor in Penticton.
Dr. George H. Lee, formerly of Prince Albert, has opened an office in the Medical-
Dental Building in Vancouver.
Dr. A. B. Nash of Victoria travelled to San Francisco and attended the Annual
Meeting of the Pacific Coast Society of Obstetrics and Gynaecology. Dr. Nash presented
a paper on "Manchester Operation for Genital Prolapse."
Dr. A. Herstein, who has recently returned after doing post-graduate work in Great
Britain, has opened offices in the Campbell Building, 1029 Douglas Street, Victoria.
%t •£. *t i%
*r »r »r '»
Dr. G. F. Amyot, Provincial Health Officer, visited Penticton and conferred with
the Municipal Board of Health.
Dr. R. P. Borden, formerly of Penticton, is now serving with the R.C.A.M.C. Capt.
Borden is stationed at Victoria.
Dr. A. T. Johnston of West Vancouver has returned from a motor trip to Edmonton.
The North Shore Medical Society was provided a clinical meeting on November 12th,
at 2700 Laurel Street, Vancouver, by the staff of the Division of Venereal Disease
Control.
Dr. and Mrs. C. C. Browne of Nanaimo have returned after two weeks in California.
We are glad to report that Dr. P. L. Straith of Courtenay is showing improvement
following his recent illness.
Major C. A. Watson and Capt. R. Scott-Moncrieff of No. 13 Field Ambulance, while
at the camp in Nanaimo, have joined the doctors there in the odd duck hunt, with some
success.   No doubt Capt. Moncrieff takes his bagpipes along as a decoy.
Dr. J. Bain Thom of Trail was called to Vancouver at the time of his sister's final
illness.   The profession extends sympathy in his loss.
«■      *      *      *
Dr. and Mrs. H. H. MacKenzie of Nelson have been visiting on the coast in Victoria,
New Westminster and Vancouver.
Page 60
m m
I '.» Dr. F. M. Auld of Nelson, representative from British Columbia on the Executive
Committee of the Canadian Medical Association, attended the meetings of that body in
Ottawa on October 24th and 25 th.
•t »t *t *^
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Dr. Reba E. Willits has completed her course in Public Health at the University of
Toronto and is now doing research in War Wound Infections at the University.
*t »t »^ *i
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Major S. G. Baldwin and Capt. M. R. Caverhill are in charge of Medical Services at
the Vernon Training Camp.
Dr. A. S. Underhill of Kelowna and Dr. H. F. P. Grafton of Kamloops attended the
meeting of the Committee on the Study of Cancer of the British Columbia Medical
Association on November 18 th in Vancouver.
Doctors Thomas McPherson and P. A. C. Cousland of Victoria travelled to Vancouver to attend the meeting of the Committee on Cancer.
Congratulations are extended to Capt. F. H. Stringer, R.C.A.M.C., upon his marriage to Miss Alfreda Thompson. The wedding took place on November 4th, in St.
Paul's Naval and Garrison Church, Esquimalt.
»?. **«, ;*» *t
Dr. and Mrs. L. G. Wood are receiving congratulations on the birth on November
24th of a son.
-"I
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DR. W. F. MACKAY
Obut November, 1940
With the passing of Dr. William F. Mackay, the medical profession of British
Columbia has lost a member of sterling worth. Dr. Mackay was not a young
man, and had recently suffered from a good deal of illness. His end was the
happiest that can befall a man: he worked up to the last minute—he was with
those he cared for, aware and in fullest possession of his faculties—and the
coming of the dark Angel was quick and merciful. For him we need have
ho regrets—only gladness that he was spared infirmity and pain. To those he
leaves behind, we extend a heartfelt sympathy.
Dr. Mackay was a general practitioner of medicine all his life—and he did
honour to that noble title. His patients were his friends and his personal responsibility, and to this day one meets former patients of his who think with the
greatest affection and regret of this man whose kindliness and care meant so
much to them when he was practising in Vancouver. He was a quiet, modest
man: a charming companion and friend, hospitable and kindly, and of a real
and rather rare courtesy and graciousness of manner. He had hosts of friends
—and at his quiet funeral in an out-of-the-way island in the Gulf of Georgia,
the masses of flowers coming from far and near in the Province testified to the
affection his friends had for him. He was a steadfast man, dependable and
loyal—and people trusted, as well as liked, him. Scrupulous to a degree about
his work, he leaves a good name. When the old Hebrew writer said "He that
sinneth before his Maker, let him fall into the hands of the physician," the
kind of physician he must have meant was surely that typified by our old friend,
Will Mackay.
Page 61 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. Murray Blair, Vancouver
First Vice-President Dr. C. H. Hankinson, Prince Rupert
Second Vice-President _Dr. A. H. Spohn, Vancouver
Honorary Secretary-Treasurer. -Dr. Walter M. Paton, Vancouver
Immediate Past President Dr. F. M. Auld, Nelson
Executive Secretary. Dr. M. W. Thomas, Vancouver
The following members of the Board of Directors of the British Columbia Medical
Association attended the meeting on Wednesday, November 27th:—Doctors Murray
Blair, President; W. E. Ainley, Vancouver; F. M. Auld, Nelson; F. M. Bryant, Victoria;
D. F. Busteed, Vancouver; W. A. Clarke, New Westminster; P. A. C. Cousland, Victoria; J. Stuart Daly, Trail; C. T. Hilton, Port Alberni; P. S. McCaffrey, Agassiz; H.
McGregor, Penticton; Thomas McPherson, Victoria; A. H. Meneely, Nanaimo; H. H.
Milburn, R. A. Seymour, A. H. Spohn, G. F. Strong, Ethlyn Trapp and C. H. Vrooman,
Vancouver; G. T. Wilson, New Westminster; Wallace Wilson, Vancouver; W. M.
Paton, Honorary Secretary-treasurer, Vancouver, and M. W. Thomas, Executive Secretary.
The business session of the Board of Directors was held immediately following dinner
in the Patricia Room of the Hotel Georgia.
The following Chairmen of Standing Committees were appointed:
Constitution and By-laws, Dr. H. H. Milburn; Programme and Finance, Dr. G. F.
Strong; Legislation, Dr. Thomas McPherson; Medical Educaaion, Dr. D. F. Busteed;
Archives, Dr. D. E. H. Cleveland; Maternal Welfare, Dr. C. T. Hilton; Public Health
and Nutrition, Dr. A. H. Spohn; Ethics and Credentials, Dr. A. H. Meneely; Economics,
Dr. W. A. Clarke; Pharmacy, Dr. C. H. Vrooman; Hospital Service, Dr. R. A. Seymour;
Cancer, Dr. Ethlyn Trapp; Editorial Board, Dr. J. H. MacDermot.
The Board of Directors appointed the following as members of the Executive Committee: Doctors Murray Blair, President; A. H. Spohn, W. M. Paton, M. W. Thomas,
ex-officio; L. H. Appleby, W. A. Clarke, H. H. Milburn, G. F. Strong and Wallace
Wilson.
BRITISH COLUMBIA CANCER INSTITUTE ||
On Monday, November 25 th, the Honorary Attending Staff of the British Columbia
Cancer Institute held its first open meeting at the Institute, 685 W. 11th Avenue.
Members of the Committee on the Study of Cancer of the British Columbia Medical
Association were invited to attend.
The programme took the form of a Symposium on "Fundamental Principles in the
Treatment of Concer"—Prophylaxis: Dr. G. H. Clement; Pathology: Dr. H. H. Pitts;
Pain: Dr. F. A. Turnbull; General Radiation Principles: Dr. B. J. Harrison; Symptomatic Treatment: Dr. C. E. Brown.
Refreshments were served and those present voted that they had had a very pleasant
and profitable evening. It is the intention of the Honorary Attending Staff to have
regular meetings, attendance at which is recommended.
Page 62 *f]
*f*
m.
COMMITTEE ON THE STUDY OF CANCER
The Committee on the Study of Cancer held a very largely attended meeting in the
Medical-Dental Building on November 18th at 8:15 p.m.
Those present included: Dr. Ethlyn Trapp, Chairman; Doctors Murray Blair, H. H.
Caple, D. E. H. Cleveland, P. A. C. Cousland of Victoria, H. F. P.. Grafton of Kamloops, K. J. Haig, F. J. Hebb, A. Taylor Henry, J. . Kitching, J. W. Lang of West Vancouver, R. E. McKechnie II, Thomas McPherson of Victoria, H. H. Pitts, J. W.
Thomson, F. A. Turnbull, A. S. Underhill of Kelowna and M. W. Thomas.
It was decided that regular meetings would be held on the second Monday of each
month.
Chairmen of Sub-Committees were appointed as follows:
1. Committee on Records and Cancer Record Forms—Dr. H. H. Caple.
2. Committee on Biopsy Service—Drs. H. H. Pitts and A. Y. McNair.
3. Committee on Educational Programme—Di*. G. F. Strong.
4. Committee on the Development of Study Groups—Dr. W. J. Dorrance.
5. Committee oh Publications—Dr. D. E. H. Cleveland.
6. Committee on Public Health Relations—Dr. J. S. Kitching.
7. Speakers' Bureau—This would comprise all members of the Committee—Dr. Thomas
to act as correlating agent.
ft
LIBRARY NOTES
NEW BOOKS RECEIVED IN LIBRARY
Expectant Motherhood, by Nicholson J. Eastman.
A Synopsis of Surgery, by Ernest W. Hey-Groves.
As I Remember Him, by Hans Zinsser.
A Symposium on the Flood and Blood-Forming Organs, Various Authors.
Surgical Clinics of North America, October, 1940—Symposium on Common Problems
in Surgical Diagnosis.
Transactions of the American Proctological Society, 1940.
Transactions of the American Therapeutic Society, 1939-40.
Treatment of Diabetes Mellitus, 7th ed., by Elliott P. Joslin et al.
Surgery of the Hand, by John Harold Couch.
Principles of Surgical Care, by Alfred Blalock.
Page 63 College of Physicians and Surgeons
President Dr. L. H. Appleby, Vancouver
Vice-President Dr. W. A. Clarke, New Westminster
Treasurer Dr. W.  E.  Ainley
Members of the Council—Dr. J. Bain Thom, Trail; Dr. Thomas McPherson, Victoria; Dr.
Gordon C. Kenning, Victoria; Dr. Osborne Morris, Vernon.
Registrar Dr. A. J. McLachlan
Executive Secretary I , Dr. M W. Thomas
MEDICAL ECONOMICS
For the information of all members we publish the following list of firms from
which the required majority of employees and dependants are now enrolled as contributing members of the Medical Services Association:
Henry Birks & Sons (B.C.) Ltd.
Dorninion Income Tax Office Employees.
Powell River Co. Ltd. (Vancouver).
Seaboard Lumber Sales Co. Ltd.
Shell Oil Co. (B.C.) Ltd.
Roy Wrigley Printing & Publishing Co. Ltd.
Yorkshire & Pacific Securities Ltd.
At this date, 40% of the active practising profession is enrolled in professional
membership.
It is requested that all doctors in private practice sign a membership card in order
that they be known to the M.S.A. office.
The present Enrolled Employee Members are now being provided with Medical Services under this plan. The Employee Member is now asking the M.S.A. office for assurance that his own doctor has signified willingness to provide Services.
Under the M.S.A. the patient is definitely promised that his own doctor will provide
the service.
It is imperative that the doctor's application card be filed at the College Office to
complete the roster. Those who have delayed sending their signed application cards are
urged to phone, write or call at 203 Medical-Dental Building (MArine 9634) and
attend to this at once.
Please Note: Doctor's Report and Account Forms are distributed on application to
the M.S.A. office.
There has been some misunderstanding regarding the avanability of
M.S.A. Service throughout the Province.
While, at its inception, solicitation for membership has been necessarily confined to the Greater Vancouver and New Westminster areas,
it should be definitely understood that where employee groups in other
areas make application for membership, the M.S.A. is ready and willing
to accept them.
Some of the present enrolled members are either resident or travel
in other areas in connection with their particular employment.
PLEASE SEND IN YOUR APPLICATION CARD FOR PROFESSIONAL
MEMBERSHIP.
Page 64
ti I?
DOMINION INCOME TAX RETURNS
BY MEMBERS OF THE MEDICAL PROFESSION
As a matter of guidance to the medical profession and to bring about a greater
uniformity in the data to be furnished to the Income Tax Division of the Department
of National Revenue in the annual Income Tax Returns to be filed, the following matters are set out:—
INCOME
1. There should be maintained by the Doctor an accurate record of income received,
both as fees from his profession and by way of investment income. The record should
be clear and capable of being readily checked against the return filed. It may be maintained on cards or in books kept for the purpose.
EXPENSES
2. Under the heading of expenses the following accounts should be maintained and
records kept available for checking purposes in support of charges made:
(a) Medical, surgical and like supplies;
(b) Office help, nurse, maid and book-keeper; laundry and malpractice insurance
premiums. (It is to be noted that the Income War Tax Act does not allow as
a deduction a salady paid by a husband to a wife or vice versa. Such amount,
if paid, is to be added back to the income);
(c) telephone expenses;
(d) Assistants' fees;
The names and addresses of the assistants to whom fees are paid should be furnished. This information is to be given each year on or before the last day of
February on Income Tax Form known as Form T.4y obtainable from the Inspector of Income Tax. (Do not confuse with individual return of income. Form
T.l, to be filed on or before 30th April in each year);
(e) Rentals paid;
The name and address of the owner (preferably) or agent of the rented premises should be furnished (see (j));
(f) Postage and stationery;
(g) Depreciation on medical equipment;
The following rates will be allowed provided the total depreciation already
charged off has not already extinguished the asset value:—
Instruments—Instruments costing $50 or under may be taken as an
expense and charged off in the year of purchase;
Instruments costing over $50 are not to be charged off as an expense in
the year of purchase but are to be capitalized and charged off rateably
over the estimated life of the instrument at depreciation rates of 15 per
cent to 25 per cent, as may be determined between the practitioner and
the Division according to the character of the instrument, but whatever
rate is determined upon will be consistently adhered to;
Library—The cost of new books will be allowed as a charge.
Office furniture and fixtures—10 per cent per annum.
(h) Depreciation on motor cars on cost;
Twenty per cent 1st year;
Twenty per cent 2nd year;
Twenty per cent 3rd year;
Twenty per cent 4th year;
Twenty per cent 5 th year;
For 1940 and subsequent years the maximum cost of motor car on which depreciation will be allowed is $1500.
Page 65 I»l
The allowance is restricted to the car used in professional practice and does not
apply to cars for personal use.
(i)    Automobile Expense; (one car)
This account will include cost of licence, oil, gasoline, grease, insurance, washing, garage charges and repairs; (Alternative to (h) and (i) for 1940 and subsequent years—In lieu of all the foregoing expenses including depreciation there
may be allowed a charge of 4^4c a mile for mileage covered in the performance
of professional duties. Where the car is not used solely for the purpose of
earning income the maximum mileage which will be admitted as pertaining to
the earning of income will be 75% of total mileage for the year under consideration.
For 1940 and subsequent years where a chauffeur is employed partly for business purposes, and partly for private purposes, only such proportion of the
remuneration of the chauffeur shall be allowed as pertains to the earning of
income.
(j)    Proportional expenses of doctors practising from their residence—
(a) owned by the doctor;
(b) rented by the doctor.
(a) Where a doctor practises from a house which he owns and as well resides in,
a proportionate allowance of house expenses will be given for the study,
laboratory, office and waiting room space, on the basis that this space bears
to the total space of the residence. The charges cover taxes, light, heat,
insurance, repairs, depreciation and interest on mortgage (name and address
of mortgagee to be stated);
(b) Rented premises—The rent only will be apportioned inasmuch as the owner
of the premises takes care of all other expenses.
The above allowances will not exceed one-third of the total house expenses or
rental unless it can be shown that a greater allowance should be made for professional purposes.
(k)  Sundry expenses (not otherwise classified) —
The expenses charged to this account shall be capable of analysis and supported
by records.
Claims for donations paid to charitable organizations will be allowed up to 10
per cent of the net income and for patriotic donations up to 50% of the net
income both upon submission of receipts to the Inspector of Income Tax.
The annual dues paid to governing bodies under which authority to practice is
issued and membership association fees not exceeding $100 to be recorded on the
return, will be admitted as a charge.
The cost of attending post-graduate courses or medical conventions will not be
allowed.
(1)   Carrying charges;
The charges for interest paid on money borrowed against securities pledged as
collateral security may only be charged against the income from investments
and not against professional income.
(m) Business tax will be allowed as an expense but Dominion, Provincial or Municipal income tax will not be allowed.
PROFESSIONAL MEN UNDER SALARY CONTRACT    W lSj
3. For 1939 and subsequent years the salary of professional men will be taxed in
full without any deductions other than those specified in the Income War Tax Act such
as charitable and patriotic donations and payments to superannuation or pension funds.
In particular, the cost of operating an automobile, including depreciation thereon, and
the annual fees paid to governing bodies will not be allowed.
WOS:IH   13th Nov., 1940. J|
Page 6$
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W.
THE OBSTRUCTING PROSTATE—RECOGNITION
AND TREATMENT    |||i
Earle R. Haul, M.D.
Read before Vancouver Medical Association, Nov. 12, 1940.
The problem of bladder obstruction caused by changes of the prostate gland still|
remains a most important part of medical practice. Patients and members of their
f amilies have frequently made reference to its increasing occurrence. This incident is,
no doubt, due to its earlier recognition and improvement in methods of treatment. As
a result, the patient will submit more willingly to operation, and a more favourable
prognosis can usually be issued.
It has been stated that of men who have reached sixty years of age, thirty-four per
cent have enlarged prostates, but only about half of these are affected by symptoms.
The prostate, being a sexual organ, is probably passive as regards urination; however, the
symptoms of prostatic disease are predominantly urinary.
The family physician usually sees these cases first, and thus holds a very important
position as to the future of the man's life. If his advice is good, he will carry him over
this serious urinary event to future good health; but if, on the other hand, his advice
is wrong, he may lead him into a miserable existence, and eventually death from pyelonephritis.
Symptoms and Diagnosis.
Slow enlargement of the prostate may take place for many years without the production of symptoms sufficient to call the attention of the patient to his trouble. Perhaps he may get into the habit of rising once during the night to pass urine, or he may
notice at times that there is a smaller stream passing, or the necessity to wait longer for
it to start. These latent cases are relatively common, and many receive their first real
warning that something is wrong, in the shape of a sudden attack of complete retention.
When this is encountered and urination is again established by perhaps one or two
catheterizations, the patient should not be allowed to go on until he has another sudden
complete blockage. This may not occur for several years. Prostatic obstruction should
be recognized at the first instance, and suitable treatment advised. The advice to the
prostatic should always be surgical treatment. There is no other treatment worthy of
consideration.
Enlargement of the prostate is usually attended by an obvious alteration in micturition. This may begin so insidiously that the patient is unable to state when it was
first noted. Usually it takes the form of increased frequency of micturition. I believe
that nocturnal frequency is especially characteristic of prostatic enlargement. The
explanation of this is not that the frequency is actually greater during the night, but
that the necessity to get up and pass urine arrests the patient's attention, whereas a
slightly greater frequency by day passes unnoticed. I have frequently been impressed,
during the taking of a history, by the patient admitting the necessity of voiding several
times at night, but insisting that during the day there was no change in urination.
Associated with frequency is a certain amount of difficulty. More straining is required
in order to pass urine. There is a marked delay before the flow begins, and when started,
the stream often does not take the usual curve, but drops vertically between the legs.
Less urine is passed at each act, and the time taken for its passage is longer. Urgency is
often present, the patient being compelled, once the desire has arisen, to hurry to the
nearest urinal in order to avoid disaster. This urgency is probably due to two causes,
namely, impaired action of the sphincter and hypertrophy of the bladder walls. It is
well to remember that the symptoms of prostatic enlargement are, as a rule, irregular
Page 67
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-1; . periods of difficulty alternating with times during which the patient notes nothing
wrong beyond a slight frequency. They may also vary in severity throughout the day,
the greatest difficulty often being present during the first few hours on rising in the
morning. Later in the disease, there is dribbling at the end of micturition, the voiding
of the main quantity of urine being followed by a period during which small quantities
are expelled, so that the patient has difficulty in deciding when the act of micturition is
finished. This occurs during the stage of dilatation of the bladder, when the quantity
of residual urine is on the increase. It is explained by the fact that the impaired, contractile power of the bladder fails to project into the membranous and bulbous urethra
a sufficient quantity of urine for the voluntary muscles of the perineum to act on it.
Intermittent urination may also occur, the flow suddenly stopping and then, for no
apparent reason, beginning again. This is usually due to an intra-vesical projection
acting as a ball valve, and being forced down on the internal meatus in a manner that is
also characteristic of a vesical calculus.
Guyon subdivided the symptomatology of prostatic enlargement into three periods:
1. The period of premonitory troubles during which the bladder is still capable of
emptying itself, and the symptoms are due to congestion.
2. The period of incomplete retention without distention, characterized by imperfect
emptying of the bladder.
3. The period in incomplete retention with distention, during which the bladder is not
only incapable of emptying itself completely, but is actually distended by the urine
it contains.
The symptoms may change very little for months or years, the compensatory Tiyper-
trophy of the trigone and bladder being able to take care of the obstruction. While the
urinary symptoms in such cases may remain slight, the spasmodic action of the trigone
in emptying the urine, being more frequent and prolonged than normal, may lead to
distention of the ureters and kidney pelves, and result in impariment of renal function.
It is when the patient passes into this latter stage that all his old symptoms become
aggravated and -new ones appear. The hypertrophied trigone and bladder walls are no
longer able to cope with the progressive obstruction, and as in the case of other hollow
organs, dilatation occurs. The residual urine, which at first may have amounted only to
an ounce or two, steadily increases; frequency becomes greater, and later only a few
teaspoonfuls are passed on each occasion. This may give place to incontinence. The
patient still feels the desire to micturate, although his urine is continually dribbling from
him. The condition is one of distention with overflow. With the development of these
later symptoms associated with reduced kidney function, further symptoms of urinary
toxaemia will occur. These may be so marked that they overshadow the local troubles
of prostatic obstruction. The symptoms of a case if he is seen for the first time in this
stage may mislead both patient and doctor as to the true nature of the condition. Dizziness, headache, and loss of appetite occur. Digestive troubles are common, associated
with nausea and vomiting. Sometimes there is abdominal distention with, as complications, prolapsus ani and haemorrhoids. Increasing thirst, and a dry, coated tongue are
usually present. Some form of cardio-vascular disease is also frequently found, "the more
common being arteriosclerosis, hypertension and myocarditis. The patient loses flesh, the
skin becomes dry, and he may finally pass into a condition of cachexia, resembling
strongly that of a sufferer from malignant disease.
Spontaneous hematuria is not a common symptom in the early stages of prostatic
obstruction, but occurs more frequently during the periods of incomplete retention. In
intensity it may range from a slight colouration to a sudden severe haemorrhage. I have
found marked bleeding, often with the passage of clots, to be more common in benign
enlargement than in carcinoma of the prostate. As a rule, haematuria is explained by
congestion of the urethra and bladder base, but sometimes it is the result of a calculus
or of a bladder growth, associated with the enlargement.  The existence of one of these
Page 68
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compfications should always be suspected when abundant spontaneous haematuria occurs
in the absence of retention, and when, contrary to rule, the bleeding is more marked
toward the end of the act of micturition.
Pain and irritation vary greatly as symptoms. In many cases they are not present,
even with marked obstruction, and great enlargement. In other cases there may be a
disagreeable burning sensation or irritation. In some instances the pain is severe and may
radiate to other regions. This, however, is not nearly so common as with carcinoma of
the prostate.
A patient may remain for many years with only the early symptoms of enlargement
present, and then within a few weeks develop signs of increasing obstruction—others
will deny having suffered from any premonitory symptoms and will be compelled to
seek medical aid for the first time on account of a sudden retention. There are also a
few fortunate patients whose condition does not progress and who suffer from nothing
beyond a slight frequency or an occasional difficulty in micturition, for the remainder of;
their lives. It is, therefore, impossible on examining a patient with premonitory symptoms of enlargement to foretell what his future will be. It must be remembered, however, that in the great majority of cases the condition of enlargement is a progressive
one, and that, should unfavourable factors intervene, such as infection, the patient may
pass rapidly from a state of comparative comfort to one which gives rise to grave
anxiety. For this reason an expectant attitude can rarely be retained for long after a
diagnosis of enlargement has been made.
With the onset of infection, the symptoms are usually aggravated, and the case
immediately assumes a much more dangerous aspect. The initial symptoms of infection
are usually chill, fever, irritability, and increased frequency, though in some low-grade
infections there may be little or no change in the symptomatology. The greatest danger
with infection is the development of compfications such as pyelonephritis, urethritis,
peri-prostatic and peri-urethral abscess. Infections occur most frequently as a result of
catheterization or other forms of instrumentation, but are not infrequently found in
cases with large residual urine when no instrument has ever been introduced.
Diagnosis.
The examination of the patient consists of:
1. The taking of an accurate history of the onset of the disease, the nature of the
symptoms, and the order of their appearance.
2. The physical investigation of the case.
Careful clinical and laboratory studies will give a comprehensive opinion as to the
conditions present. The development of clinical and laboratory methods, function tests,
blood chemistry, the use of the cystoscope, and a very careful general physical examination have been responsible for the lowering of mortality in prostatic surgery.
Rectal Examination will furnish considerable information in cases where prostatic
enlargement and obstruction are suspected. Some practice is required in order to judge
whether a prostate is enlarged or not. The prostate, like the external genitalia, varies
considerably in size in different individuals. In carrying out palpation, a determination
of the size is first noted, both as regards its depth and its side-to-side diameter. In a case
of marked enlargement, it is difficult and sometimes impossible to feel the upper limits
of the prostate. The next point to note is the condition of the gland, and whether the
enlargement is regular or irregular. The position of the median sulcus should be defined,
and any asymmetry in the enlargement noted. Great variation will be found in the
extent to which the prostate projects into the rectum. Sometimes it forms a marked
prominence, and sometimes it encroaches but little into the bowel. Mobility is tested
by pressing the gland forward in the direction of the pubes and noting whether it can
be displaced or whether either one or both lobes are at all fixed. Except in cases of
very great enlargement or in cases complication by infection, a certain degree of
mobility can always be imparted to the gland. If the prostate is fixed, and especially
if to fixity is added hardness and regularity, malignancy should be suspected. The texture of the gland should be investigated.   In testing the consistency of the gland, the
Page 69 whole of its surface must be palpated, since it is not uncommon in cases of malignancy
to find only one area in which there is definite hardness in the gland, the remainder
of the prostate being soft and elastic, as is usually described in the case of a benign
enlargement. Elasticity, however, is not always present, and I have often found induration more or less marked. It has been stated that absence of the median furrow is usually
found in cases of malignancy. My experience has shown many cases of chronic prostatitis having absence of the sulcus—these cases usually showing varying degrees of
induration present also. In a case of benign enlargement, where palpation discloses
two definite enlargements of lateral lobes with a median narrow groove or sulcus
between, the notch at its upper end may be replaced by a rounded mass suggesting the
presence of a median lobe.
The size of the prostate varies greatly; in many cases it remains small or only slightly
enlarged for many months, while in others it may very rapidly assume great proportions.
I have often been surprised at the amount of obstruction present when rectal palpation
discloses a gland appearing normal in size. This occurs when the enlargement is intravesical. I recently had a case in which the prostate per rectum was not enlarged, and
the previous history of urinary disturbanes was limited to nocturia several times. This
man developed acute complete retention, and examination showed the prostatic urethra
to be much elongated. A cystoscope was not long enough to pass through the internal
urethral orifice. Prostatic resection was impossible on account of the length of the
urethra, and I removed the gland by suprapubic enucleation. This prostate, while not
appearing enlarged on rectal examination, weighed 195 grammes.
Before urethral instrumentation, such as cystoscopy or the passing of a catheter for
determination of residual urine, it is well to percuss the abdomen to determine whether
the bladder is greatly distended after voiding. If the bladder is well above the pubes, it
should be slowly decompressed. Although a diagnosis of prostatic enlargement may be
arrived at by other means, precise knowledge can only be obtained by the use of the
cystoscope. Cystoscopy alone can furnish information as to the exact form the enlargement has taken, the condition of the bladder, and the presence of such complications as
calculus or diverticula. The presence of a large diverticulum, without its existence being
known, may lead to an error as to the quantity of residual urine obtained. In every case
in which it is considered desirable to pass a catheter or cystoscope, every possible precaution should be taken to avoid introducing infection. Should the form of obstruction
be such as to make the passage of an instrument difficult, the examination should be
abandoned rather than any risk run of inflicting trauma.
Differential Diagnosis: Frequency and difficulty in micturition, the two chief symptoms of prostatic enlargement, are also important symptoms in other lesions of the
lower urinary tract. For this reason, it will be convenient to deal briefly with the subject of differential diagnosis.
Chronic Prostatitis*. This condition may occasionally be mistaken for simple enlargement, when frequency and dysuria are prominent symptoms. These cases are usually
seen in patients below the "prostatic age," and a careful history will often reveal symptoms antedating the appearance of those of which he now complains. On rectal examination the prostate may be enlarged, but far more important is the discovery of a
tender gland with irregularity, and the prostatic secretion showing the presence of a
large number of pus cells. It must be remembered, however, that many cases of chronic
prostatitis will be associated with benign enlargement. In some cases of chronic infection, it may be very hard to differentiate without cystoscopy to show absence of intravesical and intraurethral lobes characteristic of a simple enlargement.
Prostatic Calculus'. Here the signs are the same as in the case of chronic prostatitis,
although, as a rule, pain is more severe and haematuria more frequent when a stone is
present. On rectal examination, in addition to induration, irregularity and tenderness
of the prostate, an area of stony hardness may be felt in its substance. This is more
likely to be noted if the calculus is a large one, and if it lies near the rectal surface of
the prostate. A characteristic sign noted in cases of multiple calculi is due to the grating
Page 70
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of one stone against another. This crepitus may be obtained on attempting urethral
instrumentation. A case of prostatic calculus is more likely to be confused with one of
malignant disease rather than of simple enlargement of the prostate. The differential
diagnosis rests on the presenece of the signs of inflammation together with the existence
of a shadow or shadows in the prostatic region produced by X-ray.
Tuberculosis: Although a primary focus may be found in the prostate and vesicles,
tuberculosis of these structures is usually associated with similar lesions elsewhere in the
genito-urinary tract, and especially in the epididymis or the kidneys. There is usually no
obstruction to urination, no residual urine and no marked vesical disturbance, until the
bladder beomes involved in the tuberculous process. The symptoms of frequency and
dysuria then become so marked that there is very little probability of the condition being
mistaken for one of benign prostatic enlargement. In early cases, the condition of the
prostate as felt by rectal examination, resembles that found in chronic prostatitis. Later
in the disease, the prostate feels definitely nodular, and the vesicles, which are almost
always implicated, possess the consistency of tallow candles. By this time, one or both
epididymes are almost always affected, and associated with the local condition are such
general symptoms as loss in weight, night sweats, and pyrexia.
Prostatic Abscess: This has signs of acute inflammation in the prostate, often preceded by a history of urethral discharge or some other acute inflanimatory process in the
body. On rectal examination, an acutely tender, fluctuating swelling is found in the
situation of the prostate, from which pus can usually be expressed by gentle massage.
An acute prostatitis may be considered under this heading, as it frequently leads to
abscess formation. The gland is very firm and exceedingly tender. There is sudden onset
accompanied by signs of acute infection. One or both epididymes frequently become
involved as a metastic infection.
Stricture of the Urethra: Symptoms of this usually appear earlier in life than do
those of enlargement. Sometimes, however, the stricture does not become manifest until
the bladder muscle begins to fail, or, in other words, until the patient is of prostatic age,
so that too much reliance must not be put on this method of distinction. Of more
importance is the history and the appearance of the urine. The urine passed by a prostatic is clear and free from pus, unless, of course, the bladder has become infected. The
urine of a patient suffering from stricture almost always furnishes evidence of past
infection, in the form of pus and threads. Exploration of the urethra will put the
matter beyond doubt. Occasionally, of course, stricture and prostatic enlargement occur
as associated conditions in the same patient. In such a case, it will be necessary to dilate
the stricture and then to carry out a cystoscopy.
Malignant Disease: In certain cases of malignant disease, the differential diagnosis
from an innocent enlargement of the prostate is easy, but there are others in whom it is
extremely difficult. Carcinoma, unlike henign enlargement, usually begins in the
posterior lobe of the prostate from when it extends upward toward the bladder to involve
seminal vesicles and the bladder neck region. It usually gives no early manifestation,
but works its way insidiously and often is well advanced before being suspected. It is
often co-existent with an ordinary hyperplasia, the latter producing urinary disturbances
which are the cause for examination. With malignancy, the age at which symptoms
most frequently appear is somewhat later than in the case of simple enlargement, and
as a rule difficulty is a more marked feature than frequency. The most noteworthy
features are the hardness and fixity of the prostate. Not all carcinomas of this gland,
however, are scirrhous and stony hard. Medullary and glandular types may be soft.
Cystoscopy, even when carried out in the earlier stages of the disease, may reveal the
presence of a considerable amount of residual urine without there being any marked
intravesical projection. The trigone is usually raised, and if it be watched, will often be
seen not altering its position during emptying and filling of the bladder, owing to
fixation by the growth. At cystoscopy, I have often noticed cedema of the bladder
mucous membrane, especially at the base. The striking feature being the presence of
this cedema in the absence of much obstruction or infection of the bladder.
Page 71 Nerve Lesions of the Bladder: Impaired innervation of the bladder resulting from
lesions of the cord may produce symptoms very similar to those of prostatic obstruction.
Of these spinal lesions, tabes dorsalis is the commonest and the one most likely to cause
confusion in diagnosis, since bladder symptoms may arise very early in the disease, and
long before lightning pains, ataxia, and ocular troubles are noted. Even after a careful
investigation of the patient from a neurological standpoint, the diagnosis may still be
in doubt, for the bladder is sometimes affected without there being any alteration in
the knee-jerks or in the pupil response. The tabetic bladder shows an increased tolerance,
so that the patient only voids from habit, and not infrequently presents himself for
examination with a bladder that reaches to the umbilicus, and yet occasions very little
inconvenience. Rectal examination shows the absence of prostatic enlargement and often
a wide median furrow and notch suggesting a dilated prostatic urethra. The diagnosis
is further made clear by cystoscopy, revealing a dilated vesical sphincter, fine trabecula-
tions, and atrophy of the trigone.
Obstruction at the Bladder Neck: It has long been recognized that there are cases
in which all the symptoms of prostatic obstruction are present, and yet when a careful
examination is made, little or no enlargement of the prostate is discovered. This condition is known as a prostatic or median 'bar, or is often called a contracture at the
vesical neck. The essential feature in these cases is a failure of the bladder neck to open.
This failure is usually the result of infiltration of the neck with fibrous or glandular
tissue. In the glandular type, the tissue that forms the thickening round the internal
meatus is mainly composed of glandular elements. Sometimes the glandular enlargement
is localized in the form of an adenoma, but not infrequently there is a generalized
increase of glandular tissue in which are found, at various points, localized adenomata.
In the fibrous type, the normal structure is replaced by dense fibrous tissue; this sclerosing process may be found invading the prostate also. Signs of inflammation are usually
present, and many think this condition to be inflammatory in origin—perhaps a sequel
to a chronic prostatitis. These types of obstruction, recognized by use of the cystoscope,
produce some of the most marked changes of back pressure, at times even more than
hyperplasia, and with the formation of large vesical diverticula, hydro-ureters, and
hydro-nephroses.
Treatment.
Prostatic obstruction, with all its resulting changes, is caused by one of three conditions:—Median bar, hyperplasia, or malignancy. The treatment is surgical intervention, and in this respect there are three routes of choice—the transurethral, the
suprapubic, or the perineal. During the past few years, a tremendous amount of discussion has arisen as to which is the method of choice. I think this is best answered by
stating that each individual should employ that particular method which in his own
hands gives the most satisfactory results—that is to say, the method best adapted to his
individual talents and experience. In the hands of a master of any particular method,
any of the several procedures is successful in overcoming prostatic obstructions. Various
individuals develop a knack or aptitude for a particular method that may prove difficult
and unsatisfactory in the hands of others.
The method of transurethral resection is, I think, standing the test of time. Unfortunately, this method received a good deal of unwarranted criticism in its earlier years,
chiefly due to the belief that it was an easy and simple procedure. For this reason, the
operation was performed by many with little regard for preoperative care or cystoscopic
experience and skill. This naturally led to many unfavourable results. The procedure
of resection, apart from being technical, entails an anatomic knowledge of the posterior
urethra and bladder neck with the changes produced by the various types of obstruction.
This method appeals to me because of certain advantages it possesses. It has brought
about the possibility of a large number of patients obtaining relief from their prostatic
condition, who, because of serious coexisting disease, or results of long standing obstruction, were very poor surgical risks. The economic factor is worthy of consideration, as
hospitalization is greatly reduced in the majority of cases.   Added to this, many men
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will seek relief of their obstruction at a very much earlier period than they did in the
days of open surgery; hence many serious compfications are avoided, and there is a
marked reduction in the mortality rate. Formerly, the patient often sought relief late
in the course of the disease, and the result was that serious lesions from obstruction and
infection occurred, increasing the operative mortality. This method is used with satisfaction by many in the treatment of prostatic carcinoma, and often successfully combined with radium or deep roentgen therapy.
In conclusion, I wish to point out that, no matter what treatment is adopted, all
cases require careful preoperative care, which must also be carried over to a close supervision of the post-operative course as well.
P
m
BENZOL (BENZENE) POISONING
DIVISION OF INDUSTRIAL HYGIENE
Department of Pensions and National Health
Benzol (benzene) is obtained by distillation of coal tar and by recovery from coke
oven gas, illuminating gas, crude petroleum of certain types as well as from cracking of
crude petroleum. It must not be confused with benzine which is a fraction of crude
petroleum and which does not possess the poisonous properties of benzol  (benzene).
Pure benzine is a colourless liquid with a characteristic agreeable odour. It boils at
80° centigrade (176° Fahrenheit). Benzol is a commercial product containing approximately 90% of pure benzene. It evaporates readily when exposed to the air and gives off
a vapour which is three times as heavy as air and which, therefore, may collect at floor
level. Benzol (benzene) is highly inflammable and its vapour forms an explosive mixture
when mixed with air.
Industrial Uses
The following types of workers are most likely to be exposed to the danger of benzol
poisoning:
Aeroplane dope workers, aniline workers, artificial leather workers, benzol still
workers, blenders (motor fuel), brake-lining makers, chemists and chemical workers,
cleaners and spotters, coal tar workers, coke oven workers, degreasers, dry cleaners,
explosives workers, fur cleaning workers, furniture stainers, gas (illuminating) workers,
hat sizers, lacquer workers, linoleum workers, nitrobenzene workers, oil cloth makers,
paint removers, patent leather workers, peat workers, phenol workers, photogravure
workers, pyrOxlyn-plastic workers, rotogravure workers, rubber cement makers, rubber
workers (dippers), sanitary can workers, shade cloth workers, shellac workers, shoe
finishers, shoe repair workers, spray painters, varnish workers.
Poisoning by Benzol (Benzene)
Poisoning by benzol (benzene) occurs as a result of breathing the vapour, which is
absorbed into the body by way of the respiratory tract. Because benzol (benzene)
evaporates so rapidly when exposed to air, dangerous quantities of the vapour will be
present in the air unless evaporation of the liquid benzol is prevented. When once
absorbed benzol (benzene) exerts its poisonous action on the nervous tissues and on the
blood-forming structures.
Acute Poisoning.—Acute poisoning by benzol (benzene) results from the breathing
of air containing large amounts of benzol vapour. Accidents such as failure of ventilation equipment and spilling may result in acute poisoning to workers exposed. Acute
poisoning may also occur in the case of workers entering enclosed spaces containing
benzol fumes—spaces such as tanks, etc. The effects of breathing the benzol-laden air
occur rapidly. The worker exposed becomes dizzy, breathless or excited and if not
removed at once loses consciousness.   Frequently the effects of such exposure are fatal.
Page 73 Chronic Poisoning.—Chronic poisoning is the commoner type of benzol poisoning in
industry. Chronic poisoning occurs as a result of continued daily breathing of air containing low concentrations of benzol vapour. This vapour, when absorbed into the
body, causes injury to the blood-forming structures and in time the affected worker is
unable to produce normal blood, his resistance to infection thereby being impaired.
It cannot be too strongly stressed that chronic benzol poisoning can develop to a
critical stage without the worker being aware, for some time, that he is poisoned. Death
may even occur without benzol poisoning being suspected as the primary cause.
When a worker is exposed to benzol and notices such signs as weakness, frequent
headaches, dizziness, nausea, loss of appetite, pallor, tendency to bleeding of the gums
and of the nose and tendency to bruise easily, he should report to a physician and should
inform the physician of his exposure to benzol. Cases of benzol poisoning should be
reported to the employer and to the provincial health and labour departments so that
adequate steps may be taken to protect other workers.
Treatment.
Acute Poisoning.—In treatment of workers who have collapsed as a result of acute
benzol poisoning the following measures must be taken without delay and before a
physician has arrived: (1) remove worker from exposure to open air, (2) keep worker
warm, (3) if breathing is weak or suspended apply artificial resuscitation.
Chronic Poisoning.—Treatment of chronic poisoning should be carried out only by
a physician.
Responsibility of the Employer.—(1) To introduce less toxic substitutes for benzol.
Prevention.
(2) If necessary to use benzol, isolate benzol processes and confine the material in closed
vessels wherever practicable. (3) To remove benzol vapour by exhaust ventilation at
the point of origin when the material requires to be used in open vessels. (4) To provide adequate ventilation, in addition to exhaust hoods, for all workrooms in which
benzol is being handled. (5) To insure that ventilating equipment is operating satisfactorily by having workroom air tested for benzol routinely. Seventy-five parts of
benzol vapour per million parts of air is now considered the maximum safe concentration.
(6) To insure that no worker may enter a tank or enclosed space until thorough ventilation has been carried out. Persons required to enter tanks or enclosed spaces which
hav contained benzol should be provided with gas masks of a type approved by the
Provincial Department of Health. Workers entering tanks and enclosed spaces should
be proetcted by a safety belt and by the presence of another worker on the outside. (7)
To provide protective clothing for workers required to use liquid benzol. (8) To insure
frequent periodical medical examination of all workers exposed to benzol. Euch examination should be carried out by a physician familiar with benzol poisoning and should
include a blood examination. Health records of benzol workers should be kept and
medical advice as to transfer of an affected worker from benbol work to more inocuous
duties must be acted upon promptly. (9) To insure that both employer and employee
know when benzol is being handled. Benzol is frequently contained in materials that
are distributed under a trade name, therefore all benzol and benzol-containing products
should be labelled "Contains Benzol."   (10) To insure that all those connected with the
manipulation of benzol are made aware of its toxicity.
Responsibility of the Employee.— (1) To carry out, in detail, all safety measures
which are advised in connection with the use of benzol. (2) To make use of ventilating
equipment, gas masks and protective clothing supplied for protection against benzol and
to report when this equipment is not in good order. (3 ) To report physical complaints
early. Benzol poisoning is insidious in its onset. When a physician is consulted he should
always be told if benzol is being handled, since such information may assist in a diagnosis.
Page 74
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|       HYPERVENTILATION SYNDROME        |
Geo. H. Anderson, M.D., Spokane.
Read before the B. C. Medical Association at Nelson, B.C, September, 1940.
In the practice of medicine one is daily impressed with the number of patients that
present themselves with symptoms which have resulted from their effort at adjustment
to life and their search for contentment and security.
Although this struggle is not new, it seems that the complexity of living in the last
few years has increased the difficulties and with this increase the number of individuals
who are unable to "take it." As a result, various nervous manifestations have resulted
from mild behaviour problems to true psychosis. In recent years, many of these have
been put in a group which has been classified as anxiety tension state.1' 2*
During the first world war, many individuals, reasonably well adjusted in civilian
life, found difficulty in adapting themselves to military life. With anxiety or effort palpitation, dizziness, weakness and fainting spells occurred. To this disorder, various
names were given: Effort Syndrome, Neurocirculatory Asthenia, Functional Cardiovascular Disorder, Disordered Heart Action. Obviously these terms did not fit, since
the name reflected only one aspect of the condition. It is apparent that all of these
should be grouped in the anxiety tension state group, even though automatic instability
predominates more than the psychological disturbances.
All of us know how the neurotic patient with these symptoms goes from one doctor
to another seeking relief from symptoms that are real and distressing to him. Too often
he is given little consideration and no attempt is made to understand his problem. It is
now realized that emotion can precipitate symptoms of physical disease by provoking
hyperventilation with subsequent blood changes. Symptoms vary from palpitation and
dizziness to those of mild or extreme tetany. Physicians unaware of this possibility
diagnose a variety of conditions, many of them serious, that this condition remotely
resembles. The additional emotional upset brought on by a grave diagnosis often increases the frequency and severity of their symptoms. It is this group of patients
showing symptoms of tetany that I particularly wish to discuss.
Although this condition usually occurs in the anxiety tension group, it must be kept
in mind that anything which causes hyperventilation may cause an attack. Instances of
tetany being provoked from prtracted laughing spells have been reported.
It is best to discuss the subject of tetany in general so as to bring out the manner in
which emotional upsets can produce symptoms of tetany. Tetany that results from
removal of parathyroids is best explained on the basis of calcium deficiency. The low
calcium in tetany of rickets, osteomalacia and sprue indicates that this is the cause also3.
Tetany of alkalosis, whether it results from loss of hydrochloric acid by excessive
vomiting, ingestion of sodium bicarbonate, or hyperventilation, cannot be explained by
low serum calcium. It has been suggested that a shift of the blood to the alkaline side
may cause a reduction of the ionic calcium fraction without reducing the total calcium
of the serum. Proof is insufficient to warrant such an explanation, whereas careful
studies indciate that tetany in these instances is due to a tissue alkalosis in itself.3, 4-
The train of events leading to production of anxiety state and subsequent hyperventilation syndrome is described by Kerr et al as follows:
"An individual has a difficulty to meet. The reaction psychologically may be one of
two types: The individual may face his problem squarely and find a solution; or he
may attempt to ignore the difficulty and deny its existence. Regardless of any attempt
on the part of the patient to deny the existence of his difficulty, nevertheless it still
exists. In our opinion, it is the suppressed emotion associated with the difficulty that
directly stimulates the autonomic nervous system. The sympathetic nervous mechanism
is aroused, and the most outstanding reaction is stimulation of secretion by the adrenals.
The cerebral cortical centres are stimulated directly and also by oversecretion of adrenalin. Adrenalin irritates also the cardiac and respiratory centres, causing at first slow
heart rate with a large stroke volume output, and later a rapid heart rate. There is
speeding up of the respiratory rate and increase in ventilation.    With the increase in
Page 75 ventilation the carbo dioxid in the alveolar spaces is expelled, and more is shifted from
the blood stream and tissues into the alveolar spaces. Chlorides are retained in the blood
and phosphates likewise. Urea is not produced by the liver, hence ammonium salts are
decreased in the urine. These later manifestations are the result of an attempt on the
body to prveent too great a shift to the alkaline side because of the sudden loss of carbon
dioxid and as a result the patient suffers from the lack of sufficient acid ions and experiences irritability' of muscle tissue because of alkalosis."
Symptoms of hyperventilation, although variable, are readily recognized if one has
the condition in mind. This is particularly true when symptoms of tetany occur.
When symptoms are less marked the condition may not be recognized as being due to
hyperventilation. Most patients complain of dizziness followed by numbness or tingling
of the hands and feet. There may be a sense of constriction of the throat or a itghtness
in the chest or discomfort in the epigastrium. Twitching of the facial muscles may
occur. In severe cases, laryngeal stridor, general convulsions and unconsciousness may
take place. As a rule, tetany does not progress beyond the point where spasm of the
muscles of hands and feet occurs.
In an extensiv estudy of 35 cases, Kerr et al found a number of patients with precordial pain and palpitation that had been diagnosed coronary occlusion, angina pectoris
or aneurysm of the aorta. Others had symptoms suggesting Raynaud's in which spasm
of the arterioles had been initiated by hyperventilation. Other conditions with which
the syndrome was confused were thyrotoxicosis and Meniere's disease. The diagnosis
was proved by using hyperventilation test, by obtaining relief with carbon dioxid during
attacks or use of acid salts and acid ash diet.1
For the study of these cases, the hyperventilation test has been devised. Before using
this, however, it is important to obtain a complete history and do a complete physical
examination, including a neurological. This should include a nattempt to elicit Chvos-
tek's and Trousseau's signs. The patient, lying in a comfortable position, is then instructed to breath at the rate of 18-20 a minute, the hand of the examiner being placed
on the epigastrium regulating the rhythm. Time at onset of test and onset of symptoms
is noted. An effort is made to produce tetany or the symptoms of the complaint. If
unsuccessful in 30 minutes, the procedure is discontinued. The spasms and symptoms
are relieved by carbon dioxid holding breath or rebreathing in a sack.
The establishment of the diagnosis in this manner is extremely important, as well as
impressive to the patient. An explanation of the mechanism in simple language show
the part that he plays in the initiation of the symptoms. He realizes just how he can
help prevent the attacks. The dramatic demonstration makes him. feel that his physician
thoroughly understands his case. The confidence established in the physician makes
psychotherapy, so important in treatment, much more readily carried out.
When attacks continue even though the mechanism of production has been thoroughly explained to the patient, an acid ash diet, acid salts such as ammonium chloride
or sedatives may be of value in treatment.
The following case illustrates most of the features of hyperventilation that have been
discussed:
A youth 17 years old was admitted to the hospiatl on June 25, 1940, having been
sent in by his doctor from the country. No definite diagnosis had bee nmade, but cardiac condition had been suspected because of two unusual spells, five and three days
before entrance. He had never had any illness of importance, but had always been a
nervous, sensitive type of individual. Although he had been interested in various types
of athletics, he had never taken very active part in any excepting basketball. He had
attempted to play basketball, but because he became very white when playing, the
coach had seldom permitted him to play. He had attended a few parties and dances, but
with little interest, being definitely asocial.
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The situation at home seemed to have been a factor in his nervousness. He was the
oldest of 10 children, having three brothers and six sisters. His relationship with his
sisters and brothers had always been very pleasant, but he had had difficulty getting
along with his father. He had never been particularly interested in farm work. It had
been his ambition to be a depot station agent. This was due perhaps to the fact that
he had been friendly with the local agent and had always been interested in telegraphy.
His father felt that he should become a farmer, and that hard work would solve the
boy's difficulties. For the work that he had to do at home, he had been given very little
spending money and had had very little opportunity for pleasure. His mother and sisters
had been very sympathetic to him; perhaps too much so.
On entrance into the hospital he stated that he was weak and unable to work. His
illness had begun a year before when he returned to the ranch and attempted to do
heavy work after having spent the winter attending high school and living with his
sister in a neighboring town. He was unable to do any work that summer and spent
his time lying around home. When school opened in the fall, he returned to high school
and, except for mild spells of weakness, had no difficulty through the school year. Upon
returning to the ranch after school this spring, and attempting to work, he again became
weak.   Nervousness increased with his dislike for his work and scolding from his father.
Five days before entrance in the hospital after a tense situation, he experienced his
first spell, which he described in the following words: "I couldn't tell when I was getting
one of these spells. It seemed to begin with a slight headache—sort of dizziness. My
hands begin to tingle, so do my lips and around my eyes, and my feet. Both my hands
and feet draw back stiff and grow numb at the same time. My stomach starts to draw
up in a knot and the muscles get hard. Then my hands let loose all of a sudden and
start to tingle again. My stomach then lets loose gradually." Further questioning
revealed that the headache was occipital and that he did not lose consciousness, the
entire spell lasting but a few minutes.
Examination revealed a slender but well nourished boy of 17 years. Although he
appeared apprehensive and uneasy, he answered qustions promptly and intelligently.
Physical examination, including a careful neurological examination, was essentially negative, except for a rapid heart, cold, moist hands and feet, and hyperactive reflexes. Blood
pressure was S. 130, D. 70.
Laboratory tests: Urinalysis negative. Blood count: Hb. 17 grams. R.B.C. 5,150,000,
W.B.C. 10,500.  Differential normal.  Blood calcium 10 mgs.
Hyperventilation Test: Patient was instructed to breathe deeply and regularly. The
rhythm was inititaed by placing the hand of the examiner lightly on the epigastrium so
as to make respirations occur at the rate of about 18-20 Oper minute. Within two
minutes he complained of dizziness and a prickly sensation in his lips, hands and feet.
This was followed by numbness. Within three minutes a marked carpo-pedal spasm
appeared. The spasm was more severe, and remained longer in the right hand. Five
. minutes after stopping the test and starting the rebreathing in the sack, normal function
had returned to the hands. A striking feature was the cold, moist cyanotic hands and
feet that occurred during the test.
Following the test he complained of weakness and epigastric discomfort which had
resulted from the spasm of the abdominal muscles. The test was repeated several times,
always with the same result. Chvostek's and Trousseau's signs were negative before and
during the tests.
REFERENCES:
1.     Kerr, W. J., Dalton, J. W., and Gliebe, P. A.—Ann. Intern. Med., 11:961  1937.
- 2.     Sargent, W., and Fraser, R.—Brit. Med. J., 1:378, 193 8a.
3. Best, C. H., and Taylor, N. B.—Physiological Basis of Medical Practice: 1937: Wm. Wood & Co.:
pp. 1100-1107.
4. Soley, M. H., and Shock, N. W.—Amer. J. Med. Sci., 196:480, 1938.
Page 77 V
ancouver
G
enerai
Hospita
clinical applications of vitamin b complex
By J. G. Reid, M.D.
Senior Resident in Medicine, Vancouver General Hospital.
Vitamin B is of peculiar interest because this complex was the first to be recognized
as a nutritional factor and labelled as vitamin. Recent work has developed an almost
unbelievable complexity in the subject and investigation leads into an ever-deepening
maze of facts and hypotheses. Extensive papers have been written on small aspects of
the subject but, in a brief review of the whole complex, one is confined to superficial
details of a few components which have a clinical application.
The subject is discussed under the following headings:
(1) Method of diagnostic approach to vitamin deficiency.
(2) Individual components of B complex: (a) Parts; (b) Disease entitities with which
the parts are more or less accurately linked, and their diagnosis; (c) The question
of accuracy in drawing conclusions as to direct relationship between a vitamin and
a clinical picture, with an example of how a well accepted relationship has no
proven basis.
(3) Treatment, and sources.
1.    Method of Approach
Vitamins have made a tremendous impression on the laity and on the medical profession. The layman feels the truth of the saying that "a man is what he eats." The
medical profession has found a new and useful therapeutic weapon. It is of interest to
note that in 1938, in the United States, more than one hundred million dollars were
spent in vitamin preparations by the laity without doctors' prescriptions. In the same
year, twenty-five million dollars were spent additionally under the direct prescription of
physicians.
The administration of vitamins has been recommended in many conditions, but there
is support for their use only in those entities in which there is definite clinical evidence
of a deficiency. If this policy is disregarded the present enthusiasm will lead to disillusionment and bring discredit on the true value of nutritional therapy.
There are a few general principles in avitaminosis. Although deficiency states are
usually associated with patients in poor economic status, it must be remembered that
such states also exist not infrequently in the higher wage groups due to factors such as
(a) Poor choice in buying and eating foods.
(b) Excessive use of alcohol and restricted intake of food.
(c) Increased bodily demand for vitamins.
There are certain predisposing causes of which note should be made.
(1) Restricted or unbalanced diet: anorexia, food fads, excessive alcohol, special diets:
gastro-intestinal disturbances, diabetes, obesity.
(2) Defective absorption: edentula; achylia, pyloric stenosis, malignancy, chronic enteritis or steatorrhea, surgical short circuits, gall-bladder disease.
(3) Increased requirements: rapid growth (infancy), pregnancy and lactation, physical
labor, hyperthyroidism, prolonged fever.
(4) Defective utilization (liver disease).
The early changes in deficiency states are changes in biochemical function rather
than organic changes. When changes have become structural they are often permanent
(e.g., bony changes in rickets) and it is thus neessary to make early diagnoses, for which
purpose symptoms are obviously more important than signs which develop subsequent
to organic changes.
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It must also be remembered that a single dietary deficiency is very rarely encountered in medicine. The classic pictures of beri beri and pellagra are now known to be
multiple deficiencies.
It is recommended that a very careful history be taken, with special emphasis on
certain phases.
(1) Age and sex.
(2) Diet.
(3) Economic status which is a good indication of food buying.
(4) Family.
(5) Personal habits, including alcoholism.
(6) General health.
In the functional enquiry special emphasis should be laid on certain systems as, for
example, the muscle pain of thiamin deficiency; the night blindness of vitamin A deficiency; the cardiovascular changes of beri beri; the gastro-intestinal symptoms of
anorexia, sore tongue, constipation, and especially pyrosis, of pellagra; and the central
nervous system changes associated with nicotinic acid deficiency. This should be supplemented by a careful physical examination directed toward such complaints as noted
above. Special emphasis should be laid on examination of the skin with the hyperkeratoses of vitamin A deficiency, the pellagrinous dermatites and the cheilosis of riboflavin
deficiency in mind.
2.  (a)    Parts of Vitamin B Complex
The parts of the B complex are:
Bi—thiamin hydrochloride.
B2—nicotinic acid, riboflavin (concerned with oxidation—reduction system of cells
—Warburg's "yellow enzyme").
B3, B4, B5—associated with growth, weight maintenance and dermatoses in chicks,
pigeons and rats.
Bg—pyridoxin, associated with growth in rats.
Pantothenic acid—associated with anti-dermatitis in chicks.
A simplified schematic arrangement is:
B Water Soluble
Thermostable
Adenylic acid
Thermolabile
B3
B,
Thiamin hydrochloride
Non-adsorbable in Fuller's earth
Pantothenic acid
Adsorbable in Fuller's earth
J.l I
Pyridoxin Riboflavin       Nicotinic acid
Page 79 2. (b) Thiamin Hydrochloride: Thiamin hydrochloride is mainly associated with
beri beri, a disease which predominantly attacks the cardiovascular and peripheral nervous
systems. In the peripheral nervous system the changes are those of a symmetrical peripheral neuropathy with degeneration of muscles supplied by the affected nerves. The
changes of this type, which are found in excessive alcoholism, pellagra and in some
cases of pregnancy, are essentially identical with the changes in beri beri and are due
to the same causes. The changes in the cardovascular system are those of dilatation
of the heart, especially the right heart, speeded circulation time, high venous pressure,
prolonged electrical systole and "wet" beri beri cedema. However, we are more interested in the prodromal symptoms and an early diagnosis, in order to avoid the series of
changes as described above. Prodromal symptoms, in brief, are those of loss of weight,
strength, and appetite, vertigo, burning paresthesia:, nervousness, and, especially typical,
muscular pain and tenderness.
- Nicotinic Acid: Nicotinic acid is associated mainly with the clinical syndrome of
pellagra, a disease predominantly attacking the skin, the central nervous system, the
gastro-intestinal system and the blood. The skin shows such changes as stomatitis,
glossitis, and the peculiar, usually symmetrical erythematous dermatitis which is typically most marked on the exposed parts of the body, and may, by the uninitiated, in
the early stages be confused with sunburn. The change in the central nervous system
may be mania, conf usional states, and hallucinations. The gastro-intestinal symptoms may
be constipation, early, and later, diarrhea, and frequently nausea and anorexia. The blood
changes in a certain percentage of cases are those of a macrocytic anasmia. Again,
however, we are more interested in the prodromal symptoms and these are such that it
is very probable that in the past the diagnosis of psycho-neurosis has been made when
the true affection was a nutritional deficiency. To make the diagnosis of vitamin deficiency it must be emphasized again that organic disease must be ruled out and there
must be a suggestive history of inadequate food intake. The outstanding prodromal
finding in pellagra is hyperkeratosis. This may become manifest in the form of calluses
developing with inadequate stimulation, often over mild pressure points, wrinkled scaly
skin over the insteps and knees, thickening and whitening of the skin of the fingers, a
lacquer change of the skin on the shins with an overlaid cracked mosaic appearance.
Early changes in the" tongue may be swelling and reddening at the tip and edges, and
there may often be a thick coat in the mid portion. Other symtoms are nervousness
and easy fatiguability, cephalalgias, parasthesia, pytalism, constipation, anaemia, and, of
special interest, pyrosis, often taking the form of a continued epigastric burning unasso-
ciated with food intake.
- Riboflavin: Riboflavin deficiency has lately been shown to be associated specifically
with macerated excoriation at the angles of the mouth, formerly called angular stomatitis,
greasy seborrhcea, often on an erythematous base, in the naso-libial folds, a thickening
of the skin of the nose, the so-called "shark-skin" nose, and redness and denuding of the
mucous membrane of the lips, designated as cheilosis. Further attributed to riboflavin
deficiency are certain affections of the eyes such as conjunctivitis and keratitis.
Riboflavin: Riboflavin deficiency has lately been shown to be associated specifically
tional states in which the other vitamins have been administered without total relief of
such symptoms as easy fatiguability, the addition of pyridoxin has corrected these
symptoms. It also appears to be of value in the relief of muscular rigidity. For these
reasons investigation is progressing on its use in such diseases as Parkinsonism and
myasthenia gravis.
Pantothenic Acid: Pantothenic acid has also been inadequately investigated but it has
been shon to have a twenty-five to fifty per cent (25%-50%) decrease in its normal
blood level in deficiency states such  as pellagra  and beri beri  and the intravenous
administration of pantothenic acid in these states has given rise to an increased blood
level not only in pantothenic acid but also in riboflavin for a period of a few hours.
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2. (c) In passing it is of interest to note that thiamin hydrochloride, which has
long and widely been accepted as the anti-neuritic vitamin by well informed authorities,
has recently been shown to have no proven basis for this claim. It is of interest to
quote the comments of certain authorities:
"The most constant and striking symptoms of a vitamin Bi deficiency arise from
degeneration in the nervous system."—Williams and Spies.
"Beri beri involves a peripheral atrophy,  a so-called polyneuritis,  and can be
cured and prevented by vitamin Bi."—Harris.
If true polyneuritis of nutritional origin is due to deficiency in vitamin Bi it should
require the administration of thiamin alone for its cure. This idea has arisen in the following manner: At the beginning of investigation of the vitamin B complex, Eijkman
noted that Javanese prisoners fed polished rice developed the symptom* of beri beri and
on feeding a similar diet of polished rice to fowls he noted that they developed opisthotonos and inco-ordination with true anatomical changes in their peripheral nerves. It
must be noted that this was due to deficiency of the whole B complex. However, following these experiments it became the habit to take the sign of opisthotonos as an index
of a true anatomical peripheral neuritis. When the B complex was divided into some of
its various factors it was shown that vitamin Bi complex deficiency caused opisthotonos
in fowls but it was never shown that true peripheral neuritis was associated with this.
It is further obvious that the opisthotonos and inco-ordination were not due to true
peripheral anatomical nerve changes because of the acute onset with the disappearance in
a few hours of the symptoms after the injection of thiamin hydrochloride which would
have been impossible had there been true anatomical changes in the peripheral nerves.
It is further shown by Peters that the opisthotonos was due to an excessive accumulation
of pyruvic acid in the muscles, that is, that the changes were those of a biochemical
functional nature and not of an organic nerve lesion. It has been shown that prolonged
deficiency of thiamin is associated with true peripheral nerve degeneration but in these
cases the invariable development of anorexia, nausea, and, usually, vomiting gives rise
to the possibility that other vitamins are being absorbed improperly. It has further been
shown that true anatomical peripheral nerve degeneration occurs in other deficiency
states such as that of vitamin A deficiency and deficiency of the B2 complex. It must
be noted that vitamin Bi in the literature previous to 1936' did not mean thiamin hydrochloride and quotations of observations in that period in support of thiamin as an antineuritic vitamin are not applicable. More recently workers on thiamin in various
nervous diseases and peripheral neuritis have based their claims for its effect on the relief
of symptoms rather than signs of peripheral nerve degeneration. The symptoms relieved
by thiamin are pain, muscular weakness and inability to walk, but thiamin has also been
shown to relieve certain cases of intermittent claudication, perhaps due to an excessive
accumulation of pyruvic acid in the muscles following an upset in carbohydrate metabolism and this may be caused not only by defective intake of thiamin but also perhaps
by defective administration of thiamin to the muscles due to poor circulation. The
relief of these symptoms is not diagnostic of the relief of peripheral neuritis and is
usually much too rapid to be associated with recovery of anatomical nerve changes. It
is felt that thiamin acts either on the acetylcholine liberated at the nerve-muscle junction
or on cholinesterase. One would not expect thiamin to act on the peripheral lesions seen
in diabetes mellitus as the "biochemical lesion" in this disease occurs at a different site
in the cycle of carbohydrate metabolism. The polyneuritides associated with excessive
alcoholism, some cases of pregnancy, and gastro-intestinal disturbances, are nutritional
and are essentially identical with those in beri beri but are not proved to be due to
thiamin alone. Therefore, in the treatment of these cases, the whole B complex should
be administered in large doses.
3.    Treatment and Sources
In treatment of nutritional deficiency it must be emphasized that the basis is not the
use of the expensive synthetic products but rather the use of constituents containing
Page 81 the whole B complex. Clinical syndromes are the result of multiple deficiencies although
various prominent features may respond to one particular component of the B complex
when this deficiency is predominant. Moreover, the full crude complex is advantageous
not only from the standpoint of cost but because it probably contains X-factors not
present in purified synthetics and it further contains minerals and salts of nutritional
value.
Thus, in treatment of nutritional deficiency B one should use brewer's yeast (75-100
grams daily being an adequate dosage). If patients object to its taste it can be palatably
combined with ketchup or peanut butter. Other satisfactory sources are crude liver
extract (75-100 grams daily) or wheat germ (150 grams daily). These should be
supplemented by a diet consistently high in vitamins and protein, as deficiencies other
than B complex are probably co-existent.
Of food sources there are many containing vitamin B, but no one which is so rich
in content that if included in the diet it will meet the whole requirement. The best
sources are germ portions and outer layers of seeds, legumes, nuts, and whole grain, eggs,
lean meats and organ meats. Vegetables are a moderately good source, and fruits,
although originally less rich, are often eaten raw and may therefore be of value. It
must be remembered that Bi is thermolabile and that cooking, especially in water which
is thrown away (for example, vegetables)  may reduce the vitamin content materially.
Synthetics should be reserved for use in conjunction with the above to treat outstanding clinical pictures.
In the cardiovascular changes of beri beri, thiamin may be administered (10-50
milligrams daily, intravenously or orally); in pellagra, nicotinic acid (200-500 milligrams daily, orally, in divided doses to reduce flushing). It is of interest that nicotinic
acid amide is of equal effect in treatment and gives no peripheral vasodilatation. In
cheilosis, riboflavin may be given (5-10 milligrams daily, orally or intravenously in
normal saline, preferably orally as riboflavin is rather insoluble in normal saline). Pyridoxin (50 milligrams daily) has been used for muscular rigidity.
There is no doubt that mild nutritional deficiencies are widespread in our country.
In the United States it is estimated that thirty-two per cent (32%) of the families or
individuals earn less than seven hundred and fifty dollars ($750.00)  per year, which is
not considered enough to buy adequate diet.   Finally, it must be emphasized that in the
treatment of nutritional deficiencies one should use the crude complex supplemented
by a high vitamin and high protein diet with the occasional use of specific synthetics to
treat predominant or outstanding clinical symptoms.    It should be noted further that
when the deficiency has been corrected the patient should be directed by his physician
not to the pharmacist but to the grocer with some good advice as to the correct spending
of the money devoted to food in order that he will be permanently free of nutritional
deficiencies.
REFERENCES:
Meiklejohn, A. P.—The Vitamins.   New Eng. Jour of Med., Vol. 222, No. 8.
Meiklejohn, A. P.—Is Thiamin the Anti-Neuritic Vitamin? New Eng. Jour, of Med., Vol. 223, No. 8.
Meiklejohn, A. P.—Diagnosis and Treatment of Nutritional Deficiency.   New Eng. Jour of Med., Vol. 222,
No.  18.
Field, H., Parnall,  C, and Robinson, W.  D.—Pellagra in Average  Population of the Northern  States.
New Eng. Jour, of Med., Vol. 223, No. 9.
Shields, W. P.—Riboflavin Deficiency.   New Eng. Jour, of Med., Vol. 223, No. 6.
Spies, T. D., and Bean, W. B.—Vitamin Deficiency in Diarrhceal States.   Jour. Amer. Med. Assoc, Vol.
115, No. 13.
Spies, T, D., Ladisch, R. K., and Bean, W. B.—Vitamin B6   (Pyridoxin)   Deficiency in Human Beings.
Jour. Amer Med. Assoc, Vol. 115, No. 10.
Spies, T. D., Hightower, D. P., and Hubbard, L. H.—Some Recent Advances in Vitamin Therapy.   Jour.
Amer. Med. Assn., Vol. 115, No. 4.
Spies, T. D., Stanbery, S. R., Williams, R. J., Jukes, T. H., and Babcock, S. H.—Pantothenic Acid in
Human Nutrition.—Jour. Amer. Med. Assoc, Vol. 115, No. 7.
Weiss, Soma—Occidental Beri Beri with Cardiovascular Manifestations.   Jour. Amer. Med. Assoc, Vol.
115, No. 10.
Sebrell, W. H.—Nutritional Disease in the United States.   Jour. Amer. Med. Assoc, Vol. 115, No. 10.
Page 82
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GREATER VANCOUVER HEALTH LEAGUE
Last year at this time the Greater Vancouver Health League conducted a survey of
the prevalence of venereal disease infections in Vancouver and the results of the survey
were published in the Bulletin. It was gratifying at that time to receive completed
forms from 96 per cent of the practicing doctors in Vancouver. This year a similar
survey, designed to ascertain the number of cases under treatment or observation on
December 31st is planned in order that the results may be compared with those of last
year. Every doctor will shortly receive a form and a self-addressed envelope, and the
co-operation of all members of the profession in returning these as soon as possible is
earnestly desired.
On January 27th Dr. Walter Clarke of New York, Director of the American Social
Hygiene Association, will visit Vancouver for one day. The Greater Vancouver Health
League will arrange a dinner meeting in one of the hotels in his honour. Since there will
be no opportunity for Dr. Clarke to address the profession as a body, an invitation is
extended to all doctors to attend the dinner meeting.
MY OLD MAN ON DOCTORS
By Damon Runyon
My old man used to say that he guessed the percentage of scoundrels was less among
doctors than any other class of men, professional or otherwise, in the world. He said that
in his whole life he had never encountered more than two or three doctors who were
out-and-out bad 'uns.
My old man said that whenever his faith in humanity commenced to falter, he just
contemplated the character and works of the doctors he knew and that bolstered him
up right away. He said that whenever he passed certain doctors in our old home town
of Pueblo, he felt like taking off his hat as a mark of respect to them, only that action
would have embarrassed the doctors.
My old man said people took doctors too much for granted. He said if a fellow
jumped into a river and, at no great risk to himself, rescued a drowning man or woman,
the papers made a big noise about the incident and pronounced the rescuer a hero.
Maybe he even got a medal or some other token of his bravery, but my old man said
the very same day some doctor might save the lives of half a dozen people by his skill
and devotion, and you never heard of the matter.
My old man said you might read stories in the papers every day over quite a period
about the fight some prominent man or woman was making for life against illness, and
about how, eventually, they won out, but he said you never read anything about some
doctor's part in that battle. He said you never read how the doctor sat there day and
night struggling for the patient's life even when the task seemed hopeless.
He said you would think from what the papers said that the patient's own fortitude
was responsible for defeating death rather than the skill of the doctor. He said a lot of
patients generally thought pretty much the same way after they got well, especially
when the doctor's bill came in.
My old man said it was astonishing how little credit a patient whose life had been
saved was willing to give the doctor after he got the bill. He said any person at death's
door would always be glad to give all they possessed to live a while longer, even though
their possessions amounted to millions, but after some doctor pulled them back from the
dark abyss and they got to walking around again, they were not willing to pay even a
minute percentage of their holdings.
My old man said he never could understand why most people seemed to feel that
the doctor's bill was the very last they were obliged to pay. He said his own life had
been saved several times by doctors and that he always paid the doctor first and let the
other debts incurred during his illness wait. He said he figured that had the doctor not
saved him and put him in action again, the others would never have been paid anyway.
Page 83 My old man said he knew fellows there in our old home town of Pueblo who always
kept their doctor waiting for months and even years for his money, while in the meantime they lived high themselves and entertained and wore good clothes. He said that
these fellows, even while indebted to the doctor, had no compunctions of conscience
about calling him again in case of illness.
He said the amazing thing was he had never known a doctor who would not always
respond to a call, even when he knew he was not going to get paid. My old man said
everybody always seemed surprised when a doctor died, but he guessed nobody figured
that maybe his health might have been undermined by getting out of bed at all hours
of the night in all kinds of weather and losing sleep in long vigils at desperate bedsides.
He said he guessed that nobody figured that the strain on a doctor's nerves and mind,
as well as on his body, might affect him the same as it would other mortals. He said
that it was constantly a wonder to him that doctors lived as long as they did when you
considered the work they had to do.
My old man said he had known doctors who should have been in hospital beds themselves to get up and go out in snowstorms on calls that they knew woould not yield a
dime for their services, and might indeed be a personal expense to them for medicines,
or fuel, Or even food.
He said it was rarely you heard of a doctor demanding that a patient in physical
stress lay a little something on the line in advance. He said that was why he always
cheered when he heard of some man of means handing over a right royal fee to a doctor
in gratitude for services rendered.  He said whatever a doctor got it was seldom enough.
My old man said a doctor's patients expected him to dress neatly, to have a neat
office and nice tools and to be of tranquil, reassuring mood and manner and of steady,
gentle hand. But he said how in the dickens could he have those things and be that way
if the patients did not pay their bills and the doctor had to always be worrying about
his own debts?
He said doctors should have peace of mind more than any other persons in this
world to properly discharge their functions, and he thought there ought to be some kind
of law to make this possible.
GRAVITY CURVES AND THE ANTI-GRAVITY JACKET
Gerald L. Burke, M.D.
Presented by request before the meeting of the Clinical Section.
The correction of antero-posterior curves of the spine has been regarded, during all
past ages, as a practically hopeless proposition. Treatment by exercises, long periods of
recumbency on Bradford or Whitman frames, with or without head and leg traction,
followed by the usual type of plaster cast or a back brace, presents a dismal end-result
spectacle.
Through the medium of two cases of vertebral epiphysitis, a common and determined
producer of antero-posterior curves, I am going to introduce you, in a ten-minute discussion, to an important achievement of a distinguished orthopaedic surgeon. This work
has not yet been published but nevertheless it has become quite widely known in orthopaedic circles in the United States.
The term "vertebral epiphysitis" has been applied to a chronic affection of the epiphyses of the vertebral bodies characterized clinically by fatigue and pain in the back,
by stiffness and tenderness in the spine, and by a gradually increasing kyphosis. The
process involves a number of contiguous vertebrae and is usually most marked in the
dorsal spine. The condition may progress to the point of extreme disability or it may
cause very few symptoms.
Page 84 mi
The diagnosis is easily confirmed by X-ray which shows:—
1. Wedging of the vertebral bodies.
2. Persistence of the vascular groove, a horizontal cleft in the vertebral body which
should normally disappear at the fifth or sixth year of fife.
3. Irregularity of the upper and lower surfaces of the vertebral bodies, particularly
at the anterior margins.
4. Irregularity in the calcification of the epiphyses giving the appearance of fragmentation.
5. Areas of decreased density in the vertebral bodies called Schmorl's islands.
Side view.
Back view.
THE ANTI-GRAVITY JACKET.
M
j*i
\m
Other laboratory findings are negative, except for a constant mild hypothyroidism
with a B.M.R. ranging from low normal down to —20 and only rarely lower than —20.
So thyroid is administered more or less empirically. Vertebral epiphysitis is now regarded
as one of the family of aseptic bone necroses with which a mild hypothyroidism is associated, such as apophysitis of the tibial tuberosity; Perthe's aseptic necrosis of the upper
femoral epiphysis; and possibly also Kienbock's disease of the carpal lunate, Preiser's
disease of the carpal navicular, and Kohler's disease of the tarsal navicular.
The treatment of vertebral epiphysitis has, as we have hinted, been notoriously unsatisfactory. The deformity is not reduced by months on a Bradford frame, which is a
miserable sentence for a child, and one that should be avoided if it is possible to do so.
The usual body cast, or a back brace, is merely a gesture. A recent survey has shown
that the standard text-book treatment leaves one out of four patients with interscapular
or low back pain on exertion for the rest of their natural lives.
Page 85 The successful treatment, and it is a highly successful treatment, is the Risser
"anti-gravity" jacket. Dr. J. C. Risser of Los Angeles is a name well known to the
orthopaedic surgeons present.) This jacket has been applied in three cases at St. Paul's
Hospital, nineteen cases at the Crippled Children's Hospital in Vancouver and over two
thousand cases at the Los Angeles Orthopaedic Hospital.
The jacket is based on the principle that the spine should be straight not only in the
lateral plane but also in the antero-posterior plane, that the physiological curves are
certainly curves but that they are equally certainly not physiological. A brief consideration of the "physiological curves" indicates that they are anything but desirable, from
the point of view of function, good health, or good looks.
A cervical lordosis throws the weight of the head off balance. Any degree of
thoracic kyphosis will produce a corresponding degree of flattening of the chest. Any
degree of lumbar lordosis will produce a corresponding degree of pot belly. If the spine
is straight the head will be balanced, the chest elevated and the abdomn retracted. . The
stagnant pool of blood and tissue fluids lying in the pendulous abdomen will be forced
to move on by virtue of deeper breathing and increased intra-abdominal pressure. I do
not need to remind you that the venous system of the trunk is designed to function in
the horizontal position and is without benefit of valves.
The illogically named physiological curves are in reality the result of inherited soft
tissue contractures, aided and abetted in producing deformity by growth, and by gravity.
Hence the terms "gravity curves" and "anti-gravity jacket."
Consider that respected primeval ancestor of ours, who first crawled out of the
primordial ooze upon dry land. He crawled out with a flat back. As he evolved his
eyes moved medially from the sides of his head to the front so he raised his head and
developed a cervical lordosis, a tendency to which we inherit. After aeons, when man
began to stand up on his hind legs, he inherited the short hip flexors of the quadruped,
and the semiquadruped, such as the ape. His flexion contractures in the upright position
necessitate a lumbar lordosis unless the knees are maintained in a semi-flexed position.
The anti-gravity jacket straightens these curves, in fact it slightly reverses them.
The jacket is applied in two stages. First with the lumbar spine flexed, second with the
thoracic spine extended over the apex of the kyphosis. The method of application is
easier to demonstrate than to describe. A few days after application of the jacket the
pain, in even the most severe cases of vertebral epiphysitis disappears permanently and
completely. A few months later the wedged vertebral bodies are fully filled out. While
the spine is still growing all cases can be straightened. After growth has ceased only
one case in one hundred can be materially improved.
Children adjust themselves to the jackets overnight and continue with all their usual
activities. In fact the smaller children often object to having them removed. The
improvement in the general health of these children is striking. They put on weight,
their colour improves, they sleep better.    So much for the "physiological curves."
Besides being used in the treatment of antero-posterior curves of the spine in children,
the anti-gravity jacket is also used after spinal fusion; as a comfortable immobilization
in fractures of the dorsal and lumbar spine; and in certain cases of low back pain.
The first patient I have to show you this evening had only moderate gravity curves
but she had severe pain in the dorsal region for about one and a half years. She was
unable to go to school or do anything else. A few days after application of the jacket
the pain disappeared.    She has returned to school and resumed all her normal activities.
The second child had severe gravity curves but no pain. She was, however, a frail
and delicate child. She has put on so much weight in the four months of her enforced
anti-gravity posture that her cast has had to be changed three times.
Page 86
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