History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1948 Vancouver Medical Association Feb 29, 1948

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Full Text

 THE
BULLETIN
Published By
The Vancouver Medical Association
EDITOR:
DR. J. H. MacDERMOT
EDITORIAL BOARD
DR. D. E. H. CLEVELAND DR. J. H. B. GRANT
DR. H. A. DesBRISAY DR> D. A< STEELE
Editorial and Business Office
203 MEDICAL-DENTAL BUILDING Publisher and Advertising Manager
VANCOUVER, B. C. W. E. G. MACDONALD
W.XXIV
FEBRUARY, 1948
OFFICERS, 1947-48
Db. 6. A. Davidson Db. Gobdon G. Johnston Db. H. A. DesBbisay
President Vice-President Past President
Db. Gobdon Burke Db. W. J. Dobbance
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Db. Roy Htjggabd, Db. Henby Scott
TRUSTEES
Dr. A. M. Agnew Db. G. H. Glement Db. A. C. Fbost
Auditors: Messbs. Plommeb, Whiting & Co.
SECTIONS
Clinical Section
Db. Reg. Wilson Chairman Db. E. B. Tbowbbidge Secretary
Eye, Ear, Nose and Throat Section
Db. Gobdon Large Chairman Dr. G. H. Francis Secretary
Paediatric Section
Db. J. H. B. Grant Chairman Db. E. S. James Secretary
Orthopaedic and Traumatic Surgery Section
Db. J. R. Naden I Chairman Db. Clabence Ryan Secretary
Neurology and Psychiatry
Db. J. C. Thomas Chairman Dr. A. E. Davidson Secretary
STANDING COMMITTEES
Library:
Db. J. E. Walker, Chairman; Dr. W. J. Dorrance, Dr. D. E. H. Cleveland,
Db. P. S Hobbs, Db. R .P. Kinman, Db. S. E. C. Tubvey.
Publications:
Db. J. H. MacDebmot—Chairman; Db. D. E. H. Cleveland, Db. H. A.
DesBbisay, Db. J. H. B. Gbant, Db. D. A. Steele. SUBSTITUTE
~&t< S&ttfuottt-ffiee' 'ffiefc
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Patients will faithfully adj^&^s5
salt (sodium)-f3^e%3dl£^^
NEOCURTAS^^^^^^
This' salt subifi^i^^^p^'
tastes and- lookiitij^|$6b
salt but contain^ |pJ%o<^tlfd.
Available in^^p^^l.
shakers c^^^^|s^|
bottlapmp^fefi»|i;
N EO C U RTASAL
■ WtMTHROP-STtMUIS
WMA SODIUM-FREE SEASONING A6#if
^J&aM^
INC*
New York 13, N. Y.    Windsor, Omi
The businesses formerly conducted by Winthrop Chemicot/C-omptmyi t£sm
and Frederick Stearns & Company ore now owned by Wplhrop-SSgimj
1019 Elliott Street, West, Windsor. Ont.
423 Ontario Street, East, Montreal, P VANCOUVER MEDICAL ASSOCIATION
Founded 1898    :    Incorporated 1906.
Programme for Fiftieth Annual Session
(Spring Session)
''. v'.i'J:«
ebruary 17th    CLINICAL MEETING—St. Paul's Hospital, Nurses' Auditorium.
karch    5th (Friday)    OSLER DINNER AND LECTURE—Hotel Vancouver, Ban-
quet Room.
Osier Lecturer—Dr. Murray Blair.
liarch 16th        CLINICAL MEETING—Children's Hospital.
Ipril    6th GENERAL MEETING—Auditorium, Medical-Dental Building.
Speaker—to be announced.
kpril 20th CLINICAL MEETING—Place of meeting to be announced.
■vfay    4 th
ANNUAL MEETING—Auditorium, Medical-Dental Building.
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian
circulation and thereby encourages a
normal menstrual cycle.
• MARTIN H. SMITH COMPANY
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam.
■;■ *
■'•'•;. .
if:
y.' .v.
..-I- -V. : -.-
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Page 142 successful active type-specifiA
immunization against
pneumococcal pneumonia
"The evidence... demonstrates dearly that immunization of man with the specific capsular polysac-j
charides of pneumococcus types I, II, V, and VII is
effective in preventing the development of pneumonia due to these types in the immunized subjects."
MacLeod, CM.; Hodges, R. G.; Heidel berger, M., and J
Bernhard, W. G.; J. Exp. Med. 82/445 (Dec. 1) 1945.|
In the above mentioned investigation on 17,035 subjects with a preparation
made by Squibb, pneumonia of the types represented in the vaccine was entirely eliminated in the immunized group (8,586), excepting for four cases j
which developed before specific immunity had been established. And in the
non-immunized group of 8,449 controls, all of whom were closely asso- j
ciated with the immunized group, the incidence of these types of pneu-;
monia was greatly lowered through the reduction of "carriers." Reactions j
were mild. The slight arm soreness reported by those injected lasted
only 3 to 4 days.
Solution of PNEUMOCOCCUS
POLYSACCHARIDES Type-specific |
supplied in two combinations of types to which adults and children,
respectively, are generally most susceptible.
Containing types 1, 2, 3. 5, 7 and 8. (Primarily for adults)
Containing types 1,4,6,14,18 and 19. (Primarily for children)
A single subcutaneous injection of 1 cc. for adults, or children
over 12 years of age; 0.5 cc. for children under that age. Immunity usually develops within 6 to 9 days and is effective for
at least one year.
available:   Each combination supplied in 1 cc. and 5 cc. rubber-stoppered
vials.
Professional leaflet, "Active Immunization Against
Pneumococcal Pneumonia" is available upon request.
Far Literature unite
E. R. SQUIBB & SONS CANADA LIMITED
36-48 CALEDONIA ROAD • TORONTO
MANUFACTURING  CHEMISTS TO THE  MEDICAL PROFESSION SINCE   1858
28-^A VANCOUVER HEALTH DEPARTMENT
lSES OF COMMUNICABLE DISEASE REPORTED IN THE
CITY
STATISTICS—DECEMBER,  1947
Total  Population—Estimated 11 1  339,350
Chinese                               "         l  5,980
Hindu          "                   "        ^  118
Number    Kate Per 1,000 Population
Total  deaths z 409 13.9
Chinese  deaths 22 43.3
Deaths,   residents  onlyy 378 13.8
BIRTH REGISTRATIONS
Male 407
Female 377
784 27.2
INFANT MORTALITY December,  1947 December,  1946
Deaths under 1 year of age 15 21
Death rate per  1,000  live birth 25.5 25.5
Stillbirths   (not  included  above)       7 6
CASES OF COMMUNICABLE DISEASE REPORTED  IN THE CITY
Number    Rate Per 1,000 Population
December, 1947 January, 1948
JIR Cases        Deaths Cases        Deaths
arlet Fever  12
phtheria  1
phtheria   Carrier _:  0
licken Pox  36
easles  (,\
ubella \ 7
tumps  27
'hooping Cough  8
yphoid   Fever  0
ndulant Fever  2
pliomyelitis  0
tuberculosis !  54
rysipelas .  5
eningococcus    (Meningitis)  1
lfectious   Jaundice  0
ilmonellosis  1
ilmonellosis     (Carrier)  0
pysentery  0
•ysentery    (Carriers)   0
etanus  0
vphilis  61
fonorrhcea  209
lancer— (Reportable)
Resident   97
Non-Resident   44
0
0
0
0
0
0
0
0
1
0
0
13
0
1
0
0
0
1
0
0
4
0
0
0
18
4
1
71
157
7
30
10
0
0
0
33
1
2
0
3
0
0
0
0
0
0
92
18
Page 143 CRYSTALLINE   PENICILLIN
X
PHOTOMICROGRAPH
OF PENICILLIN  CRYSTALS
It has been widely established that Penicilln G is a highly effectivi
therapeutic agent.   The crystalline form of Penicillin G prepared an<
supplied by the Connaught Medical iH^&
Research Laboratories is highly puri- \
fied.    Because of this high degree of \\ |
purity, pain on injection is seldom
reported   and   local   reactions   are
reduced to a minimum.  Crystalline
Penicillin G is heat-stable, and in the
dried form can be safely stored at
room temperature for at least three
years.
HOW SUPPLIED
CRYSTALLINE PENICILLIN  G IN VIALS
Highly purified Crystalline Potassium Penicillin G is supplied by the Laboratories in sealed rubber
stoppered   vials   of   100,000,   200,000,   300,000   and   500,000   International   Units.    No   refrigeration  i
required.
CRYSTALLINE PENICILLIN G IN OIL AND WAX (ROMANSKY FORMULA)
A heat-stable and conveniently administered form of Crystalline Sodium Penicillin G in peanut oi
and beeswax is available in 1-cc. cartridges for use with B-D* disposable plastic syringes, or as replace
merits with B-D* metal cartridge syringes. Each 1-cc. cartridge contains 300,000 International Units o
Crystalline Sodium Penicillin G.
Liquid, free-flowing Penicillin in Oil and Wax, prepared from Crystalline Potassium Penicillin G
is also supplied in 10-cc. vials each containing 3,000,000 International Units. No refrigeration o
pre-warming is required.
* T.M.  Reg.  Becton, Dickinson & Co.
CRYSTALLINE PENICILLIN G IN TABLETS FOR ORAL USE
Buffered tablets of Crystalline Sodium Penicillin G are distributed by the Laboratories in tubes oi
12. Two strengths are supplied, 50,000 and 100,000 International Units per tablet. No refrigeration U
required.
CONNAUGHT MEDICAL RESEARCH LABORATORIES
||j University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. r
Ike. ZdUvihi Paye.
Vs another session of the Provincial Legislature approaches, the perennial demand
I-Iealth Insurance is being again heard in the land. Quite understandably, the most
1 element is to be found among the ranks of Labour, and those of the community
se incomes are on the lower levels—and with the costs of hospitalisation as they
and with a constantly rising index of prices in every department of life, one cannot
sympathise with those who feel that things are rapidly coming to the breaking
at. Our new Premier, Mr. Byron Johnson, is evidently deeply concerned over this
ter, and he is reported to have stated that his government is proposing to look into
matter of hospitalisation. It is not clear, from the published reports* whether or not
5 thinking of going any further at the present time, or whether this is to be regarded
he first step in a wider scheme, to be completed in stages.
From time to time, in the discussions which have been held within the ranks of the
Lical profession on this matter, it has been suggested that Health Insurance, to which
[n organized body we have given our approval, should be arrived at by a series of
>s, and not as an entity complete from the beginning. Some of our wisest leaders
e urged that it is too big a thing to tackle all at once, and that we should make what
nges must be made, gradually and with due attention to the giving of relief from
present strain, by deciding where the need for relief is the greatest. It can hardly be
osaid that at the present time, the cost of hospitalisation is the heaviest burden on the
L Not only is the cost of hospital care becoming prohibitive, but the drastic shortage
hospital accommodation is rapidly reaching the danger point. We think that Premier
nson is to be commended in that he has grasped this point, and is going to do some-
rig about it.
If this step could be successfully taken, we feel that a great deal will have been done.
W scheme of the sort will in all probability entail a considerable deal of new hospital
lding—since any plan which provides free hospital care will undoubtedly lead to
lefinite increase in the number of hospital patients. This does not at all imply that
pre will be any abuse of the scheme—there would be a great many more anyway, if
those who should have hospital care but cannot now afford it, or cannot get beds to
:upy, were able to obtain it.
j What the next step should be is a matter for very careful consideration. Certainly
p last step should be the provision by any means whatever of free medical care, and
hen we say "free," we include prepaid medical care of any kind. The burning desire of
pie of those who are demanding Health Insurance most loudly, is just this — free
:dical care. And not yet, to our knowledge, has any governmental body been willing to
[y a fair figure for medical care. The figures quoted from Saskatchewan, for instance,
pnot possibly provide even fairly good service. And our experience in British Columbia
jve shown us that unless there is to be a complete change of attitude on the part of
k planners of a Health Insurance scheme, we shall have to be on our guard against
[e introduction of a cheap plan which will not provide the service that should be
ailable. For medical service is a commodity like anything else that one has to buy,
id has its unit costs—so much service, so much cost. These unit costs are pretty well
|iown by now, and are available to anyone who wants to find out the facts. We cannot,
"en if we wanted to, resist the ever increasing demand for a plan whereby everyone in
lie community can be assured of proper medical care when he needs it—but we can and
lust insist on certain things. The first is, that the scheme adopted must provide real
[id adequate medical care, and not merely a sham. The second is, that it must include
ll those who need it, and not merely those who can afford to pay for it.   The third is
bat it must be tied up with a real and adequate scheme of preventive medicine, which
lone will give real relief to the community from the cost of sickness, by lessening its
Page 144
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incidence. There are other considerations, but the last one, and one that is natural
of great importance to us, is that payment must be adequate for the work done, al
must be in accord with present-day conditions of medical work—whether payment!
made by panel, or according to a scale of fees or otherwise. We must not be asked
provide out of our own pocket half the cost of the scheme, as was done before.
During the controversy we had some years ago, we were asked, on more than oJ
occasion, to give the Health Insurance Plan, to which we objected, a trial. It was suj
gested that we might try it for a year or so, and if it didn't work, we could cor]
back and ask to have it modified. There was absolutely no support for this on our sidj
and indeed we have only to look at Great Britain to see how fatal such a course woul
have been. Our sympathies must surely be with our colleagues in that unfortunal
country, and we must all hope that they will be able to find a way out of their vei
difficult and unsatisfactory situation.
LIBRARY NOTES
RECENT ACCESSIONS—
The Clinical Examination of the Nervous System, 1947, 8th ed., by G. i%. Monrad
Krohn.
Transactions of the Association of American Physicians, 1947.
Medical Clinics of North America, Symposium on Endocrinology, Chicago Numbei
January, 1948.
Annals of the Barber-Surgeons, 1890.    (Gift of Dr. William T. Barrett.)
IMPROVEMENTS IN LIBRARY
Rearrangement of Books.
A complete rearrangement of the books and bound journals in the Stack Room hai
been completed recently, and it is hoped that it will prove to be more satisfactory tluuj
heretofore.
All text-books and monographs have been brought forward to the front shelves)
where they will be more accessible. They are, of course, still arranged according to th<
Boston Medical Library classification. New signs will be set up as guides in locating th<
various subjects.
The bound journals are now arranged in alphabetical order by title, and the unbounij
journals are also in alphabetical order by title, on the back shelf.
Lighting
A special type of flood lamp is to be installed in the stack rooms. These provide
much better lighting and show up the lower shelves to advantage.
Two new floor lamps, of the tri-lite variety will be placed in the Reading Room, as it
was felt that addiional light was needed there, as well.
Page 145 j ANNOUNCEMENT—LIMITATION OF BOOK LOANS
The Library Committee wishes to announce that because of greatly increased demands
for book loans, a list of books to be designated as "Standard Texts," will be restricted
to a twenty-four hour loan period, with the privilege of renewal for a further twenty-
four hours if there have been no prior requests. Following is a list of books to be so
restricted:
MEDICINE
BECKMAN—Treatment in General Practice.
BOCKUS—Gastro-enterology.
CECIL—Textbook of Medicine.
CHRISTIAN'S—Osier's Principles and Practice of Medicine.
COMROE—Arthritis and Allied Conditions.
CUSHNEY'S—Pharmacology and Therapeutics.
DUNCAN—Diseases of Metabolism.
JOSLIN—Diabetes Mellitus.
KRACKE—Diseases of the Blood.
LEVINE—Clinical Heart Disease.
TAYLOR'S—Medical Jurisprudence.
WINTROBE—Clinical Haematology.
DERMATOLOGY
SUTTON & SUTTON—Textbook of Dermatology.
NEUROLOGY n PSYCHIATRY
BRAIN—Diseases of the Nervous System.
HENDERSON & GILLESPIE—A textbook of Psychiatry.
KINNEAR WILSON—Neurology.
WECHSLER—Textbook of Clinical Neurology.
ANATOMY, PHYSIOLOGY, PATHOLOGY
BEST & TAYLOR'S—Physiological Basis of Medical Practice.
BOYD'S—Pathology  of   Internal  Diseases.
BOYD'S—Surgical Pathology.
CUNNINGHAM'S—Text-Book of Anatomy.
GRAY'S—Text-Book of Anatomy.
LABORATORY DIAGNOSIS, ETC.
KOLMER'S—Clinical Diagnosis by Laboratory Examination.
TODD & SANFORD—Clinical Diagnosis by Laboratory Methods.
SURGERY
CALLENDAR—Surgical Anatomy.
CHRISTOPHER—Textbook of Surgery.
THOREK—Surgical Technique.
WATSON-JONES—Fractures and Joint Injuries.
EYE, EAR, NOSE & THROAT
ADLER'S—Gitford's Textbook of Ophthalmology.
BALLENGER'S—Diseases of the Nose, Throat & Ear.
DUKE-ELDER'S—Textbook of Ophthalmology.
WILMER'S—Atlas Fundus Oculi.
OBSTETRICS & GYNECOLOGY
CROSSEN & CROSSEN—Diseases of Women.
CROSSEN & CROSSEN—Operative Gynecology.
CURTIS—Obstetrics and Gynecology (3 volumes).
BERKLEY & BONNEY—Gynecological Surgery.
DE LEE—Practice of Obstetrics.
Page 146
:* ■■'
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Ik-,CT*?t«
mm
117* ft  •**** ;  ,
S&gi NOVAK—Textbook of Gynecology.
NOVAK—Gynecology & Obstetrical Pathology.
TE LINDE—Gynecological Surgery.
TITUS—Management of Obstetrical Difficulties.
BOOKS NOT LOANED
BRENNEMAN'S—System of Pediatrics.
FRENCH'S—Differential Diagnosis.
NELSON'S—Loose Leaf System.
OXFORD MEDICINE.
BOOK REVIEW — PSYCHOSURGERY
By WALTER FREEMAN and JAMES W. WATTS
Published by Charles C. Thomas, 1942.
The authors are pioneers in the major advance made in physical methods of treatment
in Psychiatry since electro-shock. Their book is the first text on prefrontal lobotomy
for disabling psychoneuroses and psychoses of functional origin and serves both to introduce the subject and to be a handbook for the selection, operation and after care of
patients coming to psychosurgery. There are five sections, commencing with a historical
introduction and following with the physiological and pathological evidence for our
knowledge of frontal lobe functions, clinical observations on prefrontal lobotomy and
its relation to mental disorder and concluding with theories of psychopathology arising
out of the concepts of the procedure.
What vagotomy is to internal medicine, lobotomy is to psychiatry. Several hundred
cases have been operated by various workers since this volume was published and in the
main the author's conclusions have been borne out. Sectioning all four quadrants in
both lobes remains the operation of choice. The chief indication for operation is pathological emotional tension shown as persistent anxiety, its equivalent of obsessions and
compulsions or its projected counterparts of auditory hallucinations and persecutory
delusions when they dominate behaviour. In psychosis results vary directly with adequate
emotional responses, periodicity of attacks and the effort to adjust shown.
It is a permanent procedure producing no measurable loss of intelligence but diminished self-consciousness, perfectionism, foresight and ambition.
COLLEGE OF PHYSICIANS & SURGEONS
NOTICE
LOCUMS TENENS
Last year there were few doctors available to do locums and, in some cases, doctors
were unable to obtain a substitute and had to do without a holiday.
It is hoped that there will be more men available for short term locums this year
and, in fact, a few men have already indicated that they will be available.
If any doctors have already made their plans and require a locum for any period
during the coming summer months, will they please communicate with the undersigned
as early as convenient.
F. L. WHITEHEAD, M.D.,
Evecutive Secretary,
College of Physicians & Surgeons.
Page 147 Vancouver Medical  Association
President -1= Dr. G. A. Davidson
Vice-President ! . Dr.   Gordon  C.  Johnstone
Honorary Treasurer Dr. Gordon Burke
Honorary Secretary Dr. W. J. Dorrance
Editor- Dr. J. H. MacDermot
Members elected during the past fiscal year to the Vancouver Medical Association.
[stin, W. E.
Lnall, A.  W.
Ifour,  John
M J- H-
yd, R. W.
wker, C. A. M.
isholm, Hugh A.
Lrke, Waldo B.
ltart, J. L.
oper, H. G.
bnelly, A. W.
pyer, Charles H.
tfott, F. N.
^iott, J. A.
is, J. P.
fans, Maxwell A.
ans, Wilford G.
nrni, Brock M.
ttler, H. K.
xgord, R. N.
ost, J. W.
raid, Grant A.
mid, C. E. G.
fimmett, R. S.
Active Membership
Hardyment, A. F.
Haszard, J. F.
Henderson, Hugh A.
Herstein, Archie
Ireland, J. A.
Irving, John A.
Johnston, Fergus D.
Kaplan, Sidney
King, Donald M.
Kirby, Orville E.
Kirk, David Keith
Knott, Nairn D.
Landa, Eastwood
Lehmann, P. O.
Lewison, Edward
MacCrostie, M. W.
McCallum, Donald
Macdonald, R. J.
Margetts, E. L.
Mathison, A. K.
Minnes, J. F.
Olacke, Frank A.
O'Neil, Agnes
Patterson, Frank P.
Patrick, W. H. L.
Pinkerton, E. K.
Poole, John C.
Rennie, C. S.
Robertson, C. E.
Robertson, Ross
Rutherford, P. S.
Salsbury, C. R.
Shallard, Bruce T.
Shea, Marguerite
Skinner, Frank L.
Sloan, W. L.
Stanley, R. A.
Stanwood, David H.
Steinman, I.
Sparkes, John W.
Tait, Wm. M.
Tanton, B. W.
Watson, G. L.
Weaver, Howard G.
White, J. V.
Wilson, Roger
Word, E. F.
jexander, H. J.—Vernon, B.C.
rmstrong, C. A.—New Westminster
Neman, J. U.—Duncan
|)dds, W. A.—Ladner
lpin, R. R.—Victoria
iudin, M. L.—New Westminster
ckson, J. M.—Essondale
ktz, Max—Haney
pk, Louis—New Westminster
cLaughlin, G. A.—North Vancounver
ivwood, A. K.
Associate Membership
Perrett, T. S.—Kamloops
, Simpson, Glen—Victoria
Toone, W. M.—North Vancouver
Venini, P. G.—West Vancounver
Volland, D. D.—Caulifield
Wilson, James W.—New Westminster
White, W. H.—Penticton
Whitman, R. L.—Essondale
Wylde, E. W.—New Westminster
Life Membership
Robertson, F. N.
Page 148
r THE PROBLEM OF DIZZINESS
By DR. LAURENCE SELLING
(Read before Vancouver Medical Association, January 6, 1948)
The subject of Dr. Selling's paper was "Dizziness," Unfortunately, he spoke fror
notes, and not a written paper, which would have not only greatly lightened our burdei
but would have been of far greater value to our readers.
Dr. Selling is evidently a born teacher, and has, by assiduous practice as lecturei
developed his natural talent to a very high degree of excellence. He speaks clearly an
concisely, and tabulates as he goes, has no asides, and no disturbing excursions dow
tempting, but confusing side paths. A clearer picture of what is a very difficult subject
and a monstant trial to all practitioner of medicine, could hardly have been given. T^
following notes are necessarily rather scrappy, but contain, we think, the gist of what Dl
Selling told his audience, which listened with keen attention from beginning to the en<
of his address.
One probably hardly realises, Dr. Selling began, how frequently dizziness appeal)
on the list of complaints made by patients visiting doctor's offices. A large percentagj
of our daily run of patients lists dizziness as one of their complaints—often as a minoj
complaint, but in a large number their prime, sometimes their only complaint.
It is of extreme importance, in the evaluation of the complaint of dizziness, ty
work out a rational method of approach, along systematic lines, to the problem, with i
view to diagnosing its nature and cause.
Dizziness the speaker defined as "a disturbed relation to space." It may be of drl
ferent forms, ranging from a mere sense of uncertainty or insecurity, with giddiness
weakness and a feeling of blankness, to the whirling, turning sensations of vertigo, o
varying intensity, with acute nausea, vomiting, and intense misery.
Many varying sensations are associated with giddiness, and there is hardly a part o
the body that may not be concerned with dizziness. Accordingly, unless one can in*
mediately locate the causative lesion, one must be prepared to make a very exhaustivi
phyical examination.
Thus the eyes are frequently the source of dizziness. The proprioceptive system, th
statikinetic system, the cerebellum, and lastly the cerebrum itself must, if necessary
all receive a careful searching, to determine the cause of the dizziness.
We must first get an accurate description from the patient of his exact sensations
their period, their intensity, etc.
If there is true vertigo, with whirling or rotatory sensations, the lesion can be con
fined to a relatively small part of the body. If more vague, less possible to localise, w;
must examine the whole body.
Dr. Selling reviewed the main areas as follows:
1. The eye. We know that looking down from a height causes dizziness. Errors o^
refraction, muscle imbalance, mild glaucoma, will all cause dizziness. So a careful
ophathalmological examination must be made.
2. The proprio-ceptive system must be carefully checked. We all know the un«
steadiness and dizziness of the tabetic with his loss of muscle sense, his inability to kno^
where he is—and, too, the pernicious anaemia case, with its tendency to postero-Iateraj
lesions of the cord; the loss of vibration sense—all these lead to incoordination.
3. The cerebellum—'the functions of this are well known in their relation to tht
stability of the individual, and lesions here must be excluded.
Lastly 4. The brain. A tremendous variety of things affecting the brain will caus<
dizziness. And among the first of these Dr. Selling placed cerebral anoxia. This maj
be due to arterio-sclerosis, with its curtailment of the cerebral blood-supply—hyperten-j
sive and cardio-vascular disease, vasospasm, all these may cause intermittent or paroxysmal anoxia, and lead to dizziness.
Page 149 Anaemia of any variety may give rise to dizziness—e.g. the marked anaemia follow-
j severe haemorrhages, such as follow duodenal haemorrhage, etc. The dizziness here
easily understood, but it must be remembered too that blood dyscrasias, even poly-
thaemia, may impair the blood-supply of the brain, to produce dizziness.
Infections that attack the brain—the meningitides, encephalitis, syphilis, etc., will
give rise to dizziness.
In all these brain conditions, however,  the dizziness is merely one among many
tures of the whole. It is overshadowed by other symptoms and signs, and is rela-
ely minor, even as a complaint. In tumour, for instance, unless the site of the tumour,
cerebello-pontine, or cerebellar, predetermines acute dizziness of an aggravated
ture, dizziness is a minor, often unimportant, symptom.
Trauma too, with its disturbance of the brain, frequently multiple haemorrhages,
111 produce a degree of dizziness—but generally of a minor degree, and tending to
[appear as the condition improves.
But it is when one comes to the compensation neurosis following a head injury,
|it one really has complaints of dizziness, far and away more than where there is
Jly organic damage.
Dr. Selling felt that in practically every case of compensation neurosis, dizziness
complained of—there is a complaint of intense headache and sensitiveness located at
e site of the injury. Here th dizziness is  due not  to organic  but  to psychogenic
pses. He knows of no systematised criteria by which to distinguish the real from
: imagined dizziness, and wishes he did. But one suggestive feature in the examination
all these people is that they react immediately to suggestion and agree immediately
th any suggested cause of the dizziness. "Does walking bring it on?" "Oh yes, im-
bdiately, doctor." "Is it worse after meals?" "Always, doctor," and so on. This is
be in any neurosis, also.
A group of conditions which produce symptoms due to anoxia, more or less tem-
prary and paroxysmal.
Paroxysmal tachycardia at the onset of the attack, frequently dizziness is the first
mplaint.
Aortic stenosis—heart block—partial Stokes—Adams syndrome—carotid sinus sensi-
rity with its dizziness and syncope.
Postural hypotension—sudden drops in blood pressure on rising quickly from a
rizontal position.
These of course all give rise to anoxia of the brain, and dizziness accompanies them,
also in ordinary fainting or syncope, under strong emotion, in a warm room, etc.
i A group associated with endocrine disorders
Tetany I In these frequently dizziness is marked and is the most trying
Hyperinsulinism S  symptom.
Adrenal tumour
A very important clinical entity, as a diagnostic problem where dizziness is con-
rn, is petit-mal epileptic attacks in children.  It is amazing, he said, how often  a
pld complains of dizziness. This dizziness is paroxysmal, attacks occurring sometimes
«ks or months apart—accompanied with sensations of fear.
The parents come in saying that their child keeps having attacks of dizziness. One
wst keep petit-mal in mind, especially since tridione, a new drug, gives spectacular
pults in this" condition.
Psychoneurotic. This is the largest group of all, and as with compensation neuroses,
le cause and manifestations of dizziness are protean and conform to no pattern.
Dr. Selling then turned to Vertigo—here we have a very different situation. Verti-
► is sharply distinguished from other forms of dizziness by the systematised movement
[ turning or rotatory sensation. This the patient may feel as a turning or whirling
[ himself or his environment. With his eyes closed, he feels himself turning, when they
£ open, everything near him is flying around him.
Here the area affected is sharply limited to a certain definite area of the body, the
stikinetic system, which includes
Page 150
m-mm
m$m
«**^ The vestibule, and vestibular branch of the 8 th nerve
The labyrinth
The brain stem.
Of these the labyrinth is the periphery, the brain stem and the vestibular nerve, the
centre. The vestibular nuclus is also frequently involved.   ||g
We must try and locate the exact site. The most important thing here is whether
the lesion is in the periphery, i.e. the labyrinth, or in the brain stem.
The patient who is merely dizzy has no objective signs—merely the subjective symptoms of dizziness. The patient with vertigo is apt to have one objective sign, i.e.
nystagmus. When this appears, it means that the lesion is somewhere in the area mentioned above.
Nystagmus (true nystagmus) is a quick movement of the eyes in one direction,
slow in the other.
When the quick movement is to the right, it is called "right nystagmus"; similarly
"left" when in the other direction. We may also have vertical nystagmus, and diagonal
nystagmus.
A warning note here is that so-called physiological nystagmus may be produced
where there is no lesion present—by having the patient look far in one direction, i.e.
extreme turning of eye to on dirction. ,
To elicit nystagmus—have patient look straight ahead into distance, staring out
ahead; then have him focus his eyes on a near object. The staring ahead will elicit it
and keep it going; focussing his eyes on an object stops it.
Other methods are used to elicit it; e.g. the placing of a double convex lens in
front of the eye—use of the ophthalmoscope, directing light into the eye—quickly
placing patient on his back and having him look up at the ceiling.
There is one type of nystagmus—"oscillatory nystagmus," which has nothing to do
with vertigo. This is not a quick movement followed by a slow—but a continual oscillation at an even rate, present always in the patient—it is often occupational in origin,
e.g. in miners, and men who work for long periods in the dark; sometimes congenital.
Having observed the nystagmus defined previously—does this indicate a lesion of
the labyrinth or of the brain stem?
Some types—horizontal or rotatory nystagmus—may indicate a lesion in either
place.
The vertical type is almost always indicative of a lesion in the brain stem; the
diagonal type always.
A second point has to do with the anatomy of the stati-kinetic system.
In considering the periphery, i.e. the labyrinth, we have to remember that this is
very close to the cochlea, or auditory sense-organ—hence disturbance of the labyrinth
is practically always associated with disturbances of hearing, tinnitus, etc. If these are
present, the labyrinth (the periphery) is more strongly indicated.
As regards the periphery, we must consider the ear as a cause of vertigo, since
disturbances here may set up irritation or trouble in the adjacent labyrinth.
Cerumen, a foreign body in the ear, may cause vertigo in this way—blocking or
inflammatory processes of the Eustachian tube; suppuration and its end results, e.g.
cholesteatoma or fistula.
Hence a thorough examination by a specialist may be necessary, and should always
be resorted to if there is any doubt.
We come now to toxic labyrinthitis: the commonest cause of vertigo by far, in Dr.
Selling's opinion.
The sources of such toxaemia are legion.
1. Drugs—Quinine and the salicylates are two classical examples: may produce
tinnitus, as we all know, and by extension, vertigo—by its effect on the labyrinth.
2. Infections—Upper respiratory infections—inflammation of tonsils, etc., are
probably the commonest cause of toxic labyrinthitis.
Patients are extremely miserable with this; they have vertigo, vomiting, and nausea. Frequently they are badly frightened;  everything is going round,  and they are
Page 151 vomiting. One must remember that most cases of toxic labyrinthitis are self-limited—
last only a few days; but one must reassure the patient and restore his self-possession,
by telling him this, giving him sedatives, etc. Dr. Selling finds placebos of considerable
value here, since the condition is self-limited, and clears up with the disappearance of
the cause. This vertigo, (toxic labyrinthitis) is more or less a constant phenomenon
while it lasts—not intermittent as in Meniere's disease, which is episodic and recurring, at more or less long intervals.
There are other causes of vertigo.
Cerebello-pontine angle tumour. This is rare (9% of all brain tumours). Very
rarely is the vertigo here intense, and rarely is it a prominent symptom. Other things
help to make the diagnosis.
There is a growing mass here compressing the eighth nerve and its nucleus—and
we get increasing deafness—tinnitus—loss of the corneal reflex—especially with the
patient lying on back. Then the seventh nerve is involved, and we have drooping of the
face and facial, paralysis. As the cerebellum is compressed, unsteadiness becomes increasingly marked.
"Vascular lesions. In arterio-sclerosis, the vestibular artery may be involved, and give
rise to dizziness, tinnitus, deafness, etc. But in a patient with arterio-sclerosis who
begins to have dizziness, we must not neglect to hunt for symptoms of toxic labyrinthitis.
Haemorrhage into labyrinth, either from arterio-sclerosis or as an episode in a blood
dyscrasia, gives a most dramatic picture. Suddenly, without warning, intense vertigo
appears with nausea, vomiting, whirling, terrific roaring in ears. The diagnosis is easy to
make, and the course is typical. Within three weeks, symptoms tend to subside, as the
death of the nerve-endings in the labyrinth removes them—the other labyrinth takes
over, and the patient improves greatly. Tinnitus and loss of hearing persist, on account
of the involvement of the adjacent cochlea.
As regards the nerve trunk—here the nerve to the labyrinth and ear run together,
and symptoms run pari passu. The meningitides here are a common cause of trouble.
Of course, in this case, the meningitis causes more concern than the vertigo, and is of
far greater importance.
The nuclei. The nerve tracts from the vestibular nucleus run to the cerebellum, the
brain stem, the cerebrum.
Many of the scleroses: posterior lateral sclerosis, multiple (disseminated) scleroses,
may give rise to lesions in this area, especially in the tracts of the posterior bundle.
Lesions may be multiple and confusing, since as one recovers, another appears.
Epidemic encephalo-myelitis
Thromboses
Tumours of the cerebellum, by involving terminal (cerebellar) endings of the
vestibular nerve. All these may give rise to vertigo—but (1) all these are rare (2)
other features of them, much more prominent and much more important, than the
degree of vertigo present, give the clues necessary for a differential diagnosis.
It is not so terribly hard to limit the field, really, if one remembers
1. that true vertigo can practically always be limited to the area of the stati-
kinetic system
2. that toxic labyrinthitis is by far the commonest cause of it.
3. that infections of the upper respiratory type are the commonest causes of toxic
labyrinthitis.
Syphilis, meningitis, etc., are often causes, but are detected anyway by other means,
and the vertigo here is quite secondary. It is the vertigo that appears without reference to
any major systemic condition that gives us the trouble.
Meniere's disease. This is a condition characterized by sudden paroxysmal attacks of
intense vertigo with nausea and vomiting. These attacks may be severe, even cataclysmic—but they have features which are characteristic and diagnostic.
They are episodic, appear suddenly, last less than forty-eight hours, generally only
a few hours—and disappear, to leave the patient absolutely free of any symptoms, no
Page 152 matter how severe the attack was. Intervals between attacks may be months or years.
There is usually impairment of hearing; this is less marked between attacks.
The cause is unknown—but the condition appears to be an endo-lymphatic hydrops,
and oedema of the cochlea and labyrinth.
There is no definite treatment. Nicotinic acid gives relief in some cases, and has
been used—prostigmin too, and even histamine, but as the attack is not of long duration,
evaluation of these remedies is difficult.
Salt restriction with administration of ammonium chloride is of value.
Doyen's operation for permanent relief consists of section of the vestibular partion
of the eighth nerve.
A more modern operation now used, consists of trephining into the labyrinth, and
draining off the fluid in it. This kills the labyrinth, and within three weeks the other
labyrinth assumes the duties of the dead labyrinth.
Streptomycin has been tried, on account of its capacity to impair hearing, and so
affect the labyrinth by extension. There there is no certainty as to how far we may
obtain the desired labyrinthine impairment without permanent damage to hearing, and
this method requires a good deal of study before it can be depended upon at all.
NOTICE
RELIEF    ADMINISTRATION
It is necessary that the forms for all Social Assistance cases, including Old
Age Pensioners and Mothers' Allowance cases, be completed in full as the information given is the basis on which payment is made.
Accounts must be rendered before the 5 th of the month following treatment. Funds are received and disbursed monthly and accounts that are substituted after the percentage is set by the Committee cannot be paid.
PRINCE RUPERT MEDICAL ASSOCIATION
The first clinical meeting of the year was held at Miller Bay Hospital on February
3rd, 1948. Dr. J. D. Galbraith presented a short paper on the present status of streptomycin therapy in tuberculosis.
The following officers were elected for the ensuing year:
President | Dr. J. D. Galbraith
Secretary-Treasurer p Dr. A. W. Large
Representative to the Prince Rupert Hospital Board Dr. W. S. Kergin
Representative to the Board of Directors of The British Columbia
Medical Association - Dr. L. W. Kergin
Page 153 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President—. _ 1—. Dr. Lavell H. Leeson
President-elect [ Dr.  Frank Bryant
Vice-President . Dr. W. Laishley
Honorary Secretary-Treasurer j Dr. J. C. Thomas
Immediate Past President Dr. Ethlyn Trapp
Ex. Secretary ! Dr. F. S. Whitehead
EDITOR'S NOTE:
So far as can be ascertained at this time, the only changes which have been
authorized by the Income Tax Department are:
(a) an increase in the ceiling figures of the cost of a motor car to $2,500.00
effective January 1st, 1947.
(b) 7 cents a mile for mileage covered in the performance of professional
duties instead of 454 cents.
There may be some further changes which, if authorized, will appear in
the daily press.
With the exception of the items given above, the deductions allowed and
the manner of rendering Income Tax returns by doctors are the same as was
published in the February, 1947, Bulletin, but the whole article with the
alterations is reproduced herewith for easy reference.
DOMINION INCOME TAX RETURNS BY MEMBERS
OF THE MEDICAL PROFESSION
As a mater 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 Dept. of National
Revenue in the annual Income Tax Return to be field, 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 bookkeeper; laundry and malpractice insurance
premiums. (It is to be noted that the Income War Tax Act does not allow as
a deduction a salary paid by a husband to a wife or vice versa. Such amount, if
paid, is to be added back to the income):
(c) Telephone expenses:
(d) Assistant's fees:
The names and addresses of the assistants to whom fees are paid should be
furnished. This information is to be given each year on Income Tax form known
as Form T.4 obtainable from the Inspector of Income Tax.
Page 154 (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:
i   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:
Office furniture and fixtures—10 per cent per annum.
Library—The cost of new books will be allowed as a charge.
(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.
The allowance is restricted to the car used in professional practice and does not
apply to cars for personal use.
Effective January 1st, 1947, depreciation on motor cars used in professional
practice may be claimed on cars costing up to a maximum of $2,500.00. The
effect of this regulation is to raise the ceiling on depreciation from the former
figure of $1,800.00.
(i)  Automobile expense; (one car)
This account will include cost of license, oil, grease, insurance, washing, garage
charges and repairs.
Alternative to (h) and (i) for 1940 and subsequent years—
Effective January 1st, 1947, in lieu o fall other expenses connected with the
operation of a motor car, including depreciation, a doctor may be allowed to
charge 7 cents 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 pertinent to the earning of income
will be 75 54 of the total mileage for the year under consideration.
For 1940 and subsequent years where a chauffeur is employed, partly for business 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:
Where a doctor practices from a house which he owns and as well resides,
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, address
of mortgagee to be stated):
(b) rented by the doctor:
The rent only will be apportioned inasmuch as the owner of the premises
takes care of all other expenses.
The above allowance will not exceed one-third of the total house expenses
Page 155 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 should 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 upon submission of receipts to the Inspector of Income Tax. This is provided for in the Act.
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 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
3. It has been held by the Courts that a salary is "net" for Income Tax purposes. The
salary of a Doctor is therefore taxable in full without allowances for automobile expenses, annual medical dues, and other like expenses. If the contract with his employer provides that such expenses are payable by the employer, they will be allowed
as an expense to the employer in addition to the salary paid to the assistant.
THE BRITISH COLUMBIA MEDICAL ASSOCIATION
A meeting of the Executive Committee was held on January 29th, 1948. This was
a special meeting to appoint representatives from the B. C. Division to General Council
of the Canadian Medical Association. Our Division is entitled to nine seats on General
Council in addition to seats for the President ad Secretaries.
Several other matters were discussed, the most important being the policy to be
adopted in relation to the formation of the various Specialist Societies in British
Columbia.
SPECIALISTS' SOCIETIES
Since the Board of Directors' meeting which was reported in the December issue of
the Bulletin a great deal of discussion has taken place regarding these societies. Some
information on the set-up of national specialist organizations has been obtained and more
is awaited.
The doctors who become members of a specialist society are, also, members of The
British Columbia Medical Association. Many doctors feel that the time has, perhaps,
arrived when we should seriously consider amending our Constitution to provide for
the setting up of sections, chiefly on a clinical basis, but with provision for the con-;
sideration of business matters affecting that particular specialty.
From the financial side it is felt that some arrangement could be worked out whereby
doctors would not be put to extra expense in feeling that they had to join their own
section or society.
The Chairman of the Committee on Constitution and By-Laws has been asked to
consider the amendments which would be necessary to the Constitution and By-Laws
of The British Columbia Medical Association to include the specialists' societies already
formed, and those which may form in the future.
Observations on the specialist societies already set up are interesting and some of
these are presented here.
Page 156
*m (a) Any society representing a small number of the doctors of British Columbia
can have very little, if any, influence in Government circles.
(b) If it can be arranged for specialists' groups which desire to do so to organize
themselves officially into groups within the framework of The British Columbia Medical
Association, one would presume that all the doctors in that specialty would automatically be members of that particular section. There is a danger in the present set-up that
only those doctors who feel that they can attend the meetings easily will join in the
first place or will keep up their membership. If these societies are to fill any real purpose it is important that they actually represent the considered opinion of all the doctors
in British Columbia concerned in that particular group.
(c) The knowledge and clinical experience of such a group should be available to
the whole profession on an organized basis, and the section should be responsible for providing suitable lecturers for district meetings, for their part in our Annual Meeting,
and for any special meetings which might be held throughout the Province.
(d) If there are too many specialists' societies functioning independently there is
a danger that the courses of instruction arranged by each group will conflict one with
the other, and in some cases overlap, with the probable result that the main efforts of
our whole Association along these lines would, in time, be dissipated.
(e) Should groups of men with the same interests be able to form themselves into
groups recognized by The British Columbia Medical Association it would seem reasonable to expect them, in the course of time, to exercise some degree of supervision over
the standard of medical practice in their own specialty, and to become sufficiently well
informed of problems throughout the Province and elsewhere in Canada which are confronting the profession as a whole, with particular reference to the rapidly increasing
proportion of specialists to general practitioners.
(f) Those who have the responsibility thrust upon them of advising specialists
whether to come to British Columbia and where to go when they get here would be
placed in a much stronger position if specialist sections were well organized and if their
Executives felt that they were actually speaking for the doctors of the Province in the
opinions they might give. This is an important task at present imposed upon the Executive Secretary alone. The number of inquiries received from doctors in other parts of
Canada, Great Britain and many other countries is quite large, and there is a very real
danger that this Province would become even more oversaturated with doctors than it
is at present unless the correct information on the existing situation is disseminated
through the proper channels.
The opinion has been expressed by several doctors whose experience in medical affairs
is large and whose opinions are founded on sound observation that we should make
every effort to include organized specialist groups within the framework of The British
Columbia Medical Association, that we should encourage them in every possible way to
develop their knowledge and interest in the general affairs of the practice of medicine
as a whole, and that it should be to these bodies that we would turn when we want to
know what the actual position is regarding the opportunities available on a long term
basis, the standards of specialist practice in our Province, and, most of all, what is
required to improve the service given to the public.
The Executive Secretary is obtaining all available information on the specialists'
organizations in Canada and the United States and the whole matter will be reviewed
at the next meeting of the Board of Directors. Should it be decided to proceed, the
whole project will have to be submitted to the next Annual Meeting of The British
Columbia Medical Association.
Page 157 REPORT OF THE MEETING OF THE WORLD MEDICAL
ASSOCIATION fe
By DR. WALLACE WILSON
Herewith is submitted for the information and interest of readers of the "Bulletin"
a brief report on the agenda and the main decisions of the First Annual Meeting of the
World Medical Association held in Paris, September 17-20, 1947.
At the invitation of the British Medical Association, a preliminary meeting was
held in London in September, 1946. It was attended by representative of 32 National
Medical Organizations henceforward known as the Founder Member-Associations Committee. This Committee, composed of representatives from ten countries and under
the Chairmanship of Dr. T. C. Routley from Canada, was instructed to proceed to
draw up a Constitution with its Articles and By-laws and to set the time and place
of the First General Assembly. Inside a year the Committee was ready and representatives to the second meeting met in Paris on the morning of September 17.
There were present 125 delegates and observers representing 45 National Associations and, under the Chairmanship of Sir Hugh Lett, President of the British Medical
Association, the first part of the meeting took the form of a conference to receive and
act on the report of Dr. Routley's Committee.
The report evoked prolonged discussion. The suggested Constitution had been
circulated to all national bodies some time previously, and it was evident that many
of the delegates had given much thought to both the wording and the content of the
Articles and By-laws, and that they were not prepared to accept the recommendations
of the Organization Committee in their entirety without full and free discussion. The
Chairman wisely and patiently gave each delegate full latitude and while the Constitution as amended did not finally pass the Conference until the afternoon of Thursday,
the 18 th, it speaks well for the soundness of the work of the Organization Committee
that there were comparatively few changes and amendments.
It is important that the aims and objects of the World Medical Association as set
down in the adopted Constitution should be known to all medical men. They are as
follows:
1. To promote closer ties amongst National Medical Associations and amongst the
doctors of the world by personal contact and all other means available.
2. To maintain the honour and protect the interests of the medical profession.
3. To study and report on the professional problems which confront the medical
profession.
4. To organize an exchange of information on matters of interest to the medical
profession.
5. To establish relations with, and present the views of, the medical profession to
the World Health Organization, the United Nations Educational, Scientific and
Cultural Organization and other appropriate bodies.
6. To assist all peoples of the world to attain the highest possible level of health.
7. To promote World Peace.
The work of the preliminary conference having been completed in the mid-afternoon
of September 18, the following formal declaration was then made:
"In the City of Paris at 3:40 p.m. on the 18th September,  1947, the World
Medical Association came into being."
The first Annual Meeting of the General Assembly then started work. Professor
Eugene Marquis (France) was installed as the first President, Dr. Charles Hill (Great
Britain) was appointed Acting Honorary Secretary and some of the important decisions
made by the Assembly were:
Location of Permanent Headquarters
It was decided that these offices should be somewhere on the North American Continent, the exact location being left to the Council for decision.
Page 158
« Funds
The Treasurer (Dr. Leuch of Switzerland) reported very little money in the treasury, and because of the difficult financial situation facing many of the National Organizations, the prospect of obtaining sufficient monies through member contributions
appeared rather remote.
At this point, the American delegation reported that some business men in the
United States, who were friends of the American Medical Association, being convinced
of the potential value of the World Medical Association to world medicine, health and
peace, were willing to make available to the Association an annual income of $50,000.00
for five years, provided the funds, administered by a joint supporting committee of
American doctors and laymen, were used for certain specific purposes.
After considerable discussion, the Assembly passed the following resolutions that
conformed largely to the suggestions of the American delegation.
1. That the General Assembly accept with gratitude the offer of the friends of the
American Medical Association and place on record its deep appreciation of their
generosity in making available funds sufficient for the. establishment of the
World Medical Association on a satisfactory basis.
2. That the funds thus made available be utilized to defray expenditure under the
following headings:
(a) The remuneration and expenses of the Secretary, other officials and clerical
staff;
(b) the rents, rates and other disbursements in connection with the official headquarters;
(c) the general office expenses of the headquarters office staff;
(d) the cost of the publication of the Association's official bulletin or journal;
(e) the travelling expenses of the Council.
3. That the costs of the developments listed above be estimated at not more than
$50,000.00 for the first year.
4. That the Council be authorized to act on the Assembly's behalf in appointing
the Secretary of the World Medical Association and to make all other staffing
arrangements, regional and other.
5. That the Council be instructed to explore the possibility of making arrangements
for gifts to the World Medical Association to be made tax-free.
6. That Member-Associations be recommended to consider the formation of World
Medical Association Supporting Committees in their several countries.
7. That the Council be authorized to prepare plans of development, to enter into
any necessary consultations and to submit its proposals to the General Assmbly.
8. That nothing in these resolutions shall diminish the authority of the General
Assembly for the full control of the policy and affairs of the Association as provided in Article 8 of the Constitution.
The Assembly then set the annual subscription for Member Associations at a flat
rate of 20 Swiss centimes per member with a minimum of 1,000 and a maximum of
10,000 Swiss-francs. For the Canadian Medical Association, this will amount to something between $300.00 and $400.00, and the total subscriptions will amount to approximately $20,000.00.
War Crimes
After a discussion of the motions on the agenda by Denmark and Great Britain and
the British memorandum relating to the attitude of the profession to war crimes, and
after hearing statements by members of the Assembly and by a French medical victim
of war crimes, the Assembly appointed a small committee to formulate a recommendation. The following report of the committee was subsequently adopted by the Assembly:-
(i)  That a report on crimes committed since 1933 by doctors and medical organizations in Germany and other countries and on this violation of the medical ethic, be prepared and made available to doctors throughout the world.
Page 159 (ii) That the World Medical Association solemnly condemns the crimes against
human beings committed by certain members of the medical profession such
as are described in the British memorandum.
(iii) That every doctor, at the time of receiving his medical degree or diploma, be
required to subscribe to the following oath:-
"My first duty, above all other duties, written or unwritten, shall be
to care to the best of my ability for any person who is entrusted or entrusts himself to me, to respect his moral liberty, to resist any ill-treatment that may be inflicted on him, and, in this connection, to refuse my
consent to any authority that requires me to ill-treat him.
Whether my patient by my friend or my enemy, even in time of
war or in internal disturbances, and whatever may be his opinions, his
race, his party, his social class, his country or his religion, my treatment
and my respect for his human dignity will be unaffected by such
factors."
(iv) That the World Medical Association endorse judicial action by which members of the medical profession who shared in war crimes are punished.
(v) That the World Medical Association request the German medical syndicates
to make the following public declaration:-
(a) We, members of the German medical syndicate, are aware of the very
large number of acts of cruelty committed, both by individuals and collectively, since 1933 in mental hospitals and in concentration camps,
and of the violation of the medical ethic. These acts have resulted in
the death of some millions of people. A large number of our members
have been inmplicated in these acts, either as instigators or as technical
agents or as actual perpetrators;
(b) We regret that the organized medical profession in Germany has not
made any protest and has been content to ignore these acts, of which
it could not have been unaware;
(c) We undertake solemnly to condemn these crimes, to expel from our organization the criminals who have committed them, and to remind all
our members of the respect due, not only to life, but to human personality, dignity and liberty.
The Assembly instructed the Council to prepare a report incorporating these resolutions and also to take into consideration the following motion by the Netherlands:
That the Council be instructed to prepare a report on the collaboration of medical practitioners in the preparation of means of warfare.
With the election of Council, the General Assembly decided to hold its 2nd
Annual Meeting in Prague in 1948 and then, finding it impossible to complete the
agenda in the time allotted, certain items were referred to Council whose composition
is as follows:
Ex-officio President: Professor E. Marquis (France)
President-Elect: Dr. J. Stucklich (Czechoslovakia)
Treasurer: Dr. O. Leuch (Switzerland)
Chairman: Dr. T. C. Routley (Canada)
Vice-Chairman: Dr. D..Knutson (Sweden), Dr. L. H. Bauer (U.S.A.), Dr. J. A.
Bustamante (Cuba), Dr. P. Cibrie (France), Dr. A. Hartwich (Austria), Dr.
P. Z. King (China), Dr. J. A. Pridham (Great Britain), Dr. S. C. Sen (India),
Dr. L. G. Tornel (Spain).
Matters Referred to Council
1. The general arrangements for the organization and publication of a bulletin or
journal.
Page 160 Sl'll.
;
2. The preparation of a report on the enquiry into the present position of the medical profession in relation to the state.
3. The motions of Luxembourg supported by Australia, recommending the preparation of a comparative statement on standards of training for the medical profession and conditions of registration, and of a comparative statement on the
qualifications of specialists.
4. The following motions by India—
(a)  That the Council be requested to study and report on the question of the
advertisement of cures and medicines in the lay press.
(b)  That the Council be requested to study and report on the question of unqualified and unauthorized medical practice.
Council met for the first time at the close of the Assembly Meeting and, accepting
the principle approved by the Assembly of Assistant Secretaries, appointed Dr. Busta-
mante Secretary of the Pan-American Medical Confederation as Honorary Assistant Sec- ■
retary for matters pertaining to the Latin-American countries. Earlier in the Assembly
Meeting, the Pan-American group had guaranteed all expenses of a Regional Assistant
Secretary for their area.
Council has asked Member Associations to make known the coming appointment
of a General Secretary so that there may be an opportunity for applicants with suitable
credentials to apply.
Council has further decided on New York for the permanent headquarters of the
World Medical Association and suitable office space will be provided in the building
of the New York Academy of Medicine.
The next Meeting of the Council will, therefore, be held in New York on April
26*-29, inclusive. Following this meeting, Members of Council, through the generosity
of the American Medical Association, will travel as far west as Minneapolis, visiting
the Mayo Clinic and certain university centres.
Now that the World Medical Association has been definitely formed, what of its
future? No observer present in Paris could doubt the sincerity of the delegates or their
anxiety to see functioning a strong and active association. All believed that such an
organization could play an important part in the future of World Medicine, Health and
Peace and, thanks to the generosity of its American friends, they saw the Association
start off with the stability of its finances secured for some years to come.
But more is needed than money. Above all else is required the active interest and
support of every individual of each Member-Association. All members of the Canadian
Medical Association should realize that they are now also members of a World Medical
Association, that they should be ready to support it and be behind our National Association in the part it will play in the work of both the Council and the Assembly. That
the Latin-American countries, for instance, which were not represented at the 1946
meeting in London but which were all present at the Paris meeting, are genuinely prepared to back the World Medical Association, is shown by the facts that not only are
they paying all expenses in connection with a Regional Secretary for their own area,
but also have invited Dr. Routley, as Chairman of Council, to address the delegates at a
state dinner of an important Pan-American meeting to be held in Havana, Cuba, in
April next.
The Canadian Medical Association is proud of the work of its General Secretary
in this World Medical Association. More than any other delegate, he has provided enthusiasm, optimism and wise counselling and the respect and confidence of Council has
been shown in his unanimous election to the position of its first Chairman.
Page 161 VoHcatutek Q&n&uU JlcMpUcd Section
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PERNICIOUS  ANAEMIA   AND   ITS RELATIONSHIP TO
CARCINOMA  OF THE  STOMACH
A review of 203 cases in the Vancouver General Hospital.
By A. W. WALLACE, M.D.
The purpose of this survey was to study the relationship of  carcinoma of the
stomach to pernicious anaemia as found by the Department of Medicine in the Vancouver General Hospital, and to compare the results obtained with those found by previous investigators.
Procedure:
Cases studied come from three sources.
(1) Hospital admissions from 1940 to 1945 were examined and from these 98 cases
were selected. It is to be noted that there were in addition a number of cases found
with a diagnosis of pernicious anaemia which had to be discarded from the series
because the history and recorded laboratory work did not justify the diagnosis.
(2) Out Patient Department files were examined and 92 additional proven pernicious
anaemia cases were found. These were taken from a pernicious anaemia treatment
list compiled in 1943 and revised and kept up to date since.
(3) Private physicians were asked to contribute case histories and follow-up reports
on pernicious anaemia cases under their care. 13 cases were obtained in this way.
Private physicians under whom the hospital admissions mentioned above were admitted, were written to for specific follow-up notes On their cases.
A total of 203 cases were considered on which the average follow-up was 5 years.
43 cases were lost after a follow-up of a variable number of years, but all of these
cases were in poor health when last seen.
A relationship between pernicious, anaemia and gastric carcinoma has been suspected
for many years and some of the work in this respect is reviewed here. Collins, Gover
and Sorn (1) by x-raying at random a large group of people over 40 years of age, concluded that 0.3% of the population over 40, living at any one time would have carcinoma of the stomach. Jenner (2) in 1939 in a study of 181 living pernicious anaemia
cases found gastrict carcinoma in 4.4%. Roehring and Eusterman (3) in 1942 in a
series of 1,000 living pernicious anaemia cases found 1.6% with gastric carcinoma.
Kaplan and Rigler (4) studied reports on 43,021 consecutive autopsies on people over
45 years of age. 293 pernicious anaemia cases were found, of which 36 had carcinoma
of the stomach. This was an incidence of 12.3%, which was over three times the incidence in the remainder of the group. Torgerson (5) in a study on causative factors of
carcinoma reviewed 106 cases of gastric carcinoma arising in pernicious anaemia cases.
He found the site of the malignancy to be significantly more frequent on the greater
curvature than in gastric carcinoma generally. He pointed out that this is in support of
the theory that gastritis is a precursor of carcinoma, since the gastritis of pernicious
anaemia is generally in the region of the fundus glands, rather than the more common
gastritis in the pyloric area. Rigler, Kaplan and Fink (6) in reviewing the literature
up to June 1945 compared the incidence of carcinoma in the general population to the
incidence in pernicious anaemia patients. Their conclusions are summarized in the
following table:
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From The Department of Medicine, Vancouver General Hospital.
Page 162 Living     By Death
Gastric carcinoma in all people over 50     .3% 4%
Gastric carcinoma in pernicious anaemia 1.6% 12%
They pointed out that as pernicious anaemia cases are apparently more susceptible
to gastric carcinoma than the general population that it is advisable to x-ray them often
in search of this lesion.
In the present series 203 histories of pernicious anaemia cases were examined. These
cases were followed for an average of 5 years. From this group 30 deaths were reported
and of these 2 died of carcinoma of the stomach. 2 other cases with stomach lesions
were found; 1 with a benign polyp which conceivably could have become malignant
if it had been left in situ; another a malignant polyp which was removed by gastric
resection with a nine year apparent cure.
In this group, of the total cases studied, 1.47% had carcinoma of the stomach,
while of the deaths 6.77% were due to gastric carcinoma. It is apparent that if we are
to detect gastric carcinoma in its earliest stage we must x-ray apparently well people.
Since the incidence of carcinoma of the stomach is higher among cases with pernicious
anaemia it is obvious that these patients must be x-rayed at regular intervals if carcinoma is to be found. There is difficulty in carrying out this procedure both because of
the expense and because of the facilities required.
Conclusions:
This is a report of a relatively small series of cases. The results, however, are not at
variance with previously reported work, in that they show a greater incidence of
gastric carcinoma in pernicious anaemia cases than that generally reported for people of
the same age group.
In pernicious anaemia we apparently have a selected group more susceptible to
gastric carcinoma than the general population. It is thus important to be continuously
conscious of the possibility of carcinoma in these patients, and if at all possible, even
if there are no symptoms, to have periodic stomach x-rays.
Author*s Note. This Survey was undertaken at the instigation of Dr. G. F. Strong,
to whose help and critical comments the author hereby acknowledges his indebtedness.
Bibliography
1. Collins, S.D., Gover, M., and Sorn, H.F. "Trend and Geographic Variation in
Cancer Mortality and Prevalence, with special reference to Gastric Cancer." Journal
Nat. Cancer Institute 1:425.1941.
2. Jenner. "Perniciose anamie und Magenkarzinom." Acta med Scandinav 102:529.1939.
3. Roehring, P. C, and Eusterman, G. B. "Association of Pernicious Anaemia and Carcinoma of the Stomach." Archives of Surgery 45:554.1942.
4. Kaplan, N. S., and Rilper, L. G. "Pernicious Anaemia and Carcinoma of the Stomach. Autopsy studies concerning their inter-relationship." Am. J.M. Sc. 209:339.1945.
5. Torgerson, J. "Localization of Gastritis and Gastric Cancer, Especially in Cases of
Pernicious Anaemia." Acta Radiol. 25:845-855.1944.
6. Ripler, L. G.., Kaplan, M. D., and Fink, D. L. "Pernicious Anaemia and the Early
Diagnosis of Tumors of the Stomach." J.A.M.A. 128:426.1945.
Page 163 TUBERCULOSIS AND PREGNANCY
By G. F. KINCADE, M.D.
Tuberculosis being a disease of young adults and taking its greatest toll amongst
females in the age group from 20 to 40, during the child-bearing period, the complication of pregnancy and tuberculosis is a very common concern. The general practitioner
and obstetrical specialist will see this situation arising frequently and in a tuberculosis
clinic it is something that is constantly dealt with.
There should be no doubt that in the last decade our views of this subject have
almost completely reversed. The present concept is almost directly opposite the former
by which almost any person with the diagnosis of tuberculosis would automatically
be recommended for interruption of a pregnancy. We have now \ reached a more modified attitude to this problem and large numbers of women with tuberculosis are bearing
healthy children without detriment to themselves and certainly none to their offspring.
In reviewing the literature it will be seen that at the time of Hippocrates and Galen,
pregnancy was actually recommended as a treatment for pulmonary tuberculosis. This
view prevailed until the middle of the nineteenth century and it was generally believed
that the health of a tuberculous woman was improved during pregnancy. Following this
period there was a complete change. When faced with the problem of pulmonary tuberculosis and pregnancy, even though the tuberculosis were controlled, therapeutic abortion was the rule. This latter opinion has prevailed almost until the present time and
even now there is a minority which holds the same view.
It is difficult to understand how these changes come about, but in medicine we find
that the pendulum swings from one extreme to the other and eventually comes to rest
somewhere in between. Probably the greatest influence in this changing concept has been
the admittedly poor results from therapeutic abortion in tuberculous subjects, and the
realization that this measure is not necessarily the lesser of two evils. All too often
abortions have been done thinking that the tuberculosis would remain controlled only
to find that the disease became reactivated following this procedure. With the notable
advances that had been made in the diagnosis and treatment of tuberculosis in the past
twenty-five years, it again became necessary to review our position in this matter.
During the past ten years considerable attention has been paid to it.
Considering the previously gloomy attitude towards this subject, a review of the
literature at the present time will disclose a much more hopeful outlook. There is now
a fairly wide literature on the subject of tuberculosis and pregnancy, and the evidence
of those who hold that pregnancy need not be harmful with tuberculosis is much greater
than the opposite school of thought and much more authoritative. A brief mention of
some of the articles appearing in the literature will show that in the experimental
field, Burke (1) in 1940 showed that in a comparative group of males and pregnant
female rabbits infected with tubercle bacilli, pregnancy had no influence on the progress of the tuberculous infection. Wade (2) in 1942 in a somewhat similar experiment
found that pregnancy had no influence on the expectation of life in infected rabbits.
In studies of tuberculous women, Jameson (3) at Trudeau Sanatorium showed that of
451 married women who were admitted to that institution there was no difference in
death rate from tuberculosis in women whose tuberculosis was related to a full term
pregnancy as compared to nulliparae of the same age group and having lesions of a
similar extent. Hill (4) in 1928, rveeiwing 349 pregnant tuberculous women compared
with 160 tuberculous women not pregnant, concluded that pregnancy had no appreciable bearing on the progress of the disease and that the maternal mortality rate corresponds to that of the non-tuberculous women. Lyman (5) in 1943 made a statistical
analysis of 1,818 cases of tuberculous women. He divided them into three groups,
namely, 728 married before sanatorium admission, 315 married after discharge, 712 remaining single. From this survey it was shown that the group marrying after treatment
for tuberculosis had a prognosis four times better than the group that remained single
-  *
(Read at Staff Clinical Meeting. Vancounver General Hospital, October 9th, 1947.)
Page 164
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and three times better than those who were married before treatment. In the group
marrying after discharge from sanatorium, 192 out of the 315 had histories of pregnancy, the average being 2.25 each. From these figures we can apparently conclude
that matrimony and child-bearing are by no means out of the question for tuberculous
cases provided their disease is properly arrested and that they have a proper understanding of their diease, and a realization of their limitations.
Of those authors in the literature who claim that pregnancy has a deleterious effect
on pulmonary tuberculosis, most refer to the harmful effect on uncontrolled tuberculosis. They usually agree that when proper facilities exist and adequate treatment can-
be undertaken the continuation of pregnancy is no more harmful than the hazards of
abortion. Cohen (6) in 1946 in an experience of 177 consecutive pregnancies in tuberculous women states that "the results appear to show that pregnancy and labour rarely
harm the pulmonary disease. In the great majority of these tuberculosis women, pregnancy was little more than an important incident in the course of their illness. Quiescent,
arrested or recovered pulmonary tuberculosis ran slight risk of harm and for these patients therapeutic abortion would not have been justified. When the pulmonary disease
was active, abortion would have been justified only if under proper treatment and
supervision favourable progress could not have been anticipated. The crucial circumstance was to decide whether or not the pulmonary disease could be controlled."
From the evidence presented it would then appear that when one is faced with a
problem of tuberculosis and pregnancy, certain points must be considered.
The stage of disease. Is it of importance whether the patient is minimal, moderately
advanced or far advanced? Not necessarily. The far advanced case which has had treatment and is arrested or apparently cured is much better suited for pregnancy than the
minimal case which is active or unstable. However, when we are faced with an active
case of tuberculosis, the stage of disease is most important. While a minimal or moderately advanced case might readily be brought under control and pregnancy continued,
the far advanced is not likely to and for that reason therapeutic abortion will be
indicated.
The chief consideration is always the clinical status of the patient, i.e. the determination of whether the case is active, arrested or apparently cured. If the lesion can be
considered arrested and if there are no other medical grounds for interruption, then
the pregnancy can be continued without more than the normal hazards of child-bearing.
This is always providing conditions can be so arranged that the patient may conduct
herself within the same limits of exercise that her tuberculosis will permit. In other
words the treatment of a tuberculous lesion is the first objective but the usual regime of
pregnancy will impose other restrictions and limitations on her activities. However, this
should not mean that a tuberculous patient, who has successfully graduated her activities up to several hours exercise daily or part time work, should again become a bed
patient because of pregnancy. Quite the contrary. If her tuberculosis remains controlled
during pregnancy and the reaction to pregnancy is normal, there is not much need for
restricting her activities, particularly in the first two trimesters. However, in the last
trimester we are all inclined to advise a certain amount of restriction.
So much for the case in which the tuberculosis is controlled. What about the active
case? If through bed rest or collapse therapy the active case of tuberculosis can be
brought under control, there is no indication for therapeutic abortion. If the tuberculosis can be treated, the response to treatment will be much the same as if the pregnancy
did not exist. Naturally, the decision as to whether or not treatment will be effective is
often difficult and sometimes impossible. The early, soft infiiltrate will usually respond
to bed rest. The unilateral disease with cavitation may have pneumothorax but the
advanced lesion, with evudative and acute types of disease, are more unpredictable and
not likely to be brought under control readily. This is the group in which therapeutic
abortion is indicated. Even in this group the picture may eventually change with the
advent of streptomycin. This drug has shown promising results in the more acute types
of tuberculous lesions but its effect in pregnancy has not been investigated, to my
knowledge, nor the possible harmful effects on the foetus known.
Page 165 The prevailing view-point as to when an interruption of pregnancy should be undertaken is that after the third month of pregnancy, interruption should not be attempted.
Up to the end of the third month, the interruption may safely be undertaken by the
vaginal route but after that hysterotomy becomes necessary. The consensus is that
if an abdominal operation is necessary for termination, the continuation of the pregnancy is preferable regardless of the activity of the disease. If therapeutic abortion is
clearly indicated it is best that it should be done as early as possible. However, one
may temporize in doubtful cases, instituting treatment to determine its effectiveness
and delaying the decision regarding interruption as long as can be safely permitted.
Therefore in summarizing we may say that if the case is over three months pregnant
therapeutic abortion will not be recommended. Similarly, if the disease is arrested or can
be brought under control through treatment, therapeutic abortion will not be recommended. If the pregnancy is under three months duration and the nature of the disease is such that it canot be controlled, therapeutic abortion should be done.
There may be one other justification for interruption of pregnancy in tuberculous
women. In those cases with arrested disease having children at short intervals it seems
reasonable to expect a deterioration in their general health and a consequent lighting-
up of the tuberculosis.
When it has been decided that the active case of tuberculosis may continue with her
pregnancy with prospects of the tuberculosis being brought under control, the usual
forms of treatment are those of bed rest and pneumothorax, with division of adhesions
if indicated. It is usually well to reexpand the lung almost completely during labour
so as to prevent the formation of hydrothorax. Operations such as phrenic nerve crushing or avulsion are usually avoided so as not to interfere with the mechanics of labour.
Major surgical procedures such as thoracoplasty and pulmonary resection are not
undertaken during this period.
It should be pointed out that any form of treatment that is undertaken should be
continued for a considerable period of time after the confinement. It is a well known
fact that most cases of tuberculosis do well and even improve during pregnancy while
the months following confinement produce the breakdowns.
This discussion has mainly been that of pulmonary tuberculosis. In the matter of
extra-pulmonary tuberculosis the same princples apply as to whether the disease is controllable during pregnancy. In the case of bone and joint tuberculosis certain mechanical
factors must be considered and decided on their own merits.
The problem of sterilization comes up for consideration and it is undoubtedly indicated in unstable cases who have repeated pregnancies. However, it is not always
possible in institutional practice due to legal complications.
It is not my intention to dwell on the technical aspects of labour, but merely to
point out that in this phase the response of the tuberculous patient is much the same as
in the non-tuberculous. Generally speaking the indications for early induction of labour
or for Caesarean section are not influenced by the tuberculous lesion. Similarly the
choice of anaesthetics need not be limited because the supposedly harmful effects of
ether and chloroform have not been substantiated.
Having dealth with the case of the pregnant woman with tuberculosis, what of
the tuberculous patient who is contemplating marriage and pregnancy? Experience has
shown tha£ the arrested case after living two years under normal conditions may
safely undertake a pregnancy. If these conditions can be met the other factors are
laregly economic. For those in whom the disease has not been arrested for a sufficient
length of time, pregnancy should be advised against and contraceptive methods should
be practised until satisfactory evidence of stability has been shown.
In the event of pregnancy, one of the first questions asked by the mother is usually
"Will my baby have tuberculosis?" Congenital tuberculosis is such a rare occurrence
that the mother can be assured the child will be born free of tuberculosis and will never
contract the disease unless exposed after birth. Even those children born of mothers
with far advanced and active disease have been shown to remain healthy with a negative tuberculin test the same as children born of non-tuberculous mothers.
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Page 166 Having concluded that pregnancy is quite compatible with tuberculosis, provided
the existence of tuberculosis is known, the majority of cases can be safely guided
through pregnancy while only the occasional case will need be interrupted. However,
it should be pointed out that probably the greatest danger is to the undiagnosed case
of tuberculosis that goes through pregnancy and childbirth without proper treatment
for her tuberculosis. This frequently produces a fulminating type of disease discovered
several months after confinement and often brought to light only when the infant
has succumbed to tuberclous meningitis. In this type of case one mother out of three
is dead one year after delivery. For this reason the chest X-ray of pregnant women
should be routine procedure. Far too many women fail to have this important investigation and disastrous results occur. One should recommend its wider application both
during and after pregnancy.
REFERENCES
(1)  Burke, H. E.: Surg., Gynec, Obstet., 71: 615, 1940.
.2)  Wade, L. J.: Amer. Rev. Tuberc, 46: 93, 1942.
(3)  Jameson, E. M.: Amer. Jour. Obstet. Gynec., 36: 59, 1948.
(5)  Hill, A.: Amer. Rev. Tuberc, 17: 113, 1928.
(5) Lyman, D. R.: Yale Journ. Biol. Med., 15: 465, 1943.
(6) Cohen, R. C: Brit. Journ. Tuberc, 40: 10, 1946.
SYPHILIS IN PREGNANCY
By GEORGE ELLIOT, M.D.
In spite of widespread recognition of the magnitude of the problem of syphilis, the
diagnosis, treatment or prevention of prenatal syphilis does not seem to have been
sufficiently emphasized.
In British Columbia in the six-year period of 1941-1946 inclusive, there were 1,761
reported new cases of syphilis in females between ages of 15 and 50, which can be
considered as the child-bearing group. Studies prove conclusively that in a group of
syphilitic women who have never received anti-syphilitic therapy only 17% of known
conceptions result in living non-syphilitic children. The remaining 83% will terminate
in miscarriages, still births or living children with syphilis. In other words if among
above 1,761 syphilitic women there were 1,761 pregnancies and syphilis was not
treated in the mother, there would be only 299 healthy non-syphilitic children resulting.
The high incidence of congenital syphilis and the enormous toll which it annually
takes is very alarming, and it is particularly alarming because it is so readily preventable.
The prevention of congenital syphilis depends on three principles:
1;. The recognition before the 5 th month of pregnancy of infection with syphilis in
the mother which antedated or coincided with the pregnancy.   (This implies the
necessity for prenatal examination, including a serologic test for syphilis, in first
half of pregnancy.)
2. The recognition of syphilis acquired during pregnancy. (This implies the necessity
of repeating serologic test for syphilis at least once during pregnancy, preferably at
about the seventh month.) |£&
3. The proper treatment of all expectant mothers found to have a checked positive
serologic test for syphilis.
If these principles are applied prenatal syphilis can almost be wiped out.
Manner and Time of Infection of Fetus.
The manner of infection of the fetus in utero and the time during pregnancy at
which infection takes places have been the subject of much speculation and somewhat
less   clinical   and   experimental   observation.   Out   of   these   has   come   the   accepted
Read at Staff Clinical Meeting, Vancouver General Hospital, October 9th, 1947.
Page 167 fact that paternal transmission of syphilis (i.e. infection of the child from the father
without the mother being diseased) does not occur, and the working hypothesis that
infection of the fetus rarely, if ever, occurs before the fifth lunar month of gestation.
The actual infection of the fetus is throught to begin with spirochetemia (frequently transient) of the mother, a phenomenon which may occur at any time in patients with syphilis but which varies in frequency, intensity and duration depending
on the state of the disease, the presence or absence of previous treatment and (especially
with the older infections) other poorly understood factors. In general, however, in
the absence of treatment, the more recent the mother's infection with syphilis, the
longer, more intense and more frequent the bouts of spirochetemia and, therefore, the
greater chance of infection of the fetus.
The organisms reach the fetal circulation from the maternal circulation by way of
the placenta during one or more of these bouts of spirochetemia. From the incomplete
evidence available, it seems to be possible in some cases for the placenta to present a
barrier through which the organisms do not penetrate. There is also some evidence to
indicate that the spirochetes may reach the fetal circulation from the maternal circulation through the placenta without causing readily detectable lesions in that organ.
In general, however, syphilitic lesions are produced on the maternal side of the placenta
by localization there of organisms brought by the maternal circulation. The lesions
extend to the fetal side of the placenta, invade the fetal circulation, and infection of
the fetus occurs. Finally it may be said without question that whether pre-conceptional
or post-conceptional syphilis is in point, diaplacental invasion, especially in latter half
of pregnancy, is the habitual route.
The Treatment of Familial and Prenatal Syphilis.
General Principles.
The value of treating the syphilitic pregnant woman to prevent prenatal syphilis,
recognized since the middle of the seventeenth century, has never been more conclusively demonstrated than in the last twenty-five years, and if it is possible, even
more markedly shown with the introduction of penicillin. Studies conducted in the past
half century by prominent physicians, too numerous to enumerate, have shown that
from the therapeutic standpoint, syphilis transmitted from parent to offspring is practically a preventable disease. Its prevention rests upon the diagnosis and treatment of
syphilis complicating pregnancy.
For more detailed discussion of treatment it seems advisable to discuss first:
(1) the use of arsenicals and heavy metals.
(2) the use of penicillin alone.
(3) the use of both (1) and (2).
Arsenicals and heavy metals
From an examination of some of the massive amount of literature available on this
subject, it seems quite definite that better than 90% normal children result when the
trivalent arsenicals are used in sufficient amounts. The best results have been obtained
when treatment is given both before and during pregnancy, but since the fetus often
is not infected until late in term, it is never too late to begin treatment. With arsenicals
and heavy metals a satisfactory outcome can usually be expected if it is possible to
start arsenical therapy by the twentieth week and active treatment is continued until
time of delivery.
Stokes (1) Recommended Principles of Treatment, Syphilitic Pregnant Woman:
1. Begin treatment of the syphilitic pregnant woman as soon as the diagnosis is
established. A delay of even a few days may mean a syphilitic child.
2. To be effective the drugs must be spirillicidal. Intravenous neoarsphenamine and
mapharsen are the drugs of choice. The heavy metals (mercury or bismuth) have relatively much less protective effect for the fetus.
3. Protection of the child is the primary aim of treatment during pregnancy.
Maternal syphilis must be treated after delivery. p^ lip
Page 168
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Year
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Benensohn
1942
7%9
146
Moseley,
1940
21
Callaway
and
Sharpe
66
-'vi
17
56
Halloran
1939
84
149
264
16
Cole et al
(CCG)
1934
131
39
132
University of Penn-
1944-
121
slyvania and
1946
Johns Hopkins
Bellevue Hospital
1944-
261
Rapid Treatment
1947
Centre
Treatment given Mother
Neoarsphenamine and Bismuth
None
Neoarsphenamine before and
during pregnancy
Neoarsphenamine during
pregnancy only
Neoarsphenamine before
pregnancy only
None
More than 10 weekly
neoarsphenamine
6 to 10 weeks neoarsphenamine
None
Trivalent arsenical and heavy
metal begun before fifth month
Same as preceding but more than
weeks trivalent arsenical
Same as preceding but begun
after fifth month
Penicillin (aquesous)  1.2 to
4.8 units
Penicillin (aqueous) 4 M. units
Percentage
Normal
Children
93.3
60.0
100.0
90.9
88.2
53.6
92.9
72.4
18.8
78.4
90.7
60.6
96.7
97.0
4. Treat largely with ansenicals during the late months, largely with heavy metal
during the early months. The fetus is seldom infected prior to the 20th week.
5. Reduce the initial dose of arsenicals if treatment is begun after the fifth month.
The first injection may be 0.2 Gm. of neoarspenamine (or its equivalent); the average
dosage for the first three weeks should not exceed 0.3 Gm. for the 150 pound adult.
6. Continuous alternating is preferred to concurrent treatment.
7. After the fifth lunar month the length of the bismuth course should not exceed
4 to 6 weeks lest infection of the fetus result from lack of spirillicide.
8. Treatment should be continuous. No rest interval.
9. Arsenicals should be given for 4 to 6 weeks immediately before delivery.
10. If reactions occur stop treatment and re-evaluate. Do not injure the mother
from the overzealous applications of treatment for the unborn child. The average pregnant woman tolerates normal antisphilitic therapy well, but should reactions occur they
may be serious and should not be considered lightly.
It would seem that the use of trivalent arsenicals has perhaps one contentious
factor: neoarsphenamine is perhaps the drug of choice, although mapharsen is advocated
by many authorities; if mapharsen is used it should be given every five days. Intramuscular arsenical preparations (Bismarsen) are not effective; the use of the intensive
5 or 21 day massive arsenic therapy is not advocated owing to risks involved and the
excellent results normally obtained with more conservative treatment.
Some difference of opinion is also encountered about the use of an arsenical and bismuth concurrently. It seems that as heavy metals such as bismuth have relatively little
Page 169 protective effect for the child, such a scheme is unnecessary, especially when use of heavy
metal concurrently increases the risk of complication for the mother.
Control of Treatment Reactions.
Anti-syphilitic treatment during pregnancy should be accompanied by more than
ordinary prenatal care.
With normal precautions, standard treatment as outlined previously may be given
without hesitancy to the pregnant woman. When complications of syphilis occur, such
as cardiovascular, treatment of this stage of syphilis takes precedence over the protective
treatment for the child. When special types of treatment are indicated such as fever
therapy for C.N.S. involvment), these had best be postponed until after the termination
of pregnancy, continuing normal protective treatment for child until delivery occurs.
Spinal fluid studies should be postponed until after delivery. Tryparsamide should be
withheld since its effect on the optic tract of fetus is unknown.
Collateral Aspects of Treatment of Syphilis and Pregnancy.
It seems advisable to discuss a few of the commoner statements relative to syphilis
and pregnancy.
(a) It has been advised by some writers that pregnant women be treated on mere
suspicion of syphilis. There is no reason to treat a pregnant woman for syphilis unless she is definitely known to have or to have had the disease.
(b) It has been said that the expectant mother should be treated if her husband has
syphilis. Since the mother frequently escapes infection even though the father may be
syphilitic, and since infection of the fetus occurs via placenta and not from seminal fluid
there seems no reason to treat a mother merely because her husband is diseased.
(c) It has been said that active syphilis complicating pregnancy may be an indication for inducing abortion. Syphilis in itself is no reason for interference with preg-
ancy.
From the standpoint of the mother, carrying the pregnancy to term may be conceived as a reinforcement of her defence mechanism, and moreover adequate treatment
of the mother during pregnancy almost always ensures a healthy child.
(d) It has been said that a woman once syphilitic should be treated through each
subsequent pregnancy. Conservative opinion suggests that with our present day knowledge, a syphilitic woman should be treated through every pregnancy regardless of duration of her infection, her serologic status, or the amount or type of antecedent therapy.
The only exception is a congenital syphilitic woman, provided previous treatment,
adequate to control the activity of congenital infection (not necessarily to reverse the
blood serology), has been carried out. If previous treatment has not been adequate,
treatment is advised throughout pregnancy, more for the sake of the mother than the
child. Third generation syphilis is excessively rare.
(e) That the syphilitic mother should not nurse her infant after delivery. As a
rule if the mother has no infectious lesions she may nurse her newborn child. Stokes and
associates (1) state they have never seen .an exception to this statement. It is necessary,
of course, that the mother with active syphilis be receiving treatment for her disease.
The question occasionally arises as to whether anti-syphilitic therapy given to the
mother prenatally may ever be harmful to the fetus. In general the amounts of arsenical
and heavy metal (and penicillin can be included) which traverse the placental barrier
with normal treatment are not injurious to the unborn child.
Use of Penicillin in Syphilis in Pregnancy
The use of penicillin in treatment of syphilis must still be regarded as experimental.
However, its use in early syphilis, certain types of neurosyphilis, congenital syphilis
and syphilis in pregnancy seems to be established as good therapy, and little doubt exists
as to its value.
Penicillin has proven a particularly valuable agent in the prevention of prenatal
syphilis .It has fulfilled the requirements for the ideal anti-syphilitic agent better than
any drug previously employed.
Page 170
*<3
;■.-/«;■
J^lftJkl;
' Mm
MM  * * In a recent series of 261 pregnancies in 259 patients, 95% of the results were non-
syphilitic, 1.5% were definitely syphilitic and 3.4% were possibly syphilitic It is
quite apparent from a study of previous remarks and the table that no previous method
of anti-syphilitic therapy with arsenicals and heavy metals has yielded such satisfactory
results. No severe toxic manifestations have been observed, and this includes no
tendency to increase abortion.
Penicillin therapy is of value if instituted as late as the last 8 weeks of pregnancy, and
healthy babies will be obtained. With arsenicals and heavy metals one can give
similar assurance only when started prior to 16-weeks of pregnancy .
It is not possible to state what the optimal dosage of penicillin is but it is safe to
say that a total dosage of less than 2.4M. units of this antibiotic is inadequate. Relapses may occur even when higher dosage is used, and it is thus essential that frequent
quantitative serologic tests be done, and any definite rise should demand re-treatment.
The decline in quantitative STS in patients treated for latent syphilis is much less
marked than following therapy for the early infectious stages. In the Bellevue Hospital
Rapid Treatment Centre (2) a quantitative value of 16 Kahn units or higher is an
indication for re-treatment unless there is evidence of a preceding rapid decline to this
level.
The conclusion of the study recently completed at Bellevue Hospital Rapid Treatment Centre (2) are as follows:
(1) Penicillin in adequate dosage is effective in preventing congenital syphilis. At
the present time it is the most satisfactory agent for the treatment of the pregnant
syphilitic woman.
(2) A total dosage of less than 2,400,000 units of penicillin alone is not advised.
At present Bellevue Hospital is using a total dosage of 4,000,000 units (40,000 units
every 3 hours for 100 doses).
(3) Non-syphilitic babies may be obtained regardless of the period of gestation in
which penicillin therapy is started.
(4) Frequent observation during the prenatal period is essential to detect evidence
of serologic and clinical relapse.
(5) If a relapse occurs during the prenatal period, a healthy baby may be obtained if re-treatment is instituted promptly .
(6) A patient who has responded satisfactorily following previous penicillin therapy need not be re-treated during an ensuing pregnancy if adequate follow-up observation is assured.
(7) Re-treatment is advocated during pregnancy only in those patients who have
not shown satisfactory progress.
A word of caution is advanced in use of penicillin in treatment of syphilis in pregnancy. Certainly more of the resultant healthy babies treated with penicillin than with
arsenical and bismuth therapy will represent cases of prenatal syphilis which were cured
in utero by penicillin given the mother. If this should be so, the possibility of relapse,
comparable to relapse seen in acquired type of syphilis* is possible.
Recently a report has been published by the above mentioned authors (3) as to the
use of penicillin in oil in treatment of syphilis in pregnancy. The dosage used was 4.8M.
units given over 9 days as follows:
1st day 150,000 units
2nd day 450,000 units
3-9 day 600,000 units
These were given as single injections daily at 4 p.m.
The overall results in use of penicillin in oil and beeswax are approximately equivalent to those of aqueous solution. There is, however, some indication that penicillin in
oil-beeswax is less effective for symptomatic early syphilis in late pregnancy, if the fetus
Page 171 is already infected. In this situation it would appear better results can be obtained more
uniformly by using aqueous penicillin in hospitalized patients.
Use of Penicillin and Arsenicals and Bismuth in Syphilis
in Pregnancy.
In the Division of V.D. Control, Department of Health and Welfare, we have
adopted the conservative view point and still feel that penicillin must be regarded as
experimental. As a result we treat no types of syphilis with penicillin alone, but always
combine it with arsenicals and heavy metal.
Our recommended treatment for syphilis in pregnancy is as follows:
All cases of syphilis in pregnancy, irrespective of previous treatment, be hospitalized
for penicillin therapy, i.e. intramuscular injections of 40,000 units every three hours
for eight days. This treatment is then followed by regular weekly injections of alternating courses of mapharsen and bismuth. The courses of bismuth after the fifth month
of pregnancy should not exceed four consecutive injections and the last six to eight
injections before term should be arsenicals. Blood pressure reading and urinalysis are recommended weekly while the patient is receiving arsenotherapy, and haemoglobin taken
every three months. The serology should be followed monthly, and if there is any
evidence of a rising titre we would recommend that consultative service be requested
with the view to possibly repeating the penicillin course.
If the cerebrospinal fluid has never been taken, and if it is indicated in the routine
follow-up of these patients, the Division recommends that advantage be taken of the
woman's hospitalization (at delivery) and the spinal tap be performed during this
postpartum period rather than in the prenatal period.
It is recommended that a routine Cord Kahn be taken at birth. If this is negative
the infant's blood test should be repeated at six weeks and three months of age.
If the Cord Kahn is positive, treatment should not be given unless there are confirmatory clinical or x-ray evidence of infection. In many cases the positive Cord Kahn
is due to carry over of reagin from the mother. These patients should have repeated
quantitative Kahn tests. If the titre is rising the diagnosis is confiermed and treatment
should be started. If the titre falls the child should be kept under observation until
freedom from infection is established.
Finally in Stokes' own words (1): "Once progress has been made in any community
or organization in control of prenatal syphilis, it then becomes an easy matter to expand
into a comprehensive programme which will embrace the many public health and social
implications of infectious early and symptomatic late syphilis. Within the last few years
a veritable wave of premarital and prenatal examination laws have swept the country.
The private practitioner, the obstetrician and the pediatrician have been placed in an
unparalleled position of responsibility which they will live up to only after they have
subjected themselves to a complete reappraisal of their knowledge of the control of
syphilis in marriage, in pregnancy and in early infancy."
Bibliography
(1) Stokes, Beerman, Ingraham: Modern Clinical Syphilology, W. B. Saunders Company, Philadelphia and London, 1944.
(2) United States Public Health Services: The Journal of Venereal Disease Information,
United States Government Printing Office, Washington, D.C., June, 1947.
(3) United States Public Health Service: The Journal of Venereal Disease Information,
United States Government Printing Office, Washington, D.C., August, 1947.
(4) United States Public Health Service: Syphilis in Mother and Child, United States
Government Printing Office, Washington, D.C., 1940.
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Page 172 DIABETES COMPLICATED BY PREGNANCY
By W. W. SIMPSON, M.D.
j
The diabetic female of child bearing age is faced with a number of problems the
chief of which are:-
(1) that of becoming pregnant.
(2) of surviving the course of a pregnancy.
(3) of producing living children.
(4) of transmitting the tendency to develop diabetes in her offspring.
Prior to the advent of insulin, sterility in a diabetic woman was a major problem.
Few of them conceived and those that did were subject to a high incidence of abortion
and miscarriage. Since the discovery of insulin and more recently of protamine zinc
insulin, sterility in the diabetic female has not been nearly so common. In fact with good
diabetic control the fertility rate of such patients has approached that of the non-
diabetic The cause of sterility is not definitely known but evidence would seem to
indicate that it is a hormone imbalance chiefly due to a decrease in pituitary gonodo-
tropins. In uncontrolled diabetes nutritional disturbances may also play an important
role.
Maternal Mortality.
The maternal mortality among diabetic pregnancies has shown marked and progressive diminuation in recent years. Not many years ago it amounted to 30%. With
modern methods this has been reduced in large series to the order of 0.4-0.8%. This
improvement has resulted from better diabetic control in part but largely from the
recognition and treatment of hormone imbalance.
Foetal Mortality.
The high incidence of foetal mortality in diabetic pregnancies is still a major problem. Different authorities quote rates in large series as high as 25-60%. Duncan states
that the incidence is still six times that of the non-diabetic—and further, that this high
figure prevails as well during he five years preceding the onset of diabetes in the mother.
If hormone balance is normal throughout pregnancy one can expect a foetal mortality
of only 4%. In genral, foetal mortality can be greatly reduced by: strict control of the
diabetes; prediction of toxaemia by increased serum prolan levels after the sixth month;
treatment of such toxaemia by cestrin and progestin; and emergency deliveries in cases
where toxsemia develops.
Abnormalities of Pregnancy When Complicated by Diabetes.
Let us now consider the more important abnormalities of the diabetic mother. White
has divided these into maternal, obstetrical, chemical, foetal and placental categories.
The maternal abnormalities may be further subdivided into two, namely, vascular disease and hypo-ovarianism. The diabetic shows widespread arteriosclerotic disease many
years before the non-diabetic These changes are diffuse and may involve kidney, coronary vessels, peripheral vessels and those of the retina. Usually the young diabetic woman
will show some of these changes after five years duration of her diabetics. Such changes
are marked when the disease has been present for fifteen or twenty years, so that the
woman who developed diabetes in childhood has widespread vascular disease by the
time she has reached marriageable age. After twenty years of diabetes seventy per cent
of women show these changes. Hypo-ovarianism manifests itself in amenorrhcea, men-
orrhagia, metrorraghia, chronic cystic mastitis, and retardation of growth. Diabetic
women have normal or high blood values for follicle-stimulating hormone and low
urinary levels of 17-ketosteriods. Such findings suggest a failure of gonad and/or
adrenal function. The high level of pituitary F.S.H. may be due to failure of suppression by ovarian follicular hormone. The diabetic woman is gynaecologically old before
her time. This is perhaps related to associated arteriosclerotic vascular disease. From an
Read at Staff Clinical Meeting, Vancouver General Hospital, October 9th, 1947.
Page 173 obstetrical viewpoint the diabetic woman often shows an increased uterine irritability.
This may result in contractures throughout pregnancy and lead to early spontaneous
rupture of membranes with loss of amniotic fluid but without delivery. Miscarriage is
common. The incidence of breech presentation is high. During labor uterine inertia is
often encountered.
Among the chemical abnormalities one finds a low renal threshold for glucose. This
complicates the control of the diabetes, since overtreatment will result in hypoglycemia
if control is based on urinary findings alone, and under treatment leads to acidosis.
There may be carbohydrate deficiency from loss of sugar in the urine, increased demands
from the foetus, and glycogen blockage in the tissues. Such carbohydrate deprivation
results in increased consumption of body fat with tendency to acidosis. The acidosis
causes anorexia and the resulting low food-intake in turn aggravates the deprivation of
carbohydrates. The pregnant diabetic is also prone to disturbance of water balance in
the direction of water retention. This abnormality leads to abnormal gain in weight,
oedema, by dr amnios, hydramia and foetal oedema. The most important chemical abnormality however is imbalance of the sex hormones. White states that this occurs in 80%
of cases. The usual findings in such cases are a low excretion of pregnandiol, a low
serum oestrin, a high serum chorionic gonadotropin, and disappearance of basophilic
cells from the vaginal smear. These changes are thought to be due to a failure of production by the ovary of progesterone and oestrogen and a compensating increase in
chorionic gonadotropins.
Foetal abnormalities are very common. The foetus tends to be larger than normal, owing to increased fat, oedema, and large size of the visceral organs, (splanchromegaly).
There may also be advanced bone development. The heart frequntly shows glycogen infiltration. Jaundice sometimes occurs with normal red blood cell count and no bleeding
tendency. Pulmonary atelectasis is found in all fatal cases and in one third of living
births. Congenital defects are present in 12% of infants as compared to 1.8% in the
non-diabetic .If the mother's diabetes is poorly controlled, islet cell hyperplasia is common in the foetus.
The placenta is usually large but occasionally may be very small. A thickened un-
bilical cord and placental infarcts are common findings.
The Management of the Pregnant Diabetic.
General Measures.
These include general hygiene and exercise. There should be close co-operation
between obstetrician and internist. The patient should be seen every two weeks in the
first and every week in the last trimester.
(A) Diet. An adequate diet should contain thirty calories per kilogram body weight
and should be increased parallel to gain in weight. Protein should be supplied at the rate
of two grams per kilo body weight. The diet should contain a minimum of 200 grams
of carbohydrate per day. The remainder of the caloric requirement can be made up in
fat. Adequate supply of vitamins A, B, C, D, E, and K, must be given. Calcium need
can be fulfilled with one quart of milk per day .Otherwise it may be supplied as calcium
lactate or gluconate by mouth.
(B) Insulin. Many authorities advise the routine use of insulin whether or not the
patient has needed it previous to pregnancy. There is usually a loss of carbohydrate
tolerance and increased insulin requirement in the first trimester. This requirement
may be three or four times the dose needed before conception. In general the insulin requirement increases with increase in weight. It should be given in sufficient dosage to
maintain normal blood sugar levels.
Management During the First Trimester.
If pernicious vomiting is encountered the patient should be given intravenous glucose and insulin may be necessary. Frequent small feedings every two or three hours may
be helpful. The insulin requirement nearly always increases durnig the first trimester.
Page 174
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^11] Management During the Second Trimester.
Having passed the first three months' period one does not usually have further
trouble during the second trimester .During this period the insulin and caloric needs
often remain at a constant level.
Management During the Third Trimester.
It is in this period that the major problems arise. One finds a great variation in the
carbohydrate and total food tolerance and with it therefore a great variation in insulin
requirement. If the diabetes has been under good control the insulin requirement increases steadily throughout the third trimester. If diabetic control has been poor there
may be a fall in hyperglycaemia and glycosuria owing to compensatory overactivity of
foetal islet tissue. Good control spares the foetal pancreas and prevents hypoglycajmia
in the new-born. Parallel to the increasing need for food and insulin there runs an increasing requirement for vitamin which is proportional to the total metabolism.
If oedema occurs salt restriction is indicated. Sodium bicarbonate is contraindicated.
The diet should be high in protein. Laboratory facilities for quantitative estimation of
serum and urine sex hormone levels are unfortunately not generally available, but where
they are they should be routine. If such procedures are not available substitution hormone therapy may be given according to dosage table suggested by White.
Daily or every second day.
Week of Pregnancy Prolution      Stilboestrol
20 5 mgm. 5 mgm.
20-24 10 10
24-28 15 15
28-32 20 20
32-36 20 25
36 15-50 30-50
Cesarean section should be done immediately with onset of signs of toxaemia.
Termination of Pregnancy.
Caesarean Section vs. Spontaneous Delivery.
There is considerable difference of opinion among the experts on this question.
Caesarean section spares the mother of normal labour but also adds a major surgical procedure. Some favour section unless the patient has had diabetes for less than five years
and has had a pregnancy which has been normal clinically and chemically. In this case
the diabetes PER SE is not considered an indication for section. If hormone levels have
been done then sponteneous delivery is probably best in those with normal serum prolan
values. Spontaneous delivery may be allowed also in those in which serum prolan is
reduced to normal by oestrin and progestin therapy. Caesarean section however should
always be done in those with failure of hormone control and immediately with onset
of signs of toxaemia.
Treatment During Labor and Delivery.
The incidence of ketosis in prolonged labour will be greatly lowered if the patient
is routinely given 10-15 grams of carbohydrates per hour during labor T.his may be
given by mouth or as 10% glucose in distilled water intravenously. Regular, insulin
should be given in small doses every four hours according to urine sugar determinations.
If delivery is normal sedation should be minimum. Spinal anaesthesia is the anaesthesia of
choice. Spinal, caudal, or nitrous-oxide, and episiotomy are advised for the third stage.
Following delivery the obese mild case soon gets along without insulin. However if the
diabetes was not controlled during pregnancy and the foetal pancreas was overactive
the patient may need more insulin post partum. Usually it is wise to give regular
insulin two or three times a day after delivery for a few days. A six-hour program of
feedings and insulin is an excellent routine. In this way the twenty-four hour feeding is
divided into four parts of equal caloric and carbohydrate value and the insulin divided
into four equal doses. Intravenous glucose in water should, be repeated twice daily for
Page 175 three days post partum. One hundred grains of carbohydrate in warm liquid by mouth
may be given daily and soft diet started by the fourth day.
Post-Partum Complications.
Eclampsia may follow delivery as in the non-diabetic Similar treatment is advocated
pllus control of the diabetes. Eclampsia must be differentiated from hypoglycaemia. Pye
lonephritis is treated with sulfadiazine, penicillin, mandelate or streptomycin, depending on the infecting organism. Lactation seldom occurs in the diabetic mother. This may
be due to failure of pituitary lactogenic hormone. In the rare instance in which the
mother does nurse her baby she may need less insulin while nursing. The lactating
mother may be very sensitive to insulin. Since the presence of lactose or lochia in the
urine will give false urine sugar tests, the insulin dose must be controlled by frequent
blood sugar determinations.
Prognosis of the Child.
The infant born of the diabetic mother faces increased hazards in early life, but if
he survives his ultimate outlook is good. Neo-natal mortality in the experience of White
in recent years is only 4% as compared to the non-diabetic of 3%. Mortality rates in the
first year are now only 5%, th esame as the non-diabetic The child cannot inherit diabetes from the mother alone. Diabetes is a recessive Mendelian trait and unless the father
has diabetes or carries a recessive factor for diabetes the child will not develop the disease.
References
White—Treatment of diabetes mellitus—1946. Joslin et al.
Duncan—Diseases of Metabolism—1947.
LOW BACK PAIN
By F. P. PATTERSON
TABLE I.
Classification of Low Back Pain Excluding Posture, Dists, and Fractures
A. Extrinsic.
1. General Infectious—Poliomyelitis, Meningitis, Onset of Infectious Diseases
2. Genito-Urinary Lesions—Prostate, Cervix.
3. Gastro-intestinal Lesions—Cancer of Rectum.
4. Senile Osteoporosis.
5. Psychiatric
Intrinsic.
B
I. Congenital Anomalies
(a) Spina Bifida.
(b) Sacralization—Unilateral and Bilateral
(c) Hemivertebra with Scoliosis
(d) Congenital Dislocation of the Hip
(e) Spondylolisthesis
II. InYammatory Lesions
(a) Pyogenic Osteomyelitis
1. Acute
2. Subacute, Insidious Onset
3. Chronic
(b) Tuberculosis
(c) Marie Strumpell Spondylitis
(d) Fibrositis
jjm>
Presented at Staff Clinical Meeting, Vancouver General Hospital, Dec. 23rd, 1947.
Page 176
1 III. Degenerative Lesions.
(a)  Osteoarthritis
IV. Neoplastic Lesions
(a) Primary Bone and Spinal Cord Tumours
(b) Secondary
V. Traumatic
(a) Contusion
(b) Muscle and Ligament Sprain
(c) Sacro-iliac Strain—Including Pregnancy
(d) Lumbosacral Strain
(e)  Aggravation of Pre-existing Conditions. .
The portion of this symposium allotted to me deals with low back pain excluding
fractures ,intervertebral disc lesions, postural back ache and pain referred to the back
from the pelvis.
A classification on an etiological basis if offered. (See Table I.) This is incomplete
but will serve the purpose for tonight.
Of foremost importance is the history and examination. This should include first
a general history and examination to avoid many errors .It is important to know the
type of pain, with its onset, gradual or acute; whether or not preceded by injury and in
what manner it is affected by rest, motion, posture, etc.
In the physical examination the patient should be completely undressed. One should
note deformity, such as scoliosis, trunk list and tilt of pelvis. Spinal motion in various
planes is observed noting how the patient bends as well as the extent. Points of tenderness are of great importance and frequently are the main sign in arriving at a diagnosis.
Hamstring spasm, tested by straight leg raising, flexion deformity of the hips causing
an increased lumbar lordosis and many other features should be noted. A neurological!
examination, including reflexes and sensations, is to be included, and rectal or pelvic
examination is part of the general physical examination. In the majority of cases x-rays
should be made of the spine and pelvis with particular reference to the lumbosacral
region.
The classification is as shown and is divided into two main groups. The extrinsic are
those which should be ruled out by the general examination. The main factor of diagnostic value is that it is rarely, if ever, that these so-called extrinsic back pains are affected by posture or motion of the body.
Of the intrinsic low back pain group, first are the congenital anomalies:
(a) Spina Bifida is mentioned only because of the frequency of its appearance radio-
logically. It is rarely, if ever, a cause of low back pain.
(b) Sacralization of a 5th lumbar vertebra is considered to be evidence of a transitional
state in the evolutionary process. This may be unilateral or bilateral. Many think
that pain or disability is much more common with the former than the latter.
This anomaly is seen quite frequently but is not often a cause of pain. Its presence
is a factor predisposing to low back strains. If the lumbosacral region is more stable
because of sacralization, the joint between the 4th and 5 th may be more unstable.
Lesions such as disc protrusions between the 4th and 5 th are not uncommon in
such a case. If the fusion of the transverse process to the iliac bone is incomplete
and at this site sclerosis of bone is seen it is probably indicative of arthritic changes.
This may require treatment such as a support in the form of a belt or corset.
(c) Hemivertebra is mentioned as it is occasionally seen and is likely to be the cause of
a congenital scoliosis.
(d) Congenital Dislocation of the Hip may cause pain in the lumbosacral region owing
to the increased lumbar lordosis resulting from the flexion deformity of the hip,
or from postural change due to a short leg.
(e) Spondylolisthesis is a term which indicates a forward slipping of one vertebra on
another, due to a defect in the pedicles of the vertebra. It is most commonly seen
Page 177 ■^E-mm
at the 5 th lumbar. The neural arch remains fixed posteriorly and the body is displaced forward. The defect in the pedicles may be present without displacement
and the condition is then called pre-spondylolisthesis or spondylolysis. This condition is very much more common than ordinarily supposed.
The patient may be seen because of gradual onset of pain of a fatiguing nature, or with an acute onset following trauma. It is present in the lumbosacral
region, with or without sciatica, and is aggravated by bending and lifting, particularly the latter. The physical signs may vary, depending on the severity. The trunk
may appear shortened with the thorax sunk into the pelvis. Transverse soft tissue
folds may be present in the loins and there may be forward shift of the spine. This
may be palpable with a prominence of a lower spinous process which is posterior.
There is limitation of spine motion with increased pain on backward bending. The
diagnosis is confirmed by x-ray.
Treatment consists in rest, avoiding lifting, and back support in the form of a
belt, corset or brace. In cases unrelieved by conservative treatment stabilization of
die spine by fusion operation may be necessary. This anomaly is of importance in
industrial cases where disability frequently results owing to aggravation by trauma.
I. INFLAMMATORY LESIONS
(a) Pyogenic Osteomyelitis is of three types:
(1) That with acute onset is a fulminating disease of considerable severity.
The patient is acutely ill with severe pain unrelieved by rest, marked muscle
spasm, fever and leukocytosis. The treatment consists of management of the
infection and rest of the spine.
(2) The more common type is the subacute, of insidious onset, in which
there may be no fever, but presence of more or less constant pain, not relieved by rest with muscle spasm and restriction of motion. X-Rays will
show rarefaction of bone with areas of bone destruction and reactive new
bone formation. Treatment is that of the infection plus long term splinting
of the spine usually in bed on a frame or in plaster.
(d) In Chronic Osteomyelitis of the spine the diagnosis is made by history
and the presence of sinuses and x-ray changes. The treatment is prolonged,
unsatisfactory and the prognosis poor.
(b) Tuberculosis of the spine occurs more frequently in the dorsal or upper
lumbar than in the low back. It also occurs in the sacro-iliac joints. Tuberculosis of the spine is the commonest site of bone tuberculosis in children. It
is a slowly progressive disease with pain even at rest. Physical signs may consist of general signs of tuberculosis such as weight loss, night sweats, active
sedimentation rate and spinal deformity, such as kyphosis, muscle spasm,
limitation of motion and tenderness. X-Rays reveal a destructive lesion
without new bone formation and at first one might see only some narrowing
of an intervertebral space with increased perivertebral shadows from abscess
formation.
A search for tuberculosis elsewhere should be made. Treatment consists
of prolonged bed rest on frame or in plaster, prevention of deformity and
sooner or later spinal fusion operation.
(c) A third inflammatory lesion to consider is the severe crippling disease called
Marie Strumpell Spondylitis. It usually affects young males about 20 to 30
years old. The onset is usually in th6 sacro-iliac joints with extension up the
spine and eventual fixation. Ocassionally the onset is in other large joints such
as the hips. If untreated the patient will be deformed with fixed flexion of the
trunk. In nearly every case the thorax is involved with fixation and marked
diminution of chest expansion. The complaint is pain and stiffness and the
outstanding feature seen in the rigidity of the spine—usually with flexion.
It is interesting to note that these patients are often shorter in height in the
evening than in the morning, due to flexion. There is usually a secondary
Page 178
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«
* .'■■'--•■$- »•■'■'" ®fl
■J     ,-.- .-■ - r   ;    «."_
■ ^'>,";-' anaemia and an active sedimentation rate. X-Ray findings reveal sacro-iliac
arthritis, often with ankylosis as the first sign. Later on one sees calcification
in the ligaments of the spine with the typical bamboo spine.
Treatment consists of rest, elimination of the infection, and prevention or
correction of deformity. The latter is done by splinting, traction and immobilization. The patients require combined medical and orthopaedic care.
When the disease is quiescent, the patient may be up and often will require
a brace. The prognosis depends to a great extent on the success achieved in
preventing deformity. After a period of ten to fifteen years as a rule progress
ceases and if ankylosis is complete, the patient is then free of pain.
(d) Fibrositis vs often called muscular rheumatism or lumbago. This is a nonsuppurative inflammatory lesion affecting fibrous tissues, and muscles. It affects both sexes and different age groups. The etiology is unknown. Focal
infection, climate and occupation are considered to be causative factors. The
diagnosis is made by the presence of pain associated with tender areas, usually at muscle attachments. Sciatic radiation may be present. Treatment involves rest, heat, novocaine injections of tender areas followed by massage
and exercises, and elimination of infection.
III. Of the degenerative lesions, ostoearthritis is of major importance. This is a very
common cause of low back pain occurring in an older age group, more commonly
in males. There is pain, limitation of motion and x-ray changes. Treatment consists of rest, restriction of activity and support in the form of a belt or brace. A
firm bed with fracture boards is often beneficial, and local heat frequently gives
temporary relief.
If arthritic changes are seen confined to a localized area, in younger patients
it is usually indicative of a localized response to trauma. This is most frequently
seen at the lumbosacral region and frequently here one also sees associated with
it disc lesions. In these cases in which adequate conservative treatment has failed,
operative treatment may be useful.
IV. Of the neoplastic group very little will be said. Primary tumours are very rare and
are usually haemangioma, sarcoma or Ewing's tumour. Spinal cord tumours may
be a cause of back pain.
Secondary tumours from breast, bronchus, thyroid, prostate, uterus and kidney occur and show multiple lesions with pain not relieved by rest, and occasionally
pathological fractures.
V. The Traumatic Group is the largest group seen.
(a) Contusion is similar to that seen seise where. Resulting from a blow, there is
bruising, pain, muscle spasm and tenderness. Treatment consists of rest, a
firm bed, possibly adhesive strapping and later physiotherapy.
(b) Muscle and ligamentous sprain may be similar to contusion. This results
from trauma and lifting, or falling and wrenching the back. The pain may
be severe, and rest, heat and support by adhesive strapping may be all that
is necessary. If a well localized tender area is present, novocaine injection
is beneficial combined with the other treatment.
(c) Sacro-iliac strain is mentioned as a definite entity. Strains of this joint do
occur, although infrequently. Many of the cases formerly labelled sacro-iliac
strain were probably disc lesions. It is a stable joint which is not easily injured. Actual subluxation is most uncommon.
During and following pregnancy there is very definite relaxation of the
joint. This may be extremely marked. The clinical picture then shows pain
and tenderness in the region of the joint, limitation of flexion of the spine
through the last portion. This may not be noticed with the patient sitting
down. There is limitation of straight leg raising. In old sacro-iliac conditions arthritic changes are frequently seen by x-ray.
Page 179 Treatment consists of rest, support by a belt or corset and occasionally
physiotherapy. In acute sacro-iliac sprain manipulation is frequently indicated.
(d) Lumbosacral strain is the name given for the majority of conditions which
cause pain in the low back. It is very common, and with good reason, for this
is the most unstable portion of the spine, which is in a transitional state between the mobile spine and fixed pelvis. There are numerous ligaments and
muscles supporting the joint, and many variations from the normal bony
architecture. Disc protrusions are most commonly seen at this level. Lifting
or bending injuries are usually the cause of the pain. There is localized pain,
tenderness, muscle spasm and limitation of motion, frequently with some
fixation of the lumbar curve. There will usually be limitation of straight
leg raising with hamstring spasm and pain in the lumbosacral region on passive spine flexion. A true lumbosacral strain is a ligamentous sprain. It is
often impossible to know exactly what the pathological lesion is.
The treatment includes adequate rest with fracture boards, strapping
the back, limitation of activity and heat. Later more vigorous physiotherapy with exercises for rehabilitation, and in the chronic cases support in
the form of a wide pelvic belt, brace or corset.
(e) Pre-existing anomalies which have been aggravated by trauma include a
fairly large group of patients. In these the recovery is slow and prognosis
often doubtful. Some will eventually require operative treatment.
In conclusion I wish to emphasize the complexity of the problem and the impossibility of making a quick diagnosis without a proper history, physical examination and
investigation. In addition to this there is the second very important factor dealing with
treatment. This is to emphasize the importance of conservative treatment for a good
trial before considering operative interference, in spite of an apparent clear cut diagnosis. It will be found that the vast majority of patients will be relieved in time without
operative treatment. It should also be noted that no patient is entirely free of disability
following any operation on the back.
MEDICAL MANAGEMENT AND HYPERTENSION
By F. CROFTON, M.D.
This is one of the many unsuccessful chapters in therapeutics. The fundamental
causes of essential hypertension are obscure and so far we can neither remove nor combat them. Medical treatment of essential hypertension has not changed in the last
twenty-five years.
Salt Restriction.
One of the older forms of treatment has been salt restriction. Allen and Sherrill reported good results with this treatment. However they were not confirmed by other
investigators. McLester, O'Hara and Walker did not obtain better results with severe
salt restriction than with moderate restriction. Mosenthal, Berger and Feneberg cut
down salt intake, then raised it above normal with no significant change in blood
pressure. Renger and Billoon did not obtain better results than with ordinary treatment.
Nitrites and Nitrates.
These drugs produce only temporary lowering of blood pressure with a temporary
rise following. Grollman in 1940 reported testing sodium nitrite, erythrol tetranitrate,
allium sativum, acetyl beta-methylcholine, potassium thiocyanate and sodium chloride
Read at Staff Clinical Meeting, Vancounver General Hospital, March 27, 1947.
MiitgH
;K*   i '. ■' t-
to--', ii;
■■ ■■'■'■&&& Mi
Page 180
•*?*?*•*■•' on experimental hypertensive animals without lowering of blood pressure. He found
only renal extracts produced lowering of blood pressure.
Renal Extracts.
Stevens et al treated a few patients with kidney extract; some had lowering of blood
pressure but also fever and hypersensitivity reactions. They considered it too toxic at
present. Schales, Stead and Warren treated seven patients with significant lowering of
blood pressure in five, related directly to amount of fever, sweating, weakness and local
reactions. Patients with no reactions had no lowering of blood pressure.
Vitamin K.
Rosenthal and Shapior gave synkayvite to fourteen patients, 25 mg. orally daily
for three to six weeks, and claimed fair results. However, the blood pressure drop was
not significant and could have occurred in the course of normal variation.
Moss and Wakerlin reported no effect of vitamin K on experimental hyptertensive
dogs.
Vitamin A.
Taylor et al studied effect of vitamin A on sixteen patients without any significant
change in blood pressure.
Moss and Wakerlin in December, 1946, reported the effect of various vitamin A
products on experimental hypertensive dogs and found varying responses depending
on the preparation and different lots of the same preparation. They feel fairly sure that
this anti-hypertensive principle is not vitamin A but some impurity and they have yet to
separate and identify it.
Potassium Thiocyanate.
This drug has had periods of popularity and there are many reports of its effective
use. However, it is a toxic drug and there is little difference between the blood concentrations that produce therapeutic and toxic effects.
Goldring reports it as causing effective lowering of blood pressure in 30% of
sixty-nine cases. However, he had thirteen cases of toxicity and two deaths.
Many patients had subjective improvement without lowering of blood pressure.
In most cases the results claimed are no better than those by other less dangerous
methods. The drug is not accepted by the American Council on Pharmacy and Therapeutics.
Drugs and Other Compounds.
Many papers have been written advocating a great variety of treatments.
Ayman made a study of thirty-five papers. Some of the methods of treatment
were:-
1. Irradiation of suprarenal region.
2. Mistletoe.
3. Low.salt diet.
4. Liver extract.
5. Radium to skull.
6. Dia therm v.
7. Corpus Luteum.
8. Subtonin.
9. Watermelon extract.
10. Calcium salts and low protein diet.
11. Benzyl benzoate.
12. Benzyl succinate.
13. Radium water.   •
to mention a few of the less bizarre ones. Practically every article claimed complete
or partial symptomatic relief. In the majority of cases there was a moderate reduction
in blood pressure, in a few cases marked reduction. However, symptomatic relief was
greater than one would expect from blood pressure drop and frequently out of all
proportion to blood pressure fall. Sometimes marked  relief occurred without blood
Page 181 pressure drop. Ayman then teated forty unselected cases with dilute hydrochloric acid
with enthusiasm and 82% showed definite improvement of symptoms.
O'Hare in reporting average drop of 34 mm. systolic pressure in twenty-five cases
treated with mistletoe admits that on the basis of past experience such variations occur
without therapy. He also- noted that patient's blood pressure drops gradually and to
a considerable extent on every visit up to five or six visits to his office even without
treatment. Other men have reported these constant variations in blood pressure. These
variations make it extremely difficult to evaluate the true worth of any type of treatment.
In view of these findings it would appear best to use a simple routine for the treatment of hypertension. Patients should not be told what their blood pressure level is, only
that it is slightly above normal, so as to prevent them from develloping a phobia over
it—feeling much better when it is down a few points and worse when it rises a few
points. The blood pressure should be taken infrequently. If overweight patients should
be given a reducing diet. To quote Wilkins—"instability, anxiety, fear, resentment and
alternate aggression or dependence are typical emotional attitudes of these patients.
They are sensitive to petty annoyances and especially to personal slights and disagreements. Self-recrimination for these traits is also commonly indulged in and they may
revolve in an emotional vicious circle, especially when they have been told that
emotionality affects the blood pressure."
The patient will derive a great deal of benefit subjectively if the doctor gives him
sympathy, encouragement and reassurance, and listens to his personal troubles and
difficulties. Sedatives such as phenobarbital given t.i.d. are of great benefit in cutting
down the patient's anxiety and tension. They should be encouraged to sleep long hours
if possible and rest for an hour or so during the day. They should be encouraged to
slow down generally but to continue with mild, not too strenuous exercise, and to take
as many vacations as financially possible.
In treatment of complications, cardiac failure is benefitted by treatment with digitalis, diuretics and bed rest.
I will end with two reports on results of sympathectomy. Ryland reports forty
patients with generally poor results; one, brilliant result; five, fair result; nine, no
change; eight, died within two weeks of operation; eleven died within one and one-half
years.
Flaxman compares 244 of his medically treated cases with 350 of Peet's surgically
treated cases. He did not consider subjective symptoms, cardiac status, slight blood
pressure changes as subject to personal interpretation. He found significant blood pressure drop in comparatively the same percentage and mortality in the two series the same.
The number of cases of malignant hypertension alive at the end of five years was the
same in both series.
'     1
wist
'■'    VTw'i
BIBLIOGRAPHY
Allen, E. V. and Adson, A. W.—The Treatment of Hypertension:  Medical versus
Surgical. Ann. Int. Med. 14: 288, 1940.
Ayman, D.—Present Day Treatment of Essential Hypertension. Med. Clinics of N.A.
28: 1141, 1944.
Ayman, D.—An Evaluation of Therapeutic Results in Essential Hypertension. J.A.M.A.
96: 2091, 1931.
Bing, R. J. and Thomas, C. B.—The Effect of Two Dioxane Derivatives on Normal
Dogs and on Animals with Neurogenic and Renal Hypertension. J. Phar. & Exper.
Ther. 83: 21, 1944.
Binger, C.—A Critique of Psychotherapy in Arterial Hypertension. Bull. New York
Acad. Med. 21: 610, 1945.
Berger, S. S. and Feneberg, M. H.—The Effect of Sodium Chloride on Hypertension.
Arch. Int. Med. 44: 531, 1929.
Page 182 Del Solar, A.—Fatal Poinsoning from Potassium Thiocyanate used in the Treatment of
Hypertension. Arch. Int. Med. 75: 241, 1945.
Fanson, E., Kindsey, D. and Palmer, R. S.—Potassium Sulphocyanate in Essential Hypertension. New Eng. J. Med. 229: 540, 1943.
Flexman, N.—The Treatment of Hypertension: Comparison of Mortality and Medically and Surgically Treated Cases. Ann. Int. Med. 20: 120, 1944.
Golding, W.—The Management of Hypertension. Bull. New York Acad. Med. 19: 317,
1943.
Grollman, A., Harrison, T. R. and Williams, J. R.—The Therapeutics of Experimental
Hypertension. J. Pharm. & Exper. Therap. 69: 76, 1940.
Grollman, A.—Preparation of Extracts from Oxidized Marine and other Oils for Reducing Blood Pressure in Experimental and Human Hypertension. J. Pharm. &
Exper. Therap. 84: 128, 1945.
Grollman, A. et al—Sodium Restriction in the Diet for Hypertension. J.A.M.A. 129:
533, 1945.-
Gnebea, C. M. and Shackelford, H. H.—The Effect of Phenobarbital on Blood Pressure
in Arterial HypertenJaon. Arch. Int. MMed. 36: 366, 1925.
Kurtz, C. M. et al—Results of Sulphocyanate Therapy on Hypertension. Amer. J. Med.
Sc. 202: 378, 1941.
McLester, J. S.—Influence of Rigid Salt Restriction in Diet. Am. J. Med. Science. 163:
794, 1922.
Moss, W. G. and Wakerlin, G. E.—Vitamin A in the treatment of Experimental Renal
Hypertension. J. Pharm. & Exper. Therap. 86: 355, 1946.
O'Hare, J. P. and Walker, W. G.—Observations on Salt in Vascular Hypertension.
Arch. Int. Med. 32: 283, 1923.
Rosenbluth, M. B.—The Practical Management of Hypertension. Bull. New York
Acad. Med. 20: 557, 1944.
Rosenthal, N. and Shapiro, S.—The By-Effects of Anti-haemorrhagic Quinones. J.
Pharm. & Exper. Therap. 85: 294, 1945.
Schales, D. and Stead, E. A.—Non-Specific Effect of Certain Kidney Extracts in Lowering Blood Pressure. Am. J. Med. Sc 204: 797, 1942.
Wakerlin, G. E. and Johnson, C. A.—Treatment of Experimental Hypertension with
Vit. A. concentrates. J.M.A. 122: 60, 1943.
Wald, M. H. and Lindberg, H. A.—The Toxic Manifestations of the Thiocyanates.
J.A.M. 112: 1120, 1939.
Walkins, H.—The Treatment of Hypertension. Med. Clin. North Am. 30: 1079, 1946. A STUDENT'S APPEAL TO THE GENERAL PRACTITIONER
DONALD B. McCONACHIE
National Director of Public Relations, C.A.M.S.I., Toronto, Ontario
(Reprinted from February Issue, Canadian Medical Association Journal)
Are you interested in furthering the art of general practice in Canada? The Medical
students of Canada are!
At its eleventh annual conference in November, The Canadian Association of Medical
Students and Interns incorporated ito the miutes of a motion, the essence of which is,
"Whereas there is a growing problem of inadequate medical care in some communities
of Canada, and whereas there is a decreasing incentive for medical students to seek
general practitioner careers, and whereas the incentive to specialize is increasing out of all
proportion to the country's need, therefore be it resolved that—C.A.M.S.I. favor the
principle of stimulating more interest in general practice. . . ."
What lies behind this "incentive to specialize" that is so evident in Canada's medical
colleges today? It may be a result of uncritical monetary consideration on the part of
the student. It may be that modern literature and the cinema have influenced the student to consider the specialist as a figure of some romance—a glorified Martin Arrow-
smith. More probably it is simply ignorance on the student's part as to the function,
need, and value of a general practitioner in a community. Throughout his entire medical
course the student is lectured to by specialists in every subject, he observes large laboratory facilities for making complicated diagnoses, he takes clinics in large hospitals admirably equipped for the specialist approach to every condition. How many bewildered
students are heard to remark, "I'm certainly going to specialize! However, can I
remember everything about everything? How could I be safe in drawing any conclusion
if stuck 'up-country' with no bacteriologist ,no pathologist? . . ."
Yet, despite the fears voiced by such students, the general practitioner in Canada is
still maintaining the high standards of medical practice. Since he is deprived of some
of the more highly specialized media for diagnosis and treatment, he must have some
other means at his disposal in order to maintain these standards and these are experience,
and integrity; experience in recognizing the signs by the methods available to him, and
integrity in deciding the course of action.
The whole problem, therefore, seems to be one of education. CA M.S.I. has initiated
a plan in order to bring this education to the student. Efforts are being made to familiarize all general practitioners through the country with the scheme, which essentially
is this: the doctor is urged to accept a medical student during the summer months as an
apprentice. These clinical year students, besides being of aid to the physician (by doing
routine blood work, etc.) will have an opportunity of viewing first-hand the functioning of a community doctor. He will be able to observe techniques and methods perhaps
not emphasized at college, he will see an aspect of the doctor-patient relationship not
seen in his clinical classes, and it is hoped he will be able to discern something of the
unique position of the doctor in his community.
Doctors who are interested in this plan are invited to write to the National Executive
of C.A.M.S.I.: Miss Joan Vale (Secretary, C.A.M.S.I.) Room 107, Anatomy Building,
University of Toronto, Toronto 2, Ontario. Those writing should include their names,
addresses, and special qualifications required of the student if desired. All such names
received will be sent at once to the various medical schools in the country. The student
will then complete the arrangements in a personal basis.
You are reminded that this scheme applies to all provinces. Although it actually
acts regionally, all initial arrangements are made through the National Executive to
insure complete distribution.
The C.A.M.S.I. is most concerned that the true value of the general practitioner be
made known to the student, and urges the co-operation of all doctors in solving this
problem of education.
/!•'.*•
nsip
Page 184 all
We regret to record the death of one of our pioneer M.D.'s, Charles M. Kingston.
Dr. Kingston graduated from Trinity Medical School in Toronto and did post-graduate
study in surgery in New York. He practised in the Grand Forks district of British
Columbfo for over forty years, before retiring to West Vancouver two years ago. He
built and operated the hospital at Grand Forks, doing most of the hospital surgery as
well as his general practitioner's duties. In 1928 Dr. Kingston was elected MX.A. for
Grand Forks-Greenwood.   We extend our sincere sympathy to Mrs. Kingston and family.
We note with interest that Dr. W. C. Gibson of Victoria has accepted an appointment at the University of Sydney in Australia, where he will teach neuropathology and
conduct research in nervous and mental diseases.
Dr. D. E. H. Cleveland attended a meeting of the Los Angeles Dermatological Society
during February, at which tentative plans were made for the organization of a Western
Dermatological Society.
We extend our heartiest congratulations to Dr. R. B. White, who has been named
Penticton's First Citizen for 1947-48,* the first time the distinction has been given to
anyone. Dr. White's name will head the list of ''good citizens" on a bronze plaque to
which annual additions will be made.
Dr. S. A. Strachan has recently gone to Kimberley for a short period to relieve Dr.
H. I. O'Callaghan while the latter visits the Old Country.
Dr. G. C. Robinson of Vancouver is now associated with the Hospital for Sick
Children in Toronto.
Our deepest sympathy is extended to Dr. Elaine Peacock on the death of her father,
and to Dr. J. K. Kelly on the loss of his mother.
We regret to record the death of Dr. Wilfrid Stringer, who died suddenly at Port
Alberni only two days after he had arranged to start practice there. Dr. Stringer was
a Surgeon Lieutenant-Commander with the Royal Canadian Navy during the last war
and has only recently registered with the College of Physicians and Surgeons of British
Columbia.   We extend our sincere sympathy to Mrs. Stringer and family.
Dr. N. B. Reilly has left Montreal to accept an appointment with the Royal Jubilee
Hospital in Victoria.
Dr. J. W. Neville, formerly of Kamloops, has gone to Williams Lake to practise.
Dr. I. B. Cameron of Youbou is now associated with the Irving Clinic in Kamloops.
Dr. D. M. Boyd has left Cowichan to do post-graduate work in Toronto.
Dr. A. E. Shore, formerly of Calgary, Alta., has recently settled in Victoria.
Dr. L. C. Grisdale has left Langley Prairie and is now associated with the Royal
Alexander Hospital in Edmonton, Alta.
Congratulations are extended to the following doctors and their wives on their recent.
good fortune: Dr. and Mrs. S. Z. Bennett, Salmon Arm, a son. Dr. and Mrs. W. S. Maddin, Van-
ouver, a son. Dr. and Mrs. W. J. S. Melvin, London, England, a son. Dr. and Mrs.
}. R. Warriner, Vancouver, a son.
Dr. J. S. Cull, for ten years deputy provincial health officer, will leave that position
o become a provincial medical director in the Canadian Red Cross Transfusion Service.
Dr. W. O. H. Perry has left Shaughnessy Hospital to take up residence in Montreal.
Dr. A. J. Kergin of Prince Rupert is, at present, doing post-graduate work in
[oronto.
Dr. A. L. Lynch, since 1934 chief medical officer for the C.P.R., has resigned. Dr.
j. A. Petrie has been appointed to succeed him, according to an announcement from
jeorge H. Baillie, vice-president of the Pacific region.
ANNOUNCEMENT
MRS. D. M. ARCHER  |
Until recently, in charge of the Physiotherapy department,
Shaughnessy Hospital, Vancouver
and
MISS E. J. ELY
Recent adviser in physiotherapy to:—D.G.M.S., Ottawa
Have opened offices at 1470 West 12th Avenue, Vancouver, for the
practice of physiotherapy under medical direction.
Members of Canadian Physiotherapy Association.
Chartered Physiotherapists (B. C.)
CEdar 6644 1470 West 12th Ave., Vancouver
ARTHRITIS and ECZEMA
of endogenous origin
claimed to be allergic, may be
favored or induced by calcium
and sulphur deficiency, impaired
cell action, and imperfect elimination of toxic waste.
LYXANTHINE ASTIER
administered per os, brings about
improved cell nutrition and activity, increased elimination, re-
suiting symptom relief, and general functional improvement.
Write for Information
L-17
Ciiiiiitiietn D/sf rihulors
ROUGIER FRERES
350  Le Moyne   Street,  Montreal
Nuttn $c
1
2559 Cambie Street
Vancouver, B.C.
<•
Page 186 "MERCURIAL DIURETICS IN HEART FAILURE— . . . They
often yield splendid results in individuals in whom physical signs of
dropsy are lacking but water retention is demonstrated by the
large loss of weight that follows the administration of a diuretic."
Fishberg, A. M.: Heart Failure, 2nd Ed., Phila., Lea & Febiger, 1946, p. 733.
"IN PERSONS WITH HYPERTENSION and in instances of heart
failure with pulmonary congestion but without peripheral
edema, mercurial diuretics may be helpful in hastening the loss
of sodium or in permitting a somewhat more liberal diet. . . .
In most cases hypertensive patients with normal blood urea
levels can be safely tried on sodium depletion."
The Treatment of Hypertension, editorial. J. A. M. A. 135:576 (Nov. 1) 1947.
". . . [By] the more frequent usage of the mercurials in cardiac
dyspnea the attending physician . . . PROLONGS THE LIFE AND
COMFORT of his patient."
Donovan, M. A.: New York State J. Med. 45:1756  (Aug.  15)  1945.
I
aaLaumz
J
MERCUHYORIN
Meralluride Sodium Solution
vjeLl ioLEtatsd iocaLLu, a diWisiic of choice
• "Local effects of intramuscular injection. . . . The result!
strongly favored MERCUHYDRIN."
Modell, W., Gold, H. and Clarke, D. A.: J. Pharm. & Exper. Therap. 84:284 (July) 1945.
• "The authors favor the  administration  of mercury intramuscularly
rather than intravenously and for this purpose employ
preparations such as MERCUHYDRIN."
Thorn, G. W. and Tyler, F. H.: Med*. Clin. North America (Sept.) 1947., p. 1081.
• "The results of our experiments suggest that the greatest
cardiac toleration for mercurial diuretic occurs with
MERCUHYDRIN."
Chapman, D. W. and Shaffer, C. F.: Arch. Internal Med. 79:449, 1947.
• "We have limited the use of chemical diuretics almost
entirely to . . . MERCUHYDRIN."
Weiser, F. A.: Grace Hospital Bulletin, Detroit (Jan.) 1947, p. 25.
ak&±Ldz
auoxaboxLzi, i n c
For Literature, Write
MARSH, WILDE & CO.
628 Vancouver Block
Vancouver, B.C.      Phone PA. 8818

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