History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1943 Vancouver Medical Association Oct 31, 1943

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       t wHir
of the
MEDli^IMS«wB)N
Vol. XX.
OCTOBER, 1943
No*^
With Whu%$£ Incorporated
■ Transactions of the
Victoria Med^^^mocie^
the
Vanemiverpeneral^o
and-
St Pc^mH0S^S'\--:
In This Issue:
NEWS AND KOTES
PROVlJg^LAL BOARD CS^EAjgpl_........'.' 	
^^^P^JJSIQ^^^^^^ - -----
THE SEX STEROID^ifiGENE^H^MEDl<|Ki^(tW^C
19 Diethyl-stilboestrol diproplonate,
A synthetic oestrogen for
oral administration
Diethyl - stllboestrol
diproplonate It proving especially valuable
In the treatment of
Prostatic ffeopfasms.
Under Its definitely
an tl-androgenic
Influence, prostatic
growths ^often and
diminish In size,
urinary retention decreases, and patients
report easing of pain.
ORESTOL C.B.S.
is available in bottles
of 100 or 500.
C.C.T, §530—0,5 mg.
C.C.T. §531 —1.0 mg.
C.C.T. §532 — 5.0 mg.
ORESTOL  E.B.S.,
the dipropionate of diethyl-
stilboestrol, has been found to
be less toxic, and to give effective relief, for
longer periods, than the parent compound,
diethyl-stilboestrol. (Freed, Eisin, and Greenhill,
J.A.M.A., Vol. 119, No. 17, p. 1412-1414).
The Council on Pharmacy and Chemistry of the
American Medical Association accepted, over a
year ago, *(JA.MA., June 20,1942) the use of
diethyl-stilboestrol, for the following conditions:
Senile Vaginitis Kraurosis Vulvae
Gonorrhoeal Vaginitis ^Infantilism in Women
Menopausal Symptoms
•Since the above report was published, extensive research,
in U.SJL particularly, is corroborating the findings of
earlier investigators that the oral administration of
diethyl-stilboestrol and its derivatives is of definite value
in treating: Suppression of lactation, breast engorgement,
dysmenorrhoea, amenorrhoea, habitual abortion, hypersexuality in the male, and prostatic neoplasms.
Wh*n
Prescribing
SjMctfy E.B.S.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TOPONfO
MANUFACTURING   CHEMISTS
CANADA BRITISH
liovi
43
THE   VANCOUVER   MEDICAL   A S jjOCXA T I O N
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Asociation
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Dr. 6. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XX.
OCTOBER, 1943
No. 1
OFFICERS, 1943-1944
Db. A. E. Thites Db. H. H. Pitts Db. J. R. Neilson
President Vice-President Past President
Db. Gobdon Bubke Db. J. A. McLean
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Db. J. R. Davies, Db. Fbank Tubnbull
TRUSTEES
Db. F. Bbodie Db. J. A. Gillespie Db. W. T. Lockhabt
Auditors: Messbs. Plommeb, Whiting & Co.
SECTIONS
Clinical Section
Db. J. W. Milleb Chairman Db. Keith Bubwell Secretary
Eye, Ear, Nose and Throat
Db. C. E. Davies Chairman Db. Leith Websteb Secretary
Pediatric Section
Db. J. H. B. Gbant Chairman Db. John Pitebs Secretary
STANDING COMMITTEES
Library:
Db. A. Bagnall, Chairman; Db. F. J. Bulleb, Db. D. E. H. Cleveland,
Db. J. R. Davies, Db. J. R. Neilson, Db. S. E. C. Tubvey
Publications^:
Db. J. H. MacDebmot, Chairman; Db. D. E. H. Cleveland,
Db. G. A. Davidson
Summer School:
Db. J. C. Thomas, Chairman; Db. J. E. Harbison, Db. G. A. Davidson,
Db. R. A. Gilchbist, Db. Howabd Spohn, Db. W. L. Gbaham
Credentials:
Db. D. E. H. Cleveland, Chairman; Db. E. A. Campbell, Db. D. D. Fbeeze
V. O. N. Advisory Board:
Dr. L. W. MacNutt, Db. G. E. Seldon, Db. Isabel Day
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont
Representative to B. C. Medical Association: Db. J. R. Nehson
Sickness and Benevolent Fund: The Pbesident—The Trustees MULTIVITE
Registered Trade Mark
(Vitamins A, Bi, C and D)
Multivite, the B.D.H. preparation of the four vitamins, A,~Blf C
and D, in the form of chocolate coated pellets, provides an
acceptable means of correcting the most commonly-occurring
dietary vitamin deficiencies.
Two pellets, taken daily, will provide sufficient of these four
vitamins to prevent the appearance of deficiency symptoms in
an otherwise normal person whose diet is completely lacking in
these vitamins. Taken, therefore, in addition to an average diet,
two pellets of Multivite daily will not only provide the full amount
of these vitamins necessary for the maintenance of normal health,
but will provide also a reserve with which special temporary extra
demands can be met.
As examples, the increased needs imposed by a period of pyrexial
infection or unwonted physical exertion (causing increased
metabolic rate) will be met by the content of Vitamins Bi and
C of two Multivite pellets, as will the Vitamin D deficiency which
may result from a period of night work.
It will be seen that the possible applications of Multivite in
general war-time practice are numerous and that the frequent
prescribing of Multivite can be an important factor in maintaining the highest standard of health and efficiency in adverse
circumstances.
Stocks of Multivite are held by leading druggists throughout the Dominion, and full particulars are obtainable from
THE       BRITISH
Toronto
DRUG       HOUSES
(CANADA)       LTD.
Canada
-Mlvt/Can/4310 VANCOUVER HEALTH DEPARTMENT
STATISTICS—AUGUST, 1943
Total   Population—Estimated   _
Japanese  Population	
Chinese   Population—Estimated
Hindu  Population	
Total  deaths	
Japanese deaths	
Chinese deaths	
Deaths—residents only	
BIRTH REGISTRATIONS:
Male, 331; Female, 316.
Number
_    282
16
.    227
.    647
INFANTILE MORTALITY— Aug., 1943
Deaths under one year of age 19
Death rate—per 1,000  births       29.4
Stillbirths (not included above)       10
       288,541
 Evacuated
  5,541
  301
Rate per 1,000
Population
11.5
Population evacuated
34.0
9.3
26.4
Aug., 1942
11
18.7
15
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
July,
Cases
16
0
Scarlet Fever	
Diphtheria J
Diphtheria Carrier  0
Chicken Pox  28
Measles            , 2 5
Rubella          - I ;  2
Mumps ,  0
Whooping Cough .  13
Typhoid Fever 	
Undulant Fever
Poliomyelitis 	
Tuberculosis  	
Erysipelas   	
  0
  42
  1
Meningococcus Meningitis , . 1
1943
Deaths
0
0
0
0
0
0
0
0
0
0
0
17
0
0
August, 1943
Cases      Deaths
19 0
0
18
7
1
18
17
37
1
1
0
0
0
0
0
1
0
0
0
23
Sept. 1-
Cases
10
4
5
15,1943
Deaths
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Syphilis.
Gonorrhoea.
V, D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
West North       Vane.
Burnaby    Vane.   Richmond   Vane.      Clinic
Figures not yet available
Hospitals &
Private Drs.
Totals
BIOGLAN-A       I
The most effective therapy for waning mental and physical energy,
deficient concentration and memory, reduced resistance to infection,
muscular weakness and debility, neurasthenia and premature senility.
The efficacy of this very potent endocrine tonic has been confirmed by
the clinical evidence of many thousands of cases treated since  1943.
Phone MA. 4027
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C.
Page One LIVER EXTRACT INJECTABLE
Purified  and  Concentrated
15 U.S.P. UNITS PER CC.
The best therapeutic measure at present available for the treatment of
pernicious anaemia is the intramuscular injection of a potent, concentrated,
and purified liver extract. The concentrated extract prepared by the
Connaught Laboratories has the following advantages:—
A SSI IRFD POTFNK^Y     ^ac^ 'ot is testeclcZmica%for therapeutic activity.
The potency is 15 U.S.P. units per cc.
PURITY
The extract is a clear, light brown
solution, containing less than 100
mg. solids per cc-
SMALL  DOSAGE
In most cases initial treatment with
one cc. per week is sufficient — for
maintenance, one cc. at less frequent
intervals is generally adequate.
LIVER EXTRACT INJECTABLE is supplied by these Laboratories in 4-cc.
rubber-stoppered vials, and in 12-cc. vials for hospital use.
CONNAUGHT LABORATORIES
University of Toronto    Toronto, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. VANCOUVER     MEDICAL     ASSOCIATION
FOUNDED 1898    ::    INCORPORATED 1906
PROGRAMME OF THE FORTY-SIXTH ANNUAL SESSION
(WINTER SESSION)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings are to be amalgamated with the clinical staff meetings of the various
hospitals for the coming year.   Place of meeting will appear on the agenda.
General meetings will conform to the following order:
8:00 p.m.    Business as per Agenda.
9:00 p.m.    Paper of the evening.
November 16—COMBINED CLINICAL MEETING and CLINICAL STAFF MEETING at ST. PAUL'S HOSPITAL.
13 th Ave. and Heather St.
Exclusive Ambulance Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE  IN AMBULANCE SERVICE   ONLY
J. H. CREL.LIN
W.  Li.  BERTRAND
Nuttn Sc 3lj0mjs0tt
t
2559 Cambie Street
arte ouver
,B.C
Page Two  EDITOR'S PAGE
It is some months now since Vancouver accepted the ruling of the Dominion Public
Health authorities, that the water supply of the city and its neighbours, North Vancouver and New Westminster, be chlorinated, as a war measure. Recently this has been
put into effect: and it has certainly stirred up a hornet's nest. One had thought that
everything had been said about this matter—and that we had all accepted it, if not
entirely with enthusiasm, at least as the wisest step under all the circumstances. Our
leading health authorities were unanimous in their support of the scheme—and surely
they are best qualified to judge. If we cannot trust these experts, who devote their
lives and energies to the study of epidemiology and public health, whom can we trust?
There is, however, a considerable amount of public opposition and dislike of the scheme,
and there is certainly a state of public anxiety, amounting to a real fear of the dangers
of chlorinated water. Daily we read in the newspapers, and hear over the telephone,
tales of sickness and disability, supposedly caused by the drinking of chlorinated water.
These, we verily believe, are entirely groundless—but the public is gradually developing,
to an ever-increasing degree, a genuine fear of chlorniated water, and a marked hostility
to this measure, and to those who are responsible for it.
We feel strongly that this is a case in which measures should be taken to allay this
anxiety, and to dispel this fear. This can only be done, in our opinion, by the Public
Health authorities, either Provincial or Federal, or better still, both. They owe it, we
think, to the public to take steps to do these things. They have the knowledge and the
facts, and should make a careful, categorical, public statement. Most people are reasonable and intelligent, and if the facts are dispassionately and simply placed before them,
they will, we are sure, accept and believe them: and a great deal of anxiety and worry
will be removed. We must not adopt an Olympian attitude of detached superiority:
this will not do, and is neither fair nor safe. People are entitled to be told, clearly and
fully, all the facts. They should be told, again, of the need for chlorination—and of
its harmlessness and safety. They might be told that all the big cities from here to
Montreal, and from here to San Diego, are drinking chlorinated water and have done so
for a long time, without any ill effects. In many cases, the water in these cities requires
far more chlorine to make it safe than does ours—and yet the inhabitants remain
healthy, and drink the water without any harm. Here every cold, every sore throat,
every attack of diarrhoea in children, is being blamed on the chlorine in the water. xOf
course, we know that this is not a reasonable view to take—but we cannot expect the
average man to know this, especially when he reads all these letters and statements in
print.
We hope that the Public Health people will take this under advisement. It would,
we sincerely believe, be a public service, and would do a great deal of good. From our
point of view as practitioners of therapeutic medicine, it would be of very great help
to us, who have to spend a great deal of time explaining to individuals what could most
easily be explained, once and for all, to the whole public.
As for us—our duty is, we feel, a clear one. We should support and endorse the
action of our colleagues in the Public Health service. They are the experts, their action
is impersonal, and based only on their scientific knowledge and judgment—and we
should back them up. The Vancouver Medical Association formally passed a resolution
endorsing chlorination, and stating that we believed it should be done, and we should
stand by that.
In this connection, we greatly deplore the attitude of certain members of the City
Council towards the Medical Health Officer. These members seem to feel that they are
entitled to the "support" of Dr. Murray in this matter. Dr. Murray is a doctor, and a
medical health officer. His duty, and we need not say so to him, is to give his medical
opinion honestly and without any consideration other than what is based on the best
and most up-to-date scientific and medical knowledge. The wishes of any person on
earth, pro or con, cannot influence his opinion in any degree. We, on our part, should
hold up his hands and support him to the best of our ability.
Page Three ■KB
pHBjnai MJHn
NEWS    AND    NOTES
BIRTHS
To Dr. and Mrs. W. F. Anderson, Kelowna; a daughter.
To Dr. and Mrs. H. J. Alexander, Vernon; a daughter.
To Dr. and Mrs. C. E. Davies, Vancouver, a daughter.
To Dr. and Mrs. W. L. Turnbull, Vancouver; a son.
To F/L. and Mrs. H. G. Cooper; a son.
To F/O. and Mrs. J. W. Whitelaw; a son.
To S/L. and Mrs. E. T. W. Nash; a daughter.
OTHER NEW ARRIVALS
Dr. Maitland Young in Victoria, from Iroquois Falls, Ont.'
Dr. W. A. McElmoyle in Victoria, from Winnipeg.
NIMRODS AND PISCATORS
Dr. Wm. Leonard, Trail; at Vernon.   Object: Pheasants.
Drs. R. A. Hunter and R. B. Robertson, Victoria; on Mainland.   Object: Unspecified and several.
Dr. D. J. Millar, North Vancouver; in Cariboo.   Object: Fish.
STEPS
Major S. L. Williams, Nanaimo.
Major W. H. Moore, Victoria.
MOVES
Dr. C. E. McRae; Kamloops to Salmon Arm.
VISITS
Capt. F. L. Wilson, in Trail.
Capt. W. J. Endicott, in Trail.
Dr. J. S. Burris of Kamloops, in Montreal and Nova Scotia.
Dr. H. F. P. Grafton of Kamloops, in Quebec and Ontario.
Dr. R. V. McCarley of North Vancouver, in Kingston.
Dr. C. M. R. Onhauser of West Vancouver, in eastern Canada.
Dr. J. W. Lang of West Vancouver, in New York.
Dr. J. R. Naden, Vancouver.
Dr. M. G. Archibald, Kamloops.
Dr. L. W. Cromwell, Victoria.
Dr. H. Dyer, North Vancouver.
CONVALESCENT
At the recent Annual Meeting of the Victoria Medical Society, the following were
elected to the executive for the ensuing year: President, Dr. J. W. Lennox; Vice-President, Dr. J. H. Moore; Honorary Secretary, Dr. T. M. Jones; Honorary Treasurer, Dr.
P. A. C. Cousland.
Page Four The following non-profit plans, operating among employees, who have
formed their own association, have been approved by the Council of the College
of Physicians and Surgeons of B. C:
Medical Services Association
Telephone Employees' Sick Benefit
B. C. Electric Railway Co. Ltd. Office Employees' Medical Aid Society
B. C. School Teachers' Medical Services Association
Vancouver School Teachers' Medical Services Association
Cunningham-Western Drug Sick Benefit Association
Yarrow's Employees Health Association
West Kootenay Power & Light Company.
LIBRARY NOTES
RECENT ACCESSIONS:
Surgical Clinics of North America, Symposium on Orthopedic Surgery, Mayo Clinic
Number, August, 1943.
Studies of the Eighth Nerve, 1937, Research Study Club of Los Angeles (Gift of
the publisher, The Laryngoscope Press).
Resources of the Pacific Northwest Libraries, 1943, John VanMale.
Exploring the Dangerous Trades, 1943, The Autobiography of Alice Hamilton.
First Aid, Surgical and Medical, 2nd ed., Warren H. Cole and Charles B. Poestow.
Psychosomatic Medicine, 1943, Edward Weiss and O. Spurgeon English.
PACIFIC NORTHWEST BIBLIOGRAPHIC CENTRE
Recently the Library Committee was approached with reference to participation in
a bibliographic centre which was being organized by Mr. John VanMale at the University of Washington Library for the purpose of extending and expediting inter-library
loans. The Committee expressed its willingness to co-operate, and is now an active
member.
It will be seen that this arrangement will extend our library facilities greatly, as it
will give us access, through inter-library loans, to the medical libraries of the King
County Medical Society in Seattle, the University of Washington, Seattle, and the
University of Oregon Medical School at Portland. Moreover, the time factor will be
greatly reduced, as the Centre will have accurate and detailed information of the various
library holdings.
The Centre also includes most of the law and technical libraries as well as college
and public libraries in Washington, Oregon, Idaho, Montana and British Columbia.
To supplement this service Mr. VanMale has published a book, which the Library
has recently acquired, entitled "Resources of the Pacific Northwest Libraries." It lists
the participating libraries, and gives a general outline of the resources of each. It contains an interesting account of library backgrounds and the history of libraries in the
Pacific Northwest, as well.
Page Five wi9V9|K^V4BaHPBWMHnM*WBp
HnMaannn
<mmmr*mmm
HSBSSIGH
SgHgHS ^n
BOOK REVIEW
MANUAL OF DERMATOLOGY: Donald M. Pillsbury, M.D., Marion B. Sulzberger,
M.D., and Clarence S. Livingood, M.D.    Philadelphia and London: W. B. Saunders
Company, 1942.
This is a small manual of less than 400 pages designed by a group of dermatologists
of eminence, at present commissioned officers in the armed forces of the United States,
for the instruction of medical officers serving in those forces. In the preface it is stated
that in the United States Army (1940) skin diseases produce 9.80% of all sick list
admissions, and 10.41% of all days lost. Venereal diseases (exclusive of gonorrhoea)
produced an additional 3% of all admissions. In the United States Navy during the
last 10 years, the picture was almost exactly the same. It is emphasized that these are
peace-time figures, and that this class of diseases has always shown a rapid relative
increase under conditions of military expansion and warfare. Beyond this it is estimated
as a conservative figure tljat 20 to 25% of all diseases in the armed forces become the
object of dermatosyphilologic management.
The necessity for a small compact manual instructing in the diagnosis and management of the commoner skin diseases is obvious. This need has been met by the authors
of this book in a most satisfactory manner. The book is one which every general practitioner in or out of military life would do well to keep at his right hand, or in his
pocket.    Clarity has at no time been sacrificed to brevity.
Tabular presentations of symptoms and procedures have been freely and advantageously used. The photographs are excellent and unlike many in larger text$, they
really do illustrate. They are accompanied by captions which extend their usefulness.
A most valuable feature is the manner in which photographs of different parts of the
body have been grouped together, presenting the different lesions which may be encountered in those parts. This gives a most graphic presentation in many cases of differential diagnosis.
Principles of local treatment are well shown in photographs, of which the only criticism is that a few more might well be added.
The fact that this is a military manual is never lost sight of, and while investigation
and treatment under field or ambulant conditions is given the largest consideration, hospital or sick-bay methods are dealt with adequately.
The Formulary which is appended is not cumbersome, but sufficient, containing less
than 90 formulae.
The volume is small and compact, and an admirable piece of book production.
ADVANCE    NOTICE
MEDICAL SERVICES ASSOCIATION
M-S-A ANNUAL MEETING
FRIDAY, NOVEMBER 26th, 1943
8:00 p.m.
MEDICAL-DENTAL BUILDING AUDITORIUM
VANCOUVER, B. C.
Page Six PROVINCIAL BOARD OF HEALTH
Division of Venereal Disease Control
Dr. J. H. MacDermot, Editor,
Vancouver Medical Association Bulletin,
Daer Dr. MacDermot:
Some misunderstanding exists concerning the matter of certificates of freedom from
venereal disease as was evidenced by a letter from a medical practitioner in the Province
a short time ago. This doctor stated he understood the medical profession had been
instructed that under no circumstances were certificates of freedom from venereal disease to be issued by doctors. A difficulty arose therefore from the fact that the Army
requires all young men contemplating matrimony to produce a certificate to the effect
that the proposed bride is free of venereal disease. In addition to this since a venereally-
infected soldier is always asked to name the source of his venereal infection, if possible,
and this is followed by the alleged source being required to apply for an examination to
confirm that she has an infection and bring her under treatment, or on the other hand
to clear her of the suspicion of venereal disease, what is the doctor to do in case he finds
no evidence of infection in the alleged source? The following states in brief the principles to be observed in such a situation:
"The strictures upon giving certificates of freedom from venereal disease were
specifically aimed at giving such statements to prostitutes.
"A certificate stating that the woman whom a soldier proposes to marry has
been examined and shows no evidence of venereal infection is quite in order. In
fact under the legislation re premarital examinations, which has been enacted but
which has not yet been put into force, this is exactly what a doctor is required to
do. This is a certificate for a specific purpose and should be carefully worded to
the effect that examination has revealed no signs of venereal disease. Examination
should of course include laboratory as well as clinical findings although in the
case of a woman who shows no suspicious discharges one is not expected to take
smears or material for culture for gonococci. When all clinical and laboratory
findings are negative then one may be morally certain that the patient has not
a venereal infection. Nevertheless in the case of a statement in writing it is
better to say that the patient shows no evidence upon examination rather than to
state unequivocally that the patient has no venereal disease.
"Where a girl has been named as a source of disease a certificate of lack of
evidence of venereal infection is not given to the girl. If she is negative on both
clinical and laboratory examination a statement to that effect should be furnished
the Division of Venereal Disease Control but not given to the patient. If a girl
has been named by two or more as a source of disease it is probable that she is
prostituting herself and the question to be decided is whether she should be
treated or not. Establishing her freedom from infection probably establishes
completely her non-infectivity. No patient should be treated for syphilis until
the diagnosis is positive beyond all peradventure. Such a case, if the allegation
by the soldier appears to have been made in good faith, and unquestionably if the
allegation has been made by two or more, should be re-examined again in three
months at the most. In the case of gonorrhoea there are three criteria for diagnosis: a suspicious clinical history including being named as a source of gonor-
rhceal infection, a suspicious discharge and positive laboratory findings. If any
two of the three are present this should be sufficient grounds to require a woman
to take treatment."
It has been requested that the information given to this doctor should receive wider
circulation to all members of the profession in the Province through the medium of the
Bulletin.   This is therefore submitted to you for publication.
Yours truly,
D. E. H. Cleveland,
Acting Director, Venereal Disease Control.
Page Seven t
REGULAR MEETING OF THE
VANCOUVER MEDICAL ASSOCIATION
October 5, 1943.
This was the first meeting of the 1943-4 Session, and was presided over by Dr. A.
E. Trites, President.
The chief items of the business part of the meeting were the Reports of the Executive Meetings during the summer, and the Report of the Summer School Committee.
We publish these below—and add our sincere congratulations to the many so well-
deserved laudatory comments received by those in charge of the Summer School.
Nominations were made of the following gentlemen, first for active membership,
as follows:
Drs. Gordon S. Hutton, Gordon F. Kincade, Webster T. Maguire, Mackenzie
Morrison;
second for associate membership:
Dr. Arnold Francis, New Denver, B. C; Dr. J. C. Kovach, Quesnel.
These will be voted on at the next regular meeting.
Dr. S. E. C. Turvey then read the paper of the evning: "Epilepsy as a Problem in
the Community." This excellent paper, presented by one whom we may rightly regard
as a leading authority on the subject in Western Canada, is published elsewhere in this
number. A very good discussion followed the paper, led by Dr. Frank Turnbull of
Vancouver and Dr. A. M^ Gee of the Essondale Mental Hospital's medical staff.
REPORT OF THE SUMMER SCHOOL COMMITTEE
FOR THE 1942-43 SESSION
The twenty-first Annual Summer School was held in the Hotel Vancouver, June
22 nd to 25 th, inclusive.
The total registration this year set an all-time-record at 400. Of this number 156
were members of the Armed Services and 25 were hospital internes. Comparison of
these figures with those of last year is interesting. The number of hospital internes is
approximately the same, but there is a tremendous increase in the number of men in
the Services from 32. Surely this is due to the fact that the Summer School is recognized as a desirable refresher course by the Senior Medical Officers in the Services.
The number of paid admissions rose from 183 to 216.
The fee was increased to $6.00 this year. The Committee Was fortunate in receiving
help from the R.C.A.M.C. in providing three speakers. Because our Summer School
coincided with that of the B. C. Pharmacists, we shared one of their speakers who was
sponsored by John Wyeth & Brothers for their meeting. The hearty thanks of the
Committee have already been tendered on behalf of the Association.
The total receipts amounted to $1,475.00
Total disbursements 1,520.80
Leaving a deficit of $     45.80
It should be pointed out here that payment of expenses for Dr. Foster Kennedy had
to be made in U. S. funds, and the exchange on this was over $60.00.
The attendance at the luncheon was 186, a big increase over last year.  The address
delivered by Dr. Foster Kennedy has been published in a recent issue of the Journal of
the Canadian Medical Association.
Page Eight The usual Thursday golf tournament was played at Point Grey. On that evening
the Round Table on Thyroid Disease was held.
This year an extra clinic was held, making use of material at Shaughnessy Hospital.
The clinics were all well attended, with more than 175 at each one.
The success of the 1943 Summer School may be taken as a mandate from the profession at large to continue holding these meetings in war-time, in spite of the added
difficulties in obtaining speakers encountered each year.
The Chairman and members of the Committee wish to take this opportunity to
thank teh staffs of Shaughnessy, St. Paul's and the General Hospitals for their courtesy
in providing cases and accommodation for the afternoon clinics.
Respectfully submitted,
J. C. Thomas, Chairman.
*      *      *      *
REPORT OF EXECUTIVE COMMITTEE MEETINGS
DURING SUMMER MONTHS, 1943     X.'
Regular meetings were held as usual during the Summer.
The question of fees for medical service to dependents of members of the Armed
Forces again came up for discussion, following a complaint from one of our members.
As this had previously been referred to the British Columbia Medical Association for
action, they were again written, with a request for a reply. Subsequently they informed
the Executive Committee that the schedule of rates was being revised and it was
expected that the new tariff would be higher than the average rates of the Workmen's
Compensation Board.
The subscription to War Medicine, donated to Camp Nanaimo, was renewed.
The matter of a classified listing of doctors' names in the telephone directory was
taken up, and a form letter was sent out to all members of the Vancouver Medical
Association advising them of the Committee's motion:
"That the whole matter be left in abeyance until such time as the official classification of specialists by the Royal College of Physicians and Surgeons of Canada be received."
A joint meeting with members of the Publications Committee was held, to discuss
the affairs of the Bulletin, and later a special meeting of the two committees was held,
at which time suggestions for changes and additions to the Bulletin set-up were discussed.
It was decided that in future lectures given at the Annual Meeting and the Osier
Lectures should be specially bound and kept in the Library.
Arrangements for the Fall and Winter programme for general and clinical meetings
are being completed.
J. A. McLean, Hon. Secretary.
GOLF
The 1943 golf tournament finished at Capilano on Thursday, October 7th.   Thirty-
six players took part in the final play.
At dinner the prizes for the season were presented to the following winners:
The Bilodeau Memorial Trophy awarded to the low gross score of the third game of
the season was won by Dr. Leith Webster.
The Worthington Cup, donated by Dr. George Worthington, was won by Dr. George
Seldon, with the low net score for the third game of the season.
The Ram's Horn Trophy, donated by Dr. Daniel McLellan for the low net in two
of the three games of the season was won by Dr. S. C. Peterson.
The Macdonald Trophy, donated by Macdonald's Prescriptions, Limited, for the low
Page Nine mB^m      ngmnnBMB
Hnmnn^ni
gross in two out of three games for the season was won by-Dr. J. E. Harrison.
The handsome sweater donated by George Straith Limited was won by Dr. T. R.
Harmon for the second low net on the day's play, while the set of club covers was won
by Dr. T. A. Johnston with the second low gross of the day.
The prize for the long drive was won by Dr. Jack Millar, while the prize for the
closest to the pin was won by Dr. Tom Nelles.
Dr. Leith Webster was elected Captain for 1944, with Dr. J. W. Millar as Vice-
Captain. Dr. J. C. Thomas was elected as a non-playing member of the Committee for
1944, to act in an executive capacity.
The retiring Captain, Dr. A. E. Trites, is to be congratulated on the successful season
under his guidance.
No. 4 DISTRICT MEDICAL ASSOCIATION
I      §    ANNUAL MEETING
The annual meeting of No. 4 District Medical Association was held in Vernon on
September 30th. A large attendance rewarded the Executive Committee for its effort
in providing a very full programme, commencing at 2.00 o'clock and finishing at 10.30
p.m. This included an afternoon clinical session, a social hour followed by dinner, and
a discussion on Health Insurance and other economic problems which was participated
in freely by a number of members. Doctor P. A. C. Coulsand, President of the British
Columbia Medical Association, was in attendance and opened the discussion. He was
followed by Doctor M. W. Thomas, Executive Secretary of the College, and other
speakers who contributed to the discussion were: Doctors W. J. Knox, Kelowna; R. W.
Irving and C. J. M. Willoughby of Kamloops; H. I. Campbell-Brown of Vernon.*
Doctor J. E. Harvey, President, presided over all sessions and was ably assisted by
the Honorary Secretary-Treasurer, Doctor H. J. Alexander. Doctor H. A. DesBrisay
gave two lectures and Col. Lavell H. Leeson one lecture at the afternoon session.
Doctor W. B. McKechnie of Armstrong was in attendance and moved a vote of thanks
to these gentlemen who had come to Vernon as guest speakers under the aegis of the
Committee on Programme of the British Columbia Medical Association.
The election of officers resulted as follows: Doctors L. A. C. Panton, Kelowna,
President; C. J. M. Willoughby, Kamloops, Vice-President; W. F. Anderson, Kelowna,
Honorary Secretary-Treasurer. Doctor L. A. C. Panton was appointed representative
to the Board of Directors of the British Columbia Medical Association.
The members decided that the next annual meeting would be held in Kelowna and
this was agreeable to the members from that place.
Those present at the meeting included Doctors H. S. Stalker, E. A. Gee, H. A. Jones
and R. H. Irish of Tranquille; G. E. Wride, Creston; A. F. Gillis, Merritt; W. A. Drum-
mond and S. Z. Bennett of Salmon Arm; W. B. McKechnie and R. Haugen of Armstrong; J. H. Kope, Enderby; B. de F. Boyce, W. J. Knox, L. A. C. Panton, W. F.
Anderson of Kelowna; A. L. Jones of Revelstoke; R. W. Irving, C. J. M. Willoughby of
Kamloops; L. F. Brogden, G. C. Paine, R. B. White of Penticton; Capt. W. R. Walker,
formerly of Penticton; J. E. Harvey, H. J. Alexander, H. I. Campbell-Brown, F. E.
Pettman, N. W. Strong of Vernon. From Vernon Camp the following were in attendance: Lt.-Col. G. A. Bird, Major Hamilton, Captains C. G. G. Maclean, D. W. Moffatt,
Govan and G. McL. Wilson. Lt.-Cl. R. L. Miller of Headquarters was in the area and
attended the dinner. Others in attendance included Doctors P. A. C. Cousland of
Victoria, H. A. DesBrisay, Lavell H. Leeson and M. W. Thomas.
Page Ten THE PROBLEM OF EPILEPSY IN THE COMMUNITY
S. E. C. Turvey, M.D.
(Read before the Vancouver Medical Association, October 5, 1943)
In this twentieth century, the empire of medicine has been extended to frontiers
beyond the dreams of optimists of three decades ago. Yet there remains a common
affliction about which the majority of practitioners have the general conception of
twenty to fifty years ago and the average layman of one to two centuries ago. Epilepsy,
so common that in Canada there are probably over fifty thousand persons subject to it,
and two thousand of these in Vancouver, still puzzles laity and physicians almost as
much as it did in the time of Hippocrates. It is as common as tuberculosis or diabetes.
Epileptics occupy ten per cent of the beds in hospitals devoted to nervous and mental
diseases. In 1940, in the armed forces of the United States, epilepsy ranked next to
schizophrenia as the most common cause of discharge. For every epileptic, there are
about twenty citizens who are predisposed to it. I propose to outline some of the
reasons why our profession is not coping with this problem adequately and to suggest a
rough pattern for the future. The idea that epilepsy is being inadequately handled is
not original, for neurologists the world over have been repeating it for over four decades.
The International League Against Epilepsy was formed in 1909 in Budapest, with Dr.
J. J. Muskens of Amsterdam as the prime mover, and has branches in five countries.
Needless to say, it has had to be suspended for the duration of the war, but Dr. William
Lennox of Boston remains President and is still active on this continent. The League
publishes a journal, "Epilepsia." On this continent there are the Section on Convulsive
Disorders of the American Psychiatric Association, the American League Against Epilepsy, and the Laymen's League Against Epilepsy. All these organizations are cognizant
of the tragic need for a change in the methods of medicine and of society in dealing
with epilepsy.
At the present time, there are only two methods of handling the epileptics, and
.these in a way are at opposite extremes. On the one hand, they may be cared for in the
home, and in a majority of cases this is far from satisfactory. Parents rarely have the
special skill to teach these patients discipline, to give them the self-confidence to meet
the world, or even to understand their problems of personality and adjustment. Oftentimes the parent is as horrified by the seizure as the veriest aborigine, and they impart
this attitude to the patient, as well as to the other members of he family and the public.
On the other hand, there is only the recourse of committing them to hospitals for the
insane or feeble-minded, a sorry alternative.
The great majority of epileptics are not congenitally defective, the potentialities of
good citizenship are present, and they are a very valuable group to be salvaged for the
community. If the seizures can be eliminated, either by medicine or surgery, the resulting individual is a social and economic asset. Also, the majority of epileptics are normal
except for very short periods of time, and the majority do not deteriorate mentally with
adequate treatment. Even aside from the obvious humanitarian aspects of the issue,
the economic aspects alone would be worthy of consideration. In the last three years,
out of a total of four hundred and ten epileptics, I have records of eighty-six who are
carrying on successfully in full-time remunerative jobs at union rates of pay. Admittedly, this has been possible only under the conditions of war, but they still can do their
job and could in peace time if given a chance. I would hesitate to divulge some of the
subterfuges, to which I am forced, to help them past the personnel manager or the suspicious employer, but in no instance has any catastrophe resulted. However, the em-
ployability and the employment of epileptics is a very sore subject to any thoughtful
physician. The main reason for employers refusing to employ epileptics is a law which
makes the employer liable for injuries which employees may sustain while at work. As
a member of our local Compensation Board recently stated to me in private conversation,
"an employer takes a man with all his disabilities." This is extremely unfair to the
employer and still more unfair to the epileptic, who is thus condemned to idleness all
his life.   It should be possible for an epileptic to waive his right to compensation if thfi
Page Eleven injury results from a seizure while at work. As a consequence of these conditions, a
person who has seizures must conceal his disability, which means that neither he nor
the employer are able to use safeguards against injury which might be used if the true
state of affairs was known. A remedy for this unhappy situation has been taken in
seven states in the United States but in Canada we have no such provision. I should add
that many of my epileptic patients who are working are doing so for employers who
are fully cognizant of their illness and they are kept on their jobs and their rare seizures
are ignored because of special abilities and because they are good workers. A more
general employment of epileptics is urgently needed, as it is estimated conservatively
that approximately seventy per cent of all epileptics are found to be employable in
industry.
From the viewpoint of clinical and laboratory research on humans, there is no more
fertile field than the epileptic. Usually they give excellent co-operation, they even seem
pathetically^ anxious to be the subject of any experiment or new cure. Researches so
far have yielded invaluable data on the influence of the acid-base equilibrium, of the
fluid-balance of the body, of the oxygen tension in the blood, and on concentration of
certain chemicals in the blood on the frequency of seizures. The electroencephalogram
is in its infancy but has already given a practical basis to a classification of epilepsy and
is useful in diagnosis. The normal brain exhibits rhythmic changes of potential, which,
after being led off from the scalp and stepped up by radio amplifiers, are recorded in ink
on a moving strip of paper. There are two main rhythms, the alpha waves from the
occipital region (10 per second) and beta waves from the frontal regions (22 per second). The rhythms are very irregular in epileptics, and not only during the seizure.
Three types of abnormality have been found:
I.    Grand mal—high voltage, fast waves.
II.    Petit mal—fast wave and spike, or slow wave and spike.
III.    Psychomotor seizures—high voltage, square and six per second waves.
The two thousand epileptics in Vancouver should be utilized by a properly organized team to further such researches.
A frequent point of misunderstanding between the physician and the epileptic is the
belief on the part of each that neither is very interested in the other. All of us have
these patients who come to us once or thrice, and then disappear. The fault lies at our
doorstep. The principal mail order house for the treatment of epileptics is run by
Doctor James in Chicago, and he is an M.D. who graduated with honors from a Grade
A medical school. I venture to guess that he asks the patient more questions than the
average physician does, that he gives them fairly "adequate" drug therapy, that the
amount of real investigation is about the same in each instance. We must do more for
these people than ask questions and give prescriptions, or we shall never hold them as
patients, rarely cure them, and we shall be fighting a losing battle with the quacks and
proprietary medicine-men. It costs a patient about five to eight dollars monthly to
receive Doctor James' advice and medicines, and I am amazed at the numbers of patients
from Vancouver who have turned to him, and turned in desperation because our advice
did not serve to control their seizures as well as his advice. A smaller number of
patients get their medicines from England from a similar source and for the same money.
It is rare for a patient to come to the Outpatient Department of the Vancouver General who has not attended at least three physicians, and it is much rarer that one of them
has received adequate investigation or treatment.
What are the reasons for this? The chief reason is economic, but lesser ones are lack
of education of the public, of the patients, of the physicians, and in many instances, lack
of technical facilities. We must not tell parents not to worry because their child "will
grow out of the little faints," that they should use as little "drugs" as possible "because
it slows up the brain and is habit-forming," or that "no cure is known for fits," that
fits are a sure sign the brain is permanently damaged, that he is teething, that his
stomach is upset, that he has worms, that his diet is wrong, that he needs a tonic. These
are a few of the dangerous fallacies we hear every month.    Nor must the public be
Page Twelve allowed to consider epilepsy a family disgrace, as syphilis now is and as cancer and
tuberculosis used to be. The general attitude of defeat surrounding epileptics must be
enlightened. The epileptic can, in all but a few cases, be cured insofar as he can become
a useful citizen, economically self-supporting.
The economic barrier for an epileptic who seeks adequate medical attention is a
serious one.   A thorough investigation requires the following:
(1) History—birth, development, past, present, family, and psychiatric (including
level of intelligence).
(2) Physical and Neurological Examinations—including, if possible, observation of
a fit.   (Sometimes a fit should be induced for observation.)
(3) Haemoglobin, leukocyte count, Kahn, sedimentation rate, urine.
(4) Spinal puncture, always with measurement of the pressure, and examination of
the fluid for: Cells; Kahn; Protein, Colloidal Gold.
(5) X-ray of the skull—two views; and not infrequently encephalography.
(6) Occasionally:   (a) electroencephalogram,
(b)   arteriography following injection of  a radio-opaque substance.
It must be emphasized that epilepsy is not a "disease entity" but a symptom due to
one or several etiological elements, and hence its accurate diagnosis can be very difficult.
The necessity for the first three of these investigations is obvious, but too often a spinal
puncture and X-ray of the skull are omitted from the examination. About ten per cent
of our epileptics have abnormalities of the skull, demonstrable by the roentgenogram.
One girl had seven physicians over a period of nine years without a spinal puncture or
X-ray, and then the X-ray showed a calcified tumour. This is not an isolated
instance by any means. Another man attended four physicians for three mild seizures
or "strokes" in five years, from all of which he recovered, yet never had a spinal puncture, evidently because his blood Kahn was always negative, though the spinal Kahn
finally proved to be positive. I do not cite these instances to prove any superior skill
of specialists, but rather to point out two facts. The first is that no one or two or
even three specialists can perform all those six investigations. The second is that the
cost of these investigations ranges from a minimum of one hundred dollars to over two
hundred dollars. Is it any wonder that so few epileptics are ever properly investigated?
Add to this the cost of daily medication over months or years, as well as regular visits
to the physician, and the burden becomes almost unbearable to most families. The
monthly cost of medicines varies from two dollars to eighteen dollars, and there are
many patients who have had to stop the treatment because they could not afford that
much.
The treatment of idiopathic epilepsy remains largely medicinal but, as both Mallory
and Lennox have insisted, the vast majority of epileptics can be cured if they are treated
early enough, long enough, and with enough medicines.
Frequently the physician is asked "Can you cure epilepsy?" The answer is "Yes"
and hopefully "Yes" except in a very few instances. We can cure it in the sense that
epileptics can be made to carry on useful and successful lives, that they can be made to
be proud of carrying on in spite of their handicap, that they can be trained to
think of themselves as people who are the same as all other people. They can be
cured by medicines which reduce the number and severity of their attacks to the point
where the seizures do not interfere with normal activity and business. These medicines
are not "drugs," they are not "dope," they are not "stupefying," they do not poison
the system, they do not form a drug habit, they do not cause mental deterioration.
They only keep the electrical waves of the brain in their usual slow and rhythmical
beat. They must be given in adequate doses, and most epileptics are so foolishly frightened, of them that they are taking inadequate doses. I know one boy of fourteen who
has taken ten tablets a day for six years, and yet he leads his class at school, has a very
high intelligence quotient, and is a good athlete.   I know a lady of fifty who has taken
Page Thirteen nine grains of phenobarbital a day for twenty-two years "and is a brilliant clubwoman
and a good mother. I must emphasize: Don't be afraid of the medicines; don't prescribe
too little and too late; remember that under-treatment is the rule and the curse of
epilepsy.
You may ask "Should every child who has a seizure be considered to be an epileptic?"
I think not. The child with a sudden illness and high fever who has a seizure may have
no more all his life. Two seizures should be viewed with grave suspicion, and the worried parents should not be reassured too completely until prolonged observation has rendered recurrence unlikely. More than two seizures is very likely to be epilepsy. About
twenty per cent of patients whose seizures began at puberty or later had an isolated
convulsion in infancy. The portion of the adult population which has epilepsy is about
one-tenth of the proportion of children who have had one or more convulsions (0.5 pet
cent against 5 per cent).
Physicians are asked frequently by their epileptic patients concerning the advisability
of marriage and having children. The Committee of the American Neurological Association for the Investigation of Eugenical Sterilization, of which Abraham Myerson was
chairman, published their report in 1936 and they stated that "there was some constitutional etiologic basis, but that it was not proved to be of hereditary origin." They
referred to the Boston group of workers, Lennox, Gibbs and Gibbs, who thought that
it undoubtedly had an hereditary basis, and based this opinion on a study of the brain
waves. However, they also quoted the works of Finley and Dynes, which tended to
contradict the finality of studies based on brain waves. They finally said that "the most
that as yet can be said as to its relationship to heredity is that some individuals and
familial groups are more liable to it." I usually adopt the attitude that, if the patient's
seizures have been completely controlled for two or three years, and if they come of a
good family stock which is not heavily tainted with epilepsy, and if they marry a normal
person who has had no fits and whose family history is clear, then there is no bar to their
marriage or procreation. I would concur in any programme that advocated the eugenic
sterilization of feeble-minded epileptics.
The drugs most commonly used are four—bromides, phenobarbital, dilantin and
mebaral. The bromides are much less used nowadays because they are not as effective
as the others as a rule, they frquently cause cutaneous lesions, they are more depressant
to the mental activity, and they may accumulate in the body to cause a toxic psychosis.
Its use should be restricted for the occasional patient who cannot take the other three
because of sensitivity or whose seizures are not controlled by them.
Phenobarbital is a more effective drug and rarely causes toxic manifestations. If
large doses are necessary, mental slowing may result, but this is easily abolished by the
additional exhibition of benzedrene or caffeine before breakfast and lunch. Neither of
these drugs increase the incidence of seizures, nor are they toxic when administered
judiciously even over years. Nine grains of phenobarbital daily may rarely be necessary.
Sodium phenobarbital is available for intramuscular or intravenous injections or for use
in liquid prescriptions, but it contains ten per cent less phenobarbital than does phenobarbital itself.
Dilantin is a relatively new drug and an invaluable adjunct. It has high anticonvulsive power combined with a minimum of hypnotic effect or mental dulling.
Four to nine grains may be given daily to an adult. It is more liable to cause toxic
phenomena than phenobarbital but these are rarely serious. If it causes gastric distress,
it should be taken midway during a meal or with milk. It may cause nystagmus,
diplopia, blurring vision, pupillary dilatation, dizziness or staggering gait, and these may
pass off in a few days, or the drug may have to be discontinued. Rarely it causes fever
and dermatitis. It commonly causes hyperplasia of the gums, but the mechanism of
this is unknown, and if the oral hygiene is good and the gums be massaged frequently,
it is rarely necessary to discontinue the drug. It should be noted that dilantin is of least
effectiveness in petit mal, and of most in psychomotor seizures (so-called psychic variants or motor automatism)  which are little influenced by phenobarbital or bromides.
Page Fourteen Mebaral is usually used if phenobarbital or dilantin fail. It is relatively non-toxic,
produces little hypnotic or toxic effects, and as much as sixteen grains a day may be
given. It is much less widely used than either dilantin or phenobarbital but is still
useful at times.
Successful treatment frequently involves tedious and painstaking trial. The drugs
must be changed, the dosage varied, the hours of administration made to suit the activities of the individual and, above all, unwearying patience and encouragement are essential. The patient and the parents must be seen frequently until the seizures are controlled, and preferably seen by the one who institutes the treatment. Neurologic consultations are frequently obtained, the diagnosis is confirmed, the particular medicine
recommended, and the patient sent back to his physician. When the patient continues
to have seizures, he moves on to a third physician, who is apt to send him to another
neurologist. This is actually occurring time after time in Vancouver. This is not the
treatment of epilepsy.
I should very imperfectly execute the task which I have undertaken if I did not
offer some solution of the vast problem of the epileptic in our community. There is
a need and an opportunity, and, fortunately, the means at hand. A co-ordinated programme is possible because of the relatively small number of investigators involved, but
the scope of the programme must be wide enough to include the patient, his family, the
public, the physicians, the specialists, and serious social and economic questions. If
epilepsy were infectious, this programme would have been inaugurated years ago. And
any programme must be sustained over many years by a persisting group truly interested
in epilepsy, a group driven by an inner compulsion rather than drawn by a chance to
spend a grant.
In Table I, I have outlined such a tentative programme.
Table I.
Division of Control of Epilepsy  (Chairman at Head)
Committee
of
Neuropsychiatrists
Business Management
Publicity
Endowments and Donations
Research
Group
Investigation
and Treatment
Neuropsychiatrists
Neurosurgeon
Internists
X-ray and
E.E.G.
Laboratory
Drugs Epileptic   colony
Mental hospital
Social Service
Home Conditions
Follow-Up   and
Attendance
Employment
Marriage
Educational Supervision
Ordinary Schools
Special Classes
Handicraft
Artisan
Trade or Profession
Recreations
Social Adaptation
Public and
Parents
To implement this proposed scheme, I would like to see the usual procedure in medicine reversed. In the past, whenever we as a group of physicians failed to solve a
problem in medicine, it has been taken over by the state. This is epitomized in dealing
with the insane, the tuberculous, those with venereal disease, those with cancer, and in
Page Fifteen a portion of the field of diagnosis by laboratory measures? Could we not launch this
programme ourselves? The problem of a director of the unit should not be difficult
and he should be chosen by you for his organizing abilities, his zeal and his professional
skill. He should be responsible to you for the success of his unit. For the rest of the
personnel, there is no dearth of skill in British Columbia but there should be a flexibility
of membership to allow for substitution if a change of technique is required. Though
the unit should have resting place in a hospital, where patients, operating rooms, diagnostic facilities and a pharmacy are available, it should possess mobility and be prepared
to "set up" in some other institution (epileptic colony, school laboratory or other hospital) if conditions or opportunities make this advisable. One of the researchers might
go from centre to centre, not only in the province but to other countries to centres
where epilepsy is being studied. And, though this is controversial, X-rays, laboratory
studies and drugs should be available to this group of patients at near-cost, or free for
those who cannot afford them. It is interesting to note that the province of Quebec
leads Canada in agitating at the present time for a colony for epileptics.
The problem of finance is difficult but not insurmountable. Grants-in-aid could
go to research students attached to some organization such as one of our excellent service
clubs. The Welfare Federation might not be aloof. Some patients can pay and should
within their means. Endowments for medicine in this province are shockingly small,
and we have some wonderfully public-spirited citizens. If a wealthy family would only
oblige by begetting a child with seizures, it would help a great deal, just as an afflicted
scion of royalty in England was responsible for Queen Square. Our established provincial institutions would surely make available their X-ray and laboratory facilities.
Now would be the time to bespeak two or three beds for epileptics in the projected new
psychiatric wing at the Vancouver General Hospital. Our government might well
make a grant to start and help maintain such a programme, for, though the cost of
epilepsy falls on the individual and the family affected, it is a heavy burden on the
community. And for every epileptic that is kept out of a state institution, the saving
is large. The cost of one aeroplane would be an ample yearly budget. Lastly, our medical society could afford to help financially, even if it were a small amount.
A more difficult question would be the solution of the ultimate relationship between
the general practitioner and this group for the treatment of epilepsy. It would have to
be understood that the group is not trying to steal business or patients from the individual physician. Let the group treat only referred patients if you wish, let the group
de all the investigation and research, let the group "stabilize" the treatment satisfactorily, then that group would be only too pleased to have the physician carry on. But
if the patient lapses from treatment, or if the seizures recur for any reason, the group
would wish to be informed so that their social service could reclaim the lost one; and
the privilege of follow-up studies would be an inherent privilege for the benefit of
research and teaching. The remuneration of the specialists concerned would, of necessity, be nominal in the early years of such a programme.
In conclusion, the following three objectives are proposed:
For the patient—adequate investigation and treatment, cure, rehabilitation.
For society—awareness of the magnitude of the problem, of the present neglect of
.incipient cases, of their duty to help the epileptic.
For us physicians—a wider diffusion of present knowledge, more research, more will
to work together towards the common end, which is the final eradication of
epilepsy.
(Slides were shown illustrating various methods of investigation, Table I, and the
electroencephalogram.)
1. Cortical calcification in Stiirge-Weber's disease. The patient was an epileptic idiot with a large port
wine naevus on the right side of the scalp—the same side as the calcification in the cortex. At first
it was thought to be a calcified angioma but one can see the gyri and also the microgyria.
2. Calcified frontal tumour—a history of epilepsy for six years.
3. Aneurysm  of Circle  of Willis,  using  thorotrast.     Epilepsy  began  six  months   after  an  episode  of
spontaneous subarachnoid hemorrhage.
Page Sixteen 4. Aneurysm of the anterior communicating artery. Epilepsy of many years duration, then more recent
headaches and visual field defects.
5. Calcified wall of an arterial aneurysm, known as "Albl's ring."
6. A large temporal meningioma shown by thorotrast injection. There is much distortion of the
normal direction of the middle cerebral artery. This patient had homonymous hemianopia, uncinate
fits, and some mental impairment.    The tumour was removed "almost entirely" in two stages.
7. Cysticercosis of thigh muscles from a patient with epilepsy due to cerebral cysticercosis.
8. Patient was a girl eighteen years of age who attended seven physicians over a period of nine years for
uncontrollable epilepsy.    Patient has now had no seizures for nine months and is at work.
REFERENCES:
Lennox, W. G.: The Campaign Against Epilepsy, A. J. Psychiatry, Vol. 94, No. 2, September, 1937.
Ibid: The Problem of Epilepsy, Epilepsia, May, 1937.
Gibbs, Gibbs and Lennox: Epilepsy: a paroxysmal cerebral Dysrythmia.    No. XXV, Studies in Epilepsy.
McEachern, Donald: Epilepsy, Can. Med. J., 45, 106-111, 1941.
Lennox, W. G.: Metabolism in Epilepsy, Arch. Neur. & Psych., July, 1928, Vol. 20, 155.
Lennox, W. G.: Science and Seizures, Harper and Bros., 1941.
Putnam, J. J.: Convulsive Seizures, J. B. Lippincott Co., 1943.
Myerson, A.: Eugenic Sterilization, Annals Int. Med., Vol. 18, 4, April, 1943.
Lennox, W. G., and Cobb, S.: Employment of Epileptics, Industrial Medicine, December, 1942.
Eugenical Sterilization: By the Committee of the American Neurological Association for the Investigation
of Eugenical Sterilization, 1936, The McMillan Co., New York.
Lennox, W. G, Gibbs, E. L., and Gibbs, F. A.: The Inheritance of Epilepsy as Inherited by the Electroencephalograph, /. Am. Med. Assoc., 1939, CXHI, 1002.
Finley, Knox H., and Dynes, John B.: Electrc-encephalographic Studies in Epilepsy, Trans. Am. Neurol.
Assoc, 1942, William Byrd Press, Richmond.
WEST KOOTENAY MEDICAL ASSOCIATION
ANNUAL MEETING
The West Kootenay Medical Association held its annual meeting at Nelson on September 25th, 1943.   Doctor N. E. Morrison of Nelson, President, and Doctor W. Laish-
ley, Secretary, had made provision for the comfort of those who attended and excellent
appointments for the various sessions of the meeting.
Doctor P. A. C. Cousland of Victoria, President of the British Columbia Medical
Association, was in attendance and contributed a paper to the afternoon programme,
which was devoted to clinical features. Doctor W. K. Massey dealt with the newer
surgery of the chest, and Doctors Daly, Krause and Hoare of Trail rounded out a very
full programme, which was followed by motion pictures shown by Doctor Laishley.
A social hour preceded the dinner, following which the annual business session was
held. The elections resulted in placing the following in office: Dr. C. M. Kingston of
Grand Forks, Honorary President; Dr. E. E. Topliff of Rossland, President; Dr. J.
Vernon Murray of Creston, Vice-President; and Dr. Wilfrid Laishley of Nelson, Honorary Secretary-Treasurer. Doctor E. E. Topliff, the new President, will be the representative from the West Kootenay on the Board of Directors of the British Columbia Medical Association. It was reported that Doctor Kingston, Honorary President, was ill and
the secretary was asked to send him flowers with the good wishes of the Society.
Doctors Cousland, F. M. Auld, J. S. Daly, Arnold Francis and others discussed the
present status of Health Insurance legislation at Ottawa. Doctor M. W. Thomas,
Executive Secretary of the College, was also present and discussed several items of interest
to the profession at this time. A Committee was appointed to study Health Insurance
and be prepared to report to the Association on those features upon which the profession
in general will be asked to voice an opinion, with particular, reference to such questions
as administration, standards, methods of remuneration and income limits.
The meeting was attended by Doctors Morrison, President; W. Laishley, Honorary
Secretary; W. A. Coghlin, M. E. Krause, J. S. Daly, D. J. M. Crawford, E. S. Hoare
from Trail; E. E. Topliff of Rossland; W. H. Ormond of Slocan; V. B. Goresky of
Castlegar; Arnold Francis of New Denver; Soldier-interne G. R. Collbeck of Nelson;
F. M. Auld, R. B. Brummitt, G. R. Barrett, R. B. Shaw of Nelson; P. A. C. Cousland
of Victoria, and M. W. Thomas, Vancouver.
Doctor W. O. Green of Cranbrook, President of the East Kootenay Medical Association, and Doctor D. W. Davis of Kimberley, travelled to Nelson and participated in
the annual meeting of the West Kootenay Medical Association.
Page Seventeen British  Columbia  Medical   Association
(Canadian Medical Association, British Columbia Division)
President Dr. P. A. C. Cousland, Victoria
First Vice-President Dr. A. Y. McNair, Vancouver
Second Vice-President Dr. A. H. Meneely, Nanaimo
Honorary Secretary-Treasurer Dr. G. O. Matthews, Vancouver
Immediate Past President Dr. A. H. Spohn, Vancouver
Executive Secretary : Dr. M. W. Thomas, Vancouver
Dr. K. D. Panton, Chairman of the Committee on Medical Education, gave an
excellent report at the Annual Meeting of the B. C. Medical Association. Shortage of
space forbids its publication in full,, unfortunately: but the original report can be seen
and read at the Library.  Meantime here are the highUghts.
The pre-medical work at the University of B. C. is not yet satisfactory from the
standpoint of the student who wishes to go to an Eastern university. These have varied
requirements, and it is often very difficult, owing to lack of accommodation in their
entrance classes, and the need for competitive examinations, for a student from B. C.
to secure a place.
The post-graduate work in B. C. Hospitals is not satisfactory—the teaching of
internes is often poor or non-existent. So the hospitals find it very difficult to secure
internes.
"The obvious solution of these difficulties," states Dr. Panton, "is to form a medical
faculty at U.B.C." He shews how this could be done—the Rockefeller Foundation has
offered to subscribe $500,000 on condition that B. C. puts up an equal amount.
He shews that approximately 150 men a year leave B. C. to study medicine: and
these men could be accommodated here. The University, however, lacks buildings and
equipment at present. Clinical material of high value is available to a satisfactory degree.
The writer points out the urgent need, growing yearly, for more graduates in Medicine—and refers to the estimate of increased need that will follow the introduction of
Health Insurance.
He makes recommendations with a view to expediting the formation of a Medical
Faculty. We heartily agree with him and hope the B. C. Medical Association will take
steps to implement this report. —Ed.
In presenting Dr. Strong's report of the Committee on Economics, we would suggest
that our readers give this careful study. This Committee has been very active, and its
Chairman, Dr. Strong, has been also a member of the Committee of Seven, appointed by
the Canadian Medical Association to meet the Government of Canada and discuss Health
Insurance from the profession's point of view. This report is therefore of special interest.
The Bulletin hopes at an early date to be able to give a summary of the Round Table
Discussion held at the B.C.M.A. meeting.
Page Eighteen ANNUAL REPORT
COMMITTEE ON ECONOMICS
B. C. DIVISION OF CANADIAN MEDICAL ASSOCIATION
September 8, 1943
(By Dr. G. F. Strong, Chairman)
Your committee has been more than usually busy in the past year because of the
action of the Dorninion authorities in connection with Health Insurance. After our last
annual meeting at Jasper we learned that this legislation might be introduced at the
1942-43 session of parliament. At that time there were many decisions that still had to
be reached by the medical profession, one of the first being to define our own attitude
toward the subject of Health Insurance in general. This was done at a special meeting
of the General Council of the Canadian Medical Association held in Ottawa on January
18th and 19th. Proceding this meeting, and in an effort to secure the views of organized medicine in B. C, an important meeting of key men from all over the province was
held in Vancouver on January 7th. Present at. that time, in addition to members of the
Council of the College of Physicians and Surgeons, were the members of the Board of
Directors of the B. C. Medical Association, the Committee on Economics of both the
College and the B. C. Medical Association, the Health Insurance Committee and the
President and Secretary of each district society. After a full discussion the following
resolution was unanimously passed:
"As part of a Canadian post-war reconstruction programme, which would
also include adequate provisions to prevent and relieve want and idleness, to furnish adequate housing, to overcome inadequate nutrition, and to attack similar
problems, the British Columbia Division of the Canadian Medical Association is
in favor of an adequate Health Insurance, provided that the service offered, is
complete, including full preventive and Public Health measures as well as a
complete plan of curative medicine, both domiciliary and institutional."
The same meeting endorsed the principle of the capitation method of remuneration
for general practitioners under the scheme.
You are all now f amiliar with the action of the Council of the Canadian Medical
Association in endorsing the principle of Health Insurance and favouring a plan which
would secure the highest standard of health services.
After the introduction of the proposed Health Insurance, it was referred to a special
committee on Social Security which proceeded to hold a series of meetings in order to
secure the views of various interested organizations. The Committee of Seven of the
Canadian Medical Association was instructed to prepare a brief for submission to this
Committee on Social Security and asked for comments and suggestions for that brief
from the various divisions. We would take this occasion to commend this action as an
indication of the earnest effort of the Canadian Medical Association to be an organization
truly representative of opinion throughout the Dominion. The first submission was made
on April 6, 1943, and is familiar to all since it was distributed in booklet form to every
doctor in Canada. A second submission was made on June 22nd and emphasized among
other things, the need of bursaries for training in clinical medicine, and grants for postgraduate education; safeguards for clinical teaching; comments regarding the financial
structure. The difficulty in obtaining a considered medical opinion during the war with
so many of our profession in uniform was also pointed out, as was the unfairness of
starting such a scheme with 30% of medical men away from their usual civilian work.
In order to keep members of the profession in B. C. informed, an abstract of those
portions of the Dominion and Provincial Acts that are of direct concern to medical men
has been prepared, as well as a digest of the proceedings and evidence submitted to the
metings of the Committee on Social Seecurity.
Page Nineteen Your committee is convinced that the profession must proceed forthwith to make
up its mind regarding many of the controversial aspects of this whole subject. We can
not afford to present a divided house in our dealings with the government. Granted
that complete unanimity is impossible, we must secure the considered majority viewpoint
and agree to unite on that. It is hoped that the round table conference arranged for
tomorrow night will go a long way toward settling some of the contentious points.
The whole question of the costs of this scheme must be more closely studied. Your
committee is convinced that we, either of the Canadian Medical Association, or the
B. C. Division itself, should secure the services of some thoroughly competent authority
to assist us in this work. As medical mien we know only in a general way the financial
implications of this scheme. It is of interest that the advocates of Health Insurance
stress the large amount of medical work that is not being secured by the public under
our present system and yet when these same advocates attempt to ascertain the cost of
Health Insurance, they take the total costs expended on present health services. In other
words, while admitting that the present coverage is inadequate, they use that service as
the basis for estimating cost. Also it is to be pointed out that in this method of ascertaining costs, no account is taken of the large amount of free medical care rendered
under the present system. The free service rendered every year in our medical schools
alone is of normous value, and even greater is the value of the free medical work given
to the indigent and low income groups both in and out of hospitals all over the Do-
minnin. There is, of course, in addition, a great deal of medical work that is not done
as charity but for which no payment is ever received. The sum total of all these free
services would considerably augment the figure used, from which the estimate of $26.00
per year per capita was secured. Offsetting these factors, it is recognized that the principle of compulsory universal insurance will permit a saving in unit cost.
In conclusion, therefore, your committee wishes to make two recommendations
which it would urge that you endorse:
1. That we attempt immediately to crystallize our views re Health Insurance in
order to present a united front;
2. That we obtain the services of a statistician, actuary, or business adviser to assist
us in obtaining our own estimate of the costs of an adequate Health Insurance.
All of which is respectfully submitted.
G. F. Strong, Chairman.
OBIIT
DR. JOHN A. WEST
October 22, 1943.
Dr. West was well known in British Columbia, since he practised in Prince
Rupert and Vancouver, over a period of 23 years: of which he spent 15 in
Vancouver. His professional ability was of a high order, and he was a very
skilful and able surgeon. Latterly, since an attack of illness he had a year or
more ago, it required much courage for him to carry on, as he was obviously
far from well. As a man, he had a charming personality—and his friendly,
courteous manner endeared him to all who knew him. We extend our sincerest
sympathy to his wife and family.
Page Twenty THE SEX STEROIDS IN GENERAL MEDICAL PRACTICE
By Max M. Cantor, B.Sc, M.D., F.A.C.P.
Assistant Professor of Biochemistry, University of Alberta.
Paper read at the Summer School Session of the Vancouver Medical Association, Vancouver,
June 22nd,  1943.
It is impossible to give anything but the highlights of the subject announced. For
that reason, this paper will be limited to a discussion of the sex steroids—a group of
pure substances which have been isolated from the ovary and testis and which have all
been synthesized. It will be further limited to a discussion of the use to which these
can be put in general practice.
The sex steroids are conveniently classified into three groups depending upon their
natural source: the androgens, substances like testosterone, which is the primary hormone of the testes and which produces the same physiological effect; oestrogens, which
imitate the action of oestradiol, the primary ovarian follicular hormone, and progestogens, the activity of which resembles in effect that produced by progesterone, the natural
secretion of the corpus luteum. Table I presents the classification and summarizes their
action.
Table I.
NOMENCLATURE, SOURCE AND ACTION OF SEX STEROIDS
Name
Androgens:
1. Androsterone
2. Dehydroandrosterone
3. Anhydro-iso-androsterone
4. Testosterone
Testo, propionate
Methyl testosterone
Oestrogens:
1. Oestrone (Theelin)
2. Oestriol (Theelol)
3. Conjugated oestrogens
4. tf-cestradiol
^-oestradiol benzoate
tf-cestradiol dipr'opionate
Description
Excretory product
of Testosterone
Intermediate in
the metabolism of
Testosterone
Excretory product
closely related to
sex steroids
True testis hormone
Synthetic derivatives
Source
Male urine
and synthetic
Male urine
and synthetic
Adrenal cortex
and synthetic
Male urine
and synthetic
Synthetic
Essential Action
In the male:
Normal development of the
reproductive tract, maintenance of secondary sex characters and male pattern be-
aviour.
In the female:
Suppression of rhythmic men-
archial phenomena
General—both sexes:
Increase in skeletal growth and
in weight in cases of endocrine underdevelopment except when due to hypothyroidism. Cardiac and vascular tonic.
Excretory product | Urine
of tf-oestradiol
Excretory product
of a-cestradiol
Water-soluble
glycuronides
True follicular
hormone
Synthetic
Pregnancy urine
and placenta
Pregnant   mares'
urine
Ovary and pregnancy urine.
Synthetic
Initiate and control functional activity of female, produce
the proliferative phase in
vaginal mucosa and endometrium, cause increase in secretion of uterine serous glands,
enhance myometrial .activity
and promote activity of the
mammary duct system.
Progestogens:
I.   Progesterone
2.   Pregneninolone
True corpus
luteum hormone
Anhydro-
hydroxy-
progesterone
(Ethinyl-
testosterone)
Corpus  luteum
of ovary and
synthetic
Synthetic
Converts vascular proliferated
endometrium into secretary,
type, produce myometrial relaxation, stimulate acinar development in breast, nullify
oestrogen action (convert active oestradiol into relatively
inactive oestriol).
Page Twenty-one Metabolism of the Sex Steroids
Testosterone produced by the testis or injected therapeutically produces its characteristic effect and is altered to dehydroandrosterone, and excreted as androsterone in the
urine. In this process it loses much of its activity although it can produce some effect.
Oestradiol in the same way is metabolized to oestrone (theelin) and excreted both as
oestrone and as oestriol (theelol). This conversion is effected by the corpus luteum
hormone progesterone and occurs only in the presence of a functioning endometrium.
In the process of conversion oestradiol loses nearly all of its activity. This is an important process physiologically, since oestradiol inactivation (to oestriol) renders the uterus
quiescent so that the secretory phase of endometrial change can take place and pregnancy
is stabilized. Progesterone undergoes similar inactivation and its excretory product
pregnandiol is completely-inactive physiologically. In all three cases, then, the primary
hormone possesses the greatest physiological activity.   This is illustrated in Table II.
Table II.
STANDARDIZATION OF SEX STEROIDS AND COMPARISON OF ACTION
I:U:/ntgm.
Other units used
Abbreviated definition of stand
Name
per mgm.
ard international unit
Androgens:
Activity of 0.1  mg. of andro
Testosterone
100
70-100 capon U.
sterone as measured by a specific
Androsterone
10
10 capon U.
biologic   test   such   as   Capons
D ehydrondrosterone
10
Comb growth or seminal vesicle
response in rat   (castrate).
Anhydro-iso-androsterone
4
Specific oestrus-producing activ
Oestrogens:
ity   in   0.0001   mgm.   standard
d-cestradiol
120,000?
12,000 R.U.
oestrone.                                     »
Benzoate  standard—specific oes
a-oestradiol benzoate
10,000 B.U.
10,000 R.U.
trus-producing activity in 0.0001
mgm.    of   oestradiol    monoben-
<r-cestradiol dipropionate
10,000 B.U.
18,000 R.U.
zoate.
oestrone (theelin)
10,000
1,000 R.U.
The activity present in 1 mgm.
or one unit of these is not the
oestriol (theelol)
1,500
150 R.U.
same.
Conjugated cestrog.   (orally)
4,000
400 R.U.
The Allen-Doisy method commonly employed.
Progestogens:
•
Progesterone
1
1 Corner-Allen
The I.U.  is defined as the spe
Rabbit unit
cific activity of 1  mgm. of in
2 Clauberg U.
ternational standard progesterone
4 European U
using Clauberg's  rabbit  method
Pregneninolone
0.25
quantitatively determined by
McPhail on the rabbit's uterus.
Pregnandiol
inactive
It may be noted here that chemical manipulation has improved on nature. It was
found that if testosterone and oestradiol were combined with acetic acid, benzoic acid
or propionic acid, the intensity and duration of their action was enhanced. Thus esteri-
fication of testosterone with propionic acid increases its effect seven times and doubles
the duration of its action. In the same way oestradiol dipropionate possesses double
the intensity of action of oestradiol and its effect lasts six times as long. Esterification
also increases their solubility in oil, so that greater concentration may be obtained in
small volume for injection. All in all, this provides greater comfort and economy for
the patient when therapy is continued for long periods.
Page Twenty-two Route of Administration and Choice of Material
The primary sex steroids are active orally, by inunction and intramuscularly. The
intensity and duration of effect varies, however, with the route chosen. Testosterone
propionate intramuscularly is the material and route of choice. For purposes of inunction or oral administration, methyl testosterone is more economical but the dose must
be four times as great by the oral route and twelve times as great by inunction as the
intramuscular dose to produce the same effect. Quite commonly, the propionate intramuscularly is supplemented by therapy either orally or by inunction. Progesterone is
not effective orally or by inunction. It should be given by intramuscular injection.
Supplementary therapy with pregneninolone (oral progesterone) is a good procedure and
if used early in six times the intramuscular dose can replace progesterone by injection.
Oestrone is effective by all three routes, but its low solubility precludes the possibility
of its use in adequate dosage and makes it unsuitable and uneconomical for prolonged
therapy. The recent introduction of aqueous suspensions of oestrone overcomes this
drawback but does not overcome its low comparative potency. Oestriol is effective
orally only, and in the form of the water soluble conjugated glycuronide it has about
three times the activity of oestrone. Oestradiol is active by all three routes, 1 mg.
intramuscularly producing the effect of 12 mg. orally or 6 mg. by inunction or 3 mg.
by vaginal insertion. The chief value of the esterified form, especially the dipropionate
as in intramuscular injection or by inunction. This is illustrated in Table III and
Table IV.    By all criteria, oestradiol dipropionate is the most potent oestrogen known.
Table IK.
ACTIVITY OF ONE MILLIGRAM BY VARIOUS ROUTES AND IN VARIOUS VEHICLES
(OESTROGENS)
Substance
Oestrone  (oil)  	
Oestrone  (water) -	
Oestradiol   (oil)	
Oestradiol  (tablets) _._
Oestradiol in prop, glycol 1,000
Oestradiol benzoate  (oil) 2,000
Oestradiol Dipropionate   (oil) • 6,000
Oestradiol Dipropionate in prop,  glycol     8,000
Conjugated   Oestrogen     3,000     	
Oral progesterone is about one quarter as effective as by the intramuscular route.    Methyl testosterone by
mouth is above one-tenth as effective as by the intramuscular route.
Table IV.
COMPARING THE ACTTVTTY OF 50 GAMMA  (0.005 MGM.) OF VARIOUS OESTROGENS
IN WATER AND OIL INJECTED INTRAMUSCULARLY IN RATS
Oral
Intramusct
dar
Inunction
Sublingual
R.U.
R.U.
R.U.
R.U.
50
1,000
160
?
100
2,000
000
?
1,000
8,000
2,500
?
1,000
10,000
18,000
4,000
3,000
6,000
12,000
Substance
Oestrone    	
Oestrone    	
Oestradiol   	
Oestradiol benzoate   	
Oestradiol dipropionate
Conjugated   oestradiol   .
Vehicle
Duration of Effect
water
2 days
oil
4 days
oil
7 days
oil
14 days
oil
42 days
tablets
2 days
oral
Human dose equivalent
for one month
60-70 mgm. in 18 doses
30-35 mgm. in 12 doses
26 mgm. in   8 doses
8 mgm. in   4 doses
4 mgm. in   2 doses
3 5 mgm. in 90 doses
Diagnostic Methods
The diagnosis of thyroid dysfunction is based on the history and physical examination of the patient, the degree of dysfunction is measured by the metabolic rate. Symp-
tome and signs suggest the diagnosis of diabetes mellitus, the glucose tolerance curve
estimates the degree of insulin deficiency. In both cases, laboratory techniques confirm
diagnosis and provide a mathematical index of the severity of disturbed function. The
same procedures are used in following the effects of treatment.
The symptoms and signs associated with impaired gonadal function, especially those
related to ovarian disease, are very difficult to assess, unless fully detailed menarchial his-
\ Page Twenty-three 4
tory is obtained.    Evaluation of the degree of ovarian function may be obtained from
several sources: hormone excretion studies, endometrial biopsy, and the vaginal smear.
Hormone excretion studies are complicated procedures which are time-consuming
and expensive. They need to be carried out frequently and except for investigational
purposes are not feasible. Endometrial biopsy involves histological section and study
and is a procedure for the expert. The vaginal smear, taken at frequent intervals, is an,
excellent reflection of ovarian activity. It is simple to perform and is readily interpreted,
especially if the smears are prepared with Shorr's Trichrome Stain. By this method it is
a relatively simple matter to differentiate the proliferative from the secretory phase of
the cycle and detennine approximately the period of the cycle. In the early part of the
cycle the smear is composed of leucocytes, debris and a few cornified cells which stain
blue. When full cornification sets in (full oestrogenic effect) the cells are colored an
intense red, and no leucocytes are present. This is the mid-point of the cycle. Reappearance of leucocytes and change in staining of the cornified cells to green indicates
the early luteal phase. The cells then degenerate and appearance of red cells among"
the debris herald menstruation.
Atrophic spheroidal cells which stain blue or lavender are common in the menopause
and indicate oestrogenic deficiency. The response to adequate therapy is indicated by
the appearance of well formed cornified cells and the disappearance of lucocytes.
The vaginal smear provides a simple and accurate method for controlling the therapeutic use of sex hormones. It has special value in differentiating between symptoms
due to ovarian deficiency of the menopause and those of non-menopausal origin. The
latter will persist even when enough hormone has been given to produce full cornification. In amenorrhcea, replacement therapy with oestrogens or stimulative therapy with
gonadotropins will transform the smear so that the small-blue-green cells with large
nuclei are replaced by the deep red flat cornified cells with small nuclei. Androgens
cause the disappearance of the red cornified cells and their replacement by small, round
or oval blue-green cells with large nuclei.
Clinical Application of Sex Steroids in General Practice
The symptoms of female sex endocrine disorders which we meet most commonly in
general practice are concerned with:
I Irregularities in menstrual flow
II Dysmenorrhea a
III Menopause
IV Threatened or Habitual Abortion.
I.    Functional irregularities of uterine bleeding.
The differentiation of an irregularity which is significant, from a minor variation in
the normal, is difficult. The use of certain terms like amenorrhcea, oligomenorrhcea,
metrorrhagia, etc., in the literature tend to confuse the issue since they do nothing but
describe the duration, quantity and cyclicity of bleeding. A recent practical classification tends to qualify these terms by relating them to ovarian function. Thus menstruation is bleeding from a progestational endometrium which has been preceded by
ovulation—it terminates a fertile cycle. Menorrhagia is excessive bleeding of the same
type.   Metrorrhagia is oestrogenic bleeding.
A. Progestational {menstrual type) bleeding
1. Normal menstruation
2. Infrequent bleeding
3. Too frequent bleeding
4. Prolonged bleeding
5. Excessive bleeding
B. Oestrogenic (interval type) bleeding
1. Cyclic bleeding
2. Infrequent bleeding
3. Too frequent bleeding
Page Twenty-four 4. Prolonged bleeding
5. Excessive bleeding
C. Non-occurrence of Heeding amenorrhcea).
To use such a classification the diagnosis has to be established before therapy is begun.
This is possible by obtaining a biopsy specimen of the endometrium within 12 to 18
hours from the onset of bleeding or vaginal smears at three-day intervals during the
asymptomatic period.
A. Progestational Irregular Bleeding
In these cases some progestational effect is generally present. Where bleeding is more
frequent than normal this is usually from an immature progestational endometrium and
treatment should either substitute for the deficiency in corpus luteum activity or
attempt to prolong the luteal phase by ovarian stimulation. Substitution may be accomplished with progesterone, 5 mg. every other day together with l/z mg. oestradiol dipropionate every alternate dose. This procedure is carried out for 10-12 days commencing
about the mid-interval of the cycle. Where the symptoms are mild pregneninolone daily
by mouth will produce the desired result.
Infrequent progestational bleeding (delayed menstruation) is never of much consequence unless hypothyroidism is associated with it. Where the thyroid is not involved
prostigrnine 1 mg. daily by intramuscular injection for 2 or 3 days will usually bring
on menstruation. Incidentally this is a nice means of differentiating between delayed
menstruation and early pregnancy—the latter condition is not affected-.
Prolonged bleeding of the progestational type is nearly always due to endometrial
pathology and responds best to thorough curettage. Where there is an endocrine basis
for the disorder, testosterone propionate in doses of 25-50 mg. daily for three or four
days is of definite value.
B. Oestrogenic bleeding
This bleeding is interval in type and comes from an oestrogenic endometrium. It
is commonly associated with severe flowing and/or sterility. The bleeding may occur
in cycles and may be associated with sterility. In these cases the evidence for oestrogenic
failure is not marked. The ovaries are refractive and do not produce the full response.
This type of refractivity is seen in climacteric women due to aging and treatment is
not effective. An attempt may be made to stimulate the ovaries with charionic gonadotropins (F.S.H.), 500 I.U. daily for 10 days followed by daily therapy with 500 I.U.
charionic gonadotropins (L.H.) for the next ten days. The appearance of a progestational endometrium or characteristic vaginal smear is indicative that a specific response
has been obtained.
It is our opinion that prolonged therapy of this type is not justified by the results
and its use should be limited to those cases in whom it is desired to secure pregnancies.
Infrequent oestrogenic bleeding, unless it is associated with hypothyroidism or produces sterility, does not require treatment since there are no symptoms. The administration of thyroid to these patients even in the face of a normal B.M.R. will frequently
bring the character of the bleeding to normal proportions and render it progestational in
type. If thyroid substance is not effective, a trial with gonadotropins by the procedure
outlined is justified.
Frequent and prolonged oestrogenic bleeding which is acyclic in character generally
produces a severe secondary anaemia and is associated with sterility. Curettage may
effect temporary haemostasis but does not cure the condition. The only effective therapy
is found in the use of sex steroids. Large doses of oestradiol benzoate will produce
hasmostasis. Introduction of progesterone in addition will subsequently re-establish
normal rhythm and bleeding. The procedure will vary with the degree of symptoms
and is usually as follows:
Oestradiol benzoate (Ben ovocylin) 5-10 mg. daily until bleeding stops.  Then
Daily injection oestradiol benzoate 2 mg. for 10 days followed by combining this
with 5 mg. progesterone (Lutocylol) every day or every alternate day for the next ten
Page Twenty-five days. If bleeding starts during the second phase of treatment, therapy is discontinued
and resumed again at the end of 4 or 5 days. Three such courses generally suffice to
produce a progestational phase in the cycle and quite frequently cyclic bleeding continues thereafter. Where sterility is an associated complication, gonadotropins may be
tried after the cycles are established. The use of stilboestrol in the control of this type
of bleeding is in my opinion contraphysiological since it does not produce a progestational effect. In large doses orally or by intra-cervical injection, stilboestrol will produce haemostosis but it does not salvage endocrine ovarian function.
Endocrine therapy for excessive and prolonged bleeding of the oestrogenic type in
the menopausal woman is not justified until a diagnostic curettage is first performed to
rule out malignancy. Even where malignancy is ruled out, it is more economical to
negate ovarian function with a little radium and treat these patients with small weekly
or bimonthly injections of oestradiol dipropionate (diovocylin)  for four or six months.
C. Non-occurrence of bleeding—amenorrhcea
Amenorrhcea is more frequently a symptom of organic disease elsewhere in the body
than it is an indication of ovarian failure. Treatment is indicated only where it is
associated with Sterility. Even if hypothyroidism is ruled out completely, small doses of
thyroid extract are occasionally efficacious and should in any event be used as an adjunct
to sex hormone therapy. Adequate therapy consists in complete replacement by this
procedure.
Day:      1 5 9        11        13        17       21       25
Diovocylin    : mg. 1.0 2.5 2.5                   5.0      5.0      2.5 1.0
Equine Gonadotrop  (F.S.H J.U. 0 0 500 500 500          0          0 0
A.P.L.   (L.H.)     0 0 0 0 100     100          0 0
Lutocylin     0 0 0 0          0          5 10 5.0,
Such a cyclic routine builds up the endometrium and provides stimulative therapy to
the ovary.   The substitution of synergistic preparations of gonadotropins such as syna-
poidin for F.S.H. and L.H. factors simplifies the procedure.    Quite frequently uterine-
refractivity is the major factor in the aetiology and normal cycles may be re-established
without recourse to gonadotropins at all.
The use of testosterone propionate in the control of excessive bleeding is not contra-
physiologic in our opinion. The normal female produces androgenic substances and
there is a good body of evidence to suggest that these play an essential role in the
phenomena of menstruation. In doses of 25-50 mg., testosterone propionate is extremely
useful in the immediate treatment of uterine bleeding no matter what the cause.
II. Dysmenorrhea is a term used to denote the exaggeration of pelvic discomfort associated with menstruation. It may be functional or organic. There are three theories
with regard to the aetiology of functional dysmenorrhcea:
(a) Deficiency of progesterone permitting unopposed oestrogen action on uterine
muscle.
(b) Excessive oestrogen production causing hypermotility of uterine muscle.
(c) Excessive progesterone activity.
None of these theories can boast of adequate support, but therapy is based on all three.
Progesterone and more commonly testosterone propionate are used for their oestrogen-
antagonistic effect. It has also been suggested that dysmenorrhcea represents an androgen
deficiency and results in the unopposed action of ovarian hormones. Our experience
with the use of testosterone propionate (perandren—Ciba) has been quite satisfactory.
Relief is generally prompt and complete. Our practice is to administer between 10 and
25 mgm. of perandren daily or on alternate days for 2 to 4 doses commencing a day or
two before the usual expected onset of pain. The use of methyl testosterone (metan-
dren) 10 mg. twice or three times daily is quite frequently a useful procedure in milder
cases.   We are not in favour of using androgens throughout the entire period and prefer
Page Twenty-six total monthly dosage not to exceed 200 mg.   This is well below the amount which may
produce masculinization phenomena and will not produce an oestrogen deficiency.
We have had no experience with the use of oestrogens in dysmenorrhcea. The effect
produced by them is parasympatheticomimetic and is mediated by the inhibition of
acetylcholine esterase. This produces a blocking effect on the sympathetic component
of dysmenorrhcea. The total doses commonly used by proponents of this theory vary
from 6 to 20 mg. of oestrogen administered over ten days in the first half of the cycle.
The material of choice is oestradiol diproprionate (diovocylin) although good results are
also shown with the oral preparations.
m.    Menopausal Symptoms.
The severity of the symptoms in this condition varies with the degree of ovarian
failure or oestrogen deficiency. This is well indicated by hormone excretion studies and
the appearance of the vaginal smear. From what is known of the autonomic influence
of oestrogens it seems more than likely that hot flushes are part and parcel of the same
syndrome and not as is commonly suggested evidence of a psychic disturbance. The
value of oestrogens in the therapy of menopause is well established, but there is still
some question as to the material to be used and the frequency of administration. Thyroid
extract definitely has a place in the routine if the B.M.R. is not greater than plus 15.
We are firmly of the conviction that the great majority of menopausal patients benefit
from small doses of thyroid and suggest no less than 1 gr. a day for six weeks, followed
by a rest period of three weeks and the course repeated.
With regard to oestrogens we prefer the long acting diovocylin since it reduces the
number of injections necessary. When menorrhagia is not prominent, 5 mg. at weekly
intervals for three or four weeks is followed by smaller doses, 1 to 2 mg. at weekly or
10-day intervals. The dose is reduced gradually and the interval between injection
lengthened until 1 mg. at monthly intervals controls the symptoms. Frequent vaginal
smears should be taken as a gauge of the effectiveness of treatment and sufficient oestrogens should be provided to maintain it in a cornified state. Usually subjective symptoms are relieved within 24 hours and cornification of the vaginal epithelium is complete in about six days.
Symptoms referable to the vaginal tract, atrophic vaginitis and pruritus, also disappear with this form of therapy but some assistance is afforded by the use of vaginal
suppositories containing 0.4 mg. oestradiol every alternate night until symptoms are controlled.    The effect produced in the mucosa by this procedure is often very dramatic.
Occasionally patients are encountered who do not respond to oestrogens. Failure to
improve after three weeks' trial with adequate dosage is an indication for a change in
tactics. These patients usually complain of excessive bleeding and best results are
obtaind with testosterone proprionate (perandren) 10 to 25 mg. or more at weekly
intervals, the total monthly dose not exceeding 200 mg. With control of symptoms,
the dose is decreased and the interval between injections lengthened.
When symptoms are moderate, control may be effected by oral oestradiol (ovocylin)
or conjugated glycuronides of oestriol (premarim).
IV.    Threatened or Recurrent Abortion.
The causes of spontaneous abortion are many. We are concerned here only with
those of endocrine origin.   In these the fault is of three types:
(a) Faulty development of the chorio-placental system. This is generally due to
an incomplete progestational effect associated with a deficient functioning corpus
luteum. There is a deficiency of progesterone produced. This failure is in
greatest evidence in the initial stages of pregnancy and the embryo is lost
because the process of nidation is inadequate
Page Twenty-seven (b) Failure of the placenta to take on the function of the corpus luteum. This
normally occurs about the third month. When the placenta is at fault in this
respect, insufficient progesterone is available for the metabolism of oestradiol.
This produces an irritable uterus and results in loss of the embryo. Such a
deficiency is usually seen at about the third lunar month.
(c) Abortion late in pregnancy, or premature labour, is associated with failure in
progesterone production and consequent relative increase in "active" oestrogen.
The best measure of progesterone production is in the measurement of its
excretory product pregnandiol. The method of estimation is not easily performed outside of a laboratory. Where facilities are available it is an excellent
aid in diagnosis and prognosis.
Therapy in all these cases is with progesterone (lutocylin). Successful therapy depends
upon anticipating the crises or in early and adequate therapy. It is of no value after
the os is dilated. Doses from 20 mg. daily to 2 to 3 times a day are necessary in the
severe types, supplemented with 10 mg. three times a day by mouth. Milder cases may
be controlled by 10 mg. a day orally commencing two or three days before the expected
missed period and continuing through the interval. We make a practice of giving
thyroid extract in small dosage to all such patients. Our own experience is not very
extensive, but large clinics which follow this procedure report more than 80% salvage
in large series of cases.
Indications and Contraindications
The intelligent application of sex hormones demands a precise knowledge of the
agent used, and its pharmacological and physiological effects. An essential antecedent is
clear understanding of the nature of the sex cycle.
The steroids are pure chemical substances and should contain no contaminants. Pain
following injection of the oily material can be avoided if the outside of the neeVlle is
wiped clean of oil with some sterile gauze. Oestrogens suppress pituitary function and
assist in the closure of un-united epiphyses. There is a danger of stunted growth. They
also cause retention of water and electrolytes such as sodium. This may cause an increase in weight and complicate cardio-renal failure. Oestrogens may produce bleeding,
especially in overtreatment for the menopause. Poor results from oestrogen therapy in
the conditions in which it is indicated are most frequently due to ineffective dosage.
Like oestrogens, progesterone may produce oedema and depress pituitary function.
Given in the middle of the period it may induce intermenstrual bleeding and may aggravate flow if given during a period of bleeding. Overdosage is precluded by the cost of
the preparations.    Ineffective dosage is the rule and commonest cause of poor results.
Testosterone is a pituitary depressant and it also has a retention effect for sodium and
water. In addition it produces a positive nitrogen balance and promotes somatic growth.
This property makes it useful in the treatment of some types of dwarfism. Overdosage
with testosterone is common and produces abnormal sexual development. More than
300 mg. a month may produce masculinization in women. Testosterone is of value in
stimulating libido in males but it is contraindicated in male sterility since it depresses
spermatogenesis.
I have left out of this discussion the very controversial subject of the treatment of
sterility in both males and females as well as the discussion of other uses to which the
sex steroids have been put. The use of androgens in the male climacteric, in prostatism
and in coronary heart disease is still in the experimental stage. As more information
regarding their pharmacological action becomes available it appears possible that the sex
steroids will assume a larger sphere of usefulness. Until that time their use should be
limited in practice to those conditions in which their action is definitely known. Such
rational and judicious use will yield desrable therapeutic salvage. Empiricism may be
followed by irreparable damage to the physiologic economy of the patient.
Page Twenty-eight (jU00t
11
MOID THAT UN*
Soon the infectious diseases of Winter will again
threaten Canada's health line and extra supplies of
vitamins A and D will be needed to supplement
deficient diets, "Alphamettes" and "Alphamette"
Liquid—standardized, concentrated cod liver oil,
fortified with irradiated ergosterol—will be found
effective media for the administration of these important vitamins.
AIlFH Al*! E'JL'l'ES "  For adults and older children.—Each gelatin
077
capsule contains 5,000 International Units of vitamin A and 1,750 of vitamin D.
U ALPH AMETTE" LIQUID For infants and young children.
Each drop contains approximately 1,500 International Units of vitamin A and
300 of vitamin D.
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from blue through green to orange, and indicating sugar
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Complete set (with tablets for 50 tests) costs patient
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FRED.     J.
Sale Canadian Distributors
WHITLOW   &   CO.,     LTD.,     187    DUFFERIN    STREET,   TORONTO WINTHROP CHEMICAL COMPANY, INC Genera/office*
^Professional service office: Dominion Square Bldg., Montreal, Que.     WINDSOR, ONT. 1930 Tisd^ F- F- Drake, T. G. H.. and
Brown, A.: A new cereal mixture containing vitamins and mineral elements. Am.
J. Dis. Child. 40:791-799, Oct. 1930.
iQli Tisdalli F. P.: Dietary factors and
x:'JX health. Soc. Tr., Am. J. Dis. Child.
42:1490, Dec. 1931.
1932 Summerfeldt, P.: The value of an in-
creased supply of vitamin Bt and iron
in the diet of children. Am. J. Dis. Child.
43:284-290. Feb. 1932. • Morse. J. L.: Fads
and fancies in present day pediatrics, Pennsylvania M. J. 35:280-285, Feb. 1932. Hen-
ricke, S. G.: The vitamin B complex: Its role
in infant feeding in the light of our present
knowledge. Northwest Med. 31:165-169,
April 1932. -Langhorst, ,H. P.: Vitamins:
Their role in the prevention and treatment of
disease. M. J. & Rec. 135:326-329. April 6,
1932. Crimm, P. D.: Dietary of Childhood
Tuberculosis: Cereal as a source of added
mineral and vitamin elements; preliminary
report. J. Indiana M. A. 25:205-206, May
1932. Troutt, L.: Quality studies of therapeutic diets: I. The ulcer diet; a committee
report, J. Am. Dietet. A. 8:25-32. May 1932.
Summerfeldt. P., Tisdall, F. F., and Brown.
A.: The curative effects of cereals and biscuits on experimental anaemias, Canad.
M.A.J. 26:666-669, June 1932. Sneed,' W.:
Ununited and delayed union of fractures,
Kentucky M. J. 30:363-370. July 1932.
Silverman, A. C: Celiac disease. New York
State J. Med. 32:1055-1061, Sept. 15, 1932.
von Meysenbug, L.: Infant feeding with
especial reference to some of its problems
during the first year, Texas State J. Med.
28:543-547, Dec 1932.
1933 Sampler. F. J., and Forbes, J. C: Cal-
cium and phosphorus metabolism in a
case of celiac disease. South. M. J. 26:555-
558, June 1933. Brown, A., and Tisdall,
F. F.: The role of minerals and vitamins in
growth and resistance to infection, Brit. M.
J. 1:55-57, Jan. 14, 1933; Effect of vitamins
Orleans M. & S. J. 87:738-743. May 1935.
Tarr. E. M., and McNeile, O.: Relation of
vitamin B deficiency to metabolic disturbances during pregnancy and lactation. Am.
J. Obst. & Gynec. 29:811-818, June 1935.
Blatt, M. L., and Schapiro, I. E.: Influence
of a special cereal mixture on infant development. Am. J. Dis. Child. 50:324-336. Aug.
1935. Coward, N. B.: Infant feeding.
Nova Scotia M. Bull. 14:525-532, Oct. 1935.
Tisdall, F. F.: Inadequacy of present dietary
standards.-Tr. Sect. Pediat.. A.M.A., 1935:
Canad. M. A. J. 33:624-628. Dec. 1935.
Marriott, W. McK.: Infant Nutrition, second
edition, C. V. Mosby Co., St. Louis, 1935. p.
202. Summerfeldt, P.: Iron and its availability in foods, Tr. Sect. Pediat.. A.M.A.
1935. pp. 214-220.
1936 Dafoe, A. R.: Further history of the
care and feeding of the Dionne quintuplets, Canad. M. A. J. 34:26-32. Jan. 1936.
Conn. L. C. Vant, J. R., and Malone, M. M.:
Some aspects of maternal nutrition, Surg.,
Gynec. & Obst. 62:377-383. Feb. 15. 1936.
Ross, J. R., and Summerfeldt. P.: Haemoglobin of normal children and certain factors
influencing its formation, Canad. M. A. J.
34:155-15X, Feb. 1936. Smyth, F. S.: Allergic diseases, J.   Pediat.  8:500-515,   April
1936. Lemmon, J. R.: Problems of the crying infant. Southwestern Med. 20:24S-250,
July 1936. Rice. C. V.: The success of treating
celiac disease from a standpoint of vitamin
deficiency. Arch. Pediat. 53:626629, Sept.
1936. Smith, C. H.: Management of nutritional anemia in infancy, M. Clin. North
America 20:933-950. Nov. 1936. Strong.
R. A., editor: Nutritional anemia of infants,
Orleans Parish M. Soc. Bull., pp. 6-9. Nov.
9. 1936. Jeans. P. C: Specific factors in
nutrition. Round Table discussion, J. Pediat.
9*93-698, Nov. 1936. Young. J. &.:
Meeting the requirements for proper nutrition in infancy. Texas State J. Med. 32:531-
533, Dec. 1936.
1Q37 Stearns, G., and Stinger, D.: Iron re-
tention in infancy, J. Nutrition 13:127-
ner, B., and Gruehj, H. L.: Anaphylactogenic
.properties of certain cereal foods and bread-
stuffs: Am. J. Dis. Child. 57:739-758. April
1939. Monypenny, D.: Early introduction
of solid foods in the infant diet, Soc. Tr., Am.
J. Dis. Child. 58:1144-1145, Nov. 1939. Brown.
A., and Tisdall. F. F. Common Procedures in
the practice of paediatrics, third edition, McClelland & Stewart, Ltd., Toronto, 1939, pp.
77-79.
1940 McDougal, L. L., Jr.: Feeding a nor-
mal infant. Mississippi Doctor 17:437-
442. Jan. 1940. Monypenny. D.: The early
introduction of solid foods in the infant diet,
Canad. M. A. J. 42:137-140. Feb. 1940.
Robinson, E. C: A study of two hundred and
forty breast-fed and artificially fed infants in
the St. Louis area. Am. J. Dis. Child. 58:816-
827, April 1940. Ratner, B.: Round Table
discussion On food allergy, J. Pediat. 16:653-
672. May 1940. Rosenbaum, I., Jr.: The
management of the allergic child, Kentucky
M. J. 38:199-203. May 1940. Barondes. R.
de R.: Report of a case of pellagroid, M. Rec.
151:376-380. June 5. 1940. Brown. A.:
The fourth Blackader lecture on a decade of
paediatric progress, Canad. M. A. J. 43:305-
313. Oct: 1940. Drueck. C. J.. Vitamin
therapy in colon and rectal disease, Illinois
M. J. 78:337-341, Oct. 1940. Swift. F. L.:
Infant feeding, Lackawanna Co. M. Soc.
Reporter, 33:16-18, Nov. 1940. B.ogert.
L. J., and Porter, M. T.: Dietetics Simplified,
ed. 2, Macmillan Co., New York, 1940, p.
181. Davison, W. C.: The Compleat Pediatrician, third edition, Duke University Press,
Durham. N. C, 1940, No. 216. Hawley.
E. E., and Maurer-Mast. E. E.: The Fundamentals of Nutrition. C. C. Thomas. Springfield, 111., 1940. pp. 296. 456. Kugel-
mass, I. N.: The Newer Nutrition in Pediatric
Practice, J. B. Lippincott Co., Philadelphia,
1940, p. 372. Leaman, W. G.. Jr.: Management of the Cardiac Patient. J. B. Lippincott Co.. Phila.. 1940. p. 549. Paterson,
D., in Index of Treatment, edited 4iy R.
Hutchison, ed. 12, revised, Williams & Wilkins
Co.. Baltimore. 1940. p. 491.     Thomas. G.
SCIENTIFIC   BACKGROUND
Mead's Cereal was introduced in 1930, and Pablum in 1932, by
Mead Johnson & Company. Since then, the growing literature
indicates early recognition and continued acceptance of these
products and the important pioneer principles they represent.
and the inorganic elements on growth and
resistance to disease in children. Ann. Int.
Med. 7:342-3527 Sept. 1933. Crimm. P. D..
Raphael, I. J., and Schnute, L. F.: Diet of
tuberculous and non-tuberculous children:
Effect of increased supply of vitamin B concentrate and minerals. Am. J. Dis. Child.
46:751-756. Oct. 1933.. Smith, A. D.: Consideration of various infants' foods. Pacific
Coast J. Homeop. 44:463-465. Sept.-Dec. 1933.
1 Q"\ A Somers, R., Rotton, G. C, and Rown-
tree, J. I.: Possibilities of improving
dental structures, Soc. Tr., Bull. King Co. M.
Soc. 13:6, Jan. 15, 1934. Blatt, M. L.:
Development of infants on a diet of a special
cereal mixture, Soc. Tr., Am. J. Dis. Child.
47:918. April 1934. Rice, C. V.: Anemia of
infancy and early childhood, J. Oklahoma
M. A. 27:125-129. April 1934. Hawk. W.
A.: A few of the commoner feeding problems
in infancy. Univ. Toronto M. J. 11218-229,
May 1934. Ross. J. R., and Burrill, L. M.:
The effect of cooking on the digestibility of
cereals. J. Pediat. 4:654-659, May 1934.
Rice. C. V.: Sauerkraut juice for the acidification of evaporated milk in infant feeding,
Arch. Pediat. 51:390-395. June 1934. Eder.
H. L.: Iron therapy: A routine procedure
during infancy. Arch. Pediat. 51:701-713,
Nov. 1934. Lynch, H. D.: Fundamentals
of infant feeding, J. Indiana M. A. 27:571-
574, Dec 1934. Chaney, M. S.. and Ahl-
born, M.: Nutrition, Houghton Mifflin Co.,
Boston, 1934, p. 323.
1935 Bailey, C. W.: Anemia in infants and
young children, J. South Carolina M.
A. 31:54-58, March 1935. S Kugelmass, I.
N.: The recent advances, in treatment, of
nutritional disturbances in infancy and'childhood, M. Comment 17:5-13, March 1, 1935.
Ross, J. R., and Summerfeldt, P.: Value of
increased supply of vitamin Bt and iron in
the diet of children: Paper II, Am. J. Dis.
Child. 49:1185-1188. May 1935. von Meysenbug, L.: Breast feeding with especial
reference   to  some   of  its  problems.   New
141. Feb. 1937. Strong. R. A.: Nutritional
anemia, Mississippi Doctor 15:13-16, Aug.
1937. Smith, C. H.: Prevention and treatment of nutritional anemia in infancy. Preventive Med. 7:115-124, Aug. 1937. Saxl,
N. T.: Pediatrics, in Dietetics for the Clinician, edited by M. A. Bridges, third edition.
Lea & Febiger, Philadelphia, 1937. pp. 637-
639. Boyd. J. D.: Nutrition of the Infant
and Child. National Medical Book Co., Inc.,
New York, 1937, p. 110. Brennemann, J.:
' Practice of Pediatrics, W. F. Prior Co., Inc.,
Hagerstown. Md.. 1937, Vol. 1. Ch. 25, p. 19.
Griffith. J. P. C, and Mitchell. A. G.: The
Diseases of Infants and Children, second
edition, W. B. Saunders Co., Philadelphia,
1937. pj>. 106, 111. Saxl, N. T.: Pediatric
Dietetics, Lea & Febiger, Philadelphia, 1937,
pp. 131-133.
1938 Hoffman' s- J- Greenhill, J. P., and
.  Lundeen, E. C: A premature infant
weighing 735 grams and surviving, J.A.M.A.
110:283-285.. Jan. 22. 1938. Krasnow. F.:
Nutritional influence on teeth. Am. J. Pub.
Health 28:325-333. March 1938. Ratner, B.:
Round Table discussion on asthma and hay
fever in children, J. Pediat. 12:399-413,
March 1938. Ratner, B.: Panel discussion
on the role of allergy in pediatric practice,
J. Pediat. 13:582-604, Oct. 1938. Snelling,
C. E.: Nutritional anaemia. Bull. Acad. Med.
Toronto 12:710, Oct. 1938.. Dauphinee.
J. A.: The iron requirement in normal nutrition,   Canad.   M.A.J.   39:483-486.   Nov.
1938. Summerfeldt, P., and Ross, J. R.:
Value of an increased supply of vitamin Bi
and iron in the diet of children. Paper III,
Am. J. Dis. Child. 56:985-988, Nov. 1938.
Tisdall, F. F., and Drake, T. G. H.: The
utilization of calcium, J. Nutrition 16:613-
620. Dec. 1938. Drake, T. G. H.: Introduction of solid foods into the diets of children. Canad. M. A. J. 39:578-580, Dec. 1938.
1939 Strong,   R. A.:  The most frequent
causes of vomiting in infancy, Texas
State J Med 34:665-670, Feb. 1939.     Rat-
I.: Dietary of Health and Disease, ed. 3, revised. Lea & Febiger. Phila.. 1940, pp. 171.
IQ^l Gipson, A. C: The role of allergy in
pediatric practice, J. M. A. Alabama
10:272-274. Feb. 1941. Ross. J. R, Monypenny, D., and Jackson, S. H.: II. The effect
of cooking on the digestibility of cereals, J.
Pediat. 18:395-398. March 1941. Kennedy,
A. S., Snider, O., Hazen, J. S., and McLean,
C: The dietary management of intestinal
tuberculosis, Canad. M. A. J. 44:380-385,
April 1941. McAlpine, K. L.: Management of the nutritional anaemia of infancy,
Canad. M. A. J. 44:386-390. April 1941.
Patek, A. J., Jr., and Post. J.: Treatment of
cirrhosis of the liver by a nutritious diet and
supplements rich in .vitamin B complex..J.
Clin. Investigation 20:481-505. Sept. 1941.
Bercovitz, Z.. and Johnson, H. J.: Ulcerative
Colitis, in Dietetics for the Clinician, by M.
A. Bridges, fourth edition, revised. Lea &
Febiger, Phila., 1941. p..295. Bridges, M.
A.: Dietetics for the Clinician, fourth edition,
revised. Lea & Febiger, Phila., 1941, pp. 727,
751. 809. Griffith, J. P. C, and Mitchell.
A. G.: Textbook of Pediatrics, ed. 3, revised,
W. B. Saunders Co., Phila.. 1941. pp. 87, 91.
Rowe, A. H.: Elimination Diets and the
Patient's Allergies,  Lea & Febiger,   Phila.,
1941, p. 230. Twiss, J. R.: Gall-bladder
Disease, in Dietetics for the Clinician, by
M. A. Bridges, fourth edition, revised. Lea &
Febiger, Phila., 1941, p. 401.
1Q42 Gleich, M.: The premature  infant.
^    Part II, Arch. Pediat.59:99-135. Feb.
1942. Part IV, Arch. Pediat. 59:241-263.
April  1942.       Brown,   A.,  and   Robertson,
E. C: Factors to be considered in the construction of the diet of the older child, J.
KansasM.Soc. 43:237-244. June 1942. Porter, L-, and Carter, W. E.: Management of the
Sick Infant and Child, ed. 6, C. V. Mosby Co.,
St. Louis, 1942. p.  125.       Proudfit, F. T.:
1 Nutrition and Diet Therapy, ed. 8, Macmillan
Co., New York. 1942, p. 515. Willard, J.
H.: Digestive Diseases in General Practice,
F. A. Davis Co., Phila.. 1942. p. 147. 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.
Since the best evidence is clinical
•evidence, write for literature and
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.ECENTLY reported developments
in research as to the mode of laxative operation of ALL-BRAN added to unrestricted and
uncontrolled diets are of considerable interest. Evaluations by the use of measuring
methods that have been found consistently
reliable indicate that:
• When bran is added to the diet a desirable
change takes place in the waste material-
it becomes bulkier and softer.1
• Bran exerts its laxative effect primarily
in the colon; it does not interfere with normal processes of digestion in the stomach or
small intestine.2
• Bran has little effect on the emptying
time of the colon when this emptying time
is as it should be. But among subjects with
a delayed emptying time, bran has a distinct
accelerating effect.2
• It is not necessary to control rigidly the
quantity of bran eaten, as 2 ounces (double
the usual cereal serving) eaten daily does
not result in a corresponding increase in
laxation.3
• Bran eaten every day for an extended
period of time has no adverse effects on normal intestines; its continued use does not
lessen or increase its laxative effect.3
1 "Mode of Action of Bran," Journal of Laboratory
and Clinical Medicine, August, 1941.
2 "Roentgen Study of Intestinal Motility as Influenced by Bran," The Journal of the American
Medical Association, February 3, 1940.
3 "Effect of Long-Continued Consumption of
Bran by Normal Men," Journal of American
Dietetic Association, April, 1942.
• Any or all of these reports are available.
Requests for reprints relative to the action of
KELLOGG'S ALL-BRAN should be made to
KELLOGG COMPANY OF CANADA LIMITED, London, Ont. flDount pleasant Xttnbertahing Co. 5ltb.
KINGS WAY at 11th AYE. Telephone FAirmont 0058 VANCOUVER, B. C
R. F. HARRISON W. E. REYNOLDS
Jfead Cold* Checked J    § {
WITH 3 DROPS IN EACH NOSTRIL . . .
PRIVINE"Ciba"
(1:1000 solution of 2—(naphthyl—1-^methyl)—imidazoline hydrochloride)
NASAL   DROPS!
Clinical investigations on Privine Nasal Drops have proved that
they are excellently suited for the treatment of all forms of nasopharyngeal affections. In head colds, a few moments after the
instillation of 3 drops of Privine in each nostril, the headache and
sensation of heaviness in the head disappear, while the nasal respiration becomes easier, the watering of the eyes stops, the voice regains
its normal tone and the sense of smell is restored.
ISSUED:
In bottles of Vi ounce with dropper, and bottles of 4 ounces.
CIBA COMPANY LTD.
Montreal GRATIFYING RELIEF
at diUrefolna bumhtamA ity
CYSTITIS
PYELONEPHRITIS
PROSTATITIS
URETHRITIS
/T^HE prompt symptomatic relief provided by
^ Pyridium is extremely gratifying to the patient suffering with distressing urinary symptoms
such as painful, urgent, and frequent urination,
tenesmus, and perineal irritability.
Conveniently administered perorally in the
average dosage of 2 tablets t.i.d., Pyridium possesses a combination of advantages. It is relatively nontoxic, is-effective in the presence of
either acid or alkaline urine, is well tolerated,
and has a local analgesic effect on the urogenital mucosa.
Literature en request
PYRIDIUM
REG. U. S. PAT. OFF.
(Phenylaxo-alpha-alpha-diamino-
pyridine mono-hydrochloride)
More thai
decade
vore man a
of service in
urogenitaHhfettions
Li
MERCK & CO. Limited   <Ma*iu<factuKiny 9£Aemtit4   Montreal and Toronto IIIMII1IIIIIIIIIIIII1IMIII11IIIIII.I
.iiiiuiuimmiiiituiiiiiiiiiiitiiiiiiiiiiiiiii
I'm off the bottle-
but I'm sticking with Carnation!
When, along toward the tenth month, your Carnation
feeding formula prescribes a whole-milk dilution, there
is no need to change to any other form of milk—and
many good reasons for "sticking with Carnation." These
are the same reasons that have made Irradiated Carnation
Milk a preferred milk for infant feeding—and the added
reasons of established taste-habit and digestive acceptance.
JLhysicians are invited to write for "Continuing After Weaning With Irradiated Carnation Evaporated Milk" Address Carnation
Company limited, Toronto, Ont.
IRRADIATED
Carnation
I    y'jIRRADlMED
Utonatiffl1
\» fim. C..t~lrJ ft"
"FROM CONTENTED COWS"
Milk
A Canadian Product ^Prescription Specialists
»
That phrase has been the Keynote of Georgia
Pharmacy for 35 years. The war has. reduced our staff of registered pharmacists^but
it hasn't lessened our skill nor the quality and
accuracy of our dispensary.
Phone
MArine 416
,JL*^^.JU*d*4**\
GEORGIA PHARMACY
I.  I V  I  T
^nter^c2|anttalltb
ISTABLISHED 1891
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C. Ji ^ttff
(So. Ctmttf &
New Westminster, B..C.
For the treatment of
NEUROPSYCHIATRIC
DISORDERS
Reference—B. C. Medical Association
For information apply, lif*
Medical Supekintenden^New Westminster, B.^i^
or 721 Mewcal-De^^IBuilding, Vancouver, B.:^
PAcific^7823
Westminster 288
>S7

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