History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1945 Vancouver Medical Association Jul 31, 1945

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 The .
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of the . . §
VANCOUVER
MEDICAL
ASSOCIATION
With Which Is Incorporated
Transactions of the
VICTORIA MEDICAL SOCIETY
the
VANCOUVER GENERAL HOSPITAL
and
ST. PAUL'S HOSPITAL
In This Issue:
Page
B. C. M. A. ANNUAL MEETING PROGRAM ..t  243
B. C. M. A. COMMITTEE REPORTS -||X ^245
LEUKEMIA AND ALLIED DISEASES
Henry Jackson, Jr. M.D. 2l|—, i3|_- 253
BRONCHIECTASIS IN SERVICE PERSONNEL
Wing Commdr. R. C Laird, R.CA.F...: Jfe.  261
NEWS AND NOTES II 4 M263
BRITISH COLUMBIA MEDICAL ASSOCIATION
ANNUAL MEETING
SEPTEMBER 12, 13, 14—HOTEL VANCOUVER,
VANCOUVER, B. C.
VOL. XXI. NO. 10
July, 1945 OESTROFORM
Trade Mark
The Natural Oestrogen
:3___3-*
m®m
The use of Oestroform still remains the most satisfactory method
of controlling the symptoms of the menopause, since it provokes
no toxic reaction as the synthetic oestrogens may do; further, as
Oestroform is administered by injection, all stages of treatment
are under the practitioner's supervision.
Oestroform is indicated also in genital infantilism and delayed
puberty, in primary and secondary amenorrhoea, in sterility and
dysmenorrhoea due to uterine hypoplasia, in pruritus and kraurosis
vulvas and for the induction of labour and for the inhibition of
lactation.
Stocks of Oestroform are held by leading druggists throughout
the Dominion, and full particulars are obtainable from
THE BRITISH DRUG HOUSES (CANADA) LTD.
Toronto Canada
.Oes/Om/457
wmmmmm THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Db. G. A. Davidson Ob. D. B. H. Cleveland
All communications to be addressed to the Editor at the above address.
VoL XXI
JULY, 1945
No. 10
OFFICERS,  1945 - 1946
Db. Frank Turnbull       Dr. H. A. Des Brisay Dr. H. H. Pitts
President Vice-President Past President
Dr. Gordon Burke, Dr. G. A. Davidson
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. R. A. Gilchbist, Db. D. M. Meekison
TRUSTEES
Db. J. A. Gillespie        Db, A. W. Hunter Db. W. T. Lockhabt
Auditors: Messbs. Plommeb, Whiting & Co.
SECTIONS
Clinical Section
Db. S. E. C. Tubvey Chairman Db. E. R. Hall Secretary
Eye, Ear, Nose and Throat
Db. Gbant Lawbence President Db. Roy Mustabd Secretary
Paediatric Section
Db. Howard Spohn Ciurirman Db. Harry Bakeb Secretary
Orthopaedic and Traumatic Surgery Section
Db. D. M. Meekison Chairman Db. J. R. Naden Secretary
STANDING COMMITTEES
Library:
Db. W. J. Dorrance, Chairman; Dr. P. J. Bulleb, Db. R. P. Kinsman,
Dr. J. R. Neilson, Dr. D. E. H. Cleveland, Dr. S. E. C. Turvey.
Publications:
Dr. J. H. MacDermot, Chairman; Dr. D. E. H. Cleveland, Dr. G. A.
Davidson, Dr. J. H. B. Grant, Dr. S. E. C. Tubvey, Db. Grant Lawrence
Summer School:
Dr. G. A. Davidson, Chairman; Dr. J. C. Thomas, Dr. R. A. Gilchrist,
Dr. A. M. Agnew, Dr. L. H. Leeson, Dr. L. G. Wood.
Credentials:
Dr. J. R. Netlson, Dr. H. H. Pitts, Db. A. E. Tbites
V. O. N. Advisory Board:
Dr. Isabel Day, Dr. J. H. B. Grant, Dr. G. F. Stbong
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont
Representative to B. C. Medical Association: Dr. H. H. Pitts
Sickness and Benevolent Fund: The Pbesident—The Trustees Whether rationing is more or less liberal,
the pediatrician as always has the problem of
supplying sufficient vitamins A and D to his young
patients. Vitamin D in particular must be supplied
abundantly to insure adequate structural development and calcium-phosphorus metabolism.
For this purpose Navitol* with Viosterol offers
these features:
1. It has an unusually high vitamin A and D
content per gram—65,000 units of A—
13,000 unite of D.
2. An average daily dose of THREE DROPS
supplies 5000 unite of A—1000 unite of D.
3. Cost per daily dose about one-half cent.
4. Highly palatable.
Navitol with Viosterol thus affords a convenient
and economical means of supplying the fat-soluble
vitamins A and D which every infant needs every
day. Specify it for expectant mothers, infante,
children, and patients requiring a vitamin A and D
supplement.
Navitol with Viosterol conforms to the maximum vitamin A and D potencies of U. S. P. XII
Concentrated Oleovitamin A and D.
WcOu
V'ufo-
Dltt*
HSU
IN
P
H>\WWCS
♦Navitol is a trade-mark of E. R. Squibb flk Sons.
For literature write
36 Caledonia Road
Toronto,  Ont.
ERtSqjjibb & Sons
of Canada. Ltd.
ilanu/octurini Chemists to the Medical Profession
Since 1858 VANCOUVER HEALTH DEPARTMENT
STATISTICS—MAY, 1945
Total population—estimated  ^	
Japanese Population—Estimated
Chinese  population—estimated  	
Hindu population—estimated 	
  311,799
-Evacuated
I       6,395
  335
Total deaths 1323
Chinese  deaths 13
Deaths—Residents only 297
BIRTH REGISTRATIONS:
Male,  307;   Female,   309.
616
Rate per 1,000
. Population,
12.2
23.9
11.2
23.3
INFANT MORTALITY: May, 1945
Deaths under one year of age 11
Death   rate—per   1,000   births 23.0
Stillbirths   (not included above)       10
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
April, 1945
Cases      Deaths
May, 1945
Cases      Deaths
June 1-15, 1945
Cases      Deaths
Scarlet Fever j  36
Diphtheria  0
Diphtheria  Carrier  0
Chicken  Pox _ 57
Measles  441
Rubella  24
Mumps   ;  12
Whooping Cough :  3
Typhoid Fever :  0
Undulant Fever  0
Poliomyelitis   0
Tuberculosis  ;  3 9
Erysipelas  3
Meningococcus  Meningitis   —  2
Paratyphoid Fever  \   0
Infectious Jaundice   3
Salmonellosis —  3
Dysentery  0
Syphilis \	
Gonorrhoea  j ———  M«
8
0
1
0
0
0
55
0
62
0
20
0
7
0
3
0
0
0
0
0
0
0
1
0
0
0
f-°&\
0
:B
0
1
0
1
0
BI OG LAN-A
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 during
1932-1943. 0j£,    i     ;;      <    j
Stanley N. Bayne, Representative
Phone MA. 4027        I   1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page Two Hundred and Thirty-eight EPINEPHRINE ...
THE PRESSOR PRINCIPLE OF THE ADRENAL GLAND
EPINEPHRINE is prepared by Connaught Laboratories from beef
adrenal glands as a pure crystalline compound which is used for three
preparations.
•    EPINEPHRINE  HYDROCHLORIDE SOLUTION  (1:1000)—
a sterile solution in 30-cc. rubber-stoppered vials to be given
by intramuscular, intravenous or subcutaneous injection as
a heart stimulant and to raise blood pressure.
•    EPINEPHRINE   HYDROCHLORIDE  INHALANT  (1:100)—
distributed in special dropper bottles containing 6 cc. to be
used in the treatment of bronchial asthma.
• EPINEPHRINE IN OIL (1:500)—a sterile suspension in
oil in 20-cc. rubber-stoppered vials for use intramuscularly
when a prolonged effect is desired.
Each of these preparations is fully potent, is highly stable and
is economical.
CONNAUGHT LABORATORIES
University of Toronto Toronto 5/ 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-EIGHTH
ANNUAL 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 will continue to be amalgamated with the clinical staff meetings of
the various hospitals for the coming year. Place of meeting will appear on the agenda.
October    2—GENERAL MEETING.    Psychopathic Personality.
Major C. H. Gundry.
October 16—COMBINED   CLINICAL  MEETING   AND   STAFF   MEETING   AT
VANCOUVER GENERAL HOSPITAL.
November 6—GENERAL MEETING.    Protruded Intervertebral Discs—Analysis of
Sixty Cases.  Major P. O. Lehmann, R.C.A.M.C.
November 20—COMBINED CLINICAL MEETING AND STAFF MEETING AT
ST. PAUL'S HOSPITAL.
Olrutrr $c I
ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C.
Page Two Hundred and Thirty-nine IMMUNIZATION
TECHNIQUE
CONVENIENT
AND EFFECTIVE
NO TIME-CONSUMING DILUTION of allergens is
needed, for TUBEX* are available filled with a sterile
solution of the specific allergen in 5 different degrees of
concentration suitable for immediate injection.
^m     A Sterile needle is affixed to the Tubex syringe.
O
pooipUt* teiting i*f« feeie«t*t
thtm 2<W T»fet>x of ****niiai
<liMCRBM> «»♦ &QX&& n»*j&k* «m_
A graduated Tubex of the specific allergen is
inserted into the syringe with the white rubber
diaphragm toward the needle.
The Tubex is then gently pressed down until the
0 white diaphragm is pierced by the inside point
of the needle. The syringe is then closed and
ready for use.
The allergen in the Tubex remains unexposed
Oand sterile and is now ready to be injected
according to the dosage schedule which accompanies each treatment set.
*TUBEX Trademark Reg. in Canada.
JOHN WYETH & BROTHER (CANADA) LIMITED
REICHEL   DIVISION
Walkerville - Ontario ^Ite £ detail Pcuje, .
We have been hearing recently of the new social programme for the people of Canada
which is contemplated by the Donunion Government. The part of it that particularly
interests us as a profession is that dealing with Health Insurance, which we are assured
will soon be put into effect. This, of course, is an inevitable and integral part of the
whole effort, and we take it for granted that some form of Health Insurance will come
before very longhand, as we have so often said, we intend to support the principle of
such insurance, and co-operate with the legislative authorities in bringing it into being.
But we must be satisfied that it will be instituted in such form, and along such lines,
that it will accord with the underlying principles which we feel after very long consideration must be observed, if in the long run Health Insurance is to mean what its name
suggests.
We note that the government plans to introduce Health Insurance gradually, and in
instalments, so to speak. This is quite in line with our suggestions on the matter. But a
disturbing note is struck by the announcement, or rather the intimation, that the first
step will be "general practitioner" service—to be followed by increase in hospital service,
specialized service and so on.
We hope sincerely that our representatives will examine this proposal very seriously,
and, we feel like saying, with very grave suspicion. To us, "general practitioner service"
sounds very much like a panel" system such as has obtained in Great Britain. The panel
system is a pernicious and inefficient system of medical practice that he hope we shall
never see in Canada. And once we get it, we shall find it next to impossible to obtain
a good medical service.
What is the object of Health Insurance? Is it not to ensure that every member
of the community shall be assured of a complete, and adequate, medical service, preventive
and therapeutic, with hospital service, laboratory service and so on, at a price that he
can afford? There is no other reason for it. As things are, most people cannot afford the
high cost of complete medical service—and so we feel that it must be made available on
a system of collective payment.
But the service, if it is to be worth having, if it is to lessen the incidence of disease,
to anticipate and prevent it, and to give adequate treatment, must be complete. It must
include surgical and specialist care as much and as inevitably, as it includes general practitioner service, whatever that phrase may mean. In this day and age, the general
practitioner must be allowed and equipped—even compelled—to give adequate service,
including hospital care, X-rays, etc.—and anything less will lead to bad and inadequate
medical service.
If this thing has to be done in stages, the stages should be so arranged as, first, to
give relief where it is most needed; second, to lead to the best kind of medical service;
third, to lead to the lessening and shortening and preventing of loss of health and time
due to illness.
We have said again and again, that the first step should be extension and increase
of hospital facilities, diagnostic facilities, etc., which should be available to all, and which
should be provided for the use of the medical man, specialist, general practitioner, or
whatnot. This is the first need. Its lack is one of the greatest of reasons why illness
causes so heavy and intolerable a burden. The cost to the sick man of general practitioner service is the smallest of his burdens, and is not what makes illness so hard to
pay for. It is hospital care, now regarded as an essential in almost any illness, the cost
of specialized care, of operations, etc. These are the things which the average man
cannot afford—and we shall not lighten his burden to any appreciable extent by such a
plan as is being suggested.
As a profession, we should set our face firmly against any such proposal.   It will split
our profession in two, and make unity of action impossible.   But worse still, it will
Page Two Hundred and forty condemn us to work under an antiquated and outworn system which we all despise, and
which can never give good medical service to our patients. We should and must stick to
our demand for an adequate, properly integrated, coherent scheme, which will take into
account the demands and necessities of modern medical practice. And will not merely
satisfy a supposed popular clamour for relief at any price, so long as it is a cheap price.
It is particularly important that we should be especially vigilant just now. Hundreds,
or thousands, of medical men will be coming back to practice. Their way will at first
be hard; the temptation to take on work, even on terms which are not of the best, will
be great; it is for us who are at present in the position of negotiators to take the long
view, and refuse to agree to anything which, no matter how desirable it looks in the short
view, will ultimately be a betrayal of our principles, and a serious detriment to the later
generations of medical practitioners.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY—
Heart Disease, 3rd ed., 1944, by Paul D. White.
Lead Poisoning, 1944, by Abraham Cantarow and Max Trumper.
Surgical Clinics of North America, Symposium on Thyroid Surgery and Symposium
on Gynaecological Surgery, June, 1945, Lahey Clinic Number.
Transactions, Section on Ophthalmology, American Medical Association, 1944.
Text-Book of Ophthalmology, V. Ill, Diseases of the Inner Eye, by Sir W. Stewart
Duke-Elder.   (Reprinted January, 1945.)
JOINT STUDY COMMITTEE ON
HEALTH INSURANCE
A Joint Study Committee, consisting of five representatives of each of the
following five organizations—British Columbia Hospitals Association, British
Columbia Dental Association, British Columbia Medical Association, Registered
Nurses' Association of British Columbia and the Pharmaceutical Association of
British Columbia, met monthly during the past winter, and discussed Health
Insurance as it affects their organizations.
Much mutual benefit accrued from these meetings, and it is very opportune
that these same organizations have arranged a Round Table Conference on this
subject, on September 11th, notice of which appears elsewhere in this Bulletin.
(See page 264).
Page Two Hundred and Forty-one RELIEF ADMINISTRATION COMMITTEE
Dear Doctor:
This letter is for the information of all medical practitioners in the City of Vancouver.
The Vancouver Medical Association receives from the City of Vancouver each month
a sum of money in payment for medical services rendered Old Age Pensioners, recipients
of Mothers' Allowance and Social Assistance cases. The sum received is estimated to pay
approximately 75% of minimum fees for services rendered.
These services are limited to house and office visits, including such minor surgery as
can safely and properly be performed in a patient's house or a doctor's office.
Services of any kind rendered to a patient in hospital will not be paid for.
Such diagnostic aids as X-ray, Basal Metabolism, Electrocardiograms, Cystoscopy and
complete Blood Counts will not be paid for. Patients requiring any of these procedures
or major surgery or hospital care of any kind should be referred as staff cases to the
Vancouver General Hospital.
No extra fee will be paid for Urinalysis, Haemoglobin estimation or Leuocyte count
done in house or office.
The hypodermic administration of diphtheria toxoid, staphylococcus toxoid, scarlet
fever toxoid and pertussis vaccine will be paid for at the rate of $1.00 per injection.
Injection of vaccine for colds will not be paid for.
Vaccination for smallpox will be paid for at the rate of $1.00.
The hypodermic adrninistration of estrogenic substances and other hormone preparations will not be paid for.
Circumcision of newborn infants will be paid for at the rate of $10.00 and of adults
under local anaesthesia at $25.00.
Treatments by physiotherapy will not be paid for.
Physical examinations for the purpose of certification will not be paid for.
Post operative, treatments and dressings following discharge from hospital will not
be paid for, save in exceptional cases for which the approval of the Chairman of the
Relief Administration Committee must be obtained.
The treatment of Venereal diseases will not be paid for.
Electrocauterization of the cervix uteri will be paid for at the rate of $5.00.
Necessary visits for threatened or actual abortion will be paid for up to $25.00 for
any one case.
Maternity cases confined at home will be paid for at the rate of $35.00.
Injection of varicose veins will be paid for at. the rate of $5.00 for each injection
up to $15.00 for one leg and $25.00 for both legs. Extra fees for treatment of a concurrent ulcer will not be paid.
All fees mentioned in this letter are subject to a reduction of approximately 25%.
All accounts are carefully scrutinized and payment will not be made for services
considered excessive or unnecessary.
Accounts for each month must be rendered before the 5 th of the following month
on the authorized forms which may be obtained at the Library—one form for each patient
—and THESE FORMS MUST BE COMPLETED IN FULL.
Yours sincerely,
J. A. SUTHERLAND, M.D.
Secretary, Relief Administration Committee.
Page Two Hundred and Forty-two BRITISH COLUMBIA IDOL ASSOCIATION
1PU1L MEETING
September 12, 13, 14 :: Hotel Vancouver
SPEAKERS:
Dr. W. G. Cosbie, Assistant Professor of Obstetrics and Gynecology, University of
Toronto.
Dr. John H. Fitzgebbon, Assistant Clinical Professor of Medicine,  University of
Oregon Medical School.
Dr. John Hepburn, Associate in Medicine, University of Toronto.
Surgeon Lieut. Commander John MacLean, R.CN.V.R., Consultant in Urology.
Lieut.-Colonel H. S. Mitchell, R.C.A.M.C., Medical Division, Montreal Military
Hospital.
Dr. H. G. Pretty, Lecturer, Department of Surgery, McGill University.
Dr. Forrest E. Rjeke, Medical Director, Oregon Shipbuilding Corporation, Portland,
Oregon.
Group Captain F. F. Tisdall, R.C.A.F., Consultant in Nutrition.
Colonel A. B. Walter, R.C.A.M.C., Consultant in Medicine.
REPRESENTING CANADIAN MEDICAL ASSOCIATION:
Dr. Leon Gerin-Lajode, Montreal, President.
Dr. T. C. Routley, Toronto, General Secretary.
The Comrnittee on Programme has prepared an excellent programme for this three-
day meeting.
• Fifteen lectures on three mornings
• Afternoon sessions:
Wednesday    -   Surgical Clinic—St. Paul's Hospital.
Eye Clinic—Vancouver General Hospital.
Venereal Disease Demonstration—2700 Laurel St.
Industrial Medicine—Ballroom.
Thursday -    -   Cancer—Dr. Cosbie—Ballroom.
Clinical and Pathological Demonstration—-B. C. Cancer Institute.
Friday      -    -   Medical Clinic—Vancouver General Hospital.
Tuberculosis Demonstration—Ballroom.
Annual Meetings:
Wednesday evening
Thursday evening
College of Physicians and Surgeons.
All doctors should attend.
British Columbia Medical Association (Canadian Medical
Association, British Columbia Division).
Page Two Hundrred and Forty-three • Golf—Thursday afternoon.
• Official Luncheon—Wednesday—Addresses by Dr. Leon Gerin-Lajoie and Dr. T. C.
Routley of the Canadian Medical Association.
• Annual Dinner—Friday evening—Guest  speaker,  Very  Reverend  Cecil  Swanson,
Dean, Christ Church Cathedral.
• Dancing—Friday evening—Hotel Vancouver, Panorama Room.
• Entertainment for Ladies.    Tea—Dinner.
• Commercial Exhibits—A large number of firms are participating.
\r*%oa zammz
Wednesday, September 12th
8:00 a.m.    Registration.
9:00 a.m.    Col. Walter: "A Synopsis on Atypical Pneumonia."
9:45 a.m.    Dr. Fitzgibbon: "Gastroscopy and its Role in Present Day Medicine."
10:30 a.m.    Dr. Pretty: "Pitfalls relative to Hernial Repairs."
11:15 a.m.    Dr. Cosbie: "Uterine Haemorrhage."
12:15 p.m.    Official Luncheon—Hotel Vancouver, May fair Room.
Speakers: Dr. Leon Gerin-Lajoie,
Dr. T. C. Routley.
2:30 p.m.    Surgical Clinic—St. Paul's Hospital.
2:30 p.m.    Eye Clinic—Vancouver General Rospital.
2:30 p.m.    Venereal Disease Demonstration—"Recent Advances in Venereal Disease
Control."    2700 Laurel Street.
4:00 p.m.    Dr. Rieke: "Industrial Medicine."
Followed by open discussion.    Hotel Vancouver, Ballroom.
8:30 p.m.    Annual Meeting—College of Physicians and Surgeons of B. C.
Hotel Vancouver, Ballroom.
Thursday, September 13 th
Lt.-Col. Mitchell: "Infectious Hepatitis."
Group Capt.  Tisdall:   "Nutrition  from  the  Standpoint  of  the  General
Practitioner."
Dr. Fitzgibbon: "Proctoscopy for the General Practitioner."
Dr. Hepburn: "Heart Disease and Pregnancy."
Surg. Lt. Cmdr. MacLean: "Genito-Urinary Tuberculosis."
Golf Tournament—Capita no Golf Club.
Dr. Cosbie: "Early Diagnosis of Gynaecological Cancer."
Hotel Vancouver, Ballroom.
3:00 p.m.    Clirdcal and Pathological Demonstration, and informal discussion led by
Dr. Cosbie.
B. C. Cancer Institute, 685 West 11th Avenue.
Tea will be served and transportation provided.
8:30 p.m.    Annual Meeting—British Columbia Medical Association.
Hotel Vancouver, Ballroom.
Friday, September 14th
8:00 a.m.    Dr. Hepburn: "Recognition of Heart Disease."
8:45 a.m.    Lt.-Col. Mitchell:   "Diagnosis  and Early Treatment  of Acute Anterior
Poliomyelitis."
9:30 a.m.    Group Capt. Tisdall: "Gingivitis from the Standpoint of the Physician."
10:15 a.m.    Dr. Pretty: "Lesions Pertaining to the Vascular System of the Lower
Extremities."
8
:00
a.m.
8
:45
a.m.
9
:30
a.m.
10
15
a.m.
11
00
a.m.
1
30
p.m.
2
00
p.m.
Page Two Hundred and Forty-four .11:00 a.m.
11:45 a.m.
12:30 p.m.
2:30 p.m.
2:30 p.m.
7:00 p.m.
Col. Walter: Subject to be announced. '~r~-
Surg. Lt. Cmdr. MacLean:  "Diagnosis and Treatment of Chronic Prostatitis."
Luncheon—Board of Directors,,
Hotel Vancouver.
Medical Clinic—Vancouver General Hospital.
Demonstration of Diseases of the Chest,
Vancouver Unit, Tuberculosis Control.
Hotel Vancouver, Ballroom.
Annual Dinner (Dinner Jackets).
Hotel Vancouver—Banquet Room.
Guest Speaker: Very Rev. Cecil Swanson, Dean, Christ Church
Cathedral.
10:00
p.m.
Dancing-
-Hotel Vancouver, Panorama Room.
British Columbia Medical Association
REPORTS BY CHAIRMEN OF STANDING COMMITTEES
The following reports of Committees of the British Columbia Medical Assoication
are published in advance in the hope that time will be saved at the Annual Meeting
of the Association on Thursday, September 13 th.
Members are requested to read these reports. They contain much valued information
and will be open for discussion at the Annual Business Meeting.
REPORT OF COMMITTEE ON CONSTITUTION AND BY-LAWS
The Committee on Constitution and By-Laws of the British Columbia Medical
Association held one meeting during the year to consider the proposed changes in the
Constitution and By-Laws of the Canadian Medical Association.
D. F. Busteed, Chairman.
REPORT OF COMMITTEE ON PROGRAMME AND FINANCE
In the Fall of 1944 your Committee arranged for speakers at the Annual Meetings
of the Medical Associations in the Interior of British Columbia. Dr. G. O. Matthews,
the President of the British Columbia Medical Association, accompanied by Dr. H. H.
Milburn, President of the College of Physicians and Surgeons at that time, and the late
Dr. M. W. Thomas, attended these meetings and presented reports on the affairs of the
Association, and papers were read by Dr. D. M. Meekison.
The following places were visited:
District No. 4 Medical Association—Kelowna, October 2_th.
West Kootenay Medical'Association—Rossland, October 28 th.
East Kootenay Medical Association—Cranbrook, October 29th.
A large number of doctors in these areas attended the meetings, and these were
followed by the Annual Dinners.
The Upper Island Medical Association held its Annual Meeting in the Spring of this
year. Dr. G. O. Matthews and Dr. H. H. Milburn attended, giving the large attendance of members a comprehensive talk on matters pertaining to the profession with
special reference to the British Columbia Medical Association plans. Dr. D. M. Meekison presented a paper.
Page Two Hundred and Forty-five No special meetings of the British Columbia Medical Association were held during
the year.
Preparations have been made for the Annual Meeting to be held in Vancouver, September 12-14 inclusive. We, as a Committee, are pleased to present a full programme of
outstanding speakers in the important branches of our professional work.
The Committee wishes to acknowledge the provision by the Canadian Medical
Association of four speakers on the lecture programme.
We wish to record our thanks to the Directors of the Medical Services, Navy, Army
and Air Force, for speakers.
The adoption of this report is moved.
Lavell H. Leeson, Chairman.
REPORT OF COMMITTEE ON ARCHIVES
Herewith the report of the Clommittee on Archives for the year 1944-1945.
Dr. G. E. Kidd consented to act with me on this Conunittee, but there is nothing
particularly of interest to report except in relation to the following letter from H. D.
Parizau of the Canadian Department of Mines and Resources, which was written to
Dr. Lennox, President of the Victoria Medical Society, and sent to Dr. A. J. MacLachlan,
Registrar, College of Physicians and Surgeons of B. C, who in turn forwarded- it to me:
"Canadian Dept. of Mines and Resources, Surveyors and Engineering Branch,
319 Post Office Bldg., Victoria, B.C., June 7th, 1944.
Dr. Lennox, President, Medical Society,
1207 Douglas St., Victoria, B. C.
Dear Sir:
This office would like to perpetuate the names of any prominent members of your
profession, more especially those who have passed away, who, by their pioneering work
or in other ways are deserving of remembrance.
If this proposal is acceptable to you, it would be necessary to accompany each name
with a short history of the owner for record purposes to be forwarded by us to the
Geographic Board of Canada for acceptance. I suppose the names submitted would cover
the whole of the B. C. coast.
Yours very truly,
(Signed)  H. D. Parizau."
Nothing further has been done in regard to this up to the present time.
Respectfully submitted,
H. H. Pitts, Chairman.
REPORT OF THE COMMITTEE ON THE STUDY OF
MEDICAL ECONOMICS
In the absence of any further activity by either the Federal or Provincial Government in regard to the enactment of the Health Insurance legislation, this committee
has devoted itself to the study of certain general features of the whole scheme.
Last year, in canvassing the ways by which we might improve our understanding
of the whole subject of health insurance, we decided to set up a Joint Study Committee,
consisting of representatives from those professions or organizations vitally interested
in the problem. During the past year this Joint <_D__mittee has had regular monthly
meetings. The Committee is composed of five representatives from each of the following organizations: the British Columbia Medical Association, the British Columbia Hospital Association, Pharmaceutical Association of B. C, Registered Nurses' Association
of B. C, and the British Columbia Dental Association.
Page Two Hundred and Forty-six
__J. These meetings have proven most valuable, and all of us have learned a great deal.
The plan that was followed was that each group in turn was responsible for the programme at one meeting. There was in every case a full round table discussion of the
problems presented. Our programme started with a meeting in September at which
Doctor Harris McPhedran and Doctor Routley were the speakers, and at which the
subject was chiefly a review of the attitude of organized Medicine. In October the
Hospital Association in their presentation revealed the fact that we were all still somewhat in the dark as to the hospital needs under health insurance, and they instituted
an up-to-date survey of our present situation. The November meeting was a presentation of the Public Health aspects of health insurance, by Doctor J. S. Kitching. In
December the Nurses were in charge of the programme and in January the Druggists.
In February the Hospital group reported again on their findings, and in March the
Dentists made a very excellent summary of the dental aspects of health insurance. The
April meeting was devoted to a summary in which an abstract of each presentation was
made and a general round table discussion followed.
The results of these deliberations have been of surprising benefit. While the medical
members of this Joint Study Committee felt that they knew pretty well the problems
of health insurance, all have learned much by securing the viewpoint of the other
interested groups. We would recommend that other Divisions might with profit follow
this or some similar plan. It is our hope next year to continue this activity and invite
•other groups such as labour, women's organizations and so forth, to join in the round
table discussions.
Another part of our work has been the consideration of certain aspects of the problems related to medical fees. While any thought of revision of fees has of necessity
been postponed much thought has been given to the whole subject of the relation between
charges for various types of service. The recently prepared new schedule of fees for
the use of the Dependents' Board of Trustees has been carefully studied; it is noteworthy
for nothing except a general reduction in fees which seems to be as far as bureaucratic
thinking can go.
Your present Committee is still convinced that the ultimate solution of the problem
in Canada will depend upon the utilization of a unit plan by which relation between
the charges for various services can be adjusted, while the value of each unit might.
v_ry from Province to Province. There is too great a disparity between surgical fees
and charges for other types of medical service. As far as the welfare of our country is
concerned, with particular regard to the future, maternity service is a most important
part of medical care. The charge for maternity service should be increased and the
profession should render adequate antepartum and postpartum care in order to assure
the lowest maternal and infant mortality.
There is a tendency to demand an itemized account for services in any medical
condition and to be satisfied with a blanket fee for surgery. The medical skill and experience required to adequately and efficiently treat diabetic coma is greater than that
required to remove an uncomplicated acutely inflamed appendix. In the first instance
the account must be itemized and may entail only a few visits, some of the treatment
being directed by telephone or dependent on laboratory reports. In the case of the
appendectomy a fee is paid which would be ridiculous if itemized as to actual time
the surgeon spent with the patient.
The romance and drama have largely left the surgical theatre, and surgical fees
should be adjusted accordingly. Since the bulk of the work of any general practitioner
consists of house and office visits, that must remain the principal source of medical
income for this group. On the basis of the first examination and diagnosis much of the
future of the patient depends. The fee for this first examination should, therefore, be
sufficient to secure a high standard of service.
There can be no doubt that the profession should set its own house in order in
connection with fee schedules before it is done for us.
All of which is respectfully submitted. G. F. Strong, Chairman.
Page Two Hundred and Forty-seven REPORT OF THE COMMITTEE ON PHARMACY
During the past year there has been no new business on which decisions had to
be made.
Throughout the year we received several communications from Dr. V. E. Henderson, Chairman of the Committee -on Pharmacy of the Canadian Mediacl Association.
These dealt solely with the new Canadian Formulary, and after discussion in Conunittee
our comments were forwarded to him.
Concerning the matter of the new sections on Hormone and Vitamin Therapy for
the B. C. Formulary—due to a misunderstanding on the part of your new chairman
these have been held up. However, I can report that the first meeting of the Joint
Conunittee to be held early in September will clear up this unfinished business.
Respectfully submitted,
R. A. Gilchrist, Chairman.
REPORT OF THE COMMITTEE ON THE STUDY OF CANCER
Three meetings were held during the year. Your Committee comprises twenty-three
members, and as far as possible, meetings are held to conform with the meetings of the
Board of Directors of the British Columbia Medical Association in Vancouver. In addition, two extra sub-committee meetings were held to study and draft the questionnaire
form which will be used for research purposes.
Several important recommendations have been made which, it is hoped, will further
the interest of the Profession in Cancer.
1. Reporting:
At present approximately one case is reported for every death. According to some
authorities there should be three to four cases per death. There are discrepancies between
the onset of symptoms and dates of notification. To increase the volume of reporting
which will give a truer picture of the incidence, several recommendations have been
made. Hospital laboratories which perform Pathological Diagnoses on Biopsy specimens, submitted by physicians, are requested to notify the Provincial Board of Health
of positive cases. The Provincial Board of Health has advised that such caess will be
followed and information pertinent to the case will be requested. This information will
be asked for through a joint appeal by the Provincial Board of Health and your Committee. Mere reporting is insufficient, unless every case receives adequate treatment as
early as possible, and to this end it is hoped that reporting as such will further this
objective.
2. Educational Activities:
The war has curtailed the activities of many local study groups, but several centres
have reported that interest in Cancer has by no means lagged. The resumption of local
study groups is to be desired.
Your Committee is prepared to carry out as many procedures as possible contained
in the recommendations of the Executive Committee of the Canadian Medical Association, Department of Cancer Control. Last year your Conunittee was asked to endorse
and make further suggestions regarding a National Education Programme. It may be
recalled that a very complete set of recommendations was forwarded to Doctor Routley
at that time.
In the past your Committee has, on request, provided speakers, films and educational material for medical and lay meetings and is still prepared to carry on this service.
3. Research:
A determined effort has been made to start the Research Study of Cancer of the
Breast. After several meetings the Sub-Committee has drafted a detailed questionnaire
and report form. Under the scheme, student nurses entering the Vancouver General
Hospital will be given a very complete examination with special emphasis on the condi-
Page Two Hundred and Forty-eight tions which lead to Breast Cancer. Periodically the nurses will be re-examined and the
project is expected to carry on over as many years as possible. The Central Committee
of the Canadian Medical Association endorses the project and at least one other hospital,
the Women's College Hospital, in Toronto, will carry on the same programme.
Your Conunittee is indebted to its contemporary, the B. C. Branch of the Canadian
Society for the Control of Cancer, for a donation of $500.00 to further this project.
Acknowledgement must also be made to the Provincial Board of Health for the assistance of Mr. J. H. B. Scott, Director of Vital Statistics, in helping to frame the form
and have it printed to conform with a punch card system. The final draft is now
ready and the first group of volunteers will be examined in September, by Dr. Olive
Sadler, who is in charge of this research scheme.
Finally, your Q>n_mittee wishes to express its appreciation of the service given by
the late Doctor M. W. Thomas, Executive Secretary to this group. His loss is keenly felt.
• Respectfully submitted,
Ethlyn Trapp, Chairman.
REPORT OF THE EDITORIAL BOARD
During the past year the B. C. Medical Association has enjoyed free access to the
columns of the Bulletin of the Vancouver Medical Association. A column of "News and
Notes" from all over the Province appears in each issue, and is regarded very highly
by the Profession at large. We owe a great deal in this regard to the late lamented
Dr. M. W. Thomas, who really made this column the success that it has been, by his
untiring efforts in the collection of news items, and by his unfeigned personal interest
in the doings of the medical men of the Province. Since his death, Miss V. Smith, of
the Staff of the Vancouver Medical Association, has carried on the work with great
devotion and success. We desire here to acknowledge, very gratefully, her work in
this regard.
Any reports of meetings, transactions of the Council, reports of Committees, have
met with generous response from the Bulletin, that is, from the Vancouver Medical
Association, and space has always been furnished liberally. This is in accord with policy
laid down by that Association which has offered the Bulletin's facilities to constitute
an organ for the B. C. Medical Association. We see, for instance, in the publication
in this issue of the Bulletin of reports of Standing Committees, how valuable this is—
in that we can reach every medical man in the Province, whether he is able to attend
the Annual Meeting or not.
Our policy, in return, has been to furnish the Bulletin, as far as we have been able
to secure them, with copies of the addresses made before the B .C. Medical Association
at its Annual Meeting.
Our Editorial Board has furnished news to the Journal of the Canadian Medical
Association, each month, and has given accounts of Branch Association activities,
obituary material, etc. These the Journal has always accepted, and given liberal space for.
We hope to secure the material of lectures given at the Annual Meeting next month,
for later publication.
All of which is respectfully submitted.
J. H. MacDermot, Chairman.
REPORT OF THE COMMITTEE ON MEMBERSHIP
Your Committee has met on two occasions during the past year, the two meetings
being mainly due to the exigencies of practice. The Chairman has failed to attend only
one meeting of the Board of Directors. A meeting of the Central Committee on Membership of the Canadian Medical Association has not been possible owing to war conditions. However, active correspondence has been carried on with Dr. W. G. Beaton,
Chairman of the Central Committee on Membership of the C.M.A., and a report of
Page Two Hundred and Forty-nine our Provincial Cornmittee was presented at Montreal by Doctor Gerald Burke, a member
of our Committee deputized to act.
It is interesting to note that New Brunswick and Alberta give 100 per cent enrolment in the C.M.A. through the assessment of a combined fee.
In something over a year I have addressed nine local medical societies, always urging
enrolment in the C.M.A. The only district not covered is the Prince Rupert and
Prince George area.
However, our membership in the CM.A., although substantial, is not as high as we
would like it to be, and your Committee feels that our aim, like New Brunswick and
Alberta, should also be 100 per cent.
Therefore, your Conunittee would suggest that the plan of an all inclusive fee be
given further study in the hope that perhaps British Columbia could also in a legal
way obtain a more complete membership in the C.M.A.
Your Clornmittee also feels that if special concessions were given to our returning
medical men, which is to be done in Ontario and which is proposed in British Columbia,
this would go a considerable distance in increasing our membership in the C.M.A.
All of which is respectfully submitted.
D. M. Meekison, Chairman.
REPORT OF THE COMMITTEE ON INDUSTRIAL MEDICINE
For the past three years the activities of this Conunittee have been directed toward
two main objectives:
(1) To interest Government, industrial management and medical practitioners in
the value of a health service in industry.
(2) To advise and co-ordinate existing industrial medical services.
These are activities usually undertaken by a provincial division of industrial health.
Since such a division has not yet been established in B.C, the Committee believes its
advice is necessary to maintain a rninimum standard of quality in industrial medical
services. Failing such a standard, the existing interest of both industry and labour would
be lost.
This is a large Committee representing most of the industrial areas of the Province.
Although distance prevented a full attendance at each of the quarterly meetings, during
the past year the average attendance has been ten. The Q>nunittee has an excellent
Secretary in the person of Dr. A. M. Menzies, who sends a full report of the meetings
to each member.
In addition to the four meetings of the General (Z^mmittee, there was one meeting
of the Adxisory Sub-committee and numerous meetings of the Committee on Education
and of the Executive.
The Sub-committee on Health Education, under the chairmanship of Dr. R. A.
Walton, has prepared and published in local trade journals, a number of articles on industrial health matters. It also sends to each committee member the monthly "Bulletin" on
industrial health, prepared by The Health League of Canada, as well as articles prepared
by the Industrial Hygiene Division of the Dominion Dept. of Health.
The Advisory Sub-committee, Dr. G. L. Hodgins, Chairman, has continued its
interest in the health service of Wartime Shipbuilding Ltd., and has advised in regard
to the teaching and practice of industrial first-aid.
Other industries given help and advice during the year include Pacific Veneer, New
Westminster; B. C. Telephone, through Dr. J. W. Thomson; and Pacific Mills, Ocean
Falls, through Dr. Armstrong.
The Committee has maintained contact with the Canadian Medical Committee on
Industrial Medicine, and one of our Members, Dr. H. H. Milburn, attended the annual
meeting of Dr. Cunningham's Committee in Montreal.
Page Two Hundred and Fifty At the present time the Conunittee is completing a brief to the Provincial Secretary,
urging the establishment of a division of industrial health in the Provincial Government. The brief includes submissions from public health groups, labour and industry;
the preparation of the statement has meant many hours of work, most of which was
done by the Secretary of the Conunittee.
Respectfully submitted.
W. G. Saunders, Chairman.
REPORT OF THE DIVISIONAL ADVISORY COMMITTEE
The Divisional Advisory Conunittee of the Canadian Medical Procurement and
Assignment Board, has completed its sixth year of war service. The Committee has
met ten times during the past year, and the attendance continues at a high level. We
again express our appreciation of the regular attendance of the Medical heads of the
Armed Services in this Command. Lieut.-Col. F. J. Simpson, the direct representative
of the G.O.C. and a member of National Selective Service, has been regular in his attendance and most co-operative and helpful in every way.
During the past year our activities have gradually swung toward the problem of
rehabilitation. With the declaration of peace, the activities of this Conunittee should
be entirely rehabilitation in character.
It is, therefore, felt that many changes should take place in the personnel of the
Committee. Senior medical men, who have taken an active part in World War' II, and
who have been personally in touch with Medical Officers, and who know their problems
first-hand, should naturally be the men who should conduct the affairs of the revised
Divisional Advisory Committee.
It is hoped that the Conunittee will remain as an adjunct of the Canadian Medical
Procurement and Assignment Board.
E. Murray Blair, Chairman.
REPORT OF THE COMMITTEE ON EMERGENT EPIDEMICS
I am happy to report that during the past year there has been no need for this
Conunittee to function. The organization work was completed over a year ago and
Sub-committees set up in each British Columbia division, which, with the active cooperation of the Disaster Relief Conunittee of the Red Cross, are in a position to look
after any emergency without any delay.
It is unlikely that this conunittee will ever need to function, but I feel that it is
very wise to be prepared, and in case of any sudden emergency or catastrophe the
organization is there, and could be used immediately.
G. O. Matthews, Chairman.
REPORT OF THE COMMITTEE ON HOSPITAL SERVICE
Herewith is the Annual Report of the Committee on Hospital Service for the
year 1944-45.
No problems or matters have been referred to this Committee during the present
year and therefore no meetings of this Committee have been called. There is nothing
further to report.
R. A. Seymour, Chairman.
REPORT OF THE COMMITTEE ON MEDICAL EDUCATION
The main interest of this committee during the past year was the promotion of a
Faculty of Medicine at the University of British Columbia. Several meetings were
held by your <_ommittee with a Committee from the Board of Governors of the
University, including the Deans of the various Faculties.   It was apparent from these
Page Two Hundred and Fifty-one discussions that the Deans were not unanimous in their desire for a Faculty of Medicine,
their feeling apparently being that they needed money urgently for their own Faculties,
and they considered that their needs should take precedence over a new and expensive
Faculty. However, negotiations proceeded satisfactorily, and on January 16th last a
deputation met Mr. John Hart and his Cabinet at Victoria. The deputation was representative of organized medicine and consisted of Dr. K. D. Panton, Chairman; Dr. G:
O. Matthews, President, B. C. Medical Association; Dr^H. H. Milburn, President of the
College of Physicians and Surgeons; Dr. C. E. Dolman, Professor of Bacteriology and
Preventive Medicine at the University of British Columbia, and Dr. G. E. Seldon,
senior surgeon of the Vancouver General Hospital. This Committee was joined in
Victoria by Dr. P. A. C. Cousland, and Dr. Thomas McPherson. The project was
thoroughly discussed with the Cabinet, and we received a very friendly and attentive
hearing. Premier Hart intimated that the Government was contemplating a large grant
to the University, which would include sufficient funds to establish a Faculty of
Medicine.
Since that time we have learned that five milUon dollars was set aside for University
needs, and of this sum one and one-half nullion dollars Was earmarked for the Faculty
of Medicine. This sum will be sufficient to erect a large building on the University
Campus for the primary years, another building on the Campus for the Institute of
Preventive Medicine, and a third building near Vancouver General Hospital to house
the students in their final years. It will also be sufficient to provide equipment for
these buildings. Premier Hart also stated that the Government would be prepared to
provide funds for the maintenance of this school. Figures from Eastern Medical Schools
indicate that student fees provide only about 25 per cent of the cost of maintenance,
the balance being provided by government grants and endowment funds.
The establishment of a Medical Faculty now seems assured, and as your Committee
has no mandate to concern itself with the details of its organization, its active interest
in the project is completed with the exception of one point.
At a meeting of the Board of Directors of the B. C. Medical Association on April
19th it was decided that the Association should undertake a survey of modern medical
education to ascertain the best teaching material and methods for our new school. A
small delegation from your Cornmittee met Dr. MacKenzie, President of the University,
and discussed the matter. We were informed that the University proposed making
such a survey and that Dr. C. E. Dolman would undertake it. Dr. MacKenzie also
stated that he hoped to have the first classes in Medicine started in 1946. We hope
it will be possible. It is still proposed that the B. C. Medical Association should conduct
its survey, in addition to that made by the University. A study of two reports made
independently will undoubtedly result in much added information on many points. Dr.
MacKenzie is quite in favor of it. Up to the present time no person has been decided
upon to undertake it.
On May 8 th your <_ommittee met Dr. Warner, Medical Director of the Department
of Veterans Affairs. Dr. Warner is most anxious to give veterans in hospital the best
possible medical and surgical treatment. To this end he is planning to have part-time
consultants from the'various medical schools of the country appointed to the staffs
of Veterans Hospitals. They will be senior to the full-time medical officers at the hospi-
talys and will therefore be able to supervise all professional work. To make this scheme
attractive to the medical schools the patients in Veterans' Hospitals will be made
available for clinical teaching. Until such time as the medical school is functioning
in Vancouver, he suggested that these part-time consultants for B. C. should be selected
from names recommended by the B. C. Medical Association. This idea was endorsed by
your Conunittee, and it was recommended that when such names are called for by the
Department of Veterans Affairs, that the B. C. Medical Association should in the first
instance ask the district medical society of the city concerned for its nominations.
Page Two Hundred and Fifty-two These would be considered by the B. C. Medical Association when making its recommendations to the Department of Veterans Affairs.   No requests have as yet been
All of which is respectfully submitted.
K. D. Panton, Chairman.
REPORT OF COMMITTEE ON PUBLIC HEALTH
Your Committee has very little to report. During the war, Army and other regulations helped materially in keeping Public Health fairly well adjusted. The presence
of a large number of troops in B. C. accelerated cosniderably certain unfavourable health
conditions, and it is to be hoped, that the laxity of peacetime will not permit a deterioration. Chlorination of water in military areas and the increase in pasteurization of milk
has accomplished something long delayed.
During the last six months there has been a very serious increase in intestinal infections, due chiefly to the paratyphoid group. This has been especially marked in children.
One must, therefore, view with alarm the notices that have appeared in the papers in
regard to a discontinuation of chlorination of drinking water. Now that a Medical
School is in the process of being established, it may be expected that this Association
will have decided views to express on Health and other medical matters of vital interest.
It will, therefore, he assumed that your Health Committee may have more to do now
that restrictions from authoritative agencies may be to some extent withdrawn.
During the year your Chairman has furnished literature requested from several
remote areas in the Province, and has attended some very active discussions at the meetings of the Health Bureau of the Board of Trade.
All of which is respectfully submitted. Howard Spohn, Chairman.
LEUKEMIA AND ALLIED DISEASES
By Dr. Henry Jackson, Jr.,
Assistant Professor of Medicine, Harvard Medical School, Boston, Mass.
Read at the Vancouver Medical Association Summer School, 1945.
Leukemia may be defined as an acute or chronic systemic disease involving primarily
the blood-forming organs, characterized by a widespread, disorderly and profitless
proliferation of the leukocytes and their precursors, manifest by the. presence, often in
very large numbers, of immature or abnormal white cells in the peripheral blood
stream, and leading, art least in the vast majority of cases, to death within a com-
paratively short time. Classification
From a clinical viewpoint, there is a rather sharp distinction between acute and
chronic leukemia, and some authorities believe that there may be a fundamental difference in their essential nature and etiology. It is usual to classify the leukemias according to the particular type of white cell involved. We have, therefore, myelogenous,
lymphatic and monocytic leukemia. The latter is almost always acute, and in the
opinion of some investigators constitutes the majority of the cases of acute leukemia
in adults. In addition, there have been described eosinophilic and plasma-cell leukemia.
For practical purposes it is sufficient to disregard the latter two forms, which at best
are extremely rare, and to group all types of acute leukemia together as one clinical
entity. It is advantageous, however, to retain a sharp distinction between chronic
lymphatic and chronic myelogenous leukemina.
General Observations
Fortunately, leukemia is a rare disease.   One case of leukemia occurs in every 1000
general hospital admissions.   All types of leukemia are much commoner in men than
in women.  This is especially true of chronic lymphatic leukemia.
Acute leukemia is commonest in the early decades, a major peak being reached in
the first five years of life, and a secondary though still significant rise occuring early
Page Two Hundred andFifty-three in the second decade.  While the disease may be seen at any time of life, it is distinctly
rare after the age of fifty.
Chronic myelogenous leukemia is most commonly encountered between the ages of
twenty and sixty, and reaches its greatest incidence between the ages of twenty-five
and thirty-five, whereas chronic lymphatic leukemia is most often seen in persons
between'forty-five and sixty years of age. Any form of chronic leukemia is rare under
the age of ten.
There are certain changes in the bodily economy common to all types of leukemia,
and these should be referred to briefly. In all, the basal metabolic rate may be considerably increased. The nitrogen balance varies within wide limits, but particularly
in acute leukemia it is liable to be negative and the serum proteins tend to be low.
These facts should be borne in mind when considering the therapy of the disdase.
Anaemia of the normocytic and normochronic type is an almost invariable accompaniment of the disease sooner or later. The presence or absence of anaemia is of great
diagnostic value in the acute forms, and in both acute and chronic leukemia, progressive
anaemia may bring about symptoms of major importance and call for specific and energetic therapy. The presence of severe anaemia usually indicates an early fatal outcome,
especially in the acute and the chronic lymphatic types.
Any form of leukemia, but more especially the acute, may be accompanied by
spontaneous haemorrhages of minor or major clinical importance.
It is of the utmost importance to recognize the fact that any organ or structure
of the body may be involved by the leukemic process, for thus are the extremely protean
signs and symptoms of the disease brought about. It is perhaps germane to the present
purpose to draw attention to lesions of five systems in particular, for lack of recognition of the fact that these systems are frequently involved may lead to failure to
recognize the fundamental systemic disorder, or failure to treat as leukemic manifestations symptoms or signs easily attributable to other causes.
In the mouth and pharynx, there may be ulcerations, necrosis, bleeding and even
noma, especially in the acute forms of the disease. It is not unusual to find in acute
leukemia that the first symptom is unexpected bleeding following a minor operation
such as a simple tooth extraction.
The eye is involved sooner or later in over half the cases of leukemia, though obvious
clinical manifestations may not be present. Retinitis, retinal haemorrhages, oedema of
the disks and marked engorgement of the vessels are the commonest changes noted.
Diminution of visual acuity is not rare, and sudden blindness may be the first symptom
noted. . . .
The central nervous system is similarly often involved, lesions of the cramal nerves,
reflex changes and hemorrhages, large or small, being the most commonly seen.
In the skin, a bewildering variety of lesions occurs. Indeed in certain cases the
chief, if not the only, clinical manifestation is a dermatologic one. There may be single
or multiple nodules often of a quite nonspecific character. Or there may be, particularly
in chronic lymphatic leukemia, a diffuse reddening and scaling of the skin accompanied
by intense itching. As in the non-leukemic lymphomas, herpes zoster is not uncommon,
and in rare cases it may be of universal distribution.
Changes in the bones or symptoms related thereto are common and important,
particularly in the acute leukemia of children, in whom rheumatic fever may be closely
simulated. The fact that children with leukemia often present a peripheral blood
picture which is atypical makes this fact particularly significant, for the joint symptoms
may so dominate the clinical picture that the true diagnosis is completely overlooked.
Periosteal infiltrations and a moth-eaten mottling of the ends of the long bones as
shown in the roentgenogram are particularly suggestive of a leukemic process.
As has been said above, for most practical purposes all types of acute leukemia,
whether lymphocytic, monocytic or myelogenous, may be regarded as one and the same
disease.   This is so because the prognosis and treatment in all are essentially the same.
Page Two Hundred and Fifty-four Acute Leukemia
The onset of acute leukemia is usually insidious, more rarely abrupt. It should be
constantly borne in mind that the disease is essentially one of infancy and childhood
though no age is spared. Often an ill-defined and gradually increasing weakness or an
unexplained torpor and lassitude constitute the presenting symptoms. Equally common,
and equally deceiving to the unwary, are symptoms of sore throat, ulcerations of the
buccal mucosa or hemorrhages following some minor surgical procedure. Only too
often, the localized nature of the symptoms overshadows the systemic nature of the
disease. In many cases the first symptoms seem to be related to upper respiratory infection from which the child does not recover as it would seem he should. A gradually
increasing pallor may be the sole sign apparent. Nausea, vomiting, abdominal pain,'
melena and anorexia are not infrequent. Occasionally these may be of such character
as to suggest an acute abdominal emergency and patients have been operated on for
supposed appendicitis or acute intestinal obstruction. Fever, often of a septic type,
is usually present, and may be seen even when the patient appears to be in good general
condition.
Early in the course of acute leukemia the physical examination may be essentially
normal. Sooner or later, however, there is usually generalized enlargement of the lymph
nodes and the spleen is commonly palpable on deep inspiration. Hemorrhages into the
skin, mucous membranes and eyegrounds are common. The frequent oral lesions have
already been discussed. Occasionally—and these cases may be most deceptive—acute
leukemia in children masquerades as rheumatic fever. It is most important to remember
that under a variety of signs and symptoms—many of them apparently of minor importance—may lurk one of the most dreaded of all children's diseases.
The peripheral blood in the majority of cases shows a characteristic picture. The
white-cell count may be normal, moderately elevated or markedly depressed. Leukopenia is particularly prone to be found in the early stages of the disease. Only rarely
does one encounter the great increase in white-cell count so frequently seen in the
chronic leukemias, and it cannot be emphasized too often that the total white-cell count
per se has little or nothing to do with the diagnosis.
In the classic case, there is a preponderance of very immature white cells of one
or another series. Often stem cells, characterized by their deep blue cytoplasm and
their prominent nucleoli within the nucleus, predominate in the blood smear. If 90
per cent of the white cells—no matter what the total count and no matter what the
symptoms—are true stem cells the diagnosis is almost certainly acute leukemia. But
an occasional stem cell may be found, especially in children, in a large variety of conditions, and one must always be cautious before making a final diagnosis. Relatively
mature white cells of any series may compose the majority of the white cells in the
blood smear, and rarely there are but few very young white cells present. Under the
latter circumstances it is most difficult to diagnose acute leukemia with any assurance.
The platelets in acute leukemia are almost invariably greatly reduced in number,
and this fact is of the highest importance in differentiating this disease and certain
cases of overwhelming infection in which as a rule the platelets are increased in number,
often markedly so.
Sooner or later in acute leukemia a moderate or severe anaemia develops. It must
be remembered, however, that the life of the red cell-in the peripheral blood is such
that anaemia arising primarily, from bone-marrow failure does not take place for a
matter of weeks, so that the absence of anaemia in the presence of other unequivocal
signs and symptoms of leukemia should not be construed as evidence against such a
diagnosis if the case be seen early.
Thus progressive anaemia, a preponderance of very immature white cells in the
blood smear and thrombocytopenia usually indicate the presence of acute leukemia.
If there be in addition splenomegaly and slight generalized lymphadenopathy, the diagnosis becomes practically certain. It is important to remember, however, how protean
may be the clinical manifestations of the disease and how variable the blood picture.
Page Two Hundred and Fifty-five Acute leukemia must be differentiated chiefly from infectious mononucleosis,
aplastic anemia, agranulocytic angina and overwhelming sepsis.
Infectious mononucleosis may usually be distinguished by the presence of the
characteristic white cells of this disease, by the absence of anemia and thrombocytopenia and by the presence of a positive sheep-cell agglutination test.
In aplastic anemia there are few if any really immature white blood cells in the
peripheral smear, and classically all three essential formed elements of the blood are concomitantly diniinished. Yet in certain cases it may be impossible without bone-marrow
biopsy to be confident of the diagnosis.
Cases of acute leukemia have often been erroneously diagnosed as agranulocytic
angina. In view of the different prognosis and treatment of the two conditions, it is
of the utmost importance to differentiate them clearly. In general it may be said, in
agranulocytic angina, anemia and thrombocytopenia are absent, that extreme leukopenia
is the rule, and that one rarely sees immature white blood cells in any number during
the acute stage of the disease. During recovery, however, the white-cell count m&y
occasionally rise to 20,000 or even 100,000 and there may be many myelocytes and
even younger white cells in the blood. Under these circumstances it may be difficult
to say whether one is dealing with a marrow overactive following a period of pathologic
inactivity or with leukemia. Agranulocytic angina is very rare in children, but to make
matters more difficult, what appears to be the true disease has been followed after weeks
or months of remission by true acute leukemia. The majority of these cases have been
those of children or very young adults, so that one should always be most cautious in
regard to prognosis of the leukopenic state in this age group.
Overwhelming sepsis may manifest itself by anaemia, and by the presence in the
blood of extremely immature white cells, often in considerable number. Usually, however, the 'platelets are increased rather than decreased in number and, in the majority of
cases, the infection has obviously preceded the development of the abnormal blood
picture, so that the differential diagnosis is clear. But when one remembers that sepsis
is a common complication of acute leukemia, one realizes the difficulty of making an
accurate diagnosis in any given case. When in doubt, it is probably wise to treat the
case as one of infection and give a guarded prognosis.
The course of acute leukemia is almost invariably progressive onward to death
witiiin a few weeks or months. Very rarely there may be remissions of considerable
duration, during which the patient returns to apparent health and the blood picture
to normal. The physician must be careful not to allow such temporary improvement
to lull him into a false sense of security.
There is no form of treatment known that affects the course of acute leukemia.
X-ray therapy is seldom of even temporary advantage, and it may cause severe reactions.
If the diagnosis of acute leukemia is clear, radiation is probably contraindicated. If
there is an anaemia, causing untoward symptoms, transfusions of blood may be given,
but severe reactions are liable to take place, even with correctly matched bloods. One of
the most difficult tasks which confront the physician is that of withholding any treatment other than symptomatic in these cases. Yet such is usually the wisest course,
and the best that one may hope for is that the end will come quickly or that one's
diagnosis is incorrect.-
Chronic Myelogenous Leukemia
The onset of this disease is usually insidious, and the condition has most often been
in progress for many months by the time the patient seeks medical advice. The commonest symptoms are loss of weight and strength, increased sweating, weakness and distention of the abdomen. Often there is generalized abdominal discomfort especially
after meals, owing to the presence of a greatly enlarged spleen which encroaches on
and interferes with the gastrointestinal tract. More rarely there may be acute pain
in the splenic region,attendant upon the very common splenic infarcts. Pallor, dyspnea,
nausea and anorexia are common.   Occasionally there may be a marked hemorrhagic
Page Two Hundred and Fifty-six
-U. I
tendency.   Eye symptoms are not unusual, and may be due to retinal exudate, hemorrhages or edema of the disks.
When the patient is first seen, the spleen is usually enlarged, often greatly so; but
early in the disease, splenomegaly does not exclude a diagnosis of leukemia.
The total white count is classically elevated—often to a very great degree. White
counts of 200,000 to 500,000 are not unusual, and counts well over a million have been
reported. It must, however, be constantly borne in mind that the total white count
per se is not the most important factor in the diagnosis. One may find white counts
of 150,000 and over in patients who do not have leukemia and patients with leukemia
may show a marked lowering of the total white count. The important feature, insofar
as the blood is concerned, is the increased percentage of very inimature cells. In the
average case, myelocytes in various stages of development form the majority of the
cells, varying from 10 to 80 per cent. Stem cells are seen in the more rapidly advanc-
mg types, but very rarely to the degree seen in acute leukemia. It is important to bear
in mind that marked fluctuations in the total white-blood-cell count and in the differential may occur without any treatment whatever and that these variations are of
little or no prognostic value.
Sooner or later a normocytic, normochromic anemia develops and the red cells often
show a polychromatophilia and a considerable number of nucleated red cells. The platelets may be normal, increased or decreased in number. A marked decrease is of grave
prognostic import.
The usual case with splenomegaly, greatly increased white-cell count and immature
granulocytes can be diagnosed with. some assurance, but it is important to recognize
that a wide variety of conditions may give rise to a leukemoid blood picture. It. should
be mentioned that blood pictures simulating myelogenous letikemia may be seen in
sepsis, metastatic carcinoma, miliary tuberculosis, sulfanilamide poisoning, polycythemia
vera and especially in myeloid metaplasia. In this last condition, which may very closely
simulate myelogenous leukemia, particularly in the aleukemic phase, X-ray treatment
should be given with the greatest caution if at all, for the chief seat of blood formation
in these cases is the spleen. It is obvious that if by radiation one destroys even in part
the sole or major source of blood formation, one may do more harm than good.
The disease is usually steadily progressive and leads to death in two to four years.
Some 10 per cent of patients survive ten years or more from onset. In the majority of
cases the course of the condition is such that the experienced physician Can foretell
with some accuracy when a fatal termination is near, but it should be pointed out that
sudden and unexpected death (usually from cerebral or gastrointestinal hemorrhage)
occasionally occurs, and the family should be apprised of this fact.
To date, the most effective treatment is irradiation of the spleen. It is best to leave
the exact amount of irradiation given to the radiologist in charge but certain generalities
may properly be pointed out. As a rule, one gives to the spleen approximately 60Or
or 250 kilovolts in divided doses over a period of a week to ten days, watching the
white cell and differential counts carefully during the treatments. The white-cell
count should not be allowed to fall below 15,000 or 20,000 (when it. has previously
been greatly elevated). If the initial counts are already relatively low, X-ray treatment
should be undertaken with caution. The beneficial results insofar as the patient's
general sense of well-being is concerned often do not take place for a matter of several
weeks, and this fact should be drawn to the patient's attention before therapy is instituted. If the initial red-ce^ count is below 3,500,000, one or more blood transfusions
are indicated before irradiation therapy is undertaken. If the platelets are few, X-ray
therapy should be undertaken with caution.
Further treatment, after the first course, may be withheld until such time as the
patient's symptoms appear to call for alleviation. It is well to, remember that it is
problematical whether life is prolonged by irradiation and* that our efforts should be
aimed chiefly at the alleviation of symptoms rather than the mere reduction in the
total white-cell count.
Page Two Hundred and Fifty-seven In our enthusiasm for X-ray therapy and our satisfaction with the results obtained,
we should not lose sight of the advisability and indeed the necessity of general supportive measures. An adequate diet, plentiful in vitamins and proteins, should be
maintained. Proper rest periods during the day may enable a patient to carry on his
activities with reasonable success. Iron in the form of ferrous sulphate is frequently
helpful. Transfusions of blood—often repeated many times—are of great advantage
if there be a marked anaemia.
Chronic Lymphatic Leukemia
There is a close relation between lymphatic leukemia and lymphosarcoma. The
latter condition may be widespread and reach massive proportions without there being
any manifestations of the condition in the peripheral blood, but not infrequently a
patient with an isolated lymphosarcoma will, with the passage of time, develop the
peripheral blood picture of classic lymphatic leukemia, and conversely there may arise
in patients with lymphatic leukemia large tumour masses in the mediastinum or elsewhere.
Chronic lymphatic leukemia occurs in an older age group than does chronic myelogenous leukemia and is less amenable to treatment, but is more likely to run a long
and relatively benign course.
Not infrequently the disease is for a long time symptomless. The commonest symptoms are weakness, pallor, general malaise, vague gastrointestinal symptoms, general
enlargement of lymph nodes and a haemorrhagic tendency. In certain cases a diffuse
reddening and itching of the skin is the presenting and indeed the only symptom. Both
melaena and haematuria are seen with sufficient frequency to merit particular attention.
On physical examination, one may find nothing of note. More usually, however,
there is a widespread lymphadenopathy, the lymph nodes themselves being of a fairly
uniform size and distribution and of the consistency of soft rubber. The spleen is
usually enlarged, though only rarely does it reach the massive size attained in chronic
myelogenous leukemia.
The white count may be normal, subnormal, or—mostly commonly—greatly
elevated. White-cell counts of over 500,000 are not unusual. The differential count
shows an overwhelming preponderance of lymphocytes, the majority of which appear
normal. In the more rapidly advancing cases it is usual to find a certain percentage of
young lymphocytes, though their presence even in considerable quantities does not
invariably indicate an early fatal outcome, as is witnessed by the fact that one patient—
a sixty-five-year-old man—has had some 20 per cent of lymphoblasts in the peripheral
blood stream for a period of six years but is still able to carry on an active and strenuous career. Anaemia is an almost invariable accompaniment sooner or later. The platelets may be increased in number but more commonly they are sharply' decreased and
their paucity in this disease does not carry the same unfavorable prognosis that the
similar finding in chronic myelogenous leukemia does.
In the typical case the diagnosis can hardly be missed, but when there is an associated
leukopenia it may be almost impossible to make, and from pertussis, infectious mononucleosis, aplastic anaemia on occasion, and rarely atypical tuberculosis, the disease must
be distinguished.
On the average, patients with chronic lymphatic leukemia survive only three or four
years from onset of the disease, but fully 10 per cent live ten years or more, and rarely
the patient may survive an even longer time, and even then succumb to some other
quite unrelated condition. This fact should be borne in mind particularly in elderly
people with few or no symptoms referable to the leukemic picture.
As with chronic myelogenous leukemia, irradiation of the spleen or chest, preceded
by blood transfusions if there is a co-existing anaemia of movement, is the treatment of
choice. It is very questionable, however, whether there is any advantage in treating those
patients who are symptomless. The details of the X-ray therapy should be left to the
radiologist in charge, but the same general principles hold as with chronic myelogenous
leukemia.
Page Two Hundred and Fifty-eight In certain cases, Navitol in large doses—50 or 75 drops a day—seems to be advantageous, particularly in alleviating itching in those patients who have generalized skin
lesions. If tumor masses of lymphosarcoma rise and cause symptoms, irradiation should
be given directly to them.
Two other subjects should be mentioned: namely, aplastic anemia and agranulocytosis.
Aplastic anemia is a disease in which the bone marrow as a whole fails. The red
count, white count and platelets all fall often to extremely low levels. They do not,
however, necessarily fall pari passu. The white count may drop to very low levels
many weeks {before the red count decreases, and the platelets often fluctuate remarkably
from time to time. One small boy I saw had a white count in the vicinity of 1000 for
nearly seven weeks before there was any appreciable fall in red count; yet he died six
months after I first saw him with a red count of only 450,000 and virtually no
platelets.
The condition may be seen at any age though it is more frequent in young people.
The cause is frequently completely obscure. In children it may apparently be caused
by severe chronic infection. In adults there are a variety of preceding factors—one
has to be cautious in using the word cause. It may be seen during the course of miliary
tuberculosis and it may follow the ingestion of certain chemicals or may follow exposure
to benzol fumes, even in small amounts. In this respect it should be noted that the
condition may not follow such exposure for many years and it further should be noted
that not all people are equally susceptible. I cared for one family who was heavily
exposed to benzol over a period of years. One died of aplastic anemia, one of leukemia,
one of myeloid metaplasia and the fourth member of the family is perfectly well.
The signs are what one would expect: anemia, leukopenia and thrombocytopenia.
In addition these patients are very prone to infection of a severe sort and indeed they
frequently die of infection.
The treatment is to remove the cause if known, to prevent infection if possible
and to transfuse as often as necessary. I know of one patient who is alive and comparatively well after well over 200 transfusions and one of our own patients wisely
went to another physician who cleared up a severe sinus infection and incidentally, the
aplastic anemia.
The prognosis is, nevertheless, extremely poor and unless one can find and remove
the presumptive cause the outlook is well-nigh hopeless.
Agranulocytosis is an acute fulminating disease characterized by extreme leukopenia,
accompanied by ulcerations of the mucous membranes, skin, or gastrointestinal tract,
and when untreated, leading to death in the great majority of cases.
While the cause of some cases is entirely obscure, many follow the ingestion of such1
drugs as aminopyrine, the sulpha-drug, causalin and other substances containing a
benzol ring. It is important to remember that the disease may follow the ingestion
of very small quantities of any such drugs, and patients using them must be followed
with the greatest care. That agranulocytosis does not always follow the use of these
substances in no way justifies lack of care.
The first stage of the condition is characterized 'by extreme leukopenia and neutropenia. The onset of the clinical condition is sudden with marked prostration, malaise,
headache, high fever and sore throat. The white count may fall to 500 or less but
there is no anemia and the platelets are normal. Sepsis and ulcerations in various regions
occur with astounding rapidity and are probably the true cause of Ideath. Following
recovery, either spontaneous or induced, there may be a very rapid rise of white count
to very high levels and the appearance of myelocytes in considerable numbers. I have
seen the white count go as high as 86,000 with 20 per cent myelocytes. Under such
circumstances one may easily be trapped into thinking that one is dealing with leukemia
and overlook the infection that is causing the leukocytosis.
The treatment is far from satisfactory. I personally believe that transfusions are
contraindicated, but there are very competent men who disagree with me.   All agree
Page Two Hundred and Fifty-nine that any drug which might cause the condition should be summarily stopped. Contrary to some reports, however, the mere withdrawal of the drug does not always
suffice to effect a cure. In addition one should attempt to stimulate the bone marrow
to renewed activity and one should, further, combat the existing infection. Possibly
the 'best combination of therapeutic agents is penicillin and pentnucleotide. If pentnucleotide is given, it must be in full doses—that is 44 c.c. a day intramuscularly. A
test dose of three cc. should be given first to be sure that the patient is not sensitive.
The pentnucleotide should be continued until the white count is normal. If penicillin
is used, a minimum of 200,000 units should be given each day. If the infecting
organism is penicillin sensitive it is probable that this drug alone will be curative. It
would seem wiser -however to use both agents. Complications arising during convalescence should be treated exactly as if the underlying condition did not exist.
The prognosis of agranulocytosis must always be guarded. I have seen patients
recover who had had profound leukopenia, extreme ulcerations and very severe infection
and I have on the other hand seen patients die when the white count was definitely rising
and the infection seemed to be under control.
Finally there is a very peculiar blood condition to which I would like to refer
briefly, namely myeloid metaplasia. In this condition, which is more of a syndrome than
an entity, the bone marrow gradually fails, and the potentially hematopoetic organs such
as the spleen take up the task of forming blood. The bone marrow if examined microscopically may be found to be aplastic, fatty, hyperplastic or fibrotic. But no matter
what its microscopic appearance it is forming blood poorly if at all. The spleen and
other organs that have taken over the hematopoetic function are, nevertheless, unable
to form good blood with ease and the result is a bizarre picture. Early in the disease
there usually is a mild form of polycythaemia, the red count rising to six or perhaps
seven miUion. At this stage the spleen is only slightly enlarged and the patient often
feels perfectly well. Sooner or later, however, an anaemia develops and the spleen becomes
very greatly enlargd. The blood picture then resembles that of chronic myelogenous
leukemia. The white count is slightly elevated, there are numerous myelocytes in
various stages of maturity and there are usually a moderate number of nucleated red
cells. In addition there is very great variation in the size and shape of the red cells.
It must be emphasized that these changes take place over a long period of time—that
is many months and even years. Eventually the spleen becomes enormous and the
anaemia very marked.
The cause of this condition is not entirely clear but there is increasing evidence
that substances containing the benzene ring are provocative. I recently saw a boy of
20 with a red count of 6,800,000. He flatly denied that he was exposed to benzpjl
or any such chemicals, but when State chemists investigated the firm in which he
worked, the establishment was found to be literally reeking with benzol. One of our
early patients, who has since died, was exposed to benzol fumes over a period of many
years.   We have obtained a similar history in practically every instance.
The condition may be suspected, therefore, if there is a history of exposure, an
early polycythemia and the subsequent development of a marked and peculiar anaemia
and a leukemoid white cell picture. The suspicion becomes almost a certainty if, in
addition, the story is one of years and the spleen is greatly enlarged. Actual proof that
the condition is at hand is impossible without bone marrow biopsy and splenic puncture, procedures that are somewhat difficult and seldom necessary.
Though these patients live a comparatively long time, up to ten and even fifteen
years, there is unfortunately very little that can be done for them other than giving
very small amounts of X-ray to the spleen if the size of the organ becomes distressing
in and by itself. The great danger is to mistake the condition for leukemia and treat
it as such. Such treatment may well destroy virtually all the remaining blood forming
tissue and simply makes matters worse. It is entirely possible that if a patient is found
in the very early stages, before any anemia or real splenomegaly has developed, and
completely removed from any exposure to noxious agents that the condition might be
arrested.  The experiment is certainly well worth trying.
Page Two Hundred and Sixty BRONCHIECTASIS IN SERVICE PERSONNEL
Wing Commander R. C. Laird, R.CA.F.
Read at Vancouver Medical Association Summer School, 1945
The purpose of this paper is to review briefly the etiology, pathology, symptomatology
and general principles of treatment of bronchiectasis, and then to discuss more fully a
series of fifty cases of bronchiectasis seen in Service personnel at Christie Street Hospital
in Toronto since 1941. The surgical treatment of these patients has been under the
direction of Dr. Norman Shenstone, to whom I have been deeply indebted for many
years. The general care and investigation of most of these cases has been the responsibility of Dr. George Anglin, chief of the Chest Clinic at the hospitaL
Bronchiectasis means any permanent dilatation of the bronchial tree. This dilatation
may be of any degree, in almost any part of the tree, but generally it is much more common in either of the lower lobes, and to a certain extent the degree of involvement is
reflected in the clinical signs and symptoms. The classification of bronchiectasis into
cylindrical, fusiform and saccular, is a descriptive one, and there seems to be little difference in the types, other than degree of dilatation and subsequent stagnation of secretions.
Etiology
The causative factors in bronchiectasis are still far from being thoroughly understood.
There are two main theories as to the actual sequence of events in the development of
bronchiectasis. The one suggests that infection in the bronchi and lung causes a destruction of muscle and elastic tissue, and a later fibrosis in the parenchyma which leads to
bronchial dilatation. The other claims that bronchi become obstructed by mucous secretions, the peripheral lung collapses, and this collapse leads to, first, temporary dilatation
of the bronchi and later permanent changes in the bronchi, followed by fibrosis in the
collapsed lung. The associated mucosal changes in either case will assist in the stagnation
of secretions. The obstructive theory is supported by the cases of bronchogenic carcinoma which have collapse and bronchiectasis beyond the obstruction. It has always
been considered that frequent attacks of bronchitis or pneumonia, chronic pan-sinusitis,
or chronic bronchitis have been important precursors of a well-developed case of bronchiectasis.
Pathology
The morbid anatomy of this condition is well known. The bronchial mucosa loses
its cili and becomes cuboidal or squamous. The muscle and elastic tissue in the bronchi
and bronchioles are destroyed and replaced by fibrous tissue, and this fibrosis also spreads
to the lung parenchyma. Early in the course of the disease there is diffuse infiltration
of the bronchioles and parenchyma by acute inflammatory cells, described as bronchiolitis, and pneumonitis. The degree of involvement varies considerably, and the large
pockets of pus which were a feature of this disease some years ago, are now rarely seen.
Symptomatology
The clinical history of a well-developed typical case of bronchiectasis has usually
been characterized by a chronic cough persisting between acute attacks of respiratory
infection, with varying amounts of sputum, which may or may not have a foul odor.
There has been some variation from this in the series here reported, but the symptoms of
cough, sputum, pain in the chest, hemoptysis, general malaise, loss of weight and appetite
have all been present in varying degree in the whole group. The signs found on physical
examination also vary considerably, and the number or extent is rarely an indication of
the severity of the disease. Limited movement of the chest, dullness to percussion, diminished breath sounds, and moist rales over the involved lung are the common findings.
There has always been thought to be some connection between the presence of chronic
sinusitis and the incidence of bronchiectasis, so that the sinuses should be checked carefully in each case.   The final diagnosis actually rests with the bronchogram, which tells
Page Two Hundred and Sixty-one of the presence and the extent of the disease.    Routine bronchoscopic examination is
done in each case.
General Treatment
The first objective in the treatment of bronchiectasis is the improvement of the
general physical condition of the patient. This is accomplished by rest, fresh air, graduated exercise and a full nourishing diet with tonics and vitamines if necessary. The
purulent secretions are drained from the dilated bronchi by constant postural drainage,
or occasionally may be sucked out by bronchoscope. There is likely to be a great improvement, and the patient may become quite symptom-free on this regime. There is
always a recurrence of cough and sputum on resumption of the erect position and increased physical activity. The decision with regard to more radical treatment must be
reached, and generally speaking the presence of definite bronchiectasis in one or two
lobes in a patient who is otherwise in fair condition, is an indication for the operative
removal of the diseased portions of the lung. Lobectomy and pneumonectomy have become the only really satisfactory methods of surgical treatment of bronchiectasis, and in
fact, are the only hope for cure of the disease. With the decrease in operative mortality
and the consistently good results, there is now no hesitation in recommending lobectomy.
Review of Cases
This series comprises the records of fifty patients, service or ex-service personnel, on
whom were performed 56 operations for lobectomy. The ages in the group varied from
18 to 47 years, with an average of twenty-four. The majority were younger than 25
years of age, there being 11 under 20, and 24 between 20 and 25 years. The Service
to which they had been attached was: Army 23, R.CA.F. 22,. Navy 5. The site of*
the disease was the left lower lobe in 30, the right lower lobe in 26, and the right
middle in 4. There were three cases of bilateral lobectomy, and in two cases the right
middle and lower lobes were removed.
With regard to the previous history in these cases, they were all ostensibly symptom-
free and the X-rays of chest were passed as clear when they enlisted. There were, however, twelve who had had some definite respiratory infection prior to 1939. In 16
patients there was no history of pneumonia at any time, but they had had recurrent
upper respiratory infections since 1940. In only one was there a story of chronic cough
and sputum as long as he could remember, and he had never had pneumonia. Fifteen
patients had had one attack of pneumonia since 1940, and no history before that, and
sixteen individuals had two or more attacks of pneumonia. Briefly, there were only
seventeen who had repeated attacks of pneumonia or a chronic cough for years, and over
thirty who had only one recent attack of pneumonia or no pneumonia at all, but repeated upper respiratory infections. This may be compared with series reported before
the war, in which the great majority had either chronic cough for years or repeated
attacks of pneumonia.
At the time of admission to hospital all these patients complained of chronic cough
with varying amounts of sputum. On the whole the sputum was not copious or foul-
smelling. There was a history of haemoptysis in only 6, shortness of breath in 3, and
pain in the chest in 2.   Loss of strength was noted in 7, and loss of weight in 3.
Examination of the chest revealed all the usual signs in some of the groups, but the
predominant positive finding was moist rales- heard over the involved area. Broncho-
grams were done in all to establish the diagnosis and localize the disease, and bronchoscopic examination confirmed the presence of pus in most of them and eliminated obstruction from new growth. In the great majority, examination of the upper respiratory
passages, especially the sinuses, was negative.
In preparation for the operation each patient had a period of constant postural drainage, with full nourishing diet. The technique of operation was very nearly the same in
all cases. All were dissection lobectomies except one, in which a tourniquet was used.
In the first 34 operations sulphathiazole powder was used in the chest wall muscles before
Page Two Hundred and Sixty-two .
I  I
the pleural cavity was opened, and again in that cavity just before it was closed. In the
last twenty-one operations, penicillin cream was applied, to the muscles, and penicillin-
sulphathiazole powder in the pleural cavity. A closed intercostal drain was used in each
one, the tube being removed in 48 hours. The patients were confined to bed for two
weeks at least, and then gradually resumed activity. Post-operative days in hospital
varied from 20 days to 150 days, with an average of 54. One of the longer periods was
due to the patient remaining in hospital all the time between bilateral lobectomies, and
was no indication of the patient's condition. Twelve of the patients were in hospital
35 days or less.   The diagnosis was confirmed by the pathologist in each case.
Complications following operation were relatively few. There were 6 empyemata,
three of which required rib resection and drainage, and the other three needing only
repeated aspiration and penicillin. Only one of these occurred in those cases treated
routinely by penicillin, and it was very slight and of brief duration. There was one
broncho-pleural fistula, but this gradually closed without further complication. The
only other incident was a lipoid pneumonia in a patient who had lipiodol studies too
short a time before operation.    There were no deaths in this series.
Summarizing this review, it is of interest to note that 55 lobectomies were performed
in young adult males, who were in good physical condition except for the disease being
treated. The duration of the disease was relatively short, and symptoms few. The postoperative course was fairly uneventful, and the complications neither frequent nor
serious. The role of penicillin in the prevention of complications is not definitely established but there is a suggestion that it is helpful. The low operative mortality tends to
increase one's confidence in the efficiency of the treatment of bronchiectasis by lobectomy.
NEWS    AND    NOTES
Congratulations are being received by the following on the birth of daughters:
Capt. and Mrs. Douglas Telford, Dr. and Mrs. S. E. C Turvey, and Dr. and Mrs. J. W.
Millar.
Dr. and Mrs. W. E. Milbrandt are being congratulated on the birth of a son, born
on July 29th.
Major J. H. Sturdy, R.C.A.M.C, back from service overseas, called at the office
while on leave in Vancouver. Major Sturdy has been posted to Dundurn Military Hospital, Dundurn, Sask.
Capt. J. A. McCaffrey, R.C.A.M.C, is now out of the Service and in practice in
Vancouver
Lieut.-Col. J. U. Coleman, R.C.A.M.C, returned from service overseas, is retiring
from the Army.
Lieut.-Col. J. A. MacMillan and Capt. W. H. Sutherland, recently returned from
overseas, have been posted for duty in the Pacific Command.
Dr. G. B. Helem of Port Alberni called at the office when in Vancouver recently.
Dr. G. F. Enns of Chilliwack spent a short vacation with his family visiting points
in the Okanagan.
Page Two Hundred and Sixty-three ROUND TABLE CONFERENCE ON
HEALTH INSURANCE
Under auspices of
JOINT STUDY COMMITTEE
TUESDAY, SEPTEMBER 11th, 1945
HOTEL VANCOUVER—SALON "A"
8:15 P.M. |
Speakers will represent:—
British Columbia Medical Association
Registered Nurses' Association of British Columbia
British Columbia Dental Association
Pharmaceutical Association of British Columbia
British Columbia Hospitals Association
Questions to be discussed at this meeting are invited from all who
attend.
The meeting will be open to all members of the five organizations
listed above.
The following Medical Officers have returned from service overseas and are on leave:
Lieut.-Col. J. S. McCannel, Victoria; Lieut.-Col. C. E. G. Gould, Vancouver; Major
R. D. Coddington, formerly Ocean Falls; Major G. B. Bigelow and Major N. C Cook
of Victoria; Major A. Maxwell Evans, Vancouver; Major J. A. Ganshorn, Vancouver;
Major Gordon C. Large, Vancouver; Major D. B. Roxburgh, Victoria; Major A. J.
Stewart of Prince Rupert, and Major J. Moscovich, Vancouver.
■> "_* •-" »B*
Dr. and Mrs. G. A. Roberts of Ciilhwack are vacationing on Vancouver Island.
Dr. G. R. Barrett of Nelson is now associated with Dr. N. E. Morrison in that city,
taking the place of Dr. L. E. Borden who retired a short time ago.
Dr. R. S. Woodsworth, formerly of Kimberley and latterly of Port Alice, is now
associated with Doctors W. J. Knox and J. S. Henderson of Kelowna.
Dr. C A. Armstrong, formerly of Ocean Falls, is now located in New Westminster.
••> •? •_* *_■
Dr. J. S. Daly and family of Trail have returned from a vacation spent at Summer-
land.
»_■ -_■ -_* -c
Dr. D. J. M. Crawford and family of Trail are spending a month's vacation at
Medicine Hat, Alberta.
Dr. E. S. Hoare and family of Trail have returned from Christina Lake, where they
holidayed for three weeks.
S_* *-* *i* •_■
The Bulletin has received letters from Capt. Douglas Telford, R.CA.M.C, now in
England, and Capt. Kenneth Telford in Petewawa. The former, whose family has just
been increased by the arrival of a daughter on July 16th, deserves further congratulations on his success in becoming a Fellow of the Royal College of Surgeons of Edinburgh.
Page Two Hundred and Sixty-four ** HI  _etho*
form oT       .   ^ith   *he   .    *"*   The*'
i_—-r__ ^nc:_„_ ** »••*"
X0*.**0** N^OKTR-AUCA _^^^
__J fp
,w»
••
UW
etude
Pre-eminent... in clinical effectiveness, in patient
acceptance and in physician preference.
Because Ortho-Gynol Vaginal Jelly possesses the
highest degree of effectiveness—tolerability
—and stability, it has been accorded the American
Medical Association seal of approval.
Hi
«££>*    *    •    •
—'    a* _____ ^ -*     _.  **^     ______
^•••*Vv° -_0___i
IIP* *   *  « H_ ^        v .*5^''"#   _^^B
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Bv
Ortho Products of Canada  Limited  •  Toronto P  UVE8   Dtt
PMArtrlAMIDI
ISlfHJITHIAZOlE
Vttazofe L8.S. has three octfve ingredient^ blended In a bl^Hwmenf
base ;~l|f- - - fog* treating infection
through the broken skin.
Bactericidal:
Here is a 'cod liver oil ointment* for the
treatment of burns and abrasions. Vitazole
E.B.S. quickly clears out invading organisms and stimulates a rapid regeneration
of lost tissues.
The marked bactericidal action of he cod
liver oil itself (i) is strengthened in Vitazole
E.B.S., by the bacteriostatic effect of two sulpha drugs. Sulphanilamide, being rapidly soluble in serum gets to work quickly; sulphathiazole, being less soluble gives a more prolonged action. Vitazole,
E.B.S. contains 4% of each of them, combining the well known
selective action of sulphanilamide against haemolytic streptococci,
with that of sulphathiazole against staphylococci. Recently Kirby
(2 ) and McClintoch and Goodale (3 ) have found that urea will counteract the inhibitory effect of p-aminobenzoic add on the action of the
E.B.S. contains 5% of urea.
sulphonamides. Vitazole,
Ifgal jri-f " ^0(* -kiver oil has been used from time immemorial by fisher folk for relieving
«* " the pain of injuries and to promote the healing of wounds. During the past
decade, extensive clinical trials (4) have demonstrated repeatedly to the medical profession that
cod liver oil does stimulate granulation and epithelial regeneration. At the same time it forms a
bland, protective film over the raw surfaces of the wound, aiding in the diminution of pain.
Vitazole, E.B.S. is 50% cod liver oil, incorporated in a soft ointment base and is fortified to contain in each gram, 1000 International units of Vitamin A and 100 International units of Vitamin
D, both of which appear to be closely concerned with regenerative processes in traumatized areas.
Urea also stimulates epithelial repair and general healing
processes. It has a further value in its power of dissolving the protein wastes of necrosis, thus helping to
overcome the offensive odor of badly infected wounds.
Indications:    Wounds, burns, ulcers, abrasions.
525 Logan Avenue, Toronto 6
Ontario
A wholly Canadian company
ESTABLISHED 1879
Composition of Vitazole
E.B.S.
Cod Liver Oil 50%
Urea 5%
Sulphanilamide 4 %
Sulphathiazole 4 %
Ointment Base 37 %
Each gram contains:
Vitamin A
1,000 International units
Vitamin D
100 International units
VITAZOLE E.B.S.
is supplied in 1 oz. tubes,
4 oz. jars and 16 oz. jars.
REFERENCES:
1 Lichenstein, M.: Lancet 2:
1623, 1939, Nellis, P. &
Thomas, G.: Compt. Bend.
Soc. Biol. 130: 1074, 1939.
2 Kirby, W. M. M.: Proc.
Soc. Exp. Biol. 53: 109.
1943.
3 McClintoch L. A. and
Goodale R.H.U.S. Naval.
Bull.   41:   1057-64   (1943).
4 An extensive bibliography
will be furnished to interested individuals upon request. iBal
I
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OF     C/»NAD»      _imii¥lD-**0/vrPf^i >v
Less Need for Restricted Diets
"The diet has become more liberal since the use of Aluminum Hydroxide has
been included as part of management. Three meals a day, consisting of the
usual bland diet, were used at the start of treatment, and within the first week,
meat was added. Ground meat was used at the start of treatment in cases of
massive hemorrhage. By the end of the second week, vegetables and fruit in
cooked form and soon thereafter citrus fruit juices were included. The importance of a well-balanced diet has been emphasized in all instances."
1. COLLINS, E. 2V., PRITCHETT, C. P. and BOSSMILLER,
H. R.: The use of Aluminum Hydroxide in the treatment of Peptic
Ulcer. J.A.M.C., 116: 109 (Jan. 11) 19 U.
The Convenient Supplement to Amphojel* Therapy
AMPHOJEL TABLETS Wyeth
Each tablet produces the antacid effect of
two teaspoonfuls of Amphojel.
DOSE: Place one-half or one tablet on the tongue and SIP one-
half glass of water as tablet dissolves. Repeat five or six times
daily between meals and on retiring. Supplied in bottles of
50 tablets.
AMPHOJEL __
ALUMINUM HYDROXIDE GEL
•Trademark reg'd in Canada
JOHN   WYETH   &   BROTHER   (CANADA)   LIMITED, WALKERVILLE,   ONTARIO ?a^f"
In the treatment of trichomonas leukorrhea consideration should be given to extermination of the parasites,
and to restoration of the normal vaginal flora.
Such a dual action is achieved through treatment with
Devegan. Marked improvement is frequently observed
within three or four days. The subsidence of the profuse, malodorous discharge is accompanied by a corresponding decrease of the intense local burning, itching
and other discomfort. Even in chronic cases a cure may
result in two or three weeks.
Devegan is applied m two forms: in powder and in
tablets. The powder is insufflated into the vagina several
times a week by the physician, while the patient is instructed to use the tablets at home. Later, when the discharge has been greatly reduced, the tablets alone are
usually sufficient to complete the cure.
PAMPHLET   GIVING   DETAILED   INFORMATION   SENT   ON   REQUEST
Devegan Tablets are supplied in boxes of 25 and 250,
each containing 0.25 Gm. of acetylaminohydroxy-
phenylarsonic acid.
Devegan Powder is available in bottles of 1 oz. and 8 oz.
WINTHROP
Trademark Reg. U. S. Pat. Off. & Canada"
WINTHROP   CHEMICAL    COMPANY,    INC
NEW YORK 13, N.
the    physician
WINDSOR, ONT. I
__>ount pleasant XKnoertakina Co. Xtb.
KINGS WAY at 11th AVE. Telephone FAirmont 0058 VANCOUVER, B. C.
R. F. HARRISON W. E. REYNOLDS
Jf   Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
f   tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
i    uterus and stabilizing the tone of its
»    musculature. Controls the utero-ovafian
Ik    circulation and thereby encourages a   J
^   normal menstrual cycle. jp
1^ • MARTIN H. SMITH COMPANY      .jf
i&&, ISO IAFATITTI STRUT. NiW TOM. N. T. jttB
t^p
Full formula and descriptive
literature on request
Dosage:   1 to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when cap*
sule is cut in half at seam. m
P^ Re,ie< Is I
ana-111 * a tlis-c*
t*.\%
^^
ESTIVIN
a process
Of «o'.
CR THE   ALLE.1A'
3 INEUSION
PETALS
DN Of HAY FEVTB
Schleffelir, /v_,
ESI IVIII £s available
at all drug stores
I*©***00**
-VRiw _"*/>
J0coo-**5 I "PHENOA
C. C. T.    No.    213   "_foMK
FOR   THE   TREATMENT   OF
CONSTIPATION
IDEAL    FOR    TRAVELLING
<^^^
<^F
You can safely recommend Pheno-Active to
patients who experience
constipation when travelling or on holidays. The
tube of 25 tablets conveniently fits into a vest •
pocket or handbag.
Pheno-Active . . . the tiny bedtime laxative, restores bowel regularity in cases of
mild or occasional constipation. Its principal ingredient, Phenolphthalein, is mild,
non-toxic, tasteless and little absorbed.
Combined with small amounts of Aloin
and Ipecac, it acts on the large intestine
and results in a soft formed stool. Belladonna is present in the formula to relieve
any spastic condition.
DOSAGE
One or two tablets at night is usually sufficient.  In
more obstinate cases, one tablet after each meal; and ■
then reduced to one morning and night.
MODES  OF  ISSUE
Tubes of 25, Bottles of 100. Also dispensing bottles of
500 tablets.
efuMl_d8._^o__t&_b.
MONTREAL
CANADA
The Canadian Mark of Quality Pharmaceuticals Since 1890,
Wi&teA,
WHERE QUALITY AND PRICE ARE EQUAL OR BETTER, PRESCRIBE CANADIAN PRODUCTS aJli g «.»>»
■EOS ftlt    j
areas**       *'TJiMV
—T
SBEPs    <1_F
3fSH_3   Iffi&IEHF.
1111
MEAD'S
JJEXTRf- MALTOSE
A product consisting of maltose -
and dextrins, resulting from the
Eertzyrnte action of tjariey ma!t ■
on cereal starch.
" W!Th. -
SODIUM CHLORIDE 2%
'MEAD JOHNSON & CO.'
BEULEVtLLe,.6NX.
'   -    ii 'tb_
THE use of cow's milk, water and carbohydrate mixtures represents the
one system of infant feeding that consistently, for over three decades,
has received universal pediatric recognition.  No carbohydrate employed
in this system of infant feeding enjoys so rich and enduring a background
of authoritative clinical experience as Mead's Dextri-Maltose. Determining Hydrogen Ion Concentration
Fast and accurate methods of determining
hydrogen ion concentration are possible
with the electrometer!
This instrument operates on this principle:
An electric current passed through a
solution causes hydrogen ions to migrate toward the negative pole, the
voltage drop being measured by a
potentiometer.
The instrument illustrated consists of a
potentiometer which by means of a standard cell and variable resistances measures
the voltage (or potential) of the hydrogen
ions in an unknown solution. The resulting calculations are recorded as pH.
The pH of Amtuol, a Horner specialty, is
stabilized so that it will not vary appreciably by the addition of small quantities
of either acid or alkali (e.g. CO2 from the
air). To effect this, it is necessary to
buffer the solution. A buffered solution is
a mixture of a weak acid and its alkali salt
—or a weak base and its acid salt—(e.g.
acetic acid and sodium acetate). In such a
solution  small   amounts  of  acid   may   be
added without affecting the pH equilibrium, since the acid would combine with
the Sodium acetate and form acetic acid
which is very weakly ionized.
This buffer action will be appreciated by
physicians when prescribing Amtuol for
infective nasal conditions where the secretions are usually alkaline. Amtuol maintains its pH equilibrium under these circumstances.
In the Horner laboratories every control
possible is imposed on all specialties before
they are released for distribution to dispensaries. It is this painstaking care which
has won for us the name and reputation
for better pharmaceuticals.
Amtuol may be taken as an example of
the wide acceptance of Horner specialties
by physicians throughout this country. In
the few months since Amtuol became
available for prescription, it has become
one of the most widely used preparations
for nasal antisepsis and decongestion and
is particularly applicable to today's demand
for the relief of those suffering from hay-
fever and similar infections.
FRANK   W.   HORNER    LIMITED
Montreal
Canada *$T     SERVICE
LAB. ^.^.-—bhb^
A complete blood and urine
laboratory service that is fast
and reliable.
ASCHIEM — ZONDEK and
blood containers supplied free
off charge on request.
HOUR PREGNANCY
TEST  SERVICE
*3_2|
Starkmo
Dept. 9
Colonic and
Physiotherapy Centre
Up-to-date Scientific Treatments
COLONIC IRRIGATIONS, SHORTWAVE
DIATHERMY, SINNEWAVE GALVIN-
ISM, IONIZATION, ULTRA VIOLET
RAY, STEAM  BATHS AND SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
Superintendent:
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
1119 Vancouver Block
MArine 3723      Vancouver, B.C.
Nimtt $c
2559 Cambie Street
Vancouver, B.C.
IF ARTHRITIS and ECZEMA
ARE ALLERGIC
ETIOLQGICALLY
effective treatment suggests the use of
agents te correct mineral deficiency,
increase cellular activity, and secure
adequate  elimination  of  tonic Him.
LYXANTHINE ASTIER -<(
orally given, supplies calcium, sulphur,
iodine, and fysidln feitartrate — an
effective solvent. Amelioration of
symptoms and general functional improvement  may bo expected.
Write for Information.
L-15
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,   Montreal
J MILK--
_»___. Vital
FOOD FOR VICTORY
Milk is accepted as the most valuable protective
food because it surpasses all others in supplying
vitamins, minerals, and high quality proteins that
build and maintain sound physical fitness. No
wonder our fighting forces are among the best fed
in the world—their milk consumption is exceptionally high—and no wonder Canada's home front,
too, is by far the best fed!
A quart of milk (4 glasses) gives the following
percentages of your DAILY FOOD NEEDS.
Iron 16%
Vitamin C*% 16%
Energy 22%
Vitamin B 28%
Calcium
* Values Variable.
Vitamin A. 37%
Protein __49%
Vitamin G_ 79%
Phosphorus   ___ 69%
 100% For thirty odd years Georgia Pharmacy has
striven day by day for more perfect service,
accuracy, speed, and overall reliability. The
confidence in us by the Medical Profession is
our reward.
Phone
MArine 4161
>4uiLMs~\
13 th Ave. and Heather St.
Exclusive Ambulance Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. L BERTRAND 

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