History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1940 Vancouver Medical Association Mar 31, 1940

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The BULLJETIN
of the
K    Vancouver
MEDICAL ASSOCIATION
-Vol. XVI.
MARCH, 1940
No. 6
TTiftk Which Is Incorporated
Transactions of the
Victoria Medical'Society:
th*
Vancouver General Hospital
and
St. Paul's Hospital
In This Issue:
Page
NEWS: AND NOTES-—— i^fc.:W„ gf |j-—_._ im
NEWER lABORATORY PROCEDURlfe-Dr. |gH. Pitts -,. ^JS^Sw
MEDICAL SERVICES TO INIHGENTS-^fe^- .l|g||.  ^2
SULFANILAMIDE AND ITS DERIVATIVES—Jlp. W. Willard  164
VERIFIED BRAIN TUMOUR CASES—Drs. D. P. Robertson and C. E. Gould* 174
VENEREAL DISEASE INFECTIONS—Dr. D. H. Williams and
jjfdgar l^BroJn, B.Afc, j| - j _„_|M-.—,_^__   180
INTRAVENOUS FEEDING OF AMINO ACIDS E§»
VANC|>UVER pffiDIC^yL ASSOCIATION
SUMMER SCHOOL, JUNE 25th TO 28th INCL|fl940 Old Way| .|
CURIN|| RpKETS in the
CLEFT of an§VSH TREE
FOR many centuries,r—and apparendy down to the
presenj^nie, even in this country—ricketic children have been passed through a cleft ash tree to cure
them of their rickets, and thencefor^a sympathetic
relationship was supposed to exist between them and
the tre^J
Frazer* states that the ordinary mode of effecting
the cure i^to splljfa young ash sapling longi-
tudinalfefor a few feet and pass the chil^^iaked,
either three time^ir three times mree||irough the
fissure at sunrise.^n the Wesfplf England, it is said
the passage must b^pagainst the sujl|l|§&s soon as
the ceremony ^performed, the tree is bound tightly
up and the fissure plastered over^ith mud or clay.
The belief llljthat ju|(|as th^cleft in the tree will be
healed, so the child's body will be healed, but that if
the rift^fl: the tree femair^open, the deformity in
the child will remain, too, and if the tree were to die,
the death of thejfiiild would surely follow.
*Frazer, 3. G.sThe Golden Bough, vol. 1, New York, Macnnllaa &Co, 1988
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Ne^i Way,.
It iis ironical that the practice of attempting
to cure rickets by holding the child in.the.
cleft of an ash tree was associated with the
rising of the sun, the light of which we now,
knowilsi in itself one of Nature's specifics.
Preventing and Coring Rickets with
OLEljfM|#EReOMORPHUM
NOWADAYSjpfne physician h# at his command, Mead's Oleum Percomotv
phum^a. natural jptamin D product ^hich actually prevents and cures
rickets, when given in proper dosage.
Like other jspecifics for other diseases, larger dosage may be required for
extreme casesi^tt is safe to say that when used in the indicated dosage, Mead's
Oleum Percomorphum is0 specific in almost all cases of rickets, regardless of
degree and duration^
Mead's Oleum Percomorphum because"of its high vitamins A and D content is
; also Useful in deficiency conditions such as tetany, osteomalacia and xerophthalmia*!
Mead's Oleum Percomorphuo^^^pt advertised tig; the public and is obtainable at drug
stores in boxes of 25 and 100 10-drop capsules and 10 and 50 cc. bottles||The large bottle ¥
3a| supplied, at no extra cost, wi^jfMead's patented Vacap-Dropper.   It keeps out dust and
light, is spill-proof, unbreakable, and delivers a uniform drop.
MEAD-JQ^^^^^^O^piNAD^LTP., Belleville, Onf.
Please enclose professional card when requesting samples of Mead Johnson products to co-operate in preventing their reaching unauthorized persons. 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" Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVI.
MARCH, 1940
No. 6
OFFICERS,  1939-1940
Db. A. M. Agnew                  Db. D. F„ Busteed Dr. Lavell H. Leeson
President                            Vice-President Past President
Db. W. T. Lockhabt Db. W. M. Paton
Hon. Treasurer Son. Secretary
Additional Members of Executive: Db. M. McC. Baird, Db. H. A. DesBbisat.
TRUSTEES
Db. F. Bbodie Db. J. A. Gillespie Db. F. W. Lees
Historian: Db. W. L. Pedlow
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Dr. F. Turnbull Chairman Db. Kabl Haig 1 Secretary
Eye, Ear, Nose and Throat
Db. W. M. Paton Chairman Db. G. C. Labge Secretary
Pediatric Section
Db. J. R. Davies Chairman Dr. E. S. James Secretary
STANDING COMMITTEES
Library:
Db. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies,
Db. W. A. Bagnall, Db. T. H. Lennie, Db. J. E. Walkeb.
Publications:
Db. J. H. MacDermot, Dr. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. T. H. Lennie, Db. A. Lowbie, Db. H. H. Caple, Db. Fbank Tubnbull,
Db. W. W. Simpson, Db. Kabl Haig.
Credentials:
Db. A. B. Schinbein, Db. D. M. Meekison, Db. F. J. Bulleb.
V. O. N. Advisory Board:
Db. I. Day, Db. G. A. Lamont, Db. S. Hobbs.
Metropolitan Health Board Advisory Committee:
To be appointed by the Executive Committee.
Greater Vancouver Health League Representatives:
Db. W. W. Simpson, Db. W. M. Paton
Representative to B. C. Medical Association: Db. L. H. Leeson.
Sickness and Benevolent Fund: The Pbesident—The Trustees. tyfiz&u*i
in  the  form  you  prefer
THIAMIN CHLORIDE
Or for the Clinicians who feel
N.N.R.
it is better therapy to use the
Tablets
B-COMPLEX
1   mgm.
333  I.U.
B-Complex Syrup
5 mgm.
1665  I.U.
Derived from natural sources
—containing all  the  recognized factors in the Complex.
Vials
10 mgm. per cc.
Supplied in
3, 6 and 12-oz. bottles.
5 cc.
5 cc.
25 mgm. per cc.
B-G Capsules
5 cc.
lOcc.
50 mgm. per cc.
10 mgm. per cc.
contain not less than 150 Inter, units of Bx and 150 gammas Riboflavin.
Ampoules
6 x 1 cc. 10 mgm.
100 x 1 cc. 10 mgm.
Yeast Tablets
f| N.N.R.      ft
in bottles of 100, 250 and
1000.
As we have no trade names for these products
please specify SQUIBB on your prescription.
For Literature write
E-R:Sqjjibb &. Sons of Canada. Ltd.
MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE    1858
36 CALEDONIA ROAD, TORONTO. VANCOUVER HEALTH DEPARTMENT
STATISTICS, JANUARY, 1940
Total population—estimated	
Japanese population—estimated -,~	
Chinese population—estimated ..ii	
Hindu population—estimated :J
Number
Total deaths IL  265
Japanese deaths :  5
Chinese deaths  11
Deaths—residents only j .... 226
BIRTH REGISTRATIONS:
Male, 205; Female, 184_
389
INFANTILE MORTALITY: January, 1940
Deaths under one year of age        8
Death Rate—per 1,000 births      20.6
Stillbirths (not included in above)      10
 269,454
 9,094
      8,467
         339
Rate per 1,000
Population
11.6
6.5
15.3
9.9
17.0
January, 1939
9
25.3
8
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
February 1st
to 15th, 1940
Cases   Deaths
December, 1939
Cases   Deaths
January, 1940
Cases   Deaths
Scarlet Fever 18          0 10          0 4
Diphtheria      0           0 0           0 0
Chicken Pox 123           0 125           0 10
Measles 9           1 67           0 68
Rubella      3           0 10 0
Mumps 5           0 16           0 3
Whooping Cough 11           0 23           0 10
Typhoid Fever      0           0 0           0 0
Undulant Fever      0           0 0           0 1
Poliomyelitis      0           0 0           0 0
Tuberculosis ; ~    24         10 36         14 12
Erysipelas      5           0 7           0 0
Ep. Cerebrospinal Meningitis      0           0 0           0 0
Paratyphoid Fever      10 0          0 0
Trachoma      0           0 0           0 2
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL.
West North Vancr.
Burnaby   Vancr. Richmond Vancr. Clinic
Syphilis 1 0 0 1 24
Gonorrhoea    0 0 0 0 63
Hospitals,
Private Drs.
26
Totals
52
90
BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
Descriptive Literature on Request.
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
STANLEY    N.   BAYNE
Phone: SEy. 4239
1432 Medical-Dental Bldg.
"Ask the doctor who is using it."
Vancouver, B. C. THE  un
^f_ig«___f
_>
*o*
The
Denver Chemical
Mfg. Company
153 Lagauchetiere
St. W.,
Montreal
ANTIPHLOQISTINE
FOR THE
TREATMENT
THORACIC    •
CONGESTION
Its use is compatible with, and a valuable
supporting measure for, serum and all
other forms of medication. It is suitable
for patients of all ages.
Sample on request
MADE IN CANADA. VANCOUVER MEDICAL ASSOCIATION
Founded 1898    ::    Incorporated 1906
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
Programme of the 42nd Annual Session
March   5—Dr. D. D. Freeze: "Anaesthesia and Analgesia."
March 19—Clinical Meeting.
April   2—Dr. H. H. Boucher: "Low Back Pain."
April 16—Clinical Meeting.
April 23—Annual Meeting.
Professional Men appreciate
the Value of being well-dressed
A Suit tailored to your measure by us is your assurance of
Quality British Woollens, fine hand tailoring
and correct style.
Our new Spring patterns are now ready and your early
inspection is invited.
British Importers of Men's and Women's Wear
MEDICAL-DENTAL BUILDING VANCOUVER, B. C.
MEMBERS of THE GUILD
of PRESCRIPTION OPTICIANS of AMERICA
Always Maintain the
Ethical  Principles  of
the Medical Profession
Guilder aft Opticians
430 Birks Bldg*.       Phone Sey. 9000
Vancouver, Canada.
Page 153 Iron is the oldest and still one of the
most effective treatments for anaemia;
but the most potent form of iron medication was not definitely known until
recently.
In the past, hundreds of organic and
inorganic compounds of iron have
been tried clinically with widely varying results. This variation of result
caused investigators to continue the
study of iron absorption in anaemia.
Their recent investigations confirmed
the previously observed fact that ferrous salts are more readily absorbed
than other forms of iron, and that all
ingested iron is converted into the
ferrous state before absorption, cf.
Journal C.M.A. March '33. Lucas and
Henderson.
F. Hendrycb and K. Kltmesch, Arch.
Exptl. Path. Pbarmakol 178, 178r88,
1935, regard ferrous chloride as the
physiological form of iron. They find
that it does not cause chronic poisoning when administered orally, but
that ferrous carbonate and ferric citrate cause characteristic liver damage.
But ferrous chloride is unstable and so
unpalatable that many patients refuse
to continue treatment long enough to
raise the haemoglobin to normal.
Former objections to the use of ferrous
chloride have been overcome in Ferrochlor E.B.S. which presents ferrous
chloride in permanent and palatable
form. Each teaspoonful dose of Ferrochlor contains 2 grains of ferrous
chloride, equivalent to 30 grains of
reduced iron.
"Ferrochlor E.B.S. builds haemoglobin rapidly."
Ferrochlor is also supplied in tablet form for patients mho prefer Ms form of iron medication.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
CANADA
TORONTO MANUFACTURING   CHEMISTS CANADA
STOCKS CARRIED AT
WINNIPEG, MAN.—CAMPBELL HYMAN LTD. VANCOUVER. B. C—J. P. SOUTHCOTT & CO. LTD.
SPECIFY      E.   B.   S.      ON      YOUR      PRESCRIPTIONS The scheme worked out by the B. C. Medical Council's Committee on Economics, to
provide voluntary Health Insurance for small groups in industrial occupations, has been
presented to the public, and our readers have all had copies of the scheme.
It is, of course, largely based on the schemes already in force with certain large groups
of employed persons, and the idea was to make this type of service on a group basis available to those who could not organise on a sufficiently large scale to make this possible. The
scheme presents several options. It is, of course, tentative at present, and, we presume, open
to modification and adjustment at any time. It will be very interesting to see what
response comes from those who could benefit by such a scheme.
It is noteworthy that the only remarks on the subject, of a definitely hostile nature,
came from a gentleman who was (or is?) on the Board of the Health Insurance Commission. His remarks were, we feel, hastily made, and very inaccurate. The Hon. G. M. Weir,
Provincial Secretary, who also commented on the scheme, seemed to us to have taken a
very fair and generous attitude. One can hardly compare the scheme, of course, with a
compulsory one—which, even if all the benefits given by this scheme were granted, would
still be cheaper and more economical to run.
None of us denies that an adequate scheme of Health Insurance, actuarially sound and
satisfactory to both parties to it, would be the most generally acceptable scheme of all—
but this is at least a step towards a wider scheme, and should, we think, be given due trial.
It has the merit of aiming low at first, and not trying to do too much at one time. We
wish the scheme all the luck in the world and feel that the College of Physicians and
Surgeons deserves our thanks and congratulations for an excellent piece of work, which
has been extremely well done.
The Bulletin regards itself as especially fortunate in having several valuable surveys
to publish. These things are not essentially light reading: nor, to the man in search for
direct information as to how to deal with a knotty case which has arisen in his practice are
they apparently of very great immediate value: but they are the stuff out of which the
true scienuific structure of medicine is fashioned, and they represent accurate observation,
and in many cases years of work.
Thus, take the review of sixty-eight cases of brain tumour, of which fifty-five are
completely proven, presented from the Vancouver General Hospital records, and covering
the years 1934-38. The compilers, Drs. D. P. Robertson and C. E. Gould, are to be congratulated on a very good piece of work. It is doubtful if more than two or three men
in Vancouver realise that there had been sixty-eight cases of brain tumour in this city in
these five years. Nor would the bare statement of this fact be of any value. But here we
have histological and pathological classification, type incidence, age incidence, symptoms
and signs, operative mortality, and so on. Rigid check is kept on the accuracy or otherwise
of diagnoses made on admission. Eye-changes, the value of diagnostic X-rays, etc., are all
dealt with: and the record is well made.
The same thing applies to Dr. Gee's very able report (soon to be published) on 2069
Aschheim-Zondek tests made in the last eight years, 1932-40. This is also a splendid piece
of work. We applaud the reticence and truly scientific spirit which have kept Dr. Gee from
publishing before this. She has here ample material for a considered judgment as to the
value of this test, the degree of accuracy which can be attained, the extent to which it can
be relied on, and a host of other details. The small percentage of errors is very striking, and
shows this test to be one of very great value; twelve false positives and sixteen false negatives, some of which were later corrected, being an amazingly small number of incorrect
results.
Another survey of real value is contained in the thesis we publish in this issue, written
by Mr. J. H. W. Willard, M.A. Mr. Willard presents a survey that has taken weeks of
careful study, as his very large bibliography will show. It deals with that wonder-working
Page 154 drug, sulphanilamide, and, of course, a tremendous volume of literature is gradually being
accumulated on this subject. The Bulletin takes this opportunity of thanking Mr.
Willard for giving us this survey. It was partly at our request that he undertook it—and it
represents a great deal of work.
The Greater Vancouver Health League, through its Executive Director, Mr. Edgar N.
Brown, and the Venereal Diseases Section of the League, has been making a survey of the
Venereal Disease situation in Vancouver. The object has been to obtain as accurate a
record as possible of the number of cases under treatment by private physicians, and so
by putting this with the number under clinic treatment to arrive at as accurate a result
as possible.
The medical men of Vancouver co-operated very well indeed in this matter. That
the report has a definite statistical value is indicated by the remarks of Dr. C. E. Dolman
of the Provincial Laboratories, quoted in the survey.
One surprising feature of the report is the far greater number of cases of syphilis shown
as compared to gonorrhoea. Of course, a great many cases of gonorrhoea are self-treated,
but even so, we rather question the accuracy of this part of the report, and hope it will
be either verified or corrected as some future date.
NEWS    AND    NOTES
VANCOUVER MEDICAL ASSOCIATION
The regular monthly meeting of the Association will be held on Tuesday, March 5th,
in the Auditorium of the Medical-Dental Building. The speaker of the evening will be
Dr. D. D. Freeze, who will speak on "Trends in Anaesthesia."
Congratulations are extended to Dr. and Mrs. Donald H. Williams upon the birth of
a son on January 29th, 1940.
Dr. D. E. H. Cleveland recently addressed the Fraser Valley Medical Society <on "Diagnosis and Treatment of Early Syphilis."
Dr. H. McGregor of Penticton made a hurried business trip to Vancouver and New
Westminster on February 9th.
*r *u* "i* -r
Dr. R. P. Borden of Penticton is back at his office after a recent indisposition.
*t *>L »i *t
*ir *C *C nr
Dr. George Paine of Penticton is reported to be doing well and in better health.
Dr. W. D. Higgs, formerly of Port Alberni, has returned from London, England.
Dr. J. B. Swinden of Ucluelet has recovered from his recent illness.
Dr. W. J. Knox of Kelowna was a recent visitor to Vancouver.
Dr. B. de F. Boyce has returned to Kelowna after spending two weeks at Harrison Hot
Springs. *       g       I       |
Dr. G. E. L. Mackinnon of Cranbrook has received the nomination as Conservative
candidate for Kootenay East in the forthcoming Federal election.
*       *       *       *
Dr. and Mrs. A. N. Beattie of loco are receiving congratulations on the birth of a
daughter on February 1st.
Page 155 Dr. and Mrs. E. J. Lyon of Prince George called at the office while in Vancouver
recently.
Dr. J. H. Carson of Prince Rupert is on an extended trip to Eastern Canada and the
United States.
Dr. A. Francis of New Denver attended the miners' bonspeil in Nelson recently.
Dr. L. C. Steindel, who is associated with Dr. F. D. Sinclair of Cloverdale, will be
married in Winnipeg.
Dr. H. A. Whillans of Victoria is doing locum tenens during Dr. Steindel's absence.
Dr. Stanley P. Findlay has taken over the practice at Fraser Lake.
Lieut.-Col. Gordon C. Kenning, Officer Commanding No. 13 Field Ambulance, stationed at Victoria, has recovered from his recent illness and has returned to duty. Dr. and
Mrs. Kenning spent a fortnight at Harrison Hot Springs Hotel.
Major R. L. Miller of Victoria made another of his regular visits to Vancouver, spending the day effecting arrangements for recruiting and Medical Boards.
Dr. W. E. Henderson of Chilliwack called at the office this week to discuss arrangements for Medical Services to indigents in that area.
Lt.-Col. A. L. Jones, D.M.O., M.D. No. 11, is back at the office following a brief illness.
Lt.-Col. Thomas McPherson of Victoria has been confined to hospital, and it is hoped
he will soon be around again.
Dr. W. T. Kergin, formerly of Prince Rupert, has taken up residence in Vancouver.
The following doctors travelled to Vancouver to attend the meeting of the Board of
Directors of the British Columbia Medical Association on January 24th: Drs. F. M. Auld,
Nelson, President; P. A. C. Cousland, Victoria; W. A. Clarke, New Westminster; J.
Stuart Daly, Trail; C. T. Hilton, Port Alberni; W. J. Knox, Kelowna; A. H. Meneely,
Nanaimo; S. A. Wallace, Kamloops.
Dr. j. Bain Thorn of Trail, who was visiting in Vancouver, attended the meeting of
the Board of Directors.
Dr. R. Brynildsen has gone East to do post-graduate work in Chicago and Boston.
PRELIMINARY   ANNOUNCEMENT
A   D I N N E R    I
Complimentary to
DR. G. F. AMYOT
Provincial Health Officer
THURSDAY, APRIL 4TH, 1940
YOU   ARE   REQUESTED   TO   RESERVE   THIS   DATE
Page 156 CAMPBELL DAVIDSON
The sudden passing of Dr. Campbell Davidson of Qualicum Beach, Vancouver
Island, on February 16th, removes from the ranks of the profession a member
well known throughout the Province. Dr. Davidson had had previous warning of
further attacks of coronary trouble and had been forced during recent years to
lead a less active life.
During his twenty-three years at Qualicum he had contributed largely to all
movements for the improvement of standards of medical service in the Upper
Island District and had supported strongly the Upper Island Medical Association.
He was a happy person to know and this was reflected in the atmosphere of his
home.
Dr. Davidson served as Medical Officer of Health and Medical School Inspector
during many years. He maintained a strong interest in matters affecting the
health of the people and developed a fine organization in that area.
The late Dr. Davidson was born in Montreal, the son of Chief Justice Sir
Charles Peers Davidson, and graduated from McGill University in 1898. During
college days he played hockey on the McGill team when they won the Stanley
Cup and was on the football team when McGill won the Allen Cup.
Before settling at Qualicum, Dr. Davidson had a wide experience as ship's
surgeon, visiting all parts of the world.
To Mrs. Davidson and to his son and daughter the profession extends its sincere sympathy in their loss.
PAUL EWERT
The late Dr. Paul Ewert of Golden had just ended twenty-five years of faithful service in that district. He had endeared himself to the people as their physician and had made a fine contribution as a citizen. He possessed a personality
admirably suited to his work on the C.P.R. in this mountain section. Among the
members of his own profession he was well known and highly respected. He
possessed a directness and honesty of purpose that had a strong appeal to men.
Dr. Carl Ewert of Prince George is a brother of the late Paul Ewert, and in
the passing of years the name "Ewert" has occupied a deservedly outstanding
place of honour in the professional life of this Province. The other surgeons
serving the C.P.R. between Vancouver and Calgary held him in high respect as
a man who knew his work and did it well.
Dr. Paul Ewert came, with his family, to Manitoba from Kansas at the age
of eight. He graduated in Arts and obtained his medical degree from McGill in
1912. He served as interne at the Vancouver General Hospital and entered practice at Golden in 1914.
Dr. Ewert was active in practice during twenty-five years, and it was not until
the evening of Sunday, February 4th, that he was suddenly stricken and died
within half an hour. He was given a Masonic funeral on February 7th, and at the
cemetery the returned men sounded "The Last Post."
It is unfortunate that Mrs. Ewert has been ill. Sincere sympathy is extended
from the profession in the hope for her early recovery.
Page 157 JOHN A. AMYOT
The passing of Dr. John A. Amyot in Ottawa will be mourned by the whole profession
as a national loss. It is significant that one who was destined to make such an outstanding
contribution to Canada should have been born in 1867. His lovable personality owed some
of its natural charm to a distinguished French family of four centuries' standing in the
Dominion.
Graduates of Toronto knew him; Medical Officers in the last war knew him; British
authorities knew him; every doctor in Canada knew him through his position in Canadian
Medicine; he was known internationally in the United States and in the League of Nations.
It is not given to many to have so widely and so honourably served. To have achieved so
much in one lifetime makes it possible to cease one's labours with the satisfaction of work
well done.
The late Dr. Amyot retired in 1933 after forty-one years in Medicine. He graduated
from the University of Toronto in 1891 and after a term as House Surgeon at the General
Hospital entered practice in Toronto with a Lectureship in Pathology and Bacteriology, in
which department he was Professor when the war took him overseas in 1914.
Dr. Amyot studied with Pasteur and other distinguished teachers, then really commenced busy years of service which have been partially recognized in his lifetime. He
established and directed the Provincial Laboratory in Ontario; established the first postgraduate course in the University of Toronto leading to the D.P.H. qualification; was an
active member of the International Commission to Study Pollution of the Great Lakes in
1912; worked widely for safe water supply and pasteurization of milk.
During the years 1914 to 1919 he served overseas. Lieut.-Col. Amyot was well known
on the Western Front; in charge of sanitation in the Canadian Corps in war areas; later in
command of these services with the Second Army, which embraced 260,000 troops; was
a member of the Allied Health Committee in London and Paris; was later with London
Headquarters as A.D.M.S. in charge of Health and Sanitation Services to the Overseas
Forces of Canada.
Colonel Amyot was on three occasions Mentioned in Despatches. The C.M.G. was conferred by the late King.  By the French he was made a Knight of the Legion of Honour.
Under his administration outstanding work was done in the prevention of "trench-
feet," control of parasitic diseases, venereal disease and respiratory infections. Colonel
Amyot applied his energy and effort to the development of the outstanding Laboratory
Service of the Canadian Expeditionary Force.
At the close of the war Dr. Amyot was asked to become the first Deputy Minister of
the newly organized Federal Department of Health. Later, as Deputy Minister of the
Department of Pensions and National Health, he was able to direct many new Acts
designed to protect the health of the Canadian people. The Dominion Council of Health
was organized.
Dr. Amyot was honoured in his lifetime, serving as President in many local, national
and international Health Organizations. He represented Canada on several occasions in
the Health Section of the League of Nations, which Section was able to build very definite
world relationships.
The work of Dr. Amyot survives him and his memory will be constantly refreshed by
those who will always be gratefully appreciative of the good things which have come to us
out of his lif e.
The late Dr. John Amyot has left a challenge to Canadian Medicine to carry on the
good work. In the Province of British Columbia we have a direct descendant and disciple
in the office of Provincial Health Officer, Dr. G. F. Amyot.
In extending to our colleague, Dr. Amyot, our sincerest sympathy in the loss of his
father, we would join him in supporting the traditions which are his heritage.
Page 158 ancouver
ca
ssociation
A BRIEF DISCUSSION OF
SOME NEWER LABORATORY PROCEDURES
H. H. Pitts, M.D.
I must first express my appreciation on behalf of the medical staff of the Laboratory of
the Vancouver General Hospital for the honour of being asked to present papers to this
Association this evening. When it was suggested that we present what might be termed
"A Laboratory Evening" we were rather perturbed as to what we could provide that might
be of general interest. Dr. Gee has been gradually gathering data as to the confirmation or
otherwise of the Friedman modification of the Aschheim Zondek tests that have been
done in the Laboratory during the past 7l/z years, and we felt that a presentation of this
rather large series, done in a local institution, together with a general discussion of the
test, might be interesting and instructive. The compilation of these figures has been no
small task but has been brought as nearly up-to-date as was possible and will be presented
tonight by Dr. Gee.
Up to the present we have not compiled any statistics as to the percentage of malignancies or the relative percentage of malignancy of various organs or sites in our autopsy
records. It was thought that these figures might be of some general interest, at least as a
basis for discussion. To Dr. Creighton was allotted the rather formidable task of compiling
these statistics from the autopsy records of the past 10 years, the results of which he will
present to you this evening.
My own small part in the programme will take the form of a brief discussion of a few
laboratory procedures that I hope will be of general interest. So, as ringmaster of our three-
ring circus, I will crack the whip and ascend the podium.
While it is probably a fact that the finding of malignant cells in ascitic or pleural
effusions means that the neoplastic process is a far-advanced one and hopeless, as viewed
from a curative standpoint, nevertheless, from a diagnostic standpoint, valuable information may be gained and graver prognoses given, that otherwise might be more optimistic,
with the erroneous conception that the effusion is of tuberculous, rheumatic, cardiac or
cirrhotic origin. It must, however, be borne in mind that one does not always find these
cells when they may be present and one also finds them when they are not present. I have
been guilty on both counts. Some pathologists are in favour of centrifuging the fluid and
making a direct smear from the precipitate, but we have felt somewhat safer in the procedure of coagulating the fluid with formalin and alcohol and a few drops of glacial acetic
acid. Any cells present are usually carried down with the coagulum and then this is carried
through the various stages of fixation as for tissues, mounted in paraffin and sectioned.
One may also centrifuge the fluid and then subject the precipitate to coagulation with the
subsequent steps as above. One can frequently make a fairly dogmatic diagnosis of the
origin of the growth from the cells present, but probably, more frequently, one can state
only that it is a malignant process of uncertain origin. I have found the greatest source of
error in ascitic fluids from cases of hepatic cirrhosis, where large cells, apparently of endothelial origin, were present and which I considered to be malignant, only to be proven
wrong at the autopsy table. My object in mentioning these ascitic and pleural fluids is to
suggest that the routine examination of these fluids for malignant cells, whether malignancy is suspected or not, is a worthwhile procedure in conjunction with guinea-pig
inoculation, culture, etc.
Pneumococcus typing is not an entirely new procedure, and was first suggested by
Neufeld and perfected by Sabm in 193 3. There are now 35 isolated types of pneumococci,
types 33, 34 and 3, 5 having been isolated in the past few months, and for all of these, with
the exception of 34 and 35, antipneumococcic serum has been prepared. In the V.G.H.
Lab. we have found the Lederle typing sera very satisfactory, although several of the large
Page 159 biological houses manufacture a product probably equally as good. The Lederle sera are
supplied in six Group Mixtures with methylene blue incorporated in them, as follows:
Group A, Types 1, 2 and 7; Group B, Types 3, 4, 5, 6, 8; Group C, Types 9, 12, 14, 15
and 17; Group D, Types 10, 11, 13, 20, 22 and 24; Group E, Types 16, 18, 19, 21 and 28;
Group F, Types 23, 25, 27, 29, 31, 32. Types 26 and 6 are the same or interchangeable,
as are also Types 15 and 30. The rationale of using these group mixtures is similar to that
of skin testing with group mixtures of proteins, pollens, etc., and very materially curtails
and expedites the work required in ascertaining the specific pneumococcus responsible for
this particular infection. A drop of the sputum to be tested is first examined for the presence of pneumococci, and if they are found a drop or two of the sputum is placed on each
of 6 coverslips or slides, to each of which is added a drop or two of Group Mixtures A to F
respectively and each slide so labelled. Generally, within a few minutes, at room temperature, or after incubation for a few minutes, one will note, on examination under the microscope, swelling of the capsules of the pneumococci in one of the slides and none in any of
the other five. We will say, for example, that this occurs in Slide C. This means that
the specific organism in this case belongs to either type 9, 12, 14, 15 or 17. The same
procedure is now carried out using a drop or two of sputum mixed with an equal quantity
of each of these typing sera. After the usual time it will be found that there is swelling of
the capsules of the pneumococci in the slide labelled, say 17, and no swelling in any of the
other slides. Therefore this particular organism is Pneumococcus Type 17, and the attending physician may immediately institute specific antipneumococci serum therapy or
Dagenan therapy, a combination of both, or whatever method of choice. The earlier the
sputum is typed, the sooner the specific therapy may be instituted, and while it is claimed
by a number of writers, reporting large series of cases, that Dagenan ingestion does not
interfere with typing, our experience, in a considerable number of cases, has not supported
this tenet and that probably within 12-24 hours after fairly intensive Dagenan therapy
typing is impossible. A clean receptacle without preservative or antiseptic should be used
to receive the sputum, and if possible the specimen should be from the bronchi and not
merely salivary secretion. In infants, swabs from the laryngopharynx may be used for
typing. The value of liver function tests is a very controversial question, and of the
several that have been elaborated it would seem that the Bromsulphalein Test is the one
productive of the most information. Experimentally 85% of the amount of the dye
injected intravenously into normal rabbits is excreted in the bile within one hour. The
liver cells rapidly absorb it from the blood stream, as proved by extirpation of the liver
when the dye is retained in the bloom stream almost to 100%. Two mgm. per kilo of body
weight or the body weight divided by 55 gives the exact amount in cc. of a 5% solution
required. This is injected intravenously very slowly, and, 30 minutes after, 4-5 cc. of
blood are withdrawn from the other arm and placed in a dry test tube without preservative. It is allowed to coagulate, and, after centrifuging, the serum is pipetted off and
equally divided in two tubes. To one is added 1 or 2 drops of a 10% solution of NaOH to
bring out the rather violet color of the dye, and to the other 1 drop of 5 % HCl to clear it
of any haemolysis. The alkalinized tube is compared in a special comparator box against
tubes of known standards which give the exact percentage of the dye present in the serum.
Normally the dye is removed from the bloom stream within 3 0 minutes, but in liver disease
varying amounts from almost 100% downwards may be retained, due to the inability of
the damaged liver cells to absorb it, and the percentage retained expressed directly the
degree of impaired liver function. Several of the larger institutions throughout the United
States and Canada use this test almost exclusively, and our own Laboratory is equipped to
carry out this procedure.
During the past two or three years considerable has been added to the literature concerning vitamin K in haemorrhagic diatheses and more especially in the jaundiced patient
in whom surgical intervention is indicated. Vitamin K is a fat-soluble vitamin obtained
chiefly from alfalfa and marketed either in the form of a concentrate in gelatine capsules
or liquid extract. It is usually prescribed in conjunction with bile salts. A test which
developed from the experimental work with this vitamin is the Prothombin Time. Quick
was one of the first to elaborate a test for measuring this, as it was felt that a truer and more
delicate index of the coagulability of the blood than the clotting time was needed and
Page 160 especially to follow the effect of the vitamin K, which has been found to definitely shorten
the prothrombin time and expedite coagulation. It is generally agreed that four agents are
necessary for the clotting of blood—prothrombin (which has been termed a pro-enzyme)
plus thromboplastin or thrombokinase plus calcium which produces thrombin. This acts
upon the fibrinogen to produce fibrin, the basis of clot formation. It has been determined
that there is no appreciable deficiency of calcium and fibrinogen in jaundice that would
account for the tendency to haemorrhage, and Quick reasoned that, by keeping the
thromboplastin and calcium constant, the rate of coagulation must be dependent on the
prothrombin and could serve as a direct means for estimating this. He obtained his
thromboplastin or thrombokinase by macerating a fresh rabbit or guinea-pig brain, after
carefully dissecting away the blood vessels, in a mortar with acetone and extracting it down
to a fine powder. Five cc. of physiological NaCl containing 0.1 cc. of sodium oxalate
solution are mixed with 0.3 gm. of this powder and incubated at 45 degrees C. for 10
minutes, then centrifuged at slow speed for 3 minutes and the supernatant milky fluid is
pipetted off. One-tenth cc. of the plasma of oxalated blood is mixed with an equal quantity
of the thromboplastin solution and to this is quickly added an equal quantity of a slightly
over 1 % solution of calcium chloride. The time required for the formation of a clot after
this final step is called the prothrombin time and has been found to lie usually between 12
and 13 seconds. Quick has compiled a graph and curve from which one may readily read
off the percentage of normal for the completed test. Quick states that as much as 80% of
the prothrombin in the blood may be lost before serious haemorrhage results, but that a
prothrombin time of 15 to 20% of normal is a very critical level and should be treated by
immediate transfusion or transfusions, depending on the decrease of the prothrombin time.
Higher but still subnormal values are found to respond to vitamin K therapy in conjunction with bile salts, especially in jaundiced patients, although Quick found that the prothrombin time was normal in more than 50% of such cases in his series. Likewise in haemophilia it is normal.
We have tried Quick's method on several occasions with rather unsatisfactory results
even in normal controls, and one objection is the instability of the thromboplastin, which
retains its potency for only one week. Smith has recommended a rather simpler, although,
he claims, as informative a method using a thromboplastin made by grinding up fresh ox
or rabbit brain or lung with saline 10 gm. to 10 cc. and extracting it for two hours, then
straining through gauze. This keeps for several weeks in the refrigerator. 0.1 cc. of this plus
0.7 cc. of a known normal blood are mixed in a test tube, and this is inverted every 5 seconds until clotting occurs. If clotting occurs before 25 seconds or later than 60 seconds
the thromboplastin is too concentrated or too weak, respectively, and should be diluted
or a new lot prepared as the case may be. Normally it should clot by this method in
approximately 3 5 seconds. Blood from the patient to be tested is treated as above described
35
and the result is given by the following formula:  X ioo .   Haemorrhage
C.T. of unknown
occurs, according to Smith, when the prothrombin falls to the 30-50% of normal range.
There are several other tests, somewhat more complicated, to measure prothrombin time,
but it is stated that none actually measure it directly, as many factors may alter it besides
variations of the prothrombin itself, so that these tests on the same patient may vary at
different times under the same condtiions.
Our own experience with these tests, i.e., Quick's and Smith's, have not been particularly successful, chiefly because of difficulty with the thromboplastin. However, we hope
to perfect these tests gradually to a point in which we feel some degree of confidence in
the result, as they are apparently of definite value in certain instances of haemorrhagic
diathesis.
I fear that this presentation may have been rather boring and dry, but its purpose was
to briefly describe a few of the newer procedures and suggest that they might be more frequently used, to advantage.
In conclusion, may I again express my deep appreciation for the honour of addressing
you this evening.
Page 161 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. F. M. Auld, Nelson
First Vice-President _Dr. E. Murray Blair, Vancouver
Second Vice-President..— Dr. C. H. Hankinson, Prince Rupert
Honorary Secretary-Treasurer Dr. A. H. Spohn, Vancouver
Immediate Past President Dr. D. E. H. Cleveland, Vancouver
Executive Secretary : Dr. M. W. Thomas, Vancouver
BRITISH COLUMBIA MEDICAL ASSOCIATION
THE 1940 ANNUAL MEETING WILL BE HELD IN
NELSON IN SEPTEMBER
At its last regular meeting the Board of Directors of the British Columbia Medical
Association definitely decided that it would accept the invitation of the West Kootenay
Medical Association to hold the 1940 Annual Meeting in Nelson, the home city of Dr. F.
M. Auld, President.
Dr. J. Stuart Daly of Trail, President of the West Kootenay Medical Association,
attended the Board meeting and reaffirmed the wish of the West Kootenay Medical Association to be host to the provincial association this year.
Members are requested at this date to make plans which would allow their attendance
at the 1940 Annual Meeting in Nelson.
INCOME TAX
The Provincial returns from doctors must be made on or before March 31st.
Dominion returns fall due on April 3 0th.
If claims are made for car expenses it will be necessary to keep records that you may be
able to produce actual documentary evidence. Records are not necessary if claims are
based on mileage, which for 1939 is allowable at the rate of 8c per mile.
MEDICAL SERVICES TO INDIGENTS
For the information of all concerned it is noted that the arrangement whereby all
municipalities may receive 33c per capita governmental grant is applicable for all cases
whether employable or unemployable.
The 33c contribution by the Government is contingent upon the provision of a like or
larger amount by the municipality to build a 66c per capita rmhimum medical service
fund.
These monies are for medical services only. The medical service fund is not to be used
to purchase medicines or other supplies.
Some municipalities have made a larger contribution than the required 33c in consideration of the needs of persons who do not fall under the above classifications.
The inclusion of the unemployable persons widens the scope of the scheme. At present
those in receipt of Old Age Pensions and Mothers' Allowances do not fall under this plan.
It is urged that members of the profession in all municipalities assure themselves that
the local authority is making provision for the available governmental grant of 33c per
capita. This applies to all heads of families and single persons in each municipality. Practically all municipalities have completed arrangements for thus providing medical services
for this part of their indigent population. All municipalities may provide such a fund.
Doctors are urged to read the above and use it.
Page 162 COLLEGE^OF PHYSICIANS AND SURGEONS OF B. C.
MEDICAL SERVICE PLANS
The plans of the larger associations, such as the Telephone Employees and the B. C.
Electric Office Employees, are operating satisfactorily in providing Medical Services to
members and dependants on a prepayment basis through deductions from pay-roll.
The new "Medical Services Association" is now being actively promoted. Sufficient
interest has been shown by many groups of employees in various industries to make it
necessary to proceed with incorporation.
The object of the Association is:
"To provide or arrange for the provision to members and their dependants of
any or all services required in the prevention, diagnosis or treatment of illness on
a non-profit, prepayment and voluntary basis."
Small groups of employees are thus enabled to co-operatively join in securing through
this new association a comprehensive Medical Service.
The patient will be given "Free Choice of Doctor."
Normal Patient-Physician Relationships will be preserved.
This plan has been developed to meet the needs of employees earning less than $2400.00
per annum.
The Committee on Economics of the Council of the College of Physicians and Surgeons of B. C. has worked out the details and the terms of service, which were accepted at
the Annual Meeting last September.
At its inception the plan is being introduced in the Greater Vancouver and New
Westminster areas.
CANADIAN MEDICAL ASSOCIATION MEMBERSHIP
The Committee in charge, under the Chairmanship of Dr. W. E. Ainley, is pleased to
report that the effort to increase the membership in the Canadian Medical Association as
from British Columbia has been successful in adding fifty-five new members. The enrolment for 1940 at this date totals 300. New memberships are being received daily at this
office.
Cheques for membership are made payable to the College of Physicians and Surgeons
of B. C. The fee for membership in the C.M.A. for 1940 is $8.00. In order that no numbers of the Canadian Medical Association Journal are missed, early remittance is urged.
CANADIAN MEDICAL ASSOCIATION ANNUAL MEETING
' ILw^^ JUNE 17-21 #    Jl
The following are the representatives from British Columbia on General Council of
the Canadian Medical Association: Drs. E. Murray Blair, Vancouver; W. A. Clarke, New
Westminster; W. Allan Fraser, Victoria; Gordon C. Kenning, Victoria; H. H. Milburn,
Vancouver; G. F. Strong, Vancouver; S. A. Wallace, Kamloops.
At the last meeting of the Board of Directors it was decided that an attempt would be
made to discover members who will be able to attend the Sessions of the General Council
of the Canadian jMfedical Association at the meeting in Toronto in June. Members are
asked to notify the office well in advance of the Toronto meeting of their possible
attendance.
Page 16} THE CHEMOTHERAPY OF SULFANILAMIDE AND
ITS DERIVATIVES        §|f
By J. H. W. Wdllard, M.A.
The wealth of clinical reports on chemotherapy of the sulfanilamide derivatives seems
at this time to merit a review. This may clarify the nomenclature and conflicting notions
as to their efficacy. New and more practical derivatives are appearing rapidly and consequently the preventative and curative value of this field of drugs is enlarging. The subject
will be discussed under (1) Various derivatives, (2) absorption and distribution in the
body fluids, (3) mechanism of action, (4) administering the drug, (5) comparative values,
(6) diseases and organisms against which they are effective, (7) toxic effects.
The many derivatives of sulfanilamide were synthesized in an attempt to reduce toxic
effects, increase absorption and retention, and to improve their efficacy: they are not specifically used against certain organisms or diseases. The most popular of these drugs are
Sulfapyridine (Dagenan, M and B 693) and sulfanilamide, although recently the derivatives sulfathiazol and sulfamethylthiazol, which are closely related to sulfapyridine, have
been shown to possess greater curative powers and to be less toxic.
Among other members of this increasingly large family are prontosil (prontosil
flavum), neoprontosil (prontosil soluble), benzyl sulfanilamide (septazine, proseptazine),
sulfanilyl sulfanilamide (disulon), sulfanilyl dimethyl sulfanilamide (uliron or uleron),
4, 4 diaminodiphenylsulfone, di-(acetylamino) diphenyl-sulfone, and para-benzyl-amino-
benzene sulf anomide.
Dr. C. A. H. Buttle divides the derivatives of sulfanilamide into two groups: (a)
Those with substituents in the amino group and (b) those with them in the amide group.
Included in the first group are prontosil rubrum, prontosil soluble or neoprontosil, rubiazol,
proseptasine and soluseptasine. The activity of this group is probably due to their breakdown within the body to sulfanilamide. Drugs of this group have no advantage over sulfanilamide in the range of infections which could be dealt with, and although some were
less toxic they were also less active than sulfanilamide. In the second group were uleron
abucid, ethanol sulfanilamide, disulf anil amide, sulfapyridine or dagenan, rodilone, benzyl-
sulfanilamide and sulfathiazol. These drugs probably do not break down into sulfanilamide
within the body but are themselves active agents against bacteria.
The Absorption and Distrd3ution of Sulfanilamide in the Body Fluids
Dr. Ellison of Manhurst clinic outlined the absorption and distribution of sulfanilamide
in the body fluids as follows: (1) Sulfanilamide and acetyl sulfanilamide are found in
equal quantities of each in both the blood and urine; (2) the spinal fluid contains 25 to
30% less than the blood; (3) sulfanilamide is also found in prostatic and amniotic fluids
and breast milk; (4) Dr. W. W. Spink finds that the free sulfanilamide level of the synovial
fluid tended to approximate the level in the blood.
Mechanism of the Action.
There are many theories regarding the mechanism of the action of this class of drugs.
Edna R. Main, Lawrence E. Shinn and R. R. Mellon point out that peroxide accumulation
is associated with retardation of growth observed in pneumococcus culture containing
sulfanilamide or structurally related compounds which have anti-catalase activity. The
concentration of peroxide per unit of growth may be from two to ten times as great in the
presence of the compounds as in the control culture. P. A. Shaffer believes the drugs provide a mechanism by which the sterilizing oxidation intensity of molecular oxygen is applied
nearly at its maximum to bacteria and unavoidably also to some extent to host cells.
Some interesting facts regarding the action of this drug are:
1. Relative ineffectiveness of sulfanilamide against a strain of bacteria in vitro, while in
vivo or if reinforced by human serum the bacteriostatic action is tremendous.
2. Reports of cases where very small doses were given and where concentrations of the
drug were as low as 1 in 10,000 or 1 in 18,000 and still effected the miraculous cures.
3. Various strains of some organisms respond differently and may or may not be killed even
when the drug is administered in large doses.
Page 164 4. The fact that though there is no regular effect on phagocytosis or increase in leukocytosis, or evidence of definite opsonic effect to enhance phagocytosis, sulfanilamide
therapy is apparently potent as shown by no direct bacteriostatic action in saline media
but a marked one in human serum, even in dilutions of 1 in 100,000 sulfanilamide.
Apparently bacteriostasis and phagocytosis reinforce each other to promote cure.
Recently bacteriologists claim to obtain equal bacteriostatic effect with sulfanilamide,
in normal saline as in human sera, if the incubation temperature is raised to 40 degrees
Centigrade.
5. Some writers suggest that sulfanilamide exerts a restraining power on bacteria and holds
them in check until the body has a chance to build up its own antibodies to promote
cure. Sulfanilamide probably makes the organisms less virulent, and hence more phago-
cytized.
6. The so-called resistance factor of the host has been shown to be of importance, especially in experiments done on rabbit pneumonia. Here sulfanilamide decreases the
pneumonia proper but the host will not survive unless the so-called resistance or fitness
factor is up to a certain minimum level so that the rabbit can remove the germ from
the blood stream and in this way take advantage of the sulfanilamide action which has
held them in check and probably rendered them less virulent. This fitness factor can
be supplied or raised by administering liver extract or vitamin C or suprarenal extract.
This would suggest enzyme and coenzyme action with vitamin C as the hydrogen
acceptor and bespeaks a mechanism of biological oxidation. Perhaps some of the
f ailures can be cured with the addition of high vitarnin C and liver concentrates.
A few words must be said regarding the administration of these drugs, and their comparative values.
In most cases it is administered orally, although topical administering of sulfanilamide
has been used at the Minneapolis General Hospital in a series of compound fractures with
good results. Hypodermoclysis, except in cases of severe nausea, vomiting or coma, is of
very limited use. Rectal administration is unsatisfactory due to the uncertain absorption, in
the opinion of Dr. W. Wright of Minneapolis; whereas Professor Campbell of the British
Medical Association believes that rectal administration of the drug suspended in saline
and alkalinized to bring it into solution, should be used as an alternative to parenteral injection where severe vomiting rendered oral administration impossible. Dr. E. K. Marshall
and W. C. Cutting state that very little increased absorption occurs with a large dose of
the very insoluble compounds (for example, disulfanilamide) as compared with a small
dose. Sulfanilamide, when given in solution by mouth, is absorbed much more quickly
than when given in solid form. Absorption is very slight from the stomach, but very rapid
from the intestine. Professor Campbell of the British Medical Association maintains that
a concentration of sulfanilamide in the blood of 4 mg. per 100 cc. is probably as effective
as a concentration of 10 mg.
E. G. Lucas and D. P. Mitchell find, from a study of eleven patients given sulfanilamide
by mouth, that 1 to 2 mg. doses produce a maximum rise to 5 to 10 mg. per cent in blood
sulfanilamide in 2 to 6 hours, and higher values cannot be obtained by larger doses or
repeated administration unless there be renal damage. S The output of sulfanilamide in
urine is directly proportional to dose, 45 to 60 per cent being excreted in twenty-four
hours, and in two to four days output equals intake. After about twelve hours the majority
of sulfanilamide in both blood and urine is in the conjugate, inert form. E. K. Marshall,
Jr., states that a concentration of 10 per cent in the blood stream seems to be necessary for
full effectiveness. This could be obtained by a dosage of 1 gm. per day for every twenty
pounds of body weight; children, however, needed fifty per cent more, and infants about
three times as much per unit of body weight. Dr. W. Harry Feinstone finds that the concentration of sulfanilamide in blood of patients remains at a curative level for longer
periods when given in oil than when given in water or gum arabic. According to Dr. Sara
E. Branham, of the United States Public Health Service, the combination of these drugs
with serum gives better protection than either the drugs or the serum alone.
Page 165 Comparative Value.
There is no evidence that different members of the sulfanilamide group were more
effective for one type of bacterial infection than for another, and a development of a drug
resistance in a virulent strain had not been established. The drugs were relatively ineffective in localized infections of some duration and exo-toxin diseases, for example, diphtheria.
M & B 693 (Dagenan or sulfapyridine) was effective in infections with pneumococcus of
all types, whereas sulfanilamide acted only against Type 3. It was more effective than sulfanilamide in staphylococcal and gonococcal infections and equally effective in streptococcal and meningococcal diseases. Albucid, which appeared to be completely non-toxic,
was effective in gonorrhoea, especially in females. Dr. Sara E. Branham, of the United
States Public Health Service, fiinds that, weight for weight, sulfapyridine seems more
effective than sulfanilamide. The experience of Drs. E. N. Cook and E. B. Sutton, of the
Mayo Clinic, is that M & B 693 is more effective in gonococcal infection and sulfanilamide.
Benzylsulfanilamide is regarded by Dr. Hans Molitor and Harry Robinson as practically non-toxic although its anti-streptococcal activity was quite pronounced. Their
report culminated a large number of acute, accumulative and chronic toxicity experiments
in mice, rats, rabbits and dogs.
Dr. E. K. Marshall finds that ethanol sulfanilamide is absorbed and excreted very rapidly, while disulfanilamide is absorbed slowly and excreted rapidly in comparison with
sulfanilamide. Sulfanilamide derivatives do not all pass into the spinal fluid as readily as
do sulfanilamide. Up until recently the best of these derivatives seems to have been sulfa-
pyridine. The most recent and effective of the sulfanilamide derivatives are "sulfathiazol"
and "sulfamethylthiazol." They are chemically related to sulfapyridine. They combine
with acetic acid to a much smaller extent than sulfapyridine. Sulfathiazol has a very low
toxicity. It has been shown to be better for pneumonia treatment than even sulfapyridine.
Pus-forming staphylococci are also yielding to it, especially those that have hitherto not
responded well to chemotherapy, as larger doses can be given over longer periods (less
toxic). Nausea is practically absent with its use. Sulfamethylthiazol is proving to be even
superior to sulfathiazol for staphylococcus and at least as effective for pneumonia. Drs.
W. E. Herrell and A. E. Brown of the Mayo Clinic report on an experiment showing the
comparative effect of some of the more popular sulfanilamide derivatives. The drugs were
added in equal concentration to broth cultures containing 12-15 colonies per cc. After
seven hours: Controls had 21,360 colonies; sulfanilamide, 2,760 colonies; sulfapyridine,
2,820 colonies; sulfathiazol, 2,400 colonies; sulfamethylthiazol, 15 colonies. The germs
were completely unable to multiply in the presence of the newest chemical remedy.
Efficacy.
These drugs have now the enviable reputation of curing, and in some cases preventing,
some thirty-four diseases. Following is a list of diseases and organisms against which sulfanilamide, sulfapyridine or sulfamethylthiazol have enjoyed marked success: Type a organisms of the B. haemolytic streptococcus, gonococcus, meningococcal meningitis and the
pneumococcus, trachoma, staphylococcus, cerebrospinal meningitis, gas gangrene, streptococcal puerperal infections, undulant fever, peritonitis, pneumococcus meningitis, lobar
pneumonia. It has been of aid in recoveries from the Sonne strain of dysentery bacillus, E.
typhi, E. paratyphi, Clostridium Welchi, influenzal meningitis, actinomycosis, erysipelas,
Haemophilus influenza bacillus, tonsillitis, filarial elephantiasis, plague, acute salpingo-
oophoritis, acute gonorrhceal cervicitis, acute parametritis, bacterial endocarditis, due to
streptococcus viridans, lymphogranuloma, chancroid, some non-specific urinary tract
infections, chronic ulcerative colitis, pemphigus, and Lupus erythematosus. There are
conflicting reports regarding its effect on malaria and smallpox, and its value has yet to
be proved. It shows promise, however, in the fight against rheumatic fever. It seems to
be unsuccessful in scarlet fever and human tuberculosis, although it has been shown by
Arnold R. Rich that it inhibits the development of experimental tuberculosis in the highly
susceptible guinea pig.
Diseases and Orcanisms Against Which It Is Effective.
Pneumonia: Some conspicuous examples of the efficacy of the drug appears in 627 cases
Page 166 of lobar pneumonia with a mortality rate of only 5.4%, as reported in August, 1939, at a
meeting of the British Medical Association (by Dr. W. F. Gainsford).
Dr. W. A. MacGall reports that with the use of sulfapyridine this drug was effective
in pneumococcal infections and improvement was noted within 24 hours. The total leucocyte count seems to be the best indicator of progress. Resolution and spread of the process
are delayed when the count remains high, suggesting that specific antiserum may be of
value when the patient's antibody response is slow. In bronchopneumonia the drug seems
promising, and it has been of benefit in cases in which other treatment failed. In almost
all cases temperature fell on administering of the drug. This has been so constant that an
antipyretic effect is suggested.
O. E. Romcke reports from Norway on the use of sulfapyridine in 342 cases of pneumonia, from October, 1938, to May, 1939, that mortality was 5.8%. For 245 cases of
lobar pneumonia the mortality was 4.3 %. For patients under fifty years the mortality was
1.6%. The most frequent complications were pleurisy, otitis and empyema. The average
dose of sulfapyridine in persons older than ten years was 22 grams (total).
Dr. Maxwell Finland of Thorndyke Memorial Laboratory, Boston, states that serum can
be used and will be successful in about two-thirds of the cases of pneumonia due to
pneumococcus. Sulfapyridine is probably useful in all types of pneumococcus pneumonia
and is probably as successful if not more so than sulfanilamide, and less toxic. Typing and
other tests to determine the kind of germs causing the pneumonia should be done. Dr.
Finland believes, even if the doctor expects to treat the patient with a chemical remedy
instead of the serum. If the patient, then, cannot stand the toxic effect, the serum may be
administered without further delay.
Dr. F. G. Smith reports on 50 cases of acute lobar pneumonia in adults treated with
sulfapyridine, stating that of 5 0 unselected consecutive cases these had a mortality rate of
8% contrasted with previous mortality series of 678 cases of 32%.
Dr. W. Barry Wood, Jr., presents evidence that type-specific antibodies play an important role in the process of recovery from pneumococcal pneumonia following treatment with sulfapyridine. The lateness of the appearance of circulation antobodies is
offered as a possible explanation for the relapses which frequently occur when sulfapyridine
therapy is discontinued too soon.
Dr. E. N. McDermitt (Galway) said that he had gained the impression that in lobar
pneumonia treated with sulfanilamide resolution of the consolidated area was slower, and
in empyema the pus was thin in consistence. These changes might be due to the leuco-
penia which so often accompanied administration of the sulfanilamide.
Gonorrhoea: Dr. F. J. T. Borvie of Aberdeen reports that sulfanilamide gave cures in
70 to 80% of the cases, uleron in 70 to 90% of the cases, and sulfapyridine (M & B 693,
and Dagenan) in 85 to 95%. Sulfapyridine appeared to be the drug of choice since it
could be given at once, whereas optimal results with sulfanilamide and uleron were obtained
only if the treatment were postponed for about ten days from the onset of the disease.
After the treatment with sulfapyridine there was a very low incidence of complications
(1.5%) as compared with the high figure (25 to 30%) which was the rate before chemotherapy. A total of 20 gm. of sulfapyridine was sufficient. This could be given in daily
3 gm. doses for six or seven days, or 4 gm. could be given at once, then 2 gm. four times a
day until the total amount reached 20 gm. When the latter method was used nausea lasting
from twelve to twenty-four hours was common, but otherwise there appeared to be no
danger and the results were better. In a series of seven cases of gonococcal ophthalmia
neonatorum treated with sulfapyridine all became bacteriologically negative within thirty-
six hours; the confinement to hospital was reduced to about seven days as compared with
the much longer periods needed for older methods of treatment.
Dr. R. E. Gillett reports that acute gonorrhceal cervicitis was markedly helped but it
was of little value when the disease became chronic. Acute parametritis was likewise
markedly benefitted.
Drs. E. N. Gook and E. B. Sutton of the Mayo Clinic state that sulfapyridine is better
than sulfanilamide for gonococcus infections. It shows apparent cures in 1 to 8 days, with
no failures in 18 acute and chronic cases. They add it is not long enough time yet to be
Page 167 sure there will be no relapse.  The chemical is most effective when combined with "mild
local treatment."
Dr. W. Wright of Minneapolis reports on their results using sulfanilamide. They considered it the best therapeutic agent to date. This was two years ago. The regular course
of treatment by them in the average adult male or female consists of the following: 80
grains per day for 4 days; 60 grains per day for 3 days; 40 grains per day for 7 days; 20
grains per day for 7 days. This was administered in four equally divided doses throughout
the day, with equal amounts of sodium bicarbonate to decrease acidosis and toxic symptoms. 140 males and 49 female cases were under observation till a definite cure was established. Their test of a cure consisted of the following in the male:
1. Negative smears from prostate.
2. Negative smears after sound.
3. Urine absolutely clear, or if persistent shreds, then multiple negative smears of
shreds.
4. Negative smears after 1 % silver nitrate (1 % Ag. N03).
5. No reaction after injecting 30/100 gonococcus filtrate intracutaneously.
A cure for female cases was complete after the following:
1. At least 10 to 20 consecutive smears showing negative instead of the required 3
consecutive negative smears.
2. Clinically negative for discharge.
3. Absence of pain or masses in the pelvis.
A good result meant negative smears, clear urine, and absence of discharge within two
weeks after beginning the sulfanilamide treatment. A fair result means definite improvement with sulfanilamide, but in these cases additional medication such as neosilval,
protargol irrigations or Corbus-ferric filtrate was used. These apparent cures must be
within a month after chemotherapy is started.
Out of 140 males 68% were good results, 12% were fair results, 20% were failures-
some couldn't tolerate the drug (10%). The 40 females showed 80% cure. Of 2,672
cases from various clinics they have found 80.9% cure. Possibly failures are due to certain
strains that are sulfanilamide resistant.
They have noted that a patient treated with sulfanilamide and not responding usually
responds less to filtrate, protargol and irrigations than those not previously given the drug.
This may be due to a drug idiosyncrasy or lack of immunity built up in the patient, or an
increased resistance of the gonococcus.
The question of contra-indication of other drugs to sulfanilamide is as yet not settled.
They have used sulfanilamide along with other drugs such as bromides, luminal and other
sedatives with no unusual effect.
In gonorrhoea of pregnancy it can apparently be used with safety to mother and child
and prevent gonorrhceal ophthalmia. Dr. Speert found that by giving sulfanilamide to
mothers in labour and checking the blood in the cord after delivery, the sulfanilamide
concentration in the foetal circulation approaches the concentration of sulfanilamide in
maternal blood.  He has observed no ill effects on the newborn child.
Bacterial endocarditis due to streptococcus viridans is reported on by Drs. S. R. Kelson
and P. D. White. They employed sulfapyridine along with the blood clot-dissolving
heparin. Of three patients, three recovered and two of these remained well from 1 to more
than 5 months. The sulfapyridine checks the growth of the germs if it doesn't kill them
outright, while the heparin can, it is believed, prevent further development of clumps by
reducing the ease with which the blood clots. This also prevents the danger of an artery
getting plugged by one of the germ blood clumps that so often gets free from its location.
The growth of more vegetations is checked. They believe this treatment gives more
promise than any method they have used or heard of in the past. Patients should be watched
and diagnosis certain. The treatment can do no harm and the benefit outweighs the risk.
Drs. Meyer Friedman of San Francisco and W. W. Hamburger and L. N. Ratz of
Chicago also believe in this heparin treatment.
Sulfanilamide and sulfapyridine have both been previously tried in this fatal heart
disease with a few cases of recovery.
Page 168 Drs. W. W. Spink and F. H. Crags report on 11 persons suffering from subacute bacterial endocarditis due to streptococcus viridans and on one person showing staphylococcus
albus infection whom they treated with sulfanilamide. Except for two patients, the bactericidal effect was only temporary and dependant upon continued use of the drug. One
of the two who improved was well nine months afterward but the other eventually died of
the disease. All subjects had bacteriaemia. The drug rendered the blood temporarily sterile
in 6 of the 12. Several took the drug over a long period, with a marked erythrocyte fall
in only one and without a depression of leukocytes in any instance. A relation between the
amount of free blood sulfanilamide and its effect on the bacteriaemia was not apparent. The
doctors believe that the drug is of doubtful value in the treatment of bacterial endocarditis
because the proliferating mass of bacteria situated deep in the vegetations are probably too
well protected for the drug, although those on the surface and in the circulating blood may
be destroyed.
Peritonitis and sulfanilamide therapy is reported on by Drs. W. E. Ladd, T. W. Botsford
and E. C. Curnen of the Harvard Medical School. They find that the death rate at the
Children's Hospital, Boston, is cut from 73% to 20%. Their treatment consisted of
making a small surgical incision into the abdomen, usually under local anaesthetic, and
drawing out a bit of the pus for examination to determine the germ causing the trouble.
A drain is left in the wound to draw off more of the pus, and sulfanilamide is immediately
given by hypodermic injection until the patient is able to take it by mouth. If examination
of the pus shows that the germ is pneumococcus (in most of these cases it is either the
pneumococcus or the streptococcus), sulfapyridine is given instead of sulfanilamide and
anti-pneumonia serum of the correct type is also given.
Acute Suppurative Arthritis due to hemolytic streptococcus treated with sulfanila-
mdie is reported on by W. W. Spink. A patient with severe streptococcic infection (sepsis),
including tonsillitis, pneumonia, acute glomerular nephritis with nitrogen retention and
suppurative arthritis of the knee joint, was treated with sulfanilamide. There was complete restoration of joint function. A study of the exudate from the joint cavity obtained
before the sulfanilamide therapy showed short chains of cocci, mostly extra-cellular. After
sulfanilamide administrations large numbers of cocci were intracellular and the extracellular organisms were pleomorphic and stained poorly. These abstracts confirmed the
experimental studies of others. The free sulfanilamide level of synovial fluid tended to
approximate the level of the blood.
Streptococcal puerperal infections are reported on by Dr. N. Kenny of London, who
finds the death rate reduced from 28% to about 5% by sulfanilamide therapy. An early
series of cases had received an average of 18 gm. of prontosil rubrum and the mortality rate
in this series (5.3%) had not been improved upon by much larger doses of sulfanilamide
in subsequent series. There was now a tendency to give too large doses, and a return to
moderate doses of prontosil rubrum would produce less toxic effects. In sulfanilamide
treatment of B. coli pyelitis of pregnancy the smallest possible dose should be used in view
of the labile character of the haemopoietic system at this time. Usually 1.5 gm. in 24 hours
was sufficient and more than 3 gm. had never been necessary. The proper prophylaxis of
puerperal infections by strict attention to asepsis should not be relaxed. The sulfanilamide
drugs should be used as a prophylactic measure only when there is reason to suspect the
presence of pathogenic streptococci in the atmosphere, and in such cases the drug should
be eiven in full curative doses.
Dr. W. E. Herrell and Dr. A. B. Brown of the Mayo Clinic report that the pus-forming
staphylococci are being controlled by the new derivative sulfamethylthiazol. They have
found this effective in cases of blood-poisoning and pneumonia, and mention a five-day
cure in one case of pus-forming staphylococci as well as laboratory tests showing the new
chemical completely stopped the growth of such germs. They found it less toxic than
sulfapyridine and very effective in pneumonia treatment, as patients showed striking
recovery in forty-eight hours. They believe it promises success in controlling a whole new
group of diseases due to the staphylococci. They mention one case of staphylococci blood
infection where the temperature from from 104 to 100 degrees in the first 24 hours after
administration.  In forty-eight hours the temperature was down to 99 degrees F., and in
Page 169 five days was normal. The patient had no gastro-intestinal irritation and was able to take
meals regularly, although, with sulfapyridine treatment, which was first tried, she became
so sick the medicine had to be discontinued.
Dr. L. G. Carroll of St. Louis reports that he has had great success using sulfamethylthiazol against staphylococcus. Haemophilus influenza bacillus infection was treated by
Dr. J. H. McLeod of Washington with sulfapyridine. The subject was an 8-months-old
baby with conjunctivitis, followed by an ear infection and subsequently pneumonia. There
were a few pneumococcus germs present but lots of the haemophilus influenza bacillus.
Twenty-four hours after sulfapyridine administration, the baby was much improved and
recovered completely in a short time.
Dr. Margaret Pitman paralleled Dr. McLeod's work on haemophilus influenza bacillus
with mice. She found that 70-100% of the mice were protected against 100 M.L.D. of
the germ with 8 mg. of sulfapyridine given in one dose before infection. The drug did not
prevent blood-invasion but retarded increase of bacteria in the blood. Many of the mice
that survived developed a massive bacteriaemia.
Influenzal meningitis treated with sulfapyridine is reported on by Drs. T. R. Hamilton
and S. C. Neff of the University of Kansas Hospital. A two-year-old baby girl suffering
with influenzal meningitis was received in a prostrate condition and high fever. She was
much better after 4 days of sulfapyridine treatment and well enough to return home in one
week, and completely recovered 16 days after contracting the illness.
Cerebrospinal meningitis, which claims to be 60-90% fatal, is enjoying 95% cures
when treated with sulfapyridine, according to Drs. J. Bryant and H. D. Fairman. They
saved 20 of 21 patients treated with sulfanilamide and 160 of 168 treated with sulfa-
pyridine.
Dr. S. Stanley and Dr. S. S. Schneierson find that sulfanilamide and prontosil have a
marked bactericidal and bacteriostatic effect upon meningococci in vitro, depending upon
the concentration of the drug.
Meningococcal meningitis and sulfanilamide therapy is reported on by Dr. H. S. Banks
of London. He states that in a series of 28 cases treated with sulfanilamide alone no deaths
had occurred, and of 34 cases given sulfapyridine only one had died. Relatively high mortality rates occurred when serum alone was used, and when serum was administered in
conjunction with insufficient doses of sulphanilamide. It was a good plan to change the
drug used from sulfapyridine to sulphanilamide when mental depression became marked,
usually after thirty-six hours. Four cases had been treated in this way with good results.
The concentration of the drug in the cerebrospinal fluid had been found to follow closely
the blood level and was approximately half as high.
Gas gangrene and meningitis are effectively treated with sulfanilamide, according to
Dr. Thomas M. Rivers of the Rockefeller Institute. Drs. Long and Bliss of Johns Hopkins
Medical School also report that gas gangrene is effectively treated with sulfanilamide.
Trachoma, according to a paper by Dr. James G. Townsend, Health Director for the
U. S. Indian Service, is being effectively treated with sulfanilamide. Eight hundred and
fifty school children have been treated, besides many adult patients. The drive was started
amongst children because they can be reached through schools and watched. According
to Dr. Townsend, sulfanilamide is the best therapy doctors have had so far for fighting
trachoma among the Indians. There is no question but that it brings about a marked
improvement. Best results appear in acute rather than chronic cases. Trachoma gets
between 2000 to 3000 new eye victims every year and is very contagious. The disease was
arrested in 105 of 167 children treated at the Chemawa, Oregon, School. Twenty-three
patients treated 18 months ago have had no relapse. The patients feel better immediately
after the treatment is started and the pain and soreness in their eyes begin to abate on or
about the third day. The sulfanilamide is given three times a day by mouth every day for
five days. Then after two days of rest the treatment is resumed for another five days. At
the end of this time the eyes are much better and the condition arrested. After another
month, during which there is no improvement, the eyes begin to improve very rapidly,
suggesting an accumulative effect of the drug.
Page 170 c/
Typhoid fever treated with sulfapyridine is reported on by Drs. E. H. R. Harries,
Robert Swyer and Noel Thompson of Northeastern Hospital, London. Good results in
severe cases of typhoid fever are reported by them. The most striking example was a case
of "walking typhoid" and for whom any experienced doctor would have predicted a long
period of illness. Within ten days after entering the hospital the patient was in the recovery
or convalescent stage. He was given both sulfapyridine and the serum. The doctors suggest that this combination is probably the best thing to use for treatment of other cases.
Filarial elephantiasis, according to Dr. G. A. H. Buttle, is helped by the action of sulfanilamide due to the killing of the secondary streptococci.
Plague, according to Dr. Buttle, is also helped by treating with sulfapyridine.
Brucella (undulant fever) infections respond markedly to sulfapyridine treatment,
is the experience of Dr. Buttle.
Lymphogranuloma, trachoma, smallpox are all virus diseases, yet are directly influenced
by the sulfanilamide derivatives, according to Dr. Buttle.
Smallpox is apparently treated with some success by sulfanilamide, Dr. W. O. Mc-
Cammon claims. Seven cases of smallpox came to his attention and sulfanilamide was used
on four of them. In these four there was only a slight eruption that soon disappeared. He
believes the eruption was prevented by the sulfanilamide therapy. These four patients were
back at work a week sooner than were the other three cases, which were treated symptom-
atically and in which the typical eruption of smallpox developed. He hesitates to draw any
radical conclusion from so few cases.
Malaria in man is unaffected by sulfanilamide treatment, although it acted like a charm
in Plasmodium knowlesi malaria in monkeys, points out Dr. P. H. Manson-Bahr of London.
He also states that the results in undulant fever in man had been on the whole favourable
but not dramatic.
Actinomycosis when treated with sulfanilamide has shown favourable results, reports
Dr. Mahnson-Bahr.
Pneumococci meningitis {type 15) was treated by Dr. E. T. Lisansky with para-amino-
benzene-sulmonamide. A case of type 15 pneumococcic complicating the right antrum
sinusitis recovered when treated with this drug and radical drainage of the sinuses.
Tonsillitis treated with sulfanilamide is reported on by W. R. Snodgrass of Glasgow.
In his opinion, although there is general agreement regarding the efficacy of sulfanilamide
therapy in tonsillitis, there was actually a scarcity of properly controlled studies. It is his
experience that acute widespread and invasive infections respond best, and poorest results
were found in single walled-off lesions such as quinsy.
Erysipelas is also treated by Dr. Snodgrass with sulfanilamide. He states that in a carefully controlled study of this treatment he had found the drug was of great value and suggested that a suitable dosage in adults was 1.5 gm. of prontosil rubrum or 1 gm. of sulfanilamide every four hours until the lesion had ceased to spread and the primary pyrexia and
toxaemia had ceased; thereafter 1 gm. thrice daily should be given for 14 days to prevent
relapse. He also adds that in scarlet fever sulfanilamide therapy had no significant effect
on the initial symptoms or signs, or on the incidence or duration of complications.
Chronic ulcerative colitis shows prompt improvement when treated with neoprontosil
(oral), is the experience of Drs. A. E. Brown and W. E. Herrell. This prompt improvement, which has occurred so frequently and uniformly after the use of neoprontosil seems
to indicate that the drug is of definite benefit in this disease. The lack of toxic manifestations associated with the use of neoprontosil in general makes this drug especially adaptable
to the treatment of chronic ulcerative colitis.
Toxic Reactions of Sulfandlamide
According to Dr. Ellison of Lymanhurst Special Clinic, these vary from fatigue and
anorexia to the less common reactions of methemoglobinemia and sulphenioglobinemia.
1. Malaise: This varies from mild fatigue to almost exhaustion and prolonged deep
sleep, the patient often being too tired to eat.
2. Anorexia: Very frequently the patient loses all taste for food and frequently loses
five to ten pounds while being treated.
Page 171 3. Nausea and vomiting: This varies from mild nausea to severe vomiting. Drs. E.
N. Cook and E. B. Sutton of the Mayo Clinic find that when the drugs are given with a
small quantity of milk the stomach and intestinal distress is sometimes relieved. Also, the
administering of equal weight of sodium bicarbonate is also effective in minimizing nausea.
4. Fever is rather uncommon. It usually ranges from 100 to 101 or 102 degrees and
is accompanied with other toxic signs such as cyanosis, nausea and vomiting.
5. Dermatitis: This is also quite rare, but sometimes appears after ten days or one week
administration. It may appear after the drug has been discontinued.
Rash: Maculo-papular, most frequently on forearm, face, legs, buttocks. Quite often
it is unilateral. It usually appears 24 to 48 hours after the sulfanilamide is discontinued,
and requires no other therapy except local treatment for itching. Even if the drug is continued the rash will fade in about 72 hours. Sunlight or ultra-violet light will tend to bring
on a sulfanilamide rash.
6. Edema: This occurs infrequently.
7. Leucopenia: Agranulocytic anaemia and haemolytic anaemia are all rare. Agranulocytosis is about the only fatal complication and occurs usually late in the treatment. It is
very important to do white cell counts after treatment has been continued for ten days and
every third to fourth day thereafter. Dr. H. Myhre mentions a case and suggests that the
drug should never be used for more than seven to ten days at a time. If a second course is
needed, the blood count must be watched, especially if the temperature rises. Dr. Nathan
Rosenthal and Peter Vogal mention three cases of granulocytopenia found in children
after the use of sulfapyridine. They say sulfanilamide is also causing the trouble. They
stress the necessity of watching the blood for danger signs. Dr. Saeton Sailer reports a case
of subacute bacterial endocarditis due to a streptococcus viridans infection. The patient
was treated with 282.6 gm. of sulfanilamide over a period of 23 days, resulting in granulocytopenia. Sections of the bone marrow showed areas of aplasia, which predominated, and
of myeloid and lymphocytic hyperplasia; areas of focal necrosis were present in the intermediate zone of the liver. Pneumonic lesions were free from leucocytic infiltration.
8. Methemoglobinemia and cyanosis in a mild degree has been quite common, espcially
during the first few days of treatment when the dosage of the drug is high. Unless it is
marked or accompanied by more severe toxic signs it is perfectly safe to continue with the
regular doses of sulfanilamide together with equal amounts of sodium bicarbonate. Recent
work explains cyanosis on the basis of blue pigmentation derived from sulfanilamide, and
picked up by the red blood corpuscles to give the cyanotic-like colouring.
Drs. A. F. Hartman, A. M. Perley and H. L. Barnet report on methemoglobin formation and its control: "In the majority of patients receiving 0.1 mg. or more of sulfanilamide per kilogram per 24 hours, cyanosis develops, and so far we have been able to demonstrate the presence of methemoglobin in every case of cyanosis. There is marked variation in both the rate and the degree of methmoglobin accumulation. Methylene blue
causes a very rapid disappearance of cyanosis with simultaneous reduction in the methemoglobin concentration, when given intravenously in single doses of 1.0 to 2.0 mg. per kilogram, or when given orally in doses of 1.0 to 2.0 grains (65 to 130 mg.), repeated every
four hours. The latter method also prevents any appreciable formation of methemoglobin
if started simultaneously with sulfanilamide administration.
9. Sulphemoglobinemia is uncommon, usually associated with a history of recent
medication with sulphate cathartic, such as magnesium sulphate dressings. It can be prevented by (1) warning the patient to take no cathartic other than one ordered by the
doctor, (2) use of mineral oil and enemas if necessary, ( 3 ) limiting eggs on diet to two a
day, (4) giving enema before sulfanilamide is instituted if the patient has taken sulphate
cathartic the past day or so.
The best treatment of complications is transfusions and intravenous glucose. Oxygen
therapy is of little and questionable benefit, but is usually used in conjunction with other
treatment.
10. Haematuria sometimes appears, due to the deposition of the acetyl derivative in
the renal tract.
11. Mental depression and vomiting: Mental depression is more common with M & B
693 than with sulfanilamide.
Page 172 12. Nervous symptoms, such as atopia, atonic convulsions and paralysis were often
produced by large doses of sulfanilamide but not with benzylsulfanilamide.
13. Depressant: Dr. Ellison of Lymanhurst Clinic says that sulfanilamide is a depressant and the occasional deaths that can be attributed to the drug are caused by respiratory
and cardiac paralysis.
14. Formation of uroliths of acetylated sulfapyridine in rats and rabbits but not in
dogs or mice, are reported by Dr. Hans Molitor and Harry Robinson.
15. Acidosis is reported by Dr. T. Goodier to be one of the complications caused by
sulfanilamide therapy.
16. Dr. F. G. Smith reports that acute toxic nephritis and focal necrosis in the adrenal
appeared, and was confirmed by autopsy.
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Pharm. & Experimental Therapy, 65  (4):405-423, 1939.
Myhre, E, M.D.—"On Sulfanilamide Agranulocytosis." Acta. Med. Scand., 99  (6):614-618, 1939.
Pittman, Margaret—"Protection of Mice Against Haemophilus Influenza." U. S. Public Health Reports,
54  (39):1769-1775, 1939.
Rich, A. R., and Follis, R. H., Jr.—"The Inhibitory Effect of Sulfanilamide on the Development of Experimental Tuberculosis in the Guinea Pig."  Bull. Johns Hopkins Hospital, 62 (l):77-84, 193 8.
Rivers, T. M., M.D.—Rockefeller Institute for Medical Research.  Sc. N. L., Sept. 16, 1939.
Romcke, Olaf—"Pneumonia Treated with Sulfapyridine."  Nordisk Med., 2 (25) :1898-1906, 5pl. 14f. 1939.
Rosenthal, Nathan, and Vogel, Peter, M.D.—"Danger from Sulfapyridine." Jour. Amer. Med. Assoc, Aug.
12, 1939.
Sailer, Seaton—"Subacute Bacterial Endocarditis Treated with Sulfanilamide Resulting in Granulocytopenia
and Death."  Amer. Jour, of Clin. Path., 9  (3):269,278, 7 fig., 1939.
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Smith, F. G.—"Report of 50 Cases of Lobar Pneumonia (Acute) in Adults Treated with Sulfapyridine.''
Amer. Jour, of Med. Science, 198 (1), 1939.
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Schneierson, Stanley S.—"Effect of Sulfanilamide Upon the Growth of Meningococci in Vitro." Jour. Infect.
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Lymanhurst staff meeting, January, 1939.  Jour. Lancet, Jan., 1940.
ancouver
enera
Hospita
VERIFIED BRAIN TUMOUR CASES,
£-'       VANCOUVER GENERAL HOSPITAL,  1934-1938
By Drs. D. P. Robertson and C. E. Gould.
During the five-year period, 1934-1938 inclusive, there were sixty-eight cases of brain
tumour at the Vancouver General Hospital. Of this number, however, twelve cases were
not proven by operation, biopsy or autopsy. The diagnosis in the remaining fifty-six cases
was definitely established by one or more of the above-mentioned methods, and it is this
series of fifty-six proven cases that is summarized below.
1.   Type Incidence:
Table I.
V. G. H.
Glioma about 41   % 66.07%
Meningioma 13    %-^-12.50%
3.5%
V. G. H.
Tuberculoma and Granuloma 2.5%
Blood vessel tumour 1.7%
Choroid plexus tumour 1.0%
Cholesteatoma 1.0%_
Pineal body tumour . 3.5%
Chordoma, speno-occipital 1 case
Suprasellar cyst : 1 case
Septum pellucidum Cyst 1-case
Lindau's   disease 1 case
1.7%
Auditory Nerve Tumour 10   %.
Hypoduct Tumour 7   %
Sarcoma 7   %
Secondary carcinoma 5   %
Pituitary adenoma* 4.6% 5.3%
Pituitary adenomaf 19.2%
* National Hospital figures.     fCushing's figures.
The left-hand column in Table I represents the averages combined from two large
series of cases—that of the National Hospital for Nervous Diseases, Queen's Square,
London, and that of Harvey Cushing. The type incidence percentages were nearly identical in both series, with a single exception, viz., the pituitary adenomata, Cushing's figure
being about four times as high as that of the National Hospital.
The right-hand column gives the comparative percentages in this five-year series at
the Vancouver General Hospital. In a series as relatively small as this one is, it is not to be
Page 174 expected that the figures will be comparative with the averages arrived at with the larger
series. It is to be noted, however, that of the total fifty-six cases, thirty-seven cases, or
66.07%, were malignant gliomas—a figure significantly above the average. The meningiomas, seven cases out of fifty-six, or 12.50%, represent the average. The pituitary
adenomata total, at 5.3%, is comparative to the National Hospital figure rather than to
Cushing's.
The two pineal body tumours, the chordoma, suprasellar cyst, septum pellucidum
cyst and case of Lindau's disease represent lesions that total less than 1 % in a larger series
of cases.
2.   Location of Tumours:
Table II.
5 p JS    g^3     ,   «     ^       J«
^h *-■ — ' —'      u *zl Os*jJL*-> w Z5
I        §•       fe    I fe    2fe   "H «    2.2   fe.2*    .2-      -g
fL,       b*        (u    p«p*   Hft   H >   HO   f^ O     O       U
GLIOMAS—
Glioblastoma Multiforme  13324-2..1 ^&$
Astroblastoma  2        _        __        _        _        1         1         1         l _
Astrocytoma   _        _        3         _        _        _         1         _        _ 2
Spongioblastoma  1         2        _        _        _     , _        _        1         .. _
Medulloblastoma  ____„„__.. 3
Oligodendroglioma         _        _        1 _        _        _        _ _
Ependymoma  _______..„ I
Meningiomas—
1 overlying Rolandic fissure. 1 left temporal and frontal lobes
1 left parasellar region 1  right parietal parasagittal area.   -
1 right frontal lobe Others speak for themselves, except:
1 midline, frontal region Cholesteatoma—right frontal area.
Table II shows the variety of distribution and emphasizes the lack of a site of predilection as far as the gliomas are concerned, with the single exception of the medulloblastoma,
which ran true to type, and were found in the cerebellum in all three cases.
Table III.
Age Groups:
Gliomas—
Glioblastoma Multiforme	
Astroblastoma	
Astrocytoma    j	
Spongioblastoma	
Medulloblastoma	
Oligodendroglioma	
Ependymoma	
Meningiomas :  6 78 37.8
Chromophobe adenoma of pituitary 49, 45, 61
N. VIII neurofibroma 48, 23
Pineal body tumours 11,13
Chordoma ; :  13
Suprasellar   cyst : 3 2
Septum pellucidum cyst  23 i
Lindau's disease  2 8
Cholesteatoma i  59
ingest
Oldest
Average
Cases
13
72
49.0
16
10
60
47.8
6
5
52
26.3
6
28
60
44.0
4
■%''f
54
49
33
20.3
3
Table III shows the wide spread in the age incidence of the gliomas, the widest spread
being in the glioblastoma multiforme group, while the medulloblastomata, characteristically, are limited to younger individuals. The meningiomas are shown also to have a wide
spread in age incidence, and the pineal body tumours, as is usually the case, accurred in
children.
Page 175 4.   Operative Mortality:
Table IV.
No
Post-Operative
Operation
Operation
Deaths
26
11
18
2
1
0
1
1
0
0
2
0
1
0
0
0
0
0
0
0
0
Gliomas .	
Meningiomas	
Chromophobe adenoma of pituitary	
N. VIII neurofibromas	
Pineal body tumours	
Chordoma .	
Suprasellar   cyst	
Septum pellucidum cyst	
Lindau's   disease	
Cholesteatoma	
Table IV shows the operative mortality of all the cases operated upon in this series.
Operation mortality is reckoned as a death occurring subsequent to operation, and prior to
discharge from hospital, and may occur many weeks post-operatively.
Study of this table shows the martality rate in the different types of tumour to be comparable to the rates obtained in other centres.
5.   Incidence of Headache, Vomiting and Papillcedema:
Table V.
Headache as the first subjective symptom:
Gliomas 16 out of 34 3 no history.
Meningiomas 3   "   "    6 1 no history.
Other  tumours 7   "   "12
20
52.
Vomiting:
Gliomas 12 out of 34
Meningiomts 3 "6
Other tumours 5   "   "12
.51.9%
22   "   " 48
Papillcedema:
Gliomas 15 out of 32
Meningiomas 4   "   "    7
Other tumours 3        "9
.3 8.5 %
12
47
.45.8%
All three (headache, vomiting, papillcedema) were absent in:
Gliomas 9 out of 3 2
Meningiomas 0   "   "    6
Other tumours !  3   "   "    9
27   "   " 52 25.5%
Table V takes up the incidence of headache, vomiting and papillcedema—the cardinal
triad of increased intracranial pressure—in this series.
Headache is shown to be the most consistent first subjective symptom, occurring as
such as roughly one-half of all cases.
Vomiting occurred, although not necessarily as a first symptom, in 38.5% of all cases.
In only a few cases was it recorded as being of projectile type, although extracranial causes
were not found to account for the non-projectile cases.
Papillcedema was found in 45.8% of all cases in which the ophthalmoscopic examination was recorded—a total of forty-eight cases.
Perhaps the most interesting figure in this table is the number of cases in which all
three of the cardinal triad of headache, vomiting and papillcedema were absent—twelve
out of forty-seven cases, or 25.5%, and it is to be noted that this triad was absent in nine
out of thirty-two gliomas, but in none of the meningiomas.
Note: Totals in this table are less than the total number of cases since only those
records which definitely stated the presence or absence of the symptoms in question were
included.
Page 176 6.   Correct and Incorrect Admission Diagnoses:
Table VI.
Correct                          Incorrect
Not Noted
27                                    9
1
Gliomas
Of the 9 incorrect diagnoses:
1.     J. C, male, 60
.               Old right hemiplegia.
A. B., female, 51.
Spongioblastoma.
Menopausal depression.
Astroblastoma.
3.
5.
R. C, female, 72 Old cerebro-vascular accident.
Glioblastoma multiforme.
J. W., male, 62 Cerebral thrombosis.
Glioblastoma multiforme.
E. K., male, 54 Sinusitis.
Glioblastoma multiforme.
W. A., male, age ? Mental observation.
Glioblastoma multiforme.
E. S., female, 54	
.8     M. R., female, 16
9.
M. H., female, 5	
Haemorrhage, right internal capsule.
Oligodendroglioma.
Subacute appendicitis.
Astrocytoma of cerebellum.
Meningitis.
Medulloblastoma.
Meningiomas 5 11
1. L. E., female, 78 Cerebral haemorrhage.
2. K. T. L., male, 58 No diagnosis.
Others
Chromophobe adenoma of pituitary 3 correctly diagnosed.
N.  Vlll neurofibroma 1 cord tumour.
1 correctly diagnosed.
Pineal body tumours 1 cranial tumour, adequct of Sylvius.
1 correctly diagnosed.
Chordoma 1 cranial tumour, cerebellar.
Suprasellar cyst j 1 suprasellar tumour.
Septum pellucidum cyst 1 cranial tumour.
Lindau's disease 1 cranial tumour, cerebellar.
Cholesteatoma 1 cranial tumour, frontal.
Table VI shows the correct admission diagnoses. In the glioma and meningioma group
only the incorrect diagnoses are listed.
Some of the pertinent circumstances concerned in these mistaken diagnoses are listed:
1. J. C., male, 60—Old right hemiplegia. Admitted semi-conscious. No history. Died ten days after
admission.  Pathological diagnosis: Left temporal spongioblastoma multiforme.
2. A. B., female, 51—Depressive state, diagnosed as menopausal depression. Went progressively downhill to death about one month after admission.   Pathological diagnosis: Left frontal astroblastoma.
3. R. C, female, 72—History of ataxia of one year's duration. Right haemiparesis on examination.
Diagnosed as old cerebro-vascular accident, and transferred to convalescent home, where she died
three yeeks later.  Pathological diagnosis: Left temporo-parietal glioblastoma multiforme.
4. J. W., male, 62—Symptoms of dizziness and weakness of about one month's duration. Diagnosed
cerebral thrombosis.  Pathological diagnosis: Glioblastoma multiforme.
E. K., male, 54—Because of severe headaches of one month's duration was diagnosed as sinusitis on
admission, but diagnosis was changed to brain tumour. He was operated upon and died six weeks
post-operatively.   Pathological diagnosis: Temporo-parieto-occipital glioblastoma multiforme.
6. W. A., male, age ?—Symptoms of depression, with childish conversation and disorderly habits.
Admitted for mental observation, but diagnosis later changed to brain tumour. Operated upon, died
two days post-operatively.  Pathological diagnosis: Right temporo-parietal glioblastoma multiforme.
7. E. S., female, 54—Admitted in coma, died thirty minutes after admission. Diagnosis, haemorrhage
into right internal capsule. Pathological diagnosis: Right temporo-parietal oligodendroglioma, with
hernia cerebri.
8. M. R., female, 16—Symptoms of vomiting and headaches for two months, and abdominal pain for
ten days.' Slight tenderness to deep pressure in both lower quadrants. Diagnosed as subacute appendicitis.  Died one hour after appendectomy.   Pathological diagnosis: Astrocytoma of cerebellum.
Page 177
5. 9. M. H., female, 5—No history obtainable in this case. Brought in with moderate degree of opisthotonos, stiff neck, and positive Kernig's sign. Diagnosis, meningitis. Died one day after admission.
Pathological diagnosis: Medulloblastoma, left cerebellum, with marked internal hydrocephalus.
Note: None of the above cases were admitted under or seen by the Department of Neurology.
In the meningioma group:
1. L. E., female, 78—Admitted comatose. No history available. Complete left-sided haemoplegia.
Diagnosis, cerebral haemorrhage. Died shortly after admission. Pathological diagnosis: Dural meningioma, mid-line, frontal.
In the remaining tumours, adequate localization was accomplished in all cases but
one, viz.:
R. T., male, 48—History of difficulty in walking for five years, pain in neck for one year, radiating to
jaw for last four days. Tentative diagnosis, spinal cord tumour. Patient died suddenly on third day
of hospitalization.  Pathological diagnosis: N. VIII neurofibroma, with hernia cerebri.
7. Occurrence of Primary Optic Atrophy:
Primary optic atrophy: Table VII.
G. D., female, 33 I Dural meningioma, left
Left parasellar region.
H. F., male, 32 Suprasellar cyst.
J. M., female, 45 . Chromophobe adenoma of pituitary.
Table VII shows the incidence of primary optic atrophy in this series. Tumour arising
sufficiently near the optic foramen so as to cut off the sub-arachnoid space of the optic
nerve from the cerebral sub-arachnoid circulation will cause optic atrophy of the so-called
primary type, and not necessarily preceded by papillcedema.
The three cases in this series come within this category, two being parasellar, the third
being in the pituitary itself.
8. Occurrence of Herniation through the E or amen Magnum:
Table VIII.
M. H., female, 5 Medulloblastoma, left cerebellar lobe.
E. S., female, 54 j Oligodendroglioma, right temporo-parietal area.
S. B., male, 37 Glioblastoma multiforme, left fronto-parietal area.
M. W., female, 48 Astroblastoma, temporo-parieto-occipital lobes.
R. T., male, 48 N. VHI neurofibroma.
E. R., female, 23 N. VIII neurofibroma.
This almost invariably fatal process occurred six times in this series, and death was
averted in one case.
1. M. H, female, 5—Medulloblastoma, left cerebellar lobe. Moderate degree of opisthotonos, stiff
neck, and positive Kernig's sign. Diagnosis, meningitis. Died one day after admission. Autopsy
showed marked hydrocephalus, with cerebellum and medulla herniated into the foramen magnum.
2. E. S., female, 54—Oligodendroglioma, right temporo-parietal area. Severe occipital headaches every
three months for five years, with vomiting at night, followed by unconsciousness for a few hours.
Felt well up until three days prior to admission, and was able to do her housework the day before
admission, but developed a severe headache that night and had to be carried to bed. Did not awaken
the following morning, was brought to hospital, and died thirty minutes after admission. Autopsy
showed a duck-egg-sized tumour in right temporo-parietal area, and herniation of cerebellum
through the foramen magnum.
3. S. B., male, 37—Glioblastoma multiforme, left fronto-parietal area. Diagnosed as brain tumour.
Died one day post-operatively. Autopsy showed intracystic haemorrhage and herniation through the
foramen magnum.
4. M. W., female, 48—Astroblastoma, right temporo-parieto-occipital area. Diagnosed as brain tumour.
Lumbar puncture done on ward. Respiration ceased. Taken to operating room, burr hole made
over anterior pole of left lateral ventricle and bloody fluid withdrawn, but patient failed to revive.
Autopsy showed a large tumour, and haemorrhage into the ventricles, with a pressure cone at the
base of the brain. '
5. R. T, male, 48—N. VIII neurofibroma. Bizarre symptoms suggestive of cord tumour. Diagnostic
measures pursued, but patient died suddenly on third day of admission. Autopsy showed a cerebellopontine angle tumour with the brain stem herniated through the foramen magnum.
6. E. R., female, 23—N. VIII neurofibroma. Cerebellar decompression and removal of the tumour
done, but because of the downward herniation of the cerebellum, extension of the decompression
down to the fourth cervical vertebra was done on the twentieth day post-operatively. Recovery
uneventful.
Page 178 9. Size of Pupils in relation to Side of Lesion:
Table LX.
Noted in seven cases—
2 midline.
2 .dilated same side.
3 dilated pupil opposite side.
Relative differences in the size of the pupils was noted in seven cases. In two of these
cases the tumour was in the midline, while in two the dilated pupil was on the same side as
the lesion, and in three on the opposite side to the lesion. As a localizing sign, therefore, it
would appear to be of no value in itself.
10. Occurrence of Intracystic Haemorrhage:
Intracystic haemorrhage: Table X.
1. S. B., male, 37 Glioblastoma multiforme.
2. J. C, male, 60 Spongioblastoma.
3. A. B., female, 51 : Astroblastoma.
4. G. H., female, 16 . Astrocytoma.
5. M. W., female, 48 Astrdblastoma.
Table X shows the incidence of intracystic haemorrhage, in all cases producing a rapidly
fatal outcome. In two cases, Numbers 1 and 2, the haemorrhage produced herniation
cerebri, which was the immediate cause of death, while in the remaining three the death
might be said to be due to cerebral shock, without pressure cone formation.
11. Localizing Value of Diagnostic X-Ray:
Table XI.
Diagnostic X-Ray:       Flat plates _    18
Definite evidence of tumour location : 5
Gliomas 0
Meningiomas 2
Pituitary tumour 1
Suprasellar cyst 1
Cholesteatoma 1     1
Evidence of intracranial lesion 3
Gliomas ;     2
Pineoblastoma 1
Negative findings :     10
Gliomas i     8
Pinealoma : 1
Septum pellucidum cyst 1
Ventriculograms     16
Definite location of tumour       8
Gliomas 4
Meningiomas I     1
Pinealomas ; 2
Chordomas 1
Evidence of intracranial  lesion       5
Gliomas .—    5
Unsuccessful (but location diagnosed clinically) 2
Thorotrast
1. Intra-arterial—showed location—glioma.
2. Intraventricular—showed hydrocephalus—glioma.
Table XI summarizes the diagnostic X-ray that was done in this series. It is notable
that flat plates of the skull were of little diagnostic value as far as the gliomas were concerned. Of ten cases, local evidence of tumour was revealed in none, and only two showed
evidence of intracranial lesion.
Ventriculography Was done in sixteen case, intraventricular thorotrast being used in
one case, and cranial arteriography with thorothrast was one in one case.
Of the fifteen cases in which routine air ventriculography was done, evidence of
tumour location was afforded in eight cases, of which four were gliomas, while thorotrast
in one case revealed hydrocephalus.
Evidence of intracranial lesion was afforded in five additional cases, while only two
were entirely negative.
The intra-arterial injection of thorotrast in one case revealed the location of a glioma.
Page 179 THE PREVALENCE OF VENEREAL DISEASE INFECTIONS
IN VANCOUVER
By
Edgar N. Brown, B.A. B.Com.,
Executive Secretary, Greater Vancuover Health League
and
Donald H. Williams, M.D.,
Director, Division of Venereal Disease Control, Provincial Board of Health.
The Greater Vancouver Health League, working in co-operation with the Division of
Venereal Disease Control, has made considerable progress in an educational way in the
control of venereal disease in Vancouver, but it had been handicapped in previous years
by the absence of any reliable statistics as to the prevalence of syphilis and gonorrhoea in
the community.
Various estimates had been offered, ranging from the statement that one in seven of the
population were infected to other statements that the diseases were of negligible importance, and the result had been a confusion in the public mind which made educational
work difficult.
It was felt, therefore, that a survey of prevalence was justified and would serve a useful
purpose. The Board of Directors of the Health League authorized the study in December,
and the following committee was appointed to conduct it:
Dr. A. M. Menzies, unit director of the Metropolitan Health Board, chairman; Dr. A.
M. Agnew, president of the Vancouver Medical Association; Dr. M. W. Thomas, executive
secretary of the British Columbia Medical Association; Dr. W. W. Simpson, and the
authors.
The procedure followed was similar to that of comparable surveys conducted by the
Health League of Canada in Toronto in 1929 and 19371. The object was to learn the
number of cases of venereal disease which were under treatment on any one day, in this
case, on December 31, 1939. Since the enquiry was limited to practising physicians, hospitals and clinics, the results show only such cases as were under medical supervision and,
therefore, fall short of indicating the total of all cases of venereal disease on the given date.
A confidential printed form and a covering letter were sent to each of 3 3 8 practising
physicians in Vancouver City. The outlying suburbs usually included in Greater Vancouver were omitted. Within three weeks, 193 doctors had responded and a second letter
and form were sent to the others. Later it was necessary to send a third letter and, in the
case of a few men, to follow this with telephone calls.
The co-operation of the medical profession was generous and excellent. Of 338 names
on the list, only 13 were not accounted for, so that 96 per cent of returns were made.
Additional returns were obtained from the Vancouver Clinic of the Division of Venereal
Disease Control, the Division of Tuberculosis Control, the Provincial Mental Hospital,
the Marpole Infirmary, and similar institutions.
Under these circumstances, a total of 2054 cases of venereal disease in Vancouver were
reported. This represents an incidence of 7.75 per thousand of the population. The total
was divided into 1549 cases of syphilis (5.84 per thousand) and 483 cases of gonorrhoea
(1.83 per thousand), plus 21 additional cases which were not classified.
Private physicians (96 per cent of the profession) reported a total of 782 cases of
venereal disease, of which 528 were syphilis and 254 were gonorrhoea, as shown in Table I.
1.   Canadian Public Health Journal, March, 1930, and December, 1937.
Page 180 Total
Syphilis
528
Table I.
Cases of Venereal Disease Reported by Private Physicians.
SYPHILIS
Early Syphilis Late Syphilis
Male Female Male Female
Under      Over        Under      Over Under      Over        Under      Over
14 14 14 14 14 14 14 14
5 43 7 23 10 265 6 159
Not
Classified
10
JONORRHCEA
Total
Gonorrhoea
254
Early Gonorrhoea
Male Female
Under      Over        Under      Over
14 14 14 14
3 114 2 32
Not
Classified
21
Late Gonorrhoea
Male Female
Under      Over        Under      Over Not
14 14 14 14 Classified
2 67 3 20 11
A certain number of physicians noted that they did not treat venereal disease, and,
in addition, the list included technicians, internes and retired doctors, but of the total,
45 per cent reported one or more cases. The largest number of cases reported by an individual was 46.
As compared with institutions, private physicians were treating fewer cases of syphilis
but slightly more cases of gonorrhoea, as shown in Table II.
Table II.
Syphilis and Gonorrhoea Treated by Physicians and Institutions.
SYPHILIS GONORRHOEA
Number Per Number Per
Treated Cent Treated Cent
Private Physicians 528 34.08 254 52.48
Clinics and Institutions ! 1021 65.92 230 47.52
The majority of the cases classified under clinics and institutions were patients of the
Vancouver Clinic of the Division of Venereal Disease Control. The returns from this
treatment centre are shown in Table III.
Table III.
Syphilis and Gonorrhoea Treated by the Vancouver Clinic of the
Division of Venereal Disease Control.
SYPHILIS.
— Female
Over 16 Under 16
692 22
GONORRHOEA.
— Male — — Female
Under 16 Over 16 Under 16
1 160 9
To what extent this statistical study represents a true picture of the situation must
remain a matter of conjecture. The number of reported gonorrhoea cases seems surprisingly
low, as compared with generally accepted estimates elsewhere, even when the shorter
treatment period and the excellent results obtained by the use of sulfanilamide are taken
into account.
The proportion of venereal disease in Vancouver which is treated by private or public
medical agencies cannot be estimated. In other words, the committee had no way of determining whether the 2054 cases reported in the survey include the vast majority of
venereal infections or merely a small fraction of them. Self-treatment and treatment by
druggists and quacks undoubtedly are carried on, and certainly a considerable number of
cases, particularly of latent syphilitics, are not diagnosed or treated by anyone. It may be
possible at a later date to make a study of such extra-medical treatment, as was done in
1939 in the United States by the American Social Hygiene Association and the U. S.
Public Health Service.
However, insofar as medical treatment is concerned, the findings of the Vancouver
Laboratory of the Provincial Board of Health have provided an interesting comparison.
Dr. C. E. Dolman, director of the Division of Laboratories, reviewed the results of the
survey and made the following comment in a letter to one of the authors:
"Although the figures you have obtained in your survey are undoubtedly on the low
side, since all sources of error tend in that direction, your findings are not very discordant
Page 181
— Male
Under 16
25
Total
Over 16
Syphilis
219
958
Total
Over 16
Gonorrhoea
60
230 from those which we have been able to deduce to some extent from our laboratory work.
Thus in 1939 the total number of positive Kahn blood specimens obtained from physicians
and hospitals within the city of Vancouver, and from the Vancouver Clinic, was 3881.
The total number of positive smears for gonococcus obtained from the same sources during
1939 was 1968. Of course our own figures under both headings are subject to correction
in the opposite direction from your own, since these figures would include a goodly proportion of repeat tests. However, if all positive specimens related to separate individuals,
we should still have an incidence of the combined diseases of slightly under 2 per cent,
which is far different from the figure of 10 per cent of the population suffering from
syphilis which has been bandied about in recent years.
"I might add, for your interest and that of members of the League, that the incidence
of congenital syphilis in Vancouver, as shown by over 11,000 tests routinely done on
infants born in Vancouver hospitals over the past seven years, is at the maximum possible
rate of 0.9 per cent."
It is the hope of the Greater Vancouver Health League to conduct similar surveys at
future dates, possibly annually, in order to arrive at some conclusion as to the trend of
syphilis and gonorrhoea infections in Vancouver. Such conclusions would be an interesting
corollary to the vigorous preventive and treatment programme of the Provincial Board of
Health.
Summary.
A survey by the Greater Vancouver Health League to determine the prevalence of
syphilis and gonorrhoea in Vancouver as at December 31, 1939, resulted in a tabulation of
2054 cases under medical treatment on that date, an incidence of 7.75 per thousand of
the population. There were 1549 cases of syphilis (5.84 per thousand) and 483 cases of
gonorrhoea (1.83 per thousand) reported, plus 21 cases which were not classified. The
medical profession co-operated generously and 96 per cent of practising physicians responded, of which 45 per cent reported one or more cases.
The incidence rate represents only known cases under medical treatment and it is
incomplete to an unknown degree because the tabulation did not include those cases treated
by quacks, druggists, or under self-treatment, or the cases which have not been diagnosed.
However, insofar as medical treatment is concerned, the results obtained in the survey
were confirmed in a general way by the findings of the Division of Laboratories, Provincial
Board of Health.
THE INTRAVENOUS FEEDING OF AMINO ACIDS
By Iris Corbould, R. H. Clark and R. E. McKechnie, II, M.D.
Reprinted from the American Journal of Digestive Diseases, Vol. VI, No. 3, May, 1939.
In medical practice the feeding of human beings by other than oral means has long been
recognized as a necessity under certain conditions. Up to the present certain salts and
glucose have been the only materials injected. Patients decline fairly rapidly in the absence
of tissue-building proteins.
Aberhalden1 has established that proteins in the process of digestion are completely
hydrolyzed. Moreover, Van Slyke1 has shown, by examining the blood before and during
digestion, that it is in the form of amino acids that protein synthesis begins, since polypeptides when introduced into the blood stream are excreted unchanged.
It is not known in what proportion the various amino acids are absorbed by the tissues
from the blood. Moreover, the present price of individual amino acids would prohibit their
general use for such a purpose. In the experiments described below an inexpensive pure
protein was hydrolyzed and the resulting mixture of amino acids utilized.
Considerable work has been done on feeding animals orally with mixtures of amino
acids, but very little on their intravenous injection. Buglia2 found by injecting hydrolyzed
Page 182 proteins that a considerable proportion of the amino acids was taken up by body and suggested that the animal could probably be fed that way.
Ackroyd and Hopkins3 have shown that if hydrolyzed casein is administered orally as
the sole source of protein, the animal loses weight and ultimately dies. But that if tryptophane, which is destroyed by acidhydrolysis, is added in small amounts to the hydrolyzate,
normal growth is maintained. This seems to be due to the inability of the animal to synthesize the indol ring.
Casein was selected as the source of amino acids and hydrolyzed by means of sulphuric
acid. Enzyme hydrolysis was not considered, since ti would be difficult to separate enzymes
completely before injection, while hydrolysis by bases racemerizes the amino acids. Of the
ten indispensable animo acids it has been shown that tryptophane, histidine, phenylalanine
and methionine can be replaced for growth purposes by their antipodes. On the other
hand, only the natural forms of valine, isoleucine, lysine and threonine are available for the
use of the growing organism4.  Arginine has not yet been investigated.
Experimental.
One litre of 15 % sulphuric acid was used for each 100 grams of casein, and the mixture
was digested on a sand bath under a reflux condenser for several hours after a portion
withdrawn first gave a negative biuret test. The extra digestion was to ensure complete
hydrolysis to amino acids. The mixture was then boiled with animal charcoal until colourless and filtered. Sufficient solid barium hydroxide to almost neutralize the sulphuric acid
was added and the solution again filtered. The mixture was then diluted to two litres for
each original 100 grams of casein, since it was found that in a more concentrated solution
the more insoluble amino acids such as tyrosine and leucine tended to precipitate out on
standing. The mixture was adjusted to a pH of about 7.4 by means of sodium hydroxide
solution. Then sufficient Ringer's salt to make the solution isotonic and about 10% glucose
were added, and the pH was readjusted when necessary.
The solution was next filtered through a Seitz filter to sterilize it, although it was
found to be just as efficient to autoclave the solution before adding the glucose, and then to
add the glucose which had been sterilized in the dry form.
Rabbits were selected as experimental animals; each was fed approximately 80 cc. of the
mixture as calculated on their energy and protein requirements, depending on their weights.
At first the injections were made through a vein in the ear, but this method was found to
consume too much time, so intra-peritoneal injections were carried out twice a day. The
animals absorbed the food slowly from the peritoneal caving. A few rabbits were run as
controls, being fed the same amount of glucose solution without the amino acids. Fresh
drinking water was always available. After each experiment the animals were sacrificed
and the kidneys and liver as well as other internal organs were examined for signs of strain,
but they appeared quite normal in each case.
The rabbits lost weight slowly after the first few days, although those that were fed
amino acids as well as glucose lost more slowly than those which had only the glucose. It
was then decided to add about 0.5 grams of tryptophane per litre of solution to the same
mixture. Rabbits fed this diet were found to keep up weight fairly evenly for about a week,
then to decline at a fairly steady rate. This loss may have been due to several causes: inadequacy of the protein mixture, to improper balance among the various amino acids, or to
absence of other factors, such as Vitamin A. To test the latter supposition a Vitamin A
concentrate, "Avalon," was obtained, and one drop was injected intravenously each day in
addition to the regular intraperitoneal injections of the usual mixture plus tryptophane.
This was found to lengthen the time before the animals lost weight. Probably other growth
factors might be added advantageously.
In conclusion, rabbits fed intravenously or by intraperitoneal injections on a mixture
of amino acids from hydrolyzed casein, supplemented with tryptophane and Vitamin A,
lose practically no weight over a period of two weeks, and remain in normal physical
condition. REFERENCES:
1. Cohen, Julius B.—Organic Chemistry, Vol. Ill, p. 195, 1923.
2. Buglia, Gr. Zeit. Biol., 58, 162, 1912.
3. Ackroyd and Hopkins: Biochem. J., 10, 55, 1916.
4. Rose, W. C.:Physiol. Review, 18, 133, 1938.
Page 183 c
Tzmvutf- T 360
BIOLOGICALLY   STANDARDIZED
POTENT AND STABLE
• Four years of patient chemical, biologic and clinical investigations have
demonstrated the value of a stable preparation of histaminase—provisionally
designated "T 360"—in the treatment of allergic conditions produced by an
excess of histamine. This biologically standardized preparation is now presented under the name of Torantil. It exerts a specific detoxicating action upon
histamine within the human body. For this reason Torantil constitutes a promising contribution to everyday medical practice.
FOR DISEASES OF ALLERGY
A favorable, sometimes dramatic, response has been observed in many cases
of asthma, vasomotor rhinitis, urticaria, allergic dermatitis, and hypersensitivity to insulin, drugs, serum and physical agents (e.g., cold, heat, light and
scratch). Striking results have also been reported in cases of acne. However,
Torantil is not a panacea. Some disappointments may be experienced, particularly if the dosage is not individualized.
Booklet discussing in detail the clinical application
of Torantil will be sent to physicians on request.
HOW SUPPLIED: Torantil is supplied in tablets of 5 units, bottles of 50 tablets. One unit
is the amount which will inactivate 1 mg. of histamine hydrochloride during incubation at
37.5° C for twenty-four hours.
WINTHROP
WINTHROP
Trademark Reg;. U. 3. Fat. Off. & Canada
WINTHROP CHEMICAL COMPANY, INC. new york.n.y.. Windsor.ont.
Pharmaceuticals of merit for the physician . Factories: Rensselaer, N. Y. —Windsor, Ont.
692M flDount pleasant Tftnbertakino Co. %tb.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. F. HARRISON W. R. REYNOLDS,
mm
■MMC^^Wfifi
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
FAIR.  0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CREL.L.IN
W. L. BERTRAND EVAPORATED MILK
in theiPrevention of Rickets
BBSS)
Carnation's own bio-assays
to check tbe vitamin D
potency of Irradiated
Carnation Milk are double-
checked by the Wisconsin
Alumni Research Foundation.
"None of the 51 normal fall term infants in the 'prophylactic' group [receiving irradiated evaporated milk] developed rickets, whereas 17 of the 33
normal full term infants in the 'control' group did develop rickets. No cases
of rickets developed among the 20 weakling infants in the 'prophylactic'
group, but there were 13 cases of rickets developed among the 20 weakling
infants in the 'control' group'.'—MAY, E. W., and WYGANT, T. M., Arch.
Ped. 56:356-374 (June) 1939.
Irradiated Carnation Milk has
never been offered as other than
a prophylactic food, for the prevention of rickets, rather than its
cure. The important study quoted
here presents significant evidence
that its value in this respect has
not been over-stressed.
A BOOKLET FOR PHYSICIANS
— Write for "Simplified Infant
Feeding", an authoritative publication treating of the use of Irradiated
Carnation Milk in normal and difficult feeding cases . . . Carnation
Company, Ltd., Toronto, Ontario.
IRRADUTtO
X""N|    IRRADIATED
C     IRRADIATED    "Ik     JT
arnation Milk
A CANADIAN PRODUCT - "from contented cows" ANAMUEMIN B.D
In Nutritional Macrocytic Anaemias
Nutritional macrocytic anaemias are stated to be due primarily to a deficiency of Castle's
extrinsic factor. It is logical, therefore, to assume that they will respond to the exhibition
of Anahaemin—the product of interaction of intrinsic and extrinsic factors.
Convincing evidence of the value of Anahaemin in nutritional anaemias is provided in a
report (Response of Nutritional Macrocytic Anaemia to Anahaemin, Lancet, August 12th,
1939, p. 360), in which it is shown that Anahaemin is at least as active in its curative
effect as less highly-purified preparations of liver.
In other words, Anahaemin is of high and unvarying activity not only in pernicious anaemia
which is due to lack of intrinsic factor, but to nutritional anaemias which are due to lack of
extrinsic factor. This latter fact accounts for the restorative effect produced upon patients
after operation or who for one reason or another are maintained on a restricted dietary.
Stocks of Anahaemin B.D.H. are held by leading druggists throughout the Dominion,
and full particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse Toronto 2, Ont.
 ———— —— ^    An/Can/403
For Complete . . .
PRINTING
OF
Every
Description
A phone call -will bring
immediate attention.
Sey. 6606
Roy   Wrigley  Printing
and Publishing Co. Ltd.
300 West Pender St.
Vancouver, B. C.
ARTHRITIS and ECZEMA
of endogenous origin
claimed to be allergic, may be
favored or induced by calcium and
sulphur deficiency, impaired cell
action, and imperfect elimination
of toxic waste.
*-
lYXAHTHIK ASTIER
administered per os, brings about
improved cell nutrition and activity, increased elimination, resulting symptom relief, and general functional improvement.
iterature
Canadian Distributors
ROUGIER FRERES
3S0  Le Moyne   Street,  Montreal W^M$WMMW0Mj^S^2iiiBitM^iM^ffl0&
f   Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls the utero-ovarian
jk    circulation and thereby encourages a
Ik    normal menstrual cycle.
K,. 0 MARTIN H. SMITH COMPANY      A
^Sk ISO lAfAYITTI SHUT    NEW  YO«K.  N. T. ,
Full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in  half at seam.
A new "Ciba" product, which exhibits, according to the dose, a sedative-
antispasmodic effect of a central and peripheral nature,
or acts as a mild soporific—
NEURO-TRASENTIN
(Trasentin-\- pbenylethylbarbtturic acid)
FOR THE TREATMENT OF NEURO-VEGETATIVE DISTURBANCES
Neuro-Trasentin should undoubtedly be of
great value in the following conditions:—
Excitability, states of agitation, cardiac neurosis, angina pectoris,
vascular spasms, hypertonia, nervous dyspepsia, ulcer pains,
climacteric disturbances, dysmenorrhoea, pruritus, hyperthyreosis,
etc.
Issued:
Tablets, in bottles of 30 and 100; also 500 for hospital use.
CIBA    COMPANY    LIMITED
MONTREAL Comparison  of the   Ideal
Antacid with AMPHOJEL
THE I DEAL ANTACID
AMPHOJEL
Insoluble (in water)
Insoluble (in water)
Non-irritating to the  stomach  and
intestines
Non-irritating to the stomach and
intestines
Neutral in aqueous suspension
Capable of neutralizing acid
Does   not   unduly   alter   acid-base
equilibrium
Will not alkalize the urine with
attendant danger of precipitating
crystalline phosphates in kidney or
ureter.
Neutral in aqueous suspension
Capable of neutralizing acid
Does not unduly alter acid-base
equilibrium
Will not alkalize the urine with
attendant danger of precipitating
crystalline phosphates in kidney or
ureter.
Not laxative
Not laxative
Not constipating
Does   not   seriously   alter   mineral
metabolism.
Slightly constipating1
Does   not   seriously   alter   mineral
metabolism.
*H. Beckman: Treatment in General
Practice. 3rd Edition:  1938, p. 395.
1ANNOUNCING Amphojel with
Mineral Oil—For those isolated
cases where constipation is associated with the reduction of gastric
acidity by Amphojel (Wyeth's
Aluminum  Hydroxide Gel).
Amphojel Plain and Amphojel with Mineral Oil are supplied
in 12-ounce bottles.
JOHN WYETH & BROTHER (CANADA) LIMITED
WALKERVILLE, ONTARIO VITAMIN Bi
FOR ORAL AND PARENTERAL ADMINISTRATION
X
l|«     Cp***
I ViTAMfS* *.
i¥*
At*
»*>»*
\
f
1
50mg.
Further details
available
on request.
VL view of the greatly
varying dosages required in Vitamin 1^ therapy, the convenience of a wide range of potencies will be immediately
apparent to physicians.
Vitamin B-, (thiamin chloride) is particularly indicated in
the treatment of subclinical beriberi, anorexia, gastrointestinal disturbances and polyneuritis associated with
chronic alcoholism, pregnancy and lactation. In addition,
clinical studies suggest that Vitamin Bx is of value in
treating inflammatory or degenerative diseases of the
nervous system, e.g. subacute combined degeneration
of the cord and anterior poliomyelitis, and also for the
specific relief of tabetic lightning pains.
Ayerst Vitamin Bx/ in solution for parenteral administration, is obtainable in five different potencies and, in tablet
form for oral use, in two potencies.
AYERST, McKENNA & HARRISON LIMITED
Biological and Pharmaceutical Chemists
MONTREAL CANADA
894 Seratns, Vaccines, Hormones
'?
AND
Related Biological Products
Anti-Anthrax Serum
Anti-Meningococcus Serum
Anti-Pneumococcus Serums
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid
Old Tuberculin
Perfringens Antitoxin
Pertussis Vaccine
Pneumococcus Typing-Sera
Rabies Vaccine
Scarlet Fever Antitoxin
Scarlet Fever Toxin
Staphylococcus Antitoxin
Staphylococcus Toxoid
Tetanus Antitoxin
Tetanus Toxoid
Typhoid Vaccines
Vaccine Virus (Smallpox Vaccine)
Adrenal Cortical Extract
Epinephrine Hydrochloride Solution (1:1000)
Epinephrine Hydrochloride Inhalant   (1:100)
Epinephrine in Oil (1:500)
Heparin
Solution of Heparin
Insulin
Protamine Zinc Insulin
Liver Extract (Oral)
Liver Extract (Intramuscular)
Pituitary Extract (posterior lobe)
Prices and information relating to these preparations will be
supplied gladly upon request.
CONN AUGHT LABORATORIES
UNIVERSITY   OF   TORONTO
Toronto 5
Canada
"Depot for British Columbia
MACDONALD'S  PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C Nuttn $c
Samson
t
2559 Cambie Street
Vancouver, B. C.
Colonic
Irrigation
Institute
Superintendent:
E. M. LSOVABD, R.E.
Poet Graduate Mayo Bros.
Up-to-date treatment rooms;
scientific care for cases such as
Colitis, Constipation, Worms,
Gastro-Xntestinal Disturbances,
Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.
Individual Treatment $ 3.50
Entire Course $10.00
Medication (if necessary)
$1 to $3 Extra
1119 Vancouver Block
VANCOUVER, B. C.
Phone: MArine 3723
The Purified
ACTIVE PRINCIPLE
OF
SANDALWOOD OIL
•
4, *„«* ECONOMICAL
Dosage Form
Doctor, why use ordinary sandalwood
oil when you can just as easily administer the active principle of the oii
with the irritating and therapeutically
inert matter removed—and at a cost
to your patients of only a very few
pennies more?
You can do this by -prescribing the
new, economical 50-centigram capsules of
ARHEOL
(ASTIER)
now obtainable in bottles of 12, 24 and
100 capsules at $1.00, $1.75 and $6.00
a bottle respectively.
ARHEOL is the purified active principle of sandalwood oil. It is a uniform, standardized product with which
prompt and dependable results may
be expected. Undesirable sequelae
often associated with sandalwood therapy are either absent or reduced to a
negligible degree.
A3-BVMA
ROUGIER. FRERES, Agents
350 Le Moyne Street, Montreal.
Please send me a sample of
ARHEOL. (Astier) in the new
economical dosage form.
.M.D.
•Street	
City  Prov.
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,  Montreal j]psi Mte Nuindiotial Anemiai
WYETH'S
ELIXIR OF BEEF LIVER
(Unfractionated)
A
PALATABLE wine
containing the total soluble constituents of 2 ounces of unfractionated Fresh Beef Liver in
each fluid-ounce.
Useful   in   the   treatment   of   nutritional
Anemias,   Bepron   supplies   the   nutritive
fractions   which   are   deficient   in   these
conditions.
DOSE:—One to two tablespoonfuls twice
daily.
Supplied in 16 fl. oz. bottles.
K     WYETH'S
PURIFIED SOLUTION
OF LIVER
/^v
r     lllB ^Sr   \^^^V
■^        I-^
wuniJ
i'UTWff''^
UJt
Is?,
\M^ \.yrp^j^^^
X%ur     ^^
\>7
F.
OR parenteral use 5
or 10 units per cc. Packages of
10 cc. ampoules supplied 50 or
100 units per ampoule.
Dose: 0.1 cc. or 0.2 cc. injected
intramuscularly daily, or multiple amounts at longer intervals.
John Wyeth & BrotBg^Canada) Ltd.
WALKERVlLlSr'bNT. RESTFUL SLEEP...
REFRESHED AWAKENING
Soneryl is a specially valuable
hypnotic by reason of the fact
that in varying dosage it can produce a result ranging from mildly
sedative to powerfully hypnotic.
Whether the stimulus preventing
sleep be some painful condition
or an over-active or over-anxious
mind, Soneryl proves quickly
effective.
i**?**"
im*??,
Each tablet contains 1 Vi grs. of
Soneryl (butyl-ethyl-malonyl-
urea).
Adult dose—1 to 3 tablets half
an hour before retiring.
#h5f j
!aH?"«B0,
•«,
S'TO/Xi*
'+sa
^^
f*f£S
h
*0*r,
ftf
{*#
'&*IA
Rectal administration of Soneryl
is to be preferred in young children, in cases where there is
nausea and vomiting, and postoperatively to tide the patient
over the first few hours after the
effects of a general anaesthesia
has passed off.
Each suppository contains three
grains Soneryl (butyl-ethyl-mal-
onylurea) and three grains camphor in a cocoa-butter base.
Adult dose—One suppository.
Children 7 to 12 years old—half
a suppository.
CANADA       UIIITiD-MO/VrPF4i n
*»
0
£
Please send me complete information
about the G-E Model R-39 100-Mil-
liampere Combination X-Ray Unit.
A203
Name ,	
Address-
City-
ViCTOR X-RAY CORPORATION of CANADA, Ltd.
WSTI-IWIOIS rO* GENtlM «3> BKTIIC JH* COWC*«.«JN
TOtCNTO: 30Moor Si, W. • VANCOUVER,Mcic*Tram. BWe-370Dveiewr St
MONTOAl   «C0 Meditcl Am fcriWag   -   VfiKNtFEG: MctSccl Am Cwt&ig
v —and it will be justifiable because
an R-39 unit will equip you for a more complete diagnostic service which patients appreciate, and the quality of results it will enable
you to produce will reflect credit to yourself.
Acclaimed everywhere by value-wise medical
men as the most practical moderately-priced
single-tube unit ever designed for radiography
and fluoroscopy, the R-39 provides power,
accuracy, simplicity, and space-saving economy.
Its wide range of service includes fluoroscopy
at any angle; vertical, horizontal, and accurate
angular radiography. Its control is precise
and easy-to-operate.
But the radiographically-calibrated, unusually
efficient R-39 unit is more than just a collection
of features! It is a correctly-designed, sturdily-
built 100 ma. unit that represents a value far
beyond its moderate price.
Priced right? You bet it is! And you owe it
to yourself to find out how much more value
you will get for your x-ray dollars when you
invest in the modern R-39. For complete
details, use the convenient coupon. The Doctors Busy Season
-and Georgia Pharmacy is ready
for instant service, with full stock,
six qualified pharmacists, and a
prompt delivery system.
DAY or NIGHT MArine 4161
FREE CITY DELIVERY UNTIL 10 P.M.
<j£p*UJL ^.Jb/e*vrtB/ttar\
GEORGIA PHARMACY
U-IM   I  T  E   D
tmmmr
&mtn $c if anna Sift.
ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C. Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference*—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver.
SEymour 4183
Westminster 288
ROY WRiaUtV PRINTING'
>• PUBLISHING  CO.  LTD.

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