History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: April, 1944 Vancouver Medical Association Apr 30, 1944

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 JA&s
The BULLEIIN
of the
I    |VANCOUVER
MEDICAL ASSOCIATION
- Vol. XX.
APRIL, 1944
No. 7
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
St Paul's Hospital
In This Issue:
Pag«
SUMMER SCHOOL CLINICS—- —,    ;';M   „ ___—- 174
REMEDIABLE INTRATHORACIC CONDITIONS IN CHILDHOOD—
' By J. R. Davies, M.D.- ^^^^^^f^Sy^^-.   &^S-^~- -— 176
PRELIMINARY REPORT ON THE USE OF THIOURACIL IN TREATMENT OF HYPERTHYROIDISM—By Dr. G. F. Strong and
Dr. W. N. Bell  .pJHgg;   ••^^^^^^:::       ||- | 185
SULFONAMIDES IN SKIN DISEASE—D. E. H. Cleveland, M.D. J||fe     188
PENICILLIN IN WAR WOUNDS-:f§l|:    I^^^^^B^^^;V  -:%192
NEWS AND NOTESJfc I M-    - -IIS         : 3fel*4
(r
SUMMER SCHOOL
The Annual Summer School of the Vancouver Medical
Association will be held at the
HOTEL VANCOUVER, JUNE 20th to 23rd, Inclusive ANAHAEMIN B.D.H.
Anahaemin B.D.H. is the hasmopoietic principle ofJfj^er;jtr is
active in minimum doses witfcmaximum intervals between
injections. . Indeed/ the administration of Anahaemj^ B.D.H. is.
the most economicat§§riethod of producing blood regeneration
arid maintenance in pernicious anaemia.
Anahaemf|| B.D.H^ossesses the additional advantage of being
free from therapeutically inert reaction-producing protein substances.
The use of Anahaemin B.D.H. alone is sufficient to produce
complete recovery in all cases of pernicious anaemia and to correct all the remediable neurological signs and symptoms of subacute   combined   degeneration.    No   additional ^reatment-^re
required.
, Stocks of Anahaemin B.D.H. are held by leading druggists
throughout the Dominion, and full particulars are obtainable
from
THE      BRITISH
Toronto
DRUG      HOUSES
(CANADA)      LTD.
Canada
An/Can/444
BrVvg*«*s -Jij-* -- wiwmwj f>:
THE   VANCOUVER   MEDICAL   A SSOCI ATlb^frj
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Asociation
in this 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. B. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XX
APRIL, 1944
No. 7
OFFICERS, 1943-1944
Db. A. E. Tbites Db. H. H. Pitts Db. J. R. Neilson
President Vice-President Past President
Db. Gobdon Bubke Db. J. A. McLean
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Db. J. R. Davies, Db. Fbank Tubnbull
TRUSTEES
Db. F. Bbodie Db. J. A. Gillespie Db. W. T. Lockhabt
Auditors: Messrs. Plommeb, Whiting & Co.
SECTIONS
Clinical Section
Db. J. W. Milleb Chairman Db. Keith Bubwell Secretary
Eye, Ear, Nose and Throat
Db. C. E. Davies Chairman Db. Leith Webster.-. Secretary
Pwdiatric Section
Db. J. H. B. Grant Chairman Db. John Piters—. . Secretary
STANDING COMMITTEES
Library:
Db. A. Bagnall, Chairman; Db. F. J. Bulleb, Db. D. E. H. Cleveland,
Db. J. R. Davies, Dr. J. R. Neilson, Db. S. E. C. Tubvey
Publications:
Dr. J. H. MacDermot, Chairman; Db. D. E. H. Cleveland,
Db. G. A. Davidson
Summer School:
Db. J. C. Thomas, Chairman; Db. J. E. Habbison, Db. G. A. Davidson,
Dr. R. A. Gilchrist, Dr. Howard Spohn, Dr. W. L. Graham
Credentials:
Db. D. E. H. Cleveland, Chairman; Db. E. A. Campbell, Db. D. D. Fbeeze
V. O. N. Advisory Board:
Dr. L. W. MacNutt, Dr. G. E. Seldon, Dr. Isabel Day
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont
Representative to B. C. Medical Association: Dr. J. R. Neilson
Sickness and Benevolent Fund: The Pbesident—The Trustees
1 TOCOPHEREX       VIOPHATE-D
Suggested for Treatment
of Threatened or Habitual Abortion
Due to Vitamin E Deficiency
# Each capsule contains 50
milligrams of mixed tocopherols,
equivalent in vitamin E activity to
30 milligrams of a-tocopherol.
Tocopherex contains vitamin £
derived from vegetable oils by molecular distillation, in a form more
concentrated, more stable and more
economical than wheat germ oil.
For experimental use in prevention
of habitual abortion (when due to
Vitamin E Deficiency): 1 to 3 capsules daily for 8^£ months. In
threatened abortion: 5 capsules
within 24 hours, possibly continued
for 1 or 2 weeks and 1 to 3 capsules
daily thereafter. .
Tocopherex capsules are supplied in
bottles of 25 and 100.
For Increased
Calcium Requirements
# Each capsule of Viophate—D
contains 4.5 grains Dicalcium Phosphate, 3 grains Calcium Gluconate
and 330 units of Vitamin D. The
capsules are tasteless, and contain
no sugar or flavouring. Where
wafers are preferred, Viophate—D
Tablets are available, pleasantly
flavoured with wintergreen.
One tablet is equivalent to two
capsules.
How supplied:
Capsules—Bottles of 100 and
1,000.
Tablets —Boxes of 51 and 250.
MANUFACTURING ibllM-ISTS *tC$.ftif   MEDICAM PROFESSION *£fNC£*;|858 VANCOUVER HEALTH DEPARTMENT
STATISTICS—FEBRUARY,  1944
Total Population—-Estimated _
Japanese Population	
Chinese   Population—Estimated
Hindu Population	
288,541
Evacuated
5,541
301
Kate per 1,000
Number Population
Total deaths __, 319 13.4
Japanese deaths  :     Population Evacuated
Chinese deaths 22 48.5
Deaths—residents only ! 282 11.9
     638
26.9
BIRTH REGISTRATIONS:
Male,  339;  Female, 299	
INFANT MORTALITY: February, 1944    February, 1943
Deaths under one year of age :  21 22
Death rate—per 1,000 births  32.9 36.2
Stillbirths   (not included above)  11 8
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
January, 1944 February, 1944      March 1-15, 1944
Cases'    Deaths      Cases Deaths      Cases Deaths
Scarlet Fever        81            0              97 0 84 0
Diphtheria    ;         0            0                0 0 0 0
Diphtheria Carrier         0            0                0 0 0 0
Chicken Pox      174            0            209 0 99 0
Measles   !       10            0              28 0 17 0
Rubella          5            0              20 0 13 0
Mumps    I       66             0               3 5 0 21 0
Whooping Cough  . 31             0               32 0 23 0
         0             0                 0 0 0 0
 0             0                 0 0 0 0
 0             0                 0 0 0 0
 44           18               84 16 42
         2             0                 2 0 0 0
 2             0                 4 0 0 0
 '         0             0                 0 0 0 0
         3             0                 0 0 0 0
Typhoid Fever _
Undulant Fever
Poliomyelitis 	
Tuberculosis 	
Erysipelas
Meningococcus  Meningitis
Paratyphoid  Fever  	
Infectious Jaundice 	
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
West North       Vane
Burnaby    Vane.  Richmond   Vane.      Clinic
Hospitals &
Private Drs.
Totals
Syphilis 	
Gonorrhoea
Figures not yet available for January and February, 1944.
BIOGLAN
The most effective therapy for waning mental and physical energy,
deficient concentration and memory, reduced resistance to infection,
muscular "weakness and debility, neurasthenia and premature senility.
The efficacy of this very potent endocrine tonic has been confirmed by
the clinical evidence of many thousands of cases treated during
1532-1943.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page One Hundred and Seventy THE use of cow's milk, water and carbohydrate mixtures represents the
one system of infant feeding that consistently, for three decades, has
received universal pediatric recognition. No carbohydrate employed in this
system of infant feeding  enjoys so rich and enduring a background of
authoritative clinical experience as Dextri-Maltose* VANCOUVER     MEDICAL     ASSOCIATION
FOUNDED 1898    ::    INCORPORATED 1906
»        *        *        »
PROGRAMME OF THE FORTY-SIXTH ANNUAL SESSION
fy (SPRING SESSION)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 pan.
These meetings are to be amalgamated with the clinical staff meetings of the various
hospitals for the coming year.   Place of meeting will appear on die 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.
March   7—GENERAL MEETING:
OSLER LECTURE-
-Dr. T. H. Lennie.
March 21—COMBINED CLINICAL MEETING and STAFF MEETING at
VANCOUVER GENERAL HOSPITAL.
April   4—GENERAL MEETING:
Dr. J. R. Davies—"Remediable Intra-thoracic Conditions in Childhood." (Illustrated by brief case histories and X-ray films.)
April 18—COMBINED CLINICAL MEETING and STAFF MEETING at
ST. PAUL'S HOSPITAL.
MAY   2—ANNUAL MEETING.
13 th Ave. and Heather St.
Exclusive Ambulance  Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE  ONLY
J. H.  CRELLIN
W.  K  BERTRAND
Page One Hundred and Seventy-one ADRENAL CORTICAL EXTRACT
FOR THE TREATMENT OF ADDISON'S DISEASE
Clinical evidence has established that ADRENAL CORTICAL
EXTRACT as supplied by the Connaught Laboratories will
provide complete replacement therapy for deficinecies of
the adrenal cortex.
POTENCY
Biological assay of each
lot assures a potency
of 30 dog-units per cc.
PURITY    -
Recent researches in these Laboratories
in the method of preparation have made
possible a solution of much greater purity.
SAFETY
Careful tests on each lot ensure
its safety for either intravenous
or intramuscular injection.
ADRENAL CORTICAL EXTRACT is supplied by the
Connaught Laboratories as a sterile solution in 25 cc.
multiple dose containers.
CONNAUGHT LABORATORIES
University ofToronto    Toronto, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. The Annual Meeting of the Vancouver Medical Association was held this month, and
we welcome our new President, Dr. H. H. Pitts, most cordially. We who have known
Dr. Pitts for many years are very glad that he has been chosen as our leader for the next
year. He brings with him, as we think, excellent capabilities and sincere loyalties, and
he has the respect and liking of all who know him. We wish to him and the incoming
Executive, a very happy and fruitful term of office.
And, as they retire from the immediate scene, we take this occasion to thank Dr.
A. E. Trites, our past President, and his Executive, and to say that they have done excellent work. It is no sinecure these days, being President and Executive of this Association, but these gentlemen have done their work faithfully and have "deserved well"
of us, as the old Romans said of one who served well.
The Annual Reports, which will be published in our next issue, show the Association
to be in a thoroughly sound, solvent state. The Bulletin in particular, is smirking a
bit. Last year we were told by our auditors (good men all, but unsympathetic) that
we had a deficit of some hundreds of dollars. To us this seemed merely a way of putting it. We ourselves claimed to have made a. little profit and regarded the "deficit" as
merely money that was owing to us, but which we had no right to collect. This year
we have caught up with this, and the auditors agree that we have done so. On balance
of income and outgo we show really a larger profit than we have ever made before.
The Summer School will be held next month and the programme looks very attractive. It is hoped that everyone will find it possible to take in at least part of the pro-
* gramme. One always wishes the Summer School were held in some place whither one
could go for a holiday, and take in the School at the same time. It is so hard for one
caught in the whirl of a busy practice (and' who is not in these days of sturm wtd
drang?) to attend meetings. But the committee in charge arranges it to the best of
their ability, so that meetings do not conflict more than can be helped, with our office
hours. One feels that it should be possible to squeeze out a few hours for such a worthwhile purpose. Speaking for ourselves, we can safely say that every one of these Summer
School lectures is the source of good. One always gets something. Often one gets a
tremendous lot. And one meets fresh minds, with a new and stimulating outlook, which
is more important than the amount of new information one actually acquires.
The two big hospitals of Vancouver have recently held their graduating exercises
and some hundreds of new nurses have been initiated into their new profession, to be
an ever-present help in time of trouble for us and for their patients. We congratulate
them heartily, and wish them all the luck in the world.
Modern nursing has become a very complex thing. In our early days, the graduate
nurse was more of a nurse perhaps, and less of a technician. This is not said in a derogatory sense, as regards either generation. But the modern nurse has to learn a great
deal besides plain bedside nursing. She must know a great many procedures of which
her older sister knew nothing, and she must be qualified to do an entirely different sort
of work. And we have specialists in nursing nowadays—specialists in public health
nursing, in dietetics, in social service; not to say in tuberculosis and other highly specialized branches of medicine. And what a help and blessing to the work these women
do. They carry a torch and are the pioneers in a great public health and social service
programme which will come into being before many years are past, and to the implementation of which their work will be absolutely essential.    If and when health insurance
Page One Hundred and Seventy-two comes into being, the work of the nursing profession will be equally important with that
of the doctor and dentist who do the actual treatment.
There is a very crying need for nurses, not only for general duty and special nurses
to treat those who are actually sick—but for educational projects along the line of
health. This work which will be an essential preliminary to any such scheme, will be
nicreasingly the means of saving life and health and cost to th ecommunity. For the
experience of social workers everywhere has shown that nothing is quite so useless as
symptomatic treatment of social ills, without an attack on the causes thereof. Mere
giving of medical care, for instance, is quite useless, and a huge waste of time and
money, unless the social work necessary is done. And nurses come in here as a most
essential part of this work.
We rejoice to hear that a plan for a new and really up-to-date nurses' home is now
under way at the Vancouver General Hospital. It is, as the Superintendent and Supervisor of the Nursing School, both assure us, long overdue—and we, as citizens of Vancouver, should be deeply ashamed that we have let this state of affairs obtain for so long.
*       *       *       *
DR. J. SCOTT CONKLIN
It is with great pleasure that the writer of this is looking forward to a complimentary
dinner to be tendered to Dr. J. Scott Conklin on Tuesday, May 16th, nominally by the
Alumni of Manitoba University, but actually by the entire medical profession of Vancouver. The latter has shown the greatest eagerness to buy tickets for this function,
at which we can have a visit from our old and valued friend, "Scotty" Conklin, who,
till his enforced retirement on account of illness, was one of the best liked, most respected, and most competent of Vancouver's medical fraternity. We have missed him
very sorely all these years: have missed his geniality, friendliness, and wit: and have
hoped constantly that he would be able to return to the active ranks' of medicine. But
since this has not been possbile, we are glad indeed to have a chance to see him again.
Dr. Conklin was already in practice when this writer came .to Vancouver, in the dark
1900's. He was one of a little band of medical men practising on Hastings Street near
Carrall, and not only practising medicine most efficiently, but having a very good time
as well. Danny McKay, Carder, Jim Sutherland, Hamish Mcintosh (then a respectable
general practitioner, till he took to the dark room and the fluoroscope) and a few other
choice spirits, were associated with Dr. Conklin, and they conducted a series of researches
into certain phases of human experience which, we believe, have never been equalled since.
Dr. Conklin, too, was a leading figure in our Annual Dinners in the old days when
dinners were dinners, and his gift for entertaining was one of the great assets of the
committee which was in charge of proceedings. He always gave cheerfully and unselfishly of his best, and was a most important feature of the programme. He was quite
capable too, of gagging, and a fond memory stays with one of a scene in which he was
engaged with another leading medical Thespian, Dr. Frederic Brodie of this city. Each
had a glass of stimulant at hand, in case of faintness or exhaustion, or for any other
reason. While his co-star was busily engaged in a most dramatic monologue, Scotty,
who had already been forced to consume his own stimulant, felt again rather faint.
Putting out his hand blindly, he came in contact with the other glass. Forgetting that
he had already drunk his own, he downed this, too. The expression on his opposite
number's face when, himself faint and in urgent need of repair, he reached for his dose
of medicine and found it gone, has never faded from the tablets of our mind.
So we rejoice to see Scotty again, and do him honour, and tell him how fond we are
of him, and wish him luck and long life and better health.
Page One Hundred and Seventy-three SUMMER SCHOOL CLINICS
VANCOUVER MEDICAL ASSOCIATION
June 20th to 23 rd, 1944, incl.
HOTEL VANCOUVER, BALLROOM
List of Speakers and Their Subjects:
Surgeon Captain C. H. Best, R.C.N.V.R., Director, R.C.N. Medical Research Unit.
The Canadian Blood Serum Project.
Recent Work on Shock and Burns.
Naval Medical Research.
Penicillin (Non-clinical Aspects).
Lieut. Colonel R. I. Harris, R.C.A.M.C., Consultant in Surgery for Eastern Canada.
Foot Problems in the Army and Out of It.
Fractures of the Os Calcis: Improved Methods of Treatment.
The Management of Amputations and the Use of Satisfactory Prosthesis.
The Use of Penicillin in the Management of Infected Wounds.
Squadron Leader L. G. Bell, R.C.A.F., Medical Consultant to Command Medical
Board, No. 2 Training Command.
Rheumatic Fever.
Some Psychosomatic Aspects of Gastro-intestinal Disease.
The Diagnosis and Treatment of Headache.
The Management of Acute Coronary Occlusion.
Dr. W. A. Scott, Professor of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto.
Diagnosis of Ectopic Gestation.
Antepartum Haemorrhage. ,
Heart Disease in Pregnancy.
Treatment of Genital Prolapse.
Dr. Clifford Sweet, Chief of Medical Service and Chairman of the Executive Committee of the Children's Hospital of the East Bay, Oakland, Calif.     /
The' Child in the Family.
The Child as a Patient.
The Diagnosis and Treatment of Upper Respiratory Tract Infections in Infants
and Young Children—with Special Reference to Sinusitis.
The Role of Body Mechanics in the Health Examination and Care of Growing
Children.
Page One Hundred and Seventy-four LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY:
Surgical Clinics of North America, Symposium on Abdominal Surgery, Chicago
Number, February, 1944.
Bronchiectasis, 1943, by James R. Lisa and Milton B. Rosenblatt.
Handbook of First Aid and Bandaging, 1942, by Arthur D. Belilios, et al.
Medical Clinics of North America, Symposium on Chronic Diseases, March, 1944.
Year Book Neurology, Psychiatry and Endocrinology, 1943 .
Year Book of General Therapeutics, 1943.
M.D.
BOOK REVIEW
Pp. 614, $9.00, Oxford University Press.
PHYSIOLOGY OF THE NERVOUS SYSTEM.   By John F. Fulton, M.A., D.Phil.,
This is the second edition of a book which is not only of great interest to all those
who specialize in neuro-psychiatry or neurosurgery, but contains material which the
busiest general practitioner or the most over-wrought surgeon or internist may read with
pleasure and advantage. It is a compendium of the historical development of our knowledge of the nervous system, of the present knowledge, of the current research and of the;
clinical or practical applications of that research and knowledge. Lest this sound too
forbidding, it should be emphasized that the historical notes are in fine print at the
beginning of each chapter, as is the technical research, while at the end of each chapter
is a two-page summary of the important points.
The first two hundred pages deal with basic physiology and only the specialized few
will read any but the summaries. However, there follow invaluable descriptions that
cannot be equalled by any book. .Thus, the section on the autonomic nervous system is
concise, lucid and brief. This is followed by a description of the hypothalamus which
is more easily understood than any which this reviewer has read. This area of the brain
has become of major interest in recent years and every physician should be familiar with
its chief functions. Other chapters of great interest concern the pyramidal and extrapyramidal systems, and the newer knowledge concerning them is revolutionary indeed.
This review is not written by an enthusiast nor is the book being recommended unduly. Dr. Fulton is a great scholar, a great researcher and a great writer, and he certainly needs no introduction to those who specialize in neurology, psychiatry and neurosurgery. To those others in the practice of medicine and surgery, this book is heartily
recommended both for the reading recommended above and as a book of reference.
—S. E. T.
Page One Hundred and Seventy-five REMEDIABLE INTRATHORACIC CONDITIONS
f^g IN CHILDHOOD
J. R. Davdzs, M.D.
Read before meeting of Vancouver Medical Association, April 4th, 1944.
I should first like to express my appreciation for this opportunity to address you. I
trust that you will derive some small benefit from my remarks relating to this important
group of conditions which are capable of being remedied.
The limited time at my disposal does not permit a complete history of each case
presented and only a selected number of lantern slides can be shown.
Within the thoracic cage of the child one may encounter almost any pathological
condition found in that of the adult. In addition, there are the congenital defects of
the heart and lungs which are usually discovered in infancy or early childhood. Also, if
one remembers that the respiratory tract of the child is more liable tb infection, it
should not be difficult to picture the important role which intrathoracic conditions
occupy in paediatric practice.
It is not my desire to burden you with a discussion of status thymicolymphaticus.
However, I would ask that you bear with me while I present a case history dealing
with the thymus as an organ capable in itself of producing symptoms.
CASE (Nov. 8, 1941)—Baby B., age 6 months, was well until 3 months of age, at
which time he began to wheeze and cough. ,
Without benefit of X-ray investigation, the infant was treated for bronchitis for a
period of 3 months, following which time I was consulted.
Examination revealed a healthy looking child with a brassy cough accompanied by
both inspiratory and expiratory stridor.   There were no other signs or symptoms.
Contrary to usual procedure, a provisional diagnosis of enlarged thymus was made
and radiological investigation ordered at once.
X-ray (Nov. 9, 1941)—The thymus is markedly enlarged, particularly as to its
'right lobe which is lying high in the anterior mediastinum and practically occludes the
whole of the upper portion.
The cough and stridor disappeared completely after the third treatment by X-rays
and improved even after the first irradiation.
X-ray (Jan: 27, 1942)—The thymic enlargement which was present at the previous
examination has in a very great part disappeared.
Although the thymus appears to have been the causal factor in producing the symptoms in this case, one should never be content with such a diagnosis until all other
etiological possibilities have been thoroughly explored.
The enlarged thymus is not a common cause of such symptoms.
One of the greatest advances ever recorded in the field of intrathoracic surgery was
made on August 26, 1938. On this day, Dr. Robert E. Gross, surgeon at the Children's
Hospital in Boston, performed the first successful ligation of the patent ductus arteriosus
on the living subject.
Prior to that date, Dr. John Hubbard, a paediatrician in Boston, noted that while
some patients with a patent ductus lived a normal life without handicap, the majority
died either from heart failure (43%) or from subacute bacterial endocarditis (30%).
It was his observations that encouraged Dr. Gross to operate in order to reduce the
mortality rate in this condition.
During the next five years Gross ligated or divided fifty cases with but three deaths.
Seven of these cases had subacute bacterial endocarditis due to streptococcus viridans
infection. In two cases he did not ligate the ductus because of the presence of some
other lesion. Thus, he was correct in his diagnosis preoperatively in fifty out of fifty-
two cases. The ages of his patients varied from 11 months to 36 years and females
predominated in the ratio of two to one.
Page One Hundred and Seventy-six Other surgeons have had the same remarkable success as reported by Gross and a
renewed interest in the diagnosis of congenital heart lesions has resulted.
Patent ductus arteriosus is one of the most frequent cardiac anomalies, being next
in order to septal defects. When associated with other lesions the child usually dies
in infancy. It is only when it occurs as a single lesion and presents signs and symptoms,
that surgery is indicated.
Persistence of the ductus provides a shunt from the aorta into the pulmonary artery,
owing to the relatively higher blood pressure in the aorta. The volume of blood diverted
is 50% or more of the aortic flow. This extra quantity of blood in the pulmonary
.circulation increases the work of the heart, and may result in abnormal physical and
X-ray findings, in the course of time.
Owing to the diversion of blood from the peripheral circulation, there is a disturbance of growth of the child, and signs of pulmonary congestion may occur.
This lesion is often discovered in infancy or early childhood in the course of a general examination before any signs or symptoms are present. The child may reach adult
life without evidence of the lesion beyond the presence of the characteristic coarse
rumbling "machinery-like" murmur which is usually continuous and heard with greatest
intensity in the second or third left interspace. The murmur has a distinct systolic
accentuation and may be transmitted in several directions, depending upon the degree
of its loudness.
There is also a striking accentuation of the second pulmonic sound and an intense
palyable thrill is present over the pulmonic area and accentuated during systole, in most
cases.
As mentioned a moment ago, the murmur is often discovered in a general examination of an infant, at which time signs and symptoms referable to the patent ductus are
usually absent. However, as the child grows older and exercise increases, there may be
slight dyspnoea, increased heart rate, or a pounding cardiac beat. Cyanosis is conspicuous
by its absence in uncomplicated cases and is usually present only if a terminal stage
is reached.
In patent ductus of any consequence the heart itself is hyperactive while the pulse
is apt to be of the collapsing or Corrigan type. The systolic blood pressure is normal
while a low diastolic pressure is likely to be present, owing to diminished peripheral
resistance with a resultant high pulse pressure. Of course, this finding will vary, depending upon the severity of the condition.
Radiological investigation cannot establish the diagnosis but can suggest the presence
of a patent ductus. Actually, large hearts are rare in this condition and there is either
no enlargement or only a slight to moderate increase and this is limited mainly to the left
side of tie heart. The greatest enlargement is said to be found in the presence of subacute bacterial endocarditis or endarteritis.
The electrocardiogram has its chief value in ruling out associated defects.
Selection of cases suitable for operation is most important and must conform to the
following standard:— 'i#i
1. The diagnosis must be correct.
2. One or more of the following must be present—
(a) Retarded physical development due to ductus defect.
(b) Low diastolic pressure which falls with exercise.
(c) Signs or symptoms of beginning cardiac failure or embarrassment.
(d) Pulmonary congestion or considerable enlargement of the heart (X-ray).
(e) Early subacute bacterial endocarditis.
The preferable age range for operation is from 5 years, which will preclude all possibility of natural closure, up to 15 years, i.e., before much cardiac damage has been done.
The results following successful operation are dramatic.   They are as follows:—
(1) In most cases the thrill ceases and the murmur completely disappears.
(2) The activity of the heart is noticeably diminished, as its work is lessened.
Page One Hundred and Seventy-seven (3) Children with retarded physical development show weight gain and improvement in general condition, owing to better peripheral circulation.
(4) Several cures have been reported where subacute streptococcus viridans end
arteritis was present. Example—One girl, age 9 years, weighing only 56 pounds,
who had repeated positive blood cultures for streptococcus viridans, made a
splendid recovery. Twenty months following operation, she had gained 28
pounds, was attending school, and taking part in light athletic games.
The following case history illustrates how the patent ductus is often discovered,
namely, in routine examination.
CASE (Oct. 5, 1943)—C. S., age 2 years, was brought to the office with a history
of frequent colds.
The child was small for her age and weighed but 22 pounds. There was a loud
machinery-like continuous murmur heard best in the second left interspace. It was well
transmitted to the back, especially on the. left side. A very distinct thrill was felt over
the pulmonic area. There was no cyanosis on crying and the mother stated that the
colour had always been good.   The systolic blood pressure was 95 and the diastolic 45.
X-ray—Suggested ductus arteriosus.
The parents were informed of the cardiac anomaly present and told to return with
the child at least once a year in order to safeguard against cardiac or other signs which
might othewise progress beyond the stage at which operation would be of benefit.
Turning now to a discussion of lesions of the lungs and adjacent structures, one is
confronted with several conditions which are capable of being remedied. They are, of
course, not limited to childhood but are frequently encountered in this age period.
Pertussis, for example, is a disease which at times leaves the patient with a very distressing cough which may last for weeks to months after the expected time of disappearance. Cough mixtures, as the sole remedy in such cases, are apt to be disappointing The following case histories are good examples of the results achieved by a
form of treatment which should be more widely recognized and utilized.
CASES: B. A. R. and B. J. R. are sisters whose ages were 7 and 9 years respectively.
Both developed pertussis in June, 1939.   In spite of the usual measures employed, they,
were still coughing five months later, at which time I was consulted.   Each child presented a similar clinical and radiological picture.
X-ray (Nov. 10, 1939)—There are numerous glands in the mediastinum about the
bifurcation of the trachea.   Otherwise the findings are negative.
Each child received but two treatments of X-ray therapy one week apart and the
cough disappeared promptly.
Bearing in mind that in pertussis there is infiltration into the walls of the bronchi
and bronchioles mainly by lymphocytes and that the lymph nodes in the neighborhood
enlarge, it should not be difficult to explain the results of such therapy.
Thus, roentgen rays produce a ready response in lymphoid tissue and therefore act
upon the swollen lymphoid structure of the hilum, including the pulmonary and tracheo-
pulmonary groups of glands, causing reduction in size. The relief is chiefly, if not
entirely, of a mechanical nature and may be spectacular. I have in mind an infant of
one year of age who had a severe attack of pertussis in August, 1943, and. the mother
consulted me in November because of the persisting cough. After the. first treatment
the cough all but disappeared and was entirely gone after the second one.
Such spectacular results may not be the rule but improvement is usually shown by
reduction in the frequency and severity of the paroxysms and a final cessation of the
cough. X-ray therapy should be given a trial where severe paroxysms persist beyond
the usual duration, even in the absence of demonstrable glands.
Beyond doubt, the best treatment is "preventive" by the administration of prophylactic pertussis serum at six months of age.   This usually prevents or greatly modifies
the disease.
Page One Hundred and Seventy-eight Less there be any misunderstanding, it must be stated that in the "early" stage of
pertussis X-ray therapy has not produced results which would entitle it to be placed in
our list of remedies. The response is mainly in the second half of the disease, at which
time glandular enlargement is most likely to be present.
*       *       *       *
In 1937 a child was examined at the Vancouver Chest Clinic and the pulmonary
findings are of considerable interest. The case history is included here because of the
diagnostic difficulty encountered.
CASE: Y. A., male Japanese, age 15 years, gave a history of frequent asthmatic
attacks for the past eight years. Except for cough during an attack there were no
symptoms.
X-ray (1937—There are increased markings with some fine infiltration especially in
the third left interspace.   (Diagnosis—Suspect pulmonary tuberculosis.)
X-ray (May 5, 1938—7 months later)—There is fine infiltration over the upper
two-thirds of the left and upper third of the right chest. This infiltration is more
marked than in the previous plate. (Diagnosis—Questionable, but the infiltration is not
typical of pulmonary tuberculosis.)
This case was followed for two and one-half years before the diagnosis was finally
established. Sputum examination had been consistently negative for tubercle bacilli and
the child remained well. Then culture of sputum on Sabaroud's media showed a growth
of fungi resembling "Monilia Albicans" and repeated laboratory tests produced a similar
growth.
X-ray (at time of diagnosis—2 l/z years)—There is fine infiltration throughout both
lungs from apex to base.
Four years after the child came under observation the X-ray findings were unchanged. The sedimentation rate and blood count was normal at all times. Unfortunately, from the medical standpoint, this child was moved inland with his parents and
further study interrupted.
The diagnosis of fungus infection, in its early stage particularly, usually presents
considerable difficulty, as it did in this case. For a time it is mistaken for pulmonary
tuberculosis and may even occur in combination with it. However, fungus infection
should always be suspected when pulmonary lesions do not easily fit into one of the
accepted diagnostic categories.
The treatment for the Monilia Albicans type of infection has been potassium iodide
and cures have been reported. Quinine sulphate has more recently been suggested as a
curativ agent.
"■'- ;'- «*■ ;'-
One should always be on the alert for pulmonary complications which may follow
tonsilectomy.   The folowing case illustrates one such type of lesion.
CASE: E. S., female, age 12 years, developed laboured and rapid breathing on April
15th, which was the day following operation. The temperature rose to 102 degrees, and
marked dyspnoea, accompanied by a feeling of suffocation, developed.
Physical examination elicited dullness at the right base and absence of breath sounds
over that area.
X-ray (April 16th)—The right diaphragm is slightly higher than usual and the
heart is displaced about an inch to the right. The rib spacing suggests some retraction.
There is also some increased density shown in relation to the pulmonary tissue at the
right base suggesting "atelectasis."
Bronchoscopic examination was immediately performed under ethyl chloride and
ether anaesthesia. Following the aspiration of mucus, which acted as a bronchial plug,
there was almost immediate improvement. Sulfathiazole was then given in adequate
dosage and the temperature became normal on the fourth day following operation
(bronchoscopy).    Fluoroscopic examination n April 20th showed definite increase in
Page One Hundred and Seventy-nine hilar and peribronchial markings, particularly towards the right base. There was no
evidence of atelectasis as the diaphragm was well outlined.
The child was discharged as cured on the ninth day and it is fair to state that it was
probably on account of the early treatment instituted.
One should not wait too long for a possible natural cure by expulsion of the plug
of mucus. Although the secretions of post-operative pulmonary atelectasis are not
primarily suppurative, nevertheless suppuration usually does occur and within a week or
ten days unless the mucus plug is removed or expelled. Failure of removal by coughing
or bronchoscopy results in pulmonary abscess due to a breaking down of the walls of
the passages.
Although post-operative atelectasis is more common in adults because the operative
field is often in the upper abdomen, it may occur in children following appendectomy
or other surgical conditions in the abdomen. What was formerly called post-operative
pneumonia is now generally recognized as atelectasis.
For the next case I am indebted to Dr. R. N. Anderson of Ladner, who kindly
allowed me to follow the progress of the case on the ward.
CASE: G. G., age 18 months, was admitted to hospital on September 29, 1943.
Six weeks previously the infant had pneumonia and was treated with sulfathiazole.
Although the child seemed well within a week, the temperature never registered below
100 degrees before admission.
Two weeks after the pneumonia had subsided, slight cough, fever and listlessness
returned and a further course of sulfa drug given. In a short time he was well with
the exception of the low grade temperature. Ten days before admission the same
symptoms reappeared but in a more pronounced form. The child was then pale, respirations were rapid and laboured and he perspired at night. The temperature now ranged
from 100 to 103 degrees.
On admission on Sept. 29th he was fretful and had a frequent non-productive cough.
Percussion note was impaired over the left mid lung posteriorly and the breath sounds
were altered.
X-ray (Spet. 29th)—There is considerable infiltration shown at the left medial base,
probably atelectatic in character, as there appears to be some constriction of the ribs
on this side. On a level with the fifth intercostal space posteriorly there is a shadow
suggesting a small amount of air with a fluid level as if in an abscess cavity. (Lateral
views suggested likewise.)
On Sept. 3 0th bronchoscopy without anaesthesia was performed and the left bronchus
explored. There was a large quantity of muco-purulent material in the trachea and a
great deal of congestion in the bronchial mucosa. A short distance below the carina
the bronchus was almost completely obstructed by what appeared to be a generalized
swelling of the bronchial wall. By suction tube a small quantity of muco-purulent
material was obtained.
X-ray (Oct. 7th)—There is a radiopacity occupying the lower two-thirds of the
left chest with an area of lesser density at the level of the anterior end of the third interspace 12 mm. in^diameter.   There is no fluid level in the apparent cavity.
X-ray (Oct. 15th)—The heart is still displaced somewhat to the left but there is a
definite clearing of the shadow in the peripheral part of the left chest and no evidence
of cavitation in A.P. or lateral plates.
Three bronschoscopies in all were done and the third on Oct. 19 th showed very little
material in the left bronchus but there was still some edema of the bronchial mucosa.
Postural drainage followed each bronchoscopy.
X-ray (Oct. 26th)—The heart is in normal position and the left chest is clear.
The temperature and respirations reached normal on the 15th day after admission.
There was an appreciable gain in weight and all symptoms disappeared. The tuberculin
test was negative.   No further treatment -was indicated at that time.   The child is still
Page One Hundred and Eighty well six months later. This case was one of acute lung abscess following atelectasis
during pneumonia from a mucous plug. Not all suppurative pulmonary lesions have
such a fortunate ending.   The next case will illustrate a more advanced type of lesion.
When one realizes that bronchiectasis has its onset most frequently during the first
ten years of life then it's importance as a paediatric problem becomes evident. Although
"prevention" is the ideal form of treatment, this is not always possible. However, careful management of the common diseases that affect the respiratory tract, such as measles,
pertussis, and especially streptococcal and influenzal pneumonia, is an important aid in
prevention. The prompt removal of foreign bodies and adequate early treatment of
lung abscess, such as was present in the previous case, are essential if bronchiectasis is
to be prevented.
The following case, a patient of Dr. W. Bagnall, was admitted to the paediatric ward
on November 7, 1943, with a diagnosis of bronchiectasis of the left lower lobe.
CASE: B. L., female, age 8 years, had a history of productive cough of two years'
duration. If the child was turned head down it was not unusual to collect approximately two ounces of purulent material.
For the past several years she had suffered from many respiratory infections. Two
years ago she had pneumonia and last year developed measles complicated by pneumonia.
On physical examination she appeared to be a fairly healthy looking child. Breath
sounds were absent over the left base posteriorly and a few moist rales were present
(according to interne's notes). There was no clubbing of the fingers and the temperature ranged from 99 to 101.
X-ray (Nov. 8, 1943)—Following lipiodol injection the appearance of the right
base is satisfactory, but the left base on a level with the bronchi appears dilated and
filling of the alveolar tree is not as satisfactory as on the right -side. The filling of the
upper lobe is incomplete.
Operation (Nov. 15th)—Postural drainage was done and then left lower lobe lobectomy under cyclopropane anaesthesia. Following operation, the child was placed in an
oxygen tent and a catheter from the wound attached to the drainage bottle.
X-ray (Nov. 16th)—The upper lobe has expanded very markedly so that it now
occupies most of the left chest.
Radiological examination by Dr. Harrison on December 18 th showed the chest to
be in a satisfactory condition. As late as March 18th, 1944, her condition is still good
and she looks fine.
While some cases of bronchiectasis clear without treatment it is seldom that one sees
such a result in infants and young children. If this does occur it usually takes months
on years to do so.
When one finds an atelectatic shadow with the heart displaced towards the affected
side the condition should be considered as a potential bronchiectasis and a real effort made
immediately to clear the bronchus which serves that portion of the lung.
Medical treatment has no place in well established bronchiectasis. It may be of value
in the early stage and consists of frequent changes in position. After disappearance of
the acute pulmonary symptoms and following the onset of the moist cough one may find
postural drainage of benefit. If repeated radiological examination shows little or no
change in the size and density of the shadow then bronchoscopic aspiration may bring
about immediate results. It is better to perform the bronchoscopy within days to a
week or so following non-clearance of the shadow. Daily postural drainage is necessary
following aspiration to prevent recurring collapse. A case should not be considered as
cured until X-ray and physical findings have been negative for some period of time (due
to danger of recurring collapse).
Surgical treatment in the form of lobectomy is the only known cure in well established cases. Lobectomy in the hands of experienced thoracic surgeons is now a fairly
safe procedure. One surgeon reports a mortality rate as low as 3.3% in a series of 122
cases.
Page One Hundred and Eighty-one Thus, all children and young adults with established bronchiectasis should be carefully studied with lobectomy in mind to prevent, where possible, a prolonged miserable
life both physical and psychological.
Since the advent of the sulfonamides, one rarely sees empyema where the pneumonia
has been treated early with adequate dosage.
Once the condition has developed it becomes necessary to formulate a plan of treatment most likely to give the best results. There is no standard treatment for acute
empyema and therefore each case must be considered in the light of past experience.
In any event, it becomes necessary to perform a diagnostic aspiration, at which time
some of the fluid is usually removed as a treatment measure. One usually repeats these
aspirations at intervals of two to three days or more, depending upon the temperature,
toxicity, radiological findings and general well being of the patient. Cure may result
from this form of treatment alone.
But, if the course of the empyema is unduly prolonged or the results of aspiration
likely to be uncertain, intercostal closed drainage has been found to be satisfactory on
our wards as a further step in treatment, provided the pleural fluid is not too thick.
Many of our cases have been cured by this method without resort to open drainage, such
as rib resection.
Intercostal drainage has its greatest use where the accumulation of fluid is so large
and forms so rapidly that frequent tapping fails to give adequate relief of mechanical
embarrassment. It is important to remember that in children, where repeated needling
of the chest causes much fear and anxiety, closed drainage eliminates the necessity of
frequent aspirations.
Following aspiration, primary open resection, such as rib resection, is the form of
treatment most often employed. The reason for this and the good results obtained are
due to the fact that most empyemas are of pneumococcal origin. When the pneumo-
coccus is responsible for the empyema the underlying pneumonia has usually subsided
and the vital capacity of the lungs is such that open operation as a primary measure is
a safe procedure. However, in streptococcal and staphylococcal cases the empyema
usually appears during the active stage of the pneumonia and open operation at this
time only invited disaster. Nor is primary open operation recommended in the first two
years of life and certainly not in the first year. Closed drainage is the procedure of
choice at this age.
CASE: P. J., age 14 months, was seen at home on January 18, 1944. She had a
temperature of 103 and impaired percussion note over the greater part of the right
chest. There were crepitations in the right base and the child was very toxic. I sent
her to hospital and ordered an X-ray investigation that day.
X-ray (Jan. 18th)—There is some pleural thickening with a slight amount of fluid
shown about the lung in the right axilla and in the interlobar space between the upper
and middle lobes on the right side. There is no marked evidence of any pulmonary
infiltration.
One wishes to emphasize that in this case radiological examination suggested the
onset of pneumonia and fluid formation in the pleura at one and the same time. The
next day the temperature rose to 105 degrees and remained high for several days. Respirations were now 50 per minute and the child was receiving sulfadiazine. Next day the
picture was complete with the typical picture of pneumonia accompanied by hydro-
thorax, thus suggesting either staphylococcal or streptococcal type of pneumonia.
X-ray (Jan. 21st)—The right thorax appears to be fairly well filled with fluid and
the heart is shown displaced about an inch to the left.
Next day a diagnostic thoracentesis was done and an attempt made to aspirate as
much fluid as possible. After removing but 90 cc. the needle apparently plugged.
Staphylococcus aureus was found in culture from the pleural fluid.
Page One Hundred and Eighty-two Operation (Jan. 26th)—Under gas anaesthesia closed drainage was performed. The
child was very toxic and condition was only fair.
Within three days the temperature began to subside and reached normal in five days.
Sulfadiazine was continued with proper attention given to the white blood count and
blood concentration of the drug. It was necessary to keep the child in an oxygen tent
for several days.
X-ray (Jan. 28th)—There is still considerable thickening shown in the right thorax
and the drainage tube is in place.   There is no evidence of any collection of fluid.
The drainage tube fell out on January 30 th but this resulted in no ill effect. Keeping
the tube in place and avoiding leaks about the tubing where it enters the chest is, of
course, one of the difficulties encountered when closed drainage is used.
Following a blood transfusion for secondary anaemia, the child was discharged
Feb. 21st.
X-ray (Feb. 29th)—There is light pleural thickening but expansion and movement
of the ribs is quite satisfactory.
Aspiration of the pleural cavity, although a simple procedure, may result in a
pneumothorax by puncturing the lung itself. In the presence of purulent fluid in the,
pleural space a "tension pyopnuemothorax" may develop. Such a condition was found
in the last case to be presented. -
CASE: W. G., age 3 years, was admitted under the paediatric staff on Dec. 18,
1943, with a diagnosis of pneumonia with effusion limited to the right chest. He was
acutely ill with a temperature of 104 and had rapid laboured respirations.
X-ray (Dec. 18th)—'There is marked opacity shown at the right axillary base and
extending upwards as high as the second rib in the axillary line. There appears to be
some pleural thickening above this line which suggests that the greater part of the
opacity is due to pleural thickening and fluid, although considerable pulmonary infiltration is present.    Diagnosis—"Pleural effusion and pneumonia."
On Dec. 25th, 1000 cc. of purulent fluid was aspirated and stapylococcus aureus
haemolyticus was cultured from it.
  X-ray (Dec. 27th)—There is almost complete pneumothorax on the right side and
the heart is displaced slightly to the left.
X-ray (Dec. 29th)—Marked pneumothorax is still present on the right side and the
air extends to about % inch beyond the left side of the vertebral column.
X-ray (Jan. 6th)—The fluid is shown to be about two ribs higher than in a previous film. There is considerably less air in the right thorax and its extent towards the
left also appears to be slightly diminished.
Operation (Jan. 7th)—Closed drainage was performed under gas anaesthesia.
Later in the day on which closed drainage was done, another film was taken.
X-ray (Jan. 7th)—The pneumothorax on the right side has now been resolved.
The heart appears to be in normal position. There is some pleural thickening shown
along the right axiTary line and the drainage catheter is in position.
The child did well and was discharged six weeks after admission. He returned for
a final film in March.
X-ray (March 15th)—There is very slight infiltration shown throughout the right
pulmonary tissue but otherwise the lesion is practically resolved.
Although "open" drainage had been suggested as a "primary" measure in this case,
such a procedure is contra-indicated as it would probably result in considerable dyspnaea
and perhaps death of the patient.
"Closed" drainage is the method of choice, to be followed later by "open" drainage,
if necessary.
Much credit must be given to Dr. Elliott Harrison, who was responsible for all
operative procedures mentioned in this paper.
In conclusion, I wish to stress a few points.
Page One Hundred and Eighty-three 1. The thymus, as an organ, is capable in itself of producing symptoms, although it is
not a common cause of such symptoms.
2. Ligation or surgical division of the patent ductus arteriosus produces splendid results
in selected cases and has its greatest use in childhood.
3. In pertussis, where distressing cough persists beyond the expected time, relief may
be obtained by roentgen-ray therapy.
4. Fungus infection of the lungs presents difficulty in diagnosis and in the early stage
may be confused with pulmonary tuberculosis. Repeated X-ray investigation and
sputa examination are necessary measures in order to reach a diagnosis.
5. Atelectasis demands prompt surgical relief where bronchial obstruction is due to
mucus plugs following tonsillectomy, or in the course of pneumonia, to prevent lung
abscess and possibly bronchiectasis.
6. Lobectomy is a fairly safe curative measure in well developed bronchiectasis, provided the lesion is limited to the lobe of one lung.
Emphasis must be placed on the early age at which bronchiectasis develops.
7. Acute empyema is seldom a surgical emergency. However, careful consideration
must be given to the method of treatment to be adopted in each case. Thus, where
streptococcus or staphylococcus empyema is present in the course of pneumonia,
intercostal closed drainage is the method of choice and has given excellent results in
cases on our paediatric wards.   (Vancouver General Hospital.)
The purpose of this paper, in the main, is to suggest early and adequate radiological
investigation in every case which presents signs or symptoms referable to the chest. With
results that can now be attained by roentgen-ray therapy and surgery, no lesion amenable to treatment should be allowed to each a stage where the child may be incapacitated
for life.
AIR RAID PRECAUTIONS HEADQUARTERS
City Hall
i Vancouver, B. C,
April 14, 1944.
Dr. A. J. MacLachlan,
Registrar,
College of Physicians & Surgeons of B. C,
925 W. Georgia St.,
Vancouver, B. C.
Dear Doctor MacLachlan:
We are desirous that members of the Medical profession who are holders of special
permits for motor vehicles under the Lighting and Blackout Regulations renew their
permits for 1944-45, and to effect this, it will be necessary for them to send in their
permits, together with their 1944 licence number of their car, to the Chief Warden's
Office, Vancouver Civil Defence, City Hall, Vancouver, B. C.
Also, that present holders of the Special Permits, that haVe resigned from Civil
Defence and in consequence have no need for such permit, be asked to remove the
sticker from their windshield and return same along with their permit to the same
address.   If the sticker is destroyed in removing, please advise on returning permit.
Yours very truly,
F. O. FISH, Jig
Director, Vancouver Civil Defence.
Page One Hundred and Eighty-four V
ancouver
G
enera
Hospital
PRELIMINARY REPORT ON THE USE OF THIOURACIL
IN THE TREATMENT OF HYPERTHYROIDISM
Dr. G. F. Strong and Dr. W. N- Bell
Department of Medicine, The Vancouver General Hospital.
At the Osier Dinner in March, 1944, Col. Wallace Wilson prophesied that the
therapy of hyperthyroidism might soon be within the realm of internal medicine. Possibly the increasing use of thiouracil may be a step in that direction. The object of
presenting at this time a premature report of our experiences with the use of thiouracil
is not to condemn or to uphold it but merely to draw it to attention as a possible beneficial agent in the treatment of hyperthyroidism.
A brief review of the literature on thiouracil will be of value. Two series of chemical compounds have been found to possess the unique property of inhibiting the endocrine function of the thyroid gland. The administration of these agents to experimental
animals is followed, after a short latent period, by a lowering of the basal oxygen con*
sumption, a decrease in the rate of growth and development, and a diminished food
intake—changes which are consistent with a state of hypothyroidism. In certain species
of animals these changes are accompanied by a hyperplasia of the thyroid gland which
is apparently compensatory in nature and mediated by die anterior lobe of the pituitary.
The first series were derivatives of thiourea which exhibited some activity but varied
widely in toxicity, thiourea itself being the least toxic of all. 2-thiouracil was the most
highly active compound tested and it was found to have a low toxic effect. The second
series of active compounds included a number of aniline derivatives, such as para-amino-
benzoic acid and related compounds, and all of the commonly used sulfonamides. This
second series was found to be considerably less active than the derivatives of thiourea.
It was found that the changes induced in the experimental animals can be prevented by
the administration of desiccated thyroid or thyroxin or by hypophysectomy but not by
the administration of iodine.
Thiouracil has been found to be rapidly absorbed and rapidly excreted. On a dosage
of 0.2 gm. every four hours, it requires about twenty-four hours to reach a more or less
constant rate of excretion in the urine and a constant blood level. On this dosage the
urine excretion is about 300 milligrams per day, whereas the blood level is about 3 mgm.
per cent. Studies are being done to determine the distribution of the drug in the tissues
of human beings.
The dosage recommended is 0.2 gm. every four hours with reduction as determined
by clinical improvement. When the basal metabolic rate is normal, 0.2 gm. once or
twice daily has been found usually to be sufficient for maintenance doses. It must be
administered continuously over a period of months, as Astwood has found a recurrence
of the disease in a patient although the latter had received thiouracil for about two
months before it was discontinued. Studies have suggested that the primary action of
these compounds is an inhibition of the production of thyroid hormone, but the exact
mechanism had not been determined.
There appears to be a variable latent period following the initiation of treatment
before the metabolic rate begins to fall, and a similar though somewhat shorter period
before clinical improvement is subjectively and objectively apparent. "If the concept
that these drugs prevent the synthesis of thyroid hormone is correct, one might
expect that the rate of metabolism would remain nearly as constant as long as the store
of thyroid hormone in the gland was adequate to supply the organism. When this store
nears exhaustion, the decreased rate of thyroid hormone synthesis becomes apparent in
Page One Hundred and Eighty-five the fall of the B.M.R." Astwood finds support for this statement in the failure of four
persons with normal thyroid glands to show a decrease in metabolism when the drug was
administered for periods of two to four weeks, while his cases of hyperthyroidism
responded within ten to fourteen days. It is known that a hyperplastic gland contains
relatively little thyroid hormone and thus its store would become more quickly diminished than that of a normal gland.
It has been shown that thiouracil does not lower the basal metabolic rate of untreated
myxedematous patients, nor does it inhibit the response of the basal metabolic rate to
desiccated thyroid.
Complications occurring during the use of thiouracil do not appear to be very common. Astwood reported one case of agranulocytosis, but this occurred with a dosage of
2 gm. of thiouracil daily, a dosage that is now believed to be unnecessarily high. Williams and Bissell report two cases which developed slight pitting edema with elevation
of the serum chloride, but these changes disappeared without discontinuation of the
drug and without any alteration in the urine or in kidney function tests. There were
no ill effects noted when the drug was used in the case of a pregnant woman. In
another series, three patients developed pyrexia or rash, either alone or together, but
these disappeared without having to discontinue the drug.
We wish to report three patients, each representing different aspects of hyperthyroidism:
CASE I.—A 3 3-year-old woman, who complained of loss of twenty-two pounds,
occasional palpitations and a moderate intolerance to heat since July, 1943, and excessive
appetite, chronic fatigue, nervousness and excessive perspiration since September, 1943.
The basal metabolic rate in September was -{-IS and in February, 1944, was "over
80%." Examination revealed nervousness, loss of weight, a warm moist skin, fine tremor
of the fingers and moderate exophthalmos with slight lid-lag and poor convergence of
the eyes. The thyroid was diffusely firm and enlarged, particularly the right lobe. The
heart was slightly enlarged to the left and a soft systolic murmur could be heard over
the whole precordium, especially at the apex. Blood pressure was 130/70, the pulse 120
and regular.
On March 7, the basal metabolic rate was +69 and the blood cholesterol 95. Her
weight was 118 lbs., and the white blood count 9,000. She was allowed out of bed
with no sedation except at bedtime, and she was fed on a high caloric, high vitamin diet.
She was started on thiouracil, 0.1 gm. four times a day. On March 9, the dosage of
thiouracil was doubled to 0.8 grams daily. On March 14, the basal mtabolic rate was
+40, and the blood cholesterol 116. She had gained 2 lbs., and she felt generally
greatly improved. The tremor in her hands had decreased and her nervousness showed
marked improvement, her pulse having decreased to 80. There was no apparent change
in the size of the thyroid although she said that a feeling of "tightness" in the neck,
which she had noticed for two days before coming into hospital, had disappeared. On
March 20, the basal metabolic rate was -f-25, and the blood cholesterol 150. Her weight
was up 3 lbs., and her white blood count was 6,500. She mentioned that her eyes did
not tire so easily when reading. Her nervousness and the tremor of the hands were still
further improved but there was still no change in the size of the thyroid.
The dosage employed in this case, namely 0.8 gm., is slightly less than the recommended dose of 1.0 gm. daily, but it is the heaviest used in our three patients. It is
naturally too early to draw any conclusions from this case but the progressively decreasing basal metabolic rate, increasing blood cholesterol, and gain in weight are encouraging.
Points of interest are that no palpable increase in the size of the thyroid gland or development of agranulocytosis has occurred up to the present. The general improvement, subjectively as well as objectively, has given the patient a good deal of satisfaction, especially
since she has discovered a similar thyrotoxic patient in the same ward who is on the
usual strict bed rest with Lugol's solution. Our plan with this patient is to reduce her
basal metabolic rate to normal and then to put her on maintenance dose of 0.2 gm. of
thiouracil once or twice daily.
Page One Hundred and Eighty-six CASE II.—A 46-year-old woman, admitted February 1, 1944, complained of productive cough, chills, fever, anorexia and dyspnoea for ten days. She gave no history of
hyperthyroidism beyond the loss of twelve pounds in the previous six months, despite a
fairly good appetite.
On examination she was a well-built woman with a mildly antagonistic manner.
Her skin was warm and dry. Her eyes were moderately exophthalmic, but there was no
lid-lag and only slight difficulty in convergence. The thyroid was diffusely enlarged,
especially the right lobes. The blood pressure was 125/78, the pulse 100 and regular.
The heart was not enlarged* clinically nor were there any murmurs to be heard. There
were numerous rhonchi and a few rales throughout the chest. An X-ray examination of
the lungs revealed no tuberculosis, but increased hilar and peribronchial markings. There
was a slight fine tremor of the hands.   Sulfadiazine cured the bronchitis.
On March 8, she was started on thiouracil, 0.1 grams six times daily. Her basal
metabolic rate at this time was +39. She had been on Lugol's solution since February
14, first Mx daily, then Mxxx daily, dining which time her basal metabolic rate had
dropped from +42 to +39. She was allowed up to the bathroom, was given no sedation except at bedtime and was on an ordinary diet. Within four days she began to feel
better, her disposition improved and she was eating more. In a week her basal metabolic
rate was +37 but she had gained 4 lbs., which was more than she had gained taking
Lugol's solution for three weeks. The blood cholesterol had diminished from 220 to
210, and the white blood count remained constant.
The interesting points in this case are, first, the relative lack of response both to
Lugol's solution and thiouracil; and second, it is difficult to account for the high blood
cholesterol. Clinically, she represented a mild Graves' disease with the toxicity affecting
particularly the nervous system- although she had some paroxysmal nocturnal dyspnoea
and her electrocardiogram showed some myocardial involvement. The gain in weight
• is an encouraging sign. No signs of toxicity to the drug have appaered up to the present
time and she is doing a little work about the house. She has had no sense of pressure in
the neck and has had no trouble with her eyes. We intend to maintain the same dosage
of thiouracil with weekly estimations of the basal metabolic rate, blood cholesterol and
white blood count.
CASE HI.—A 62-year-old woman, who was operated on for Graves' disease in 1932,
had carried on a normal life with no thyrotoxic symptoms until December, 1943, when
she began to have palpitation, dyspnoea on moderate exertion, gradual loss of weight,
chronic fatigue and an increasing intolerance to heat. These symptoms have been
increasing up to the present time and lately her appetite has been poor. She has had
slight edema of the ankles at times. She had Lugol's solution for two weeks before starting thiouracil, and the basal metabolic rate dropped from +58 to +42.
On examination she was an elderly woman, well-nourished and slightly nervous. Her
eyes were moderately exophthalmic with slight lid-lag and difficulty in convergence. Her
thyroid was palpable and the operative scar was well-healed. Her heart was irregular,
at a rate of 76 to 80, the blood pressure being 160/90. The heart is enlarged to the left?;
to the anterior axillary line. The sounds were of poor quality and no murmurs could
be heard distinctly. The liver was just palpable but there was no ankle edema. There
was a slight fine tremor of the hands.
On March 9, she was started on thiouracil, 0.1 gm. four times daily, and remained
out of hospital. At that time, the basal metabolic rate was +42 and her blood cholesterol 190, and she weighed 127 lbs. She began to take digitalis on February 14 as her
electrocardiogram at that time showed auricular fibrillation with flattening of T 1, 2
and 3, and she continued the digitalis while receiving thiouracil. On March 20, the
basal metabolic rate had dropped to +28, and the blood cholesterol had risen to 200.
The white blood count had remained constant. She had gained 3 lbs. and for the first
time was doing a little work about the house and was sleeping better; In the last few
days she had a slight pressure sensation in the neck and reading has tired her eyes.   The
Page One Hundred and Eighty-seven thyroid seems to be slightly more palpable, her heart rate is now regular and her dyspnoea
has decreased.
We intend to maintain her on the same dosage as an ambulatory patient, and, should
the basal metabolic rate become normal, we may keep her on a maintenance dose, at the
same time giving her desiccated thyroid, as advised by Williams and Bissell, with a view
to possible improvement of the exophthalmos.
This patient seems to be responding well to the drug but she presents two interesting
concurrences, namely a slight enlargement of the thyroid and possibly a slight increase
of the exophthalmos. The question of the heart becoming regular five days after beginning thiouracil probably is coincidental.
In summary, after two to three weeks' treatment, all of our three patients have
gained weight, feel and look improved, and, in two cases, the fall in the basal metabolic
rate has been encouraging. No toxic reactions have been noted although the dosage has
been less than that recommended. Our ambulatory patient is of interest since it suggests a possibility of preparing a patient for operation without disturbing her normal
life-to any marked extent. So far no conclusions can be safely drawn about the drug
but we feel that it is giving satisfactory results up to the present time.
REFERENCES:
Astwood, E. D.: Journal of American Medical Association, vol.  122: 78.
Williams and Bissell: New England Journal of Medicine, vol. 229: 97.
SULFONAMIDES IN SKIN DISEASE: A WARNING
D. E. H: Cleveland, M.D.
There is a widespread and remarkable tendency to resort to the use of drugs of the
sulfonamide series in the treatment of skin affections. This is reflected in a number of
abstracts in the 1943 Year Book of Dermatology and Syphilology1. Also reflected here
is a fact of much greater significance, which the medical profession in general appears
to ignore or minimize; that is the frequency with which these drugs, whether used topically or orally, produce serious cutaneous and other reactions. These reactions are often
of greater moment and more disabling than the condition for which the remedy was
employed.
In the 1943 Year Book there are abstracted 15 papers which deal exclusively with
the use of sulfonamides in treating various dermatoses. Of these 11 contain cautionary
or critical comments directed against the indiscrirninate use of these drugs, and 7 deal
exclusively with the undesirable reactions which they frequently evoke. In addition to
these abstracts there are interpersed 5 editorial comments, to be summarized later,
strongly condemning the widespread indiscrirninate use of sulfonamides in cutaneous
disease.
H. N. Cole2, while admitting that sulfonamides have given brilliant results in certain superficial pyogenic infections, questions the advisability, of- their use unless other
well-tried medications have failed, and states that since their local use in high concentration is more liable to sensitize the individual they should not be used over a period
of more than 5 days.
Arne Ingels3 in a series of 300 cases primarily due to or secondarily infected with
pyogenic organisms, treated with topical applications of sulfathiazole or sulfadiazine,
reported sensitivity reactions in 3.3% of his cases.
Livingood and Pillsbury4 in reporting 12 cases of eczematous pyodermia treated with
sulfathiazole considered that chronically eczematized conditions were those most apt to
show sensitization reactions. These occurred only in those cases where the drug was
used for 5 days or more.    They state emphatically that sulfathiazole ointment should
Page One Hundred and Eighty-eight not be used to treat eczematous lesions with secondary pyogenic infection, or chronic
impetiginous dermatitis which has become eczematous. They also point out that since
when improvement occurs in pyogenic infections it does so early there is no necessity for
its prolonged application.
Costello, Rubinowitz and Landy5 state that toxic reactions to sulfathiazole are relatively frequent. The most common are fever, dermatitis and bilateral conjunctivitis.
The most common combination is fever and dermatitis. Twenty-one out of a group of
196 dermatological patients treated with sulfathiazole developed skin eruptions of various
types. They considered that in these patients there appeared to be little relationship
between the duration of sulfonamide therapy, total quantity of drug given and the
occurrence of toxic reactions. , * |
R. G. Park6 considered that the fact that he saw 12 cases in one hospital in three
months suggested that hypersensitivity to local applications of sulfathiazole was not
uncommon.
While the dermatitis resulting from sulfonamide sensitization is usually an explosive
"id"-like generalization, Shaffer, Lentz and McGuire7 observed in some cases a localized
dermatitis, appearing as an exacerbation of the eruption for which the patient was being
treated.
Robert8 observed similar localized sensitization phenomena as reported by trie last
observers, and stated further that in the deeper staphylococcic forms such as sycosis
vulgaris, sweat-gland abscesses and furunculosis, action of the sulfonamides is uncretain,
while in the superficial forms it is not superior to the time-proven remedies, such as
white precipitate ointment, etc.
In their comments made in connection with the 15 abstracts, the editors (Sulzberger
and Baer of the New York Post-Graduate Medical School and Hospital respectively)
state at the outset that they believe sulfonamides "should not be used in the routine
treatment of such non-dangerous, self-limited superficial infections as impetigo, folliculitis, ordinary boils, etc." Theq seriously question in what respects a 5% sulfathiazole
cream (while admitting that it will cure impetigo) is superior or inferior to the classic
older measures. They answer this question in part by stating that "because of the
dangers of sensitization and serious reactions in a certain percentage of patients, external
therapy with sulfonamides should in the editors' opinion be restricted to those dermatoses
which are severe, recalcitrant and not responsive to older orthodox methods."
The combined reactions of fever and generalized dermatitis, which not rarely result
from unjustifiable or improper use of sulfonamides are serious from an economic point
of view. They often result in confining a patient to bed for several weeks, whereas the
cutaneous disease which they were supposed to cure was not in any significant degree
disabling.
The sensitization resulting from the topical use of sulfonamides may be much more
serious for another reason. Several of the authors quoted, and the editors also, draw
attention to this. The sensitization produced in this manner may persist for a long
time. No author has been consulted yet who is willing to set a limit to this time; some
have expressed an opinion that it may be permanent. Not only does this preclude the
subsequent external use of the drug but later oral administration also may evoke cutaneous or other and more serious reactions. As Cole2 says: "Such a reaction may preclude
use of the drug later as a life-saving measure in pneumonia or bacteriaemia." The editors
remark upon the "powerful combined or synergistic effects of local application followed
by oral administration." Cohen, Thomas and Kalisch9 reported two cases of varicose
eczema of the legs, with large denuded areas to which sulfathiazole ointment had been
applied for a short time. Fever and generalized eruption developed, which subsided
upon withdrawal of the drug. In both cases the rash was reproduced subsequently by
ingestion of small doses, in one instance the cutaneous reaction being generalized within
6 hours after only gr. Ys had been taken.
The experience of the present writer in the past few years since sulfonamides, and
particularly sulfathiazole ointment, have come into general use has closely paralleled
Page One Hundred and Eighty-nine that of the writers referred to above. All of the above reactive phenomena which they
have noted have been observed in varying degrees of intensity and extent repeatedly. In
the last two years such reactions, if not a matter of daily observation, have certainly
been observed on an average of more than once weekly. At one time early in 1943
there were 4 cases of generalized cutaneous eruption, all with fever ranging up as high
as 103° and considerable prostration, following the use of sulfathiazole locally and/or
orally, all in hospital under my care at the same time. This means at a conservative
estimate not less than 60 hospital-bed-days, probably more, and in no case would the
condition for which the sulfathiazole had been used have required any hospital care.
It would appear that among a considerable proportion of the doctors in practice the
truly marvellous response of some bacterial diseases, some hitherto regarded as hopeless,
to sulfonamide therapy has entirely unseated their critical powers of judgment in respect
to these drugs. They have come to regard sulfonamides as a gift from Heaven when
they are confronted with any baffling therapeutic problem. Among these problems, as
I have before had occasion to remark, skin diseases form a large proportion. It would
appear to have been forgotten that the sulfonamides have been found to be of use only
in a certain number of bacterial infections. They have not been found to be of the
slightest value in virus or mycotic infections. Nevertheless they are daily applied in
cutaneous conditions where a minimum of investigation and thought would have shown
that bacterial invasion played little or no part whatever. Among conditions in which
I have found them ordered within very recent months are eczema, contact dermatitis,
varicose eczema and ulcers, acne, herpes zoster, herpes simplex and ringworm. They are
also used in the commonest and most trivial infections, where five years ago the doctor
would have resorted without hesitation and with a considerable measure of success to
time-tried remedies which are just as valuable today as they ever were.
In spite of the unqualified comment of some authorities that sulfathiazole will cure
impetigo, I have seen several cases of impetigo in which a sulfathiazole ointment (prepared by reliable pharmaceutical manufacturers and therefore presumed to possess the
correct physical properties which an ointment of this sort should have, and as important
for successful use as the active principle contained) had failed to give successful results,
but which were cured promptly by the proper use of a well-designed white precipitate
formula.
Warnings have not been wanting ere this. Such articles as those which have been
quoted from have been appearing in increasing numbers, from the pens of men occupying the most authoritative positions in dermatological study and teaching. These articles
have not been confined to publications devoted to a specialty but have with rare exceptions appeared in the journals having the widest circulation in Canada, Great Britain and
the United States.
As a result of what one can only call the profligate employment of sulfonamides,
particularly in forms adapted for topical medication, available to the public in every
drugstore, the people have followed the lead of the medical profession, and it is very
common to find patients resorting to self-medication with the "new miracle-drugs'' in
ointment, powder and pill form, to treat any and all skin disorders, just as they are
using the pills for colds and sore throats and "rheumatism."
The cases which I encounter follow a general pattern more or less closely. They
have had a sulfathiazole ointment prescribed with little or no good reason for some
skin disorder. After using it for a week or longer, often over extensive areas, sometimes
with temporary benefit, the.trouble has become worse. Sometimes the original eruption
has appeared to be extending much beyond its original confines, or there has instead
been a generalized eruption developing suddenly with a morbilliform, later scarlatiniform
character, accompanied by malaise or prostration, chilliness and elevated temperature.
The blood-concentration^ of the drug has not been significantly elevated. Often about
the time that it became apparent that the original skin trouble was getting worse instead
of better the topical medication has been augmented by oral sufathiazole medication.
This had the very prompt effect of precipitating an explosive type of generalization.
Page One Hundred and Ninety In one instance where sulfathiazole ointment had been used for some months without producing any effect, good or bad, on a varicose dermatitis, the patient developed a
common cold with sore throat and coryza. The administration of sulfathiazole tablets
resulted in rash and fever, whereupon a diagnosis of measles was made and the patient
sent to hospital. Other similar sequences have been observed in which there had been
an interval of several weeks between the discontinuance of topical medication and oral
administration. More rare have been the cases in which several weeks or months after
the internal use of sulfathiazole, the drug in ointment form had been used on the skin
with the almost immediate production of an acute and spreading dermatitis.
As to the value of sulfathiazole, the drug most commonly implicated, there can be
no question when it is used under proper indications. But it is impossible to overemphasize the fact that contrary to the apparent general assumption it is no panacea for
skin diseases. In the writer's apprehensions the time may not be far distant when these
drugs, to say nothing of the members of the profession who prescribe them indiscriminately for cutaneous and numerous other afflictions, will be discredited by a considerable
and disproportionately vocal number of the people.
REFERENCES:
1. Chicago: The Year Book Publishers, Inc., 1944.
2. /. Am. Med. Assoc, 123:411, Oct. 16, 1943.
3. Calif. tf West. Med., 58:269, May, 1943.
4. /. Am. Med. Assoc, 121:406, Feb. 6, 1943.
5. N. Y. State J. Med., 42:2309, Dec. 15, 1942.
6. B. M. /., 2:69, July- 17, 1943.
7. /. Am. Med. Assoc, 123:17, Sept. 4, 1943.
8. Schweiz. vied. Wchnscbr., 73:627, 1943.
9. /. Am. Med. Assoc, 121:408, Feb. 6, 1943.
NATIONAL FOUNDATION FOR INFANTILE PARALYSIS
Realizing the acute need for physical therapy personnel, partly resulting from the
war, The National Foundation for Infantile Paralysis has just made a two-year grant
totaling $34,080 to the Stanford University School of Health (Women) at Stanford
University, California, it is announced by Basil O'Connor, president of the National
Foundation.
This grant, which is in addition to other funds given by the National Foundation
to this University, is for the two-fold purpose of strengthening the physical therapy
technicians' school and of preparing syllabi and text materials for the use of physical
therapy instructors and their students.
Under this programme selected students will be provided specialized training designed to prepare them to become skilled teachers of physical therapy.
"The 1943 epidemic of infantile paralysis emphasized the serious lack of physical
therapy technicians and qualified teachers," Mr. O'Connor said. "It would seem that
the success of any attempt to develop a satisfactory corps of technicians in the United
States would depend to a considerable extent on having adequately trained instructors
engaged in teaching this subject, and suitable text materials."
Page One Hundred and Ninety-one PENICILLIN IN WAR WOUNDS
A Report from the Mediterranean
(Unsigned) Lancet, 2, 742.
THE TREATMENT OF WAR WOUNDS WITH PENICILLIN
By L. P. Garrod
British Medical Journal, 2, 755-756, 11/12/43
These are reviews of "A preliminary report to the War Office and the Medical Research Council on investigations concerning the use of penicillin in war wounds. Carried out under the direction of Professor H. W. Florey and Brigadier Hugh Cairns."
This memorandum, published by the War Office in London, has a limited circulation and
is not generally available.
Work ni England and America had established that among the organisms most sensitive to pemcillin were three of those most damaging in war wounds—Streptococcus
pyogenes, staphylococci and the Clostridia. It had further amply established that infections by the pyogenic cocci, however severe, could usually be controlled by penicillin.
When penicillin was taken to the Mediterranean theatre of war, therefore, the object
was not to establish its effectiveness, but to ascertain the best and most economical
.methods of use to prevent sepsis in battle casualties. The principles of use were those
already established in the laboratory and clinic. As supplies of the drug were extremely
limited, attention was always directed to using the smallest amount. In this series, therefore, parenteral,injection was reserved for those in whom local application could not be
expected to reach all infected areas, although with plentiful supplies many more patients
would probably be treated parenterally.
The technique of local application was studied fully. It was not found possible to
compare the results with those obtained by current methods of treatment, but it appeared that in the ordinary way large numbers of the more serious war wounds became
infected. The effectiveness of the sulphonamides, which were widely used for battle
casualties, was still neither established nor disproved.
Chronic sepsis. The first patients treated had septic wounds from 3 weeks to 4
months old, none of which had responded to sulphonamides. Considerable success was
obtained in soft tissue wounds by local application of penicillin; bacteria disappeared and
the wounds became clean. Compound fractures were beyond the effective reach of
local applications, but some recovered on parenteral administration. In others, the
extensive suppuration was maintained by insensitive organisms after those sensitive to
pemcillin had been eliminated. It was felt that to treat sepsis at this stage was wasteful
of penicillin and of man-power, both military and medical, and the next series was
treated at the Forward Base Hospital.
Recent soft tissue wounds. Current army practice was to excise the wound at the
Casualty Clearing Station and leave it open. At the Forward Base Hospital some of the
cleanest wounds were then sutured, but many were allowed to heal by granulation,
folowed lated in some cases by delayed suture or grafting. Nearly all such wounds contained pathogenic organisms, and many became septic. The technique for using penicillin in soft tissue wounds at the Forward Base Hospital was as follows. After conservative excision, the skin in particular being as far as possible preserved, the skin was
undercut to mobilise the edges. The wound was closed by deep skin sutures, occasionally
with muscle sutures in addition. From 1 to5 fine rubber tubes were inserted through
stab holes or through the incision, reaching to the base of the wound and protruding
through the dressings at the free end.   Three cm.3 of a 250 unit per cm.3 penicillin solu-
Page One Hundred and Ninety-two tion were injected immediately through a syringe attached to each tube, and thereafter
12-hourly for 4 or 5 days. Many wounds were healed in 10 to 12 days, and by 3 weeks
complete healing had taken place in 104 out of 171 cases and incomplete healing (i.e.
with a small area of granulation in some part of the wound) in 60 more. Only 7 cases
were classified as failures. Pus due to Ps. pyocyanea, B. proteus or coliform organisms
was often formed, but it caused no inflammatory reaction and did not delay healing
unless there was a dead space in which it could occumulate.
Even the largest wounds healed completely when treated in this way. There was
general agrement that healing was complete in about half the customary time, and that
scar formation and permanent disability were very greatly reduced. It is emphasized
that under no circumstances should a wound be sewn up in this way in the forward
areas, but only in a hospital where the patient can remain.
In another series of patients penicillin-sulphonamide powder, 5,000 units per gram,
was insufflated at the Casualty Clearing Station, and suture with tubes, or powder insufflation, was carried out at the Forward Base Hospital. About half the wounds were
sterile when received at the Forward Base Hospital; the final result as regards healing
was similar to that of the first group.
Compound fractures. These were too extensive for local treatment, and were treated
by parenteral administration after suture of the wounds. About 100,000 units of penicillin were given daily for the first 3 days and 50,000 for 2 days more. /On this dosage
the less serious fractures did well, but some failures were recorded, particularly in fractured femur. Out of 31 patients, complete skin union occurred in 16, partial union in
10, and failure in 5. It seemed clear that with a larger dose better results might be
achieved, and a total of 700,000-1,000,000 units in 5-10 days for femur and tibia, and
of 500,000 units for other fractures, was recommended for future use. Preliminary
treatment with penicillin powder at the Casualty Clearing Station was an asset in achieving a good result, and it was recommended that penicillin in the forward areas should be
reserved for compound fracturse. ■ Y,^,
Gas gangrene. Seven patients were' treated parenterally and 4 recovered. In 2 who
died the infection had been arrested and death was caused by toxaemia. It was concluded
that penicillin should not obscure the necessity for excision of all dead muscle and for
giving doses of anti-gas-gangrene serum. Its greatest use for gas gangrene would probably be as a prophylactic.
Head wounds. As the results of current methods of treating fresh head wounds were
very good, penicillin was reserved for penetrating wounds more than 3 days old. Of
23 wounds from 3 to 12 days old, almost all were infected with grampositive pyogenic
organisms and about half were suppurating. The principle of closure with tubes was
employed. Twenty cases healed satisfactorily and three died. In one of these the infection had been controlled, in another only coliform organisms were present at autopsy,
and the third, with an*8-day old brain wound containing pneumococcal abscesses, received too little penicillin.
Other groups of cases. A few cases of spinal cord injury and of burns infected by
sulphonamide-resistant streptococci were treated with good results.
Ten cases of gonorrhasa, 9 of them sulphonamide-resistant, were treated with an
arbitrary dose of 12 injections in 48 hours, totalling 180,000 units. Immediate cessation
of discharge, "like turning off a tap," was invariable. There was no relapse during the
time of observation (2 to 4 weeks).
LIQUOR PRESCRIPTIONS
It is requested by the Liquor Control Board that all prescriptions for liquor contain
the name and address of the patient for whom liquor is prescribed, the name and address
of the physician prescribing same and the date on which the prescription is issued.
Page One Hundred and Ninety-three NEWS    AND    NOTES
Dr. and Mrs. A. E. Davidson of Essondale are receiving congratulations on the birth
of a son born on April 25 th.
3fr 3fr 3fr 3fr
Congratulations are extended to Dr. and Mrs. Gordon Stone house of Vancouver on
the birth of a daughter, April 1 Oth.
«F ^ ^ *F
Dr. R. G. D. McNeely was married in Toronto on April 26th.
* *      *      #
Dr. J. B. Swinden of White Rock was married to Mrs. Jean Nevill on April 29th.
* *      *      *
Capt. W. J. Endicott, R.C.A.M.C, who has been stationed at Vernon Military Hospital, spent a few days' leave with his family in Trail.
* *      *      *
Capt. F. L. Wilson, R.C.A.M.C, has been in Trail during bis two weesk' leave.
* *      *      *
Dr. D. T. R. McColl of Queen Charlotte City was in Vancouver and called at the
office.
* *      *      *
Dr. A. E. Kydd, who is associated with Dr. C. E. Cook at Michel, was in Vancouver
recently.
* *      *      *
Dr. Gordon McL. Wilson has taken up practice at Kelowna.   Dr. Wilson was recently
discharged from the R.C.A.M.C
* *      *      *
Dr. L. A. C Panton, on his return from Vancouver where he attended the meeting
of the Board of Directors and the special meeting on Health Insurance, stopped off
at Little River and joined Dr. J. S. Henderson of Kelowna for a little fishing party.
They had a good rest but we have no report on the total number of fish brought to net.
A 4& 3& *'-
•V n? v ^
Dr. W. F. Anderson of Kelowna attended the meeting of the American College of
Surgeons on April 18 th and the special meeting on Health Insurance on April 19 th during his visit in Vancouver.
•fr *r *f ■!*
Dr. R. B. White of Penticton visited Vancouver recently.
* *      *      *
It is-reported that Dr. Hugo Emanuele, who was associated with the late Dr. H.
McGregor in the practice at. Penticton in the absence of Flight-Lieut. H. B. McGregor,
is planning to open an office and set up practice in Penticton.
Dr. W. H. B. Munn, who was associated with Dr. Emanuele since the death of the
late Dr. H. McGregor, is carrying on the practice in the McGregor office.
—. ««. a a
t ^ ~ ~
Dr. G. C. Paine of Penticton is, according to reports, busily engaged in practice and
enjoying a good measure of good health.
*      *      *      *
Surg. Lieut. Commander F. P. McNamee, formerly of Kamloops, has arrived at the
Coast recently.
Page One Hundred and Ninety-four It has been decided to form a society to be known as the Kamloops an4 District
Medical Society. During the past year the medical personnel of the Sanatorium at
Tranquille attended many of the regular staff meetings at the Royal Inland Hospital at
Kamloops. At a meeting in November, 1943, it was decided with the consent and
approval of the staff at Tranquille that this joint medical society be formed.
Those in charge of the Society are hoping that many of the men from nearby towns
will find it convenient to attend and contribute to the success of the meetings, which
will be held monthly. They have been invited to attend and will be given a cordial
welcome.
We are glad indeed to report that Dr. M. J. Keys of Victoria is well on the way to
recovery from a rather serious illness.
Dr. J. W. Lennox, President of the Victoria Medical Society, has recently become a
grandfather.   Mrs. Hewitt, the former Jean Lennox, has just had a new baby.
Capt. R. C. Newby, R.C.A.M.C., was in Victoria saying farewell to his friends prior
to leaving this district.
•r «r *fr *F
The last meeting of the Board of Directors of the British Columbia Medical Association was held on April 19th. Drs. P. A. C Cousland, President; G. F. Amyot, F. M.
Bryant and Thomas McPherson of Victoria attended. Others who came to Vancouver
for the meeting were: Doctors C. H. Hankinson, Prince Rupert; G. A. McLaughlin,
North Vancouver; A. H. Meneely, Nanaimo; D. J. Millar, North Vancouver; L. A. C
Panton, Kelowna; P. L. Straith, Courtenay, and J. S. Daly, Trail.
The announcement was made that Dr. M. G. Archibald of Kamloops had been
selected as Senior Member in the Canadian Medical Association, which honor would be
conferred upon him at the annual meeting in Toronto.
Dr. P. A. C. Cousland of Victoria was nominated for election as representative from
British Columbia on the Executive Committee, C.M.A. Dr. A. Y. McNair of Vancouver, first vice-president, was nominated for election as alternate representative from
B. C on the Executive Committee, CM.A. Dr. A. H. Spohn of Vancouver, who is the
present representative on the Executive Committee, C.M.A., was selected for appointment to the Nominating Committee of the CM.A.
Dr. J. R. Neilson, Chairman of the Committee on Programme, announced that the
1944 Annual Meeting of the British Columbia Medical Association would be held in
Victoria with headquarters at the Empress Hotel during four days, September 26th, 27th,
28th and 29th.
A large meeting of the profession was held on April 19th in the Hotel Vancouver.
Dr. Cousland of Victoria, President of the Association, acted as Chairman.
Dr. G. F. Strong, Chairman of the Committee on Economics., led the discussion,
which was centred on the Twenty Principles of Health Insurance, which had been prepared by the Committee on Economics and approved by the Board of Directors of the
British Columbia Medical Association. Considerable discussion ensued and many questions were asked and answered. In the end the Twenty Principles with slight modification were endorsed by the meeting.
Many members from out of town, who had been in Vancouver attending the meeting of the Board of Directors, and others who had come especially to attend this meeting on Health Insurance and had during their stay in Vancouver attended the military
sessions on the previous day of the American College of Surgeons, participated in the
meeting, which comprised representatives from practically every part of the Province.
A number of officers in uniform were present and took part in the discussion.
Page One Hundred and Ninety-five The annual meeting of the Council of the College of Physicians and Surgeons was
held in the Council offices, 203 Medical-Dental Building, Vancouver, on Monday, May
1st.   Dr. F. M. Bryant presided.
Many matters were dealt with during this long session. The elections placed the
following in office for this year:
President, Dr. H. H. Milburn, Vancouver.
Vice-President, Dr. F. M. Auld, Nelson.
Honorary Treasurer, Dr. G. S. Purvis, New Westminster.
Chairman of the Committee on Health Insurance, Dr. Thomas McPherson, Victoria.
Chairman of the*Committee on Economics, Dr. H. H. Milburn, Vancouver.
Chairman of the Legislative Committee, Dr. Thomas McPherson, Victoria.
Representatives on Board of Directors, British Columbia Medical Association: Dr.
F. M. Bryant, Victoria, and Dr. G. S. Purvis, New Westminster.
Dr. E. J. Lyon of Prince George, who has been appointed by Council to complete
the unexpired term and fill the vacancy caused by the death of the late Dr. Osborne
Morris of No. 4 District, was welcomed to his first meeting of Council.
On Tuesday, May 2nd, the Council held a conference with the Chairman and members of the Workmen's Compensation Board, and discussed a number of matters of
interest to both the profession and the Board. It was felt that such conferences will be
mutually helpful.
*
Squadron Leader Neil A. Stewart has been recently demobilized and has resumed
practice in Vancouver. Doctor Stewart is now in charge of the practice of Dr. A. J.
MacLachlan. We are pleased to report that Dr. MacLachlan is making a splendid
recovery and has benefited by several weeks' rest.
Among those from out of town who were in attendance at the meeting of the
American College of Surgeons and the Special Health Insurance Meeting held in Vancouver were: Drs. D. W. Beach of McBride, J. G. MacArthur of Prince George, H. J.
Alexander of Vernon, R. W. Irving and J. S. Burris of Kamloops, E. W. Boak of Victoria and R. G. Knipe of Prince Rupert.
Among recent promotions were Lieut. Col. K. L. Craig, R.CA.M.C, and Major R.
A. Wilson, R.CA.M.C.
The Upper Island Medical Association held its Spring meeting at the Ben Bow Inn,
Qualicum Beach, on May 4th. In the absence of Major S. L. Williams, R.CA.M.C, who
is president of the Association, the vice-president, Dr. E. D. Emery of Nanaimo, presided. Dr. C. C. Browne is the energetic secretary and is responsilbe for keeping the
Association very active.
The speaker of the evening, following an excellent dinner, was Dr. P. L. Straith of
Courtenay, who dealt with Gall Bladder Disease. Dr. M. W. Thomas, Executive Secretary of the College of Physicians and Surgeons, was present and discussed with the
members certain live topics of interest at this time and answered a number of questions.
Those, present included Doctors G. K. MacNaughton, Cumberland; P. L. Straith
and T. A. Briggs of Courtenay; Surg.-Lieut. Arbour, R.C.N.V.R.; E. N. East, Qualicum; R. W. Garner, G. B. Helem, A. P. Miller, W. C Pitts of Port Alberni;.Capt. N.
H. Jones, R.CA.M.C, formerly of Port Alberni; C C Browne, A. B. Hall, E. D.
Emery, A. H. Meneely of Nanaimo; H. G. Garrioch of North Battleford, Sask., who
Was visiting Dr. Meneely.
Page One Hundred and Ninety-six GOLF
The first golf tournament of the 1944 season was held on Marine Drive Golf Course
on Thursday, May 11th. In spite of overcast skies at noon, 40 golfers participated in the
afternoon play. Dinner was held at the Clubhouse in the evening and a goodly number
remained to watch the presentation of prizes which took place there.
The best prize of the day went to that perennial winner of golf prizes, Dr. S. C.
Peterson, whose 66 was the low gross for the day; he received a tobacco humidor.
The low net was a 66 turned in by Dr. Burroughs, one of the internes at the General
Hospital; his prize was a pair of tone-ray goggles.
The best drive was also won by a member of the interne staff, Dr. Charlton, who
received a sterling silver Foxhole lighter.
The scores will be carried forward to determine the winners of the Ramshom trophy
and the Macdonald trophy.
The next tournament is planned for the third Thursday in July, and it is hoped more
of the men will take the time to attend this tournament.
Nurnt & Styflmaott
t
2559 Cambie Street
Vancouver, B. C.
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian
circulation and thereby encourages a
normal menstrual cycle.
• MARTIN H. SMITH COMPANY
fc^ ISO IMAYtm STMT. MfW TOM. N. T.
Full formula and descriptive
literature on request
Dosage: 1 to 2 capsules
3 or 4 timet 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.
Page One Hundred and Ninety-teven \
-^u
*\-
H
\*
«„s
Jmm.
B" COMPLEX
■#s
*fi
♦ Tablets, Concentrate or Injectable for
severe deficiencies ... Compound, Liquid
or Granules for the lesser deficiencies.
This range of forms and potencies enables
you to treat every B deficient patient
according to his individual requirements.
1. TABLETS 4. COMPOUND
2. CONCENTRATE     5. LIQUID
3. INJECTABLE 6. GRANULES
202A
AYERST, McKENNA & HARRISON LIMITED • Biological and Pharmaceutical Chemists • MONTREAL, CANADA Hi
ItteTteta
ORTHO
essential set
in a convenient prescription package
pi
The sleeve type label on the Ortho Essential Set package has been-specially
designed so that it can be readily removed to make a plain package for your prescript
tion. The Set includes ... Q package Ortho-Gynol with removable label...
Ortho Diaphragm in specified'size ... Universal type Introducer.
\
ORTHO PRODUCTS
OF CANADA LIMITED
MONTREAL WYETH
A FOOD SUPPLEMENT
Dapta* with tnillr will supply all the established vitamin and mineral recruirements (except vitamin C).
An aqueous  extract of
added vitamins A, Bi, D,
Each 4 c.c. contains:
Vitamin A      «
Vitamin D
Thiamine Hydrochloride
Pyridoxine
Calcium Pantothenate
Niacin -
Choline
Iron
Iodine
Riboflavin
rice  bran  with
Iron and Iodine.
40001.U.
400 LU.
748 gamma
400 gamma
2500 gamma
7500 gamma
10000 gamma
7500 gamma
100 gamma
t
«£&
tyeSh,
<S.
*■**£'«*»«■«■
*«»«
«tcoi
'^EMENDUH*
"OLISX
New!'
50 ex. SIZE
with dropper
also In 120 cc.
size
f Riboflavin, Calcium and Phosphorous axe present
in adequate quantities in milk. Dapta with milk
requires no other vitamin ox mineral supplement
except vitamin d
DOSAGE:
Infants—2-3 drops (2 min.) in each oz.
of milk formula. 1 teaspoonful with 1 qt.
of milk or milk formula daily.
Children—1 teaspoonful daily with 1 qt.
of whole milk.
Miscible with Milk
Palatable
Proper Potency
Stability Assured
Economical
S M A—BIOCHEMICAL DIVISION
John Wyeth & Brother (Canada) Limited
Walkerville - Ontario
* TRADE MARK REGD IN CANADA FATHERS OF CANADIAN MEDICINE
*ONE  OF  A  SERIES
PHYSICIAN AND SURGEON
(1659-1734)
SARRAZ1N was the most famous physician and
surgeon of his day in Canada, in addition,
he achieved distinction as a naturalist. He was
born in Nuicts-sous-Beaune, in Burgundy, France,
in 1659. He obtained his medical degree at the
University of Rheims. The year 1686 found him
serving as Surgeon Major of the French troops
at Quebec where he remained and entered into
the life of the colony.
He was chosen as physician of PHopital General by the Sisters in 1693. A year later he returned to France for further study. Returning
to Canada aboard the "Gironde", he fought a
severe outbreak of typhus and saved many lives
including that of Mgr. de St. Vailier, Bishop of
Quebec and founder of the Hotel-Dieu, Quebec.
Papers written by Sarrazin on Canadian wild
life earned him membership in the Royal Academy oi Sciences (France). These works included
anatomical studies of the lynx, muskrat, deer,
moose, porcupine and the beaver. He catalogued 200 Canadian plants and also wrote a
treatise on the production of maple syrup.
Sarrazin operated for what is believed to
have been cancer on the persons of Sister Marie
Barbier and Sister Elizabeth Cheron. He is reported to have performed several similar opera-
Wl LUAM  R.
tions and "others more difficult". He is credited
with the introduction of the pitcher plant (Sar-
racenia Canadensis) for the treatment of smallpox.
This great pioneer .physician and surgeon received little or nothing from his patients. As
Doctor of the King, he was granted 300 livres a
year and even when this was increased to 600
livres, Sarrazin was so hard put that he expressed a desire to leave the colony. To prevent
his departure and augment his income he was
made a member of the Superior Court, later,
his emolument was increased to 2,000 livres per
annum.
Still active at 75, Sarrazin fell ill and died of
hemorrhagic smallpox at the Hotel-Dieu, Quebec, on September 8th, 1734, after two days'
illness. 'v/*. J
The example set by men of character by Sarrazin, In helping to established the practice of
medicine in Canada on a
sound foundation inspires
this company }o maintain
with unceasing vigilance its
policy — Therapeutic Exactness and Pharmaceutical
Excellence.
4 COMPANY HO.
THE SYMBOL OF
PHARMACEUTICAL
EXCE LLENCE
Manufacturing Pharmaceutists
727-733 j|lNG   STREET WEST,   TORONTO
1856 -1944 Creamd^^l^^K^^^l^es stomach hyperacidity by adsorption.
The effect is, persistent. It does not
provoke a secondary rise" in hydrochloric acid, such as is common after
alkalies, nor does it disturb the
acid-base balance of blood plasma.
^gl Relief is promptly secured and
for symptoms caused or
accompanied by gastric
hyperacidity
maintalneo^PP^I^^^^ic'e' the
very extensive application of||ll|
highly useful agent In the management of peptic ulcer and symptoms
caused by gastric hyperacidir^S
•
Supplied in
8 oz., 12 oz. bottles.
Reg. U. S. Pat. Off. and Canada
Brand of ALUMINUM HYDROXIDE GEL
NON-ALKALINE ANTACID THERAPY
.WINTHROP.
Ill*       *
INTHROP   CHEMICAL   COMPANY, UnC.
Pharmaceuticals- of merit for the physician
General Offices: WINDSOR, ONT.
Quebec Professional Service Office: Dominion Square Building, Montreal, Que. Ferrochlor Liquid, with or without
Vitamin Bi, E.B.S., is supplied in
one pound bottles, Winchesters and
gallons, and Ferrochlor Tablets,
with or without Vitamin Ei, E.B.S.,
are supplied in bottles of 100, 500
and 1,000.
When prescribing Ferrochlor in any
of the above mentioned forms, always
insert the identifying letters "E.B.S."
following the word Ferrochlor—
Thus—
]$ Ferrochlor Bi E.B.S.
Slg.—-as directed.
FOR     PRESCRIBING
FERROCHLOR
WITH Bi E.B.S.
IN SECONDARY
-.1 ANAEMIA
In Ferrochlor with BI, the iron
is present in the readily absorbed ferrous state, rather than
the biologically incompatible
ferric form.
In Ferrochlor with BI, the use
of a soluble iron salt obviates
the need for using up ... to
dissolve the iron . . . the precious acid of the achlorhydric
stomach, typical of many
anaemias.
i
Li Ferrochlor with BI, the
unpleasant taste of ferrous
chloride is successfully masked,
thus removing one hindrance
to having patients complete a
prescribed course of treatment.
In Ferrochlor with BI, the
addition of thiamin chloride
ensures that there will be no
slowing down of iron absorption through poor intestinal
tonus. Moreover, general muscular tone is so improved that
the patient feels better—a big
help in successful treatment.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING CHEMISTS VITAMIN W
COMPLEX
DEFICIENCY
4UMfteftQ44&
• The signs and symptoms of
vitamin B complex deficiency
are widespread and may involve
the skin, eyes, nervous system,
cardiovascular apparatus, and
gastro-intestinal tract.
Betaplexin is serviceable both for
treatment and for prevention of
deficiency of the various factors
comprising vitamin B complex. It
is supplied in convenient forms.
WINTHROP
ETAPLEXiN
Wudltfiop.
CHEMICAL COMPANY, INC.
Pharmaceuticals of merit
for the physician
Trademark Reg. U. S. Pat. Oil. & Canada
Brand of VITAMIN B COMPLEX
ELIXIR
SYRUP
TABLETS
CAPSULES
GENERAL OFFICES: WINDSOR, ONTARIO p jp^p^^^p^p^
Quebec Professional Service Office: Dominion Square Building, Montreal, Que. flfeount peasant XHnoertakino Co. %tb.
KINGSWAY at 11th AVE. Telephone FAirmont 005S VANCOUVER, B. C.
R. F. HARRISON W. E. REYNOLDS
PRIVINE
Trade Mark Reg'd.
POTENT VASOCONSTRICTOR FOR PROLONGED RELIEF OF
NASAL CONGESTION
PRIVINE acts quickly to clear nasal congestion due to Colds, Hay Fever,
Rhinitis and Sinusitis. Its markedly prolonged duration of effect is
outstanding. PRIVINE solution meets all requirements for modern
nasal medication. The isotonic and buffered solution restores the
normal pH of the nasal mucosa and maintains ciliary activity.
PRIVINE applied either by drops or nasal spray is preferred due to its lack
of local or systemic side-effects. Now available in a 1:2000 solution in bottles of 1 oz. and 8 ozs. at no increase in cost per dose
to the patient.
Literature and samples on request.
C IDA
' & MONTH 1
MONTREAL, CANADA s
$
R
Patient was discovered in the monkey house at the
Tiergarten by one "Iron Hermann", who noticed one
of the occupants wearing spectacles. Investigation
revealed this to be a human.
When first interviewed, a pronounced euphoria was
evident, but the reading of despatches from the
eastern front had a rapid sobering effect and it was
possible to elicit the following;
Father was a noted alcoholic and died of a fall from
a pink elephant. Financial embarrassment and inability
to work, enforced sobriety upon patient until the age
of 23. His first debauch occurred in Munich in 1923
when he participated in a beer hall orgy with a party
of dissolute companions. Following this, he entered
upon a period of prolonged alcoholism, subsisting
mainly upon rubbing alcohol, canned heat and bay rum.
He finally acquired a police post and the steady wages
enabled him to change his beverage to paregoric
While on a spree in July, 1934, he organized a "blood
bath" in which a number of his friends were most
unwilling participants.
He believes that a bomb concussion sent him Mo the predicament in which he was found, but is unable
to understand why his presence in the monkey house should have gone unnoticed for three days.
DIAGNOSIS: Patient was referred to Dr. Ley of "Joy of Living Department", who pronounced him
a clearly defined example of Polandemia (Polish great-grandmother).
TREATMENT:   Dr. Ley suggested  that the  Reich was not altogether suited to the patient's
constitution.   Immediate departure for South America was recommended and Dr. Ley insisted
that he should accompany the patient in order that he might supervise the complete cure.^
Frequent transfusions of pure Aryan blood are to be continued.
HEMATIC HIMMLER, S.S.
FORMULA:
Vitamin A
Vitamin Bt
Vitamin B2
A DIETARY  SUPPLEMENT
Infantol is a complete vitamin supplement for
infants and the aged. It is tasteless and odorless
and mixes readily with milk and other foods.
.    3750 I.U. Vitamin C   .    .      25 milligrams.
200 LU. Vitamin D    .    .    500 LU
500 gammas      Emulsified in a glucose base.
DOSE: One teaspoonful daily.        The cost is moderate.
PACK ACE: 2 oz. and 16 oz. bottles.
P
FRANK W. HORNER LIMITED
?S^£%ft
MONTREAL
CANADA NO WATER' BATH
NO FLAME
When y°u
test
URINOUS**
NOHEATINGf
CUTVIT.FST
As simple as this . • •
1 • Squeeze 5 drops (M c.c.) of urine into test tube.
2* Add 10 drops (H c.c.) of water.
3* Drop one Clinitest Tablet into test tube. Allow
for reaction ... then compare with color scale
which indicates sugar content up to 2 per cent.
JL Mk&t MS all • • • No powder to spill. No measuring of reagents. Test,is made in a matter of
seconds. Is easily done by a physician, laboratory
assistant or patient.
# Apart from forming a container for the diluted urine, the
Clinitest test tube, is a contributory factor toward accuracy in the
tests. According to Matthews' Physiological Chemistry, sixth
edition, page 41... all reducing sugars in warm, strongly alkaline
solutions are oxidized to varying extents by atmospheric oxygen.
When a Clinitest tablet reacts with an aqueous solution, a quantity
of CO2 is liberated. There is some evidence that this gas in narrow
confines of the test tube, acts as a barrier against the entrance of
atmospheric oxygen into the hot alkaline solution.
Write for full descriptive literature. Available through your
surgical supply house or prescription pharmacy.
LABORATORY
UNIT   1
The Clinitest Laboratory
Unit contains 10 vials of
25 tablets each... 250 tests
... a special Clinitest dropper; and instruction book
with color scale. Reasonably priced.
CLINITEST SET NOW $1.75
Urine-Sugar tests by the Clinitest Tablet Copper
Reduction Method, are not expensive. The Clinitest
Set as illustrated, is complete with test tube,
special dropper, tablets for 50 tests, i nstruction
book with color scale, and analysis record. Cost to
patient is now $1.75. Tablet Refill for 75 tests, $1.75.
EFFERVESCENT   PRODUCTS   INC.
FRED.    J.    WHITLOW   &
Sole Canadian Distributors
CO.,   LTD.,    187    DUFFERIN   STREET,
TORONTO ARTHRITIS and ECZEMA
of endogenous origin
claimed to be allergic, wry *>e
favored or induced by calcium
and sulphur deficiency, impaired
cell action, and imperfect elimination of toxic waste.
LYXANTHINE AST1ER
administered per os, brings about
improved cell mrrrrflou and activity, increased elimination, resulting symptom relief, and general functional improvement.
Write for Information
L-17
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,   Montreal
Colonic and
Physiotherapy Centre
Up-to-date Scientific Treatments
COLONIC IRRIGATIONS, SHORTWAVE
DIATHERMY, SINNEWAVE GALVIN-
ISM, IONIZATION, ULTRA VIOLET
RAY, STEAM  BATHS AND SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
Superintendent:
E. M. LEONARD, R.N.
Pott Graduate Mayo Bros.
1119 Vancouver Block
MArine 3723      Vancouver, B.C.
-JpMliBout the.
different bulk action
of this food cereal
ysn
^^
<*4V,
rr"-i
»«.,„
m
dk*
-vs**.-
l-Z^y rnpHE term "bulk laxative"
X covers many types, including laxatives that greatly distend themselves in
the colon.
This is NOT ALL-BRAN'S action. This food
cereal PREPARES wastes themselves for easy,
natural elimination.
For ALL-BRAN is one of nature's most effective sources of cellulosic (bulk-forming) elements.
These cellulosic elements help the friendly flora
in the colon to fluff up and soften wastes, and
prepare them for gentle elimination. This smooth
action prompts many doctors to suggest
Kellogg's ALL-BRAN in cases of constipation
due to lack of bulk in the diet.
Here's another interesting fact. In a University
test, using chemistry students on diets theoretically equalized in amounts of "crude fibre", it
was found that ALL-BRAN was more effective
in bulk-forming properties and satisfactory
laxative action than most of the fruits and
vegetables also tested.
And please remember—Kellogg's ALL-BRAN
is good food in its own right.
!  *PuH reports of experiments are available to doc-
I  tors and others interested. Please send request to:
KELLOGG COMPANY OF CANADA LIMITED, London, OnL
I
1 The label adds nothing
... yet it adds everything
The label adds nothing to the quality
of Irradiated Carnation Milk. But
could an unlabeled can of evaporated
milk ever persuade you that it was
"as good as Carnation"?
The red and white Carnation label
adds everything to the confidence
with which Irradiated Carnation Milk
is employed in the construction of
infant-feeding formulas.
It is accepted as a guaranty of
sterility, digestibility, uniform com
position, and tested vitamin D potency, created by irradiation.
And it stands for certain important
intangibles—the influence of Carnation's experimental dairy farm, the
careful supervision of milk sources by
Carnation field men, and a broad
background of quality-insistence
which, through many years, has built
a name that everyone relies oh...
Carnation Company, Limited
Toronto, Ontario.
IRRADIATED
Carnation
f) iRMounco
STlSv
Milk
^^7        "FROM CONTENTED COWS"      *<$Z^£^?     A Canadian Product
iiiiiiiiiiiiiiiiiiiiiiniiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiitnuiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiMiiiiiiiiiiiiiiiiiiiiiiifiiiiiiiiitiiiiiiuiiiiiiiiuH HOLDING THE LINE ...
It has not always been easy to dispense
every prescription in the face of shortages
and restrictions—it is easier now—-but to
Georgia Pharmacy it^as rarely been an
insurmountable problem.
Phone
MArine 4161
\jLiAi^.JL£^
GEORGIA PHARMACY
(£?tti?rp ^amtalOift
ISTAILISHID 1M1
VANCOUVER, B. C.
North Vancouver, B. C.
Powoll River, B. C.
W^PBP ■H^HuBBu^^HBUBBSu^Hi
■■■■■I ,*0& ^Uttif
HI
*
New Westminster, B. C.
For the treatment of
NEUROPSYCHIATRIC
DISORDERS
Reference—B. C. Medical A$sochtion
For information apply to
Medical Superintendent, New Westminster, B. C
or 721 Medical-Dental Building, Vancouver, B. C.
PAcific 7823
Westminster 28 S
S7

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