History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1945 Vancouver Medical Association Jan 31, 1945

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 The .£.
BULLlgT|M
of the||U •
VANCOUVER
M l|l| C _|L
ASSOCIATION
Witb Which Is Incorporated
^Transactions of the
VICTORIA MEDICAL SOCIETY
the
VANCOUVER GENERAL HOSPITAL
and
ST. PAWS HOSPITAL
In This Issue:
Page
ITEMS OF GENERAL INTEREST   .^. - Jfij. -jf" 94
A MEDICAL SCHOOL FOR BRITISH COLUMBIA-^ 96
CLUB FEET—By Gerald L. Burke, M.D-^^^^^; 99
CASE REPORT ON TULARAEMIA^i
By K. K. Pump, M.D.- ^^^ Sf8gi| 105
THE ARNOLD-CHIARI MALFORMATION—
By Allin Moore, M.D. ;_WJg^yyW
NEWS AND NOTES-._-&-_-_-_-_S--- :Wm-. _________! 113
ANNUAL SUMMER SCHOOL
VANCOUVER MEDICAL ASSOCIATION
IMay 29th to June 1st, 1945 (incl J|
Hotel Vancouver
Vol XXI. No. 4
January, 1945 CALGLUCOL D
E.B.S.
In Calglucol D,E.BS. the
presence of Vitamin D
assures that the body
will be able Cfo fully
metabolize all the calcium made available from
both the Calglucol and
dietary sources.
im&__
[^LGLUeOLD
£2T! »!•___
wTftSMUTTlEWORTH &.
Administered orally
or intravenously ^||p|
Lowered blood calcium is associated with many
diverse ailments: blood coagulation, tetany,
nephritis with uremia, obstructive jaundice,
rickets in children and bone deterioration dtcc-
ing pregnancy and lactation.
Calglucol D, E.B.S; is a useful medium for the
administration of extra calcium whenever the
need arises. Taken by mouth, it helps to relax
bronchial spasm'-and?-by decreasing capillary
permeability^it diminishes the secretions of the
mucosa of Hie respiratory tract.
In Calglucol D, E.B.S. the presence of Vitamin D
assures that the body will be able to fully
metabolize all the calcium made available from
both the Calglucol and dietary sources.
Intravenous injections of Calglucol are a means
of achieving a rapid increase in serum calcium.
Such injections promptly relieve pain in inoperable malignant disease and in lead, ureteral or
biliary colic. Eclampsia frequently yields to
injections of Calglucol D, E.B.S. t
Indicate your preference for E.B.S, preparations when
prescribing, by adding the letters "E.BA.^3
The symbol "E.B.S." denotes full potency; correct standardization; accurate compounding from materials of highest quality. All "E.B.S." preparations are
compounded under strict laboratory control and are available by prescription
from pharmacists throughout Canada.
Tablets or Ampoules
C. T. No* 149 A—Calglucol 3%
E.B.S.fof oral use is available
in the form of tablets, each
containing 10 grains of.ca%
cium gluconate and 500Inter»f
national units of Vitamin Jfj|
in bottles of 100,500 andfiOOO.
For^mjection  purposes: use
Calglucol A-31, E.B.S., whichi
is a 10% solution of calcium
gluconate, supplied in boxes
of 6 ampoulesoflOcc. each.?
' iHiiiWiK' ite
RTSS
THE E. BlSHUnLEWORTiiCHEMICAL G(K LIMITED
TORONTO
MANUFACTURING CHEMISTS
CANADA
^amssm^K -v- v* ^aggggg^ggs THE    VANCOUVER    MEDICAL    ASSOCIATION
BULLETIN
Pulished Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C.
EDITORIAL BOARD:
Db. J. H. MaoDebmot
Dr. G. A. Davidson Db. D. B. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XXI
JANUARY, 1945
No. 4
OFFICERS, 15>44 - 1945
Db. H. H. Pitts
President
Db. Fbank Turnbull
Vice-President
Db. A. E. Tbites
Past President
Db. Gordon Bubke
Hon. Treasurer
Db. J. A. McLean
Hon. Secretary
Additional Members of Executive: Db. G. A. Davidson, Db. J. R. Davies
TRUSTEES
Db. F. Brodie Dr. J. A. Gillespie Dr. W. T. Lockhabt
Auditors: Messrs. Plommeb, Whiting & Co.
SECTIONS
CUn4cal Section
Db. W. D. Keith Chairman Db. S. E. Tubvey Secretary
Eye, Ear, Nose and Throat
Db. Leith Websteb Chairman Db. Gbant Lawrence Secretary
Pcediatric Section
Db. John Pitebs Chairman Db. Harry Baker Secretary
STANDING COMMITTEES
Library:
Dr. S. E. C. Turvey, Chairman; Dr. F. J. Buller, Dr. W. J. Dorrance,
Db. R. P. Kinsman, Db. J. R. Neison, Db. D. E. H. Cleveland
Publications:
Db. J. H. MacDermot, Chairman; Db. D. E. H. Cleveland,
Db. G. A. Davidson, Db. J. H. B. Gbant, Db. W. D. Keith, Db. L. H. Websteb
Summer School:
Db. G. A. Davidson, Chairman; Db. J. C. Thomas, Db. R. A. Gilchbist,
Db. A. M. Agnew, Db. L. H. Leeson, Db. L. G. Wood
Credentials:
Db. D. E. H. Cleveland, Chairman; Db. E. A. Campbell, Db. D. D. Fbeeze.
V. O. N. Advisory Board:
Db. Isabel Day, Db. J. H. B. Gbant, Db. G. F. Stbong
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Dr. G. A. Lamont
Representative to B. C. Medical Association: Db. A. E. Tbites
Sickness and Benevolent Fund: The Pbesident—The Tbustees SORE THROAT"
ACUTE AND CHRONIC TONSILLITIS
PHARYNGITIS
AFTER TONSILLECTOMIES
Aspergum
• In chewing Aspergum, the patient
releases a soothing flow of saliva
laden with acetylsalicylic acid—
bringing the analgesic into prolonged
contact with pharyngeal areas which
often are not reached, even intermittently, by gargling or irrigations.
The gentle stimulation of muscular activity greatly helps relieve local spasticity and stiffness, increasing patient comfort, permitting an
earlier ingestion of nourishing food,
hastening convalescence.
Aspergum is pleasantly flavored
—it is readily accepted by all, in
cluding children and adults of finicky taste.
Ethically promoted—not advertised to the laity. In boxes of 16 and
moisture-proof bottles of 250 tablets. Write for samples and literature to W. Lloyd Wood, Ltd., 64-66
Gerrard Street, East, Toronto, Ont. VANCOUVER HEALTH DEPARTMENT
STATISTICS—NOVEMBER, 1944
Total Population—Estimated      299,460
Japanese Population—Estimated Evacuated
Chinese Population—Estimated  5,728
Hindu Population—Estimated  227
Rate per 1,000
Number Population
Total deaths :     289 11.8
Japanese deaths          Population Evacuated
Chinese  deaths       12 25.6
Deaths—residents   only     247 10.1
BIRTH REGISTRATIONS:
Male,  275;   Female,  256     531 21.6
INFANT MORTALITY: Nov., 1944 Nov., 1943
Deaths under one year of age       16 17
Death rate—per  1,000 births       30.1 28.6
Stillbirths   (not included above)       15 16
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
October, 1944
Cases      Deaths
November, 1944
Cases      Deaths
Dec. 1-15, 1944
Cases      Deaths
Scarlet Fever 	
Diphtheria	
Diphtheria  Carrier
Chicken Pox	
Measles	
Rubella	
Mumps
24
0
0
29
74
2
20
Whooping  Cough       32
Typhoid   Fever	
Undulant  Fever	
Poliomyelitis . .	
Tuberculosis	
Erysipelas	
Meningococcus  Meningitis	
Paratyphoid   Fever    (Carrier)	
Infectious Jaundice	
Typhi-murium  (Carrier)	
Dysentery	
0
0
1
40
1
0
0
6
6
2
0
0
0
0
0
0
0
0
0
0
0
8
0
0
0
0
0
50
1
0
43
153
9
0
37
0
0
0
53
1
0
0
1
0
0
0
0
0
0
0
0
0
•;<>;•
o
0
18
0
0
0
0
0
0
25
0
0
43
90
4
2
8
0
0
0
3
1
0
2
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Syphilis 	
Gonorrhoea
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
Rich- North
Vancouver        Richmond    North Vancr.    Burnaby
         59 0 0 0
 116 0 1 1
West
West Vancr.
0
0
B IOG LAN-A
The most effective therapy for waning mental and physical energy,
deficient concentration and memory, reduced resistance to infection,
muscular -weakness and debility, neurasthenia and premature senility.
The efficacy of this very potent endocrine tonic has been confirmed by
the clinical evidence of many thousands of cases treated during
1932-1943.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page Eighty-nine '**
i*
INSOMNIA
deroteW *«*
0t Actio"—
Dotation
IPRAL    CALCIU
The selection of a barbiturate capable
of producing a long, restful, unbroken sleep
is important. Not all barbiturates are equally
suited for the purpose. Some act rapidly
but their effects are relatively transient.
The various types of barbiturates have
definite spheres of usefulness.
In conditions such as simple insomnia,
restlessness and hysteria, where a sedative
is capable of producing a restful unbroken
sleep, a barbiturate having a moderately
long sedative effect is often preferable.
Ipral Calcium is considered as belonging
to the class of barbiturates which possess
a moderately long duration of action.
Administered orally, approximately an hour
before sleep is desired, one or two 2-grain
tablets are usually sufficient to induce a
6 to 8-hour sleep from which the patient
awakens generally calm and refreshed.
Ipral Calcium is a plain white tablet.
There are no markings of any kind by
which it might be recognized by the patient.
Ipral Calcium (calcium ethylisopropyl-
barbiturate Squibb) is widely used. It is
quite readily absorbed, rapidly eliminated"
and free from cumulative effects when
dosage is properly regulated.
Supplied in %-grain and 2-grain tablets
in bottles of 100; the 2-grain tablets are
also available in bottles of 1000.
For iteraiure write
36 Caledonia Road, Toronto
ERiSopiBB & Sons
of Canada, Ltd.
Manufacturing Chemists to the Medical Profession
Since 1858 VANCOUVER     MEDICAL     ASSOCIATION
FOUNDED 1898    ::    INCORPORATED 1906
•_" 3j* 5_" 5{"
PROGRAMME OF THE FORTY-SEVENTH
ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings will continue to be amalgamated with the clinical staff meetings of
the various hospitals for the coming year. Place of meeting will appear on the agenda.
General meetings will conform to the following order:
8:00 p.m.      Business as per agenda.
9:00 p.m.      Paper of the evening.
February    6—GENERAL MEETING:
Carcinoma of the Cervix—Dr. Ethlyn Trapp.
Late Manifestations—LJrological- -Dr. L. R. Williams.
Rectal—Dr. A. T. Henry.
Neurological—Dr. Frank Turnbull.
February 20—COMBINED  CLINICAL  MEETING  AND  STAFF   MEETING  AT
ST. PAUL'S HOSPITAL.
March    6—OSLER DINNER, HOTEL VANCOUVER:
OSLER LECTURER — DR. HOWARD SPOHN
ment of Leisure."
"The Employ
March 20—COMBINED   CLINICAL   MEETING   AND   STAFF   MEETING   AT
VANCOUVER GENERAL HOSPITAL.
April    3—GENERAL MEETING: Activities of a Field Surgical Unit:
Major Rocke Robertson, R.C.A.M.C.
April 17—COMBINED CLINICAL MEETING AND STAFF MEETING AT ST.
PAUL'S HOSPITAL.
May    1—ANNUAL MEETING.
Ol^nt^r^iiattitaSIft
ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C.
Page Ninety LIVER EXTRACT INJECTABLE
Liver Extract Injectable is prepared specifically for the treatment of
pernicious anaemia. The potency of this product is expressed in units
determined by actual responses secured in the treatment of human cases of
pernicious anaemia. Liver Extract Injectable as prepared in the Connaught
Laboratories has the following advantages:—
1. Proven potency—Every lot is tested on cases of
pernicious anaemia.
2. High concentration of potency—Small dosage
and less frequent administration.
3. Low total solids—Discomfort and local reactions
occur very infrequently because of the high purity of the product.
New Packages and Reduction in Price
Commencing January 1, 1945, the present 4-cc. and 12-cc. vials of
Liver Extract Injectable will be discontinued, and the product will be supplied
in packages containing single 5-cc. vials and in muliple-dose packages
containing five 5-cc. vials. The larger package is for the convenience of
hospitals and clinics. It is also available to physicians. The increase in
volume per vial permits a reduction in price per cc. and means a saving per
dose to the patient.
CONNAUGHT LABORATORIES
University of Toronto    Toronto 5, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. ^ke CditobtL Pa<f,e .
The Bulletin recently received a publication issued by the new Government of
Saskatchewan. This little booklet sets forth in condensed form a summary of the programme that the Government plans to initiate in the coming years of its rule. A great
deal of it is of general interest chiefly: dealing with economic questions, legislation of
various sorts, education and so on: but one section deals with the new Health Services
that the Saskatchewan Government hopes to inaugurate—"a Health Service for all."
This is of interest for several reasons: first, because according to the section referred to,
an agreement has been arrived at with the organised medical profession in Saskatchewan:
as to fees, methods of payment, amount and kind of service given, and so on. We should
be greatly interested in knowing just how this agreement was arrived at: how far it
conforms with the minima laid down by the Canadian Medical Association; just to what
extent medical service is to be given, and, quite an important matter, how it is to be
paid for, and on what scale. We would expect that the Economics Committee of the
B. C. Medical Association has already asked the Saskatchewan College of Physicians and
Surgeons for details of the agreement: and if they have not yet done so, they will probably so do very soon. We should greatly like to know how any very great extension of
medical services is going to be given anywhere, with our present acute shortage of
medical personnel. But we must confess that in the absence of direct assurance from
the medical profession of Saskatchewan that such an agreement has been arrived at, we
are rather skeptical about such a possibility. We seem to remember some years ago
reading in the public press that the B. C. Government was coming to an agreement with
the medical profession of B. C. as to a Health Insurance scheme—when as an actual
matter of fact, there was no possibility of agreement. We have an idea, that unless the
medical profession of Saskatchewan is very different from its brethren elsewhere, or the
Government of Saskatchewan has made a very different offer to any made by any government so far, there is an undue degree of optimism on the part of the said Government. But it is, of course, possible that a genuine and practicable offer has been made
and accepted.   Till we hear further details, we must suspend judgment.
Secondly: the plans put forward by the C.C.F. Government in Saskatchewan are
based on the Sigerist Health Services Survey made some time ago, and the report made
by Dr. Sigerist to the Saskatchewan Government. Dr. Sigerist is a very well-known
and able man—and his Report will be of great interest and value. We do not know if
a copy is to be obtained in the Library: but it should be easily possible to secure such
a copy.
We are publishing a large part of this Section of the pamphlet in the Bulletin.
It may not be in this number, but will be in either this or the next one.
Later in this issue, we publish a Brief prepared on the matter fo a Medical School,
and designed for the information of the members of the medical profession. We feel
very strongly that every endeavour should also be made to educate the public at large,
and give them the facts put forward in this Brief. We cannot expect the layman, the
business man, the engineer, the teacher, the man in the street, to share our enthusiasm
about a medical school, unless we tell them the facts, as fully and freely as we can, and
arouse first their interest, then their willingness to co-operate towards this end. We feel
that this is not a matter that specially benefits us as a profession, or if it does, it is only
secondarily. It is a matter that vitally concerns the citizenry of B. C. They need better
medical service, more of it, a better distribution, more prevention of disease, etc. They
need openings for their sons, who may wish to study medicine. They need the strength
that such a Faculty would add to their University. But they will not know this till
they are told. Boards of Trade, Service Clubs, Women's Organizations, etc., should be
told the facts. We feel that there is a definite job for each medical man here, to be a
missionary in this line, and a source of accurate and convincing information.
Page Ninety-one LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY—
Managing Your Mind, 1944, by S. H. Kraines and E. S. Thetford.
Young Offenders, 1943, by A. M. Carr-Saunders, Hermann Mannheim and E. C.
Rhodes.
Oxford Loose Leaf Supplements—
New Articles—
Dwarfism, by A. Grollman
Non-Bacterial Pneumonias, by H. A. Christian
•     Alcoholic Intoxication and Alcoholism, by E. A. Strecker and T. D. Rivers
Drug Addiction, by H. D. Palmer.
Revisions of Articles—
Diseases of the Aorta, by R. W. Scott
Diabetes Mellitus, by R. Fitz
Influenza, by H. A. Christian
Meningococcus Infections, including Cerebrospinal Fever, by W. W. Herrick
Poliomyelitis, by J. L. Wilson
Tetanus, by J. W. Williams and C. W. McClure
Unusual Diseases, by F. R. Taylor (part revision).
BOOK REVIEW
MANUAL OF MILITARY NEUROPSYCHIATRY, Harry C. Soloman and Paul I.
Yakovlev, W. B. Saunders Company, Philadelphia and London 1944  (price $6.00
(U.S.).
This manual is contributed to by forty-five authors and contains about seven hundred pages and the index. The preface points out that the Manual had as its predecessor
the "Collected Lectures" of the "Seventh Postgraduate Seminar in Neurology and Psychiatry, including a Review Course in Military Neuropsychiatry." It is intended as a
reference text on topics of clinical neurology and psychiatry, especially for officers who
have not access to libraries, textbooks, etc.
The Manual is divided into six sections as follows:
I.    Introductory
II.    Induction
III. Administration and Disposition
IV. Clinical Entities
V.    Prophylaxis and Therapy
IV.    Special Topics
Section One discusses neuropsychiatric experiences of the First World War and is
followed by a description of the general organization of neuropsychiatry in the army
during the current war.
This section as well as Section Two on "Induction" and Section Three "Administration and Disposition," describes the methods in use in the American services. While
these sections are of more value to our American colleagues, they are of interest in
giving us a quick resume of the organization in the American services. These sections
occupy 127 pages of the manual.
Section Four on "Clinical Entities" is contributed to by seventeen outstanding men
in the fields of neurology and psychiatry and many of the common but difficult problems are discussed in a very clear and satisfactory manner. In fact, in this section alone
there are enough excellent articles to make the book well worthwhile. To mention a few
of the subjects only is difficult but the sections of "Psychoneurosis and Psychosomatic
Medicine" by Finesinger and Cobb, "Alcohol and Alcoholism" by Strecker, "Epilepsy
and Paroxysmal Neuropsychiatric Syndromes" by Lennox, "Spinal-Cord Injuries" by
Page Ninety-two Munro and "Post-Traumatic Syndromes" by Denny-Brown give an indication of the
quality of the contributors.
Section Five on "Prophylaxis and Therapy" will be of particular interest to those
dealing with Military cases. Actually some of the articles deal chiefly with the question
of whether or not certain treatments should be used while the patient is in the service or
whether his discharge should be hastened so that treatment (if then indicated) may be
undertaken under more favourable conditions.
Section Six deals with "Special Topics" such as-"Neuropsychiatric Disorders in the
Tropics," "Physiology of Flying," etc. While these subjects have a definite place in a
manual such as this, they will, of course, have less general appeal than some other sections of the Manual.
All in all, the editors and authors are to be congratulated on the production of this
Manual and on the gathering together of so much useful material by so many noted
authorities in such a small space.
G. A. D.
The following was taken from The Highland News (Inverness paper) dated May
20, 1944.
CANADIAN SURGEON FIGHTS AS PRIVATE
(By a Military Observer)
"Before the war I was by profession a surgeon in Vancouver, but when I came to
England I gave up medical work and in 1941 enlisted in the British Army as a private
and have taken part in the fighting in Sicily and Italy. I have no wish to change now,"
said Arthur Procter, a private in the London Scottish, who was awarded the Military
. Medal in Sicily for gallantry, in an interview recently. Private (Surgeon) Procter has
relations in Inverness.
"Anzio was the dirtiest, toughest spot we have been in so far," he added. "Perhaps
the worst aspect of it all was the weather which made conditions appalling."
Private Procter acted as a countersniper during the day and at night went out on
patrol, mostly alone. One of his favourite hobbies in Canada was duck shooting and he
has found his proficiency with a sporting rifle of great service. He declared that the
fighting in the wadis at the bridge-head was so confused, especially at night, that they
sometimes found Germans behind them as well as in front.
German snipers were particularly active during the day and it was his task to outmanoeuvre them and shoot at them when they revealed themselves. To do this meant
keeping a lonely vigil for hours. Air bursts, he thought, made the wadis very uncomfortable at night and in many respects it was safer to go out on patrol armed with a
tommy-gun and grenades.
"In five nights I heard the challenge "Hands up" seven times, sometimes in English
and sometimes in German," he added. "It was always best to get away quickly because
the Germans never wasted much time in firing. Maybe they were jittery."
Private Procter was awarded the Military Medal for gallantry at the Primoscle bridge,
near Catania, Sicily. He went out sniping with his platoon commander and caused the
enemy to reveal their positions. Fire from the platoon and a supporting tank was brought
down on the enemy and, thinking they were outnumbered, nine officers and 112 men
surrendered. "They were livid when they realised they had given themselves up to such
a small force," said a London Scottish Officer.
Private Procter's home is at 1416 40th Avenue, Vancouver.
The above will, we are sure, be of great interest to many Vancouver doctors who
knew Dr. Procter when he practised here.—J_d.
Page Ninety-three ITEMS OF GENERAL  INTEREST
The Hospital for Joint Diseases, 191 Madison Avenue, New York, has sent us a
notice of several forthcoming vacancies to be filled on its general rotating service; the
notice will be found posted on the notice board at the Vancouver General Hospital.
There are twelve places—for nine months' interneship—beginning July  1,  1945.
Some of those appointed will be kept on as Junior Residents, and of these some as
Senior Residents.
The schedules cover every branch of medicine and surgery, including also physical
therapy and radiology.
The Hospital, which is approved by the A.M.A. and the American College of Surgeons, provides maintenance, uniforms and a stipend of $25.00 a month.
Graduating students and graduates of Class A medical schools are eligible.
This is a general hospital featuring orthopaedic surgery.
The Canadian Fuel Conservation Society of 31>Willcocks Street, Toronto 5, sends us
reminders of the need of conservation of fuel. It urges the greater use of weather-
stripping insulation, and deals with the respective values of hardwoods as fuel. It is of
interest to know that 1 % cords of heavy hardwoods, such as maple, beech, oak, yellow
birch, is the equivalent of one ton of anthracite. Softer woods give much less heat—
and the reference is to the use of wood in furnaces instead of coal. Probably, they conclude, "the automatic coal stoker represents by far the greatest step which the harassed
home-owner can take. ..."
Dr. Laenger, the Technical Director of T. R. Geigy, the Swiss organization, which
brought out the insecticidal properties of D.D.T., has been given the honorary degree of
Doctor of Medicine by the University of Basle.
D.D.T. is the amazing insecticide which has done so much to remove the danger of
mosquitoes, lice, etc., and so of malaria, typhus and other similar diseases among overseas
troops. In Naples, typhus was most successfully combated by its use, and in the Pacific,
malaria is being attacked.
We referred some time ago to the importance of using proper colour schemes in
tunnels and in traffic generally to cut down and forestall accidents. Another important
question is light reflection, with a view to lessening lighting bills, in schools, homes,
hospitals, etc. Careful experiments have been made along this line by the Canadian
Paint, Varnish and Lacquer Association—and a circular from them goes into this.- It
concludes: "It has been proven by scientific tests that the eyes work most efficiently
with less fatigue when the surroundings are not noticeably darker than the work that is
illuminated—therefore lightly illuminated work in dark surroundings is not conducive
to best results." In schools, factories, etc., workers and students are happier, more cheerful, and accidents and wastage are greatly lessened where proper colour schemes are
worked out.
An interesting reference is made in another circular from the Association to the
colour scheme of Canada's newest hospital ship, the Letitia, on which some of our B. C.
medical men and nurses are now working, and which is recognized as one of the finest
hospital ships in the world.
The wards are painted, not white, as was the former custom, but a soft green, of a
light tint. The corridors of the ship are finished in a darker green. The ceilings are
finished in a pleasant buff colour.
Page Ninety-four To use the words of Dr. C. Harvey Agnew, Secretary of the Department of Hospital
Services of the Canadian Medical Association, colour is "an item of major importance"
in the psychological treatment of a patient.
It is of interest, too, to know that two fire-resistant paints have been developed since
the war began for use on ships. One of them, chiefly used on steel, will discolour but
not burn—the other, for protection of woodwork, gives off a fire-smothering vapour
when exposed to flame.
We are indebted to Canadian Industries, Limited, for some of our items of general
interest. One tells of an all-plastic artificial eye fitted to a Canadian soldier who lost
an eye at Dieppe. This eye was developed by a Montreal dental technician, Russell
Copeman. It has many advantages over the glass eye hitherto used—it is safer from
breakage, fighter, less influenced by temperature or chemical reaction, and is more easily
moulded to the shape of the individual socket so that it is more easily moved, and looks
more natural.    These things are of great significance to those who need artificial eyes.
European type cheeses are now being made in Quebec and in the experimental factory at the Provincial Dairy School, Ste. Hyacinthe, Quebec, a great deal of work is
being done that is contributing greatly to one of the main industries of Canada.
Of interest to B. C. inhabitants, with our harbours and piers, is the new use of
dynamite to destroy timber-eating teredo worms, and lengthen the life of the wooden
piles, so widely used and which till recently had to be renewed so often on account of
the destruction wrought by teredos. It was found that a severe shock, such as the
dropping of a pile-driver hammer upon the head of the pile is highly destructive to the
teredos in the pile. This, however, is not a good method, as being too damaging to the
structure.
Accordingly, experiments were concluded with dynamite charges fired in the close
vicinity of the piling. Charges are suspended in the water at 10 to 12-foot intervals,
and fired at low tide. It is found that the life of the piling is lengthened by several
years.    One large operator on Vancouver Island does this at two-month intervals.
AMERICAN COLLEGE OF SURGEONS ANNOUNCES  1944
APPROVED LIST OF HOSPITALS IN U.S.A. AND CANADA
In 1918, the first survey included 692 hospitals of 100 beds or over—only 12.8 per
cent (89) merited approval.
In 1944, 2,342 hospitals of 100 beds or over were surveyed. 93.1 per cent (2,182)
were approved; of 1,119 hospitals, 50 to 99 beds, 70.3 per cent were approved; of 450,
25-49 bed hospitals, only 40.2 per cent were approved.
This represents an enormous improvement in hospital standards, and we have to
thank the American College of Surgeons, through its director, our old friend Dr. Malcolm
McEachern, for a great deal of this. This organization has high and rigidly controlled
standards.
DR. JAMES
Has removed to Broughton street opposite the City Chambers. Philip James, M.D.,
Diplomatized Eclectic Physician. Extracts Polypus and Cancer without the use of the
knife. Rheumatics cured in one hour- without pain. He is now using the Electric
Magnetic Machine with good effect in many diseases of Rheumatic, Palsy or Paralysis
and Fits.   N.B.—Special attention given to all diseases of women and children.
(From the Daily British Colonist, Victoria, B.C., Sept. 29th, 1876.)
Page Ninety-five A MEDICAL SCHOOL FOR BRITISH COLUMBIA
The following is addressed primarily to every medical man in British Columbia. If
your representative in the Legislature asked you today, "Why do we need a Medical
School in British Columbia?" could you, no matter how firmly you believe we should
have such a school, give him five or six adequate and convincing reasons for your belief?
or do you know anything of the facts which were presented to the Executive Council
of the British Columbia Cabinet by Dr. K. D. Panton and his Committee on January
17th?
We think the answer to both these questions is in the negative—and we think that
it is of vital importance that every medical man should know these facts, and be able
to give chapter and verse for his advocacy of a medical school. It is, we firmly believe,
more firmly as we know more about it, one of the prime needs of this fair Province of
ours—and indeed, it is a Canadian need, not merely a provincial one. But we ask you
to read the following Brief carefully and keep it by you—the Bulletin will keep the
type set up for a time, and if there is a demand for it, we can furnish reprints of this
Brief, for your use, and for circulation.*
A. The present situation—in Canada as a whole.
Canada needs more doctors than we have now. The present shortage is very acute.
To some extent this will be remedied after the War, but by no means completely.
1. The population of Canada has increased by more than 1,100,000 in the past
three years—and will continue to increase.
2. A large programme of social legislation is contemplated, and will, we are told,
be put into effect after the War.    This includes a programme of Health Insurance.
This is urgently necessary we all agree. But a conservative estimate is that such
a programme will require from 25% to 40% more doctors (more patients, more preventive medicine, mental hygiene, etc.) than are normally available. Where are they
to come from?
No scheme of Health Insurance can possibly be put into effect with our present
limited supply of doctors.
3. Refresher and postgraduate courses are to be given to all medical men returning
from overseas. This will greatly overcrowd the present capacity of Canadian Medical
Schools.
4. Canada has at present nine medical schools from which medical men may
graduate. The total average annual output is somewhere between 530 and 550, not
nearly enough to take care of all the needs. These schools cannot greatly enlarge their
output. Other schools are necessary. Two years ago the Deans of these schools strongly
recommended that a new medical sc/jooI be established in British Columbia.
B. The situation in British Columbia.
1. The facts as given above, applicable to Canada as a whole, are equally true of
British Columbia in particular.
2. There are at present 201 students in the University of B. C. who wish to study
medicine, and are taking pre-medical work—where are they to finish their course? Of
these a maximum of 38 may be accepted by Eastern Universities—not more—and certainly less—for they must all be high honour graduates, and must compete with entries
from all over Canada. Probably not more than 25 or 28 will be accepted. Toronto
has closed her doors to any but Ontario students; other universities will undoubtedly
follow suit. These boys have spent from six to ten years preparing for their clinical
years—and this will be a total loss to over 80% of them.
In any case we should not have to beg for places for our graduates- we should, and
can, provide for their education ourselves.
3. The cost. Today about 150 medical students from B. C. are attending Eastern
medical schools. The cost to each one is about $1500 per year—a total of $225,000
* Since the above was written, we learn that the B. C. Government proposes to devote a sum of money to
the creation of a medical faculty in the U.B.C.    The plan is not yet clear, but we naturally rejoice.    But
we are publishing the above as a brief summary of the salient facts and for future reference.—Ed.
Page Ninety-six annually. This is, first of all, a very serious drain on their parents' resources, and is,
further, a reason why many excellent students and potentially excellent doctors, are
debarred from pursuing a medical course. The expense here would be greatly less, and
the money would be spent in B. C.—and would go to the upkeep of a medical school.
British Columbia students face especial difficulties of transportation, owing to geographical conditions.
4. B. C. has already the nucleus of a medical school. It can already supply the
pre-medical education, and the Institute of Preventive Medicine now in process of construction would add further to our present equipment. Biology, Bacteriology, Public
Hygiene and Preventive Medicine, together with Chemistry, Anatomy and Physiology
are all within our present powers.
5. We have the population in B. C. both to justify the construction of a medical
school, and to provide for its maintenance and equipment. We have an excellent University to which it can be attached.
6. We have ample hospital accomm&dation and facilities. These, in Vancouver
especially, are now greater than are available in most of the university centres in Canada.
7. We have ample sources of teaching personnel in the way of specialists, well-
trained medical men, bacteriologists, chemists, pathologists, etc., to form a faculty of
teachers.
C.    What a Medical School would mean to British Columbia.
1. It would be a very powerful addition to our University of B. C, indeed a very
great asset to British Columbia. It would afford much-needed opportunities to our
young men wishing to become doctors.. It would greatly reduce the expense of medical
education to our own students—it would do much to enable improvements in social
legislation—it is vitally necessary to Canada as well as B. C.
Such a school, as time went by, and it was expanded, would attract students from
other parts of Canada, and even, as has been the experience of all Canadian schools, from
the United States.
It would elevate the standards of medical practice here, and provide opportunities
for highly-trained men to teach others.
The history of Canadian Universities has always been that a strong Medical Faculty
has been one of the greatest assets the University could have. For many years the
existence and continued activity of the Medical School was the only thing that kept
McGill University's Charter alive—and today her Medical and Engineering Faculties are
her two strongest faculties and have brought fame to the University.
In Toronto, the work of the Medical Faculty and its long list of great names, with
Banting and Best, and Gallie and Graham amnogst the leaders in Medicine on this continent, has been the outstanding contribution of the University of Toronto to Canadian
life, along with its great Qsgoode Hall Law School. And so a strong Medical School
in the U.B.C. will be a great tower of strength to the University. Other schools we
need, too, a Law School for one, but the great present crying need is for a Medical
Faculty in the University of British Columbia.
Such a Medical School would afford opportunities to citizens of means, who wished
to do so, to perform a great service to their country and province by endowing chairs,
by giving libraries, by donations to research, and in many other ways—no finer memorial
can one leave than such a gift—as every University can tell.
We need, too, other schools of allied nature—Dentistry, Pharmacy, Special Research
Departments. These would be natural developments, all now badly needed. They are
not likely to come without a Medical School—and at any rate would not reach as great
efficiency and adequacy of development.
We need, of course, in B.C. other things—a Law School, more money spent on Arts,
Engineering, Agriculture, and so on. These are all necessary too. But a Medical School
is a vital necessity.
Page Ninety-seven
II If our social progress is to be maintained, we must have more doctors. We cannot
continue to sponge on other Provinces (the Medical School pays two-thirds, the student
one-third of the cost of training a doctor), we must stand on our own feet. Every
medical man, every citizen of B. C. is vitally interested—we should all get behind this
scheme and urge it, in season and out of season. Boards of Trade, Women's Associations, Social Councils, all public groups, service clubs, etc., should be told of these things,
and their interest and support enlisted. Only so can we get an educated public opinion.
We are confident that if these facts were known to the public at large, we should receive
the support of all tliinking people.
One final word as to cost. The figures for this are at present not available to any
degree of accuracy, but we are assured by members of Dr. Panton's Committee that the
cost at the outset would be quite moderate—and well within the sums which have been
allocated by the Government of B. C. for use in such directions.
HOSPITALS APPROVED FOR GRADUATE TRAINING
IN SURGERY
The American College of Surgeons announces that 231 hospitals in the United
States and Canada have been approved for Graduate Training in general surgery and the
surgical specialties. The list of approved hospitals for this purpose is published in the
annual Approval Number of the Bulletin of the College just issued.
In announcing the new Approved List, Dr. Malcolm T. MacEachern, Associate
Director, states that 500 or more surveys of hospitals offering opportunities for graduate
training in surgery are planned during the coming year, the increased emphasis upon this
work being stimulated by the need for providing ample opportunities for resumption of
training by medical officers when they return from service with the Armed Forces.
The College, through Major General Charles R. Reynolds, Consultant in Graduate Training in Surgery; Dr. George H. Miller, Director of Educational Activities; Dr. Paul S.
Ferguson, Director of Surveys, and a field staff, helps hospitals to organize graduate
training programmes to meet the requirements for approval, and also plans to aid physicians returning from service in resuming their training in surgery.
The hospitals in this area which are approved for graduate training in surgery are
as follows:
QUEBEC
Name of Hospital and Location Capacity
Montreal
Montreal General Hospital     607	
Central Division -     450
Western Division      157
Montreal Neurological Institute
Victoria Hospital      550     General Surgery
O tol aryngology
Urology
Obstetrics and Gynecology
Neurological Surgery
Approved for Graduate
Training in
General Surgery
Otolaryngology
ONTARIO
Toronto
Hospital for Sick Children     432.
St. Michael's Hospital     643.
Toronto General Hospital   1144.
Toronto Western Hospital     518.
Page Ninety-eight
General Surgery
General Surgery
General Surgery
Obstetrics and Gynecology
General Surgery Vancouver Medical Association
CLUB FEET
By Gerald L. Burke, M.D.
(Read at meeting of Vancouver Medical Association, December 5th, 1944.)
I bring you this evening a paper on club feet, a subject, I am afraid, of not much
interest, possibly a subject of profound dullness to the profession at large. In fact, I
have wondered if there were any connection between Frank Turnbull's inviting me to
give this discussion and his precipitate departure shortly thereafter for the battlefronts
of Europe.
In the past the treatment of congenital club feet has undergone many changes and
in the future it will probably undergo others, but what has long been one of the most
arduous and unsatisfactory branches of surgery has in the past few years become both
simple and gratifying. Although if one deals with a large number of these cases it is
inevitably borne in on one's consciousness that the club foot retains still—in spite of
the amazingly satisfactory new methods of treatment—a good deal of its ancient and
fiendish ability to make the surgeon appreciate his own limitations. It is unwise to
assure a mother in a happy burst of pride that its child's" feet are completely, totally,
absolutely and one hundred percent cured; that they will not relapse! One is liable to
be shocked later at the change in the child's feet, which have undergone a reversal to
form. One may be further shocked at the change in the child's mother, once so grateful
and charming, possibly also a reversal to form.
For many, many years treatment has been directed against what were regarded as
the triple deformities of club feet—adductus of the forefoot, varus of the hind foot,
equinus of the whole foot. The attack was directed against these deformities in series.
Casts were applied and wedged to force the inturned foot outward. When this was
regarded as sufficiently "corrected" the heel was wedged outwards and finally the casts
were wedged to push the whole foot upward. These procedures took from two to five
years in the case of each patient, with casts wedged every week and changed every two
or three weeks; a pretty trying proceeding to all participants. »
After this a surgical campaign followed. Heel cord lengthening and Steindler
stripping to correct equinus; medial tarsal soft tissue strippings to overcome adductus
and tibial osteotomies to rotate the tibia externally and with it, the foot, and many variations and combinations of these. This stage being finished, more surgery was undertaken
to undo or at least modify the effects of surgery previously done. The child lived its
first several years in plaster casts on one or both legs, from the toes to the upper thighs,
after wedgings, and after operations; and it faced a further trial—operations on the
bones of the foot could not be undertaken until the bones were sufficiently mature, at
the age of about twelve years. The end results were stiff, partially deformed and undersized feet. A striking feature was the thin underdeveloped leg particularly noticeable
in unilateral cases in contrast with the chubby normal one.
I do not hesitate to state that a normal foot and leg has never been secured anywhere, at any time, or by anyone, by the use of wedging casts or surgery or by any combination of wedging casts and surgery. With the new methods of treatment I believe
that surgery will never again be necessary in uncomplicated cases in which treatment is
started in the first .few weeks of life.
The text book theories of the etiology of club feet are reminiscent of the nebulous
conceptions of the cause of malaria in the middle ages.
For instance, that they are due to muscle imbalance—when no type of actual or
theoretical imbalance could produce this deformity.
Page Ninety-nine A school of thought believes that the deformity is due to gross lesions of the central
nervous system, but no lesions have ever been demonstrated, and once the foot is corrected the muscles function normally and yield neither symptom nor sign of central
nervous system deficiency. There are several others so lacking in merit that they do
not deserve mention.
The oldest and the most logical was propounded by Hippocrates, who suggested that
the deformity of the feet was due to their moulding by the wall of the uterus. This
idea has been manfully championed by Mr. Denis Browne, who is surgeon to the Hospital for Sick Children, Great Ormond St., London. That is, he is, if there is still such
a hospital.
Mr. Browne is the originator of the splints which have had such a revolutionary
influence on the treatment of club feet. He has written nine articles on the theory and
practice of his splints, and at the same time has stoutly upheld the honour of Hippocrates. He wrote the nine articles in nine different journals, and, curiously enough,
each of the nine articles is, except for minor shufflings, a fair copy of each of the other
eight.
I regret mentioning this and, of course, regard it as confidential, but in spite of the
great and acknowledged excellence of his contribution, each one of those nine duplications of each other is a paralysing bore. And what's more, they are written in such a
complex and pompous style that with my limited intelligence I had to struggle through
all of them several times in order to get a clear idea of what he was driving at. The
following are two paragraphs quoted word for word on the etiology of this deformity
from a paper given by Mr. Browne, F.R.C.S., of the Royal College of Surgeons:
"It is interesting to examine the causes that prevent the general recognition of
what I believe to be an important and definite pathological category. First among
the difficulties comes the complication of argument. Even to state it properly would
be a long day's work, and no one could possibly imagine a busy surgeon devoting a
day to listening to it. No journal would publish such a statement except in a form
compressed to the verge of unintelligibility; a book on the subject might have a sale
of a dozen copies; and meetings of this sort are in their hurry a poor substitute for
the leisurely courts of argument of the mediaeval schoolmen.
"Then the mental process employed is one that is almost entirely neglected in
medicine. We have become used to depending on the fruitful and valuable experimental method, in which we produce artificially certain happenings, observe them and
draw conclusions.    But there is another method used in science.    No one can play
. experiments on the planets, but yet we know a good deal about them.    We have
learned it by reasoning out what would happen were a certain hypothesis true, and
comparing these results of abstract thought with what actually does happen."
I don't know exactly what this means, but it does seem to hint that he is in possession of facts of earth-shaking significance, but that he gravely doubts the ability of his
audience to assimilate even a small fraction thereof.
And here is one of his powerful supporting points of the theory that intrauterine
pressure and moulding alters the shape and function of living tissue:
"The very complicated but to me satisfactory explanation of arthrogryphosis in
terms of hydraulic pressure, with its strong confirmation from a disease of sheep."
I shall allow you to dwell upon that gem and return to it later.
The Hippocrates-Browne theory has much evidence in its favour. It is well known
that the form of tissues cap be altered by external pressure after birth.    One example
is the tiny feet that Chinese ladies used to affect, due to the tight bandaging of their
feet in childhood.   In the same way intrauterine pressure is capable of altering the shape
of parts of the body before birth.   The normal new-born child shows evidences of this
pressure in the dimples, or areas of compressed and adherent tissues, over the knuckles
and the outer surfaces of elbows and knees.    Also we have all observed the calcaneus
position of the normal new-born child's feet, the backs of the feet being forced upwards
and backwards towards the outside of the leg.    It only needs light pressure on the sole
Page One Hundred of a new-born's foot to cause the little toe to touch the front of the leg near the fibula.
Browne shows a picture of a child which actually had pressure sores on the soles of its
feet.
If a child does not take the pressure on the soles of its feet the only other part of
the foot on which the pressure can be taken is on the outer side of the foot and some
degree of club foot will result. The movements of the child in utero make no difference to the relative position of the feet. There is not enough room as a rule for a child
to move a foot from calcaneo valgus to equino varus or the reverse.
In this connection I have noted with pleasure, not unmixed with sorrow, that in
the obstetrical text "books the sketches of infants in utero show the child's feet invariably neatly folded in the position of club feet. The children in these sketches would all
have club feet. But photographs of frozen sections all show the infants taking the
pressure of the uterine wall on the soles of their feet. I have seen a photograph of a
magnificent specimen in the University College Hospital in which the anterior half of
the uterus is replaced by glass which clearly demonstrates this point. I would hesitate
to suggest that the foregoing shows a curious limitation in the powers of observation in
our obstetrical brethren.
Intrauterine pressure is fairly obviously the cause in such well known—shall we say
—deformities as the Arnold-Chiari malformation, acro-cephalo syndactyly, arthrogry-
phosis multiplex congenita and spina bifida. So also, in the commonest congenital deformity, talipes equino-varus.
At this point I might explain Mr. Browne's reference to the disease of sheep. It
seems that sheep occasionally suffer from polyhydramnios with great pressure, and shepherds can recognize the condition, observe the great hydraulic pressure and can prophesy
correctly that a stiff-jointed lamb will be born.    This lamb is arthrogryphotic.
The feet are the parts of the body most exposed to and most susceptible to moulding by the uterine wall. The hands rarely suffer. They are mobile, readily adapt themselves to the shape of the wall and are, moreover, protected by the large overhanging
head. The feet, on the other hand, if I may make a weak pun, are unprotected; they
are of a shape and consistency that does not allow them to adapt easily to the wall. If
the legs are in the normal knee-chest position with the feet in calcaneus, increased pressure will only cause increased calcaneus. This position is automatically self-correcting
because the muscles which pull the foot into calcaneo valgus are the weak toe extensors
and the weak peroneals. These are opposed by the most powerful muscle groups below
the knee, those attached to the tendo achillis, the anterior and posterior tibials andN the
toe flexors.
Now if the feet are twisted inwards, and this is the only other position they can
assume if they are not in calcaneo valgus, so that the outer side of the foot and not the
sole takes the pressure, a series of deformities results varying from slight to severe, but
all corresponding to the curve of the uterine wall on their outer side. The foot as a
whole is moulded to this curve. The forefoot is turned inwards; the heel is turned
inwards under the ankle and the foot is plantar flexed in the position of equinus due to
the inclination of the various joints in the ankle region. Here we have the middle range
of the series of deformities known as "club feet" which range from a simple inturning
of the forefoot through talipes equino-varus and on to the most severe degree in which
the forefoot swings around until the big toe points straight upwards along the tibia.
The term "talipes equino-varus" is a poor one because "talipes" means "heel-foot" or
"ankle-foot," a singularly pointless term, and "equinus" and "varus" are secondary
elements in the deformity in those cases in which they are present. The important
element is the bending of the foot on its longitudinal axis. In the mild degrees of club
feet there is neither equinus nor varus but simply inturning of the forefoot, and in the
most severe degrees the equinus is reversed, as in those cases where the big toe lies along
the tibia. "Club foot" is an unpleasant term. I have tried to think of a better term
than either of these two, one of which is inaccurate, the other insulting.    The best I
Page One Hndred and One can do is "congenital twisted foot," which being interpreted in Latin would be "Pes
Tortus Congenitalis."
In the treatment it is necessary to concentrate on the most important element of
the deformity, which is the curving of the longitudinal axis of the foot, and the most
important part of this curving is in that portion of the foot lying in front of the ankle.
If this part of the deformity is corrected, all else shall be added unto the foot, i.e., the
secondary elements of equinus and varus are automatically corrected if they are present.
The converse does not hold. It is only too easy to correct the equinus and varus without correcting the fundamental deformity. This was the common end result in the old
plaster cast treatment, and if the child were observed sitting with the legs hanging free
it would be noticed that the feet were at about a right angle. There was no or little
varus of the heel, but the feet were curved inwards at varying angles, commonly about
45 degrees. The normal infant in the same position holds its feet at about a right angle
with its feet turned out ten to twenty degrees. This position, the feet held free, turned
out ten to twenty degrees, is the aim of the treatment and the criterion of cure. One
cannot adequately judge the feet in the standing position because they can be arranged
accidentally or intentionally to give a false impression. In photographs of the end
results of treatment in .other methods than Denis Browne's, it is noted that the pictures
are all taken in the standing position.
This driving around outwards of the forefoot in the reverse direction to the curve
that it has followed in coming to its deformed position must be the aim in treating the
deformity of structure.
But there is not only structure to consider in a disability of this sort; there is also
function. The most important interference with function comes from that lack of
muscle balance which has already been described, the powerful muscles favoured and the
weak muscles stretched. To correct a disturbance of this sort it is not enough to correct
the deformity that has caused it; the muscles must be made to work against each other
in the corrected position. The holding of the limb motionless in plaster has no effect
in equalizing muscle tone once it has been upset.
The Denis Browne splint fulfills these conditions by allowing and stimulating the
child to kick vigorously in the splint and so it works its own feet into shape. We apply
the splints at the earliest possible moment. The youngest child on whom we have put
the splints was three days old. As "early as possible" is important because even a few
weeks makes a great difference in the ease of accomplishing full correction. If one carried this principle of the earliest possible application to its ideal and logical conclusion,
one should, in a breech birth, apply the splints before the delivery of the after-coming
head.
As soon as convenient—as a rule within a few days or even before applying the
splints, the feet are manipulated to a position of complete correction, that is, to equal
the range of motion of the normal new-born baby's foot so that the manipulation is
continued until the little toe touches the outside of the leg. Denis Browne describes
this as a violent manipulation. It is indeed a nerve-shattering proceeding to watch or
perform and I have used it in only the last fifteen cases, though we have treated sixty-
nine cases of club feet at the Crippled Children's Hospital in the last year and three
months by Denis Browne splints. Browne states that the result of the first violent
manipulation is, of course, considerable reaction and swelling, but says he has never
known this to cause any real anxiety. We have noted the reaction and swelling and
also, in our limited experience, have found it to be innocuous.
In the case of older children in whom the feet are too rigid to be manipulated by
the hands Browne has developed an even more blood-curdling technique. This is an
object resembling a nutcracker made of wooden blades about three feet long and three
inches wide which are hinged together. A similar but much greater force can be
applied with this instrument, which forces the foot into calcaneo valgus accompanied
by fearsome sounds of tearing and wrenching. I have used this frightful instrument a
few times and though there is great reaction, following a couple of weeks in the splints
Page One Hundred and Two it is remarkable how it mobilizes the feet and how it does not seem to damage them in
any way. Browne states that any amount of force may be used so long as it is less
than that which would cause sloughing of the skin.
After manipulation the feet are bandaged separately into the foot pieces with tincture of benzoin and adhesive tape and the feet as quickly as possible are everted to an
angle of 90 degrees in the horizontal plane, and kept on day and night until complete
correction is stable, that is, the feet in the resting position are held at about a right-angle
in the sagittal plane and held outward at an angle of 10 to 20 degrees. Then boot
splints are applied day and night until the child stands. After that the boot splints are
used only when the child is asleep and the mother manipulates the feet twice daily into
the position of complete calcaneo valgus so that the little toe touches the outside of the
leg without difficulty or pain. The child must never be allowed to stand on an incompletely corrected foot as the first mental impression of using i^s foot in the wrong position seems to be hard to eradicate.
Our experience indicates that in uncomplicated cases of club feet we should always
be able to obtain normal feet and normal legs in both structure and function. By
"uncomplicated" I mean no additional deformities such as arthrogryphosis, spina bifida
or cerebral spasticity. The degree of severity does not matter. A sharp line must be
drawn between uncomplicated cases and those in which the pressure has been of a
degree to injure muscles and stiffen joints. Nothing will restore muscle that has once
been killed and it is impossible to get free movement in a joint that has had the periarticular tissues infiltrated before birth. Such cases can be improved, but nothing
approaching a normal limb can ever be produced.
As I have stated, in the past fifteen months we have treated sixty-nine cases of club
feet at the Crippled Children's Hospital. In the uncomplicated cases we have had uniformly good results as a rule; even without using the preliminary violent manipulation
we have obtained complete correction in three or four weeks. We have recently, however, adopted Browne's recommendation of early complete correction by manipulation,
followed by splinting, which allows the very young infant to start using its feet and leg
muscles normally and at once.
There have been two articles in the Journal of Bone and Joint Surgery, one two and
a half years ago by Stuart Thompson of the Sick Children's Hospital, Toronto, which
proposed several modifications of the Denis Browne splint, and one four months ago by
Bell and Grice, of the Boston Children's Hospital, proposing modifications of Thompson's modifications and new modifications of their own. It was interesting to me to
note that the article by Thompson started as follows: "A wide provincial practice is
enjoyed at our weekly club foot clinic so that no fewer than twenty-five to thirty new
cases are seen each year." At the Crippled Children's Hospital in Vancouver, according
to these figures, we deal with very nearly as many cases each year as both these well-
known institutions put together.
We have tried the modifications suggested by these writers and have concluded that
none of them is of value. I do not believe that these authors have a clear understanding
of Denis Browne's method. Browne himself has stated that he could easily design a
splint that would be more efficient mechanically, but which would be more expensive
and even less efficiently used than his present one. I believe that this is largely Denis
Browne's own fault and that it is due to his painfully obscure method of expressing
himself.
Strangely enough, at the Crippled Children's Hospital here in Vancouver we were
the first in North America to use these splints. It was due to the urging of Dr. Reginald
Wilson, who had seen some of Mr. Browne's work, and to Miss Leighton, our surgery
nurse at that time, who had worked with Mr. Browne in London, that I read a couple
of his articles in a desultory way and applied the splints in a few cases. But his principles and practice were so different from what I had been taught that I read without
interest or discernment, and after trying them inexpertly on a few cases I reverted to
Page One Hundred and Three plaster casts.    It was not until stimulated by Thompson's article in April, 1942, that
we gave serious consideration to Mr. Browne's work.
The whole business can be summarized in a few words. The diagnosis is obvious, a
twisted foot or pes tortus congenitalis, though as always there are pitfalls. Apply the
splints immediately. Manipulate as soon as convenient, using one hand to wrench the
foot around, the other to support the tibia and to protect it from fracture. As soon as
the foot is sufficiently far around the manipulation is more effectively and safely completed by using one hand with the fingers around the tibia and the hand around the
foot. Complete the manipulation at the first attempt so that the little toe touches the
leg. Apply the splints with adhesive and benzoin; attach the feet separately to the
plates; after four or five months, when the correction seems to be complete and stable,
put the child in boot splints. Continue until the child stands. Then use the boot
splints only when the child is sleeping. Have the mother manipulate the feet to full
correction twice daily. The mother can easily be taught to do this, but a physiotherapist
will spend her time howling with anxiety over the possibility of causing flat feet—which
cannot be done by this manipulation of these feet.
I hope that this paper has been a little less annoying to you than the works of the
master have been to me.
....UUUIIIIIHHUH
tRIEfS
"THE DOCTOR'S PURITANICAL
•   STATE OF MIND"
"Too many doctors still believe that nobody
has syphilis except Negroes, prostitutes, and criminals. Their own patients, failing to fall into one
of these classes, are too well born, too moral, too
well educated, to well to do to be infected. Too
many .doctors, surprising as it seems, still think of
syphilis as a disgrace, not as a disease, and hesitate to suggest the necessary steps for
diagnosis lest the patient's feelings be wounded. Too many, even if they do recognize
syphilis, still think of it as well-earned punishment for sin, and do less than their part
in administering or arranging for proper treatment."
Dr. J. Earle Moore,
Johns Hopkins Medical School.
EVERY GENITAL SORE—POSSIBLE SYPHILIS
The diagnosis of primary syphilis is a laboratory diagnosis, not a clinical one. Positive
Darkfield examination is conclusive. Clinical variations in primary genital^ lesions are
great. Every genital sore should be submitted to Darkfield examination. Provincial
Health Departments provide specimen kits on request. Always keep a kit available.
You'll field primary syphilis when and where you least expect.
««
HOOKS AND BARBS"
Immediately before use, draw intravenous and intramuscular needles across sterile
cotton. Minute hooks and barbs, which cause pain to the patient, will catch cotton
fibres. Try another needle if the one you test catches fibres. Technical excellence keeps
patients under treatment longer.
"FIND V. D. CONTACTS
Page One Hundred and Pour
REPORT V. D. CASES" CASE REPORT
By K. K. Pump, M.D., Williams Lake, B.C. Jjj
The following is a report of a case of Tularaemia in a man, aged 45 years, who always
enjoyed good health, led an outdoor life, was robust and weighed about 180 lbs.
On September 19, 1944, this man __lled and skinned a coyote. He did not cut himself during the skinning process, but states that he had a fairly recent wound on his left
index finger at the time of skinning.
Incubation Period.—There was a definite onset of the illness, starting on September
23 at 6 a.m., and the incubation period would, therefore, be 4 days.
Symptoms during this period were feeling of lassitude and malaise. The patient
stated that "Day after I skinned coyote I didn't feel right."
First week of illness. September 23-30.—There was an abrupt onset with high
fever, severe throbbing headache, vomiting, profuse diaphoresis and general aches and
pains.   He was delirious the first night after onset of illness.
Shortly after this he complained of pain in the axilla and elbow of the left arm,
where he could feel lumps. A sore was then noticed near the tip of his left index finger.
He remembered that he had a small cut here prior to skinning the coyote. Now this
wound had developed into a circular lesion, containing a cheesy semi-solid material.
The base was deeply injected and of a dark red color. Lymphangitis was prominent
and extended from the hand to a point beyond the elbow.
A rather large, freely movable, hard lymph node could be felt on the medial aspect
of the elbow.   Several similar nodes were easily palpable in the axilla.
The circular lesion developed shortly into a circular punched-out ulcer, with raised
edges and a very angry looking base.   It was not tender.
During the first week of illness the most marked symptoms were profuse diaphoresis,
severe throbbing headaches, general aches and pains, anorexia and general weakness.
Diaphoresis was one of the severest I have ever witnessed. His bed clothes and linen
bad to be changed practically every hour and, although he was rubbed down and dried
frequently, the suprasternal notch was as a rule filled with perspiration to capacity.
Small doses of atropine and solutions of saline were given which somewhat checked
the diaphoresis. He took fluids well but nevertheless it had to be supplemented by intravenous transfusions of glucose in normal saline 1000 cc. three times a day.
The headache was apparently very severe and codeine in doses of gr. Vz were required two or three times a day. The headaches persisted throughout the first week and
the first part of the second week.
The general aches and pains were present for four days following onset. Sodium
salicylate and oil of wintergreen gave only moderate relief,
The weakness developed with the progress of the disease and was marked after the
first week of the illness.
The fever was remittent, temperature ranging from 97.6 to 103.8 F. The pulse
varied from 80-118, was regular and of good quality. Respirations were fairly constant, ranging from 20-25 and not laboured. W.B.C. 10,300. R.B.C. 4,320,000.
Urine—sugar negative, albumen plus 2. Mic.—no pus cells, no R.B.C. Occasional
hyaline cast.
A blood specimen was taken in the early part of the first week for agglutination
tests and was reported negative for typhoid, paratyphoid, Br. abortus and B. Tularense.
Towards the end of the first week he became mentally depressed. Treatment during
this period consisted of codeine for headaches, sodium salicylate and oil of wintergreen
for aches in the joints. Hot fomentations and later hot MgS04 arm baths relieved the
pain in the lymph nodes.
Sulfathiazole gm. 1 q.4.h. was given to relieve the infection but had no apparent
effect.
Glucose 5% in normal saline in 1000 cc. doses was given three times a day to restore
fluid balance.
Atropine by hypo and NaCl by mouth somewhat checked the profuse diaphoresis.
Page One Hundred and Five Second week, October 1-October 7.—During this week diaphoresis was less marked,
but the patient became weaker, more despondent, restless and nervous.
Early in the week he complained of nausea and then vomited occasionally. This
was followed by a diarrhoea of liquid greenish stools which persisted throughout the
week with an occasional remission.    He slept poorly and hajl to be given sedatives.
Towards the end of the week physical examination revealed consolidation in the
lower lobe of the left lung with a few scattered r*ales. Next day he complained of pain
in the lower anterior left chest and respirations became wheezy, laboured and more
frequent.
Tremors of hands and face developed. Patient was very nervous, melancholic and
restless.
The fever was now of a hectic, remittent nature ranging from 100-104, most of
the time being above 102 F.
Pulse ranged from 82-120, was regular and of good force in the first half of the
week, but showed slight irregularities in force and rhythm in latter part of the week.
Towards the end of the week the pulse was very irregular in force, one strong beat
would be followed by 7-8 weak, irregular beats.
Respirations increased in frequency during the last part of the week, ranging as
high as 48.    They were laboured and raspy.
Blood specimen from October 2nd was reported "Slight agglutination to B. tular-
ense to dilution 1:20."    Other tests were negative.
Treatment during this week was much the same as in the first week, except for
changing from Sulfathiazole to Sulfadiazine, the dosage being the same. It had no
apparent effect. On days when patient was vomiting sodium sulfathiazole was given
intravenously.
The arm baths were discontinued in the early part of the week. Patient was on a
high caloric diet and vitamin supplements throughout this week.
Third Week, October 8.—Patient became rapidly weaker. Pains across lower anterior left chest were marked. He developed a cough and expectorated large quantities
of bright red sputum.
Bowel movements were frequent, liquid green and involuntary. Eyes were wide
open, staring and bright. Face drawn and livid. Mouth partially open. Cyanosis appeared about the temples, point of nose and lips.
Respirations were very frequent and laboured. Oxygen inhalations gave no relief
and actually made the patient feel uncomfortable. Pulsus alternans and Cheyne-Stokes
breathing appeared shortly and were not relieved by regular Coramine injections. Muttering delirium and subsultus tendinum were observed.
A small dose (15 cc.) of concentrated anti-tularaemic serum was given intravenously on October 8. Patient showed slight improvement following the injection but
next day condition was considerably aggravated and patient expired on October 9 at
8 p.m.
A blood specimen taken immediately after death was reported to agglutinate B.
tularense 1:640.
Summary.—This case as a whole strongly resembled a severe case of typhoid.
Sulfa drugs although given in heavy doses had no apparent effect.
Penicillin was riot tried, but according to all reports is not effective in tularaemia.
The anti-tularaemic serum was not given a fair trial, simply because it was not available. Apparently there is no anti-tularaemic serum in Western Canada so consequently
it has to be obtained from the east. Even large companies in the east were unable to
send sufficiently large quantities to treat a severe case of tularaemia.
Apparently the coyote is not, as a rule, considered a carrier of tularaemia. Rodents,
such as squirrels, hares, rabbits, etc., are the more common carriers.
The coyote responsible for the transmission of the disease in this case was eating a
rabbit at the time of killing, which suggests the possibility that the former may have
been infected by direct transmission or indirectly by fleas from rabbits.
In conclusion, I wish to thank Drs. Tyerman of Ashcroft, and Schilder of Vancouver
for giving me very valuable advice in the treatment of this case.
(Dr. C. E. Dolman has kindly appended a note to Dr. Pump's unique case report.    See next page.).
Page One Hundred and Six NOTE ON CASE OF TULARAEMIA
I am glad to accede to the Editor's request for a few comments on this interesting
case report. The clinical details given above furnish a typical picture of the severe,
so-called typhoidal type of tularaemia. The symptomatology, the patient's story that
just prior to his illness he skinned a coyote, killed in the act of eating a rabbit, and
finally the laboratory findings, leave no reasonable doubt that the diagnosis is correct.
Although the causative micro-organism is seldom isolated from the blood stream of
humans, in this particular case a septicaemia was probably present, and final proof of
the diagnosis might have been accorded by blood culture, had the data and-the specimens
received been such as to warrant this procedure.
The name of the disease is derived from Tulare County, California, where a minute
cocco-bacillus was shown by McCoy and Chapin in 1912 to be the cause of a fatal,
plague-like infection in California ground squirrels. They named the organism Bacterium
tularense. In North America it is now customary to place it among the Pasteurella
(along with the plague bacillus which it somewhat resembles) and its current designation
is P. tularensis. In Great Britain, the organism is often classed among the Brucella, in
view of certain antigenic relationships shown with this group.
In the past 30 years, numerous other rodent species, including rabbits, tree squirrels,
water rats, muskrats, beavers, opossums, woodchuck and chipmunks, have been found
naturally susceptible to P. tularensis; while sheep, and certain bird- species (e.g. grouse)
may apparently harbour the organism. In 1926, Parker and Francis described the infection in a coyote. P. tularemia has also been isolated from such insects as the deer fly,
and certain species of ticks, fleas and lice. There is thus a wide variety of susceptible
animal species, and of possible insect vectors, most of which are native to this Province.
The organism has been isolated in recent years from batches of the tick Dermacentor
andersoni collected in the Interior of British Columbia, and physicians should be on the
look-out for what may well prove a disease of increasing prevalence.
Among the several thousand human cases which have now been reported in the
United States, the mortality rate has been about 5 per cent. Francis has described four
main types of the human infection. The commonest is the ulcero-glandular type, in
which a skin papule proceeds to ulceration, with enlargement of the adjacent lumph
glands, and a febrile illness. This is the type which characteristically follows an insect
bite, or from handling an infected wild rabbit. There is also a glandular type, in which
no primary skin lesion is discernible; and an octdo-glandular type, associated with a
severe conjunctivitis, and enlargement of the regional lymph nodes. In these cases, the
conjunctiva may prove the portal of entry for the infection. Finally, there is the
typhoidal type, which is responsible for most of the fatalities, including those which
have occurred among an extraordinarily high percentage of laboratory workers engaged
in experiments with P. tularensis.
In all types of the disease, prostration is marked, and relapses frequently occur. As
in the case described, there is no marked leucocytosis. Specific serum agglutinins usually
develop during the second week of the disease. (The Provincial Laboratory's report on
a blood specimen taken from this patient 9 days after onset of symptoms was: "Slight
agglutination against P. tularensis in 1:20 serum"; while a specimen taken at autopsy
16 days after onset, showed "complete agglutination to 1:640 serum".) Experience
with serum therapy, chemo-therapy and anti-biotics in tularaemia has not been sufficient
to warrant pronouncements; but any or all of these methods should be tried as early in
the course of the infection as possible.
The differential diagnosis from e.g. typhoid fever, acute brucellosis, glandular fever,
and plague must rest upon: (i) The clinical symptomatology, (ii) A history of having
handled a wild animal, or of an insect bite, within 1-4 days of the onset of symptoms,
(iii) The presence of lymphadenitis, and usually of a local lesion, often in the finger,
(iv) The development of a high titre of specific serum agglutinins against P. tularensis.
C. E. Dolman.
5-2-45.
il
Page Qne Hundred and Seven V
ancouver
G
eneral
Hospital
THE ARNOLD-CHIARI MALFORMATION
By Dr. Allin Moore
(Former Senior Interne of Neurology and Neurosurgery, The Vancouver General Hospital)
From the Neurosurgical Service of Dr. Frank Turnbull.
The Arnold-Chiari malformation is a congenital neuro-anatomical deformity of the
hind brain. Early recognition of this anomaly, and if necessary, adequate surgical
treatment, may prevent disabling or fatal sequelae.
The deformity was first described by Arnold in 1894, but in 1895 Chiari wrote a
more complete paper discussing sixty-three cases. In discussing these cases, Chiari1
described the anomaly as a downward migration of the hind brain, with protrusion of
the lowermost portion of the cerebellum and medulla through the foramen magnum.
He illustrated three types of displacement which might occur:
Type I: The elongated tonsils and medial part of the inferior lobes of the cerebellum
form a tonguelike process which descends to envelop the caudally displaced medulla, in
the upper part of the vertebral canal. In this type the lower end of the fourth ventricle
does not protrude down through the foramen magnum.
Type II: A similar displacement of the lower parts of the cerebellum and medulla
occurs, but included in the lower portion of the fourth ventricle containing the foramina
of Luschka and Magendie. These foramina, which are pushed completely through the
foramen magnum into the spinal column, allow the cerebro-spinal fluid of the ventricles
to communicate with the spinal subarachnoid space.
Type HI: The cervical spina bifida exists and the greater part of the cerebellum herniates through this opening.
In 1938 Doctors Penfield and Coburn2 presented a very plausible explanation for the
occurrence of the Arnold-Chiari malformation. Because the condition almost always
occurs in conjunction with a spina bifida or a type of meningocele, they expressed the
view that the malformation results directly from the condition in the spinal column.
They suggest that in these cases the spinal cord is adherent to the vertebral column, and
that during the period of embryonic development, when the rate of growth of the
cord and spinal column is unequal, traction is exerted on the spinal cord and brain.
Normally, in the first three months of intrauterine life, the cord and vertebral
. column grow at an equal rate of speed, so that the positions of their segments correspond.
However, after three months, the spinal column outstrips the cord until eventually the
conus medullaris lies opposite the first lumbar vertebral segment. Thus during the
rapid intrauterine growth, it is understood how an abnormal pull will be exerted on the
cord, when it is fixed to the spinal column, as in the case of spina bifida. Penfield and
Coburn suggest that this traction causes an elongation of the cord, with a caudal displacement of the brain stem and cerebellar tonsils.
Discussing the condition pathologically in 1942, Lichenstein3 showed that this
above-mentioned traction causes multiple changes in the spinal cord, brain stem and
cerebellum. The actual Arnold-Chiari malformation is the downward displacement of
the hind brain, with protrusion of the lowermost parts of the cerebellum and medulla
through the foramen magnum. He points out that when, as is common, the condition
occurs in association with a sacral spina bifida, the conus medullaris of the cord is found
abnormally low, with a resultant short cauda equina. Above the site of the fixation,
the cord is thinned, showing the effects of stretching. Because of the caudal displacement of the brain stem and cervical segments of the cord, the cranial nerves are usually
elongated, taking an upward course to their respective foramina. The brain stem and
cerebellum are* jammed into the foramen magnum, and an upset in the natural course
Page One Hundred and Eight of flow of the cerebro-spinal fluid results.    This causes a hydrocephalus, which Donald
and Russell* state may be produced in three ways:
1. Obstructive type, where the foramina of Luschka and Magendie, at the base of
the fourth ventricle, are obliterated, as a result of compaction into the foramen
magnum.
2. Communicating type, where the above foramina are patent below the foramen
magnum, with the cerebro-spinal fluid of the ventricles able to communicate with the
spinal subarchnoid space. However, owing to constriction around the brim of the brain
stem at the site of the foramen magnum, a block exists between the spinal and cerebral
subarachnoid spaces.
3. Adhesive type, where traction on the brain stem causes a mechanical irritation,
which gives rise to an aseptic inflammation in the region of the foramen magnum. An
exudate forms and adhesions occur in this area. As in Type 2, a communicating type of
hydrocephalus results, with the block occurring between the spinal and cerebral subarachnoid spaces.
It appears that the communicating type of hydrocephalus is most common, as out of
twenty cases of hydrocephalus due to Arnold-Chiari malformation, Ingraham and Scott5
found twelve cases were of the communicating type, four of the obstructive, and the
cause of the remaining four was undetermined at autopsy. Hydrocephalus occurred
in eight out of the twelve cases of conununicating hydrocephalus.
Ingraham and Scott5 in 1943 cast some doubt on the traction hypothesis put forth
by Penfield and Coburn. They point out that in thirteen of Ghiari's original sixty-three
cases, no overt spina bifida was seen. To substantiate their view they mention five
cases of the Arnold-Chiari malformation presented by McConnel and Parker in 1938
and three cases of Ogryzlo's in which no spina bifida or meningocele were evidenced at
autopsy. However, despite their rather disconcerting observation, they agree that most
cases of the Arnold-Chiari malformation occur in association with spina bifida—usually
a myelomeningocele in type, as in this type the nervous tissue of the cord is definitely
adherent at the site of the spina bifida. They cited a series of twenty cases of myelomeningocele in which the malformation was seen to be present in all cases—fifteen were
observed at autopsy, five during operation. D'Errico6 in 1939 presented ten cases of
myelomeningocele, all with the Arnold-Chiari malformation.
Although Ogryzlo1 presented a case of the malformation in which no signs or symptoms presented until the patient was sixty-eight years old, most cases are found in
infants and young children. The presenting syndrome is usually hydrocephalus associated with a myelomeningocele or some type of spina bifida. Ingraham and Scott
observed that in their series of cases, microgyri and craniolacunae as well*as hydrocephalus almost inevitably accompanied the malformation; that is, the cerebral gyri at
autopsy were abnormally small and wormlike, with definite areas of bony rarefaction in
the skull. These men suggested that an X-ray of the skull would be a useful diagnostic
measure in early suspected cases.
Owing to the fact that, once established, hydrocephalus advances very rapidly, they
suggest that early surgical treatment is imperative, when the condition is suspected.
They maintain that any patient with a spina bifida associated with hydrocephalus or
the above mentioned signs, should have the spinal defect repaired in the first few weeks
of life, and this be followed within ten days, if possible, by a decompression operation
in the region of the foramen magnum.
Their contra-indications for surgery are:
1. When the myelomeningocele has caused extreme paralysis or sphincteric disturbances.
2. When it is felt that the hydrocephalus or microgyri have advanced so far as to
render the child a pronounced mental defective.
Case Report: Baby G. was delivered by Dr. J. W. Millar at The Vancouver General
Hospital on April 6, 1943. A thin-walled pedunculated sac presented over the dorsal
midline in the region of the fifth and sixth cervical.   This sac broke during delivery and
Page One Hundred and Nine cerebro-spinal fluid drained for several days. At the age of two weeks the sac was
intact and tense, with a diameter of three centimetres. Circumference of the head was
thirty-six centimetres. Anterior and posterior fontanelles were widely open and the
longitudinal suture between them was spread about one-half centimetre. There were no
other apparent deformities and general condition was excellent.
The case was referred to Dr. Frank Turnbull.
Operation 1, April 20, 1943, baby aged two weeks. The meningocele sac was dissected free from the skin by a dorsal midline incision. The neck of the sac was found
to be one centimetre in diameter. On cutting open the sac it appeared to be lined by
normal arachnoid except for two small, firm, rounded masses, side by side, projecting
into the sac from the dorsal side just inside the neck. It looked as though they might
be communicating with the canal, although very thinned out at the neck of the sac.
They were interpreted as terminations of prolonged cerebellar tonsils, i.e., part of an
Arnold-Chiari deformity. The sac was amputated at its neck and a plastic closure
easily accomplished.
Microscopic sections through the small masses in the wall of the sac were reported
by Dr. H. H. Pitts as brain tissue. In one area there was a plaque-like mass of cartilaginous tissue. The operative wound healed well but progressive enlargement of the
head occurred. Three weeks after operation the circumference had increased by three
and one-half centimetres.
Operation 2, May 12, 1943, baby aged five weeks. The former incision was reopened and extended up in the midline to the external occipital protuberance. The
space between the occiput and the first cervical was unusually wide in both diameters
with a posterior bulging of the dura. The width of the spinal canal down to the fourth
cervical was increased by almost half its normal size. The laminae of the third cervical
barely met. The laminae of the fourth and fifth cervical were missing. The sac had
projected out between the fifth and sixth cervical. Laminectomy was carried out down
to the sixth cervical. The dura seemed to be compressed at the lower level of the first
cervical. The arachnoid was very thickened and adherent in this area. A tongue of cerebellum extended down the whole length of the exposed area; overlying this was a sheet
of filmy tissue which appeared to be thickened arachnoid. No attempt was made to
dissect the subarachnoid space laterally at the lower end of the exposure. When the
thickened arachnoid was broken there was exposed what looked like the lower end of
the fourth ventricle, i.e., at the level of the fifth and sixth cervical. At this point the
spinal cord was seen and appeared normal.
Following this operation there was no relief of the hydrocephalus. Frequent ventricular taps were necessary with the removal of thirty to sixty cubic centimetres of
fluid each time.
Operation 3, June 11, 1943. Through a small bone flap in the right temporal
region the choroid plexus of the right lateral ventricle was cauterized under direct vision.
There was an initial stormy convalescence after this third operation but it was
obvious from the start that the hydrocephalus had been relieved. The baby was discharged on June 30, 1943, in good condition. When last examined one year after this
last operation the baby was in excellent health and developing normally.
Discussion and Summary:
A review of the literature dealing with the Arnold-Chiari malformation has been
presented.' The condition occurs chiefly in infants and children who in the great
majority of cases have a spina bifida, usually myelomeningocele in type.
According to Penfield and Coburn, the spina bifida is the primary cause for the
condition due to the fact that adhesions frequently form between the spinal cord and
the vertebral column at the site of the bifida. With the result that as the cord and
spinal column grow at different rates in utero, an abnormal traction is exerted on the
cord above the site of adhesion. By this mechanism the brain stem and part of the
inferior lobes of the cerebellum are pulled down through the foramen magnum. This
theory has not been universally accepted but it is pretty generally agreed that the
Page One Hundred and Ten Arnold-Chiari malformation occurs usually in association with a spina bifida. Regardless
of the cause of the condition, the result is an area of compaction of nervous tissue in
the foramen magnum, which acts as a constricting band, to upset the natural circulation of cerebro-spinal fluid. The flow of the fluid is blocked and a hydrocephalus is
formed. One should suspect the malformation in any infant with an overt spina bifida,
showing signs of hydrocephalus.
It is suggested that the Arnold-Chiari malformation be treated surgically, as early
as possible, to prevent the hydrocephalus from advancing too far. Thus it is imperative
that the cases be diagnosed promptly.
This case history from the records of The Vancouver General Hospital is presented to
illustrate the interesting procedure of treatment used in one case of the Arnold-Chiari
malformation.
l.
2.
3.
4.
5.
6.
BIBLIOGRAPHY:
Ogryzlo, M. A., Arch. Neur. & Psych., 1942, July, 48.
Penfield,  W~., and Coburn, D., Arch. Neur. & Psych., 1938, 40, 328.
Lichenstein, B. W~., Arch. Neur. & Psych., 1942, February, 47.
Russell, D., and Donald, C., Brain, 1935, 58, 203.
Ingraham, F., and Scott, H. W., New. Eng. J. of Med., 1943, July, 229.
D'Errico, A., Yale J. of Biology & Med., 1939, 11, 425 .
LEUCOCYTE COUNT IN ECTOPIC PREGNANCY
By J. G. McPhee, M.D.
(Senior Interne in Medicine, The Vancouver General Hospital)
Recently a check-up on the association between the leucocyte count, including the
differential proportion, and ruptured ectopic pregnancy was made in The Vancouver
General Hospital. The years from 1939 to September, 1944, were examined, excluding
1941, in which year, unfortunately, incomplete records were available. A total of 104
cases were found and in 33 of these leucocyte and differential counts were carried out.
The results are tabulated as follows:
Total below 5,000 white blood cells     0
Total between    5,000 and 10,000 white blood cells-  14
Total between 10,000 and 15,000 white blood cells     7
Total between 15,000 and 20,000 white blood cells     6
Total between 20,000 and 25,000 white blood cells     3
Total between 25,000 and 30,000 white blood cells     3
Thus, of the total of 3 3 cases, 19 (57.9%) exhibited a leucocytosis of varying
degree. The highest count recorded was 26,000, the lowest 5,400. The average haemoglobin estimation was 65% (23 cases). A slight point of interest was that according
to the number of cases in each quarter there is no outstanding period of the year in
which ectopic gestation can be expected to rupture. In this series more instances occurred
in August  (15 cases)  than any other month.
ABSTRACT
"The Section of Dermatology and Syphilology of the New York State Medical
Society at the annual meeting on May 6th, 1943, passed the following resolution, introduced by Doctor Howard Fox:
"WHEREAS, Repeated administration of sulfonamides either internally or locally
may sensitize an individual to these drugs and thereby preclude their future use in serious illness, such as pneumonia, therefore be it Resolved, That the Section of Dermatology
go on record as strongly disapproving the indiscriminate use of sulfonamide drugs in
relatively harmless diseases of the skin which can be satisfactorily treated by equally
efficient drugs."
Hazards of the External Use of Sulphonamide Compounds: Abramowitz, E. William,
Arch, of Dermat. & Syph., 50 : 289, November, 1944.
Page One Hundred and Eleven • We are asked to public the following announcement which speaks for itself. We
gladly do so.—Ed.
Announcement of the
SPRING REFRESHER COURSE IN OTOLARYNGOLOGY
by the University of Illinois College of Medicine
The -fifth semi-annual refresher course in laryngology, rhinology and otology will
be conducted by the University of Illinois, College of Medicine, at the College in
Chicago, March 26 to 31 inclusive, 1945. While the course will be largely didactic, some
clinical instruction will be included. This course is intended primarily for ear, nose and
throat specialists. As the registration is limited to thirty, applications will be considered
in the order in which they are received. The fee is $50.00. When writing for application
please give details concerning school and year of graduation, and past training and
experience.
Address—Dr. A. R. Hollender, Chairman, Refresher Course Conunittee, Dpeartment
of Otolaryngology, University of Illinois, College of Medicine, 1853 West Polk Street,
Chicago 12, Illinois.
[The following items, culled from an old number of the Daily British Colonist, and
the discovery of Dr. D. E. H. Cleveland, a Victorian himself, will be, we are sure, of
interest to all our readers. At the time this was printed, there was no Medical Act, and
it is to Victoria's everlasting credit that among the prime movers in the securing of such
an Act were such men as Helmcken of Victoria, who needed no puffs in the daily press:
but whose work as a medical man of the highest order remains today as a monument
to his memory.—Ed.]
DR. MA CHOO TSUNG
(from Canton)
Surgeon and Physician
Cormorant St., opp. Orleans Hotel
Certified by English and American Consuls at Canton as being duly qifalified,
respectfully solicits the attention of the afflicted.
(From the Daily British Colonist, Victoria, B.C., Sept. 29th, 1876.)
SANITARY.—A fearful stench is caused in the vicinity of Herald and Government
streets, by the burning of an accumulation of rags, dead dogs, cats and all manner of
rubbish. The residents in that vicinity have complained frequently of the nuisance,
but it is allowed to continue in spite of remonstrances. The attention of the proper
authorities is therefore again called to the matter.
(From the Daily British Colonist, Victoria, B.C., Sept. 29th, 1876.)
DR. R. PRICE
(Late of Virginia City, Nevada)
HOMEOPATHIC
PHYSICIAN AND SURGEON
Graduate of the Universities of Berlin and Marburg, German Empire
Office one door below Mr. Lowenberg's Real Estate office, Government street, between
Fort and Broughton.   Office hours from 9 a.m. till 9 p.m.
Eye and Ear, Chronic Diseases, Obstetrics Specialty.
References—Hon. ex-Governor Brasdell, Gold Hill, Nev.; Hon. Wm. Patterson, Dist.
Attorney, Carson City; Hon. Judge C. C. Goodwin, of the Enterprise, Virginia City,
Nev.; Capt. H. H. Day, late Superintendent of the Raymond & Ely Mine, Pioche, Nev.
(From the Daily British Colonist, Victoria, B.C., Sept. 29th, 1876.)
Page One Hundred and Twelve NEWS    AND    NOTES
Sympathy is extended to Dr. W. G. Morris of Burnaby in the passing of Mrs. Morris.
We regret to learn that Dr. F. Day-Smith has lost his son, Lieut. C. Day-Smith, who
was killed in action with the Seaforths in Italy.
Congratulations are extended to Surgeon-Lieut, and Mrs. S. A. Arber on the birth.
of a daughter on January 8th, and to Captain and Mrs. R. A. Stanley on the birth of
a daughter on January 29th.
Dr. and Mrs. J. C. Becher of Vancouver and Dr. and Mrs. R. G. Knipe of Prince
Rupert are receiving congratulations on the birth of daughters.
Major F. H. Bonnell, R.C.A.M.C, who has been serving overseas for the past five
years, is now on the staff at the Vancouver Military Hospital.
•f *r »J* *r
Dr. P. S. Tennant, who is now in practice at Kamloops following service in the
R.C.A.M.C. with the rank of Lieut.-Colonel, was in Vancouver recently, and called at
the office.
Lieut.-Col. W. A. Clarke, R.CA.M.C, who has served as Assistant Command Medical Officer, Pacific Command, for over two and a half years, has now returned to
civilian life, and is resuming practice in New Westminster.
Dr. Arnold Francis of New Denver spent a week in Vancouver last month.
Dr. F. W. Green, M.L.A. from Cranbrook, is in Victoria attending the sessions of
the Provincial Legislature.
Dr. W. H. Ormond, formerly with the B. C Security Commission, is now practising
in Kimberley.
*      «■      *      *
Dr. C A. Armstrong of Ocean Falls called at the office when in Vancouver recently.
*? 5_* «V* *-"
We received an interesting letter from Capt. L. L. Ptak, R.C.A.M.C, who notified
us of a change of address. Capt. Ptak is now Officer Commanding a Field Transfusion
Unit. He has been overseas for the past two and a half years, and he states that he
enjoys receiving the Bulletin, which has reached him regularly, and that it is interesting to note what his friends in the profession are doing both professionally and socially.
*? •_■ »_* *r
At the meeting of the Coimcil of the College of Physicians and Surgeons held on
February 7th, the following attended: Drs. F. M. Bryant and Thomas McPherson of
Victoria, Dr. G. S. Purvis of New" Westminster, Col. Wallace Wilson and Dr. H. H.
Milburn of Vancouver, Dr. F. M. Auld of Nelson, Dr. E. J. Lyon of Prince George and
Dr. A. J. MacLachlan, Registrar.
The Board of Directors of the British Columbia Medical Association met following
dinner at the Devonshire Hotel on February 7th. Amongst those present were the following members from out-of-town: Dr. F. M. Auld of Nelson, Drs. D. M. Baillie, F.
M. Bryant and P. A. C Cousland of Victoria, Dr. E. J. Lyon of Prince George, Dr. A.
H. Meneely of Nanaimo and Dr. G. S. Purvis of New Westminster.
Page One Hundred and Thirteen On January 17th a dinner was held in Chilliwack by the Chilliwack Medical Society,
which was attended by members of the Society and Medical Officers of the local Military
Hospital and Regiments.
Major R. W. Patten, R.CA.M.C, who has served overseas for some time, and who
is now home on furlough, was welcomed back. Dr. Robert McCaffrey of Chilliwack was
complimented on his completion of forty years of practice in the District. Dr. McCaffrey spoke in happy vein of the experiences of the years, medical and otherwise. Major
Patten gave his impressions of D-Day and after, as he saw it.
OUT-OF-TOWN MAILING SERVICE
Associate Members of the Vancouver Medical Association throughout the Province
are reminded that they may borrow books and journals from the Library at any time.
The cost of mailing is of course borne by the member, but this is a negligible consideration now that our special library mailing rate is in effect. According to this arrangement, the return postage is prepaid from this end, and no additional stamps need be
affixed when returning books, if the franked label is used. This label will be enclosed
in the package or pasted on the reverse side of the wrapper.
The Librarian will be happy to look after your requests and will send them to you
with the least possible delay.
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
ISO lAMTITTi STIIIt. NCW TOW. N. T
Full formula and descriptive
literature on request
Dosage: 1 to 2 capsules
3 or 4 times daily. Supplied
in packages of 20*
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam.
Page One Hundred and Fourteen The haemopoietic principle of liver issued in highly active
solution
Specifically indicated in pernicious anaemia and other
macrocytic anaemias and in subacute combined degeneration of the cord
Effective in small doses at wide intervals between injections
Economical in use
Anahaemin B.D.H. is available in ampoules of 1 c.c. and 2 c.c.
Stocks of Anahcemin BJ).H. are held by leading druggists
throughout the Dominion, and full particulars are obtain-
able from
THE BRITISH  DRUG HOUSES (CANADA)  LTD.
Toronto Canada
An/Can/451 9 9 9
With our objective the making of a better
world for women through the development of
gynesic pharmaceuticals based on medical
research — we pause at this time to express
our thanks to the members of the
Canadian medical profession who have helped
us to attain the first steps in our goal.
ORTHO
CANADA       LIMITED,    TORONTO A MAN OF
FEW WORDS
AND FEWER
MINUTES -THAT'S
MY DOCTOR!
99
nt|E balks more than ever these days
M at doing things the hard way, the
wordy way, the long way.
"That's one reason he made a point
of looking into S.M.A. And then put me
on it so enthusiastically.
"He' welcomed a sound formula that
freed him from repeated juggling and
re-calculations with milk, carbohydrate,
water. It was a help to find that he
could explain to mother or nurse in just
two minutes how to rnix and feed S.M.A.
"But best of all, he feels certain that
he is prescribing an infant food that
closely resembles breast milk in digesti
bility   and   nutritional   completeness!
"Is   he   happy   today   about
S.M.A. has done for me!    I
what
can tell,
whenever he checks me over. And is
Mommy happy, too! and am I!
"I   can  tell  you—EVERYBODY'S
happy if it's an S.M.A. baby!"
S.M.A. is derived from tuberculin-tested cows'
milk, the fat of which is replaced by animal and
vegetable fats, including biologically tested cod
liver oil, with milk sugar and potassium chloride
added, altogether forming an anti-rachitic food.
When diluted according to directions, S.M.A. is
essentially similar to human milk in percentages of
protein, fat, carbohydrate, ash, in chemical
constants of fat and physical properties. A product
of the Nutritional Division of John Wyeth and
Brother (Canada) Limited.
'S HAPPY IF IT'S AN
BABT!
Trademark Reg.
in Canada soner
Wmmmm
fKwIs.*:
fm*,-<-i:
Wmpf
r- ___i_______li_i^i_i___i____^. -?J
Supplied mi PINK COMPRESSED
TABLETS Containers of 20, 100 and
500 tablets. Also in suppository form
for rectal use.
Physicians   are   cordially   requested
to  request  clinical samples.
_.4aWTO_Kv^
FOR SOUND SLEEP
'   followed by
REFRESHED
AWAKENING!
Soneryl is a medium acting barbiturate/
which is relatively free from undesirable
after-effects. Sleep is induced within thirty
minutes and continues restfully for six to
eight hours.
■J-aJknxLtxriii I oiuenx: ji&ueA
of    c a m a p a    _ ■ M ■ t e d - m o n r /> . a i "THE MEDITERRANEAN"
A study by Aristide Maillol;
reproduced  from   the   Hyperion   Press
.art book "Maillol".
*j?M JAe tAtmtcAtMi^e...
Two highly effective, clinically proved products for oral
oestrogenic therapy . . . '^Premarin" (tablets) to control even.
the most severe symptoms; "Emmenin'' (tablets and
liquid) for milder symptoms and maintenance.
"PREMARIN"
conjugated oestrogens
{equine)
and
w
EMMENIN"
conjugated oestrogens
^placental)
NATURALLY   OCCURRING   •   WATER   SOLUBLE   •   WELL  TOLERATED
ESSENTIALLY   SAFE   •   IMPART   A   FEELING   OF   WELL-BEING
^B
300
AYERST, McKENNA & HARRISON LIMITED    •    Biological and Pharmaceutical Chemists    •    MONTREAL,  CANADA *a«
(TOTAL      OPIUM      ALKALOIDS)
AMPOUtE Mo.      540 "f    ROSSI*
FOR      REDUCED      NARCOTIC      BY-EFFECTS
Many patients have an idiosyncrasy towards
Morphine and sometimes undesirable effects are
produced.
Certain alkaloids of Opium, as contained in
T.O.A., help to check these by-effects; some are
more stimulating to the central nervous system,
specifically to the- respiratory centre; others
relax smooth muscle, thus relieving the intestinal spasm which not infrequently follows the
injection of Morphine alone.
A dose of T.O.A., containing only 1/6 gr. of
Morphine, is equivalent in effectiveness to 1/4
gr. of Morphine administered alone — another
reason why by-effects are less liable to occur
with T.O.A.
MODES OF ISSUE:
1 cc. Ampoules — boxes of
6 and 100
DOSAGE:
The contents of I cc. ampoule.
(Each 1 cc. ampoule contains the
alkaloids of 0.1 G (12/3 gr.)Opium,
B.P. including anhydrous Morphine
0.01 G. (1/6 gr.) "
Gkoud&s 6 Wicx&ZcGo.
MONTREAL
CANADA
9/t06_4
The   Canadian   Mark   of Quality Pharmaceuticals Since 1899
WHERE QUALITY AND PRICE ARE EQUAL OR BETTER, PRESCRIBE CANADIAN PRODUCTS "RELIEVE BACK PRESSURE
//
When the back-water of the dam gets too high, the sluice-gate is
opened and the lake level is dropped to a safe stage.
The arrhythmic heart is prone to produce a potentially dangerous
venous congestion. DIGIFOLINE, by slowing down the rate, eliminating weak, ineffectual contractions, which take place before the ventricles have filled, causes a marked increase in the minute volume
output of the heart, thus relieving this "back pressure."
DIGIFOLINE
*
can be administered orally, intravenously, intramuscularly or rectally in congestive failure, auricular
fibrillation and certain other myocardial states. One tablet, one c.c.
of liquid or one c.c. of ampoule content represents 0.1 Gm. {\Vi
grains) of digitalis leaf (Focke method).
Trade Mark Reg'd.
C IBA
* & MrtNTRF.a I.
MONTREAL, CANADA Nitntt & (Hlf0ttt00tt
t
2559 Cambie Street
Vancouver, B. C.
CAMPBELL & SMITH LIMITED
820 Richards Street   : :   Vancouver, B.C. : :   PAcific 3053
echve   £/ rinhng THE use of cow's milk, water and carbohydrate roixtures represents the
one system of infant feeding that consistently, for over three decades,
has received universal pediatric recognition.   No carbohydrate employed
in this system of infant feeding enjoys so rich and enduring a background
of authoritative clinical experience as Mead's Dextri-Maltose. \
*
^
Y*
f9t
se.
>/
Wengine news to a large number of physji||ns:
DerWroI hydrochloride is now avpifable
H2C       £j$Sm
m   w
tt__H
ill
^n^^gmethyi-4-phenyi-
|^|g^idine-4^carboj»lr-;
li5Rf|b'%:#P o c h 1 o risfe,-.
/
f
rHE analgesic effect appears to be between that of morphine and
codeine, and it persists for from three to six hours.
Demerol has many indications in medicine, surgery and obstetrics.
Before prescribing, physicians should read carefully the booklet on Demerol
hydrochloride (sent free on request). Prescriptions are subject to Canadian
narcotic regulations.
Supplied for oral use, tablets of 50 mg.; for injection, ampuls of 2 cc.
(100 mg.).
k.'^ii^^^^^§mw^t. Off. „ Canada^
wm.
gtffiH-_i^Sfef.yk c tGit^e jj
^Sf^tt^Ji^Sri^ i^il_^iS^Sfe^3 Colonic and
Physiotherapy Centre
Up-to-date  Scientific Treatments
COLONIC IRRIGATIONS, SHORTWAVE
DIATHERMY, SINNEWAVE GALVIN-
ISM, IONIZATION, ULTRA VIOLET
RAY,  STEAM   BATHS  AND  SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
Superintendent:
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
1119 Vancouver Block
MArine 3723      Vancouver, B.C.
ARTHRITIS and ECZEMA
of endogenous origin
claimed to be allergic, may be
favored or induced by calcium
and sulphur deficiency, impaired
cell action, and imperfect elimination of toxic waste.
lyxanthinTastier
administered per os, brings about
improved cell nutrition 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
-Ifeount pleasant Tanbertafcing Co. Xtb.
KINGSWAY at 11th AVE.
R. F.  HARRISON
Telephone FAirmont 0058 VANCOUVER, B. C.
W.   E.  REYNOLDS 9
ont of 10 eases of EPILEPSY
are treated in the Home
Of the more than a half-million persons
on this continent who suffer from epilepsy, only about 50,000 are in public
institutions'. Thus, about 90 per cent of
the therapy of this disease rests on the
shoulders of the physician in private
practice.
Management of the epileptic in the
home demands the use of therapeutic
measures which will control seizures
effectively, and favorably influence such
psychological factors as make for better
adjustment of the patient to family life,
as well as to his association with others.
The objective of the physician is to
make it possible for the epileptic, adult
or child, to live a normal life with
his family.
Dilantin Sodium is a superior anticonvulsant that is relatively free
from hypnotic action. It is effective in many cases which fail to respond
to bromides or barbiturates. With dosage skilfully adjusted by the physician to the requirements of the individual patient, it provides complete
control over seizures in a substantial percentage of cases. In others it
lengthens the interval and diminishes the effect of the seizures.
1. Tracy Putnam: Convulsive Seizures, p. 4, J. B. Lippincott Co., 1943.
DILANTIN SODIUM
Diphenylhydantoin Sodium
Parke* Davis & Company
Walkerville, Ontario 1895   X-RAY'S   SEMICENTENNIAL   1945
1895 ! Chronicled one of the world's great-
test scientific discoveries, which brought
immortal fame to modest William Conrad
Roentgen, University of Wurzburg physicist. Instinctively a scientist, he investigated
a phenomenon of light observed while experimenting with an electrically-charged
vacuum tube. Today, mankind, in profound
gratitude, commemorates Roentgen's contribution—the X-ray.
This year, we at G. E. X-Ray also celebrate
the 50th Anniversary of the founding of
Victor Electric Company (presager of our
present organization) by those two well
known pioneers, the late Mr. C. F. Samms,
and Mr. J. B. Wantz who, as Consulting
Engineer, continues a notable career.
Our past record of service to x-ray science
speaks for itself and for our future efforts in
the interests of this science.
VICTOR X-RAY CORPORATION of CANADA, Ltd.
DISTRIBUTORS FOR 6ENERAL ^ELECTRIC X-RAY CORPORATION
TORONTO - 30 Bloor St., W. - VANCOUVER: MotorTfans. Bidg., 570 DHiismuirSt:
MONTREAL: 600 Medical Arts Building • WINNIPEG: Medical Arts Building MILK -
Canada r& Vital
FOOD FOR VICTORY
Milk is accepted as the most valuable protective
food because it surpasses all others in supplying
vitamins, minerals, and high quality proteins that
build and maintain sound physical fitness. No
wonder our fighting forces are among the best fed
in the world—their milk consumption is exceptionally high—and no wonder Canada's home front,
too, is by far the best fed!
A quart of milk (4 glasses) gives the following
percentages of your DAILY FOOR NEEDS.
Iron  16%
Vitamin C*% 16%
Energy  22%
Vitamin B 28%
Calcium
* Values Variable.
Vitamin A 37%
Protein .49%
Vitamin G 79%
P h osphorus    69 %
 100% We Have ClosetX^ur 36th Year
Since 1908, through World War One, through
depression arid boom, and now nearly through
World War^wo^DurMiarmaey h^^jgrown
steadily. SFpday weljbok forward to another
year in which to serve theSnedical profession
in many ways better than before.
Phone
MArine 4161
j£hJLl y. joLd&W
GEORGIA PHARMACY
13 th Ave. and Heather St.
Exclusive! Ambulance  Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
n.  UKt.LIN
MM.. BERTRAND a
0U Bu^fy
(Bo. Eimtiri_ *r
m
■
^
4
%
New Westminster, B. C.
For the treatment of
NEUROPSYCHIATRIC
DISORDERS
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
New Westminster 288
or 721 Medical-Dental Building, Vancouver, B. C.
PAcific 7823 PAcific 8036
_7

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