History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: May, 1940 Vancouver Medical Association May 31, 1940

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of the
Vol. XVI.
With Which Is Incorporated
Transactions of the
St.§^t^s: Hospital
. Iii This Issue:
PROGRAMME Vi^^^UMMER. SOHKJ^L-j^^;.       SSt  ij|||||fi|
MEDrcip|SERVIGES A^OnfA^T^M-'^^^^^^^^^^^^^^^^^g
THE DTAf^OS^^SYPT^^^li^^^^fel;ami^^^P^"- ^^^^^^g
THE WHOLE SET-UI^I WRONG4Wr; D. ifeaifc____^K-_-^^^K'242 In Acute
Qenito^urinary Inflammations
the use of Antiphlogistine constitutes a rational aid to the treatment.
Its heat and medication tend to
exert a modifying influence on the
inflammatory phenomena.
As a local adjuvant to other
therapeutfif measures* it |p£ often
Sample on request
Hypertrophic prostate.
W^Accretions ("prostatic pearls?).
sp& Overgrowth of connective tissue.
PP? Lagauchetiere SjiifW., Montreal
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
De. J. H. MacDebmot
Db. G. A. Davidson Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVI.
MAY, 1940
No. 8
OFFICERS,  1939-1940
Db. D. F. Btjsteed Db. W. M. Paton Db. A. M. Agnew
President Vice-President Past President
Db. W. T. Lockhabt Db. Mubbat Baibd
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Db. C. McDiabmid, Db. L. W. McNutt.
Db. F. Bbodie Db. J. A. Gillespie Db. F. W. Less
Auditors: Messes. Plommee, Whiting & Co.
Clinical Section
Db. Kabl Haig. Chairman Db. Ross Davidson Secretary
Eye, Ear, Nose and Throat
Db. W. M. Paton Chairman Db. G. C Laege Secretary
Pediatric Section
Db. R. P. Kinsman Chairman De. G. O. Matthews Secretary
De. F. J. Bullee, Db. D. E. H. Cleveland, Db. J. R. Davies,
De. W. A. Bagnall, Db. T. H. Lennie, De. J. E. Walkeb.
Db. J. H. MacDebmot, De. D. E. H. Cleveland, De. G. A. Davidson.
Summer School:
De. T. H. Lennie, De. A. Loweie, Db. H. H. Caple, Db. Feank Tubnbull,
De. W. W. Simpson, Db. Kabl Haig.
De. A. W. Hunteb, De. W. T. Ewing, De. A. E. Tbites.
V. O. N. Advisory Board:
De. C E. Riggs, Db. T. M. Jones, De. R. E. McKechnie II.
Metropolitan Health Board Advisory Committee:
Db. H. Spohn, De. F. J. Bullee, Db. W. T. Ewing.
Greater Vancouver Health League Representatives:
Db. G. O. Matthews, De. M. W. Simpson
Representative to B. C. Medical Association: Db. A. M. Agnew.
Sickness and Benevolent Fund: The Pbesident—The Tbustees. Endocrine Therapy
AMNIOTIN (N. N. R.)—Squibb estrogenic substance.
The established indications for this A.M.A. Council-accepted product are
vasomotor symptoms of the natural or artificial menopause; gonorrheal
vaginitis in children; senile vaginitis. There are also other conditions
where its value is under investigation.
Amniotin is a highly purified preparation of naturally occurring estrogenic
substances, derived from natural sources. It is available in oil in ampules,
in pessaries, in capsules; for administration hypodermically, intrava-
ginally, or orally; according to the condition being treated and the
individual patient.
growth-promoting effect in pituitary types of dwarfism, in diabetic children
where there is pronounced failure of growth, and in Simmond's disease.
Anterior Pituitary Extract Squibb is available in 20 cc. vials, each containing 200 growth units, for intramuscular injection.
FOLLUTEIN (chorionic gonadotropin) — anterior pituitary-like sex hormone Squibb.
In cases of undescended testes, satisfactory results have been obtained
through the use of Follutein.
Follutein is supplied in glycerin solution with sterile distilled water
diluent; mixture 5 cc.—500 International Units; 10 cc—1,000 I.U.;
5 cc—5,000 I.U.    Administered by intramuscular injection.
THYROID SQUIBB—thyroid glands dessicated. The product is standardized with respect to its iodine content, and also biologically assayed
to assure specific therapeutic activity.
These Squibb Thyroid Tablets enable accurate and controlled dosage in
hypo-thyroid states, including subnormal metabolism as in myxedema
and cretinism, mental retardation associated with thyroid deficiency,
some cases of obesity and of gonadal insufficiency in women.
Thyroid Squibb is supplied in plain or enteric-coated tablets, 1/10, 1/4,
1/2,1, 2, and 3 grains, in bottles of 100,1,000, 5,000. Also 5-grain tablets
For further information write 36 Caledonia Rd., Toronto
^/RjScgjibb & Sons of Canada, Ltd.
Total population—estimated	
Japanese population—estimated :	
Chinese population—estimated	
Hindu population—estimated	
Total deaths  263
Japanese deaths  6
Chinese deaths  8
Deaths—residents only  229
Male, 202; Female, 17L
Deaths under one year of age        9
Death rate—per 1,000 births :-—! 24.1
Stillbirths (not included in above)        8
.__ 8,467
Rate per 1,000
March, 1939
April 1st
February, 1940      March, 1940 to 15th, 1940
Cases   Deaths     Cases   Deaths Cases   Deaths
Scarlet Fever      6           0             18           0 6           0
Diphtheria 0           0               0           0 0           0
Chicken Pox 122           0           122           0 0           0
Measles 82           0             10           0 14           0
Rubella 9           0               7           0 10
Mumps 3           0               0           0 3           0
Whooping Cough 12           0             22           0 4           0
Typhoid  Fever 0           0               0           0 0           0
Undulant Fever      10               10 0           0
Poliomyelitis . 0           0               0           0 0           0
Tuberculosis 42          18             26         14 15
Erysipelas      10               4           0 2           0
Ep. Cerebrospinal Meningitis      0           0               0           0 0           0
Paratyphoid Fever Carrier      10               10 0           0
Burnaby   Vancr.
Syphilis 0 0
Gonorrhoea 0 0
North Vancr.
Richmond  Vancr. Clinic
2                 0 24
1 0 55
Private Drs.
Descriptive Literature on Request.
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
Phone: SEy. 4239
1432 Medical-Dental Bldg.
"Ask the doctor who is using it."
Vancouver, B. C.
Page 209 Professional Men appreciate
the Value of being well-dressed
A Suit tailored to your measure by us is your assurance of
Quality British Woollens, fine hand tailoring
and correct style.
Our new Spring patterns are now ready and your early
inspection is invited.
British Importers of Men's and Women's Wear
Will be received by the undersigned up to Noon, Thursday,
May 23 rd, 1940, for the purchase of one McCarthy Double
Catheterising Cystoscope, with electric cord, located at
2700 Laurel St., Vancouver, B. C.
For further information apply to Dr. D. H. Williams, 2700
Laurel St., Vancouver, B. C.
The highest or any tender not necessarily accepted.
Parliament Bldgs.,
Victoria, B. C,
April 24th, 1940.
Purchasing Agent. SUMMER SHOOL, 1940
June 25th, 26th, 27th and 28th, 1940
Tuesday, June 25 th
9.00 a.m.—Dr. Magner: "Pathogenesis of Jaundice."
10.00 a.m.—Dr. Jeans: "Recent Advances in the Diagnosis and Treatment of Nephritis
and Nephrosis."
11.00 a.m.—Dr. Reichert: "Lymphcedema in Man."
12.30 p.m.—LUNCHEON, Cafe Room Hotel Vancouver.
Speaker: Dr. W. S. Middleton:  "Some Lay Contributions to Medicine."
(Illustrated by Slides.)
3.00 p.m.—CLINIC: Vancouver General Hospital.
Dr. P. C. Jeans: Pediatric Clinic.
8.00 p.m.—Dr. Wm. S. Middleton: "Idiopathic Hypertension."
9.00 p.m.—Dr. Farmer: "Burns and Their Treatment."
Wednesday, June 26th
9.00 a.m.—Dr. Reichert: "Neuralgias of the Head and Face."
10.00 a.m.—Dr. Middleton: "Protection of the Circulation in Surgery."
11.00 a.m.—Dr. Farmer: "Emergency Abdominal Surgery in Childhood."
2.30 p.m.—CLINIC: St. Paul's Hospital.
Dr. Reichert: Surgical Clinic.
8.00 p.m.—Dr. Magner: "Clinical Aspects of Jaundice."
9.00 p.m.—Dr. Jeans: "Nutritional Requirements of the Growing Child."
Thursday, June 27 th
9.00 a.m.—Dr. Magner: "Pathogenesis of Anaemia."
10.00 a.m.—Dr. Jeans: "Calcium and Vitamin D Needs of the Child, with Reference
to Dental Cares."
11.00 a.m.—Dr. Reichert: "Anterior Scalenus Syndrome."
8.00 p.m.—Dr. Farmer: "Treatment of Avulsed Skin Flaps and Treatment of Angiomata."
9.00 p.m.—Dr. Middleton: "Post-operative Pulmonary Complications."
Friday, June 28 th
9.00 a.m.—Dr. Middleton: 'Rationalized Therapeutic Experiences."
10.00 a.m.—Dr. Farmer: "Acute Osteomyelitis."
11.00 a.m.—Dr. Jeans: 'Congenital Syphilis."
2.30 p.m.—CLINIC: Vancouver General Hospital.
Dr. Middleton: Clinic on Internal Medicine.
8.00 p.m.—Dr. Magner: "Some Clinical Aspects of Anaemia."
9.00 p.m.—Dr. Reichert: "Regional Ileitis and Other Localized Lesions of the Small
Page 210 Each tablet contains:
Theobromine -   -   - - 5 grams
*Neurobarb E.B.S.   - - J4 grain
Sodium Bicarbonate - 5 grains
Being antispasmodic and sedative in action, the ingredients of
Theobarb E.B.S. act synergistically to relieve spasm.
The prompt relief following its administration greatly improves
the patient's mental outlook and sense of physical well-being.
INDICATIONS: Angina Pectoris, Arteriosclerosis, Cardiovascular Disease, Nervous Manifestations of the
Climacteric Period, Epilepsy, Hyper Tension
and as an Antispasmodic and Sedative.
Also supplied with x/i grain Neurobarb as C.T. No. 691A Theobarb Mild
Literature and sample on request
•Neurobarb is the E.B.S. trade name for Phenobarbital.
We would call our readers' attention to certain things in this issue of the Bulletin,
which will be of interest to all medical men, and are deserving of some mention. Those
who read Collier's Magazine will have noticed the running commentary on prospective
stories, articles, etc., and the obiter dicta suggested by contributors, writers, and subscribers, which constitute a regular feature on the first page of the journal. Some such
idea would, we think, be a good one for any publication, as it gives an introduction to its
contents and provides a foretaste of good things to come.
We publish at last in this number Dr. Gee's report on the Aschheim-Zondek test as it
has been used in the Vancouver General Hospital for the past eight or nine years. We
would again suggest that this is a very fine piece of work, and well worth recording. It
required a great deal of editing by Dr. Gee before it could be published, hence the delay.
Victoria sends us, as part of its contribution for the month, a paper read by Dr. D.
M. Baillie, dealing, not with scientific matters, but with a far more important thing, one's
daily life. Most of us, in these days of stress and strain, these days, too, of transition—for
Medicine is undergoing one of its periodical new births, emerging from the general practitioner age, where all were equal, all were surgeons and obstetricians, urologists and
neurologists, and the medical man was an intense individualist—most of us, we say again,
have lost sight of the necessity for living a full and abundant life, if we are to be happy
and productive. Where are the Osiers, and the Moynihans, and the Cushings, and the
John McCraes, and the Tait McKenzies? men to whom their medical work, important
and pre-eminent as it always was, meant yet only a part of their life? They read, they
conversed, they thought, they spoke, they lived: and they made contributions of a creative
order to the life of their times. We have had them too. John Mawer Pearson, when alive,
had his hobbies. Sculpture and poetry gave to him happiness—surcease from daily care,
a spiritual.uplift. Banting of Toronto (of Canada?), paints pictures in his spare time, of
a high order of merit. Kidd, of Vancouver, by his patient, arduous efforts, has contributed
much to the knowledge of today on Canadian history, gleaned from his explorations of
the past. And there are many others, no doubt.
There should be more of this, and we should get away more, far more than we do, from
our daily grind, and escape into freer and purer airs. Only so can we avoid becoming hopelessly narrow and selfish, out of touch with realities, out of sympathy with human needs.
The fact is that we, of all men, should be in least danger of so getting out of touch—but
there are many signs that we are not as aware as we should be of modern trends, of modern
developments, of the inevitably inescapable changes that are coming, and must come, to
meet modern conditions, and this strange new world that is slowly emerging from the
ruins of the old world we knew.
We feel that such papers as that of Dr. Baillie, while they deal only with one aspect of
the case, are of great and timely value. Let us make no mistake—times are changing—
tempora mutantur. Can we say "et nos in Hits"? "And we with them"? We rather doubt
it. There is altogether too reactionary an attitude amongst medical men—a tendency to
cling to old things merely because they are old things, and we are used to them—to deprecate change—to refuse any alteration or modification of our traditions and habits.
This is dangerous-—because, if we do not ourselves welcome and direct, and even
initiate, many of these changes and modifications that are inevitable, and often long overdue, we are going to find that someone else will do it.
So we suggest a careful reading of Dr. BailhVs paper. With much of it, many of us
may disagree in detail—but if it makes us think, arouses us to suggesting our own ideas,
we venture to say that it will have served its author's purpose.
Page 211 As a proof that there are others who have constructive ideas, and that there is yet life
in the old dog, we are glad to publish in this issue a brief display representation of the work
of the M.S.A. (the Medical Services Association) which is now in existence, and is gradually, but with ever-increasing rapidity, accumulating an imposing list of prospective
This organization is endorsed by the British Columbia Medical Association, and will,
when it has been fully developed, solve a real public need, and represent a real contribution
to the common good.
We rejoice to see that this Association intends to proceed gradually, in safe stages, and
on grounds as safe as human foresight can ensure. The actuarial basis of the scheme has a
wide margin of safety—which is as it should be.
Full details of the scheme in all its aspects cannot, of course, be given here, but we are
sure that the secretary and organiser, Mr. McLellan, will gladly give any particulars and
information desired.
Dr. G. A. Davidson, Dr. Russell Palmer and Dr. S. C. Turvey attended the meeting
of the American College of Physicians, which was held in Cleveland, Ohio, during the
first week in April.
Our congratulations are offered to Dr. R. K. Brynildsen, who was married on March
26th to Miss Dorothy Rider, of this city, formerly of Regina, Sask. The marriage took
place in Christ Church Park Avenue Cathedral in New York. After a honeymoon in
the South Dr. and Mrs. Brynildsen will make their home in Vancouver.
Dr. A. L. Lynch has recently returned from Carmel, where he and his family enjoyed
a month's vacation.
* *       *       *
Dr. A. E. Trites has left for a short, but well-earned vacation in the South.
* *      *      *
Dr. W. Turnbull has returned from spending three weeks' holiday in the South.
* *      *      *
Our deepest sympathy is offered to Dr. B. D. Gillies on the death of his wife, who
passed away on March 26th.
*£ •*. *!. «t
*C •** »F *r
The following delegation from British Columbia attended the Winter Course of the
Oregon School of Medicine, Eye, Ear, Nose and Throat Convention held in April: Drs.
R. B. Boucher, Colin Graham, W. M. Paton, R. Grant Lawrence, J. A. Smith, J. A.
MacLean, J. A. Montgomery and C. E. Davies, from Vancouver; Dr. W. Laishley from
Nelson, and Dr. B. H. Cragg of New Westminster.
C;v     ■''"* ;'     :    ■'.*■'*      ;-;:4
^r *T *T *F
The Canadians were complimented on their excellent representation.
The speakers for the course were Dr. Marion Jones of New York City and Dr.
Meyer Weiner of St. Louis, Mo.
* *      *      *
Dr. and Mrs. W. F. Anderson of Kelowna are receiving congratulations on the birth,
on March 9th, of a daughter.
•*. *t *fc *t
•P »r »r *r
Dr. R. J. Wride of Princeton has returned after two months in the East, where he did
post-graduate work in Boston, New York City and at Rochester, Minn.
Page 212 Dr. Wilfrid Laishley of Nelson attended the Annual Meeting and Dinner of the Eye,
Ear, Nose and Throat Section and then travelled to Portland to attend a special course in
Eye, Ear, Nose and Throat.
4L. *&. «i. *t-
Dr. E. E. Topliff is in the Mater Misericordiae Hospital, Rossland, making satisfactory recovery from a recent illness.
* *      *      *
Capt. P. S. Tennant, R.C.A.M.C., formerly of Kamloops, now on active service with
No. 8 Field Ambulance at Calgary, was home in Kamloops for a few days.
Capt. W. Bramley-Moore, R.C.A.M.C., formerly of Blue River and Kamloops, now on
active service, was in Kamloops on a visit.
Dr. W. D. Higgs, formerly of Port Alberni, is relieving Dr. T. C. Harold at Ladysmith
during the latter's absence in the East doing post-graduate work.
Dr. C. C. Browne of Nanaimo is impatiently waiting a favourable opportunity to go
down to Victoria and bring back his new sloop.
Dr. and Mrs. R. Scott-Moncrieff of Victoria are receiving congratulations on the birth
of a son.
sj- if- jj. sj.
Dr. and Mrs. R. C. Newby of Victoria are receiving congratulations on the birth of
a daughter.
* *      *      *
Drs. G. A. McCurdy and D. B. Roxburgh of Victoria attended the meeting of the
Pacific North-West Society of Pathologists in Portland. Dr. McCurdy contributed a paper
on Tumours of the Synovial Membranes and Bursae.
* *      *      *
Dr. R. A. Hunter of Victoria attended the Annual Meeting of the American College
of Physicians and visited various centres in the East, including New York.
*£ *t *$■ H"
Dr. G. F. Amyot gave a very interesting address before the last meeting of the Victoria
Medical Society.  The paper was entitled "The Practice of Medicine and Public Health."
The Eye, Ear, Nose and Throat Section of the British Columbia Medical Association
held its Annual Meeting and Dinner in the Hotel Vancouver on March 3 Oth.
Dr. Meyer Wiener, Clinical Professor of Ophthalmology, Washington University, St.
Louis, was the guest speaker, his subject being "Some of the Newer Methods and Treatments of Glaucoma."
Dr. E. F. Raynor of Victoria gave a paper on "The Treatment of Lachrymal Duct
The attendance was large and the programme was good.
Dr. M. J. Keys, President of the Eye, Ear, Nose and Throat Association, presided.
* *      *      *
We are pleased to learn that Dr. R. W. Garner of Port Alberni is now improving,
having been seriously ill with pneumonia.
* *      *      *
Dr. J. Bain Thorn of Trail visited on the Coast at both Vancouver and Victoria during
two weeks in March.
* *      *      *
Dr. B. T. H. Marteinsson of Port Alberni, who is associated with Dr. C. T. Hilton,
called at the office while in Vancouver.
The Penticton Hospital has just installed additional X-ray equipment and a new
metabolism machine.  All the doctors require now is a new hospital building.
Page 213 The wedding is announced of Dr. G. A. B. Hall of Nanaimo to Miss Charlotte Annable,
R.N., of Nelson. Dr. and Mrs. Hall are at present motoring in the Southern States.
Dr. J. K. Kelley of Zeballos is away doing post-graduate work.
Dr. and Mrs. John U. Coleman of Duncan are receiving congratulations on the birth,
on April 23rd, of a son.
Editor The Bulletin:
Dear Doctor:
In your last issue of the Bulletin I read what I wished I had written referring to our
beloved friend R. E. McKechnie, and his services to this Province during half a century.
Without consultation, I would like to add, on behalf of his confreres in the interior in
this neck of the woods (of which he has viewed many), a tribute to his personality. It has
been my fortunate experience to call this man my friend. And those who do not know him
as I do have missed something which cannot be recaptured in these times of stress and
With his wonderful God-given gift of kindness, surgical skill and meeting S.O.S.
situations under most trying circumstances he has no equal.
His delightful personality, which everyone with whom he has come in contact admits
has been a beacon and an inspiration, will never change.
May he long continue as he is, and if he meets all the lame dogs he has helped over the
stile it will keep him from starting Golf.
Yours sincerely,
Penticton, B. C. R. B. White.
Obiit April 16, 1940.
With the passing of George Gordon a few days ago, goes another of a race of
medical men that is now well-nigh extinct—one of the "old school." The present
generation of medical men in Vancouver hardly knew his name, for it is many
years since ill-health forced his retirement into inactivity—but the writer knew
him well, and liked and admired him greatly.
Today medicine has become one of the high-pressure professions—it is
becoming an exact science, with little or no room or time for the leisurely, rather
desultory attitude of the older days—when a doctor was not so much a scientific
professional man as a guide, counsellor and friend of the family, a kindly
philosopher, cheery and optimistic, and achieving, results, perhaps, more through
his personality than through exact precision. We do not feel that the change is
anything but for the better, but sometimes we rather regret certain of the
inevitable discards that have accompanied it.
George Gordon was a well-trained, up-to-the-minute practitioner of his
specialty, urology: but he retained many of the traditions and habits of the older
school of which we speak, and was a punctilious observer of a most rigid ethical
code. He was honour itself in his dealings with his fellows—and his courtesy and
consideration for them were unfailing: he gave generously and without any stint,
of his superior knowledge and skill, where any of his brethren needed these. To
consult with George Gordon, to meet him on a case, was ever a delight, and one
knew that one was meeting and consulting with an honourable gentleman.
A warm-hearted friend, a loyal colleague, a genial host, a fine citizen in every
way, was George Gordon, and we salute his passing.
Obht April 20, 1940.
Thompson of the Yukon died suddenly, in harness, doing his job, on April
20th, and his death was a profound shock to many of the medical profession in
this city. The day before his death, he had been in the hospital, cheery and active
as ever, and one can hardly believe that we shall not again meet that tall, erect
figure, and receive from him, in answer to one's greeting, that charming smile
and friendly recognition that he gave to all whom he knew.
There are politicians and politicians, and Alfred Thompson was one of the
highest order. Of scrupulous honesty and the highest integrity of character himself, he gave full credit for these in others, and gave every man the full right to
hold his own views and beliefs. One cannot remember, in a long knowledge of
Dr. Thompson, ever hearing him speak slightingly or unkindly of any political
opponent. His own opinions were clear-cut and strongly held, and he was a loyal
party man—but he respected every other man's opinions, and gave him credit
for sincerity and honesty. A gentle, kindly humour was his, and he was a perfect loser, with no alibis, and no blame for anyone.
He had a huge acquaintance, and a vast number of friends and admirers—all
over Canada—for he was a national figure in politics, and had been a doughty
fighter for many years in the rough-and-tumble of Canadian political life. He
was one of the many medical men who have embraced a political career, and by
their methods and actions have brought honour to their profession, and made a
contribution to the true welfare of their country.
As a medical man, Dr. Thompson was popular and well known, and his work
was excellent. Latterly, one could see he felt the strain, and there can be little
doubt that the circumstances of his last call, where he turned out on foot, late
at night, to give help to a dying woman, had much to do with his sudden demise.
But we can only envy him this ending, and deem him happy to have died waging
"one more fight, the best and the last," dying with his boots on, alive to the last
minute, in full possession of all his faculties. Our memories of him will be
fragrant and pleasant ones. To his family we extend our sincerest sympathy and
This has been a month of Dinners. The Amyot Dinner has been referred to elsewhere,
and another Dinner held on April 26th was also outstanding.
It was a Complimentary Dinner given by the Graduates' Society of McGill, in collaboration with the B. C. Medical Association, to our beloved Dr. R. E. McKechnie, O.B.E.,
LL.D., F.R.C.S.(Can.), M.D., CM. (etc.), whose list of titles and positions and achievements is far beyond our power to publish in the room at our disposal.
Fifty years of medical practice, and seventy-nine years of life, are among his achievements to date, and the Dinner given last week is merely in the nature of a progress report.
It was a big and an imposing function. There must have been three hundred guests or
more, and the Banquet Room of the Hotel Vancouver was an imposing sight, with McGill
emblems flanking the British and American flags (for we had many Americans as guests),
and supported by Varsity and Queens' colours.
Medical men, of course, formed the great majority of the audience, and there were
representatives of all parts of Btriish. Columbia. Dr. F. M. Auld, President of the B. C.
Medical Association, sat at the left of Dr. C. F. Covernton, President of the Graduates'
Medical Society of McGill, and spoke for the B. C. Medical Association. Lt.-Col. A. L.
Jones, D.M.O. of M.D. XI, was there, and there were many others representing public
bodies of various kinds, gathered to do honour to this man, who has done honour to us all.
The University of British Columbia, of which Dr. McKechnie has been Chancellor for
many years, sent a strong contingent, among others Dr. Buchanan of the Faculty of
Arts and Sciences, who gave a characteristically witty speech, in toasting sister Universi-
Page 215 ties; Dean Finlayson, of the Faculty of Science; Prof. Lemuel Robertson, Mr. Wm. Powell,
erstwhile Professor in the Faculty of Science, and several others.
The Vancouver General Hospital Board of Directors, too, was represented by Mr. J.
H. McVety, Treasurer; Mr. Norman Cull, President; Mr. Frank J. Burd, Dr. A. K. Haywood, Medical Superintendent, and many besides.
The Dinner was a very enjoyable one. There were few speakers, and they were very
good. As has been said, Dean Buchanan delighted us all by his speech, and was answered
by Dr. Wallace A. Wilson, whose reply was a thing of art. He had to work hard to find in
the McGill accent a parallel to the Oxford accent, but then Toronto men have to learn to
work hard anyway to get what they are after (no slurs on Toronto are intended here) and
he did very well, and everyone enjoyed his speech.
Dr. P. A. McLennan introduced the guest of the evening, Dr. McKechnie, in a speech
which could not well have been bettered in style and material. Dr. McLennan has a
literary taste and skill based on wide reading and keen appreciation of the masters of
English, especially the translators of the English Bible—and what he says, especially if
he allows himself to speak extempore, fairly boils over with apposite quotations and
allusions. The present writer was close and could hear him—but it is a matter of regret
that the microphone did not work well for parts of his address.
Then Dr. McKechnie rose, and the walls of Jericho fell down, and he took us all over.
Modest, unassuming, gentle, he told a few simple anecdotes of the Clan McKechnie, from
which he comes, and to which he does honour—and said nothing of himself. We do not
know the motto of the McKechnie Clan, but perhaps it is "Acta, non verba," and in any
case that would be a good motto for them.
It was a heartfelt tribute of affection and esteem on the part of his fellows and those
who know him best, to a man who never sought fame or much reward, but merely has
done what he could: and has "stood by the day's work." As someone, we think Dr.
McLennan, said, he is not of any University, but of all Universities, and he belongs
to us all.
Drs. Osborne Morris of Vernon and Frank McEown of Vancouver as fellow graduates
of the class of McGill '90 were associated as honoured guests.
Drs. Frank Horsfall, Otis Lamson and Donald Trueblood of Seattle, H. Whitacre of
Tacoma, Hiram E. Cleveland of Burlington and several others were present.
Other members who had come to Vancouver on this occasion were: Lieut.-Col. A. L.
Jones, D.M.O., M.D. No. 11; Drs. R. B. White of Penticton, J. S. Burris of Kamloops,
W. F. Drysdale of Nanaimo, H. M. Robertson of Victoria, all of whom graduated in the
Nineties; Drs. Thomas McPherson, M. J. Keys, George W. Hall, A. C. Sinclair, and Lieut.-
Col. G. C. Kenning of Victoria; Drs. R. W. Irving of Kamloops, Robert McCaffrey and
W. E. Henderson of Chilliwack, E. Howard McEwen and W. A. Clarke of New Westminster, G. K. McNaughton of Cumberland, G. E. Darby of Bella Coola, D. J. Millar of
North Vancouver and Norman J. Paul of Squamish.
The Dinner given to Dr. G. F. Amyot, Provincial Health Officer, by the British
Columbia Medical Association, on April 4th, was in many ways a quite unique function.
To begin with, considered as a Dinner, it was a great success—most enjoyable in every
way. While formal dress was the general rule, there was no formality or ceremony about
the function—and the atmosphere was one of quiet, friendly cordiality. The arrangement
of the tables had much to do with this, but even more, perhaps, it was due to the excellent
stage management, if one may use the phrase, of the Committee in charge of arrangements
—and particularly one must acknowledge the staff work of Dr. M. W. Thomas, the
Executive Secretary, who spent most of his waking hours at the hotel for the day of the
dinner, making sure of exactness of detail.
Then, as a complimentary Dinner, it was a very great success. Everyone was unfeign-
edly glad to see Dr. Amyot, and he must have felt, or we hope he felt, a warm sensation
in his praecordial region, when he looked on the big gathering, drawn from all parts of
the Province, and assembled for one purpose only, to greet him and wish him all the luck
in the world, and to assure him^that we will help, to the best of our ability, to ensure that
in his new work he will be prosperous and successful.
After a preliminary cocktail or so, in the big lounge of the Banquet Room (what a
Page 216 beautiful place the new Hotel Vancouver is!) we moved into the Dinner proper. At the
Head Table, Dr. F. M. Auld, President of the B. C. Medical Association, was flanked by
various eminent members of the profession. Our guest, of course, Dr. Amyot, who probably enjoyed the dinner far less than we could have wished—since he had a speech ahead
of him: then Dr. Alexander Primrose, erstwhile Dean of Medicine at Toronto University,
well-known (and favourably) to every man whose Alma Mater bears the title of Varsity.
Then on the other side of the President, Lieut.-Col. A. L. Jones, O.B.E., M.C., D.M.O.
M.D. XI, Dr. A. L. Crease, Director of Mental Hygiene for the Province, Dr. C. E. Dolman, Director of Provincial Laboratories, and many others. Representatives of Medical
Electoral Districts were present.
The President read many telegrams from many members of the B. C. Medical Association unable to attend—for this was no local affair, but a Dinner given by all the men of
the Province: and this was one of the elements that made the mixture so unique. It was,
as Dr. Appleby said in his remarks as President of the Council of the College of Physicians
and Surgeons, a family gathering, not merely a medical dinner. He remarked, too, that in
few places could such a united and harmonious meeting be called of all sorts and conditions
of men. The Dinner was further unique in its composition. All branches of the medical
profession met on equal ground, in the greatest amity, and in a spirit of pure fellowship.
The therapeutic lamb lay down with the preventive lion, and all was happy, with no signs
of indigestion on either side. This was, we maintain, one of the finest things we have seen
in our time. No longer should there be any division or dichotomy between these two:
they should each study not only their own problems, but also each other's: and should
together, and in full agreement, settle both. There is, as Dry Amyot said in his short speech
of reply, no problem that cannot be solved by agreement and a true spirit of give and take.
Dr. Auld made an admirable Chairman and Toastmaster, and introduced each speaker
briefly. The representatives of local medical societies each spoke briefly and cordially, and
each had some contribution to make. Lt.-Col. Jones made a short and witty speech; Dr.
Agnew, for the Vancouver Medical Association, also spoke; Dr. W. A. Clarke referred
to the immense importance of the Public Health Department to the general practitioner
of medicine. Dr. McGregor of Penticton referred especially to the problems of rural
and small town areas, where conditions are so different from those in a large city. Dr.
Daly invited us all most cordially to go to Nelson in September for the Annual Meeting
of the B. C. Medical Association.
Dr. Primrose referred to the late Dr. J. A. Amyot, father of Dr. G. F. Amyot, who
was such a distinguished ornament to his specialty of Public Health, and who achieved
an international fame through his work in the war.
The guest speaker was introduced by Dr. A. L. Crease, and everyone knows who Dr.
Crease is, or he ought to, and probably will some day if he doesn't know now. Dr. Crease
spoke in terms of warm admiration and respect for Dr. Amyot, and bespoke the support
of all medical men in the province in his future work.
Dr. Amyot, in replying to the toast given in his honour, was obviously much moved
by the sincerity and warmth of the applause that greeted his rising. He expressed it as his
most sincere ambition that as time went on there should come to be a closer and closer
co-operation and harmony between all departments of medicine in British Columbia. He
felt that neither therapeutic nor preventive medicine could go very far or very fast
without the other—that there could be no problem or difficulty arising which could not
be solved or removed by goodwill, consultation and discussion in a spirit of give and take.
He suggested that a consultative group be formed, perhaps as a direct motion on the
part of the B. C. Medical Association, which could function constantly—with which he
might meet periodically, and to which problems arising from either side could be referred
for discussion and adjustment. This seems to us to be a splendid suggestion, and one that
must not be allowed to be forgotten.
Dr. Amyot spoke warmly of the personnel of his Department, and felt that with their
loyal backing, and with the support and sympathy of the medical profession as a whole,
the years should bring to B. C. ever-increasing harmony and efficiency in the promotion of
health, the prevention of disease, and thus the assurance of longer, better, and happier lives
to all who live in this Province of ours.
Page 217 Vancouver  Medical   Association
The Annual Meeting of the Vancouver Medical Association was held on Tuesday,
April 23 rd, in the Auditorium of the Medical-Dental Building.
We present in this issue most of the Reports—and only what might be called the
"negative" reports, where there was nothing to report, are omitted.
It had been hoped to hold a Dinner to mark this Annual Meeting, but, as it happened,
there have been two Dinners during the month, the one given to Dr. G. F. Amyot and
that to Dr. R. E. McKechnie later. Wisely, we think, the V. M. A. Executive decided to
waive its own claims.
However, we were not left hungry in every sense of the word. Rather, the Executive
is to be congratulated warmly on its choice of a speaker for the evening, in the person of
Professor F. H. Soward, of the Faculty of Arts and Sciences of the University of B. C.
Dr. Soward gave us a talk on "The Background of the Second World War" whcih
will not soon be forgotten by those who were fortunate enough to hear it. It was a masterly address by a man who not only knows history, but, more invaluable still, has the
historian's mind. Just to know the facts and sequences of history is a small achievement and
of small value. It is like knowing anatomy backwards, but having no knowledge of physiology and being ignorant of the uses and functions and results of action on the part of
the structures concerned.
Professor Soward knows the facts, but he can also philosophise on them, see their connection with each other, and with past and future events. This is what we, who read the
papers and read of facts and happenings, need most of all. We need the sane and considered opinion of a man whose wide knowledge of history, and intimate understanding of
its philosophy, can make for us a clear and connected picture, looking at which we shall
understand the why and the wherefore of the present struggle.
He has, too, the gift of dispassionateness. Nobody can doubt where his sympathies
lie—but he allowed no prejudice or passion to cloud his mind, and so confuse his utterance
—and this is as it should be.
Altogether, it was an excellent and an inspiring address.
We congratulate the new officers, and especially Dr. Dan Busteed, our new President.
Dr. Busteed has worked long and hard for the Association, and in every way deserves this
recognition. He will do honour to the position.
The thanks of the Association are due to last year's Executive, which has done outstanding work, and left a good record.
Following the address the business of the meeting proceeded, with the election of
Officers and the presenting of Reports. Names of Officers for the coming year will be
found on the first page of the Bulletin, and the Reports of Standing Committees and
Officers are given below.
Reports of the Clinical Section, by Dr. Karl Haig; the Eye, Ear, Nose and Throat
Section, by Dr. W. M. Paton, and the Pediatric Section, by Dr. E. S. James, were presented
and showed well-attended meetings and keen interest in the work of individual sections.
Seven general meetings were held during the year. One special meeting was held on
January 3rd, to consider the Vancouver School Teachers' Medical Services Scheme.
Membership.—Total membership of the Association, including applications for membership which are pending, is 303. This number is made up as follows: Life Members, 10;
Active Members, 246; Associate Members, 42; Privileged Member, 5.
Page 218 Thirteen new members were elected during the year.
The Association has lost three members since the last Annual Meeting: Dr. G. E.
Gordon, who was a Life Member; Dr. F. G. Logie; Dr. Alfred Thompson.
The average attendance at General Meetings during the year was 55, this being a decrease of 25 from the average attendance of last year. This may be accounted for partly
by the fact that no dinner meeting was held.
The Executive Committee held 14 meetings throughout the year.
Respectfully submitted,
W. M. Paton, M.D., Hon. Secretary.
Mr. President and Members of the Vancouver Medical Association:
I have the honour to report as follows:
I present the Auditor's report, which I shall move be taken as read. It is quite a lengthy
and intricate document and will be available in the Library for perusal by members at
their leisure.
Our trust accounts are all in healthy condition.
The Historical and Ultra-Scientific Fund shows an accumulation of interest of $491.64, which is available to the Librray Board for expenditure.
The Stephen Memorial Fund has accumulated interest of $85.61, also available for expenditure by the
Library Board.
The Sickness and Benevolent Fund Grants during the year amounted to $825.00
Returned by a Grantee 450.00
Balance   outstanding T—$375.00
Bond interest for the year 155.66
Net depletion of fund $219.34
The Sickness and Benevolent Endowment Fund $   700.00
The John Mawer Pearson Lecture Fund $3,063.52
Summer School Fund balance $3,366.49
Entertainment  Fund  balance $   103.68
Income for the year consisting of:
Members annual dues ($100 less than 1938) $4,3 88.75
Interest on Securities __      197.81
Relief Administration allowance      600.00
Profit on Bulletin             355.08
Total  Expenditure,  including  Depreciation	
Excess of Income over Expenditure	
All of which is respectfully submitted.
I move the adoption of this report.
. 4,402.66
J. W. Lockhart, Hon. Treasurer.
The President, Vancouver Medical Association.
Dear Sir:
The following is the annual report of the Trustees, in which is included the report of
the Sickness and Benevolent Fund Committee. Both bodies met at irregular intervals as
required throughout the year. Up to the end of the Association's fiscal year there was
disbursed from the Sickness and Benevolent Fund the sum of $825.00 and up to the present
date $900.00. Of this sum $450.00 has been refunded, which leaves an expenditure for the
fiscal year of $375.00.
The Sickness and Benevolent Endowment Fund has been augmented by a donation of
$200.00 from Dr. J. A. Gillespie. This has been invested in Dominion of Canada bonds.
The Committee wishes to record its appreciation of this munificence and expresses the hope
that it will act as an incentive to others to do likewise.
Page 219 The disbursements during the year have practically exhausted all current assets of the
Sickness and Benevolent Fund, and should any further expenditure be required in the near
future some of the principal sum will have to be liquidated to meet the expense. It would
therefore appear that at the present time more than at any other over a long period, the
Sickness and Benevolent Fund is in need of augmentation. The Trustees once more would
point out to the Association that if reasonable assistance is to be given necessitous members
there will have to be collections made for that purpose. The Trustees would again suggest
to the Executive that steps be taken to accomplish this.
All of which is respectfully submitted.
Signed on behalf of the Trustees,
Fred M. Brodbe, Chairman.
Books Added to the Library.
General Collection:
57 new books at a cost of	
37 gifts (including old books in library, not previously catalogued).
Nicholson Collection:
6 books added at a cost of	
.$    375.55
Total of 100 books added at a cost of - $   394.43
Nicholson Fund:
books purchased at a cost of $18.88, leaving a balance in this fund of $129.90.
Medical Journals:
69 Journals are subscribed to at a cost of $   604.52
35 Journals are received as gifts.
104 total number of Journals received in the Library.
94 volumes were bound at a cost of 286.47
Other Expenses:
Subscriptions to Medical Library Association 15.00
Boxes for storing books 13.12
Total   expenditure-
The Committee is indebted to Drs. Frank Turnbull, D. E. H. Cleveland, E. Trapp,
Tchaperoff and others for gifts of books and journals during the year.
Lists of new books have been published in the Bulletin from time to time.
A new rack for journals in the Reading Room was made necessary by the increased
number of journals received.
A list of journals was prepared and kept in the Reading Room for reference.
The'meetings of the Library Committee have been well attended throughout the year.
Before closing this report I want to express, on behalf of the Committee, our very
great regret at the resignation of our Librarian. As Miss Choate, she has given long and
most efficient service to the Library—most cheerfully and unstintingly—and I can assure
her this has been most thoroughly appreciated. As she has taken unto herself a new name
—and other, and probably more important duties and responsibilities—we wish to assure
Mrs. Van der Burg of our most sincere good wishes.
Her place is not an easy one to fill and we would bespeak on behalf of her successor,
Mrs. Craig, as much patience, tolerance and helpfulness as possible, until she has familiarized herself with this work, which is decidedly different from the usual office or Library
F. J. Buller, M.D., Chairman.
The past year of work on the Bulletin has been one of quiet progness—there has been
no change in the policy or makeup of the Journal worthy of report: but on the whole, we
feel that the standards of publication have been maintained, and perhaps in some cases
From a financial point of view, we have rather more than held our own. Advertising
has been, on the whole, satisfactory. World conditions have made the going hard for some
Page 220 of our advertisers—but the great majority have renewed their contracts with us as they
elapsed. Mr. McDonald, our publisher, tells us that we are in a fortunate position in this
Our balance sheet for the year shows a profit. Last year we had a deficit of some $250
net. This year we are some $355 ahead, so that we can, in the two years, show a clear profit
of some $105. This has, of course, been a source of great satisfaction to us.
During the year the Bulletin acted as editorial centre for two publications: the
Summer School Supplement, containing the papers read before the V. M. A. Summer School
in June, 1939, and the Supplement containing the papers read at the Annual Meeting of
the British Columbia Medical Association in September, 1939. Strictly speaking, the latter
is not a supplement to the Bulletin at all but the independent publication of the B. C.
Medical Association. We were, however, very glad to be of service in this regard and the
name of the Bulletin appears as publisher on the cover of the issue.
The Summer School Committee, wisely as we think, adopted the policy of limiting the
circulation of their printed issue to those who had bought tickets for the Summer School.
This will undoubtedly be their permanent policy. We hope to be able to extend the editorial services of the Bulletin again this year to the Summer School Committee for 1940.
An idea of the necessity for editing and concentration may be gathered from the statement
that the wordage of these papers before editing amounted to some 110,000 words—we had
to cut this down to about 80,000, without doing any harm to the papers. Some of them,
we feel, rather benefited by curtailment.
It may be of interest, as showing that our publications do reach readers, to tell you
that only a fortnight ago we had a request from the editor of a fairly prominent journal
in the southern part of the U.S.A., asking our permission to reprint one of the articles
published in one of these supplements—this is by no means an isolated instance.
Two people particularly deserve our thanks at this juncture, for the indispensable and
most valuable help they have given us.
First of all is our Librarian, Miss Jessie Choate, now, alas, happily married, and therefore about to leave us. No words of mine can express our debt to this lady. To begin with,
her interest in the Bulletin has been a personal one—she has taken the keenest possible
interest in its welfare, has given of her time, and of her overtime, freely and ungrudgingly,
in collection of items, proofreading, arranging, and so on. And personally, I do not know
how we are going to get along without her help: and especially without her enthusiasm
and friendly interest. One always knew that one could depend unfailingly on her help.
But we must bite on the bullet, and meantime we wish her, as must all who know her, the
greatest happiness and prosperity.
As publisher, Mr. Macdonald, of the Roy Wrigley Printing & Publishing Co., has also
been a tower of strength. He has been absolutely dependable, and has guarded our interests
as if they were his own. The service and devotion he has given to the Bulletin are quite
beyond any ordinary business requirements, and are, we feel, due to a pride and interest
which he, too, feels in our Bulletin.
We are very grateful, tod, to Dr. M. W. Thomas, Executive Secretary of the B. C.
Medical Association. He has, each month, rounded up the News and Notes from the whole
Province; and has been most generous with help and contributions of material.
I should like to say a good deal more about the Bulletin, but must not, yet we feel
that we have by no means attained the full stature to which we have every right to aspire.
Our Board feels that we must investigate, during the coming year, some new paths. For
instance, illustrations would greatly enhance the value of our publications, and we are now
exploring that possibility. Again, our ambitious publisher, Mr. Macdonald, feels that we
should consider ways and means of increasing circulation, and so increasing advertising
possibilities! This brings us back to a most alluring, if somewhat over-ambitious, idea that
many of us have toyed with at times—the question of expansion into wider fields. This is
by far too big a subject to deal with now, especially as it is no more than a faint cloud, the
size of a man's hand, on the far horizon, but we can assure you that no step will be taken
without the most careful and scrupulous scrutiny and investigation, and without your
fullest knowledge and endorsement.
Page 221 In conclusion, I should like to add my personal thanks to Drs. Cleveland and Davidson,
my colleagues on the Editorial Board, for their loyal help and counsel.
J. H. MacDermot, Editor.
Mr. President:
Sixteen applications for membership were sent to your Committee for consideration.
Of these, five have been elected, three for active membership and two for Associate membership. The remaining eleven have not yet completed their one year of practice in British
A. B. Schinbein, M.D., Chairman.
Your Committee wishes to draw to the attention of this Association the following
items, viz.: that the number of people on relief in March, 1939, was approximately 10,000
and in 1940 about 9,000, yet the relief accounts have continued to soar.
The gross accounts in 1938 amounted to $162,422.00; in 1939, $166,295.00; in 1940,
$174,450.00. In September, October and December, 1939, 45% was paid on accounts
received and in the other months the percentage ranged from 30 to 42%.
For these reasons a resolution was passed at the last meeting of the Relief Administration Committee reducing the maximum amount to be paid on any one account from
$100.00 to $75.00.
The total net accounts for the year were $151,532.28; the total amount paid to
debtors, $58,364.59; cost of administration, $1,523.00 or 3%; balance in bank, $143.28.
In addition to the above $3,5 88 was paid for maternity relief, $2,388 being paid to
the doctors in charge of cases and $1,200 to the Victorian Order of Nurses.
Owing to military duties Dr. Roy Mustard was obliged to resign from the Committee
in September and Dr. A. O. Brown was appointed to succeed him. Your committee wishes
to express its hearty appreciation of Dr. Mustard's good work on the Committee.
The Committee now consists of: Dr. W. T. Lockhart, Chairman; Dr. J. A. Sutherland,
Vice-Chairman; Dr. Colin McDiarmid, Dr. J. R. Davies, Dr. A. O. Brown, Dr. L. W.
McNutt, Dr. D. F. Busteed.
All of which is respectfully submitted,
J. A. Sutherland, Secretary pro-tem.
Mr. President and Gentlemen:
The report of your representative to the Executive of the B. C. Medical Association is
not lengthy, but it contains a few items of particular interest to our members.
Three meetings have been held with representatives from the sections of British
Columbia. In the past year the two large contracts, viz., the B. C. Electric Railway Employees and the B. C. Telephone Employees sick benefit associations have functioned satisfactorily. There does not seem to be any reason why the profession should be wary of contracts which seem to have worked out to the benefit of the medical practitioners. This
year saw a third large group, viz., the Teachers of the Greater Vancouver area, embraced
in a medical scheme under the same type of contract as the two previous associations. The
Economics Committee of the College of Physicians and Surgeons, working with the B. C.
Medical Association executive, have worked hard in the interests of the profession.
Several members of our Association have joined His Majesty's forces and at present a
committee is enquiring if it is possible, in some manner, to hold in part the practices of
these officers. The B. C. Medical Association has discussed the matter at length and a committee made up of members of the Vancouver Medical Association, the B. C. Medical
Association and the District Advisory Committee of the Canadian Medical Association, is
seeking knowledge in the preparation of a report which will be presented later in the year.
Page 222 There are some matters which may be brought to the attention of this organization in
the future, as it has been expressed that the Vancouver Medical Association is the "voice-
piece" of the profession in this area, and at times we are asked to consider and approve or
disapprove of certain measures which may have a bearing upon the health of this community, it might be better if more doctors in the metropolitan area were members of the
Vancouver Medical Association and so swell the "voice" which must speak with authority
on occasions.
Some of the matters that have been discussed at length are: (1) The preparation of
milk and the methods of handling; (2) The pollution of na:vigable waters inside the city
limits and the proposed use of some of these areas for sea products.
L. H. Leeson, Chairman.
British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President j Dr. F. M. Auld, Nelson
First Vice-President Dr. E. Murray Blair, Vancouver
Second Vice-President Dr. C. H. Hankinson, Prince Rupert
Honorary Secretary-Treasurer Dr. A. H. Spohn, Vancouver
Immediate Past President ._Dr. D. E. H. Cleveland, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
The Board of Directors of the British Columbia Medical Association held its regular
meeting following Dinner at the Hotel Georgia on Wednesday, April 3rd, 1940.
The following attended: Dr. F. M. Auld, of Nelson, President; Drs. W. E. Ainley,
Murray McC. Baird, Murray Blair, W. A. Clarke of New Westminster, D. E. H. Cleveland, P. A. C. Cousland of Victoria, J. Stuart Daly of Trail, Major Allan Fraser of Victoria, Captain Roy Huggard, L. H. Leeson, J. H. MacDermot, H. McGregor of Penticton,
D. M. Meekison, H. H. Milburn, P. L. Straith of Courtenay, G. F. Strong, Stewart A.
Wallace of Kamloops, George T. Wilson of New Westminster, Wallace Wilson, A. H.
Spohn and M. W. Thomas.
The Dinner held on April 4th, in honor of Dr. G. F. Amyot, Provincial Health Officer,
was largely attended by members of the profession from many parts of the Province and
was representative of all phases of medical practice. The Banquet Room of the Hotel
Vancouver provided a suitable setting and under the able Chairmanship of Dr. F. M. Auld
of Nelson, President, the whole affair proved to be a very happy feature.
Telegrams brought greetings and assurance of goodwill from Drs. G. E. L. MacKinnon
of Cranbrook, E. J. Lyon of Prince George, F. W. Green of Cranbrook, C. H. Hankinson
of Prince Rupert and W. J. Knox of Kelowna.
Lieut.-Col. A. L. Jones, D.M.O., M.D. No. 11, and Major E. E. Day, Chief Medical
Officer of the Western Air Command, travelled from Victoria ot attend the Dinner. Both
Colonel Jones and Major Day briefly addressed the gathering.
The following representatives of organized medicine spoke briefly:
Dr. L. H. Appleby, as President of the Council of the College of Physicians and Surgeons;
Major Allan Fraser, President of the Victoria Medical Society, on behalf of Medical Electoral District No. 1;
Dr. W. A. Clarke of New Westminster, member of Council from Medical District No. 2
and President of the Fraser Valley Medical Society;
Dr. A. M. Agnew, President of the Vancouver Medical Association for Electoral Ditrict
No. 3;
Page 223 Dr. H. McGregor of Penticton, President of No. 4 District Medical Association;
Dr. J. Stuart Daly of Trail, President of the West Kootenay Medical Association for
Medical District No. 5.
Dr. Alexander Primrose of Toronto was visiting in Vancouver and was present at the
Dinner. Dr. Auld introduced Dr. Primrose, who spoke brieky of his associations with Dr.
Amyot's father.
Dr. A. L. Crease, Director of Mental Hygiene in the Province of British Columbia,
introduced the Guest of Honour, Dr. G. F. Amyot.
In responding, Dr. Amot conveyed to the Association his appreciation of this overwhelming expression of goodwill from his fellow members. At the close of his very interesting discussion of the responsibilities and possibilities of the Department of Public
Health, Dr. Amyot announced that he was considering a plan by which he could have the
counsel of the profession in developing the Public Health Services in this Province.
Other members from outside points were: Drs. M. G. Archibald of Kamloops, Wr E.
Henderson of Chilliwack, R. McCaffrey of Chilliwack, P. L. Straith of Courtenay, P. A.
C. Cousland of Victoria, C. T. Hilton of Port Alberni, J.JV. Taylor of Abbotsford, L.
Chipperfield of Coquitlam, G. S. Purvis, W. R. Brewster, J. T. Lawson of New Westminster, J. R. Parmley of Penticton, Richard Felton of Victoria, N. J. Paul of Squamish,
W. G. Saunders of North Vancouver.
JULY, 1932, TO JANUARY, 1940* *
Evelyn M. Gee, M.D.
Dorothy E. Wylte, M.A.
Following the basic work of Smith, Evans, Long, Simpson, Aschheim, Zondek and
others, the Aschheim-Zondek test for pregnancy and the Friedman Modification have been
widely used in diagnosis and recommended by authorities for universal adoption. Therefore
justification of this test is no longer necessary.
The work of P. E. Smith and Leonard3 4, Evans and Associates, Brosius and Schaefer,
Collip5 and others in the isolation of the responsible hormone and its identification from
those of anterior pituitary origin is generally accepted6 8. The name chorionic gonadotropic
hormone7, indicating the origin in living chorionic tissue, appears well chosen.
Since, however, these tests are not tests for pregnancy per ses 9, being quantitative
rather than qualitative in type, many problems arise in their interpretation. To date many
thousands of tests have been reported and several investigators have reviewed them. Possibly
the only justification for a report of our tests at this time lies in a discussion of the so-called
problem cases, all of which are matched in the literature. We wish to thank the physicians
involved whose co-operation has made this possible. This report is actually written for the
doctors who have sent us these tests, asked us reasonable questions about them and listened
to our halting explanations during the past seven and one-half years.
The tests, except the first 25 which were done for training, have been strictly utilitarian
rather than experimental. In all of these the clinical diagnosis was in doubt. The adoption
of the Friedman Modification rather than the original Aschheim-Zondek test is advised by
most authorities10 1 for laboratores with like demands and facilities and by many11 8 as
the more useful of the two. Several other simple tests reported as useful, notably the Davis,
Konikov and Walker pupillary reaction and the Visscher-Bowman Chemical test have been
tried in duplicate and found inaccurate. At the present time, the only accurate test, apart
from the Aschheim-Zondek and Friedman, appears to be the test reported from South
* From the Laboratory of the Vancouver General Hospital under the direction of Dr. H. H. Pitts. We
also gratefully acknowledge the help of other members of the laboratory staff, particularly Mr. Shearer, Mrs.
Cox, Miss Nicholson.
Page 224 Africa in 193 5 by Shapiro and Zwarenstein using female South African claw-toed frogs,
Xenopus Laevis. This test is excellent, but the frogs are obtainable only in South Africa,
become useless after one month, and six are used for each test, necessitating a continuous
fresh supply, which renders it locally impracticable1 6.
Our technique has been altered slightly since 1932 and is actually a modification of the
original Friedman. In its present form it is used with occasional variations in many laboratories.
Summary of Technique:
1. Rabbits used—ordinary, mature, domestic, females weighing 4 lbs. plus.
2. Isolation in individual cages.  Used for Friedman tests only, no bacteriology discards.
3. Use in tests—
Not less than one month from date obtained.
Not less than one month following negative test.
Not less than two months following positive test.
4. Specimen requested—first morning urine, delivered as early as possible to the Laboratory—fluids
restricted previous evening—preferably not within two weeks of missed but expected menstrual period unless
actual date of impregnation known.
5. Specimens sent from a distance—preservative—1 drop of concentrated carbolic per ounce—2 ounces
6. Treatment—kept in refrigerator—filtered if turbid—tested for acidity, if alkaline made acid by
addition of acetic acid.
7. Injection—10 plus ccs. intravenously immediately and on following day (use of large amount of
urine does not lead to false positive-").
One rabbit only used for each test.
8. Operation—48 hours21 from first injection—posterior approach—examination of both ovaries in all
negative or doubtful reactions.  Ether anaesthetic. %¥&
9.—Diagnosis—gross only.
Positive reaction—presence of bulging haemorrhagic follicles.
Negative reaction—normal ovary with follicles small or large, clear and colourless.
Doubtful reaction—recheck requested.
Unsatisfactory ovaries—fibrotic without follicles or embedded in scar tissue.   Rabbit discarded.
Marked congestion of follicles—pink colour—no true haemorrhage.
Large black degenerating follicles only.
References—Laboratories using the same or slightly different technique12 13  14 ten test  conditions
described2 lx 15.
Some investigators report excellent results with single 25 cc. injections, but on the
whole the experience of men working with hormone reactions in lower animals appears to
be that frequent small injections are more effective. As suggested by Mack and Agnew8,
the uniformly good results reported seem to indicate that the many slight variations in
technique are of little significance in determining the accuracy of the test. By using one
rabbit only we have saved at least 2353 rabbits, and the repetition of doubtful reactions
due to the condition of the rabbits' ovaries has caused little inconvenience. In spite of the
above suggestion attention should be paid to details of technique, and, in view of its quantitative nature, the test repeated whenever there is any question as to interpretation in the
laboratory or clinically.
Table I.
Impossible  to  confirm	
Confirmed  as  correct	
Confirmed  as  incorrect	
% accuracy in confirmed cases-
% error in confirmed cases.
% distribution of positive and negative tests	
Uncompleted tests: 112.
The tests in Table I were done for a large group of physicians and include both normal
and problem cases. Confirmation was obtained by conversation with the doctors involved
and in part by circularization. As this is a test for hormone produced from living chorionic
tissue in connection with the blood stream, death of such tissue soon leads to failure of
production.  Negative tests in such cases cannot properly be described as false.  Workers
Page 225 in recent years8 16 refuse to classify them as errors and Aschheim and Zondek calculate only
the false reactions obtained from the urine specimens of patients known definitely to have
been normally pregnant or not pregnant. In our series we have elected to call some tests
false in which no other information was obtainable. If the clinical data were available they
would possibly be more correctly classified as true.
The number of uncompleted tests is too low, as these were not always recorded. In 56
of these cases the rabbit died before completion of the test. The toxicity of the urine was
apparently due in most cases to old specimens kept at room temperature and to specimens
sent from a distance without preservative. Alkalinity of the urine accounted for a few,
the second rabbit being saved by acidifying the urine with glacial acetic acid. Medication
including quinine and arsenic possibly accounted for several deaths and a diabetic urine
showing 4 plus acetone for one, but the various illnesses encountered in the patients were
generally not significant, as the test, except in a few instances, was successfully carried out
later. Twelve male rabbits were injected by mistake.
This number also includes tests which required recheck. These specimens were not
rcorded in the early years, which is unfortunate, as a doubtful reaction is sometimes significant. Our list includes a patient showing persistent brownish discharge two months after
curettage in which the tissue was not examined and which later proved to be an old ectopic
pregnancy, several in the menopause and abortions, one day after degenerated placental
tissue had been passed, one from a recheck of a hydatidiform mole passed 1 month previously, and several from cases of early pregnancy in which a sufficient time interval had
not elapsed. One test taken 10 days from possible impregnation, no period having been
missed, gave a doubtful positive reaction and was later checked and confirmed as positive.
Improper collection of specimens was blamed for other doubtful reactions.
Included in Table I are 198 tests done on. specimens sent from a distance containing
preservative. Of these, 80 were positive including 1 false as confirmed, 82 negative including 1 false negative, and 3 6 were impossible to confirm. The percentage accuracy of these
tests corresponds favourably with that listed above.
The physician is requested when sending in a specimen to state the age of the patient,
the date of the last menstrual period or first missed but expected one and any other detail
of the clinical history he thinks might be of help in the interpretation of the test. In 590
cases the gae of the patient was given; these are presented in Table II in the manner of
Table II.
Total: 291 tests.
Age   of   patient 16      17      18      19      20      21      22      23      24 25 26      27     28      29      30      31      32
No.   of   tests 4        3        6        7       10      15      22      16      17 12 16      16       9        8        5        5       12
33     34    35    36    37    38    39    40 41 42    43    44    45    46    47    48    49
9887582      14 12 74343       121
Age 13 14  15  16  17  18  19- 20  21  22  23  24  25  26  27  28  29
Tests 3 021533332       13      12      99776
30 31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46
22 5   3   4   3   13   6   5   5   6  13  10  17  10  7  17  9
47 48  49  50  51  52  53
9 18  4   6   4   3   2
Total: 299 tests.
This list also includes all types of case. In one negative aged 13, pregnancy was suggested by a spiritualist. These ages may possibly be some indication of the high percentage
of complicated cases. Probably few average normal cases are included and in these diagnosis
of very early pregnancy was desired.
In 352 of these cases duration of pregnancy as related to the missed period is recorded.
Where the date of the last menstrual period only was given tabulation was made by adding
28 days. All of our false negatives are placed in this table to demonstrate their position as
regards duration of gestation. The percentage of accuracy is therefore valueless.
Page 226 Table III.
Interval from Correct
missed period positive
Unknown  53 0
No missed periods  26
Periods irregular  2
1 day  1
2 days  1
4 days  2
5 days  2
6 days  2
7 days  13
8 days  4
9 days  5
10 days  11
11 days  3
12 days  4
13 days  3
2 weeks  59
Interval from
missed period
3 weeks	
4 weeks	
5 weeks	
6 weeks	
7 weeks	
8 weeks	
9 weeks 	
10 weeks	
3 months	
4 months	
5 months ,
6 months	
7 months	
8 months	
9 months	
Total, interval known..
A positive reaction can only be obtained after the trophoblast has been opened and the
maternal circulation and exchange of material between it and the circulating blood resulted9. This must be considered a limitation of the test15. The earliest date reported for a
positive reaction to occur following a known date of conception is 10 days. This was not
definitely established when we commenced use of the test and in an attempt to find this
earliest date we record several cases, included in the above series, in which the only possible
date of conception is known. We obtained a doubtful positive in 10 days which later
became positive, a false negative in 11 days, and true positives at 14 days, 18 days, 20 days
and 21 days respectively. These tests were recorded before a period was missed. Our success
in this group, however, Table III, is due to the fact that we consider and advise that negative reports made on specimens taken less than 2 weeks from the first missed but expected
period are unreliable unless the last possible date of impregnation is known or the case is of
a certain problem variety.
In the largest group where the date is known, 1 period only is missed, that is up to 4
weeks from the first missed period. From this point onwards the reason for the test changes,
becoming less a diagnosis of pregnancy before the clinical diagnosis becomes clear and
more a matter of differential diagnosis. Four false negative reactions are present in the
last group.
In 1937 Evans, Kohls and Wondre17 made a report on quantitative estimations of the
gonadotropic hormone in the blood and urine in pregnancy, disproving most previous
ideas6, and pointing out as erroneous the charts presented by Zondek, Frank, and Mazer and
Goldstein. Occasional figures reported by various authors fitted into their correct chart
and many discrepancies were explained. Their charts show the actual quantitative content
of the urine in gonadotropic hormone at various times throughout six normal pregnancies.
They show the invariable existence of an exceedingly steep and high hormone peak at a time
which is quite accurately one month from the beginning of the first expected but missed
menstruation. From the time of its first appearance the increase in concentration of
gonadotropic hormone is rapid, the peak being reached between the 20th and 50th days,
usually about the 30th, and the fall is equally spectacular, the concentration in rat units
per litre generally below 10,000 by the 56th day and continuously at this level until the
termination of pregnancy. At the peak their cases fell into two groups, one in which the
total unitage per day was between 75,000 and 150,000 rat units and another in which it
.was between 750,000 and 1,000,000 units. This normal transient hormone concentration
exceeds that reported in hydatidiform mole and chorionepithelioma. It is interesting to
note that the patients with the higher concentrations experienced none of the minor disturbances of early pregnancy, and those with the lower concentrations many of them. It
was also no indication of the sex of the foetus nor found more commonly in multiparae
Page 227 than primiparae. In view of the above findings of Evans et al, the false negatives occurring
in the third, f ourtlr and sixth months are more readily understood. Interesting in this connection is the finding, not recorded in these tables, of many doubtful positive reactions
obtained in our training period at the commencement of these tests, when our known positives consisted of specimens from the labour rooms.
Table IV.
Correct negative
No  history	
Amenorrhcea only recorded	
Amenorrhcea,   anaemia	
Possible ectopic	
Ovarian   abscess	
Acute appendicitis	
Ovarian cysts  (all types)	
Papillary Ca. ovary, with cysts	
For Sterilization Court	
Sterilization previously performed.
Pre-biopsy of endometrium-!	
Normal male	
Nephritis  ]	
Other serious illness	
Cases with history	
False positive
In Table IV are listed various conditions in which negative reactions were obtained and
confirmed as correct. Similar reports have been made by many workers. As regards the
false positive reaction, most of these workers emphasize the possibility of early unrecognized abortion and criminal abortion. The false positive of the menopause is probably
explained by the increase of a follicle stimulating gonadotropic hormone from the hypophysis. If the technician is in the least doubt as to the reading of the test, recheck should
be advised, preferably after an interval of 1 to 2 weeks. In this time if early pregnancy is
present a true positive reaction should be obtained, and a second doubtful reading should
again be viewed with suspicion. False positives in cases of ovarian cyst and ovarian carcinoma are also regarded as of this source, the same hypophyseal stimulation, which gives the
reaction in the rabbit's ovary, possibly accounting for the formation of the cysts. In our
series several types of cyst are encountered, the "correct negatives" including serous cysts,
one cystadenoma papilliferum benignum, as diagnosed in our own laboratory, and one
hasmorrhagic cyst diagnosed elsewhere. The false positives similarly include 1 cystadenoma
papilliferum benignum, 1 hasmorrhagic ovarian cyst and 1 serous cyst. The "false positive"
malignancy was a papillary adenocarcinoma of the ovaries and the correct negative ones
also papillary carcinoma.
As a diagnostic aid the Friedman test is of value both in the diagnosis of pregnancy in
the menopause and differential diagnosis between pregnancy and ovarian tumours. In the
latter instances, also, the operator should exert extreme care in the reading of the test.
Since many of these cases are hidden, in our series, within the bulk of no history cases, this
statement applies, of course, to all tests. Since, however, many other workers in well-
equipped laboratories report similar failures it should emphasize to the physician the value
of indicating such clinical possibilities in his requisition. These cases should actually be
placed in the group described below as problem cases, and our inclusion of our total of false
positives in this short series is for demonstration of the above points only. The percentage
of error in this series is also valueless.
Below "possible ectopic pregnancy" with a negative confirmed result have been placed
salpingitis, ovarian abscess and appendicitis. These were also cases of suspected ectopic
gestation.  Others, if the history were known, could possibly be similarly grouped.  How-
Page 228 ever, it should seem that some of these possible ectopics with amenorrhcea and negative
Friedman tests later confirmed as correct with the return of normal menstruation, could be
dead or completely separated extra-uterine pregnancies. With the separation of the chorionic tissue the production of hormone would cease9, and the invasion and erosion of the
fallopian tubes would cease and the symptoms and eventually the physical findings would
disappear. In several instances amenorrhcea of three months duration, pain, the presence of
a tender mass and irregular spotting are recorded, but as no operation was performed the
final diagnosis is obscured. The above cases are included in the series of ectopic pregnancies
listed below.
Problem Cases
It is observed18 that uniform accuracy in the same laboratory may vary with the proportion of problem cases. Regardless of its source, death of the ovum and its elements soon
leads to failure of hormone production and a negative test. A positive test in these cases
signifies a continuance of the biologic connection between living foetal elements and the
maternal circulation8. Positive or negative reactions are significant and should not be considered incorrect. We have, whenever possible, challenged our own readings by analyzing
the pathological reports on tissue specimens received from these patients in our own
Ectopic Pregnancy.—In 14 cases of ectopic pregnancy reported by Crew10, specimens
were taken within 8 hours after operation and thereafter daily for 7 days. A definite negative was invariably obtained 72 hours after the removal of the embryo. A positive reaction
in these cases, therefore, indicates that live chorionic tissue is present, or has been in existence within the last 72 hours; a negative, that the chorionic tissue is dead or that the hormone concentration is insufficient. Aschheim9 differentiates thus between the "living and
growing" and "dying or dead" extra-uterine pregnancy, contending that in the latter "the
foetus no longer lives, the villi no longer grow and the uterine vessels can no longer be
eroded." It would also seem possible that chorionic tissue attached in only a small area
might continue to invade the wall and cause bleeding, although insufficient to produce
enough gonadotropic hormone to give a positive Friedman test. This is possibly the answer
to at least one of our false negatives in which the tube ruptured "a few weeks" after our
report was received. We therefore consider it essential to inform the physician of this
possibility when making negative reports if we know that ectopic pregnancy is suspected.
Table V.
Confirmed correct.
{No tissue (with tissue Total False Corrected
section) section) correct       report % error
Positive test  14 15 29 2 6.4%
Negative test_ 37 10 47 2 4.0%
ovarian abscess 2
salpingitis 2
Appendicitis  2
deg. plac. tissue 4
Total confirmed tests  51 26 76 4 5.0%
Uncorrected error in negative tests  12.2%
In the above series the tests in the first column were marked "suspect ectopic" on requisition and later confirmed as correct without clinical data. In the second column tissue
was sectioned in our laboratory in all instances. Although there is no way of estimating
the morphological criteria, the actual activity of chorionic villi19, it may at least be said
that in the 10 positive tests the villi and frequently the foetus were well preserved, while
in the four true ectopics included in the 10 suspect confirmed negatives, the villi were
degenerated or necrotic and the foetus macerated. In one the structure was separated
from the tube by a thick mat of blood clot and showed degeneration microscopically. These
we have elected to place in the confirmed class as true negative reactions. The uncorrected
error, considering these tests false, is also reported. There is possibly less chance of rupture
in these cases and, as indicated in another section, similar pathology may be present in some
of the 37 in the first column upon whom operation may not have been performed. In the
Page 229 two false positives ovarian cysts were found. The confirmed positives include: 4 taken
before a period wasjnissed, one 7 days from the missed period, one 1 month, one 5 weeks,
three 6 weeks, one 7 weeks and one in which a 3 34-months foetus was found in the tube.
The 2 false negative tests include one which, according to the attending physician, ruptured a few weeks after the test was performed, no further data being supplied, and one
from another city which later came to operation and proved to be "an ectopic pregnancy";
no tissue was saved for examination.
In interrupted uterine pregnancy, as in extra-uterine pregnancy, the result of the
Friedman test should be interpreted with the clinical findings.  Once pregnancy is established the result will remain positive as long as live chorionic issue is in biologic contact
with the mother15.
Table VI.
Totals        Positive     Negative
For Therapeutic Abortion  19               19
Therapeutic Abortion: 2  weeks  previous  1                                     1
4 weeks previous ;  1                  1
6 weeks previous  1                                     1
Threatened Abortion  7                 4                 3
Incomplete Abortion:—
Retain, well preserved placental tissue  2                 2
Retain, degenerated placental tissue '.  2                                    2
Septic Abortion, for diagnosis  2                  2
Complete Abortion:    2 days previous  1                                     1
10 days previous  3                                     3
21 days previous !  1                                     1
3  months  1                                       1
No history of date '  2                                    2
Missed Abortion:—
(a) Before 4th month  18                  4                14
Irregular Bleeding, for diagnosis  4                 4
(b) After 4th month:
Living foetus  2 2
3 mos. foetus dead 6 mos.  2 2
6 mos. foetus dead 2 wekes  4 4
Totals  73 40              33
In Table VI the various problems are considered in their clinical grouping. In those
patients requiring early therapeutic abortion, the problem is a relatively simple one, that of
diagnosing pregnancy at the earliest possible date. In those next listed, in whom the
efficacy of the therapeutic abortion is in question, we list one positive test obtained after
4 weeks. In this case the laboratory worker is required to supply the information as
regards complete abortion fisted below, and the clinician to investigate the case as regards
possible incomplete abortion, extra-uterine pregnancy of hydatidiform mole. In some
places where therapeutic abortion is performed by radiotherapy Friedman tests are done
at weekly intervals and a persistence of a positive reaction taken as an indication for further
radiation2. In threatened abortion the fundamental principles of the test must be kept
clearly in mind. The positive test indicates the presence or recent presence of viable chorion
and does not indicate whether the foetus is alive or dead. In come cases it may be concluded
that when the reaction disappears after having previously been positive, the biologic contact between ovum and mother has been interrupted and the ovum has died. In cases of
clinically verified pregnancy in which the hormone test has been made only once, and has
been found negative, repeated examinations should be done9 and all clinical findings carefully considered. Cases are reported13 where a positive reaction was obtained which became
negative when the patient started to bleed and became positive subsequently when the
bleeding had stopped. Here the factor which caused the bleeding could have prevented the
production of sufficient hormone to give the test; untreated, this might have resulted in
abortion. A negative test in any pregnancy in conflict with the clinical evidence should
possibly be taken as evidence of a threatened abortion and the patient treated accordingly.
In the incomplete abortion the problem is simpler, the presence of viable chorionic
tissue being indicated by a positive test. Here again the negative test does not exclude the
Page 230 presence of degenerated placental tissue. Had the tests been negative in the two instances
of septic abortion, curettage might have been necessary to establish the diagnosis.
Under complete abortion we have listed negative tests occurring in 2, 10, 21 days and
3 months respectively. It is possibly safe to say that 24 to 72 hours after delivery either a
negative or positive reaction may be expected13. Aschheim9, however, states that although
the positive reaction usually ends by the 10th day it was be found as late as the 16 th, and
other writers emphasize this persistence in elimination of the hormone8. We have had one
case of a positive reaction obtained 17 days after tissue had been passed by the patient. This
tissue was fortunately saved and recently obtained by the laboratory, having been placed in
formalin by the attending doctor. As it proved to be what was apparently a complete
decidual cast of the uterus and no chorionic tissue was present it cannot properly be included amongst the abortions. There appears to be a definite possibility that this was a case
of tubal pregnancy or tubal abortion. It serves, however, to emphasize the value of establishing final diagnosis by tissue section and clinical findings rather than by the Friedman
test in these cases.
The cases of Missed Abortion to be investigated by the Friedman test are best divided
into two classes, those occurring before the 4th month of pregnancy and those occurring
after the 4th month13. After the 4th month death of the foetus may take place independent
of damage to the placenta or its hormone capacity and positive tests are recorded up to 30
days after foetal death at 6 or 7 months. Foetal death has been reported where a positive
Friedman test was obtained with l/40th of the normal test dose and curettings revealed
well preserved placental tissue19. Two cases listed above, in which we have fairly complete
clinical data, are here reported in brief:
Case R—Age 28, L.M.P. July 29, 1938. Clinical note—no evidence of pregnancy in
uterus—nipples show changes, patient's weight r55 lbs., November, 193 8, weight of
patient only 123 pounds, indicating illness; April 13, 1939, Friedman test No. 165 doubtful positive, patient's weight 151 pounds; April 17, 1939, Friedman test No. 168 positive;
July 18, 1939, Friedman test No. 306 positive! September 13, 1939, Friedman No. 387
negative. September 27, 1939, uterus was emptied; our pathological report S-39-3781—
Lithopedian 3 months.
In this case a positive reaction persisted after normal term but the possibility of a new
pregnancy had to be considered. Actually the foetus had apparently died during the illness
which accounted for the weight loss noted in November, 1938.
Case S—Age 20, L.M.P. February, 1938. May, 1938, pains with little bleeding (death
of foetus—missed abortion 2l/z months; note made in report sent in later by attending
doctor). November 7, 1938, uterus size of 2% to 3 months pregnancy retro verted and
retroflexed. November 8, 1938, Friedman test No. 407 positive—nine months amenorrhoea.
Patient was watched 3 weeks, no enlargement observed so abortion induced. Pathological
report December 2, 1938, our S-38-4220, degenerated foetus 1.5 cm. in length; placenta,
microscopically, showed degenerated tissue with calcareous deposits and interspersed
islands of viable tissue.
Before the 4th month more negatives were obtained owing to the death of the chorionic
To summarize this review it may be stated that a positive test does not indicate whether
the foetus is alive or dead and that the test will remain positive as long as viable chorion is
attached to the uterine wall.
Table VII.
Note: Pos. & Neg. — Friedman Reaction.  C. = Confirmed clinically.   OS. = Confirmed by
tissue section.  Chorio. = Chorionepithelioma.  H.Mole = Hydatidiform mole.
McG.—July 2, '32—4 mos. foetus delivered with H.mole, Chorio, OS.; March 13, '33—Pos. C; June 26, '33,
Pos. O; July 24, '33, Autopsy: Chorio with extensive metastases.
S.—Outside Hosp.—no date—Chorio. C.S.—April 24, 33—Pos. C.
R.—Chorio.  (Early change in H.mole); Neg. C. 5 days later; Neg. C. 8 days later; Neg. C. 8 days later;
Neg. C. 1 month later.
P.M.—Feb. 22, '36, Chorio. C.S. (no history V.G.H.); Feb. 22, '36, Pos. C.S.; Aug. 25, '36, Pos. C, rather
weak reaction; Jan. 7, '37; Hysterectomy; Oct. 8, '38, Neg. C.
Page 231 R. McV.—Jan. 29, '38, Curettings, Chorio change in H.mole; Feb. 3, '3 8 (2 ccs. only) Pos. OS.; Feb. 3, '38,
Hysterectomy:.Ohorio change in H.mole; Feb. 15, '38, 2 ccs. only, Neg. C; April 11, '38, full test,
Neg. C.
N.T.—July 27, '38, H.mole, OS.; Aug. 16, '38, Chorio change in H.mole, OS.; Oct. 18, '38, Pos. OS.;
Nov. 28, '38, Neg. C.  (using Radium for Chorio but bleeding); Feb. 11, '39, Neg. O; Nov. 20, '39,
Neg. C. (Has had Radium implants).
Positive tests—7 (including 1 dilution, l/lO). Negative tests—8  (including 1 dilution, 1/10).
Possible Chorionepithelioma—2 cases.  Neg. confirmed.
Much has been written as to the value of the Friedman test in investigation of cases of
chorionepithelioma and hydatidiform mole, especially as regards the value of dilution tests.
While some investigators have reported excellent results8 9, others have been less successful.
These discrepancies18, which chiefly arise in the original diagnosis of the condition, can
undoubtedly be explained by the occurrence in normal early pregnancy of Evans' peak
phenomenon17 of excretion of hormone, noted above. Also there is always the possibility
of one of these growths in its early stages, or a small or degenerated hydatidiform mole,
yielding a relatively small amount of hormone9. In at least two of our cases an extremely
doubtful reaction was obtained, although one later proved to show clearly chorionepi-
theliomatous change. Table VII and Table VIII have been prepared chiefly as a check of
our own tests and the clinical notes appended were reported to us. As a possible useful
course in the investigation of these cases we suggest that the Friedman test in dilution is
not a safe basis for final diagnosis where there is a possibility of early pregnancy, and similarly that a weak reaction does not rule out the possibility of these conditions. Once the
diagnosis is established by other means an estimation of the dose level required to produce
a positive reaction should be determined. This will then form a useful basis for further
observation of the case. The persistence of a positive test in the same or greater dilution
will indicate continued chorionic proliferation. The gradual dinainution of the amount of
hormone excreted may be estimated by further dilution tests. The recurrence of a positive
reaction after a negative reaction may be taken to indicate the presence of metastases. In
one of our cases the test became negative following radium therapy; the paitent is apparently free of recurrence. In all cases the most careful clinical observation is necessary and
clinical findings must not be treated lightly because of negative or doubtful Friedman tests.
Hydatidiform Mole.
Table VIII.
For abbreviations see Table VII.
McG.—4 months foetus, delivered with H.mole, OS.; July 2, '32, Pos. C.S.
M.—May, '32, Hmole, OS.; 3 months later, Neg. OS.; Dec. 1, '39, Neg. C.
P.B.—April 11, '34, Curetted: H.mole OS.; April 14, '34, Pos. OS.
E.W.—H.mole, OS.; 3 months later, Pos. OS.; 5 weeks later, Pos C.
K.—Passed H.mole; 4 weeks later, April 18, '33, Pos. OS.; April 20, '33, Panhysterectomy: early Chorio
change in H.mole; one year later, Neg. C.
/.—Passed "Frog Spawn"; 1 month later, doubtful Pos. OS.; 4 days later, Neg. C.
C.—H.mole passed 2 weeks previous. Pos. C.
D.J.S.—Jan. 3, '35, passed H.mole, OS.; 5 weeks later, Neg. O; 10 weeks, Neg. O; 4 months, Neg. O;
6 months, Neg. C.
H.J.—Pos. C.
WM.—July 3, '35—H.mole, OS.; 3 weeks, Neg. O; 10 weeks, Neg. C.
W.L.—193 6, passed H.mole; Sept. 7, '3 6, Pos. OS.; Sept. 14, '36, Pos. OS.; Sept." 18, '36, curettage persistent decidual rection following H.mole; hyperplastic endometritis, only shadowy Hmole structures
seen; Oct. 5, '36, Pos. O; Dec. 31, '36, Neg. C; Mar. 4, '37, Neg. O; Oct. 6, '37, Neg. C; Oct. 24, '39,
Neg. C.
f.L.N.—July 23, '36, Pregnant; Aug. 23, '36, abdominal pain; recovery; Oct. '36, Flow profuse; Dec. 14,
'3, therapeutic abortion. Flowed until Jan. 31, '37; Feb. 20, '37, Pos. O; March '37, Curettage: 6H.mole
(N. Westminster); Curettings sent to V.G.H.: Glandular hyperplasia; March 29, '37, Hysterectomy:
glandular hyperplasia; retained degenerated tissue, decidual or placental; May 18, '3 8, Pos.
A.K.—Feb. 23, '36, Pos. O; March 24, '36, Hmole, OS. Outside Laboratory; April 19, '36, Pos. C.
Y.—May 20, '38, H.mole; June 4, '38, Neg. OS.; July 7, '38, curettage; Aug. 9, '38, Neg. OS.; Jan. 4, '39,
Neg. O; May 11, '39, Neg. C.
K.—June 2, 538, H.mole; July 7, '38, Neg. O; April 8, '39, Neg. O
E.S.—Oct. 23, '3 8, H.mole, OS.; Nov. 14, '38, Neg. O; Dec. 19, '38, Neg. C.
H.—Dec. 9, '38, H.mole; Jan. 9, '39, Neg. O; Jan. 23, '39, Neg. OS.; Curettage: Glandular hyperplasia.
r>.—Feb. 14, '39, H.mole, OS.; Feb. 11, '39, Pos. OS.; Feb. 28, '39, Pos. O; March 13, '39, Neg. C; April
15, '39, Pos. OS.; April 26, '39, Hysterectomy: Chorio.; Aug. 30, '39, Neg. C.
Page 232 P.W.—June 17, '39, passed Hmole; June 20, '39, Pos. OS.; Aug. 15, '39, Neg. O; Sept. 28, '39, Neg. C.
O.L.—Aug. 17, '39, H.mole, OS.; June, '39, Pos. OS.
Positive tests—21.
Negative tests—27.
Possible Hydatidiform mole—9 cases, Negative, confirmed.
Possible Hydatidiform mole—5 cases, Positive, confirmed.
Most of the points emphasized in the discussoin of chorionepithelioma may be repeated
in a consideration of hydatidiform mole. Philipp9 reports a case in which a mole was isolated
from the uterine circulation by a fibrinous coating and from which no gonadotropic
reaction could be obtained from the urine although the tissue of the mole itself was effective on implantation. Here, also, the peak phenomenon must be recognized in all attempts
to relate high hormone levels with this condition. Once the diagnosis is established by
other means, monthly and later bimonthly Friedman tests with dilution tests will be found
of use in following cases as regards recurrence or malignant (chorionepitheliomatous)
change. Here also clinical signs even in the absence of a positive Friedman test must be
Review of the cases in Table VIII demonstrates that negative reactions can occasionally
be obtained as early as 2 weeks after evacution of the mole and negative reactions in 1
week are reported. It is also reported10 that cases most frequently become negative in about
three months, and the same authority reports a case in which a doubtful positive reaction
was obtained 1 year later. With the exception of the 5 cases at the bottom of the table, in
which no history was obtainable and in which confirmation of the test does not necessarily
mean a final diagnosis of hydatidiform mole, the tests in our series have been done in
investigation of proven cases, as have also those in Table VII. Five of the nine negative
cases were also investigated, by means of dilution tests, the smallest amount of urine giving
a positive test being 1/10 of the average dose; this was a case of incomplete abortion.
Testicular Tumours
Table LX.
Total        Positive     Negative
Malignant Teratoma of Testicle:
(a) Showing Chorio carcinomatous change 1 1
(b) Embryonal adenocarcinomatous type showing choriomatous
differentiation ; 1 1
(c) Possible teratoma.   No surgical specimen  1 1
Possible Malignant Teratoma—No surgical specimen  7 7
Malignant Teratoma—By tissue section  7 7
Malignant Teratoma, Embryonal Ca.—By tissue section  2 2
Tuberculous  Epididymitis  1 1
Gumma of Testicle :  2 2
Total  22 3               19
In Table LX are listed the various tumours investigated in the male. The final diagnosis
of these tumours was made histologically in all instances, except those specified. As indicated, 2 tumours, both showing chorionic epithelial constituents, have a positive test.
When these cases came to autopsy extensive metastasis was found. The third, which was
not confirmed histologically in our laboratory, is grouped with them. No such differentiation was noted in any of the other tumours examined. Although negative reactions do
not differentiate between neoplastic and inflammatory processes, nor serve to rule out
malignancy, the Friedman test has a definite field of usefulness in tumours of the testicle;
an occasional positive reaction will be obtained in some few growths of a type which may
be termed chorionepithelioma testis. Once this diagnosis is established by a positive test or
by histological section, the use of the test in following the course of the patient is the same
as in chorionepithelioma in the female.
The remaining problem cases form a miscellaneous group, as listed in Table X.  After
parturition gonadotropic substance disappears from the urine within 3 to 5 days9 1T, and
our early tests done on urine from the labour rooms gave frequent doubtful reactions.
Diagnosis of pregnancy during post-partum amenorrhcea is therefore complicated only by
the frequent impossibility of determining the date of possible impregnation and repeated
tests may be necessary. Ovulation without menstruation is also the problem factor in cases
of assault before menstruation has commenced.
Page 233 Table X.
Total        Positive     Negative
Pregnancy in Postpartum Amenorrhoea ?  13 3               10
Continued Menstruation in Pregnancy ? at 6 months  3 12
Assault  7 16
Retroverted Uterus or Pregnancy  1 1
Fractured Pelvis with Pregnancy  1 1
Pregnancy with fibroids  2 2
Mare's Urine  1 1
Glaucoma—Tumour Anterior Pituitary  1 doubtful
Totals  29 9               19
(1  doubtful)
In cases of continued menstruation during pregnancy false negative reactions are
reported, which are explained as due to hormonal-imbalance. In the cases listed above the
patients for whom negative tests were obtained were not pregnant.
The only problem in the next three headings listed is possibly that of missed abortion.
Here the problems are chiefly clinical.
It has been found impossible to obtain a Friedman positive reaction from mare's urine
during pregnancy. Positive tests may, however, be obtained from pregnancy mare serum4 7
between the 45th and 150th days of gestation. Equine gonadotropic hormone, though
apparently formed in the placenta, differs from the human variety, exhibiting the properties of both anterior pituitary and chorionic hormones.
The possible tumour of the anterior pituitary gland gave a doubtful positive reaction of
the type occasionally found during the menopause and mistaken for a true positive, then
possibly due to hyperplasia of the same organ. In summary of this complete section may
we again state that, especially in problem cases, the Friedman test should assist, not supplant, the usual diagnostic technique.
Table XI.
Case Age
No. 768 No data.
No. 169 45 Menopause.
No. 39-222 4 weeks after missed period. (Test positive.) Patient near menopause.
No. 216 45 J4 1 month amenorrhcea  (test positive).   Curetted 3 weeks after test.   Cervix hard.
Fibroid size of 2l/z months pregnancy present.
No. 37-93 45 Normal menstrual period every 21 days.  Test done 10 days after missed period (test
positive). 3 weeks after test, menstruation resumed—Doctor now thinks this was
a possible missed complete abortion and considers test possibly correct.
No. 307 Possible conception 33  days previous to test.   Patient had serious illness at time
of test.
No. 3 8-137        27 Test done 11 days after missed period.
No. 38-352 28 1  month after missed period, patient clinically pregnant   (test positive).   At 7
months, returned to doctor stating she felt movement. Uterus found to be size of
3 months pregnancy. Amenorrhcea for 7 months. (Test negative.) Tissue section
obtained by complete curettage negative. History obtained of slight bleeding in
month first test was taken.  One doctor thinks missed abortion; another, a false test.
No. 682 Possible ectopic pregnancy (test positive).  Operation at St. Paul's Hospital.  Patho
logical report medium-sized follicular cyst and larger cyst which shows some blood
clot. Microscopic examination: Sections show corpus luteum with simple cyst formation. Is3^
No. 37-170 Possible ectopic pregnancy (test positive).  Operation: Cystadenoma papilliferum
benignum of ovaries.
No. 465 35 Periods regular.   Dysmenorrhoea.   Uterus size of 4 months pregnancy  (test posi
tive). Test negative 6 days later. Operation 8 days after second test showed a serous
cyst of ovary.
No. 37-126 50 (Test positive)—Autopsy 2  months later: Bilateral papillary adenocarcinoma of
ovaries with metastases.
A complete summary of our false positive tests is given in Table XI.  Duplicate cases
are reported in the literature20 10.   The recorded information was supplied by attending
physician or physicians in all instances, generally after the test was proven false. As regards
the first case listed no comment is possible.  The second, third and fourth cases are false
positives of the menopause.  Wnile these false positives are a reflection on the skill of the
Page 234 laboratory worker, the clinician should acquaint the laboratory of the patient's age, at
least when accepting a positive report in this group, but, of course, preferably before the
rabbit's ovaries are examined. While he may be inconvenienced by more requests for repetition of the test the end result should be more trustworthy.
Case No. 37-93 was also grouped with this series until recent discussion with the
attending doctor suggested the possibility of early unrecognized abortion. The information received in Case No. 307 suggests a similar explanation.
In case No. 37-137 no clinical data can be offered in explanation. It was suggested by
the laboratory that this case possibly fell in the group of patients by whom pregnancy is
greatly feared. The incorrectness of a positive result in this group strongly suggests that
abortion has taken place. This could not be confirmed clinically. The doctor was also
questioned regarding the possibility of early unrecognized abortion but could obtain no
Test No. 38-3 52 may also possibly be classed as an unrecognized spontaneous abortion.
The duration of amenorrhcea in this case, however, also suggests some hormonal imbalance.
In case No. 682 two possible explanations are suggested. The presence of a corpus
luteum suggests the possibility of pregnancy, possibly intra-uterine, with spontaneous
abortion, missed in the signs which causes suspicion of ectopic pregnancy. The other possibility is that the reaction was due to increased gonadotropic hormone from the pituitary,
which also may have been a factor in the production of the cysts. The laboratory favors
the former explanation.
Case No. 37-170 falls under the latter explanation, as does also the first test done, No.
465, on the next case fisted. These reactions are those of the false menopausal type and
should not occur; practically all large series, however, include them.
Case No. 37-126 must also be grouped with these cases.
From the above discussion it will be realized that in 4 of these cases we consider the
explanation of the reaction adequate and do not actually consider these tests false. In 6
cases we consider the test truly false and, although similar cases are reported in the literature, feel that they should h-Tc L>een identified in our laboratory as doubtful rather than
as positive tests. Of the remaining two cases one cannot be analyzed and for the other
possible explanations were discarded by the attending physician.
No. 39
No. 38-154
of specimen
Table XII.
Time from
missed period
No. 38-96
19 days
No. 38-103
21 days
No. 37-146
No. 412
No. 74
4 days old.
Not k
ept on
Age No data.
Possible ectopic pregnancy. Confirmed at operation.
Urine sent from a distance in preservative. Surgical
specimen not obtained.
Suspected tubal pregnancy. Ruptured ectopic few
weeks after report. No other data. No surgical specimen obtained.
Nausea and vomiting 3 months. Negative test. Two
days later, operation for subacute appendix. 4 months
pregnancy noted. Fibromyoma uteri with red degeneration. Chronic productive appendicitis; 2 days later, test
Bleeding 2 days after missed period, with intermitetnt
pain, left side.
Patient withheld fluids evening previous to test—15 cc.
injected x 2.
8 months from missed period, delivered 5-lb. baby
which lived 23 hours.
Rapid growth of mass.   Operation showed a 3 months
pregnancy.  Delivered at term.
One doctor states test false.   One doctor states "speci-
25    men may have been substituted from another source, as
patient unmarried and anxious to have an operation."
Pregnancy confirmed.
No other data.
Normal delivery.
Page 235 No. 521
No. 270
No. 37-5 8
No. 780
No. 39-70
No. 39-396
No. 39-140
Possib. 6 mos.
preg. Menses
always irreg.
Last bleeding
2 mos. prev.
No missed period, 11 days
from possible
12 days
14 days
22 days
26 days
63 days preg.
by delivery date
Positive 26 days from possible impregnation.
Positive 3 3 days from missed period.
Positive 3 6 days from missed period.
Positive 42 days after missed period.
Positive 40 days after missed period.
Delivery apparently'normal in every way and course of
pregnancy normal.
In the false negative tests listed in Table XII different explanations can be made. In
case No. 39 no comment is, of course, possible, and also the following two ectopic pregnancies must be listed as false negatives, failing histological section although the chorionic
tissue in them was probably dead or separated from the wall of the tube by blood clot.
These serve to emphasize the value to the clinician of the uncorrected percentage of error
in diagnosis of ectopian pregnancy by the Friedman test, and this may be termed the
clinical error. By correction, the false positives in the ectopic list could also have been
removed, as these reactions, though false, were given by another process. It does emphasize
the fact that the Friedman test is not one for pregnancy per se but merely a reaction to
the presence of a certain amount of gonadotropic hormone present in the injected urine.
The fourth case, No. 38-273, is of interest as possibly indicating a threatened abortion
in the presence of a degenrating fibroid. Two days after the removal of this fibroid the
test was positive.
In case No. 38-96, taken with its recheck, No. 38-103, in which a definite attempt to
obtain a positive reaction was made without avail, the possibility of hormonal imbalance
must be considered. That the baby lived only 23 hours after delivery may be significant in
this respect. The low hormone content in the early part of pregnancy, however, may have
been associated with pathology of which the bleeding was another symptom. In other
words, at the time of the test the diagnosis may have been threatened abortion.
The "irregular menstruation" noted in Case No. 37-146 is more suggestive of hormonal
imbalance as an explanation.
Case No. 412 may be as indicated an example of a certain type of case which appears
in all reports of large series and always offers difficulties of classification. The false result
appears in most cases as a false positive. Here, failing to menstruate, the patient requests
a pregnancy test and after receiving a positive report has menstruation re-established. She
then either disappears, leaving a report impossible to confirm, or returns for a negative
report, making the first one appear false. When the history supports this explanation the
result should be regarded as correct.
Case No. 74. This result is no doubt due to the condition of the specimen. It is unusual
and unfortunate that it did not kill the test animal before the test was completed. In case
No. 521 two factors must be considered: the possibility of hormonal imbalance as evidenced by irregular mentsruation with persistence during pregnancy, and the factor of
actual quantitative excretion of chorionic gonadotropic hormone during normal pregnancy
as indicated by Evans. In the sixth month of pregnancy the normal excretion is relatively
low compared with that indicated by the peak phenomenon in the first 65 days.
Case No. 279 is an example of a false negative due to insufficient duration of pregnancy
and Case No. 5 8 may be classed in the same group. In this case a specimen obtained 3 weeks
later was correctly positive. Similarly case No. 780 should be placed in this group allowing
some discrepancy of normal menstruation. Many of these cases, as reported, are dated from
the last menstrual period, and the actual date of the missed but expected period is not
definitely known.  In this case, also, a positive test was obtained 3 weeks later.
The last three cases cannot be classified on this basis. All apparently conform with the
requirements of the test. There is always a possibility that the specimen was dilute.
Although we urgently advocate that only first morning specimens be submitted, when
Page 236 these were not available we have accepted others. This possibility was not accepted by the
attending doctor. Technical flaws were not admitted by the laboratory. Similar cases are
reported in the literature15, where the test remained negative until the 4th or 6th month
of pregnancy. The explanation made was in the form of a suggestion that the hormone
production did not occur to the usual extent or else the eliminative threshold of the kidney
was different from that usually found. As these tests were all obtained under ideal conditions, we have no better explanation to offer.
It will be recognized from this discussion that we suggest that all negative tests are
fundamentally correct and significant. The fundamental limitations of the test must be
considered, and technical flaws such as acceptance by the laboratory of results from
unsatisfactory test animals must be ruled out.
We beg to quote a classic case in closing. In this case, in which we reported a negative
reaction, considerable consternation was encountered. The doctor knew the patient was
pregnant. The patient knew she was pregnant, and it only remained for a positive Friedman
to establish the diagnosis. On final analysis it was learned that the patient, instead of
boiling the bottle, had boiled the specimen. The result we elected to place in the list of
confirmed correct negatives as experimental.
In conclusion, we would emphasize again the fact that is not a test for pregnancy per se
but a demonstration of the hormonal response within the body to the presence of living
foetal elements. The practitioner must understand the hormonal significance of the reaction and, in the last analysis, must depend upon his clinical judgment in evaluating the
laboratory findings in abnormal cases.
1. Weisman, A. I.: Am. J. Obs. 6 Gyn., 35:354, 193 8.
2. Spielman: Am. J. Obs. 2? Gyn., 27:448, 1934.
3. Smith, P. E.: J.A.M.A., 104:7, p. 548, 1935.
4. Smith, P. E.: J.AM.A., 104:7, p. 55 3  (Feb. 16), 193 5.
5. Collip, J. P.: J.AM.A., 104:7, p. 556, 1935.
6. Crew, F. A. E.: Brit. M. J., 2:1092, 1936.
7. Fluhmann, C. F.: Menstrual disorders, W. B. Saunders Co.
8. Mack, H. O, and Agnew, G. H: Am. J. Obs. 6? Gyn., 27:232, 1934.
9. Aschheim, S.: J.A.M.A., 104:15, p. 1324 (April 13), 1935.
10. Crew, F. A. E.: Am. J. Obs. & Gyn., 3:989, 1937.
11. Friedman, M. H, and Lapham, M. E.:Am. /. Obs. tf Gyn., 21:405, 1931.
12. Young, A. M.: /. Lab. & Clin. Med., 19:1224, 1934.
13. Feresten, M.: Endocrinology, vol. 21, 1937.
14. Kelly, G. L., and Woods, E. B.: /.A.M.A., 108:615, 1937.
15. King: Am. J. Lab. & Clin. Med., 19:1033, 1934.
16. Best, C. H., and McHenry, E. W.: C.M.A.]., 28:599, 1933.
17. Evans, H. M., Kohls, C. L., and Wonder, D. H.: J.A.M.A., 108:287, 1937.
18. Davy, L., and Sevringhaus, E. L.: Am. J. Obs. tf Gyn., 28:888, 1934.
19. Goldberger, M. A., Salmon, U. J., and Frank, R. T.: J.A.M.A., 103, p. 1211, 1934.
20. Mull, J. W., and Underwood, H. D.: A. J. Obs. & Gyn., 33:850, 1937.
21. Ware, H., and Maine, R. J.: J. Lab. 8 Clin. Med., 18:254, 1932.
The Reports of the Annual Meeting of the Vancouver Medical Association are contained in this issue. These, together with editorial matter already accumulated, make it
necessary for us to defer publication of the following important articles now in our possession. These will be published in our next issue: Low Back Pain: Dr. H. H. Boucher;
Diagnosis and Treatment of Glaucoma: Dr. Wiener; A Case of Unusual Menses: Dr. J.
W. Arbuckle; Lipoma of the Colon: Drs. G. E. Seldon, W. A. Whitelaw, W. A. Morton.
Page 237 O
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P<*£* 23 X [Our good friend Dr. D. H. Williams, who is ever on the watch for a chance to help
the man in practice, has handed us an admirable summary entitled "The Diagnosis of
Syphilis by the General Practitioner."
Issued by the United States Public Health Service, under the aegis of Dr. Thomas
Parran, Surgeon General, of the United States Public Health Service, this is a wholly
commendable little volume. It is short (36 pages) and contains excellent tables, and
condensed statements, given in aphoristic form.
We are glad to publish this in instalment form—and suggest that our readers keep
the numbers containing these instalments collected together in some convenient way,
for ready reference.—Ed.]
For modern syphilology the years 1905 to 1910 was the great period of discovery.
Within that brief span we discovered the organism, the complement fixation test, arsphenamine. In the years which followed, the still more sensitive flocculation tests were
introduced and bismuth replaced mercury in the scheme of treatment. With these new
instruments physicians developed the technics of diagnosis and treatment.
The last decade has been an equally notable period of analysis and consolidation.
Co-operative Clinical Group studies have compared the various regimens of treatment,
gleaning their data from 75,000 case histories; for no other serious disease is there so
satisfactory and so specific a treatment as those studies developed for early and latent
syphilis. The Committee on Evaluation of Serodiagnostic Tests has demonstrated that
100 per cent specificity and a sensitivity of 80 per cent are routinely obtainable objectives. Neurosyphilis, cardiovascular syphilis, prenatal syphilis have been subjected to
similarly searching inquiry. Public health administration is offering new aids to the
physician in dealing with the disease.
We are proud of the part the United States Health Service has played in this development. But our job is not finished when the data are filed. These instrumentalities have
been created for use. We hope that this little volume of Doctor Moore's own diagnosis,
and one simultaneously issued on modern treatment, may effectively serve to synthesize
these advances for the busy clinician who holds the front line against disease.
It is fitting that this series of technical monographs should begin with diagnosis. It
is the first clinical problem. In a society where even physicians have sometimes been
reluctant to face syphilis, and with a disease of so many disguises, it requires emphasis.
Half a million early cases, 600,000 advanced cases of syphilis go to physicians for the
first time each year. The advanced cases suggest that our "index of suspicion" for the
earlier diagnosis has been too low.
"But I see an incredulous look on some faces and I hear the whispered comment—'tis
heard often enough! 'Where is all this syphilis? I does not come my way.' Yes it does.
The syphilis we see, but do not recognize, everywhere awaits diagnosis, so protean are
its manifestations." Sir William Osier's warning to the Medical Society of London, like
any unlearned lesson, bears repeating. 1
Assistant Surgeon General.
General Considerations
The physician's share of the syphilis control programme hinges on two major points—
case-finding and case-treatment.    They are inextricably interwoven.    It will do little
good to bring under treatment a million patients if the treatment given them is ineffi-
Page 239 cient.   On the other hand, treatment, no matter how efficient, will not solve the problem
unless patients are actually recognized and provided with its benefits.
On the whole, experience has convinced me that in spite of all present-day shortcomings, the treatment element is better performed than case-finding. Bad as it often
is, the treatment of those patients actually submitted to it does accomplish a great deal.
That a decrease in the incidence of syphilis is not yet apparent is due, I believe, largely
to the fact that so many syphilitic patients pass completely unrecognized until the
damage of infection of others or the ultimate breakdown of the individual has already
WTiat are the reasons for this failure? Case-finding involves two elements — the
correct diagnosis by the physician of patients with actual lesions of syphilis, and organized
effort to search out the patient who has no lesions. In which of these two elements does
the medical profession fail?    I believe it fails in both, and for three reasons.
1. 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, too 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.
2. Fadlure to Realize the Prevalence of Syphdlis
Such statements as "10 per cent of the adult population is infected" fall on uncomprehending ears, and are as difficult to interpret in terms of personal experience as the
billions of the national debt. Even if the facts of 500,000 fresh infections each year
and a total of some 10,000,000 syphilitic adults in the country are accepted, there is no
appreciation of the fact that all social classes, not only the lowest, are to some extent
These two reasons combine to produce in the minds of many physicians what Stokes
so neatly calls a 'low index of suspicion." The possibility of syphilis is dismissed as
incredible. That syphilis can occur in the clientele of the family doctor, who has known
his patients for a lifetime, is beyond belief. It is likewise incredible that the specialist's
patients, well educated and relatively well to do, can be infected with a disease which he
believes to be limited to social groups with which he does not deal.
The medical profession's attitude of mind must be remedied before case-finding in
syphilis is adequately successful.
3. Inaccurate Diagnosis of Syphilis
The third and most important reason for failure in case-finding lies not in the confusion of morals and medicine, but in the diagnostic inaccuracies of medicine itself. So
far as syphilis is concerned, there is still too great reliance on clinical acumen; too little
appreciation of the fact that syphilis can so imitate or be imitated by other diseases that
clinical diagnosis is sometimes literally impossible; too little awareness that the possible
lesions of syphilis are so diverse that in these complicated days few physicians can be
expected to recognize them all.
The teaching of syphilis in medical schools is sometimes scattered through all general
and special departments, is sometimes centralized in special clinics, and is sometimes
carried on in both fashions. Whichever method is used, there is usually far too much
detail. The student is expected to learn expertness in the diagnostic differentiation of
genital lesions, or skin rashes, of ocular lesions, of cardiac disorders, of neuropsychiatric
diseases. He is expected, as part of his general training, to acquire knowledge in special
fields to which the several experts in these fields have devoted lifetimes. If he makes use
of special text books devoted to syphilis, he is faced with the same difficulty in concentrated form. There is a tendency to require that he know the differential diagnostic
points between, for example, pityriasis rosea and the macular syphilide, between hepatic
Page 240 syphilis and cholecystitis, between tabes dorsalis and subacute combined sclerosis. The
details of these and similar points are insisted upon to the exclusion of the far simpler
principles which ought to govern diagnosis. The forest is lost in contemplation of the
The Complaints of the Syphdlitic Patient
In history taking, every medical student is taught, as the first step, to record the
patient's complaint in his own words. If the syphilitic person complains at all, of what
does he complain, and how valuable is his complaint in arousing suspicion of syphilis?
Almost never does he say "I have syphilis." Instead, he says he has a sore on the penis,
a skin rash, a sore mouth or throat, sore eyes, falling hair, malaise, fever, headache,
rheumatism, pain in the abdomen, nausea and vomiting, constipation, shortness of breath,
weakness, difficulty in urination, pains in his legs—in short, the same complaints that
greet the doctor every day among his non-syphilitic patients.
Who is Concerned With Diagnosis?
To what physician does the patient go with these complaints? First and foremost,
of course, to the family doctor, the general practitioner. If he thinks himself wise enough
to choose his own specialist, or if he goes to a polyclinic hospital, his original contact is
with one or another specialist (rarely the syphilologist). Patients with primary or secondary syphilis gravitate to the urologist, gynecologist, dermatologist, ophthalmologist,
laryngologist, orthopedist, or even the neurosurgeon. The same group of specialists
encounter the patient with late syphilis. The pediatrician struggles with the problems
of congenital syphilis bequeathed to him by careless obstetrics. In short, no special
branch of medicine unless it be the allergist (and even he would find syphilis if he deliberately searched for it) is exempt from having to decide, not infrequently but often,
whether his patient has syphilis or some other disease.
Can the family physician, the general practitioner, have the clinical knowledge of
all these branches of medicine adequate to permit him to recognize syphilis when he sees
it? To ask the question is to answer it. Can the urologist or dermatologist have sufficient knowledge of internal medicine, neurology, psychiatry, and ophthalmology to enable
him to deal properly with late syphilis? Can any physician lacking special training in
dermatology recognize clinically all or even a fair proportion of patients with syphilitic
skin lesions?    To ask these questions is to answer them, too.
Who Must Diagnose Syphilis?
It is obviously impossible to expect of the general practitioner expertness in diagnostic differentiation in all the special branches of medicine in which the lesions of
syphilis may fall, and likewise impossible to exact of the specialist an adequate knowledge
of general medicine and of all other special branches than his own as well. How then
is the problem of diagnosis to be solved? Not by the creation of a special group of
syphilologists, whose function in this domain is presently described, but by leaving the
diagnosis of syphilis precisely where it is, in the hands of every physician no matter what
his special training.
If this is to prove successful in the case-finding element of the control programme,
there must, however, be less insistence on details of clinical diagnosis and more on fundamental principles. I am convinced that the average medical student, general practitioner, and specialist can be taught all that is necessary for him to know of the clinical
manifestations of syphilis and their recognition (outside his own special field) in far
simpler fashion than is the present custom, in far less time than the medical curriculum
usually devotes, and in far less space of printed matter than is expended by current
texts on syphilis.
The Role of the Syphilologist in Diagnosis
Syphilology as a diagnostic specialty does not and cannot exist. While it is true
that the syphilologist, if he is competent, is a well-trained internist with added knowledge
adequate to his special field of the particular specialties of dermatology, ophthalmology,
neurology, and psychiatry, he is far more often called upon to apply this knowledge to
Page 241 the problems of treatment than to those of diagnosis. In the latter respect he serves
only as a consultant, and rarely at that. His patients come to him for the most part
already diagnosed as syphilitic by another physician. His job is to find out what kind
of syphilis, what structures have been damaged by syphilis (and other diseases as well)
and to what extent, and to estimate the effect of this damage in planning treatment.
The Fundamental Princdples of Diagnosis of Syphilis
Considering the disease as a whole, these are only three:
1. Raise the index of suspicion of the doctor. Let him realize that syphilis is the
most prevalent of all the major infections, and that some of his own patients
may be infected.
2. Emphasize repeatedly that syphilis is often difficult to diagnose clinically, even for
the expert; that clinical suspicion is easier to arouse than is clinical certainty to
3. Emphasize still more repeatedly that clinical suspicion, once aroused, can in most
instances be accurately resolved into certainty by the serologic test. In untreated
syphilis, the serologic test is 95 per cent efficient.
(To be continued)
Victoria  Medical   Society
Officers, 1938-39.
President Dr. W. A. Fraser
Vice-President Dr. A. B. Nash
Hon. Secretary Dr. E. H. W. Elkington
Hon. Treasurer , Dr. C. A. Watson
A clinical meeting was held on Friday, March 1, 1940, at the Royal Jubilee Hospital,
under the chairmanship of Dr. H. H. Murphy.
A paper was read by Dr. D. M. Baillie, entitled: "The Whole 'Set-Up' Is Wrong."
This paper was followed by an interesting discussion, in which Dr. J. L. Gay ton gave
his experiences as a Public Health officer in the district of Trail, where the medical services are organized on a co-operative basis. He commented upon the great advantages to
be secured from the public health; point of view. He also emphasized the tremendous
benefits derived for the individual doctors concerned in the matters of opportunities for
specialization and for the increased amount of leisure that is enjoyed by them.
By Dr. D. M. Baillie.
Victoria, B. C.
Read before Clinical Meeting at Jubilee Hospital, Victoria, B. C, March 1, 1940.
We were "chewing the rag" in the Doctors' Room at the Hospital on a recent Sunday
morning, and Dr. X was complaining bitterly about the night work he had had to do
during the week. Said he, "I've been up every night but one—mostly about 2 or 3 in the
morning. Just had a bad streak, I guess, with those midders." X has a big practice; and
efficiently carries out the functions of general surgeon, obstetrician, gynaecologist, paediatrician and general practitioner, with an occasional excursion into the tonsil and adenoid
business. He does a great deal of midwifery and, all told, puts in a steady twelve to fourteen hours' work a day, not counting the work done during the hours he is supposed to
sleep. How he stands the racket, I don't know.
Page 242 A week before this, Dr. Y had told me, wearily, that he had been pulled out every night
for a week. He, also, tries to spread himself thin in the practice of surgery, obstetrics, ear,
nose and throat, and general medicine, and rarely finishes his day's work before ten o'clock
at night.
In this Province, particularly in the cities, one could multiply these examples by scores,
if not by hundreds. No doubt the war, which has plucked some of the younger men from
their practices into the army, has increased the burden of those who are left. Possibly so,
but even without this qualification the whole business spells out to bad medical organization.
Today, my task is to endeavour to tell you why I think the whole medical "set-up" as
we have it in Victoria is wrong. These remarks will apply to the rest of Canada to a great
extent as well.
A Local Survey.
It is a good thing to sit down quietly and take stock of any situation, because the
human animal, even the medical variety, is inclined to take so much for granted. So far as
I know, no serious attempt has been made an analyse the medical situation from the general
wide public health point of view in this city and district. I take it you will agree with me
that our primary function should be the safeguarding of the health of the people of our
community. Unfortunately for this point of view, the first consideration forced upon us
is that of making a living for ourselves and families, with the added hope of being able to
save enough to provide us with a competence in old age, if we ever reach that period. The
economic factor forever obtrudes itself upon those of us who are in private practice of
medicine and brings in many considerations that militate against a scientific approach tc
our work: but more about this later.
In surveying the medical scene here one is first of all struck by the confused disorderli-
ness of it—manifested in the variety of agencies involved and by the mixture of functions
carried by the individuals concerned. These weave and intertwine in the most extraordinary fashion and the situation is, at present, still more involved by war conditions and the
medical necessities thereof.
In a short paper to the Vancouver Medical Association Bulletin, of April, 1939, I
made a very sketchy survey of the activities of the medical practitioners of this city, and
stated that I found some 57% were in receipt of funds from public sources as well as from
their private practices. Since then I find that I was grossly underestimating the number,
as I had omitted any mention of relief appropriations, which I suppose all of us in private
practice share in, if only, to a modest degree. In fact, we are forced to the conclusion that
we are. all giving services to the State (Dominion, Provincial and Municipal) for benefits
received, and that we really have State Medicine without, perhaps, knowing it.
Referring to the telephone directory and other sources, I find that there are 75 medical
practitioners in the city and immediate district giving medical or health services in one
form or another. Twenty-five, or 33%$%5 of these, are simon-pure specialists—confining
their work to a single specialty. Another fifteen, or 20%, are what one might call pseudo-
specialists: in other words, they are general practitioners who have a long suit, such as
surgery, internal medicine, and so on. Adding these together, we find forty men, out of
seventy-five, specializing—more or less—making 53%$%. Of general practitioners, we
have twenty-four, or 32%, most of whom do their own surgery and obstetrics. Of full-
time salaried men, we have eleven, or 15%. Some of these men do the radiology and
pathology at our hospitals, two are in the Chest Clinic, and one is the Medical Superintendent of the Jubilee Hospital. There are two other full-time salaried men in the city—
the Medical Officer of Health and the School Medical Officer. There is also the Medical
Officer of Health for Saanich. Part-time public health work is done by three men in the
district; two of whom are specialists in other fields.
All this seems very confusing, but there is worse to come. We have to reckon up the
number of men who are working more or less part-time for the Dominion and Provincial
Governments. It is difficult to get the exact figures, but a superficial survey gives me
twelve for the Dominion and eight for the Provincial Governments. Then, we are nearly
all working for the City and Saanich Municipalities by doing their relief work, and thus
getting small accretions to our individual incomes. Finally, there is the Workmen's Com-
Page 243 pensaton Board, which paid out in 1936 the sum of $595,894 to the medical profession of
British Columbia.
You will see, then, that the medical situation in this community is one of some complexity. That would not matter so much, perhaps, if we could honestly claim to be efficient. I would like to put the question to you: Are we, as a profession, collectively and
individually, as efficient as we ought to be? For answer, I could refer you to the large number of quacks and irregular practitioners in the city, not to mention the amount of self-
medication that goes on all the time. Perhaps we are better off in this respect than most
other cities in this country, because I feel that, despite our faults, we do give in this city a
better than average medical service. But you will admit with me that most of us are daily
doing things medical and surgically that would be better done by other more qualified
practitioners. We can't afford to refer the work. Particularly is this so in the field of surgery. It is most difficult for the young man in practice to get the necessary experience to
do surgical work under our present arrangements, particularly when he has to struggle to
make a living at general practice. The same can be said of obstetrics and gynaecology,
is done by the general practitioner and pseudospecialist, largely because they feel they
can't afford to refer the work and also because such a small percentage of our people can
afford to pay specialist fees. We badly need orthopedic and skin specialists in this city, but
do you think the men generally would refer their fractures and skin conditions to them?
Most certainly not, because they would lose money by it.
In recent years we have witnessed the rise of the specialist. An increasing number of
practitioners are confining themselves to the practice of an increasing number of specialties. This, to my way of thinking, is a natural and obvious result of our unscientific way
of managing and co-ordinating our daily medical work. In a manner of speaking, it is a
compensatory mechanism, and indicates a period of transition. One perhaps can say that
the specialist is the practitioner who is trying to escape, or has escaped, from what he considers to be the intolerable drudgery of general practice. And I think we would be prepared
to admit that the specialist, in good standing, has escaped to a sphere in which he has economic security, restricted hours of work (an eight-hour day), and the time and opportunity to really develop and do his work in a scientific manner. He has also, by virtue of
these privileges, an increased allowance of that form of wealth called leisure, in which he
can develop the cultural side of his life and enjoy reading about other worlds besides that
of Medicine. It is interesting to observe that twenty years ago the only specialists in this
city were three Eye, Ear, Nose and Throat men and one Radiologist. Since then, as I have
pointed out, their numbers have increased considerably.
An interesting new development has been observed also and that is that many of these
specialists seem to revolve in a solar system of their own and refer cases to each other
without reference to the general practitioner.
I suppose, in this community, all the surgical work could be most efficiently done by
five senior and five junior men, excluding the Ear, Nose, Throat, and Eye men. Instead,
we find that quite half the men dabble in surgery to a greater or lesser extent.
And so on, throughout the whole field of Medicine, we find a lack of balance. The
more popular minority over-worked; the majority getting by, not so much because of
poor qualifications, but because they have not had the opportunity to apply their gifts to
one particular branch of Medicine. They have grown up into Medicine as individuals, got
chained to their practices, and have not had the opportunity to develop along certain
specialized lines.
Preventive Medicine
Perhaps the most serious indictment against our methods of doing "Medicine" is our
attitude towards Preventive Medicine. A great deal of work has been done, not by us
but by the State, which has, in most cases against our active resistance and hostility, made
this field peculiarly its own. A well-known New York professor of Surgery recently
quoted in American Medicine writes: "It is well known that the doctors have persistently
opposed every measure that has been conceived and dedicated to increasing the health and
longevity of the community.   We opposed the establishment of boards of health, we
Page 244 opposed the reporting of communicable diseases, and we have opposed practically every
step along the arduous course of the public health movement. We are not unlike the
weavers in the great industrial centres in England who organized mob parties to go in and
destrop the newly-made machines. They argued that one machine, run by one man, can
produce an output equal to the labour of ten men. Therefore, nine men must obviously
be through out of work.  History records that this assumption was fallacious."
In truth, this is the crisis of the medical profession today; and we have, so far, failed
to tackle the problem in a scientific way. We are practicing therapeutic medicine like the
doctors of past generations, and doing the minimum of preventive work. It really ought
to be the other way around, if we were applying scientific principles. Thirty years ago,
when I qualified in Medicine, epidemic disease was rife and constituted a great proportion
of the maladies we treated. Also, a large percentage of our patients were children. Today,
a very small proportion of our patients are children, and this fact is associated with a great
increase in the expectancy of life. We are now mostly concerned with treating the
degenerative conditions of middle life and advanced age; e.g., arterio-sclerosis, in all its
manifestations; and trying to deal with the cancer problem. How much of our time is
filled up in gently wafting people over Jordan!
Between the fields of Preventive and Therapeutic Medicine there is still a great gulf
fixed with tenuous strands of inter-communication. The former is run by the State; the
latter by private medicine. The practitioners of the former are paid by salary; those of
the latter on a basis of fees for services rendered. It is high time that, in the interests of
economy, these fields of endeavour should be merged into one, so that a scientific, co-operative, and planned medical economy should be obtained for the benefit of our pople.
Social Consciousness
Another great drawback to our Medical "set-up" is that, as a profession, we have not
developed anything like a social consciousness. We do not fully realize that, besides being
doctors, we are citizens and members of the community. There has always been the
tendency for us to shut ourselves off as individuals from active social endeavour and, as a
profession, from the pressing social and economic problems that must be solved. We have,
too long, taken the attitude that these things are none of our business. They are very much
our business, and the public are looking to us for leadership.
Sigerist, Professor of History of Medicine in Johns Hopkins University, has some very
pertinent things to say about this. In his book "Socialized Medicine in the Soviet Union"
he states: "In all Western countries there is a great deal of unrest in the medical world.
The causes of this unrest are easy to find. Society has undergone a profound change in the
last hundred years. We live in a highly industrialized, highly specialized, society. At the
same time, medical science has become revolutionized, has become highly specialized, and
highly technical also. Science and technology are the driving forces that transformed both
society and medicine. It is obvious that a new medicine in a new society calls for new
forms of medical service. Instead of recognizing this, instead of taking advantage of all
the weapons that modern medicine puts into our hands, we oppose the development and
try by all means available to preserve the old traditional forms of medical service adapted
to conditions that no longer exist. We know what should be done in medicine. We all
know that slums breed tuberculosis; that unemployment leads to prostitution and to the
spread of venereal disease; that undernourishment cripples children. We all know that,
and yet we are helpless under the present system.
"We hear complaints everywhere as to the number of physicians. There are too many
physicians to guarantee the individual doctors a decent income, under the present system;
there are not too many so far as the population is concerned. Great medical tasks have
barely been undertaken yet. Medicine is still in its first stage—that of therapy. Something
has been done in the prevention of communicable diseases, but very little in preventing
individual persons from developing diseases.
"There is unrest in medical education because we are not quite sure as to the type of
physician that is required by our modern society.  We do not know it or do not want to
Page 245 know it. There is widespread fear among the doctors of state interference in medical
matters, and"yet the same doctors call for the state to take care of the unprofitable cases;
the indigents, the mentally ill, the unemployed, the chronically sick people."
The Economic Problem
We are all only too well aware of the fact that modern medical service has become an
ever-increasing burden on our patients as well as on ourselves. Modern medical technique,
including X-ray, pathological and specialist investigation, has become very expensive. We
hear a good deal—both from doctors and patients—about X-ray and operating room
charges, despite the fact that our hospitals are mostly in debt and are carrying on with the
greatest difficulty. We know only too well that a lengthy illness is a calamity to all but
a small proportion of our patients who are fortunate in being well-to-do. Our style is
often cramped severely because we are forced to consider the effect of these expensive
diagnostic aids on the pocketbooks of our patients. We can't forget, too, that the rate of
what we may call "medical indigency" is very high in Canada and has been conservatively
estimated to be 25% of our population.
Medical Indigents in Canada, 1936
Individuals affected by unemployment      894,000
Dependents on State (Blind, Old Age Pensions, etc.)      444,436
Wage-earners and dependents incapable of defraying
medical costs 1,399,227
Total 2,737,663
In America, the figure is given as 30%.
You know, as well as I do, that these people are receiving very inadequate medical
service, and this fact is borne out by the high morbidity rate in this class as compared to
the better-to-do. It may surprise you to know that a large number of people die in Canada
every year without any medical attention. The Dominion Bureau of Statistics gives an
interesting table showing that, in 1936, of 107,050 people dying in that year, 10,505 had
no medical attention whatever. It is also of interest ot note that 45% of all wage-earning
families in Canada have a yearly income of less than $950.00, or less than $79.00 a month.
It is not surprising, then, to find that some 45 to 60% of hospital and medical bills
remain unpaid, and that the average medical income in Canada is very low. This has been
particularly marked since the "Great Slump" of 1929, and the signs are not particularly
hopeful for any appreciable improvement.
Some new method of financing medical and hospital services has got to be found.
Our Methods Are Wasteful
This is particularly true in our cities, where we have to pay rent for separate offices
and salaries to our office nurses. I suppose any of us is lucky if our annual expenses in
running our offices are less than $2000 a year. There is, also, a tremendous amount of overlapping and duplication of work involved in the inco-ordinated shifting of patients-jfrom
doctor to doctor—necessitating more X-ray and pathological investigations, which haVe
already been done on many occasions. The time is long overdue when competitive mediA
cine should give way to co-operative medicine. The old idea that salaried men are inade-\
quate, inefficient, and shiftless should surely now have no protagonists. The status of the
salaried men on our Staff here is an object lesson to us as to wn&tcan be/achieved in this
Some day, if you'll ask me, I would like to suggest to you a projected scheme for the
medical organization of this city and district.
In conclusion, I would recommend to all of you younger men to continue with general
practice. Be sure, however, to develop a "long suit," and some time, before you're thirty-
five, shut your office up, get away for at least one year's intensive study in your chosen
subject, and return as a specialist. The day of the general practitioner, in my opinion, is
rapidly coming to an end. Conditions have changed and are rapidly continuing to change.
The old shibboleths no longer ring true, and a New Era is coming for Medicine, in which
money will be the least of all values.
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often associated with sandalwood therapy are either absent or reduced to a
negligible degree.
350 De Moyne Street, Montreal.
Please send me a sample of
ARHEOL. (Astier) in the new
economical dosage form.
City.-  Prov.
Canadian Distributors
350  Le Moyne   Street,  Montreal Breaks the vicious circle of perverted    i
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
i    circulation and thereby encourages a
normal menstrual cycle. M
Full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam.
A new "Ciba" product, which exhibits, according to the dose, a sedative-
antispasmodic effect of a central and peripheral nature,
or acts as a mild soporific—
{Trasentin-\-phenylethylbarbitwric acid)
Neuro-Trasentin should undoubtedly be of
great value in the following conditions:-—
Excitability, states of agitation, cardiac neurosis, angina pectoris,
vascular, spasms, hypertonia, nervous dyspepsia, ulcer pains,
climacteric disturbances, dysmenorrhoea, pruritus, hyperthyreosis,
Tablets, in bottles of 30 and 100; also 500 for hospital use.
According to Jacobson*, approximately one-third of the
populace suffers from skin conditions of mycotic origin.
As physicians know, the commonest type encountered is
epidermophytosis interdigitale (so-called "Athlete's Foot")
which infection, because of its wide incidence, now presents
a public health problem of major importance.
"Mersagel" has been designed especially for the treatment
and control of epidermophytosis. From results following cm
extensive clinical trial, it would appear to be almost a
specific remedy for mycotic slrin infections.
* Jacobson, Harry P.: Fungous Diseases (Charles C. Thomas,
Baltimore, Md.) 1932.
The drawing below represents an
epidermophyton inguinale culture;
age one month; grown on Sabou-
raud's maltose; magnification approximately 400.
,4 «*.
,S V,.
"MERSAGEL" consists of phenyl mercuric acetate, a powerful fungicide, incorporated in a water-soluble, jelly base.
When applied to the infected areas, it exerts an immediate
and prolonged action, killing the causative fungus and, at
the same time, soothing the affected part. "Mersagel" is
non-toxic, greaseless, odourless, easy-to-apply and will not
stain the clothing.
Literature will be forwarded on request
Biological and Pharmaceutical Chemists
MONTREAL CANADA ^ir*HE use of cow's milk, water and carbohydrate mixtures represents die
A one system of infant feeding that consistently, for three decades, has
received universal paediatric recognition. No carbohydrate employed in this
system of infant feeding enjoys so rich and enduring a background of
authoritative clinical experience as Dextri-Maltose.
Please enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized persons.
 Mead Johnson & Co. of Canada, Ltd., Belleville, Ont. \ ;	 Extending Youlj
Professional Skill
Day or Night
MArine 4161
Free City Delivery till 10 p.m.
Extreme care fulness and long
years of training combine in our
six pharmacists to dispense your
prescriptions exactly a^^bu^ant
them.. Ill
,<£&J$JL ^.Jaletodskton
€mfm & ^attnalp.
North Vancouver, B. C.
Powell River, B. C. Hollywood San it arjtjrm
lp§pr the treatment of §
Alcoholic, Nervous and PsychopatnJgCases
Reference^-B^. Medical Association
For inf ormatiofi apply to J
Medical Superi^endenKNew Westminster, /B||||fc
or 515 Birks Building, Vancouver.
SEymour 4183
Westminster 288


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