History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1950 Vancouver Medical Association Sep 30, 1950

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The Vancouver Medical Association
Publisher and Advertising Manager
W. E. G. MACDONALD        Sl^ 'Jjjg&i
OFFICERS  1950-51
Db. Henry Scott Db. J. C. Grimson Dr. W. J. Dorrance
President Vice-President Past President
Dr. Gobdon Burke Db. E. O. McCoy
Hon. Treasurer Hon. Secretary
Additional Members of Executive: '$M*
Dr. J. H. Black Db. D. S. Munboe
Db. G. H. Clement Db. A. C. Fbost Db. Mubbay Blair
Auditors: Messrs. Plommeb, Whiting & Co.
Eye, Ear, Nose and Throat
Dr. N. J. Blair. Chairman Dr. B. W. Tanton Secretary
Dr. J. R. Davies Chairman Dr. C. J. Tbeffby Secretary
Orthopaedic and Traumatic Surgery
Dr. D. E. Stabb Chairman Db. A. S. McConkey. Secretary
Neurology and Psychiatry
Db. F. E. McNaib Chairman Db. R. Whitman Secretary
Db. Andbew Tubnbull Chairman Db. W. L. Sloan Secretary
Db. E. Fbance Wobd, Chairman; Db. A. F. Habdyment, Secretary;
Db. F. S. Hobbs, Db. J. L. Pabnell, Db. S. E. C. Tubvey, Db. J. E. Walkeb
Co-ordination of Medical Meetings Committee:
Db. R. A. Stanley. Chairman Db. W. E. Austin.' Secretary
Summer School:
Db. E. A. Campbell, Chairman; Db. Gobdon C. Laege, Secretary;
Db. A. C. Gabdneb Fbost; Dr. Peter Lehmann; Dr. J. H. Black;
Dr. B. T. H. Marteinsson.
Medical Economics:
Dr. F. L. Skinner, Chairman; Dr. E. C. McCoy, Dr. T: R. Sarjeant,
Dr. W. L. Sloan, Dr. J. A. Ganshorn, Dr. E. A: Jones, Dr. G. Clement.
Dr. G. A. Davidson, Dr. Gordon C. Johnston, Dr. W. J. Dorrance
Special Committee—Public Relations:
Db. Gordon C. Johnston, Chairman; Dr. J. L. Parnell, Dr. F. L. Skinner
Representative to B. C. Medical Association: Db. W. J. Doebance
Representative to V.OhN. Advisory Board: Db. Isabel Day
Representative to Greater Vancouver Health League: Db. L. A. Patterson l-ffji      j!
^rndicatecl in:
Cardiac dropsy, hypertensive heart
pain, and following coronary thrombosis.
^Arvailable ad:
C.T. No. 691   Theobarb Containing:
Theobromine 5 grs.
Neurobarb     V2 Qf.
Sod.   Bicarb. > 5 grs.
C.T.  No.  691A Theobarb  Mild
Theobromine 5 grs.
Neurobarb    .— Vi gr.
Sod.   Bicarb. » 5 grs.
C.T. No.  694 Theobarb-Calcium
Theobromine 5 grs.
Neurobarb.    Vi gr.
Calcium   Carbonate   .._>  5 grs.
This sodium-free tablet is
especially indicated in cardiac edema.
Packaged  in bottles  of
100, 500 and 1,000
Representatives: Mr. V. Garnham, 3228'West 34th Avenue, Vancouver, B.C.
Mr. F. R. Clayden, 3937 West 34th Avenue, Vancouver, B.C. VANCOUVER MEDICAL ASSOCIATION
(Fall Season)
Founded 1898; Incorporated 1906.
OCTOBER 3rd—GENERAL MEETING—Speaker: Professor G. W. Pickering, Professor of Medicine, University of London.   Subject:   "Pain in Peptic Ulcer."
NOVEMBER 7th—GENERAL MEETING—Speaker:   Mr. L. Detwiller, Commissioner
British Columbia Hospital Insurance.  Also time devoted to MedicaL Economics.
NOVEMBER—ANNUAL DINNER (date and place to be announced).
DECEMBER 5th—GENERAL MEETING—Speaker: Dr. Sydney M. Friedman, Professor and Head of the Department of Anatomy, University of British Columbia.
All General Meetings will be held in the Auditorium,
British Columbia Tuberculosis Institute.
CLINICAL MEETINGS, which members of the Vancouver Medical Association are
invited to attend, will be held each month as follows:
FIFTH TUESDAY   (when one occurs in the month)—CHILDREN'S HOSPITAL.
Notice and programme of all meetings will be circularized as usual by the Executive
Office of the Association. $|
Publishing and Business Office— 17-675 Davie Street,'Vancouver, B.C.
Editorial Office — 203 Medical-Dental Building, Vancouver, B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.
Closing Date for articles is the 10th of the month preceding date of issue.
Manuscripts must be typewritten, double spaced and the original copy.
Reprints must be ordered within 15 days after the appearance of the article in question, direct from the Publisher. Quotations on request.
Closing Date for advertisements is the  10th of the month preceding date of issue.
Advertising Rates on Request.
Grades 1 to 9
A successful Boarding School
for Junior Girls situated on the
Okanagan Lake. The most
healthful climate for growing
girls. Individual instruction in
school work. Recreational life
includes riding, swimming, tennis and skating.
Prospectus on Request
Page 297 ih
§ Vasoconstriction
g:   combined with
antibiotic therapy in
(brand of phenylephrine)
In upper respiratory tract infections,
topical application of penicillin to the nasal cavity has a decided bacteriostatic action against
typical respiratory pathogenic microorganisms.
To provide clear passage for-such therapy,
Neo-Synephrine is combined with penicillin—
shrinking engorged mucous membranes and
allowing free access of the antibiotic.
Neo-Synephrine—a potent vasoconstrictor—
does not lose its effectiveness on repeated application ... is notable for relative freedom from
sting and absence of compensatory congestion.
Stable • Full Potency
Supplied in combination package for preparing 10 cc. ot
a fresh buffered solution containing Neo-Synephrine hydrochloride 0.25% and Penicillin 5000 units per cc.
New York 13, N. Y.    Windsor. Ont.
Neo-Synephrine, trademark reg. U. S. & Canada
OrthO presents
£<^&*ie^nipple cream,
Masse is an antiseptic, readily absorbed, nipple cream
containing 9-amino acridine 1:1000, and allantoin 2%.
Masse is active against a wide variety of bacteria,
stimulates healing of nipple abrasions and fissures, and
has excellent emollient properties.
INDICATIONS: For prophylactic nipple care during the
antepartum and nursing periods, and for the treatment
of cracked nipples.
«w vrt. % •%
HtPPVt        C  *  *  *  **
Advantages of Masse in prophylactic nipple care:
1. Highly effective against a wide variety of pathogenic
2. Relatively nontoxic and nonirritating.
3. Actively promotes healing.
4. Has definite debriding properties.
5. Readily absorbed, obviating the use of waxed paper, etc.,
over nipples after application.
6. Nonstaining.
7. Emollient effect helps prevent nipple trauma.
8. Need not be washed off prior to nursing.
9* Has pH of 5.6 approximating that of nipple epithelium.
yimecic iy/uwmaceidicaA Increased
vitamin absorption
and retention in
infants and young
Alphamette" Aqueous No. 929
Each drop contains approximately:
Vitamin A 1,000 I.U.
Vitamin D     500 I.U.
The suggested daily dose is 2 drops.
In  bottles of 8,   15  and  30 cc.
with dropper.
"Supplavite" Drops No. 931
10 drops (0.6 cc.) provide approximately:
Vitamin A 5,000 I.U.
Vitamin D    2,400 I.U.
Ascorbic Acid      50.0 mg.
Thiamine       1.5 mg.
Riboflavin      1.0 mg.
Niacinamide    20.0 mg.
Pyridoxine       1.0 mg.
Calcium d-Pantothenate      5.0 mg.
Mixed Natural Tocopherols...      2.0 mg.
(as antioxidant)
The suggested daily dose is 5 to 10 drops.
In bottles of 8, 15 and 30 cc.
with dropper.
/UM/VffiSAM y£Aft d
Ayerst, McKenna & Harrison Limited
Biological and Pharmaceutical Chemists
.   ■      m     CITY § 1-
Total population—Estimated ! 3 85,500
Chinese population—Estimated :     6,877
Hindu population—Estimated = j        133
June, 1950
Rate per
g^JV'- Number Rate per 1000 Pop.
Total deaths   (by occurrence) I 416 12.9
Chinese deaths '■. |       13 ,22.6
Deaths, residents only ! 370 11.5
(Includes late registrations)
Male 472
Female 492
Deaths under 1 year of age ,	
Death rate per  1000 live births" -. I	
Stillbirths (not included in above item)	
June, 1950
June,  1950
Cases Deaths
Scarlet  Fever_
Diphtheria  Carriers - "SllP
Chicken Pox 112
Measles - 243
Rubella 678
Mumps 196
Whooping Cough _  . 3 8
Typhoid Fever 0
Typhoid Fever Carriers ^^Illl
Undulant Fever 0
Poliomyelitis - 1
Tuberculosis  46
Erysipelas ! 0
Infectious Jaundice	
Salmonellosis .	
Salmonellosis  Carriers.
Dysentery Carriers ±       0
Tetanus <=I|^B{
Syphilis 18
Gonorrhoea j 141
Cancer  (Reportable): Resident— 112
0    -
Page 298 I
Clinical experience in the use of Heparin as a blood anticoagulant has
extended over many years The product has been administered intravenously
in very dilute solution.
Recent experience has shown that intramuscular injection of concentrated solutions is an effective means of prolonging clotting time. This
method of treatment provides an increased measure of freedom for the patient
and can be extended over a period of months on the basis of two or three daily
Solution of Heparin-—Distributed in rubber-stoppered vials as sterile neutral solutions of
heparin prepared from purified, dry sodium salt of heparin containing approximately 100
units per mg.   The product is supplied in the following strengths:
1,000 units per c.c.
5,000 units per cc.
10,000 units per c.c. ^jp
Heparin (Amorphous Sodium Salt)—Dispensed in 100-mg. and 1-gm. phials as a dry
powder, containing 95 to 100 units per mg., for the preparation of solutions for laboratory
Recent References:
Stats, D., and Neuhof, H.: Am. J. Med. Sci., 1947, 214:  159.
Walker, J.: Surgery,  1945, 17: 54.
Cosgriff,  S. W.,  Cross,  R. J., and Habif,  D. V.: Surgical Clinics of
North America,  1948, 324.
De Takats, G.: J.A.M.A.,  1950, 142: 527.
University of Toronto |§| Toronto 4, Canada
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. From time to time of late months, complaints have come to the Executive Secretary
of the College of Physicians and Surgeons, about the difficulty of obtaining doctors to go
on emergency cases. These calls have usually been made by the telephone operators in
the area concerned, or by the police. The most notable one was in the case of an injury at
Garrow Bay on April 23 rd, which resulted in the death, of the man concerned and was
given considerable publicity, as we remember, in the press. At this time, attempts were
made both by police and operator to get a doctor's help, for over half an hour. Several
doctors were called, and according to reports received, all refused to go. "This," says
the letter from the Assistant General Commercial Manager of the B. C. Telephone Co.,
"is still another example where emergency calls for doctors have resulted in a very poor
To what extent is a medical man obligated to take an emergency call? Perhaps
from a legal standpoint, unless he is the only doctor in the area, he cannot be compelled
to accept such a call. But there is a very much higher standard by which we should
judge our own responsibility in this matter, than the purely legal one.
There may be several factors that make it inconvenient, even a hardship, to take
an emergency call. It may come when we're in bed—when we are busy in our offices,
when we are tired, even exhausted by a long and hard day's work. But none of these
is really an excuse, when the Red Gods call.
We are doctors, first, last and all the time—and that applies whether we are specialists
or general practitioners. We have had training, we have knowledge which nobody else
has—and with this privilege comes a great responsibility. We cannot, we have no
right to refuse such a call—it is part of our tradition, part of our duty, beyond all doubt.
Nor does it matter if the case is hopeless, or even if the patient is dead, or we
believe he is. Under the law, it is our prerogative and duty to pronounce a man dead.
Nor can we tell, till we get there, whether the case is hopeless or not. If there is no
trained knowledge available, the one slim chance of recovery may be lost. It is for us
to do all that can be done, not to give up the fight without at least taking a look at the
chances of battle. No plea of personal inconvenience really justifies us in such a refusal.
And we may be sure that by the time the telephone chief operator, or the police officer
on the job, deems it necessary to summon aid, that no aid but that of a doctor will
be of any use.
And there is another aspect of the case that we may do well to consider. Much has
been said of late years of better relations between the medical profession and the public,
a better understanding of our point of view. One such incident as the one above
described does more to damage our public relations than anything else can do. It is all
very well to present our side of the question. If one has something to sell, all the advertising and public relations counsels and fair words will avail nothing, if the product one
is selling is not honest and of good repute. Integrity and dependability are the very soul
of public relations. And our commodity—all that we have to sell is service—and it
means service in any weather, at any time of day, no matter at what cost to ourselves.
If our profession is all it claims to be, and we believe its claims are justified, each of its
members will see to it that it will not be through his fault at least, that any such accusations may be truthfully made against the great profession to which he belongs, and
whose honour and repute rest upon his shoulders, equally with every other medical
Page 299 ■
Hours During the Summer Months:
Monday to Friday 9:00 a.m.-5:00 p.m.
Saturday   | 9:00 a.m.-1:00 p.m.
Evening hours will start again on Monday, October 2nd, 1950, when the library
will be open on Mondays, Wednesdays and Fridays until 9:30 p.m.
During August the Army Medical Library issued its first enlarged edition of the
Current List of Medical Literature. This publication, previously issued weekly, is to
be published monthly now and lists articles of medical interest in current journals
received in the Army Medical Library and has an author and subject index with each
issue. This valuable publication fills the need for an up-to-date index of medical
A notice has been received in the* library stating that in order to bring the
Quarterly Cumulative Index Medicus up to date as soon as possible the publication of
Volume 45, January-June, 1949, will be postponed temporarily until recent volumes are
completed. Volume 46, July-December, 1949, will appear as the next number. Because
of a change in printing style it will have a different format. It is planned in the
future for two volumes to appear each year.
Recent Accessions
American Diabetes Association—Proceedings, 1949.
German-English Medical Dictionary, compiled by F. S. Schoenewald, 1949.
Medical Clinics of North America—Symposium on Psychiatry and the General
Practitioner, Mayo Clinic Number, July, 1950.
Montreal General Hospital—Diet Manual, 1950  (gift).
Ophthalmological Society of the United Kingdom—Transactions,  1949.
Ophthalmology in the War Years, 1940-1946, 2 Vols, edited by Meyer Wiener
(gift of the editor).
Physiology and Pathology of Exposure to Stress, by Hans Selye, 1950.
Physiology in Disease of the Heart and Lungs, by M. D. Athschule, 1949.
Surgical Clinics of North America—Symposium on Anesthesia, Lahey Clinic
Number, June, 1950.
VIRUS AS ORGANISM, by F. M. Burnet, M.D., F.R.S., Harvard University Press,
1946, pp. 134.
Professor Burnet in 1944 delivered the Dunham Lectures at Harvard University and
this book, Virus as Organism, is taken largely from these lectures. Doctor Burhet, one
of the foremost virologists of this generation, has taken this opportunity to speculate
on the natural history of some of the better known viruses. His general contention
is that, with few exceptions, human epidemic diseases are derived eventually from
diseases of animal communities, and one of the main points in question throughout is
the mechanism whereby viruses survive between epidemics.
In a work of this nature, treatment of disease has no place, and the reader primarily
interested in diagnosis and treatment will find little in this book to aid him; rather, it
is intended to stimulate thought on the epidemiology of certain virus diseases, and on
the natural variation that occurs among viruses. —W. H. C.
1949 - 1950
President | . : Dr. J. C. Thomas, Vancouver
President-Elect !__Dr. Stewart A. Wallace, Kamloops
Vice-President Dr. H. A« L. Mooney, Courtenay
Honorary Secretary-Treasurer S Dr. J. A. Ganshorn, Vancouver
Immediate Past President - Dr. F. M. Bryant, Victoria
of the now defunct
||l|j of British Columbia
I would submit the following report of the activities of the Joint Committee on
Medical Economics to February, 1950.
Following the Annual Meeting of the College of Physicians and Surgeons of British
Columbia in Victoria last year, in all five meetings of the Executive of the Committee
on Medical Economics were held and one meeting of the Main Committee, the latter
on January 27th last.
All these meetings were well attended by the membership and keen interest in all
matters that came up for discussion was manifested. There was a long agenda for each
meeting and several important matters were considered and opinions formulated, a few
are herewith listed:
(I) A special sub-committee of three members was elected by the Executive to
study and bring forth specific recommendations for reform of the rules and regulations
of the Main Committee and the Executive Committee, and for keeping the profession
informed on economic matters. The report of this sub-committee was an important
item on the agenda of the meeting of the Main Committee on January 27th, 1950.
The discussion of this report was not completed, due to lack of time, but some of the
important principles were considered and the whole report was made available to a
joint study Committee of the College of Physicians and Surgeons and The British
Columbia Medical Association which the meeting, by motion, recommended be set-up
to study rules and regulations of the Committee on Medical Economics of British
Columbia, with a view to their revision.
II) A Tariff Committee, under the Chairmanship of Dr. L. G. Wood, composed
of three general practitioners and one specialist besides Dr. Wood, was set up with
Terms of Reference defined and necessary assistance authorised. This Committee on
Tariff is now a committee of the Council of the College of Physicians and Surgeons.
(III) A sub-committee on the study of Medical Services Association brought in
a report with several recommendations by way of change in the Medical Services Association contract and administration. *Jlus report, after full discussion both in the
Executive and the Main Committee, was forwarded to Council.
(IV) A small committee studied and made a report to the Executive and to the
Main Committee on the setting up of a "Committee to study the Principles relating to
Health Insurance".  Final action was not taken on this report. »
These and many other matters were studied by the Main Committee and the
Executive during the short period it was functioning, and the results of these deliberations are recorded in the minutes which were sent to all members of the Main Committee
and latterly to members of Council.
Page 301
WKS After the meeting of the Main Committee on January 27, 1950, it became clearly
evident to me, from opinions expressed within the Committee, that the Joint Committee
of the two bodies, namely: the College of Physicians and Surgeons and The British
Columbia Medical Association, was not working out, and the matter had to be clarified.
Several members of the Executive were quite vocal in their opposition to it, and the
Council itself was encroaching on its functions. This, together with the absence of an
Executive-Secretary and the lack of help necessary to carry on the business of the Committee left me only one recourse and that was to tender my resignation.
The Council of the College of Physicians and Surgeons has since set-up a new
Committee on Medical Economics to handle the economic matters of the profession.
—H. H. Milburn, M.D.
ANNUAL REPORT, 1949-1950.
The Committee on Cancer for the year 1949-1950 consisted of the following
members: A. M. Evans, M.D., Chairman; J. Balfour, M.D.; A. C. G. Frost, M.D.; J. A.
Ganshorn, M.D.; Roger Wilson, M.D.; S. T. R. Sarjeant, M.D.; Ethlyn Trapp, M.D.;
W. J. Dorrance, M.D.; G. R. F. Elliot, M.D.; H. K. Fidler, M.D.; H. M. Edimson, M.D.;
A. B. Nash, M.D.
During the year, the Committee discussed various aspects of the cancer problem
as follows:
1. Objectives of the Committee.
2. Establishment of the Biopsy Service by the Provincial Government.
3. Programme for expansion of the facilities of the British Columbia Cancer Foundation
which includes:
(a) Enlargement of facilities of the British Columbia Cancer Institute in Vancouver.
(b) Extension of the Consultative Cancer Services already in existence."
4. Aims and objectives of the Canadian Cancer Society and its relation to the British
Columbia Cancer Foundation and the medical profession.
5. Federal Cancer Grant and the method in which this money is being spent.
Several conversations were held with members of the press during the year concerning publicity on the newer forms of treatment.
Respectfully submitted,
A. M. Evans, M.D.,
August 10, 1950. Chairman, Committee on Cancer.
*r •!(" »s* it*
There have been no activities of the Committee itself during, the current year, but
as its Chairman I have regularly attended the meetings of the Board of Directors of The
British Columbia Medical Association as required.
Respectfully submitted,
Tuly 21, 1950. R. A. Palmer, M.D., Chairman.
fil   SKS
1. Your Committee continues to function along the lines indicated in the 1949
Report. As an important part of its duties, it constitutes a "Medical Advisory Board"
to the Canadian Arthritis and Rheumatism Society, B. C. Division.
2. It has been recommended to the CA. & R.S., B. C. Division (when appropriate,
after discussion with the Economics Committee):
(a) That physical therapy be provided under any circumstances where it was not
previously available, but be made available only on prescription by the patient's physician.
Page 302 (b) That medical treatment be left to the arrangements of the medical profession
in any given locality and that no interference be allowed to arise in the normal patient
doctor relationship.
(c) A travelling part-time consultant be employed to co-ordinate the services of
physical therapist and physician throughout the province.
(d) Certain radiological and laboratory services be arranged for semi-indigent
patients, at least part of the cost to be borne by the patient receiving such services.
3. One Refresher Course in the Rheumatic Diseases has been held and another is
being arranged for late in the Fall.
4. Considerable Research is being carried out here and elsewhere concerning the
Rheumatic Diseases. Issues of the Bulletin in the next year will contain all essential
advances, particularly those concerning ACTH and Cortisone.
5. Steps have been taken towards making ACTH and Cortisone available to those
who may benefit but are not sufficiently wealthy to purchase them through the "usual
6. Substantial Fellowships for Study in the Rheumatic Diseases are available for
1951-52 and subsequent years by the Canadian Arthritis and Rheumatism Society.
7. By co-operation of the medical profession and the general public, greatly
increased facilities for the treatment of rheumatic patients have become available in
several districts in B. C. during the past year. Expansion of such services to all districts
and for all rheumatic patients requires the leadership of physicians in each community.
Respetfully submitted,
A. W. Bagnall, M.D., Chairman.
* * * *
No changes in the Constitution and By-Laws have been made or considered during
the past year—1949-50.
Respectfully submitted,
D. F. Busteed, M.D., Chairman,
Committee on Constitution and Bylaws.
There have been no serious epidemics occasioned in British Columbia during the past
year, the only serious situation being an upward trend during 1949 in poliomyelitis, the
majority of the cases being centred in Vancouver and the Lower Mainland, where it
reached epidemic proportions. Although the epidemic taxed the facilities of the communicable disease hospital in Vancouver, the lessons gained through experience with
prvious recent epidemics were again brought into play to deal with the situation, with
the result that every suspected and actual case received immediate and thorough
The various Medical Health Officers throughout the province have continued to
"supervise the local situation to instigate immediate control measures for each major
infection as it appears and to notify the central body promptly.  The incidence, therefore,
remained local, capable of control by the local authorities without any additional assistance
from your Committee.
As the annual meeting draws near, the problem of Civilian Defence presents itself
and this may require greater activity from your Committee on Emergent Epidemics in
assisting in formulation of plans for Civilian Defence throughout the province.
Respectfully submitted,
G. F. Amyot, M.D., D.P.H., Chairman.
Page 303 m
No problems were placed before the Committee during the past year.
Respectfully submitted, Fffll
July 24, 1950. J. C. Moscovich, M.D.C.M., Chairman.
Your Committee had two meetings during 1949-1950. A request was received from
a member re the advisability of having a proper Board of Examiners constituted to
examine applicants for Industrial First Aid Certificates. Heretofore, individual medical
men had examined these men when asked to do so, and it was felt that the examinations
for such a high First Aid Certificate should be of a high and uniform standard, and be
carried out by duly qualified doctors.
The opinion of your Committee was that a Board of Examiners should be set up
by the Workmen's Compensation Board, consisting of medical men interested in First
Aid work and Industrial Medicine, and remunerated by the Workmen's Compensation
Board. All applicants should appear before this Board, which would hold its hearings
in Vancouver at stated times.
The Chairman of the Committee on Industrial Medicine was appointed by Council
to represent it at certain hearings of the Royal Commission on W.C.B. matters.
Grateful acknowledgment is made to the Secretarial Staff of The British Columbia
Medical Association and Council, for the courteous help provided to your Committee,
all of which is respectfully submitted.
E. W. Boak, M.D., Chairman.
*?. A *«• *t
The report from the Legislative Committee is as usual of no work done.
Since this Committee was appointed in September, 1949, no matters of legislation
with respect to the members of The British Columbia Medical Association have been
referred and I believe that this is because there have been no mattrs forwarded to The
British Columbia Medical Association during this period.
I can foresee that in the process of time a Legislative Committee may have more
arduous duties, if, as we all believe, other agencies may wish to enter the field of control
of medical practice. Until that time arrives, the Committee should watch warily for
any incursion into our field of practice and this Committee would then have more work
to do than heretofore.
Respectfully submitted,
July 24, 1950. Lavell H. Leeson, M.D., Chairman.
*r sp *c »f
This Committee has no formal report to submit, since there were no significant
developments throughout the year.
Respectfully submitted,
August 23, 1950. A. B. Nash, M.D., Chairman.
The Committee on Medical Education has a membership of twenty-one.
Five formal meetings were held during the year. On each occasion a prospective
member of the Faculty of Medicine for the pre-clinical years was presented to and
interviewed by the Committee. The names of those interviewed are: Dr. J. Auer,
University of Ottawa; Dr. and Mrs. S. M. Friedmann, McGill University; Dr. David
B. Tyler, John Hopskins University; Dr. D. H. Copp, University of California; Dr.
Harold Tarber, University of California.
Respectfully submitted,
H. Rocke Robertson, M.D., Chairman.
Total registration to date in the College of Physicians and Surgeons is 1,295, of this
number 899 have paid fees to the Canadian Medical Association.
Membership cards for signed membership in The British Columbia Medical Association were sent to registered physicians who had omitted to forward this application at
the time of their registration. Approximately 150 names were added to the signed
membership list in The British Columbia Medical Association, making a total of 94%
of practicing physicians in the province who are now signed members.
Respectfully submitted,
August 25, 1950. G. D. Saxton, M.D., Chairman.
During the past year, the Committee has been active in the revision of the B. C.
Formulary; and the revised edition is not yet complete, but it is hoped that the revision
will be completed and sent to press before the end of September, 1950.
Respectfully submitted,
August 26, 1950. W. W. Simpson, M.D., Chairman.
This Committee acts in an advisory capacity to the Association. During the past
year there have been no matters referred for consideration.
Respectfully submitted,
G. F. Kincade, M.D., Chairman.
The plans for the Annual Meeting are well formulated; the Committee has been
most active and it is planned that our Golden Jubilee Meeting will be the best yet.
The scientific programme should appeal to all members of the profession; and the
calibre of the men accompanying Dr. Norman H. Gosse, President of the Canadian
Medical Association, assures our success. Greater details of the scientific programme
are appearing in current issues of the Bulletin.
For the first time this year a Hobby Show and a Scientific Display are being planned
and many interesting hobbies from among the profession will be exhibited.
This year also marks the opening of the Medical School at the University of British
Columbia for which the Association has worked so hard. A special congregation has
been planned by the University and outstanding medical men will receive honorary
degrees. The Freshman Class in Medicine are to be our guests at the Annual Luncheon.
A Public Meeting on some aspect of Mental Hygiene is being planned jointly by the
University of British Columbia, the Provincial Mental Services, and The British Columbia
Medical Association. An outstanding psychiatrist in the person of Dr. Franklin G.
Ebaugh has been obtained as our guest speaker for this Public Meeting.
A souvenir programme, eliciting the history of medicine in British Columbia, is
being prepared, and will be of great interest to all.
The. social aspects of the Golden Jubilee Meeting, apart from the University
functions, will include a buffet dinner dance with the Hotel Vancouver Dal Richards'
orchestra, and the Annual Dinner. It is hoped that both of these functions will be
well attended by the doctors and their ladies. Dr. Norman MacKenzie, President of the
University of British Columbia, yrill be the speaker for the Annual Dinner.
\The commercial exhibitors will be well represented at this meeting, and their fees
have been raised substantially this year.
All in all, this Golden Jubilee Convention should be most successful and it is
hoped all will attend who possibly can.
Respectfully submitted,
July 19, 1950. G. R. F. Elliot, M.D., Chairman.
Page 305 IP?.
This Committee has no report of any material importance to make for the past
year. Affairs concerning the profession, especially in economic matters, were dealt
with by news-letters sent out frjOm the Executive Secretary's office. This, it was felt,
was better than publishing them in the Bulletin of the Vancouver Medical Association,
which journal reaches an audience not always entirely medical.
In other matters, the Bulletin has acted as the organ of the B. C. Medical Association
whenever necessary, and we would acknowledge with gratitude this service, which is
always so willingly given.
All of which is respectfully submitted.
Dr. J. H. MacDermot, Chairman.
It is generally agreed that each member of the community should have as his family
doctor, a good general practitioner, one who will treat or advise him well in all matters
pertaining to his health. However, the question has arisen as to what constitutes a
good general practitioner.
In casual conversation one is frequently asked, "Who is a good general practitioner
in such and such a district?" Our own central office daily irecedvelp, more officially,
the same query. Hospital boards, trying to protect themselves and their patients, are
constantly concerned over the capabilities of some of the men using their facilities.
M.S.A. and the Workmen's Compensation Board have similar problems. The popular
press is coming forth with such articles, many of them very stimulating, as: "Is your
doctor a quack?" "How good is your family doctor?" Medical Associations are seriously
concerning themselves with these matters. Our own Canadian Medical Association, in
General Council, at its recent meeting in Halifax, passed the following resolution:
"Re General Practitioner Licenses:
"WHEREAS the medical profession is subject to much criticism through practitioners attempting procedures for which they have been inadequately trained;
"AND WHEREAS it is not in the best interests of a high standard of medicine
that they should do so;
"AND WHEREAS we as a profession, through the medical staffs of our hospitals,
recognize the need for additional training before permitting a practitioner to carry out
many procedures which he is presently licensed to do;
"Therefore BE IT RESOLVED that the Council of the Canadian Medical Association recommend to the various licensing bodies of Canada and to the Association of
Canadian Medical Schools that an immediate study be made of the need, advisability and
method of granting what might be known as a general practitioner license to applicants
having the minimum requirements for licensure."
It is obvious that here exists a problem. It is equally obvious that, whereasjthe
General Practitioner himself probably knows the problem best, and of the medical
profession will be most affected by the type of solution found, he should take a major
part in seeking the solution.
It would appear that the situation is created by a combination of two factors:
1.   Our  system of  licensing, which gives  the  graduate in medicine "Unlimited
License" without subsequent review, as to what treatment he may or may not
undertake, leaving the details to circumstance and his own good judgmnt.
Page 306 2. Th variability and vagaries in human judgment, and the existence in any social
group of the so-called "Psychopathic Tenth", who will take unwarranted
advantage of any license.
If this assumption is correct, then the solution lies either in:
1. Limiting the license of the general practitioner group as a whole, to the point
where none be permitted to attempt any procedure that might be poorly
handled by another.   Or
2. Finding some means of curtailing the activities of those doctors who have not
sufficient judgment or sense of responsibility to restrict themselves within their limitations.
The first is the method suggested by the above resolution. It is the approach of
governments embarking on socialized medicine. It is the way of specialist groups,
insidiously being implemented at the present time by "in hospital" restrictions on the
general practitioner group as a whole, to curtail the activities of the wayward. Thus it is
also the solution adopted by hospitals. It appears to be the suggestion of senior medical
societies. In fact it is the only approach possible; without the unpleasantness of personal
and legal reaction. Therefore it is the approach that will undoubtedly be developed by
any group who are not themselves vitally interested. This way of solving the problem
would deny the public the benefit of the skill of a great many efficient doctors, who
would be quite capable of handling any procedure that they would undertake. Even
more important, it could, as has happened in many communities, through restriction of
privilege and incentive—lead to gradual decrease in interest and efficiency in "out of
hospital" practise.
The second approach to the problem automatically suggests two methods of application: (1) The establishment of a strong, and purposeful discipline committee, who
would have the power and will to deal with individuals, and be prepared to accept the
unpleasantness. Or (2) The development of some method of certification of those who
might be known to the public and all interested as good general practitioners. This could,
by the difficulties of original selection, and the need for regular re-assessment, be very
similar in its problems, to the discipline committee method. This is what the "American
Academy of General Practise" is trying to do. It is what our own General Practitioner
Section at Dominion level is attempting to work out. It is the hard way, but it preserves
the good in general practise, while making it possible to eliminate the bad. Certainly
the only group with enough at stake to face the detailed work, and the difficulties
involved, is the General Practitioner Group itself.
It is of this, and several other equally important issues, that we will attempt to deal
at our annual meeting at 7.30 p.m. Wednesday, 27th September, 1950, in Salon A,
Vancouver Hotel. The meeting will reconvene at 4.30 p.m., 29th September, under
the direction of its new executive.
Dr. Victor Johnston, President of the Dominion Section, will be there to help us.
We are firmly convinced that if general practitioners are to continue to serve the
community to the maximum of their usefulness, there is a great deal of thought and
planning ahead, and that General Practitioners themselves must do most of this work.
We consider it urgent that we have a strong, active and representative section. We
urge everyone to attend these meetings.
Dr. Johnston, who is also the Immediate Past President of the Ontario Medical
Association, and is taking a very active part in Canadian Medical Association activities
will address the B. C. Medical Association, including all men in medical practice, specialists
and general practitioners alike, at 11.30 a.m. Friday, 29th September. Though these
problems are in particular those of the general practitioner, they seriously involve the
whole of organized medicine, and will require the understanding and help of all, in
their solving. It is hoped that this meeting will be well attended.
Robt. A. Stanley, M.D.,
Chairman General Practitioner Section, B.C.M.A.
*G. F. Strong, G. D. Athans, A. W. Bagnall, D. E. H. Cleveland, J. R. Davies,
J. Eden, J. E. Harrison, A. M.  Johnson, H. W. Mcintosh, J. F. Minnes,
R. A. Palmer, A. J. Warren and Reginald Wilson.
When ACTH and Cortisone became available early this year for clinical research
and use. in certain emergencies, there was set up in this province a Dean's Committee
under the Chairmanship of Dr. M. M. Weaver. After that an ACTH and Cortisone
Committee was established at the Vancouver General Hospital. The Dean's Committee
has had charge of supplies of these materials made available to us through the National
Research Council and has allocated those supplies to the various approved hospitals. The
local hospital committee has been charged with the supervision of the use of these
materials in this hospital, and has had available for its use a specially organized four-bed
unit for the careful therapeutic control and study of the hormones. This included
facilities for detailed laboratory observations. There was assigned to the Committee
one of the Assistant Residents in the Department of Medicine. This was Dr. George
Athans up until June 30th, and since then Dr. William Graham. With these facilities
the group on the whole has been able to make an intensive study, not only in the
application of the ACTH and Cortisone made available to it, but also of all the rapidly
expanding current literature. The following review of the present position of ACTH
and Cortisone from both a theoretical and also a practical viewpoint is based largely
upon this study done by the Committee.
*This material was presented at the Special Staff Meeting of the V.G.H. on July 11, 1950.   The authors
are members of the V.G.H. Special Therapy Committee.
The Physiology of Pituitary Adrenal Relationship
One hundred and one years ago, Thomas Addison correlated the clinical finding of
what is known as "Addison's Disease" with the destruction of the adrenal cortex. This
was the beginning of the understanding of "Adrenal Physiology". During the years
since then, knowledge of adrenal physiology has increased extensively to such an extent
that it is now currently fashionable to consider a wide variety of diseases in terms of
"adrenal dysfunction".        |pf|
Studies of adrenal physiology have followed the classical lines of observing the
effect of removal, and restitution to normal by substitution therapy.
It was observed in experimental animals, in whom the adrenals were removed, that
death ensured. Two characteristic patterns, however, occurred. First, there was a
disturbance in the electrolyte metabolism with lowering the blood levels of sodium
and chloride and a concomitant increase in the serum potassium level. The lowering
of the sodium and chloride content of the blood could be accounted for in the most part,
but not entirely, by loss of these elements in the urine. The rest was due to shift from
extra- to intracellular fluid compartments. The second pattern observed consisted of
a tendency for these animals to become hypoglyaemic following a prolonged period of
fasting. The end result of both instances was death. Numerous investigatdfsHiave
attempted to reverse or prevent these changes from occurring by administering adrenal
extracts or replacing the electrolyte loss.
In comparatively recent years single substances have been isolated from adrenal
cortical tissue and from urine which have been effective in counteracting the changes
observed following adrenalectomy. In 1937, Reichstein and his collaborators in Switzerland synthesized a compound known as "desoxycorticosterone". This substance is most
effective in controlling the electrolyte changes in adrenalectomized  animals,  and its
Page 308 !$!f? usefulness as a therapeutic agent in Addison's Disease is well known. A number of other
steroids have been isolated and synthesized which have a predominant effect in
preventing the occurrence of hypoglycaemia following adrenalectomy. These substances
differ from desoxycorticosterone primarily in that they possess an oxygen atom at
Carbon No. 11 in the steroid nucleus. They are known, therefore, as "11 oxysteroids".
Most notable in this group is the substance known, originally, as "Kendall's Compound
E" and now as "Cortisone". This group of substances, possessing an oxygenated C 11,
acts primarily by increasing the breakdown of protein to glucose, the process known as
gluco-neogenesis, so that under fasting conditions a supply of glucose is available to the
organism with the result that hypoglycaemia does not occur. By virtue of this fact
they are also known as "glucocorticoids". These substances in addition, cause several
changes which are worthy of mention. They cause a fall in the circulating eosinophiles
and an increase in the excretion of uric acid. There is also an involution of lymphoid and
thymic tissue in experimental animals.
There has also been discovered a third group of compounds liberated by the adrenal
cortex. These compounds are androgenic in that they produce changes associated with
masculinization. CBnically, it is this group of steroids which is implicated in the changes
in sex characteristics noted in some patients with adrenal cortical tumors. By virtue of
the fact that they possess a double-bonded oxygen at C 17, they are known as "17-
ketosteroids". The measurement of 17-ketosteroid excretion in the urine affords an
index of the activity of the adrenal cortex in producing substances of an androgenic
There are then, three basic groups of functions associated with the adrenal cortex:
1. An electrolyte controlling mechanism;
2. A protein and corbohydrate controlling mechanism;
3. An androgenic mechanism.
These functions of the adrenal are under the control of the pituitary gland. The
evidence for this is that, following hypophysectomy, atrophy of the adrenal cortex occurs
and there is diminution in all functions of the adrenal, so that a clinical picture, in many
respects similar to that observed in Addison's Disease, occurs. It was found that these
changes in the hypophysectomised animal could be prevented by the administration of
a suitable extract of the anterior pituitary gland. In recent years the fraction of the
extract which exerts this eff:ect has been obtained in a relatively pure form. This\is
known as the adrenocorticotrophic hormone or ACTH. In 1947 this substance was
made available in limited amounts by the Armour Co. It was obtained by iso-electric
precipitation of an extract of hogs' pituitary glands. When this substance is administered
in very large doses to a normal individual over a 24-hour period, a number of changes
are observed. There is an oliguria and an increase in the specific gravity of urine. There
is associated with this a retention of sodium and chloride and a diuresis of potassium.
This would indicate stimulation of the electrolyte-controlling mechanism in the adrenal
In addition there is a slight increase in the urinary nitrogen excretion, a marked
increase in the excretion of uric acid, a glycosuria and an increase in the urinary
excretion of glucocorticoids. This, of course, indicates a stimulation of the protein and
carbohydrate-controlling mechanism. In digression two facts should be noted: First,
that the increase in nitrogen excretion is not sufficient to account for the glycosuria
occurring by virtue of gluco-neogenesis, and secondy that the greatest degree of glycosuria occurs on the day following the administration of ACTH at a time when there is
no extra nitrogen loss. This could be explained on the basis of impairment of carbohydrate utilization caused by a glucocorticoid type of hormone.
It is also seen that there is a marked increase in the" urinary excretion of 17-keto-
steroids indicating a stimulation of the androgenic mechanism of the adrenal.
ACTH has then been shown to stimulate all of the known functions of the adrenal
Page 309 Finally, a word concerning the mechanisms which exist in the living body which
control this pituitary adrenal relationship. The adrenal cortex is necessary for the
maintenance of life. In order to meet the stresses and strains imposed on the body,
particularly by severe trauma or disease, an increase in adrenal cortical function is
necessary. It is believed that the adrenal cortex is stimulated to further activity by
increase in the secretion of ACTH in the anterior pituitary. It has been shown that
adrenalin can stimulate the production of ACTH. It is also known that stimulation of
the pituitary from higher nervous centres will augment the production of ACTH.
Presumably then, in periods of stress, adrenalin liberation is capable of resulting in
increased adrenal cortical activity. It is .also known that adrenal cortical hormones
themselves will depress endogenous functions of the adrenal cortext, presumably by
inhibiting ACTH production. This mechanism is analogous to that of the thyroid
hormone on the endogenous activity of the thyroid gland.
Summary:   The adrenal cortex controls three primary metabolic functions:
1. Electrolyte metabolism;
2. Carbohydrate and protein metabolism, and
3. Androgen metabolism.
The adrenal cortex depends for stimulation on the activity of the anterior pituitary
gland.  This is acted on by adrenalin and impulses from higher nervous centres.
Mechanism of Action of Cortisone in Disease States
Intact adrenal cortical tissue is necessary for ACTH to be in any way effective
in modifying disease. Moreover, the adrenal cortical tissue must be capable of responding
to stimulation. In Addison's disease the adrenal gland is mainly destroyed and little or
no favourable response can be expected of ACTH. Likewise, the adrenocortical inhibi
tion resulting from a course of parenteral Cortisone renders the gland incapable of
responding to injections of ACTH for probably two weeks or more after cessation of
therapy. With these provisions to be kept in mind, the action of ACTH in disease states
can be considered for practical purposes, to be due to the adrenal steroids, mostly of the
type of Cortisone, that it causes to be produced. It appears probable that, in responsive
subjects, parenteral administration of ACTH 25 mg. q. 6 h. (100 mg. per diem)
results in the elaboration of glucocorticoids with an effectiveness equivalent, at least,
to a daily dose of 200 mg. of Cortisone. Also, there are indications that the glucocorticoid
manufactured by the adrenal cortex is Compound F and not Compound E (Cortisone).
However this may be, Cortisone is available commercially and Compound F, even more
difficult to synthesis, is not.
In deciding which of the two hormonies, ACTH or Cortisone, to employ in a given
case, there are certain attributes which may indicate preference for one or the other
although the final mechanism of action is much the same for both. If there is urgency,
and good.reason to anticipate normal adrenocortical function, ACTH is the hormone
of choice. Endogenous Cortisone is then made maximally available in 4-6 hours, whereas
the absorption of exogenous Cortisone, deposited intramuscularly, occurs over a period
of several days. Because ACTH presumably stimulates the formation of mineralocorti-
coids (such as DCA) as well as glucocorticoids, it is theoretically even more to ba
avoided in the patient with fluid retention (such as congestive heart failure). CKT^the^
other hand, if, under treatment, increased fluid retention is observed, this undesirable
side-effect is eliminated in 6-8 hours after stopping ACTH injections whereas the intramuscular depot of Cortisone continues to act for days. In allergic disorders experience
to date suggests a greater efficacy for ACTH than for Cortisone. This is neither entirely
confirmed, nor explained. Because Cortisone is synthetically manufactured, impurities
are of no consequence. ACTH has not been synthesized. Since it is a tissue extract it
may contain impurities such as pitressin that may result in untoward reactions.   This
Page 310 was much more common in the earlier preparations. Cortisone being a pure chemicalj
compound, its effects on disease states are more easily evaluated than those of ACTH. For
the sake of simplicity, therefore, the remainder of this section applies specifically to
Mechanism of Action of ACTH and Cortisone in Disease States
I. Replacement of a Simple Deficiency of Cortisone.
(1) In primary hypopituitarism (Simmond's Disease, etc.).
(2) In primary hypofunction of the adrenal cortex (Addison's Disease, etc.).
II. Modification of Disease States by an Excess of Cortisone.
(1) In Pseudodeficiencies States.   (Deficiency due to Physiological Imbalance.)
Modification of Disease by
(2) Utilization of a specific Physiological effect of Cortisone.
(3) Utilization of the Non-Specific Effects of Cortisone on Certain Signs and,
I. Replacement of a Simple Deficiency of Cortisone.
In a simple deficiency, normal body metabolism is restored by administration of
the single (or multiple) factor that is lacking. In the interval treatment of Addison's
disease, the requirement of Cortisone is only 12-25 mg. daily. (D.C.A. may be needed
in addition because it, too, is deficient.) Thus the daily "physiological requirement" of
Cortisone is 12-25 mg.
II. Modification of Disease States by an "Excess" of Cortisone.
(1) In Pseudodeficiency States.
Cortisone is just as capable of relieving the signs and symptoms of certain other
disorders, e.g., acute Rheumatoid Arthritis, but here the dosage needed is ten times the
"physiological requirement" employed for the simple deficiencies. In both instances,
exacerbation tends to occur when Cortisone therapy is stopped. In destructive lesions
of the Pituitary-Adrenocortical System, exacerbation is obligatory. In those conditions
where the deficiency is due to physiological imbalance, however, the need for continued
Cortisone administration will depend upon the nature of the underlying pathological
process. A single insulting agent, such as an acute streptococcal infection, particularly
if of short duration, may be followed by an attack of Rheumatic Fever which responds
rapidly and complete when the Cortisone deficiency is compensated for by 10-14 days
of parenteral administration. The unknown, possibly psychological, stimulus producing
Rheumatoid Arthritis is, however, a more deep-rooted and persistent noxious influence
that may simulate a destructive lesion in its demands for continued Cortisone administration. Although exacerbation does occur if the majority of treatment is stopped, the
severity is not necessarily as great and, in some instances, may be exceedingly mild.
In the Pseudodeficiency States, such as Rheumatoid Arthritis, the dosage necessary
is 100-200 mg. daily. Two explanations are available to explain this relatively huge
requirement—(1) Some strong factor is neutralizing the action of physiological quantities of Cortisone, or (2) Cortisone is not the hormone actually deficient but is partially
convertible into it in vivo. Further elucidation of this problem must await the results
of future investigation—as must the detailed explanation of the precise function of
Cortisone in tissue and body metabolism. ||||
(2) Modification of Disease by Utilization of a Specific Physiological Effect of
Cortisone may exert a modifying influence, at least temporarily, in certain disorders
in which there is no good evidence that an actual deficiency of Cortisone is the cause of
all the tissue changes. Thus, its physiological action of lysis of lymphocytes early
stimulated its trial in the lymphoma group.  Presumably because pituitary-adrenocortical
Page 311 imbalance is not a basic cause of the lymphomas, the results have been disappointing
even with persistence of Cortisone administration.
Other specific physiological effects may prove to be of greater value in therapy of
the future. Potentially important is the effect of Cortisone on tissue enzyme systems.
For example, the abnormally high faecal levels of intestinal lysozyme found in acute
ulcerative colitis revert towards normal with parenteral Cortisone. It is known that
the "spreading factor", Hyaluronidase, is antagonized, but the significance of. this
observation is not yet clear.
In a rather special category therapeutically, is the effect of Cortisone on immune
processes. The best evidence is that, during Cortisone administration, the beneficial
formation of antibodies is not interfered with, but the dangerous over-reactions between
antigen and antibody that ressult in such syndromes as "serum-sickness" j tend to be
suppressed. Upon histamine itself, Cortisone appears to have no effect, but it does
inhibit the process that produces histamine in tissue, and stimulates the enzymatic
destruction of histamine by facilitating the formation of histaminase. These are probably
some of the reasons for the observed favourable effects of Cortisone in asthma, vasomotor
rhinitis, neurodermatitis, etc.
(3)  Modification of Disease by Utilization of the Non-Specific Effect of Cortisone
on Certain Signs and Symptoms.
Malaise and fever tend to be suppressed during a period of Cortisone administration
without there being any necessary resolution of the underlying disease. Appetite and
the general feeling of "well-being" are likewise stimulated. With large doses of ACTH
there is a better tolerance for reduced atmospheric oxygen. These effects may assist the
body to cope with an infection, or they may be grossly misleading through "masking" of
the actual severity of the disorder. Atypical pneumonia, for example, may clinically
appear to subside completely without any radiological resolution. When therapy is
stopped, the disease returns with full-blown severity. In most instances, these non-specific
symptomatic effects are merely of academic interest and of comfort to the patient. In
anorexia nervosa, however, there are reports of much benefit from Cortisone. In this
case, the capacity 6f Cortisone both to stimulate appetite and produce euphoria are
Summary'. Cortisone is of most value clinically when the signs and symptoms of
disease are largely due to a deficient supply of endogenous glucocorticoids of the
Cortisone type. Unfortunately in simple deficiencies such as Addison's disease, the
need for Cortisone is everlasting. In pseudodeficiencies, such as Rheumatoid Arthritis,
there is a natural tendency of the adrenocortical imbalance towards recovery but in many
cases the course is tedious—and the need for Cortisone is "super-physiological" and
prolonged. In Rheumatic Fever, presumably because the insulting agent is a single
self-limited streptococcal infection, the outlook is brighter and the cost relatively low,
if treatment is early and adequate. Iff?
Cortisone may be of considerable value also in disorders in which there is no reason
to suspect that Cortisone deficiency plays a significant part in the pathogenesis. In
this case, one or more of the specific or non-specific physiological effects of Cortisone are
utilized to modify the disease. In all but the simple deficiencies such as Addison's disease,
the dosage of Cortisone necessary is ten times the "physiological requirement" of 12-25
mg. daily.
Clinical Applications for the Hormones
Cortisone is now available in certain limited quantities for ordinary therapeutic
uses by any qualifiied practitioner in the province. Supplies are likely to increase rapidly
in the future as was the case with Penicillin six years ago. ACTH will remain in more
limited supply for some time, as it has not been synthesized. The hormones are available
in those hospitals that are equipped to provide the necessary controls and apparently
it is not to be provided under the B.C. Hospital Insurance Scheme for the immediate
Page 312 future at least. The hormones can be secured by private purchase for patients in these
hospitals and the cost, for Cortisone at least, is about $65.00 per gram. All this
means that at the present moment we as private practitioners have opportunities for
using new therapeutic instruments which are still limited in supply, are expensive,
have certain dangers and have certin limited clinical indications.
Since the first clinical reports by Hench and his colleagues of the dramatic effect
of Cortisone in certain cases of rheumatoid arthritis and also in rheumatic fever, widespread hopes were raised that effective therapy for many formerly hopeless conditions
was at hand. To a very limited extent this still seems true, but the more one reads, and
as one also gains some personal experience, one is impressed with the narrow limitations
of therapeutic usefulness still imposed. The vast amount of work that has been done
in pituitary-adrenal mechanisms in many centres, especially in the past three years, has
opened new lines of thought that must completely revolutionize medical thinking, but
unfortunately the substances presently available for therapy have limitations much
greater than was originally hoped.
It is therefore timely to review the present situation from the standpoint of practical
treatment—how good are ACTH and Cortisone as therapeutic agents? Where, when,
and how should they be used?
In considering the therapeutic application for new drugs, one must have available
all the known information about their mechanism of action so that as far as possible
their clinical application should follow along rational lines. There are then certain
additional questions of practical importance:
1. What conditions are likely to be benefited?
2. What are the risks of using these substances?
3. What are the costs in time, in money, in trouble?    ||||
4. What are the exact techniques employed, dosage, and when should one employ
one hormone or another?
What conditions are likely to be benefited?
It is the intention in this review to comment only upon those clinical conditions
which are relatively common and not to comment at all upon the numerous rather rare
diseases and syndromes which will be seen infrequently even by consultants. Clinical
uses for the hormones may be divided into two main groups, firstly those conditions of
known hormonal insufficiency and secondly a large miscellaneous group in which specific
hormonal deficiency has not been satisfactorily demonstrated.
(a) States of known hormonal insufficiency (primary or secondary).
Panhypopituit arism.
Functional hypopituitarism.
Addison's Disease.
Functional adrenocortical insufficiency.
In these conditions the hormones will provide specific substitution therapy.
(b) Miscellaneous other diseases.
Presumably in these various states there is also some pituitary-adrenal imbalance,
presently being dimly recognized and which the hormones may alleviate. The
lengthy list of conditions in which trials have been made has been summarized
by Thorn and his colleagues and his "preliminary grouping of diseases" appears
to be the most authoritative available to date. . More extensive experience is
likely to amend such grouping considerably in the future.
Page 313
fess- Diseases in which drugs ate most useful (Thorn et al)
Addison's Disease.
Functional adrenocortical insufficiency.
Functional hypopituitarism.
Anorexia nervosa.
Idiopathic hypoglycaemia.
Acute rheumatic fever.
Acute gouty arthritis.
Status asthmaticus.
Serum sickness.
Exfoliative dermatitis.
Loeffler's syndrome.
Acute inflammatory disease of eye.
Acute rheumatic fever—Apparently dramatic response consistently obtained to
both ACTH and Cortisone; the effect on early carditis may also be most
favorable, but this aspect is still under study and it will undoubtedly require
years for full assessment.
Acute gouty arthritis—Reported trials have been principally with ACTH and
dramatic effects are promptly attained with small dosages.
Status asthmaticus—Reported  trials mainly with ACTH,  dramatic relief often
being attained in severely ill patients within three to thirty-six hours.  Our own
experience in the use of Cortisone in one case was followed by marked relief
Up within forty-eight hours, apparently as a result of treatment.
Serum sickness—ACTH has principally been reported and apparently gives dramatic
relief in a few days.
Acute inflammatory disease of the eye—ACTH has been employed principally and
there have been some preliminary favorable reports. Our own experience in
several cases has been rather inconclusive as yet.
Diseases in which drugs may be useful {Thorn et al)'.
Rheumatoid arthritis.
Disseminated lupus erythematosus.
Periarteritis nodosa.
Acquired haemolytic jaundice.
Vasomotor rhinitis.
Multiple myeloma.
Nephrotic syndrome.
Ulcerative colitis.
Regional enteritis..
Pulmonary beryllosis.
Rheumatoid arthritis—Cortisone mainly employed; response is usually good when
the disease is acute or subacute or at least active, but of little value when
tissue destruction is advanced. Prolonged therapy is usually required, that is,
one to six months and one must be prepared to cope with relapses.
Psoriasis—Temporarily effective, but apparently relapse occurs quickly in most
Vasomotor rhinitis—ACTH mainly reported and appears to be effective when other
treatments failed,  the result often being dramatic.
Urticaria—A limited trial with ACTH is encouraging.
Malignant lymphomas and leukaemias—ACTH mainly reported; temporary remissions only in some instances with eventual relapse in nearly all reported cases;
complete failure to produce any significant effect in most other instances.
Nephrotic syndrome—A late diuretic effect may be induced by either hormone,
hut the course of the disease is apparently not altered.
Page 314 Ulcerative colitis  and regional  enteritis—ACTH  mainly reported,  and  marked
symptomatic improvement appears to have been attained in most cases.
Diseases in which drugs are of questionable value {Thorn etc al):
Multiple sclerosis.
Mental disease.
Myasthenia gravis.
Paget's disease.
Pernicious anaemia.
Liver disease.
Malignant exophthalmus.
In some of these conditions further assessment is needed, as at least temporary partial
effects may be induced; e.g., in schleroderma, pernicious anamia, glumerulonephritis.
Diseases in which drugs are of no value {Thorn et al):
Herpes simplex.
Herpes zoster and varicella. .
Progressive muscular dystrophy.
Progressive muscular atrophy.
Cystic fibrosis of pancreas.
Peptic ulcer.
Sarcoidosis—may need further evaluation.
Of the others, one can only emphasize the reported failures with herpes, poliomyelitis, progressive muscular atrophy and peptic ulcer.
Diseases in which drugs may be detrimental {Thorn et al):
Diabetes mellitus.
Cushing's syndrome.
Congestive heart failure.
This list includes a number of common clinical conditions which appear to be
contraindications to the use of the hormones except in some very selected instances.
II.    What are the dangers of using the material?
Grave fears about the hazards of therapy arose after the use of ACTH in a case
of lymphatic leukaemia in the Vancouver General Hospital which ended in acute
peritonitis, presumably caused by dissolution of lymphoid tissue in the gastro-intestinal
tract. Acute peritonitis in two cases under ACTH therapy was reported from Montreal
a little later. However, it has become apparent from growing experience here and
elsewhere that these episodes are very unusual and that deleterious side effects are much
less serious as a rule.  Common side effects which may be observed are as follows:
1. Disturbances in salt and water balance.
2. Obscuring of "normal" signs of disease.
3. Lowering of the serum potassium level.
4. Suppression of adreno-cortical and pituitary function with Cortisone and of
pituitary function alone with ACTH.
Page 315
—■a 5. Rounding of face.
6. Acne vulgaris.
7. Hirsutism.
8. Striae on the abdomen.
9. A tendency to hyperglycaemia and glycosuria.
These side effects do not occur in all cases in any really significant degree especially
when the hormones are used over a short period of time. However, because they may
present certain therapeutic hazards, particularly in certain predisposed individuals, and
when the hormones are used in a large dosage over an extended period of time, clinical
management must provide the same meticulous care used with any other potent drug,
such as insulin or dicumarol. However, if qualified practitioners are prepared to apply
them in this spirit, employing all the necessary clinical and laboratory supervision,
the above side effects or therapeutic hazards need not prevent the application of the
hormones in properly selected cases.
One other aspect should be given careful consideration. In many chronic or subacute
conditions such as rheumatoid arthritis, rheumatic fever, scleroderma, chronic asthma,
psoriasis, an initial improvement may be followed by a relapse which may be quite severe
and some cases may be less responsive to renewed therapy. This possibility should be
anticipated as for as possible, so that both the practitioner and the patient may be
prepared to cope with it by providing more hormone, time, inconvenience, and hospital
bed space. jpp||
III. What are the costs?
As with many other potent substaiices the cost of using these hormones must be
reckoned, not only in terms of cost of the material alone but also the cost of bed space,
of laboratory observations, nursing care, the amount of practitioner's time required, all
of which will vary to a considerable extent with the nature of the particular clinical
situation. The cost of the material itself is considerable, though in view of the vast
amount of preliminary work required by the manufacturers in developing efficient
methods of production, it is rather remarkable that the present costs are not substantially
higher. Cortisone is likely to cost about $67.00 per gram in Canada which would be
$6.70 for 100 mgs.; thus the daily cost of this drug as present would ordinarily lie
somewhere between $6.70 and $13.40. The cost of ACTH is approximately $140.00'
per gram but as the daily dosage usually lies between 40 and 100 mgs. the therapeutic
cost would be comparable to Cortisone as a rule. It is to be hoped that these costs
will be materially lower in the course of time as has been the cast with other important
drugs developed in recent years.
None of these costs, nor the total of them, should stand in the way of the necessary
employment of these hormones, though we must weigh these costs carefully together
with the possible therapeutic hazards in any given case, against the likelihood of
therapeutic benefit.
IV. What are the therapeutic techniques, dosages and which drug is to be selected
in any given case?
ACTH is supplied as a powdered extract of pituitary which must be kept refrigerated, and when required for use, it is made up in a saline solution, being used the same
day. Cortisone is supplied as a suspension of the material in saline, and refrigeration is
not advised as it is relatively thermostabile. As the effects of AQTH are transftory^-
owing to excretion and rapid utilization it must be given in divided dosage every six
hours, whereas Cortisone is more slowly absorbed, having an effect which lasts over
several days, so that any one dose has a certain depot effect; for this reason the required
dose may be given once a day intramuscularly. Cortisone is a single pure substance
and has effects upon the body that are highly specific. ACTH is also very nearly a pure
substance though it has a' relatively large protein-like molecule, and its exact nature
Page 316 and formula is still unknown; as stated above it acts by stimulating the adrenal cortex
which responds by an increased production and liberation of all its end products; only one
of these end products is Cortisone and there are probably 25 or 30 other active steroids
including the potent mineralo-corticoids (DCA like material) and Compound F which
apparently has an activity nearly 100 times that of Cortisone. It can be seen therefore
that ACTH may, and usually does, have an action potentially much greater than the
administration of pure Cortisone and in actual practice it appears that a dose of 200
mgs. of Cortisone is roughly comparable to 100 mgs. of ACTH. It must always be
remembered that as ACTH acts by stimulating the adrenal cortex its action depends
upon a responsive adrenal; it would obviously be futile to give it in situations in which
the adrenal cortex was destroyed or insufficient, such as is Addison's disease. Because
the ACTH stimulates the whole range of adrenal cortical steroids, including the so-called
mineralocorticoids (salt and water controlling factors) its use would ordinarily be
contraindicated in clinical situations in which retention of salt and water is a problem,
such as any form of congestive heart failure or other manifestation of oedema.
There is a wide range of total dosage and duration of therapy required in both
ACTH and Cortisone, e.g., from the relatively small total dose of 200-300 mgs. of
ACTH in the course of 2-3 days in acute gout or status asthmaticus to 17,000-18,000
mgs. of Cortisone in the course of 5-6 months for rheumatoid arthritis. A great deal
of individualization is required in the various disease entities and in the separate cases
within any one group. As a rule in adults the daily dose of Cortisone varies between
100-200 mgs. given in one dose intramuscularly while that of ACTH varies between 40
to 100 mgs. given in equal divided doses intramuscularly every 6 hours. In treating
any particular case one would have to be guided in dosage by the literature, and eventually
by one's own experience. The recent summary put out by Merck and Co. as a package
insert with their material "Cortone" (Cortisone acetate Merck) appears to be a useful
practical guide, based upon information presently available from various centres throughout the continent.
During therapy the laboratory provides certain dosage controls particularly in the
eosinophile response to ACTH as described below. One must be continually watchful
for clinical and laboratory evidence of unfavorable side effects as listed above and also,
of course, for indications of favorable clinical response. One should seize opportunities
to add to the general fund of information regarding effects of these hormones both
from a clinical as well as a laboratory standpoint.
In summary 0f these various clinical and practical considerations, one should
emphasize again that from a therapeutic standpoint we have now been provided with two
potent and costly agents each capable of certain limited therapeutic attainments, and
each attended with certain treatment hazards and disadvantages.
None of the hazards are sufficiently great to prevent the use of the hormones by
any qualified practitioner employing ordinary clinical care and judgment, provided that
he has at hand the facilities for the necessary laboratory controls as well. For a time at
least, until the profession as a whole has had the opportunity to become more familiar
with the use of these hormones, it would be wise to encourage consultation with specialists
who are informed and interested as far as practicable, as additional assurance that costly
material may be efficiently and safely applied. The need for consultation of this sort
will diminish as more general experience is obtained.
Controls Required During Therapy with ACTH and Cortisone
Soon after the early trials of Cortisone, Kendall reported "This stuff is dynamite",
and indeed the administration of both Cortisone and ACTH is potentially hazardous. It
is therefore necessary that treatment with these hormones be carefully controlled so that
early danger signals may be appreciated and therapy adjusted before further deleterious
effects are produced.   It is difficult to enumerate a definite series of tests as individual
Page 317 ft
■ m
patients vary considerably in their reactions but a knowledge of the more common
effects of Cortisone and ACTH suggest a pattern which can be followed to ensure the
immediate detection of dangerous "side-effects".
ACTH is predominantly a gluco-cortico-trophic hormone, that is, it stimulates
the production of Cortisone and Compound F by the adrenal cortex. Thus, whatever
is said of the effects of administration of Cortisone is also applicable to therapy with
ACTH except that, under certain conditions, ACTH will also stimulate the production
of mineralo-corticoids from the adrenal cortex. It is also important to appreciate that
Cortisone is more slowly absorbed and more slowly excreted than ACTH so that when
ACTH therapy is stopped, the effects of this hormone will be practically nil in 24 hours
whereas the effects of Cortisone will persist for a much longer period.
Cortisone is a glucocorticoid and, as its name implies, this steroid effects carbohydrate metabolism facilitating the conversion of non-sugars into sugars. Under the
stimulation of Cortisone gluco-neogenesis takes places especially at the expense of protein
and results in an elevation of the fasting blood sugar either with or without glycosuria,
depending on the effects of the hormone on the kidney tubules. Such changes are usually,
maximal in the first 24 to 48 hours of therapy and then gradually return towards normal
limits. During this period there is an increased deposit of glycogen in the liver and the
glucose tolerance is decreased so that a glucose tolerance test reveals a "diabetic-like"
curve. These changes are not serious hazards to life except in case of diabetes mellitus
when they are greatly emphasized. However, the rise in the fasting blood sugar may be
used to demonstrate that the adrenal cortex is capable of reacting to the stimulation of
exogenously administered ACTH.
The effects of these hormones on body protein metabolism and one certain of the
body tissues may be more serious. They produce an increased activity in the reticuloendothelial system, marked lysis of lymphatic tissue and inhibition of wound healing.
Dangers arising from these effects of the hormones may be completely masked clinically
by the marked euphoria which all patients under treatment demonstrate so that signs
and symptoms which are usually associated with specific catastrophes may be entirely
absent. For example, peritonitis may be present and yet the patient complains of no
pain or tenderness when the abdomen is examined. Some of these changes may be reflected
in the peripheral blood count as an eosinopenia, lymphopenia and polymorphonuclear
leucocytosis. Depression of the circulating eosinophils is dramatic and constant when
ACTH is administered in sufficient quantities to cause the endogenous production of
adrenb-cortical hormones, but it is not very marked when exogenous Cortisone is
administered. This is the basis of "Thorn's Test" for adreno-cortical reserve and it is
advisable to enumerate the circulating eosinophils daily when a patient is being treated
with ACTH in order to ensure that adrenal cortex is capable of responding and that the
hormone is not being wasted on someone who has functionally inactive adrenal cortices.
This procedure is not necessary when Cortisone is administered as the eosinophils response
to this hormone is variable. It is advisable in both instances to check the haemoglobin,
white cells and differential count at least once a week whilst the patient is under
The alterations in serum proteins are reflected in the erythrocyte sedimentation rate
which tends to decrease when Cortisone is administered. Mineralo-corticoids tend to have'
the opposite effect on the E.S.R. and in this respect they act as antagonists to Cortisone.
Other effects on body proteins are shown by an increased excretion of nitrogen which
may produce a negative nitrogen balance and effects on the metabolism of uric"ac£d so
that early in treatment there is a constant increase in excretion due to an increased
production and an elevated renal clearance for this substance. It is suggested that the
increased production is an intimate reflection of the lysis of lymphoid tissue aided by
a breakdown of brain cell nuclear protein which occurs in certain conditions. It is not
recommended that alterations in protein metabolism be followed except insofar as they
affect the E.S.R. which should be evaluated weekly.
Page 318 All gluco-corticoids so far examined possess some mineralo-corticoid activity and it
is through their action upon sodium, chloride, potassium and water metabolism that
their most dangerous side-effects are produced.   The pure mineralo-corticoids are much
more potent in this respect but these hormones possess no gluco-corticoid activity.  The
changes in mineral and water metabolism which are observed following the injection of
ACTH are due partly to this effect of gluco-corticoids and also to the increased production of mineralo-corticoids which ACTH evokes.   Under treatment with either ACTH
or Cortisone the extra-cellular sodium, chloride and water are increased.   The retention
of sodium may be profound. For instance, on an intake of 74 m. eq. per day, 64 m. eq.
were regained when only 40 mgs. of ACTH were administered daily.   Along with this
sodium retention there is a marked fall in intra-cellular potassium which is reflected
by low serum potassium levels.   Different patients behave differently in these respects,
the individual's  response  probably  depending   on  pre-existing  water   and  electrolyte
balance.   It is extremely important to note these "side-effects" of treatment and they
may be best followed by maintaining accurate intake and output charts, weighing the
patient daily at a specific time, preferably before breakfast and after voiding, and by
evaluating  plasma  chloride  and carbon dioxide levels  at  least  twice weekly.   These
latter simple chemical estimations may be used to assess serum sodium and potassium
levels.   For example, an increasing carbon-dioxide combining power associated with a
normal or decreased chloride content of the plasma would suggest potassium deficiency.
Hematocrit readings are not only valuable indications of haemodilution but they are
essential for the proper interpretation of plasma electrolyte levels. As potassium depletion
may of itself occasion important physiological effects it is advisable to estimate the
serum potassium level at least once per week during therapy and also to add extra
potassium to the diet.
Experimentally these hormones cause severe lesions in the kidney if large quantities
are administered over prolonged periods, so it is important to perform routine urinalyses
on all patients under treatment.
As the hormones themselves tend to cause lysis and dissolution of fibrous and
lymphatic tissue it may be unwise to administer them to patients with pulmonary granu-
lomata and so a preliminary chest X-ray is advisable. Simmilarly, a preliminary E.C.G.
is indicated to exclude severe myocardial insufficiency as it would be unwise to subject
any such patient to a form of treatment which is known to cause salt and water retention.
In summary it is suggested that the following examinations be performed as the
minimal for controlling therapy with ACTH or Cortisone.
During Treatment:
1. Chest X-Ray.
2. E.C.G.
1. Daily—
(a) Weight at a fixed time.
(b) Fluid Intake and Output Record.
(c) Physical Examination and B.P.
(d) True Eosinophile count (ACTH only).
2. Twice weekly—
(a) Plasma chloride.
(b) Plasma carbon dioxide combining power.
(c) Routine Urinalysis.
3. Weekly—
(a) Haemoglobin.
(b) Total White Cell Count.
(c) Sedimentation Rate.
(d) Serum Potassium.
(e) Haematocrit.
1. Hench et al.
The effects of a hormone of the Adrenal Cortex (17 hydroxy 11 dehydrocorticosterone:Compound
E) and of Pituitary Adrenocorticotropic Hormone on Rheumatoid Arthritis: Preliminary report.
Proc. Staff Meet. Mayo Clin. 24: 181: 1949.
2. Hench et al.
The effects of the Adrenal Cortical Hormone  (17 hydroxy 11 dehydrocorticosterone: Compound
E)  on the acute phase of Rheumatic fever: Preliminary report.
Proc. Staff Meet. Mayo Clin. 24: 277:  1949.
3. Sprague et al.
Observations on the metabolic effects of administration of ACTH and Cortisone to patients with
Rheumatoid Arthritis.
4. Thorn et al.
Medical Progress: The clinical usefulness of ACTH and Cortisone.
New England J.  of Med. 242:  865:   1950.
5. Mote, J. R.
Clinical ACTH.   Blakiston Press,  1950.
For a period of one year, commencing this Fall, the doctors of British Columbia
will receive free copies of an American publication, "The Cancer Bulletin". This service
is being paid for by Thie British Columbia Division, Canadian Cancer Society.
"The Cancer Bulletin," published bi-monthly by the Medical Arts Publishing
Foundation with the assistance of the Texas Cancer Co-ordinating Council and the
American National Cancer Institute, was started early in 1948. Originally, it went to
all the physicians in Texas, subscriptions paid for by the State Department of Health
and the American Cancer Society, Texas Division. Later, the National Cancer Institute
of the United States granted $19,600 to help the Cancer Bulletin reach every physician
in the country, and the circulation has risen from 8,000 to about 100,000. .
In addition, the physicians of Saskatchewan also receive copies, sponsored in this
instance by the Saskatchewan Division of the Canadian Cancer Society.
Dr. G. R. F. Elliot, of the Provincial Department of Health and Welfare, first put
the idea to the British Columbia Division of the Cancer Society whose Education and
Publicity Committee, pursuing its policy, whenever practicable opportunity presents
itself, of assisting the doctors in their fight against cancer, sought the advice of the
medical profession. The British Columbia Medical Association, and Dr. M. M. Weaver,
on behalf of the Faculty of Medicine at the University of British Columbia, endorsed
the project, and the Society allocated the necessary funds for the purpose.
"The Cancer Bulletin" is a forthright magazine with a progressive approach to the
problems of Cancer. It has an attractive appearance with modern letterpress and layout
and some excellent artwork, and it should make informative reading for our profession.
In a growing New Westminster area.   Suitable for two Doctors,
reasonable rent.   For further particulars phone New Westminster 225.
Page 320 Dr. J. B. Fenwick, of Vancouver, is now doing post-graduate work in London,
England, on a fellowship awarded by the Canadian Arthritis and Rheumatism Society.
Dr$. N. B. Hall and John Depew are to occupy a new medical clinic building at
Campbell River.
Dr. Raymond Duncan, of Duncan, has with him a new assistant, Dr. W. D.
Dr. Prouse, of Smithers, is filling in for patients in Hazelton in the absence of a
doctor in that district.
Dr. E. N. MacKay, Saanich Health Officer, has been transferred to Creston. Her
successor will be Dr. Adam Beattie, of Nanaimo.
Drs. White and Parmley, of Penticton, have been successful in getting conviction
of a herbalist for "practising medicine" unlawfully.
Dr. W. M. Gilmore, formerly of Ontario, has been appointed to the radiology staff
of the Royal Jubilee Hospital in Victoria.
Dr. W. H. Hatfield has been elected president of the Canadian Tuberculosis Society
and has embarked on a two-month trip to England and Denmark.
Dr. D. J. Oakley, of Vancouver, has become associated with Dr. R. C. Talmey, of
Lulu Island.
Dr. H. Pitts, son of Dr. H. H. Pitts, of St. Paul's Hospital, is now interning in
urology at the Vancouver General.
Dr. J. C. Sullivan, of Vancouver, is now studying at the Iowa Methodist Hospital
in Des Moines.
A member of our Association has been honored by an invitation from the Canadian
Medical Association to speak at their annual meetings. Dr. E. C. McCoy will address
the meetings in Saskatchewan and Alberta on the subject of General Practice.
That the following members of the profession were successful in passing the membership examinations of the Royal College of Obstetricians and Gynaecologists (M.R.C.
O.G.), which were held in Canada in May.
Dr. H. A. Henderson, Vancouver.
Dr. A. C. Gardner Frost, Vancouver.
Dr. Mellis Mair, Victoria.
Dr. W. Douglas Marshall, Victoria.
To Dr. and Mr(s. Ross McNeeley, of Victoria, a daughter.
To Dr. and Mrs. W. Tait, of Vancouver, a daughter.
To Dr. and Mrs. J. W. Warne, of Vancouver, a daughter.
To Dr. and Mrs. A. C. Walsh, of Vancouver, a son.
To Dr. and Mrs. Clifford Ames, of Vancouver, a son.
To Dr. and Mrs. Leslie R. Williams, a son.
To Dr. and Mrs. F. D. Mackenzie, of Vancouver, a son.
Page 321 a parasympathomimetic vasodilator EFFECTIVE BY MOUTH
vasomotor disturbances
painful   manifestations   of   the   extremities
migraine, meningeal headache, glaucoma
vascular diseases of the limbs
muscular cramps in pregnancy
tablets of 10 and 50 mg.
ampoules of 2 c.c. (5 mg.) used only
in emergency therapy
information and samples upon request
I:      LimiTCD
with mon
A special type of enteric coating
reduces the possibility of gastric
irritation, at the same time permits
disintegration of the tablet within,
the duodenum assuring maximum
Purified Selected Bone Meal  5 grains       Thiamine Chloride   0.75 milligram
Ferrous   Sulphate  U.S.P.   Crystal Riboflavin     0.75 miligram
5 grains
Vitamin   A    500 International Units       Ascorbic   Acid        25 milligrams
Vitamin   D    500 International Units |l'Iodine ..._ _. 0.05 milligram
CANADA V*LB  WT .2..-SM.* j
WMmsx* of oatmeal, malt-syrup. E '*****?
C^**^ prepared (or human use,sodium cH«**
^»"veast, and reduced iron. Pabena is »<***■■
M?*<f thiamine and supplies nrt***?-
>I«* °f thorough cooking and d»«g, «**£
*** <%*ted. It is paiatetre, convert^* t**1*
economical to use.
8*D John so v * C«-j
PABENA... precooked oatmeal
specified by physicians
PABENA* is oatmeal, and has the rich, full oatmeal
flavor. Its nutritional qualities and its vitamin and
mineral content are similar to those of Pablum.*
PABENA is valuable for infants and children who
are sensitive to wheat, and is an ideal first solid food.
PABENA, like all Mead's products, is advertised only to the medical profession.
*T. M. Beg. i ■ I
V Thiamine 5     mg.
V Riboflavin 1.0     mg.
V Niacin 5.0    mg.
V *Pyridoxine 5     mg.
V *d-Pantothenic Acid 2.5    mg.
V *Biotin 004 mg.
Also contains significant amounts of the lesser known
factors as found in rice bran extract.
*The significance of these vitamins in human nutrition is not yet established.
fcv.tarodTN4.MMk Cafergone
(E.C. 110)
Oral Migraine Therapy
CAFERGONE is the first highly effective oral preparation providing rapid and sure relief to the
migraine sufferer. Each tablet contains:
1 mg. ergotamine tartrate
100 mg. caffeine (Free Base).
. i . "Practically all of the patients in this series had previously
used ergotamine tartrate to abort or relieve headache and they
uniformly stated that E.C. 110 was more effective than ergota-
mine used alone1'' . . .
{Horton, Ryan & Reynolds, Proc. Staff Meet., Mayo Clin., 23:105,1948).
. . . "Although E.C. 110 (CAFERGONE) was developed
primarily for the relief of the migraine attack, it is uniformly
effective and has a much wider range of usefulness in the relief
of headache of all other types, especially typical and atypical
histaminic cephalgia" . . .
{Hansel, Ann. Allergy, 6: 155 — 16h 1949).
. . . "CAFERGONE . . . definitely seems to be an excellent
preparation to use to abort headaches, especially those of the
migraine and histaminic cephalgia types" . . .
{Ryan, Postgrad. Med., 5: 330, 1949).
Literature and samples available on request,
MONTREAL, P.Q. non-caloric
sweetener stays sweet
§:. . . even  in  cooking,
baking, canning
If ith SUCARYL Sodium, Abbott's new
non-caloric sweetening tablets, your
diabetic and reducing patients will
have immeasurably greater freedom
in menu-planning—for now even those
foods prepared by cooking, baking
or canning can be sweetened without
adding forbidden calories or
And whether used in cooking, or
simply added to hot or iced drinks,
SUCARYL has no b/ffer after-taste
when used in reasonable amounts.
Reports of clinical trials convey the
enthusiasm with which patients have
accepted SUCARYL. They not only
welcome its wide range of uses as
contrasted with saccharin, which loses
its sweetness in cooking processes, but
are virtually unanimous in their
preference for the taste of SUCARYL.
Each eighth-gram tablet of SUCARYL
Sodium is equivalent in sweetening
power to one teaspoonful of sugar.
Tablets are effervescent to shorten
dissolving time, grooved for easy
separation to suit individual tastes.
Supplied in bottles of 100 tablets,
at pharmacies only.
• Non-caloric sweetener for Diabetic and low-calorie diets
LIMITED   -   MONTREAL Naturally . j • the Product of Choke
"Not primarily because of the content of thiamine,
niacin and riboflavin but rather as a source of other
B Complex nutrients not yet synthesised"—Jolliffe,
Norman, J.A.M.A. 129:9, 613.
Each daily dose of three teaspoonfuls of Vibelan B.D.H.
represents proportionate amounts of all the factors normally
found in the following natural sources:—
and is standardised to contain:
Rice Bran.... 300Gms. Thiamine Natural... 1.80 mgm.
Fresh Liver... 15 Gms. Riboflavin Natural... 2.25 mgm.
Brewers' Yeast     3 Gms.    Nicotinamide Natural   15.0 mgm.
DOSE: One teaspoonful three times a day.
Issued in bottles of 4 and 16 fluid ounces
5-50B JfrcZZ- jfi»t QiuctC yZjUe/t&KCZ
* vv
The product with   J
the  PLUS  factors
Treatment   of   oestrogen   deficiency   symptoms   with   Questrin
Compound presents several advantages:
• The addition of vitamin B complex assures adequate concentration of B factors which are essential for the full capacity of
the liver to metabolize oestrogenic hormones.
• Questrin Compound contains natural oestrogenic hormones.
• Questrin Compound is orally active, readily absorbed and
rapidly effective.
&CT. No. 430 'Satf S.C.T. No. 429 "Sort
Coloured Pink Coloured Orange
Each tablet contains:
Questrin,    equivalent    to   the §p*$. Each tablet contains:
activity of Questrin,  equivalent  to the   activity  of
sodium oestrone sulphate  1.25 mg. sodium oestrone sulphate.... 0.625 mg.
plus plus
Brewer's yeast concentrate.... 100 mg.                  the same factors listed under
Thiamine HO  3 mg.                              S.C.T. No. 430
Riboflavin  2 mg.
Niacinamide  10 mg.                                         DOSE
Pyridoxine HCI  1 mg.                           1 to 3 tablets daily.
Calcium d-pantothenate  5 mg.
Ascorbic add  25 mg.                        MODES OF ISSUE
Vitamin D  500 LU.                 Bottles of 20 and 100 tablets.
*"QUESTR1N"—"SmmT brand of naturally occurring,
orally active, water soluble, oestrogenic conjugates
(equine),    standardized    colori metrically    and    by
^J^gj^z^ biological assay.
Charte* &§r*o*st&&>.
GttOO&t  ) \\
An Aqueous Preparation     W
OSTOCO DROPS contain vitamins A, D, B, and C
which aid growth and normal function of the body,
together with Iodine for prophylaxis against Iodine
Infants — 5 to  10 Ostoco Drops (0.25 to Each cc contains:
0.5 cc) from precision dropper added to Vitamin A   8,000 Int. units
one feeding bottle of the day's supply. Vitamin D   4,000 Int. units
when cool. Shake well and use this bottle Vitamin Bi        4 mg.
for the next feeding. Vitamin C......           .*   120 mg!
Children— 5 to 10 Ostoco Drops (0.25 to *Niadnamide      10 mg.
0.5 cc) daily, mixed thoroughly in a glass- Sodium iodide 0.02 mg.
ful of milk or cocoa. *Not dedared on label.
If desired Ostoco Drops may be administered directly into the mouth.
Bottles of 8, 15 and 30 cc with precision dropper.
ekvik* §.3ttxttt&&>.
pjfers& McKenna & Monism Limited
Bmf&giccft and Pharmaceutical Chemists
Montreal Canada: NOW...in Chemotherapy of tuberculosis
Calcium Chloride Complex
Acid Merck
(and the Sodium Salt)
Merck Antituberculosis Agents
Calcium Chloride Complex
Pa ra-A m in osa I i c y I i c
Acid Merck
(and the Sodium Salt)
D i h ydro *t rept e mycin ■
Merck Clinical experiences have demonstrated
that the administration of xanthines |RaS
double coronary^cfifculation and allow a
greater amountj^(^rl^fcMbe#erformed.
ROUGIER FRERES, 350 Le Moyne Street, MONTREAL (1) An average can of
gives babi/allthis/
PIUS! 75% of the phosphorus*
and 12% of the calories
baby requires every day.
Current Clinical
Meat Feeding
This study was established to investigate the
effects of including
Swift's Strained Meat
in the infants' diet for
periods of at least a year
in length. Numerous
observations have been
made and the results are
being tabulated to
obtain information on
the relationship of dietary meat to growth,
blood composition, incidence and severity of
infections, and general
well-being of infants.
This study is part of
an extensive clinical research program now being conducted through
grants-in-aid made by
Baby's limited capacity
demands that foods in his diet
be qualitatively and quantitatively high in essential nutrients. Meat is such a food. That's
why so many doctors recommend a daily serving of Swift's
Meats for Babies early in life.
Excellent Protein Source
All Swift's Meats for Babies
offer an excellent source of
complete, high-quality proteins and iron. These nutrients
are all required by infants in
optimum amounts every day.
Six Meats for Variety
To help establish nutritionally sound eating habits, Swift's
offer a complete variety — in
either Strained or Diced form
—beef, lamb, pork, veal, liver,
heart. All six, 100% meat, are
trimmed to reduce fat content
to a minimum. All are carefully cooked, ready to serve.
*3}4 ounces, approximately 700 gm.
per can. All approximate percentage
figures above based on Recommended
Dietary Allowances of National Research Council for an infant under
one year, except figurefor phosphorus,
which is based on TJ. S. Food and
Drug Minimum Daily Requirement
for a one-year-old baby. Note: Protein percentage applies for infant under
one year weighing 22 pounds. The
above figures will necessarily vary
according to natural variances in meat.
All nutritional statements
ntade in this advertisement are _
accepted by the Council on
Foods and Nutrition of the
American Medical Association.
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Six physicians' helpers, qualified — every one!
1 DRYCO . . . an easily digested,
vitamin fortified infant food, which
hastens recovery of birth weight, and
supplies optimum nutrition during the
early months of most rapid growth.
Because of its high protein, low fat and
moderate carbohydrate content, Dryco
enables you to prescribe a formula with
a wide range of adjustment for the
special as well as the normal feeding
2C.M.P. PROTEIN MILK ... a high-
protein, lowered fat and low
carbohydrate acidified milk. It has
been used with great success for infant
feeding in cases of diarrhoea in the bottle
fed infant, dyspepsia, malnutrition due
to gastro-intestinal disturbances, coeliac
disease, and as a feeding for the premature infant when breast milk is not
spray-dried pasteurized milk inoculated with a culture of lactic acid bacilli
and incubated to a definite acidity.
CMP. Lactic Acid Milk has all the
excellent qualities of the freshly prepared
product, and in addition is uniform
and stable. It is easily and quickly
reliquefied for instant use.
A MULL-SOY ... an emulsified soy
^* bean food used as a replacement for
milk in cases of milk allergy in infants,
children and adults. It is palatable,
well-tolerated and easy to digest.
Mull-Soy diluted with equal volume
of water contains all the essential
nutritional properties of average cow's
... a pure, fresh whole milk
evaporated to double concentration,
and homogenized for extra smoothness
and ease of digestion in infant feeding
formulas.   Vitamin D increased.
6KLIM . . . spray-dried, powdered
milk containing all the valuable
nutritive qualities of fresh whole milk.
A simple effective means of providing
extra milk solids without increasing
the total bulk of the diet.
The spray drying process results in
soft filocculent easily digested curd
particularly desirable in infant feeding
formulas. '
Formula Foods
Professional Literature on request. Mailed,
postage paid, to any physician in Canada.
Formula Foods Department
Spadina Crescent, Toronto 4, Ontario
FAir. 0080
NW.   60
When prescribing Ergoapiol
(Smith) for your gynecologic patienls,
you have the assurance that it can be obtained only
on a written prescription, since this is the only manner
in which this ethical preparation can be legally
dispensed by the pharmacist. The dispensing of this
uterine tonic, time-tested ERGOAPIOL (Smith) —only
on your prescription — serves the best interests
of physician and patient.
INDICATIONS: Amenorrhea, Dysmenorrhea, Menorrhagia,
Metrorrhagia, and to aid involution of the postpartum uterus.
GENERAL DOSAGE: One to two capsules, three to four
times daily—as indications warrant.
In ethical packages of 20 capsules each, bearing no directions.
Literature Available to Physicians Only.
Ethical protective mark,
M.H.S., risible only   -
when capsule is cut in
half at seam..
-ty of British Columbia Li1
DATE tv'f,
" Jf  


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