History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1939 Vancouver Medical Association Jan 31, 1939

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 o
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The BULLE\|p|
VANCOUVERTfl^'
MEDICAL ASSOCIATION
Vol. XV.
JANUARY, 1939
No. 4-
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
St Paul's Hospital
In This Issue:
CONGENITAL DISLOCATION OF THE HIP
TWO CASES OF CRETINISM
ROUND TABLE DISCUSSION ON PREMATURITY BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED    WITH   CASCARA    AND
BILE   SALTS PRODUCE   BULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER ^BRITISH COLUMBIA
(Or «t all Vancouver Drug Co. Stores) THE    VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices:
203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDebmot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XV.
JANUARY, 1939
OFFICERS  1938-1939
Dr. G. H. Clement
Past President
Dr. D. F. Busteed
Hon. Secretary
Dr. Lavell H. Leeson Dr. A. M. Agnew
President Vice-President
Dr. W. T. Lockhart
Hon. Treasurer
Additional Members of Executive: Dr. J. P. Bilodeau, Dr. J. W. Arbuckle.
Dr. F. Brodie
Dr. Neil McDougall
TRUSTEES:
Dr. J. A. Gillespie
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommer.
SECTIONS      I
Clinical Section
Dr. W. W. Simpson .^...Chairman     Dr. F. Turnbull Secretary
Eye, Ear, Nose and Throat
Dr. S. G. Elliott Chairman     Dr. W. M. Paton Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Davies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Rot Huggard Secretary
STANDING COMMITTEES
e
Library:
Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland,
Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davies.
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird.
Summer School:
Dr. A. B. Schinbein, Dr. A. Y. McNair, Dr. T. H. Lennie,
Dr. Frank Turnbull, Dr. W. W. Simpson, Dr. Karl Haig.
Credentials:
Dr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J. Buller.
V. O. N. Advisory Board:
Dr. I. Day, Dr. G, A. Lamont, Dr. Keith Burwell.
Metropolitan Health Board Advisory Committee:
Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller.
Greater Vancouver Health League Representatives:
Dr. W. W. Simpson, Dr. W. N. Paton.
Representative to B. C. Medical Association: Dr. G. H. Clement.
Sickness and Benevolent Fund: The President—The Trustees. Concerning the effect of glycocoll in
the asthenic though otherwise normal
adult, Wilder1 has stated that "patients and subjects who are simply
tired obtain relief" and they "seem to
be able to go farther and do more before fatigue sets in."
Glycolixir is a most palatable preparation of Glycocoll Squibb. By reason of
its glycocoll content it exerts definite
protein-sparing and detoxifying actions which, singly or together, effect
beneficial results in underweight, loss
of weight, anorexia, nervousness, and
easy fatigability as well as non-specific asthenia.
Glycolixir is absolutely distinct from
all other so-called "tonic" substances.
Its effect is strictly physiologic. It is
a "tonic" preparation, the action of
which may be proved and determined
biochemically. In no sense is it a
"-whip to a tired horse." Overdosage
is impossible, and there are no ki own
contra-indications.
i Wilder, R. M.: General Discussion:
Proc. Staff Meet, Mayo Clinic, 9:606 (Oct.
3), 1934.
SUPPLIED IN TWO HIGHLY PLALTABLE
DOSAGE FORMS:
ELIXIR—One tablespoonful presents 1.85 Gm. glycocoll in a specially blended base of fine wine. Average
adult dose: three tablespoonfuls daily.
TABLETS—The tablets present 1.0 Gm. glycocoll
each. They are pleasantly flavored and distinctively
colored. Also useful where the alcohol in the elixir
may be undesirable. Average adult dose: two tablets
t. i. d.
For literature address Professional Service
Department, 36 Caledonia Road, Toronto.
IR:Squibb &.Sons of Canada,Ltd.
MANUFACTURING   CHEMISTS   TO   THE    ME.DJCAL    PROFESSION   SINCE    1858 VANCOUVER HEALTH DEPARTMENT
STATISTICS—NOVEMBER, 1938.
Total Population—estimated _ ^  259,987
Japanese Population—estimated  8,685
Chinese Population—estimated  7,808
Hindu Population—estimated  335
Rate per 1,000
Number Population
Total deaths 1 r,    242 11.3
Japanese deaths        4 5.6
Chinese deaths        8 12.5
Deaths—residents only    212 9.9
BIRTH REGISTRATIONS:
Male, 172; Female, 168    340 15.9
INFANTILE MORTALITY: Nov., 1938 Nov., 1937
Deaths under one year of age      15 3
Death rate—per 1,000 births      44.1 8.4
Stillbirths (not included in above)        3 12
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
December 1st
October, 1938 November, 1938 to 15th, 1938
Cases  Deaths       Cases  Deaths       Cases  Deaths
Scarlet Fever  22 0 40 0 29 0
Diphtheria  .  0 0 0 0 0 0
Chicken Pox .  27 0 73 0 76 0
Measles   2 0 4 0 10
Rubella    3 0 5 0 5 0
Mumps  6 0 4 0 5 0
Whooping Cough  19 0 21 0 21 0
Typhoid Fever .  3 0 10 10
Undulant Fever  0 0 2 0 0 0
Poliomyelitis   0 0 0 0 0 0
Tuberculosis  20 15 41 9 23
Erysipelas     4 0 10 3 0
Ep. Cerebrospinal Meningitis  0 0 0 0 0 0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL.
West North      Vancr.    Hospitals,
Burnaby   Vancr.   Richmond  Vancr.      Clinic   Private Drs.   Totals
Syphilis       0 0 0 0 60 30 90
Gonorrhoea        0 0 3 1 82 28 114
BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
Descriptive Literature on Request.
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
STANLEY    N.   BAYNE
1432 MEDICAL-DENTAL BUILDING
"Ask the Doctor Who Is Using It"
Phone: SEYMOUR 4239 VANCOUVER, B. C. iiilill
liillllililllltesa
1      •
llllllillill
iiiiiililillil
I   "*^
■Hi
SHOR
OBESITY contributes to many diseases.
Overweight predisposes to such serious afflictions as diabetes, hypertension, arterio-sclerosis, heart disease, disorders of the kidneys and blood
vessels and lowered resistance.
Efficient reduction without drastic dieting or excessive exercise can be
accomplished with IODOBESIN, a potent combination of many glandular
substances.
IODOBESIN
For sustained pluriglandular reduction
MONTREAL, QUE.
Literature and samples from:
ANGLO-FRENCH DRUG CO.      - VANCOUVER MEDICAL ASSOCIATION
Founded 1898    ::    Incorporated 1906.
GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8 p.m.—Business as per Agenda.
9 p.m.—Papers of the evening.
Programme of the 41st Annual Session (Winter Session)
1939
January 3rd--GENERAL MEETING.
Dr. G. E. Kidd: "Points in Physical Anthropology."
January 17th—CLINICAL MEETING.
February 7th—GENERAL MEETING.
Dr. Murray McC. Baird: "Some Remarks about 'Rheumatism'.
February 21st—CLINICAL MEETING.
March 7th—OSLER LECTURE: Dr. J. H. MacDermot.
March 21st—CLINICAL MEETING.
April 4th—GENERAL MEETING.
Dr. H. A. DesBrisay: Subject to be announced later.
April 18th—CLINICAL MEETING.
April 25 th—ANNUAL MEETING.
MEMBERS of THE GUILD |
of PRESCRIPTION OPTICIANS of AMERICA
Always Maintain the
Ethical  Principles   of
the Medical "Profession
Guilder aft Opticians
430 Birks Bldgf.        Phone Sey. 90OO
Vanconver, Canada.
Page 89 EDITOR'S PAGE
To all its readers the Bulletin extends its most sincere wishes for a Merry Christmas
and Happy New Year. At the time of writing, Christmas is still in the future, and we are
uncomfortably conscious, with Charlie McCarthy, that there are only 6 x/z shopping days
left—by the time this reaches the aforesaid readers, Christmas will be a thing of the past—
yet not so remote but that the atmosphere of Christmas will be still a fragrance in the air,
and the echo of its happy voice will still linger. And a New Year will have been born, and
may it be a year of growth and happiness, and of peace. Surely soon this present madness
of men will find surcease, and reason and commonsense and the Golden Rule will again
govern men's thoughts and actions. It is a good world we live in, if we are only allowed
to live in it: and with all our hearts we wish to everyone a Happy and Prosperous New Year.
Through the courtesy of Dr. H. M. Cassidy, Director of Social Welfare, we received
a very interesting paper read before the National Conference on Social Work held at
Seattle in July, 1938.
The paper, read by Martha Chickering, Director of University of California Social
Service Curriculum, is entitled "What a Visitor in a Public Agency Should Know."
This apparently limitless question she delimits by explaining that she is referring to
agencies which are created to give mass public relief. She very wisely begins by laying
down as a primary consideration the necessity for every social worker to learn the legal
limitations of a public agency. The social worker sees need, urgent and clamorous—and
is apt to try and stretch the powers he or she has beyond the legal limits. This, while doing
credit to the heart of the worker, is wrong, useless and even dangerous—and does not
eventually do any good to the recipient of relief.
Next, the visitor must know bow to help people. For relief and help does not merely
imply material relief—food, clothing and so on; and here Miss Chickering does a real service
by reminding us that the beneficiary of relief is not an object of machine-like, efficient
and Prussianized charity. He is himself important: and his personality, his individuality,
his self-respect, his capacity for further usefulness as a self-reliant citizen must at all
costs be fostered and preserved, if our notions of a democracy as the ideal form of government have any merit at all.
"One of the first measuring rods ... is a measure of the agency's effect on the indi*
vidual human beings dependent upon it."
This involves understanding of psychology, sympathy, knowledge of behaviour problems, reverence for the personality of others, and above all "skill in dealing with people."
For this, of course, a certain inherent capacity is a primary essential. But training is
also an important desideratum. A public agency must use the personal material at its
command, and however good this is, it needs training, discipline and direction. Team-work
is a sine qua non.
Again, the visitor must, above all, be practically competent and •efficient. Accurate
and fluent command of language, both oral and written, ability to write clearly and concisely and accurately, and express oneself lucidly, are of the greatest value. Minor details,
such as ability to prepare budgets, to recognise medical problems, to understand and appreciate local and topical problems, can only be made available by training. In fact, we see
that the social worker must acquire the professional outlook on her work.
"The visitor is a person of enormous importance. Through her must flow all the best
the agency has to give, because she is frequently the only direct contact the agency has
with the needy citizen."
Adequate early education, including university training, recognition of the professional aspect of the work, opportunities for promotion, inter-organization training and
discipline, are all called for.  Only so can the visitor's work be adequately objective and
Page 90 creative—only so can we avoid allowing mass relief to become a merely degenerative process, defeatist and sclerosing; and only so can we take advantage of our misfortunes and
turn them to a positive gain—that "somehow good may be the final goal of ill."
Miss Chickering's paper is a timely one, and is well worthy of a careful study. It
illustrates how essential clear thinking and objective thinking are, and how only by the
use of these, and the acquirement of mental discipline and order, can we avoid waste of
energy and time and material, if not actual damage to the social structure. The trained
social worker of today is no longer the Mrs. Jellyby of the old days, voluble and nosey
and emotional, often a busybody and) a nuisance, governed chiefly by sentimentalism and
a vague yearning to do good, which, being interpreted, meant to mind someone else's
business. She is a professional—detached, impersonal, efficient and cool, yet fully motivated by a sincere consciousness of social need and her duty in connection therewith. She
deals with the problems of this objectively, yet always as an individual, personal problem.
The doctor in active practice at first resented her coming, if the truth be told, and at
first he had perhaps some ground for his objections. Some of the earlier workers did rather
tread on his toes and interfere with his work—often exceeding, as Miss Chickering warns
us is a possible danger, her legal and legitimate powers and duties, and allowing personal
bias and opinion to sway her. But today the administration which governs these workers
controls this, and the work of the visitor of the public agency, whether relief or school
nurse or what not, is one of the great and necessary factors for good in our social economy:
to the doctor she can be of untold help and service, and to the beneficiary of relief or
other form of social service activity she is "a guide, a counsellor and friend."
We tender herewith our congratulations to Dr. Lyle Telford, our newly elected Mayor
of Vancouver. Dr. Telford conducted his campaign for election in a model manner. He
studiously avoided personalities and scurrility—a thing that cannot be said of all the candidates in this contest; he made few promises, avoided sectionalism, anol spent less than
three hundred dollars on the whole affair. His election would seem to be far more than a
party matter; or if he owes his success to members of the C.C.F. alone, this party must
be far stronger and more numerous than even its fondest supporters have imagined.
An old writer advises the man who is in dire need of aid, from; illness and disease, to
do all he can to help himself by cleaning house personally, putting his affairs in order, and
so on. "Then give way to the physician," he goes on to say, "for1, there is a time when
in their hands is the very issue for good. . . . He that has sinned before his Maker, let
hini fall into the hands of the physician."
Evidently Vancouver in its need and rather dire straits has taken the advice of this
old sage. We wish Dr. Telford, its new medical attendant, all the luck in the world.
NEWS AND NOTES
The Bulletin would like at this time to call the attention of its readers, especially
those living in Vancouver, to the fact that Mrs. Agnew, the widow of the late Dr. F. V.
Agnew, who practised for some years at Smithers, B. C., is the proprietor and manager of
a book store and lending library, known as the Bridge Library, situated on Burrard Street,
formerly Cedar Street, between Eighth Ave. and Broadway. Mrs. Agnew is well equipped
to supply any book that any person may need, and her Lending Library is well stocked,
and contains the latest books in every line. She has not long started this venture, and the
Bulletin is very happy indeed to take this opportunity of bringing it to the attention of
medical men, who, we are sure, would be glad to take advantage of her services, with
mutual profit and satisfaction.
Dr. H. H. Macintosh is enjoying a well-earned vacation, and will be away for about
a month.
Page 91 Dr. Colin Graham has returned from a vacation spent in Southern California.
* *      *      *
Dr. E. J. Curtis is spending a month's vacation in the South.
Dr. R. J. Nodwell, who has been stationed at the Jericho Royal Air Force Station, has
recently been transferred to the Royal Canadian Naval Station at Esquimalt. After a
vacation spent in Eastern Canada he will join a destroyer.
* *      *      *
We have learned with regret that Dr. J. Mair Robertson is confined to St. Paul's Hospital and will not be able to spend Christmas at his home. We wish him a speedy recovery
in the New Year.
* *      *      *
Dr. D. B. Collison has recently opened offices in the Medical-Dental Building. He will
confine his practice to Obstetrics and Gynaecology. Dr. Collison, who is a native of Red
Deer, Alberta, graduated from McGill University in 193 3, and has since done one year's
post-graduate work at Montreal General Hospital and four years at the University of
Rochester, N. Y.
9fr 9{* ^r Sp
Dr. and Mrs. Leith Webster have returned from a trip to European countries. Dr.
Webster did post-graduate work in London and other centres.
We offer our congratulations to Dr. Douglas Telford on the occasion of his* marriage
on December 27th to Miss Shirley Schmidt. Dr. and Mrs. Douglas Telford will make their
home in Vancouver, where Dr. Telford is now practising.
At the regular monthly meeting of the Penticton Medical Society Dr. R. B. White
addressed the Penticton medical men, dealing with early practice in the Okanagan. Drs.
F. W. Andrew of Summerland and A. W. Vanderburgh of West Summerland were also
present.
*
*
Dr. Gordon C. Kenning of Victoria was elected president of the Pacific Northwest
Surgical Association ati its annual session in Spokane. Victoria was selected for the 1939
session. Dr. A. J. MacLachlan, Vancouver, was elected councillor..
Dr. R. A. Hunter of Victoria has recently been elected Fellow of the Royal' College
of Physicians of Canada.
Dr. L. Giovando of Nanaimo suffered an operation for acute appendicitis. We are
pleased to report a rapid recovery.
Dr. R. W. Garner of Port Alberni has had a week's hunting up the Canal.
*       *       *       *
Dr. and Mrs. Alan Hall and Dr. and Mrs. E. D. Emery of Nanaimo plan a New Year's
skiing trip on the Forbidden Plateau.
Dr. C. J. M. Willoughby, President of District No. 4 Medical Association, has just
returned from a month's post-graduate tour of New York, Toronto and Montreal hospitals.
af, ,       «L «L }b
Dr. W. Bramley-Moore, formerly of Blue River, has just returned from a post-graduate
and holiday tour as far south as Los Angeles, Calif.
Dr. Osborne Morris of Vernon and Dr. A. Llewellyn Jones of Revelstoke were in Vancouver for the C.P.R. dinner in honour of Mr. J. J. Home.
Page 92 Dr. C. J. M. Willoughby of Kamloops, Dr. C. T. Hilton of Port Alberni, Drs. W. A.
Fraser and P. A. C. Cousland of Victoria and Drs. W. A. Clarkel and F. R. G. Langston
of New Westminster were in Vancouver on December 14th to attend a special meeting of
the Board of Directors of the British Columbia Medical Association.
Dr. Frederick Reiss, Professor of Dermatology and Syphilology in the Union Medical
College of Shanghai, called at the offices of the Association, Vancouver, B. C, on December 9th.
Dr. Reiss, who is a well-known authority on such subjects as Leprosy, Tuberculosis
of the Skin, Lymphogranuloma inguinale, and a frequent writer in American and European
dermatological journals, is returning to China at the end of his biennial visit to Paris,
Buda Pest, London, and also American medical centres.
Dr. Reiss expressed himself as "pleasurably astonished at the size, accommodations and
reference facilities in the Library and Reading Room."
LIBRARY NOTES
RECENT ADDITIONS TO THE LIBRARY.
The Truth About Vivisection, by Sir Leonard Rogers; 1937.
A small volume which presents the case for the "Anti-Vivisectionists" and the
Medical Scientists.
Introduction to Dermatology, by R. L. Sutton and R. L. Sutton, Jr.; 1937.
In one volume.  This work is NOT a new edition of the "Diseases of the Skin," by
the same authors, but an entirely different work.
Meningiomas, by Harvey Cushing; 1938.
This book, donated to the Library by Dr. Frank Turnbull, is an inclusive work,
dealing with the classification, regional behaviour, life history and surgical end results
of meningiomas.  It is beautifully illustrated.
Therapeutic Problem in Bowel Obstruction, by O. H. Wangensteen; 1938.
"One of the best books of its kind. A comprehensive treatise with particular reference to the physiology and biochemistry as well as treatment."—R. H.
ITEMS FROM THE JOURNALS
Tick Paralysis, by G. Allen Mail and J. D. Gregson: C. M. A. Journal, December, 1938.
This article should be of particular interest to physicians in the interior of British
Columbia, as an analysis is given of all recorded cases in British Columbia. The authors
are connected with the Entomological Laboratory at Kamloops, B. C.
Thoracic Surgery, Symposium, from the Clinic of Dr. Evarts Graham: Medical Clinics
of North America, October, 1938.
NOTICE
The Librarian would be glad if those members whose papers are published in other
journals would supply name and date of the journal, as well as the title oi the paper, in
order that a record may be kept of publications of members.
During the past year the following articles have been published in the Canadian
Medical Association Journal by members of this Association:
Cleveland, D. E. H.—"Treatment of Acne."  C.M.A.J., May, 1938.
Galbraith, J. D.—"Case Report of Ruptured Achilles Tendon," C.M.A.J., December, 1938
Hall, E. R., and Hall, N. D.—"Vesicointestinal Fistula." C.M.A.J., April, 193 8.
Strong, G. F.—"Pick's Disease"; Report of case and discussion. C.M.A.J., September, 1938.
Trapp, E.—"European Trends in Irradiation Therapy."  C.M.A.J., July, 1938.
Wilson, Reginald—"British Post-Graduate Medicine."   C.M.A.J., December, 1938.
Page 93 liWh »!■' inri-irM-.gMSM
■ioai^Ma
COLLEGE OF PHYSICIANS AND  SURGEONS
OF BRITISH COLUMBIA     §
MESSAGE FROM THE PRESIDENT
The year 1938 has been a very active one in provincial medical organization.
The aim has been to maintain and improve the present high standard of
medical practice in British Columbia and to co-operate in any measures designed
to improve the health of the people.
Each representative on the Council appreciates fully the support given by
individual members of the College throughout the Province, in an endeavor to
achieve these objectives.
It is our hope that a continuance of this unanimity may enable your representatives for 1939 to face their problems with increasing courage and confidence.
May I extend to every member of the College my best wishes for the coming
year.
Gordon C. Kenning,
President of the Council.
VANCOUVER MEDICAL ASSOCIATION
The regular General Meeting of the Vancouver Medical Association will be held on
Tuesday, January 3rd, in the Auditorium of the Medical-Dental Building. The speaker
of the evening will be Dr. G. E. Kidd, whose subject is "Points in Physical Anthropology."
Just prior to Dr. Kidd's address, Dr. S. Stewart Murray will make a short address to the
members present.
FRANCIS XAVIER McPHILLIPS
OBIIT DECEMBER 23,1938.   AET. 7 3.
In the death of Dr. F. X. McPhillips, following a long illness, the medical
profession of Vancouver loses one of its oldest members, and the city itself has
lost one of its pioneers, a man who has for very many years been very closely
identified with one of its two major hospitals, and has had a distinguished
career both as a surgeon and citizen.
Dr. McPhillips first became a member of the staff of St. Paul's Hospital
in 1894—44 years ago. When the writer of this obituary came to Vancouver,
some thirty years ago, Dr. McPhillips was at the height of his active career
and was known throughout the city as an able and even brilliant surgeon,
while up and down the coast the logging and mining camps, in which hospital
tickets were sold in large numbers to the men, furnished him with ample exercise for his surgical skill. To medical men he was always cordial and friendly:
helpful to the younger ones, and always generous with counsel and aid. He
was one of a generation that had no professional snobbishness—all working
men together, doing whatever came to tfheir hand, and doing it, on the whole,
very well—hardly knowing what a specialist was used for, and caring less.
For many years, ill health has kept him from the practice of his profession,
but he liked to come round to the doctors' room as long as he was able, and
chat with old friends, of whom he had many.
Those of the older generation knew him and liked and respected him—
he had no enemies. His gentle, kindly friendliness was always welcome, and
in his departure we have lost a friend.
Page 94
BB CONGENITAL DISLOCATION OF THE HIP AND
TREATMENT OF THOSE WHICH ARE REDUCIBLE
Karl Haig, M.D.
(Read before the Vancouver Medical Association, December 6th, 193 8.)
Although congenital dislocation of the hip is not nearly as common on this continent
as it is in certain parts of Europe, it is met with sufficiently often to make iti a subject of
interest and importance. An increasing amount of attention has been paid to this deformity
for the past number of years, yet there is still no general agreement as to treatment. This
is due to the fact that treatment must necessarily vary with the age tof the patient and
the extent of the pathological changes found in the affected parts. In this paper the discussion of the treatment will be limited to those hips which are reducible by either the
closed or open methods, because management of the irreducible congenital dislocations
found in the older individuals isi a separate problem.
The Modifications of the Normal Anatomy of the Hip Joint Found in
Congenital Dislocations.
Acetabulum:. This is the cup-like cavity which receives the head of the femur, deepened by a cartilaginous ring, the labrum glenoid ale, which is firmly attached to the bony
rim and the transverse ligament that bridges the acetabular notch below. The source of
all the trouble lies in the acetabulum. In an early case, besides the slight displacement of
the head of the femur, the poor development of the upper margin of the acetabulum is
striking. This is considered the primary fault to which all the other changes are secondary,
arid must be kept in mind in the treatment.
This malformation involves not only the labrum glenoidale but the cartilage and even
the bone. The acetabulum gradually becomes triangular in outline, with the apex pointing
upward and backward, and the base toward the obturator foramen. This is because of the
continued growth of the upper and posterior boundaries of the acetabulum uncontrolled
by the pressure of the head of the femur. The growth of the posterior boundaries of the
acetabulum is excessive, owing to the unusual stresses and strains induced by the dislocation.
The cavity of the socket, which is lined by cartilage, may be partly filled with fatty and
fibrous tissue.
The Femur: The head of the femur is smaller than normal, although it is relatively
large compared with its acetabulum. The head gradually becomes flattened on the inner
and posterior aspects from the pressure against the ilium. Erosion of the cartilage may be
seen, especially after forceful manipulations; and often it is found to be loosely attached,
being easily removed by undue pressure against the acetabular margin during reduction.
In the early cases, the angle of inclination which is formed by the axis of the head and neck
with that of the shaft, is not sufficiently altered to be of clinical importance. Many
writers have attributed failure in the maintenance of reduction to thel increased angle of
antitorsion (the angle made by the axis of the head and neck with the transcondylar line),
but accurate estimation is very difficult and such wide variations in reports have occurred
that its importance has been questioned. Nevertheless, failure to consider this departure
from normal during treatment will result in occasional failures.
The Capsular Ligament: In a normal hip the capsular ligament encloses the joint and
a portion of the neck of the femur. Above and behind, the capsule is directly attached to
the bone, just wide of the labrum glenoidale, while below and in front it is attached to
the bone, labrum glenoidale and the transverse ligament. Distally the capsule is attached
in front to the intertrochanteric line and behind at the junction of the distal one-third and
proximal two-thirds of the neck. This capsule is strengthened in certain places by thickened bands of fibres which are named after the regions of the acetabulum, i.e., ilio-femoral
(Y ligament), pubo-capsular and ischio-capsular ligaments. In the dislocated hips the
capsule, which is carried upward with the head of the femur, blends with the periosteum
above and behind the acetabulum. It is greatly thickened, especially in front, where are
found the ilio-femoral fibres, and behind, where is found the ischio-capsular band, which
passes upwards to arch over the neck of the femur and blend with the anterior fibres. This
Page 95 ptfSAflMKMttfcWH
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forms a sling which aids in control of the upward displacement of the head, and tends to
direct the head and neck of the femur posteriorly in relation to the acetabulum. The
ischio-capsular fibres passing over the neck of the femur are always thickened to a greater
extent than that portion of the capsule over the head, emphasizing its importance in
stabilizing the upper end of the femur.
The constriction of the capsule between the true and false joints has been described
many times, and prevents reduction in a number of instances, especially in older patients.
It is rarely seen under the ages of 2 l/z to 3 years, as there is not sufficient upward displacement of the head. There is, however, an important fold of capsule running from the
posterior and inferior portion upward and anteriorly which is put on the stretch on weight
bearing and reappears when the tension is relieved. This is a fold of the synovial and fibrous
layers of the capsule which on attempted reduction piles up at the edge or enters the
acetabulum in front of the head. This is one of the reasons of recurrences in; apparently
satisfactory reductions and also explains the ease with which, in some hips at the time of
reduction, the head slips in and out of the acetabulum. The difficulty is lessened by lifting
the head into the acetabulum rather than levering it in. The ligamentum teres is present
in the younger children but may be absent or unimportant in the older ones, especially if
there has been previous manipulative treatment or an excessive amount of displacement.
Occasionally it is found to be abnormally large and interferes with a satisfactory reduction.
The Muscles: The adductor group is always shorter than normal, and may offer resistance to reduction except in the younger group. Stretching or rupturing may be necessary.
Rectus Femoris. The long head is shortened and aids in stabilizing the dislocated head.
It does not offer difficulty to reduction, as the tension is relieved by the flexing of the hip.
Ilio-Psoas. Instead of running downward and inclining backward from the interior of
the pelvis, it passes much more definitely backward and horizontally in close contact with
the capsule to its insertion on the lesser trochanter. When the femur is displaced upward,
this muscle and tendon takes a large amount of the strain and acts as a sling to support the
pelvis on the femur. This is demonstrated by the deep groove below the anterior inferior
spine found in adult specimens. This tendon may prevent reduction and tenotomy is
often necessary.
The Glutei. There is no important alteration in length of these muscles, as the greater
trochanter, to which they are attached, is displaced outward as well as upward. The
gluteus minimus is in close contact with the capsule and aids in support of the displaced
head.
The External Rotators. This group of muscles, namely, the obturators, gemelli and
quadratus, have an important function in helping to keep the head of the femur held
snugly into the acetabulum. In dislocations the direction of the fibres is changed from
a horizontal direction to horizontal and upwards, which also acts as an additional sling to
the pelvis. Following reduction they are slack, but they gradually regain their tone and
assume their normal function of maintaining the5 head in the acetabulum.
Suspension of the Pelvis on the Femur. From the anatomical study this mechanism
can now be understood. The work is divided between the capsule! and the muscles, the
bones playing very little part. In the capsule special thickened bands take most of the
strain, especially the ischio-capsular sling from behind. The important muscles are the
ilio-psoas in front, the obturators and gluteus minimus behind.
The Signs and Symptoms Useful in Making an Early Diagnosis.
In the past, this condition has been rarely recognized before the child began to walk
and the limp became noticeable. Radiological examination, which is necessary for accurate
diagnosis, cannot be carried out on all infants as a routine, but there are certain early
suggestive signs which should warrant this examination. Eighty-five per cent of dislocated
hips are found in females and unilateral cases outnumber the bilateral two to one.
1.   Congenital deformities are often multiple, so in the presence of such a defect, i.e.,
club-feet, cleft palate, etc., other such lesions should be searched for.
.2   In the presence of a congenital dislocation of the leg or legs are maintained in an
accentuated position of flexion on the abdomen for some time following birth.
Page 96 3. Upon examination a hollow can be felt, anteriorly, over the hip joint. In a unilateral case, comparison with the other side is useful.
4. If, when the side of the pelvis is fixed with one hand, the femur can be felt to move
upward and downward by alternate pressure upward and pull downward on the
leg with the other hand (telescopic movement), it is very suggestive of the
presence of a dislocation.
5. When a mother suggests the possibility of something being wrong with the legs
it is best to investigate, because they commonly notice the slight difference between
the two limbs.
6. The hip joint is abnormally mobile in all directions except abduction, which is
restricted.
7. Children with bilateral dislocation often learn to walk later than usual.
8. In unilateral cases shortening may be demonstrable with the greater trochanter
displaced above Nelaton's line.
After walking begins, the characteristic gait with the limp becomes noticeable.
The Trendelenburg sign is important, which is as follows: When a normal child stands
on one leg with the opposite thigh flexed on the abdomen, the side! of the pelvis with the
flexed thigh will rise to get the centre of gravity over the centre of support. If the hip
on which he stands is dislocated, the opposite side of the pelvis lowers, because there is no
firm point upon which to adjust the centre of gravity and the pelvis tips to impinge
against the shaft of the femur. The gait is a repetition of the above procedure at each step.
The Trendelenburg sign may be found in other conditions, such as: (1) Ankylosis of
the hip joint in adduction; (2) severe coxa vara preventing adduction (Perthes'); (3)
paralysis of the abdominal muscles, as found in poliomyelitis. These conditions can be
differentiated by a complete history, examination and x-ray.
There are two other conditions which cause a limp in young children and may confuse
the diagnosis:
1. The mild cerebral spastic in which only one lower limb is affected. In these cases
the history is that of a backward child, slow in development such as sitting up,
talking and walking. The muscles are spastic and reflexes are exaggerated. There
is no real shortening present.
2. Early T.B. of the hip. Pain is usually complained of in the knee and all motions of
the hip joint are restricted. X-ray examination is useful. There is no real shortening present.
Treatment.
The treatment of congenital dislocation of the hip has undergone changes in the past
with advocates for both the closed or open methods. In the more recent years it has been
shown that no one method is suitable for every case but that both methods have their
place. With a better knowledge of end results, the term "successful reduction" has had
to be revised, as a basis of evaluation of treatment depends on precise observations of
patients over a period of years.  Organized clinics have made this possible.
Putti, with his associates, has shown the tremendous advantage of treatment during
the early months of life. At the end of five years, more than' 80% have been cured by
closed manipulation, which proves the value of early diagnosis, but there are the remaining
20% for which some other type of treatment is necessary.
The first important problem is to differentiate as early as possible between the two
groups: (1) Those cases that closed reduction will cure, or (2) those in which closed
reduction will not effect a cure.
Closed or Bloodless Reduction. No definite age limit can be set for successful closed
reduction, as there are other important factors upon which success depends. However,
the possibility of satisfactory replacement is poor after the age of three or four years.
Before or shortly after walking begins, the upward displacement of the head of the
femur is slight, and it is during this time that this method of treatment is most satisfactory.
No preliminary traction is necessary and the manipulation should be carefully and gently
Page 97 done to prevent damage to the cartilaginous surfaces. The head is best lifted into the
acetabulum at its upper border to mitigate the chances of having a portion of the capsule
enter in front of it. If, at this time, the characteristic "snap" is associated with the entering
of the head into the socket, reduction is almost certain to be successful. On the other
hand, if the head slips easily in and can be easily re-dislocated, one of three conditions may
be present: (1) The capsule has been invaginated; (2) the acetabulum is inadequate,
either being relatively too small or insufficient development of the superior and posterior
portions; (3) the ligamentum teres is large and prevents the head from entering snugly.
Although it may be felt that successful reduction has not been accomplished, it is wise
to continue with the conservative treatment, with immobilization in plaster, beginning in
wide abduction and gradually decreasing the abduction at each change of cast. The j
immobilization is maintained for six months. X-ray examination should be made after
reduction and after each successive change of position. At the end of this time the cast is
removed and the child is allowed to be free in the crib for a few weeks. If re-dislocation
does not occur, walking is allowed, with x-ray examination every four or six weeks. At
the end of nine to ten months, all being well, the child may be discharged after definite
arrangements have been made for future interval examinations.
Open Reduction. An open reduction should be done if either partial or complete
re-dislocation occurs during the above treatment. At the operation it is not only necessary
to replace the head, but the condition which has prevented closed reduction must be corrected. When there is very little upward displacement of the head, reduction can be
accomplished without undue intra-articular tension, which must be avoided. The cast is
applied with the leg in abduction 20 to 30 degrees with some internal rotation and maintained for three months. The amount of internal rotation should vary with the degree
of antitorsion of the head and neck, otherwise re-dislocation may occur.
In older children up to the age of nine or ten years open reduction is almost routinely
necessary. The shortening must; be first corrected by gradual traction, the most efficient
being skeletal traction. This may take a few weeks or even months, and when the head
has arrived at the level of the acetabulum, traction should be maintained for a further
two to three weeks to allow the shortened structures to become accommodated to the new
position. At the operation it may be found that the head cannot be readily placed in the
socket.  The conditions which may prevent reduction are:
1. The adherence of the capsule to the ilium above the socket, which was described
by Kidner in 1931. This must be reflected downward and backward. The tendon
of the ilio-psoas may be found encroaching on the cavity from below, which may
need tenotomy.
2. Close adherence of the ischio-capsular portion of the capsule to the neck of the
femur, which prevents bringing the head forward to enter the socket. This may
have to be stripped away to mobilize the head.
3. Small, shallow acetabulum which needs deepening. It frequently contains fatty
and fibrous tissue, which is removed with scissors or scalpel, and if the ligamentum
teres is elongated and thickened it must be excised. Further deepening is usually
necessary, and it is better not to remove all the cartilage to expose the bone, thus
endangering the mobility of the joint, but to turn down a sufficiently large shelf.
The shelf is the outer table of the ilium turned downward and maintained by bone
wedges above it.
Immobilization in plaster is necessary for ten to twelve weeks, following which physiotherapy treatment aids in the return of function. Weight-bearing is then allowed ,and if
the head of the femur shows changes, such as erosion or flattening, a walking caliper is
used to relieve the pressure on the head. The Bradford abduction type is useful and is worn
for six to twelve months.
Summary.
A description of the pathological changes found in congenital dislocation of the hip
has been discussed, pointing out its important relationship with the treatment.
Emphasis has been placed on the necessity for early diagnosis and treatment, at which
time closed reduction gives the best results. In those cases where partial or complete recur-
Page98 rence follows closed reduction, open operation is necessary not only to reduce the hip but
to correct the pathological conditions found. Observation of each case for a period of years
is necessary before the end result can be evaluated.
A normal hip joint is often not obtained in the older age group, but two important
advantages are gained: (1) The shortening is eliminated; (2) in later life, if the hip
becomes painful, arthrodesis can be carried out.
Without treatment in early life, very little can be done for the painful congenital hip
in adult life.
The discussion which followed this paper was of great! interest. Among those taking
part were Drs. Meekison, Boucher and Naden, and certain points were stressed by these
speakers. The importance of early diagnosis, and the necessity for impressing on the
obstetrician and paediatrician the necessity for watchfulness, since most, if not all, of these
cases can be recognised early in life, but will often not be recognised, because the medical
man is not thinking of the possibility of the condition. The early manifestations are
rather obscure at times, and may easily be missed. But since the best results can only be
obtained by early diagnosis and treatment, it is incumbent on those who are in charge of
children to be on the constant lookout for the suggestive signs, and to confirm or exclude
the possibility of congenital dislocation by x-ray examination.
One speaker referred to the suggestion that had been made as to etiology: viz., that the
growing size of the human head makes a wider pelvis necessary in female children; this
predisposes to congenital dislocation by accentuating the angle of the femoral head with
the acetabulum. Since most cases are in females, this suggestion sounds plausible; but to
the unspecialised thinker it occurs that there is very little sexual differentiation at the time
of birth. Also, we remember having seen negro children with congenital dislocation, and
the pelvic girdle in the African race has not, we think, changed for these reasons at least.
—Ed.
British   Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. D. E. H. Cleveland, Vancouver.
First Vice-President Dr. F. M. Auld, Nelson.
Second Vice-President f Dr. E. Murray Blair, Vancouver.
Honorary Secretary-Treasurer Dr. A. H. Spohn, Vancouver.
Immediate Past President Dr. Gordon C. Kenning, Victoria.
Executive Secretary Dr. M. W". Thomas, Vancouver.
A MESSAGE FROM THE PRESIDENT
"Hands All Round"
1939 is the first year that begins with the provincial medical association bearing its
augmented title, British Columbia Medical Association (Canadian Medical Association,
British Columbia Division). By this title is implied no abridgement of its rightul position;
it has lost nothing of its autonomy. On the contrary, by amalgamation with and becoming
a division of the Dominion association, it has, paradoxically perhaps, become greater. It
has ceded nothing, but it has gained, and the Dominion body has gained. If "One for all
and all for one" was hitherto but a pious aspiration, it is now an accomplished reality.
Medicine in Canada is today faced with a formidable array of quicksands and mazy
jungles opposing its progress. Progress it must, that civilization may endure. It cannot
progress and function unless it moves as an intelligent and organized body. This applies
not only to provinces but to individuals. Organs which function are necessary to a living
body.  Organs are not composed of disparate particles of matter.
Our organs are our district societies and our standing and special committees. These
are strong and active organs.   Not a doctor in British Columbia but has profited in
Page 99 numerous ways by their activities. But not all who have thus profited have been members
of organized medicine.
The Canadian Medical Association is seeking to increase its membership. Appeal is
made not merely to a spirit of altruism. No one is being asked to "help a cause." Under
amalgamation the problems and difficulties facing the doctor in Saskatchewan, Ontario
and Nova Scotia can be helped by organized medicine in British Columbia, just as we here
in the Pacific region can and will profit by the work and weight of organized medicine in
the other provinces.
In wishing the members of the medical profession in British Columbia, a Happy and
Prosperous New Year it is in the firm belief that the realization of this wish is at our hands,
and will be accomplished by—taking hands.
D. E. H. Cleveland.
BUILDING MEMBERSHIP IN THE CANADIAN
I MEDICAL ASSOCIATION  f
When the British Columbia Medical Association in\ September last became the British
Columbia Medical Association (Canadian Medical Association, British Columbia Division),
we assumed the responsibility of furthering the interests of the national body in British
Columbia in a much more definite way than heretofore. We are now an integral part of
the Canadian Medical Association. IT IS OUR ASSOCIATION. HOW CAN WE
HELP?
First, by building up as large a membership in the Canadian Medical Association from
British Columbia as possible. To this end your Constitution and By-laws Committee has
been carefully selected with a view to having a local man int nearly every district in the
province assisting in the work.
The Council of the College of Physicians and Surgeons has gladly consented to collect
the annual fee for membership in the Canadian Medical Association, which for 1939 will
be $8.00 instead of $10.00 as formerly, and remit to the C. M. A. Notice of this will be
mailed with their usual letters around the first of the year. It is hoped that many new
members will be obtained in this way.
All members of our provincial society received copies of the Canadian Medical Association Journal in December, non-members of the C. M. A. receiving complimentary
copies through our own Division. I wish to draw attention to the article by Doctors
Leggett and Routley on page 589: "Why should I belong to the Canadian Medical Association?"  Space does not permit us to comment further.
Itl will be the aim of your Committee this year to build up this membership and we
thrust and hope that all members will take this matter under serious consideration. Certainly the need for a strong national association is becoming more apparent every day.
You can help materially by joining the Canadian Medical Association now, receiving the
Journal, which in itself is worth $8.00.
Copies of the new Constitution and By-laws of our provincial association are being
mailed tq every member. I shall have the privilege of including a letter which will deal
in a little more detail with this whole matter.
Harry Milburn, Chairman,
Committee on Constitution and By-laws.
Dr. and Mrs. H. H. McKenzie of Nelson are holidaying in Seattle and coast cities.
Dr. J. A. Murison of Powell River is away for two weeks during the holiday seasOn.
Dr. W. J. Elliot is assisting Dr. O. O. Lyons during Dr. Murison's absence.
Page 100
1U ■■■■■! CANCER IS ECTION
CANADIAN SOCIETY FOR THE CONTROL OF CANCER
On November 1st, immediately following the meeting of the Department of Cancer
Control, the first meeting of Grand Council of the Canadian Society for Control of Cancer
was held. This Grand Council is composed of two representatives from each province and
a central board of directors in Toronto. The two representatives from each province are
the chairman of the provincial branch and a lay councillor. Mr. Duncan Bell-Irving accompanied your chairman to this meeting, at which the attendance was 100 per cent. It
was a meeting largely to determine policy and many matters pertaining to organizaiton.
A very full agenda was submitted, on which much discussion arose. Of particular
interest to everyone was the report submitted by each of the provincial Grand Councillors. British Columbia gave a good account of its activities to date. As we are considerably further advanced in our organization, our report was considerably fuller than
those of the other provinces. Alberta, Saskatchewan and Manitoba gave a good account
of their work, while the eastern part of Canada has just started on the organization. But
now that a start has been made, the eastern provinces will greatly benefit by the round
table discussion of our common problems.
The aims and objects of the society were fully outlined in the report of the Board of
Directors and some of them discussed.
Publicity.
Publicity received a great deal of attention and free discussion. It divides itself into
two groups: (a) general from Headquarters to consist of a bulletin, phamphlets, and at
times, probably, radio broadcasts by selected speakers whose broadcasts will be previously
approved by the Board of Directors. In this connection, the bulletin will be published
as soon as possible, to be supplied to each member and to be used to disseminate cancer
knowledge for organization purposes. The sum of $5,000 was very generously given for
this purpose by Mr. J. K. Morrow, one of the Board of Directors. Pamphlets will be prepared and will be obtainable from the Secretary's office on request, (b) Local publicity,
censored by the Provincial Publicity Committee before release to the Press.
Membership Fees and Campaign.
It has been decided to continue with the One Dollar annual membership fee for the
present year at least, in accordance with our agreement with the Cancer Foundation of
British Columbia, so as not to interfere with their plans for the collection of larger sums
where possible to aid in the operation of their radium therapeutic and diagnostic unit
already established in Vancouver.
The matter of membership campaigns was left entirely to the provincial bodies as to
type and time. No national campaign, as such, will be inaugurated.
Membership cards will be issued by the General Secretary, Dr. Ross, on receipt by
him of the stubs and the 2 5 cents for each member. Membership will be for the calendar
year and at the discretion of the provincial committee, membership this year during the
organization period will be renewable in 1940. The renewal notices will be sent out from
Headquarters to the provincial branches for mailing and the local units will be responsible for these renewals by personal contact with the members, where possible.
Medical Speakers.
A formal request to the Canadian Medical Association for medical speakers was sent
forward. While it has already been definitely part of the policy and activity of the Canadian Medical Association to supply medical speakers, it was courtesy on the part of this
society to so request them to do this. This doubly assures the Canadian Society for Control
of Cancer of the co-operation and support of the Canadian Medical Association and at
the same time strengthens the provincial committee's hand in their request for speakers.
Page 101 The formation of a Speakers' Bureau in British Columbia assures the society that only those
duly qualified and approved by the Canadian Medical Association, British Columbia
Division Speakers Committee, are available on request to give addresses to lay audiences
on cancer.
Library At National Headquarters.
There will be established, as time goes on, a Library for books, literature and educational films. We have already requested the use of suitable films for organization and
educational work. When these will be available largely depends on what funds are available for that purpose, over and above organization expenses.
Emblem.
The selection of an emblem for the Canadian Society for Control of Cancer was left
to the Board of Directors.
The problem of enlisting the aid of national bodies, such as service clubs, etc., will
be taken up by the Board of Directors through the headquarters of these national bodies,
thus enlisting their support from a national point of view.
Organization .
The programme of cancer control is definitely set out, both as far as the medical profession and the laity are concerned. It is our task to assist in carrying this out. Help to
organize your hospital study groups and your local unit. In supporting these two you are
greatly helping your profession and your community. The Canadian Medical Association,
Department of Cancer Control, through your provincial committee chairman, Dr. Roy
Huggard, earnestly solicits your co-operation. The Canadian Society for the Control of
Cancer thanks you for your support in the past and solicits your continued effort so that
we may maintain our high place in the development of our provincial branch.
CANCER
With reference to the reports of the meeting of the Canadian Society for the Control
of Cancer and the Department of Cancer Control of the Canadian Medical Association
contributed by Dr. A. Y. McNair, it is interesting to note that an account of both of these
meetings appears in the December number of the Canadian Medical Association Journal,
giving a rather fuller account than was possible in Dr. McNair's account.
At the request of the Directors of the British Columbia Cancer Institute, a Committee
of the Directorate of theB. C. Medical Association met them and held a conference. The
upshot of this was briefly as follows:
The B. C. Medical Association agreed to furnish a list of names to the Board of Management of the Institute, from which would be chosen an Active Attending Staff. This
list will comprise names of physicians practising in Vancouver, and the members of it
will treat only patients within the actual institute, if and when this body has arrangements
for treating intramurally those who need treatment. Otherwise, no interference with
existing systems will occur. Patients referred to their1 own physician or to the Hospital
Staffs will be looked after by one or other of these. Presumably diagnosis will be a function
of the Attending Staff of thd Institute.
The B. C. Cancer Institute, in turn, binds itself to select its Attending Staff from this
list exclusively.
A Consulting Staff will similarly be appointed, and selected from a list furnished by
the B. C. Medical Association. This Staff wilt; have representatives from every district of
the Province at large.
A representative will also be appointed to the Board of Management of the Cancer
Institute by the B. C. Medical Association.
Page 102 It is noteworthy that in choosing these staffs, the Directors of the B. C. M. A. have
taken great care to see that every interest is fully represented. Both the big hospitals will,
it is hoped, have the fullest representation, and it must be clearly understood that the
B. C. Cancer Institute is a separate organization, and its plans are to remain so, and to
grow as an integral unit of a wider scheme, which willj be provincial in scope. The Directors of the institution have assured us that this is their intention. Questions of medical
policy will be decided by the medical staffs in conjunction with the present medical directors of the institute. Every precaution will be taken by all those concerned to ensure that
certain conditions are fulfilled. Among these are to ensure that adequate treatment and
diagnosis are available to everyone who needs them, regardless of financial circumstances.
• Again, in the case of those who are able to pay for these things, no unfair competition with
practising physicians, or those who are especially fitted to deal with radiology, etc., will
be allowed, and every precaution will be taken to prevent this.
The British Columbia Medical Association was asked by the management of the Institute for its co-operation and help in the proper organization, staffing, etc., of this new
institution, and has agreed to provide such aid. In this way, the profession of medicine in
British Columbia will be able to do its share in the fabrication of this new weapon of
warfare against cancer, and will at the same time be able to exercise its duties of control
of diagnosis, prevention and treatment.
THE EDUCATIONAL ADVANTAGES OF THE
TUMOUR CLINIC
By George M. Dorrance, M.D.
Philadelphia, Pennsylvania.
Reprinted from The American Journal of Roentgenology and Radium Therapy, Vol. 3 8, No. 4, Oct., 1937.
No single factor in the treatment of tumours has contributed as much in a scientific
way to both patients and doctors as the properly conducted tumour clinic.
It is unreasonable to expect any physician to be as familiar with surgical and medical
specialties, the specialized diagnostic and therapeutic treatments, or roentgen rays, radium,
etc., as specialists devoting their entire time to their specialty.
Likewise, it is inevitable that specialization contracts a man's vision often to a point
where his particular part or organ alone comes into focus, and he develops medical astigmatism and gets a distorted view of any disease.
Doctors being human are prone to overemphasize the importance of the particular type
of treatment with which they are most familiar. Witness the absurd claims made by
surgeons doing radical surgery alone, roentgenologists, radiologists, and others, in the
treatment of various malignant conditions, not only in the past but even at the present
time.
At the American Oncologic Hospital in Philadelphia, a hospital devoted exclusively
to the treatment of tumours, we have a staff composed not only of leading representatives
of each specialty but a number of older and experienced general practitioners.
This clinical conference conducted by senior members of each department meets once
a week. To these meetings are invitedi any physicians interested in tumours or in having
a study made of their patients. In this way, we give the general men a post-graduate way
of keeping up. The resident interne presents the history and the report of the physical
and laboratory examinations in a chart given to each person attending the clinic. Each
man present is invited to examine the case and express an opinion, and his remarks are
recorded.
At these meetings our average roll call reveals two; or three roentgenologists, radiologists, three pathologists, two or more surgeons, one plastic surgeon, two oral surgeons, one
genito-urinary surgeon, one gynaecologist, one or two dermatologists, one or two internists
Page 103 and one or two dentists, besides the full-time staff. The patient coming before such a
group is assured of obtaining a worthwhile opinion on diagnosis and treatment.
This group consultation, m the beginning at least, does more for the doctors than for
the patients. It is a revelation to see how the narrowed viewpoint of the specialist becomes
increasingly broader as he reviews the work of his colleagues. In a comparatively short
time we find the ophthalmologist or otolaryngologist patiently waiting1 for a review of
the general health of the patient, the report of his blood chemistry, the results of his prostatic examination and so forth before venturing an opinion of the local lesion present.
This is true in each department, and after a year or more of these clinics, while arguments continue to be as prolific as ever, there) is engendered a feeling that the individual
as a whole must be carefully studied, regardless of the local manifestations of the disease
presenting itself for treatment.
The surgeon is at first as amazed at the suggestions offered and the results obtained by
the roentgenologist as the latter is by thd former's statements. Each learns quickly the
limitations of their own specialty and readily adopts the combined methods, with infinitely
better results.
The pathologists see, often for the first time, living pathology—see the biopsy done;
study the fresh tissue; and report the findings to the clinic. They see the tumour removed
and have an opportunity of rechecking their findings. They follow the case in the clinic
often over a period of years. Their viewpoint^ are certain to be influenced by their intimate contact with the patient, and unquestionably their ability to prognosticate the
activity of the cells present is enhanced by this experience. Perhaps pathology as a whole
has been modified more than any other specialty by these group meetings.
We insist on free discussion of all cases after the patient has left the room. A careful
record is kept of each man's opinion and his prognosis. Six months or a year' later, when
the patient has returned during the course of the follow-up, these opinions are available,
and in many cases their authors are loath to claim them. It sooner or later gives onei a
much better ability to make a prognosis.
It is the younger man, however, who receives a real education by attending these clinics.
It has been gratifying to note how quickly he loses his cocksureness and what his professor
has told him, and how rapidly he progresses in his ability to weigh the various possibilities
present before venturing a diagnosis or an outline of treatment.
In a single year a man will see more varieties of tumour cases studied from all angles
than most of us have had the privilege of seeing in a lifetime.
I am convinced that our group study has done more to systematize the study and
treatment of tumours, and to give all of us a broader viewpoint of the subject in the past
five years than any one of us working alone could have hoped to accomplish in twenty years.
THE LAST FEE
The late Dr. B , of Bristol, who died very rich, coming into the bedroom of a
patient a very few minutes after he had expired, perceived something glittering through
the clenched fingers of one hand; he gently opened them, took out the guinea, and put
it into his pocket, observing, "This was certainly intended for me."
Dr. Edward Stephen Hoare and Miss Ruth Crump, a graduate of Royal Alxeander
Hospital, were quietly married in Nelson on December 2nd. We wish them every happiness. They will reside in Trail.
Dr. and Mrs. G. S. Gordon left on the R.M.S. Niagara for the Antipodes, where they
will spend several months.
Dr. R. N. Dick of Chemainus called at the office when in Vancouver last week.
Dr. K. Wray-Johnston was married on November 5th.   After a honeymoon in the
South he is now back at Pender Harbour.
Page 104 Preventive
THE TREATMENT OF EARLY SYPHILIS
(Part I.)
Donald H. Williams
Early syphilis includes all acquired syphilitic infections less than four years in duration.
It is divided into the following types:
1. Primary syphilis or chancre, which may be genital or extragenital in site, and seronegative or seropositive depending on the results of the serodiagnostic test.
2. Secondary syphilis, all infections exhibiting clinical evidence of disease. It may
involve any organ or tissue in the body, but its main manifestations are: (a) Skin
and mucous membrane; (b) nervous system; (c) visceral—liver particularly;
(d) ocular; (e) bone.
3. Latent (early type) includes all other syphilitic infections than those above of
less than four years in duration. This diagnosis is^ based on exclusion and is made
when the history suggests the infection is less than four years in duration, and
thorough physical and laboratory examination reveals no other evidence of syphilis
than a positive blood Kahn.
How to Determine the Duration of a Syphilitic Infection.
Where there is a definite history of primary or secondary syphilis no difficulty is presented. Many persons, however, do not. have primary or secondary manifestations and in
others, if they do occur they are evanescent and not observed by the patient. In these individuals it is more difficult to determine whether; their infection is more or less than four
years in duration.  The following generalisations may be of assistance:
1. Since many women acquire their infections maritally it can be assumed that they
are infected within the first year after marriage, unless there is evidence to the contrary.
The date of marriage, therefore, in many instances will serve as a guide to the date of
infection in a woman.
2. A history of gonorrhoea in a man or woman suggests promiscuity and it may be
assumed that the syphilitic infection may have been acquired about the same period as the
gonorrhceal one.
3. The majority of syphilitic infections in men are acquired before thirty years of age.
If there is no evidence to the contrary it may be assumed that syphilis in a man under thirty
years is of less than four years in duration and therefore of early type.
The above generalisations are by no means always correct, but where there are no other
guiding facts they will apply to the majority of cases.
It is important to determine whether the syphilitic infection is less or more than four
years in duration because:
1. A routine treatment is applied to all types of early syphilis (less than four years in
duration).
2. Individual treatment must be applied to all types of late syphilis (more than four
years in duration). njifanmiarr im
Vi
ctoria  Medical   Society
Officers, 1938-39.
President Dr. P. A. C. Cousland
Vice-President Dr. W. Allan Fraser
Hon. Secretary Dr. W. H. Moore
Hon. Treasurer Dr. C. A. Watson
The Provincial Royal Jubilee Hospital
Victoria, B. C.
CLINICAL PATHOLOGICAL CONFERENCE
A clinical Pathological Conference was held at the Royal Jubilee Hospital on Friday,
October 21st, 1938, at 12 noon, under the chairmanship of Dr. G. A. McCurdy. Three
very interesting and unusual cases were presented.
FIRST: Dr. H. M. Robertson presented case No. 4102 (E.J.T.) aged 72 years.
Complaints:
Diarrhoea previous to admission—one day five bowel movements.
Nervous, upset, past two or three days.
Nerve pains in legs off and on for a numbre of years.
Present Illness:
Admitted to hospital after having pain in abdomen all night unrelieved by sedatives.
Past History:
Patient stated that he apparently was in good health until 1922. From 1922 until the present time he
has had sixteen admissions to hospital. Complaints on various admissions have been—sciatica, pleurisy,
rhfeumatsim, stomach trouble, prostatic gland trouble, weakness, stomach disorder, artery and nerve pains,
general breakdown, haemorrhoids, diarrhoea, influenza and various/ other vague aches and pains. During all
these years, when complaining of pains in various parts of abdomen, the x-ray (examinations have been'
negative for any organic lesion. The vague abdominal pains have been attributed to arterio sclerosis of the
abdominal vessels. Diagnosis—In the past has always been arterio sclerosis, until Sept. 21st, 1938, when he
commenced complaining of the above symptoms.
Personal History:
Has lived in Victoria for several years and in the past has been a rancher at Sooke and has always lived
out of doors.
Present Condition:
White male of 72 years. Very pale. Sitting up in bed. Looks very ill. Very weak and rapid pulse. Complaining of considerable pain just behind the sternum. Looks like a case of coronary thrombosis but no pain
radiating to neck or arm and pain in chest and in abdomen- Cardiac examination—Practically no air entry
into left chest, suggesting complete collapse of the lung on that side. Chest normal contour, expansion most
marked on right. Increased resonance to percussion entire left chest. Right chest apparently normal. Vocal
fremitus markedly increased on right. No transmission of vocal friemitus on left. Posterior chest—Right side
■expansion adequate. Outline of heart not percussible. Heart tones not distinguishable in any position. Abdomen—Flaccid musculature, suggestion of muscle guard in epigastrium, no abnormal masses palpable, no
distinct tenderness.   Hernial rings firm.   Genitals—No pathological findings.   Extremities—Negative.
Provisional Diagnosis—Coronary thrombosis; collapse of lung, L.; acute pancreatitis;
acute pleurisy; acute cardiac thrombosis.
As far as abdominal rigidity was concerned, it differed from that of acute perforation,
in which one would get more board-like rigidity. In this case occasionally one would feel
relaxation of the abdominal muscles and the rigidity would let go.
Progress^—23-9-38—a.m., patient complained of nausea and severe pain in lower chest,
most marked on the left. Some pain under sternum. 23-9-38—p.m., patient semi-stupor-
ous. Skin cold and very moist. Considerable pain in chest and epigastrium, most marked
on left. Pulse rate very rapid. Respirations markedly increased.  Sudden collapse. Expired.
Page 106 Dr. McCurdy exhibited slides and diagrams of the chest condition found at P.M.:
(1) Perforation of oesophagus with ulceration into the pleural cavity.
(2) Acute oesophagitis.
(3) Acute pleuritis.
(4) Acute bronchitis.
Differential Diagnosis was discussed by Dr. McCurdy:
(1)  Acute oesophagitis
(2 )   Carcinoma.
(3) Syphilis.
(4) Tuberculosis.
The etiology was not decided upon.
SECOND: Dr. Thos. Millar presented case No. 2575 (Mrs. C. M.) aged 68 years.
Point of interest—Patient surviving several months massive embolism of right lung.
Complaints:
Sudden difficulty in breathing, severe.   Inability to stand on feet.
Past History:
Five years ago stated that she had some kind of nervous breakdown. B.P. was high. Has had five children. No miscarriages. Some years ago (2) was several wfceks in hospital with pneumonia. B.P. has varied
from 175/80 to 145/70 under treatment. About a year ago attempted to commit suicide. Was very depressed. Tried to poison herself. Was then treated in hospital to reduce heart action. Digitalis did not seem
to help very much at first.  Was then sent to the Old Ladies' Home.   Had previously lived in the country.
Present Illness:
June 11 th developed dyspnoea, cyanosis, cardiac pain, nausea and vomiting. Condition not improving,
she was brought into hospital June 13 th.
Present Condition:
Very cyanosed. Difficult in standing. Difficult breathing. B.P. 160/70. Lips and finger-nails cyanosed.
Extremities blue and clammy. B.S. broncho-vesicular, rales at both bases. Heart enlarged to the left, sounds
faint and irregular. Pulse irregular and weak. Liver edge palpable. Spleen not palpable. No free fluid.
Extremities very cyanosed and cold. No evident oedema. Patient rational and apprehensive. N.P.N. 7Jmg.
R.B.C. 6,030,000, Hgb. 117%.   Color index .97.
Clinical Diagnosis—Myocardial degeneration.
P.M. revealed marked thrombosis r. pulmonary artery.
Dr. T. Miller: "After P.M. would phlebitis be part and parcel of the whole condition
that was tending on to thrombosis?"
Dr. McCurdy presented diagrams of the condition found at the P.M. in pulmonary
artery.
Pathological Diagnosis—
(1) Embolism 1. pulmonary artery.
(2) Organized thrombosis r. pulmonary artery.
(3) Infarction of kidneys and spleen.
(4) Chr. vascular nephritis.
(5) Gangrene both feet.
(6) Arterio sclerosis.
(7) Hyp. of fibrosis of heart.
Interesting point—Healed right pulmonary artery thrombosis. Death due to massive
embolism in left pulmonary artery.
Dr. McCurdy: "Strange that patient lived after thrombosis of right pulmonary artery."
Slides were exhibited by Dr. McCurdy of the pulmonary artery.
Page 107 -,-«aMSEa»g,ii<a irr«.»nir in
"i¥«r i ITTdi'W .. .fflrrSsE
THIRD: Dr. R. C. Newby presented case No. 2669  (A.J.)  aged 63 years.
Complaints:
Vomiting "gallons" after meals.
Loss of weight.  Loss of strength and marked weakness.
Past History:
In hospital for two months in 1937 with diagnosis of cystitis and hypertrophy of prostate. In hospital
March, 1938, for cystitis and diagnosis of pernicious anaemia. In hospital two weeks in May, 1938; diagnosis
—pernicious anaemia and cystitis.
Present Illness:
Since leaving hospital, one month ago, patient has been much the same, but for the past three weeks
states that he vomits "gallons" after every meal and has btjen losing weight and strength. His burning and
pain with frequent micturition have persisted.
Present Condition:
General physical examination essentially negative apart from sausage-shaped mass felt in epigastrium.
Diagnosis——Small bowel obstruction was made in spite of the x-ray examination being negative. Patient at
all times refused operation and died 4-7-3 8.
Dr. W. E. M. Mitchell, as consultant in the case: "Small bowel obstruction although
x-ray examination negative."
Dr. Murphy exhibited films and explained the negative findings, of the case, and
compared them with the positive findings of another case, also showing the films. The
second case was one of carcinoma of the jejunum, correct diagnosis being made by x-ray
with operation following and favorable results. Operation in 1932. Patient still alive and
well today. Specimen of growth removed was exhibited.
Dr. McCurdy exhibited diagrams of condition found at the P.M. of stomach, jejunal
flexure and intussusception of jejunum beginning at the ligament of Trites, also showed a
rather beautiful colored photograph of the specimen m situ.
Pathological Diagnosis—
(1) Carcinoma of jejunum.
(2) Intussusception of jejunum.
(3 )  Dilation of stomach*
(4)  Paralysis of ileus.
(5 ) Early broncho pneumonia.
(6) Chr. pericarditis.
(7) Chr. vascular nephritis.
(8) Cystitis.
Dr. Millar asked: "Had it been possible to get patient to x-ray would diagnosis have
been made easier?" (Second case presented.)
Dr. Murphy answered that he did not think so.
Dr. Murphy then exhibited films of diverticulum, showing possible basis of the etiology
of the perforation.
Dr. McCurdy thanked Drs. H. M. Robertson, T. Miller and R. C. Newby for presenting their cases and also Dr. Murphy for his demonstrations.
The meeting then adjourned.
Page 108 Vancouver  General   Hospita
CASE REPORTS
I.—DISSECTING ANEURYSM OF THE AORTA
Dr. D. M. McLaren.
Male. White. Age 5 5.
Entrance Complaints: (1) Pain in the region of the umbilicus and low sub-sternal pain for five hours;
(2) dyspnoea at rest for five hours;  (3)  nausea, five hours.
Past Illnesses: (1) Shrapnel wound in 1917, liver and right kidney damaged; (2) has had hypertension
for several years;  (3) nervous breakdown seven years ago.   Recovery complete (?).
H. P. I.: Patient was well until 4 p.m. July 12, when he suffered a sudden, severe sub-sternal pain at the
level of the fifth costal cartilage. This occurred two hours after a normal meal, while he was resting. It was
not relieved by walking about for 15 minutes, so he lay down, and pain appeared to radiate into his abdomen,
being most severe below his umbilicus. Accompanying this was marked shortness of breath and nausea. An
enema given produced normal returns.   This was his condition on admission to hospital at 9 p.m.
Functional Enquiry: C.V.—Exercise tolerance previously good.   No cedema.
P. X.—T., 97.1.   P., 65.   R., 22.
Patient was extremely restlses, perspiring freely, felt cold, no cyanosis. He alsoj was definitely confused mentally.
The apex beat was in the fifth interspace and left nipple line, with the left border of the heart a half to
one inch to the left of normal.  Pulse was of fair volume.  Blood pressure 148/98.
The abdomen was soft? and flabby, no rigidity, but some voluntary resistance present. Slight tenderness
in the epigastrium. Definite tenderness below and lateral to the umbilicus, but more marked on the left side
than on the right.
Progress: Morphia, gr. %> was administered, and condition remained unaltered until
11 p.m., when respirations ceased, but apex beat was palpable.
Oxygen and adrenalin with artificial respiration proved of no avail, and patient died
at 12:15.
Autopsy Report: On opening the pericardial sac approximately 100 cc. of blood was
found. The intima of the aorta was covered with numerous yellowish plaques. On severing
the aorta at its bifurcation a soft clot was discovered between the media and adventitia,
and this was found to extend throughout the whole length of the aorta. At the site of the
origin of the left innominate artery there was a rupture through the intima and media in
the area of some atheromatous degeneration. This proved to be the site of origin of the
aneurysm, which extended upwards also into the right subclavian and common carotid
arteries, and, as well proximally to the base of the aorta, and here ruptured into! the pericardial sac to produce the blood found there.
Clinician's Diagnosiss (1) Dissecting aneurysm of the aorta. Also found: (2) Twisted
ureter; (3) ureteral stone.
Pathologist's Diagnosis: (1) Dissecting aneurysm of the aorta.
R. D. MacLaren, M.D.
II.—REGIONAL ILEITIS
Dr. W. L. Graham.
Male.  Italian.  Age 26.
An Italian man, 26 years of age, who complained of abdominal pains, nausea and vomiting, weakness and
alternating constipation and diarrhoea of one month's duration. Previous1 to this he had been in good health.
The pains were crampy in nature and localized around the umbilicus. At the onset nausea and vomiting persisted for three days, then disappeared. He had several attacks at intervals of one day to a week. The pain
was more severe when standing or walking and was relieved by lying down. On one occasion the vomitus was
foul smelling and brownish in color, and on one occasion the stoofi were bright red but usually very dark.
His appetite was good but he was afraid to eat because food aggravated the pain. He was admitted! to the
Hospital on April 2, 19398, previous to which he had been vomiting} for two days. The past illnesses and
family history were not of interest. He was a poorly nourished, pale man, who weighed 106 pounds. The
abdomen was round in contour; there was no visible mass or peristalsis.
Page 109 He was observed for several days and given supportive treatment. On April 5 th an
exploratory laparotomy was done and under anaesthesia a sausage-shaped mass was palpable
in the right lower quadrant. On opening the abdomen there was a very congested thickened
area of bowel involving about 8 inches of the terminal ileum and the caput of the caecum.
The bowel above this area was moderately dilated for three or four feet. I thought at this
time that it probably would be wiser to do a jejunostomy rather than to attempt an immediate resection, and this was done through an upper right rectus incision.
The post-operative course was uneventful except that the patient continued to have
crampy abdominal pain with distention and at times visible peristalsis. The jejunostomy
continued to drain well. On April 26th, no progress having been made, the abdomen was
reopened through the original right paramedian incision, the jejunostomy tube being left
in place. The mass still appeared as previously described, with no reduction in the distention
of the proximal bowel. A resection of the terminal 2 l/z feet of ileum and the caecum was
accomplished and an end-to-side ileocolostomy was done and the abdomen closed.
The post-operative course was uneventful. The jejunostomy tube was removed in one
week and there was no discharge from this wound. The patient was discharged on June 4th.
The pathological report showed the appendix to be normal; the wall of the ileum was
markedly thickened, was patchily covered with a fibrinous exudate, and on opening the
bowel there was extensive ulceration of the mucosa and the ileocaecal valve was almost
completely occluded by a somewhat proliferating type of ulceration. It did not appear
neoplastic. The microscopic diagnosis was a hypertrophic tuberculosis of the ileum with
inflammatory hyperplasia of the regional mesenteric glands.
Remarks: This boy of 25 was admitted to hospital with recurrent crampy pain associated with nausea and vomiting. A barium enema showed no pathology. A laparotomy
revealed an infection of the terminal ileum and the caecum which produced a high grade of
obstruction- Lederer tells us that these cases should be resected immdiately. In this case
the distention of the bowel extended up some two or three feet above the involved portion
and in my judgment it was wiser to do a jejunostomy. The jejunostomy worked exceptionally well, but after three weeks the patient showed no improvement and on reopening '
the abdomen the distention was not relieved. It was gratifying that after five weeks the
jejunostomy, which was done with the Witzel technique, did not leak. The pathological
report was somewhat of a surprise to me in the diagnosis of a hypertrophic tuberculosis.
Subsequent x-ray of the chest showed no pulmonary tuberculosis.
The only point one might make in the review of this case is that if one is dealing with a
terminal ileitis that has gone on to practically a complete obstruction one must resect the .
involved portion.  In a similar case I would not do a jejunostomy as a primary operation.
III.—RECONSTRUCTION OF THE COMMON DUCT
Dr. W. L. Graham.
The next case to be reported is one of reconstruction of the common duct after accidental severance during cholecystectomy.
The patient was an adult male, 52 years of age, who was admitted to my service on
April 1, 1938. The patient complained of recurring pains in the right upper quadrant of
four months' duration. He was jaundiced and had a general pruritus. The history, apart
from the digestive disturbance due to gall bladder disease and the associated colic, Was
essentially negative. Following the attacks of pain his stools were clay colored. On admission his temperature was normal. The blood count was normal. Coagulation time was
4 minutes, bleeding time was 2l/z minutes, and the Kahn was negative. His icterus index
was 10. The patient was prepared by intravenous medication of saline and glucose and
calcium gluconate. A cholecystectomy was performed on April 9, 193 8. A right paramedian incision was made and the duodenum found to be adherent. The under surface of
the liver and the gall bladder was not visible. The duodenum was dissected from the liver
until the fundus of the gall bladder was visualized. There was no cholecystic duodenal
fistula.  After the upper inch of the gall bladder had been exposed the fundus was opened
Page 110 on the anterior surface and a large stone removed. Palpation revealed a column of stones,
each loculated. Dissection was continued, and four or five stones removed, the incision
in the gall bladder wall being continued. A small catheter was inserted in what appeared
to be the cystic duct at the junction of the common! duct. Twenty cc. of saline was
injected without pressure and this catheter was sutured in place. On attempting to remove
the gall bladder it was found that the common duct was completely severed. It was judged
then that the catheter entered the distal portion of the severed common duct. The proximal end of the common duct was anastomosed to the duodenum over a rubber tube. One
drain was inserted to Morrison's pouch. There was a small tear on the anterior surface of
the liver which necessitated packing with a sponge and the abdomen was closed in layers.
The patient had a rather stormy convalescence and the temperature and pulse remained
elevated for several days. The icterus index was repeated on April 30th and; June 10th
and found normal. On April 20th and x-ray revealed the tube still situ. An x-ray repeated
on May 26th showed that the tube had been passed. The patient was discharged on June
10th with his wound well healed, no evidence of jaundice and no discomfort.
Remarks.—This man, aged 52 years, has had several attacks of acute abdominal pain
during the past year, associated with fever, jaundice and clay-coloured stools. The x-ray
showed stones in the gall bladder. When the abdomen was opened the duodenum was
found adherent to the liver, burying the gall bladder. On palpation it felt very much like
a carcinomatous mass. I felt that this might be a case in which it would be wiser to do a
partial cholecystectomy. The accidental severance of the common duct presented a new
problem. However, the anastomosis which was done has worked very well and today he
has no clinical jaundice and one hopes that there will be no constricture of the anastomosis
at a future date. "We shall be interested in a progress report later.
CLINICAL PATHOLOGICAL CASE REPORT: SYPHILITIC AORTITIS.
D. S. Munroe and S. A. Creighton.
Mr. S. U., Japanese, aged 42, millworker by trade, first seen on August 23rd, 1938,
complaining of pain in the chest since April.
Born in Japan; came to Canada 21 years ago. Past' history entirely negative except
for a mild injury to right knee and some trouble with back some years ago. Married; one
child alive and well.  Family history irrelevant.
Through an interpreter the patient stated that he was in good health until April, 1938,
when after lifting a heavy object he first felt pain in the chest, located under the upper
part of the sternum, and felt only after exercise or exertion. He did not have pain on such
movements as bending or turning; there was no tenderness at the site. The pain was
brought on by a fairly constant amount of exertion and radiated down both arms to below
the elbows. It lasted about five or six minutes on the average, and during the pain the
patient was forced to stand still. Rarely, also, the pain radiated to the neck. He was not
dyspnceic and did not complain of palpitation.
Examination: This revealed a fairly well nourished middle-aged Japanese showing slight pallor of the
facies.  Weight 126 lbs.  Heart normal in size, and regular in rate and rhythm.   There was an early diastolic
murmur heard at the apex which tended to disappear after exercise.   Pulse 66.   B.P. 90/50 in both arms.
Apart from slight diffuse hypertrophy of the prostate, examination was negative.
Tentative Diagnosis: Angina Pectoris.
Hgb. was 82%; Kahn test was positive. Urinalysis revealed nothing of significance. X-ray of heart
showed slight left ventricular hypertrophy, with, however, no broadening of the base or of the aorta. Electrocardiogram showed low ST segment in leads 1, 2 and 3, and high in lead 4. T was inverted in leads 1, 2 and
3—definite evidence of coronary insufficiency.
On August 26th the patient was found dead in bed and was transferred to the Vancouver General Hospital for autopsy.   No treatment had been given. fc
Autopsy Examination: Gross: Autopsy 24 hours postmortem. No excess of pericardial fluid; pulmonary
artery free of embolus. The aorta presented no aneurysmal dilatation, but anteriorly was noted a rather
hemorrhagic soft area 2 cm. in diameter. The remainder of the aorta was fibrotic to palpation. Exploration
revealed a typically puckered syphilitic aorta with a very slight outpouching of the intima at the above noted
spot. There were some scattered atheromatous plaques over the intima. The coronary orifices were markedly
narrowed, and the right almost obliterated by scar tissue, the point of a very fine probe not being passed.
The arteries themselves were patent throughout, showing no narrowing, and only a minimal amount of
sclerosis.
Page 111 The heart weighed 420 gms.   The myocardium throughout was quite flabby.   The liver presented a
slight nutmeg appearance.
Microscopic: All sections of ascending aorta, including the areas adjacent to the coronary orifices, showed
a marked perivascular lymphocytic and plasma cell infiltration in both adventitia and media. Throughout
was a great deal of hyalinized scar tissue, with puckering of the intima. Sections through the soft area
revealed a marked degenerative process with some necrosis in the media and a granulation tissue healing process, the vascular channels of this having distinct mantles of lymphocytes and plasma cells. In the necrotic
area were seen a moderate number of polymorphonuclear leucocytes. The intima over this area showed
marked dimpling, but there was no break in the coat.
The coronaries themselves showed no evidence of any syphilitic process. There was a minimal amount of
hyaline change in the wall.
The myocardium revealed some hypertrophy and degeneration but no infarcts, either recent or old.
The remainder of the sections revealed nothing relevant.
Diagnosis: Syphilitic aortitis with marked narrowing of coronary orifices and an accompanying moderate degree of arteriosclerosis.
Comment: Syphilitic aortitis results in a destruction of the media of the vessel by a
mechanism not definitely known but probably beginning in an obliterative endarteritis
involving the vasa vasorum. This necrosis strikes chiefly the elastic tissue and healing
occurs by formation of fibrous tissue which contracts with resultant longitudinal wrinkling of the overlying intima—the characteristic gross, but relatively ilate, finding in the
focus of the disease. The intima in addition shows marked fibrous thickening which later
may become hyalinized. As a result of the loss of elastic tissue in the media, a similar
process in the aortic commissure and the intimal changes, one of three may occur—
aneurysmal formation, aortic regurgitation, or narrowing of one or more of the branches
of the thoracic aorta, the most important of which are^ the coronary arteries. The last
mentioned was the one present in the case reported above. The existence of the angina
with definite and marked electrocardiographic changes) is readily explained by the myocardial ischaemia due to the narrowed coronary mouths. It is interesting to note that
while this man's symptoms had existed for five months, he had' been able to work until
one week prior to consultation.
Angina pectoris, particularly in a middle-aged man, must always raise the question of
syphilitic aortitis. The patient's history is frequently without a clue and physical examination may reveal nothing abnormal in early cases or in cases wherein neither aortic regurgitation nor dilatation of the vessel is present. The changes in the electrocardiogram are by
no means specific and until dilatation of the aorta has occurred the x-ray is likely to be
normal. Blood flocculation tests are, however, positive in almost 100% of cases and consequently should be performed routinely in all patients with angina.
STATE OF PHYSICIANS IN SPAIN
Even in the present day the fee of a physician is twopence from the tradesman, tenpence
from the man of fashion, and nothing from the poor. Some of the noble families agree
with the physician by the year, paying him annually fourscore reals, that is, sixteen shillings,
for his attendance on them and their families. They all acknowledge thati the monks are
more liberal than people of the first fashion, especially if confidence and secrecy are needful.
CUSTOMS AND SALARIES OF PHYSICIANS
BEFORE THE CHRISTIAN ERA
Boerhaave takes notice that, before there were any professed physicians, it was the
custom among the ancient Egyptians, when anyone was sick, to enquire of neighbours and
passengers if they knew any proper remedies for the patient. But ever since the study of
physic has been a profession, it has been both honourable and lucrative. The customary
yearly salary which princes paid their physicians, about the time of Christ's birth, was
250 sestertia, or above 2018£ sterling. Stertenius complained that he had only a salary of
500 sestertia or £4036 9s. 2d. sterling, when he had, by his private practice, 600 sestertia,
or £4843 15s.
Page 112 ROUND TABLE CONFERENCE ON PREMATURITY
INTRODUCTORY REMARKS
Dr. A. Howard Spohn.
The treatment of prematurity depends, of course, chiefly on keeping up bodily heat
and the ingestion of a sufficient quantity of easily assimilable food, but other adjuncts
often adjust the balance so that life is spared.
Atelectasis is a much more frequent cause of death inj early infancy than is generally
supposed, and probably every premature infant has some degree of atelectasis.
The continuous inhalation of oxygen in a tent or oxygen room is essential in the treatment of all atelactic infants, especially the premature baby. The benefits of this treatment are so great that one should advocate oxygen inhalation as a routine measure in every
premature child. The beneficial effect of oxygen administration in mild cases of cerebral
haemorrhage should be more widely appreciated.
The use of theelin injections in prematurity seems to be based on solid scientific
grounds. Nature is a great economist and thq presence of the pregnancy hormone in the
maternal blood has a very definite purpose. The sudden stoppage of this maternal supply
with birth can only be compensated by the administration; of the hormone in some way.
One need only mention the administration of tablets by mouth in order to condemn the
procedure. Prematurity demands prompt measures, and there is no justification for using
the least efficient of several methods. Administration of the hormone by injections of
aqueous solutions is also not advisable, as the injections of oily) solutions is much more
efficient. The first injection should be given a few hours after birth and should be continued during the first 10 days of life. The average dosage would be 1000 to 2000 rat
units in 1 cc. of oil every second or third day during the first two weeks lof life. If the
oily solution is given in the above dosage there can be an interval of one or two days between
injections. The administration of the hormone (cestrin, theelin, etc.) appears to accelerate
the depressed metabolism of the premature and enable it to gain weight more satisfactorily
and be less drowsy. Some investigations have been made in which results were rather
uncertain, but the dosage did not appear to be large enough and the method of administration varied.
Thyroid Therapy. Within fairly recent times small doses of thyroid have been given
to prematures with beneficial effect. In such cases one employs the thyroid as a pharmacodynamic agency, not as a hormone to supply an individual deficiency. It has been shown
that a premature baby's thyroid is usually active. More investigation is required, but sufficient data has accumulated to warrant the consideration of this type of therapy in prematurity. The expected result is a hastened development rather than an increase in growth.
As far back as twenty-five years ago it was demonstrated that the feeding of thyroid to
tadpoles hastened their development into frogs but did not promote growth. An influence
on respiration, digestion, etc., might be expected. Moncrieff, in the Archives of Diseases
of Children, March, 1937, reported an investigation on 62 premature babies (all under 5
lbs.) who were given one-twentieth grain per pound of body weight. The babies were
easier; to keep warm but there was no apparent advantage in temperature readings. The
mortality of the thyroid-fed babies was only one-third of control babies, and this may
have great significance.
Page 113 FEEDING
Dr.R. P. Kinsman
I wish merely to stress a few important points in the feeding of/ premature infants,
over which controversy sometimes arises.
For the first twelve hours the infant is better without food; then for thirty-six hours
alternate feedings of milk and water every two hours. I believe most premature babies
do well and can be made to gain sufficiently if fed in this way—milk every four hours and
water every four hours. It is important to remember that 3 5 calories per kilo, is necessary
to maintain life.
Food. The importance of mother's milk as food for the premature infant cannot be
too strongly emphasized. Julian Hess says: "Human milk is essential to a low mortality."
Greenlee says: "Proper nourishment of the premature infant depends on the supply of
mother's milk." Next choice of food is a mixture of mother's milk with powdered, evaporated, or lactic acid milk.
Manner of Feeding: (1) Some premature babies are able to nurse at the breast; (2) If
the infant becomes fatigued from nursing at the breast, a medicine dropper may be used,
or a Brick feeder, or the baby may nurse from a bottle; (3) if unable to swallow well, the
child should be fed by gavage. This feeding should not be given oftener that every four
hours, and by an experienced nurse only. Small quantities of water may be given between
feedings with a medicine dropper.
CAUSES OF PREMATURITY
Dr. E. S. James
Definition: In obstetrics a mature infant is one born at term, that is, at the end of from
270 to 290 days, irrespective of the development of the baby. Hess classifies all infants,
whether they are born before or at term, x>r even past term, as immature infants if the
birth weight is below 2500 gm. (5l/z lb.).
Premature infants form the major proportion of immature infants, and may therefore
be defined as immature infants born before 270 days of gestation have elapsed.
Causes of prematurity: Premature labour may be caused by constitutional disease in
the mother, by local uterine pathology, or by disease of the placenta.
The more common constitutional causes of premature labour are the toxaemias of late
pregnancy, namely, chronic nephritis and eclampsia. Syphilis may produce an abortion,
miscarriage, or premature birth, depending upon the length of time the mother has had
the infection. Any severe acute infection, such as pneumonia, may be a cause. Vitamin E
deficiency is usually described as producing an abortion or early miscarriage, but could be
the cause of prematurity if the deficiency were limited to late pregnancy, or if it were
added to some other factor.
The most important local causes in the uterus are uterine tumours, such as fibroids
and carcinomata of the body of the uterus. Other causes are placenta praevia, hydramnios,
and twin pregnancies. Infarction of the placenta may cause premature labour, possibly
by being a factor in the development of toxaemia in the mother.
Prematurity occurring when the mother is apparently healthy may be explained on a
physiologic basis, according to Schiller. Labour is produced at the usual time by the rela-
tice increase in the blood of the hormone cestrin, so that it predominates over the luteal
hormone progesterone. If the increased production of cestrin were to occur earlier it would
induce an earlier labour.
Page 114 Duyzings of Rotterdam states that the age of the mother is a factor in producing jpre-
maturity. Analyzing the histories of 1900 prematures over a thirty-year period, he found
that young: primiparae and women over 3 5 years of age had a greater proportion of premature births than other age groups.
CLINICAL PICTURE OF PREMATURE BABY
Dr. J. H. B. Grant
A premature baby is not only a small baby, it is an undeveloped baby. It is not ready
to be born or to live under extra-uterine conditions. It is intended to float in warm water
of a constant temperature, but it has, instead, to be handled and exposed in air to varying
temperatures. Its circulation is compelled to change from the fcetali to the adult form
weeks or months before it is ready for the change. It is compelled to breathe air into lungs
only partially ready for use, with an undeveloped thorax and respiratory muscles. It is
obliged to use digestive organs only partially completed, instead of obtaining nourishment,
already prepared, through the circulation. In short, it has to depend for its life on organs
only partially ready to perform their functions.
External examination shows us: A small, thin, limp5 body; the skin is very soft, varying in colour, maybe red, maybe blue, or again almost transparent; the cry is feeble, often
a while resembling the mew of a kitten; the breathing is irregular, shallow, sometimes
barely perceptible for seconds at a time; the movements of the extremities infrequent and
never vigorous; the muscles of the mouth, cheeks and tongue may lack the necessary force
for sucking, so that this is practically impossible, and even swallowing is slow, difficult
and prolonged; the body temperature fluctuates easily and widely, and without artificial
heat will be subnormal.
Examination of many premature babies at autopsy has shown the following changes
in some of the vital organs:
(a) The Lungs: They contain comparatively little alveolar structure and, on account
of the loose attachment of the blood vessels, are very prone to congestion and inflammation.
Out of 79 premature babies autopsied by Dr. J. H. Hess, 46 showed atelectasis and 23
showed broncho-pneumonia.
(b) The Heart: Poor development of the muscles, which in life caused irregular, weak
pulse. Hess reports that 29 of 79 autopsied showed patent foramen ovale and 29 showed
patent ductus arteriosus.
(c) Skull and Brain: The fontanelles and sutures are wide, the bones abnormally
movable. There is very frequent tearing of the tentorium and rupture of the blood vessels,
with resultant haemorrhages into various parts of the brain. Hess found that 49 % of his
cases, whose skull caps were removed at autopsy, showed intracranial hcemorrhages.
(d) The Digestive Organs: All the functions of digestion are present in premature
babies but are often feeble; the capacity for sugar digestion is more developed than those
for fat, starch and proteins.
(e) The Skin: The sweat glands are not developed at all and the infant is thus deprived
of one of the most important ways? of losing heat. High external temperatures are therefore dangerous and may comparatively easily cause a "heat-stroke." On the other hand,
they have practically no fat tissue to conserve heat and are very subject to "chilling" on
exposure to cold or drafts. The skin is very subject to infection.
Malformation of one or several parts is more frequent in premature infants than in
normal babies.
Prognosis:   The prognosis in premature babies depends:
(1) On the degree of prematurity—rarely do they survive if born before the 27th or
28th week of pregnancy. Very few survive if weight at birth is under 2 lbs. or length of
body under 13 inches. The closer to term and the larger and stronger the baby is, the
better the chance of survival.
(2) On the care of the baby after birth—feeding and the prevention of infection.
Page US TWO CASES OF CRETINISM AND SOME GENERAL
OBSERVATIONS ON THE THYROID GLAND
From the Paediatric Department of St. Paul's Hospital, Vancouver, B. C.
A. Howard Spohn, M.D.
I wish to present two very interesting cases of extreme hypothyroidism that have been
under my personal observation for a number of years. Both might be classed as cretins;
both have been saved from states which would have approached idiocy, by continuous
thyroid feeding over a period of years, and both have developed cancerous growths—one
a carcinoma of the thyroid and the other a carcoma of the kidney. These patients were
operated upon in St. Paul's Hospital—the thyroid carcinoma case twelve months ago, the
kidney case six months ago. Both have received deep x-ray therapy besides operation, and
both children are at present enjoying good health with as yet no determinable evidence of
secondary invasion from the primary foci. Only a short resume of each case will be given,
as each one is of sufficient interest to warrant a fairly extensive and particular report when
a greater time has elapsed since the operation.
Case 1.—M. L., female: Cretinism. Case seen first in August, 1932. Family history
negative. Parents intelligent; two other children living and well. Residence, Vancouver
Island. On first examination there was no difficulty in diagnosing this child as an extreme
case of cretinism. The child weighed 11 pounds. There was a profuse growth of hair on
the scalp and a good deal of hair on the back. The neck was short. The child could not sit
up, the tongue protruded, the voice was deep and coarse, and the general appearance was
almost that of a little animal. The eyes did not resemble those of the Mongolian Idiot.
There was also a history of peculiar breathing spasms. The patient was given thyroid gr. %
(B. & W.) twice a day for eight days and then returned for examination. Even with so
small a dose and over such a short period of time the improvement was remarkable, and in
passing through my office I did not at first recognize the child. This brings up the point
that it is always wise when dealing with infants and children to start with a small dosage
and make frequent examinations. I have known treatment to be discontinued by parents
because the first dosage was too large and caused disturbances. I have several cases in which
cretins were deprived of treatment for several years on this account. The patient has,
since 1932, been supplied with thyroid through the courtesy of the Burroughs & Wellcome
Company, and all observations have been with the one preparation. From a peculiar-looking
little elf she developed into quite a handsome attractive child, with a well-developed body.
She has been, and is, slow and deliberate in her talk, but her answers are accurate and her
formation of ideas and her memory for past events is almost normal. She is obedient,
responsive, and observant of things occurring in her presence; she plays well and happily
with other children, and no one would pick her out as a cretin without obtaining her past
history. If she is deprived of thyroid for four to five days signs of deterioration are quite
apparent.
In February, 1938, she came to Vancouver on account of a large mass, estimated at
about 6 y/'xS", on the right side of her abdomen. The mother states that she was conscious
of the mass for only six to eight weeks and that the increase in size was very rapid. X-ray
examination indicated an extra-renal tumour. She was given a full course of deep X-ray
therapy at St. Paul's Hospital, was then discharged, and returned for surgical treatment.
On May 16th, 193 8, Dr. Earle Hall removed the tumour, and after a fairly stormy convalescence she was discharged in June, 1938. On her last examination, October 3rd, 193 8,
she was in good health; her haemoglobin 8 5%, R.B.C. 4,000,000, and there was no evidence
of recurrence. In May, 1938, X-ray pictures of the chest and skull were negative.
Page 116 Case II.—R. S., female: Cretinism. First seen in May, 1926, when the child was 7
months old. Family history negative. Both parents in good health and above average intelligence. Residence, Ashcroft, B. C. There are no other children in the family. Physical
examination showed an infant of 7 months, weighing 12 pounds, with an unintelligent
expression, a dry skin, flaccid muscles, poor hand grip, protuberant abdomen and a large
umbilical hernia. Although underweight there was evidence of myxcedema and the hands
were square and pudgy with wrinkled cedematous wrists. The pupils reacted to light but
the eyes followed objects very slowly; the eyes were not almond shaped and the longitudinal
eye slit did not incline towards the inner canthus as is characteristic in Mongolian idiocy.
There was a slight systolic murmur. In spite of the enlarged heart the circulation did not
give much evidence of embarrassment except for cold extremities. This child was placed
on thyroid therapy, but for several reasons contact was not maintained and there was an
interval of ten years before the patient came to Vancouver. During this interval thyroid
therapy was maintained, but not in sufficient dosage, so that the physical and mental
development did not attain to as great a degree as it might have. In January, 1936, the
child was unintelligent in appearance, but the answers to questions and other tests showed
her mental age to be only about two years below normal. At this time a cyst about the size
of a small hen's egg was present on the right lobe of the thyroid. The heart was still enlarged. The thyroid dose was increased and she was asked to report in a few months. She
did not return to Vancouver until August, 1937, and I did not see her as I was away. At
this time the cyst had increased in size and another cyst had appeared in the left lobe, and
the mother had consulted an internist and surgeon in regard to removal of the thyroid. At
this time her physical condition and the enlarged heart caused the surgeon to advise against
operation at that particular time. In December, 1937, the patient returned to' Vancouver
on account of pressure symptoms from the rapidly growing cysts. The right cyst was
about as large as a Japanese orange and the left cyst slightly smaller. There was a great
deal of dyspnoea, especially on exercise, and it was evident that the patient could not go
along much farther without an operation. She was put to bed for ten days, an electrocardiograph taken showed only right axis deviation, and Dr. Lennie removed the thyroid
on December 7th, 1938. The child stood the operation well and only a very small amount
of tissue was left. At this time there was some doubt on section about malignancy, and
X-ray treatment was delayed for some weeks. The stained sections confirmed the tentative
diagnosis of carcinoma, and on account of the infrequency of carcinoma of the thyroid
the pathologist submitted the sections to two other well-known pathologists who have concurred in his diagnosis. At one time while in hospital, during convalescence, thyroid was
withheld for a period of only four days before very definite symptoms of hypothyroidism,
such as slurring speech, mental dullness, appeared. A recent examination 11 months after
operation shows the patient enjoying better health than at any time in her life. She still
slurs in her speech but cerebrates well, is accurate as any child of her age in answering ordinary questions, assists her mother in a grocery store on occasions, is attending regular school,
reads quite well, plays well with children of her own age, and is obedient, conscientious and
kind. Her general appearance is not as favorable as it might be on account of a very serious
defect of vision in one eye.
General Observations.
The various conditions arising from dysfunction of the thyroid are of especial interest
in this region and therefore it will be permissible on this occasion to review a few of the
many features that present themselves in a study of the thyroid gland..
The thyroid, while primarily belonging to the alimentary tract and taking part in
digestion, has, through metamorphoses, lost its connection with the alimentary tract and
developed a new function, that is, the role of digestion has been substituted for a role in
growth and metabolism, and it has become a gland not of external, but of internal secretion.
Growth of the Thyroid.
Statistical studies on the growth of the thyroid show that it is relatively more rapid
during the periods of lighter body weight, that is, at the earlier ages.  The human thyroid
attains its largest size just prior to puberty, and as the size of an organ is related to its
function, one can assume that the greatest load on the thyroid is normally about the time
Page 117 of puberty.   The follicles form the primary or secretory units of the gland.  The cells of
the follicles are the makers of hormone and their lumina form the warehouse for storage.
The physiologic study of the hormone dates back sixty-seven years, when Fagge, in
1871, started his work in cretins. The various activities of the hormone may be classified as
1. Calorigenic activity (metabolism estimate);
2. Action of the distribution of body water salts and colloid;
3. Action on growth and differentiation of tissue;
4. Action on carbohydrate metabolism;
5. Action on the nervous system;
6. Action on the muscular system;
7. Action on the circulatory system;
8. Action on other endocrines.
Only a few of the various activities will be mentioned in this discussion.
Action upon Growth.—Deprivation of thyroid in man or animals leads to dwarfism,
cretinism, juvenile undevelopment, etc. Derangement in various tissues such as skin, hair,
nails, etc., is seen in athyreosis. All such structures grow more slowly in the absence of
thyroid and the rate of growth is speeded up when thyroid is given.
In children, deprivation leads to serious derangements of the osseous development. In
athyreosis there is delay in the appearance of bone nuclei as well as in epiphyseal union. The
X-ray of such regions as the carpal areas furnish an excellent aid in the diagnosis and progress of thyroid deficiencies. No, better test than the roentgenogram is known in the
diagnosis and test of treatment of juvenile myxcedema. It is as important in this condition
as blood counts are in anaemia. One must remember the changes of rickets and not confuse
the two conditions in studying roentgenograms. Imperfect development of wrist bones is
present in about 25% of rickets, in some types of dwarfism, in hypophyseal infantilism
and a few other diseases. The determination of the bone age of a child suspected of thyroid
deficiency is most important.
The diuretic action of the thyroid hormone is one of the earliest and best known actions
and is made use of therapeutically in obesity and other conditions. This action takes place
not only in hypothyroid individuals but also for a time in normal individuals. In myxcedema
there is an "extroduction" of protein in the tissues which appears as swellings in legs,
abdomen, supra-clavicular regions, etc.
Action in Carbohydrate Metabolism.—Coggeshall and Green, 1933, showed that
thyroid feeding depleted the liver of glycogen, even though the animals had been on a
good carbohydrate diet. Animals which had been merely starved could rapidly replace lost
liver glycogen if given glucose by mouth or intraperitoneally—those which received thyroid
were unable to do so. The conclusion was that thyroxine not only depleted the liver of
glycogen, but also injured it so that it was unable to store glycogen. The degree of inability
to store glycogen is in proportion to the amount of thyroid given.
Action on the Nervous System.—Excess of thyroid hormone increases nervous irritability and reaction time. Scarcity of thyroid decreases nervous reactions. The hypothyroid
fives on a low emotional plane, cerebrates slowly and reacts to stimuli sluggishly. The
hyperthyroid has heightened emotions, emotional instability, greatly increased irritability
and sometimes gross derangements of cerebration. The mild hyperthyroid may be more
active, more efficient, more emotionally and intellectually stimulating until fatigue or
toxicity finally intervenes. The attractive, sparkling eye of young females often denotes
hyperthyroidism.
Action on the Circulatory System.—An increase in metabolism brings an incerased
mass movement of blood due to increased heart action, peripheral dilatation and increased
stroke volume of the heart. Zondeck, 193 5, notes a shift in the oxygen dissociation curve
of the blood which facilitates delivery of oxygen to the tissues as metabolism increases.
Thyroxine increases the demand for oxygen but also provides the wherewithal for this
demand to be satisfied.
Action on the Endocrines.—Thyroxine in a dilution as high as 1 in 5000 will cause
increased acceleration of metamorphosis of tadpoles. Eggs from non-productive hens in
a goitre belt may proceed to hatching if dipped at intervals during the hatching period in
mild iodine solutions,  Fertility may result in previously non-fertile animals from thyroid
Page 118 feeding seen in dogs, colts, calves and humans. Keith's observations on animals in Pember-
ton Meadows furnished some of the most interesting data that have appeared in medical
literature. Other substances than iodine will accelerate metamorphoses in tadpoles, however, but it is taken as proven that hormones do work in very high dilutions. They are,
therefore, according to Zondeck, in the nature of "catalysts."
Thyroxine accelerates the metabolism of all cells in the body, but other agencies as
adrenalin and dinitrophenol do the same, but in addition to being a catalytic agent,
thyroxine affects the life of the cell in every major aspect of its existence, that is, its
physico-chemical state, its irritability, its rate of maturation, its rate of mitosis, that is, the
length of life of the cell.
The body uses iodine only in the manufacturing of thyroid hormone and any excess is
promptly elimiated. We should, of course, distinguish between the demands for hormone
formation and the use of iodine for its pharmacodynamic action. In the latter case the
amounts used are much greater. Iodine may be used in a therapeutic sense for such purposes as the destruction of growth of certain micro-organisms such as treponema pallidum,
or actinomyces, and also as a depressor or as an expectorant, etc. Iodine used as a drug
circulates in the body as an inorganic salt, but plays no part in metabolism except up to the
capacity of the thyroid to store it. Its presence in the body has no effect on the function of
the thyroid except to stabilize colloid storage. The iodine content of the blood is made up
of passive iodine and also of circulating hormone. The passive circulating iodine fluctuates
with iodine intake—the circulating hormone, iodine, is related solely to the function of
the thyroid.
The usual rate of iodine absorption is through the alimentary canal, but it may also be
absorbed through the skin, the lungs, or any mucous membrane. The rate of absorption
depends on the solubility of the compound in which the iodine occurs. Thyroxine polypeptide is almost wholly absorbed; thyroxine is absorbed to between 10 to 20%.
Thyreosis in Children.
Thyroxine increases the process of breaking up of fat and carbohydrates as well as
the proteins. With hypothyreotic conditions, on the other hand, the metabolism is, on the
whole, diminished. The thyroid hormone furthers growth and the differentiation of the
organs has been shown in experiments on animals. The function of thyroxin is, then, of
special interest in the growing child.
With cretins and hypothyroid cases of marked degree the treatment must go on
during life. However, and especially in goitre belts, there are many cases of mild thyroid
dysfunction which appear before and during puberty when the demands on metabolism
are so great. These mild cases are frequently overlooked, and in young girls amenorrhcea
is one of the prominent symptoms. These are the cases which will respond so well and
often with great rapidity and with small doses. Remember that normally there occurs at
puberty an increase in thyroid function and many cases of dysfunction (undescended
testicle, etc.) will correct themselves successfully without treatment. Surgical treatment
for undescended testicle is rarely necessary and is usually very bad treatment.
Congenital Goitre.
Congenital goitre is a partial or diffuse hard enlargement of the gland of the newborn
and may be associated with iodine deficiency in the mother. Only local symptoms from
various degrees of obstruction of the respiratory tract may be present. The mortality may
be as high as 60%. Pressure on the trachea which is still soft and catarrh of the air passages
lead to tracheal stridor or obstruction. The newly born child is very sensitive to iodine
and may react with toxic symptoms (diarrhoea, weight loss, etc.) with very small doses.
It is often best to start with minute doses of .1 mgm. and repeat in several days. Intubation
and tracheotomy has been necessary.
Juvenile Myxoedema.
The picture of myxcedema depends on the age, the time of onset and the degree of
thyroid deficiency. Infections often play an important part in the production of myxcedema in children previously showing no thyroid dysfunction. Hyperthyroidism resulting
from no or insufficient thyroid secretion in children manifests itself as athyreotic cretinism,
endemic cretinism, or myxcedema. Athyreotic cretinism may be untreated sometimes,
because children with retarded growth are diagnosed incorrectly as suffering from pituitary
Page 119 dysfunction, rickets, achondroplasia or chondrodystrophy. Basal metabolic rates in children under 6 years of age are unsatisfactory and one should not place too much reliance on
the readings. However, accurate readings as low as 2 5 or 30 are seen. The X-ray of the
wrist is a much more satisfactory guide to thyroid sufficiency in children and an estimation
of blood cholesterol is also an extremely important test. The quantity may range normally
from 110 mg. per cent to 200 mg. per cent. The most usual normal is 190 mg. per cent.
In myxcedema values as high as 250 to 700 have been obtained from partial or complete
failure of development of a functioning thyroid in intra-uterine fife. In athyreotic cretinism the parents are normal and the individual does not suffer from lack of thyroid until
after birth.
Endemic cretinism is a congenital hypothyroid state in a child in which one or both
parents suffer from insufficiency of thyroid secretion. Such cases occur chiefly in endemic
goitre districts and there is usually marked mental backwardness in such cases. These
cases show the effect of deprivation of thyroid during intra-uterine life and may be diagnosed early, while in an athyreotic cretin some weeks elapse before diagnosis is possible.
It will be seen, therefore, that many points must be considered carefully in studying the
various conditions of thyroid deficiency.
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Protection Against Typhoid
Typhoid and Typhoid-Paratyphoid Vaccines
Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly
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The preventive values of typhoid vaccine and typhoid-
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Information and prices relating to Typhoid Vaccine and to
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CtyeMt
ANTIPNEUMOCOCCUS
SERUM
(RABBIT) Type 1
is standardized to contain
50,000   International   Units
in each package.
CfyeMt
ANTIPNEUMOCOCCUS
SERUM
(RABBIT) Type 2
is standardized to contain
20,000  International   Units
in each package.
Prices, typing instructions and information as to dosage will
be supplied gladly to any physician or hospital upon request.
AYERST,  McKENNA  & HARRISON  LIMITED
Biological and Pharmaceutical Chemists
MONTREAL
CANADA
No. 865
■* The New Synthetic Antispasmodic
Trasentin "Ciba"
(Diphenylacetyldiethylaminoethanolester-hydrochloride)
SUPPRESSES SPASMS OF THE GASTRO-INTESTINAL
TRACT, GENITO-URINARY SYSTEM AND
OTHER SMOOTH MUSCLE ORGANS
Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20.
1 tablet or 1 ampoule contains 0.075 grm.
of the active substance.
CIBA COMPANY LIMITED
MONTREAL
ijstfstfoWK^
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
FAIRMONT  80
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. L. BERTRAND For Either "lazy
a
or Spastic Colons—try
MUCILOSE
(STEARNS)
The therapeutic value of this bland, bulk-producing hemicellulose
which stimulates a "lazy" colon or relieves a spastic colon is constantly being recognized more and more by clinicians.
Mucilose helps to correct constipation by holding water in the feces
and thus producing a large, soft and pliable stool which is easily
expelled.
It is prepared by a
special process from
thePlantago lceflingii.
Pleasant to take, does
not interfere with
digestion.
Literature and professional sample
on request.
Frederick Stearns & Company of Canada, Ltd.
WINDSOR ONTARIO
Makers of Kasagra.
Detroit, Mich. New York, N.Y. Kansas City, Mo.
San Francisco, Calif. Sydney, Australia. Doctors-
YOUR
PRESCRIPTION
AND
RECOMMENDATION
Is Our Guide
Always--
OUR
MECHANICAL
and
SCIENTIFIC
ORTHOPAEDIC
EQUIPMENT
7s At Your Service
Avail Yourselves
of   our   experience   in   last
making to aid correction in
Minor Foot Ailments.
PHONE
Pierre Paris
FOOT CLINIC
Sey. 3 778      51 W. Hastings
>
>
IS IT
IS IT
Soreness, stiffness, slight enlargement of the phalangeal
joints (other joints may be involved), impaired motility, or
progressive loss of function . . .
particularly manifested about
middle-age—such Is the symptom-picture many cases present.
It suggests either a case of
gout, or one of arthritis . . .
LYXANTHINE ASTIER
given per os , in teaspoonful
doses, once or even twice dally,
usually brings about prompt
amelioration of the condition,
and, if administered persistently, often a complete disappearance of all symptoms.
Lyxanthine Astier so acts by
virtue of its associated synergists—Iodine, Calcium, Sulphur,
Lysidine bitartrate*; the latter
a powerful solvent and elimi-
nant of metabolic waste.
'Ethylene-ethenyl diamine.
<
<
COUPON
Dr. P. Astier Laboratories
36-48 Caledonia Rd., Toronto.
Please send literature and
sample of LYXANTHINE
ASTIER.
Dr. P. ASTIER LABORATORIES
36-48 Caledonia Road, Toronto t&ttir^mmesza&eu
STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office. Supplied in one yard, five
yards and twenty-five yard packages.
ESTABLISHED   NEARLY  A
Phone Seymour 698
B. C. STEVENS CO.
730 Richards St., Vancouver, B. C.
s.
LOWELL
&
SON
Distinctive   Funeral
Service
Phone 993
66 SIXTH STREET                                         NEW WESTMINSTER, B. C.
PHI
ill
m
pi
1
Break^^^^iaous ci|l||j|pf perverted
menstjpal function in cases of amenorrhea,
^rdy^^^^^non-physiolo^cal) and dys-
menorfnejl&ffords remarkable symptomatic
ptlief by stimulating the innervation of,the
uterus and  stabilizing||pe ^prii^^^ni^
musculature. Controls the utero-ovarian
circulatior^ind thereb^^^purages a
norgp||menstrual cycle.
% MARTIN H. SMITH COMPANY
fe. MO lAFATITTI STRUT. NEW YORK, N. T.^S*-''
MM!
Full formula and descriptive
literature on request
MSfmmm
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is  cut  in half  at seam.
I
1
1
1
8:i r o m   Pa s t u r c s
reen
sv%
$?3I
#::
3m$
m
JERSEY FARMS Jersey milk is truly
"The Milk With a Pedigree"
produced  on  the   farms  of  members  of  the
Co-operative Pure Bred Jersey Products Association  from  Pedigree   prize-winning   Jerseys.
Perfectly pasteurized in a modern and
sanitary dairy.
IT PAYS TO BE SURE OF YOUR MILK SUPPLY
MILK   CREAM   BUTTERMILK S.y.P. 36
c. . . in a variety of inflammatory conditions.'
 M. B., Ch.B.
A mass of evidence has accumulated since the introduction of S.U.P. 36
over twelve years ago, testifying to its value in a wide range of inflammatory conditions. This range is indicated in a letter received from a
physician, in which he states:—
'I have used S.U.P. 36 . . . wtih great success in a variety of
conditions ranging from acute pleurisy to septicaemia, and
some other types of inflammation such as ascending phlebitis
and acute fibrositis of the shoulder muscles . . .'
Stocks of S.U.P. 36 are held by leading druggists throughout the Dominion,
and full particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse Toronto 2, Ont.
^RTTP/Pan/afll
flDount flMeasant IHnbertakino Co. %tb.
KINGS WAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C
R. P. HARRISON W. R. REYNOLDS Antiphlogistine .. always indicated i
TONSILLITIS, PHARYNGITIS,
LARYNGITIS, BRONCHIOLITIS
Write for sample and literature
THE DENVER  CHEMICAL  MANUFACTURING  CO.
153 Lagauchetiere St. W.
Montreal
Made in Canada. STHAPPED FDR RICKETS
The swaddled infant pictured at
right is one of the famous works
in terra cotta exquisitely modeled
by the fifteenth century Italian
sculptor, Andrea della Robbia.
In that day infants were bandaged from birth to preserve the
symmetry of their bodies, but
still the gibbous spine and distorted limbs of severe rickets
often  made  their appearance.
Qwaddling was practised down
**-* through the centuries, from Biblical times to Glisson's day, in the
vain hope that it would prevent the
deformities of rickets. Even in sunny
Italy swaddling was a prevailing custom, recommended by that early pediatrician, Soranus of Ephesus, who
discoursed on "Why the Majority
of Roman Children are Distorted."
"This is observed to happen more
in the neighborhood of Rome than in other places," he wrote. "If no one oversees the
infant's movements, his limbs do in the generality of cases become twisted.... Hence,
when he first begins to sit he must be propped by swathings of bandages...." Hundreds
of years later swaddling was still prevalent in Italy, as attested by the sculptures of the della
Robbias and their contemporaries. For infants who were strong Glisson suggested placing
* Leaden Shooes" on their feet and suspending them with swaddling bands in mid-air.
How amazed the ancients would have been to know that bones can be helped to grow
straight simply by internal administration of a few drops of Oleum Percomorphum. What
to them would have been a miracle has become a commonplace of science. Because it can
A bambino from the Foundling Hospital, Florence, Italy,—A. della Robbia
/
\
Oleum Percomorphum offers
not less than 60,000 vitamin A
units and 8,500 vitamin D (International) units per gram.
Supplied in 10 and 50 cc. bottles, also in boxes of 25 and 100
ten-drop soluble gelatin capsules containing not less than
13,300 vitamin A units and
1,850 vitamin D units (equal to
more than 5 teaspoonfuls of
cod liver oil*).
*U.S.P. Minimum Standard
\
/
be administered in drop dosage, Oleum Percomorphum is especially suitable for young and premature
infants, who are most susceptible to rickets. Its vit- j
amins A and D derived from natural sources, this-
product has 100 times the potency of cod liver oil. *
Important also to your patients, Oleum Percomorphum is an economical antiricketic.
MEAD JOHNSON & CO. OF CANADA, LTD.
BELLEVILLE, ONTARIO
Please enclose professional card when requesting samples of Mead, Johnson products to
co-operate in preventing their reaching unauthorized persons. ig3Q
We are ready and able to meet every demand of the
Medical Profession—with highest grade medicinals,
and a service which recognizes the urgency of every
order.
PHONE YOUR PRESCRIPTIONS-
PROMPT DELIVERY
Seymour
2263
OMNAll
*    WIOWT
GEORGIA PHARMACY
LIMITED
W.OIOROIA
STRBIT
Only One Store
<&mttx $c ijamta IGft
Established 1993
VANCOUVER, B. C.
North Vancouver, B. C.   Powell River, B. C. BUI PpIB 5§t' 11 ife I
Hc: j flS                                                                            BHbI
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. 0, Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183                                            Westminster 288
nev wrioukv printing
* PUBLISHING CO. LTD.
^»».

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