History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1947 Vancouver Medical Association Sep 30, 1947

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 The
IIULLETIP
E XIBRA.R
of the
1
• •
MNCOVyER
M E§D ICAl
ASSOCIATION
With Which Is Incorporated
Transactions of the
^VICTORIA MEDICAL SOCIETY
the
VANCOUVER GENERAL HOSPITAL
and
|ST. PAUL'S HOSPITAL^
In This Issue:
REFUGEE PHYSICIANS—By A. D. Kelly, M.D..._.--llBl
Page
328
SYMPOSIUM—By A. J. Elliot, M.D.
Treatment of Ocular Injuries in General Practice',^^^^|--333
Opthalmic Indications of Systemic Disease. -^C^^^^^fe' 3 3 6
Ocular Finding in Important Neurological Conditions---!!§■ 340
The Differential Diagnosis and Treatment
of an Acutely Red Eye.-; '^#||^^^fs?|^?^
LUMBAR AND SACRAL INTERVERTEBRAL DISCS
. —By J. Gordon McPhee, M.L>^^^ffff|f^^fegj
NEWS AND NOTES
344
348
356
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SEPTEMBER, 1947 » r.
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THE
Cardiac dropsy, hypertensive heart disease,
agina pectoris, cardiac
pain, and following
coronary thrombosis.
C.T. No. 691 THEOBARB CONTAINS:
Theobromine ..£*%$&,,..5 grs.
Neurobarb•^^■.vj5^.iS....% gr.
Sod. Bicarb.......>^.;*.Ii....5 grs.
Packaged in bottles of
100, 500 and 1,000
NOTEi^ At   present   Theobarb
mild is not available.
HUTTLEWORTH  CHEMICAL CO.,  LTD.|TOR0NT0, CANADA 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
De. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XXIII
SEPTEMBER, 1947
No. 12
OFFICERS, 1947-48
Dr. G. A. Davidson Dr. Gordon C. Johnston
President Vice-President
Dr. Gordon Burke
Hon. Treasurer
Dr. BE. A. DesBrisay
Past President
Dr. W. J. Dorrance
Hon. Secretary
Additional Members of Executive: Dr. Roy Htjggard, Dr. Henry Scott
TRUSTEES
Dr. A. M. Agnew Dr. G. H. Clement Dr. A. C. Frost
Auditors'. Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Dr. Reg. Wilson Chairman Dr. E. B. Towbridge Secretary
Eye, Ear, Nose and Throat Section
Dr. Gordon Large Chairman Dr. G. H. Francis Secretary
Paediatric Section
Dr. J. H. B. Grant Chairman Dr. E. S. James Secretary
Orthopaedic and Traumatic Surgery Section
Db. J. R. Naden Chairman Db. Clarence Ryan Secretary
Neurology and Psychiatry
Dr. J. C. Thomas Chairman Dr. A. E. Davidson Secretary
STANDING COMMITTEES
Library:
Db. J. E. Walker, Chairman; Dr. W. J. Dorrance, Dr. D. E. H. Cleveland,
Db. F. S Hobbs, Db. R .P. Kinman, Db. S. E. C. Tubvey.
Publications:
Db. J. H. MacDebmot—Chairman; Db. D. E. H. Cleveland, Db. H. A.
DesBbisay, Db. J. H. B. Grant, Dr. D. A. Steele.
V. O. N. Advisory Board:
Db. Isabel Day, Db. H. H. Caple, Db. E. J. Cubtis.
Summer School:
Db. L. H. Leeson, Chairman; Db. E. A. Campbell, Db. J. A. Ganshobn,
Db. D. S. Muneo, Db. D. A. Steele, Db. L. G. Wood.
Credentials:
Db. H. A. DesRbisay, Db. H. H. Pitts, Db. Feank Tubnbull.
Representative to B. C. Medical Association: Db. H. A. DesBbisay.
Sickness and Benevolent Fund: The Pbesidfnt—The Tbustees.
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1 Mi 8.00
10.00
12.00
3.00
6.00
8.00
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The failure of standard hospital diets...
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to supply adequate nutrition is becoming better recognized
daily by both staflF members and hospital personnel—
because . . • "infections and injuries (and the latter include major
surgical operations) produce rapid wastage of protein tissues
and of stores of vitamins and minerals."1
because . . • standard hospital diets do not provide adequate nutrition,
particularly during the early stages of recovery from disease
or injury.
because . . even a full diet meeting all nutritional standards cannot
always be eaten.
"Recendy . . . nutrition has been found so important in the
recovery of patients with various 'surgical* diseases that the
surgeon himself has been forced to pay more attention to the
diets and dietary supplements, such as vitamins, that are
given his patients."1
^aM&^o/9n//^^fmfi^
1. Editorial: J.A.M.A.
134:292 (May 17) 1947.
Vitamin Tablets
To help restore tissue levels prompdy and to replace the
"rapid wastage" of vitamins in the sick, Squibb Basic
Formula Vitamin Tablets supply truly therapeutic doses of
the four critical water-soluble vitamins.
Each tablet contains:
Thiamine HCI 10 mg.
Riboflavin 5 mg.
Niacinamide 150 mg.
Ascorbic Acid.: 150 mg.
Botdes of 30, 100 and 250.
Sqijibb
Manufacturing Chemists To The Medical Profession Since 1858.
For Literature write
E. R. SQUIBB & SONS OF CANADA LIMITED
36-48 CALEDONIA ROAD   •   TORONTO
11e47A VANCOUVER MEDICAL ASSOCIATION
Founded 1898; Incorporated 1906.
*    *    *
PROGRAMME FOR THE FIFTIETH ANNUAL SESSION
October    7    GENERAL MEETING—"The Treatment of Peptic Ulcer."
Dr. A. H. Gordon, Montreal.
October 21    CLINICAL MEETING—Vancouver General Hospital.
November    4    GENERAL MEETING—"Sympocium on Peripheral Vascular Disease."
Dr. Rocke Robertson and associates.
November 18    CLINICAL MEETING—St. Paul's Hospital.
December    2    GENERAL MEETING—"Symposium on Pre-frontal Leucotomy."
Dr. Frank Turnbull
Dr. Allan Davidson
Dr. R. Whitman.
December 16    CLINICAL MEETING—Shaughnessy Hospital.
Kit'
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
I    uterus and  stabilizing the tone of its
f|    musculature. Controls the utero-ovarian
s\   circulation and thereby encourages a    j
Ik    normal menstrual cycle. M
Hk J A
"V « MARTIN H. SMITH COMPANY
S», ISO L»F»TIIII   STRICT.   MlW  TOM.  N. T. .
Full formula and descriptive
literature on, request
Dosage:   l to 2 capsules
3 or 4 times daily.  Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam.
Wm
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TABLETS
NATURAL CONJUGATED ESTROGENS
(equine)
ORAL THERAPY WITH CONESTRON provides safe, dependable control of
menopausal symptoms and restores the patient's sense of well-being.
ORAL THERAPY WITH CONESTRON is relatively free from undesirable side effects.
ORAL THERAPY WITH CONESTRON is most desirable from the standpoint of convenience and time economy.
CONESTRON TABLETS
May be prescribed in any quantity. Available at all
pharmacies in two strengths.
.625 mg.
TABLETS
1.25 mg.
TABLETS
WgeOf
Registered Trade Mark
JOHN WYETH & BROTHER (CANADA) LIMITED    •WALKERVILLE, ONTARIO VANCOUVER HEALTH DEPARTMENT
STATISTICS—JULY, 1947
Total Population—Estimated 339,350
Chinese Population—Estimated       5,980
Hindu Population—Estimated Hg
Rate Per 1000
Number Population
Total  deaths 329 11.4
Chinese deaths  i         9 17.7
eaths, residents only ! 286 9.9
BIRTH REGISTRATIONS:
Male 	
Female
502
490
992
36.3
INFANT MORTALITY:
July, 1947
Deaths under 1 year of age       23
Death rate per 1000 live births 23.2
Stillbirths   (not included  above) 11
July, 1946
26
31.6
11
CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY
. ",_f!
June, 1947
July, 1947
Scarlet Fever
Diphtheria
Diphtheria Carrier
Chicken Pox	
Measles   	
Rubella 	
 1 ■— 7
  0
  0
  64
  29
 ,     ... 2
Mumps  80
Whooping Cough  70
Typhoid Fever  0
Typhoid Fever Carrier  0
Undulant Fever   1
Poliomyelitis  13
   *   52
  0
  1
  0
  18
  1
  0
  0
  0
  78
Tuberculosis
Erysipelas
Meningococcus   (Meingitis)
Infectious Jaudice 	
Salmonellosis    	
Salmonellosis  (Carrier)  	
Dysentery 	
Dysentery   (Carriers)
Tetanus	
Syphilis
Gonorrhoea 211
Cancer (Reportable)
Resident   	
Non-Resident
82
28
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0
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0
0
0
0
0
0
0
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17
0
0
0
0
0
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3
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4
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27
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9
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2
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18
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13
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40
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49
19
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251
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August,
1947
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62
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95
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196
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Page 326 t!
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CRYSTALLINE   PENICILLIN   G
It has been widely established that Penicilln G is a highly effective
therapeutic agent. The crystalline form of Penicillin G prepared and
supplied by the Connaught Medical **$&w^mr^
Research Laboratories is highly purified. Because of this high degree of
purity, pain on injection is seldom
reported and local reactions are
reduced to a minimum.  Crystalline |
Penicillin G is heat-stable, and in the %
dried form can be safely stored at
room temperature for at least three
years.
I
\
PHOTOMICROGRAPH
OF PENICILLIN CRYSTALS
HOW SUPPLIED
CRYSTALLINE PENICILLIN  G IN VIALS
Highly purified Crystalline Potassium Penicillin G is supplied by the Laboratories in sealed rubber-
stoppered   vials   of   100,000,   200,000,   300,000   and   500,000   International   Units.    No  refrigeration  is
required.
CRYSTALLINE PENICILLIN G IN OIL AND WAX (ROMANSKY FORMULA)
A heat-stable and conveniently administered form of Crystalline Sodium Penicillin G in peanut oil
and beeswax is available in 1-cc cartridges for use with B-D* disposable plastic syringes, or as replacements with B-D* metal cartridge syringes.   Each 1-cc. cartridge contains 300,000 International Units of
Crystalline Sodium Penicillin G.
* T.M. Reg. Bccton, Dickinson _ Co.
CRYSTALLINE PENICILLIN G IN TABLETS FOR ORAL USE
Buffered tablets of Crystalline Sodium Penicillin G are distributed by the Laboratories in tubes of
12. Two strengths are supplied, 50,000 and 100,000 International Units per tablet. No refrigeration is
required.
•
CONNAUGHT MEDICAL RESEARCH LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
|1 MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C.
;i *lk* ZditosA Paaa
We are reproducing in this copy an article written by Dr. A. D. Kelly, (assistant to
Dr. T. C. Routley, General Secretary of the Canadian Medical Association, which we
consider is well worth a careful reading by every medical man.
Dr. Kelly has dealt very objectively with his subject, "Refugee Physicians"—a difficult thing to do, since so often we are prone, in considering whejther or not these men
should be allowed to enter Canada, to be influenced by feelings of pity, or even by
fallacious reasoning as regards the need of more physicians in Canada. It is not easy to
clear one's thinking of these factors, and to avoid the short view—but it is very necessary—and Dr. Kelly's plain statements of fact help us greatly in taking a longer and
more objective view of the subject.
Dr. Kelly has drawn attention also to the fact that there is a section of the population which would like to see a more unrestricted admission of doctors, from more or
less interested motives. One is reminded in this regard of the very thinly-veiled threat
of the Saskatchewan government, recently made, to the effect that if doctors are not
as amenable to its projects of socialised medicine as the government feels they should be,
it may be necessary to let down the bars, and import physicians from the distressed areas
of Europe and elsewhere. In this connection, we would draw special attention to the
point made by Dr. Kelly, that Canada has international obligations which would make
her hesitate to allow the immigration of refugee physicians to Canada, when they are
so badly needed to improve and maintain health conditions in their own countries. The
health standards of Canada are not going to be maintained at their highest level, if
health conditions in other parts of the world are allowed to deteriorate continually.
As Dr. Routley pointed out in his address in Vancouver some months ago—and Dr.
Kelly summarises this part of his address in review—these war-torn countries are desperately in need of medical men. The few they have do not begin to meet this need—
and it would be almost desertion and treachery on the part of physicians, say in Czechoslovakia, to leave the country to which they owe a duty which must be discharged in
their own country, nor can Canada countenance such action.
As regards the need for more physicians in Canada, Dr. Kelly's figures seem to show
that we are fairly well supplied at present, under conditions of medical practice, and
he argues that we shall be able to produce enough to maintain this level. There will he
those who will not fully agree with this—there is a crying need in areas of Canada for
more and better medical service; more general practitioners; more men trained in public-
health. If, too, health insurance becomes an actuality, we shall need many more doctors.
But this is to some extent a matter of redistribution, and it can be met, too, by the establishment of medical schools in some of our Universities, and the expansion of those that
exist. Certainly, it cannot be met by robbing Peter to pay Paul—nor, as Dr. Kelly says,
can we do it by importing inadequately trained men. A gap of seven or eight years in
medical training, in hospital and university teaching, with the enormous loss of medical
schools and medical centres of education, must infallibly have led to a serious deterioration of medical standards of knowledge and practice.
This is not to say that we must not allow the entrance to Canada, under properly
supervised control, by our recognised standards of examination, of men from foreign
lands; as Dr. Kelly says, "Medical immigration to Canada is a continuous process.' This
has always been allowed, and should be. His conclusion is pithy and deserves quotation.
"'It is my opinion that the needs of this country for doctors will best be served by
depending on the product of our own medical schools, augmened by selective immigration of this type."
Page 327
fjviiiii
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REFUGEE PHYSICIANS
By DR. A D. KELLY
Assistant Secretary of the Canadian Medical Association.
The question of the admission to Canada of refugee physicians has recently become
a matter of some public interest. Various opinions on this matter have been attributed
to the Canadian Medical Association, and it appears opportune to examine the problem
and to state my own views based on the appraisal of the opinion of Canadian doctors.
In any discussion of this sort, it is important that we be clear in our terms, and I
would define a refugee doctor as a physician qualified in his own country who through
the dislocation of war or political or racial persecution cannot, or does not desire to
return to his native land to practice medicine. There are undoubtedly among the Displaced Persons of Europe a number of physicians, mainly from the nations of Central
and Eastern Europe, who qualify under this definition. You will note that I do not
include in the classification of refugee physicians those doctors from the United Kingdom, the British Commonwealth, the United States or those democracies in Western
Europe which opposed Nazi and Fascist aggression in the recent war.
Those Canadians who favour the unrestricted immigration of refugee physicians
justify their stand on two main premises: a humanitarian duty, and a means of satisfying a need for more physicians which is said to exist in Canada. In most presentations
of the subject which I have read or listened to, these motives are inseparably mixed.
This is quite natural, as in most of our dealings either as individuals, as organizations,
or as nations, our benevolent impulses are conditioned by a measure of self-interest.
It will scarcely be denied that the medical profession by tradition and by its everyday work is sufficiently humanitarian in its outlook to comprehend the plight of Displaced Persons generally, and of our professional colleagues among them in particular.
Moreover, our viewpoint has of late years been enlarged to encompass world conditions
as they exist and to seek to assist in their amelioration. The receipt service pi several
thousand Canadian doctors in the Armed Forces has given them the opportunity to see
at first hand the medical services of many nations and to compare them with similar
activities in Canada. More recently, Canada and the Canadian Medical Association has
taken a leading pare in the formation of two complementary bodies, the World Health
Organization and the World Medical Association, which have as their primary objectives
"the attainment by all peoples of the highest possible level of health." My senior colleague, Dr. T. C. Routley, General Secretary of the Canadian Medical Association, has
for over a year been actively engaged in the organization of these two great international
health groups, and this work has given him a unique opportunity to learn much about
the world's medical needs. He has been convinced that the shortage of, doctors in large
populous areas of the world is desperate, and that the need for additional medical practitioners is imperative.
Here are some facts reported by Dr. Routley after consultation with the medical
leaders of tjie countries concerned. Czechoslovakia, which had 12,000 doctors in 1939,
lost irretrievably 60% of them during the years of the German occupation; China, with
a population of 400,000,000, has fewer than 12,000 doctors, only one-third of whom are
adequately trained; Liberia, with a population of 2,600,000, has one doctor. Ethiopia,
with a population of 12,000,000, found ijtself after the war without a single doctor or
trained nurse in the country. We have recently learned that 16 physicians trained in
European schools have settled in Ethiopia to practice their profession.
It is possible to point to many other countries where the need is only slightly less,
but by comparison, |the position in Canada is most favourable. As a nation, we have one
qualified physician for every thousand of our population.
It must therefore be a very narrow humanitarian viewpoint which will suggest that
refugee physicians should be brought to Canada when their services are so urgently
required elsewhere.
Page 328 The Parliament of Canada was the first legislative body in the world to ratify the
Charter of the World Health Organiza/tion. In so doing, our country was pledged to
support the instrument of the United Nations which is attempting to improve the health
of all the peoples. The health conditions in Poland and China and Greece and Egypit are
important to Canadians as never before, since an aircraft carrying people from many
nations may arrive at Edmonton or Montreal or Vancouver within less than twenty-four
hours from its departure. Human beings are the commonest carriers of human diseases,
and elaborate precautions must be set up to prevent the introduction of maladies from
other lands. It is therefore elementary public health practice to protect the Canadian
people by raising the standards of health throughout the world.
It is incomprehensible to me that the Government of Canada will so disregard its
international obligations that refugee physicians will be admitted to Canada, when all
indications point to the wisdom of settling them in the needy areas of the globe.
The other half of the question is Canada's need of doctors. I have stated that Canada
is one of the favoured nations in this respect, and I propose to present some figures which
bear upon this assertion.
Just over a year ago, there was published by the Department of National Health and
Welfare a most interesting booklet entitled, "Survey of Physicians in Canada, July,
1946." The information concerning the present supply of physicians and their location
was an up-to-date continuation of the registry established and maintained by the Canadian Medical Procurement and Assignment Board, and predictions of future supply and
demand were obtained mainly from the Report of the National Health Survey, another
war-time activity of the C.M.P.A.B. As of July 1, 1946, there were reported to be
11,901 active civilian physicians in Canada, serving a population estimated by the
Dominion Bureau of Statistics in 1945 to be 12,102,000, giving a ratio of 1 physician to
each 1,017 residents in Canada. At the time, tshere were 1,417 medical officers serving in
the Armed Forces and, assuming that they have now resumed their civilian status, it is
possible to amend these figures to fit present conditions in the Autumn of 1947 as follows:
Active civilian physicians, July, 1946     11,901
Demobilized medical officers 1,417
1947 graduates in medicine :  531
     13,849
From which must be deducted:
Estimated number of M.O. with armed forces  130
Deaths   and retirements 1946-47 (estimated)  300
    •     430
For an estimated total of civilian physicians
at present     13,419  active
Presuming the population to have increased to 12,300,000, (the estimated present physician-population ratio is 1 : 916.
Is this ratio adequate to insure a high standard of medical care to the people of
Canada? It is not possible to give a categorical answer to the question, as no one to my
knowledge has been bold enough to state the ideal or optimum ratio of physicians to
population, and to support his assertion with adequate reasons. Just as it is impossible
to specify the appropriate number of journalists or farmers or cabinet ministers, because
the answer must be qualified by a multitude of circumstances^and conditions, so we
must not indulge in generalizations in respect to the adequacy or inadequacy of our
medical personnel.
However, if we recognize the limitations of the physician-population ratio as a
measuring stick for the adequacy of medical care, it is possible to gain some information
on the position which Canada occupies in relation to other countries by comparing the
respective ratios.
Page 329
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Figures quoted in the House of Cornmons in 1943 show the following countries with
more favourable ratio: U.S.A. 1 - 796; Sweden 1 - 723; Union of South Africa 1 - 728.
New Zealand and the United Kingdom with ratios of 1 - 923 and 1-937 are practically
on even terms with Canada, while the remainder of the major powers of the western
world show ratios which vary from 1,087 in the case of the Argentine to 1 - 1621 in
the cost of U.S.S.R. (in Europe), and 1-1651 in the case of Eire. The only other
member of the British Commonwealth of Nations which can be closely compared with
Canada on the basis of large area and small population is Australia, where the physician-
population ratio is 1 - 1,139, a much less favourable figure than Canada's 1 - 916.
It appears therefore that Canada as a whole is more adequately supplied with physicians than most countries and, speaking broadly, requires no major additions to meet
its present needs.
However, the practice of medicine is not undertaken as a national effort) but as a
very personal relationship between an individual doctor and his patient. This implies a
reasonable distribution of physicians in relation to the people in need of their services.
An examination of the distribution of physicians by provinces, shows considerable disparity .to exist. It is not possible as yet to indicate by provinces the effect of further
demobilization or the annual output of Canadian medical schools, so the following figures
are taken from the Survey of Physicians in Canada, July, 1946:
Population
Province Physicians    Per Physician
Prince Edward Island  74 1,243
Nova Scotia '. 492 1,262
New Brunswick 293 1,597
Quebec j 3,334 1,068
Ontario     4,752 843
Manitoba 706 1,042
Saskatchewan ,        562 1,504
Alberta \ 676 1,222
British Columbia 1,012 938
Before any reasonable judgment of the adequacy or inadequacy of the supply and
distribution of physicians in any specified area can be made, an intimate knowledge of
local conditions is required. The needs of any area depend not only on population but
on many attributes such as economic status, attitude toward medical care, density of
population, topography, climatology, accessibility of transportation, the availability of
facilities such as hospitals, and the location of special facilities for medical care.
It is quite evident from a more detailed study of the distribution of physicians in
Canada that urban communities are more adequately supplied with physicians than are
rural areas. The urbanization of the medical profession is not an isolated phenomenon,
but runs parallel with the growth of cities and the shift in population which has been
evident in Canada for over forty years. It must be remembered also that not all of the
physicians in urban centres are engaged in the direct medical care of the persons within
their respective conununities. In the larger cities, many of the physicians are employed,
in medical schools and hospitals as teachers or post-graduate students, in research, industrial medicine, medical administration and other capacities not directly connected with
practice. Furthermore, there are in urban areas a considerable number of specialists and
consultants who serve a much wider area than the municipality in which they live. It
was shown in the National Health Survey (1943) fthat "concentration of physicians in
urban areas is in large measure more apparent than real insofar as community medical
care by general practitioners is concerned."
Notwithstanding these observations, there are areas in Canada where sparse population, difficult communication and transportation and other factors, combine to make
them unattractive to physicians, and where medical services are scanty or lacking. We
recognize that this situation must be corrected and organized medicine is making every
Page 330 effort through placement services to encourage the location of doctors where no medical
service now exists.
Poor economic conditions in these medically marginal areas are by no means the only
deterring factors to the settlement of physicians. Equally important are the lack of thise
hospital, diagnostic and consultative services upon which the modern practice of medicine is built, as well as the absence of the amenities in the field of education and culture
which the doctor desires for his family.
I would like to make it clear that the importation of refugee physicians will not
correct this lack of medical manpower in certain rural communities. A limited experience in Canada, and a much more extensive experience in the United States, has shown
that foreign graduates very rarely proceed to the areas of greatiest need, but almost
invariably settle in the large metropolitan centres. It is wishful thinking to assume
that the adoption of a policy of wholesale immigration would do anytjhing but accentuate the disparity which has been noted.
The future supply of physicians in Canada will in large measure depend on the
output} of Canadian medical schools. Nine Canadian Universities now teach the full
medical course, and two additional schools will within the next few years be graduating
students in Medicine. In all of these schools registration in medicine is the highest ever,
and a very large proportion of the undergraduates are veterans of World War II.
For the period 1920-1939, the average annual number of graduates was 519;
For the period 1940-1945 (the war years), the average output was 630;
For the period 1946-1952 it is estimated that the graduates will number 627 annually.
In the next five years, 1947-51, it is anticipated that 3,277 new graduates in medicine will be produced. Past experience has shown that ten per cent of these will leave
Canada to follow a career elsewhere, and an additional five per cent will be foreign-born
students who return to the country of their origin. These factlors will reduce the available doctors by 491. During the five-year period, death and retirement of physicians now
active will account for a loss of 1,150 doctors. Deducting these latter two figures from
the estimated output of the schools, we should have 1,586 more doctors in Canada in
1951 than we have today.
The Dominion Bureau of Statistics estimates that the population of Canada may be
from 12,722,000 to 12,943,000 in 1951. Adding present medical manpower to the anticipated net gain, and taking the higher population forecast, the physician-population
ratio in 1951 should be of the order of 1-868, the most favourable figure in Canada's
history.
Future trends in the provision of medical services include the growth of prepayment
plans on either a voluntary or a compulsory basis, and the wide extension of these plans
would undoubtedly increase the demands for the services of physicians. To offset this
possible future requirement, we have two additional medical schools now preparing to
teach the full course and a third University which is seriously considering the establishment of a Faculty of Medicine.
In this discussion, I have attempted to present a medical viewpoint on the question
of the advisability and the necessity of permitting unrestricted immigration of refugee
physicians to Canada. The other important consideration, which would become operative
only if these foreign medical graduates were actually in Canada, relates to their ability
to meet the exacting tests of professional knowledge and skill which have been set up
to protect the Canadian people from practitioners of inferior qualifications. The possession of a degree in medicine is not the final criterion for fitness to practice, and in every
province in Canada there is established by an Act of the Legislature a licensing body
usually called a College of Physicians and Surgeons whose duty it is to demand of applicants for registration proof of preliminary education, evidence of undergraduate training in medicine, equivalent to the course taught in Canadian schools, and usually evidence of having passed the examinations of the Medical Council of Canada. Additional
requirements include evidence of good character and ethical behaviour, and in certain
provinces the applicant for registration must either be a British subject or a Canadian
Page 331
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citizen. It is not in the pubhc interest that any relaxation of the high standards of medical licensure should be permitted either in the case of foreign-trained physicians or for
the graduates of our own schools.
Medical immigration to Canada is a continuous process. I answer every week at least
four letters of enquiry from doctors in the United Kingdom desiring information on the
possibilities of practice in Canada. They are given the facts on medical conditions in
this country as we know them, as well as full information on licensing requirements.
We do not paint a picture of urgent need or unparalleled opportunity, but they are told
that there is always room for a well-qualified man who is prepared to enter rural practice.
Many of these enquirers are already in Canada refreshing their knowledge by a hospital
internship and learning the unfamUiar features of our administration of health and
medical services, and qualifying themselves for the examinations of the Medical Council
of Canada. It is my opinion that the needs of this country for doctors will best be served
by depending on the product of our own medical schools, augmented by selective immigration of this type.
LIBRARY NOTES
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RECENT ACCESSIONS TO LIBRARY:
Surgical Clinic of North America, Symposum on Gynecology, Mayo Clinic Number,
August, 1947.
Diseases of Children, Vol. I, 4th ed. 1947, edited by Dr. Donald Paterson and Alan
Moncrieff.
Diseases of the Breast, 1943, by Charles F. Geschickter.    (Gift of Dr. G. E. Seldon.)
ANNOUNCEMENT
ANNUAL DINNER — VANCOUVER MEDICAL ASSOCIATION
The Annual Dinner of the Vancouver Medical Association will be held in
the Banquet Room of the Hotel Vancouver on the evening of Tuesday, November 18th, 1947, at 6.30 o'clock.
Further particulars will be published in the next issue of the Bulletin.
OPIUM AND NARCOTIC DRUG ACT
Effective November 7th next, Amidone, which is also known as Methadon, and by
various other trade names, is being added to the Schedule of the Opium and Narcotic
Drug Act, and will be administered in precisely the same manner as morphine, heroin or
any other narcotic drug. Amidone is a synthetic chemical, which has not an opium
base, but it definitely possesses addiction-forming and addiction-sustaining liabilities.
You may be interested to know that at the present time, this drug comes under narcotic
control in the United States.
Page 332 TREATMENT OF OCULAR INJURIES IN GENERAL
PRACTICE*
By A. J. ELLIOT, M.D.
Toronto
From the Department of Ophthalmology, University of Toronto, and the Toronto
General Hospital.
Although many serious injuries of the eye require hospitalization and the surgical
care of an ophthalmic specialist, there are a large number of ocular injuries which
the general practitioner may well care for and to which he can render the appropriate
treatment. It is my purpose to discuss the treatment of ocular injuries in general
practice.
Foreign Bodies—Small sharp objects often become firmly fixed upon the conjunctiva or cornea; very frequently the small foreign body becomes lodged underneath the
upper lid and may be retained for a long time, producing much irritation and some
discharge; it may be overlooked unless the lid is everted. The upper lid may be
everted by placing a small probe or a thin pencil horizontally along the skin at the
level of the upper border of the tarsus. With the patient looking down towards his
feet the lid is everted by seizing the lashes and drawing the lid away from the globe.
The foreign body is usually easily located and removed with a small spud or cotton
tooth pick. If there is considerable irritation present, warm, wet compresses are advised t.i.d. followed by the instillation of a soothing antiseptic eye ointment, such as
Boracic Acid 10%, into the fornix.
Particles of steel and emery frequently become imbedded in the cornea, penetrating
into the epithelium or corneal stroma. A record of the visual acuity in both eyes
should be obtained before the foreign body is removed and at the termination of the
treatment. The cornea should be anaesthetized with a suitable local anaesthetic, e.g.
Pontocaine 1% drops or Butyn 2% drops and the cornea thoroughly examined under
strong artificial illumination. It is sometimes not easy to discover a foreign body upon
the cornea. A small lens is very useful in focussing the beam of light on to the
cornea. Having located the foreign body, it should be removed with a sterilized spud.
Frequently a brownish rust-ring remains at the site of the imbedded foreign body and
it is often difficult to remove this in its entirety at the first visit; in these cases ft
is better to remove the rust-ring the following day when it has become loosened and
in some cases removal of the rust-ring should be carried out piece-meal over a 2 or 3
day period. If the cornea or conjunctiva does not appear to be infected an antiseptic
ointment, e.g. Metaphen or Boracic Acid should be instilled into the lower fornix and
a snug-fitting patch applied to the eye. The patient should always be examined the
following day and the cornea stained with aqueous fluorescein 1% to determine whether the epithelium has completely regenerated. Atropine should not be used routinely,
as it is generally unnecessary, and also produces prolonged blurring of vision, sometimes
for days after the cornea is completely healed. However, if the eye is irritable and
remains painful, atropine may well be instilled with resulting amelioration of pain and
marked improvement in the patient's symptoms. The eye should be patched continually
until the cornea is completely healed. Cocaine drops are not recommended as a local
anaesthetic as the corneal epithelium rapidly becomes desquamated with its use. The
continued use of cocaine as a local anaesthetic without a dressing predisposes the eye
to infection—the one complication which is feared in corneal foreign bodies.
*Read before the Vancouver Medical Association Summer School, Vancouver, British Columbia, June 2 - June 6, 1947.
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The immediate removal of multiple foreign bodies in the cornea is sometimes unwise,
as the manipulation necessary for their removal may do more harm than good. A
protective dressing and removal of the more prominent ones at the first visit is often
sufficient, the remainder being removed at subsequent visits or falling out of their
own accord.
The frequency of imbedded foreign bodies in the cornea and the loss to industry
involved in these cases, emphasizing the necessity of the physician advising the use of
protective goggles and other safety measures. Industrial workers should be educated
to go directly to the First Aid station for proper care, and warned against allowing
their fellow workers to attempt the removal of the foreign body.
Large particles of steel and, less commonly, stone, glass, etc., may perforate the
globe. The foreign body may be so small and the accident happen so quickly
that the patient may not experience much pain. There is immediate loss of vision and
if infection occurs, successful removal of the foreign body is not easily effected. These
cases should be referred for specialized opthelmic care.
Intraocular foreign bodies may be overlooked for several days. When a history
of hitting metal on metal is given, such as hammering, a careful examination of the
eyes with x-ray studies of the orbit should be made and if there is a suspicion of an
intraocular foreign body the case should be referred for further care to an eye physician.
Burns and Chemical Injuries.—Burns by hot water, steam, hot ashes, molten metal,
caustics, such as lime, strong acids or alkalis endanger the eyes in two ways, viz. by
injuring the cornea and producing adhesions between the lids and the eyeball. The
immediate care of severe burns is that of protecting the globe bv frequent instillation
of non-irritating oils and ointments. If the burn is caused by caustic, the excess of the
material must be removed by copious irrigation with water. If the burn is severe, the
patient must be admitted to hospital and treatment instituted to prevent adhesions
between the eyeball and lids by using a glass rod well coated with boracic acid ointment. Usually the cornea is involved and in those cases atropine ointment should be
instilled daily. In the most severe cases daily treatment with vaseline or boracic acid
ointment will usually allow the tissues to heal satisfactorily. An eye patch should be
worn until the denuded surface of the conjunctiva and cornea are well healed. The
prognosis should be guarded, however, and care taken to impress the patient with the
gravity of the injury and the necessity for continued supervision.
Exposure to infra-red and ultra-violet light rays frequently results in an acutely
red eye. In such cases the history is important, as the patient must be within a distance of 8 feet from the offending source of light and must be exposed for approximately
30 seconds. The eye condition should be manifested from within 8 to 12 hours. An
anaesthetic ointment, such as epinephrin 1-4,000 and butyn 2%, followed by a patch
on the eye usually relieves the congestion in 24 to 36 hours.
Ocular Contusions.—Injuries by blunt instruments vary in severity from a simple
corneal abrasion to rupture of the globe. The cornea may suffer a simple abrasion from
a scratch by a child's finger, etc. The abrasion may be recognized by the green stain
on the cornea following the instillation of aqueous fluorescein 1%. There is usually
considerable pain, tearing and sensitivity of the eye to light. In these cases boracic
aoid ointment and a snug-fitting eye patch, changed daily, usually will suffice and the
cornea heals in a few days.
If the contusion is more severe, there may be a small haemorrhage in the anterior
chamber lying in front of the iris. The pupil is often large and reacts sluggishly to
light stimulation. The iris may be torn away from its ciliary attachment for a variable
distance. Treatment consists of rest in bed and the application of cold compresses several tmes a day until the haemorrhage is absorbed. Atropine should never be used
as an acute secondary glaucoma may result because of blockage of the filtration angle in
Page 334 the anterior chamber by red blood cells. All cases in which a haemorrhage occurs
within the eye should be given a guarded prognosis, and in some cases it is wise to admit
the patient to hospital.
Case Report: J. C, a male, aged 12, was hit in the right eye by a small rubber
ball following which there was loss of vision. On examination 12 hours later there
was a frank, small haemorrhage in the anterior chamber; the vision was 20/20-2 and
the pupil reacted sluggishly to light. The tension was normal. He was admitted to
hospital, kept quietly in bed, and the haemorrhage in the eye rapidly cleared up. Two
days later, in the middle of the night, he suffered a severe pain in the eye with marked
loss of vision. On ophthalmoscopic examination the fundus details were not visible;
the eyeball was soft to the palpating finger and there was marked circum-corneal injection. The patient was kept in bed for another week at which time the secondary
haemorrhage from the iris absorbed completely and the vision returned to normal.
Treatment of the more serious complications of contusions of the eyeball, e.g. dislocation of the lens, detachment of the retina, haemorrhage into the vitreous, rupture of
the choroid, etc., require the care of an ophthalmic specialist.
Fractures of the walls of the orbit frequently produce emphysema in the tissues
of the orbital lids. This is due to a communication with the nasal air sinuses, air being
forced into the orbital tissues with the blowing of the nose. There is great swelling
with a peculiar, soft crepitation on palpation of the eyeballs. X-ray examination will
usually demonstrate a small fracture. The treatment of simple contusions with
ecchymosis of the lids requires only cold compresses. Emphysema should be treated
with a pressure bandage and all straining, blowing of the nose, etc. should be avoided.
Laceration of the lids.—Lid lacerations should be repaired at once, unless signs of
infection are already present, the edges being apposed as accurately as possible with fine
silk. These lacerations may be either horizontal or vertical. The horizontal ones take
the general direction of the fibres of the orbicularis muscle and do not tend to gape;
they usually heal without appreciable scar formation and require few sutures. Vertical
wounds tend to gape widely and a serious deformity of the lid results if careful apposition
is not secured. Lacerations through the lid margin require meticulous repair if the
result is to be both cosmetic and functional. The least debridement possible should
be done, and fine silk sutures on atraumatic needles used. The most important suture
to be placed is that uniting the intermarginal groove. This is the grey line situated
between the openings of the Meibomian glands and the eyelashes. The lid border will
be in perfect alignment if the first suture placed passes through this line, down into the
substance of the tarsus, and then across the line of laceration to enter the tarsus at
the same distance from the lid border and comes out in the intermarginal line on the
other side of the laceration. The sutures and knots should never be left in contact
with the corneal surface since the movement of the globe will cause abrasion and
scarring. In the care of severe lacerations where dirt has been carried into the wound,
it is safest to give a prophylactic injection of anti-tetanus serum.
Conjunctival Lacerations.—These usually heal spontaneously and require suturing
only if there is wide separation of the edges of the wound. Sub-conjunctival haemorrhage should be treated with cold compresses for the first 48 hours, after which time
absorption of the blood may be hastened by the use of heat.
Conclusion.—I have reviewed the treatment of ocular injuries which may be well
cared for by the general practitioner. The majority of such injuries can, and should
be, the responsibility of the physician first seeing the patient. In all cases it is important to record the visual acuity at the outset and at the termination of treatment as
so frequently this information is.required if further care is necessary, or subsequently
compensation for loss of vision is sought. The physician would be well advised to
refer the more serious ocular injuries inunediately to an ophthalmic specialist for more
detailed examination and treatment.
Page 335
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OPHTHALMIC INDICATIONS OF SYSTEMIC DISEASE*
By A. J. ELLIOT, M.D.
Toronto
From the Department of Ophthalmology, University of Toronto, and the Toronto
General Hospital.
There are a number of systemic diseases which exhibit ocular manifestations that
may be of diagnostic and possibly prognostic importance to the physician. It is my
present purpose to discuss briefly a few of these diseases.
In the investigation of these cases there are certain points in the ocular history
about which the physician should inquire. Has there been a loss of vision and if so
was it gradual or sudden in onset? Is it in one or in both eyes? A Snellen chart is
always available to record the visual acuity. Does the patient complain of a loss of
part of his visual field? Detailed studies of the visual fields on a perimeter are not required as these may quickly be determined by the confrontation method, using a small
white-headed pin. Has the patient complained of double vision? A pencil flashlight
is all that is required to test the motility of the extra-ocular muscles.
Of fundamental importance is the actual and symmetrical size of the pupils and
their reaction to light and accommodation. The direct and consensual reaction to
light should be noted. The accommodative reaction may be determined by having the
patient look at a close object such as the examiner's finger held at about six inches from
the eye.
Ophthalmoscopic study through the undilated pupil may be made easier by instructing the patient to turn the eye slightly inwards. This will prevent the sudden
constriction of the pupil and will allow inspection of the optic disc and adjacent retina.
When the pupil is too small for satisfactory ophthalmoscopic examination a few drops
of homatropine 1% may be safely used to partially dilate the pupils.
I shall now discuss a number of ophthalmic manifestations which indicate general
disease.
Infectious Diseases.—Measles, scarlet fever, influenza and certain cases of pneumonia not uncommonly are accompanied by conjunctival inflammation, corneal ulceration or iritis. Herpes zoster may give rise to severe iritis and iridocyclitis with
resultant loss of vision. Diphtheria sometmes causes paralysis of accommodation with
blurring of vision at the reading point and, more rarely, paralysis of the external rectus
muscle. Erysipelas may cause abscesses and gangrene of the lids, orbital cellulitis and
thrombosis of the orbital veins and cavernous sinuses. Animal parasites may infect the
eye; trichinosis is perhaps the most common; the larvae lodge in the eye muscles, producing localized inflammation with tenderness and pain on movement of the eye and
oedema of the eyelids.
Diseases of the Respiratory Tract.—Conjunctival haemorrhages are common in
whooping cough and retinal haemorrhages may also occur. Herpes frequently occurs
in pneumonia. Infrequently there is a blood-born bacterial infection to the retina and
choroid in pneumonia. This is a metastatic infection and in most of these cases the
eye is lost, the ocular inflammation being a complication of the illness.1
Case Report J. S., a male aged 28, became ill with lobar pneumonia and 14 days
later he complained of marked swelling of the eyelids and bulbar conjunctiva. The
eye became proptosed and the cornea opaque; there was rapid loss of vision. A diagnosis
of Metastatic Panophthalmitis following lobar pneumonia was made. The eyeball
perforated subsequently and a heavy growth of haemolytic streptococcus was cultured
:A<
■'McKee, S. H.: Metastatic Ophthalmia in a Patient with Pneumonia, Arch. Ophth.  15:787, 1936.
*Read before the Vancouver Medical Association Summer School, Vancouver, British Columbia, June 2 to June 6, 1947.
Page 336 from the conjunctiva at the site of the slough.    The eye continued to atrophy and
later it was removed for cosmetic reasons.
Diseases of the Circulatory System.—
In Essential Hypertension the diagnostic points of retinal arteriosclerosis are compression of the veins at the arteriovenous crossings, narrowing and irregularity in the
calibre of the retinal arteries and flame-shaped haemorrhages alongside the vessels.
Arteriosclerotic retinitis is a further stage after the above changes have been present
for some time. Hard white exudates are present between the disc and the macula
and at times there is an irregular macular star or fan. There is usually no oedema
at the disc nor large cotton wool patches of exudation.
A detailed ophthalmoscopic study of the retina is important when considering the
advisability of Smithwick's sympathectomy for the surgical relief of hypertension.
Malignant Hypertension is the malignant phase of essential hypertension in which
the increased intracranial fluid pressure results in headache, loss of vision and papil-
loedema. These patients often first present themselves at eye clinics. The fundus
picture reveals a bilateral papilloedema with numerous flame-shaped haemorrhages
alongside the blood vessels. The exudates are soft, cotton wool patches and macular
star may appear later.
Digitalis Intoxication with visual hallucinations may occur when this drug is
being used in normal amounts in auricular fibrillation. This results in yellowish-
green vision which usually disappears within 2 or 3 weeks following cessation or
reduction in the dose of digitalis.2 It is thought to be a visual hallucination due to
cortical stimulation from digitalis intoxication and is frequently associated with
depression of electro-cardiagraphic ST wave.
Diseases of the Kidneys.—Blindness occurs^in cases of uraemia, particularly in acute
nephritis, e.g. pregnancy and scarlet fever. It is also found with chronic nephritis.
The onset of blindness is sudden—in a matter of hours and is bilateral and complete.
The fundus shows no changes unless there is a co-incident albinuric retinitis. The
vision usually improves in 10 to 18 hours and may be restored in about 48 hours.
Loss of vision is due to the circulation of toxins in the visual centres. Bilateral
detachment of the retina may occur in eclampsia; the detachment usually clears
up on termination of the pregnancy.
Albuminuric Retinitis usually refers to chronic nephritis with hypertension. Retinal lesions are rare in chronic nephritis without hypertension. In albuminuric
retinitis papilloedema is present but is less marked than in malignant hypertension and
is not confined to the area around the disc but spreads extensively into the surrounding retina. The retinal vessels show the changes of arteriosclerosis and flame-shaped
haemorrhages are present alongside the vessels. Well marked soft cotton wool exudates with blurred edges are usually found around the disc. The macular star figure
is present and the retina has more pallor than in malignant hypertension.
Diseases of the Blood.—Retinal haemorrhages frequently accompanied by white
spots or exudates in the centre of the haemorrhage often occur in the secondary
anaemias of carcinoma and are prominent signs in pernicious anaemia and leukaemia.
Great loss of blood may result in a marked loss of vision which is often permanent.
Ophthalmoscopic exaniination in these cases reveals the bilateral pale discs of optic
atrophy. The optic atrophy is thought to be due to degeneration of the retinal
ganglion cells and their nerve fibres from the toxaemia of the haemolysis.
Case Report: L. B., a male age 60, suffered recurrent haemoptyses from a duodenal
ulcer. On one ocasion the haemoglobin fell to 28.5% and on leaving hospital a month
later he complained of blurring of vision. Six weeks following this severe haemoptysis
it was noticed that both optic discs were slightly pale and that the visual acuity was
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2Carroll, F.: Visual Symptoms Caused by Digitalis, Am. J. Ophth. 28: 373, 1945.
Page 337 I '
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reduced and could not be improved with lenses.    The visual acuity was not altered
on examination two years later.
Diseases of the Organs of Digestion.—Oral sepsis, especially pyorrhoea, is an important cause of iritis and may cause inflammation deeper within the eye, such as
choroiditis. Mal-development of the enamel of the teeth in children is frequently
associated with congenital cataracts.
Case Report: G. C, a boy aged 9, was referred by the school nurse because of
defective vision and retarded progress in school. On examination with the pupils dilated
there was a congenital lamellar cataract in both eyes. There was marked hypoplasia
of the enamel in his permanent teeth which had an eroded appearance with transverse
lines across them, the incisors and canines being most affected.
Metabolic Diseases.—
Thyroid Disease and Exophthalmos. Deficiency in function of the thyroid gland
results in myxoedema and cretinism which give rise to swelling of the eyelids and
sometimes produce changes in the lenses. Hyperactivity of the thyroid gland constitutes the disturbance known as exopththalmic goitre or Graves' disease. Although
the ocular symptoms are not an essential part, the eyes exhibit one of the most striking manifestations of the affection.    Some or all of the following may occur:
The exophthalmos is usually bilateral but unilateral proptosis does occur. Also
the cardinal signs of exophthalmic goitre, e.g., lid lag retraction of both upper and
lower lids, may be more marked on one side. There are cases of exophthalmos without thyroid intoxication in which there is a paralysis of the extraocular muscles. Also
there are cases of very severe exophthalmos in which there is oedema of the lids and
conjunctiva. There is danger of corneal ulceration in marked exophthalmos if the
lids are not sutured together.
In addition to the above causes of •exophthalmos there are sinus disease, sinus
mucocele, carcinoma of the antrum, meningioma, aneurysm of the cavernous sinus
and orbital cellulitis. These more commonly result in unilateral proptosis. In examining for unilateral exophthalmos it is wise for the examiner to stand behind the
patient and look down over the patient's forehead so as to compare the relative
amount of protrusion of each eyeball.
Diabetes. Ocular complications are common in diabetes mellitus but bear little
relation to the severity of the disease. They occur chiefly in longstanding cases and
are not usually seen in younger individuals with severe diabetes. Remarkable changes
in the refraction of the eye, both in the direction of hypermetropia and myopia, not
infrequently occur in diabetes due to alteration in the refractive index of the cortex
of the lens brought about by osmotic changes. This may be characterized by a
sudden decrease in vision which had previously been normal or may take the form
of repeated smaller changes in vision necessitating frequent changes of glasses.
The ability to use the eye for close work may become impaired in some diabetic
patients, because of a weakened condition of the accommodation. This invariably
necessitates a stronger lens for reading and close work. Occasional cases of paralysis
of the extraocular muscles are also encountered. The sixth nerve is the one most
frequently affected by impaired action of the external rectus muscle.
The occurrence of cataract in patients suffering from diabetes is very common
especially among older patients but it is observed infrequently in diabetic children.
The development of a senile cataract in diabetes bears a closer relationship to the
duration of the diabetes rather than to the severity of the disease A true diabetic
cataract is rare and occurs in a younger age group and differs from the ordinary type
of senile cataract found more commonly in older diabetics.
In diabetic retinitis both eyes are nearly always affected but not necessarily to the
same extent. As diabetes is a disease more common in middle life, arteriosclerosis of the
retinal vessels is present and vascular hypertension is closely associated. On ophthalmo-
Page338 scopic examination the optic discs are usually found to be normal, and the retinal vessels show few changes other than those associated with the patient's age. The haemorrhages and exudates are well defined and characteristic; they are small and deep and
are usually not close to the blood vessels. The exudates are opaque, white and shiny,
usually placed centrally at the posterior pole of the fundus. At first the exudates
appear white but may soon take on a glistening, yellow, waxy appearance. Retinal
oedema, papilloedema and soft cotton wool patches do not usually occur in diabetic
retinitis. Many patients continue for years with only gradual or slight loss of vision,
unless the haemorrhages occur in the macula in which case there is a serious impairment of vision.
Less common ocular complications of diabetes are retrobulbar neuritis, vitreous
haemorrhages and retinitis proliferans, lipemia retinalis, diabetic iritis, hypotony in
diabetic coma and optic atrophy.
Rheumatoid Anthritis. Chronic rheumatoid arthritis is sometimes associated with
low-grade iritis in one or both eyes.3 As a rule the ocular inflammation is minimal and
the patient complains of slight pain in the eyes at night time but there is rather
rapid loss of vision. Atropine ointment 1% should be instilled into the eyes three
times a day. Relief from pain may be obtained from the use of warm, wet compresses
to the eyes three times a day along with sodium salicylate gr. x by mouth t.i.d. .
Diseases of the Generative Organs.—
Gonorrhoea. The ocular complications from gonorrhoea are serious and frequently
result in loss of vision in the eye if it is not effectively treated. Gonorrhoeal conjunctivitis is more serious in adults than in babies but fortunately it is comparatively rare.
Gonorrhoeal iritis is probably more common than is generally supposed. It frequently
follows an attack of gonorrhoeal arthritis, usually in the knees. The patients are
almost always men and both eyes may be affected, though not at the same time. Immediate instillation of atropine 1% with the usual supporting treatment for acute
iritis is necessary to prevent adhesions forming between the iris and the lens with the
resultant loss of vision.
Syphilis. Interstitial Keratitis occurs in congenital luetics, more frequently in girls
than in boys between the ages of 5 and 12. After slight irritative symptoms with
some redness of the eye, one or more hazy patches appear on the cornea until finally
the whole cornea becomes lustreless and dull. In 2 to 4 weeks the cornea becomes
vascularized and the whole eye has a dull reddish-pink "salmon" appearance. Active
treatment of the iritis with instillation of atropine 1% several times a day is necessary. In practically all cases the vision improves remarkably and, in the majority,
the residual visual loss is not great.
Syphilitic iritis occurs from 3 to 6 weeks after the primary infection. It rarely
affects both eyes simultaneously but very often the two eyes in succession. Secondary
syphilitic iritis accounts for about 15% of the cases of acute iritis in adults.
Disseminated patches of choroiditis due to syphilis are not uncommon and are
usually scattered about in the periphery of the retina; usually both eyes are affected.
These patches are sharply outlined with black pigment, in the centre of which are
areas of choroidal atrophy.
Optic neuritis may occur during the secondary stage of syphilis. It develops 6
to 8 months after the primary chancre. The retina, and often the vitreous, becomes
blurred and hazy and there may be well-defined white patches of exudation near the
optic disc.
Summary.—In conclusion, although the above remarks were of necessity briefly
presented in a somewhat dogmatic fashion, my purpose was to call your attention to
the help that these ophthalmic indications of systemic disease can give to the physician
in solving some of the problems with which he is so often confronted.
sSorsby, A. and Gormaz, A.: Iritis in the Rheumatic Affections, Brit. Med. J. 4450:597, 1946.
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OCULAR FINDING IN IMPORTANT NEUROLOGICAL
2       CONDITIONS* J|
By A. J. ELLIOT, M.D.
Toronto
From the Department of Ophthalmology, University of Toronto, and the Toronto
General Hospital.
The general practitioner is frequently requested to examine patients in whom symptoms of intracranial lesions are found or suspected. It has been said that the practitioner
should regard the opthalmoloscope as an instrument as valuable as a stethoscope. He
will find the ophthalmoscope distinctly useful in the diagnosis of many obscure cases.
With a little experience he can learn to detect the pathological alterations important
in the diagnosis of intracranial tumours, viz. optic atrophy and papilloedema.
Pupils.—Normally the pupil measures from 2.5 to 4 mm. The pupil is usually
smaller in hyperopia than in myopia, and it is small in infancy and old age. A dilated
pupil may follow trauma, the use of a mydriatic, a psychic stimulus, stimulation of the
cervical sympathetic nerve, glaucoma, or paralysis of the III nerve. Miosis or contracted pupil will result from the use of a miotic, from synechiae, from stimulation
by light or accommodation, in acute iritis, following the administration of morphine, and
in paralysis of the sympathetic nerve or stimulation of the III nerve.
The physician should note whether the pupil of one eye is equal in size to the
pupil of the other eye and whether it remains so as the intensity of the illumination
is increased. If the inequality in the size of the pupils (anisocoria) exists it may be
considered physiological if both pupils react alike to all stimuli and to the instillation
of cocaine.
In examining the direct and the consensual pupillary reactions to light, care
should be taken to ensure that the patient is regarding a distant object and the eyes
are well shaded. Note if the constriction of the pupil is well maintained as the lack
of sustained constriction is of diagnostic significance in acute retrobulbar neuritis. In
testing the accommodative-convergence response, have the patient look in the distance
and then quickly have him look at the index finger of the examiner held six inches
from the patient's eyes.
If the pupils do not react to light but do react to accommodation-convergence they
are called Argyll Robertson pupils. These pupils are small, irregular in shape and
often unequal in size. They dilate slowly and unevenly with atropine and do not
constrict after the instillation of eserine. The fully developed Argyll Robertson pupils
are most frequently seen in tabes but they occur at times in disseminated sclerosis, encephalitis, diabetes, midbrain tumours, chronic alcoholism, syringobulbia and in trauma.
The lesion is thought to be somewhere between the point where the pupillary fibres
leave the optic tract and the constrictor centre in the III nerve nucleus.
The myotonic (or Adie's) pupillary reaction resembles the Argyll Robertson but
occurs in the absence of all signs of syphilis. The tonic pupil is always larger than
its fellow and there is a very sluggish reaction directly and consensually to continued
light stimulation and to accommodation. It is more common in young women and is
often asymptomatic but in others there may be a blurring of vision. The tendon reflexes may be absent. The pupil dilates after remaining in a dark room and eserine
constricts the pupil as in the normal pupil.
In Horner's syndrome the pupil is small and there is an incomplete ptosis with a
slight enophthalmos. The lesion may be in the descending sympathetic fibres from
the hypothalamus or in the cervical sympathetic chain and as a result the pupil cannot
be dilated on instillation of cocaine.    The most frequent causes of Horner's syndrome
* Read before the Vancouver Medical Association Summer School, Vancouver, British
Columbia, June 2 - June 6, 1947.
Page 340 are spinal cord tumour and syringomyelia above the second thoracic segment. Less
commonly enlarged lymph nodes, cervical rib, aortic aneurysm, mediastinal tumour,
oesophageal disease and trauma produce the syndrome.
Traumatic paralytic mydriasis may occur after contusion to the eyeball and is
probably due to damage to the short ciliary nerves in their passage through the
ciliary body. The pupil usually remains moderately dilated and is accompanied by a
loss of accommodation.
Optic Atrophy.—The distinction between primary and secondary optic atrophy is
an ophthalmoscopic one rather than a pathological differentiation; the essential feature
in both instances is a pallor of the disc. In primary optic atrophy the edges of the
disc are sharp, the vessels appear normal and the physiological cup is not filled in; whereas in secondary optic atrophy the disc margins are blurred, the vessels are contracted
and the physiological cup is obliterated.
The chief cause of primary optic atrophy is tabes. It may be the first sign and
other signs and symptoms may be long delayed. The patient should be examined
for the presence of Argyll Robertson pupils; the pupils are small, often irregular in
shape and unequal in size, and there is absence or impairment of the light reflex with
marked accentuation of the accommodative response. The visual fields show progressive peripheral contraction which may result in blindness in a year or two. Less common causes of primary optic atrophy are disseminated sclerosis, cerebral tumours, certain
hereditary diseases and poisons such as lead, methyl alcohol and quinine.
Secondary optic atrophy follows long-standing cases of papilloedema and optic
neuritis. The opthalmoloscopic appearance is due to inflammatory reaction and the
production of fibrous tissue at the nerve head.
Papilloedema—or choked disc, is due to a swelling of the optic nerve head as a
result of increased intracranial pressure or interference with the venous circulation of
the orbit. Intracranial sinus thrombosis and subarachnoid haemorrhage are causes of
such swelling.
In the early stage of papilloedema the retinal veins are congested and the disc is
pink, the margins are blurred above, below and nasally, and the physiological cup
is filled in. Minute pin point haemorrhages should be noted as their presence will
differentiate this stage from the similar appearance of the disc in high degrees of farsightedness. In the later stages the nerve had is well elevated, the retinal veins are
distended, haemorrhages are marked and a macular fan may be seen.
Symptoms may be extremely vague at first. The central vision may be quite normal
in which case the pupils will also be normal in size and reactions; this is important
to remember and emphasizes the importance of examining the fundus in all cases complaining of headache. However, well developed papilloedema may be present without
a history of headache. Normal vision usually remains for a long time after papilloedema has become established. At times there may be transient periods of blurred vision
lasting for a few minutes or an hour or two. However, the visual acuity may remain
practically unaltered or, if it is diminished slightly, the visual loss bears no direct
relationship to the amount of swelling of the discs. If the increased pressure of the
intracranial fluid persists, optic atrophy results with permanent loss of central vision
even to complete blindness.
Case Report.—D. B., A married woman, aged 42, complained of frontal headache
of three years' duration and blurring of vision for one year. Her glasses were changed
several times without improvement of vision. During the previous three years she
had noticed progressive loss of smell. On examination the vision in the right eye was
5/200 and in the left eye 20/30. The right optic disc was pale; the disc margins were
blurred and the blood vessels were sheathed as they left the optic nerve head, indicating
papilloedema with advanced secondary optic atrophy. There was marked papilloedema
of die disc in the left eye but no pallor. The right visual field was contracted inferiorly
while the left visual field revealed enlargement of the blind spot.    The sense of smell
Page 341
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was defective. X-ray examination of the skull showed an area of increased vascularity
and erosion of bone in the left supraorbital region. Ventriculography revealed a shift
of the ventricles to the right with a backward displacement of the left lateral ventricle.
A diagnosis of Meningioma of the Olfactory Region was made. A large Meningioma
was removed successfully at operation.
There are instances, especially after a recent head injury, where the disc appears as
if an early papilloedema were present. In these cases a study of the visual fields is of
assistance in differentiating a pathological disc from a normal one with blurred margins.
The earliest visual field sign in papilloedema is an enlargement of the blind spot due
to oedema at the disc. If this oedema involve the macular area, there may be a blurring
in the central part of the visual field. In the later stages the visual field indicates a
concentric contraction, which marks the onset of optic atrophy and consequent loss
of vision.
The diagnosis of papilloedema is not difficult in severe cases; however, it may be
exceedingly so in slight cases. The higher degrees of astigmatism cause apparent blurring of the disc margin, and in markedly far-sighted eyes the disc has the appearance
of papilloedema although it is due only to the shortness of the eyeball. In such cases
attention must be directed to other signs, such as exudates or haemorrhages. In some
cases it is necessary to keep the patient under observation for a period before the
presence of papilloedema may be definitely ascertained.
Optic Neuritis and Retrobulbar Neuritis.—These result in a loss of central vision
usually in one eye and commonly in the young adult. There may be pain in and around
the eye on movement of the globe or on digital pressure over the insertion of the superior rectus muscle. Often the contraction of the pupil is not sustained on prolonged
stimulation by light.
In optic neuritis the inflammation is at the nerve head, and on ophthalmoscopic
examination there is hyperaemia of the disc with blurring of its margins up to five
dioptres of swelling. In retrobulbar neuritis the inflammation is behind the nerve head
and the optic disc appears normal. This latter condition has given rise to the aphorism, "the patient sees nothing and the doctor sees nothing".
Visual field examination is important in both conditions and a large central scotoma
is always found sooner or later.
In the majority of these cases the patient later develops Disseminated Sclerosis; a
careful neurological examination is thus indicated-. In some, many years may pass
before other manifestations of this sclerosis appear. The local inflammation in the
optic nerve subsides in 2 or 3 weeks in the majority of cases with a return of normal
vision.
Less commonly, Bilateral Retrobulbar Neuritis with central scotomata occurs in
Disseminated Sclerosis, Methyl alcohol poisoning and certain hereditary optic atrophies.
Case Report—J. P., a married woman aged 29, complained of pain over her right
eye and pain on movement of the eye. The following day she noticed a blurred area
in the centre of her right visual field and the pain on movement of the eye was diminished. Ten years previously she had had a right foot drop with loss of skin sensation
from the waist down which remained three months. Ocular examination at the present
time revealed marked loss of vision in the right eye with normal vision in the left eye.
There was lack of sustained constriction of the right pupil to light. There was pain
on palpation over the insertion of the superior rectus muscle of the right eye. The
field of vision revealed a large central scotoma which was outlined by the examiner
sitting in front of the patient using a white-headed hat-pin. Ophthalmoscopic examination showed normal discs in both eyes. A diagnosis of Retrobulbar Neuritis of the
right eye was made. In one month the vision of the right eye had returned to normal.
Neurological consultation was advised in view of the previous history and a provisional
diagnosis of Disseminated Sclerosis was made.
Ocular Palsies.—Ocular palsies may be supranuclear, nuclear or infranuclear. If
the paralysis be in terms of movements of both eyes the lesion is either in the nucleus or
Page 342 supranuclear in the cerebral hemispheres. Infranuclear palsy is the common finding in
which an isolated muscle is paralysed. The third and sixth nerves are affected more
frequently than the fourth.
In third nerve palsy there is a partial or complete ptosis; the pupil is dilated and
there is no reaction to light or accommodation and the eye is turned downwards and
outwards. In sixth nerve palsy the eye is deviated inwards and there is a constant and
annoying double vision. A paralysis of the sixth nerve cannot always be used to determine the site of the intracranial lesion as it is often a false localizing sign.
There are numerous causes for ocular palsy. Trauma frequently affects the third and
sixth nerves. Of the inflammatory causes syphilis is the most important and may take
the form of a gummatous meningitis or tabes dorsalis. Other inflammatory lesions
are pneumococcal meningitis and chronic otitis media with petrositis. Disseminated sclerosis practically never involves the third nerve while the sixth nerve is frequently
affected. Of the neoplasms producing ocular palsy there are meningiomata of the
lesser wing of the phenoid, metastases to the orbit, and carcinoma of the naso-pharynx.
Vascular lesions from intracranial aneurysms, diabetes and hypertensive accidents are
not uncommon causes of ocular palsies.
Hemanimopia.-~llemamzxiopia. denotes the loss of half of the visual field. The
commonest clinical form is homonymous hemanianopia in which the left or right half
of the binocular field of vision is lost; this condition may be due to a lesion situated
in any part of the visual paths from the occipital lobe to the chiasma. Disease in this
area causes loss of vision in the corresponding halves in each retina, which results in
loss of the opposite halves in the visual fields. Right hemanianopia is more quickly
discovered than left, owing to the fact that reading is impossible. The majority of
cases of hemanianopia are due to lesions in the occipital lobe or optic radiations; the
chief causes are injury by blows on the back of the head or gun-shot wounds, brain
tumour, cerebral softening due to syphilis or thrombosis of the blood vessels supplying
the occipital cortex.
Lesions between the eyeball and the optic chiasma produce severe damage to only
one eye. As a rule, lesions in the chiasma affect both visual fields. A pituitary tumour
may result in bi-temporal hemanianopia and, if it grows asymetrically, may cause
blindness in one eye and loss of the temporal field of vision in the other. Enlargement
of the pituitary body leads to visual defects in about 80 per cent of the cases due to
pressure upon the chiasma which lies immediately above, and upon the inner sides of
the optic tracts. The visual field is lost from the temporal side and from above downwards, finally involving the nasal field and leading to complete blindness of the affected
eye. Soon the vision of the other eye becomes affected in a similar manner. Ophthalmoscopic examination frequently reveals normal discs, or, if the tumour has been present
for a considerable time, there may be pallor in the temporal portion of the discs. Papil-
doedema or choking of the disc is not commonly found in pituitary tumours. In all
cases x-ray studies of the skull should be made and often the sella turcica will be found
enlarged.
Case Report:—R. W., male, aged 25, complained of dull coronal headaches for
the past year and a half, infrequent in periodicity and varying from 2 to 6 hours in
duration. He noticed that his lower jaw had enlarged during the past two years. Ocular
examination revealed 20/15 vision in both eyes. Visual field examination with a 1 mm.
test object at 1 meter's distance indicated contraction of the upper temporal fields of
both eyes. X-ray examination revealed a normal condition of the sella turcica. A
provisional diagnosis of early acromegaly was made. In view of the commencing visual
field loss, radiological therapy to the pituitary body was given.
In conclusion, it is a well-established fact that the eye findings are most important,
clinically, in many neurological conditions. The diagnosis will often be delayed if the
physician ignores these ocular complaints; whereas, familiarity with some of the more
common ocular manifestations will, in many instances, lead to the correct diagnosis.
Hllil
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THE DIFFERENTIAL DIAGNOSIS AND TREATMENT
1 OF AN ACUTELY RED EYE*
By A. J. ELLIOT, M.D.
Toronto
From the Department of Ophthalmology, University of Toronto, and the Toronto
General Hospital.
An acutely red eye is a not uncommon medical condition with which the general
practitioner is confronted. In its minor forms there may be only slight discomfort and
no loss of vision, but in its more serious types it may be fraught with disastrous results
and even blindness. It is my purpose to review briefly the differential points in the
diagnosis of acute conjunctivitis, acute iritis, and acute glaucoma and in each case to
mention the accepted forms of therapy which the general pactitioner may utilise.
Of the three conditions mentioned above, the differential diagnosis of acute glaucoma and acute iritis is of the utmost importance since the treatment of the two is
diametrically opposed, atropine being a necessity in iritis and disastrous in glaucoma;
on the other hand, it is not necessary or wise to use atropine incUscriminately in cases
of acute conjunctivitis where local antiseptics are all that are required in the more
benign forms of inflammatory conditions of the conjunctiva.
Conjunctivitis.—Acute conjunctivitis is a common condition which in its minor
degrees causes more discomfort and annoyance than its seriousness warrants, but which
in the more aggravated types may result in marked loss of vision.
Clinically there are two groups:
1. Those which run an acute course and when successfully treated leave no permanent damage. This group includes simple acute conjunctivitis or "pink eye", and inflammation of greater severity, such as gonorrhoeal conjunctivitis.
2. Those which run a chronic course exhibiting hyperplasia to a marked degree
and tend to leave permanent defects. In the latter group trachoma is the chief example.
Signs and Symptoms.—The typical signs and symptoms of conjunctivitis are redness, swelling, pain and conjunctival discharge. Redness occurs from hyperaemia of
the blood vessels of the conjunctiva and sometimes from minute haemorrhages. Swelling
varies from a barely perceptible oedema to a swelling so intense as to render the lids
and globe immobile. Pain is always present in acute cases and these patients complain
of a sensation of sand or grit in the eye. The inflammatory reaction affects all the
neighboring glands; the tears are excessive, the Meibomian glands are stimulated, the
mucous secretion of the conjunctival cells is greatly increased, small pledgets of mucus
are seen in the tears, and in more severe case pus cells mingle with the discharge in large
numbers. The discharge may become muco-purulent and in severe cases frankly purulent. In intense inflammation the initial discharge may be serous or sanguinous and
the discharges readily dry on the edges of the lids, sealing them down. In mild cases
there is some blurring of vision while in severe cases the blurring is more marked
because of the swelling of the corneal epithelium.
Bacteriological Investigation.—Bacteriological study of the secretion is important
in order to determine the aetiological agent. This examination includes smears, scrapings and cultures of the conjunctiva. The cultures are taken with sterile cotton
swabs moistened in 1% glucose infusion broth and then streaked over the surface of a
blood agar plate. The smears and cultures should be taken directly from the surface
of the conjunctiva. The smears are stained by the Gram method and the scrapings
by the Giemsa stain.
Treatment of Acute Conjunctivitis.—As in all diseases the most important factor
in the treatment is prophylaxis, and once it is developed, the prevention of its spread.
Its spread among contacts should be guarded against by scrupulous care of the hands,
handkerchiefs, towels and other possible sources of contamination with the discharge.
* Read before the Vancouver Medical Association Summer School, Vancouver, British Columbia, June 2 - June 5, 1947.
Page 344 In wiping the eyes, cotton wool or tissue handkerchiefs should be used and then destroyed. The affected eye should not be bandaged or treated with the old fashioned
remedy of poultices of tea leaves, oatmeal or bread. Care should be taken to keep
the lids open. If photophobia is present dark glasses may be advised. Before bedtime
the conjunctiva should be smeared with an ointment to prevent the lids from sticking
together.
The most important single factor in the treatment of acute conjunctivitis is the
frequent washing out of the conjunctival sac for its mechanical cleansing action. Warm
boracic or saline bathings several times a day with cotton wool pledgets are advised.
Local treatment consists of the application of drugs to the eye by lotion, drops or
ointments. Drops are instilled into the lower fornix after the lower lid has been pulled
down. A large number of drops are in use. Some of the more common are: zinc sulphate gr. l/c\ to the ounce, boracic acid gr. 1 to the ounce, argyrol 10%, sulphonilamide
or sulphathiazole drops 0.8%, sodium sulphacetamide drops 2^4 to 10% and penicillin in
saline 200 to 1,000 units per c.c. Ophthalmic ointments may be used instead of drops.
The most frequently used eye ointments are: mercury bichloride 1:2,500, metaphen
1:3,000, sulphathiazole 5%, sodium sulphacetamide 2J_%, and penicillin 200 to 500
units per gram. These ointments should be instilled into the lower fornix 3 or 4 times
per day.
The most serious acute conjunctivitis which must be diagnosed as soon as possible
is gonorrhoeal conjunctivitis. In this condition penicillin drops 1,000 units per c.c.
are instilled into the conjunctival sac every hour. Frequent copious irrigation of the
conjunctival sac with boracic acid or saline solutions are required. Intramuscular injections of penicillin should be given. Great care must be taken to prevent the infection
from spreading to the other eye and to other individuals.
Ophthalmia Neonatorum.—It is important to remember that Ophthalmia Neonatorum is not always caused by gonorrhoeal infection. In one series1 of 261 cases of
Ophthalmia Neonatorum reported in the United tates 51% were due to staphylococci,
13% were pneumococcal, 8.8% demonstrated epithelial inclusion bodies, and only
0.5% were gonococcal. However, these figures vary in different centres, as McKee2
in Montreal found 20% of 55 cases of Ophthalmia Neonatorum due to the gonococcus
and 65% demonstrated epithelial inclusions.
Inclusion conjunctivitis of the newborn begins acutely from the 5 th to the 8 th
day after birth and is characterized by severe conjunctival inflammation with oedema
and infiltration which is most marked in the lower lid. The acute stage lasts 2 to 3
weeks and is followed by a chronic stage of some weeks' duration. The prognosis is
good and a return to normal may be expected in all cases. The condition responds well
to the sulphonamides locally and systemically. The diagnosis depends on careful
scrapings of the conjunctiva and staining with Giesma stain to show the inclusion
bodies.
Chronic Catarrhal Conjunctivitis.—No single causative factor may be responsible
for the condition. Among the important aetiological agents are the following: bacteria,
principally the staphylococcus and the diplobacillus of Morax-Axenfeld; viruses, such
as those causing molluscum contagiosum and the common wart; acme rosacea; allergy
streptothrieal concretions of the canaliculi; trichiasis; minute foreign bodies; irritants,
such as smoke jrefractive errors; excessive secretion of the Meibomian glands; vitamin
deficiency; deficient lacrimal secretion; and chronic sinusitis. The treatment of chronic
catarrhal conjunctivitis must be directed towards the removal of the responsible aetiological agent.
Acute or chronic conjunctivitis more commonly affects both eyes than one eye only.
Even with the utmost care in the prevention of spread from one eye to the other, this
eventuality occurs frequently; hence it is important to note that conjunctivitis is
often bi-lateral, whereas acute iritis or acute glaucoma is almost invariably uni-lateral.
In addition, it should be remembered that conjunctivitis is common in children while
1Thygeson, P.: Bacteriologic differentiation of the Common Forms of Conjunctivitis with Particular
Reference to Types Prevailing in Iowa, J. Iowa State Med. Soc. 27:15, 1937.
Wl<t
^cKee, S. Hanford: Inclusion Conjunctivitis, C. M. Assoc., J. 41:535,   1939.
Page 345 'H
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iritis and glaucoma are rare in this age group; on the contrary, acute iritis and acute
glaucoma  occur more  frequently in  adults.
Acute Iritis.—An acutely red eye due to iritis is characterized by a rather sudden
onset of marked redness of the eyeball, severe neuralgic pain in the eye and over the
forehead, usually worse at night-time, blurring of vision, sensitivity to light and watering of the eye. The clinical course of the disease varies with its severity but the average
case lasts from 3 to 6 weeks. The objective signs are redness of the eyeball with a
marked circum-corneal blush, exudates into the anterior chamber resulting in cloudiness of the aqueous or solid deposits in the pupillary area and often on the iris, constriction and irregularity of the pupil. On palpation through the lids there may be slight
tenderness of the eyeball but the ocular tension is not elevated and it is unusually
normal or may be slightly low. %$k
If the patient is seen early and adequate treatment is instituted, the symptoms
usually diminish rapidly and in most cases the conditions clears up quickly; the iris
returns to normal, the exudates disappear, adhesions between the iris and lens are broken
down and there is little, if any, loss of vision. If, however, treatment has not been
adequate or timely, the story may be very different, for the iris is permanently bound
down to the lens, the inflammatory condition is increased, useful vision is irretrievably
lost and the patient is functionally blind in the affected eye.
Aetiology of Iritis.—Iritis is frequently dependent on some systemic disorder, e.g.
syphilis or tuberculosis. It may result from a toxin derived from a septic focus in
some part of the body, e.g. tonsils, teeth, nose and nasal accessory sinuses, prostate and
female genito-urinary organs. In the young adult male it is commonly caused by a
previous gonorrhoeal infection. In many cases, even after the most diligent search for
a focus of infection, no aetiological agent is discovered.
Treatment of Iritiss—Prompt treatment is a vital factor in the prognosis in acute
iritis. This involves rest following atropinization at the earliest possible moment, local
heat in the form of warm compresses to the eye several times a day, massive doses oi
salicylates and a thorough search for the aetiological factor and its elimination.
Atropine 1% or 2% in aqueous solution or ointment diminishes congestion of the
iris, puts the iris at rest, dilates the pupil and prevents the formation of adhesions
between the iris and the lens or tends to break up those which have already formed.
Sufficient atropine should be instilled to keep the pupil widely dilated, every two hours
at first and latterly, after the pupil is well dilated, 3 or 4 times a day. Moist hot compresses several times a day diminish pain and inflammation and, with the atropinization,
assist in breaking down adhesions which may have formed between the lens and the
Salicylic Acid gr.x t.i.d gives relief from pain in the acute stages of iritis.    Other
ins.
important indications are rest in bed in the early stages, protection from light by
tinted lenses or a shaded room, a light diet, catharsis and avoidance of all use of the
eyes for near work. In the more serious forms of acute iritis the injection of boiled
milk 5 to lOcc. into the gluteal region or intravenous injection of typhoid vaccine,
starting with 5 million bacilli and increasing the dosage every 2nd or 3rd day to 60 or
70 million bacilli is often of great therarjeutic value.
Glaucoma.—One out of ten blind persons in this country is so because of glaucoma.
Gluacoma is a pathological condition of the eye which is characterized by an increase
in intraocular pressure. When glaucoma is not treated, blindness invariably results if
the patient lives long enough.
Acute Congestive Glaucoma.—Acute congestive glaucoma has a stormy beginning.
It manifests itself by excruciating pain in and around the eye, head, ears or teeth.
Sometimes there is nausea or vomiting; and there may also be fever. Such attacks
have been diagnosed wrongly as "bilious attacks". The visual acuity rapidly diminishes
and the field of vision is considerably reduced, mostly on the nasal side. Usually only
one eye is affected and it quickly becomes very red. One may feel he is dealing with
an acute conjunctivitis or iritis. However, the eyelids are never matted together in
acute congestive glaucoma and the eye is always hard. The cornea is cloudy and it is
almost insensitive to touch with a small piece of cotton wool. The anterior chamber
is shallow, the iris discoloured and the pupil dilated. There is usually a greyish-green
reflex in the pupillary area. Immediate action is necessary to save this eye from blind-
Page 346 ness. A miotic such as eserine 1% or pilocarpine 2% must be instilled every few minutes. At no time must atropine be put into an acutely glaucomatous eye, and such
ointments as yellow oxide of mercury or metaphen have no therapeutic value. It can
be seen that there is nothing insidious about this type of glaucoma.
Chronic Non-Congestive or Simple Glaucoma.—-For every case of acute glaucoma
there are ten cases of simple glaucoma. This is a disease of the eye which slowly and
without the patient's knowledge, robs him steadily and painlessly of his sight. It is in
this type of glaucoma that the medical practitioner's help is needed for its early
discovery.
The impairment of vision is usually at first only in one eye. It may occur as
early as 40 years of age with an occasional blur in front of one or both eyes. The
blurred vision may last several hours and is often accompanied by a slight one-sided
headache. Sometimes he may complain of tearing or experience some difficulty in
reading. However, the eye is never red. These symptoms often occur at times of
excitement, overindulgence or worry, or after attending the theatre. The vision is
often blurred at night and he may see halos around street lights or car lamps; and
walking at night is difficult.    Sleepless nights accentuate these symptoms.
This dangerously mild course may last months or years before the patient becomes
aware of the loss of his central vision. He may have had his glasses changed several
times during this period without much improvement in his vision. All this while
there is a serious defect developing in his peripheral visual field. When treatment is
instituted at this stage it is usually impossible to recover lost vision and the problem
now is to arrest the progress and prevent further loss of vision.
The question arises as to how the medical practitioner may acquire the essential
points which will assist him in recognizing or at least suspecting glaucoma.3
First, he must measure the visual acuity with a Snellen chart with and without
the patient's glasses. Any case of subnormal vision in one eye or both eyes must always
be investigated further.
Second, he must ask the patient about the occasional occurrence of blurring or
clouding of vision, of seeing coloured rings around distant lights, of one-sided headache, or discomfort in and around the eyes after attending theatres, excitement or worry.
Third, he must feel with his fingers whether the eyes are normally soft or abnormally
hard.   One can easily acquire the sense of normal tension of the eyeball.
Fourth, he must examine the size of the pupils and their reaction to light. Inequality of the pupils or poor reaction to light must be checked further.
Fifth, he should examine each eye with the ophthalmoscope noting whether there
is pallor of the optic discs and any excavation. The technique of using the ophthalmoscope is not difficult and one is soon able to acquire sufficient skill to be able to see the
optic discs in the majority of patients.
Sixth, he should inquire if there is a history of glaucoma in the family.
These six points will enable the general practitioner to suspect or even detect a case
of glaucoma. Having done so he should then direct his patient to an eye clinic or to
an eye physician for more detailed ophthalmic examination. Above all, the practitioner
should exercise great tact so as not to alarm the patient unduly until the diagnosis of
glaucoma is confirmed. Once the diagnosis is established the patient will remain a
glaucoma patient, with all that this entails, for the rest of his life.
The general practitioner should remember also that this blindness from glaucoma
is frequently preventable. He should know that prevention of blindness from glau-
cmoa is often attainable by early diagnosis,, early treatment and constant watchfulness.
On the other hand late diagnosis and late treatment in the majority of cases mean
failure.
Summary.—Although the above remarks have been briefly presented, my purpose
has been to call your attention to the importance of differentiating between acute conjunctivitis, acute iritis and acute glaucoma when confronted with an acutely red eye.
It is not my wish to convert the general practitioner into an ophthalmic specialist but to
make him conscious of the important differential points which may be of assistance to
him in taking care of this common ophthalmic problem.
*_choenberg, M. J.: The General Practitioner's Part in the Campaign for the Prevention of Blindness
from Glaucoma, N. Y. State J. Med., 41: 2216, 1941.
Page 347
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Mi; LUMBAR AND SACRAL INTERVERTEBRAL DISCS
J. Gordon McPhee, M.D.
An analysis of one hundred and sixty-eight cases of suspected intervertebral
disc  protrusion  admitted  to  The Vancouver  General Hospital  from   1939
to 1946.
From the Department of Radiology, Bede J. Harrison, M.B., Director
if.
According to the records the first laminectomy for protruded intervertebral disc at
The Vancouver General Hospital was done on the fourth of November, 1939. Since
then, one hundred and sixty-seven others have been done. Eighty-one have been preceded by myelography. Air was used in three as the contrast medium but in the
remainder Lipiodol or Pantopaque was used. Usually myelography is requested in cases
where confusion or uncertainty exists. We think the request has been necessary in many
cases. Operations have proved our point. We wish to state as our thesis that myelography is worthwhile and to prove it we wish to review one hundred and sixty-eight
records. Little or no information has been discovered and there is only one legitimate
cause for this publication, i.e., to encourage the average practitioner to take more seriously the complaint of low-back pain, whether or not a history of trauma can be obtained. Many practitioners will feel that such a plea would have been correct two or
three years ago but that it is unnecessary at the present time. Still it is certain that
at least one positive fact appeared out of the cases analyzed, which is, that nearly every
individual in this series received therapy of some form or other which in most instances
could not possibly have any effect upon a protruded intervertebral disc and less still
upon a disc which had ruptured into the neural canal. The writer feels that much
time is wasted and that this is the direct result of lack of appreciation of the various
manifestations on the part of the patient who has a disc injury.
There is no consistent relationship between protrusion and clinical signs and/or symptoms. It is quite wrong to adopt the attitude of "wait and see," when one keeps the
diagnosis of this injury in the differential and it seems unwise to treat the complaint
with massage, manipulation, sedation, heat for a prolonged length of time, or, in the
writer's opinion, traction of the painful limb. Regarding traction anyone who has
dissected in detail the vetebral column will appreciate that a great amount of weight
would have to be applied to increase the circumference of any of the lumbar intervertebral foramina in order to diminish pressure upon a nerve root. Even if one admits
that such increase of circumference can occur, such a procedure does nothing to alter
the relationship betwten root, protruding disc and the ligamentum subflavum.
ETIOLOGY: In this series there were forty-three instances in which no known
factor could be discovered to account for the complaint. This would tend to emphasize
th eneed to keep a disc lesion uppermost in mind. Of this number twenty-five were
males and eighteen were females. Straining to lift, move or carry heavy weights accounted for the largest single group of known factors which resulted in disc injury. A
significant number of these individuals recalled slipping while attempting to perform
a difficult task. This group was comprised of forty-four males and two females. These
and other causes in order of frequency are tabulated in Chart No. 1.
Page 348 NtURAL CMK
-IMTCRVCRTEBAL
OISC
AXIU-AftY POUCH
ROOT SLE.VE
OuRfmATCft.
By "repeated minor trauma' one refers to the
occasional patient whoes job is that of driving a
truck, tractor, etc., which entails much bouncing
on the seat of his machine.
"Recurrent factors" refers to the rate patient
whose occupation results in repeated, very minimal, low-back strain, i.e., elevator operators,
(opening and closing the elevator doar), operators
of compressed air-guns.
The one cause of childbirth and disc lesion
was interesting. The patient had had four children. During the third trimester of the second,
third and fourth pregnancies, lumbar pain ap-
pared and gradually dominated the patient's life.
Following delivery of the second and third pregnancies the pain was greatly diminished. Only
because of considerable disability of the left leg
following the fourth delivery did she receive attention to the back. A neuro-surgical consultation resulted in the proof of the existence of a herniated nucleus pulposus.
The unfortunate epileptic had complained of lumbar discomfort for years and so
repeatedly informed the various medical officers of the Outpatient Department. Following a grand mal attack he was brought into the Emergency Department refusing to
move because of the low-back pain which, he stated, radiated as far as the toes of both
feet.
Seventeen individuals gave a history of a second severe accident which resulted in
back injury. When these individuals were surgically explored a protruding disc with
extensive rupture of the amtulus fibrosus was found in every case, and often pieces of
disc fibro-cartilage were found lying free in the neural canal.
-jy The average time interval between the onset
of signs or symptoms and operations, whether
or not a history of injury is obtainable, for the
group twenty to twenty-nine years has been
3.05 years; for the group thirty to thirty-nine
years ,it has been 5.3 years; for the group forty
to forty-nine years, it has been 4.2 years; and
for the group fifty to fifty-nine years, it has
been 0.80 years.
Chart No. 2 indicates the number of patients in various ten-year age groups at the
time of admission for surgical exploration of
the lumbar neural canal.
SIGNS AND SYMPTOMS: Lumbar pain,
discomfort or distress was easily the most impressive symptom. The great majority of individuals felt some degree of pain at the time of injury but a large number of this group
were able to continue working after a few minutes' rest. Disablement occurred after
an interval of days or weeks or months and gradually developed into either a constant
or intermittent character. An equally large number complained that the pain occurred
subsequent to the injury becoming more severe in a relatively short space of time. This
pain also developed into a persistent or an intermittent type.
__
I
HERNIATION - 0_UT-RfVT>ON  AXILLARY POUCH
W  LS-Si  LtFT SIDE
Wt!
The incidence of these findings is recorded in Chart No. 3.
Page 349 1
a.
v<
I 3U
m.
One-third of the patients complained of the pain
radiating to one or other hip. This type of pain was
apparently particularly aggravating and extremely
difficult for the patient to relieve by himself. It is
pointed out that this type of distress, as well as that
characerized by radiation to involve the lower extremities, only rarely occurred at the time of injury.
It is often noted that only after an interval of
months or subsequent to further trauma does the
patient complain of changes in the integrity or function of the lower limbs. There was the infrequent
case in which only the area of the knee or lateral
ankle or the toes was involved and the explanation
for such a picture is quite difficult to find since the
disc injury in such cases showed no signficant gross
differences from that found in an individual with extensive objective and subjective
findings.
KW
^\-
RUPTUREO OlSC.
-OEFECT
Si I.
'•
The large number of factors which aggravated the pain is indicated in Chart No. 4.
This is impressive when compared with the smaller
number of methods by which a patient could obtain
relief and also the small number of patients who did
obtain relief by using such techniques. This chart
should not be regarded as a true indication of the
number of times each complaint was made, since
many of the histories read by the recorder were not
at all complete; but one can say that at least fifty-
nine patients complained of aggravation of pain on
coughing; and at least thirteen complained of discomfort while walking.
___
l\
OEFECT
*~-
5 L
HERNIATED    NUCUCUS     Pvu.*OiUS
ft
_
w
3_-
t'L
S*_
OtFECT
MCRttWTO huC_.m ?ux*o<u-
Page350
Chart No. 5 illustrates the variety of possible
complaints the patient may present. It also reveals
the most common objective findings. The reader is
cautioned not to regard these as absolute figures;
once again one can merely state that at least sixty-
six patients had loss of the ankle jerk and that muscle
wasting was noted in twenty-five cases.
Twenty-four patients stated that they observed
a definite sensation described as a "tightening up,"
"crack," "snap," "click," "something giving away,"
"something tearing," or a sudden feeling of weakness
in the lower back, at the time of injury. -ZI
OPERATIVE FINDINGS: Chart No. 6 classifies the findings at operative exposure of that portion
of the intervertebral disc forming part of the anterior
wall of the neural canal. The term "protrusion"
usually indicates that there has been a separation of
all but the outer layer of the fibres of the annulus
fibrosus, with herniation of the nucleus pulposus into
the partial defect. This is the only type which is
correctly termed a herniation of the nucleus pulposus, and, in this series, occurred more often than
the other possible types.
-OEFECT
HERNIATED NUCLEUS PULPOSUS-
__D_
The term "protrusion and rupture" refers to the state of affairs in which the annulus
fibrosus has been torn to the extent that intravertebral dis fibro-cartilage is found protruding into the neural canal. There were sixty-two examples of this type, and, as such,
were found in the patients who had the most serious symptoms and were the most
disabled. It is suggested that this finding may be due to the fact that, subsequent to
partial extrusion of the fibro-cartilage, a greater amount of pressure is placed upon a
nerve root which is often found pinched between the protrusion anteriorly and the lig-
amentum subflavum posteriorly.
The third group is composed of rather a small number of cases in which disc fibro-
cartilage was discovered lying outside the traumatized disc and therefore lying in various
positions and at varying distances from the damaged disc.    An example of this type is
well illustrated by the case of one man upon whom a
laminectomy was performed a second time because of
gradual increase of symptoms following the first exposure which had not revealed the cause of the complaint. At the second exposure a large elongated
piece of fibro-cartilage was located down outside the
neural sheath, (root sleeve), of one of the nerves and
therefore situated well outside the neural canal
proper. The possibility of noting whether or not the
original tear in the posterior ligament has healed
depends upon the length of time between the injury
and the operation.
There were four instances of negative findings at
operations.
Chart No. 7 shows the intervertebral spaces at
which disc lesions were found on surgical exploration. The percentages compare f abourably with those
of most investigators. An exception is that only a
very few have recorded the positive findings at the
space between the first and second sacral bodies.
3 HERNIATED  NUCLEI   pulpos!
SDL
Mi
HERNIATION P60DUCW6   PMfriAL  BLOCK.
Page 351 *i
OEFECT
Rupture o o\sc.
RUPTURED OISC
RUPTURED DISC
lHT£RvERTt6RAL DISC I  KSSOCIKTCO
PoiTERvaK    »ROTftUSK)N
Right-sided disc lesions occurred in eighty-two cases and left-sided disc lesions in
ninety cases. The discrepancy betwen the number of patients and the number of disc
lesions is readily explained by the fact that in eleven cases more than one protrusion was
discovered.
The estimation of the spinal fluid protein was carried out on fifty-three cases. The
highest recorded was 286 mg. per 100 cc. of spinal fluid. The lowest was 20 mg.
No concrete aid is to be expected from this procedure for in twenty-two cases the level
was under 50 mg. per 100 cc. of spinal fluid, which figure is only slightly above
normal. Nor does it aid in concluding whether one is dealing with an extensive rupture
of the annulus fibrosus and extrusion of fibro-cartilage or with a simple herniation of
the nucleus pulposus. The principle reason for estimating the spinal fluid protein level
is to discover if one is dealing with a neoplasm.
There were two instances in which the myelogram was interpreted as negative whereas the operation revealed a herniated disc which was situated laterally.
Also there were four cases in which the myelogram was interpreted as being positive
and the operative findings negative. This might be interpreted in the light of the
knowledge that the anatomical configuration of the neural canal is not always quite
Page 352 smooth and can have an intermittent, undulating course which is normal for the particular individual undergoing examination. It is necessary to point out here that the
dural sac occupies only two-thirds of the neural canal and therefore it is readily conceivable that disc protrusion can exist but fail to create a defect in the contrast medium
contained within the dural sac. No practical method of visualizing the extra-dural space
is as yet available. This admittedly is an ever-present and serious shortcoming in each
myelographic investigation, and one which has so far proved insurmountable. No doubt
there are many cases of low-back distress due to disc protrusions of small size.
Altogether six instances of bi-lateral protrusion at one level were found. There
were five instances of two protrusions; in one case one protrusion was on the left and
one on the right; in three cases the lesions were on the same side, and in the fifth case
one lesion was on the left and the second was bi-lateral.
There is only one instance each of associated spondylolisthesis and spina bifida with
disc lesions.
In four instances the signs and symptoms were, considered by the surgeon to be due
to localized hypertrophy of the annulus fibrosus in the region of the nerve root.
In eleven instances very firm adhesions had formed between the disc and the nerve
root which aggravated the difficulty of the operative procedure. In one case adhesions
were the only finding but they had obviously interfered with the integrity of the nerve
root.
MYELOGRAPHIC TECHNIQUE: The vertebral levels of disc protrusion as indicated by Chart No. 7 would seem to force one to place the spinal puncture needle in
the interspace between the spinous processes of lumbar 1 and 2. Our experience has led
us to believe that any level can be chosen providing the proper precautions are taken
during the positioning and control of the bevelled tip of the needle. However, it is
recommended that the interspace between the spinous processes of lumbar 3 and 4 be
used since it has become apparent that it is from this region that the contrast medium
can be most readily aspirated after the completion of the examination.
It is essential that the needle tip be centrally placed in relation to the anterior aspect
of the dural sac if one desires to spend as little time as possible in removing the oil and
to avoid the frustrating manoeuvres of tilting the table or the patient, or both, in order
to keep the oil and needle in contact. The correct positioning of the needle tip will
also result in the removal of the oil with very little spinal fluid being withdrawn. It
has become evident that a redesigning of the shape of the needle or the provision of
accessory stomata will be required to increase the facility with which the oil can be
removed in each case.
At the X-ray Department of The Vancouver General Hospital the entire procedure
is carried out by one member of the staff with the assistance of one technician. Preparation and positioning the patient are carried out according to the desires of the radiologist.
Usually simple iodine sterilization of the lumbar area, with the height of the iliac crest
being indicated by a thin mercurochrome line, is performed by the technician. The
radiologist inserts the needle, at all times making certain of the position of the needle
tip and altering the bevel in order to keep the instrument in the mid-line. Having
entered the dural space, three cc. of spinal fluid are withdrawn for protein estimation.
One cc. of oil is injected and the patient is fluoroscoped to make certain that the oil is
in the dural sac by noting its single mass and its rapid movement up and down the
canal as the table is tilted. Having positioned the oil under the needle, more oil, usually
three to five cc. is injected. Three views of each disc level are taken, i.e., A.P., right
and left posterior oblique, with four Bucky films being made by the technician after
the lesion has been located. These are repetitions of the spot films with the addition of
a prone lateral view. The latter film has proved extremely valuable in all positive cases
and has many times been instrumental in allowing us to conclude the presence of a
protrusion in doubtful cases.
Page 353
ilMll A.;..
i:!,
:_.
5   i
I
<
Figure 1 illustrates the outline of the normal lumbo-sacral neural canal. It is on
the basis of defects of the contours of the dura mater that a disc lesion can be ascer-
ained. Figures II to XI. show a variety of alterations in neural canal contours or anatomical landmarks, e.g., axillary pouch, which have been observed on myelographic
films. Figure XII illustrates a lateral view of a disc lesion showing disc material protruding posteriorly and marked narrowing of the intervertebral space. The titles of
each drawing indicate the operative findings at exploration.
SUMMARY:
1. The pre-operative and operative findings of one hundred and sixty-eight cases of
suspected intervertebral disc protrusion have been presented.
2. A plea is made that in cases of low-back distress, damage to an intervertebral disc
should be given a more prominent position in the list of differential diagnosis of the
cause of this symptom.
3. Examination of the lumbo-sacral neural canal by contrast myelography has been
proven to be a valuable aid in confirming a clinically presupposed level of disc protrusion
and of revealing the occasional existence of multiple protrusions in those cases where
only a single protrusion had been suspected.
Chart No. 1.
ETIOLOGY
Type Male
Unknown  25
Weight bearing strains (associated -with slipping)  44
Direct  trauma  23
Sudden twisting or bending forward  16
Fall   j j  16
Repeated  minor   trauma  3
Indirect trauma ! .  1
Associated with:
1. Fracture  1
2. Dislocated hip  2
3. Recurrent factors  2
4. Epilepsy  1
5. Childbirth  0
Female
18
2
3
5
4
0
0
0
0
1
0
1
134
34
Final
Total
43
46
26
21
20
3
1
1
2
3
1
1
168
Chart No. 2.
AGE
Years
10 - 19	
20 - 19	
30 - 39	
40 - 49	
50 - 59	
Final
Wale
Female
Total
1
1
2
22
8
30
47
15
62
38    .
14
52
18
2
20
Chart No. 3.
Imm
Onset
ediate   \
-.set     |
CHRONOLOGY OF PAIN
Delayed       C
Onset      1
Constant   	
Intermittent
Constant   	
Intermittent
Final
Male
Female
Total
46
7
53
.     25
4
29
.     18
3
21
.     11
4
15
.00
18
118
Page 3 54 Chart No. 4.
DISTRIBUTION AND CHARACTERISTICS
Site No.
Lumbar  110
Hip, right   36
Hip, left  26
Right Thigh   26
Calf
11
Foot  48
Left Thigh   23
Calf  18
Foot  46
Both Legs  11
Aggravated By No.
Coughing 59
Sneezing 5 2
Bending 29
Straining 19
Walking   ______
13
Movement (any type)  10
Sitting  8
Standing  6
Flexing hip  4
Straight leg raising  2
Laughing  2
Low temperature  1
Lying down  1
OF PAIN
Relieved By No.
Bed  rest    ■  25
Buck's extension  10
Heat  7
Manipulation
(Chiropractic)     6
Physiotherapy
(Unqualified)   3
Sitting  3
Flexing at hip  3
Walking  1
Chart No. 5.
ASSOCIATED SYMPTOMS AND/OR SIGNS
Symptom No.
Sensation of numbness 49
Sensation of "pins and needles"   25
Easy fatiguability of back 12
Sensation of stiffness of back 7
Sensation of stiffness of leg 2
Sensation at time of injury of:
1. "a snap'* in the back:  8
2. "weakness** in the back  8
3. "a click" in the back  3
4. "tearing** in the back	
5. "tightening up" in the back.
6. "crack" in the back	
7. "giving away" in the back	
Sensation of cold in leg	
Sensation of cramps in leg	
2
1
1
5
5
1
Sign No.
Muscle spasm
1. hamstring ;  66
2. erector spin a e  13
Absent ankle jerk  35
Anaesthesia, thigh  24
calf  37
ankle j  25
foot  34
Lumbar scoliosis
£ 21
_ 13
_ 25
Reduced lumbar lordosis	
Wasting (muscle) i	
Absent knee jerk  10
Sciatic nerve tenderness  5
Forward  bending  restricted .  5
Backward bending restricted  4
Foot drop  2
Lumbar spine pain (elicited by firm
pressure on the spinous process) L.3- 2
L.4-20
L.$-15
S.1- 5
01
m,
Chart No. 6.
Protrusion
Protrusion with rupture-
Loose fibro-cartilage  	
Negative	
TYPE OF DISC LESION SEEN AT OPERATION
Male
 68
■ 12
130
Female
19 •
15
2
1
37
Total
87
62
14
4
167
Page 355 : n>
^
Chart No. 7. VERTEBRAL LEVEL OF DISC LESION
Male
Lumbar 2 and 3 ,  1
Lumbar 3 and 4  6
Lumbar 4 and 5  73
Lumbar 5 and S 1   54
Sacral 1 and 2  0
134
Female
Total
0
1
0
6
9
82
24
78
2
2
35
169
Congraulations to Dr. James Rankine of Kelowna who was recently awarded the
Fellowship to the American College of Surgeons, at the convocation of the College in
New York.
Dr. H. E. Taylor, newly-appointed pathologist at Shaughnessy Military Hospital, will
lecture in the Department of Bacteriology and Preventive Medicine at U.B.C. We
welcome Dr. Taylor to Vancouver and extend best wishes to him in his work.
We note with interest that Dr. V. J. Guttormsson has left his practise at Vander-
hoof and is at present studying law at the University of British Columbia.
Dr. A. W. Mooney, of Vancouver, has taken over Dr. Guttormsson's practise at
Vanderhoof.
Dr. John Cruise, formerly of Winnipeg, has joined Mr. L. A. C. Panton in Kelowna,
and will limit his practise to opthalmology.
Dr. R. W. Woodsworth has moved from Kelowna to Langley Prairie where he will
be associated with Dr. A. O. Rose.
Dr. and Mrs. W. J. Knox has returned from a trip to Montreal, Kingston and
Toronto.
Dr. H. B. MacGregor has returned from a successful fishing trip to the Cariboo, and
Dr. and Mrs. D. J. M. Crawford had a most enjoyable holiday at Banff.
Dr. W. H. White of Penticton has gone to Montreal for several months to do postgraduate work in surgery.
We regret to report the death of Dr. F. Hi Trousdale, who has for many years practised in Vancouver.    Sincere sympathy is extended to Mrs. Trousdale and family.
Dr. Hugh K. Atwood has moved from Kelowna to take up practise in Vancouver.
Dr. F. W. Brason is now with the Edward J. Meyer Memorial Hospital, Department
of Pathology, in Buffalo, New York.
Members of the profession extend deepest sympathy to the following doctors on
their recent bereavements: Dr. A. J. Cook, on the loss of his wife; Dr. J. P. Ellis, on the
loss of his mother; Dr. L. Friesen, on the loss of his mother; Dr. and Mrs. N. A. Stewart,
on the loss of their infant daughter.
Dr. T. C. Harold, resident doctor at Wells, has left for Vancouver, where he has
accepted a position with the Workmen's Compensation Board.
Dr. D. T. R. McColl, formerly of Sardis, is now practising at Wells.
We note the appointment of Dr. D. G. Ulrich as medical health officer for the
Zeballos district.
Dr. H. S. Hamilton is at present doing post-graduate work at the University of
Toronto in opthalmology.
Dr. Douglas Findlay has left Vancouver to join Dr. R. N. Dick at Chemainus.
Congratulations to the following parents on their recent good fortune: Dr. and Mrs.
N. J. Blair—a son. Dr. and Mrs. M. L. Edgar—a son. Dr. and Mrs. A. S. McConkey
—a danghter.
Dr. F. P. Patterson will be resuming practise with Dr. J. R. Naden in Vancouver.
Page 356 FOR   SALE!
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1100s mg.) and tablets of 50 mg. Narcotic blank required.
CwP;ll Ir
Write for detailed literature
HVDR0CHL0 RD E
Brand of meperidine hydrochloride (isonipecaine)
DEMEROL, trademark Reg. U.S. Pat. Off. & Cqnada
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The prompt sympomatic relief provided by Pyridium is extremely gratifying to the
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Pyridium, administered orally in a dosage of 2 tablets t.i.d., will promptly relieve
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Since Pyridium acts directly on the mucosa of the urogenital tract, this important
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Therapeutic doses of Pyridium may be administered with little fear of serious toxic
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• LITERATURE ON REQUEST •
PYRIDIUM
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INDICATIONS
ICTERUS — ANGIOCHOLITIS — CHOLECYSTITIS
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AMPHOJEl IN A NEW FORM
AMPHOJIL
Magnesium Trltilicat* AdJ»d
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Bottles of 12 ft. ox.
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THE INDISPENSABLE IN
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A comparatively new development found to
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Dosage: In the menopause, initial
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In addition to its value as a
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Professional Pack containing lib. 370A
'NIVEA' and 'EUCERITE' are registered Trade Marks
Made in Canada by NIVEA PHARMACEUTICALS LTD., 387 College Street, TORONTO
Distributing   Agents:   VANZANT  &  COMPANY,   367   College   Street,   TORONTO
(C29) G-E X-RAY PROUDLY ANNOUNCES
THE NEWEST ADDITION TO THE FAMILY
P '
The G-E Prescription Model Ultraviolet Lamp offering you all the famous
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This new, economically priced lamp features
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The compact, sturdily constructed burner
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Plan now to offer your patients the benefitfts of ultraviolet
the year-round with the G-E Prescription Model Ultraviolet
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nearest office of Victor X-Ray Corporation of Canada, Ltd.
VICTOR X-RAY CORPORATION of CANADA, Ltd.
DISTRIBUTORS FOR GENERAL ^ ELECTRIC INCORPORATION
TORONTO: 30 Bloor St., W. • VANCOUVER j MotorTrans. Bit, 570 Dunsmuir St.
MONTREAL: 600 Medical Arts Building -. WINNIPEG: Medical Arts Building
Name.
Please send me detailed information on your new
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Address.
State oc Province.
2667
. I BULLETIN
of the
Vancouver Medical Association
Volume XXIII.
1946 - 1947
a*-*'-.>'-:<W.»h3"" WW
;'»
BULLETIN OF THE VANCOUVER MEDICAL ASSOCIATION
VOLUME XXIII.
1946-47
INDEX
A
Page
ABDOMINAL PAIN IN INFANTS AND CHILDREN, CAUSES OF—Clement A. Smith....  302
AMERICAN COLLEGE OF SURGEONS—Sectional Meetings -    98
AMERICAN UROLOGICAL ASSOCIATION—Urology Award     67
ANGINA, AGRANULOCYTIC,   TREATED WITH PYRIDOXINE  HYDROCHLORIDE—
E.   S.   James       58
ANTHONY, A.  R.—Highlights   of   Ophthalmology     81
APPLEBY, L. H., & JACKSON, PAUL P.—Case of Unusual  Mesenteric Tumour     20
APPLEBY,  L. H.—Vagotomy       84
—Surgery   or   Propyl   Thiouracil  -135
ARTHRITIS,  RHEUMATOID—Russell  L.  Cecil     40
BAKER.  H.—Kernicterus -   239
BALFOUR. JOHN—Sterility in the Male  112
BLOOD DISEASES—Discussion of some Aspects of Leukemia, Infectious Mononucleosis
?nd Agranulocytosis—Cyrus C.  Sturgis  277
BLOOD  BANK  SUPPLIES—Growing  Deficit .".  322
BRITISH COLUMBIA MEDICAL ASSOCIATION—
Annual Meeting   250
Annual  Reports    i  252
Benevolent Fund  151
Report of  Representative on Executive Committee C.M.A   320
Southern  Interior  Medical  Association     11
Upper Vancouver Island Medical Association Annual Meeting     51
West Kootenay Medical Association Annual Meeting  11
BURKE MEMORIAL CANCER FUND   '        9
BURNS, TREATMENT OF—Roy D. McClure     270
CANTRIL, SIMEON T.—The Use of Radioactive Isotopes in Biology and Medicine   152
CECIL,   RUSSELL   L.—Rheumatoid   Arthritis i    40
CHEMOTHERAPY IN INFECTIONS OF THE EARS AND PARANASAL SINUSES—
J.  R.  Lindsay :     35
CHEMOTHERAPY IN SURGERY—Roy D. McClure   267
CHEST DISEASE,  NON-TUBERCULOUS,  SURGERY  FOR—Elliott  Harrison  121
CHIVERS, N., and VICKERS, K.—Progress in the Treatment of Meningitis     44
CHIROPODY—AN AUXILIARY TO  MEDICAL PRACTICE—J.  H.  MacDermot   296
CLEVELAND. D. E. H.—Preparation of Maru^cripts for Publication  137
COLLEGE OF PHYSICIANS AND  SURGEONS—
Appointment of Dr.  F.  L.  Whitehead  223
Coroners Act  „; '.__  322
COLON,  POLYPOSIS OF—C.  G.  Pow Ill  178
CORRESPONDENCE— '
Moukden Medical College ;     186
Pharmaceutical Association of B. C .; i .*     52
Specimens mailed  to  Provincial  Laboratory   218
Vancouver General Hospital  Staff Appointments   218
DIRECTION IN WHICH WE ARE GOING—A. E. Grauer.
224
X!
ELECTROLYTES, RECENT ADVANCES IN ADMINISTRATION OF—A.  -. Hardyment    60
ELLIOT,  A.  J.—The Treatment of Ocular Injuries in General Practice ;„„?_;..-ftt...ft   333
—Ophthalmic Indications of Systemic Disease ;2  336
—Ocular Findings in Important Neurological Conditions „._„......-:....,B#r. 340
—The Differential Diagnosis and Treatment of an Acutely Red Eye ._.. 344
EPILEPSY, A CASE OF PSYCHOMOTOR—W. J.  Fowler --&■■--    66
EUSTACHIAN TUBE FUNCTIONS AND ITS RELATION TO DEAFNESS—
J. R. Lindsay  1C0
EYE, EAR, NOSE AND THROAT,  SYMPOSIUM -...ii, _.«     76 INDEX—Continued
Page
FACE AND JAW, INJURIES OF—Robert G. Langston  168
FAMILY WELFARE BUREAU—The Unmarried Mother  249
FOWLER, W. J.—A Case of Psychomotor Epilepsy     66
—Tetanus—A Case Report _ „ 236
FROST, A. C, and FROST, A. C. GARDNER—Review of 422 Cases of Sterility.
in  Private Practice  103
GANSHORN, JOHN A.—Acute Pancreatitis  ... 12
GASTROSCOPY, MODERN, and GASTRIC DISEASE—Roger Wilson..  272
GEORGE WASHINGTON, UNIVERSITY SCHOOL OF MEDICINE—
Post Graduate Course    „        52
GRAUER, A. E.—The Direction in Which We Are Going   224
HARDYMENT, A. F.—Recent advances in Administration of Electrolytes       60
HARRISON, BEDE J.—Medicine  and   Some  Orthodoxies   (Osier  Lecture)  197
HARRISON, ELLIOTT—Surgery  for Non-Tuberculous Chest Disease       121
HEART AND GREAT VESSELS, SURGICAL CONDITIONS OF—Ross~Robertr-on       130
HUGGARD,   ROY—Vagotomy '_   211
HUNT, LEIGH—A Changed Concept of Pelvic Inflammation   109
INCOME TAX RETURNS.  DOMINION, BY MEMBERS OF THE
MEDICAL PROFESSION  ..     . 99
INTERVERTEBRAL DISCS, LUMBAR AND SACRAL—J. Gordon MePhoe  34S
JACKSON, PAUL P., and APPLEBY, L. H.—Case of Unusual Mesenteric Tumour     20
JAMES,  E. S.—Agranulocytic Angina Treated with Pyridoxine  Hydrochloride     58
—A Case of  Obstructive Jaundice  175
JAUNDICE, A CASE OF OBSTRUCTIVE—E. S. James :  175
KELLY.   A.   D.—Refugee  Phvsicians  328
KERNICTERUS—H.  Baker    239
LANGSTON, ROBERT G.—Injuries of the Face and Jaw .||_  168
LEESON,  L.  H.—Recent  Advances in  Otolaryngology . -    78
LINDSAY, J. R.—Chemotherapy  in Infections  of  the Ears and  Paranasal  Sinuses     35
Eustachian Tube Function and Its Relation to Deafness  160
M
MANUSCRIPTS FOR PUBLICATION, PREPARATION OF—D. E. H. Cleveland  137
MEDICAL EDUCATION,  PROBLEMS AND TRENDS  IN—Edward  L.  Turner  29
MEDICINE AND SOME ORTHODOXIES—Bede J. Harrison  197
MENINGITIS, PROGRESS IN THE TREATMENT OF—N. Chivers and K. Vickers  44
MESENTERIC TUMOUR, CASE OF—Paul P. Jackson and L. H. Appleby  20
MURRAY, STEWART—Acute Anterior Poliomyelitis  221
Mc
MACDERMOT, J. H.—Chiropody, An Auxiliary to Medical Practice  296
McCLURE,  ROY D.—Chemotherapy   in   Surgery  267
—The Treatment of Burns  270
McLEAN,   JOHN  A.—Highlights  of  Ophthalmology \     76
McLEAN, T. K.—Treatment of an Unusual Case of Spontaneous Pneumothorax  176
McPHEE, J.  GORDON—Lumbar and  Sacral  Intervertebral   Discs  348
|Sf   _T
NATIONAL FILM  BOARD - ------     75
NEWBORN, DISEASES OF, ASPHYXIA,  ATELECTASIS,  ERYTHROBLASTOSIS-
Clement A.  Smith  i}%
NEWBORN,  DISEASES OF.  DIARRHEA,   PREMATURITY—Clement   A.   Smith         316
NEWBORN INFANTS, PHYSIOLOGICAL PECULIARITIES OF—Clement A.  Smith     30 .<
NEWS AND NOTES          22,   47,  69,   115,   139,  181,  214,  244,  285,   323,  356 I
INDEX—Continued
Page
OBITUARIES—
BLACKWOOD,  BERTIE ._-: i	
GRAHAM,  WILFRED  L i	
GRANT,   JAMES   F	
MacEWAN,  S.  C	
MOONEY, WILBUR CRAIG  _	
SAUNDERS,   THOMAS   FISON	
SCATCHARD,   WALTER   	
WALTON,   R.   A _"._	
OBSTETRICS,  MODERN TRENDS  IN—N. W. Philpott .-.	
OCULAR FINDINGS  LN  IMPORTANT NEUROLOGICAL CONDITIONS—A.   J.  Elliot....
OCULAR INJURIES IN GENERAL PRACTICE, TREATMENT OF—A. J. Elliot	
OPHTHALMIC INDICATIONS OF SYSTEMIC DISEASE—A.  J.  Elliot	
OPHTHALMOLOGY, HIGHLIGHTS  OF—John   A.   McLean	
—A.   R.   Anthony	
OREGON ACADEMY OF OPHTHALMOLOGY & OTOLARYNGOLOGY—
Post Graduate Course	
OSLER LECTURE—Medicine and Some Orthodoxies—Bede J.  Harrison	
OTOLARYNGOLOGY, RECENT ADVANCEMENTS IN—L. H. Leeson	
243
180
138
243
19
.185
180
43
88
340
333
336
76
81
102
197
7S
PAEDIATRICS,  SYMPOSIUM ON RECENT ADVANCES     53
PAEDIATRIC DISEASE, A MODERN RE-EMPHASIS OF THE ROLE OF
INFECTION  IN—R. A.  Wilson _     53
PAEDIATRICS,  NEO-NATAL,  RECENT ADVANCES  IN—Harold  Stockton     55
PANCREATITIS, ACUTE—John A.  Ganshorn     12
PELVIC INFLAMMATION,  A CHANGED  CONCEPT—Leigh  Hunt   109
PHILPOTT, N. W.—Modern Trends in Obstetrics     88
PHYSIOTHERAPISTS &  MASSAGE PRACTITIONERS  ACT  213
PNEUMOTHORAX, SPONTANEOUS, TREATMENT OF AN UNUSUAL CASE OF—
T. K. McLean   176
POLIOMYELITIS, ACUTE ANTERIOR—Stewart Murray  221
POW, C. G.—Polyposis of the Colon   ,  178
PROVINCIAL BOARD OF HEALTH DIVISION OF V. D. CONTROL—
Recent Developments in Venereal Disease Treatment   68,    93
Cardiovascular Syphilis  _  210,263
R
RADIOACTIVE ISOTOPES IN BIOLOGY AND MEDICINE, THE USE OF—
Simeon T. Cantril  152
RED EYE, ACUTE, DIFFERENTIAL DIAGNOSIS AND TREATMENT OF—A. J. Elliot 344
REFUGEE PHYSICIANS—A.  D. Kelly  328
ROBERTSON, ROSS—Surgical Conditions of Heart and Great Vessels  130
S
ST. PAUL'S HOSPITAL—Case Reports	
SAXTON,  G. D.—Some  Observations  on  Streptomycin	
—Surgical Treatment of Pulmonary Tuberculosis	
SMITH,  CLEMENT A.—The Causes of Abdominal Pain in Infants and Children	
—Physiological Peculiarities  of Newborn  Infants	
—Diseases of the Newborn; Asphyxia, Atelectasis,
Erythroblastosis   !	
—Diseases of the Newborn; Diarrhea, Prematurity	
STERILITY IN THE MALE—John Balfour	
STERILITY IN PRIVATE PRACTICE—A. C. Frost and A. C. Gardner Frost	
STREPTOMYCIN IN TUBERCULOSIS, SOME OBSERVATIONS ON—G.  D.  Saxton.
STOCKTON.  HAROLD—Recent Advances in Neo-Natal  Paediatrics	
STURGIS, CYRUS C.—Discussion of some Aspects of Leukemia, Infectious
Mononucleosis and Agranulocytosis  	
SURGERY OR PROPYL THIOURACIL—Lyon H. Appleby	
. 20
63
127
302
307
311
316
112
103
63
55
277
135
TETANUS—A Case Report—W. J. Fowler  ..
THORACIC SURGERY—Symposium  on	
TUEERCULOSIS, PULMONARY,  SURGICAL TREATMENT OF—G. D. Saxton
TURNER, EDWARD L.—Problems and Trends in Medical Education
236
121
127
29
  84
 : ; 211
12, 44, 63, 66, 175, 176, 178, 236, 239, 272, 348
VAGOTOMY—Lyon H. Appleby 	
VAGOTOMY—Roy  Huggard   	
VANCOUVER GENERAL HOSPITAL—
Case  Reports ilvv	
VANCOUVER MEDICAL ASSOCIATION-
Arthsml   Reports   ("1946-1947) ;....
History of—Dr. G. E. Kidd   5,  86,  l6i,  148, 195,  233,  264,
Library   4,  28,  51,  74,  120,  144, 184, 218,  248, 289,
New Members    29
Summer School  ?       .]......"   145^
VICKERS, K. and CHIVERS. N.—Progress in the Treatment of _£ari_"fffti_*^S!S_l -
VICTORIA MEDICAL SOCIETY	
W
WILSON, R. A.—A Modern Re-Emphasis of the Role of Infection in Paediatric Disease
WILSON,  ROGER—Modern Gastroscopy and Gastric Disease :	
1S7
289
332
53
229
44
11
53
272
__■ Constant Carefulness
Onlm anigunderstanding professional
skill could maintain the confidence of
the Medical Profession which we enjoy.
Phone MArine 4161
Leslie G. Henderson
Gibb G. Henderson
¥
OMM ML
MIOMT
GEORGIA PHARMACY
_. I M  I T E D
W. OIOROIA
ITKilT
Gfcttter ^||Ht|ta2Iti
ESTABLISHED 189S
VANCOUVER. B. C.
North Vancouver, B. C.
Powell River, B. C.
h^___k_________- s,
I m
If
*b **ttif
Ifi
ffl-:
ii,
i
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.   Hi.
*,
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m
New Westminster, B. C.
For the treatment of
NEUROPSYCHIATRY
DISORDERS
Reference—B. C. Medical Association
<fc
4'
For information apply to
Medical Superintendent, New Westminster, B. C.
New Westminster 288
or 721 Medical-Dental Building, Vancouver, B. C.
PAcific 7823 PAcific 803 *
,97    w
versity of British Columbia Librar
DUE DATE    I
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