History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1940 Vancouver Medical Association Jan 31, 1940

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 The BULL Elf
of the
m   t/ANcfcuVER
MEDICALJASSOCIATION
Vol. XVI.
JANUARY, 1940
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
St Paul's Hospital
In This Issue:
theptreatment of #unctional menstrual
disorders: ^1[8hS
ectodermosis erosivi^luriorificialis
news and notes
VANCOUVER ^DICAI^SSOCIATICH^
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456 BROADWAY WEST
VANCOUVER J§ BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Store*) 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. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVI.
JANUARY, 1940.
No. 4
OFFICERS,   1939-1940
Dr. A. M. Agnew                  Dr. D. F. Btjsteed Dr. Lavell H. Leeson
President                            Vice-President Past President
Dr. W. T. Lockhart Dr. W. M. Paton
Hon. Treasurer Son. Secretary
Additional Members of Executive: Dr. M. McC. Baird, Dr. H. A. DesBrisay.
TRUSTEES
Dr. F. Brodie Dr. J. A. Gillespie Dr. F. W. Lees
Historian: Dr. W. L. Pedlow
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Dr. F. Turnbull Chairman Dr. Karl Haig Secretary
Eye, Ear, Nose and Throat
Dr. W. M. Paton Chairman Dr. G. C. Large Secretary
P&diatric Section
Dr. J. R. Davies Chairman Dr. E. S. James Secretary
STANDING COMMITTEES
Library:
Dr. F. J. Bulleb, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Db. W. A. Bagnall, Db. T. H. Lennie, Db. J. E. Walkeb.
Publications:
Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. T. H. Lennie, Db. A. Lowsie, Db. H. H. Caple, Db. Fbank Tubnbull,
Db. W. W. Simpson, Db. Kabl Haig.
Credentials:
Db. A. B. Schinbein, Db. D. M. Meekison, Db. F. J. Bulleb.
V. O. N. Advisory Board:
Db. I. Day, Db. G. A. Lamont, Db. S. Hobbs.
Metropolitan Health Board Advisory Committee:
To be appointed by the Executive Committee.
Greater Vancouver Health League Representatives:
Db. W. W. Simpson, Db. W. M. Paton
Representative to B. C. Medical Association: Db. L. H. Leeson.
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MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE    1858
3 6 CALEDONIA ROAD TORONTO VANCOUVER HEALTH DEPARTMENT
STATISTICS, NOVEMBER. 1939.
Total population—estimated	
Japanese population—estimated.
Chinese population—estimated	
Hindu population—estimated	
Total deaths	
Japanese deaths	
Chinese deaths	
Deaths—residents only.
  263,974
      8,891
      7,728
         389
Rate per 1,000
Population
13.6
5.5
33.1
11.1
BIRTH REGISTRATIONS:
Male, 230; Female, 178 408 18.8
INFANTILE MORTALITY November, 1939 November,
Deaths under one year of age ■  12 15
Death Rate—per 1,000 births  29.4 44.1
Stillbirths (not included in above  17 3
Note: Delayed registrations of deaths under one year
occurring prior to 1939 (not included)  30
Delayed registrations of stillbirths occurring
prior to 1939 (not included)  20
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
1938
October, 1939
November
0
1939
0
December 1st
to 15th, 1939
Diphtheria       0 0
Scarlet Fever    40           0             31           0             13 0
Chicken Pox    46           0            134           0             94 0
Measles         3 0 2 0 10
Rubella       0           0               6           0               2 0
Mumps        8           0               7           0               4 0
Whooping Cough    13           0              14           0               6 0
Typhoid Fever      0           0               0           0               0 0
Undulant Fever      0           0               0           0               0 0
Poliomyelitis       0           0               0           0               0 0
Tuberculosis      26 23 32 18 5
Erysipelas        3           0               3           0               2 0
Ep. Cerebrospinal Meningitis      0           0               0           0               0 0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL.
West North      Vancr.   Hospitals,
Burnaby   Vancr.   Richmond  Vancr.      Clinic  Private Drs. Totals
Syphilis     0              0              0              1              18              31 50
Gonorrhoea     0               0               0               0    '          62               19 81
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60 international units of
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400 international units of
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20 units Vitamin K
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SPECIFY     E. B. S.     ON     YOUR     PRESCRIPTIONS THE   EDITOR'S   PAGE
EDITOR'S PAGE
In another column of this issue of the Bulletin we publish an account of an address
given by Dr. D. H. Williams before the Vancouver Medical Association at its regular
meeting. We regret that Dr. Williams' remarks cannot be published verbatim, as he spoke
extempore, and there is no written paper. What he said, however, we feel should have been
heard by every medical man. As is so often the case, most of us are not completely up-to-
date in this matter. We are still uttering the phrases, and repeating the time-worn platitudes about venereal disease, prostitution, etc., that were coined many years ago. Modern
public health and preventive medicine, not only in Canada, but throughout the whole
civilised world, have, through accurate research into facts and carefully-compiled statistics, completely revolutionised the status of our knowledge in these matters. The careful
studies made over many years by the League of Nations, through its committees, composed
of internationally known authorities on Public Health, have revealed errors in our habits
of thinking and speaking: and we are at a point now where only too often the medical
practitioner, all unwittingly, and generally quite conscientiously, is actually giving mistaken advice and expressing opinions which are quite at variance with the real truth.
This is deplorable, for various reasons. In the first place, we are actually helping to
thwart and hinder the work of those who, with a knowledge far superior to our own, and
with the actual responsibility for safeguarding public health, are striving to reduce to a
minimum the social evils and threats to social well-being which we, too, are only too anxious
to see abolished or mitigated. In the second place, we are helping those subversive and evil
forces which prey upon humanity and threaten its progress and well-being. The fact tlia*
we do these things in good faith does not excuse us, nor does it alter the harm we may do.
Of course, this is not true of all medical men—but it is too often the case; the average man
or woman meets the medical practitioner before he or she meets the public health official,
and is much more apt to listen to the former—he is the first line of defense. So it is all the
more necessary and advisable that he be brought up to date, given the facts of the case,
shown where he has been thinking wrongly. There is no doubt, then, what he will do. He
will gladly accept this teaching, gladly acknowledge the error of his ways, and gladly work
in every way possible with those of his brethren who are charged with prevention of disease, and the spread of knowledge. We can assure Dr. Williams, if he ever had the slightest
doubt of it, which we do not believe that he had, that the therapeutic side, the family
physician, the general practitioner and the specialist among us, all welcome his talk, and
are grateful to him for it. We applaud! his frankness and enterprise in coming to us and
talking so plainly on this subject.
It is a very hopeful and an excellent sign of progress in our methods of thanking, and
a good augury for the future, when the leaders in public health and preventive medicine
come, as Dr. Williams and others have done, and talk freely and frankly to us. The
Executive are to be commended on their policy of having such addresses. We hope for
many more:—and the closer liaison thus established between the preventive and curative
sides of medicine can do nothing but good to both, and, more important, to the community
that we both serve.
Listening to the Minutes of the November meeting, which we unfortunately were
unable to attend, we were more than delighted to hear that real progress has been made in
the establishment of a John Mawer Pearson Lectureship, suggested by Dr. W. D. Keith
shortly after the death of our old friend, and now an established feature of our medical
life in Vancouver. The following extract will show to what we are referring.
Under the heading of New Business, the establishment of the John M. Pearson Lectureship was discussed, and resolutions were passed: (1) That the Lectureship be established,
Page 91 and that the Lecture be given by an outstanding member of the Medical Profession on
some phase of Internal Medicine; the arrangements concerning the Lecture to be left in
the hands of the Executive Committee; (2) That a Fund be established, known as the
John Mawer Pearson Lecture Fund, and the income therefrom to be used for the sole purpose of carrying on the Lecture; ( 3) That sufficient funds be transferred from the general
invested funds of the Vancouver Medical Association to bring the John Mawer Pearson
Lecture Fund up to $3 000.00.
A Special Meeting of the Vancouver Medical Association was held on Wednesday,
December 27th, for the purpose of discussing the arrangements for medical services to be
given under an agreement with the Vancouver School Teachers' Medical Service Association.
It is good that this has not been allowed to be sidetracked and put off till possibly
brighter days, financially speaking. The above extract from the Minutes will show our
readers the present state of affairs in this connection, and we hasten to congratulate the
Executives and the Trustees on a wise and constructive use of Association funds. Of all
words in the English language, "thrift" is the most capable of abuse. The only conceivable
value of money, as far as wa can see—and here, no doubt, we irwite criticism—is that it
should be profitably spent. The accumulation of a large balance, which is not being used,
and which is merely drawing interest, i.e., removing more active money, more potential
fertilizer of social growth, from the possibility of exercising such powers, is, in our opinion,
the height of folly and the acme of timidity. We can always save more, accumulate more
—but it should be put back into active circulation, to do more work, as fast as it is gathered; and we do not gladly see funds of various kinds accumulating to large proportions
and lying idle. We feel that such money might be doing a lot of good work. What are we
saving it for, anyway? There is no added security in its possession. Surely the events of the
past few years should have taught us this. So we rejoice that at least some of our accumulated store has been put to use.
There are other uses we could think of to which to put other moneys we may possess,
but perhaps we have said enough for the present—and, in any case, we do not wish to
suggest anything but the utmost trust and confidence in the actions of our Trustees and
Executive. They have our confidence in fullest measure, and by this latest action have, we
think, justified and increased it.
To return to the Lectureship. This, we believe, is quite the best way we could ever
have chosen to honour our departed friend. In a slang phrase, it was just "up his alley."
Those who devised it, knew and understood Pearson thoroughly—his passion for research,
his love of abstract knowledge, science without the strings of commercial exploitation.
In the Elysian fields, where no doubt he is even now exploring some angelic pathology, he
will have a more cheerful smile on his face than ever, as he reads this number of the
Bulletin, as we are sure he will do. We have no definite exchanges with the Celestial
Medical Association Library, but no doubt the Bulletin will reach John Mawer Pearson
somehow. For it was his creation and his child (at least, it was left on his doorstep by its
more or less legitimate parent, Dr. Milburn, and Pearson brought it up), and he is, we are
sure, as much interested as ever in its growth and progress. So, as he reads these minutes,
published for his behoof, entre autres, may he feel that it is our hail to him across the gulf
that we, too, must some day span—and that it is our way of saying to him, "Well done,
thou good and faithful servant!"
SPECIAL AND IMPORTANT NOTICE
The regular General Meeting of the Vancouver Medical Association, usually
held on the first Tuesday in the month, will be held on January 9 th, instead of
January 2nd. The Agenda for the meeting is enclosed with this number of the
Bulletin.
Page 92 NEWS    AND    NOTES
Dr. L. H. Appleby will leave early in the New Year for the Eastern States. He will be
away for about eight or nine weeks.
Dr. G. F. Strong has left with his family to spend the Christmas holidays in California.
Congratulations are extended to Dr. and Mrs. P. Ragona on the birth of a daughter
on December 10th.
Dr. H. A. Robertson, Lieutenant, and Medical Officer in the 72nd Battalion, Seaforth
Highlanders of Canada, left with his regiment for "an unknown destination" on December 15th. Dr. Robertson is the first member of the Vancouver Medical Association to leave
for active service abroad, in the present war, and we wish him Godspeed, and the very best
of luck.
We are very glad to report that Miss Firmin, for many years the Librarian of the
V. M. A., who has been seriously ill with pneumonia in the Vancouver General Hospital,
is making steady improvement, although still confined to hospital.
Dr. E. J. Gray, who has been confined to hospital for some time, is very much better,
and has been able to return to his home. He expects to be back in his office early in February.
Dr. H. H. Milburn expects to leave for a few weeks' holiday early in the New Year.
*% *t *£» 25p
Dr. and Mrs. J. M. Hershey are receiving congratulations' on the birth of a daughter
on December'1st at the Kelowna General Hospital. Dr. Hershey, formerly of the Peace
River Block, is now in charge of the District Health Unit.
Dr. J. A. Street of Woodfibre has been appointed Medical Health Officer for Woodfibre
and surrounding district, and School Health Inspector, in place of Dr. E. K. Hough,
rescinded.
Dr. John A. MacDonald was appointed a Marriage Commissioner for the registration
district of Anyox, with offices located at Kincolith, in place of Dr. D. J. MacDonald, who
has left the district.
Dr. A. K. Haywood and Mr. Whittaker are to consult on proposed site and plans for
a new hospital in Penticton.
There has been a good deal of activity in St. John's Ambulance work in the Okanagan;
two classes of over a hundred have taken examinations in Penticton, one in Kaledemand
one in Oliver.
Dr. Alan Beech of Salmon Arm visited the office while in Vancouver on a short vacation.
We are pleased to note that Dr. M. J. Keys of Victoria has recovered sufficiently from
the fracture of his ankle to contemplate some winter golf.
5f* Sfr S^ 3£
Dr. A. G. MacKinnon has taken over the Hospital at Queen Charlotte City, Dr. D.
T. R. McColl having left for the East.
:;- 55- sT- s[-
Dr. P. S. Tennant of Kamloops has left for Calgary to join the 16th Field Ambulance.
Page 93 The December meeting of the North Shore Medical Society took the form of a dinner
at the Olympic- Club. The meeting was largely attended, and Dr. M. W. Thomas, the
Executive Secretary, was the guest on this occasion. Dr. R. V. McCarley, President, was
Chairman.
Dr. H. A. Whillans of Victoria has been assisting Dr. G. A. Lawson of Port Al
ice.
Dr. Ralph S. Woodsworth has returned from England and is relieving Dr. J. C. Poole
of Wells, while the latter is on vacation.
Dr. W. B. McKechnie of Armstrong has been visiting Vancouvr and Victoria.
Dr. W. J. S. Millar is carrying on the practice at Blue River.
Dr. John Piters of Vancouver has recently returned to open offices, confining his practice to Paediatrics.
Dr. J. E. Whiting is associated with Dr. W. E. Austin at Hazelton.
Dr. Donald W. Beech, who has practised for several years at Langley Prairie, has taken
over the practice at McBride.
•£ jj. 35. »t
Dr. J. C. Thomas, who is well known to the profession in this province, has established
himself in Vancouver and will confine his practice to Internal Medicine and Neurology.
Dr. A. P. Miller of Port Alberni, while in Vancouver recently, attended the Rotary
Ice Carnival.
*i" *S" *V *V*
Five Port Alberni doctors were rushed to attend the injured when a logging train,
carrying men to work, crashed through a 50-foot trestle.
Dr. T. Dalrymple of Vancouver spent a week-end on the Island.  He managed to bag
several ducks.
* * * K-
Dr. W. E. M. Mitchell of Victoria has been appointed Surgical Specialist of the Alder-
shot Command. He is now Major, R.A.M.C.
Congratulations are in order for Dr. and Mrs. Norman C. Cook of Victoria, on the
birth of a son.
•8* **• *if •»•
Dr. F. M. Bryant of Victoria has left for the south for one month's holiday.
Dr. G. G. B. Buffam has come to Victoria and taken over the office of Dr. C. A. Watson, who is on active service.
,The Annual Dinner of the Victoria Medical Society was held! at the Union Club on
Saturday, December 9th. The feature of the evening was a "broadcast" over station
"TWAG." A very pleasant evening was enjoyed by the excellent turnout of members
and guests.
Page 94 DR. C. A. DRUMMOND
We regret to record the passing of Dr. Charles A. Drummond of Ashcroft,
who at the age of seventy-two finished a useful life in practice.
Dr. Drummond had recently gone to Ashcroft to live with his son, Dr. W.
A. Drummond, who is now located at Salmon Arm in association with Dr. Alan
Beech.
Dr. Drummond has carried on the practice at Ashcroft during the past year.
He was born in Meaford, Ont., was a graduate of Trinity Medical School in
Toronto, and practised for many years at Meaford, and latterly at Conquest, Sask.
Dr. W. A. Drummond has the sincere sympathy of the profession in the loss
of his father.
LIBRARY NOTES
Recent Additions to the Library.
Nomenclature and criteria for diagnosis of diseases of the heart, 1939. (Published by the
Criteria Committee of the New York Heart Association.)
Intrduction to Dermatology, 10th ed., 1939, by Norman Walker and G. M. Percival.
Introduction to Medical Mycology, 1939, by G. M. Lewis and M. E. Hopper.
Textbook of Clinical Neurology, 4th ed., 1939, by I. S. Wechsler.
Primer of Allergy, 1939, by Warren T. Vaughan.
Caesarean Section, 1939, by C. Mcintosh Marshall.
Problems of the Ageing, 1939, ed. by E. V. Cowdry.
From the Nicholson Fund.
Story of Surgery, by Harvey Graham, 1939.
Priests of Lucina, the story of Obstetrics, by Palmer Findley, 1939.
The Library Committee also acknowledges with many thanks the following additions,
which were gifts.
Atlas of Congenital Heart Disease, 1936, by Maude E. Abbott.
Occupational Disease Symposium, Northwestern University School of Medicine, 1939.
Transactions of the Association of American Physicians, 1939.
V
ancouver
Medi
Cd
ssociation
NEW YEAR MESSAGE FROM THE PRESIDENT OF
§ THE VANCOUVER MEDICAL ASSOCIATION
May I, speaking for the Executive of the Vancouver Medical Association, extend to
the readers of the Bulletin the compliments of this New Season.
Since we have survived the strain of succeeding crises and the actual outbreak of war
and the initial stages of this rather unusual war, we are somewhat prepared for what may
be a new year of trying times and circumstances,, requiring many changes and readjustments. May these be met with the same spirit as during the last war.
Slf A. M.Agnew.
The following were elected members of the Vancouver Medical Association at the
General Meeting on November 7th: Drs. R. A. Gilchrist, J. S. Batching, E. B. Trowbridge,
R. A. Walton, L. G. Wood; Associate members: Drs. Ivan F. Martianoff and John M.
McDiarmid.
Page 95 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. F. M. Auld, Nelson
First Vice-President Dr. E. Murray Blair, Vancouver
Second Vice-President Dr. C. H. Hankinson, Prince Rupert
Honorary Secretary-Treasurer JDr. A. H. Spohn, Vancouver
Immediate Past President . Dr. D. E. H. Cleveland, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
A MESSAGE FROM THE PRESIDENT
As the end of the year approaches one's thoughts turn to the ancient Roman deity,
Janus, who had two faces—one looking towards the front and one in the opposite direction.
In the affairs of our Association this is an appropriate time to cast a backward glance
over the road by which we have travelled. The outbreak of war is an event that overshadows all else in importance, to which all other interests and events are subordinates.
This event has far-reaching implications for our profession, both in this Province and in
Canada as a whole. The acceptance by} the Dominion Government of the offer made by
the Canadian Medical Association to advise in the matter of medical service to the military
and the civilian population and to perform any other functions that properly come within
the scope of the profession's activities is a step of far-reaching importance. The profession
may well be proud of this honour; but equally will it be animated by a determination to
measure up to the responsibilities implied, and the sense of duty required for their proper
performance.
The future has many problems—known and unknown—which are the concern of our
standing committees and our membership as a whole. But given co-operation and goodwill
these may be faced with confidence.
Cordial Christmas and New Year greetings to all.
Fred M. Auld.
COUNCIL OF THE COLLEGE OF PHYSICIANS
AND SURGEONS OF BRITISH COLUMBIA
A MESSAGE FROM THE PRESIDENT
Approaching the New Year, we once again find our world tightly in the grip of another
international conflict at arms—this time of a type wholly beyond the comprehension of
most of us—with the combatants—like dogs—watchfully ignoring each other.
Circumstances of the past few years have welded our profession into a harmonious
unit to a degree never before known amongst us, and as I survey such a large part of the
world—peopled by fellow creatures much like ourselves—burdened under the yoke of
perpetual hatreds barnacled with the habit of mistrust, it is with deepest thankfulness
that I sense the feeling of concord in the hearts of my professional colleagues in British
Columbia.
It is my hope for 1940 that we may continue to submerge our natural tendencies to
steer our respective ships by the fixed star of individual self interest, and that we may, in
the troublous year which would appear to lie ahead, work together with the same spirit of
mutual confidence and trust which you have at all times exhibited during the past few
years, and in the acknowledgment of which I tender each of you, on the behalf of my
Council, my grateful thanks.
Lyon H. Appleby.
Page 96 CANADIAN MEDICAL ASSOCIATION
All Dues—National and Provincial—Have Been Reduced.
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MEMBERSHIP (including Journal)  IN CANADIAN MEDICAL
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THIS PLACES YOU IN FULL MEMBERSHIP IN ORGANIZED MEDICINE
The Journal Speaks for Canadian Medicine.
Read the articles on Medical Economics. Special Series by Mr. Hugh Wolfenden.
THE TREATMENT OF FUNCTIONAL MENSTRUAL
I- i "|    1  DISORDERS |:
Dr. A. E. Trites
The modern treatment of functional menstrual disorders is based upon a knowledge of
the physiology of menstruation and of the various sex hormones concerned in uterine
haemorrhage. Typically the bleeding occurs from a disintegrating endometrium which
has undergone a definite preparation as a result of the development of a Graafian follicle,
ovulation and consequent corpus luteum formation in the ovary. The sum total of these
changes constitutes a menstrual cycle. Since the essential function of the female genital
apparatus is reproduction, and menstruation occurs only when this function has been
thwarted, the actual bleeding phase of the cycle has therefore a negative significance,
being, in a sense, an epiphenomenon or anticlimax.
Two inter-related groups of changes occur to complete the normal reproduction or
menstrual cycle; first, those occuring in the endocrine glands (anterior pituitary and
ovary), and second, those occurring in the endometrium. The anterior lobe of the pituitary,
the so-called "motor" of the sex glands, stimulates the ovary and maintains ovarian
function. These anterior pituitary hormones are thus known as gonadotropic and produce
two main series of effects in the ovary. First, those produced by the follicle-stimulating
factor (formerly known as Prolan A) and then those produced by the luteinizing factor
(Prolan B). Whether these are two distinct and different hormones has not as yet been
definitely proven, but certain experimental evidence would suggest it. The follicle-stimulating factor causes the primordial follicle of the ovary to develop into a mature Graafian
follicle which discharges its ovum on or about the fourteenth day of the cycle. The
luteinizing factor then transforms the granulosa cells which line the collapsed follicle into
a corpus luteum. As a result of this activation by the gonadotropic hormones of the
anterior pituitary, the ovary in turn elaborates its own hormones: first, oestrogen (cestrin,
follicular hormone, etc.), which is a product of the cells of the Graafian follicle; and
second, progestin (progesterone, corpus luteum hormone), a product of the cells of the
corpus luteum. Oestrogen causes the endometrium to grow or proliferate, and progestin
causes the endometrial glands to secrete and at the same time transforms the endometrial
stroma into decidua-like cells.
Fluhmann1, for descriptive purposes, considers the menstrual cycle as falling into six
phases, beginning with the third day:
(1) The stage of regeneration (3rd—5th days). During this time the desquamation of the
epithelium terminates, healing begins and the new follicle develops in! the ovary.
(2) The pre-ovulatory state (6th—14th days) is characterized by the growth and development of the Graafian follicle, and the proliferation of the endometrium.
Page 97 (3 )   Ovulation—rupture of the follicle.
(4) Post-ovulatory stage (14th—25th days) when an active corpus luteum develops in
the ovary, and the endometrium is influenced by progestin to produce the typical
secretary changes.
All of the foregoing stages are essential for the implantation of the fertilised ovum
and are designed for pregnancy. If fertilisation fails to occur, the following phases ensue
to complete the cycle:
(5) Pre-menstruation stage (25th—28th days). The corpus luteum begins to degenerate,
and changes in the endometrium appear which precede the advent of desquamation.
(6) The menstrual stage (1st—4th days) when disintegration of the endometrium and
bleeding occurs.
Phase
Regeneration
Preovulatory
( Ovulation *
Post-
ovulatory
Premenstrual
Menstrual
Approximate Day
3-5
6-14
14
14 - 25
26 - 28
1-4
Ovary
Growth and maturation
Graafian follicle
Ovulation
Active
Corpus
Luteum
Degeneration of
corpus luteum
Endometrium
Repair
Proliferation
Secretion
Leukocytes
Vasoconstriction
Desquamation
©estrogenic
Hormones
Progressive increase in
blood and urine
Peak of
Concentration
Diminution
Secondary rise (?)
Progestin
Absent
Present
Absent
Uterine Contractions
Increased
Increased
Let us consider in greater detail the histologic changes which occur in the uterine
mucosa. The endometrium is composed of two well-defined layers. The superficial layer
is known as the stratum functionale which undergoes the various cyclic changes in response
to hormonal stimulation. The deeper layer, the stratum basate, remains practically
unchanged at all stages of the cycle, and from it the regeneration of the stratum functionale occurs after menstruation, pregnancy, or the operation of curettage.
With the cessation of the menstrual flow the stratum functionale begins to develop in
response to cestrogenic hormones produced by the growing follicle. This is the stage of
proliferation—the mucosa increases in thickness, the glands become larger and more tortuous. During the post-ovulatory phase the endometrium undergoes the characteristic
changes of the stage of secretion under the added influence of progestin. The endometrium
becomes still thicker and is soft and cedematous. Secretory activity within the glands is
evident. The deeper glands become dilated, convoluted and serrated. The stromal cells
enlarge to resemble decidual cells. Accompanying these changes is a marked vascularity
and late in this stage there is a definite leukocytic infiltration. Beginning necrosis terminates this stage, and menstruation now sets in. The stage of regeneration begins very soon,
probably before the menstrual flow ceases. The loss of tissue during menstruation may be
regarded as an ischaemic necrosis due to vasoconstriction.
Though the correlated series of events in the ovary and uterus during the menstrual
cycle are well known, the actual cause of menstruation itself has not been satisfactorily
explained. As a result of his experiments with the Macacus Rhesus monkey, Allen2
attributed menstruation to be due to a temporary cyclic reduction of the amount of
oestrogen available in the body. However, when a prolonged daily injections of cestrogenic
substances into castrated women or monkeys is made, bleeding occurs during the period
of administration. Also, the use of large doses of cestrogen in the late post-ovulatory phase
fails to prevent the onset of normal menstruation. On the other hand, it has been definitely
shown that degeneration of the corpus luteum is associated with the onset of menstruation.
A premature menstruation may be induced by destruction of the corpus luteum in the
course of an operation. It is also known that the administration of progestin will delay a
Page 98 menstrual period. A few days after the progestin is discontinued bleeding occurs. As an
explanation for the degeneration of the corpus luteum it has been suggested that the high
peak of oestrogen concentration reached soon after ovulation has an inhibiting effect on
the anterior pituitary, the corpus luteum, therefore, receiving insufficient stimulation,
undergoes degeneration and menstruation occurs. The mechanism by which the deprivation of hormones may set up the disturbance of the endometrial blood vessels is still unexplained. It may be due to the toxic action of certain sterols derived from the cestrogens.
In addition to the normal type of menstrual cycle, in which the endometrium exhibits
the various changes just described, it is now well known that another type, unaccompanied
by ovulation and therefore not preceded by the usual secretory changes in the endometrium,
may occur. This is known as anovulatory menstruation. As shown by Corner3 and
Hartman4, this phenomenon is of frequent occurrence in monkeys. Clinically, the bleeding is in no wise distinguishable from "normal" menstruation. Such a variety1 of menstruation may be quite rhythmic and regular. It probably occurs quite frequently at
puberty, at the menopause, and also in certain cases of sterility. Novak5 believes that
functional menorrhagia is frequently associated with an anovulatory mechanism. Its
existence may, of course, be determined by a microscopic examination of the endometrium
just before menstruation. Absence of secretory changes in the endometrium implies failure
of ovulation.
Let us now briefly consider the nature and origin of the various sex hormones which
are so vitally concerned in the reproductive process. They may be considered as falling into
two main groups: first, the gonadotropic substances which stimulate the function of the
ovary; second, the ovarian hormones which act on the accessory sex organs.
Gonadotropic Hormones
Three main groups with different actions may be described:
(1) Anterior Pituitary Gonadotropic Hormones,
(2) Chorionic Gonadotropic Hormone, and
( 3 )  Equine Gonadotropic Hormone.
The close association of the anterior hypophysis with sexual functions has long been
known. The operation of removal of the pituitary in various laboratory animals is followed
by atrophy of the sex organs. The administration of fresh extracts of the anterior pituitary
gland in immature female rats or mice causes a marked increase in size of the ovaries with
the development of large numbers of Graafian follicles and corpora lutea. These changes
lead to the production of cestrogenic hormones which ,in turn, induce a marked growth in
the uterus and the development of secondary sexual characteristics. As suggested previously, two factors of the anterior pituitary hormones have been demonstrated—a follicle-
stimulating hormone and a luteinizing hormone. The primary use of these preparations
clinically is to stimulate follicle growth and development. The commercial preparations
are chiefly "soup-like" extracts of the pituitary glands of sheep and cattle.
Chorionic Gonadotropic Hormones
In 1928 Aschheim and Zondek6 announced that the urine of pregnant women contains large amounts of gonadotropic substance, and that its presence would serve as an
accurate test for pregnancy. This gonadotropic substance has also been found in the blood,
placenta, amniotic fluid and other tissue fluids during gestation. It was at once considered
that this was a pituitary principle, since it produced somewhat the same effects in the
ovaries of immature rodents as the true anterior pituitary extracts. However, a comparative study of the respective changes induced by the two substances showed that there was
a significant difference in the effects. Accordingly, the gonadotropic hormone of pregnancy was called the anterior pituitary-like hormone by some. It is now considered that it
is manufactured in the placenta.
The chorionic hormone does not stimulate follicle growth in women. On the contrary, it may produce atresia of the follicles. Since this hormone was found to produce
excessive lutednization in the ovaries of some animals, it was thought that it might be useful
in inducing similar effects in women. However, the human ovary does not respond in this
way, as has been repeatedly shown by the studies of Hamblen.
Page 99 Equine Gonadotropic Hormone
In 1930 Cole and Hart reported that the blood of mares in, the mid-period of pregnancy contained a large amount of a gonadotropic hormone. Present evidence indicates
that this hormone not only differs from the human chorionic hormone but is present in
greater concentration. It has been found to be capable of inducing ovulation in some
species, and recent studies of Davis and Kofi7 suggest that the hormone is capable of
inducing ovulation in women, but this requires further corroboration. Should it prove
true, this hormone should be of considerable value.
All gonadotropic hormones are standardized by a modification of the Aschheim-Zondek
test and the dosages expressed in rat units. The gonadotropic hormones exert no recognizable effects when given orally. They are administered by the intramuscular route.
The Ovarian Hormones
The oestrogenic hormone is primarily a growth hormone, since its action is to promote the development of the accessory sexual organs. It not only causes proliferation of
the endometrium, but also produces enlargement of the uterus, the mammary glands, and
stimulates uterine contractions.
Biochemists have shown that several allied chemical compounds may be grouped under
the inclusive term cestrogenic substances. Three of these have been isolated in pure form,
viz.:
Oestrone (ketohydroxycestrin);
Oestriol (tri-hydroxycestrin);
Oestradiol (di-hydroxycestrin).
It is now believed that oestradiol is the true follicular hormone and that the others are
excretion products. Oestradiol is by far the most potent, and has been isolated from follicular fluid. Commercially these preparations are manufactured from pregnancy urine or
from the placenta. The familiar emmenin is cestriol glucoronide.
The standardization of cestrogens is conducted with the Allen-Doisy test, which consists of the induction of oestrus changes in the vaginal mucosa of castrate rats or mice.
The international unit of cestrone is 1/10,000 of a milligram. While the international
unit for oestradiol benzoate has the same mass, it is considerably more potent and is a
different chemical entity. Much confusion has arisen from the many and varied trade
names under which the oestrogenic preparations are dispensed, and the fact that there are
two international units of different potency further complicates the picture.
In addition to the natural cestrogens, a new synthetic oestrogen, di-ethyl stilboestrol,
has appeared on the scene. It was isolated by Dodds and Lawson in 1938. Its oestrogenic
activity is about two and a half times as great as cestrin. It has the further advantage of
being highly effective by mouth. Recently, several British investigators have affirmed the
idea that stilboestrol can replace the natural cestrogens in all their therapeutic applications.
Some caution must be used in the administration of stilboestrol, since in large dosage or
prolonged use it may cause gastric irritation with nausea and vomiting. Moreover, the
appearance of albuminuria and cedema have been noted in a few instances following its use.
Thus it would appear that it has the property of producing a renal irritation also.
To clarify the comparative potency of the various preparations, we thus may say that
oestradiol preparations are from 5 to 10 times as potent as oestrone preparations, and that
stilboestrol is 2.5 times as potent as oestrone. The rat unit used by some companies is
approximately five times the strength of the international unit.
Turning now to the corpus luteum, it should be noted that it produces oestrogen as well
as its specific hormone, progestin. In addition, the preliminary action of oestrogenic substance is necessary before progestin can induce its characteristic effect in the endometrium.
This sequence was described by Hisaw as the "One-Two" reaction in the endometrium. Progestin is responsible for the safe nidation of the ovum, and tends to inhibit uterine contractions. Progestin has been isolated in crystalline form, and is now manufactured synthetically from the soya bean. It is so standardized that one international unit is the equivalent
of one mgm. of crystalline progestin.
Venning and Brown8 have shown that progestin is excreted in the urine in the form
Page 100 of the inactive compound pregnandiol glucoronidate, and have shown that the amount of
pregnandiol excreted is an index of progestin activity.
Below is given a table of the various commercial preparations of the sex hormones
which are available in Canada.
COMMERCIAL PREPARATIONS OF GONADOTROPIC HORMONES
1. Anterior Pituitary Gonadotropic Hormone.
A. Gonadotropic Hormone, formerly Maturity Factor (Ayerst, McKenna & Harrison).
B. Preloban (Winthrop).
2. Chorionic Gonadotropic Hormone.
A. Antuitrin-S (Parke, Davis & Co.).
B. A.P.L. (Ayerst, McKenna & Harrison).
C. Follutein (E. R. Squibb & Sons).
D. Gonan (B.D.H.).
E. Korotron, formerly Antopbysin (Winthrop).
3. Equine Gonadotropic Hormone.
A. Gonadin (Cutter Labs.).
B. Serogan (B.D.H).
COMMERCIAL PREPARATIONS OF OESTROGENIC HORMONES
1. For intramuscular injection:
A. Amniotin (E. R. Squibb & Sons
B. Oestrone (Abbott). }   Oestrone.
C. Theelin  (Parke, Davis & &Co.).   J
D. Oestroform (B.D.H.). ) «
tj     t> d/ci.-/^       \     c Oestradiol Benzoate.
h.     Progynon-B   (Schenng Corp.).   j
2. For oral administration:
A. Amniotin (E. R. Squibb & Sons).
B. Emmenin (Ayexst, McKenna & Harrison).
C. Estriol (Abbott).
D. Progynon-DH (Sphering Corp.).
E. Theelol (Parke, Davis & Co.).
3. For oral or intramuscular administration:
A. Stilboestrol  (B.D.H).
B. Stilboestrol  (E. R. Squibb & Sons).
C. Oestrobene (Ayerst).
4. For intra vaginal application:
A. Amniotin Pessaries (E. R. Squibb & Sons).
B. Oestroform Pessaries (B.D.H.).
C. Progynon-DH Suppositories (Schering Corp.).
D. Theelin Suppositories (Parke, Davis & Co.).
5. For topical application:
A.    Progynon-DH Lanol (Schering Corp.).
COMMERCIAL PREPARATIONS OF PROGESTIN
A. Lipo-Lutin (Parke, Davis & Co.).
B. Progestin  (Eli Lilly & Co.).
C. Progestin  (B.D.H.).
D. Proluton (Schering Corp.).
Discussion of the sex hormones would not be complete without reference to the
androgens or male sex hormones, which have created much interest among endocrinologists
recently. Two chemical substances have been isolated—androsterone from urine, and
testosterone from testicular tissue. The androgens are chemically closely related to the
oestrogens, and, curiously enough, androsterone is especially abundant in pregnancy urine.
Physiologically, as might be expected, the androgens are antagonistic to the cestrogens—
presumably through their effect on the anterior pituitary. Thus they have the properties
of causing a cessation or delay in the menses, producing an atrophy of the endometrium
and tending to produce masculinization of the external genitalia. Though several favourable reports have been presented of their clnical use in such conditions as menorrhagia and
dysmenorrhcea, present preparations on the market are much too expensive in the dosage
required to be of practical use at this time, but it may well prove that many of the dysfunctions of menstruation may prove amenable to therapy with the male sex hormones.
All of the sex hormones are sterols and are closely related to cholesterol in structural
formula.
Page 101 In the investigation of menstrual disorders, we must remember that many of them, are
not primary conditions, but are secondary to systemic or pelvic diseases. All such patients,
therefore, should receive a careful general and pelvic examination. In many, special procedures, such as a complete blood count, basal metabolic rate, X-ray of sella turcica, visual
fields, and sugar tolerance tests, may be indicated.
Apart from the useful Friedman modification of the Aschheim-Zondek test, we have
not as yet local laboratory facuities for the special biologic tests for hormone assays in the
blood and urine. Many of these are expensive and time-consuming! to perform. Doubtless in the not too distant future such tests will be simplified and! thus made available for
the laboratory of the average general hospital. In the meantime, however, two relatively
simple methods are available as a guide in the study of menstrual disorders. The first is the
careful use of a calendar. By this simple means a doctor with a knowledge of the physiology
of menstruation can often make an accurate estimate of the endocrine disturbance involved. A small calendar card may be furnished to the patient so that she may mark the
days of menstruation and also indicate thereon any abnormal bleeding or other symptoms.
Secondly, since we have seen that the endometrium reflects the functional activity of the
ovaries, a histological examination of the uterine mucosa is often of considerable value.
This is especially true in the investigation of functional uterine haemorrhage, amenorrhcea
and sterility. While a thorough curettage under anaesthesia provides the most information
in such cases, the necessary hospitalization and expense involved are disadvantageous. An
endometrial biopsy may be readily obtained as an office procedure, using either a very small
curette or the newer suction curettes such as those of Novak or Randall. Naturally, strict
aseptic technique must be employed and the portio of the cervix and cervical canal should
be painted with an antiseptic solution as a preliminary. The specimens are best obtained
from fairly high up on the anterior and posterior uterine walls. The procedure should be
timed so as to furnish the most information——for example, when one suspects deficient
corpus luteum activity the specimen should be taken about a week before an expected
menstruation. The specimen should be immediately placed in 10% formalin solution and
the date of the last menstrual period furnished, to the pathologist. In cases where carcinoma might be present such an examination is, of course, inadequate and may be dangerous.
The suspicion of carcinoma demands a complete and careful curettage.
After this somewhat lengthy preamble, which, however, I believe is necessary to an
understanding of the factors involved in treatment, let us now turnl to the consideration
of the therapy of some of the more common disorders of menstruation. I Would here like
to emphasize that one should spare no efforts to be sure that the disorder is truly a functional one. It is probable that quite a large percentage of indifferent results in endocrine
therapy is due to a faulty diagnosis.
Dysmenorrhoea.
Essential or primary dysmenorrhoea has proved, through the years, to be one of the
most bafflng symptom-complexes which fall to the lot of physicians to alleviate. No definite anatomical disturbance is associated with this condition, though not infrequently a
hypoplastic anteflexed uterus of the so-called infantile type may be present. The immediate
cause of pain would appear to result from excessive spasmodic contractions of the uterine
muscle. Experimentally the cestrogens initiate rhythmic uterine contractility and sensitize
the myometrium to pituitrin, whereas progestin causes a diminution or quiescence of uterine
muscle activity. However, there is no basis to substantiate the theories that painful menstruation may be due either to an excess or deficiency of either oestrogen or progestin.
Whatever the mechanism for its causation may be, it is certain that constitutional and
psychogenic factors are of prime importance in the development and perpetuation of
dysmenorrhoea. In treatment, therefore, a serious attempt to regulate the patient's mode
of life in respect to diet, exercise, rest, bowel function, and so on, should be made. Reports
from various schools have particularly stressed the importance, of special exercises during
the early years of menstruation. The mental attitude of the patient is also of importance.
Frequently a discussion with an explanation of the significance of menstruation is helpful.
Underlying fears and anxieties should be removed, and in this connection the familiar picture of the over-solicitous mother should be remembered.
Page 102 The drugs used in the past and even at present in the treatment of this complaint are
legion, and their very number bespeaks their inefficiency. Since dysmenorrhoea is a symptom, and because of the wide range in the individual sensitivity to pain, the estimation of
the efficacy of any particular drug or treatment is especially difficult. Undoubtedly many
of the favourable results must be put down to suggestion.
During the actual attack of pain, belladonna, with its chief alkaloid, atropin, has been
used for years with some degree of success. Phenobarbital may be combined with the belladonna. The various combinations of aspirin with or without codeine are of value. The use
of benzedrine sulphate has recently been reported, with effectual results in more than 50%
of the treated subjects.
With the advent of potent endocrine preparations much hope was entertained for their
successful use in this troublesome complaint. Although a fair percentage of good results
have been reported with various types of hormones, the conclusions in general have not
been very convincing. Israel9, in a careful study of the results of treatment following the
use of oestrogenic and gonadotropic hormones, found the results of therapy disappointing
as a whole. On the other hand, Watson10 reported almost 50% complete relief of pain in
cases treated with the placental extract emmenin. My experience with this drug would
suggest that it is not effective frequently in dysmenorrhoea, but when it does prove helpful, the relief of pain is often dramatic. Theoretically, cestrogenic therapy should be of
value in cases associated with hypoplasia of the uterus, and the evidence of reports would
seem to support this contention.
On a physiological basis, progestin should prove of considerable value, since it has the
property of relaxing the uterine muscle. A number of reports have accrued, generally
favourable. My personal experience is that progestin is usually valuable given in doses of
1 to 2 mgm. during the few days immediately preceding menstruation. It would naturally
be assumed that the relief obtained would be of temporary value only. However, I have
been impressed in a few instances with the fact that the menstrual pain was thereafter
never severe. A recent article by Kurzrok and Livingston11 reports their similar experience.
Dilatation of the cervix still remains a popular method in the treatment of severe dysmenorrhoea, though it has been shown that cervical obstruction must be a rard cause for
pain. From reports submitted, apparently 40% to 60% of patients are relieved by this
procedure, though the relief may only be temporary.
Finally, the operation of resection of the superior hypogastric plexus may be considered.
In the absence of other reasons for performing laparotomy, this would seem to be a major
procedure whose merits as yet have not been completely evaluated.
Functional Amenorrhoea.
Functional amenorrhoea may be primary in which menstruation has never occurred,
or secondary when the menses cease after a longer or shorter period of menstrual function.
Normal menstruation depends on general good health, and its disappearance may be
the first indication of a systemic disease. It follows, then, that before any treatment is
considered a careful general examination should be undertaken. In particular, tuberculosis,
cardiac disease, dietary deficiencies, blood dyscrasias, unhealthy environmental surroundings and change of climate may cause cessation of the menses.
The majority of patients, however, who consult a physician (apart from those with a
physiological amenorrhoea) suffer from an endocrine disturbance or dysfunction. The
exact nature of this is often difficult to determine. The three endocrine glands most
important in this connection are the pituitary, the thyroid, and the ovary. When the dysfunction is primary in the pituitary or thyroid there frequently are associated disturbances
of metabolism such as obesity, lowering of the basal rate and so forth.
The marked pituitary dyscrasias have given rise to well-known clinical syndromes
accompanied by amenorrhoea, such as Frolich's syndrome and Simmond's disease. Minor
pituitary dysfunctions affecting the ovaries may show no obvious bodily stigmata in the
patient, though mild grades of Frolich's syndrome are not uncommon.
It is well known that disturbances of the thyroid gland may be associated with
amenorrhoea or menorrhagia. The combination of hypothyroidism, moderate generalised
obesity and amenorrhoea is frequently seen.  As pointed out in a recent paper by Dodds
Page 103 and Robertson12, the hypothyroidism may not be apparent unless a basal metabolism determination is made.
While ovarian deficiency may be primary, as when a corpus luteum persists, usually the
faulty ovarian function is secondary to pituitary failure. However, Stein and Leventhal13
have pointed out the association of amenorrhoea with polycystic changes in the ovaries
accompanied by thickening of the tunica albuginea, reporting a series of cases in which
normal menstrual function returned after wedge-shaped resection of the cystic ovaries.
The findings on endometrial biopsy in amenorrhcea are not constant, though in the
longstanding cases atrophy of the endometrium is usually found. Its occurrence is an
unfavourable sign in prognosis.
The outlook for the restoration of normal cycles depends on many factors. The age
of the patient and the duration of the amenorrhcea are of prime importance. In general, an
amenorrhcea of over 24 months gives a poor prognosis. Fluhmann states that 45% of
patients at the Stanford University Clinic observed spontaneous uterine bleeding within
a few weeks of observation whether they were treated or not. This tendency to spontaneous recovery must be remembered in the estimation of the virtue in any specific method
of treatment.
Concerning treatment, I shall here express my own views for what they may be worth.
Systemic diseases having been excluded, attention should be paid to the diet and personal hygiene. A well-rounded diet supplemented by sufficient vitamins and minerals is
prescribed. A serious attempt should be made to bring the patient to her ideal weight.
This usually means a reducing diet. Thyroid extract is given in accordance with the level
of the basal metabolism. The latter should be checked periodically to see that the rate is
being kept within normal limits (preferably on the plus side) on the dosage taken. Regarding further endocrine treatment, I believe that judgment should be used in the selection
of cases. In very longstanding cases, or in patients over thirty years of age, it is doubtful
if the game is worth the candle. After all, amenorrhoea is compatible with fairly good
general health. Those cases showing marked evidences of pituitary dysfunction are also
disappointing to treat.
On the other hand, in young women who are desirous of marriage and a family, I
believe that further treatment is indicated.
Kaufman14 described the first complete replacement therapy of amenorrhoea in 1934.
In this brilliant work, he showed that one could reproduce the whole of the menstrual cycle
in castrated women by first injecting oestrogenic hormone followed by progestin, thus
duplicating the events which occur in the normal cycle. Large doses of the cestrogenic
hormones were necessary. The application of this treatment to patients with amenorrhoea
was then tried. The results in secondary amenorrhcea were usually successful, while the
response was less certain in primary amenorrhoea. Since this was substitution therapy in
most of the cases, amenorrhoea reappeared when the treatments were discontinued. The
problem is to stimulate the ovaries to a return of normal function. My method of procedure
is as follows: A preliminary course of fairly large doses of cestrogenic hormone (oestradiol
benzoate—2,000 to 10,000 R.U. for five or six injections) is given to induce growth and
increase vascularity in the usually atrophic uterus. Not infrequently uterine bleeding
(probably anovulatory in character) will follow the cessation of this course of treatment.
If bleeding occurs, a series of daily injections of anterior pituitary hormone (gonadotropic
factor) is immediately carried out from 10 to 14 days. A rest period of two weeks is then
given. Should menstruation ensue, a shorter course of anterior pituitary hormone is
repeated. Should bleeding not occur, after the original injection of oestradiol benzoate,
five or six doses of progestin (1-2 mg.) is given every other day. Bleeding will nearly
always follow within a few days after stopping the progestin—provided the original
dosage of oestradiol was adequate. One then proceeds to the anterior pituitary hormone as
previously mentioned. Fluhmann believes that the effect of anterior pituitary hormone
may be enhanced by the concomitant adminisiration of chorionic gonadotropic hormone.
Obviously considerable patience must be exercised by both patient and doctor, and the
expense involved is a considerable item. However, I believe that if the cases are carefully
chosen, treatment will be successful in the majority of instances. The great need, however,
Page 104 in this connection is for more potent and purified anterior pituitary gonadotropic preparations, as well as a substantial reduction of the cost of endocrine preparations. The organic
chemist may solve both angles of this difficulty.
In several clinics the use of low dosage irradiation of the ovaries and pituitary has been
undertaken in the treatment of amenorrhoea. Mazer goes so far as to say that irradiation
is the most satisfactory treatment. Probably because of the known narrow margin of
safety involved, this form of treatment has not become popular. Since the mode of action
of the X-ray is primarily destructive to the Graafian follicle, it is difficult to understand
the rationale for its use as far as the ovary is concerned. As an experiment, a few longstanding cases of amenorrhoea presumably of pituitary origin were treated by X-ray of the
pituitary from the gynaecological endocrine clinic with absolutely negative results.
Functional Uterine Haemorrhage.
The last disorder of menstruation to consider is functional uterine haemorrhage. The
employment of this term should be limited to those patients with grossly normal pelvic
organs. This disorder may occur at any age during the menstrual life of a woman, though
it is typically found between the ages of 38 and 45. About 5'% of all cases, however, occur
at puberty. A relatively large number of cases with functional haemorrhage develop after
a pregnancy, especially an abortion. It would seem to occur at a time when the ovarian
function is undergoing a period of change or readjustment. A study of the ovaries in
these cases characteristically show an absence of corpora lutea and a persistence of unruptured follicles. The endometrium is always of the non-secretory type, usually markedly
thickened and hyperplastic. Often the surface is irregular and shows prominent elevations
—the so-called polypoid formation. Microscopically the endometrium is thick and heavy,
the glands are markedly increased in number, often irregular with much variation in their
size and shape. Cystic glands lined with a low cuboidal epithelium—'the so-called Swiss
cheese pattern—is frequently present. Some glands may show stratified epithelium. Such
an occurrence may lead to an erroneous pathological diagnosis of squamous carcinoma, as
Fluhmann has demonstrated. If the endometrium is examined during a bleeding phase,
areas of necrosis with thrombosis of neighbouring bloodi vessels and a marked leukocytic
infiltration are seen. This is the picture formerly described as hyperplastic endometritis.
The changes in the endometrium are due to failure of corpus luteum formation and
activity, so that there is a persistence and abnormal exaggeration of the proliferative phase
of the cycle. While hyperplasia of the endometrium is the typical microscopic picture,
functional bleeding may occur from other types of non-secretory endometrium. It seems
clear that the hyperplasia is not the cause of bleeding, but rather the result of the continued
oestrogen stimulation.
Schroder has applied the term metropathia haemorrhagica to functional uterine bleeding, and this is the expression commonly used in Europe for such cases. The bleeding may
be of the menorrhagic type with shortened intervals, or both menorrhagia and metrorrhagia
with totally irregular periods, may occur. The association of hypothyroidism is found
fairly frequently.
Before consideration of the treatment of functional uterine bleeding it must be emphasized that organic causes for the haemorrhage must be eliminated. With the exception of
puberty bleeding, the employment of a diagnostic curettage should be considered. This is
especially important in women over 35 in order to exclude carcinoma. Even in younger
women, bleeding first considered as functional may prove to be due to an endometrial
polyp, submucous fibroid, or a small portion of retained placental fragment. In particular,
inter-menstrual bleeding demands curettage as a preliminary to any treatment.
When the haemorrhage is severe it is often necessary to institute measures for its control pending an exact diagnosis or response to endocrine therapy. Such procedures include
the use of bed rest, ergot (preferably the newer preparations), vaginal or uterine packing,
and the use of blood transfusions and iron preparations to control the anaemia. It is not
necessary to further dilate on such wtell-known procedures.
Regarding the specific and endocrine treatment of functional bleeding, I believe it is
an advantage to consider the treatment according to different age groups.
Group I—Functional Bleeding of Puberty.
Page 105 Abnormal bleeding during the early years of menstrual life is fortunately not common,
as it is frequently troublesome to control. Assuming that a careful general examination has
eliminated a systemic cause, a course of treatment with chorionio gonadotropic hormone
should be instituted. A course of daily intramuscular injections (250 to 500 rat units)
for 6 to 10 days, beginning with the onset of bleeding, is carried out. The administration
of thyroid in suitable cases is of great value.
The mechanism by which the chorionic gonadotropic hormone controls bleeding is not
clear. It probably does not produce luteinization in the human ovary. It may act through
producing atresia of the growing follicles, thus cUminishing the cestrogenic overactivity.
At any rate it has survived the test of extensive clinical trial.
Jeffcoate has stated that puberty bleeding may be controlled in over 80% of cases by
this means alone. In the more intractable cases, curettage and the us of small blood transfusions (possibly from pregnant donors) may be necessary. In extreme cases small doses
of radium may be required.
Group II—Functional Bleeding occurring during active sexual life.
I group here the patients usually seen between the ages of 25 to 38. Frequently, a
pregnancy has preceded the onset of symptoms. In this group, also, the chorionic hormone
is of real value, and should be employed in a similar manner as in the previous group, but
in somewhat larger dosage. Curettage should not be delayed too long—not only because
of its diagnostic value, but also because the removal of the excessive growth of uterine
mucosa apparently favours a more immediate action from the endocrine therapy. Should
the use of chorionic hormone fail, and I believe that in cases where it wjill be of value
the response is fairly prompt, one may then change to corpus luteum hormone (progestin).
This is replacement therapy, but often is effective when the chorionic hormone fails. A
specific treatment devised by Browne and Allbright is as follows: Two weeks after a preliminary curettage a course of four injections of progestin, in doses of from 2 to 5 mg., is
given every other day. They claim that the ensuing menstrual period is usually normal in
amount and duration. A similar course is repeated twenty days after the period commences. In some few instances I have noted the association of small ovarian cysts with
cases of functional bleeding which failed to respond to endocrine therapy. In three instances, resection of the cyst from the ovary was followed by a prompt return of regular
and normal menstruation.
As a last resort, I believe that hysterectomy is preferable to irradiation in this group of
cases, as the ovaries may be conserved and the untoward effects of a premature menopause
avoided.
Group III—Function Uterine Bleeding bi the Age Group 38-50.
This group is, on the whole, less responsive to endocrine therapy. A diagnostic curettage should precede all therapy, as the possibility of carcinoma must be eliminated. The
general practice in many clinics is to institute radium therapy at the same sitting as the
curettage, provided no organic lesion is discovered to account for the bleeding. In the
younger patients of this age group I believe that such a procedure may be somewhat radical.
My own choice of procedure is based on the following factors:
(1) The type of endometrium found at curettage;
(2) The severity of the bleeding, and
( 3 )   The age of the patient.
For instance, in a woman of 39 or 40 with only moderate bleeding, and the curettings
showing a mild or moderate degree of hyperplasia, the curettage would be followed by a
trial of endocrine therapy. If this is successful, frequently radiation is not necessary at all.
On the other hand, should the bleeding recur, one can then resort to the induction of an
artificial menopause by X-ray treatment. On the contrary, should the patient be 45 or
more, with a marked degree of endometrial hyperplasia, or the bleeding profuse and more
or less continuous, the immediate insertion of radium into the uterus is preferable. Thus,
by individualisation of cases with a corresponding difffference in treatment, I believe that
better results can be obtained than would follow the routine use of radium in this age
group.
In conclusion, endocrine therapy now forms a valuable contribution to our medical
Page 106 armamentarium and has undoubtedly come to stay, despite occasional disappointing results
in individual cases, and we await its future developments with interest.
REFERENCES:
1. Fluhmann—Menstrual disorders.   "W. B. Saunders Co.; 1939.
2. Allen—Am. Jl. Anat.   42:467, 1928.
3. Corner—Am. Jl. Ob. & Gyn.   3 8:862, 1939.
4. Hartman—Contrib. Embryol.   23:1, 1932.
5. Novak—Am. Jl. Ob. & Gyn.   37:605, 1939.
6. Zondek—Hormones des ovarium, etc.   Julius Springer, Vienna; 193 5.
7. Davis & Roff—Am. Jl. Ob. & Gyn.   36:183, 1938.
8. Venning & Browne—Endocrinology.   21:711, 1937.
9. Israel—J. A. M. A.   106:1698, 1937.
10. Watson—C. M. A. J.   34:293, 193 6.
11. Kurzrok & Livingston—Am. Jl. Surg.  46:353, 1939
12. Dodds & Robertson—Jl. Ob. & Gyn. of B. E.   46:213,
13. Stein & Levanthal—Am. Jl. Ob. & Gyn.   29:181, 1935.
Kaufman—Proc. Roy. Soc. Med.   27:849, 1934.
Novak—in Curtis—System of Obstetrics and Gynaecology
Curtis—Textbook of Gynaecology.   Saunders Co.; 193 8.
Hundley, Krantz & Hibbits—Med. Clin. N. A.   March, 1939, 373
1939.
Saunders; 1933, v. 3.
PROSTITUTION—FACTS AND FALLACIES
(Abstract of an address given before the Vancouver Medical Association, December 5th, 1939.)
Dr. D. H. Williams
Director of Venereal Disease Section, Provincial Department of Health.
Prostitution is a problem, a social problem, which is also related to venereal disease, and
this constitutes our justification for dealing with the subject. It is not merely, or even
mainly, a moral problem, but one that must be solved if we are to reduce the incidence of
venereal disease to a minimum.
Pelouze, in his book on the Treatment of Gonorrhoea, says in a chapter he devotes to
prostitution: "The chief interest of the physician in prostitution is neither as vocation,
avocation nor as an art, but as a potent means whereby genital infectious disease is spread."
Most of the opinions of the average layman, even of the average" physician, are 100%
fallacious. We must correct these mistaken ideas, especially in the minds of doctors, on
whom so many must depend for authoritative instruction. Venereal disease is a major
health problem in British Columbia today. We have not recognized this fact—primarily
because of the secrecy usually attached to discussions of this subject, and the complete
absence till lately of any attempt to give the public information about it. Only within the
last two years has any adequate attempt been made to bring the true state of affairs' in
British Columbia to the light of day.
In 1938, 92,000 tests for V.D. were made in the Public Health Laboratories of the
Province. Five-sixths of these were made for private physicians, and this statement will
give some idea of the volume of venereal disease in the hands of the private physician.
28,791 doses of antisyphilitic medication were distributed; 998 written consultations
were sent to doctors; 3034 new notifications of venereal disease were made in 1938, and
since we know that only one in three is usually reported, this means nearly 10,000 new
infections. The number reported, however, is steadily increasing.
Something must be done about it, and something is being done. Roseneau, perhaps the
outstanding authority in this regard, says: "Any sanitary measures taken for the prevention
of venereal disease which do not include some method for handling the problem of prostitution are doomed in advance to failure, since they will ignore the chief root and source
of the disease."
Page 107 Last year, in Vancouver, it was quite impossible for the V.D. Clinic to keep up with
the flood of cases which were infected in the brothels, and this means that if we are going
to do anything effective about venereal disease we must begin with prostitution, and do
something about that.
There are two types of prostitute, the clandestine and the professional. It is a fact that
the clandestine prostitute greatly outnumbers the professional. But she is a different type
of woman—generally she is mainly engaged in other work, often confining her favours to
one man, at most to one or two a week, and so far less likely to become infected and spread
the disease. Further, if she does become infected, she usually goes promptly for treatment,
and suspends her sexual activities while undergoing this.
The commercial prostitute presents an entirely different problem. Dr. Williams suggested that we should employ the utmost frankness in this matter and thought that we
might well drop a great many outworn words and phrases. Thus he feels that "bawdy-
house" is not a good term, and he suggests some such word as "fornicatorium," a word of
his own coining. This would be definable as "a place where the daughters of the underprivileged classes are exploited by third parties, and the use of their bodies sold for the
profit of these latter."
We are faced with the question: "What are we going to do about bawdy-houses?" and
right here we run into trouble and obstruction. The situation is one that demands, first,
education of the public in the actual facts.
The Department of Health is appointing educators, whose function it will be to see
that every citizen in the Province has the opportunity to learn the facts about bawdy-
houses, about prostitution, the facts about its relation to venereal disease, the danger it is
to him personally and the country at large, and the latest opinions of authorities as to how
it should be dealt with.
There have been two ways suggested for dealing with the brothel, or bawdy-house,
the "fornicatorium":
1. Segregation and control. Until lately, this was the policy adopted in British
Columbia, and it is still advocated by many, including many people who conscientiously
believe it will achieve the desired result. We were, until recently, a new country, a
pioneering country, with a very mobile population, and the method of segregation had,
no doubt, certain advantages. But we are getting past that stage. We have a settled type
of society, with definite laws, with a Criminal Code. This Criminal Code, as it stands
today, makes the existence or establishment of a bawdy-house, frequenting of the same,
renting one's house for such use, all illegal, and a crime. But we have tolerated daily
breach of this law in all these ways, and so venereal disease has grown steadily. This is the
considered and unanimous opinion of all authorities on this subject.
"Everything that is said bi favour of segregation and control, and all the propaganda
about it, comes from the bawdy-houses and those who run them." The. public does not
know this fact and believes the untruths that are handed out to it. Segregation is impossible and has never been accomplished. The reports of the League of Nations show this.
It is, in the nature of things, doomed to fail. Thus Paris, where segregation has for generations been the settled policy, has 5000 known and licensed prostitutes, and 50,000
unlicensed ones known to be practising. It is the same in any community. It is impossible
to limit these people to brothels. The nature of the business is such that the girls in the
houses must constantly be changed, as they lose their freshness or become diseased. Then
they get out of control.  They are on the move all the time.
As regards "control." There are two factors in this:
1. Police control. The police keep a check, as far as they are able, on the movements
of these girls, fine them more or less regularly, so that this fine is really a form of license.
It is a most pernicious system—in that it constantly exposes the police force to the possibility of demoralization, as we see in certain cities.
2. Medical control. This is another fallacy. Last year 2% of all loggers and miners
in B. C. had new infections. A girl has no chance of escaping infection, and) of those
inmates of brothels examined at the V.D. Clinic last year, 84% were found to be infected.
Page 108 There are all sorts of reasons why even a recent certificate of negativity is of no value
whatever; when obtained it has usually been from a practising physician. Girls may use
drops, take alum douches, etc., before going for examination; a known healthy girl may
obtain certificates under false names for a dozen infected ones. In one case cited by the
speaker, a cook in one house, not infected herself, visited 12 different doctors, obtaining
negative certificates in 12 different names, and sold them for $2.00 each over the price
she paid for the test, etc.
Too, if control were really put into effect, we should have to begin by stopping 85%
of the girls from working till they were treated and cured. The rest would soon be infected;
no girl could afford to spend most of the working year idle, and undergoing treatment, and
as it would not pay them they would not report for examination, and would evade the
regulations in some way.
Segregation and control are an impossibility, and we may as well recognize this fact,
and also the fact that they are chiefly urged by those whose interest it is to maintain the
system, or by those who do not know the facts of the case.
2. Suppression.—This is the other method of dealing with prostitution, and is the
method advocated by all health authorities.
. No economic or health expert advocates segregation and control—every known expert
in these matters, in all countries, advocates and urges the method of suppression of bawdy-
houses.
Dr. Williams emphasized the fact that the Public Health authorities do not advocate
abolition of prostitution. They recognize this is impossible, a Utopian dream. The policy
of the modern Public Health leaders may be stated thus: "We must reduce prostitution,
and so venereal disease, to a minimum, by the enforcement of the existbig laws, education
of the public, and suppression as far as possible."
If the Criminal Code were enforced, the population of Essondale would be markedly
lessened, an enormous financial burden on the community removed, a main cause of
sterility largely wiped out, numberless mutilating pelvic operations rendered unnecessary.
There is a tremendous inescapable responsibility on the shoulders of those who countenance
the breaches of the law, and the ignoring of it.
There are those who speak of the ill effects of suppression. Let us see what would
happen if suppression were put into effect as far as possible.
The evil effect on the tourist trade is often referred to. It is stated that this business
is being damaged by all this publicity. It is a fact that the existence of prostiution, with
the attendant risk of venereal infection, constitutes the greater threat to the safety of
those travelling in our country.
When we have houses of prostitution, we have a force of hotel clerks, bellboys, pimps
and procurers, taxi-drivers, etc., all directing people to these houses, feeding the trade.
The average girl inmate, protected by our present methods, may deal with as many as 3 0
men a week. Suppose we close the houses and suppress them to this extent. If this girl is
out on her own, she is lucky to get as many as 7 or 8 customers a week. This greatly lessens
at once the danger of spread of venereal disease. Morover, this does not pay, and the girl
is likely to pack up and leave town. Reports from the East are already available to show
that many of the girls formerly operating in Vancouver have gone back East to find a
market for their wares, since this market was practically closed to them. Many girls, too,
who have not been engagejd in the trade for long, take up other ways of earning* a livelihood.  Many marry and live respectably afterwards.
Instead of 100 girls, who are now inmates of known houses in Vancouver, with an
average of 30 exposures a week each, we might have 30 or 40 under the method of suppression, with an average of 7 or 8 exposures a week, thus, as has been said, greatly lessening
the opportunities for spread.
It is charged, again, that under this method prostitution will spread all over the city.
This is not actually the case, and this fallacy can be exposed—but those who are exploiting
it have a recognized technique in the matter. They make a noisy nuisance of themselves,
infest residential streets, etc., in the hope that decent citizens in disgust will come to the
conclusion that brothels would be better than this. This is all done to impress the public
Page 109 and obtain the end they are seeking. The obvious remedy is to enforce the law against the
landlords who let them operate on their property, and against those who are operating
thereon things which are against the law.
It has been charged that sex crimes increase when bawdy-houses are closed. The League
of Nations' studies have shown that this is not true; that they actually decrease.
All these lies and fallacies are mere propaganda, deliberately put out by those who are
interested, and accepted by an uninformed public as facts. Dr. Williams states that his
department intends to see that they get the true facts of the matter.
What are the results of closing the houses and enforcing the law? Here we have the
reports of many years of investigation by the League of Nations' several committees, the
British Ministry of Health, of Scandinavia, and fifteen other countries. In 1919 conditions
in Great Britain were so extremely bad that the government appointed Col. Harrison to
make a study and report. There were at that time 112 cases (new yearly) of syphilis per
100,000 of population. As a result of suppression this has been reduced to 47 per 100,000
in 1935.
Scandinavia has reduced her incidence from 93 in 1919 to 19 per 100,000. In Vancouver, even the partial efforts we have been able to make are showing results, some houses
having been closed since February, 1939. Between this and August,, the level of new
G.C. in men has dropped 39%. The type of syphilis seen at the V. D. Clinic has also
changed. Instead of 20% of new cases being early syphilis, now the figure is only 8%.
It is most important that the public be informed of these facts and others, that fallacies
be exposed, that a clear knowledge of the truth be spread. It.is equally important that the
medical profession should really know the facts and be educated out of what in most cases
is merely ignorance.
The Department needs the wholehearted and informed support of the medical profession in its effort to disseminate knowledge in health matters. Dr. Williams, in closing,
paid a sincere tribute to the co-operatoin of the police authorities, especially the Provincial
Police, and also the Vancouver Folice force. As a result of this co-operation, houses have
been closed as follows: Vancouver, 33; Nanaimo, 10; Victoria, 7; Zeballos, 1.
The Department, the speaker said finally, is not going to rest till all houses are closed.
ancouver
enera
Hospita
ECTODERMOSIS EROSIVA PLURIORIFICIALIS
D. E. H. Cleveland, M.D., CM.
From the Section of Dermatology, Dept. of Medicine, G. Lyall Hodgins, Chief,
Vancouver General Hospital.
The infliction of such an unwieldy sample of terminology upon a patient medical public
calls for some justification. First, in excuse of its length and many syllables, it is to be
said that this is a descriptive name, like many in dermatologic nomenclature; thus it
should really mean something to us, possessed as we all are of the necessary smattering of
classic tongues. As the late F. J. Shepherd, of immortal memory, was accustomed to say
to his freshmen classes, "Blessed be he who knows Latin and Greek, for he shall never be
discomfited." It is better that a disease should bear a name which conveys some information of its nature than a bare eponym which not only means nothing but is often attached
to two diseases simultaneously which have nothing in common. Two examples which come
readily to mind are the diseases bearing the names of von Recklinghausen and Paget.
If it is asked why we cannot call this disease by a plain English name, the reply is that
we can, and we will just as soon as plain English equivalents replace the Greek polysyllabic
names by which we call many familiar animals and plants. If we speak of Horny Nose,
River Horse and Golden Flower instead of rhbioceros, hippopotamus and chrysanthemum,
Page 110 then the name at the head of this paper can be more simply if not economically replaced by
Erosive Outbreak of the Skin Involving Several Orifices.
The discussion in a general medical journal of a disease which is rare and of no general
interest is not desirable perhaps, but this disease is probably not rare, and many may
realize that they have encountered but not recognized it before. Its appearance and
behaviour is so formidable, however, that it impresses the inexperienced with the necessity
for making a grave prognosis. Nevertheless its management is simple, serious complications are unusual, a favourable outcome is to be anticipated and no bad after-effects are
seen. For these reasons it is believed that its characteristics and management should be a
matter of general knowledge.
Cases have been reported by a number of French and Italian writers, but J. W. Klauder1
of Philadelphia was the first writer in English to describe it as a clinical entity. His presentation and discussion of cases is very complete, as his bibliography also appears to be up to
his date of writing (1937).
The disease bears some resemblance to the more severe forms of erythema multiforme,
especally those affecting the buccal mucous membrane, and its relation to or identity with
that disease is still under discussion. It also is apt to be confused with the human formi of
foot and mouth disease. Its features distinguishing it from these two conditions are readily recognizable, and the distinction from the latter disease is important to make.
The syndrome consists of a vesicular and bullous eruption involving especially the
hands and feet, and some or all of the body orifices. The onset is acute with fever and
severe constitutional symptoms. Young males are most frequently attacked, and the
occurrence is principally in late winter or spring.
Stomatitis and bilateral conjunctivitis are the most conspicuous features at the outset,
and are constant in all cases. Sore mouth and throat is complained of at the beginning, and
the erosions extend into the pharynx. Balanitis, especially with vesicles about the meatus,
is common. Proctitis, urethritis and rhinitis may occur, and ulcers in the vulva and vagina
have been described in one female case. These orificial lesions begin as vesicles on all mucous
surfaces, involving in the mouth the tongue, lips and buccal mucosa, and the severe
stomatitis which follows is characterized by a pseudo-membrane, removal of which causes
bleeding. Epistaxis is frequent, resulting from removal of crusts from the nose. The
conjunctivitis rapidly becomes purulent.
The skin lesions usually appear a few days later and may extend sparsely from the
hands and feet to the forearms and legs. They begin as erythematous macules, often with
vesicles suggestive of varicella, but with a livid red halo, and iris-like lesions. Crusting
usually follows.  Little if any regional lymphadenopathy is found.
The temperature is usually about 103° or 104° at first, and subsides gradually. Prostration may be severe and the patient suffers much from pain on eating and drinking.
Photophobia is usual. The course appears to be self-limited, terminating in from four to
six weeks, according to most authorities, but relapses have been reported. The mucosal
lesions bleed less, become less painful and gradually heal, the cutaneous lesions dry into
crusts which are shed, and the patient regains his appetite and sense of well-being.
Klauder1 lists the following symptoms which distinguish foot and mouth disease in the
human from ectodermosis erosiva pluriorificialis, which it often closely resembles: considerable burning and dryness in the mouth, inflammation, redness and swelling around the
nails, and desquamation usually occurring at the site of vesicles on fingers and toes.
Owing to the common finding of Vincent's organisms in the mouth they are usually
regarded as the cause of the symptoms and treatment is directed in accordance with this
view. There is no evidence that these commonly saprophytic organisms have anything to
do with the disease in question.
Treatment consists of general measures such as confinement to bed, simple bland
washes or ointments for the mouth, nose, eyes and other mucosal lesions, liquid and later
soft diet, and the usual nursing care. Warm Dobell's solution for the mouth and weak boric
solution for the eyes, used frequently, and borated vaseline for the lids, nares, lips, urinary
meatus and skin lesions seem to be adequate. Special requirements for high caloric diet,
augmented vitamin intake and haematinics may arise.
Page 111 Small doses of sulphanilamide by mouth appears, in the two cases presented, to have
had some effect in shortening the course of the disease.
Case Reports
Two cases have been observed within a period of 15 months in the Vancouver General
Hospital, which presented the typical symptom-complex. One of these appeared to have
an extension of the mucosal involvement greater than has previously been reported. Possibly, as in pemphigus, extension to the respiratory and gastro-intestinal tracts may be very
considerable in severe cases.
SI:
>^3§^*
M
m
m
Case 2.—Purulent conjunctivitis, cheilitis and
stomatitis.
Case 2.—Distribution of maculo-vesicular lesions
on extremities.
Case 1.—A man, aged 20, was admitted to the Infectious Disease Department of the Vancouver General
Hospital on April 6th, 1938, as a private patient of Dr. S. Graham Elliot, to whom I am indebted for the
privilege of reporting it.
Three days earlier blisters had appeared in. the mouth. The next day the eyes were sore, and a day later
an eruption appeared on tbe skin. The patient was examined by me on the day following admission. The
mouth temperature was 103 degrees. He was pale, prostrated, drowsy and appeared toxic. The buccal mucosa
was deep red and stripped off at a touch, leaving a raw bleeding surface, but there was no evidence of necrosis.
There was a purulent conjunctivitis. He expectorated a considerable quantity of bloody, muco-punilent,
ropy sputum.
On the forearms and legs there was a sparse eruption of erythematous macules from pea- to bean-sized,
and a number of flaccid blebs with a dusky red halo. There was very little eruption on hands or feet. A
purulent erosion surrounded and dipped into the urinary meatus. No superficial lymph-nodes were enlarged.
Except for difficulty in eating and drinking there had been no complaints. There had been no skin discomfort
except smarting or stinging when the blebs were wet with water as in washing.
Vincent's organisms were recovered in fair abundance from the mouth. There was no leucocytosis and
except for an absence of eosinophils in 200 cells counted there was nothing noteworthy in the smear. The
blood-culture was negative.
In addition to local care to the mouth, eyes and skin, and general measures such as suitable diet and
confinement to bed, the soft palate was swabbed with 10% arsphenamin in glycerin followed by hydrogen
peroxide gargles and prontylin gr. v (gm. 0.32) by mouth four times daily.
Page 112 Improvement began almost at once, and six days after admission, and nine days after onset, the patient
was feeling decidedly better, the daily temperature not rising above 101 degrees, appetite returning and local
discomfort being greatly decreased.
On th 17th day of the disease, the patient was discharged from hospital. His mouth was still somewhat
sore, and the lips bled slightly on handling, but the temperature had been normal for four days and he
felt well.
Case 2.—A man aged 22 was admitted to the Eye, Eear, Nose and Throat Department of the Vancouver
General Hospital, under the service of Dr. Lavell Leeson, on July 14th, 1939.
On July 7th he had felt feverish and fatigued. He consulted a physician, who found a temperature of
104 degrees and advised rest in bed. The temperature fluctuated between 100 and 102 degrees until July 11th,
when it became normal, and he drove home to Pitt Meadows in his car. On July 13 th the temperature again
became elevated and for the first time he had sores and blisters in his mouth. On July 14th his eyes became
sore and he was admitted to hospital.
He related that he had four similar but less severe attacks in the past ten years. In 1936 he had been
told that he had Vincent's angina.   In 1937 he had lobar pneumonia followed by empyema.
He had a bilateral purulent conjunctivitis and a generalized stomatitis with glossitis and cheilitis. The
mucosa was raised up by confluent blebs, and there was copious bloody, muco-purulent and ropy expectoration. Except for some lymphadenopathy in the anterior cervical region there were no other noteworthy
physical findings.   The temperature was 102.3 and hq felt very ill and depressed.
On July 17th a sparse eruption appeared on the arms and legs of erythematous macules which quickly
developed into lax blebs which rapidly eroded, Iqaving a moist surface. There was no special localization in
the extremities, and the palms and soles were spared. They were somewhat more numerous about the upper
parts of the body. Not only were the mou(th and eyes involved, as has been described, but there was a vesicular
eruption about the urinary meatus and the anal opening. Neither in this nor in the former case did the
eruption in the latter sites become very severe or cause any considerable degree of discomfort. These lesions
were only discovered on examination, not having been mentioned by the patient.
As the provisional diagnosis on admission had been "septic sore throat," sulphanilamide in the form of
neoprontosil, gr. lx (4.0) daily, had been commenced at once. I did not consider that it was responsible for
the skin eruption and recommended its continuance. On July 19th the dose was lowered to gr. xx (1.3)
daily. Gentian violet and acriflavian solution was applied thrice daily to the gums and pharynx, hot saline
throat irrigations were given hourly and 2% hydrarg. ammoniat. in vaselin was applied to the cutaneous
lesions.  The eyes were irrigated with oscol argentum.
Cough with profuse muco-purulent sputum developed on the fourth day in hospital and respirations
were laboured. Profuse sweating was present and there were signs of moisture in the larger bronchi. X-ray
examination did not reveal any signs of active disease in the chest and the sputum was negative.
Improvement, indicated by increasing strength and co-operation oh the part of the patient, was becoming evident by July 20th, although his outward appearance was still alarming due to the severe conjunctivitis,
cheilitis and coughing, and the temperature still reached 102 degrees daily and did not fall below 99.2.
Following this date, however, it subsided gradually with daily remissions, and except for one brief febrile
period about August 2nd it was normal after July 28th.
Laboratory findings were negative except for a moderate leucocytosis. Only the common saprophytic
organisms were found in the throat culture, and it was noteworthy that Vincent's organisms were not found
in the mouth.
The patient was discharged from hospital on August 15 th, feeling well except for slight soreness of the
gums, 39 days after the onset.
Summary
Two cases of a disease resembling erythema multiforme with buccal involvement, but
with certain special features distinguishing it from the usual forms of that disease, are
described.
The history and symptomatology correspond with those of a disease described by
Klauder and some European writers as Ectodermosis Erosiva Pluriorificialis.
Other diseases with which it has been or may be confused are the human form of foot
and mouth disease, streptococcal pharyngitis, pemphigus and Vincent's angina.
For reasons indicated in the preceding paragraph and the fact that it has been described
as a self-limiting disease, it is considered that it is less rare than hitherto believed, and
should be recognized more commonly in the interests of a good prognosis and avoidance
of misdirected effort.
The exhibition of sulphanilamide appears to be of some value in shortening the course
of the disease.
1.     Ectodermosis Erosiva Pluriorificialis: Klauder, Jos. V.—Arch. Derm. & Syph., 36:1067  (Nov.), 1937.
Page 113 CONGENITAL POLYCYSTIC DISEASE OF THE LIVER
Lyon H. Appleby, M.D., F.R.C.S. (Eng.)
Mrs. V., age 46. Married; 4 children, all healthy, youngest now 12 years old. Family
history quite negative.
Past History.—Tonsillitis, age 14. Tonsillectomy same year. Past labours all difficult,
instrumental deliveries. Four years ago, while playing badminton, developed kink in her
neck and was forced to stop playing. Was in bed 3 days following and one side said to be
numb and partially paralysed; recovered. Following recovery went to Dr. Mason; exhaustive physical examination was quite negative, except that he thought she might have some
minor gall bladder disturbance.  No X-rays taken at that time.
Present Condition.—Twelve months ago noticed a lump in her upper abdomen, centrally situated, quite painless, unassociated with symptoms of any kind; all functions normal. States that the lump has been slowly increasing in size and that the last three months
it has doubled in size. It is now larger than a good-sized grapefruit. Appetite is good,
digestion normal. Bowels act normally daily. All functions normal, and apart from the
presence of the mass believes herself to be in perfect health. Plays badminton twice a week
and last week a friend asked her if she were pregnant so decided its size must be becoming
obvious to her friends and that it was time she consulted a physician.
Physical examination.—Healthy-looking woman, weight \22l/z lbs. Throat, nose and
sinuses clear; tonsils out; several dentures. No thyroid enlargement of cervical adenopathy.
Chest perfectly clear.  Heart apparently normal.  Breasts negative.  B.P. 138/80.
Abdomen showed a conspicuous mass in epigastrium extending downward below the
umbilicus on the left side. This mass was not tender, seemed tense and fluctuant and was
obviously cystic in character. The margin of the liver was indistincly felt but the right
kidney seemed to be prolapsed and easily palpated. It was not tender. Spleen not felt.
Hernial orifices normal. The mass was about the size of a small football.
Vaginal examination showed all pelvic viscera normal in size, shape! and position. No
tenderness. Cervix showed minor lacerations. Very slight vaginal discharge. Menses
always regular.
Urinalysis—Acid, 1018. Albumin, negative. Sugar, negative. Micro., few epithelial
cells. Red cell count, 4,300,000; haemoglobin, 78%; white cells, 9,700; polymorphs, 64;
lymphocytes, 36; no marked eosinophilia.  Kahn, negative.
Chest X-ray was negative. No gastro-intestinal X-rays were taken, as the need for
surgical exploration appeared obvious.
On the morning of October 3, 1939, under general anaesthesia, the abdomen was
opened through an upper left rectus incision, with a pre-operative diagnosis of mesenteric
cyst. An extraordinary condition presented itself. The large cyst seemed to be growing
from the under surface of the left lobe of the fiver, or what ought to have been liver. The
entire fiver was a solid mass of cysts about the average size of walnuts, and there was no
recognizable liver tissue present anywhere, both lobes being equally involved. The gall
bladder was perched on top of a cyst and seemed to be in every way normal, containing
an ounce or so of bile; no calculi or adhesions. The spleen was normal in size, non-cystic.
The left kidney was normal in size but contained about a dozen sub-capsular cysts about
the size of a pea. The right kidney, which could' easily be felt pre-operatively, contained
a large cyst in its lower pole projecting downwards behind the caecum, and the kidney
proper contained numerous small cysts of smaller size. The kidney itself was normal in
size and not prolapsed as previously thought. Pelvis and other viscera were normal and
quite healthy. The large cyst was then aspirated and a clear opalescent fluid obtained. An
attempt was made to remove this large cyst, but owing to the blending of its wall, with the
Page 114 walls of more deeply situated cysts within the lobe of the liver itself, that complete removal
proved to be impossible. The greater part of the sac, however, was secured for pathological
examination. One other cyst was aspirated and a different coloured fluid obtained, there
being a faint suggestion of bile staining in the fluid from the second cyst. The abdomen
was closed without drainage.
Post-operative History.—Uneventful until the fifth day, when patient complained of
lassitude, weakness, headache and itchiness. It was noticed that she had developed a slight
icteroid tinge. Van den Bergh was 28. Continued to run a low temperature of 99 for 8
or 9 days. Sutures were removed on the 11th day; soundly healed. Some fluid obviously
present in the abdomen. Jaundice had disappeared; Van den Bergh now 18. Out of bed
on 12th day, and while not very strong, allowed to her home on the 14th day.
Pathological Report—
(a) Sac Report: Gross—Specimen received consists of serous membrane with multi-
unilocular cystic areas in the wall of this cystic membrane. (1)—Section taken from
largest cyst; sectioned en masse; (2) section taken from cross section of one of the smaller
cysts. Microscopic—Sections of liver cyst show these cysts to contain some serous material,
which coagulated on fixation. These cysts are lined by a single layer of flattened, or very
low epithelium, in places suggesting a flattened duct epithelium. Cysts of various sizes
are seen, and in the larger ones the walls of the cysts are thickened, hyalinized, and fined
by flattened layer of epithelial cells. Liver cells, themselves, stain well. Surrounding architecture shows increase in connective tissue. Apart' from the thickening of the cyst wall,
an hyafinization of this connective tissue, there is no microscopical evidence of any inflammatory process.
(b) Fluid Report: Examination of the fluid aspirated from the cysts shows no evidence
of ecchinococcus infection and the culture was sterile.
Cystic degeneration of the liver.
Dr. A. Y. McNair, Pathologist.
Subsequent History—Seen at her home 10 days after leaving hospital, she was very
uncomfortable from the pressure of accumulated ascitic fluid. Paracentesis was done and
8 quarts of deeply bile-stained "pea soup" ascitic fluid removed. Three weeks later a
second paracentesis was done and 7 quarts of identical fluid removed. On December 12
was brought into St. Paul's for the weekly ward round clinic, where it was anticipated
that a third abdominal paracentesis would be done, but she presented herself immeasurably
improved. There was less than a quart of fluid present, which was not touched. Her general condition was greatly improved during the past week, appetite good, was gaining
weight and strength and getting around more normally. Haemoglobin was 73%.
Comment—Congenital polycystic disease of the liver is a very rare condition, particularly when it is so extensive that no recognizable fiver tissue can be found. Many solitary
or multiple non-parasitic cysts of the liver are reported, but I have been unable to find,
so far, a report of any similar case to the above, in an adult, although I have found a few
autopsy reports of somewhat similar conditions in the new-born. As to prognosis—I am
slightly bewildered.
FEVER THERAPY IN RETRO-BULBAR NEURITIS
Dr. A. R. Anthony
While there is seldom any difficulty in establishing a diagnosis of retro-bulbar neuritis,
this condition is one of the most trying in ophthalmology in finding the cause and in
applying the treatment which will result in a complete return of function of the optic
nerve. Undoubtedly a great number of cases arise from disseminated sclerosis, a few cases
are the result of sphenoidal and ethmoidal sinusitis, but there has been a great tendency in
the past few years to overexaggerate the importance of sinusitis as a causative agent, even
to the point of some surgeons advocating sphenoidal and ethmoidal operations in spite of
negative X-rays and negative nasal findings. All too often we are left without any tangible
focus of infection even after X-rays of teeth, sinuses, gastro-intestinal tract, a complete
physical examination and blood tests.
Page 115 The customary behaviour of this disease is a spontaneous improvement to useful vision
regardless of the cause, although the great majority of cases result in reduced vision, central
scotomata and partial optic atrophy. Empirical remedies such as sodium salicylate, potassium iodide, cyanide of mercury injections locally and pilocarpine sweats have been used
with little or no success.
In January, 1936, Dr. Frank Emmons had a patient referred to him as a brain tumour
suspect, showing cedema of the optic disc, reduced vision and injection of the conjunctiva
in one eye and blurring of the disc margins with obliteration of the physiological cup in
the other eye. The patient complained of photophobia, violent localized headache, f ailing
vision and loss of colour vision for one week. Dr. Neil MacDougall was called in consultation as neurological findings were negative except for the local condition. Dr. MacDougall
was of the belief that the patient was suffering from an atypical form of retro-bulbar
neuritis. It was decided to subject the patient to artificial fever therapy in place of the
conventional methods of treatment. The result in this case was most gratifying, with the
prompt return of normal vision.
Case 1.—Mr. P., age 48, came under observation on January 4th, 1939. The vision in his right eye had
been defective since birth. He noticed a gradual loss of vision in. his good eye beginning one month ago.
Two weeks later he was unable to read newsprint and the last week he was unable to drive a car. He had no
symptoms and otherwise felt in perfect health. Past history was entirely negative; patient had always
been well.
Eye examination: Right eye—External examination was negative, media were clear, fundus examination
was negative, high hyperopia was present. Vision was 20/70 due to amblyopia exanopsia and fields of vision
were normal. Left eye—No conjunctival injection was present, cornea was clear, anterior chamber clear,
media were clear and intraocular tension was 22 Schiotz. The pupil was two-thirds dilated and reacted sluggishly and inadequately to light and accommodation. The fundus showed a marked oedema of the optic disc
with engorgement of the retinal vessels. There were very numerous small petechial haehorrhages in the area
of the nerve head and the swollen nerve tissue was of a definite pinkish color. The retina adjacent to the
nerve head appeared elevated and was thrown in folds.
The vision was reduced to 20/200. Fields of vision showed a generally contracted field with a large
defect on the temporal side. The blind spot was greatly enlarged and a large central scotoma was present.
The patient could not distinguish green or red objects.
The patient was referred for general physical examination but no positive findings were made. X-rays
of sinuses, teeth and gastro-intestinal tract were negative. Complete blood examination showed normal
relationship of haemoglobin, red .and white cells. Sedimentation rate and Kahn test were negative. Spinal
fluid tests were made; normal pressure, negative Kahn, no increase in cells or protein was found.
On January 8, 1939, patient was given his first session of fever therapy. The temperature was elevated
to 104 degrees F. and maintained for six hours. Within 36 hours the patient's vision had improved from
20/200 to 20/40 and oedema of the optic disc appeared to have diminished 50%. One week later the patient
was given another similar fever treatment and again within 48 hours there was an improvement of vision
from 20/40 to 20/25. Only a small amount of oedfema on the upper margin of the optic disc remained. By
January 28, 1939, the vision was 20/20 and fields of vision were normal except for a small enlargement of
the lower portion of blind spot. Color fields were normal and one month later the fundus appeared normal.
The vision was 20/20 and fields of vision were normal.
Case 2.—Bobbie B., aged two, came under observation on May 22, 1939, with the history that two
weeks previously the mother had noticed the child appeared to have a head cold and a troublesome cough
developed. The family doctor diagnosed whooping cough, although it was a mild case. The child was kept
indoors but not in bed. The mother began to notice that the child appealed clumsy, falling over big objects,
and awkward about picking up toys from the floor. This condition became increasingly worse until the day
he was brought in, the morning of which he awakened and asked his mother why it was still dark. The child
cried a great deal and said his head hurt him, he groped for everything and refused to walk at all. The past
history until present sickness was entirely negative.
Eye Examination: There was no conjunctival injection. The pupils were widely dilated and did not react
to light. There was no apparent light perception. The media were clear. The fundi showed a marked
swelling of the optic discs and the retinal vessels were tremendously engorged. There were flame haemorrhages
about both discs and the retina surrounding the discs was grayish and swollen in appearance. The eyes were
straight and there was no apparent extraocular muscular weakness.
A pediatric consultation revealed no other physical findings other than the fact that the child was
recovering from a mild attack of whooping cough. The central nervous system was negative. There were no
symptoms of meningeal irritation.  Kahn test was negative.
Fever therapy was commenced the evening of the day of the first visit. Within 12 hours the patient had
recovered light perception and the pupils were back to normal size and reacted briskly to light and accommodation. The choking of the discs appeared to have receded to about half the original amount. Within
three days the child was able to pick up a common pin from the floor. One week later all signs of oedema
were gone and the nerve heads had a normal appearance. Due to the child's age it was naturally impossible
to measure fields of vision or visual acuity, but from all appearances one would assume his vision to be normal
Page 116 in either eye.  A second fever therapy was1 given five days after the first treatment.   In both cases the temperature was elevated to 104 degrees for 6 hours.
The first case cited illustrates the case of retro-bulbar neuritis in which, after a thorough focal search, no focus of infection is found and the physician is left to various
empirical remedies of doubtful value. Undoubtedly, without any treatment at all, this
man's vision would have improved, but having only one good eye it was vital to him that
he should regain the best possible visual acuity. Whether he had some form of toxic neuritis
or an undiscovered focus of infection, fever therapy appeared to be a reasonable treatment.
In the second case cited the acuteness of the onset with sudden and complete blindness
associated with such a severe cedema of the nerve heads made it appear that this was an
emergency which needed immediate and drastic treatment. While the retro-bulbar neuritis
was presumably a secondary infection from the whooping cough, it still presented a difficult problem for treatment by the conventional methods. Certainly the fever therapy
resulted in sudden restoration of sight as dramatically as it was lost.
In cases of this nature it is my belief that fever therapy is of value and will save many
eyes which otherwise would have permanent partial disability.
Discussion by Dr. Frank Emmons.
Inflammation of nerve tissue in general has been shown to be particularly amenable to
hyperpyrexia therapy. This is the rational of the modern treatments of multiple sclerosis,
syphilis of the central nervous system and severe cases of neuritis. In my experience, artificial fever has also benefited neuritis of the cranial nerves, notably the eighth or auditory
and vestibular mechanisms where tinnitus and dizziness have existed. It was on the basis
on this knowledge that in January, 1936, Dr. MacDougall and I decided to treat the patient
referred to in Dr. Anthony's paper with artificial fever, resulting in the prompt and satisfactory return to normal vision.
Dr. Anthony's two cases illustrate the value of fever therapy in definite retro-bulbar
neuritis. In the first case there was no demonstrable etiological factor and in the second it
could be assumed that secondary infection from whooping cough was the underlying
cause. It is of interest to record improvement in these two cases by the same form of treatment. The temperature was raised by means of induced current to a point of maximum
dilation of the capillary bed. In the first case a temperature of 106° F. was used, but as
experience has now shown, the lower temperature of 104° F. is just as efficacious. In
addition to the two cases cited above, two others have since been successfully treated by
the same method.
Victoria  Medical  Society
Officers, 1938-39.
President Dr. W. A. Fraser
Vice-President  Dr. A. B. Nash
Hon. Secretary. . -Dr. E. H. W. Elkington
Hon. Treasurer Dr. C. A. Watson
"THE CERVIX A FOCUS OF INFECTION"
A. M. Agnew, M.D.
The role of foci of infection in the etiology of a multitude of pathological conditions
has long been well established, and daily the cloudy sinus, the exuding tonsil and the dead
tooth come under suspicion and under active treatment, to the betterment of the body
physiology and to the greatly increased general sense of well-being of the patient.
For some time past, in treating infected cervices, to clear up an offending discharge or
because its unhealthy appearance brought a fear of some malignant process in the future,
Page 117 it has gradually been borne in upon me, by gradually increasing clinical evidence, that here
is a chronically infected organ, the commonest focus of infection in the female body.
Throughout the various periods of a woman's fife the cervix, it seems, is always playing
an offending part. As a young woman it has been held responsible in some way for- her
dysmenorrhoea. During her active reproductive life it gives offense in painfully prolonging
an already painful function, that of labour. Then in her later years it adds to her discomfiture by appearing, literally, at the introitus, and, to her at least, gradually dragging
everything else with it. However, a better knowledge of physiology is bringing relief in
her dysmenorrhoea; the pains of labour have been greatly alleviated, and proper surgical
treatment entirely relieves the prolapse. Something the cervix has not been sought out
and blamed for is a focus of infection in the etiology of pathological conditions which are
often apparently entirely unrelated to the pelvis, and this I think is its commonest offense
against the female physiology.
The cervix is at all times exposed to a myriad infecting organisms from the vagina,
which is never a sterile tract. These organisms, of low virulence to the host, gain entrance
to the deep glands of the endocervix. These glands become infected also, often with more
virulent organisms, during attacks of acute or sub-acute cervicitis, which is a fairly common occurrence. The trauma of abortion, miscarriage and labour open up the portal of
entry for these ever-present organisms. Following acute salpingitis, post-abortal parametritis, etc., organisms remain deep in the glands of the endocervix. Here, being well
protected and well incubated, they multiply and produce multiple small abscesses. These
small abscesses enlarge, the infecton extends and the whole cervix may become riddled
with these small infected cysts, the so-called chronic cystic cervicitis. The cervix is richly
supplied with blood and lymphatic vessels, through which absorption from this infected
organ takes place into the systemic circulation. In spite of our knowledge of the existence
of this chronically infected organ in the female pelvis, we have never considered it sufficiently as a focus of infection, as we have the cloudy sinus, the infected tooth and the
exuding tonsil, as prime factors in the causation of general systemic disease. This is due,
no doubt, partly to our own neglect in not making a careful pelvic examination in the
woman whose symptoms are not referable to the pelvis, and partly also to the fact that the
patient herself so often has had a slight or moderate vaginal discharge for so many years
that no importance is attached to it in her mind, it being just one of those annoyances that
women have to bear.
In reviewing cases, in search of evidence of the importance of the) cervix as a focus of
infection, I have divided them roughly into three classes as follows:
A. Those where the symptoms were referred to the pelvis;
B. Those where the symptoms were not referable to the pelvis, and
C. Those with general systemic symptoms together with some gross pelvic pathology.
Under each of these headings, let us consider several groups of patients.
A.   (1) —Those whose only complaint is of a vaginal discharge.
In the great majority of these cases this is a misnomer, as it is not a vaginal discharge
but a cervical discharge, and vaginal douches and tampons will only give slight relief, permanent cure only being effected by treatment applied to the cervix.
A. (2)—The patient who complains of chronic aches and pains referred to the lower
abdomen and pelvis, with a heaviness and bearing-down sensation, usually more pronounced
just before and during menstruation and often accompanied by a feeling of distension in
the lower abdomen and gas. On pelvic examination, the uterus feels bulky and heavy and
with the adnexa is very tender on palpation and to movement. Usually examination of
the cervix shows it to be infected and it is for this reason that the usual treatment of hot
douches and sitz baths give only temporary relief and not permanent cure. The absence
of blue domed cysts or a discharge of pus from the cervical canal on examination does not
mean that this organ is clean and healthy, for such a cerJvix may and likely does contain
numerous infected cysts high up in the canal and deep in the tissue, which are only reached
by treatment with the actual cautery.
So many patients in this group become entirely symptom-free with no other treatment
than that directed toward the elimination of infection from the cervix, that one feels the
Page 118 focus of infection here was the sole cause, eradication of which stopped absorption from
this infected organ, which resulted in the clearing up of the congestion in the pelvic viscera
and the return of these to normal.
Into this group fall those, usually younger, women who have had an acute salpingitis
with pelvic peritonitis, or a post-abortal parametritis with or without peritonitis. TTiose
patients treated with hot foments and hot douches, diathermy or Elliot treatment, etc.,
respond nicely and apparently leave hospital cured, only to reappear at a later date as
chronic complainers with chronic aches and pains as mentioned above. In these cases the
treatment is not complete when they are discharged from hospital apparently well recovered from their acute illness, for a focus of infection, the source of future trouble, has
been left in the cervix, and to complete their cure should be eliminated.
A. (3)—The patient with low back pain. What a common complaint amongst
women. Varying greatly in degree and amount of disability, but constant in its frequency,
this complaint, "I have a backache, Doctor," finally classes many patients as neurasthenics
or neurotics.
In this group is the woman who has worn pessaries for years, has consulted the
herbalist and the naturopath, who has had her dislocated vertebrae replaced by the chiropractor and been manipulated by the osteopath; who comes to your office with arch supports in her shoes and wearing a sacro-iliac belt which in turn hides the scar of a uterine
suspension. With her purse empty now, but for a box of Dodd's Kidney1 Pills, she comes
to yet another doctor, but still with the same complaint, "I have a backache." How easy
to say "neurotic."
Here, again, in spite of the note of pessimism, an encouraging number of these patients
will gradually lose their backache as the infection, which is so often to be found, is eliminated from the cervix by thorough treatment.
In reference to the uterine suspension mentioned above, done to relieve the backache,
one should be very careful in advising this operation even though the test of manual
replacement and insertion of a pessary to maintain a correct position of the uterus has
given a lot of immediate relief. If there is an infected cervix present the relief will be only
temporary, and the backache will recur to plague both patient and doctor. Be certain
before resorting to operation that any infection in the cervix has been removed, and frequently the backache is relieved even though the uterus remains in a position of retroversion.
A. (4)—Sacro-iliac Pain. The patients in this group come with the same complaint
as those in the preceding one, but here the pain is definitely localized to one or other sacroiliac joint, with greatly varying degrees of pain and disability. Those with minor degrees
of disability in this region are quite common, and relief from symptoms is very gratifying.
The importance of this focus of infection, in sacro-iliac disease of long standing, is best
illustrated by the following case. A young married woman, 32 years of age, whose chief
complaint was of severe pain in the right sacro-iliac region with marked disability. Her
early history was negative and there was no history of injury. She had had one pregnancy
six years before, during which at the fifth month she had an acute pyelitis, with a recurrence following a normal delivery, and was confined to bed for four weeks post-partem.
In the next few months she began to have pain in the sacro-iliac region which gradually
increased in severity as time went on, until she was barely able to carry on the lightest
household duties. During this time she had had various forms of supportive and manipulative treatments with only occasional temporary relief. Pelvic examination showed a congenital type of retroversion with a short anterior vaginal wall, and small amount of mucopurulent discharge from the cervical canal. The cervix was dilated and cauterized high up
and a good deal of pus obtained. This was repeated three times in three months, at which
time the patient was getting around and doing her own work without any difficulty, her
only complaint being that when she went to a dance she seemed to get tired before anyone
else. She has been well now over a period of one year..
B. Those where the symptoms are not referable to the pelvis. Attention was drawn
to this class of symptoms and definite pathological diseases in patients who have come in
for periodic examination over a period of years, often the symptoms were minor in nature
Page 119 and only mentioned as an afterthought or on more direct questioning, but the observations
have been very interesting.
B. (1) —The first group in this class are those with neuritic or myalgic pains, usually
in the shoulders and upper extremities. The severity of this complaint varied greatly, but
in some the pain was quite troublesome. It was noted a good many times that where some
infection was evident in the cervix and treated that these neuritic and myalgic pains disappeared. This result has occurred so often that now in such cases a careful examination
of the cervix is made for signs of infection as well as the presence of other foci.
B. (2)—As you all know, secondary anaemia with its associated symptoms of eye,
headaches, tiredness, etc., is extremely common amongst women. These women at each
yearly examination would require iron therapy, with which they would be greatly improved, but by the next visit they would be back to the same low level again. Quite by
accident again this chronic anaemia was overcome in treating the cervix to get rid of a
vaginal discharge or because of the palpable or visible presence of cysts in this body. All
other foci having been cleared up at some time or other, this was apparently the only
remaining focus and the cause of the recurring anaemia. It is now part of the treatment to
eliminate this infection.
B. (3 ) —Arthritis. This is a very important group, as arthritis is one of the bugbears
of medical practise, and I cannot stress too much the importance of a thorough pelvic
examination in the course of investigation in a case of arthritis in a woman. A prolonged
and expensive course of treatment may be instituted while the only remaining focus of
infection, which in the occasional case is the responsible factor, remains neglected. This
is borne out in the following cases:
(a) A woman fifty years of age, who for three or four years had arthritis involving
the small joints of both hands with considerable swelling and a great deal of pain. All of
the foci of infection had been investigated and she had had considerable treatment during
those years. Pelvic examination revealed a chronically infected cystic cervix, which was
treated and cauterized. Arthritis in hands has cleared up and the patient is entirely free
of pain.
(b) A woman, fifty-four years of age. Arthritis in the right knee. A lot of swelling
and a great deal of pain. Here again the focus of infection that had been overlooked was
in the cervix, and the symptoms entirely disappeared upon its elimination.
B. (4)—Essential Hypertension. This is an important group to medical men, and the
observations made among this group have been very interesting. Essential hypertension,
hypertension with no demonstrable cause, is certainly one of the unsatisfactory conditions,
from a therapeutic standpoint, which every one meets only too frequently. You have all
seen in textbooks, and many of you have likely had experiences of your own, that, in
women, hysterectomy has been one of the numerous and varied procedures suggested as
having some beneficial effect in cases of essential hypertension. I believe, in many cases,
it has. Many of you, too, have possibly made the observation that women running a fair
degree of hypertension show a considerable regression in their tension following hysterectomy for some other pathology, such as simple fibroids or excessive uterine bleeding. This,
too, is true in many cases, but not in the empirical way it has always been used, but because,
in removing the uterus, we have removed the focus of infection which was an etiological
factor in the hypertension in that particular case. Even with a subtotal hysterectomy
there is sufficient interruption of blood and lymphatic supply to the cervix, with resulting
atrophy and lessened absorption, to be of definite benefit to the patient, but here I would
put forward the much greater symptomatic improvement to the patient by including the
almost invariably infected cervix in the extirpation of the uterus.
I have seen many women with records of periodic examination going back for many
years showing the presence of essential hypertension, who have developed evidence of
some infection in the cervix. This was treated with cauterization, and where no other
treatment was given regressions of pressure from 15 to 40 or 50 points occurred and the
pressure remained at this lower level. I feel that in all of these cases, and in myocardial
anginal and cardio-renal disease, this focus of infection should be sought out and eliminated, as with any other evident source of infection.
Page 120 C.    Those with general systemic symptoms together with gross pelvic pathology.
This group of patients include those who have had a hysterectomy for some gross pathological condition in the pelvis. Most of these women have numerous symptoms, many of
those already enumerated, which are quite apart from the symptoms due directly to the
fibroids, excessive bleeding, etc., for which the operation is being done. It is a common
thing in these patients, when you see them six months after operation, to find they have
not only lost their pelvic pain or pressure symptoms, but that their whole general health
has been improved, better color, more energy, no little aches and pains, and they state
emphatically that they haven't been as well in years. In examining the uterus after removal, the cervix is always the site of a chronic cystic cervicitis, varying in degree, but
always infected. It is the removal of this very definite focus of infection, which is a large
factor in the improved general health of the individual. This finding is also a strong argument in favor of a total hysterectomy, where a hysterectomy has to be done; more so, I
think, than is the possibility of the development of a cancer in the remaining stump,
though this should always be borne in mind. If there is pathology of the body of the uterus
or adnexa which is sufficient to warrant hysterectomy, then the focus of infection in the
cervix should be removed to give the patient the full benefit which should be derived by
her from such a major surgical procedure. In chronic pelvic inflammatory disease, with old
pus tubes and a frozen pelvis, where the tubes and uterus are removed, it will be found
that where the cervix is removed the patient is a great deal better off in her general health
when seen some months later. If, because of technical difficulties in these old inflammatory
pelves, the cervix is not removed, it should be most thoroughly cauterized.
Treatment. Hot douches, medicated douches, tampons, silver nitrate diathermy and
Elliot treatment are only aids in treatment. The infection in this organ can only be
eliminated with the use of cautery or its entire removal at operation. Visible and palpable
cyst must be opened with the cautery and destroyed. The cervical canal, if necessary,
dilated and then cauterized. Frequently the cervix, on visual examination, will appear to
be perfectly clean, but on dilating the canal and cauterizing well up inside, numerous
infected cysts are opened and pus discharges freely around the cautery point. This procedure should be repeated at monthly intervals until the cervix is free of infection. Stenosis
of the cervical canal following cauterization is due to too enthusiastic use of the cautery
at any one treatment, and burning into the muscular layers near the internal os, with
resulting scar tissue formation and contraction. If ordinary care is used this complication
will not arise.
Conization, or coring out of the cervix by means of the high frequency radio cautery
cold cutting loop, is a most satisfactory method of treatment giving the same good results,
but with a much more expensive piece of apparatus.
If this should all sound to you like a pet enthusiasm of my own, possibly you are right,
but I hope that I have been able to give you some evidence in support of my belief that, in
those conditions mentioned and many others in which the search for and eradication of
foci of infection plays such an important part in their treatment, the cervix should be
included.
MEMBERS of THE GUILD     f
K       of PRESCRIPTION OPTICIANS of AMERICA
Always Maintain the
Ethical  Principles   of
the Medical Profession
Guilder aft Opticians
430 Birks Bid?.       Phone Sey. 9000
Vancouver, Canada.
Page 121 CORYPHEDRINE
A USEFUL COMBINATION OF
Acetylsalicylic acid grs. 7 l/z
Ephedrbie Hydrochloride gr.    %
INDICATIONS
CORYZA
HAY FEVER
RHINITIS
SINUSITIS
TRACHEITIS
The association of acetylsalicylic
acid and ephedrine hydrochloride, as
represented by Coryphedrine, possesses in numerous cases valuable
therapeutic advantages over acetylsalicylic acid alone.
Taken at the first signs of an approaching cold, Coryphedrine often
wards off the cold completely. If
the coryza is already well established,
many of the disagreeable secondary
symptoms are invariably lessened by
the use of Coryphedrine.
ADULT DOSE:
1 to 4 tablets per 24 hours.
Coryphedrine is supplied
in tubes of 20 and
bottles of 100 tablets.
CLINICAL SAMPLE AVAILABLE TO PHYSICIANS ON REOUEST ••     #♦*•
•?*♦•
THEELIN   -THEELOL
ESTROGENS IN PURE CRYSTALLINE FORM
Isolation of hormones to crystalline purity is a goal of endocrine
research. The advantages of such
products—precision in dosage
and dependability of therapeutic effects—are universally
recognized.
Theelin and
Theelol are
crystalline estrogenic substances manu-
Theelin (ketohydroxyestratriene) is available as
Theelin i n Oi I Ampoules i n potencies o f 1000,
2000, 5000, and 10,000 international units
each—in boxes of six and twenty-five 1-cc.
ampoules. Theelin Vaginal Suppositories,
2000 international units each,are supplied in
boxes of six and fifty. Theelol (trihydroxy-
estratriene) is available as Kapseals Theelol,
0.06, 0.12, and 0.24 milligram—in bottles of
20, 100, and 250.
factured by Parke, Davis & Company under license from St. Louis
University. They are widely used
to control menopausal symptoms
and sequelae (kraurosis, pruritus vulvae, atrophic senile va-
gin itis and
vaginal ulceration), and
gonorrheal
vaginitis in
children.
PARKE, DAVfS & COMPANY • Walkerville,Onf.
The World's Largest Makers of Pharmaceutical and Biological Products ennuis* Vaccines* Hormones
}y
9
AND
Related Biological Products
Anti-Anthrax Serum
Anti-Meningococcus Serum
Anti-Pneumococcus Serums
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid
Old Tuberculin
Perfringens Antitoxin
Pertussis Vaccine
Vaccine Virus
Pneumococcus Typing-Sera
Rabies Vaccine
Scarlet Fever Antitoxin
Scarlet Fever Toxin
Staphylococcus Antitoxin
Staphylococcus Toxoid
Tetanus Antitoxin
Tetanus Toxoid
Typhoid Vaccines
(Smallpox Vaccine)
Adrenal Cortical Extract
Epinephrine Hydrochloride Solution (1:1000)
Epinephrine Hydrochloride Inhalant   (1:100)
Epinephrine in Oil (1:500)
Heparin
Solution of Heparin
Insulin
Protamine Zinc Insulin
Liver Extract (Oral)
Liver Extract (Intramuscular)
Pituitary Extract (posterior lobe)
Prices and information relating to these preparations will be
supplied gladly upon request.
CONNAUGHT LABORATORIES
UNIVERSITY   OF   TORONTO
Toronto 5
Canada
Depot for British Columbia
macdonalds Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. t
2559 Cambie Street
ancouver
i B. C
Colonic
Irrigation
Institute
Superintendent:
B. M. LEONABD, B.H.
Post Graduate Mayo Bros.
Up-to-date treatment rooms;
scientific care for cases such as
Colitis, Constipation, Worms,
Gastro-intestinal Disturbances,
Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.
Individual Treatment $ 2.50
Entire Course   $10.00
Medication (if necessary)
$1 to 93 Extra
1119 Vancouver Block
VANCOUVER, B. C.
Phone: Sey. 2443
506-7 CAMPBELL BUILDING
VICTORIA, B. C.
Phone: Empire 2721
W&ifaadian Distributors^
ROUGIER FRERES
350   Le  Moyne   Street,   Montreal 6^
B*i*ii^
•>*
tie orJh
~ac
tlve
oedroq
eyiic
I hormone
in
tie trea-
Iryien
t
*
Ol
je»»l*
Steri»ity
u»l   te»sioB
887 Exclusive Ambulance  Service
FAIR.  0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRBLLiIN The Treatment of Febrile Inflammatory Conditions
The intramuscular injection of S.U.P. 36 in the treatment of inflammatory and septic
conditions, particularly of the respiratory system, has been an established routine in
clinical practice for many years.
Moreover, the field of application of S.U.P. 36 has been considerably widened and this
product is now employed in a variety of inflammatory conditions often encountered in
general practice.
For purposes of classification these conditions may be divided into four groups, (a)
respiratory infections with pyrexia, (b) genito-urinary infections, (c) skin affections and
(d) miscellaneous; in all these the injection of S.U.P. 36 may be expected to produce
an immediate abatement of symptoms and a fall in temperature.
S.U.P. 36
Stocks of S.U.P. 36 are held by leading druggists throughout the Dominion,
and full particulars ase obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse Toronto 2, Ont.
S.U.P. 36/Can./401
tetaiKU
w
Made in Peterborough,
Canada,
By A. WANDER
LIMITED
A    Protective    Factor
in  Mid-winter  Diet
Low temperature and lack of sufficient sunshine
combine to give the family physician many problems at this season. Vitality in many cases is
at a low ebb.
Ovaltine, the well-known tonic food beverage,
has been found by physicians everywhere an
invaluable winter ally. It builds resistance. It
supplies those "protective" nutrients the midwinter diet of this country too often lacks, particularly the vitamins—A, B, D and G and the
minerals calcium, phosphorus and iron.
The wholesome flavour of Ovaltine makes it
acceptable to all ages. It is quickly and easily
absorbed.
Why not advise it in your own practice?
OV4LT1NE
THE TONIC FOOD BEVERAGE Georgia Pharmacy's
New Telephone Number:
MA
SINE
Telephones can changesitmt
there is no change in Georgia
Service to you.
georgiarharmacy
'£*M*J: TiefeQ
6EORGIA
Gkttfrr $c fiattna Sift.
BMtmklhM 1191
VANCOUVER, B. C.
North Vancouver, B. C.   Powell River, B. C. Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Aieooiation
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
WlSTMINBTBR 288
MOV wmOUY PRINTING <
»• PUBUISHINO CO.  LTD.

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