History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1945 Vancouver Medical Association Jun 30, 1945

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 The • . •
It U L LlE T 1
G
of th-f. . |
VANCOUVER
MEDI€ A L
ASSOCIATION
With Which Is Incorporated
Transactions of the
^TICTORIA MEDICAL SOCIETY
the
VANCOUVER GENERAL HOSPITAL
and
ST. PAUL'S HOSPITAL
In This Issue:
Page
SALMONELLOSIS—By J. S. Kitching, M.D..^^_M-_. :217
COMMON INJURIES IN THE REGION-OF THE
SHOULDER—By Wing Cmdr. LsurdM-^^^^^^M^. 220
SURGICAL TREATMENT C*F PULMONARY
TUBERCULOSIS—By Wing l^di^ _-aird__^^^fc 222
SOME CASES OF EXTRA-PULMONARY TUBERCULOSIS JJI2 9
By G. D. Saxton, M.D.
PATHOLOGICAL  CONFERENCE" ^^fa^^^^^^^^ll
By J. G. McPhee, M.D.
IMPORTANT!
The annual meeting of the British
Columbia Medical Association will be
held as planned, September 12, 13, and 14, 1945, at the
Hotel Vancouver, Vancouver, B. C. It is imperative that
reservations be made nowx directly -with the hotels in
Vancouver.
VOL XXI.   NO. 9
June.1945 SICCOLAM
Trade Mark
Forjjftie Treatmenj(|of Eczematous and Exudatory
Dermatoses
Siccolam ^^^ivalied «1 its^jowe^g^Controlling exudation and
relieving irritation in eczjgmatous and other intractable dermatoses.
It is a paste containing zinc oxide, titanium dioxide and kaolirlir. a
fat-free bas&Ji| can b^effectivel^feapplied, therefore^|^ree^
exuding lesions to which ointmentsi^plfatty base cannot be suffix
cientiy intimately. applied.vtgjg orderJS*' exert thta* full therapeutic
effect.
Siccolam acts principally by adsorbing exuded aqueous ffeid and
promoting its evapbration.fgBeing fat-free, Siccolam also adsorbs
sebaceous exudates; althouglMof coursejJIt cannot promote their
evaporation.;||h addition, Siccolam exerts the familiar soothing and
healing action of the insoluble zinc compounds.
There ar@© contra-indications to Siccolamig^^nay be applied jig
any exuding fesion, before a final diagnoS^has been made, ^jtfioiit
prejudice to the success of any subsequent treatment^!
i$iqiffi$$i$' Siccohm jf^jheW^the hading druggists throughout the
Dominioft, end full particulars are obtainable' from
IN^BRI^fSH DRUG HOUSES (CANADA) j|tD.
Toronto Canada
Sie/C-n/456 /"~
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:
Db. J. H. MacDermot
Dr. G. A. Davidson Ob. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XXI.
JUNE, 1945
No. 9
Dr. Frank Turnbull
President    £iii
Dr. H. H. Pitts
Past President
OFFICERS,  1945 - 1946
Dr. H. A. Des Bbisay
Vice-President
Dr. Gordon Burke Dr. G. A. Davidson
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. R. A. Gilchrist, Dr. D. M. Meekison
TRUSTEES
Dr. J. A. Gillespie        Dr. A. W. Hunter Db. W. T. Lockhart
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Dr. S. E. C. Turvey Chairman Dr. E. R. Hall Secretary
Eye, Ear, Nose and Throat
Dr. Grant Lawrence President Dr. Roy Mustabd Secretary
Paediatric Section
Db. Howard Spohn Chairman Dr. Harry Baker Secretary
Orthopaedic and Traumatic Surgery Section
Dr. D. M. Meekison Chairman Dr. J. R. Naden Secretary
STANDING COMMITTEES
Library:
Dr. W. J. Dorrance, Chairman; Dr. F. J. Buller, Dr. R. P. Kinsman,
Dr. J. R. Neilson, Db. D. E. H. Cleveland, Db. S. E. C. Tubvey.
Publications:
Dr. J. H. MacDermot, Chairman; Dr. D. E. H. Cleveland, Dr. G. A.
Davidson, Dr. J. H. B. Grant, Dr. S. E. C. Turvey, Dr. Grant Lawrence
Summer School:
Dr. G. A. Davidson, Chairman; Dr. J. C. Thomas, Dr. R. A. Gilchrist,
Dr. A. M. Agnew, Dr. L. H. Leeson, Dr. L. G. Wood.
Credentials: j|y
Dr. J. R. Neilson, Dr. H. H. Pitts, Dr. A. E. Trites
:V V. O. N. Advisory Board:
Dr. Isabel Day, Db. J. H. B. Gbant, Db. G. F. Strong
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Db, G. A. Lamont
Representative to B. C. Medical Association: Dr. H. H. Pitts
Sickness and Benevolent Fund: The President—The Trustees TOCOPHEREX       VIOPHATE-D
Suggested for Treatment
of Threatened or Habitual Abortion
Due to Vitamin E Deficiency
# Each capsule contains 50
milligrams of mixed tocopherols,
equivalent in vitamin E activity to
30 milligrams of a-tocopherol.
Tocopherex contains vitamin E
derived from vegetable oils by molecular distillation, in a form more
concentrated, more stable and more
economical than wheat germ oil.
For experimental use in prevention
of habitual abortion (when due to
Vitamin E Deficiency): 1 to 3 capsules daily for 83_ months. In
threatened! abortion: 5 capsules
within 24 hours, possibly continued
for 1 or 2 weeks and 1 to 3 capsules
daily thereafter.
Tocopherex capsules are supplied in
bottles of 25 and 100.
For Increased
Calcium Requirements
# Each capsule of Viophate—D
contains 4.5 grains Dicalcium Phosphate, 3 grains Calcium Gluconate
and 330 units of Vitamin D. The
capsules are tasteless, and contain
no sugar or flavouring. Where
wafers are preferred, Viophate—D
Tablets are available, pleasantly
flavoured with wintergreen.
One tablet is equivalent to two
capsules.
How supplied:
Capsules—Bottles of 100 and
1,000.
Tablets —Boxes of 51 and 250;
ERfe<_jJlBB SlSONS OF CANADA, Ltd.
MANUFACTURING  UNEMIST&lTO   THE   MEDICAL   PROFESSION   SINCE  1830 VANCOUVER HEALTH DEPARTMENT
STATISTICS—APRIL, 1945
Total population—estimated 511^799
Japanese Population—Estimated    Evacuated
Chinese population—estimated ." . 6,395
Hindu population—estimated .  335
Number
323
13
Total   deaths	
Chinese  deaths ' \	
Deaths—residents   only         28.2
BIRTH REGISTRATIONS:
Male,  333;  Female,  3 32     665
INFANT MORTALITY: April, 1945
Deaths under one year of age       17
Death rate—per 1,000 births       25.6
Stillbirths   (not included above)         9
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
Rate per 1,000
Population
12.6
24.7
11.0
25.9
April, 1944
March, 1945
Cases      Deaths
April, 1945
Cases      Deaths
May 1-15, 1945
Cases      Deaths
Scarlet Fever       50             0 36 0
Diphtheria             0              0 0 0
Diphtheria Carrier         0             0 0 0
Chicken   Pox Li      113              0 57 0
Measles    •     415             1 441 1
Rubella ;feg_ |        18             0 24 0
Mumps       14             0 12 0
Whooping  Cough i         6             0 3 0
Typhoid   Fever   (Carrier)         0             0 0 0
Undulant Fever         0             0 0 0
Poliomyelitis         0             0 .0 0
Tuberculosis _       54           20 39 12
Erysipelas         4             0 3 0
Meningococcus Meningitis.         0             0 2 0
Paratyphoid Fever         0             0 0 0
Infectious Jaundice  ,         5             0 3 0
Salmonellosis         6             0 3 0
Dysentery         2             0 0 0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
North
Vancouver       Richmond Vancouver
Syphilis              56             0 _             0
Gonorrhoea            153             0 _             0
West
Vancouver
BIOGLAN-A
The most effective therapy for waning mental and physical energy,
deficient concentration and memory, reduced resistance to infection,
muscular weakness and debility, neurasthenia and premature senility.
The efficacy of this very potent endocrine tonic has been confirmed by
the clinical evidence of many thousands of cases treated during
15>32-15»43.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page Two Hundred and Twelve PENICILLIN    THERAPY
CONVENIENCE   IN   ADMINISTRATION
»
SODIUM
PENICILLIN
100,000 UNITS       I
§K> units per mj-       jl
^gLot 172-1
SOUGHT -ASORA^fS
SODIUM PENICILLIN
In convenient vials containing
100,000 Oxford units, permitting of the addition of the
quantity of diluent desired.
Ready
For
Immediate
Use
PVSIOLOGlCAt
SALINE
Diluent for
PENICILLIN
20 cc.
JLot 4-1
^fe*S*EHT tJiBORATORM
"•WeSSITY OF TOROtffJ
?Q»*qntq, can'ao*
PSYCHOLOGICAL SALINE
In convenient vials of 20 cc.
—pyrogen-free, sterile physiological saline for diluting Penicillin.
SODIUM    PENICILLIN —CONNAUGHT
100,000 Oxford Units
PHYSIOLOGICAL   S A L I N E —C O N N A U G H T
20 cc. in Vials
CONNAUGHT LABORATORIES
University of Toronto    Toronto 5, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. an important
therapeutic principle
&mts*?mm
<m
mi*
IT %
Hi*!
_«fx'
KAOMjJj***
vnn MNERM c*
* ***•* *__*_ tST«*» !8_
*-___i1i^*,ir
,,„,.«w«-**   ,;;*•.-•»
<-*__ «** ****** *™^
s*ak* *«*£
John Wvetb & Brotn*
wALKERVfU-
♦ADSORPTION is the process by
which substances are attached to the
surface of the adsorbing material.
Kaolin, a neutral, chemically inert
powder, is an outstanding example of
an adsorptive substance. It adsorbs
fluids, bacteria and toxic material on
the surface of each particle when it
comes in contact with them. This is a
purely physical phenomenon. Obviously, as adsorption is surface attachment, the greater the surface exposed
the greater the adsorption will be.
Thus "the dispersion of kaolin in
aluminum hydroxide gel, as in Kaomagma, greatly enhances the adsorptive effect.
KAOMAGMA
FOR   DIARRHEA
FROM ANY CAUSE
JOHN WYETH & BROTHER (CANADA) LIMITED
WALKERVILLE ONTARIO Analgesia and lubrication of the tonsillar fossae can both be accomplished pleasantly and efficiently
by chewing Aspergum.
This simple procedure is so effective an aid in relieving patient discomfort and even hastening post-tonsillectomy convalescence that many laryngologists incorporate it routinely in their postoperative instructions.
Chewing Aspergum, the patient releases a soothing
flow of saliva laden with acetylsalicylic acid. The gentle
stimulation of muscular action helps greatly to relieve
local spasticity. The patient is more comfortable,
nourishing diet can be resumed early, convalescence
hastened.
f)tila*d% Aspergum
In packages of 16, moisture-proof bottles of 2<
tablets. Ethically promoted—not advertised to the
laity. White Laboratories of Canada, Ltd., Toronto,
Canada.
i 7<4e ZdUotb Paae.
We learn from the daily press that a Law School will be inaugurated at the University of British Columbia during the corning season. This is all to the good—and we
think, quite sincerely, that it is a forward step in the development of our University.
British Columbia should have a Law School, and a good one: and this new departure
adds to the stature and strength of the University.
But we do not hear of a similar move with regard to the Medical School which we
all so strongly desire—and which, quite apart from our predilections or wishes in the
matter, is so urgently necessary—even more necessary, we venture to believe, than a
Law School or an Engineering School- Nothing can be gained by reiterating the arguments and considerations that we have already put forward—but it is keenly to be
regretted that progress is so slow in this regard. Perhaps it cannot be otherwise—while
a matter of ten thousand dollars is adequate to start with in the establishment of a Law
School, a Medical Faculty will cost approximately two or three hundred-times as much.
But the money is not the real difficulty. It is, we are told, already available, and has
been earmarked for this purpose.
True, too, there are other obstacles to a speedy realisation of this project. New
buildings will be necessary, new orientation of medical and hospital facilities—clinics,
laboratories, and the like. All this is true—and is so much more an argument for expedition, and a real effort towards making a beginning. The need is so urgent that no
mere matter of form or desire for perfection should stand in the way. We have more
now to start with, and make an immediate start, than had most of the Canadian Universities when they began—but they had the courage and vision to start, even though it
meant a rather uphill fight, with not much in the way of ammunition or weapons. We
hope sincerely that things are far more advanced than we think, and that we shall soon
hear an announcement to the effect that work on the Medical Faculty has actually
begun. We know that those of our profession who have met the Government have
don, and are doing, all they can—but they cannot do much more than they have done,
to bring the facts of the situation before the authorities.
After all, a Medical School is not for our benefit, nor is it we that need it. It is for
the benefit of the people of British Columbia, who need more and better medical care,
and who will be the chief sufferers from the present lack of this. It is for the benefit
of those of our sons and daughters who wish to study medicine, and who are thwarted
at every turn, and who, lacking adequate facilities, must face disappointment and frustration. We wish that every service club, every board of trade, every women's organisation, every trade union, could hear the case put before them, as it was so eloquently put
by young Pat Fowler when he spoke to the Vancouver Medical Association the other
llay. We believe that, if they did, they would be working for the estabHshment of a
Medical Faculty in our Provincial University. He put before every one of us, a challenge and an appeal, neither of which we can ignore, if we are to deal faithfully, according to our means and ability, which are both quite ample, with those of the coming
generation—with those returning from overseas, and with the community at large, the
ultimate consumer, and the ultimate loser, if we do not do all we can in this matter.
Page Two Hundred and Thirteen LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY—
Brennemann's Practice of Pediatrics, 4 volumes and index.
Medical Clinics of North America, Symposium on Internal Medicine and Symposium
on Rehabilitation, May, 1945, New York Number.
Technical Methods for the Technician, 1944, by Anson Lee Brown.
Transactions of the Americal Ophthalmological Society, 1944.
Oxford Loose Leaf Supplements, as follows:
New Articles:
Haemolytic Streptococcus Pneumonia, by Dr. M. Finland.
Staphylococcus Aureus Pneumonia, by Dr. M. Finland.
Coccidioidomycosis, by Dr. C. E. Smith.
Lymphogranuloma Venereum, By Dr. G. A. Harrop.
Granuloma Inguinale, by Dr. F. M. Thurmon.
Food-Borne Diseases, by Dr. V. A. Getting.
Leukopenia, by Dr. W. Dameshek.
Revisions of Articles:
Leukemia, by Dr. R. Isaacs.
.Diseases of the Bones, by Dr. A. Grollman.
Sprue, by Dr. F. M. Hanes.
Chronic Cardiac Valvular Disease, by Dr. G. Herrmann.
Agranulocytosis, by Dr. W. Dameshek.
Sulphonamides in Treatment (Partial revision), by Dr. M. A. Schnitker.
Histoplasmosis, by Dr. H. Pinkerton.
Infectious Mononucleosis, by Drs. C. A. McKinlay and H. Downey.
Toxoplasmosis, by Dr. H, Pinkerton.
BRENNEMANN'S SYSTEM OF PAEDIATRICS
Brennemann's Practice of Paediatrics in four volumes covers very fully the whole
field of Paediatrics.
Each chapter or each subject is by a different author, an authority on his subject.
This "system" is most comprehensive, and always up to date, each author re-writing
his subject matter in whole or in part when necessary to keep pace with new discoveries
or new methods.
The books are kept up to date by discarding obsolete pages or parts of chapters and
replacing them by recent corrections which are received quarterly.
R. P. K.
NOTICE
Owing to the installation of X-ray equipment and alterations, the
British Columbia Cancer Institute will be closed during the month of
August.
ETHLYN TRAPP, M.D.,
Medical Director,
B. C. Cancer Institute.
Page Two Hundred and Fourteen 3-
BRITISH COLUMBIA MEDICAL ASSOCIATION
1945 ANNUAL MEETING
SEPTEMBER 12th, 13 th, 14th
HOTEL VANCOUVER, VANCOUVER, B. C.
'M\
|BI IS II I 11 9j ^
•if a — ■ • 1
Bt (E ss    t,
I El Sf
E> "  IB
»Ii
»3jl
lll-illl,
You are advised to make early reservations directly with the Hotel Vancouver, stating that you are attending the meeting, the date of your arrival, and your needs. It
may be necessary to double up as rooms are at a premium in Vancouver.
The Conimittee on Programme, of which Dr. L. H. Leeson is Chairman, and Dr. S.
E. C. Turvey is Secretary, is arranging a splendid programme.
The following, speakers are announced for the lecture programme:—
DR. W. G. COSBIE, Toronto, Ont., who will speak on Cancer.
DR. JOHN H. FITZGIBBON, Portland Oregon.
DR. JOHN HEPBURN, Toronto, Ont., physician.
LIEUT.-COLONEL H. S. MITCHELL, R..CA.M.C, i/c Medical Division, Montreal Military Hospital.
DR. H. G. PRETTY, Montreal, Que., surgeon.
*
DR. FORREST E. RIEKE, Medical Director, Portland Shipbuilding Corporation,
Portland, Oregon.
COLONEL A. B. WALTER, R.C.A.M.C, Consultant in Medicine, Ottawa.
GROUP CAPTAIN F. F. TISDALL, Consultant in Nutrition, R.CA.F.
Representing the Canadian Medical Association:
DR. LEON GERIN-LAJOIE, Montreal, President.
DR. T. C. ROUTLEY, Toronto, General Secretary.
The mornings will be devoted to lectures; the afternoons to clinics and demonstrations; the evenings to the annual meetings of the College of Physicians and Surgeons,
and the British Columbia Medical Association, and the Annual Dinner. The Official
Luncheon will be held on Wednesday, September 12th, and the annual Golf Tournament
on Thursday afternoon, September 13 th.
Special Committees have been appointed with the following as chairmen:—
Reception and Registration: Dr. F. J. Hebb.
Arrangements and Transportation: Dr. J. C. Thomas.
Entertainment: Dr. H. H. Pitts.
Golf: Dr. D. Fraser Murray.
Press: Dr. D. E. H. Cleveland.
Commercial Exhibits: Dr. J. R. Neilson, Dr. S. E. C Turvey.
There will be a programme for the ladies.
Make your plans and reservations early.
Page Two Hundred and Fifteen CANCER REPORTING IN BRITISH COLUMBIA
Submitted by the Committee on the Study of Cancer, B. C Medical Association.
Following a regulation making Cancer a reportable disease in B. C. the first returns
were made to the Provincial Board of Health in 1932. A total of 72 cases were reported.
In the same year 762 persons died from cancer in British Columbia. Cancer reporting
has improved through the years but the number of cases reported has never exceeded
deaths. In 1941 the closest approximation occurred, namely 1178 cases and 1194 deaths.
There still is need for improvement.
The above figures suggest that cancer is on the increase. In order to determine
whether this is real or apparent, changes in population figures and age groups must be
considered.
Deaths from Cancer
Population B.C.      Deaths from Cancer      per 100,000 population
1924   571,000        457 80
1942   870,000       1194 137
The figures would seem to indicate an apparent increase in deaths from cancer. However, the figures must be balanced against several important factors; improved diagnostic
facilities with more autopsies performed giving more accurate diagnoses. Any improvement in diagnostic facilities would thus tend to more closely approximate the true incidence of cancer, revealing cases otherwise missed. .jrJjS
Cancer is more commonly discovered in persons over middle age. The proportion of
persons in British Columbia 45 years of age and over has increased.
Percentages of population
in B.C. age 45 and over
1921 I 21.8
1931   28.5
1941 j ;  32.5
Any assumption that cancer is increasing in British Columbia is not supported by figures
presented.
How is cancer reported? Approximately 50% of primary notifications are received
through death certificates, hospitals report 24%, physicians 15% and 11% are reported
by the B. C Cancer Institute. These comparisons refer to 1942-43 Provincial Notifications which include 3682 cases.    This reflects a considerable delay in reporting.
Pathological Laboratories in many instances are the first to make a diagnosis of
Cancer from biopsy specimens submitted from the field. There is _t present no uniform
biopsy service in the Province although several Hospital Laboratories are performing this
service for physicians. This service'is valuable and needs expansion. The Laboratones
of the Provincial Board of Health make available to physicians a full diagnostic service
for communicable diseases. The Public Health Laboratories have made possible many
of the control measures for our major diseases through efficient and prompt reporting.
Cancer requires a similar service. It is a truism that if cancer is to be controlled
cases must be diagnosed early, and physicians are too often handicapped in making an
early diagnosis through lack of adequate diagnostic facilities.
It would seem reasonable that the Laboratories already performing biopsy service
should report positive cases. One Hospital Laboratory is already doing this. It has been
recommended that the Provincial Board of Health request monthly returns from all hospitals performing pathological diagnosis. If this is carried out cases will be reported early
and a more accurate picture of the incidence established.
Page Two Hundred and Sixteen. SALMONELLOSIS
Dr. J. S. Kitching,
Metropolitan Health Department, Vancouver, B.C.
A new diagnostic term has appeared in the list of reportable diseases in British
Columbia. The designation is new but the disease is old and until recent years we
should have been satisfied with the diagnosis of Paratyphoid Fever. In an effort to keep
pace with modern nomenclature, and especially as the Western Division of Laboratories
is able to identify these organisms by type, it is certain that Salmonellosis will become
an accepted term.
Salmonellosis is the generic name given to a group of diseases associated with certain
bacteria which cause acute intestinal disease. The generic name, Salmonella, was adopted
in honor of Daniel E. Salmon, who with Theobold Smith, 1885, described the first bacterium of this group, cholerasuis, or suipestifer. Since that date there have been found
many such organisms capable of giving rise to disease in man, and, according to the
Kaufmann-White Schema, 1944, 117 organisms of this type have been differentiated
throughout the world. More have been identified since. Actually, E. Typhi and the
Paratyphoids are members of this, group. Clinically it is unlikely that Typhoid Fever
will be called by any other name, as it has many characteristics which set it apart from
the other morbid conditions caused by allied pathogens of the Salmonella group. Paratyphoid Fever, considered at this point a separate entity, while having characteristics
somewhat akin to Typhoid, is intermediate but closely related to other Salmonella infections both in respect to the shorter incubation period and symptoms such as diarrhoea.
Therefore, for simplicity, Paratyphoid Fever has been placed under Salmonellosis.
Salmonella infections have been usually considered under the head of food poisoning.
Cases have been traced to a wide variety of infected foods. The early history of epidemics from enteriditis and aertrycke represent classical illustrations. Animals, both
•domestic and wild, fowls, flies, may suffer from and harbour the infection and pass it
■ along to meat, milk, foods, eggs and, in the case of flies, the egg, larva, pupa and second
generation. S. Seftenberg has been isolated from a commercial egg preparation. Mosquitoes (Culex pipiens) may serve as additional vectors. The Rocky Mountain Wood
Tick (Dermacentor Artdersoni) has been shown to transmit S. enteriditis experimentally. The list of possibilities appears endless. Host specificity is by no means limited
to man.
The real dangers of' epidemics from infected food and water supplies which are
not protected cannot be ignored. Members of the Salmonella group grow rapidly in
most foodstuffs without producing much evidence of their existence. They do not grow
well in acid media and in most fruit juices a rapid destruction of the organisms takes
place.
Salmonellae are readily destroyed by heat but produce a heat stable toxin. It has
been suggested that toxins may cause symptoms when food vehicles have been contaminated. However Dack1 states that filtrates or heat stable products of a freshly isolated
culture after passage through man are harmless when fed to man. Dolman2 also has
questioned the role of toxins in human symptomatology. The present evidence suggests
that Salmonella food poisoning is essentially due to infection and the role that toxins
may play is indefinite.
Salmonellosis is stated to have a short incubation period, 6-48 hours, usually about
24 hours. The disease in man may be indistinguishable from typhoid, although the
symptoms are usually milder. The onset is usually sudden with abdominal pain, fever,
nausea, vomiting and diarrhoea. All cases are by no means typical and Strong3 recognizes several types, viz.—Dysenteric, Nephritic, Rheumatic and Influenzal. Pulmonary
involvement has also been reported and the organisms may localize in the meninges.
The organisms may appear early in the blood and shortly in the faeces. Cases with enteritis have frequent mucoid grayish to green stools and in severe cases blood is passed.
■ Two Hundred and Seventeen The fastigium is usually 3 to 4 days, although debility may persist for a time. Herpes,
rose spots and a palpable spleen are rarely observed. In the more severe cases leucopenia
with increase in large mononuclears is suggestive. Mortality rates are quoted as from
1-2%, the aged and very young being hit the hardest. There does not seem to be any
specific correlation between clinical symptomatology and type of Salmonella infection.
The laboratory identification of the strains is useful in epidemiological study and follow up.
Laboratory diagnosis is established by the finding of Salmonellae in samples submitted. Blood cultures in early stages may be positive. It appears that specific blood
agglutinins do not develop in every case and there may be cross agglutinins with typhoid
types. However, the finding of an increasing titre to the typhoid antigens is helpful in
ruling out other Salmonella infection.
Despite their possession of common antigens, Salmonellae may he identified by means
of agglutination absorption tests and categorized according to the complex antigenic
formulae of Kaufman-White Schema. This Schema was recommended for adoption by
the Salmonella Sub-committee of the International Society of Microbiologists, 1934, and
an International Salmonella centre was established at the State Serum Institute, Copenhagen. Sera and cultures are supplied from this Institute to laboratories which perform
serological diagnoses. Such a centre has been established in Vancouver, under the Western Division of the Connaught Laboratories.
Rubenstein, Feemster and Smith4 have reviewed the cases of Salmonellosis reported
in Massachusetts, 1937-44. This article contains an excellent review of the subject and
particularly emphasizes the role of man himself in transmission and the persistence of a
carrier state following recovery. After 67 weeks 4.9% of those infected with S. Para-
typhosus B. were still excreting the organism in the faeces. No cases of S. Typhimurium
infection were excreting the organism, although 1.3% were still positive after 60 weeks;
also after 67 weeks 1.1% of cases with other types were still positive. Burt5 followed
one case four years and S. Typhimurium was intermittently found over this period.
X-ray showed calculus and loss of gall-bladder function. Finally at operations S. Typhimurium was isolated from the gall-bladder membrane, the bile and the centre of the
gall stone.    Following operation all speciments were negative.
With Salmonellosis the laboratory has presented us with a new set of diagnostic
terms which have to be translated into clinical and Public Health practice. We cannot
ignore the increasing frequency of Salmonellosis in our midst and the following table
illustrates the comparative incidence during recent years.
REPORTED CASES AND CARRIERS OF ENTERIC DISEASE.
VANCOUVER METROPOLITAN AREA.
1«4?
Typhoid
Fever
5
Paratyphoid
B.
0
9
1
Bac.
Dysentery
0
9
20
Salmonellosis
0
1943
2
            12
1
1944 	
19
Thus far in 1945 there does not appear to be any hope that fewer cases will be
reported.
Types encountered have been'S. Typhi-murium and S. Newport. S. Cholera-suis has
been reported nearby. S. Oranienberg and S. Madelia have been reported in 1945. One
adult death for S. Newport associated with bronchopneumonia was reported in 1944.
Recently an infant has died from S. Madelia. Altogether eleven homes were affected in
1944 and in four homes secondary cases developed or asymptomatic carriers were found.
In one family three asymptomatic cases proven by -stool culture were discovered.
The sporadic development of cases in different parts of our area does not suggest a
common source and our investigations to date have failed to suggest other than human
contact as the possible source.
Page Two Hundred and Eighteen As Salmonellosis is now a reportable disease .in British Columbia under the recently
revised Communicable Disease Regulations 1945, more cases should be found. Physicians
and hospitals are warned to be on the lookout for suspicious cases and are advised to take
necessary tests for diagnosis. It is pure folly to suggest that everyone with diarrhoea
should have a stool test. The laboratories are already carrying a heavy load and discretion must be used in submitting samples. However, the judicious testing of suspicious
cases, particularly in hospitals and institutions and where history suggests multiple cases
in families, should do much toward controlling the condition and preventing its spread.
The potential danger of human, bird and animal transmission to food, milk and water
calls for renewed effort to close the gaps in our sanitary control measures. The possibility of food-borne outbreaks cannot be denied. We may even have to revive the examination of food handlers with particular emphasis on diagnostic tests. Control measures
for Salmonellosis will be as stringent as for Typhoid and cases followed until proven
negative.
Salmonellosis appears to be here to stay. Whether the term sticks or we go back to
the old Paratyphoid designation is immaterial. Its presence, however, calls for an expansion of our diagnostic facilities and should encourage our executive bodies to meet a
more demanding challenge to the Public Health.
Treatment does not enter the scope of this article. However, it is rather disappointing to note that penicillin to date does not appear very effective in the treatment of
enteric disease.
REFERENCES
1. Dack, G. M.: Food Poisoning, The University of Chicago Press, Chicago, 1943.
2. Dolman, C. E.: Canadian Public Health Journal, 1943, 34, 47.
3. Strong, R. D.: Stitt's Diagnosis, Prevention and Treatment of Tropical Diseases, 7th Ed. 1944, Vol.
1, The Blakiston Co., Philadelphia.
4. Rubenstein, A. D., Feemster, R. F., and Smith, H. M.: American Journal of Public Health, 1944,
34, 841.
5. Burt, H.: J. Path. & Bact., 1944, 56, 209.
URETHRITIS IN THE MALE
Urethritis in the male refers to a clinical diagnosis based on history and physical
findings of an urethral discharge.
The results of laboratory procedures will differentiate the cases into gonorrhoea and
non-specific (non-gonococcal) urethritis.
Patients on whom the diagnosis of non-specific urethritis is made include two groups:
(a) Those cases of gonorrhceal urethritis which are misdiagnosed as non-specific
urethritis because of inadequate laboratory examination or because of too few
gonococci being present to be readily demonstrated, and
(b) Those cases of urethral discharge not caused by gonococci.
4?o* Sale I
1 BAUSCH & LOMB MICROSCOPE (AS NEW)
AND OTHER SURGICAL INSTRUMENTS.
Phone Mrs. McGregor
KE. 2496-R
Page Two Hundred and Nineteen Vancxuute/i MedUcal AtejocUUton
COMMON INJURIES IN THE REGION OF THE SHOULDER
Wing Commander R. C. Laird
Read at Vancouver Medical Association Summer School, 1945
This discussion will be a review of the commoner injuries in the region of the
shoulder joint, with their pathology, symptoms and signs, and treatments. For simplification they will be divided into fractures,, dislocations, and sprains, and will be dealt
with completely in turn.
Fractures
The commonest fracture in this region is at the surgical neck of the humerus. The
exact pathology varies from a simple crack without displacement, through the slightly
impacted crush fractures, and the more damaging adduction and abduction fractures to
the complete irregular fracture with more or less complete displacement of the fragments. They are caused by direct fall on the shoulder, or more commonly, by fall on
the outstretched hand. They are characterized by pain, deformity and loss of function,
largely in keeping with the actual amount of damage to the bone. The rather uncommon
complication of damage to the circumflex nerve must always be checked.
The great majority of these fractures have either no displacement, or a minor displacement which is readily corrected by manipulation, and the fragments tend to remain
in contact and position. For these the best immobilization is provided by the chest wall,
the arm in a sling being bandaged to the side. The most important feature in the treatment of all these fractures is early mobilization. After a week, the forearm is freed from
restraint and the elbow joint moved daily. After ten days to two weeks, all bandages
are removed daily, and the arm swung freely from the shoulder. This mobilization is
increased daily by bending forward, and after four weeks, gentle abduction can be
started. This treatment is particularly indicated in older individuals, in whom prolonged
immobilization is very likely to result in permanent freezing of the shoulder joint. In
those fractures with marked displacement, many can be reduced and will remain in
position. These can be treated as already described. Those that do not remain in position and cannot be irnmobilized at the side may need fixation in plaster spica or abduction splint. The proper position for fixation is where the fragments are in best contact
and line. Early mobilization can also be applied here by removing the upper part of the
cast, but generally speaking more prolonged fixation is necessary.
The other common fracture is of the greater tuberosity of the humerus.. This may
be associated with dislocation of the shoulder, or may occur alone. There may be a
simple fracture without displacement, or a definite separation with retraction of the loose
fragment upward. In the first case, there will be local pain and tenderness, with hesitancy on the part of the individual to move the arm, but no definite deformity or weakness. If there is retraction of the upper fragment, however, there will be definite weakness of abduction as the efficiency of the short rotators of the shoulder is interfered with.
The treatment in this fracture also depends on the degree. The simple fracture without
displacement may be immobilized while the pain is acute, but should be started on movement very early. When there is displacement, the upper fragment cannot be controlled,
so the lower fragment is brought up to it by means of an abduction splint. Mobilization
is usually not possible much under six weeks. In the occasional case the fracture unites
satisfactorily, but there is a greater prominence of the tuberosity, which impinges on the
acromion in abduction.   This is remedied by removing the outer end of acromion.
Dislocation
Acute dislocations of the shoulder are generally antero-inferior, with the head of the
humerus resting under the coracoid or the glenoid.   The usual position of dislocation is
Page Two Hundred and Twenty with the arm in full abduction, and the head is forced through a weak area of capsule
antero-inferiorly, or the capsule is torn off the glenoid margin. When examined the arm
has almost always been brought down to the side, and the elbow cannot touch the side,
of the body because of the position of the humeral head. There is the typical squaring
of the shoulder, due to the absence of the head from the glenoid, with marked pain, and
inability to move the arm. There is generally no linear tenderness of bone, unless there
is an associated fracture. An X-ray will confirm the diagnosis, and presence of complications. The treatment of acute dislocation is to return the humeral head to the glenoid
fossa, preferably through the tear in the capsule through which it dislocated. The
Kocher maneuver for this is familiar to all, as is the Hippocratic method of foot in the
axilla. A very satisfactory method of reducing an acute dislocation is the so-called
French or abduction method, in which the arm is slowly raised above the head, to the
position in which it probably dislocated, and then upward traction is applied, the body
acting as counterweight.   This can frequently be accomplished without any anaesthetic.
The problem of recurrent dislocation of the shoulder is one which has interested orthopaedic surgeons for many years. These recurrences are seen chiefly in athletes, or in
epileptics, that is, young adults exposed to frequent trauma. The pathology as described
by Bankart is certainly correct in the majority of cases as many surgeons have checked
this since it was first described. There is variation in the degree of tearing of the labrum
from the bone, but this is the fundamental defect. There is also a marked difference
in the force necessary to dislocate the shoulder, and to reduce it. There have-been about
sixty different methods devised for the radical cure of habitual dislocation of shoulder.
They may be divided roughly into two classes, those which provide some support to the
weak capsule below, and those which make a sling to hold the head in the glenoid from
above. Bankart claims that fixation of the glenoid labrum to the bone is all that is necessary. Gallie's operation provides a fascial support to the capsule below and anteriorly,
and fixes the labrum to the bone as well. The Nicola operation is best known and simplest, providing a sling from above by means of the long head of biceps. All of these
operations give satisfactory results in the majority of cases, and recurrences are not common in the most frequently used methods.
Dislocations at the acromio-clavicular joint are in reality chiefly tears of the coraco-
clavicular ligaments, and these tears may be partial or complete. In the case of partial
tear, there is seen some definite separation at the acromio-clavicular joint, with an increased mobility, but there is still some support, and the clavicle does not lie completely
free in the subcutaneous tissues. In the complete tears, there is marked deformity, and
the clavicle is very mobile, being readily reduced and as readily dislocated. The treatment of the acute dislocation is reduction at once and fixation. This is accomplished by
pushing down on the clavicle and up on the elbow, and maintaining this position by
strapping or plaster. In practically all partial tears, this treatment is all that is necessary
to allow sufficiently firm healing of the ligaments to hold the bones in position. In many
complete tears, however, this will not suffice, as there is no foundation for the healing
process between clavicle and coracoid. Some other support is necessary, and this may
be supplied by a screw through clavicle into coracoid, or by Kirschner wires across the
acromion into the distal end of clavicle. These hold the joint in position, but have possible disadvantages such as more easily fractured clavicle, or travelling of wires. The
fascial repair of the coraco-clavicular ligaments does improve the support, but does not
give perfect maintenance of the joint.
Sprains
The conditions to be considered now are not actually sprains, but are tears of tendons in close association with joint capsule. Rupture of the supraspinatus tendon, either
partial or complete, has been a popular subject in the literature of recent years. Trauma
{Jays a very definite part in the origin of this condition, but it is generally considered
that there must be some abnormality of the tendon-capsule, either degeneration or tendonitis, which allows separation at this point.   The tear is at or very close to the inser-
Page Two Hundred and Twenty-one
_~U tion of tendon into greater tuberosity, and this region is also known to be the site of
calcification or inflammation. The tears may be partial, either longitudinally or transversely, on outer or inner surface of tendon-capsule, or complete, with open communication between sub-deltoid bursa and shoulder joint. The complete tears may be of any
degree, from partial involvement of supraspinatus segment to complete separation of
whole rotator cuff. If the joint is opened several weeks after injury, the torn margin is
rounded off, with formation of melon seed-like fibrinous tags.
Clinically torn supraspinatus tendons occur in individuals over 40 years of age who
have worked hard with their arms, and who have had a fall on the elbow or shoulder, or
have flung the arm out to protect from such a fall. They have had moderate pain in
the shoulder at" once, but this is usually increased the next day, and is then accompanied
by marked stiffness of shoulder, well named "frozen shoulder." This painful stiffness
may persist for a week or two, and other signs are difficult to elicit. There is diffuse
tenderness of joint in the acute phase but later this may localize to the site of the tear,
usually just beyond the tip of the acromion. This tenderness will disappear as the arm
is passively abducted at the shoulder. At first no active movements will be attempted,
but after the acute reaction has subsided, or after novocaine has been injected into the
traumatized area, assessment of the degree of tendon damage can be made. If the tear
is a partial one, the function of the supraspinatus muscle is not interfered with and movements of the shoulder are full, complete and strong, showing normal scapulo-humeral
rhythm. In a complete tear, this rhythm is disturbed, and the exact way varies with
each case. As the function of the supraspinatus is partly to hold the head of the humerus
in the glenoid and partly to assist in abduction, the disturbance of such function may be
demonstrated in several ways. There may be no abduction, partial weak abduction, or
full weak abduction. There should be no limitation of passive movement in the joint.
The treatment of partial tears of the tendon-capsule is rest of the arm in a sling during
the acute phase of one to two weeks, then mobilization gradually as described for fractures of the surgical neck. There is usually no permanent disability. Complete tears
should be operated on, and repaired as soon as possible. Generally speaking, the earlier
the operation, the better the result. The tendon is identified, approximated to the
groove in the anatomical neck of the humerus and sutured to the bone with silk or fascia.
Post-operatively the shoulder is treated as for a partial tear. Good results have been obtained by operation as late as three months after injury, but ordinarily such delay should
be avoided.
Rupture of the tendon of the long head of biceps is not a serious incident but it
will give a permanent disability of varying degrees of weakness. There is here also some
predisposing change in the tendon, similar to that in the supraspinatus. A sudden strain
applied to a weakened tendon results in rupture. Clinically the slack bulging of the
long head of biceps in the middle of the arm is typical and very familiar to all. Treatment should .be undertaken' when the diagnosis is made, and consists in fastening the
long tendon snugly to bone in the bicipital groove, or to the tendinous origin of the
short head nearby.
SURGICAL TREATMENT OF PULMONARY TUBERCULOSIS
Wing Commander R. C. Laird
Read at Vancouver Medical Association Summer School, 1945
Introduction
There is no doubt that surgical treatment of one kind or another has made a tremendous difference in the hospitalization and in the mortality of pulmonary disease, and
the medical profession as a whole should become familiar with the principles and details
of such treatment.
In this review of the surgical treatment of pulmonary tuberculosis it is intended first
to discuss briefly the pathogenesis and symptomatology of the disease, then the general
principles of treatment, the details of the various procedures in common use, with their
individual indications and results in some of the operative groups.
Page Two Hundred and- Twenty-two Pathogenesis
The great majority of cases of all types of tuberculous infection in this country are.
now due to the human tubercle bacillus. There is an occasional infection with the bovine
tubercle, but these are fortunately becoming relatively rare. Practically all pulmonary,
tuberculosis is human in type, and is spread by direct contact with a known or unknown
open case of the disease. The tubercle bacillus is aspirated, located in the apices of the
lungs, and in proliferation there sets up the tissue and cellular reaction which is known
as the tubercle. This tubercle may resolve if the individual's resistance is good, or it may
spread and caseate. When cessation has proceeded sufficiently, the necrotic material may
be coughed up and a cavity left. This is the life history of pulmonary tuberculosis
from the bacillus to the cavity. The variations that may occur at any stage, and the
rapidity or slowness of development are familiar to all. Healing of tuberculosis is by
fibrosis, and this may take place even in the small cavities, but with large cavities, some
other factors must be introduced to approximate the walls of the cavities and allow
elimination of the disease by fibrosis.
Symptomatology
The typical symptoms and signs of pulmonary tuberculosis are very familiar, but it
is the absence of these in many diseased individuals wihch makes the disease so insidiously dangerous. The taking of routine chest X-rays in the Armed Services and in
many industries has been of very great importance, not only in the early diagnosis of
tuberculosis, but also in the decrease in the spread of the disease in the forces and in
industry. The well-established cough, with or without haemoptysis, is always an indication for an X-ray of the chest, but we should look forward to the day, in the very near
future, when every member of the community has at least a routine chest X-ray at
periodic intervals.
Principles of Treatment
The cardinal principle in the treatment of tuberculosis is rest. This is generally considered to be rest of the body as a whole and is carried out by varying degrees of confinement to bed. This is assisted by such things as fresh air, good food, and alternating
mental relaxation and stimulation. There is in addition the local rest of the diseased
tissue, and this is generally achieved by surgical means and may be considered the first
fundamental principle of the surgical treatment of pulmonary tuberculosis. The other
fundamental principle depends on the degree of involvement by the disease, and is the
elimination of cavities in the lung. The collapse therapy which has been developing
over a number of years includes both these principles, while the excision of diseased
lung which has become popular more recently is directed toward the second principle
only.
Surgical Procedures
There are, then two groups of surgical procedures which are used in the treatment
of pulmonary tuberculosis. Collapse of the lung, either temporary or permanent, will
give local rest associated' very often with elimination of cavities by pressure. Those
methods in common use are pneumothorax, phrenic crush, intrapleural and extrapleural
pneumonolysis, and thoracoplasty. Naturally the reasonable method of eliminating disease completely is to remove the diseased tissue when possible. This has been applied to
pulmonary tuberculosis, and lobectomy and pneumonectomy are the excision procedures
carried out.
The simplest surgical method of collapse is the artificial intrapleural pneumothorax.
By the introduction of air by stages and in varying amounts into the pleural cavity,
varying degrees of collapse are-obtained. This air must-be added to at intervals, and the
degree of collapse kept under close observation. It may be said that pneumothorax
should be attempted in all cases of pulmonary tuberculosis except early minimal lesions,
or in very far advanced almost moribund individuals.. Even in early minimal lesions it
is possible that the institution of pneumothorax will so shorten the period of hospitali-
Page Two Hundred and Twenty-three zation necessary, that it is definitely indicated for economic reasons. As the great
majority of sanitarium patients lie between these two extremes, pneumothorax is the commonest collapse therapy at the present time. It may be used with bilateral disease, and
in the presence of cavities. It must be watched carefully, and if it is found to be inefficient, as in collapse of cavities, it is much better to allow the lung to expand, and to
proceed with some other method.
The unilateral paralysis of the diaphragm has been used for years in the treatment of
pulmonary tuberculosis. It has been permanent by exeresis of the phrenic nerve, or temporary, by simple crushing of the nerve. The latter has become more popular recently,
because of the possible need of the lower lobe in the respiratory function at a later date.
It is, of course, possible that the temporary crush may not be of sufficient duration, and
may need repeating. This is a more difficult operation, but the disadvantages of this are
far outweighed by the disadvantages of the permanent paralysis. Many prominent thoracic surgeons believe that phrenic paralysis is an important step in a large majority of
cases, but there are also many who believe that it may be used alone chiefly in lower lobe
lesions, but in conjunction with some other procedure in the majority of lesions elsewhere. Its efficiency is at times increased by the addition of pneumoperitoneum. The
phrenic nerve is approached through an inch long incision, one finger's breadth above
the clavicle, at the lateral border of the sterno-mastoid muscle. The nerve is identified
as it crosses the scalenus anterior muscle obliquely from its lateral towards its medial
border. It is injected with novocaine and crushed with a small haemostat. The paralysis
lasts about an average of six months.
With the almost routine use of pneumothorax as the collapse procedure of choice,
there are bound to be a relatively large number of cases in which pleural adhesions prevent any air entry at all, or prevent complete or efficient collapse of the diseased lung.
Where no pleural space is identified, some other method of collapse is indicated, but if
the adhesions are thin and easily identified, it may be possible to eliminate them, and
carry on with pneumothorax. . This intrapleural pneumonolysis is generally done through
the thoracoscope, by cautery, and if care is taken, and the dangers understood, it is a
very satisfactory adjunct to pneumothorax. The dangers are of haemorrhage, tuberculous infection of the pleura, and bronchopleural fistula. These are avoided by proper
selection of adhesions to be cut, and careful technique in the cutting. In the occasional
case, a larger type of adhesion may be cut under direct vision by open intra-pleural
pneumonolysis. This is rarely used, as it is generally more satisfactory to employ some
other method of collapse.
The two other means of collapse are extrapleural thorax and thoracoplasty. In the
extrapleural pneumothorax the parietal pleura is stripped from the endothoracic fascia
and the lung collapsed, the space formed being refilled at regular intervals with air as
in the intrapleural pneumothorax. This really gives a more selective collapse than
intrapleural, and leaves the uninvolved lung expanded and functioning. It is a little
more difficult to maintain, and a little more prone to infection. It is not suitable for
large peripheral cavities, because of the danger of opening into them during the stripping.
It is a much less extensive operation than thoracoplasty, but its real place in this surgery
is still controversial. The operation is performed through the space left by removing
about four inches of the fourth rib in the posterior axillary line. The space is identified
between the pleura and the endothoracic fascia and stripped gently with sponges. Haemorrhage is usually slight and readily controlled by warm packs. The space is extended
medially to the hilum, anteriorly to about the third space and posteriorly to the seventh
rib. A relatively air-tight closure is effected and air is re-inserted in 48 hours. There
is still no definite time limit for the maintenance of the pneumothorax, and it may be
difficult to get the lung to expand when it is considered healed.
The most extensive operative procedure in the collapse treatment is the thoracoplasty.
This is generally a localized' removal of ribs to give selective collapse of diseased lung only.
It is usually apical in site, and the number of ribs removed depends on the extent of the
disease.   Any cavity in diseased lung which cannot be closed by more conservative meas-
Page Two Hundred and Twenty-four ures is definite indication for a thoracoplasty unless the disease or the patient's condition
are such that operation would hasten the death of the patient or do no good. This does
not limit the disease to one side, nor to any special age group. Contra-indications to
the operation include a predominance of exudative disease in either lung, definite tuberculous ulceration in the bronchi or scar stenosis of the bronchus secondary to such ulceration, and the presence of bilateral kidney infection or active tuberculous enteritis.
Generally speaking, the collapse is achieved in two or more stages, the first three ribs
being removed in the first stage, and the others necessary in subsequent stages two or
three weeks apart.   This multiple operation has definitely lowered the mortality.
The excision procedures of lobectomy and pneumonectomy have been considered for
some years as the ideal technique for ehminating localized tuberculous disease, but the
complications were so frequent and so serious that relatively few operations were done.
When the dissection method of lung removal was perfected, it was thought that the
operation would be safer in tuberculosis, so that since 1940 a fair number of excisions
have been carried out. In general, the chief indication for excision is scar stenosis of
the main or branch bronchus secondary to tuberculous bronchitis. Naturally there must
be no suspicion of the slightest activity in the bronchial mucosa at or near the site of
division. A further indication is the persistence of cavity and positive sputum in spite
of an apparently adequate collapse. Where less radical measures are likely to be ineffective, excision does offer definite hope of cure.
Results
The measure of the effectiveness of any treatment is the degree to which that treatment carries the patient back to health, compared with any or all other methods. The
more or less minor procedure of pneumothorax is in such general use that definite figures
are difficult to obtain, but general statistics show a definite improvement in length of
* hospitalization and in mortality. Reports of large series of extrapleural and thoracoplasties appear occasionally in the literature. As a concrete example of results, may I
offer the figures at one sanitarium. Here in the past three years there have been done
19 extrapleural, and 12 of these patients have already been discharged from hospital
with negative sputum. There was one death in this group. Multiple stage thoracoplasties have been done on 47 patients during the three years, and of these, 19 have
already left hospital. When one considers that most of these individuals had apical
cavities which would not have healed, and which would ultimately have led to the
patient's death, the results of operative collapse may be deemed satisfactory. A small
series of total and partial pneumonectomies was reported by Dr. James last year. Of
eight upper and middle lobectomies, six were well and two dead; of nine lower, seven
living and two dead, and of fifteen total pneumonectomies, ten were well or fairly well,
three dead, and two in poor condition. For such a relatively small number, these results
also are considered satisfactory.
Page Two Hundred and Twenty-five fyoHcotwek QeHetoal cMo4fUt(U Section
SOME   CASES   OF   EXTRA-PULMONARY   TUBERCULOSIS
By G. D. Saxton, M.D.
The presentation of these cases which are in themselves simple, requires some justification. That justification is the tendency of many of us to forget tuberculosis in the!
differential diagnosis of inflammatory lesions, particularly lesions which are slow in
developing and reluctant to heal. These are signs which indicate a chronic type of infection and which should warn us of the possibility of tuberculosis. Unfortunately this
warning is sometimes not heeded. The elimination of syphilis is rendered simple by the
blood Kahn. There is no such simple test for tuberculosis.
We are all familiar with tuberculosis in its common sites and automatically consider
it in the differential diagnosis of pulmonary conditions, joint or spine disease, enlarged
cervical glands and renal lesions—to mention the more obvious few, but tuberculosis
may be manifested in any organ in the body and this possibility should be kept in mind.
To illustrate this I should like to give short accounts of several cases that occurred
in my own practice or were seen on the wards of the Vancouver Unit of the Tb. Division
within the past few months.
Case I.—B. S., Hindu wood merchant, age 32.
This man was first seen by me in February, 1944, with bilateral discharging cervical
sinuses. Enlarged cervical glands had been incised two months previously, following
swellings that had been present 3 weeks before incision. These were apparently tuberculous and this was confirmed by biopsy. An X-ray of the chest was negative. The blood
Kahn was negative.
At the same time attention was drawn to the left tibia. Nine months previously he
had been struck on the shin by a block of wood. This was followed by swelling which
had persisted. Examination showed a raised bluish swelling two inches by one inch in
the middle third of the leg on the antero-medial aspect of the tibia. This was covered
by a thin epithelium broken down over a small area. X-ray showed a local periostitis
with surface destruction of the bone. Tuberculosis, despite the cervical gland lesions,
was not considered. It was felt the lesion was simple periostitis following a subperiosteal
haematoma.
Under general anaesthesia the cervical sinuses were curetted. At the same time the
area on the tibia was incised, the granulation tissue removed and the bone curetted to
the edge of healthy bone. The appearance of the opened tissue suggested tuberculosis,
being of the greyish pink colour and soft consistency usually seen in Tb.
This suspicion was confirmed by pathological examination.
Pathological Report (Dr. H. H. Pitts): Diffuse granulomatous appearing infiltration, with scattered indefinite tubercle formations consisting or rather poorly defined
giant-cells and some epithelioid cells, with here and there very indefinite caseation.
Diagnosis: Tuberculous osteitis, left tibia.
X-ray therapy was given to the neck with eventual healing of the sinuses. The tibial
lesion slowly healed over a period of months.  A recent chest X-ray was still negative.
Case II.—J. W. S., age 37, Male—Dispatcher for Cartage Company.
First seen March 11, 1944.
Complaint was a swelling of the right anterior chest wall which had been present
one week.
History: Six years previously while riding a horse was thrown forward, and this area
of his chest had struck the pommel of the saddle.  A swelling appeared.  This persisted
Page Two Hundred and Twenty-six for one year at which time it was aspirated and a fluid, which was apparently serum,
was obtained. The swelling disappeared. There were no further symptoms until the
present.
Examination showed a soft fluctuating inflammatory mass 4 cm. in diameter overlying the 5th right costal cartilage at the sternum. Tuberculosis was suspected. An
X-ray of the chest showed bilateral pulmonary tuberculosis. There was no evident
disease of the ribs.   Pus aspirated from the abscess cavity contained tubercle bacilli.
Diagnosis: Tuberculosis of 5th right costal cartilage and pulmonary tuberculosis.
The man was admitted to Tranquille for sanatorium treatment. He has recently been
discharged with arrest of his pulmonary disease and healing of the cartilaginous lesion.
Case III.—Mrs. W., age 23, Housewife.
The third case was admitted on the wards of the Tb. Division in April, 1944. Past
history revealed that for four years she had had a vague lower back ache but not
sufficient to be disabling.
Present History: In January, 1944, patient developed a purulent discharge from the
right nipple. This was followed by a painless swelling in the lower part of the breast.
An abscess was incised by her attending physician. About this time the back pain became more severe. X-ray showed tuberculous disease of the 12 th thoracic and 1st lumbar bodies. Following this a chest X-ray revealed pulmonary tuberculosis for which she
was admitted to the Vancouver Unit.
The breast lesion, for which she first consulted a physician, continued to discharge
from the sinus made by the operation. A biopsy done in the Vancouver Unit confirmed
the now suspected diagnosis of tuberculous mastitis and a simple amputation of the
breast was done in June, 1944.  Primary healing occurred.
Pathological Report (Dr. H. H. Pitts): Diffuse granulomatous infiltration consisting of numerous tubercle formations, made up of giant and epithelioid cells and considerable caseation in many, is noted. Diffuse lymphocytic and plasma cell infiltration is
also present.  Diagnosis: Tuberculous mastitis.
She remains in the Unit. Her pulmonary disease is healing but the spinal disease has
extended.
Case IV.—Th., age 38, Radio mechanic.
This man is also a patient on the wards of the Tb. Unit.
History: In April, 1943, the right ring finger was amputated. A swelling had been
present on the palmar aspect for 18 months. A biopsy done previous to amputation was
positive for tuberculosis.   Primary healing occurred.
Patient remained well until February, 1944, when he had an attack of right renal
coEc. There was subsequent swelling of the right testicle. In April, 1944, his physician
incised an absecess in the right scrotum.  A discharging ^sinus persisted.
In July, 1944, an abscess developed in the region of the right shoulder which was
also incised with a persisting sinus. This, despite the available history of tuberculosis
of the finger.
This man continued to work. It was only when an X-ray of the chest was taken
by the Mobile Chest Unit during a mass survey at Boeings that tuberculosis of the lungs
was discovered.  Admission to the Sanatorium followed in September, 1944.
In October the right testicle with the scrotal skin surrounding the sinus was excised,
the cord being removed to the external ring.  There was no evident disease of the duct.
Pathological Report (Dr. H. H. Pitts): The epididymis is thickened, nodular and on
one section shows extensive caseation, typically tuberculous in type. This is confirmed
microscopically, no involvement of the testicle proper being present.
Diagnosis: Tuberculous epididymitis.
This man remains a patient of the Unit, being treated for pulmonary Tb., tuberculosis of the left shoulder, and being watched for further development of genito-urinary
tuberculosis.' His prognosis is not good.
Page Two Hundred and Twenty-seven M
^___ ___k  _^_V       _^_^_^. ^_B
AXOL eb.s
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The ingredients combine to form a balanced product,
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DILAXOL E.B.S. has two separate
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4 The physical adsorption of Dilaxol is high, because it forms a
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4% Chemical action: The chart above shows how abnormal condi-
-"■ tions, such as hyperacidity, are controlled by neutralization of
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high, yet it cannot cause alkalosis, because the unused ingredients are
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Ingredi
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Trisilic
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Hyperacidity
Enteritis
Gastric Ulcer
Adsorptive
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Normal
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•
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Protective
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Insoluble—■
Forms protective
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Very active—should
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No effect
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Neutralizes
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Mild laxative
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Actively neutralizes
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Laxative if excess
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Less irritating than
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Highly adsorptive
Slight laxative
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hoea
Diminishes^
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Demulcent action—
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Some adsorbent property   —   Removes
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Effect is only on inflammation, not peristalsis;
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CANADA Case V—Miss W. C, Age 18, Stenographer.
This young woman was first seen by me on October 25, 1944.
History: Two and one-half years ago she developed a "pimple" over the left patella.
This persisted as a hard nodule for several weeks, then ulcerated. She was seen by a
physician who advised the use of iodine locally. The ulcer gradually enlarged.
A second lesion developed a year later two inches above the former one. This behaved the same way, later ulcerating. These two ulcers gradually enlarged until they
became, the one 4 by 2 cm., the other 2.5 by 1.5 cm. She was seen at intervals by three
different physicians who applied various ointments and took blood Kahns, all of which
were negative. The last physician referred her to Dr. John Christie whose clinical diagnosis was tuberculous ulceration.  He referred her to me for biopsy.
The blood Kahn was again negative. An X-ray of her chest taken in a shop survey
a short time previously was negative.
Following biopsy to prove the tuberculous nature of the lesions, wide excision of
both ulcers was done under local anaesthetic. The wounds healed without event and
have remained healthy.
Search for a source was made.   There was no family history of tuberculosis, no
known contact with human cases, she had not lived on a farm.    She will obviously?
require watching in case tuberculosis in another site develops.  An X-ray of her chest
taken one week ago was again negative.
Pathological Report (Dr. H. H. Pitts): "Sections show a diffuse granulomatous infiltration in the subepithelial and to some extent the deeper tissues with ulceration of
the squamous epithelium in many instances. A few circumscribed tubercle formations,
giant and epithelioid cells are seen in practically all the sections, some of these showing
very indefinite early caseation. I believe that this is probably a tuberculous lesion but
there is the possibility of a luetic process.
However, the repeatedly negative blood Kahns eliminate the possibility of syphilis
and we are left with the diagnosis of tuberculous ulceration of the skin.
The failure to diagnose tuberculosis might not be so important if we were, in most
instances, dealing with isolated surgical lesions; but that is rarely the case. The type of
lesion I have indicated implies a blood borne infection, except possibly in the case of the
ulcers of the knee. That infection must have a source. As we are treating a patient and
not a discharging sinus it is obviously our duty to find that source. If tuberculosis is$
thought of an X-ray of the chest automatically follows. Frequently the diagnosis becomes evident on that simple and easily available procedure. Failing X-ray evidence of
pulmonary disease, the taking of a biopsy, the examination of the discharge by smear,
culture or animal inoculation, particularly before secondary infection has occurred, will
in most cases indicate the true nature of the disease.
PATHOLOGICAL CONFERENCE
Department of Pathology, The Vancouver General Hospital
(Director, H. H. Pitts, M.D.)
J. G. McPhee, M.D.
A 21-year-old male complained of pain in the right subscapular region of three
weeks' duration, stiff neck, and head-colds of two weeks' duration. At that time he
gave a history of having been in usual health until January 15, 1945, when he contracted an "ordinary head-cold." In a few days he noticed the pain in the region of
the right scapula which persisted and spread over the right chest and up into the right
sterno-mastoid region long after the head-cold cleared up. On February 5 he complained of a severe right-sided headache which extended from the sterno-mastoid muscle
to the temporal region. Two days later numbness about the left corner of the mouth
and cheek developed. At this time there was no cough, nausea or vomiting, rash or
jaundice, but the patient felt quite feverish and had intense head-pains.
Page Two Hundred and Twenty-eight The patient's past history and family histories were negative with the exception of
a bout of infectious jaundice in 1940 from which he recovered completely.
On February 20, 1945, his temperature was 102°, pulse 100, and respirations 20 per
minute. He appeared acutely ill' and complained bitterly of head-pain. Ocular examination was negative. There was anaesthesia over the entire chin from both corners of
the mouth to the mental symphysis and over both sides of the tip of the tongue, but
there was no wasting or fibrillation. The tongue protruded to the left but there was
. no facial weakness. There was photophobia, marked neck rigidity, and positive Kernig's
signs. A tender swelling was palpated below the tip of the right mastoid but because
of the extreme tenderness over the right sterno-mastoid muscle, this could not be investigated further and it was assumed to be swollen lymph glands. No further lymph
adenopathy was noted, and the remainder of the examination was negative.
During the evening of February 22, 1945, the patient complained of abdominal
cramps producing nausea but * no vomiting. By morning the pain had become severe
over the right lower quadrant. On examination, the temperature was 100°, the abdomen was distended and tympanitic, and although there was generalized tenderness, no
rigidity or localized tenderness was found. There were no palpable masses in the abdomen. An enema, which released a large amount of flatus and loose foul-smelling stool,
relieved the abdominal discomfort.
These complaints, i.e., headache, abdominal pain, and the temperature, persisted until
March 3, 1945, when the patient began to complain of a sharp knife-like pain in the
right axilla, aggravated by deep breathing. The radiograph showed a small pleural
effusion in the right base. There had been no change in the neurological signs with the
exception of considerable decrease in the neck rigidity. During examination on March
6, a number of enlarged lymph glands were palpated in both posterior and anterior cervical chains, axillary, supraclavicular and inguinal regions. On March 9, the spleen
became palpable one finger-breadth below the costal margin. A biopsy of a gland
showed Hodgkin's disease, so deep X-ray therapy was commenced and by March 18 most
of the lymphadenopathy had disappeared. However, the patient's general condition was
rapidly deteriorating, and he died on March 26.
^«_*a
The following laboratory procedures were carried out:
Spinal Puncture:
February   11—Fluid—clear;  no cells;  protein—40;  initial  pressure—120  mm.
H-O.
February 22—Same.
Radiography:
Chest—February 24—Negative.
March 5—Right pleural effusion with some collapse of lung; some widening
of superior mediastinum.
Skull—February 21—Negative.
Cervical Spine—February 24—Negative.
Abdomen—February 2—Negative.
Urinalysis: February 21—Acid 1020; albumin 0; sugar 0; micro 0.
March 18—Acid 1022; albumin trace; sugar 0; micro 0.
Blood: February 9—W.B.C. 12,150; P. 56; S. 13; L. 30; E. 1.
February 21—W.B.C. 11,000; R.B.C. 4,100,000; Hb. 87%; Sed. 4mm./1 hr.
March 15—W.B.C. 13,000; R.B.C. 2,900,000; Hb. 40%; P. 54; S. 11; E. 1;
M. 1; L. 33.
"Blood Kahn: Negative.
Blood Culture: February 21—negative; March 21—negative.
Heterophile antibodies: February 21—Negative.
Page Two Hundred and Twenty-nine Autopsy:
The body is poorly nourished. There are numerous nodules beneath the skin of the
forehead and scalp. There is a well-healed scar in the right supraclavicular fossa, and
lymph nodes can be felt in the supraclavicular fossae, inguinal regions and the axillae.
On reflecting the sternum and costal cartilages, the left lung is free in its pleural
cavity. The right lung is bound by fibrous adhesions and there is a large quantity of
bloody fluid, approximately 2000 c.c, present in the pleural cavity. The lung has a
rather compressed appearance and there are plaque-like cellular tumour growths scattered over the parietal pleura, involving the third and fourth ribs, and in the actual
muscle. In the mediastinum there are a large number of markedly enlarged lymph
nodes, fairly firm to feel. The tumour growths have a white "fish-flesh" appearance to
the cut-surface, and the enlarged lymph nodes have a similar white homogeneous cut-
surface. The right lung weighs 500 grams, the left 480 grams. On section, they are
markedly congested and oedematous and in the bases there are granular, firmer areas,
suggestive of a beginning broncho-pneumonia. The bronchi contain a thick mucopurulent material and in the right main bronchus, almost completely obstructing it,
there are three raised, irregular tumour growths measuring approximately 1 cm. in diameter. One of these is larger than the others and appears to infiltrate the nearby lung
parenchyma as well as the bronchial wall. The remaining two appear to be confined to
the wall of the bronchus.
In the pericardial sac, there are 150 c.c. of clear straw-colored fluid. The heart
weighs 240 grams. Present on the epicardial surface are white firm cellular tumour
growths, also in the auricles and ventricles. On section the muscle is soft and of a light
reddish-brown colour, and there are a number of tumour growths scattered through it,
and one very large at the base of the heart and the intraventricular septum. There are
no tumour nodules in the pericardium. The coronary arteries are patent throughout.
The ascending aorta is normal.
The abdominal viscera are in their usual positions. Examination of the gastrointestinal tract reveals no abnormality other than considerable distension of the bowel
wall by numerous large lymph nodes, many of which are degenerated. The retroperitoneal and mesenteric glands are enlarged. Near the aorta is a dense fibrous tumour
measuring 20 x 10 x 6 cm., resembling fused lymph nodes.
The kidneys each weigh 130 grams. The parenchyma is markedly oedematous and
in the right kidney there is a tumour growth with indistinct margins, measuring 1.4 x
0.8 cm.    The ureters and the urinary bladder are normal.
A section of the pelvis reveals numerous tumour growths, scattered along the periosteum, and tumour growths can be found along the vertebrae. Many of these appear
to involve the foramina.
On the periosteum and beneath the periosteum of the skull are many flat plaque-like
tumour growths, some of which have eroded the bone and some appear to be actually
rising from the bone. The brain weighs 1320 grams, and is normal. There are tumour
growths beneath the periosteum which have surrounded and compressed the Gasserian
ganglion on the right side and appear to have actually infiltrated the ganglion on the
left side.    They also surround the facial nerve on the right side.
Exaniination of the bone marrow reveals it to be heavily infiltrated by a similar
soft cellular tumour growth.
Microscopic Examination:
Tumour: Sections were taken through the tumour infiltrating the bronchus. They
show a diffuse carcinomatous growth involving the mucosa, sub-mucosa and extending
into the surrounding lung parenchyma. It consists of columns of atypical cells varying
in size and shape with hyperchromatic nuclei showing frequent mitotic figures. Here
and there are tumour giant cells and in some portions of these sections there is considerable lymphocytic infiltration.   In still other portions the tumour cells are arranged in
Page Two Hundred and Thirty nests, with a slight tendency to acinar formation. The stroma is very sparse, but what
there is, is fibrous in character.
Lymph Nodes: Sections through the various lymph nodes show an almost complete
replacement of the lymphadenoid structure by a tumour growth similar to that described in the lungs.
A number of sections were taken through the ribs and sternum and these show a
diffuse infiltration of the tumour growth into the bone marrow. The marrow of the
vertebrae and pelvis bones are involved but to a lesser extent.
Final Diagnosis:
1. Marked hypochromic normocytic anaemia.
2. Anaplastic bronchogenic carcinoma of the right lung.
3. Metastases to lymph nodes, heart, kidneys, pleura, bone marrow, and sub-periosteal
metastases to pelvis, vertebrae, ribs, and skull.
Summary:
An instance of carcinoma of the lung at the age of twenty-one with an unusual
clinical picture is discussed.
_•••••••*•••
J___a*P?
••••
HRIifS
MANAGEMENT OF EARLY SYPHILIS
Important Points
1. Laboratory proof of diagnosis.
2. Complete history and physical examination.
3. Accurately written record of the case.
4. Adequacy and regularity of treatment.
5. Blood test every 6 months during the first two years, and every year during the next
three years.
6. Examination of cerebrospinal fluid at the completion of treatment.
7. Reporting of the case and investigation of contacts.
TRIWEEKLY MAPHARSEN
Eagle has devised various schedules of treatment for early acquired syphilis where
mapharsen 0.06 is injected three times a week for a period of 10 to 12 weeks. When
mapharsen alone is given, the results are uniformly poor. When bismuth injections are
given in addition to mapharsen, the results are satisfactory.
CORRECTION
In the May issue of the Bullettn, page 201, last line, in the article on "Penicillin
—Venereal Infection," should read:
". . . adjusted for continuous absorption over 24-hour period*' instead of "40-hour
period."
Page Two Hundred and Thirty-one .  B. C. PROVINCIAL BOARD OF HEALTH -
Division of Venereal Disease Control
Physician Bulletin April 27, 1945.
DISTRIBUTION FREE PENICILLIN —
VENEREAL INFECTION
1. In keeping with the policy of the Provincial Board of Health to provide physicians
upon request with approved medications for the treatment of venereal disease, it is
announced that this policy now includes the provision of penicillin for the following:
I    All proven and suspected   (clinical and/or epidemiological evidence)   cases of
gonorrhoea.
II    Cases of early syphilis which fall into one of the following categories:
(a) Serious reactions to routine arsenic-bismuth therapy.
(b) Relapsing, resistant or fulniinating forms of early infection.
(c) Early syphilis in asocial promiscuous persons.
(d) Early syphilis in persons unable to obtain regular weekly treatment (remote
rural areas, certain seamen, fishermen, loggers, miners, etc.).
(e) Elderly persons with early infection.
(f) Persons with "difficult" veins—addicts, obesity.
2. Free penicillin is available to physicians upon request at all Provincial Board of
Health V.D. Clinics and full time Health Units.
GREATER VANCOUVER:
Vancouver City—Division of V.D. Control, 2700 Laurel Street.
Burnaby—Metropolitan Health Unit, Municipal Hall, Edmonds.
North Vancouver—North Vancouver Health Unit, 251 E. 14th Ave., N.V.
NEW WESTMINSTER:
New Westminster—Division of V.D.  Control Clinic, Royal Columbian Hospital
(Friday and Saturday weekly).
GREATER VICTORIA:
Victoria—Division of V.D. Control Clinic, Royal Jubilee Hospital.
VANCOUVER ISLAND:
Nanaimo—Central V. I. Health Unit, Nanaimo.
PRINCE RUPERT: (including Queen Charlotte Islands and Terrace)
Prince Rupert Health Unit, West 2nd and 4th Street, Prince Rupert
WEST KOOTENAY:
Trail Clinic, 901 Helena Street, Trail.
LOWER OKANAGAN:
Kelowna-Penticton—Okanagan Health Unit, Kelowna.
NORTH OKANAGAN:
Vernon-Kamloops—North Okanagan Health Unit, Vernon.
PEACE RIVER:
Peace River Health Unit, Pouce Coupe.
OTHER AREAS NOT SPECIFIED:
To nearest full time Health Unit or 2700 Laurel Street, Vancouver, B.C.
3. It is essential that each request for penicillin be accompanied by a Form Nl "Notification of Venereal Infection" duly filled out. In cases of suspected gonorrhoea the form
should be provided with the words "suspected—clinical" or "suspected—epidemiological"
whichever applies. In cases of early syphilis a note should be added indicating into which
of the specail categories, outlined in paragraph 1. II above, falls.
4. Reference is made to the Physician Bulletin "Penicillin—Venereal Infection" on
April 3, 1945, outlining recommended treatment plans for gonorrhoea and syphilis. If
an extra copy of this bulletin is required please write to Provincial Board of Health,
Division of V.D. Control, 2700 Laurel Street, Vancouver, B.C.
Page Two Hundred and Thirty-two MEDICAL "CERTIFICATES" FOR PROSTITUTES
From a conunittee report, House of Delegates, American Medical Association, June
8, 1942.
"It is inconceivable that any reputable physician should so degrade his profession
and himself as to issue certificates to prostitutes to the effect that they are free from
venereal disease."
PHOTOGRAPHY EXHIBIT
"One of the outstanding exhibits of Canadian amateur photography that I have
seen/'
These are the words of Mr. Raymond Caron, A.R.P.S., A.P.S.A., one of the judges
at the recent Canadian Physicians' Camera Salon held at the Eaton Art Galleries in conjunction with the Canadian Medical Convention.
This exhibit, the first of what is hoped will become an annual show, was held under
the auspices of the Montreal Camera Club and was sponsored by Frank W. Horner
Limited.
The exhibition was formally opened at 10 a.m. June 11th by Dr. Fred J. Tees, P.S.A.
-Judges were Dr. Tees, Mr. Caron and Mr. F. T. Clayton.
Organized to give Canadian physicians an opportunity to display their photographic
talents—the exhibition was divided into two classes: one for physicians, the other for
laymen. Each class was divided into two groups, Prints and Kodachrome—feature being
that the exhibit was the second time that Kodachrome has been exhibited in Canada.
Winners in each group are as follows:
For Prints in the Physicians' Class-—First, Dr. G. B. White, Port Colborne, Ont.,
"A Gallant Company"; second, Dr. H. Campbell Brown, Vernon, B.C., "China Missionary"; third, Dr. Claude Lamarche, St. Therese, P.Q., "La Cabane"; Honourable
Mentions: Dr. W. K. Blair, Oshawa, Ont., "Snow and Mist"; Dr. L. J. Notkin, Montreal, P.Q., "Within Thy Portals"; Dr. G. B. White, Port Colborne, Ont., "Decorations
by King Winter."
For Prints in the Laymen's Class—First, Dr. L. G. Saunders, Saskatoon, Sask., "White
Winter"; second, Hugh W. Frith, Vancouver, B.C., "Apache"; third, J. Fraser Byrne,
Toronto, Ont., "Putting Out"; Honourable Mentions: F. C. Houghton, Montreal, P.Q.,
"Dahlias"; W. D. Jewette, Woodlands, P.Q., "Youth Steps Out"; Dr. L. G. Saunders,
Saskatoon, Sask., "Sleepy Little Spruce."
Of special interest was the colour photographic section, the second time in Canada
that colour slides have been shown.
Colour Transparencies—in the Physician's Class: First prize, Dr. Harvey Agnew,
Toronto, Ont., "Peggy's Cove, N.S."; second prize, Dr. R. Coyle, Windsor, Ont., "The
Bow River Valley"; third prize, Dr. E. J. Trow, Toronto, Ont., "Clear and Cold."
Colour Transparencies—in the Laymen's Class: First prize, Charles Schroeter, Vancouver, B.C., "Gilded Splendour"; second prize, W. B. Piers, Haney, B.C., "Autumn";
third prize, Marcel Cailloux, Montreal, P.Q., "Parure Lacustre."
Large crowds attended the exhibition daily and all expressed the hope that this would
be just the beginning of such amateur photographic exhibitions.
Page Two Hundred and Thirty-three J.
L
COLIN ANDREW McDIARMID, M.D. CM. (McGill)
Obiit July 11, 1945.  Aet. 69.
Vancouver has lost one of its oldest and most valuable practitioners in the
recent death of Dr. Colin McDiarmid. The Vancouver Medical Association has
especial reason to mourn his passing as he was a recent President of the Association, and had served long and faithfully in various official capacities other
than the presidency. Thus he had for many years worked at one of the most
thankless, yet most important tasks of the Association—as member of the Board
which deals with relief and old age pension cases and their accounts: a task
which takes a lot of time and hard work.
Colin McDiarmid was an old-timer in Vancouver. He graduated from
McGill just after the turn of the century, and came West almost immediately.
He was at Atlin in the Yukon Territories for a short time: then came to Vancouver, where he settled down to general practice, which branch of the profession he continued to adorn till his death. He was a sound and conscientious
medical man, doing excellent work and holding the confidence and affection
of his patients. He was in harness till very nearly the end, when a cerebral
haemorrhage forced him to give up work.
As a man and a citizen, Dr. McDiarmid deserved well of his friends and
his country. In the first Great War, he served as Medical Officer to the famous
29th Battalion of Vancouver, and was in the thick of the fighting in France.
He never lost touch with this Battalion, and the surviving members of it were
all devoted to him, and as they well might, regarded him as one of their best
friends. In any trouble, in any jam they might get into, "Doc" was the first
man to whom they took their troubles. He had a gift for friendship, and for
loyalty to his friends, and could always find time to help out.
His fellows in the profession liked him more than well, and he was always
welcome in any gathering of medical men. He had a quiet manner, but a keen
sense of humour, and a capacity for enjoyment of life and companionship with
others.
His home life was a very happy and successful one, and he leaves a wife
and three daughters, to whom he was greatly devoted. To them we can only
feebly express our deep sympathy in their loss. For those of us who had known
liim for years, there is too a great sense of loss, of a friend and trusted colleague.
DR. WRAY-JOHNSTON
Obiit July 15, 1945.  Aet. 3 8.
It was with a sense of shock that we heard of the sudden and untimely
death of Dr. Wray-Johnston. One of the most recent additions to the Vancouver medical profession, he was rapidly coming to the front in this city, as
a very competent and skillful physician and surgeon. He had served for a time
as interne at the Vancouver General Hospital, and later, we understand, joined
the Armed Forces, but had to give up this work on account of ill-health.
His death is a tragic one. A young man, with his life all before him, and
every promise of success in his profession, he had also recently become a father,
and a happy home life has been cut short by his death. To his widow we
extend, most respectfully, our sincerest condolences and sympathy.
Page Two Hundred and Thirty-four The profession extends sympathy to the family of Dr. W. E. Scott-Moncrieff of
Victoria, who died on June 22nd. Dr. Scott-Moncrieflf, well-known eye, ear, nose and
throat specialist, practised in Victoria for many years, following his retirement from
the Indian Medical Services.
_% A __ «_
We regret to report the loss of another member of the profession in the passing of
Dr. Colin A. McDiarmid of Vancouver, on July 12 th, following a brief illness. Deepest
sympathy is extended to his family.
Colonel W. A. Fraser of Victoria, who went overseas in June, 1942, has been
awarded the O.B.E.
-r nr «jt -r
In recognition for services rendered in the Italian theatre of operations, the following
British Columbia doctors have been honoured: Lieut.-Colonel J. S. McCannel, O.B.E.,
who practised in Victoria before er__sting in 1939 and proceeding overseas in November,
1941. Major W. M. G. Wilson, M.B.E., practised in Kamloops before enlisting in June,
1940.   He went overseas in November of that year.
•S* **" •? *r
Colonel Wallace Wilson of Vancouver, Command Medical Officer in the Pacific
Command since June, 1942, has retired from the Army, and has taken on a new post as
Regional Medical Officer for Western Canada with the Department of Veteran Affairs.
* *      *      *
Colonel W. E. Hume is now Command Medical Officer, Pacific Command.
* *      *      *
Wing Commander C. Buck has taken over the position of Principal Medical Officer,
Western Air Command.
* *      *      *
Lieut.-Colonel J. U. Coleman, formerly of Duncan, Lieut.-Colonel J. A. McMillan,
Vancouver, and Captain W. H. Sutherland, Vancouver, have just returned from service
overseas, and are on leave.
*_ _t __ *t
*r nT *P *e
The following Medical Officers, returned from overseas, have completed their leave,
and are now posted for duty in the Pacific Command: Major L. W. Bassett, Major C. H.
Gundry, Major J. Ross Davidson, Major J. A. Ireland and Major J. A. Wright.
• *r *F nT V
Lieut.-Colonel R. A. Palmer, R.C.A.M.C., has gone to Germany with No. 16 Canadian General Hospital.
„. ^ nr *P *r
Major A. C. Gardner Frost, R.C.A.M.C, is now with No. 22 General Hospital in
Great Britain.
Dr. and Mrs. Thomas McPherson of Victoria spent a short holiday at Qualicum
Beach. u^
* *      *      *
Dr. H. M. Robertson of Victoria was away for a few days at Comox.
* *      #      *
Dr. T. M. Jones of Victoria has been in Kamloops on holiday.
Page Two Hundred and Thirty-five j       IMPORTANT!
The annual meeting of the British Columbia Medical Association will be
held as planned, September 12, 13, and 14, 1945, at the Hotel Vancouver, Vancouver, B. C. It is imperative that reservations be made now,
directly with the hotels in Vancouver.
Dr. W. J. Knox of Kelowna has returned from a visit to Chicago and the Mayo
Clinic.
* *       *       *
Dr. D. J. Millar of North Vancouver is expected back from his ranch at Horsefly
Lake, B.C., where he has spent the past month.
Dr. J. D. Galbraith, formerly of the Coqualeetza Hospital, Sardis, has taken over
the position of Superintendent of the Miller Bay Hospital at Prince Rupert, a new hospital of 150 beds, under the Indian Affairs Branch.
-£ 5fr *fr «fc
Dr. R. W. Irving of Kamloops has recently been honoured in being made the first
Governor of District 103, International Rotary. He has just returned from a trip to
Chicago, where meetings of the Governors took place. District 103 resulted from a
split-up of the former 101, which was too large, and the new territory comprises the
Interior of British Columbia and parts of Idaho and Washington.
On the evening of June 11th, Doctors J. C. Thomas and G. A. Upham of Vancouver
met with a number of men in the Kamloops area. Each read a paper on Venereal Disease, after which there followed an interesting and helpful discussion.
* *       *       *
Lieut.-Colonel R. A. Hughes, R.C.A.M.C., has joined the Burris Clinic in Kamloops
as eye, ear, nose and throat specialist, following his release from the Army. Colonel
Hughes was latterly O.C, Terrace Unit Hospital, and Eye, Ear, Nose and Throat consultant for the Northern area.
50,000 PERSONS NOW ENROLLED IN
BRITISH COLUMBIA BLUE CROSS
HOSPITAL PLAN
The Associated Hospitals Services of British Columbia, 77th baby of the famous
Blue Cross Hospital Plan, a lusty infant of one year, continues to grow satisfactorily and
is steadily putting on weight.
This non-profit organization, which originated in the United States and is spreading
throughout Canada, now eases Hospital burdens of 20,000,000 members and thus contributes in probably the most effective manner to the better health of the Community.
This British Columbia Blue Cross Plan was started by the Public Hospitals on the
Lower Mainland and Victoria to fill a long felt need in the Community. Because the
Plan is under the direct sponsorship of the Hospitals themselves and operates on a truly
Non-Profit basis, it is equipped to render a Community Hospital Service not before
available. The Plan has been well received here by both Management and employed
groups. Employees of 650 firms and organized Associations have formed groups and
there are now 50,000 persons enrolled for Hospital Benefits. Members have received
Hospital Care amounting to over $165,000, and those who have received benefits have
been very high in their praise of the easy, efficient manner in which they were taken
care of when Hospital Care was needed.
The Plan is a simple one and devoid of all red tape. There is no exemption for any
pre-existing or chronic conditions.    There is no waiting period, benefits beginning
Page Two Hundred and Thirty-six immediately, with the exception of maternity where there is a twelve months waiting
period. For a subscription of $1.50 per month for a family, and 60c per month for
a single person, Hospital Care for 30 days each in any contract year is provided, based
on the standard Ward rate. For semi-private or private accommodation the subscriber
pays the difference in rates to the Hospital. All the extra Hospital services are provided
as a bed patient, with the exception of Blood, Oxygen, Radium Therapy and X-Ray
treatments.
This B. C. scheme is the most ambitious ever attempted in Canada. It acts as a
middleman between the Public and Hospitals, with the fullest co-operation of the Hospitals. It will promote better health conditions because of the facility with which
patients can obtain Hospital treatment without worry about the consequent bills. No
profit can be made under the Plan; all funds, with the exception of a low administration
cost, are used to meet needs of members and as the surplus grows it will be diverted to
greater benefits to subscribers.
Enrolment in this Plan is entirely voluntary, but by group enrolment and co-operative action, members can protect themselves and their families against the-emergency
of unexpected Hospital bills, at very low cost. Besides being of great service to the
Community by raising health standards and putting immediate Hospital Care within
reach of everyone, it will be of real assistance to the local Hospitals by giving them
sounder financing and will help generally to upgrade Hospital services.
The members of the Vancouver Medical Association enrolled as a group on June 1st,
1944, and already many of them have received benefits under this Plan. The Directors
of the Blue Cross Hospital Plan have expressed their appreciation of the wonderful cooperation received from the members of the Medical Association and solicit their continued support in educating the general public to the advantage of joining this prepaid
Plan for Hospital Care.
(ttettfrr $c Ifatma IGtk
ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C.
Page Two Hundred and Thirty-seven DURING THE HAY FEVER SEASON
Prolonged symptomatic relief lasting from
2 to 6 hours with
'PRIVINE?
T. M.Reg'd.
Physicians and patients alike will welcome the unprecedented comfort
PRIVINE will afford those who are allergic to dusts and pollens.
Almost immediately following the application of a few drops of
PRIVINE in the nose and eye, secretion is diminished, sneezing
reduced, tearing, swelling and adhesions of. the eyelids checked for
several hours.
Treatment of hay fever symptoms with PRIVINE is most economical
and convenient. Issued in bottles of 1 oz. with dropper, also bottles
of 8 ozs.
C M 11 M,
' OF ftMVUTRl
MONTREAL, CANADA _"
I   DOSAGE TABLE*
INDICATIONS
INITIAL
DOSE
(UNITS)
CONTINUING DOSAGE
(UNITS)
UNITS IN
24 HR.
REMARKS
Serious Infections (staphylococcus, Clostridium,
hemolytic streptococcus,
anaerobic streptococcus,
pneumococcus, gonococcus, anthrax, meningococcus)
Adults and children
(a) Intravenous drip:
2000 to 5000 every
hr. „&£
40,000 to
120,000
or more
(a) Dissolve !_ of 24 hr. dose in
1 liter (1000 cc.) normal saline;
let drip at 30 to 40 drops per
minute.
15,000
to
20,000
or
(b) Intramuscularly:
10,000 to 20.000
every 3 or 4 hr.
40,000 to
120,000
or more
(b) Concentration: 5000 U.
cc. normal saline.
per
or
(c) Intramuscular drip
40,000 to
120,000
or more
(c) Total daily dose in 250 cc.
normal saline.
Infants
5000
to
10,000
3000 to 10,000 in*
tramuscularly every
3 hr.
20,000 to
40,000
or more
Each dose in 1 or 2 cc. of normal
saline.
10,000 every 2 hr. or
20,000 every 4 hr.
intramuscularly or intravenously. Larger
doses may be necessary at times.
Chronically infected compound injuries, osteomyelitis, etc
Adults and children
5000
to
10,000
40,000 to
120,000
or more
Concentration for intramuscular
kjj.:   5000   U.   per  cc.  normal
saline.
For  intravenous   inj.:   1000  to
5000 U. per cc.
Supplement with local treatment.
Gonorrhea
20,000 every 3 hr. intra-
muscularly for 5 doses
100,000
Results of treatment should be
controlled by culture of exudate.
Empyema
Adults and children
30,000 to 40,000 once or twice
daily into empyema cavity
30,000 to
80,000
Dissolve in 20 to 40 cc. normal
saline and inject into empyema
cavity after aspiration of pus.
Meningitis
Adults and children
10,000 once or twice daily
into subarachnoid   space   or
intracistemally
10,000 to
20,000
Concentration: 1000 U. per cc.
normal saline.
Bacterial Endocarditis
Adults and children
25,000
to
40,000
25,000 to 40,000
every 3 hr. intramuscularly
200,000 to
300,000
Continuous treatment for 3 weeks
or longer. In a few cases the intravenous drip is more advantageous.
Accepted
Tmedical
ASSN.
*Based upon recommendations by Chester S. Keefer^^^^^^wfueWon Board Penicillin leaflet,
Apr. j^fe945; and by Wallace £, Herrefl and Roger Li|SriKenned^p^^»^af Pediatrics,
25:505, Dec,\1944.^
It/tite fa, pocket tife coftieA _^MtU ^bodacfe Valde
Penicillin Sodium—Winthrop is available ifPvials *|With rubber diaphragm stopper) of 100,000 Oxford Umts®^
|1hHR0P^€HEMI^^ CQMPAN Y7||h
PltatuMaceuticald. 0^ m&ut £<*i the pJufAiciatt.
NEW    YORK    13,    N
MNDSORltONT, -lfcount pleasant IHnbertaking Co. %tb.
KINGSWAY at 11th AVE. Telephone FAirmont 0058 VANCOUVER, B. C.
R. F. HARRISON W.  E. REYNOLDS
fssmmmm
m.
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus arrd  stabilizing the tone of its
musculature. Controls the utero-ovarian
circulation and thereby encourages a    i
normal menstrual cycle. _T
V'-' M
^♦MARTIN H. SMITH COMPANY      JS
!§W ISO l*f ATIITI  St«flT.   NIW TOfUC  N. T. ''._■
Full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, risible only when cap-
side is cut in half at seam. *_ -*/A
ii
YS
STOVAGINAL
Stovaginal is especially indicated in pathological conditions of the vaginal mucosa resulting from or associated with the Trichomonas Vaginalis. It is also
indicated in cases where the leucorrhoea may be the
result of mixed and non-specific infections of the
vagina.
Vaginal Tablets in Bottles of 20, 100 and 500
Vaginal Powder in Jars of 30 gm. and 200 gm.
Physicians are invited to request clinical sample.
iH* B o&k ATOIY
JANADA   L*fD.
204 YOUVILLE SQUAtf* $B|  ^loK-WEAL VITAL REASONS
FOR  PRESCRIBING   ORTHO-GYNOL   VAGINAL   JELLY
No other Vaginal Jelly can make all these claims ... substantiated by 34
clinical projects, involving 13,000 patients . . . with reprints of published
articles in authoritative medical journals available on request.
ORTHO-GYNOL is the most widely prescribed Vaginal Jelly.
ORTHO-GYNOL Vaginal Jelly is effective on contact—
without any delay after application.
ORTHO-GYNOL Vaginal Jelly is non-irritating to the vaginal mucosa..
ORTHO-GYNOL Vaginal Jelly has uniform stability over long periods.
ORTHO-GYNOL Vaginal Jelly is readily available throughout Canada.
ORTHO-GYNOL Vaginal Jelly has received A.M.A. Council acceptance.
ORTHO  PRODUCTS OF CANADA LIMITED, TORONTO
1.
2.
3.
4.
5.
6.
Ortho-Gynol
Active ingredients: ricinoleic
acid, 0.7%, boric acid, 3.0%,
"oxyquinoline sulfate 0.025%. A STUDY BY ARISTIDE  MAILLOL;  REPRODUCED FROM THE HYPERION PRESS ART BOOK,  "MAILLOL'
All patients, however severe or mild their symptoms, can be
treated effectively with these orally-active natural oestrogens.
"Premarin'* (No. 866) for the most severe symptoms; the new Half-Strength
"Premarin'* (No. 867) when symptoms are moderately severe;
"Emmenin'* for mild symptoms.
"PREMARIN"-"EMMENIN"
conjugated oestrogens (equine)
Tablets No. 866; Tablets No. 867
conjugated oestrogens  (placental)
Tablets No. 701; Liquid No. 927
NATURALLY OCCURRING   •   WATER SOLUBLE    •    WELL TOLERATED
ESSENTIALLY   SAFE     •   IMPART   A   FEELING   OF   WELL-BEING
|1W (rfvmldw%
J^jL. A new potency for those p0tiont»'!l*lioso,'|jtt|i^^i^fliough severe,
do not require the intensive therapy provided b^*r*rew^i^|>'^p^l*engrth.
Bottles of 20 and 100 to_l«tS y
AYERST,
MONTREAL
McKENNA   &   HARRISON
Biological and Pharmaceutical Chemists
LIMITED
CANADA
CKf i
ill ftMsH5"
«jps.---
Each tablet contains 3.TJf
(0.25  Gm.)   of   sulfathiazole.
SlILFATHIAZOLE GUM
IpelK^Whai^^Wotherapy
The unique value of this new, effective method for the local treatment
oifScertain throat "infections consists in this:
IH Chewing one tablet provides a
high salivary concentration (averaging 70 mg. per cent) of dissolved
sulfathiazole . I .
2. that is maintained in immediate
and prolonged .contact with oropharyngeal  areas   which are  not
Supplied in packages
of ^tablets-
sanitaped in slip-sleeve
prescription boxes
'~*^^n:prescriptioif>0nly'.
similarly^ reached   bjf? gargles   or
^l^ith a relatively small ingestion
of the drug.yfath either dosage, and
consequent negligible systemic absorption.
Ty pical |§h-f ectioiisi% ]Mhich ^ have
show^-excellent response to treatment^^itfc|||v"hite's Sulfathiazole
Gum^pftre rltcutej^pnsillitis and
pharyngitis, septic sore throat, infectious gingivitis and stomatitis
ea u sed by I sulfonamide-susceptible
microorganisms.; Also indicated in
the preventiotfpaf locaT|^nfection
1^1 pharyngeal
: a&rgery^A
IMPO_rPAN^:;^r_%a^J!_Mti^ that
ypur^^ittien^lequires your prescription ^^^^tain^ tjhis product from
the pharmacist.
WHITE LABORATORIES OF CANADA, LTD., Toronto, camada SAFE • Four years of intensive clinical research, with more than 1,400 published cases, have
established Demerol analgesia in labor as a safe procedure. Demerol analgesia is harmless
to mother and baby. It does not weaken uterine contractions or lengthen labor. There are no
post-partum complications due to the drug.
SIMPLE AND EFFECTIVE • Demerol hydrochloride is administered orally or by intramuscular
injection. Average dose: 100 mg., when the pains become regular, repeated three or four
times at intervals of from 1 to 4 hours. In analgesic power Demerol hydrochloride ranks
between morphine and codeine; it also has a spasmolytic effect comparable with that of atropine, as well as a sedative action. It may also be used in conjunction with scopolamine or
barbiturates for amnesia.
WRITE
FOR
LITERATURE
DETAILED
EMERDL	
Trademark Reg. U. S. Pat. Off. SCanada
HYDROCHLORIDE
BRAND OF MEPERIDINE HYDROCHLORIDE
(Itonipecaiml
SUBJECT   TO   REGULATIONS   OF   THE   CANADIAN   NARCOTIC   DIVISION
WINTHROP    CHEMICAL    COMPANY,   INC.
PHARMACEUTICALS     OF     MERIT     FOR     THE     PHYSICIAN
General Offices; WINDSOR, ONTARIO
Quebec Professional Service Office:  Dominion Square Building, Montreal, Quebec A complete blood and urine
laboratory service that is fast
and reliable.
ASCHIEM — ZONDEK and
blood containers supplied free
of charge on request.
HOUR PREGNANCY
TEST SERVICE
*3_-,0
Storhma
ttltat* 4
Dept. 9
Colonic and
Physiotherapy Centre
Up-to-date Scientific Treatments
COLONIC IRRIGATIONS, SHORTWAVE
DIATHERMY, SINNEWAVE GALVIN-
ISM, IONIZATION, ULTRA VIOLET
RAY,  STEAM   BATHS AND  SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
Superintendent:
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
1119 Vancouver Block
MArine 3723      Vancouver, B.C.
2559 Cambie Street
Vancouver, B.C.
IF ARTHRITIS and ECZEMA
ARE ALLERGIC
ETIOLOCICALLY    §|
effective treatment suggests the use of
agents to correct mineral deficiency,
increase cellular activity, and secure
adequate  elimination  of toxic  waste.
f
orally given, supplies calcium, sulphur,
iodine, and lysidln bitartrate — an
effective solvent. Amelioration of
symptoms and general functional improvement  may  be   expected.
LYXANTHINE ASTIER -<
Write for Information.
L-15
J
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,  Montreal •nuiiiHiiiiiiimiiiniiiiiiiiiiiiiiiiiiiiiiiiiiiiiHiiMMiiiiiiiiniiiuiiiiiiiiiiiiiiiiiiiiuiiiiiiiuiiiiiiiiiiiiiiiim
Proper diet vs.
dental caries...
"There is much evidence that, with wise supervision of the diet, caries [in children] is lessened
in occurrence and extent.... Surely, the dietary
approach offers the most effective means of attack
on the problem of caries now available, and
furthermore is one which is in step with current
policies for the furtherance of public health....
With the assurance of ideal nutrition for the
individual throughout childhood, there is reason
to hope that caries will be abolished."
—BOYD, J. D.; J. A. D. A., 30:670, May, 1943.
Observations like that quoted
above, and numerous studies that
emphasize the interrelationship of
diet and dental caries, plainly indicate that the attack on this
problem is a duty of the physician
as well as of the dentist.
Proper diet—prenatal, in lactation, and continuing from infancy
into adult life—is clearly seen as
indispensable   to   sound   tooth
formation in the first place, and
to the later protection of tooth
structures.
Carnation Milk may be relied
on as an admirable constituent of
a tooth-building, tooth-conserving diet. It is an excellent source
of essential calcium and phosphorus, and its fortification with
vitamin D promotes effective
utilization of these minerals.
CARNATION CO. LIMITED, TORONTO 1, ONTARIO
Carnation
"FROM CONTENTED COWS'
Milk
A Canadian Product
ui iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii iiniiiuiiiiiiiii n iiiiiiiiiiiniiiiiiiiiiii niiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiniiiiiiiiiiiiiiiii iiiiiiiiiiiiiiii iiniiimiiiiiiift 304ttiMU€wl^^
Fdi^p^fecdd^eai^iGeorgia Pharmacy has
striven day by day forj^br^i^^gfect se^fce,
accuracy, speed, and overali^pRabni^^^fhe
confidence fpi*us by the Medical Prpfessidr^^
our reward.
Phono
MArine 4161
.! VlHJi!_!_MAtY
13 th Ave. and Heather St.
Exclusive Ambulance Service
FAirmont^0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE^!** AMBULANCE SERVICE OHtM
i. H. CRELLIN
W. L. BERTRAND _____
*fc *«*//
New Westminster, B. C.
For the treatment of
NEUROPSYCHIATRIC
DISORDERS
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
New Westminster 288
or 721 Medical-Dental Building, Vancouver, B. C.
PAcific 7823 PAcific 8036
>_7

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