History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: April, 1941 Vancouver Medical Association Apr 30, 1941

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of the
Vol. XVII.
APRIL, 1941
With Which Is Incorporated
Transactions of the
Victoria Medical Society
Vancouver General Hospital
ISfe, Paul's Hospital
No. 7-
■  <
mn This Issue: f|
NEWS AND NOTES-M   ■jfl Sip- -J1SI-- '^ipl*81
Doctors James F. Weir, Hugh R. Butt, A. M. Snell | ^188
R. EvMcKechnie, II, M.D.C.M., M.S. v^^^^^^^^Sl— ||t 1*4
ENDOCRINE DISTURBANCE—E. F. Raynor, M.D., C.M.!"^^>- 197
Frank Turnbull, M.D. - ;'j|f. M ^iS~—- 201
Reginald Wilson, M.D., D.C.H., M.RXJ).-_-J_^__ I 205
MEDICAL EXAMINATION OF TRAINEES ilL 1 -..afe' /■       ■    209
■ - • - ~ *•'••■  '-" .8?0S*
that each and every one of our one hundred and
forty-seven employees have voluntarily pledged to
systematically serve by purchasing War Savings
Certificates.      .    lillilil
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.
Dr. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVII.
APRIL, 1941
No. 7
OFFICERS, 1940-1941
Dr. D. F. Busteed Dr. w: M. Paton Dr. A. M. Agnew
President Vice-President Past President
Dr. W. T. Lockhart Dr. R. A. Palmer
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. C. McDiarmid, Dr. L. W. McNtjtt.
Dr. F. Brodie* Dr. J. A. Gillespie Dr. F. W. Lees
Auditors: Messrs. Plommer, Whiting & Co.
Clinical Section
Dr. Karl Haig Chairman Dr. Ross Davidson Secretary
Eye, Ear, Nose and Throat
Dr. J. A. McLean Chairman Dr. A. R. Anthony Secretary
Pcediatric Section
Dr. R. P. Kinsman Chairman Dr. G. O. Matthews Secretary
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. W. A. Bagnall, Dr. T. H. Lennie, Dr. J. E. Walker.
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. H. H. Caple, Dr. W. W. Simpson, Dr. Karl Haig, Dr. J. E. Harrison,
Dr. H. H. Hatfield, Dr. Howard Spohn.
Dr. A. W. Hunter, Dr. W. T. Ewing, Dr. A. E. Trites.
V. O. N. Advisory Board:
Dr. E. Riggs, Dr. W. C. Walsh, Dr. R. E. McKechnxe II.
Metropolitan Health Board Advisory Committee:
Dr. H. Spohn, Dr. F. J. Buller, Dr. W. T. Ewing.
Greater Vancouver Health League Representatives:
Dr. G. O. Matthews, Dr. M. W. Simpson.
Representative to B. C. Medical Association: Dr. A. M. Agnew.
Sickness and Benevolent Fund: The President—The Trustees.
Total population—estimated .            272,352
Japanese population—estimated
Chinese population—estimated .
Hindu population—estimated _
Total deaths   245
Japanese deaths j  5
Chinese deaths  13
Deaths—residents only  219
Male, 221; Female, 194	
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths (not included in above)
Feb., 1941
Rate per 1,000
Feb.. 1940
January, 1941
Cases   Deaths
February, 1941
Cases   Deaths
Scarlet Fever      19
Diphtheria         0
Chicken Pox |    134
Measles  I 1 1171
Rubella       115
Whooping Cough	
Typhoid Fever	
Undulant Fever 	
Meningococcus Meningitis
Paratyphoid Fever 	
Mar. 1
Syphilis _.
Hospitals &
Private Drs.
Bioglan products differ in that they are derived from original material."
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
Phone: MA p. 4027
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Descriptive Literature on Request
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(100 International Units per c.c.) is recommended.
Special literature available on request.
Biological and Pharmaceutical GUemi&U
Founded 1898 .. . Incorporated 1906
GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at
8:00 p.m. Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
Just off the Press...
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orally given, supplies calcium, sulphur,
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Page 179 H
Squibb Vitamins A, B, D and B-Complex
in stable, tablet form, chocolate-coated.
These tablets produce no flatulence, leave
no oily taste. An economical vitamin
supplement for routine use during the
winter months and in pregnancy.
E-R. Squibb &. Sons or f axaba. u*
Capsules A, B, C, D and B-Complex.
Each small, easy to swallow capsule
contains not less than:
10,000 Int. U. Vitamin A
200 Int. U. Vitamin Bi
500 Int. U. Vitamin C
1,000 Int. U. Vitamin D
100 Micrograms Riboflavin
18 Micrograms Pyridoxine  (Be)
5 J.L. units Filtrate Factors
5 Milligrams Nicotinic Acid
For convalescents, patients on restricted
diets, malnourished children or for children
or adults whose diets do not provide
adequate vitamins.
How supplied:
In bottles of In bottles of
80, 250 and 1,000 25, 50, 100 and 250
For literature write 36 Caledonia Road, Toronto
E-R:Squibb &. Sons of Canada, Ltd.
The meeting "put on" by the Cancer Section of the B. C. Medical Association, on
April 1st, was a noteworthy one, and several things about it seem to deserve comment.
In the first place, it was extremely well arranged, and there were a continuity and a
coherence in the programme that enabled those contributing to give a definite picture of
cancer as it is at present, and to add their share of emphasis to the urgent need of early
recognition, early diagnosis, early treatment, adequate records and reporting, and team
work in handling the cancer problem.
Theoretically, perhaps, we all know and academically agree with all that the speakers
said, and yet the impression one continually received, as one listened, was that we are
much to blame still for much of the apathy and delay that seem to cling about this
subject. It is a sort of defeatism, really: as if one should feel that if a patient has cancer,
there is nothing much one can do about it anyway, beyond relief of pain. This was the
attitude forty or more years ago, and was perhaps inevitable—till the profession began
to find to their surprise that there was hope in cancer—that early diagnosis, with its
corollary, early treatment, meant real cure. And now everywhere the leaders in the
profession, and those who know cancer, stress this note of hopefulness and assurance of
permanent relief. More and more, our statistics are improving. They will not, however,
shew the big improvement that they should and could shew, till the whole profession,
every man jack of us, is seized of the vital importance of this subject, and of the fact
that what each one of us can do by being cancer-conscious, by early recognition of
cancer, by early reporting, by energetic and constructive attack, is the most important
single factor towards attaining this improvement. This was suggested very strongly by
what some of the speakers said. We cannot all use radium, we cannot all do the major
surgery sometimes necessary—we have not yet got inf allible criteria of diagnosis, though
the work of Dr. F. N. Robertson in Vancouver holds out much hope in this direction,
but we have plenty to go on with—and if we will use our present facilities to the
utmost, we shall do a very great deal towards reaching that goal to which we all press
on, the making of cure in cancer the rule rather than the exception. We can at least,
at the very least, report our cases—and not continue to deserve the gentle reproof of
Dr. Amyot, whos statistics of reported cases shew "well over" 100% of deaths. This
means that practically the only reporting done is through the death certificate.
Many years ago, this same defeatist attitude was seen in relation to tuberculosis.
Today, as a result of organised, co-ordinated, and intelligent attack, tuberculosis is
headed for the limbo of forgotten diseases. The same attitude towards cancer, "Audace,
toujours Vatidace" will eventually bind in chains this ancient enemy of mankind.
Please Note: Examining Physicians will obtain the notice for medical
examination from the man and attach it to the certificate and forward to
Divisional Registrar.
Examining physicians are requested to note under "Remarks" any identification marks or scars.  Please write "Nil" where there is none.
Page  ISO
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We are very glad to report that Dr. T. W. Walker, Medical Superintendent of the
Royal Jubilee Hospital in Victoria, is making satisfactory progress following a serious
Dr. F. M. Auld of Nelson has returned from Ottawa, where he attended the meeting
of the Executive Committee of the Canadian Medical Association on March 14th and
15th as the representative from British Columbia.
Lieut. W. R. Walker of Penticton is now serving with the R.C.A.M.C and on duty
at Esquimalt Military Hospital.
Dr. M. R. Basted of Trail accompanied the recruiting officer in the capacity of medical examiner during a recent tour of the Arrow Lakes District.
Dr. J. Bain Thorn of Trail has been in Vancouver for some weeks.
Dr. J. E. Harvey of Vernon visited Vancouver recently. He has now returned home.
Dr. P. M. McLean of Chemainus visited the office while in Vancouver.
Surgeon-Lieutenant A. C. McCurrach, who is leaving for duty Overseas, and Miss
Alison Easton, R.N., of Kelowna, were married on February 11th at Kamloops.
It is rumoured that Dr. G. A. B. Hall of Nanaimo has purchased a home in Victoria
and that he contemplates retiring from active practice.
Dr. W. F. Drysdale of Nanaimo will bq honoured when he has Senior Membership
in the Canadian Medical Association conferred upon him at the Annual Meeting at
Winnipeg in June.
U      *      *      *
Dr. R. Gibson has taken up practice at Port Washington.
«*. *t »L *t
•»* *? *C *E*
Dr. W. D. Sharpe of Zeballos was in Vancouver recently.
Dr. H. Emanuele of Pioneer Mine was appointed Health Officer for that District.
Dr. G. A. Lawson, formerly of Port Alice, is. now in .Toronto, andreports that he is
in a class of thirty medical officers taking a course in Aviation Medicine.
Dr. H. H. G. Coulthard, who took up practice in Vancouver in 1910 following a
period as ship surgeon on the Empress of Japan, and who left for service with the
R.A.M.C. early in the last War and has been residing in London since, has returned to
Vancouver and has been renewing acquaintances. Doctor Coulthard is in residence at
the Hotel Vancouver.  He is not planning to enter practice.
A very interesting letter was received from Lieut.-Col. J. F. Haszard, formerly of
Kimberley, who is now somewhere in England and Officer Commanding No. 8 Canadian
Field Ambulance. He mentioned that Capt. J. H. Sturdy and Capt. W. Bramley-Moore
are serving with him as Medical Officers in this Unit.
Page  181 Dr. R. D. Nasmyth, who has been at Parksville for several years, has taken up residence in Victoria. Dr. Robert Elliot, also of Parksville, continues on in the practice there.
Dr. W. Ross Stone of Vanderhoof is coming to Vancouver for the months of April
and May where he proposes to do post-graduate study. During his absence Dr. R. D.
Nasmyth will act as locum tenens.
The long-needed hospital at Vanderhoof is now nearing completion and will be
opened shortly. This hospital will serve that great area which has previously had to
depend on the hospitals at Prince George and at Burns Lake.
Dr. H. A. McDonald, who has been at the Bella Coola Hospital, has been forced to
come to Vancouver owing to Mrs. McDonald's ill health. Dr. J. H. Rivers, who has
retired from practice at Cochrane, Alberta, and is now residing in British Columbia, will
carry on the work at Bella Coola.
Dr. G. E. Bayfield of West Vancouver has left for the Morgan Camp on Moresby
Island, in the Queen Charlotte group.  A small hospital at that point serves all the lo
ging operations along the coast of the Island.
Dr. D. E. H. Cleveland has been asked to give a series of broadcasts in April and May
over the CBC Western Network. The subject is Medical Folklore. The titles and dates
will be: April 23rd, "On Skin Ailments"; April 30th, "On Food and Diet"; May 7th,
"On Contagion"; May 14th, "On the Moon and Man"; May 21st, "On Sleep"; and
May 28th, "On Miscellaneous Matters." The time of delivery will be listed in the timetable of radio events, but we gather it will be about 9:45 p.m.
*       *       *       #
The profession extends sympathy to Dr. J. W. Shier in his recent bereavement, his
mother having passed away.
-J. »g. *J. ;J.
It is interesting to note that Dr. Isobel Day of Vancouver has been appointed Provincial Commandant of the Woman's Ambulance Corps, which is now officially recognized by the British Columbia A.R.P. Association. The Corps is to be congratulated on
this appointment.
Dr. Arthur W. Bagnall, son of Dr. A. W. Bagnall of Vancouver, and Senior
Resident at the Toronto General Hospital, was married to Miss Mary E. Phillips, R.N.,
of St. Catharines, on March 8th. The Field Ambulance, of which Dr. Bagnall is an
officer, has just been mobilized.
Drs. G. F. Strong, S. E. C. Turvey, R. A. Palmer and W. W. Simpson attended the
Meeting of the North Pacific Society of Internal Medicine in Seattle, on March 22 nd,
1941. §f&
Dr. Jack Frost, son of Dr. Anson Frost of Vancouver, has just obtained his F.R.C.S.
(Can.)   degree:  and we hereby tender congratulations.   He has joined His Majesty's
armed forces, and is now the third son of the family in uniform.   Their father served
in the C.A.M.C. in the Great War.
WINNIPEG, June 23 rd to 27th.
Please notify Dr. Thomas if you are travelling by rail.
Special cars are contemplated.
Page  182 mm
Surgical Clinics of North America—Symposium on Minor Surgery, February, 1941.
Newer Nutrition in Paediatric Practice, 1940, by I. Newton Kugelmass.
A Textbook of Surgery, 5th ed., 1940, by John Homans.
Heart Failure, 2nd ed., 1940, by Arthur M. Fishberg.
1940 Year Book of Neurology, Psychiatry and Endocrinology, edited by Hans H.
Reese, Nolan D. C. Lewis and Elmer L. Sevringhaus.
Office Urology, by P. S. Pelouze.
An Introduction to Gastro-Enterology   (3rd ed.  of Mechanics of  the Digestive
Tract), by Walter C. Alvarez.
MurrelPs What to Do in Cases of Poisoning, 14th ed., edited by P. Hamill.
1940 Year Book of General Therapeutics, edited by Oscar W. Bethea.
Transactions of the Ophthalmological Society of the United Kingdom, 1940, vol. 50,
60th Session.
' Nil
During the past few months a number of books on War Medicine have been purchased by the Library Committee, as listed below:
Aviation Medicine, by Harry G. Armstrong.
The Soldier's Heart an dthe Effort Syndrome, 2nd ed., 1940, by Sir Thomas Lewis.
Organization, Strategy and Tactics of the Army Medical Services in War,  1940,
revised edition, by Lt.-Col. T. B. Nicholls.
Medical Diseases of the War, by Sir Arthur Hurst.
In addition to this list, a Bulletin of War Medicine is now published by the Medical
Research Council. The first number was issued in September, 1940, and three copies
have been received to date. They contain a valuable collection of abstracts of relevant
articles in all branches of Medicine, Surgery, and kindred subjects.
The Canadian Medical Association has included a section on "War" in its Journal
since last July. A wide range of subjects is covered and the first number contains an
extensive bibliography on war work and war medicine publications available at that time.
The Journal of the American Medical Association has also devoted a section each
week to "Medical Preparedness" since its introduction in the June 22nd, 1940, issue.
"War Medicine," a new bi-monthly journal brought out by the American Medical
Association, has been subscribed to by the Library and the first two numbers have been
received. It is described as "A periodical containing original contributions, news and
abstracts of articles of military, naval and similar interest related to preparedness and
war service." Following are a few of the articles included.
Industrial Hygiene and the Navy in National Defence.   Ernest W. Brown, M.D.,
New York.
March Fracture: Report of Three Cases.  Prentice L. Moore, M.D., and Allen N.
Bracher, M.D., Schofield Barracks, Territory of Hawaii.
Nutrition Planning for the National Defense.  Russell M. Wilder, M.D., Rochester, Minn.
The Soldier and His Heart.   Paul D. White, M.D., Boston.
Symposium on Psychiatric Aspects of Military Medicine:
Neuropsychiatry Aspects in the First World War and in the Present Emergency.
The Army Medical Officer Looks at Psychiatry,
Psychiatric Examination in the Armed Forces.
The Neuroses of War.
There is also an abundance of interesting material in the British Medical Journal,
Lancet, Post Graduate Medical Journal, and many others.
Page   183 Vancouver Medical Association
The Vancouver Medical Association was honoured by the visit and address of Dr.
Henrik Dam, of the University of Copenhagen, the internationally known chemist, and
discoverer of vitamin K, that latest of the miracle-working vitamins to be made available for our daily use. On March 3 he addressed the Association: was introduced by
Dr. D. F. Busteed, President .of the Association, as a pioneer in the biological sciences,
and as one who has deserved especially well of mankind for his work in connection with
vitamin K: work which has promptly received acknowledgment clinically, and has
brought an immense benefit to humanity, and given a weapon of the utmost value to
the medical profession.
Dr. Dam, a keen, vital personality, speaks perfect idiomatic English with little or no
accent, and his address was a masterpiece of conciseness and compression. It was also
fascinatingly interesting, and utterly free from pedantry or ultra-scientific obscurity.
Dr. Dam revealed himself as a very fine chemist, completely familiar with all that is
most modern and advanced in chemistry and biology. He is a philosopher in the exact
sense of the word, a lover of wisdom, not merely a seeker after facts—but bent on
finding the underlying truth which these facts illustrate.
He told us how this work on vitamin K has occupied much, if not most, of his
time for years—this vitamin K which is really a multiple, at least a dual, personality, and
includes two main substances. The first, Kj_, is found in green leaves, green vegetables,
etc., while K2, its running mate, is derived from bacterial action, often putrefactive
bacterial action.  The chemical composition of both these substances is known.
The discovery of vitamin K followed a long series of observations made by various
men on hemorrhagic diseases. These were first observed as they affected chicks, later
as they occurred in human beings. Chemists became interested in these observations,
and vitamin K was identified later as a main factor.
It was found that certain chicks shewed a pronounced tendency to bleeding. The
patches of haemorrhage were usually visible through the skin, and occurred in the parts
of the body most exposed to trauma. Dr. Dam shewed slides of chicks shewing such
haemorrhages in legs and head. These observations were first made in 1928-9. At the
time, Dam was working on cholesterol, and attempted to correlate the two. He found
that the symptoms were not due to lack of cholesterol; lemon juice and cod liver oil
made no difference.
McFarlane and others gave careful descriptions of the disease but didn't find the
cause. Others found a contributing cause was lack of vitamin C, and that fresh cabbage
was of value in certain cases—this is, of course, in line with our knowledge of scurvy,
and the haemorrhage therefrom—but these haemorrhages were not scorbutic.
Dam, after finishing his studies in cholesterol, took up this work, and concentrated
an this haemorrhagic disease. In 1934-5 he found that it was certainly due to the lack of
some other substance of the order of a vitamin. The disease was associated with a
definite lack of clotting power in the blood. McFarlane confirmed this finding. Minute
lesions due to trauma, which in normal individuals stop bleeding because of clotting,
failed to do so in these chicks, and went on bleeding.
It was found that in the normal chick the wounded cells contribute an enzyme
from their juice which in the presence of calcium gives rise to thrombin, and so clotting.
This substance, prothrombin, is only present and only appears after injury when this
new vitamin Ki is present.
The chick was used in the investigations for several reasons:
1.   It is easily liable to the disease, and there is thus abundant clinical material
for study;
Page   184
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2. Chicks do not, as do mammals, furnish thrombokinase in their blood: hence blood
taken from tissues is easily centrifuged without clotting.
Certain errors must be avoided. Since vitamin K2 can be formed by putrefaction,
especially intestinal putrefaction, the chicks must be kept under clean conditions, and
intestinal contamination excluded.
Secondly, a vitamin K-free diet must be used. In chicks, a serial examination of
clotting power shews that the disease begins to appear within 2 days after vitamin K
is withdrawn.   The reduction of prothrombin to 1% requires 2-4 weeks.
Coagulability is not entirely lost: and sometimes the disease resolves without alteration of diet, or addition of vitamin K.
There are certain broad principles and axiomatic statements to be made:
The prothrombin of plasma is found to be completely converted into thrombin
when thromboplastin or thrombokinase is added. Here prothrombin is the only factor
in clotting time, if no anticoagulation substance is present.
Plasma with normal prothrombin requires one unit of thrombokinase.
With l/z normal requires 2) thrombokinase.
With Yxq normal requires 10 times the amount.
The use of bruised tissue extract for quantitative estimation involves thus the use
of known dilutions—and they are mathematically exact, as shewn above. In the chick,
of course, where there is no thrombokinase present, this estimation can be done as
shewn, but in the human or mammalian blood, there is normally thrombokinase, and
this vitiates the experiment. Fortunately, the addition of a small amount of heparine
removes this tendency to spontaneous clotting.
Now if K is added, the production of prothrombin rises pari passu, but with this
important limitation, that the amount of prothrombin produced will never pass 100%
(i.e., normal) no matter how large the doses of K that are given.
A unit of vitamin K (the standard unit of measurement) is that quantity per
gramme of the body weight of chick, which will raise, in three days, prothrombin to
the normal level.
Vitamin Kj is found in the vegetable kingdom in abundance in all kinds of green
leaves. Fruits, except tomatoes, are a poor source. Cereals, beans and peas are also poor,
carrots contain practically none—vegetables grown in the dark, or underground, contain none. An essential factor for the production of Ki is the presence of chlorophyll
-—but when this disappears, when the leaves fade and wither in the fall, the Ki does
not disappear, so that the dry leaf contains as much K as does the green leaf. Mushrooms contain very little K and yeast has none.
Certain bacteria are potent factors in the production of vitamin K2, especially those
found in the bowel, so that faeces are a rich source of this vitamin. It is only found in
very small quantities in the organism of the hen, not in its liver or eggs. The liver of
hogs contains the largest amount of animal organs.
Milk, both mammalian and human, is a poor source of it.
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Chemistry of Vitamin K
The vitamin K produced from bacterial action (K2) has a somewhat different
chemical composition from that of Ki, derived from green leaves.
Ki is destroyed by saponification, may be extracted by gasoline and purified by
molecular distillation. It is destroyed by alkaline absorption. Abundant supplies are
obtained from alfalfa.
Pure vitamin Ki is a clear yellow oil, which crystallises at low temperatures, shews
a characteristic spectrum, is composed of carbons, hydrogen and oxygen, and has a
strength of 12,000,000 units per gramme.
It is now prepared synthetically in the chemical laboratory, and in this form is
more stable.
K2 is prepared from putrefied fish meal, and is a solid crystalline substance, melting
at 54° C.  Its formula is somewhat different.  It has 8,500,000 units per gramme.
Page  185 Other substances resembling Ki and K2 occur in nature, and certain artificially prepared derivatives have highly active K powers, some being much more active than Ki.
They are, as said above, more stable, less easily oxidised. Even water-soluble derivatives
are very potent. So it happens that in practical use, we employ these derivatives rather
than the pure K.
Dr. Dam gave a graphic description of the molecular structure of the two K elements in vitamin K, and while it is not practicable to reproduce his illustrations here,
it may be said that various chains and radicals enter into the various substances with
the properties of K, giving rise to the varieties in action.
Vitamin K is essential to the maintenance of a normal prothrombin level in the blood.
Given in cases of haemorrhagic diathesis, it acts rapidly, but not instantaneously.
If the prothrombin content is less than 1%, it takes 5 hours, when given by hypo,
to reach the normal level. Very small doses are no good: it must be given liberally in
adequate doses.
The action of vitamin K takes place not in the blood, but in the tissue cells: most
likely in those of the liver. It is quite certain that this organ is concerned in the formation of prothrombin. Damage to the liver, e.g. by chloroform, causes a rapid fall in the
prothrombin level, and prevents its formation even when vitamin K is given.
How K Affects Prothrombin Formation
It is not identical with prothrombin, as if so the latter would have K properties,
but does not.
K enters the molecule of prothrombin as a group: and becomes a constituent of a
new group so formed.
It appears that the presence of vitamin K enables certain cells to produce prothrombin, but the mechanism by which this is done is unknown.
The action of bacteria in the large intestine and the absorption from the latter of
the K2 so produced is of great interest.
If the bile is sidetracked, as in biliary fistula, of if the bile ducts are tied off, there
develpos a marked deficiency of clotting power. This can, however, be remedied by
giving large amounts of K.
The first instance recognised in man was in cholaemic haemorrhage, e.g. in obstructive jaundice. Here prothrombin diminishes rapidly—but the haemorrhagic condition can
be cured by giving suitable amounts of vitamin K.
The critical days come sometimes many days after operation, and even after bile
flow has been restored.
It is the bile acids that are necessary and the ability of the blood to produce bile
acids is limited by obstruction and the resulting jaundice.
Sometimes a normal prothrombin level before operation will drop to 10% in 6 days.
The use of K is advisable, and sometimes even necessary, before operation, even when
there is no haemorrhage: this refers to operation on obstructive jaundice especially.
Tablets of vitamin K, e.g. of the water-soluble derivatives, may be given every day
before and after operation, one to two units per gramme of body weight being the dose.
In emergency give it intravenously, if possible at least six hours before operation.
As shewn above, it takes at least 5 hours for the K to raise the prothrombin level to
normal. Overdoses are in no way dangerous, so the vitamin should be given freely in
adequate amounts.   Sometimes there is a temporary influence on the respiration.
Bile is the natural remedy in these cases, of course, but it would require too much.
Blood transfusions are useless, as the amount of prothrombin present is to small and
disappears too rapidly.
Certain forms of hypoprothrombinaemia cannot be cured by K, as has been shewn
by Snell of the Mayo Clinic et al.
Other diseases have to be considered from the relation to vitamin K: thus sprue
was suspected to be a K avitaminosis.   There is hypoprothrombinaemia in this disease.
In colitis lack of K2 is caused by the abnormal condition of the large intestine.
Page 186
\\ lillr
m< Ill
: j=i;
M |r
As regards diet, while it is true that green leaves contain and furnish K, no ordinary
ration could supply an adequate amount in emergency. 50,000 units per day represent
the normal requirements. To get this one would have to eat at least a kilogramme of
spinach: quite a dose.
The most interesting, and one of the most important, cases of avitaminosis K in
man, is that found in newborn infants. Here there is very often at first a lack of K.
especially when there is actually bleeding—and so a very low prothrombin level.
Slides were shewn of various prothrombin levels in children. Where this was 100%,
there was no bleeding.
The first two to five days of life most often shew the lack of prothrombin, and
even in the first few months we find many apparently normal children with low levels,
thus in 43 apparently normal infiants in the first 2 to 5 months, 14 had levels ranging
from 100% to 50%, 14 from 49% to 20%, 7 from 19% to 10%, 4 from 9% to 1%,
and 7 from 9% to 0.
One can see the danger from rough handling or surgery in these children.
In the case of 24 cases of haemorrhage in infants, 18 had from 9% to 0, and all
were below 50%.
Ingestion of vitamin K raises these children to normal in 24 hours, and makes them
safe in 6 hours. So, if the patient can be kept alive long enough, cases of subcutaneous
haemorrhage, melaena, etc., can be cured by vitamin K.
Intracranial haemorrhage in newborn infants is a matter of great importance. While
frequently due to trauma, it is not always a culpable trauma that is responsible, but a
very low prothrombin level. Thus, even after caesarean section we see it, and sometimes
several weeks post partum, where prothrombin level has not risen.
Not only actual mortality is to be considered, but morbidity and lesions which will
only shew up in later life.
The effect of giving vitamin K varies, of course, with the time at which it is
given, and with other factors—but of 17 cases not treated all died, while of 14 treated,
only 6 died, in one series alone.
Preventive treatment has a much greater chance of success. Here we treat the
mother ante-partum: she should be given, by injection or otherwise, a suitable amount
of a water-soluble preparation a few hours before pains set in: it can be given long
before birth, and will prevent the fall in the child's prothrombin level. The best results
are obtained by treating the mother some time before birth, and the baby just after.
Hill, of Johns Hopkins, treated several hundred mothers, having several hundred
untreated mothers as controls. He found a very materially lessened incidence of
haemorrhage in the newborn. There was a marked increase in the mother's prothrombin
level, but this prothrombin does not pass into faetal circulation. Evidently the K is
handed on by the mother, and the prothrombin is built up in the child's own liver.
Perhaps the mother uses up her K faster at this time, as the need for it is greater, and so
deprives the baby of the K it needs: perhaps the baby needs more K than the mother's
normal supply can give her.
All these are things to be investigated. There are seasonal variations in the prothrombin level in the blood—this being lowest in March, highest in June and July.
In the first few days, the baby gets little or no K, hence there is a natural fall in
the prothrombin level.
Again, in the first few days, there are no bacteria in the infant's intestine, so no K2
is formed—as the bacteria increase the prothrombin level rises.
Other diseases in infants are accompanied by a K avitaminosis. Again certain
haemorrhagic conditions are not affected at all.
■' ■
This very sketchy summary of Dr. Dam's address does not, of course, do justice to |
it in any way—but will give a rough idea of the ground he covered. His work is on I
record, and can be consulted at any time in any Library—but it was a stimulating and ■
delightful experience to hear these things, told at first hand by the man chiefly respon- I
sible for the discovery of what constitutes one of the most important contributions to |
medical knowledge of the twentieth century.
By James F. Weir, M.D., Hugh R. Butt, M.D., and A. M. Snell, M.D., Rochester.
Condensed from the American Journal of Digestive Diseases.
Deficiency of vtiamin K may be defined tentatively as a condition associated with
actual or latent haemorrhagic manifectations and characterized by prolonged prothrombin clotting time or diminished quantity of prothrombin in the blood. Several factors
are important in the development of hypoprothrombinaemia. These include inadequate
intake of food that contains vitamin K, impairment of absorption owing to lack of bile
in the intestine and owing to a deficient intestinal absorptive surface, and hepatic injury.
Starvation, impaired appetite, vomiting (functional or organic in origin), diarrhoea, discharge from intestinal fistulas, continued aspiration of gastric or intestinal content, diseases of the intestinal mucosa, short-circuiting of the intestine, biliary obstruction,
external biliary fistula, disease of the liver and operative procedures and complications
are factors that may influence the concentration of prothrombin in the plasma.
Deficient absorption of vitamin K from the intestinal tract is a factor common in
the group. Vitamin K deficiency of this type is readily amenable to treatment with
various extracts that contain the vitamins or with certain quinoid compounds. This
fact is now recognized so generally and treatment is so well standardized that so-called
cholemic bleeding has become decidedly uncommon. So far as the danger of bleeding
after operations on the biliary tract is concerned, difficulties now arise chiefly in cases
in which jaundice is not present but in which severe degrees of cholecystic and biliary
infection are. In such cases, the danger of postoperative hypoprothrombinaemia has not
been generally appreciated.
The practice of repeated gastric lavage or continuous aspiration of the intestinal
content, so often necessary in the postoperative management of patients who are seriously ill, seems to have a definite tendency to deplete the bodily stores of prothrombin,
presumably by removing the coagulation vitamin from the intestine.
Certain other observations also seem worthy of note: 1. Vitamin K or some compound with similar antihaemorrhagic activity probably is formed in the gastro-intestinal
tract; this is an exception to the general rule that the organism cannot elaborate vitamins. From what is known of the antihaemorrhagic activity of certain products of
bacterial growth some of the material may be assumed to be a product of bacterial
action. 2. There is little or no storage of vitamin K in the body, as has been demonstrated by Greaves (3,4) and by numerous clinical observers. Fatal hypothrombinaemia
has been known to develop in a far shorter time (one week or less) than that required
for the development of other vitamin deficiencies.
In the earlier period of investigation of vitamin K, therapy was handicapped by the
lack of a suitable preparation of vitamin K for intramuscular or intravenous administration. However, when the quinoid structure of vitamin K was recognized and the
anti-haemorrhagic properties of various nahthaquinones were recognized experimentally,
several compounds that could be used intravenously became available for clinical trial.
These bear approximately the same relation to vitamin K concentrates as thyroxin does
to thyroid-extract: an exact dosage is possible and parenteral administration is facilitated.
We have had an opportunity to use in clinical cases four synthetic compounds that
have vitamin K activity. Table I is a comparative representation of our experience with
them. All of these agents are relatively easily administered by the intravenous route.
The preparation, 2-methyl-1, 4-naphthaquinone, has been supplied in the form of tablets
and in ampules and vitamin K has been supplied in ampules. The ampules may be
given to the patient directly or their content may be added to solutions of glucose that
are being adrninistered. Results with all compounds have been eminently satisfactory.
All of these compounds seem satisfactory from the standpoint of clinical efficiency in
controlling hypoprothrombinaemia. Factors such as ease of administration and cost probably will determine the preparation that will be routinely used.
Page  188
lift r
Serious degrees of prothrombin deficiency develop in the presence of advanced
hepatic injury, and neither the administration of concentrates of vitamin K orally or
parenterally, nor the use of the more potent compounds of naphthaquinone, will correct
the condition completely. The liver is the principal site of formation of prothrombin
and when a sufficient degree of hepatic injury is present no appreciable formation of prothrombin occurs, even when the supply of the antihaemorrhagic vitamin is ample. As
clinical experience has increased, more of these cases have been encountered. With good
reasons, clinicians have concluded that a prolonged prothrombin clotting time which
does not ressond to adequate therapy with vitamin K is indicative of irreversible hepatic
damage and a poor prognosis.
No local or systemic reactions have occurred and there has been no evidence of
Comparison of Naphthoquinones from the Therapeutic Standpoint.
Patients Treated—10
(Oral                            1 case
8 cases
jlntravenous               9 cases
10 cases
5 cases
45 cases
50 mg.
(25 to 50 mg.)
10 to 25 mg.
1 to 2 mg.
1 to 2 mg.
-  '^1
Some difficulty
in preparation
Some difficulty
in preparation
Used intravenously as a
soluble sodium
sulfonate addition compound
Can also be
given orally or
*  1, 4-dihydroxy-2-methyl-3-naphthaldehyde.
t 7 cases received both oral and intravenous administration.
•\> •*■;
• !«ii
British  Columbia IMedical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. Murray Blair, Vancouver
First Vice-President Dr. C. H. Hankinson, Prince Rupert
Second Vice-President Dr. A. H. Spohn, Vancouver
Honorary Secretary-Treasurer- -Dr. Walter M. Paton, Vancouver
Immediate Past President I Dr. F. M. Auld, Nelson
Executive Secretary. JDr. M. "W. Thomas, Vancouver
By-laws Governing Membership in and Attendance at Annual
Meetings of the Canadian Medical Association
Now that all Provincial Medical Associations have become Divisions of the Canadian
Medical Association, the By-laws for Divisions become applicable to Canada as a whole.
It is well, therefore, that all members, both of the parent Association and of Divisions,
Page  189
it il!
•ai !■■; clearly understand the basis of membership and annual meeting arrangements, including
With that end in view, the following extracts from the By-laws of the Canadian
Medical Association are published:
Chapter I—Divisions
A Branch Association may become a Division as outlined in Article V of the Constitution and enjoy all the rights and privileges of a Division in the following manner:
1. By intimating to The Canadian Medical Association in writing that it desires to
become a Division.
2. By agreeing to amend, where necessary, its Constitution and By-laws to place
them in harmony with the Constitution and By-laws of this Association.
3. By agreeing to collect from! all of its Divisional Members who desire to be members of The Canadian Medical Association such annual fee as may from time to
time be set for membership and remit same to this Association.
4. By agreeing to take such steps as seem proper to the Division to increase membership in the Association.
Chapter II, Section 9
Registration at Meetings
No members shall take part in the proceedings of the Canadian Medical Association
or in the proceedings of any of the sections thereof, or attend any part of the meetings
until he has properly registered. Only members and invited guests are eligible to register
and attend an annual meeting."
Chapter IV—Section 2
Arrangements for Annual Meetings
When the Canadian Medical Association meets- in any province where there is a
Branch Association or Division, the meeting of that Branch or Division for that year
shall be for business purposes only. The local arrangements shall be under the direction
of the Executive Committee of The Canadian Medical Association, which may enlist the
assistance of the Branch Association or Division or one of its component societies. The
Canadian Medical Association assumes full control of the proceedings of the meeting
and of all financial obligations save entertainment.
Medical practitioners in good standing resident in Canada may become members of
the Canadian Medical Association in one of two ways:
By-laws, Chapter II, Section 1—Ordinary Members.
Every member in good standing in a Division shall be automatically an Ordinary
Member of the C.M.A. on payment of the annual fee as levied by the General Council.
By-laws, Chapter II, Section 2—Members-at-Large
Any graduate in medicine residing in Canada who is not a member of a Division may
be accepted as a member of the C.M.A. provided that, with his application, a certificate
of approval from the Executive body of the Division in which the applicant resides, be
furnished to the General Secretary. In the case of an applicant residing in Canada in a
territory beyond the jurisdiction of a Division, the applicant must be endorsed by two
members of the C.M.A. Such members shall be designated Members-at-Large and shall
pay the annual fee as levied by the General Council.
The foregoing extracts from the By-laws, read in conjunction, make it clear that,
applicable to all of Canada save that portion which is outside the jurisdiction of any
province, all members of the C.M.A., whether ordinary members or members-at-large,
must have the sanction of the Division in which the member resides.
Page  190 1
Only members of the C.M.A. may register at a meeting of the C.M.A. and attend
The annual meeting of the Division, which may be held at the same time and place
as the annual meeting of the C.M.A., is for business purposes only; and as this meeting
is entirely separate and distinct from the annual meeting of the C.M.A., membership in
the Division only qualifies for registration to attend the business meeting of the Division.
I.   INVESTIGATION when albumen is found:.
Catheter specimens exclude contamination;
Microscopic—to exclude pyelitis;
Exclude Severe Anaemia and Congestive Heart Failure;
When these are ruled out, a small unexplained residue of cases remain in which the
albumen is slight, transient, and unaccompanied by symptoms.
II.   The above requires no further elaboration except for a few words about NEPHRITIC TOXAEMIA as distinguished from Pre-Eclamptic Toxaemia:
(a) The association of Chronic Nephritis and Pregnancy is uncommon.
(b) Its differential diagnosis is from Pre-Eclamptic Toxaemia and Essential Hypertension.   The important points follow:
(1) History of earlier Acute Nephritis.
(2) Onset of  albumen in pre-eclampsia is late—rarely before  twenty-
eighth weeks; in Nephritic always before twentieth week.
(3) Cardiovascular Changes (Enlarged Heart and Albuminuric Retinitis)
are strong evidence of Nephritic.
(4) Hypertension less marked in Nephritic.
(c) Prognosis and Treatment in Nephritic.
(1) Serious risk if, Blood Urea above 40, Albuminuric Retinitis, increasing
(2) Early termination of pregnancy indicated.
(3) Milder cases have 50% chance of success, i.e., live baby and mother
no worse.
(a) Trace of albumen—mild cases.
No oedema—no abnormal weight gain—B.P. under 140/100.
Reasonable rest and exercise;
Reduce salt, increase carbohydrates and accessory food factors, especially Calcium and Vitamin D;
Re-examine in one week.
(b) Albumen definitely present—more severe cases.
B.P. 130/70 to 150/100, with or without oedema or excessive weight gain.
Rest in bed—preferably hospital;
Fruit and Milk diet with Calcium and Vitamines;
If oedema, consider purgation and sweating;
Watch output, albumen and B.P.
If improving in a few days  (which is usual)  gradually increase diet.   If
not clearing fairly well in a few days on rigid treatment, induce; or if
relapse later, induce.
Never use Quinine in induction in albuminuria because of risk to baby.
Page  191 (c) Albumen ABUNDANT—Pre-Eclampsia.
These have also B.P. 150/100 or over; may have Oliguria, Oedema, Drowsiness, Visual Disturbance or Epigastric Pain.
These must be treated almost as if actual Eclamptics;
Strict Bed and Starvation;
Glucose only by mouth;
Possible venesection.
If not rapidly improved in a few days, Terminate Pregnancy.  (Puncture
of Membranes.)
It is not wise to Induce Labour or perform Caesarean without at least a day
or two of preliminary conservative treatment, lest this precipitate convulsion.
(d) Albumen SOLID—Actual Eclampsia.
The last regular meeting of the Board of Directors of the British Columbia Medical
Association was held following dinner at the Hotel Georgia on Wednesday, March 19 th.
The meeting was largely attended by members from many sections of the province
and added interest was developed by the presence of Surgeon-Commander D. W. Johnstone, Senior Medical Officer of the Naval Services, Esquimalt; Lieut.-Col. G. C.
Kenning, District Medical Officer of this Military District, and Wing-Commander E.
E. Day, Principal Medical Officer, Western Air Command, with headquarters in Victoria.
Those present included: Doctors Murray Blair, Chairman; G. F. Amyot, F. M.
Bryant, P. A. C. Cousland and Thomas McPherson of Victoria; E. D. Emery and A. H.
Meneely of Nanaimo; F. E. Coy, formerly of Inivermere, representing East Kootenay
Medical Association, J. S. Daly, President, West Kootenay Medical Association; H.
H. McGregor of Penticton, President, No. 4 District Medical Association; H. L. Burris
of Kamloops; E. Therrien, President, North Shore Medical Society; P. S. McCaffrey of
Agassiz; W. A. Clarke of New Westminster; L. H. Appleby, D. F. Busteed, H. H. Mil-
burn, R. A. Seymour, A. H. Spohn, G. F. Strong, Ethlyn Trapp, C. H. Vrooman, Wallace Wilson, W. M. Paton, Honorary Secretary, and M. W. Thomas, Executive Secretary.
The three Senior Medical Officers in this District, who attended as guests, representing the three arms of the Services, told the members somewhat of the problems and
needs of Medical Services in War. A demand for medical officers in all three Services
still exists. Just at this time there is urgent and immediate need for a considerable number of medical officers in the R.C.A.M.C. Colonel Kenning pointed out that rapid
expansion of the Service in this area, together with the departure of some of his officers
for Overseas Service, had made it imperative that more officers be taken on strength
at once.
The selection of Dr. W. F. Drysdale of Nanaimo as Senior Member in the Canadian
Medical Association as from British Columbia was announced. This honour will be conferred upon Doctor Drysdale at the Annual Meeting of the Canadian Medical Association at Winnipeg in June..
Dr. G. F. Strong, Chairman of the Committee on Programme, reported that arrangements had been made for the Annual Meeting in September with headquarters in the
Hotel Vancouver. At this date six visiting speakers had been secured, five of whom
would come from the Canadian Medical Association. The tentative dates of the meeting
are September 10th, 11th and 12th.
A Nucleus Committee to study Industrial Medicine had been appointed. Doctors
A. W. Bagnall, Internal Medicine; D. E. H. Cleveland, Dermatology, and W. M. Paton,
Eye, Ear, Nose and Throat, would form the Nucleus of this Committee and would be
Page   192
I'll I.
I1 fa'
ready to collaborate with Dr. G. F. Amyot of the Provincial Board of Health. Questions
arising out of Industrial Medicine during war would require the very active interest of
this Committee.
Reports were submitted by Dr. D. F. Busteed, Chairman of the Committee on
Medical Education; Dr. A. H. Spohn, Chairman of the Committee on Public Health,
and Dr. C. H. Vrooman, Chairman of the Committee on Pharmacy. Dr. Vrooman told
of the work of the Committee in assisting the British Columbia Pharmaceutical Association in the compilation of the new medical formulary, which was being published by
the Pharmaceutical Association.
Doctor Ethlyn Trapp, Chairman of the Committee on the Study of Cancer, reported
on the programme of medical education which was being stimulated among the various
medical associations in the province by the Sub-Committee on Educational Programme,
of which Dr. G. F. Strong is Chairman. She spoke appreciatively of the action of the
Vancouver Medical Association, which in response to this request had invited the Committee on the Study of Cancer to present a programme dealing with this subject at its
general meeting on April 1st.
Please Note: Full instructions regarding Dominion Income Tax returns
were printed in the December, 1940, number of the Bulletin.
1. Doctors in Receipt of Salary.
Where the doctor on salary provides office, motor car or other equipment and uses
same in providing service in a salaried position or under contract, and where no extra
remuneration is provided to cover these items, the income tax return should show what
amount of the salary should be applied to services rendered and what amount may be
regarded as legitimate expense in providing service.
This applies particularly to full-time salaried or contract positions and should not
affect the exemptions claim by those in receipt of salaries in part-time positions where
other professional fees provide for the normal exemptions of a doctor in general practice.
2. War Guests.
In the case of war guest children from Great Britain now domiciled in private homes
in Canada, if brought into Canada under governmental auspices, $400.00 per year for
each child may be claimed.
This ruling does not apply to children brought out privately.
[The following letter from our old friend, Col. Lavell Leeson, will interest our
readers.  We trust that his hope of seeing us in April will be realised.—Ed.]
Debert, N.S.,
Dear Jack: 21 Mar., '41.
There is no real reason why I should write you except to express my reactions after
reading the editorial in the Bulletin, which arrived this morning.
The sentiment expressed in your writing should be the means of bringing the doctors
in Vancouver and British Columbia together as a unit so that they may fulfil their
obligations when hosts. The lack of regard for hospitality by Vancouver men has been
the subject of conversation on many occasions. So many are prone to follow the idea
of "let George do it," with the result a few are recognized as hosts, while the many
bask in the reflected glory.
A few days ago I received the preliminary notice enclosed with this letter. These
few doctors in Portland have for the past five years put on the courses as outlined, and
the reputation that has resulted from these meetings is so well recognized that doctors
from B. C. as well as from all the Western States attend. Surely if Portland, a smaller
city than Vancouver, can do this, how much better Vancouver could do the same things.
Page  193. Vancouver hospitals have more facilities and clinical material than Portland, and
I think our doctors are as well able to present the cases as they are in the latter city.
These well-timed writings of yours will, I hope, be a means of stimulating interest
for the benefit of the many. I shall watch with added interest the Editorials in the
Bulletin in the future and note whether your words have produced the results, as you
would wish to see them, or have fallen on barren ground.
Our Third Division formed a Medical Society last November as a means of bringing
our medical officers into a more closely knit body. The meetings are held semi-monthly
and are well attended. Each meeting is the time we gather for an evening of bringing
forward matters relative to the work, and a paper or talk is given by one of the outstanding men in the division.. Last Wednesday a paper was given by Major Noble on
"The Soldier's Foot." This was a masterpiece in fact and ingenuity, so much so, that I
am forwarding it to the D.G.M.S. in Ottawa, where it may, if favourably received,
become a part of instructions in the examination and treatment by M.O's.
I cannot speak too highly of two Vancouver doctors whom it is my good fortune to
have associated with me in the division, Dr. Gordon Large and Dr. Jack Wright. Both
of these have proven their worth by their wholehearted support and work for their
officers and men. If there are others of like ability still in Vancouver, who feel that the
cause is worth giving up civilian practice for, they will, I know, find in the Service a
ready welcome.
Winter is on the wane, or at least the calendar so states; we are unbelievers, for snow
and frost are still with us, and will be until the end of April. Sometime in April I
expect to have a spot of leave, and if plans unfold as expected, some day ;you may
expect me to walk into your office, and say "hello."
I read with regret the passing of Dr. Corry. You and I have lost a very dear friend.
You especially for your close daily association with him, I, for he was a close neighbour
and a true friend.
From the Atlantic we watch with pride our friends at home, and hope that the day
will be not long before we may be permitted to return and enter the fellowship, which
for the time being is lost.
With the kindliest of feelings and remembrances to all at home,
Case Report
R. E. McKechnie, II, M.D.C.M., M.S.
It is difficult to say whether the title of this case report is correct or whether it
should be termed "Pancreatitis with Associated Cholecystitis." The reason for the association of these two conditions lies in the anatomical structure of the hepato-pancreatic
There are three recognized variations of the pancreatic and common bile ducts:
(a) The common bile duct and the duct of Wirsung do not join and empty into
the Ampulla of Vater separately.
(b) The common bile duct and the duct of Wirsung join and empty via the common duct into the Ampulla of Vater.
(c) The two ducts empty separately into the duodenum. In this last variation there
is no connection between the pancreatic and hepatic systems, and in consequence
a reflex is not possible.
However, in the two previously mentioned systems a reflux is not only possiblefi but
frequently does occur.
Westphal in a study of fifty consecutive autopsies found that forty-two of the cases
had anatomical structures that would allow the reflux of bile or pancreatic juice in the
hepato-pancreatic systems.   He suggested that this reflux could be brought about by
Page   194
v 1J I
I   ;!-
1' "
spasm of the sphincter of Oddi, an obstructing calculus in the region of the Ampulla of
Vater, or an inflammatory reaction in the duodenum causing oedema of the Ampulla.
In 1919, Archibald first demonstrated the association of the reflux of bile into th
pancreatic duct with acute and subacute pancreatitis.
Poper examined bile, usually taken from the gall bladder, in 219 surgical cases.
These cases were being operated upon for a number of different reasons, i.e., cholelithiasis,
tumours of the pancreas, acute pancreatitis, and cases with a healthy biliary system.
The bile was examined carefully for the presence of pancreatic ferment. These ferments
were found in 17% of the cases. Excluding those cases with acute pancreatic disease, it
was found that 10% of the 219 surgical cases had pancreatic ferment in the biliary
system. Those cases with ferment in the bile duct differed in no respect as to history,
clinical, surgical and post-operative courses. Follow-up showed no difference whatsoever.
The conclusion was reached that the reflux of pancreatic ferment into the bile passages
is of no pathological significance except when there is prolonged blockage of the Ampulla
and a change of the pH of the bile allowing activation of the pancreatic ferment.
Colp, Gerber and Doubilet of the Mount Sinai Hospital in New York City agree
with Poper and report three cases of acute cholecystitis associated with the pressure of
pancreatic ferment in the gall bladder bile. They felt that in these cases, cholecystitis
(acute) was directly associated with the presence of the pancreatic ferment.
The following case report is that of a woman with intermittent blocking of the
Ampulla of Vater and evidence of damage to the biliary tree and the pancreatic duct
because of the ensuing reflux of pancreatic and hepatic secretions into the liver and
Case Report.
Mrs. M. R. B.—Married, white, female, aged forty-nine.
This woman presented herself for examination at the Medical Clinic complaining of:
(a) Feeling old and fatigued for the past year; (b) intermittent attacks of pain in the
abdomen, present on and off for the past year.
Her past history was essentially negative except for similar attack of abdominal pain
seven years previously.
The history of the present illness commenced one year ago when the patient first
noticed gaseous indigestion after meals. This indigestion had become more marked and
some of the "gas pains" became quite severe. She did not wish to complain about her
health and so did not go to see a doctor until about four weeks ago when she had a very
severe colicky pain in the upper right quadrant of the abdomen. This pain radiated
around to the back and to the right shoulder blade. It was also associated with some
pain in the mid-epigastrium that went directly to the back. Her doctor administered
morphone and she was relieved, but since that time she had more frequent attacks of
the pain, and they were corning every day or so. The mid-epigastric pain was quite
severe at times.
Physical Examination: This revealed a small thin woman weighing eighty-five
pounds.  Blood pressure 110/76; temperature 98 degrees Fahrenheit; pulse rate 80.
Examination of the heart and lungs, etc., was essentially negative. The abdomen
was thin and flat, and there were no palpable masses or organs. There was some tenderness in the epigastrium- under the right costal margin but not marked. The patient was
not jaundiced.
Laboratory Examination: Urinalysis, negative. Red blood cells, 3,880,000; white
blood cells, 7850; haemoglobin, 80%; sedimentation rate, nine at the end of forty-five
minutes.  Kahn test was negative.
X-ray of the chest was negative. X-ray of the gall bladder after the ingestion of
stipolac revealed a poorly functioning gall bladder with a calcareous shadow in the region
of the gall bladder. Another small calcareous shadow was isolated from the gall bladder
and was in the region of the common bile duct.
A diagnosis of chronic cholecystitis with cholelithiasis was made and the possibility
of a stone in the common duct was considered.
Page   195
m The patient was hospitalized for a week in an attempt to build up her general condition, but as she was having frequent attacks of pain, it was not thought wise to delay
operation. Consequently, a 500 cc. transfusion of citrated blood was given and the
patient was subjected to surgery. On opening the abdomen the gall bladder was found
to be markedly thickened with a great deal of inflammatory reaction around the gall
bladder and the common bile duct. The wall of the common bile duct was unusually
thick and the lumen was rather small for the general size of this duct. A cholecystectomy was done. There was considerable calcareous material in the gall bladders. The
common bile duct was explored and three small putty-like stones that were rounded
together in a ball were removed. A tube was placed in the common bile duct and the
operation completed.
The post-operative convalescence of this patient was fairly satisfactory. There was
a moderate amount of thick bile drainage from the tube in the common duct and the
patient felt very well. About the fourteenth post-operative day the T tube was clamped
for an hour twice daily and the patient promptly had some colic pain in the mid-
epigastrium radiating directly through to the back. This was a little puzzling, but as
there were only one or two other mild attacks when the tube was clamped off constantly,
it was thought the pains were not of any great moment. The bile was passing freely
into the duodenum and on the twentieth post-operative day the tube was completely
removed.  The biliary fistula had promptly healed.
The patient was then dismissed from hospital and on returning home was up and
around. However, about two weeks after arriving home, she began having attacks of
sharp colicky pain in the mid-epigastrium radiating directly through to the back. She
was not jaundiced with these attacks. The bile was flowing freely into the duodenum
and her stools were well coloured. It was thought that possibly there was another stone
in the common bile duct and she was taken to the clinic where a flat plate of the
abdomen was taken. No evidence of any calculus was seen on x-ray. At the suggestion
of Doctor Whitelaw a lateral view was taken and a small round shadow was seen over
the body of the second lumbar vertebra. The patient was then placed in a semi-lateral
position and another angle shot taken with X-ray and a calcareous shadow demonstrated
in the region of the head of the pancreas.
After careful consideration it was thought that this patient had a calculus in the
pancreatic duct. This calculus was causing the intermittent bouts of obstruction and
The patient was re-admitted to St. Paul's hospital and her urinary and blood diastase
were taken during the early part of an attack. The urinary diastase was 16 and the
blood, 8. These were considered to be normal values. It was thought that they were not
raised very high because of the short duration of the attack.
The patient was dieted in an attempt to relieve any strain on the pancreas. There
was no improvement and as she was steadily losing weight it was thought wise to subject her to surgery once more.
After again transfusing the patient, she was explored arid the head of the pncreas
examined. A small round stone about 1 Vz cm. in diameter was found in the pancreatic
duct. This stone shuffled back and forth like a pea in a pod, nd quite evidently caused
intermittent obstruction of the pancreatic duct. The common bile duct was then
exposed, considering that it might be easier to remove this stone through the common
bile duct. However, this was not possible and the stone milked up to the Ampulla of
Vater and firmly held there. The duodenum was opened and the stone removed through
the Ampulla of Vater. A small straight catheter was then placed in the Ampulla and
into the common bile duct, hanging down into the duodenum and fixed with a piece of
plain cat gut. The duodenum was closed in the usual manner using three layers of
sutures and the operation completed.
The post-operative course of this patient was very satisfactory. Her appetite promptly
returned and she gained weight extremely rapidly. She left hospital at the end of three
weeks feeling very well and having gained about twelve pounds. Since then her course
has been very satisfactory and she has had no recurrence of any abdominal distress. She
is able to eat well and has had no attacks.
Page  196
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E. F. Raynor, M.D., CM.
(Presented at the Clinical Meeting of the Staff of Vancouver General Hospital, Tuesday, March 25, 1941.)
Because the eye especially, and the ear, nose and throat to a lesser extent, are so
readily available for the study of manifestations of general disease of the body, and
because general diseases often manifest themselves first in these organs, it is important
that these manifestations be recognized when they occur. We all know how fundus
examinations can give a very accurate idea of the prognosis of certain general diseases
such as hypertension and nephritis. We also find certain signs and symptoms of endocrine disturbance in the eye that are reliable indicators of dysfunction of the various
endocrine glands.
A great deal is still to be learned about the endocrine glands, although during the
past few years great strides have been made in our knowledge of them. Their secretions
are affected by many factors such as environment, emotional states, vitamins, biochemical processes, and the nervous system. They are closely interrelated with each
other and the diagnosis of glandular dysfunction is often a difficult one. I will endeavour
to discuss only the signs and symptoms of endocrine disturbance as they mainfest themselves in the eye, ear, nose and throat that have been more or less proven to be due to
glandular dysfunction of some sort or other. I will omit signs and symptoms that have
not been so proven, or if I do mention them will indicate that the subject is controversial.
Any discussion of the endocrine glands must necessarily begin with the thyroid.
Dysfunction of the thyroid affects the body profoundly and more is known about this
gland than any other. It also has a marked effect on the other endocrine glands, and
Duke-Elder describes is at 'the leader of the glandular orchestra."
Overaction of the thyroid is a common condition, and exophthalmos, or a protruding
of the eyeball, is frequently associated with it. Besides exophthalmos, which many men
believe is the only ocular sign associated with hyperthyroidism, there are about 20 others.
The most important are: widening of the palpebral fissure, exophthalmos, muscle weakness and paralysis.
Dalrymple's Sign, or widening of the palpebral fissure, gives the appearance of
exophthalmos and is responsible for the typical stare in these cases. It usually precedes
any actual exophthalmos and is readily cured by thyroidectomy. Reudemann states that
"widening of the fissure is more commonly encountered than is exophthalmos and can
be ascertained more easily."
Spasm of the Levator Palpebrae, the muscle that raises the upper lid, is a closely
associated sign. It was be unilateral or bilateral and is responsible for the photophobia
and tearing in these cases due to corneal exposure. Reudemann claims that it bears a
more direct relationship to the degree of toxicity than does exophthalmos. The degree
of widening varies greatly, is very unconstant, and like exophthalmos, if allowed to
remain too long, will not be corrected by thyroidectomy.
Exophthalmos is always bilateral but the amount may be unequal in the two eyes.
It is due, in the early stages, to oedema of the retrobulbar tissues including the extraocular muscles, and in the later stages to fibrosis, round cell infiltration, and degeneration of tissues. The degree of exophthalmos is no indication of the severity of hyperthyroidism but rather of its duration. It may range from a nearly normal postiion of
the eye to anterior luxation of the globe. The progressive type of exophthalmos should
be operated on early.  Some cases go on to what is called malignant exophthalmos. This
Page   197
■w. usually occurs after thyroidectomy in the presence of a hypothyroid state. In this connection it is of interest to note recent experimental work on this condition. Marine and
Rosen, Friedgood, and Aird have shown that when guinea pigs are given prolonged injections of chemically crude extracts of the anterior lobe of the pituitary body hyperthyroidism is produced which lasts about two to three weeks and then the B.M.R. falls
in spite of continued injections of the extract. Exophthalmos occurs during the height
of the hyperthyroidism, increases when the hyperthyroidism lessens, and is most marked
when the B.M.R. is low. During thej early weeks of these injections the exophthalmos
fluctuates, and if the injections are discontinued the exophthalmos disappears; but if the
injections are continued for several months, then the exophthalmos remains permanently
whether the injections are discontinued or not. Aird showed that the permanent exophthalmos in guinea pigs was due to myopathy with similar changes in the extra-ocular
muscles as reported by Naffziger in human beings. It was also shown during these
experimments that the thyrotropic factor in the anterior lobe extract was the one responsible for the hyperthyroidism and exophthalmos. Friedgood suggests that patients with
hyperthyroidism, where the B.M.R. drops below minus 20 percent as a result of iodine
therapy or of thyroidectomy, may be candidates for malignant exophthalmos. He suggests that thyroid substance be administered to those cases early in the disease because
the exophthalmos is then reversible but later on may become permanent. His rationale
for this is that the administration of thyroid substance depresses the secretion of the
pituitary thyrotropic hormone and thus probably also interferes with the closely associated exophthalmos-producing substance. Vail reported two cases of hyperthyroidism
without exophthalmos who showed signs of pituitary dysfunction and who developed
exophthalmos of the malignant type after thyroidectomy. He suggests that cases showing pituitary dysfunction might also be candidates for malignant exophthalmos.
Paresis of Convergence and Accommodation is common in hyperthyroidism. These
vary considerably from time to time and glasses should not be prescribed till about six
months after thyroidectomy and reading should be restricted.
Muscle Paralysis: There may be a paresis or paralysis of a single muscle, usually the
external rectus or superior rectus, or complete external ophthalmoplegia may occur. The
latter is of grave prognostic significance, as all cases showing this condition have died.
Muscle paralysis is a late development in hyperthyroidism and the fact that surgical
correction of these paralyses is unsatisfactory is a strong argument for early thyroidectomy.
Fundus Changes: Reudemann states that there were no diagnostic changes in the
fundus in nearly 2000 cases examined. Ford, in his book on "Diseases of the Nervous
System in Infancy and Childhood," describes several cases of wrinkling of the retina
due to hyperthyroidism and I have seen one case of this myself.
Glaucoma: Reudemann reports 11 cases of raised intraocular tension with corneal
anaesthesia and shallow anterior chamber. Ten of these cases cleared up completely after
thyroidectomy and one case was lost sight of. Most forms of glaucoma are not considered as a result of endocrine imbalance.
Other ocular signs of hyperthyroidism ave been described but they are not of great
importance as aids in diagnosis.
In marked cases of hypothyroidism the skin of the eyelids is dry, scaly, and edematous. The brow hairs are sparse and brittle and the eyelashes may fall out. There may
be marginal blepharitis, eczema, and chronic conjunctivitis. In advanced cases there is
sometimes a yellowish fold of oedematous conjunctiva in the lower cul-de-sac. The
lacrimal secretion is diminished and the eye feels dry to the patient, giving the feeling
of foreign body in the eye. The frequency of blinking and squinting is increased. Stanford reports several cases of episcleritis and interstitial keratitis cioassated with hypothyroidism which cleared up rapidly under administration of thyroid extract. Multiple
non-infected chalazia are frequently the result of hypothyroidism. Some cases of cortical cataracts have been ascribed to this condition.   Lemoine describes a sign which he
Page  198 •
considers is associated with hypothyroidism. He states: "There is an oedema of the
retina around the disc and macula extending into the retina as much as 4 or 5 disc
diameters. I have found the disc elevated as much as 3 diopters and the vision reduced
to 20/40 by this oedema. At first, this condition was attributed to allergy, but in a
number of these cases it Was not possible to demonstrate an allergy to any known
allergen. Further investigation demonstrated deficient thyroid function in most of
these non-allergic patients." Headaches, eye fatigue, dizziness and peripheral contraction of the visual field especially for green, may be a manifestation of thyroid deficiency,
according to Howard. These patients sleep well but wake up tired. All these symptoms
are aggravated in cold weather and patients usually volunteer the information that they
feel better during the summer. It seems significant that myopia is always associated
with cretinism but thyroid deficiency in most myopes cannot be demonstrated. Nager
thinks that endemic deafness as the cause of the well-known high frequency of deafness
in mountainous countries is a result of endemic hypothyroidism.
Next in importance to the thyroid are the gonads. The male gonad forms an internal
secretion in addition to the external one and this hormone has recently been isolated in
pure form. It is also believed that the ovary forms an internal secretion in addition to
that of the corpus luteum. This hormone has not as yet been isolated. More attention
has been paid to the effect of the ovary on menstruation than to its effect on the body
generally. This gonadal hormone in both the male and female exerts its influence on the
vegetative nervous system, acting as a stabilizer. The characteristic clinical finding in
deficiency of this hormone is instability of the vegetative nervous system, the most
common manifestation being the hot flash, due to peripheral vasodilatation. Deficiency
also results in a state of hyperexcitability. Patients with deficiency of gonadal hormone
are extremely emotional, varying from states of euphoria and elation to states of melancholy and depression. The former state, being a pleasant one, is often overlooked, but
the latter state is recognized more often and many of these patients are considered
psychoneurotic and treated as such. The diagnosis of hypogonadism in the female cannot
be based on the menstrual history because menstruation may or may not be normal in
this condition. Symptoms of hypogonadism in the female, however, are often more
severe just before the menstrual periods.
Ocular Manifestations of Hypogonadism- (Marinus):
1. High incidence of astigmatism which is frequently variable so that changes of
glasses are necessary at short intervals to maintain eye comfort. Marinus states that it
is not at all uncommon to observe a change in degree or angle of astigmatism during
the first six months that the patient is on specific treatment, suggesting that the astigmatism is due to ciliary muscle spasm rather than to permanent distortion of the cornea.
2. Development of symptoms of eyestrain from a refractive error so small that it
would ordinarily be well tolerated.
3. High frequency of extra-ocular imbalance, with or without a refractive error.
The muscle error is frequently corrected by glandular treatment and astigmatism is
decreased but does not disappear with treatment.
Ear, Nose and Throat Manifestations of Hypogonadism (Marinus):
1. Headaches, occipital in location and radiating to the vertex and down between
the shoulders and accompanied by spasticity of the neck muscles. It is throbbing and
heavy in character and occurs most commonly just before the menstrual period.
2. Frequent head colds occurring regularly before the menstrual period. Patient is
not ill as in acute coryza but there is stuffiness of the nose with an excessive watery dis-<
charge. It clears up with the onset of menstruation. The nasal congestion may be so
severe in some cases as to stimulate acute sinus disease but there is no general reaction of
infection. Shrinkage of the miucus membrane of the nose relieves the symptoms but
there is no purulent discharge. Some cases resemble hay fever but these patients are not
allergic and do not show reaction to any specific antigen.
Page  199
A !'•« • 3. Aching and stiffness in the back of the throat with a feeling of a lump in the
throat. Examination shows congestion of the lymphoid bands in the pharynx with a
peculiar dry glossy appearance. These symptoms are also greatest just before menstruation. Local treatment is of no avail but it clears up readily with glandular therapy.
4. Pre-menstrual asthmatic attacks. These patients have a condition simulating true
asthma but show no sensitivity to specific antigens. They respond fairly well to glandular treatment but are usually relieved permanently following normal pregnancy.
Marinus points out that all these symptoms of hypogonadism are based on a disturbance of vasomotor control. There is a vasodilatation with engorgement and stagnation
yi blood with increased secretion of fluid. This vasomotor instability also accounts for
the characteristic general symptoms that these patients exhibit.
Hypoinsulism (Diabetes Mellitus)
Diabetes mellitus is regarded more as a metabolic disturbance than as an endocrine
dysfunction but I would like to deal with it under this heading. Diabetes affects the
;yes in various ways and certain ocular signs and symptoms are diagnostic of the condition; indeed, eye symptoms may be the first indication that the patient has diabetes.
\ characteristic finding in these patients, especially when on active treatment, is a
Harked change in the refractive power of the eye. It is always associated with sudden
changes in the blood sugar and most authorities consider that it is due to an altered
refractive index of the lens cortex. Cataracts and iritis are common findings in diabetics
but are probably the result of the general low resistance of these patients. Diabetic
retinitis is usually associated with arteriosclerosis but the picture is typical. It is characterized ophthalmoscopically by the presence of small punctate haemorrhages and chalky
white dots in the macular region. The optic disc is normal in appearance. An uncommon fundus picture but one due directly to diabetes is what is called^ lipaemia retinalis
md occurs in no other condition. MUkiness of the blood, resulting from an excessive
lipoid content, gives a pale tone to the whole eyeground, and the retinal vessels in
jxtreme cases appear almost white. Retinal and pre-retinal haemorrhages occur frequently in this disease and are due largely to a lack of vitamin P (part of vitamin C
complex) in the diet producing increased capillary permeability. Optic atrophy and
paralyses of the extra and intra-ocular muscles form a part of the general peripheral
neuritis so often seen in diabetes. Retrobulbar neuritis is often a presenting symptom in
this disease. Central vision in these cases is impaired but the peripheral fields are normal.
Finally, and mainly of interest of ophthalmologists, there is a characteristic diabetic
lesion occurring in the pigment layer of the iris. Fluid accumulates under this layer
forming little blisters or cysts and separates the pigmented from the non-pigmented
[ayer of the iris. These blisters sometimes burst, scattering pigment over the anterior
surface of the lens. If an iridectomy is done in these cases the pigment layer is often left
behind in the eye.
Parathyroid Gland
Ocular signs of hyperparathyroidism are rare and blue sclerotics associated with
brittle bones is about the only one. Zonular cataract is thought to be due to hypoparathyroidism. Ciliary spasm, blepharospasm, twitching movements of the lids and eyeballs,
ind hypersecretion of tears may be associated with hypoparathyroidism and are all the
result of calcium deficiency.
Pituitary Gland
There are not many ocular signs associated with pituitary dysfunction. Retinitis
pigmentosa may be associated with hypofunction of the pituitary and 35 cases have
oeen reported as Laurence-Beidl syndrome. Leber's disease (hereditary optic atrophy)
has been said to be a result of combined dysfunction of the pituitary and gonad and
restoration of vision has been reported following the use of the pituitary gland. Changes
»n the visual fields are not always the typical bitemporal hemianopsia. There may be
jconcentric contraction of the fields or they may be atypical. It is not generally recognized that there may be no visual disturbances in involvement of the pituitary gland.
There are cases where involvement of the ocular and trigeminal nerves comprise the
Page 200
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..: '    ■
exclusive picture of pituitary adenoma and various combinations of ocular, trigeminal,
and optic nerve involvement may occur.
Drury, in an examination of 1000 cases of deafness from an endocrine standpoint,
reports the finding of deafness, tinnitus, and vertigo to be the result of endocrine
imbalance in 56% of cases. 15% presented thyroid disease and of these 80% were
hypothyroid. 29% had frank pituitary involvement. 12% showed ovarian dysfunction.
He reported marked improvement in most cases with glandular therapy.
Summary and Conclusions
Most of the conditions described in this paper are based on direct clinical evidence
and therapeutic proof of endocrine dysfunction. I have made no attempt to cover the
extensive literature on this subject. However, I have tried to convey to you some of
the more important manifestations of endocrine disturbance on these organs and
attempted to show how some of these signs and symptoms are of value as an aid to
diagnosis and an indicator of the progress of certain disease conditions.
Reudemann, A. D.: Ocular Changes Associated with Hyperthyroidism. Diagnosis and Treatment of Diseases of the Thyroid Gland, George Crile and Associates, W". B. Saunders Co., 1932, pp. 196-208.
Marine, D., and Rosen, S. H.: Exophthalmos in Thyroidectomized Guinea Pigs by Thyrotropic Substanc?
of Anterior Pituitary and Mechanism Involved.   Proc. Soc. Exper. Biol. & Med., 30:901:33.
Aird, R. B.: Experimental Exophthalmos and Associated Myopathy Induced by the Thyrotropic Extract.
Arch, of Ophth. 24:1167:40.
Friedgood, H. B.: Discussion on Aird's Paper.
Vail, Derrick: Discussion on Aird's paper.
Naffziger, H. C: Pathologic Changes in the Orbit in Progressive Exophthalmos.   Arch of Ophth. 9:1:33.
Stanford, J. B.: Episcleritis and Interstitial Keratitis from Hypothyroidism.   South M. J. 33:27:40.
Lemoine, A. N.: Ocular Manifestations of Endocrine Disturbance. Trans. Amer. Acad, of Ophth. &
Otolaryng.  1937.
Howard, H. J.: Relationship of Hypothyroidism to Ophthalmology.   South. M. J., 32:1112:39.
Nager, F. R.: Nelson's Loose Leaf Medicine of the Ear, p. 252, 1939.
Marinus, J. M.: Relation of the Endocrines to Eye, Ear, Nose & Throat. Trans. Amer. Acad, of Ophth,
& Otolaryng., p. 238, 1933.
Friedenwald, J. S.: The Pathology of the Eye, p. 211, 1929.
Weinberger, L. M., Adler, F. H., and Grant, F. C: Primary Pituitary Adenoma and the Syndrome of
the Cavernous Sinus.   Arch, of Ophth. 24:1197:40.
Drury, D. W.: Chronic Deafness: An Endocrine Study of 1000 Cases.  Laryngoscope 39:559.29.
By Frank Turnbull, M.D. &J||
Presented at the Staff Clinical Meeting, Vancouver General Hospital, January 28,  1941, from the
sub-department of Neurology and Neurosurgery.
[Our readers will remember an article published in 1940 by Dr. Turnbull dealing
with Brain Tumour. At the time we were editorially surprised at the large number
reported. Evidently the incidence of tumours of the brain is even larger than Dr.
Turnbull had reported them to be in his first article. We think this is a very significant
Mortality rate is not the only criterion of good neurosurgery. But anyone who has
read the papers and books of Dr. Harvey Cushing, the greatest of modern neurosurgeons,
cannot fail to recall his insistence that the surgeon should always keep a score. It is only
by his score that a player can tell whether his game is improving or falling off. Statistics
about the brain tumour cases who were treated in the Vancouver General Hospital from
1934 to 1939 inclusive, have been previously reported1. I have recently reviewed our
experiences with 33 cases of brain tumour during 1940. Possibly the publication of this
report will help to offset the widespread impression among medical men that brain
tumours are a rarity and that operation for brain tumour offers little chance of survival to the patient.
The proportion of patients who are admitted as ai forlorn hope in the terminal stages
of their malady is almost as large as it was eight years ago.   We have not avoided the
Page 201
t *>:- treatment of patients who might easily have been considered hopeless and left alone for
the sake of one's record. On the other hand we are striving more and more to find ways
and means of diagnosing the inoperable cases, so that they and ourselves may be spared
a useless major operation.
Table I.
Major Operations
Surgical Intervention Only
No Operation
A. C.
L. Frontal
M. S.
R. Frontal
A. R.
L. Frontal
C. M.
R. Temporal
D. W.
R. Parietal
T. D.
L. H.
A. L.
R. Temporal
I. McE.
R. Temporal
R.   .
R. Frontal
C. S.
L. Frontal
W. S.
R. Frontal
E. T.
Secondary Ca.
L. Occipital
E. L.
Partial Resect.
W. T.
tt              tc
E. McC.
tt                tt
C. S.
L. Temporal
D. H.
L. Temporal
E. Q.
E. W.
R. Frontal
E. F.
Acoustic Neuroma
R. B.
L. Temporal
A. B.
3rd Ventricle
E. W.
3rd Ventricle
B. F.
W. S.
L. Frontal
F. M.
Secondary Ca.
L. Temporal
A. N.
L. Temporal
J. H.
3rd Ventricle
L.   H.
3rd Ventricle
G. C.
Secondary Ca.
L. Parietal
T. R.
Secondary Ca.
L. Temporal
T. F.
R. Temporal
Discussion will be limited to a consideration of the twenty-five patients on whom a
major operation was performed. A report about the mortality rate on this group can
be made now because they have all either left hospital or died. No. 24 was transferred
to a convalescent hospital. The table requires a few additional notes. In patients 20-24
inclusive the tumour was seen at operation but for one reason or another no tissue taken
for biopsy. We classify them as "Brain Tumour—Unverified." The remainder fall into
the category "Brain Tumour—Verified." It is obvious that the notation "Home. Well"
has no reference to the ultimate prognosis. A pituitary case, for example, has many
years of normal activity and restored vision to anticipate, whereas the patient who has
had a glioblastoma resected has an average life expectancy of not more than a year.
Table II.
Total number of patients who had major operation 25
Total deaths : 4
Mortality rate : 16 %
What of the four patients who died?
No. 3. This child has rather confusing signs indicative of tumour of the left cerebral hemisphere.  At operation the left frontal lobe was found to be densely infiltrated
Page 202
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m \lW
by tumour. Resection of the lobe did not improve him. Post-mortem examination two
months later disclosed neoplastic infiltration of the white matter of every lobe in both
cerebral hemispheres, a rare condition which is called gliomatosis.
No. 15. This man had suffered from headaches, drowsiness and mental disturbance
for 17 years, total blindness for 17 months, and epileptic seizures for 15 months. He
died 25 hours after partial resection of a large, very vascular, bi-frontal meningioma.
No. 16. This eloerly lady had suffered from headache, vomiting and dizziness for 2
years. She had been in bed in a nursing home for 18 months, confused and incontinent.
She showed choked discs, generalized weakness, and spasticity of her extremities. Ventriculography disclosed internal hydrocephalus. The ventricles drained for 4 days but
her condition became progressively worse. Major operation was carried out as a last
hope and revealed a meningioma which lay in front of the left lateral sinus, invading
cerebellum and occipital lobe. Partial resection of this tumour was no help, and she died
the day after operation. It is sad to relate that the only two meningiomas of the year
have died, for these are the most benign of brain tumours. We have no excuses for the
surgery, but would like to have met these patients a little earlir.
No. 25. This young woman had a history and signs which suggested a tumour of
the pons. A few minutes after removal of a fragment of tissue for biopsy she suddenly
expired. Autopsy demonstrated a tuberculoma of the pons and a tuberculoma of the
Thirty-three cases of brain tumour were admitted to the neurological service of the
Vancouver General Hospital during 1940. Major operation was performed on twenty-
five of these patients with a mortality rate of 16%.
1.    Robertson, D. P., and Gould, C. E., Bull. Van. M. A., 1940, 16, 174.
"Doctors treating patients on relief will please take notice that chronic cases
which apply for relief, month after month, should be referred to the Out-
Patients' Department, Vancouver General Hospital.
"Medical Relief funds are inadequate to permit payment of fees in such
The above notice, which appeared on page 173 of the Bulletin of the
Vancouver Medical Association, March, 1941, has been found to be too
broad in its application.
Patients have been referred to the Out-Patients' Department of the Vancouver General Hospital who should not have been sent.
The chronic cases referred to in the above notice are cases of Pernicious
Anaemia and Diabetes, for whom the O.P.D. has special clinics. Appointments
should be made with the Out-Patients' Department prior to sending the patient
to the hospital.
Page 203 Victoria  Medical   Society
Officers, 1939-40.
Honorary Secretary
Honorary Treasurer
Dr. A. B. Nash
Dr. D. M. Baillie
Dr. O. C. Lucas
Dr. P. A. Cousland
The Victoria Medical Society is, at the present time, faced with the serious problem
of re-arranging its agreement with the Gity of Victoria for the medical treatment of
indigent persons,
On December 17, 1940, our Society was notified by the Victoria City Council that
the agreement that had been in force for the preceding five years, and under which the
City had apparently been satisfied with the medical service rendered to its wards, was
abrogated, and that a flat rate of thirty-three cents per individual on relief per month
was to apply in the future.
This abrogation was apparently the result of:
first, the action of the Provincial Government in giving notice to the municipal authorities that it would in future pay only sixteen and one-half cents per individual on relief
per month in place of the $425 that it had paid per month in the preceding five years;
secondly, the precipitous action of the Vancouver Medical Association in agreeing with
the Vancouver City Council to a flat rate of thirty-three cents per individual on relief
per month, and
thirdly, the fact that the Victoria City Council did not realize, and apparently does not
wish to realize, that all indigents within its boundaries are its direct responsibility regardless of what financial assistance it might obtain from the Provincial Government.
In January, 1941, our Society met the representatives of Victoria and Saanich municipalities and explained our position. Figures were quoted showing the amount of work
done, the remuneration received, and the percentages paid to doctors, and the manner in
which accounts are regularly scrutinized by a special committee of the Society was carefully outlined. The municipal representatives expressed themselves as favourably impressed
with our arguments for a fairer scale of payment for services rendered and promised to
do their best to meet our wishes after interviewing the Minister of Labour.
At a later joint meeting, the Society again stated its position, stressing particularly
its stand concerning (1) free choice of doctor, and (2) payment for service rendered.
The City is paying the Society for services it requires for its wards, and we are ready and
willing to co-operate with them in furnishing the necessary medical care, but the City
broke the agreement—not the Victoria Medical Society. We ate not seeking their services, they are seeking ours. We pointed out that in Vancouver there is a closed hospital
with a large staff of internes, where all indigent work is done free, whereas in Victoria
the work done in the hospitals is done by the practicing physician. It was apparently
hard for the City representatives to grasp the difference.
Finally, it was pointed out that, on March 17th, the Society would have carried on,
as evidence of good faith, for two months (the agreement officially terminated January
17th) without remuneration, and that after that date, unless a satisfactory agreement
could be reached, the Society could do only emergency work, and the City would have
to make its own provision for those requiring medical attention. Here the matter rests
at the date of writing, as we have not heard further from the City.
We feel that the argument we have on. our hands concerns every medical man in
British Columbia. It would seem that agreements between Medical Practitioners and
Municipal Authorities should be carefully perused and approved by the Committee on
Page 204
<    if (iii   IJ
fit: Economics of the B. C. Medical Association before any final action is taken locally, so
that an agreement in one part of the province will not prejudice negotiations in another
part. It is up to the Committee on Economics to lead the way. It is our representative
body in these matters and should show a lively interest in all such matters for the benefit
of organized medicine and individual practitioners throughout the province.
By Reginald Wilson, M.D., D.C.H., M.R.C.D.(Lond.)
(Delivered before the Victoria Medical Society, February 3, 1941)
A discussion of the pitfalls in paediatric practice involves a review of most of the
commonplace events and problems of this specialty. These have always provided the
material for controversy, both for laymen and the profession, because they include so
many of the daily nuisances of our own households and our practices. Many of them
seem so trivial that they have not been the subject of the same research as have the more
fatal diseases; yet in many ways they are equally important. In my own practice, I have
tried to find reasonable explanations for these problems, to reduce the number of pitfalls,
and to profit by my mistakes. Tonight I felt it would be of mutual interest to discuss
some of these difficulties.
The practice of children's medicine has one main difficulty in addition to the usual
difficulties of diagnosis for the reason that, "The patient cannot describe his symptoms
and fights all attempts of the examiner to find their cause." My first pitfall, then, concerns the fractious child and the timid doctor. It is so easy to neglect an important
part of the examination in order to avoid a fight with an unmanageable child. I have
no magic rule to help one to avoid this mistake, but I do know I have much more frequently regretted the incomplete examination than I have the numerous rows that I
have had in an attempt to obtain a clear view of an ear or throat. I think the best way
to avoid this mistake is to take the precaution of wrapping and pinning the child securely
in a blanket. Then, even if the view of the affected part is a fleeting one, you will at
least have retained your temper and composure. It is hardly necessary to illustrate the
danger of neglecting to remove ear wax in a febrile child, for we have all had the
experience of having a parent tell us by telephone that the child's pillow was covered
with pus and that his unexplained fever was now better.
Pitfalls of the Neonatal Period
The great problem ojf'preventative^paediatrics at present, is to reduce the death rate
in the neonatal period. While the infantile death rate has been cut in half in the last
twenty years, the neonatal death rate has hardly been affected at all. Many of these
neonatal deaths are due to congenital malformations and are therefore not likely to be
much influenced by obstetrics or paediatric care. But there are about twenty-five per
cent (25%) of these deaths, which are due to intracranial haemorrhage. Also many
such cases which do not die are left with Epilepsy or Hydrocephalus. The pitfall here
concerns the physician who fails to detect and treat the earliest and slightest sign of
haemorrhage in a new-born infant. It is not necessary to await the development of the
whole syndrome of haemorrhagic disease of the new-born. An intramuscular injection
of the parent's blood cannot possibly do any harm and will arrest any tendency to haemorrhagic disease. Lately we have used Vitamin K for the same purpose with equal
success, and evidence is accumulating that it may possibly be used prophylactically by
administration to the mother in the last weeks of pregnancy in cases where a difficult
labour is anticipated.
While investigating the causative factors in fifty (50) cases of intracranial haemorrhage which occurred at the Vancouver General Hospital, I was surprised to find that
twenty-five per cent (25%) of them occurred when Pituitrin had been used for induction.   This drug carries with it a real danger for the infant.
Page  205 r
Feeding: During infancy the question of artificial feeding presents certain pitfalls.
The current vogue for the use of evaporated milk has led to the frequent use of very
strong formulas. It is rarely necessary to give more than twelve ounces of the plain
evaporated milk in the total day's formula. I believe the most frequent cause for indi-
eestion is the formula which contains amounts far in excess of this.
Iron Deficiency: Scurvy and Rickets are mostly well controlled in our country today,
but a similar deficiency disease, that is, iron deficiency, Anaemia, is still very prevalent
here. Lately we have done routine estimations of haemoglobin on all children attending
the Outpatient Department of the Vancouver General Hospital, and I was surprised to
find that a very high percentage have a Hypochromic Anaemia. Many infants and
children have a constitutional hypo- or a-chlorhydria which impairs the absorption of
iron from their diet. They will, however, absorb sufficient iron to prevent anaemia if this
is added to the milk. In spite of theoretical considerations to the contrary, I think the
addition of one-half to one teaspoon of Iron citrate crystals to the day's formula is the
most satisfactory preventative or cure.
Pitfalls in the Older Infant
Teething: The diagnosis of teething is so readily advanced by parents to explain a
child's illness that it is unwise ever to accept it without a thorough examination. Serious
disease in children so frequently begins with mild symptoms of fretfulness that it provides a common pitfall for the unwary. For example, in hospital practice such a story
as this is so frequently heard in a case of Meningitis.
"We thought it was only his teeth, doctor, but when he began to have fits we
decided we should bring him to hospital."
However, I do not hold with the purist who contends that teething is responsible
for nothing but the cutting of teeth. Rather I am guided by those physicians with large
families who say it is a physiological process which, like childbirth, may occasionally
become pathological. It should never be accepted as a cause of fever and if this symptom
is present, the diagnosis of teething should not be made unless the ear drum, urine and
throat are definitely proven to be normal.
On the other hand, certain symptoms quite frequently accompany dentition and may
be explained on this basis. Excessive salivation is a common accompaniment of teething
and the aspiration of the saliva, especially at night, may cause cough. A neuralgic type
of pain may cause extreme fretfulness, and this will usually subside if the teeth are
rubbed through. Whatever our views on the subject, the wise physician should never
neglect to obtain the clinical benefit which will result from the simple procedure of
rubbing the teeth through the gums. Occasionally, the cutting of each tooth may be
accompanied by a digestive upset; infants who are prone ,to have rashes will have an
exacerbation at teething time, and occasionally mildly rachitic or mentally defective
children will have fits at this time.
Worms: Current paediatric teaching is that the common thread worm causes no
symptoms, except possibly an insomnia due to irritation of the anus by the worms.
They are said to infect debilitated children rather than to cause the debility. This is
substantiated by the experience of veterinarians who say that their puppies are more free
from worms if they are given cod liver oil regularly. Nevertheless, the presence of thread
worms should be treated with seriousness by the physician because they at least are an
evidence of poor health and they are also notoriously resistant to treatment. The pitfall
to avoid here is the failure to prevent re-infection by the regular use of antiseptic ointment on the anus where the eggs are deposited. There are now two methods of treat-
men advocated which are said to be great advances on the old Santonin and Quassia
technique. With the first of these, gentian violet, we have had an experience in the Outpatient* Department of the Vancouver General Hospital with a small series of patients.
The drug is given in Yz -grain enteric-coated capsules one-half hour before meals in
alternate courses of one week's treatment and one week's rest. There have been no
failures to date or relapses over a period of three months.  The second drug, phenothia-
Page   206-
Iff '.! 9H
■ j; .ft
zine, is distantly related to the sulphanilamide dyes.   Both are simple, non-toxic and
rapid in their action.  I have had no personal experience with the latter.
Circumcision: The value and possible dangers of circumcision have been the subject
of medical controversy for years. I am unable, because time does not permit, to give you
all the arguments, but I consider that as a routine procedure in the first two weeks it is
unwise. It should not be undertaken unless the child is thriving satisfactorily. Whenever there is no special contra-indication circumcision should be done, if for no other
reason than that venereal infection is much less prevalent in circumcised males.
Pyelitis: The diagnosis of urinary infection in childhood is a frequent source of error
for the paediatrician. The failure to find pus in a single specimen of urine does not-
necessarily exclude the diagnosis of pyelitis in a child and the presence of pus in a voided
specimen does not necessarily confirm this diagnosis. Frequently the pus is present only
in bouts, possibly due to spasm of the ureters. Bacteria may be present but not there in
sufficient numbers to be seen in the direct microscopic examination. Two methods may
be used then to confirm this diagnosis:
1. Examination of several successive voided specimens;
2. Culture and examination of the catheterized specimen.
The former is suitable for practice in the office, whereas the latter is the method of
choice in hospital patients and should be done in all cases to determine the causative
organisms. There should be no difficulty or danger in catheterizing even the youngest
female child.
The great majority of these cases are in girls and are due to bacillus coli. When a
case does occur in a boy, a very meticulous search should be made an anatomical abnormality of the genito-urinary tract, for the infection is often based on such a malformation.
Focal Infection: The theory of focal infection in adult medicine has been overworked and has fallen somewhat into disrepute because of the frequent useless operations for removal of so-called "septic foci." However, in children's disease, it is my
opinion that there is to be a return to a greater emphasis on the general systemic effects
of localized chronic infection. I refer to the effects of chronic infection as a precipitating cause or aggravating factor in such diseases as asthma, epilepsy, eczema, nutritional
anaemia, thrombopenic purpura, coeliac disease, etc. Moreover, the symptom complex
called acidosis which reached such popularity amongst a certain class of parents in the
past decade is best explained on the basis of mild chronic infection. Naturally where
there are specific drugs such as adrenalin or phenobarbital for the treatment of these
diseases, these should not be neglected, but it is useless to continue the specific treatment
until a thorough search for chronic infection has been made in such sites as the throat,
ears, urine, antra, bowel, teeth, etc. The search for any eradication or treatment of
such foci will remove many of the pitfalls in the management of these cases.
Nervous Diseases: The diagnosis of nervous and mental disease in childhood is
fraught with many dangers. There is no offence greater to a parent than an insinuation
that their infant is not normal mentally. During infancy a shrewd suspicion may be entertained, but it is very difficult to be certain and it is wiser to reserve opinion. The early
development of mild hydrocephalus is frequently misdiagnosed in cases of severe infantile debility where the head appears abnormally large. The diagnosis often should not
be made until the circumference of the head has been observed for some time and its
growth noted. Likewise, a common pitfall is to suggest that a child's symptoms are due
to spoiling. Usually when that is done, the child will be taken elsewhere and it will be
discovered that the bad temper is due to some illness. Nowadays it would seem, as Sir
Robert Hutchinson recently put it, that many "only" children are over-studied and
their progress is retarded in the same fashion as a plant which is regularly pulled up by
the roots to see how it is growing.
Rheumatic Diseases: We are all anxious to make an early diagnosis of rheumatic fever
in childhood so that early treatment may be instituted and cardiac involvement avoided.
Page 207 Frequently so-called "growing pains" in children are confused with early rheumatic
arthritis. So much has this been so that some physicians consider it safest to treat all
pains of this character as rheumatic fever. Usually I believe "growing pains" can be
differentiated on clinical grounds. True rheumatic joint pains are confined to the joints
and their onset usually follows some upper respiratory infection. These involve both
upper and lower extremities and are worse during activity but do not wholly improve
on the patient's going to bed. Nosebleeds, skin rashes, and fever are common accompaniments and the sedimentation rate is accelerated. Growing pains, on the other hand, tend
to develop towards the end of the day and they improve after the warmth and rest of
a night in bed. These pains are in the legs and thighs and the joints themselves are never
hot or swollen. Unlike true rheumatic fever they are not accompanied by fever or
increased sedimentation rate.
In such a child, it is often difficult to judge if a cardiac murmur is due to organic
disease. Many children have been needlessly forbidden exercise because of some innocent
cardiac murmur. Marked variation of a murmur during the phases of respiration and
in different postures is usually good evidence that the murmur is not significant of
rheumatic heart disease. Another simple confirmatory test is to note the difference
between the day time pulse rate at rest and the sleeping pulse rate. If there is a marked
difference, the case is not likely one of organic heart disease. In children, such tests are
usually of much more value than an electrocardiogram.
In conclusion, I would like to apologize for reviewing so many minor and, some
might say, trivial complaints, many of which are already only too familiar. However,
I find these problems are troublesome, yet interesting, and I hope that I have aroused
your interest in them also.
Speaker: DR. G. F. STRONG.
This was held on March 12th, at the Hotel Georgia, in the Windsor Dining Room,
and was in every way up to the highest standards of this, the high water mark of the
season's activities of the Vancouver Medical Association .
There was a very large attendance, and many guests from out of town were with us
for the evening. At the head table, where Dr. D. F. Busteed, president of the Association, was in the chair, all previous Osier Lecturers were seated: the only surviving Lecturer absent was Dr. Glen Campbell, who was unfortunately unable to be present.
Dr. Busteed introduced this year's Osier Lecturer, Dr. G. F. Strong, who, from a
wide experience as a specialist in cardiology, spoke on Coronary Diseases of the Heart.
Dr. Strong's address displayed evidence not only of a very extensive knowledge of his
subject, but of a very great deal of hard work in preparing his paper—it is a difficult
subject with which to hold an audience's interest firmly and without flagging, but Dr.
Strong succeeded in doing just this. He covered the entire subject in a masterly way—
and his address was admirably illustrated by a comprehensive series of electrocardiograph
tracings, which in themselves are, to the average practitioner of medicine, an almost
unknown land, but which Dr. Strong's lucid explanation made quite clear and very
helpful in following his discourse.
At the close of his address, Dr. Strong was presented with the Osier plaque, given
to all other Osier Lecturers. The presentation was made by the previous Lecturer, Dr.
J. H. MacDermot. 	
The newly-elected members of Council of the College of Physicians and Surgeons of
British Columbia has now been published. There are several new faces: in Vancouver,
Drs. Wallace Wilson and H. H. Milburn, in Victoria, Dr. F. M. Bryant, in Nelson, Dr.
F. M. Auld, late president of the B. C. Medical Association. We congratulate all these
men, and ourselves: since we have elected to serve our interests, an admirable lot
of men—all well-equipped by long service and experience to deserve our entire trust
and confidence.
Page 208
III:. ■ '• -!..-.
i *•.
The following extract from a letter speaks for itself. Our Vancouver readers at least
will remember Dr. Walter Clarke, who spoke to us some weeks ago on Venereal Disease
Control. His eminence in this department qualified him thoroughly to speak, and what
he says is therefore the more gratifying.
Vancouver, and indeed B. C, is gradually coming to the front in health matters.
The recent reports on infant and maternal mortality are astoundingly good. We speak
from memory, but we believe we are right in saying that these are surpassed, if at all,
by very few places in the world. Our record in infectious disease for 1940 shews, as
has been recently stated in the papers, a practically complete disappearance of diphtheria. And this record as regards Venereal Disease Control is one to be very proud of.
We congratulate the Public Health Department of British Columbia sincerely on their
excellent work.
1790 Broadway, New York, N.Y.
Dr. William H. Avery, March 13, 1941.
Venereal Disease Control Officer
Department of Pensions and Public Health
Ottawa, Canada.
Dear Doctor Avery:
Several weeks ago I had the pleasure of spending two days in Vancouver, B.C., and
saw something of the splendid work which Doctor Amyot, Doctor Donald Williams, and
other leaders in that province have been doing with regard to the control and prevention
of syphilis and gonorrhoea. It seemed to me that the venereal disease control work in
Vancouver is one of the best and most efficient pieces of public health work I have seen
in America. The reduction of venereal diseases in the civil population has been spectacular. I did not see any figures for the military population stationed in that part of
Canada and affected by the work in Vancouver, but I have no doubt that the reduction
in rates in the civil population would be reflected in a lower venereal disease rate among
any troops stationed near the city.
I do not know that there is any assistance which the American Social Hygiene Association can render to Canada in its present struggle, but I wish to assure you that this
Association, which is recognized in its field by the United States Government, will gladly
co-operate with the Canadian health and medical authorities in any way that may be
Yours sincerely,
Walter Clarke, M.D.,
Executive Director.
Wrong Categorization
The Department of National War Services at Ottawa has recently brought to the
attention of the Divisional Registrar of Administrative Division "K", Vancouver, B.C.,
the fact that a very considerable number of men in B.C., following examination by
their private physicians, have been sent to Camp in Category A, BI, or BII, only to be
sent home again after examination by the Army Doctors.
This is to be regretted in that not only is there a very definite financial loss to the
Government, but in addition, the man loses time from his work and is more or less
Page 209 unsettled in the procedure.   The difficulty seems to be not in a question of diagnosis
but in the private physicians not carefully reading the instruction booklet.
A private physician may, for example, examine a man and find he has lost one eye,
and looking over the Category requirements, may think the man could be fitted into
BI or BII, but if he had read on further under the section on requirements regarding
eyes, he would have found the regulations definitely state that a man with only one eye
must be placed in Category CII. This leaves no option and he should be placed in that
Category by the physician who first examines him.
Many other similar examples could be cited of men with certain disabilities being
placed in Category A, BI, or BII, by their private physician when a perusal of the regulations with regard to those disabilities would show that the men must be rejected.
It is hoped that in all further examinations of trainees, private physicians, on finding
a disability and before placing men in Category A, BI, or BII, will be sure that the
disability is not one which by regulations should call for rejection.
According to the latest supplementary regulations published recently, only men
placed in Categories A, BI, or BII, are accepted by the army. All others placed in Categories CI, CII, D, and E, are rejected by the Army Doctors, when the men reach Camp.
Until last month, men in Category CI were acceptable.
Temporary Unfitness
It has been suggested that in cases where men are placed in Category D, as being
temporarily unfit, it should be stated on the Medical Form the length of time in the
opinion of the private Examining Physician the man is to be unfit for duty—one month
—three months—or six months—if Over six months, he should be placed in Category CI,
CII or E as the Examining Physician sees fit.
As the Department is trying to standardize this work throughout Canada, it is suggested that work should be done carefully and in accordance with the book on Physical
Standards and Instructions for the Medical Examination of Recruits. For instance, in
examination of the Eyes, a standard Eyechart should be used and the result marked on
the Medical Form as 20/20—20/40, etcetera, as the case may be, and not as good,
normal, OK and so forth.
The Hearing should be marked as Conversational Voice (C.V.) at 20, 10 or 5 feet
from the Candidate as the case may be, and not as Whispered Voice, W.V., Normal,
OK, Good, etc.
To Facilitate the Payment of Doctor's Examination Fee
Recruit's Notice Attached to Medical Certificate
Notice of Call for Medical Examination as presented by the Recruit to the Examining Physician must be collected by the Examining Doctor and attached by him to
the Medical Examination Certificate Form which in this Province is sent to Division
"K", Department of National War Services, Vancouver, B.C.
Care Means Saving
If, as stated above, these Examinations are made carefully by the private Exarnining
Physician, there will be a great saving to the taxpayers of the country, which no doubt
will be appreciated at this time.
Page 210 »;
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