History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1940 Vancouver Medical Association Jul 31, 1940

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 8*
Tfhe BULLlHP**
of the
VANCOUVER
MEDICALlASiOCIATION
Vol. XVI
JULY, 1940
No. 10
With Which Is Incorporated
Transactions of the
Victoria Medical Society
tt*
Vancouver General Hospital
*nd
St^auTs^Hospital
In This Issue: H
NEW||XND NOTES ^^^^^^^^^^^^^^^^^^^^^^^^^P82
LIPOMA OF THE COLON—Dr. V. J^forto^^^^^^^^p;   -^^^^7
CYST OF LIVER WITH PLEUROBRONCHIAL FISTULA-S
Dr. d||E. ^AuM^^fe^^MJ^^^^,  '-^^^^^^^^'-      W  _||288
CASE OF DIFFUSE LYMPHOSARCOMA
WITH PATHOLOGICAL RKPOKTg||p- '|||§lf   .  '.        pp: ■      ^»
ACTIVE BlMUNIZATICHSttNT GENERi^PRACTICE--^ I^B
Dr. J.jiL. Murray Anderson, r>.P.H;:^^^gi^^^^^^^^^^g^^r^^|?9 S
THE CERVIX A FOCUS OF INFECTION^^eMa. M. Agnew- Jl§|;- ft>2
BRITISH COLUMBIA MEDICAL ASSOCIATION
ANNUAL MEETING—NELSON—SEPT. % 10, 11. In Dermatological Conditions
such as Acne
Eczema
Psoriasis
Urticaria
Abrasions
and other inflammations of the skin, the attention of the physician is called to the use of
■i
^H 8Y ALL OmtQ&fl*
n*x^em^maju>m
It is Osmotic
Non-irritating
Bacteriostatic
Detersive
Anti-pruritic
Repair-promoting
Sample on request
The
Denver Chemical
Mfg. Co.
153 Lagauchetiere St. W.
Montreal
Made in Canada
7«,-_--T"v^-.     -.---J-fW.«;~ .^   - THE    VANCOUVER    MEDICAL   ASSOCIATION
BULLETIN
I'nblished Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDebmot
Db. G. A. Davidson Db. D. B. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVI
July, 1940
No. 10
OFFICERS,  1939-1940
Db. D. F. Busteed                Db. W. M. Paton Db. A. M. Agnew
President                           Vice-President Past President
Db. W. T. Lockhabt Db. Mubbay Baibd
Ron. Treasurer Hon. Secretary
Additional Members of Executive: Db. C. McDiabmid, Db. L. W. McNutt.
TRUSTEES
Db. F. Bbodie Db. J. A. Gillespie Db. F. W. Lees
Auditors: Messbs. Plommeb, Whiting & Co.
SECTIONS
Clinical Section
Db. Kabl Haig Chairman Db. Ross Davidson Secretary
Eye, Ear, Nose and Throat
Db. W. M. Paton Chairman Db. G. C. Large Secretary
Pwdiatric Section
Db. R. P. Kinsman Chairman Db. G. O. Matthews Secretary
STANDING COMMITTEES
Library:
Db. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies,
Db. W. A. Bagnall, Db. T. H. Lennie, Db. J. B. Walkeb.
Publications:
Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. T. H. Lennie, Db. A. Lowbie, Db. H. H. Caple, Db. Fbank Tubnbull,
Db. W. W. Simpson, Db. Kabl Haig.
Credentials:
Db. A. W. Hunteb, Db. W. T. Ewing, Db. A. E. Tbites.
V. O. N. Advisory Board:
Db. C. E. Riggs, Db. T. M. Jones, Db. R. E. McKechnie II.
Metropolitan Health Board Advisory Committee:
Db. H. Spohn, Db. F. J. Bulleb, Db. W. T. Ewing.
Greater Vancouver Health League Representatives:
Db. G. O. Matthews, Db. M. W. Simpson
Representative to B. C. Medical Association: Db. A. M. Agnew.
Sickness and Benevolent Fund: The Pbesident—The Tbustees. m
Endocrine Therapy
AMNIOTIN (N. N. R.)—Squibb estrogenic substance.
The established indications for this A.M.A. Council-accepted product are
vasomotor symptoms of the natural or artificial menopause; gonorrheal
vaginitis in children; senile vaginitis. There are also other conditions
where its value is under investigation.
Amniotin is a highly purified preparation of naturally occurring estrogenic
substances, derived from natural sources. It is available in oil in ampules,
in pessaries, in capsules; for administration hypodermically, intrava-
ginally, or orally; according to the condition being treated and the
individual patient.
ANTERIOR PITUITARY EXTRACT SQUIBB is indicated for its
growth-promoting effect in pituitary types of dwarfism, in diabetic children
where there is pronounced failure of growth, and in Simmond's disease.
Anterior Pituitary Extract Squibb is available in 20 cc. vials, each containing 200 growth units, for intramuscular injection.
FOLLUTEIN (chorionic gonadotropin) — anterior pituitary - like sex hormone Squibb.
In cases of undescended testes, satisfactory results have been obtained
through the use of Follutein.
Follutein is supplied in glycerin solution with sterile distilled water
diluent; mixture 5 cc.—500 International Units; 10 cc—1,000 I.U.;
5 cc—5,000 I.U.    Adnainistered by intramuscular injection.
THYROID SQUIBB —thyroid glands dessicated. The product is standardized with respect to its iodine content, and also biologically assayed
to assure specific therapeutic activity.
These Squibb Thyroid Tablets enable accurate and controlled dosage in
hypo-thyroid states, including subnormal metabolism as in myxedema
and cretinism, mental retardation associated with thyroid deficiency,
some cases of obesity and of gonadal insufficiency in women.
Thyroid Squibb is supplied in plain or enteric-coated tablets, 1/10, 1/4,
1/2, 1, 2, and 3 grains, in bottles of 100, 1,000, 5,000. Also 5-grain tablets
enteric-coated.
For further information write 36 Caledonia Rd., Toronto
ERiScojibb &.Sons of Canada.Ltd.
HANUFACTUBING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE   1859 VANCOUVER HEALTH DEPARTMENT
STATISTICS, MAY, 1940
Total population—estimated 269,454
Japanese population—estimated I j      9,094
Chinese population—estimated j 8,467
Hindu population—estimated         339
Rate per 1,000
Number Population
Total deaths  253 11.9
Japanese deaths  6 7.8
Chinese deaths .  11 15.3
Deaths—residents only .  220 9.6
BIRTH REGISTRATIONS:
Male, 222; Female, 216    438 19.1
INFANTILE MORTALITY: May, 1940 May, 1939
Deaths under one year of age        9 8
Death rate—per 1.000 births      20.6 22.9
Stillbirths (not included in above)        S 6
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
June 1st
April, 1940 May, 1940             to 15th, 1940
Cases    Deaths Cases   Deaths Cases Deaths
Scarlet Fever      15           0 9           0               3 0
Diphtheria        0           0 0           0               0 0
Chicken Pox I    234           0 203           0              89 0
Measles         39           0 102           0             76 0
Rubella           10 0           0               0 0
Mumps        5           0 6           0               3 0
Whooping Cough      18           0 13           0                0 0
Typhoid Fever        0           0 0           0               0 0
Undulant Fever        0           0 0           0               0 0
Poliomyelitis        0           0 0           0                0 0
Tuberculosis      32          16 32          18              15
Erysipelas        3           0 4           0               0 0
Meningococcus Meningitis        0           0 10               0 0
Paratyphoid Fever        10 0           0               0 0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL.
West North Vaner.   Hospitals,
Burnaby   Vancr. Richmond Vancr. Clinic   Private Drs. Totals
Syphilis    2                1                1 1                18               25 48
Gonorrhoea      0               0               1 0                33               26 60
§ BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
Bioglan products differ in that they are derived from original material."
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
STANLEY   N.   BAYNE
«
Phone: MAr. 4027
1432 Medical-Dental Bldg.
Descriptive Literature on Request
Vancouver, B. C.
281 Each fluid ounce of Dilaxol E.B.S. contains:
Bismuth Subsalicylate -------     4 grains
Digestive Enzymes   --------      l grain
Magnesium Trisilicate,
Carbonate and Hydroxide -   -----   75 grains
Dilaxol is alkaline in reaction and, in contrast to the strong
alkalies, does not stimulate the secretion of surplus acid; yet it will
neutralize many times its volume of excess acid in the stomach.
This unique property of Dilaxol is akin to the buffer action of the
blood. Dilaxol neutralizes free acid and does not interfere with
the natural digestive process, nor does it cause alkalosis.
Indicated in Dyspepsia, Duodenitis, Flatulence, Hyperacidity,
Vomiting  of Pregnancy and other  gastro-intestinal disorders.
Palatable and Protective.
Also supplied in powder form.    Sample on request.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA
SPECIFY     E.   B.   £     O   N     YOUR      PRESCRIPTIONS In another column we give a very brief outline of some extremely interesting work
being done by a member of our profession in Vancouver, Dr. F. N. Robertson, of the
Medical Staff of the Vancouver General Hospital.
Dr. Robertson, we understand, allows the publication of this with considerable
misgivings, and some doubt as to its wisdom. The danger of publishing anything
experimental about cancer is that its value is apt to be very badly appraised. This work
of Dr. Robertson's is purely experimental, and he claims nothing for it, except that the
test he has evolved is simple, easy to make, and has so far been accurate in practically
every case to which it has been applied, where cancer has been proved to exist.
But, of course, this test has only been made in a very small number of cases, and
only by a widespread application of it, over many hundreds of cases, will it be possible
to determine its value. If it continues to be as accurate as it has so far appeared to be,
one envisions a great many important potentialities in its use,—and all sorts of questions arise in one's mind.
Can it be used to determine the presence of cancer at an early stage in the development of the latter?
Can it be developed quantitatively as well as qualitatively?
Can it be used after operation or irradiation to determine the success or failure of
such treatment?
All these questions, and others which flock into one's mind, can only be answered by
time and much work. Hence Dr. Robertson's article is really an appeal to all medical
men to co-operate with him in making such study possible—the test is rather time-
consuming, and the technique, though simple, must be followed accurately.
We hope to see a widespread response to this appeal. Hospitals, laboratories, the private practitioner, can all co-operate here and help to give this fair trial. It seems to us
it is very well worth real, honest study and investigation—for this smiple test of Dr.
Robertson's contains in it a hope, an idea, a constructive piece of thinking, and while
this is all it is at present, it rests with each one of us to try it out. Nobody would be
more sincerely glad to see it clearly either proved or disproved than its originator.
3$* *£ *•* *S*
At the time of writing, the Summer School of the Vancouver Medical Association is
in full swing. Judging from a very cursory glance, there is a large representation from
other parts of the province, and we were talking to a doctor from Medicine Hat who
is taking in the School. There are no doubt many from other Southern and Eastern
points.
NEWS    AND    NOTES
Dr. C. F. Govern ton of Vancouver travelled to Montreal, his son graduating this
year from McGill. En route he stopped at Penticton to visit his daughter, Mrs. Peter
O'Brien.
*t *t *t, »t
5S" »(* *i* *?
Dr. R. E. McKechnie,, Sr., visited Pentiston. He was on his annual fishing trip in
the Okanagan.
Dr. W. H. White of Penticton travelled to Kelowna to attend the opening of the
new General Hospital.
282 Dr. R. P. Borden of Penticton was visiting in Vancouver.
Dr. Norbert J. Ball of Oliver will soon move into the new Medical Building constructed for him.
jj. *5, »*. *^
Doctors F. E. Pettman, H. J. Alexander and H. I. Campbell-Brown of Vernon have
established themselves in their new offices. Dr. Pettman is taking advantage of the
opportunity afforded in the new partnership to get away for three months' post-graduate
work in Toronto, Montreal and Chicago. He will attend the Canadian Medical Association meeting at Toronto and be present at the Toronto 1910 Class Reunion.   It is
reported that he took his golf clubs.
* *       *       *
Dr. E. A. Martin of North Vancouver has returned from a holiday in Eastern
Canada.
Dr. and Mrs. A. R. Anthony of Vancouver are receiving congratulations on the birth
on May 28 th of a daughter.
* *       *       *
The new building of the Kelowna General Hospital, which was officially opened on
the 26th of May, was erected and furnished at a cost of $140,000.00. It is of reinforced
concrete and tile construction. The ground floor houses the administration offices, X-ry,
kitchenas nd dining-rooms. The second floor provides an up-to-date obstetrical suite
and wards. The third floor1 is given over to wards and a complete surgical suite. The
former maternity wing in the older building which was recently constructed is being
used for medical and paediatric cases.
The following are members of the medical staff: Dr. L. A. C. Panton, President;
Dr. W. F. Anderson, Secretary; Doctors B. de F. Boyce, W. J. Knox, A. S. Underhill,
J. S. Henderson and J. M. Hershey, Medical Officer of the Okanagan Health Unit.
The Kelowna Hospital Society, the City of Kelowna aided by the Provincial Government, are responsible for the provision of this excellent institution.
Dr. N. E. Morrison of Nelson has been doing post-graduate work at Eastern centres.
»r *r *r *?
Dr. D. J. Barclay of Kaslo has moved to Golden, where he will do the practice formerly carried on by the late Paul Ewert.
•r *v *s* *T
Dr. H. R. Christie of Rossland was called to Edmonton owing to his mother's illness.
Capt. J. A. Ireland, R.C.A.M.C., C.A.S.F., of Kamloops, has been moved to Eastern
Canada.
i'i-
Dr. M. G. Archibald of Kamloops travelled to Nova Scotia by plane, it being his
intention to go to Toronto for the C. M. A. meeting.
Dr. W. K. Massey of Ashcroft visited Vancouver recently.
Dr. A. H. Meneely of Nanaimo called at the office when in Vancouver recently.
^ *r sp 5?
Doctors John Christie, D. E. H. Cleveland, W. T. Lockhart, H. A. McKechnie,
T. R. B. Nelles and D. H. Williams attended the spring meeting of the Northwest Der-
matological meeting held at Portland in May.
*^ *t sS» *t
Dr. R. E. McKechnie, Sr., returned from his annual fishing trip at Kelowna.   He
adr.-«its that the fishing was good.
*       #       *       *
Dr. Murray McC. Baird fished in the Kamloops area during one week and reports
excellent sport.
283 Dr. Hugo Emanuele has been at Wells assisting Dr. J. H. Black.
Dr. D. B. Ryall of Alert Bay is on vacation and attending the Summer School.
Dr. W. B. Clarke has been relieving Dr. R. N. Dick of Chemainus.
*      *      *      *
Dr. Wr. R. S. Groves of Port Renfrew is in the East.
Dr. R. Gibson is doing locum tenens for Dr. R. Elder of Vancouver.
The Western Branch of the American Urological Association meets in Victoria at
the Empress Hotel, July 29th, 30th and 31st.
An invitation to attend these meetings is extended to the medical profession of
British Columbia.
CANADIAN MEDICAL ASSOCIATION
ANNUAL MEETING      J
British Columbia was represented at the Meeting in Toronto by Doctors F. M. Auld
of Nelson, W. T. Barrett of Victoria, H. Baker formerly of Salmon Arm, L. F. Brogden
of Penticton, W. A. Clarke of New Westminster, W. R. Sutherland Groves of Port
Renfrew, F. E. Pettman of Kelowna, A. W. Bagnall, F. J. Buller, Wilfrid L. Graham,
Earle R. Hall, A. J. MacLachlan, H. H. Milburn, J. R. Naden, Stanley Paulin, G. F.
Strong, M. W. Thomas, K. W. Whittaker and Wallace Wilson of Vancouver.
Dr. G. F. Strong attended the sessions of the Executive Committee on June 14th and
15th, and also along with nine others the meetings of General Council. Dr. F. M. Auld
of Nelson, President of the British Columbia Medical Association, was elected representative on the Executive Committee for next year.
Doctors Wilfrid Graham and Earle Hall presented papers to the Sectional Meetings
in Surgery and Urology respectively. Dr. Stewart A. Wallace of Kamloops was unable
to attend and present his paper in Urology.
Dr. Wallace Wilson is Chairman of the.Committee on Economics of the Canadian
Medical Association and presided at the Dinner and Conference on Economics which was
addressed by Mr. Hugh H. Wolfenden, the consulting actuary who has been retained as
advisor to the Canadian Medical Association on Economics. This Dinner was largely
attended and much interest shown in this important] phase of Medicine.
Dr. H. H. Milburn attended the meeting of the Department of Cancer Control and
remained over an extra day to represent the British Columbia Branch at the Meeting of
the Grand Council of the Canadian Society for Control of Cancer.
Doctors Auld, MacLachlan, Strong and Thomas attended a conference on Medical
Education and Licensure.
Doctor Thomas attended the Conference of Medical Secretaries, at which meeting
eight provinces were represented.
Doctor B. de F. Boyce of Kelowna had Senior Membership conferred upon him in
absentia.
The next Annual Meeting will be held in Winnipeg. Dr. Gordon S. Fahrni of Winnipeg was chosen as President-elect of the Canadian Medical Association. Toronto has
been considered an ideal place for such meetings and this year added further to its
popularity.
284 LIBRARY NOTES
SPECIAL NOTICE:—During the months of July and August, the Librarain will
observe hours from 9:00 to 5:00 instead of the usual 10:00 to 6:00 arrangement.
New Books Added to the Library
Clinical Diabetes Mellitus and Hyperinsulinism, 1940, by Russell M. Wilder.
The Displacement Method, 2nd ed., 1940, by Arthur W. Proetz.
Collected Papers of the Mayo Clinic, Vol. 31, 1939.
New and Nonofficial Remedies, 1940.
Medical Clinics of North America, May,   1940—Symposium on Recent Advances in
Therapy.
BRITISH COLUMBIA MEDICAL ASSOCIATION
1940 ANNUAL MEETING
NELSON — SEPTEMBER 9th, 10th, 11th
Our Colleagues in the Kootenays invite the whole membership to attend the Annual
Meeting in September. Nelson in September provides a setting that one will long
remember. You may be assured of a welcome and hospitality that will make the heavy
scientific sessions very easy to take.
The visiting speakers include:
1. Dr.  Duncan Graham,  Professor of Medicine,  University of Toronto.     President,
Canadian Medical Association.
2. Dr. George H. Anderson (Medicine), Spokane, Wash.
3. Dr. J. Harold Couch, Toronto, Department of Surgery, University of Toronto.
4. Dr. Stuart W. Harrington, Rochester, Professor of Surgery, Mayo Foundation.
5. Dr. J. W. Lynch (Surgery), Spokane, Wash.
6. Dr. Walter de M. Scriver, Montreal, Lecturer in Medicine, McGill University.
7. Dr. Albert M. Snell, Rochester, Professor of Medicine, Mayo Foundation.
8. Dr. Harold W. Wookey, Toronto, Department of Surgery, University of Toronto.
9. Dr. T. C. Routley, General Secretary, Canadian Medical Association.
Other sessions will be provided for, and taken altogether, the 1940 Meeting will be
outstanding.
Golf?   Yes.  Luncheons and Dinners?   Yes.  Entertainment for Ladies?  Yes.   Dance?
Yes.
The roads in British Columbia will be excellent in early September.
Make your plans now and notify the office for Hotel Reservations.
STUDY THE MAP ON PAGE 299.
285 NELSON, B. C.
Where the Annual Tournament will be held.
Beautiful Kootenay Lake—Nelson, B. C.
286 V
ancouver
G
enera
Hospita
LIPOMA OF THE COLON
From the Surgical Service of Doctor G. E. Seldon
Radiology by Doctor W. A. Whitelaw
W. A. Morton, Senior Resident in Surgery, Vancouver General Hospital
A white male, forty-two years old, was admitted to the Vancouver General Hospital
on January 18, 1940.   His complaints on admission were:
(1) Intermittent crampy pains starting in the right iliac fossa, and spreading over the
lower abdomen—eighteen months.
(2) Nausea and vomiting—eighteen months.
Three years ago he had symptoms suggestive of peptic ulcer and two years ago a
gastro-enterostomy was done. He was free of symptoms for six months following this
operation.
In March, 1939, X-rays were taken and he was told he had a "leakage of the
bowels." At a second operation in March, 1939, no "leakage" was found, so only the
appendix was removed.   His symptoms had persisted ever since .
Exclusive of adenomatous polyps, lipomas are the most common benign tumours of
the gastro-intestinal tract. Pemberton and McCormack in 1937, found in the literature
one hundred and thirteen (113) submucous lipomas of the large bowel to which they
added three (3) of their own, making a total of one hundred and sixteen (116); of these
one hundred and sixteen (116) only fourteen (14) were in the transverse colon. Since
this report, in 1937, at least six (6) others have been reported but none in the transverse colon.
The first report of a lipoma of the large bowel was by Bauer in 1757, the lipoma being
passed spontaneously. The first report of a successful removal of a lipoma of the
transverse colon was by Gross in 1900.
Lipomas of the large bowel arise either from the submucous or subserous layers of
the bowel—very occasionally from both. They are said to be slightly more common in
the female. The youngest patient reported was sixteen years of age and the oldest
eighty-seven, while seventy-two per cent (72%) of these cases reported by Pemberton
and McCormack were over thirty-nine years of age—within the cancer period. Usually
lipomas are single, vary in diameter from one to twelve centimetres (1 to 12 centimetres), the average being about four (4) centimetres.
They may be sessile or pedunculated. They protrude into the lumen of the bowel
and may be lobulated, ovoid or pyriform in shape. Microscopically they are typical
lipomas although the stroma may be more irregular and the vascularity more marked
than usual. A dimpfing of the serosa of the bowel over the tumour is common and
has been pointed out by Bland-Sutton as a definite characteristic of the lesion.
There is no characteristic clinical syndrome, although of the one hundred and sixteen
cases, reported by Pemberton and McCormack, ninety-seven (97) had symptoms. These
symptoms were mainly obstructive, acute, subacute or chronic, partial or complete, constant or intermittent. A feeling of fullness, particularly after heavy meals, and definite
abdominal distension were early symptoms.
The diagnosis cannot be more accurate than that of a benign tumour except in those
cases when the tumour can be seen through a microscope or after it has prolapsed externally.
The commonest complication is intussusception. Comfort in 1931 recorded thirty-
three (33) such phenomena out of seventy-five (75) cases. Spontaneous expulsion seems
to be common.   Dewis noted it in twenty per cent (20%) of the cases he reported.
287 The treatment is removal and the method depends on the site of the tumour and the
choice of the surgeon. There have been operations on at least eighty-five (85) of the
cases in literature, with nine (9) deaths. The deaths occurred in the early years of
oprating. Pemberton and McCormack record the last death from operation as being in
1921, and until 1927, thirty-three (33) operations had been performed without a death.
Discussion
Dr. Whitelaw demonstrated the X-rays and reported on them as follows:
"A complete gastro-intestinal examination was made by both the ingested meal and
the barium enema.
"The stomach showed a posterior gastro-enterostomy opening placed somewhat to the
left but functionally well. There was evidence of considerable gastritis. The distal
third of the stomach showed some deformity interpreted as post-operative adhesions.
"The duodenum and small bowel were negative. At the twenty-four observation
an almost round smooth filling defect was seen in the transverse colon at a point three
inches to the left of the midhne. There was associated distortion of the haustrae and
the normal lumen for a space of six inches proximal to the filling defect. When the
barium enema was given, the defect had shifted and was noted in the transverse colon
three inches to the right of the midline. The barium forced the tumour into the hepatic
flexure where it was sharply checked and produced a partial obstruction. Otherwise the
colon was not remarkable.
"The lesion seen was considered to be a benign tumour with a pedicle from four
to six inches in length, capable of traversing the colon from the hepatic flexure to a point
three inches beyond the midline on the left."
In discussion, Dr. Seldon warmly congratulated Drs. Whitelaw and Mcintosh on their
brilliant pre-operative diagnosis.. In happy vein, he reminisced that roentgenologists
used to be of use only in the diagnosis of bony lesions, but that nowadays they are
improving so that they are becoming of real help to the surgeon. He outlined the technical details of the removal of this lipoma and reported that the patient had made an
excellent recovery, though gas gangrene and some signs of obstruction had developed
post-operatively.
CYST OF LIVER WITH PLEUROBRONCHIAL FISTULA
From the Medical Service of Dr. Lyaix Hodgins and the Surgical Service of Dr. A. B. Schinbein.
By C. E. Gould, M.D.
Senior Resident in Medicine, Vancouver General Hospital.
A fifty-year-old white male was admitted to the Vancouver General Hospital on
August 28, 1939, with a history of having been well until two weeks prior to admission,
when there was onset of sharp, crampy pain in the right upper quadrant, radiating across
to the left upper quadrant, and through to the right subscapular region. These pains
were accompanied by a generalized soreness over the entire abdomen, so that he could
not bear the pressure of a hot water bag. Attacks lasted from two) hours to two days,
and were accompanied by severe vomiting. The vomitus was not abnormal in any way.
Stools were fight-coloured on several occasions, but never clay-coloured or bloody. The
periods between attacks were rarely longer than twenty-four hours. He was never
jaundiced.
Past History. Bilateral herniotomy in Calgary, 1922; appendectomy, cholecystectomy
and excision of a tuberculoma on the anterior border of the liver, at the Mayo Clinic,
in 1923; hemorrhoidectomy at the Mayo Clinic in 1927. Otherwise he had enjoyed good
health following discharge from the Mayo Clinic in 1923 until his present illness, and
had worked as a labourer during this period.   There was no history of venereal disease.
Examination: He was well-developed and well-nourished, appearing five to ten years
younger than his age, with ruddy complexion, and in no apparent distress. The head,
neck, and lungs were negative. The heart was not enlarged, the sounds were rhythmical
and of good quality, no murmurs, blood pressure 140/90.   On the abdomen were her-
288 niotomy and laparotomy scars, but there were no masses, rigidity, or tenderness. The
liver, kidneys and spleen were not palpable. There were no other physical signs. The
temperature on admission was 101.4°, pulse 96, and respirations 22.
Laboratory Investigation: The white blood cell count was 9,200, with polymorphonuclears 66%; lymphocytes 19%; monocytes 2%; eosinophiles 5%; disintegrated cells
8%. The red cell count was 4,900,000, with haemoglobin 102%, and a colour index of
1.04. The sedimentation rate was 31/74 (modified Westergren). The blood Kahn was
negative. The urinalysis was negative. The icterus index was 8, while the Van den
Bergh was 2.5 mg., with a delayed direct reaction. Gastric analysis revealed normal
amounts of both free hydrochloric and total acids, and a trace to -j-1 occult blood in
the specimens. Sedimentation rate repeated on the twelfth day, two days prior to discharge, was 21/82.
The electrocardiogram was "within normal limits." X-ray of the chest showed
"slightly increased detail of the bronchial markings throughout but otherwise no evidence of lesion.   The right diaphragm appears slightly irregular."
X-ray examination of the gastro-intestinal tract with barium revealed no abnormalities of note other than "a slight amount of irritation" of the cardiac antrum, and
a slight amount of spasticity in the colon.
Flat plate of the abdomen taken before the barium series had revealed no evidence of
stone in the upper right quadrant, or other abnormality, and this was followed up eleven
days later with examination of the biliary tract following ingestion of "Stipolac," by
double dose method, in an attempt to obtain visualization of the common duct despite
the absence of the gall-bladder. This was not successful, and no information was
obtained.
Progress: On admission he was put on a fat-free diet. During his stay in hospital
the temperature, which during the first three days swung between 99° and 101°, tended
to level off rapidly, but never quite to normal, and up to the day of his discharge rose
to 99° daily.
During the two weeks he was in the hospital he had no severe abdominal pain, and
no nausea or vomiting. On the fifth day he complained of pain in; the right shoulder,
along the border of the trapezius, and also medial to the inferior angle of the right
scapula, of a dull aching character. This subsided in a few hours, and did not recur.
During the last week he was free of symptoms and was comfortable and cheerful.
Because of his good general condition, he was discharged to the Outpatient Department on the fourteenth day. No definite diagnosis had been made, and it was realized
that his temperature was not quite normal, and that his sedimentation rate was high.
He was readmitted September 22, eight days later, with a history of having developed severe cramping right upper quadrant pains the day after discharge, when he had
walked a few hundred feet. These passed away on lying down, but recurred the next
day while in bed, and had continued to recur, although he remained in bed.
Physical examination was the same as on his previous admission. Temperature 99°,
pulse 84, respiration 20. The white blood cell count was 10,600, with polymorphonuclears 42%; staff cells 4%; lymphocytes 40%; monocytes 2%; eosinophiles 3%;
basophiles 2%; and disintegrated cells 7%. The red cell count was 4,800,000, with
haemoglobin 84%, and a colour index of 0.9. The sedimentation rate was 1/62, and
repeated on the eleventh day was 10/76. The urinalysis was negative. X-ray of the
chest showed "some densely calcified nodes in the right hilum with slight hilar scarring.
There is no definite evidence of active parenchymal disease." During the first four days
abdominal pain was frequent but not very severe, and was temporarily relieved with
nitroglycerin gr. 1/100, and trasentin tab. i.
The Section of Neurology saw this patient in consultation and felt that there was a
background in the patient's social history that might be contributory to a psychoneurosis,
On neurological examination he feigned several positive signs. The cerebrospinal fluid
was normal.
He was in the hospital for twenty-one days, and was free of symptoms for the last
ten days.   He was again discharged to the Outpatient Department, with a diagnosis of
289 psychoneurosis, although it was realized at the time that this was probably an incomplete diagnosis because of the persistent low-grade temperature, and the high sedimentation rate.
He was readmitted November 13, thirty-two days after discharge, with a history of
having been well, except for occasional twinges of right upper quadrant pain, until one
week previously, when there was onset of severe pain in the right lateral chest, radiating
up toward the right shoulder. This pain was practically constant, and accentuated by
coughing, and by any torsion movements of the thorax. The pain became progressively
more severe, until, on the morning of admission, he suddenly "felt something give" in
his chest, the pain disappeared, and he coughed up about a pint of foul, yellow-green
material.
The temperature on admission was 98.6°, but within forty-eight hours was 102°,
and swung between 99° and 103° during the first week. Examination revealed percussion dullness in the lower third of the right chest, with coarse, moist rales in this area.
The patient continued to expectorate large amounts of foul yellow-green material, which
on repeated examinations was found to contain hooklets of Echinococcus granulosus.
X-ray of the chest showed irregularity of the right diaphragm, with marked infiltration of the pulmonary tissue for an inch above it. Blood studies were unchanged from
the previous admissions, with the exception of the sedimentation rate, which dropped to
1/18. Intradermal skin test for echinococcus was strongly positive. An irregularly
febrile course ensued, usually to 100° daily, but occasionally as high as 103°, and on
the fourteenth day a chest X-ray showed a very marked infiltration at the right base,
extending as high as the fourth rib anteriorly. The diaphragmatic outline was not visible
in the infiltration.
Dagenan was started on the ninth day, and discontinued five days later because of
renal symptoms, with blood and dagenan crystals in the urine. It lowered the temperature somewhat, but did not appear to have any beneficial clinical effect.
On December 12, the thirtieth day of admission, rib resection was done, four inches
of the tenth rib in the mid-axillary line being removed. A large cyst cavity was found
filling the entire right pleural space, and on exploration a tract was found leading from
the right lobe of the liver through the cupola of the diaphragm to the right pleural
space. The cavity in the liver appeared to be about the size of a hen's egg. As much
as possible of the lining of the cyst in the pleural cavity was removed, together with
numerous daughter cysts.   The wound was packed with vaseline gauze and left open.
Following operation the patient ran a low-grade febrile course and required large
amounts of opiates for chest pain. The wound drained profusely, and expectoration of
large amounts of yellow-green purulent material continued. Repeated examination of
this material throughout January, 1940, revealed no evidence of echinococcus, however, and the patient's general condition improved slowly. At time of writing (February 1, 1940) he is afebrile, the drainage is diminishing, and his general condition is
fairly good, although still in hospital on complete bed rest.
Comment:
This man presented an unsolved diagnostic problem on two admissions, while on the
third the pathological lesion was obvious upon admission, and it only required examination of the sputum to determine the etiological agent. Tentative differential diagnosis
on the third admission, pending sputum examination, was:
(1) Tuberculous abscess of the liver with hepato-bronchial fistule;
(2) Subphrenic abscess with hepato-bronchial fistula;
(3) Echinococcus cyst of liver with hepato-bronchial fistula;
(4) Actinomycosis of liver with hepato-bronchial fistula.
An interesting aspect of this case was the remarkable manner in which he improved
on rest in bed and a fat-free diet on his first two admissions. This fact, with the absence
of objective findings, the feigning of signs on neurological examination, and some reluctance to be discharged, together with a social history that appeared sufficient cause
for a neurosis, were the factors that led to a diagnosis of psychoneurosis at his second
290 .
admission although his slightly elevated temperature and increased sedimentation rate
were not overlooked, and an organic basis was suspected.
With the diagnosis established, the question arose as to how long he had had hydatid
disease. His past history was rechecked, and it was1 revealed that his domiciles had been
Wales, England, the southern and middle western United States, and British Columbia;
that he had never had anything to do with sheep; and that he had kept dogs as pets
most of his fife. A letter was written to the Mayo Clinic regarding the excision of a
tuberculoma from the anterior border of the liver in 1923, and their answer, following
re-examination of the specimen, is quoted in part as follows: "The mass shows marked
calcareous degeneration, necrosis and fibrosis. I am unable to find hooklets; however,
there are remnants of chitinous membrane, which is strong presumptive evidence that
this lesion is an old echinococcus cyst. The calcareous degeneration and necrosis led us
to make a diagnosis of tuberculosis in 1923."
Having harboured echinococcus at least since 1923, it is most probable that his
present troubles are due to the onset of secondary infection within the cysts, and his
immediate prognosis would appear to depend upon his ability to overcome the existing
secondary infection, both in the thorax and within the fiver, and allow the parasite to
settle down again to a period of quiescence.
Final diagnosis: Echinococcus cyst of the liver, with rupture through the diaphragm,
and pleurobronchial fistula.
CASE OF DIFFUSE LYMPHOSARCOMA
WITH PATHOLOGICAL REPORT
[We regret that owing to an unfortunate oversight this contribution from St. Paul's Hospital was
omitted last month. We were heavily overset, and in selecting material, a mistake occurred, owing to
which this article was left out. We tender our apology herewith to the energetic Publications Committee
of the Staff of St. Paul's: and assure them it was entirely an oversight on our part.—Ed.]
H.M.: aged 15 years, white, male. Admitted to Hospital March 26, 1940. Only
child. Father and mother alive and well. No history of t.b., cancer, diabetes, rheumatic
dyscrasia or mental disease in the family history. On admission, this boy gave the following history: He was apparently well up to two months prior to admission. At that
time he noticed a small lump in the right submaxillary region. This small lump gradually enlarged and occasionally became tender. Nothing further was noticed subjectively,
but one month prior to admission he developed a fever which did not abate but was
present continuously. At that time he was in bed, and it was believed that he had a
slight attack of 'flu, but he never seemed to recuperate fully, and gradually weakness
ensued, with some shortness of breath, general debility and vague malaise. However, he
continued on in school until three days before admission to Hospital on March 26. At
that time he noticed that his abdomen had become gradually enlarged, and he complained
of a heavy sensation and, dragging in his epigastrium. His appetite had been capricious
but not altogether absent. Bowel movements were regular, and he had no urinary disturbances.
The past history revealed the usual childhood diseases, such as measles, mumps and
chicken pox.
On examination at time of admission, temperature was 99, pulse 100, respirations
22, blood pressure 110/90. Nutrition appeared to be good, although the boy appeared
to be pale; there was marked circumoral pallor. Skin was moist. Respirations were
rathe rshallow.    He was bright mentally and answered the questions quite lucidly.
291 Exmaination of the head: Pupils react to fight and accommodation. Fundi were
normal. The face was flushed. Nose essentially negative. Ears negative. Mouth: teeth
were good. Mucous membrane appeared pale. Notning remarkable in the gums. Tongue
slightly coated.   Minimum amount of pharyngeal injection.
Examination of the neck: revealed a marked adenopathy of both submaxillary
regions. There was one large lymph gland, about the size of a large walnut, present in
the left submaxillary region. This was freely movable, discrete, resilient. Numerous
smaller glands could be palpated on the other side, and also underneath the sternomastoid
muscle. Supraclavicular glands were easily palpable and had the same consistency as
described above.
Examination of the chest: The heart was not enlarged to palpation and percussion.
On auscultation, a faint systolic murmur, probably of haemic origin, was heard in the
apex. Otherwise heart sounds were closed. The rate was increased to 100, and also
there was a slight accentuation of the first sound. The lungs expanded bilaterally well.
There were no adventitious lung sounds an auscultation and percussion. Palpation
revealed nothing significant.
Examination of the abdomen: There was a large mass in the right hypochondriac
region, which could be palpated. It reached almost a hand's breath below the costal
margin and signified a greatly enlarged liver. The left hypochondrium was dull as well,
although the spleen could not be palpated easily. There was some dullness in the flanks,
suggesting some ascites. The abdominal veins appeared to be more pronounced than
usual. W^
Examination of the inguinal and axillary regions revealed the same discrete, diffuse
lymphadenopathy.
Examination of the extremities, both upper and lower, was essentially negative.
Neurological examination proved to be negative.
Rectal examination was performed, and nothing out of the ordinary was found.
Lab. examinations: Agglutination tests for typhosus, paratyphosus A. and B. and
B. abortus were all negative. Heterophile agglutination for infectious mononucleosis was
negative. Complete blood count was as follows: Hg. 57%; R.B.C. 2,850,000; W.B.C.
4,200; Poly. 60%; Eos. 1%; Lymph. 39%.
The first urinalysis report showed: Sp. Gr. 1008; acid reaction Albumin, sugar and
ketones were not present.
The second urinalysis report on March 30, showed: Sp. Gr. 1010; Acid reaction;
plus 1 albumin; sugar and ketones negative. There were a few epithelial cells and some
bacteria.
The second blood count March 28, showed: Hg. 54%; R.B.C. 2,730,000; W.B.C.
4,000; a few nucleated reds were seen. Blood smear revealed the following: segmented
14; stabs 27; juveniles 9; lymphocytes 48; eosinophiles 2.
Reticulocyte count was less than .05%. Platelet count revealed 115,000. Icterus
index was 6.9.   Kahn test was negative.
X-ray was taken of the kidneys, ureters and bladder by means of intravenous
pyleography. The preliminary film showed a generalized greyness and lack of detail,
which was probably due to intra-abdominal fluid.
The films of the kidneys after the intravenous dye injection showed the appearance
of the calyx and pelvis of the kidney on either side in the usual interval. The minor
calices were well pointed and the outline of the kidney pelvis, although large, was regular
with no filling defects.
There was still generalized lack of detail which obscured the film of the lower pelvis.
There was also density in the right quadrant which was attributable to an enlarged
fiver.
The conclusions from the X-ray report were: negative for opaque calculi, negative
for any filling defect or evidence of focal lesion of the kidneys, but there was a suggestion
of generalized ascites and possibly an enlarged liver.
Page 292 An exploratory operation was performed on March 30, 1940. The abdomen was
opened through an upper mid rectus incision, and a very large liver presented itself.
There was very little fluid in the abdomen, but the entire mesentery was a solid mass of
glands, the aorta and vena cava being practically encased in the glands. The spleen
was enlarged. Both kidneys were approximately four times normal size retaining their
kidney shape, adherent, but seemed to be distended. A gland was removed from the
undersurface of the transverse mesocolon for microscopic examination. The abdomen was
closed without anything further being done. There was no evidence of metastatic deposits in the liver.
Following operation, patient's immediate condition was fair, but two hours afterward his pulse became slow and irregular, and the boy went into an acute collapse and
quickly passed away about six hours following the exploratory laparotomy.
The pathological report of the gland that was removed at operation was as follows:
The specimen consisted of a small mass of tissue, apparently a lymph gland which appeared
white and homogeneous, on section showed nothing remarkable in the gross.
On microscopic examination it was very homogeneous in appearance. The normal
architecture of the gland was entirely replaced by large sheets of cells, fairly uniform
in size, dark staining, with hyperchromatic nuclei showing a very large number of
mitotic figures. Small capillaries were engorged with blood, and a few fine trabecular
ran through the gland structure. This had the appearance of a lymphosarcoma which
was exceedingly malignant.
A post-mortem was performed by Dr. McNair on this patient on April 1, 1940.
The following is the post-mortem report:
Body was that of a white boy, apparent age 16, well developed and nourished, with
reddish-brown hair, clear complexion, blue eyes, some slight cedema of the lower extrmei-
ties. There was an operative wound to the right of the umbilicus 6 inches in length,
closed by suture. This boy died approximately 5 x/z hours after laparotomy. The abdomen was very full. Liver dullness was very marked, extended well below the umbilicus
in the right mammary line.    There was no demonstrable ascites.    Body was quite pale.
Body was opened in the usual way. Anterior superior mediastinum showed an
enlarged thymus, weight 70 grams, extending well down over the heart, l/2 inch in
thickness, tapering from above downwards. It had two long superior poles, each attached
to the lower end of the thyroid gland. Thymus was removed together with numerous
small glands on the antero-lateral aspect of the thyroid. Consistency of this gland varied
greatly, was distintly nodular and rubbery in consistency, and gave one the impression
of this being part of the general enlargement of lymphatic tissue.
Heart was of normal size, appeared healthy. There was no pulmonary embolus
and there was no pulmonary thrombosis.
Lungs were soft and pliable throughout, and showed moderate edema and congestion. This congestion was somewhat marked on the posterior portion of the lower
lobes, was somewhat hemorrhagic in type. Bronchi and vessels were clear. The hilus
of the lungs, posterior, superior and inferior mediastina showed numerous glands which
varied in size from a small pea, to a large peanut, many of them elongated. On section
they were pearly white in colour, soft and rubbery in consistency.
Abdomen showed a very large liver, extending well down half way to the pubis,
light brownish red in color, rubbery in consistency, with rounded lower margins. Gall
bladder was healthy.
Glands along the vessels leading into the liver were very markedly enlarged, and
quite numerous, and all glands in the abdomen from diaphragm to the floor of the pelvis
were involved, were larger, rubbery, discrete and similar to those in the thorax. Many
of these glands measured 2 y2 inches to 3 inches in length, and 1 l/z cm. in diameter.
Liver was removed. On section was deeply engorged, weighed 2,475 grams. There
appeared to be no blockage of the venous return, and on section liver was yellowish-brown
in color and central vein areas were quite prominent. There was no evidence of any areas
of cellular infiltration which could be distinguished in the gross.
293 :Ji Spleen was double normal size, very soft in consistency, reddish in color, and
exceedingly cellular.
Stomach and duodenum were normal.    Esophagus was negative.
Pancreas was enlarged and showed numerous islands of pearly-white, soft, tissue
scattered through the pancreas. These cut very readily and gave the pancreas a distinctly
irregular and nodular feeling.
Left kidney was very large. It very readily shelled out from its bed. Suprarenal
body was very small, situated at the top of the kidney, and was removed with it. Ureter
showed no evidence of any obstruction, was normal in appearance and color. Vessels of
the kidney were large. There was no involvement of the vein. Right kidney was
similar to the left, was slightly larger, and combined weight of these kidneys was 1913
grams. When the kidneys were sectioned, capsule was not adherent to the surrounding
tissues, stripped readily from the kidney substance itself. There was a distinct rubbery
feeling in the kidney. Capsule was quite tense and on opening the kidney it was pearly-
pink in color and at the upper and lower poles three or four medullary cones were seen.
The equator of the kidney and for some considerable distance on each side of it showed
complete absence of kidney tissue in the gross. Lining of the pelvis in these kidneys was
smooth and showed nothing remarkable, except that they were increasde in size particularly elongated.
Aorta and inferior vena cava were negative. Pelvic veins and vessel were normal.
Small and large intestines were negative.
Testicles were examined for embryonic tumour. Right testicle was removed and
in the gross showed nothing abnormal.
Anatomical diagnosis: 1. Myocardial degeneration secondary to anemia and toxemia.
2. Diffuse lymphoblastoma, involving the entire lymphatic system and both kidnyes. 3.
Fatty degeneration of liver.   4. Chronic passive congestion of all viscera.
Microscopic: Section of heart: muscle stains well. Nuclei are distinct. There is
considerale fragmentation of the muscle fibres and many other areas in which muscle
fibres stain poorly, and in which numbers of the nuclei have disappeared. Heart cells
show cloudy swelling. Epicardial layer shows a diffuse and very extensive infiltration
of all epicardial fat with cells which are very even in size, very darkly staining and
pyknotic nuclei. These nuclei almost completely fill the entire cell. Some of these are
seen in cell division. Infiltration with these cells does not extend past the surface of the
heart except in one or two places where they are seen between heart fibres.
Liver shows a very extensive replacement of liver tissue with the same type of cell
as is seen infiltrating the heart, invading and replacing very extensive areas of liver, and
in many places it has completely obliterated every trace of liver tissue, and is seen between
almost every liver cord. These cells are very densely packed together, and many of them
are seen actually in mitosis. Remaining liver cells show quite marked cloudy swelling.
Cell margins are indistinct, and the liver cells swollen and somewhat granular. Blood
vessels in the portal areas nearly all show a very heavy mantling with the same type of
cell.
Sections taken from upper and lower end of the kidneys show very extensive infiltration similar to the liver, destroying and in other places very widely separating what
remains of the tubular and glomerular apparatus. In many places this replacement has
been complete, so that only an occasional remnant of a tubule is seen. In other areas a
few glomeruli are still present. Bowman's space is filled with an albuminous matreial.
Casts are seen in the lumen of the tubules which in many places show complete degeneration of the epithelium lining these tubules. There is no increase in circulation or
vascularity in these invaded areas. Most of the vascular bed is seen as a few scattered
capillaries. Section from the middle portion of the kidnyes shows a very marked, almost
complete replacement of kidney tissue by these rapidly proliferating cells.
Lungs are moderately congested, show rather extensive areas of infiltration around
the bronchi, and to a lesser extent in the inter-alveolar septa.   Numerous heart failure
294 IT
cells are seen in the alveoli laden with brownish pigment together with quite marked
edema, in many places filling them.
Spleen shows no thickening of the capsule. Trabecular are very thin and there is
a normal amount of supporting splenic stroma. Malphighian bodies are not well marked,
but can be made out. Three is a fairly well marked, diffuse infiltration and replacement
of the splenic pulp with the same type of cells as has been seen invading the other organs.
Lymph glands show solid sheets of cells of very uniform size, with very hyper-
chromatic nuclei and very little protoplasm, in many places showing numbers of mitoses.
Glands are not very vascular. Capsules are practically all invaded and cellular infiltration extends through the capsule into the surrounding soft tissue.
Pancreas shows quite an extensive post-mortem degeneration and extensive infiltration with these hyperchromatic cells very extensively replacing masses of pancreatic
tissue.
Section of testicle shows extensive involvement and infiltration of the capsule and
the sub-capsular space, and the trabeculi forming supporting structure of the gland.
Gland itself otherwise appears normal.
Pathological diagnosis: Diffuse lymphosarcoma.
Pathological report courtesy of Dr. A. Y. McNair; Case report courtesy of Dr. Appleby.
Victoria  Medical  Society
Officers, 1938-39.
President . Dr. W. A. Fraser
Vice-President ,  Dr. A. B. Nash
Hon. Secretary ; Dr. E. H. W. Elktngton
Hon. Treasurer , Dr. C. A. Watson
ACTIVE IMMUNIZATION IN GENERAL PRACTICE
J. L. Murray Anderson, M.D., D.P.H.
The practice of active immunization of the members of a community is a procedure
based on the two-fold purpose of guarding the health of the individual, and of protecting the entire population from any specific disease.
In Victoria our insular position has given us a relative freedom from the more
serious infectious conditions. This has meant that our children have had little or no
contact with these diseases either in their clinical or subclinical forms, and their naturally
acquired immunity will be low. It is necessary for our own peace of mind, as for the
safety of the children, to provide some form of artificial protection where it is available.
It has long been a personal conviction that the place a child should receive any form
of immunization is in the office of the family physician. This conviction has only been
confirmed by practice in the field of Public Health.
Health Officers are always glad to educate the public, through various forms of
publicity, on the personal and community benefits of immunization. They can confer,
too, with physicians on approved forms of technique, and they are prepared to supply
without charge the necessary biologicals. However, with these preparations all available
to the family doctor, it is his privilege to provide them for the childrerii under his care.
In our type of practice, each family has an attending physician at the birth of an
infant, and that physician is usually expected to supervise the management of the child
at least through the first year. This means that every child is under the care of a private physician, nominally at)any rate, durin gthe period when most forms of immunization are indicated.
The administration of the available protective preparations during the latter half of
the first year is not only a means of immunizing the. children, but maintains contact
295 with the family, and establishes a sense of confidence and security* in the minds of the
parents.
In the selection of types of immunization, as well as in thej choice of antigens, we
must be guided by the epidemiological and laboratory studies on the various preparations.
While biological products can hardly compete with the vitamins in their multiplicity of
forms, there are a limited number of preparations presenting competitive claims and we
must keep an open mind on the choice of materials.
In organized public health there is a tendency to continue a given technique without
variation in a large number of cases. Such a procedure permits a critical analysis of
results on a large scale. The private practitioner is not so interested in mass results and
can select those preprations best suited to his individual patient.
Most antigens in general use have their merits, and the important thing is not what
we shall use, but that we use something.
Let us then examine those common diseases in which active immunization shows
promise, giving due regard to the techniques involved.
Smallpox
Smallpox vaccination was the first form of active immunization to establish its
claim, and the results achieved need no emphasis here. In the European countries not
only vaccination, but revaccination is a universal requirement. Because of our relative
freedom from smallpox on Vancouver Island, there is a laissez-faire attitude on the part
of the public, with' the result that a small percentage of our children are vaccinated on
reaching school. Children are accordingly growing up without the immunity enjoyed by
most of their parents.
Our position as a port city, in close proximity to the Orient, presents a constant
potential hazard. It is interesting that vaccination is almost universal with our Oriental
children, whose parents have reason to know the menace of variol major.
The technique of vaccination has been greatly simplified in recent years, and the
virus itself improved so that the reactions are now much smaller than in the past. It is
not surprising that many parents are skeptical on thes subject of vaccination, for most
of the vaccination scars seen in adults here consist of multiple large cicatrices, frequently
four, spread widely over the arm. One can imagine the painful reaction associated with
the production of such mutilating scars.
It is now recognized that the degree of immunity hasi no relation to the size of the
scar, and the gridiron form of inoculation is a thing of the past. With a single puncture,
or a short scratch, the scar is now usually less than one cm. in diameter.
Our practice, borrowed from the Vancouver School Service, is to vaccinate on the
lateral surface of the left arm in boys, the medial surface of the arm in girls, using a
single puncture through a drop of living virus. The arm is previously thoroughly
cleansed with alcohol and the alcohol given ample time to dry before applying the vaccine.   No dressing is indicated in most cases.
Vaccinations in infancy are associated with less reaction and a smaller scar than is
usual with children or adults, and this is the time of choice, though there is no contraindication to vaccination as early as the first week of life, where this is necessary. It is
a good practice to see vaccinations at the end of 48 hours to pick up the red papule
known as the immediate reaction that develops in immunq individuals. This is just as
much a successful vaccination as the more demonstrative primary take, and if looked
for regularly will obviate the frequent comment of the patient, "It didn't take." A
certificate should be given the patient on the appearance of the immune reaction, both
as a protection to the physician and an acknowledgment of immunity to the patient.
Vaccination has been shown to confer a complete immunity for a variable number
of years, seven usually given as a minimum, and to modify the disease for the balance
of fife. The instance is cited of a man of 80, vaccinated 60 years before, who was
infected in an epidemic of haemorrhagic smallpox. He still retained sufficient immunity
to modify the attack, and he recovered.
296 Diphthpria
Diphtheria presents one of the classic examples of the successful application of widespread active immunization to control a serious infectious disease. In Canada diphtheria
toxoid came into general use on a wide scale about 1929, and in each of the provinces,
and in each of the large cities, the incidence of diphtheria dropped sharply in the next
few years. In the United States alum precipitated toxoid is widely used with similar
results.
To appreciate the nature of these preparations it might be of interest to recount a
romantic incident leading to the discovery of toxoid,—as it is reported by a recent
article by Donald Fraser1.
Ramon, working in a suburb of Paris, had left standing a row of glasses containing
diphtheria toxin, and antitoxin in varying proportions, preparatory to carrying out the
biological titration of his toxin after the technique of Ehrlich. He noticed that certain
of the tubes, on standing, showed a cloudy suspension, and put it down to contamination. He went on with his test and inoculated a series of guinea pigs. The usual number
of animals died from the effect of the unneutralized toxin. He noticed that the cloudy
tubes were those in which the toxin was just neutralized! by the antitoxin. Repeating
the experiment, he added formalin to control the supposed contamination, but again
the turbidity appeared. This time, however, instead of the usual number of animals
succumbing, all survived.
Ramon had thus demonstrated the turbidity that is the basis of the flocculation test
for titration of toxins. At the same time he showed that formalin, added to diphtheria
toxin, reduced its toxic effect. It was later shown that in spite of this loss of toxicity,
the formalin did not interfere with its power as an antigen to call forth the production
of antitoxin. This preparation was first called ana-toxin (Ramon), and later, for convenience, toxoid.
Diphtheria toxoid has been further modified in recent years by the addition of potassium alum. This addition undoubtedly increases the antigenic power of the toxoid, and
a good deal of work has been done to compare the relative merits of the unmodified
toxoid, and the alum toxoid.
Alum precipitated toxoid is usually given in one or two doses, unmodified toxoid in
three. Alum toxoid is less readily absorbed, and frequently leaves a red nodule at the
site of injection, with occasional abscess formation. Measurements of circulating antitoxin at intervals following injection would indicate that 3 doses of unmodified toxoid
produce a greater and more prolonged response than 2 doses of alum precipitated toxoid,
and certainly more tha non edose of A.P.T. In Canada it is generally felt that in spite
of the extra injection required, unmodified toxoid is the preparation of choice, and this
is the product commonly distributed by Health Departments.
"How long will the immunity last?" is a question often asked by parents. Wtih
adequate dosage of either antigen the immunity conferred is about 95 per cent. This
gradually drops until, at the end of the fifth year, one-third of the children have lost
their immunity. It is accordingly recommended that where toxoid or alum toxoid have
been given in infancy, a single reinforcing dose of a similar product be given the child
on entering school.
It is of interest that where any appreciable amount of circulating antitoxin is present
in the blood stream, the response to any antigen is great. Those with little or no measurable antitoxin to start with show a poor response and probably constitute the 5 per cent
who do not acquire a satisfactory immunity. It is again a case of "to him that hath shall
be given."
In the use of diphtheria toxoid there is almost a complete absence of local or general
reaction during the first five years of life. Over that age, reactions usually occur,
increasing in number and intensity until by the age of 14 some 20 per cent of individuals show some degree of local or general disturbance. A fairly general practice is
to apply the intradermal reaction test to all children over 10 years of age, before immunization.
297 The time of choice is, as in smallpox, 6-12 months of age, to protect the children
during the vulnerable preschool period. At this age, few have natural immunity and
reactions to injection are rare.
Scarlet Fever
The incidence of scarlet fever has fluctuated widely in the last decade, and the
disease has lately appeared in a rather mild form. There has been an average of 5.5
deaths annually in this province directly attributed to scarlet fever—not a high rate,
but none the less 55 children who have died from a so-called preventable disease in the
past 10 years. However, the physician respects the disease not so much for its fatality
rate, as for its unpleasant sequelae, and as the source of various forms of streptococcal
infections.
Because of the difficulty in recognizing all cases of scarlet fever, and in isolating all
cases, contacts and carriers, the only adequate method of controlling the disease is the
immunization of all susceptibles in a given group.
This procedure, while applicable in institutions, presents very practical difficulties in
the field. Scarlet fever toxin is the only satisfactory antigen at present available, and its
administration is often followed by fairly smart rections, particularly in adults. Further,
the course of five injections is objectionable to some parents.
In spite of these difficulties, it is a reasonable procedure to provide this protection for
infants and young children, particularly those seen in private practice.
Following an outbreak of scarlet fever in Peterborough, Ontario, in 1937-38, Dr.
Murray Fraser2, the local Health Officer, found a general demand for scarlet fever inoculation. He conducted Dick tests on most of the school children, and found in that
group, age 5-16, that 71 per cent were positive, that is, susceptible to scarlet fever. 1100
of these susceptibles were immunized with five doses of toxin. In the year following the
campaign, 51 cases of scarlet fever occurred among the school children. None of these
cases were in children who had completed a course of immunization.
A large study is reported from Edmonton by Little2. In 1936-37 nearly 7000 school
children were immunized (47 per cent of the enrolment). In the following three years,
447 cases of scarlet fever occurred, distributed as follows:
No. in group Cases Rate per 1000
Immunized :  6982 29 4.1
Non-immunized     8063 418 51.8
Had the case rate of the immunized group been the same as in the non-immunized
children, there would have been 361 cases in that group. It is reasonable to assume that
332 cases of scarlet fever were prevented by immunization in Edmonton during that
three-year period.
A nation-wide study of scarlet fever by the Committee on Cost of Medical Care,
and the U. S. Public Health Service3, covering 9000 families in 18 States, has shown
that while the peak of scarlet fever morbidity is 6 years, the peak of mortality is 3 years.
Since the Peterborough and Edmonton campaigns showed such results among school
children, we would feel that even more important results could be obtained in the older
infant, and preschool groups—and for these one must rely almost entirely on the private
physician.
Scarlet fever toxin, treated with formalin, has been tried, but, unlike diphtheria
toxin, it loses its antigenicity when so modified. George and Gladys Dick4 have reported
immunization of part of a group of volunteers by oral administration of 500 cc. scarlet
fever toxin in graded doses. It is interesting that oral administration gives some results,
but our patients might find a pint of toxin rather a stiff cocktail.
The usual technique consists of 5 weekly injections of l/z cc. scarlet fever toxin.
Each dose is considerably more potent than the preceding one, the successive ampoules
containing 330, 1000, 2500, 5000 and 10,000 skin test doses of the toxin. This dosage
is considerably smaller than that advocated by Dick4, but even in this strength causes
frequent reactions. Where such reactions are encountered the series may be extended
with smaller doses, having due regard to the increasing potency of the toxin in the suc-
(Continued on page 301.)
298 HOW TO
REACH
NELSON
BY TRAIN—C. P. R.
] KETTLE   VALLEY  ROAD,
24-HOUR  JOURNEY.
BY AUTOMOBILE
Route 1
Via   SPENCE'S  BRIDGE
^ MERRITT-PRINCETON
HEDLEY-FENTICTON-OLIVER
GRAND   FORKS-ROSSLAND-
TRAIL  TO NELSON.
Route 2
Via   LYTTON-ASHCB<
VERNON-KELOV
OLIVER-GRAND
NELSON.
299 Route 3
Route 4
Route 5
OOPS- ^mSPoSoSSDEN?^     via   XAMLOOPS-VERNON- Via   KAMLOOPS-REVELSTOKI-
ECTON- (BIG BEND   HIGHWAY)- MONASHEE PASS-NAKUSP- GOLD EN-FIELD-BANFF -
MX*- INVERMERE-CRANBROOK- NELSON. CRANBROOK-NELSON.
CRESTON-NELSON.
300 ACTIVE IMMUNIZATION IN GENERAL PRACTICE
(Continued from page 298.)
cessive ampoules.   Dick also suggests taken up 3-5  min.  1:1000  epinephrine solution
in the same syringe as the toxin to control reactions.
Whooping Cough
Whooping cough causes many more deaths each year than measles, scarlet fever,
diphtheria and smallpox together, and constitutes a major challenge in the field of
immunization.
The results obtained by using whooping cough vaccine from stock cultures have been
singularly disappointing. Recently Sauer has prepared a vaccine using strains freshly
isolated from cough plates, or from immediate subcultures, and he has shown by epidemiological studies that these confer a considerable degree of protection to children.
Silverthorne in Toronto has confirmed these results in a well controlled series. From
a group of vaccinated children, 41 were directly in contact with whooping cough and
only 2 took the disease. Neither of these had completed the course within four months
before exposure.  In the control group, 23 of 27 contacts developed whooping cough.
Whooping cough is probably the infectious disease most feared by parents today.
The Sauer vaccine, though still requiring complete confirmation, gives definite promise,
and may reasonably be provided to young or debilitated children, and those whose parents
request this form of protection.
Since the full response to this antigen is not obtained for a period of four months
after injection, it cannot be used in the face of an epidemic.
The recommended dose of the Sauer vaccine is 1 cc. in each arm on four successive
weekly visits, a total of 8 cc.
Another type of whooping cough antigen is that prepared by a commercial firm
(Lederle). It has been shown that this "detoxified antigen" in rabbits rapidly produces
an antibody that prevents local necrosis around the site of an injection of living culture
of H. Pertusis. It is assumed that thisvprotection is a form of antitoxin called forth by
the antigen. While this product is apparently giving satisfactory results in early treatment, and as a prophylactic over short periods, there is a lack of independent reports
on its use for general immunization.
Typhoid
Typhoid vaccine is today indicated only under specia 1 circumstances. Where it is
given in private practice one might be mindful of the reactions, and except in robust
individuals start with a small dose, say 1/10 cc. instead of the usual % cc- Sharp reactions are not appreciated by either the physician or) the patient.
Other forms of active immunization are not so widely applicable, and will be considered beyond the scope of this paper.
The various forms of immunization discussed may seem to present a formidable
programme for the infant of a year. In private practice one will not attempt to regiment all patients for the full series, but the choice of antigens will be directed by the
discretion of the physician, and the response of the parents. It is reasonable, however,
that the physician should discuss the field of immunization with the parents of the
babies under his care and provide those forms of protection that seem indicated, having
in mind the welfare of the community, as well as of the individual patient.
With the falling incidence of smallpox and diphtheria, the physician's responsibility
is today shifting from therapy to prophylaxis in these fields. The practicing physician
is in the best position to provide protective measures for the infants and young children
of the community.
The Health Departments and School Health Services offer immunization to those
who have not received it from the private physician, and constitute a secondary line of
defence of personal and community health.  But the best interests of the community, as
301 well as of the individual, will best be served when every patient looks with confidence
to his family doctor for the prevention of illness as well as for its cure.
REFERENCES:
1. Fraser, Donald T.: Diphtheria Toxoid—C. P. H. J., 1939, v. 30, p. 469.
2. Little, G. M., and Fraser, G. Murray: Scarlet Fever Immunization—C. P. H. J., 1939, v. 30, p. 488.
3. Collins, Selwyn D.: FEstory and Frequency of Scarlet Fever Cases—P. H. Reports, 1938, v. 53, p. 409.
4. Dick and Dick: Scarlet Fever—Year Book Pub., Chicago, 193 8, 89 and 134.
5. Silverthorne, Nelles: Whooping Cough—C. M. A. J., 193 8, v. 556.
THE CERVIX A FOCUS OF INFECTION
A. M. Agnew, M.D.
(Red before Victoria Medical Society.
The role of foci of infection in the aetiology of a multitude of pathological conditions has long been well established and daily, the cloudy sinus, the exuding tonsil, and
the dead tooth come under suspicion and under active treatment, to the betterment of
the body physiology and to the greatly increased general sense of well being of the
patient.
For some time past, in treating infected cervices, to clear up an offending discharge
or because its unhealthy appearance brought a fear of some malignant process in the
future, it has gradually been borne in upon me, by gradually increasing clinical evidence,
that here is a chronically infected organ, the commonest focus of infection in the
female body.
Throughout the various periods of a woman's life, the cervix, it seems, is always
playing an offending part. As a young woman it has been held responsible in some way
for her dysmenorrhoea. During her active reproductive life it gives offense in painfully
prolonging an already painful function, that of labour. Then in her later years it adds
to her discomfiture by appearing literally at the introitus, and to her at least, gradually
dragging everything else with it. However, a better knowledge of physiology is bringing
relief in her dysmenorrhoea; the pains of labour have been greatly alleviated, and proper
surgical treatment entirely relieves the prolpse. Something that the cervix has not been
sought out and blamed for, is as a focus of infection in the aetiology of pathological
conditions which are often apparently entirely unrelated to the pelvis, and this I think is
its commonest offense against the female physiology.
The cervix is at all times exposed to a myriad infecting organisms from the
vagina, which is never a sterile tract. These organisms, of low virulence to the host,
gain entrance to the deep glands of the endocervix. These glands become infected also,
often with more virulent organisms, during attacks of acute or sub-acute cervicitis,
which is a fairly common occurrence. The trauma of abortion, miscarriage and labour
open up the portal of entry for these ever-present organisms. Following acute salpingitis,
post abortal parametritis, etc., organisms remain deep in the glands of the. endocervix.
Here, being well protected and well incubated, they multiply and produce small abscesses.
These small abscesses enlarge, the infection extends and the whole cervix may become
riddled with these small infected cysts, the so-called chronic cystic cervicitis. The cervix
is richly supplied with blood and lymphatic vessels through which absorption from this
infected organ takes place into the systemic circulation. In spite of our knowledge of
the existence of this chronically infected organ in the female pelvis, we have never considered it sufficiently as a focus of infection, as we have the cloudy sinus, the infected
tooth and the exuding tonsil, as prime factors in the causation of general systemic disease.
This is due, no doubt, partly to our own neglect in not making a careful pelvic examination in the woman whose symptoms are not referable to the pelvis and partly also to the
fact that the patient herself so often has had a slight or moderate vaginal discharge for
so many years, that no importance is attached to it in her mind, it being just one of
those annoyances that women have to bear.
302 In reviewing cases, in search of evidence of the importance of the cervix as a focus
of infection, I have divided the mroughly into three classes as follows:
A. Those where the symptoms Were referred to the pelvis.
B. Those where the symptoms were not referable to the pelvis.
C. Those with general systemic symptoms together with some gross pelvic path-
olo
gy-
Under each of these headings let us consider several groups of patients:
A. (1)     Those whose only complaint is of a vaginal discharge.
In the great majority of these cases this is a misnomer as it is not a vaginal discharge
but a cervical discharge, and vaginal douches and tampons will only give slight relief,
permanent cure only being effected by treatment applied to the cervix.
A. (2) The patient who complains of chronic aches and pains referred to the
lower abdomen and pelvis, with a heaviness and bearing down sensation, usually more
prnounced just before and during menstruation and often accompanied by a feeling of
distension in the lower abdomen and gas. On pelvic examination, the uterus feels bulky
and heavy and with the adnexa is very tender on palpation and to movement. Usually
examination of the cervix shows it to be infected and it is for this reason that the usual
treatment of hot douches and sitz baths give only temporary relief and not permanent
cure. The absence of blue domed cysts or a discharge of pus from the cervical canal on
examination does not mean that this organ is clean and healthy, for such a cervix may
and likely does contain numerous infected cysts high up in the canal and deep in the
tissue, which are only reached by treatment with the actual cautery.
So many patients in this group become entirely symptom-free with no other treatment than that directed toward the elimination of infection from the cervix,, that one
feels the focus of infection here was the sole cause, eradication of which stopped absorption from this infected organ, which resulted in the clearing up of the congestion in the
pelvic viscera and the return of these to normal.
Into this group fall those, usually younger, women, who have had an acute salpingitis with pelvic peritonitis, or a post abortal parametritis with or without peritonitis.
These patients treated with hot foments and hot douches, diathermy or Elliot treatment,
etc., respond nicely and apparently leave hospital cured, only to reappear at a later date
as chronic complainers with chronic aches and pains as mentioned above. In these cases
the treatment is not complete when they are discharged from hospital apparently well
recovered from their acute illness, for a focus of infection, the source of future trouble,
has been left in the cervix, and to complete their cure should be eliminated.
A. (3) The patient with low back pain. What a common complaint amongst
women. Varying greatly in degree and amount of disability, but constant in its frequency, this complaint, "I have a backache, Doctor," finally classes many patients as
neurasthenics or neurotics.
In this group is the woman who has worn pessaries for years, has consulted the
herbalist and the naturopath, who has had her dislocated vertebrae replaced by the chiropractor and been manipulated by the osteopath. Who comes to your office with arch
supports in her shoes and wearing a sacro-iliac belt which in turn hides the scar of a
uterine suspension. With her purse empty now, but for a box of Dodd's Kidney Pills,
she comes to yet another Doctor, but still with the same complaint, "I have a backache."
How easy to say "neurotic."
Here again, in spite of the note of pessimism, an encouraging number of these
patients will gradually lose their backache as the infection, which is so often to be found,
is eliminated from the cervix by thorough treatment.
In reference to the uterine suspension mentioned above, done to relieve the backache,
on should be very careful in advising this operation even though the test of manual
replacement and insertion of a pessary to maintain a correct position of the uterus has
given a lot of immediate relief. If there is an infected cervix present the relief will be
only temporary, and the backache will recur to plague both patient and doctor.   Be
303 certain before resorting to operation that any infection in the cervix has been removed,
and frequently the backache is relieved even though the uterus remains in a position of
retroversion.
A. (4)     Sacro-iliac Pain.
The patients in this group come with the same complaint as those in the preceding
one, but here the pain is definitely localized to one or other sacro-iliac joint, with greatly
varying degrees of pain and disability. Those with minor degrees of disability in this
region are quite common, and relief from symptoms is very gratifying. The importance
of this focus of infection, in sacro-iliac disease of long standing, is best illustrated by the
following case. A young married woman, 32 years of age, whose chief complaint was of
severe pain in the right sacro-iliac region with marked disability. Her early history was
negative and there was no history of injury. She had had one pregnancy six years before,
during which at the fifth month she had an acute pyelitis, with a recurrence following
a normal delivery, and was confined to bed for four weeks post partum. In the next
few months she began to have pain in the sacro-iliac region which gradually increased
in severity as time went on, until she was barely able to carry on the lightest household
duties. During this time she had had various forms of supportive and manipulative
treatments with only occasional temporary relief. Pelvic examination showed a congenital type of retroversion with a shorter vaginal wall, and small amount of mucopurulent discharge from the cervical canal. The cervix was dilated and cauterized high
up and a good deal of pus obtained. This was repeated three times in three months, at
which time the patient was getting around and doing her own work without any difficulty, her only complaint being that when she went to a dance she seemed to get tired
before anyone else.    She has been well now over a period of a year.
B. Those where the symptoms are not referable to the pelvis. Attention was
drawn to this class of symptoms and definite pathological diseases in patients who have
come in for periodic examination over a period of years, often the symptoms were minor
in nature and only mentioned as an afterthought or on more direct questioning, but the
observations have been very interesting.
B. (1) The first group in this class are those with neuritic or myalgic pains,
usually in the shoulders anfl upper extremities. The severity of this complaint varied
greatly but in some the pain was quite troublesome. It was noted a good many times
that where some infection was evident in the cervix and treated that these neuritic and
myalgic pains disappeared. This result has occurred so often that now in such cases a
careful examination of the cervix is made for signs of infection as well as the presence
of other foci.
B. (2) As you all know, secondary anaemia with its associated symptoms of eye,
headaches, tiredness, etc., is extremely common amongst women. These women at each
yearly examination would require Iron therapy with which they would be greatly
improved but by the next visit they would be back to the same low level again. Quite
by accident again this chronic anaemia was overcome in treating the cervix to get rid
of a vaginal discharge or because of the palpable or visible presence of cysts in this body.
All other foci having been cleared up at some time or other this was apparently the only
remaining focus and the cause of the recurring anaemia. It is now part of the treatment
to eliminate this infection.
B. (3) Arthritis. This is a very important group, as Arthritis is one of the bugbears of medical practice, and I cannot stress too much the importance of a thorough
pelvic examination in the course of investigation in a case of Arthritis in a woman. A
prolonged and expensive course of treatment may be instituted while the only remaining
focus of infection, which in the occasional case is the responsible factor, remains neglected.   This is borne out in the following cases.
(1) A woman fifty years of age, who for three or four years had arthritis, involving the small joints of both hands with considerable swelling and a great deal of pain.
All of the foci of infection had been investigated and she had had considerable treatment
304 during those years.    Pelvic examination revealed a chronically infected cystic cervix,
which was treated and cauterized.
Arthritis in hands has cleared up and the patient is entirely free of pain.
(2) A woman, fifty-four years of age. Arthritis in the right knee. A lot of
swelling and a great deal of pain. Here again the focus of infection that had been
overlooked was in the cervix, and the symptoms entirely disappeared upon its elimination.
B. (4) Essential Hypertension. This is an important group to medical men, and
the observations made among this group have been very interesting. Essential Hypertension, hypertension with no demonstrable cause, is certainly one of the unsatisfactory
conditions from a theurapeutic standpoint, which every one meets only too frequently.
You have all seen in textbooks and many of you have likely had experiences of your
own, that, in women, hysterectomy has been one of the numerous and varied procedures
suggested as having some beneficial effect, in cases of Essential Hypertension. I believe
in many cases it has. Many of you, too, have possibly made the observation, that
women running a fair degree of hypertension, show a considerable regression in their
tension following hysterectomy for some other pathology, such as simple fibroids or
excessive uterine bleeding. This too is true in many cases, but not in the empirical way
that has always been followed, but because in removing the uterus we have removed the
focus of infection which was an aetiological factor in the hypertension in that particular
case. Even with a subtotal hysterectomy there is sufficient interruption of blood and
lymphatic supply to the cervix, with resulting atrophy and lessened absorption, to be of
definite benefit to the patient, but here I would put forward, the much greater symptomatic improvement to the patient by including the almost invariably infected cervix
in the extirpation of the uterus.
I have seen many women with records of periodic examination going back for
many years showing the presence of Essential Hypertension, who have developed evidence of some infection in the cervix. This was treated with cauterization, and where no
other treatment was given regressions of pressure from 15 to 40 or 50 points occurred
and the pressure remained at this lower level. I feel that in all of these cases and in
Myocardial, Anginal and Cardio-Renal disease, that this focus of infection should be
sought out and eliminated, as with any other evident sourc^ of infection.
C. Those with general systemic symptoms together with gross pelvic pathology.
This group of patients are those who have had a hysterectomy for some gross pathological condition in the pelvis. Most of these women have numerous symptoms, many
of those already enumerated, which are quite apart from the symptoms due directly to
the fibroids, excessive bleeding, etc., for which the operation is being done. It is a
common thing in these patients, when you see them six months after operation, to find
they have not only lost their pelvic pain or pressure symptoms, but that their whole
general health has improved, better colour, more energy, no little aches and pains, and
they state emphatically that they haven't been as well in years. In examining the uterus
after removal, the cervix is always the site of a chronic cystic cervicitis, varying in degree,
but always infected. It is the removal of this very definite focus of infection, which is
a large factor in the improved general health of the individual. This finding is also a
strong argument in favor of a total hysterectomy, where a hysterectomy has to be done,
more so, I think, than is the possibility of the development of a cancer in the remaining
stump, though this should always be borne in mind. If there is pathology of the body
of the uterus or adnexa, which is sufficient to warrant hysterectomy, then the focus of
infection in the cervix should be removed to give the patient the full benefit which
should be derived by her from such a major surgical procedure. In chronic pelvic inflammatory disease with old pus tubes, and a frozen pelvis, where the tubes and uterus
are removed, it will be found that where the cervix is removed the patient is a great deal
better off in her general health when seen some months later. If because of technical
difficulties in these old inflammatory pelves, the cervix is not removed, it should be most
thoroughly cauterized.
305 Treatment.
Hot douches, medicated douches, tampons, silver nitrate diathermy and Elliot treatment are only aids in treatment. The infection in this organ can only be eliminated with
the use of the cautery or its entire removal at operation. Visible and palpable cysts must
be opened with the cautery and destroyed. The cervical canal if necessary, dilated and
then cauterized. Frequently the cervix on visual examination will appear to be perfectly
clean, but on dilating the canal and cauterizing well up inside, numerous infected cysts
are opened and pus discharges freely around the cautery point. This procedure should
"be repeated at monthly intervals until the cervix is free of infection. Stenosis of the
cervical canal following cauterization is due to too enthusiastic use of the cautery at any
one treatment, and burning into the muscular layers near the internal os, with resulting
scar tissue formation and contraction. If ordinary care is used this complication will not
arise.
Conization, or coring out of the cervix by means of the high frequency radio
cautery cold cutting loop is a most satisfactory method of treatment, giving the same
good results, but with a much more expensive piece of apparatus.
If this should all sound to you like a pet enthusiasm of my own, possibly you are
right, but I hope that I have been able to give you some evidence in support of my
belief, that in those conditions mentioned and many others in which the search for and
eradication of foci of infection plays such an important part in their treatment, the
cervix should be included. •
THE BRITISH COLUMBIA CANCER INSTITUTE
The British Columbia Cancer Institute has been established by the British Columbia
Cancer Foundation at 68 5 West Eleventh Avenue, Vancouver, for the diagnosis and
treatment of cancer and depends for its operating expenses; on private and public subscriptions.
No patient is admitted to the Institute for diagnosis or treatment unless referred
by a doctor and when a diagnosis is made the patient is referred back to his own physician with the recommendation of the staff of the Institute unless the doctor requests
that treatment be carried out at the Institute.
No patient is refused admittance due to lack of funds. There is a scale of fees in
force at the Institute and every patient is expected to pay according to that scale unless
his income places him within the indigent class. The scale of fees will be mailed upon
request.
Physicians who wish to refer a patient to the Cancer Institute for diagnosis or
treatment are requested to communicate with the Medical Superintendent of the Institute before sending the patient to Vancouver so that all necessary arrangements can be
made in advance. In the case of an indigent patient, arrangements should be made
through the Municipality where possible.
While there is no direct connection between the British Columbia Cancer Foundation
and the Canadian Society for the Control of Cancer, both these bodies and the British
Columbia Medical Association have four representatives each on the Cancer Council,
whose policy and aim is to co-ordinate as far as possible the work being carried out in
the fight against cancer in British Columbia. The British Columbia Branch of the
Canadian Society for the Control of Cancer at the present time is an organization
designed to acquaint the public and the medical profession with the latest facts about
cancer. The membership fee of $1.00 is used by the Society to maintain and increase
their work of general education.
(We have been asked by the B. C. Cancer Institute to publish the above, and
would suggest a careful reading of it by every doctor in B. C. It answers several'questions that are frequently asked, and is an authoritative statement of policy, of which
we all must take careful note.—Ed.)
306 INVESTIGATION INTO SOME POINTS WITH REGARD
^^^^^M I TO CANCER
By Dr. F. N. Robertson,
Medical Staff, Vancouver General Hospital.
The, following is a preliminary report upon an investigation which has been quietly
conducted at the Vancouver General Hospital during the past few months. This investigation is still being carried on in the hope that it may lead to a test for the presence
of cancer. In a series of some fifty cases of cancer and fifty controls there has been a
remarkably high percent of accuracies.
Much credit must be given to Drs. E. White and P. A. Jones for their assistance and
their sacrifice of so much of their spare time. Without their aid this report could not
be made.
It was discovered that the blood of a cancer patient in his own urine reacted differently to the blood of a non-cancerous patient in his urine. This led to further experimentation and the following technique was evolved.
About 2 ounces of urine from a known or suspected cancer case are placed in two
kidney basins. The same amount of urine from a non-cancerous patient is placed in
two other kidney basins. From 2 cc. to 5 cc. of blood is taken from the veins of the
cancer patient and from the control. This amount of blood is placed beneath the surface of the urines—cancer blood in cancer urine—cancer blood in normal urine—
normal blood in cancer urine and normal blood in normal urine. The placing of the
blood under the urine may be done by placing the needle under the surface of the urine
and emptying the syringe. It may also be done by tipping the basin so that the urine
is at the low end and then squirting the blood into the; upper end of the basin and it
will run down under the urine. From this stage for the next 45 minutes the fluids in
the basins must be periodically disturbed. It is sufficient just to lift one end of the
basin, allowing the fluids to gravitate to one end and then set the basin down again.
This causes a wave to flow from end to end, back and forthj for a few seconds. This
disturbance of the fluid should be done at least once every five minutes. In from 40 to
45 minutes a peculiar looking clot or sometimes clots will form in the cancer blood
cancer urine basin. Sometimes a slight clot is found in the cancer blood normal urine
and normal blood cancer urine basins. This is rare. But on no occasion in all the control tests has normal blood clotted in normal urine. All urine should be clear, filtered
if necessary.   Neither patient should be taking any of the Sulphanilamides.
The degree of accuracy in cancer and non-cancer cases as proved by biopsy, operation or autopsy has been remarkable. But a small series of some fifty malignant cases
and an equal number of non-malignant cases is not large enough to either prove or disprove these observations as being a test for the presence of cancer. The investigation is
still being pursued but it is time consuming and the accumulation of statistics is very
slow. So, should any reader care to carry out this test upon any of his patients it would
be greatly appreciated by the author if he would allow him to include his findings in the
latter's list, or to communicate with the author.
This is just a preliminary report and this test must in no case be considered as a
sure sign either for or against cancer, but by enlarging the list of cases its value as a
test for cancer may be more quickly determined and it may become a boon to the profession and through them to the whole of humanity.
307 THE DIAGNOSIS OF SYPHILIS BY THE
MEDICAL PRACTITIONER
Reprinted from Supplement No. 5, United States Public Health Service.
(Continued from June issue)
SECONDARY STAGE
The Diagnostic Maxims
Six relatively simple maxims (fig. 5) should, like those for primary syphilis, be
learned by heart. The clinical diagnosis of secondary syphilis, often extraordinarily difficult even for the expert, will thereby be enormously simplified.
Figure 5.
DIAGNOSTIC MAXIMS IN SECONDARY SYPHILIS
1. Do blood serologic follow-up—3 months—on any lesion which was possibly primary syphilis.
2. For any generalized skin eruption—do a serologic test.
3. For any sore mouth or throat which does not heal in 10 days—do a serologic test.
4. For any unexplained patchy loss of hair—do a serologic test.
5. For any iritis or neuroretinitis—do a serologic test.
6. For any vague bone pains or polyarticular arthralgia—"acute, subacute, or chronic infectious
arthritis—do a serologic test.
The first of these—the serologic follow-up on any lesion which might possibly have
been primary syphilis, takes into consideration two important points: That it is highly
desirable to recognize secondary syphilis before it develops (the serologic test always
becomes positive before the actual appearance of lesions), and that the lesions of secondary syphilis may either be completely lacking or so trivial and evanescent as to be
overlooked by patient and physician alike.
The next fixe maxims draw attention to the fact that the common lesions of secondary syphilis are five—generalized skin eruptions, mucosal lesions, alopecia, iritis, and
arthralgia. There are of course other manifestations which may and do occur, but in
comparison with these five they are rare. Ninety-five per cent of all patients with
secondary syphilis will present one or a combination of these five manifestations.
The maxims also emphasize, by indirection, that the clinical differentiation of these
lesions from other conditions is often difficult or impossible, and that diagnostic safety
depends entirely on two points:
1. That the physician suspect secondary syphilis when any one of the manifestations occurs and
2. That he check his suspicion by a blood serologic test.
Fotunately for accuracy of diagnosis, the serologic test has its highest negative value
during the secondary stage of syphilis. It is always positive (100 per cent). If it is
negative, there is practical assurance that the clinical suspicion was wrong, and that the
patient has some other disease.
The Diagnosis of Cutaneous Secondary Syphilis
In figure 6 are listed 40 skin diseases (though not in order of frequency or importance) which may mimic or be mimicked by secondary syphilis.
These range from such common conditions as ringworm (dermatophytosis), boils,
pityriasis rosea, hives (urticaria), and the itch (scabies), to such rare ones as smallpox,
leprosy, and pityriasis lichenoides chronica. Even this imposing list is not complete;
many still rarer skin diseases might be added, since there is hardly any skin condition,
no matter how exotic, in which confusion with syphilis has not arisen.
308 w
Figure 6.
A LIST OF 40 SKIN DISEASES
Wh
ich Secondary Syphilis May Reserr
ible.
Nodular leprosy
Scabies
Eczema (palmar)
Acne vulgaris
Arsenical keratosis
Lichen scrofulosorum
Seborrheic dermatitis
Varicella
Pityriasis rubra pilaris
Pityriasis rosea
Dermatitis venanata
Keratosis pilaris
Tinea versicolor
Pyoderma
Lichen spinulosis
Measles
Ecthyma
Dermatophytosis   (ringworm)
Scarlet fever
Urticaria
Impetigo contagiosa
Typhoid fever
Leukoderma
Granuloma annulare
Typhoid fever
Arsphenamine dermatitis
Acne cacheticorum
Toxic erythema
Variola
Acne scrofulosorum
Maculo-anxsthetic leprosy
Pityriasis lichenoides chronica
Acne necrotica
Erythema multiforme
Lichen planus
Gumma
Chloasma
Papular tuberculides
Furunculosis
Psoriasis
DO  A  BLOOD  SEROLOGIC   TEST
Yaws
Figure 7.
PALMAR AND PLANTAR SYPHILIDES (Early or Late)
Are easily confused with—
Dermatophytosis  (ring worm)
Psoriasis
Eczema
The palmar and plantar syphilides deserve special mention (fig. 7) since their clinical
differentiation from three other disease, including the almost universal (if current day
advertisements are correct) "athlete's foot," may be literally impossible.
It is, of course, not contended that such diseases as acne vulgaris, scabies, or any of
the list of 40, always look like secondary syphilis or even that they frequently do so. In
the vast majority of cases, clinical differentiation is readily possible for the trained dermatologist, though there are just enough instances of any of them which even the most
expert dermatologist cannot identify clinically to lend the novice pause. The word
"novice" is used advisedly. In no field of medicine is the average physician less skilled
than in dermatology.
For any practitioner therefore—for any physician no matter what his specialty,
unless he has special dermatologic training—the only safe rule in diagnosis is to disregard
entirely the niceties of clinical diagnosis, to suspect secondary syphilis in any patient with
a generalized skin eruption no matter what its duration, or appearance, and to test the
suspicion by an immediate serologic test of the blood.
The Diagnosis of Mucosal Secondary Syphilis
Figure  8  is designed  to draw special  attention to a  fact  too often forgotten—
secondary syphilis may completely spare the skin, and involve only thd mucous membranes.   Equally important, the mucosal lesions may be and often are extroardinarily
trivial, a single mucous patch on the lip, an eroded surface of a hemorrhoid.
Figure 8.
SECONDARY SYPHILIS
The only visible lesions of secondary syphilis may appear
on the mucous membranes, the skin being entirely spared.
(To be continued)
309 Professional Men  appreciate
the Value of being well-dressed
A Suit tailored to your measure by us is your assurance of
Quality British Woollens, fine hand tailoring
and correct style.
Our new Spring patterns are now ready and your early
inspection is invited.
British Importers of Men's and Women's Wear
MEDICAL-DENTAL BUILDING VANCOUVER, B. C.
MEMBERS OF
THE GUILD
OF PRESCRIPTION OPTICIANS
OF AMERICA
Always maintain the
ethical principles of
the medical profession.
Guildcraft Opticians
430  Birks  Building Phone  SEymour   9000
Vancouver, Canada
IS THERE ftN
ART HRIUS-ECZEMA
:. stsoROW???:
Both are claimed to be allergic.
Both suggest mineral deficiency and
impaired elimination. Clinically,
each is symptomatically improved
by the oral use of
LYXANTHINE ASTIER
which    combines   the   therapeutic
actions of iodine, calcium, sulphur,
and lysidin bitartrate — a potent
eliminator    of    endogenous    toxic
waste.
Since the best evidence is clinical
evidence, write for literature and
sample. _     |
L-l 6
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,  Montreal L;!
Take along PABLUM
... so easy to prepare
Whether or not there is a baby in your family Pablum is a convenient, nutritious food to include in the
vacation kit. This unique cereal can be served in an instant... almost anywhere, any time. No cooking
is required. All that's needed is to add water or milk of any temperature. As a physician you will
appreciate the advantage that Pablum, unlike so many camp rations which tend to be concentrated
carbohydrate lacking in minerals and vitamins, supplies generous amounts of calcium, phosphorus,
iron and vitamins Bi and B2 (riboflavin). Packed without water, Pablum is light and easy to carry, yet
its iron and calcium content is far higher than that of bulky, perishable vegetables.
Pablum consists of wheatmeal (farina), oatmeal, wheat germ, corn-
meal, beef bone, alfalfa, yeast, sodium chloride and reduced iron.
MEAD JOHNSON  &  CO. OF  CANADA,  LTD.,    •   BELLEVILLE, ONTARIO ANAHUEMIN B.D.H.
for
Economy of Treatment in Pernicious Anaemia
The following case report of a patient, a typical case of pernicious
anaemia as used in the routine clinical testing of Anahaemin, demonstrates the effect produced by a single injection of only 1 cc.
of Anahaemin.
Initial counts:
R.B.C.    1.76   millions,   Haemoglobin   42%,   Colour
Index   1.19,   Reticulocytes  2.8%
Treatment,  Injection   1   cc. Anahaemin
5th day counts: R.B.C.   2.49   millions,   Haemoglobin   51 %,   Colour
Index  1.03,  Reticulocytes  17.4%
10th day counts: R.B.C.    2.64   millions,   Haemoglobin   60%,   Colour
Index   1.12,   Reticulocytes  2.2%
15th day counts: R.B.C.   3.18   millions,   Haemoglobin   69%,   Colour
Index 1.08
The reticulocyte peak of 18% was reached on the 6th day
One single injection 1 cc. Anahaemin, acting over a period of 15
days, raised the red cell count from 1.76 to 3.18 millions, and the
haemoglobin percentage from 42 to 69.
Stocks of Anahcemin B.D.H. are held by leading druggists throughout
the Dominion, and full particulars are obtainable from:
THE   BRITISH {DRUG   HOUSES   (CANADA)   LTD.
Terminal Warehouse Toronto, 2, Ont.
An/Can 7407 i
PARKE-DA VIS
THEELIN
Two Hundred Published Reports
Two hundred and fifteen reports on Theelin and Theelol have
appeared in the medical and other scientific journals of this country
alone. A substantial portion of references to estrogenic therapy have
been based on the use of these original products.
Ten Tears' Clinical Experience
Ten years' clinical experience with Theelin and Theelol has familiarized the physician with the therapeutic applications of these
products. It has thoroughly established their use in modern
medical practice.
Millions of Doses of Theelin
Millions of doses of Theelin have demonstrated its clinical value.
They have also indicated the confidence of the medical profession
in the original product—the first estrogen to be isolated in pure
crystalline form, the first pure estrogen to be used clinically, the
first to be reported in medical literature.
Theelin (ketohydroxyestratriene) is available as Theelin in Oil Ampoules in
potencies of 1000, 2000, 5000, and 10,000 international units each, supplied in
boxes of six, twenty-five and one hundred 1-cc. ampoules. Theelin Vaginal Suppositories, 2000 international units each, are supplied in boxes of six and fifty.
Theelol (trihydroxyestratriene) is available as Kapseals Theelol in three
strengths, 0.06 milligram, 0.12 milligram, and 0.24 milligram—supplied in
bottles of 20, 100, and 250.
PARKE, DAVIS & COMPANY, Walkerville, Ontario Seruins, Vaccines, Hormones
AND
Related Biological Products
Anti-Anthrax Serum
Anti-Meningococcus Serum
Anti-Pneumococcus Serums
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid
Old Tuberculin
Perfringens Antitoxin
Pertussis Vaccine
Vaccine Virus
Pneumococcus Typing-Sera
Rabies Vaccine
Scarlet Fever Antitoxin
Scarlet Fever Toxin
Staphylococcus Antitoxin
Staphylococcus Toxoid
Tetanus Antitoxin
Tetanus Toxoid
Typhoid Vaccines
(Smallpox Vaccine)
Adrenal Cortical Extract
Epinephrine Hydrochloride Solution (1:1000)
Epinephrine Hydrochloride Inhalant   (1:100)
Epinephrine in Oil (1:500)
Heparin
Solution of Heparin
Insulin
Protamine Zinc Insulin
Liver Extract (Oral)
Liver Extract (Intramuscular)
Pituitary Extract (posterior lobe)
"Prices and information relating to these preparations will be
supplied gladly upon request,
CONNAUGHT LABORATORIES
UNIVERSITY   OF   TORONTO
Toronto 5
Canada
"Depot for British Columbia
Macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C H        E
L        P
W
N
THE
WAR
OF NATIONAL IMPORTANCE
TO CANADIAN PHYSICIANS
^ Sulfapyridine is now made in Canada and offered
through the laboratory facilities of Ayerst,
McKenna and Harrison Limited under the name
of "Sulf adine'\
^. Physicians are now assured of constant supplies
of sulfapyridine ("Sulfadine") from a source
within Canada . .  .
^. They will welcome the opportunity of using and
prescribing a Canadian-made product.
(JfyeMt
COMPRESSED TABLET No. 818
U
SULFADINE
if
brand of 2-sulfanilyl aminopyridine
7/4 grains (0.5 Gm.)
Bottles of 100, 500 and 1000
AYERST,   McKENNA   &   HARRISON   LIMITED
Biological and Pharmaceutical Chemists
MONTREAL CANADA
909
BUY   WAR  SAVINGS   CERTIFICATES   —   PRESCRIBE  CANADIAN-MADE   PRODUCTS PROMOTES HEALING WITHOUT
INJURY TO HEALTHY TISSUE.
Propidex contains the killed cultures and filtrates of those organisms which occur most frequently in infected lesions. It is
presented in the convenient form of an ointment, which permits
a direct and prolonged application of the vaccine to the affected
parts. Propidex does not contain any chemical antiseptic agents
which may be harmful to healthy tissue.
INDICATIONS
Superficial wounds, accidental or
surgical, whether infected or not.
Burns, Bruises, Sunburn,  Blisters.
Skin diseases of pyogenic origin,
Styes, Blepharitis.
Cracked breasts, Perineal tears and
superficial irritation of the genital
organs.
Varicose ulcers, Fissures, Inflamed
piles, Bed sores, Long-standing ulcerations.
Send for  Free   Clinical Sample
in ovm*
<»m
Oft kHO
VMlOPIOON
HV
,ccv
#p
£m£*
!
SUPPLIED IN HANDY 1-OZ. TUBES
*t«5j
CANADA       LIMITED-MO  N T R E A  L I RULE OF THUMB"
A WORLD-FAMOUS diagnostician,
entering a hospital ward, once sniffed
and said: "I smell typhoid here!' And he
was right! ... The physician knows that,
with every scientific device at his command, he can never dispense with those
intuitive tests of sight, sound, touch, and
smell. . . . Similarly, with Irradiated
Carnation Milk, precise automatic controls
and laboratory determinations are always
supplemented by human judgment. A
"Rule   of thumb" expert  samples every
batch of milk, every day, in every Carnation evaporating plant. He tastes for flavor,
eyes for color, spoons for consistency—to
make assurance doubly sure that every can
of Irradiated Carnation Milk will confirm
the high standard of quality that the
medical profession has learned to expect
of this accepted food.
A BOOKLET FOR PHYSICIANS
— Write for "Simplified Infant
Feeding", an authoritative publication treating of the use of Irradiated
Carnation Milk in normal and difficult feeding cases . . . Carnation
Company, Ltd., Toronto, Ontario.
CI   IRRADIATED   "i     r       ^w
arnation Milk
A CANADIAN PRODUCT - "from contented cows" Ntttm $c
®Jf0ttt00tt
t
2559 Cambie Street
Vancouver, B. C.
Colonic
Irrigation
Institute
Superintendent:
E. M. LBONABD, B.H.
Post Graduate Mayo Bros.
Up-to-date treatment rooms;
scientific care for cases such as
Colitis, Constipation, Worms,
Crastro-Intestiiial Disturbances,
Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.
Individual Treatment... f 3.50
Butlre Course $10.00
Medication (If necessary)
$1 to $3 Extra
1119 Vancouver Block
VANCOUVER, B. C.
Phone: MArine 3723
The Purified
ACTIVE PRINCIPLE
OF
SANDALWOOD OIL
*„ a ^ECONOMICAL
Dosage Form
Doctor, why use ordinary sandalwood
oil when you can just as easily administer the active principle of the oil
with the irritating and therapeutically
inert matter removed—and at a cost
to your patients of only a very few
pennies more?
You can do this by prescribing the
new, economical 50-centigram capsules of
ARHEOL
(ASTIER)
now obtainable in bottles of 12, 24 and
100 capsules at $1.00, $1.75 and $6.00
a bottle respectively.
ARHEOL is the purified active principle of sandalwood oil. It is a uniform, standardized product with which
prompt and dependable results may
be expected. Undesirable sequelae
often associated with sandalwood therapy are either absent or reduced to a
negligible degree.
A3-BVMA
ROUGIER FRERES, Agents
350 Le Moyne Street, Montreal.
Please send me a sample of
ARHEOL (Astier) in the new
economical dosage form.
 M.D.
Street	
City  Prov	
Canadian j^fributors
ROUGIER FRERES
350  Le Moyne   Street,   Montreal flfoount pleasant XHnoertakino Co. %to.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C
R. P. HARRISON W. R. REYNOLDS
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
FAIR.  0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. L. BERTRAND for solving the
therapeutic problem of symptomatic
relief in common urogenital infections
CYSTITIS-PROSTATITIS-PYELONEPHRITIS-URETHRITIS
Pyridium is widely reported in the literature as
effective for the alleviation of painful, difficult and
excessively frequent urination, tenesmus and perineal
irritability. The therapeutic effect of Pyridium is not
incumbent upon adjustment of the urinary pH, use of
a special diet, or application of laboratory control for
toxicity. It is conveniently administered in tablet form.
■ l ———■—-
IIMI^ttP^P;
PYRIDIUM
TRADE   MARK
Literature on Request
( Phenylazo-Alpha-Alpho-Diamino-
Pyridine Mono-Hydrochloride)
•j^^fecade of service
^i^ogenita!
infections
MERCK   &   CO.    LIMITED      Manufacturing Chemists     MONTREAL n
i
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls the utero-ovarian
i    circulation and thereby encourages a    j
normal menstrual cycle. Jf
k\# MARTIN H. SMITH COMPANY     J$
^=&. ISO LAfAYlTTt STRUT. NEW YORK. N. Y.
Full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is cut  in half  at seam.
m
■
A new "Ciba" product, which exhibits, according to the dose, a sedative-
antispasmodic effect of a central and peripheral nature,
or acts as a mild soporific—
NEURO-TRASENTINJ
(Trasentin-\-phenyletbylbarbituric acid)
FOR THE TREATMENT OF NEURO-VEGETATIVE DISTURBANCES
Neuro-Trasentin should undoubtedly be of
great value in the following conditions:—
Excitability, states of agitation, cardiac neurosis, angina pectoris,
vascular spasms, hypertonia, nervous dyspepsia, ulcer pains,
climacteric disturbances, dysmenorrhoea, pruritus, hyperthyreosis,
etc.
Issued:
Tablets, in bottles of 30 and 100; also 500 for hospital use.
CIBA    COMPANY    LIMITED
MONTREAL pHOUR ASSURANCE
Whenever yotir patients need .sick-,
roorrt^supplies or prescriptions—
they can get them from Georgia
Pha rmacypWe've co-operated with
the medical profession for 30-odd
years.
Free City Delivery Until 10 P.M.
For Your Convenience
Open Day and Night
MArine 4161
,<fC&£uL ^.JckmdeAAon
GEORGIA PHARMACY
st33Kr -i -r e d
eeonciA
(ht\i^x$Mwxtm ICiiL
ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C. Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. G. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. Clf
or 515 Birks Building, Vancouver.
SEymour 4183
Westminster 288
ROY WRIOLKY PRINTING
A  PUBLISHINO  CO.  LTD.

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