History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1944 Vancouver Medical Association 1944

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 The .IK
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With Which Is Incorporated
Transactions of the
In This Issue:
By G. -H. Stevenson, \C-->t;.:^^f|^.^: ---0^^^^?^:. 63
By H ^BeU, M.E^g^^^^^^^^te 67
PNEUMATIC TOOLS By E. H. Cooke, M.D^ft 71
By WY A|; Scott, MTV ^^^^^^^^^p^^;,7 S
By I! A. Scott, M.T.. jfflgiMffl^H^B^^HH 78
By     H ^^B ™ n B^^B^^^^B|^^^B *
NEWS AND _______■ '&      ^^^_^^^^^^^B  86
:VOL. XXL NO. 3=
DECEMBER, 1944 The secretion of mucus
has at least two beneficial results—the
protection of tissues, and the excretion
of wastes from infections in the mucous
membranes. In the treatment of bronchitis we can assist nature in achieving
the latter end by admirustering expectorant drugs which increase the volume
of respiratory tract fluid-^These expectorant drugs keep the mucus thin
and fluid so the tracheal cilia can move
it along to the throat, from which
coughing and expectoration finally
remove it. Thus, two benefits are
achieved. First, natural excretion is
aided. Second, the accumulation of
mucus in the lungs, with the attendant
threat of pneumonia, is avoided.
But sometimes it is important that the
patient get some rest, especially from
exhausting periods of night coughing.
A sedative is needed to temporarily
depress the activity of the "cough
To aid in the achievement of these aims
in the treatment of bronchial conditi-
tions, the E.B. Shuttleworth Chemical
Company offers two preparations: Sci-
lexol (plain and with sedatives) and
E. B. S.
Contains in each fluid ounce:
Ammonium Chloride. 16 grs.
Chloroform. J||^*^5|- | mins.
Acid Hydrocyanic
Dil. B.P. ^M%0^M h mins.
Syrup Scillae. . y:.-^\y.M mins.
Syrup Toftt.^plg.. .120 mins.
DOSE:      One   bijpiwo   fluid
drachms, every four hours.
Scilexol is also supplied with
your choice of the following
sedatives3" when specified:
80 mins. per ounce
{Dionin). J_ gr. per ounce
S—Heroin H <tr. per ounce
%—Codeine..1 gr. per ounce
Note: The addition of Tincture
Opium Camphorated markedly
increases the expectorant action
of Scilexol.
*Narcotic order required.
E. B. Sit
Contains in each fluid ounce:
Ammonium Carbonate. 8 grs.
Ammonium Chloride. .16 grs.,"!■
Prunus Serotina.'.:■'_&. 6 grs~*S,
Senega ._pt*3^^_^3^^v 8 grs.,:
Menthol. •.m&^MJ<<&' J_ 9T. ■
Chloroform .'S^Sifeivgi--* mins.
fflycyrrhiza$*$0y%Sr&$. s.
Honey. 7>3&&iij0i^^iQ- s-
DOSE:      One   or^prb! fluid .-
drachms, every three hours.—|g
Indicated in recent tight bronchial conditions.
When prescribing specify E.B.S.
Pulished 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.
Db. J. H. MacDermot
Db. G. A. Davidson Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XXI.
No. 3
OFFICERS, 1944 - 1945
Db. H. H. Pitts
Db. Frank Turnbull
Db. A. E. Tbites
Past President
Db. Gordon Burke
Hon. Treasurer
Dr. J. A. McLean
Hon. Secretary
Additional Members of Executive'. Db. G. A. Davidson, Db. J. R. Davies
Dr. F. Brodle Db. J. A. Gillespie Db. W. T. Lockhabt
Auditors'. Messrs. Plommer, Whiting & Go.
Clinical Section
Dr. W. D. Keith.-. Chairman Dr. S. E. Turvey Secretary
Bye, Ear, Nose and Throat
Db. Leith Websteb Chairman Db. Gbant Lawbence Secretary
Pediatric Section
Db. John Pitebs Chairman Db. Harry Bakeb Secretary
Dr. S. B. C. Tubvey, Chairman; Db. F. J. Bulleb, Db. W. J. Dorrance,
Db. R. P. Kinsman, Db. J. R. Neison, Db. D. E. H. Cleveland
Db. J. H. MacDermot, Chairman; Dr. D. E. H. Cleveland,
Dr. G. A. Davidson, Db. J. H. B. Gbant, Db. W. D. Keith, Db. L. H. Websteb
Summer School:
Db. G. A. Davidson, Chairman; Db. J. C. Thomas, Dr. R. A. Gilchrist,
Dr. A. M. Agnew, Db. L. H. Leeson, Db. L. G. Wood
Db. D. E. H. Cleveland, Chairman; Db. E. A. Campbell, Db. D. D. Fbeeze.
V. O. N. Advisory Board:
Db. Isabel Day, Db. J. H. B. Gbant, Dr. G. F. Strong
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Db. G. A. Lamont
Representative to B. C. Medical Association: Db. A. E. Tbites
Sickness and Benevolent Fund: The President?—The Trustees  VANCOUVER HEALTH DEPARTMENT
Total Population—Estimated . 299,460
Japanese Population—Estimated Evacuated
Chinese Population—Estimated 5,728
Hindu Population—Estimated 227
Rate per 1,000
Number Population
Total  deaths 282 11.1
Japanese deaths      Population Evacuated
Chinese   deaths       25 51.6
Deaths—residents only 237 9.7
Male, 296;  Female,  315 j 611 24.1
INFANT MORTALITY: October.1944 October, 1943
Deaths under one year of age 6 g
Death  rate—per   1,000  births 9.8 13.7
Stillbirths   (not included above) 5 11
September, 1944        October, 1944      Nev. 1-15,1944
Cases      Deaths      Cases      Deaths      Cases      Deaths
Scarlet Fever 20 0 24 0 26
Diphtheria 0 0 0 0 0
Diphtheria  Carrier 0 0 0 0 0
Chicken  Pox 19 0 29 0 14
Measles 21 0 74 0 77
Rubella 6 0 2 0 3
Mumps 14 0 20 0 3
Whooping  Cough 20 1 32 0 12
Typhoid Fever 0 0 0 0 0
Undulant   Fever : 0 0 0 Q 0
Poliomyelitis 0 .        0 1 0 0
Tuberculosis 87 7 40 8
Erysipelas 1 0 10 1
Meningococcus Meningitis   .       1 0 0 0 0
Paratyphoid Fever   (Carrier) 0 .        0 0 0 0
Infectious Jaundice 0 0 6 0 0
Typhi-murium 6 0 6 0 0
Dysentery 0 0 2 0 0
Rich- North
Vancouver mond Vancouver       Burnaby
Syphilis   (September)	
Gonorrhoea   (September) ■.	
(Figures for October not yet available.)
The most effective therapy for waning mental and physical energy,
deficient concentration and memory, reduced resistance to infection,
muscular -weakness and debility, neurasthenia and premature senility.
The efficacy of this very potent endocrine tonic has been confirmed by
the clinical evidence of many thousands of cases treated during
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
Page fifty-nine can now be treated more economically with
The new economy size vials of
Amniotin offer two distinct advantages. They provide a substantial
saving over the cost of Arrmiotin
in ampuls and they facilitate dosage
adjustments to meet the wide
variation in requirements of women
with menopausal symptoms.
The effectiveness of Amniotin in
relieving the distressing vasomotor
symptoms of the menopause has
been amply demonstrated by numerous clinical reports published during the past 12 years. The product
has Kkewise proved valuable in
treating other conditions due to
estrogen deficiency.
In the new economy vials of
Amniotin there has been no sacrifice
of activity, uniformity or stability.
Remember, Amniotin differs from
estrogenic substances containing or
derived from a single crystalline
factor! Amniotin is a highly purified,
non-crystalline preparation of naturally occurring estrogenic substances
derived from pregnant mares' urine..
In addition to the economy vial
packages and the ampuls (both of
which are for intramuscular injection)
you can secure Amniotin in capsules
for oral administration and in
pessaries for intravaginal use.
10,000 I. U. per cc
20,000 L U. per cc
2,000 L U. per cc
Squibb Preparation of Estrogenic
Substances Obtained From
the  Urine   of Pregnant Mares
For literature writ* £ ft. Squibb & Sons of Canada Ltd.
36-48 Caledonia Rd., Toronto, Oat.
ERiSqtjibb &Sons of Canada.Ltd.
FOUNDED 1898    ::    INCORPORATED 1906
*       *        *       *
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings will continue to be amalgamated with the clinical staff meetings of
the various hospitals for the coming year. Place of meeting will appear on the agenda.
General meetings will conform to the following order:
8:00 p.m.      Business as per agenda.
9:00 p.m.      Paper of the evening.
January    2—GENERAL MEETING: Cancelled.
February    6—GENERAL MEETING:
Carcinoma of the Cervix—Dr. Ethlyn Trapp.
Late Manifestations—Urological- -Dr. L. R. Williams.
Rectal—Dr. A. T. Henry.
Neurological—Dr. Frank Turnbull.
* April    3—GENERAL MEETING: Penicillin Therapy.
Discussion to be led by Major W. W. Simpson, R.C.A.M.C.
Ofenfrr & Jfamta Hiix
North Vancouver, B. C.
Powell River, B. C.
The death rate from diphtheria and whooping cough is highest among
children of pre-school age. It is desirable, therefore, to administer diphtheria
toxoid and pertussis vaccine to infants and young children as a routine
procedure, preferably in the first six months of life or as soon thereafter as
For use in the prevention of both diphtheria and whooping
cough the Connaught Laboratories have prepared a combined
vaccine, each cc. of which contains 20 Lfs of diphtheria
toxoid and approximately 15,000 million killed bacilli from
freshly-isolated strains (strains in Phase 1) of H. pertussis.
The combined vaccine calls for fewer injections, and, in consequence, the number of
visits to the office or clinic may be considerably reduced. It is administered in three doses
with an interval of one month between doses.
by the Connaught Laboratories in the following packages:  *
Three 2-cc. ampoules—For the inoculation of one child
Six 6-cc. ampoules—For the inoculation of a group of six children
University of Toronto    Toronto 5, Canada
With this, the somewhat overdue but final number of the Bulletin for 1944, we
take the opportunity of wishing all our readers all happiness and prosperity for the
future. This, of course, is the conventional greeting we all utter at this time—but
surely, in this the end of the fifth year of war, the wish is more than a mere form of
words. We all long for the end of this horror of great darkness, this terrible agony of
a whole world. We in B. C. hardly know, except for our personal losses and bereavements, that a war is raging—but that is mere luck and circumstance—and anything
may yet happen. But meantime, we, with all the rest of the world, have only one wish,
one prayer—to see peace again and the light of a day free from the menace and destruc
tion of war.
We do not, perhaps, take sufficient thought of the changes that this war is going to
make in our lives: changes great enough, as we think they will be, to constitute a revo-
•lution. There is a grave danger, in our opinion, of thinking that what peace will and
should mean, will be a return to our old ordered ways of a more or less static social
order, similar in all main respects to the one that held its uneasy footing before 1939.
We can hardly expect, and still less should we hope, to return to such a "normalcy," to
use the abominable word introduced into our common language by the late President
Harding. Surely out of this monstrous evil of world war, some better thing must come
than that. But in what form, or according to what social, economic and political
theories the new order will finally emerge, we cannot say. We can only hope that it
will be based on a wider view of human values: if it is not, we have suffered a countless
and irreparable loss largely in vain.
How will it affect us in medicine? and should we not, even now, be tliinking in
constructive terms of some of the problems that our profession will have to face?
Constructive, and unselfish, too. If the war ended tomorrow, we should be faced with
certain immediate questions, demanding immediate solution—some of them questions
that have long remained unanswered, and which the war and its social upheaval have
merely brought to a head where prompt and decisive action is now necessary. Such
questions as the more even and equitable distribution of medical services (health insurance, if you like, or its equivalent), the much wider application of preventive medicine
(this is perhaps even more vital as an immediate problem), the huge question of mental
hygiene—of child welfare—and the great problems of housing, clothing, social adjustments—one's head reels as these questions, largely unsolved, but insistent of solution,
bob up in rapid succession. Of what value is health insurance, no matter how excellently conceived and how loyally implemented, if these other greater factors in the
social muddle are not accounted for? Work, wages, freedom from want, social security,
physical wellbeing—these are all links in the same chain—snapping one, all are in danger
of being lost.
What are we as a profession going to do about it? The wisest of our leaders keep
constantly warning us that it is not enough for us to be on the defensive, as regards
our own rights and privileges—not enough even to work for adequate schemes of
health—not even if these take due cognizance of preventive measures. We must consider other causes of disease, social as well as physical disease; we should know and be
able to advise about such things as shoes, diet, dental requirements, lighting, housing,
ventilation, school conditions. The trouble is that the therapeutic half of the medical
profession has, so far, been the only side that has taken any part in medical economics.
Circumstances of employment and service have made this perhaps inevitable. But this
has led to a state of affairs that is bad, from our point of view as well as that of the
public. Thise factors that we refer to above are not strictly our business as therapeutists, though we are told by everyone that we neglect them.    They are the affairs
Page Sixty-one of our brothers who work at Public Health and Preventive Medicine. They have not
been consulted as they should have been—their knowledge, which is ample and would
be freely at our disposal, has not been made available to us in our consultations amongst
ourselves, and with the authorities. It is high time that the medical profession took
steps towards a more complete integration of its two main sections, therapeutic and preventive, that it became more socially conscious, and assumed its rightful duties and
position as advisor and counsellor to the public, not only for the care and treatment of
the sick, but with a view to prevention of sickness and lessening the amount of disease.
Till we become much more aware of our duties and our capacities in this direction, we
shall not be doing our full share in the community, nor contributing all we should and
can contribute to the common welfare.
Nor can we reach satisfactory decisions and agreements without a much wider contact with the rest of the community than we now enjoy. We should consult with social
workers, nurses, members of other professions allied to our own—we should (here comes
King Charles' head) have a wider contact with the public, through proper means of
publicity, and should keep them informed. Those whose work takes them into immediate touch with the disorders and trouble of the body politic, have information and
points of view which we greatly need—they need us, we need them. The wider the
base on which the structure we must build shall stand, the more secure and permanent
will it be—the fewer the points of weakness, the greater its value to all concerned.
A Century of Butler's Hospital, 1844-1944, by Wm. R. Roelker, et al.
Medical Clinics of North America, Symposium on Recent Advances in Medicine,
Philadelphia Number, November, 1944.
An Outline of Tropical Medicine, 1944, by Otto Saphir.
Pioneers of Pediatrics, 1943, by Abraham Levinson.
Modern Clinical Syphilology—Diagnosis, Treatment, Case Study, 1944, by John H.
Stokes, H. Beerman and N. R. J. Ingraham.
Psychosomatic Diagnosis, 1943, by Flanders Dunbar.
Text-Book of Ophthalmology, V. L, 1944, by Sir W. Stewart Duke-Elder.
Obiit Dec. 24, 1944
To the great regret of a wide circle of friends in the medical profession of Canada Doctor
M. G. Archibald passed away at his home in Kamloops on December 24th, at the age of 71.
No medical man in British Columbia was more respected and loved, both by his patients
and the medical fraternity, than Doctor Archibald. He served the people of Kamloops for
almost forty years. He was not only deeply respected and loved for his medical skill, but also
for his great patience, understanding and kindliness.
Doctor Archibald was born at Middle Musquodoboit, N.S., April 17, 1873. He graduated
in medicine from Dalhousie University in 1898. After practising in Nova Scotia for four years
he came to Kamloops in 1905 and joined Dr. J. S. Burns. Doctor Archibald had been medical
health officer of the city and acted as coroner for a great many years.
He was very active in medical association affairs, and in 1944 was made an honourary life
member of the Canadian Medical Association. Outside of his medical activities he took a very
great interest in all parts of community life. He was a keen worker in the church, past president of the Canadian Club and associated with many other organizations.
Doctor Archibald was one of our finest medical gentlemen, and his friendship was an
inspiration to all who had the privilege of enjoying it.
The medical profession extends sincere sympathy to the bereaved family. He is survived
by his wife, two daughters, Mrs. C. J. M. Willoughby, Kamloops, Mrs. H. E. Rand, Montreal;
three sons, Surgeon-Lieut. W. S. Archibald, R.CN.V.R., Dr. J. S. Archibald, Kamloops, Cpl. G.
D. Archibald, R.CA.F.; and a brother and sister at Middle Musquodoboit, N.S.
Page Sixty-two British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. G. O. Matthews, Vancouver
First Vice-President Dr. A. H. Meneely, Nanaimo
Second Vice-President . Dr. Ethlyn Trapp, Vancouver
Honorary Secretary-Treasurer Dr. S. G. Baldwin, Vancouver
Immediate Past President Dr. P. A. C. Cousland, Victoria
By Dr. G. H. Stevenson (Toronto)
Read at British Columbia Medical Association Annual Meeting.
In an era of preventive medicine, largely successful for many physical diseases, preventive psychiatry has also been playing its part. The mental hygiene movement dates
back to 1908, when Clifford Beers, a New England business man, after a lengthy mental
illness, founded with others the Connecticut Society for Mental Hygiene, and the following year the National Cornmittee for Mental Hygiene was begun. With its counterpart, the Canadian National Committee for Mental Hygiene, it has sought to establish
better mental health and the prevention of mental diseases, by mental health education,
improved teaching of psychiatry in our medical schools, by the encouragement of research into the causes and cure of mental diseases and by improvement in the treatment
of the mentally ill in our mental hospitals and elsewhere.
Having used the terms "mental health," "mental hygiene" and "mental disease,"
perhaps I should attempt to define them.
The mentally healthy person is one who seeks to make satisfying adjustments to the
living of his life (not by escaping from it via narcotics, alcohol, suicide, and not at other
people's expense, e.g. Hitler), who is efficient at his work, who gets along well with his
fellows and who in times of severe stress is still able to preserve reasonable efficieincy and
Mental hygiene refers to the techniques, methods and habits by which one helps
himself in good ment-al health.
Mental disease might be defined as a more or less prolonged departure from the individual's usual manner of thinking, feeling and acting, with materially reduced capacity
for satisfactory adjustments.
It will be obvious from a contemplation of these definitions that none of us has perfect mental health, as we all have periods of decreased satisfactions, with depression,
discouragement, or we temporarily engage in unhealthy escapes; we are not always at
our peak of efficiency, we do not always make good social adjustments, at times perhaps
being unfriendly, domineering, asocial, suspicious and we have not always that reserve
of mental strength in times of crisis that we might desire. This parallels physical
health. While we aim at physical perfection, we have to be satisfied with minor degrees
of physical ill health—arthritis, sinuses, hearing defects, elevated blood pressure, infected
tonsils and so on.
Fortunately few of us have frank mental disease, but more people enter mental
hospitals than enter universities. The only way we have of calculating the incidence
of mental disease is by the statistics published by individual provinces, which are brought
togehter by the Dominion Bureau of Statistics, the 1942 report of mental institutions
being the most recent. This slide shows that admissions to mental hospitals in Canada
increased steadily 1935-38 with a reduction for the next few years and a rise again in
Page Sixty-three
n: 1941 and 1942. The reasons for the decline are not known, but the rise in other years
is probably due to population increase and the more ready acceptance of mental hospital
The public, and perhaps some physicians, have the idea that mental diseases are on
the increase. There is very little evidence to support this belief, rather the reverse.
In New York State, having a large population and careful statistical records over a great
many years, certain rather definite trends can be shown. This chart shows that dementia
praecox has remained stationary since 1918, that manic-depressive psychosis has definitely decreased, offset to some extent by an increase in involution melancholia; psychoses
due to syphilis have declined, the alcoholic psychoses remain fairly constant. The only
psychosis showing an unmistakable increase, but perhaps not as great as indicated, is
the combined senile and cerebral arteriosclerotic groups. During the last thirty years
there has been a 100% increase in these groups, whereas people above the age of sixty,
in which decades these conditions occur, have increased only about 50% (from 8y_i%
to 12% of the population). These figures are for Ontario, and show what many of
you have doubtless suspected for a long time, that Ontario is very definitely becoming
Before discussing the mental diseases, just a word about mental deficiency. This is
not a disease or illness but an intellectual arrest at birth or very early life, so that the
individual at maturity fails to achieve normal intelligence. Perhaps Lto 2% of people
are mental defectives, approximately 50% of whom inherit their defect from intellectually defective parents. The other 50% are the victims of obstetrical accidents or
to illnesses or accidents during the first year of life. Most of both these groups are
theoretically preventable by some control of the persons who may bring people into the
world, and by improved pre-natal, obstetrical, post-natal care of the mother and by good
pediatric supervision of the child during its first years of life.
Before discussing the preventability of individual mental disorders one might quarrel
wth the term "mental diseases." It is certainly a better term than insanity, lunacy or
madness, but its vagueness seems to make it inaccessible, giving no clues to etiology or
pathology or to classification. It is as vague a term as the once well-known "fever diseases," which told us nothing but that the patient had an elevation of temperature.
However, for want of a better one, we shall use it. But I like to subdivide it immediately into two main divisions, the delirious mental disorders (the actual psychoses) and
the non-delirious mental disorders (the psychoneuroses, alcohol and drug addictions, the
reactive depressions). I urge strongly that we use the term delirium for this first group,
implying mental confusion, perhaps with hallucinations or memory loss and an inability
to realize he is really sick. There is no need, I suggest, to limit the use of the word
delirium only to states of mental confusion dependent on an acute toxaemia or head
injury, and if look upon all states of mental conditions as delirious states we can
insist that all such conditions are within the realm of the general practitioner, challenging us to our best investigative and therapeutic efforts.
The psychotic or delirious group can be readily divided into three sub-groups: (a)
deliria due to intoxication, (b) deliria due to organic brain disease, (c) deliria due to
mental frailty and a too harsh environment. This last group is best known as the
biogenic group, that is, having its origin in the life experiences of the individual. It is
sometimes spoken of as the functional or psychogenic group.
Returnng to the deliria due to intoxication. Here, a toxin circulating in the blood
stream interferes with cerebral function as long as it is present. Alcohol is the commonest toxin producing abnormal mental states from ordinary intoxication, through
pathologic intoxication to chronic alcoholism and the alcoholic psychoses. The steadily
increasing consumption of alcoholic beverages, as shown on slide 4, indicate that the
fairly stable incidence of alcohol psychoses in past years may be due for a rise. This is
not the time to discuss the reasons why so many people drink to excess (Omar is a good
reference on this question), but there can be no doubt that we are dealing with a public
Page Sixty-four
, health problem of considerable magnitude.    There can be no doubt either that alcoholic
psychoses and pathologic intoxication-never develop in total abstainers.
A less common but exceedingly important delirium due to an imbibed toxin is
caused by bromides. We are apt to be over-confident in our use of bromides and we
value their undoubted therapeutic effects in various conditions, but there are some people
who accumulate bromides through poor kidney function or by taking larger doses than
ordered or by self-medication of patent medicines containing bromides. Every mental
hospital admits a few such cases every year, psychoses that should have been prevented
by administration of bromides only with extreme caution, and the occasional check on
the bromine content of the blood. A concentration of 150 milligrams per cent in the
blood is the toxic level for most people.
Toxaemais may arise in the body from infections or from toxic thyroids or cardiac
decmpensation, or from the toxa-mias of pregnancy. It may not be correct to say that
all these are preventable, but the better they are controlled by early and adequate treatment, the less liklihood there is of the individual becoming mentally ill as an effect
of them.
A few words concerning the so-called puerperal psychoses. These unfortunate complications of pregnancy and childbirth may be due to exhaustion, haemorrhage and septic
pelvic or uterine conditions in whole or part. They sometimes occur in entirely uncomplicated easy labours, but when they do one can be sure that there is great emotional
stress, not always easily seen. That is, the psychosis may be due to an intoxication, in
which case its outcome depends on the outcome of the physical factors. Where the
emotional disturbances are strong, the delirium will be either a schizophrenic or a manic-
depressive attack. It should be remembered that obstetrical schizophrenias are almost
invariably malignant whereas the manic-depressive reactions terminate with complete
recovery. It is almost always unwise for such mothers to again incur the risk of
In the second large group, delirious states due to organic brain disease, we have a
variety of clinical states. Huntington's chorea, perhaps the only truly inherited mental
disease, is preventable only by potentially affected individuals foregoing their right to
have children. General paresis, due to syphilis, is preventable by avoidance of sexual
promiscuity and the active and complete treatment of all infected persons, in the early
stages of the disease. Brain tumours are still as much of a mystery as to etiology as
other forms of cancer and at the present time we are helpless in preventing these conditions. Early diagnosis and operative treatment offer the only hope of avoiding extensive brain damage and mental deterioration. Mental symptoms due to trauma are commonly the result of war injuries and motor accidents. We can only hope that the greater
use of intelligence may reduce both these hazards to the next generation.
By far the largest representative in this group is the senile-cerebral arteriosclerotic
combination. I have already indicated that these groups constitute 25% to 35% of the
admissions to mental hospitals in recent years and they are really the only form of
mental disease to show a substantial increase, having doubled their incidence in the last
thirty years, although this age group has increased itself by only 50%. How to grow
old gracefully is our problem. How to care for our arteries, heart and kidneys well
when they are young so that they will not let us down when we are old. How to make
our neurones and cerebral vessels last longer than our myocardium and coronaries is one
of the most challenging clinical puzzles confronting us. There is no virtue or happiness
in growing old if we cannot have reasonably good mental health during our senescence.
At present all we can say is that a life well-lived, keeping our bodies and minds in
healthy action with the avoidance of physical and mental excesses, with hobbies and a
satisfying philosophy of life, all these may help. What hormones and vitamins may
also do to help is still largely speculation, but there is reason to think that concentrated
attention on these and other aspects of geriatrics may greatly reduce the incidence in
these later decades.    That great centenarian, Sir William Mulock, while still in his
■>' fit! • Page Sixty-five
i *' eighties, gave his own opinion of his health vitality in the following quotation—"The
castles of enchantment are still ahead of me."
The biogenic deliria are chiefly manic-depressive psychoses and schizophrenic. The
former is characterized by states of elation and hyperactivity or depression and inactivity. Schizophrenia (formerly known as dementia praecox) is essentially a disorder of
young people, showing disintegration of personality with delusions and hallucinations.
So far as we know the biogenic reactions are not dependent on organic brain change or
toxic states. Curiously enough these groups, constituting 25% of the admissions to
mental hospitals, have nothing wrong with their brains. Like the psychoneuroses—
hysteria, neurasthenia, anxiety states, reactive depressions and alcoholic addictions—
they are reactions of frail personalities to difficult or insoluble life problems. The frail
personality is usually an inherited frailty, poorly trained for life or inadequate for life,
overwhelmed by problems too difficult for him to solve. The maniac-depressive conditions
tend to spontaneous recovery. Schizophrenia, in spite of the unodubted value of shock
treatment, too often fails to respond.
These conditions are theoretically preventable—the slide shown earlier indicates they
are not increasing and perhaps even decreasing. Prevention on a large scale of these
disorders, including the psychoneuroses, will depend in the long run on our ability to
rear children from mentally healthy parents, to provide the developing child with mental
hygiene training so he may develop good mental hygiene habits, to surround him with
an environment in which his personality can thrive and to keep him physically fit
throughout his Hfetime. With wars and economic depressions a large part of the
environment for so many years, we have all been handicapped. We can still hope
through eugenics, education and statesmanship to ultimately reduce these etiologic factors of these psychoses.
In conclusion let me suggest that better mental health in the public can be achieved
by the medical profession through the wider use of mental health clinics, of psychiatric
wards in general hospitals, through learning and teaching mental hygiene principles to
parents and children, by the school, the church, the press and the radio. We can keep
people in better physical health through the use of the annual health examination and
thereby make it easier for them to enjoy good mental health. We can work with all
other men of good will to make this a world not only fit for heroes to live in but fit for
the great mass of average people to live in healthfully, happily, hopefully.
Sex and Calendar Period
White males Expectation of Life, Years
1900-1902 48.23 50.59       42.19       34.8 8 27.74      20.76 14.35         9.03 5.10
1940 62.94 5 6.91       47.61       3 8.64 29.8 5       21.77 14.86        9.26 5.20
White females
1900-1902 :  51.08 52.15      43.77      36.42 29.17      21.89 15.23         9.59 5.50
1940 67.31 60.63       51.15      41.98 33.01       24.48 16.75       10.27 5.50
Year Total Per cent            Per cent 60 and over
Population under 40            40-59 Number Per cent
1881  1,927,000                 79.28                  14.56 118,700 6.16
1891  2,114,000                 77.67                 15.54 152,019 7.10
1901    | i 2,183,000                 73.70                 17.91 183,220 8.39
1911  2,527,000                 72,24                 19.26 214,932 8.50
1921  2,934,000                 70.32                 20.51 269,133 9.17
1931  3,432,000                 67.99                 12.84 349,108 10.17
1941  3,848,000                 64.83                 23.39 453,142 11.78
Page Sixty-six V
A Review of the Literature and Case Report
Dr. W. N. Bell
From the Service of Dr. S. E. C. Turvey
Follicular lymphoblastoma, although usually regarded as an interesting rarity, should
be considered in any case of generalized lymphadenopathy. Although inherently benign,
on occasions it may be malignant. It was first described by Becker in 1901. Brill, Baehr
and Rosenthal presented the first American report in 1925 and it was they who first
drew attention to its benignancy, although, in a later report, they began to ascribe to
the disease a more malignant nature. In 1931, Baehr and Rosenthal outlined the chief
characteristics of thiss disease as follows:
1. Lymphadenopathy, due to hyperplasia of the germinal centres of the lymph
2. Splenomegaly, due to enormous enlargement of the Malpighian bodies.
3. Absence of abnormal cells in the blood.
Absence of anaemia and cachexia.
Tendency to development of serous effusions in pleural and peritoneal cavities.
Absence of involvement of tonsils and the lymphatic apparatus of the gastrointestinal tract.
Tendency to lymphatic infiltration of the lachrymal gland, resulting in unilateral exophthalmos.
Multicentric origin, throughout the body, in the lymph follicles.
There are still differences of opinion as to the classification and pathogenesis of fol-
*licular lymphoblastoma. Most investigators feel that it is only the early stage of a
process terminating in lymphosarcoma, lymphatic leukemia, or Hodgkin's disease. In
one series of twenty-five cases, seven terminated as lymphosarcoma, seven as Hodgkin's
disease, and four as lymphatic leukemia. Ross calls it a "lymphatic reticulosis," while
Symmers believes in an inflammatory or toxic origin. Different diseases of the lymphatic
system affect different structural components of the lymph nodes. In follicular lymphoblastoma the germinal centres of the secondary follicles are the point of departure of
the pathological process. Hadfield and Garrod in "Recent Advances of Pathology"
suggest the following classification:
The Reticuloses
Medullary Reticulosis:
Primary,     (a)   Undifferentiated.
(b) Haemic (the Leukaemias").
(c) Fibro-myeloid  (Hodgkin's Diseas).
(d) Histiocytic.
Metabolic.    The Generalised Lipoidoses.
Follicular Reticulosis:
(a) Lymphoid.
(b) Fibrillary.
Sinus Reticulosis'.
Infective. In typhoid, trypanosomiasis, kala-azar, malaria and secondary syphilis,
The average age of onset in various series of cases was. thirty-nine years, being twice
as common in males as in females. The average duration is five years although a few
cases have been reported alive and well as long as seventeen years after the disease was
first discovered.   Symmers thinks it is wise to divide all cases into two groups:
Page Sixty-seven
!i' 1. Those cases in which the hyperplastic follicles in the nodes and spleen maintain
their structural identity for months or years or the affected nodes may undergo
reduction in size and disappear temporarily for no apparent reason. Again, they
may show histological signs of healing irrespective of treatment.
2. Those cases in which the condition alters its course into cases of lymphosarcoma,
lymphatic leukaemia, or, rarely, Hodgkin's disease.
In affected nodes the enlarged follicles can be seen with the naked eye. The follicles
vary in size and number. The central portions generally consist of larger cells with
large, faintly staining nuclei and numerous mitotic figures. These are usually regarded
as lymphoblasts but some may be derived from reticulum cells. At the periphery of
the follicles lymphocytes are densely packed. No reticulum fibrils are demonstrable in
the tissue but there is an increased proliferation of capillaries and endothelial cells. The
lymphatic sinuses are compressed. This marked numerical and dimensional increase in
the follicles was found to be the most helpful histological method of distinguishing the
condition from inflammatory hyperplasia. In the spleen there is a numerical and dimensional increase in the Malpighian bodies. The interfollicular splenic pulp and sinuses
are compressed. The follicles tend to fuse and present a studded, greyish, nodular appearance against the purplish-red background. Should the lymph follicles show necrosis
they may rupture, giving rise to a thin, clear or slightly cloudy fluid and the resulting
sinuses tend to heal slowly.
The disease usually begins insidiously as an enlargement of local lymph nodes, unaccompanied by any feeling of ill-health on the part of the patient. The absence of
anaemia or cachexia may lead the unwary into suspecting an inflammatory or toxic agent
as the cause of the lymphadenopathy. The lymphadenopathy may be local or general,
the cervical group often being the first to be enlarged. In the early stages the nodes are
discrete, movable and painless. Later, they are closely packed and appear to be confluent. The nodes may diminish spontaneously in size or may disappear for a time.
Gastro-intestinal symptoms, e.g., flatulent dyspepsia, diarrhoea, anorexia or nausea, are
fairly common. In one series of cases, splenomegaly occurred in 61%,6 hydro thorax in
13%, hepatomegaly in 9%, and ascites in 6%. Anaemia, if present, is of the hypochromic type and is not severe. Slight leukopenia may be present. Osseous, cutaneous,
pulmonary, genito-urinary, gastro-intestinal and tonsillar involvement have been reported. Some authors recommend that all patients exhibiting chronic eczematoid dermatitis with lymphadenopathy should have a biopsy examination, preferably on the
nodes of the cervical region, as this syndrome is frequently amenable to radiation
therapy, in small repeated doses, although there is a tendency towards radio-resistancy in
succeeding courses.   No cases of permanent cure have been reported.
Case Report
Mr. W. N. B., age 42 years.
This patient was first seen by Dr. S. E. C. Turvey on July 10, 1939, when he was
referred for a general and neurological examination because of a previously positive
Kahn. At that time the physical examination, including full neurological examination,
was entirely negative. Lumbar puncture showed 6 cells per c.m.m., protein 40, Kahn
negative and colloidal gold of 0000000. A blood Kahn was also negative. He had had
adequate treatment, so he was advised to have only annual injections of bismuth for a
few years. At that time there were no complaints except an anxiety state about his
previous infection, and there was no enlargement of the lymph nodes. He was next
seen in September, 1941, for a lumbo-sacral strain. At this time his haemoglobin was
82%, white cell count 12,900, urinalysis negative, sedimentation rate 31 mm. in an
hour, Kahn negative. The differential white cell count showed 72% polymorphs, 22%
lymphocytes, and no immature white cells were present in the smear. By November,
1941, he had recovered sufficiently to return to work.
He was seen again on February 14, 1942, when he began to complain of having no
pep or energy for the previous three weeks.   He said that he was too tired even to read.
Page Sixty-eight He had no actual pains or aches or discomfort but had been sleeping poorly and was
very "nervous." He had lost only two pounds in weight in the previous six months.
General physical examination was entirely negative at this time. There was no lymphadenopathy. A month later he had gained four pounds, was working steadily and felt
much better. By December, 1942, he had injured his back again,, had lost twelve pounds
and was unable to work.
He was re-examined on January 19, 1943, and at this time there was noticed a
generalized enlargement of the lymph glands throughout his body. There was one
mass the size of a large egg in the left axilla, a mass the size of a walnut in the left
groin, and all the superficial lymphatic glands throughout the entire body were palpable.
He said that he had first noticed this himself three weeks ago and both he and his wife
were certain that there was no visible or obvious enlargement before that time. The
glands were smooth, movable, rubbery and not tender. The spleen was not enlarged.
By this time he was fourteen pounds under his usual weight, haemoglobin was 75%,
red cell count was 4,660,000, white cell count 17,900, with 70% polymorphs, 29%
eosinphils, and 1% mononuclears. There were no immature white cells. Sedimentation
rate was 50 mm. in an hour. Urinalysis was negative. A blood Kahn and cerebrospinal fluid Kahn were entirely normal at this time also.
In January, 1943, a lymph gland was removed for biopsy from the right groin. Dr.
H. H. Pitts of the Department of Pathology at the Vancouver General Hospital examined this and his report is as follows:
"The specimen consists of an elongated, fairly firm lymph gland the size of an
almond kernel which, on occasion, presents a fairly firm, homogeneous, grayish-white cut
"A number of sections were taken at different levels through the gland and they
show a very definite hypertrophy and hyperplasia of the lymphoid follicles, not only in
the peripheral portions of the gland but throughout the more central and hilar portions.
The cells appear fairly uniform, there is no fibrosis and there is no suggestion of any
tubercle formation or metastatic involvement. The pathological diagnosis is follicular
On admission to hospital on January 27, 1943, the patient complained of a dull,
constant ache in the epigastrium when he took a deep breath. There were no disturbances in function of the gastro-intestinal tract. On examination there were many
rhonchi in the left chest and there was clinical evidence of fluid in the right side. The
abdomen was tense and slightly bulged but not tender on palpation. The spleen was
not palpable.    There was generalized lymphadenopathy, especially on the left side.
An X-ray picture on January 30, 1943, revealed considerable fluid at the right base
as high as the fourth interspace anteriorly and extending upward into the axillary line
to the level of the tiiird rib. There was also considerable infiltration shown in the lung.
Sixty ounces of slightly turbid, serous fluid were removed. Microscopical examination
showed "a very large number of all types of leucocytes, with many very large spherical
cells, at least five to six times the size of polymorphs, with large nuclei and rather pinkish staining, scanty cytoplasm. They somewhat resemble very large plasma cells but
are probably of a mononuclear type and very atypical" (Dr. H. H. Pitts).
During his four weeks' stay in hospital he lost six pounds. On February 1, 1943, the
white cell count was 14,800, with 56% polymorphs, 25% staff forms, 29% lymphocytes, 2% monocytes, 6% eosinophils, 1% basophils, 6% disintegrating cells. The
haemoglobin was 70% and sedimentation rate 8/50. Five days later the white cell
count was down to 6,700 (following the thoracentesis), composed of 66% polymorphs,
25% lymphocytes.
X-radiation was commenced on February 1, 1943. Between February 1 and February 17, the whole body was exposed anteriorly and posteriorly to doses of 10 "r" units
each, up to a total of 100 "r" units, using 200 K.V. and 2.0 mm. of Aluminium. From
February 8 to February 12, he was given 1,000 "r" units over the epigastrium at a
Page Sixty-nine "r"
units, using 200 K.V., 0.5  mm. of Copper and 2.0 mm. of
daily dose of 200
The patient was discharged from hospital on February 28, 1943, feeling much better. The epigastric distress had disappeared and he felt stronger, although he was still
losing weight.
Two days after being discharged, he was readmitted in a very dyspnceic condition.
Despite the removal of 2,000 c.c. of straw-coloured fluid from the chest, the patient died
four hours later.
Unfortunately permission for an autopsy could not be obtained.
This patient presented typical clinical features of follicular lymphoblastoma. There
was the sudden, non-painful, generalized lymphadenopathy and gradual, progressive
weakness, appearing in a previously healthy, middle-aged male. The absence of splenomegaly is not unusual. The predominating role played by the pleural effusion is of
interest in view of the above figures of its incidence. The absence of any marked degree
of anaemia or of any abnormal cells in the blood are quite in keeping with the typical
1. Follicular lymphoblastoma is an inherently benign, generalized disease of lymph
nodes, of indefinite etiology and pathogenesis, sometimes progressing towards a more
malignant form.
2. Splenomegaly, hepatomegaly and effusions into serous cavities may occur.
3. An increase in the follicles, both numerical and dimensional, is a constant pathological feature of the disease.
4. The disease is not characterized by the constitutional signs and symptoms such
as anaemia, cachexia, marked loss of weight, which are present in the more malignant
5. It affects twice as many males as females and it is very sensitive to small repeated
doses of roentgen rays.
6. A case is presented of a middle-aged male with pleural effusion but no splenomegaly.
1. Symmers—Arch of Path., 26, Sept., 1938.
2. Bagenstoss and Heck—A. J. M. Sc, 200, July, 1940.
3. Combes and Bluefarb—Arch, of Dermat. and Syphilology, 44, Sept., 1941.
4. Rubenfeld, S.—Am. Jour, of Roentgenology, 44, December, 1940.
5. Held and Chassnoff—A. J. M. Sc, 204, August, 1942.
A programme of special interest has been planned for the January meeting
of the Clinical Section, when Surg. Lieut.-Comdr. M. Digby Leigh, R.C.N.V.R.,
Consultant in Anaesthesia to the R.C.N., will present a paper on "Paediatric
Anaesthesia."    This will be illustrated by a film and lantern slides.
In addition, Dr. C. E. Battle will give a paper on "Modern Conception of
the Treatment of Burns," and Dr. G. D. Saxton will present "Some Cases of
Extra-pulmonary Tuberculosis," while Dr. Ernest Boxall of the Interne Staff
of the General Hospital will give a paper on "Results of the Use of Penicillin
in the Vancouver General Hospital.
Page Seventy Vancouver Medical Association
E. H. Cooke, M.D.
(Given at meeting of The Vancouver Medical Association, November 7, 1944)
The disabilities arising from occupations in which frequent repetition of movements,
constant pressure or repeated shocks are a feature, have long been recognized as occupational hazards.
Bulletin No. 41, issued by the United States Department of Labor, gives a list of 58
occupations which offer such exposure. Blacksmiths, carpenters, hammermen, milkers,
polishers, pressers, telegraphers, typists, and lastly, pneumatic tool workers, are a few
The last group is the subject of our paper tonight and is a preliminary statement
based on the study and observation of 32 selected cases of the so-called Pneumatic Arm,
occurring in the four principal shipyards in Vancouver.
Until recent years little attention has been given to the condition, and references to
it in literature are few and far between.
There are several reasons for this indifference in the past:
1. Firstly, the paraesthesiae, muscular pains and weakness were regarded as functional
and designated as an occupational neurosis and forthwith the case lost most of
its interest.
2. Then there is a tradition among life-time users of pneumatic tools that more or
less discomfort in the upper limbs is inevitable in beginners, but with patience
and a correct technique in holding the gun, this usually passes off spontaneously
in the course of a few weeks—hence few are encouraged to seek medical relief in
the early stages.
3. And lastly, the more susceptible and less persevering among the beginners quit
their jobs after a brief trial and so are unlikely to come under skilled observation.
On the other hand, the great increase in shipbuilding on this continent, the "freezing" of workmen to their jobs in the yards, the recognition of these cases as compensable
by the Workmen's Compensation Board, and the creation by the Wartime Shipbuilding
Limited of an Industrial Health Division under a Medical Director with full-time medical
officers in the principal shipyards, have contributed much to the better understanding
and therefore prevention of these conditions and industrial hazards generally.
A brief description of the pneumatic tool, or gun or as it is commonly called, as used
by the riveter, his mate the holder-on, the caulker, the reamer and the bolter-up will
assist us in visualizing these men at work.
The steel plates are swung into position by the platehangers; the bolter-up now temporarily fixes the edges of the plates together by inserting a cold bolt in every other
hole and tightening the nut with his impact wrench—a pneumatic tool which weighs
about 30 pounds and delivers from 1200 to 1300 blows per minute with 90 pounds of
air pressure. The reamer uses a pneumatic gun, designed to align or ream out the opposing holes in the overlapping edges of the plates so that the heated bolts fit easily. It is
operated by one or two men who hold on to a cross bar at the butt end of the gun
which weighs 28 pounds and the bit revolves 86 times per minute with compressed air
at 100 pounds. It is claimed that the arms and shoulder muscles are subjected to considerable jerky vibrations as the bit bites into the metal, and occasionally the workmen
are knocked off their feet.
Page Seventy-one The riveter now mushrooms with his pneumatic gun the end of the red-hot bolt
onto the overlapping edges of the plates whilst his partner, the holder-on or bucker-up,
supports the head of the bolt on the other side of the plates. The gun used by the riveter and holder-on weighs from 22 to 25 pounds and delivers 1300 blows per minute.
It consists of a cylindrical barrel, at the proximal end of which.is a hand grip and an
attachment for a compressed air hose, also a trigger mechanism for releasing the compressed air which operates a piston rod plunger in the barrel. The plunger is moved to
and fro by the compressed air, alternately striking and receding from the end of the
dye—a moveable tool of hardened steel, one end of which fits into the distal end of the
barrel and is held in place by the gloved hand.
The caulker, who closes the seam between the plates, after the others have done
their work, uses a gun somewhat similar to the riveter's but it is lighter in weight and
much faster in action. It weighs about 12 pounds and delivers 2000 blows or more
per minute.
Our 32 cases fall naturally into five groups: riveters, holders-on, caulkers, reamers
and bolters-up, with whom you have already had some acquaintance.
The riveters number 12; holders-on, 8; caulkers, 7; reamers, 3; bolters-up, 2—
total, 32.
These figures indicate very roughly the relative frequency of the pneumatic arm in
the five groups.
Their ages vary from 20 to 53 years—the majority of the cases occurring between
25 and 50.
The average weight was 164 pounds—the lightest 119 pounds and the heaviest
198 pounds. This observation is mentioned as some workmen believe light weight is a
predisposing factor; but we have no proof of this as yet.
The time which elapsed between the commencement of work and the onset of symptoms averaged:
For the riveters, 9 months; holders-on, 12 months; caulkers, 15 months; reamers,
17 months; bolters-up, 10 months.
One of the earliest signs noted in those about to develop the Pneumatic Arm is stiffness and a sensation of tension or swelling in the fingers which may actually be the case.
This at first disappears overnight to recur the next working day and may continue so
for days without change. Frequently, however, numbness and tingling appear at the
tip of one or more fingers, usually the index of one hand, often associated with pallor
and coldness. This condition may spread as the days go by to the other fingers, sometimes skipping one finger for no apparent reason, then to the hand and even as far as
the elbow but seldom beyond.
There is a subjective sensation of weakness in the limb and all muscle movements
are weak, especially in the fingers, wrist and elbow joints.
There is now often definite analgesia of the skin of the fingers, hand and lower one-
third of the forearm—occasionally limited to the ulnar or medial distribution. Aching
pains extend up the limb, especially along its outer border, and there are tender areas in
the muscles, particularly the forearm and region of the external epicondyle and occasionally as remote as the deltoid, scapula and neck muscles.
Muscular cramps not infrequently occur, especially at night, and may be so severe
as to keep the patient awake.
This description is taken from our case histories and is typical of average severe cases
who have persevered with their work notwithstanding the discomforts entailed.
I would remind you of a few facts in regard to the physiology of the neuro-muscular
and vascular systems as I believe these have an important bearing on the evolution of
the Pneumatic Arm:
1. All parts of the reflex arc possess the property of excitability; i.e.y any part of it
may be independently stimulated, resulting in muscular contraction.
2. Voluntary muscle normally contracts to impulses which start in the central nervous system and pass down the efferent nerves to the muscle; but this same
Page Seventy-two muscle may be caused to contract by other forms of stimuli applied to the muscle
itself or its nerve.
3. Such other stimuli are chemical, thermal, electrical or mechanical—the latter by
pinching the muscle or by a series of carefully graduated taps to the nerve. I
suggest that the vibrations of the pneumatic gun, especially that type used by
the riveters or caulkers, fulfil the requirements of a mechanical stimulus.
Experiments with the ergograph in men shows that when fatigue sets in after
repeated contractures, it is not the muscle which is fatigued but the nerve cells in the
cord, since electrical stimulation of the muscle or its nerve through the skin results in
powerful contractions.
Physiological experiments indicate that the most readily fatiguable point is the
motor nerve cell, next the end plate in the muscle, then the muscle itself, and finally
the nerve trunk which is practically unfatiguable. From this it may be inferred that
the weakness of certain muscles or group of muscles so frequently present in sufferers
with the Pneumatic Arm is at first central rather than peripheral and is the result of
fatigue of the nerve cells.
Plain or involuntary muscle, like voluntary muscle, also responds to various stimuli
which may be chemical, thermal, electrical or mechanical.
The involuntary muscle of the blood vessel exhibits an automatic tonus and is provided with two sets of nerves from the sympathetic—one set contractor, stimulation of
which increases the tonus, and the other set inhibitor or dilator, stimulation of which
diminishes the tone of the muscle and permits vasodilation.
It is likely that mechanical stimulation of this mechanism by the vibrations of the
pneumatic gun is the explanation of the vasomotor disturbances so commonly present
in these cases.
Taking all these facts into consideration, it seems probable that in the early stages
the Pneumatic Arm is a fatigue syndrome within physiological limits which if long continued may lead to inflammatory reactions or even structural or organic changes of a
more or less permanent nature in the neuro-muscular system.
The following are a few examples of end results:
In cases 11, 23 and 25, all riveters, there was marked atrophy and weakness of the
thumb muscles in one hand.
Case No. 9, riveter, age 31, consulted us in March, 1943, for coldness and numbness
of the thumb and index finger and the radial half of the middle finger of. the left arm;
also aching pains extending up the limb.
His occupation was changed to shipwright and nineteen months later his condition
was as follows: Left forearm % inch smaller than the right, numbness of the radial
half of the middle finger unchanged, thumb and index finger presented no symptoms
except that the latter has a prickly sensation in cold weather. The small muscles of the
hand were definitely weak as were the movements at wrist and elbow joints and to a less
extent at the shoulder.
Case No. 1, age 39, a typical example of the Pneumatic Arm in a caulker, occurring
sixteen months after working daily with the caulking gun. He had well marked vasomotor disturbances in the thumb, index and half the middle fingers of the left hand and
index finger of the right hand. These became cold, pale and numb soon after beginning
work with the gun. Seen in November, 1944, 21 months after change of occupation to
Pipefitter's Helper, the tendency to vaso-spasm was still present, especially in cold
weather or if he bathes in the sea. He was very emphatic that he was not so affected
before using the caulking gun.
Exciting and Predisposing Causes
Assuming that excessive and prolonged vibration is the prime or exciting cause of
the Pneumatic Arm, what are the predisposing factors since all workers with pneumatic
tools do not develop this disability?
Page Seventy-three 4.
The following have been brought to our notice:
1. Incorrect technique in holding the gun leading to unnecessary muscular tension
and early fatigue.
2. Insufficient support for the arms, especially in overhead and shoulder-high work.
3. Overtime, record breaking and piece work—in all of which there is the temptation to avoid sufficient rest periods.
Local trauma of the limb, remote or recent.
Local diseases of joints.  Raynaud's phenomena.
Reduced health from any cause.
Overheating and sudden cooling of the body.
Excessive cigarette smoking, predisposing to vaso-constriction.
Neurotic temperament, particularly when expressed as anxiety.
Light weight and poor muscular develpoment.
As a rule this does not present any serious difficulty when the previous history and
the circumstances under which the disability arose are carefully reviewed. Organic
nervous disorder and local disease should be excluded and the possibility of a cervical rib
or band should not be overlooked, also any liability to Raynaud's disease.
In the early stages rapid improvement and disappearance of symptoms may be
expected by change of occupation to some kind of work in which muscular strain or
vibration is absent; such as burning or welding. Later on, when vaso-motor changes
are well established and muscular pains and cramps keep the patient awake at night,
complete rest to the limb is the only logical procedure and some would go so far as to
treat the case as if it were a fracture of the upper end of the humerus.
Electrical stimulation or deep massage are absolutely contra-indicated, as all such
treatments at this stage do more harm than good.
If pains in the limb and muscle cramps are severe, heat from an infra-red lamp is
comforting, applied either directly to the skin or with a moist Turkish towel interposed.
Sedative massage, such as effleurage, is also permissible if intelligently applied. By effleur-
age is meant the most superficial form of massage of the skin with the tips of the fingers
dipped in warm oil, or, as Dr. Shepley, Director of the Rehabilitation Department of
the Workmen's Compensation Board puts it, "massage as gentle as a mother would
stroke the head of her new-born baby."
As improvement takes place simple voluntary movements of the limb, deep but
controlled massage with warm oil, electric baths with the limb immersed in warm water
and cupping over tender areas, particularly if an epicondylitis is present, may be gradually instituted. Return to work should be gradual or fractional, beginning with one-
quarter of the working hours and extending to one-half to three-quarters and finally full
time. Work should be of the easy type to begin with and heavy only as competence is
It goes without saying that a thorough physical examination should be made at the
outset—not overlooking some estimate of the psychological make-up of the individual,
as this last has an important bearing on the prognosis.
• Associate Members of the Vancouver Medical Association throughout the Province
are reminded that they may borrow books and journals from the Library at any time.
The cost of mailing is of course borne by the member, but this is a negligible consideration now that our special library mailing rate is in effect. According to this arrangement, the return postage is prepaid from this end, and no additional stamps need be
affixed when returning books, if the franked label is used. This label will be enclosed
in the package or pasted on the reverse side of the wrapper.
The Librarian will be happy to look after your requests and will send them to you
with the least possible delay.
Page Seveffty-four GENITAL PROLAPSE
Dr. W. A. Scott
(Given at the Vancouver Medical Association Summer School, June, 1944)
So much has been written on the subject of genital prolapse that further discussion
would, at first, appear to be superfluous. Nevertheless, it is one of the most important
phases in the work of the gynaecological specialist, and is certainly the gynaecological
condition most frequently operated upon by the general practitioner. Most of us believe that no one procedure will suffice for all cases, and I propose to put before you
the ideas of our clinic on the various methods of handling the different types of cases.
By whatever method prolapse is treated, it is inevitable that some cases will result
in failure. The number of these failures may be reduced by selection of the proper type
of operation in a given cases. The familiarity and skill of the operator with the procedure adopted is important, but the surgeon should be familiar with several different
operative procedures if he is to achieve the best results. There is a tendency for some
particular type of operation to predominate at different times in a given clinic. This is
partially due to the desire to improve results and to changing enthusiasms, and is only
an evidence that no one type of operation is a panacea for all cases. I am aware that
there are some operators of great skill and experience that believe that practically all
cases can be satisfactorily treated by one type of operation, but it is our opinion that
each case should be individualized if we are to achieve the best results. At one time
the commonest method of treating prolapse by our staff was an anterior and posterior
repair, with an intraabdorninal correction of a retroversion, when present, in younger
women, and a vaginal hysterectomy in older patients. During the last ten years, however, the Fothergill operation has been the commonest procedure, and no cases are subjected to laparotomy if the only complaint is prolapse and there are no accompanying
pelvic lesions. It has become clear to us that if a proper repair of the supporting structures is done an accompanying retroversion will be corrected, if it is of the acquired
| variety, and will be of no consequence if it is congenital.
The term "genital prolapse" includes urethrocele, cystocele, rectocele, posterior vaginal enterocele, and prolapsus uteri. In most instances there is a combination of two or
more of these conditions. In addition, many patients have associated pelvic lesions, such
as a diseased cervix, subinvoluted uterus, fibroids, or adnexal disease. All prolapses are
true hernias, resulting from defects in the fascial supports, and the principles underlying
their correction are the same as those which are used in the treatment of hernias elsewhere.
This being true, some discussion of anatomy is necessary. No anatomical subject has had more detailed study, but the result of that study has been obscured by complicated descriptions and a variety of anatomical names for the same structures. The
essential knowledge is easily summarized. There are two layers of supporting structures
for the pelvic organs. First, and of greatest importance, are the tissues at the base of
the broad ligament. These are strong bands of fibro-muscular tissue radiating in a "fan-
shaped manner from the cervix to the pelvic walls and are called the "cardinal ligaments" or the transverse cervical ligaments of Mackenrodt. They are continuous behind
with the utero-sacral ligaments, and in front with the pubo-ceryical fascia, and form the
real support of the uterus, bladder, and vaginal vault. This support is one continuous
layer of fascial tissue which has become condensed where the greatest strain is laid upon
it, giving rise to five distinctive structures, namely, the two cardinal ligaments, the
two utero-sacral ligaments and the pubo-cervical fascia. At operation, these essential
supports are most easily reached in front of the cervix, if the operation is done from
below, and at the sides and behind the cervix, if done from above. The weakest point
in this supporting structure lies between the cervix and the pubis.
Below this plane of fascial supports, the pelvic outlet is closed by two layers of
muscles and their covering fasciae. The superior layer is composed of the levators ani
and the coccygeal muscles, and the inferior layer comprises the muscles of the vulvar
Page Seventy-five and anal openings. Muscular structures can exert only intermittent support and it follows, therefore, that the permanent or essential supports of the pelvic organs are the
fascial structures, while the muscular structures are only accessory. It is the failure to
recognize this fact that leads to many unsatisfactory operations. If the essential supports are damaged and not repaired, any operation which utilizes only the muscular
structures of the pelvic outlet will be unsatisfactory even if the uterus be removed.
Failure to repair the upper layer of structures after removal of the uterus by either the
vaginal or abdominal route leaves a potential peritoneal opening through which some
viscus will protrude, and find its way through any type of outlet repair short of complete closure of the vagina. If the uterus is not removed and these upper supports are
not repaired, a cystocele or rectocele may be cured but the descent of the uterus will
still persist. In most cases where there is descent of the uterus the cervix is elongated,
and if the uterus is to be retained an amputation of the cervix is indicated.
Occasionally the lower or accessory supports are injured, while the upper supports
remain intact. In such cases the vaginal walls descend, carrying with them bladder and
rectum, and frequently produce elongation of the cervix but without descent of the
uterus. Here a simple repair of the pelvic outlet with amputation of the cervix will
give satisfactory results, but many cases of disappointment result from the failure to
recognize that the upper supports are also injured and descent of the uterus has already
commenced. Occasionally one sees marked elongation of the cervix without descent of
the uterus, which may be mistaken for prolapse.
When this elongation is mainly in the supra-vaginal cervix it is usually congenital,
but when present in the vaginal portion may be due to injury of the outlet supports
while the upper diaphragm remains intact.
One may also point out here that where true prolapse occurs in a nulliparous patient,
the possbiility of spina bifida should always be kept in mind.
May I now outline our methods of treating the various types of prolapse that may
be encountered.
When the urethra is torn from its supports there is usually some injury to the pubo-
cervical fascia of sufficient extent to produce some degree of cystocele. Occasionally,
however, the only lesion is urethrocele, and in such cases there is frequently injury to
the sphincter of the urethra with resulting incontinence on straining. Various types
of operation have been proposed for dealing with this stress incontinence. In most cases
to expose the base of the bladder and tighten up the bladder sphincter before repairing
the fascial structures below the urethra is sufficient, but in those cases where there is
no cystocele an attempt must be made to expose and repair the urethrocelesphincter.
This may exist alone but is usually accompanied by some prolapse of the uterus. It
may follow spontaneous delivery, particularly in the elderly primapara, but most frequently is the result of instrumental delivery before the cervix is completely dilated.
The simple pecaution of always passing a catheter before the head descends beyond
the mid-pelvis will prevent many cases of cystocele that might otherwise occur. Immediate repair of damage to the pubo-cervical fascia can seldom be carried out. Proper
postpartum care, however, even where the fascia has been injured,'reduces the incidence
of subsequent cystocele.
In the repair of cystocele two principles are to be kept in mind: the elevation of the
bladder on the cervix, and the repair of the pubo-cervical fascia and its attachment high
up on the cervix. If this is accompanied by reefing of the parametrial tissues in front
of the cervix many retroversions will be corrected. If the patient is beyond the child-
bearing age and the cystocele is large, the interposition of the uterus under the bladder,
or the removal of the uterus and the interposition of the broad ligament in the same
position is often a satisfactory type of operation. It has not, however, been performed
frequently on our service. This may have been because our cases were poorly chosen,
but we had several instances of bladder irritation following the operation and saw two
Page Seventy-six cases which had been operated upon elsewhere in which the interposed uterus and bladder
subsequently prolapsed. In place of this operation we treated suitable cases by vaginal
hysterectomy and interposition of the broad ligaments. Whatever operation is done for
the cure of cystocele the tissues must be united to fixed points. The posterior repair
should extend up above the perineal body, often to the cervix. When patients with large
cystoceles first come under observation the vaginal walls are frequently thickening,
cedematous, and sometimes ulcerated. It is important to keep such patients in bed until
the prolapse is reduced and the tissues are healthy if we are to obtain proper healing.
Nearly all these cases also require perineorrhaphy, and there are nearly as many different
methods of repairing the perineum as there are operators.
Posterior Vaginal Enterocele
Prolapse of intestine through a hernial opening behind the cervix and between the
two utero-sacral ligaments is probably more frequent than is usually recognized. It is
often accompanied by other types of prolapse, but if unrecognized and undealt with, any
operation for cure of rectocele or prolapse of the uterus would be unsatisfactory. In
dealing with these cases we expose and open the sac and reduce its contents. The sac is
then resected and the hernial opening closed by approximating the two utero-sacral ligaments. Whether excision of the sac is necessary is debatable, but unless the sac is
opened it is difficult to get a proper apposition of the utero-sacral ligaments.
Descent of the Uterus
In the treatment of procidentia two types of patients must be considered. First,
women in the child-bearing age, and secondly, those past that period. During the child-
bearing age the "Fothergill" operation is usually the one of choice. This consists of
shortening the cardinal ligaments by bringing them together in front of the cervix,
followed by a proper repair of the pelvic diaphragm. When the cervix is elongated or
hypertrophied it is amputated. Many uncomplicated retroversions are corrected by this
operation, but where there is accompanying intra-pelvic pathology a laparotomy is indicated unless it can be dealt with by vaginal hysterectomy. Occasionally a retroverted
uterus is sub-involuted and heavy, yet we may not feel that its removal is indicated.
In such cases an intra-abdominal correction of the retroversion may be necessary, but
this operation is being performed on our service much less frequently than in the past.
In the patient who is beyond the child-bearing age, or in whom further child-bearing is not desirable, uterine prolapse may be dealt with by combined vaginal and
abdominal operations, or by vaginal operation alone. In the absence of any other pelvic
pathology it is our opinion that the combined operation is rarely required to cure a prolapse. In the few cases where it is indicated, and particularly where the body of the
uterus is removed, care should be exercised to see that the cervical stump is well supported
from inside. The majority of our cases, however, are treated either by Fothergill operations or by vaginal hysterectomy. The latter was the operation of choice in this group
of patients for some years, but lately has been superseded more and more by the Fothergill operation. Vaginal hysterectomy, however, still has an important place in the
treatment of prolapse, and it removes an organ which may give rise to trouble later on.
Our technique in this operation has varied slightly at times but the avoidance of
unfavourable results depends on some method of firmly anchoring the vault of the
vagina to the endo-pelvic fascia, and providing firm fascial support for the bladder and
rectum. It is usually performed by opening the anterior fornix, turning out the fundus
and severing the broad ligaments from above downward. The blood vessels are secured
by independent ligatures rather than depending on continuous sutures. The utero-sacral
ligaments are firmly attached to the vault of the vagina. The occlusion of dead spaces
is carefully carried out; the staff is about evenly divided as to whether or not a small
drainage tube should be inserted.
Many of our vaginal hysterectomies are done under local anaesthesia. It lessens the
bleeding and makes dissection easy. When general anaesthesia is employed the injection
of J_ cc. of Ptiuitary Extract into the parametrium on either side of the cervix reduces
the bleeding.
Page Seventy-seven
\l The Le Fort operation has a limited application, but in elderly patients who are poor
operative risks, and particularly in the elderly widow, it has considerable advantage. It
is easy to perform, subjects the patient to very little shock, can be readily done under
local anaesthesia, and gives good results.
You will see, therefore, that in our hands, the tendency is toward the vaginal approach in the great majority of our patients, with abdominal operations reserved for
younger women whose retroversion cannot be corrected per vaginam, or for patients
with other pelvic pathology. We do not believe in the routine use of any one operative
procedure, and stress the importance of repair of the essential supporting tissues in the
Dr. W. A. Scott
(Given at the Vancouver Medical Association Summer School, June, 1944)
Heart disease in a pregnant woman is always a complication causing anxiety.
Rheumatic heart disease is the commonest type, and mitral stenosis is the usual evidence
of its presence. It is a progressive disease which has usually begun during childhood or
early adolescence, and results in a damaged myocardium, the extent of which is often
difficult to estimate. It is frequently impossible to judge whether a heart has the
functional capacity to stand the strain of pregnancy and of parturition. During pregnancy an additional strain is put upon the heart, whether that organ be normal or diseased. The blood volume is increased; the mother gains additional body weight, to which
is added the weight of the pregnancy; changes in the maternal metabolism influence the
cardiac capacity, and the upward displacement of the diaphragm decreases the vital
capacity and displaces the apex of the heart outwards. These factors are mostly beyond
control, and may in themselves prove too great a burden for a diseased-heart to bear.
The strain of pregnancy on the heart is then climaxed by the physical effort of labour.
Although the strain of pregnancy can not be avoided, it may be minimized by
removing other sources of physical strain or by complete rest in bed. It is evident, therefore, that the progress through pregnancy of a patient with rheumatic heart disease
depends not only on the ability of the heart, but also upon the patient's opportunities
for rest. In other words, the social and economic status of the patient is of very great
importance when considering the advisability of a contemplated pregnancy, or in the
management of an already existing one.
Heart disease is often erroneously diagnosed during pregnancy. Gemmeltoft studied
239 healthy pregnant women and found that during the final two months 16.3% of
them showed signs suggestive of cardiac disease. These signs were—a rapid pulse, extra
systoles, venous pulsation or systolic or diastolic murmurs at the base. In no instance
could these be detected four weeks after delivery. De Lee says that in a routine examination of the hearts of pregnant women he found, in many cases, systolic murmurs at
the base and accentuation of the second aortic sound, and occasionally a presystolic
murmur with displacement of the apex beat to the left. This difficulty in differentiating
between functional and organic heart disease stresses the importance of a careful physical
examination early in pregnancy when repeated examinations of the heart may be made
in doubtful cases. Not only may the presence of organic disease be incorrectly diagnosed, but the contrary may be true, and it may be overlooked if the patient has not had
the proper antenatal attention. Many patients with organic heart disease may go
through labour without difficulty, while in others this disease may account for sudden
death during labour or in the early puerperium. An instance of such an undiagnosed
case is that of one of our patients. She was 33 years of age and had not been under our
antenatal care. She was in labour for the fourth time and was sent into the hospital
because of a two-day labour outside.    She had a normal delivery of a live baby shortly
Page Seventy-eight after admission, followed by normal convalescence. Two months later she was sent to
the gynaecological department for treatment of a retroversion, when a diagnosis of
cardiac hypertrophy and chronic endocarditis was made. At that time the patient gave
a history of shortness of breath and palpitation for two years; oedema of the feet and
ankles had been present for about a week.
In the past it has been generally accepted that women with heart disease who go
through pregnancy and labour tend to develop decompensation and die sooner than other
patients with the same disease. This view is open to some doubt. Reid made a study
of this question and came to the conclusion that the statistics supported his clinical
impression that "women with rheumatic heart disease die before their time, in fact,
during the child-bearing period, not because of marriage and pregnancy, but on account
of the natural evolution of this disease." He thinks that the status of the unmarried
woman with heart disease is much closer than is usually taught to that of the male
cardiac patient who is contemplating marriage. In a previous paper Dr. Nelson Henderson and I analyzed 56 postmortem cases of rheumatic heart disease. The average age at
death of male patients was 38.7 years, and of the female cases 36.4 years. For female
patients who had had more than one pregnancy the average age of death was 40 years,
while that for the nulliparous group was 30 years. We do not argue from these figures
that child-bearing tends to prolong the life of such patients, because they simply illustrate that the longer a married woman with rheumatic heart disease lives, the more children she will probably bear, but they do tend to show that pregnancy does not affect to
any great extent the age of death in a series of cases. The prime factor determining the
length of life of patients with this disease is the extent of the myocardial damage and
the frequency of exacerbations of rheumatic infection. If the damage is excessive the
patients die before they marry or have any children; if the damage is slight death occurs
later and more pregnancies occur during the longer life. We acknowledge, however,
that it is possible that these parous parents with an average age of i death of 40 years
might have lived longer if they had had no children. In this connection it is found that
a large proportion of patients with rheumatic heart disease develop some degree of failure
during pregnancy or have their symptoms aggravated shortly after delivery.
Although rheumatic heart disease as evidenced by mitral stenosis is the commonest
serious lesion, a word might be said about the usually neglected simple mitral regurgitation. I believe this is the only heart lesion that still leaves the patient eligible for life
insurance. Nevertheless, life insurance statistics show that men under 40 suffering from
mitral regurgitation have a mortality rate between two and three times normal. Women
with the same lesion show a relatively greater increase in the mortality rate than men,
but this is not marked until after the age of 40. Such figures make it evident that even
simple mitral regurgitation is worthy of study in a pregnant patient.
The relative risk of pregnancy in cardiac patients is difficult to estimate. Nearly
20% of maternal deaths at the Boston Lying-in Hospital at one time were due to heart
disease, with only about 1% of all pregnant patients having severely injured hearts. In
the same hospital in 207 cases of rheumatic heart disease there was a mortality of 8.5%.
After the instituiton of a combined Cardiac-Obstetrical Service this rate was reduced
to 3.8%. Previous to the institution of a combined Cardiac-Obstetrical Service at the
Toronto General Hospital in a series reported by Dr. W. B. Hendry there was a mortality rate of 8.9%. In the first 41 cases aftre the institution of this Service there was
only one death, or a rate of 2.3%, and since then in a series of 73 cases there were two
deaths, giving a mortality rate since the institution of the service of 2.6% One patient
died on her 64th day of multiple infarcts and bronchial pneumonia; the second patient
died on the third day of cerebral embolus. In addition, one patient had a pulmonary
embolus at home before delivery but made a good recovery, and one patient had a pulmonary embolus following delivery and was in hospital for 139 days, but recovered.
Since the institution of this special service all cases of suspected heart disease discovered in the antenatal clinic are referred to a special clinic where they are seen by a
cardiologist and an obstetrician.    The cases that have no organic lesion are referred
Page Seventy-nine
f 11 back to the ordinary antenatal clinic, but the other cases are followed throughout their
pregnancy by both an obstetrician and a cardiologist. At the time of labour a staff
anaesthetist is in attendance and the conduct of labour is supervised by the obstetrician
who has followed the case. As a result of this routine the incidence of caesarean section has been markedly reduced, and, in this last series of 73 cardiac cases only two
sections were done. As already pointed out, this has not led to an increased mortality,
but the contrary is true. In this series of 73 cases the methods of delivery were the
Forceps   42 Breech     3
Spontaneous    26 Caesarean 2
Of the caesareans, one was a Porro section in a patient with toxaemia who died, and the
second was a classical section in a patient who had had a previous section for contracted
pelvis. The duration of labour has some interest. There were 11 patients in whom the
duration of labour was over 18 hours, the longest being 60 hours, and there were 37
patients in whom the total duration of labour was less than 12 hours.
We recognize that in private practice the constant supervision of a cardiac patient
throughout her pregnancy by both an obstetrician and a cardiologist is difficult, but an
attempt should be made to approach the ideal, and the opinion of the cardiologist regarding the method of delivery should not be the final decision unless he has had a considerable experience in this particular combination of conditions.
Dogmatic rules cannot be laid down regarding the management of obstetrical
patients with heart disease, but certain general principles may be considered. Let us
consider them during pregnancy, during labour, and during the puerperium.
During Pregnancy
The economic status of the patient will have much to do with our general advice.
In the case of the well-to-do, rigid restrictions regarding household duties, exercise, and
freedom from domestic anxiety may be carried out at home. The poor patient should
be sent to hospital as soon as it becomes evident that she can not take sufficient rest at
home. However, the great middle class of our people constitute the most difficult
problem. Their resources will not provide sufficient help in the home, nor can they meet
the expense of prolonged hospitalization except in the public ward, where they will not
go. It is in this class of patients that most pregnancies are terminated which, under
other circumstances, might have been carried to term. Although physical rest is the
principal factor in treatment, the importance of avoiding intercurrent respiratory infections is to be remembered. Impending failure demands complete rest in bed until the
time of delivery. If actual failure supervenes, it, and not the pregnancy, must be
treated. No attempt at delivery should ever be made during failure if the patient is
not in labour. Many such patients go into premature labour and deliver themselves
with little trouble. In the others, if the medical measures will not overcome the failure,
attempts to empty the uterus are almost certain to prove fatal. Whether or not all
cardiac cases should be given digitalis towards the end of pregnancy is still an undecided
question. The diet of pregnant women with rheumatic heard disease should be modified
to some extent. The physiologic increase in weight occurring during pregnancy, particularly if the increase is excessive or the patient obese, should be controlled by suitable
restriction of diet, especially by restriction of the fats and carbohydrates.
During Labour
If there is no obstetrical complication I believe that vaginal delivery is best, and in
few instances, especially in multipara;, is caesarean section indicated. Many of these
patients should be sterilized to prevent future pregnancies, but the need for sterilization
is not an indication for caesarean section, because the dangers of section are considerably
greater than those of simple tubal resection in a non-pregnant woman. It is seldom
that any large series of caesarean sections shows a mortality below 3.5%, yet the operation for sterilization should not be one-third of this. In a cardiac patient sterilization
can be done after the heart has fully recovered from the additional strain of pregnancy.
Page Eighty The factors causing strain during labour are pain and anxiety, loss of sleep, lack
of food, and muscular work. Pain should be relieved during the first stage, preferably
by the use of heroin alone or in combination with one of the barbiturates. Where experience and facilities are available, caudal analgesia would appear to offer great advan-
tges, but as yet we have had little experience with this, as our total number of cases is
only about 50, and none of them have been cardiac patients. Caudal analgesia entirely
abolishes the bearing-down efforts of the second stage, and where it is not available these
efforts should be abolished by general anaesthesia and forceps delviery. Dehydration and
starvation are prevented by the adnxinistration of fluids and glucose, either by mouth or
intravenously. If caudal analgesia is used, the patient may be given any food that is
desired by mouth, as the motility of the gastro-intestinal tract is not interfered with,
and an inhalation anaesthesia is not given. Where inhalation anaesthesia is necessary, the
safest one is ether, and if cyanosis is present oxygen should be administered with it.
During Puerpermrn J
It is not unusual for a patient to go through pregnancy and labour without failure
only to develop it during the puerperium. All cardiac patients should remain in bed for
at least three weeks, and many of them for much longer periods. After she is out of
bed ample unbroken sleep is essential, and this means that nursing at night is omitted.
All cases with severe symptoms should not nurse their babies. After the patient is out
of bed her physic al efforts should still be limited. It is probable that the caring for
children by patients with cardiac disease is more important a factor in shortening life
than bearing then-.
The question of future pregnancies is one to be carefully considered. If there has
been threatened or actual failure no further pregnancies should be contemplated. The
same is true if economic conditions do not allow for proper assistance in the home. One
child well brought up, with a mother living to the age of 40, is better than three children improperly looked after, with the de.ith of the mother years before this age. The
* prevention of future pregnancies may be carried out by means of proper contraceptive
advice where the parents are intelligent and co-operative, but in other cases sterilization
should be done.
I have said nothing about the termination of pregnancy because of heart disease for,
if the patient has been properly advised, before and during her pregnancy, this is seldom
indicated. Where there has previously been congestive failure, and in patients with
present or recent rheumatic fever, pregnancy should be terminated early. As future
pregnancies are undesirable this is best done by supravaginal hysterectomy.
. -
Dr. W. A. Scott
(Given at the Vancouver Medical Association Summer School, June, 1944)
There is an old story about the professor of gynaecology who had a flair for the
dramatic. At one period of his course he would wait until the class was assembled in
their seats and silence reigned in the lecture room. He would then pick up a large
book and bring it down on the desk with a bang, after which he would begin his lecture
on ectopic gestation with the words "All of a sudden." This was dramatic, but highly
fallacious. Only a small proportion of ectopic gestations begin suddenly, and, indeed,
the majority of patients by the time they reach the operating table have had no very
acute symptoms. Of those that reach the* surgeon in a state of shock, where he who
runs can make, the diagnosis, the majority have had premonitory symptoms which might
have indicated the diagnosis for some considerable time. This paper is an analysis of
the clinical features of ectopic gestation as we have seen them over the last seven years
with the idea of indicating the findings which help the diagnosis.
Page Eighty-one Ectopic pregnancy is the implantation of a fertilized ovum some place other than
the cavity of the uterus. By far the commonest site is the fallopian tube, but implantation may occur in the ovary or in the peritoneal cavity. We have had two cases of
primary ovarian pregnancy which fulfilled all the criteria for diagnosis, In abdominal
pregnancies it is difficult in most instances to determine whether the abdominal implantation was primary or secondary. We have had six cases of abdominal pregnancy,
in two of which live babies were obtained by laparotomy, and one of these cases we
believe to have been secondary to an ovarian pregnancy. There were two deaths in the
six cases of abdominal pregnancy. Ectopic implantation of a fertilized ovum usually
leads to acute abdominal catastrophe which jeopardizes the patient's life, but this is not
always true. Occasionally haemorrhage occurs round the ovum, leading to its separation
and death with no very acute symptoms. Such death of the ovum in the tube is called
tubal mole.
The incidence of ectopic gestation is difficult to ascertain. It has been estimated by
Schumann as 1 in 300 pregnancies, but in any gynaecological service the condition is
frequently encountered because patients are immediately sent to hospital when the
diagnosis is made.
Total admissions	
Total  number ectopic pregnancies	
Number  diagnosed correctly pre-operatively	
Number  diagnosed  incorrectly pre-operatively-
1937-1943  INCLUSIVE
— 2.2%
— 86.2%
— 13.8%
31 - - 20.3%
Total  cases	
19 and under	
20 — 24	
25 — 29 45  - - 29.6%
30 — 34 39 — 25.6%
3 5  — 39 29 — 19.1%
40   and  over 6 —    3.9%
Youngest—18 years; oldest—45 years.
The commonest etiological factor in tubal pregnancy is a previous salpingitis, not
sufficiently severe to completely close the tubes, but resulting in adhesions between the
folds of the tubal mucosa. One-third of our cases present evidence of this type of
salpingitis. Tsis is the reason for the commonly observed findings of a period of relative sterility preceding tubal pregnancy. Thirteen of our cases had had a previous
ectopic pregnancy, and in one instance the patient had three successive instances of this
condition, the first occurring in the ampulla of the right tube; a portion of the tube was
left at operation: the second ectopic occurred in the other tube, and the third ectopic in
the portion of the tube left at the first operation.
Total cases . 152
Previous  Abdominal   Operations 33
One previous abdominal operation 28
Salpingo-oophorectomy 12
Appendectomy  ; 10
Cholecystectomy 2
Caesarean section ■       1
Appendectomy and cholecystectomy 1
Appendectomy and nephrectomy 1
Appendectomy and salpingo-oophorectomy 1
Two previous abdominal operations       5
Appendectomy and  salpingo-oophorectomy 3
Removal of ovarian cyst and salpingo-oophorectomy       1
Drainage of appendiceal abscess and appendectomy. 1
Tubal pregnancy may terminate in one of three ways: by tubal abortion, by tubal
rupture, or with formation of a tubal mole. With rupture of the tube and with tubal
abortion the pregnancy may become a secondary abdominal pregnancy. With all three
methods of termination some peritoneal bleeding occurs, but this is more severe with
Page Eighty-two tubal abortion or tubal rupture. It may be slight, continuous haemorrhage, with periods
of mild exacerbation leading to the formation of a pelvic hematocele, or it may be a
sudden, severe haemorrhage. In a series of 102 consecutive cases on our service, 37 had
severe internal haemorrhage, 24 being due to rupture of the tube and 13 to tubal abortion. Clinical symptoms of ectopic pregnancy largely depend on the amount of internal
bleeding. Severe haemorrhage results in sudden pain and collapse: prolonged slight bleeding causes less severe pain, no collapse, but usually varying degrees of anaemia. Some
vaginal bleeding is a common symptom, but in ten patients of our series this was not
present. It has been our experience that in about half the cases there is no definite history of a missed period, the vaginal bleeding occurring at the time of, or before, the
expected period, for which it is frequently mistaken. When vaginal bleeding is present
it is usually slight in amount, but profuse uterine bleeding does not rule out an extrauterine pregnancy. We frequently see bleeding severe enough to suggest an abortion
of an intrauterine pregnancy, and the passing of a decidual cast would further complicate the diagnosis. When this occurs, careful examination of the gross specimen will
often reveal the presence of the two uterine openings of the fallopian tube, and a
microscopic examination reveal the absence of chorionic villi.
Pain is an almost constant symptom, but varies greatly in intensity. It is usually
crampy in nature and may be more marked on the side of the ectopic, although it is
frequently present across the whole lower abdomen. Pain in the shoulder region is an
evidence of extensive intraperitoneal haemorrhage. The association of f aintness or actual
collapse is of great diagnostic importance.
Total cases 152
No vaginal bleeding of any kind  10
No pain ;  3
Nausea  41
Vomiting ! : '  3 3
*                Faintness  29
Shoulder  tip  pain _  27
Fainted __ 27
Weakness  21
Abdominal distension  6
Diarrhoea  6
Pain on bowel movements I  6
Frequency  5
Dysuria  3
Constipation .  3
Low back  pain ,  3
Mass in the abdomen, ;  2
Chest pain on breathing  2
Shortness of breath  1
Thirst  ; j  1
On abdominal examination there is nearly always considerable tenderness, although
this is occasionally only present on deep pressure over the site of the pregnancy. Rebound
tenderness and hyperaesthesia of the skin of the abdominal wall is common when the
bleeding is extensive. Shifting dullness can sometimes be demonstrated when the intraperitoneal haemorrhage is profuse. Abdominal rigidity is not common, but a characteristic doughy sensation on palpation, with varying degrees of distension, is usually found
when the haemorrhage is large.
On pelvic examination there are two important findings—tenderness and the presence of an adnexal mass, most frequently found in the pouch of Douglas. The tenderness may be confined to the side of the ectopic, but occasionally involves all the pelvis
and can best be elicited by moving the cervix or uterus. A mass can be palpated in the
pelvis in about 75% of all cases, and when this mass is large it is usually situated in the
posterior fornix and may rise above the pelvic brim. The uterus is then pushed forward
and lifted up in the pelvis, and it is often difficult to distinguish it from the mass.
When the mass is small it is usually felt in one or other fornix.
Page Eighty-three Examination under anaesthesia is sometimes of value, but in many instances more
accurate findings are made without an anaesthetic. A tubal pregnancy is often small,
soft, and indefinite in outline, and even under an anesthetic, impossible to palpate.
Without an anaesthetic the tenderness is elicited, and it has been my experience that I
could sometimes palpate a mass without anaesthesia that I was unable to feel when the
patient was asleep. When the diagnosis is in doubt a posterior colpotomy is of great
value. This may be done by means of a needle puncture, and often without anaesthesia.
A speculum is inserted into the vagina, the posterior tip of the cervix is grasped with a
tenaculum, the vagina is then prepared antiseptically, and a large-bore needle introduced
through the posterior vaginal wall and carried upward posterior to the cervix into the
peritoneal cavity. The point of the needle should be carried well up into the pelvic
cavity and suction then made on the attached syringe. The needle is then slightly
withdrawn. If the haemorrhage is slight no blood will be obtained at the start, but as
the point of the needle reaches the pouch of Douglas some dark blood will be obtained.
By this method a minimal pelvic haemorrhage may be demonstrated which might be
obscured by doing the ordinary posterior colpotomy, during which there is always some
bleeding from the incised tissue. It is to be remembered, however, that ectopic preg-
nacy may be present with no demonstrable intraperitoneal haemorrhage, and in such cases
the colpotomy incision with the insertion of a finger will allow palpation of the tubes.
Total number of ectopic pregnancies . 152
Posterior Needle Punctures
"Without anaesthesia 24
Blood obtained and blood present in peritoneal cavity 23
No blood obtained and blood present in peritoneal cavity_ 1
Under anaesthesia '. '     6
Blood obtained and blood present in peritoneal cavity in all.
Posterior Colpotomies under Anesthesia 50
Blood obtained and present in peritoneal cavity 47
No blood obtained and blood present in peritoneal cavity 3
A rise of temperature is of little value in diagnosis.
Total cases  153
98° and below 19 — 12.4%
98.2° — 99°     (inclusive) 57 — 37.2%
99.2° — 100°   (inclusive) 63 — 41.2%
100.2° — 101°   (inclusive) 10 —    6.5%
Over 101° ___       4 —    2.6%
In 76 of our cases the temperature on admission was not above 99°, and in only four
was it over 101°. The remainder had admission temperatures of 99.2° to 101°. A high
temperature may be accounted for in two ways. First, there may have been slow bleeding for some considerable time with secondary infection of the haematosalpinx; secondly,
the patient may have suspected that she was pregnant and have attempted to produce
an abortion by mechanical means, resulting in pelvic infectoin. In the latter case when
the temperature is high the haematocele may be mistaken for a pelvic abscess, but needle
puncture or colpotomy will make the diagnosis clear.
A raised white blood count is usually present, but in nearly half of our cases was
not over 10,000.
Total cases 150
10.0 and  below 70 — 47%
10.i — 12.0  19 — 12.6%
12.1 — 14.0   10 — 6.6%
14.1 — 16.0  16 — 10.6%
16.1 — 18.0  16 — 10.6%
Over 18.0 _  ,  19 — 12.8%
The sedimentation rate is usually more rapid than normal, but where greatly accelerated is usually an evidence of secondary infection.
Total cases 129
minutes   ; 1i 	
minutes  9 —
minutes  14 —
minutes  9 —
60 minutes and over  86 —
Total cases 152
30 —
40 —
50 —
60 - 78
74 —
100 — 118 34
120 — 138	
140  and over	
No pulse could be obtained in two cases.
40 and below.
41 — 50    	
51 — 60    	
61 — 70	
71 — 80	
9 — 6.7%
14 — 9.6%
28 — 19.2%
46 — 31.5%
30 — 20.5%
Over 80 19 — 13.0%
Ectopic pregnancies 152
A.Z. tests done  25
Positive 22
Negative 3
The value of an A.Z. test in diagnosis of ectopic pregnancy is not great. Where the
differential diagnosis lies between inflammatory disease and ectopic pregnancy it may be
of value. A positive A.Z. test, however, is simply an evidence of pregnancy, and does
not tell us where the pregnancy is situated. A patient with an old inflammatory lesion
and an intrauterine pregnancy will give a positive test. If she is threatening to abort
a positive test may actually obscure the diagnosis. A negative test is simply an evidence
that no living pregnancy exists, but it does not rule out tubal mole with a dead OAjum.
This presented data may be of interest, but it is obvious that none of it is conclusive except, possibly, the demonstration of free blood in the peritoneal cavity. What,
then, are the points that will increase the number of correct diagnoses of ectopic gestation before reaching the tragic state? First, and of most importance, one should suspect
it. An accurate history is often of great value, but the difficulty of getting a complete
and trustworthy menstrual history is great. It is a constant source of surprise that a
large number of otherwise intelligent women appear to be in almost complete ignorance
if their own menstrual cycle. In addition, many women are constantly irregular in
their periods, to which is added the fact that the vaginal bleeding so frequently associated wtih ectopic gestation is mistaken for a menstrual period. Lastly, some patients
deliberately attempt to deceive the clinician. They suspect that they are pregnant and
have no idea that the pregnancy can be any place except in the uterus. They hope that
with a false history a curettage may be done.
Diagnosis is further complicated by the similarity of this to other conditions, and
particularly to an abortion. Ectopic gestation can simulate any type of abortion,
threatened, inevitable, incomplete, complete, or septic. Whenever the possibility of
abortion enters the clinician's mind the idea of an ectopic should also be present. Pelvic
inflammation of a subacute or chronic variety may also make for difficulty in diagnosis.
The presence of a positive gonococcal infection of the lower genitals does not, however, rule out an ectopic gestation any more than it rules out acute appendicitis.
The findings of greatest positive value are: pain, which may be slight; pelvic tenderness, particularly marked on moving the cervix or uterus; the presence of a soft, tender,
often indefinite, mass in the pelvis; and the demonstration of blood by posterior colpotomy.
Page Eighty-five In treatment, blood transfusions are of the greatest value in all serious cases of
ectopic pregnancy. In a seriously ill patient a transfusion is started immediately on
admission, and if she is in severe shock we wait until her condition improves, when
operation is immediately undertaken. Few, if any, patients suffering from haemorrhage
shock fail to improve temporarily under the administration of morphine and transfusion,
and we do not like to operate on a collapsed patient. Except in cases with very little
intraperitonal haemorrhage, operation is limited to the removal of the affected tube.
Free blood clots should be removed with a n_inimum waste of time. The ovary of the
affected side should be preserved if at all possible, but the tube on that side should be
completely removed.
We had two deaths in 152 cases. The first case, a patient 35 years of age, was
admitted to surgery with acute abdominal pain. She was two weeks beyond her expected menstrual period and had slight red vaginal bleeding. For two weeks she had
had crampy lower abdominal pain, and 24 hours before admission became distended and
vomited. On admission she was extremely ill with pulse 140, temperature 101°, and
abdomen markedly distended and tender. On pelvic examination the uterus was slightly
enlarged with a large tender mass in the right fornix. A diagnosis of septic abortion
with tubo-ovarian mass was made, and she was transferred to our service. This diagnosis
was concurred in here. She was transfused, but died three days after admission, and the
correct diagnosis was made at autopsy. This death was directly due to our lack of
diagnostic acumen.
The second patient was 21 years of age and was admitted with a history suggestive
of ectopic pregnancy. Her general condition was good. There was no abdominal tenderness or distension, and no palpable pelvic mass. A posterior colpotomy was done and
no blood obtained. One hour after being returned to bed she became shocked and
obviously had a severe intraperitoneal haemorrhage. Transfusion was given and laparotomy done. A recently ruptured ectopic pregnancy was found. Temperature rose to
103° on the second day post-operatively, and she developed pulmonary oedema and died.
We regret to record the passing of Dr. M. G. Archibald on December 24th, and
Dr. James Franckum on December 12th. Dr. Archibald was well known in the profession, having practised in Kamloops for many years. Dr. Franckum practised at
Blaine, Wm. for a number of years.
Sympathy is extended to Dr. B. de F. Boyce of Kelowna in the loss of his wife, and
to Dr. G. H. Clement of Vancouver in the loss of his mother.
Congratulations are extended to Dr. and Mrs. Victor Drach of Vancouver on the
birth of a daughter on January 5 th.
Two British Columbia doctors have been decorated for meritorious service. Major
J. L. M. Anderson, R.CA.M.C, of Victoria, has received the M.B.E. for service in
taly. Capt. W. S. Huckvale, R.C.A.M.C, formerely of Kimberly, and at present in
Vancouver, has been awarded the Military Cross.   Capt. Huckvale served in Normandy.
Congratulations are extended to the following Officers who have received promotions recently: Surgeon Lieut.-Commander D. M. Whitelaw, Act. Surgeon Lieut.-Commander Murdo McRitchie, Act. Surgeon Lieut.-Commander A. G. MacKinnon, and
Act. Surgeon Lieut.-Commander E. W. Wylde.
Dr. Saul Bonnell of Vancouver was married to Miss Edith Hanbury on December 27.
Page Eighty-six Major Fred H. Bonnell, R.C.A.M.C, was in Vancouver and Victoria recently on
thirty days' leave after five years' service overseas.
Surgeon-Lieut. W. S. Archibald, R.CN.V.R., arrived home in December, just two
weeks prior to the death of his father, Dr. M. G. Archibald of Kamloops.  Surgeon-Lieut.
Archibald had been on loan to the R.C.N, and latterly was on duty at a Canadian Naval
Hospital in Scotland.  He is being posted for duty on the Pacific Coast.
*       *       *       *
Dr. R. W. Irving of Kamloops spent the Christmas holidays in Toronto and other
Eastern points visiting relatives and friends.
Dr. D. B. Collison has returned from service overseas in the R.C.A.M.C, and will
resume practice in Vancouver shortly.
Dr. J. W. Vosburgh of Princeton called at the office when in Vancouver recently.
Dr. S. Z. Bennett of Salmon Arm called at the office.
-r *r 3? •?
Dr. P. L. Straith of Courtenay is having a holiday in California.
Dr. J. H. MacDermot of Vancouver is spending a short holiday in Victoria.
Dr. and Mrs. F. N. Robertson of Vancouver are spending the winter in Virginia
with Doctor Robertson's brother.
Dr. W. T. Lockhart is back at his office following an accident which resulted in a
fractured leg. *       *       *       *
Dr. R. B. Boucher has recovered from a recent illness.
Dr. A. W. Hunter of Vancouver has resigned as pathologist to the coroner.
The people of Bella Bella and surrounding district recently honoured Dr. George E.
•Darby upon the completion of thirty years' service as a missionary doctor in that area.
The annual Fall meeting of the Upper Island Medical Association was held at Par.ks-
ville on November 23 rd, 1944.
The following members were present: Doctors A. B. Hall, C C Browne, E. D.
Emery, A. H. Meneely, L. Giovando and J. M. Hershey of Nanaimo; T. A. Briggs and
Wm. McEwen of Courtenay; A. R. Hicks of Cumberland; R. W. Garner, G. B. Helem,
A. P. Miller and W. C Pitts of Port Alberni; E. N. East of Qualicum; and Doctors D.
A. Hewitt, Martenmas, Chaintrees, and the two guest speakers Doctors G. O. Matthews
and H. H. Milburn from Vancouver.
The meeting opened with a tribute to the memory of the late Dr. M. W. Thomas.
Dr. Matthews spoke of those qualities which had endeared him to members of the profession throughout the Province, and called on the members to rise for a rninute of
silent respect to his memory.
The officers for the coming years 1945-46 were elected as follows: Dr. C T. Hilton
of Port Alberni, President; Dr. A. P. Miller of Port Alberni, Vice-President; Dr. W. C
Pitts of Port Alberni, Secretary-Treasurer.
The following appointments were also made: Dr. R. W. Garner, Chairman of the
Committee on Cancer; Dr. G. B. Helem, Reporter to the Bulletin; Dr. A. H. Meneely,
Chairman of the SubrComniittee on Economics.
Page Eighty-seven Dr. Matthews spoke briefly in his capacity as President of the British Columbia
Medical Association, referring to the negotiations under way for the establishment of a
Medical Faculty affiliated with the University of B. C. He also urged more members
to join the Canadian Medical Association.
Dr. H. H. Milburn addressed the meeting as President of the Council of the College
of Physicians and Surgeons.
Following this Dr. Matthews gave a very interesting and instructive talk on "Common Problems in Treatment of Infants and Children," which was much appreciated by
his audience.
A vote of thanks was given to the speakers of the evening.
The outgoing officers were thanked for their services during the past year, after
which the meeting closed with God Save the King.
NutM $c (Hljumi-im
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Breaks the vicious circle of perverted
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relief by stimulating the innervation of the
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V • a
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Dosage:   l to 2 capsules
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Page Eighty-eight CALSIMIL
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Calcium deficiency Is attributable either to lack of dietary calcium
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In every practice patients are to be found who would benefit from
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The form in which extra-dietary calcium is provided is of considerable importance, and the form must be such that absorption and
retention is adequate. Calsimil, which contains calcium sodium
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calcium deficiency, for it not only supplies the substances lacking
but also provides for the absorption and retention of the calcium.
In addition,Calsimil tablets are palatable and acceptable to patients
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Stocks of Calsimil are held by leading druggists throughout the
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Salyrgan-Theophylline is supplied in two forms:
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-JSBI This glass model of Trichomonas
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This was done in the belief that such a
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helpful in visualizing the structure and
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Most cases of Trichomonas vaginitis are
cleared up by 2 insufflations, a week apart,
using Compound Silver Picrate Powder,
plus supplemental home treatment with
Vaginal Suppositories Silver Picrate, 1
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Silver Picrate, Wyeth, 1% in purified Kaolin
SILVER PICRATE The rooster's legs
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The rooster got plenty of vitamin D.
Fortunately, extreme cases of rickets such as the one above illustrated
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One of the surest and easiest means of routinely administering vitamin D (and vitamin A)
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Drisdol in Propylene Glycol—10,000 units per Gram—Is available In bottles containing
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THE "bulk" laxative action of __xlogg_
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The above is one good reason why doctors
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These five factors are combined in
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R. F. HARRISON W. E. REYNOLDS iiiiiiiiiiiiiiiiiiiMiiiiiiitiiiiiiiiiiiiiiiifiiiiiiiiiiiiiiiiiiiiiiiiiMiifiiiitiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiMiitiiiiJiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiriiiiiMiiiiiiiiiiiiiiiiiiiiiiiiiiiiriiitJiitiiiiiiiiiittiiiir
continued undiminished
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"It is interesting that in our studies the prevalence of
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Theoretically, it does not seem remarkable that rickets
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especially when it is found so commonly in infants, because
in the case of older children administration of vitamin D is
usually omitted entirely."—Follis, R. H., Jr.; Jackson, D.;
Eliot, M. M., and Park, E. A.: Am. J. Dis. Child. 66:10
(July) 1943.
[E study quoted above presents a valid indication of the
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Irradiated Carnation Milk is
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Irradiated Carnation Milk meets
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mini iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiuiiiiuiuiiiiuiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii iiiiiiiin ii iiiiiiiiiiiiiiiiiiiiiiiiiinniiiiiiis We Have Closed Our 36th Year
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For the treatment of
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
New Westminster 288
or 721 Medical-Dental Building, Vancouver, B. C.
PAcific 7823 PAcific 803*


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