The BulleT ^^■| OF THE )MB| Vancouver Medical Association Contents Shaughnessy Clinical Meeting Medicine and the Law Laboratory Bulletin ANNUAL MEETING CANADIAN MEDICAL ASSOCIATION JUNE 22—26, 1931 VANCOUVER, B. C. Vol. VII. MARCH. 1931 Meetings General—Mar. 3rd Clinical—Mar. 16th /. STRAND THEATft£ BLDG. VANCOUVER., CANADA MB ANDERS I ALL GLASS NEBULIZERS No. 1 Reduces oils to a mist-like colloid Sprays a few minims successfully. No. 2 For coarser oily sprays. 1.50 To The Patient Seymour 57 or Seymour 575 Nebuline: A mild aromatic antiseptic nasal spray—free sample upon request. -7£JLSZ THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly By McBeath-Campbell Ltd., 326 West Pender St. under the Auspices of the Vancouver Medical Association in the Interests of the Medical Profession. Offices: 203 Medical and Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Dr. J. M. Pearson Dr. J. H. MacDermot Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the abovs address. Vol. VII. MARCH, 1931 No. 6 OFFICERS 1929-30 Dr. G. F. Strong Dr. C. "Wesley Prowd Dr. T. H. Lennie President Vice-President Past President Dr. E. M. Blair Dr. W. T. Lockhart Hon. Secretary Hon. Treasurer Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow Trustees Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson Auditors: Messrs. Shaw, Salter & Plommer SECTIONS Clinical Section Dr. S. Sievenpiper Chairman Dr. J. E. Harrison Secretary Eye, Ear, Nose and Throat Dr. N. E. MacDougall Chairman Dr. J. A. Smith Secretary Pediatric Section Dr. H. A. Spohn \ ■- Chairman Dr. R. P. Kinsman Secretary STANDING COMMITTEES Library Orchestra Summer School t-xt^t.t, t^tt>t% Dr. R. P. Kinsman SR- £•l\ ™STEED ?' T" h SAV n Dr- w- l- Gra"am Dr. D. M. Meekison Dr. J. H. MacDermot Dr C E Brown £*• J' £• DHATFIELD E|R' 5 ?' cRoBERTSON Dr.' i L." Buttars Dr. C. H. Bastin Dr. J. A. Smith Dr | h Vrooman 5R' S- ?• VrOOMAN Dr. J. W. Arbuckle Dr. C E. Brown Publications Hospitals Dr. J. M. Pearson Dr. J. W. Arbuckle Dinner Dr. j. H. MacDermot Dr. j. A. Gillespie Dr. L. H. Webster Dr- d- e- h- Cleveland Dr. W. C Walsh Dr. J. E. Harrison E>R- F. W. Lees Dr. E. E. Day Credentials V.O.N. Advisory Board » j. i n ^ » . a Dr. W. S. Turnbull Dr. Isabel Day Rep. to B. C. Med. Assn. —. A T <r T „ „ n„ tj u r. ,,* *, r Dr. A. J. MacLachlan Dr. ri. rl. Caple Dr. H. H. Milburn Dr. P. W. Barker Dr. G. O. Matthews Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT STATISTICS, JANUARY, 1931 Total Population (estimated) ' 242,629 Asiatic Population (estimated) 14,227 Rate per 1,000 of Population Total Deaths , 200 9.7 Asiatic Deaths 14 11.6 Deaths—Residents only 186 9.0 Birth Registrations 337 16.4 Female 156 Male 181 INFANTILE MORTALITY— Deaths under one year of age 21 Death Rate—per 1,000 Births 62.3 Stillbirths (not included in above) 9 CASES OF CONTAGIOUS DISEASES REPORTED IN CITY February 1st December, 1930 January, 1931 to 15 th, 1931 Cases Deaths Cases Deaths Cases Deaths Smallpox 0 0 0 0 0 0 Scarlet Fever 53 0 26 0 18 0 Diphtheria 10 2 9 0 4 0 Chicken-pox 121 0 167 0 58 0 Measles 2 0 8 0 Jl 0 Mumps 21 0 34 0 40 0 Whooping-cough ii 10 0 11 0 2 0 Typhoid Fever 9 3 2 0 10 Paratyphoid —- 0 0 0 0 0 0 Tuberculosis - 7 13 17 17 9 Meningitis (Epidemic) . 0 0 11 0 0 Erysipelas . 3 0 7 0 3 0 Encephalitis Lethargica 0 0 0 0 0 0 Is Diathermy Indispensable to Your Practice? THOUSANDS of physicians who are using diathermy diligently in the treat' ment of various conditions, answer the above question in the affirmative. They base their opinion on actual experience with efficient apparatus intelligently applied. The present wide use of and interest in medical and surgical diathermy is un' precedented. Physicians have come to a full appreciation of this form of energy as a means of producing heat for therapeutic purposes within any part of the body. Its surgical applications are recognised by well-known surgeons as of importance. Now, diathermy is being used also for the production of therapeutic fever, i. e., creating general temperature rise within the body, under absolute control and without danger of injury. In fact, it is considered paramount in the treatment of a number of conditions where artificial l fever is indicated. As to the need for diathermy in some phases of your individual practice, this i must be left for you to determine. 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CT! t T 1 1 1 I t T 1 ! 1 1 1 1 1 1 t t I I 1 I t 1 1 t 1 I I I I 1 1 I I t t T t I I 1 t T T T T~ EDITOR'S PAGE Recently, in the daily press, we saw an item to the effect that one of our city fathers, Alderman Warner Loat, in discussing the question of hospital accommodation, had intimated that doctors were a great deal to blame, inasmuch as they sent patients to hospital unnecessarily. We confess to a toral indifference as to Alderman Loat's personal opinions—but, after all, he made this statement in his official capacity. It is very much in line with a similar expression of opinion ascribed to a minister of the Crown, who, in addressing a New Westminster audience, made very much the same sort of statement. The medcal man has been having a hard time of it lately. We have, of course, our detractors and those who do not think well of us— that is inevitable—but during the last year or so, we have been held responsible for a great many of the evils that beset the body politic. Beginning with the Hospital Survey Report, and ending with Alderman Warner Loat, our iniquities and misdoings have been thoroughly exposed and given a good airing. One begins to wonder whether it might not be a good thing to do away with doctors after all. If we can believe one speaker, we are responsible for the hospital deficit; another makes us the scapegoat for hospital shortage—there is something rotten in the state of Denmark, and everyone blames it on the doctor. There is an old saying that the "bad workman quarrels with his tools." A more colloquial rendering of this would be that he looks for an alibi, or "passes the buck." This is a very human tendency—we all do it at times. In this particular instance, however, we take issue with these speakers. We are getting tired of being blamed for things which are not our fault. It should be quite obvious to any ordinarily intelligent man, who will take the trouble to look into the facts, that neither the hospital deficit nor the shortage of hospital beds can be held the fault of the medical profession. Granted that occasionally a doctor sends a patient to the hospital who might be treated at home, or granted that there has occasionally been a doctor who tried to collect his fees from a patient he has worked for in the hospital, and who has (horribile dictu) considered that he has at least an equal claim with the hospital. These are very small factors. We deny emphatically that there has been unfair treatment of the hospital by the great bulk of medical men. Vancouver has not provided hospital accommodation commensurate with its needs and its growth. The failure to do so may have been due to causes which the city could not control—it is certainly not our fault. Deficits are not peculiar to Vancouver. Dr. Haywood has taken occasion to point this out—we certainly are not responsible for them. It might be a good thing if the medical profession could some day have a chance to present its views and its side of this whole question before the bar of public opinion. We feel that a good deal of this unfair criticism of our profession would cease. In the meantime, we desire to utter our small word of protest against the unthinking and careless utterances of uninformed people, no matter what position they occupy. Page 125 NOTICES An announcement regarding a class in tuberculosis for practising physicians to be held at the Tranquille Sanatorium, appeared in a recent issue of this Bulletin. It has been decided to hold this class from May 25th to May 30th inclusive. All phases of tuberculosis will be covered, particular attention being given to special treatments such as pneumo-thorax. The Sanatorium will refund travelling expenses to all men attending this class. The class will be limited to ten men. In selecting the class from the list of applicants, an attempt will be made to make it as representative of the various districts of the Province as possible. All men in good standing in the B. C. Medical or the Vancouver Medical Associations are asked to regard this notice as an invitation to apply. Those wishing to take advantage of this invitation are asked to apply as soon as possible to Dr. A. D. Lapp, Medical Superintendent, Tranquille Sanatorium. The Annual Meeting and dinner of the Lower Mainland of B. C. branch of the Association of Officers of Medical Services of Canada will be held in the Messroom of the 18 th Field Ambulance, at 415 Cordova Street West, Saturday evening, March 7 th, at 7 p.m. All medical men who have held or are holding commissions in the C.A.M.C. are urgently requested to be present, as the formation of a medical section of the C.M.A. is to be discussed and arrangements made for holding a sectional meeting in connection with the C.M.A. here in June. This branch has the distinction of having the largest enrolment in the Dominion, and it is hoped that it may continue to. If you have not been present at previous meetings, make a special effort this time and also remind any of your friends. Get in touch with the secretary as soon as possible so that arrangements may be made for catering. Time: 7 p.m., Saturday, March 7th, 1931. Place: 415, Cordova Street West. Dress: Informal. Tickets: $1.75. H. H. Pitts, Secretary- Treasurer. Dr. R. E. McKechnie will deliver the Osier Lecture at a Dinner Meeting of the Vancouver Medical Association, to be held at the Hotel Vancouver on March 31st, at 7:30 p.m. Dress formal. Tickets $1.50. Committees of the Association desirous of calling a meeting in the Committee Room are asked to enquire beforehand from the Office whether the room is already engaged, so as to avoid two Committees being called for the same time. Page 126 ADDITIONS TO THE LIBRARY Medical Clinics North America. July, September, November, 1930. United Fruit Co. Annual Report Medical Department. Cornell University Medical Bulletin Urology. Vol. XIX. Ministry of Health Report on Cancer Lip, Tongue and Skin. Surgical Clinics North America. August, October, December, 1930. Physiological Principles in Treatment. Langdon Brown, 6th Ed. Osier's Medicine. 11th Edition, 1930. Dietary Suggestions. Christie, Beams & Geraghty, 1930. Bacteriology in Relation to Medicine. Vol. 7. Viruses and Bacteriophage. Surgery of the Temporal Bone. Ballance, 1919. 2 vols. Physical and Clinical Diagnosis. Andrus, 1930. Annual Report of the Rockefeller Foundation for 1929. International Clinics. Vol. 11. Series 40. Roentgenology of the Chest. Sante, 1930. Treatment in General Practice. Beckman, 1930. Transactions of the American Proctologic Society. 1930. Diseases of the Skin. Andrews, 193 0. Transactions of Section of Ophthalmology. A.M.A., 1930. Concerning Man's Origin. Sir Arthur Keith. Intracranial Pressure in Health and Disease. 1929. The volume of the Blood and Plasma in Health and Disease. Rowntree and Brown. Cornell University Bulletin. Vol. XX. Coll. Papers School of Hygiene and Public Health. Johns Hopkins. Transactions Section of Laryngol. Otol. and Rhinol. A.M.A., 1930. Crossen's Gynaecology. 7th Edition, 1930. Harvey Lectures. 1929-1930. Leonardo da Vinci, the Anatomist. McMurrich, 1930. Internal Secretions of the Ovary. A. S. Parkes. Allergic Diseases. Balyeat, 1930. Diet in Disease. Harrop, 1930. Neoplastic Diseases. Ewing, 3rd Edition. MEETINGS The monthly General Meeting of the Association was held in the Auditorium on February 3rd. Owing to the dense fog there was a small attendance and on motion duly seconded and carried the presentation of papers by Drs. Wallace Wilson and Dr. F. N. Robertson was postponed. A letter from the Registrar of the College of Physicians and Surgeons was read asking for the opinion of the Association as to the action to be taken in view of the proposed legislation coming before the Legislature re drugless healers and chiropractors. After considerable discussion the following resolution was carried: "That this Association is of the opinion that the B. C. Medical Council should continue to oppose by all means in its power any legislation which will empower drugless healers, or other cults to practise without adequate examination in the fundamental subjects, scientific and otherwise, necessary to an adequate knowledge of disease, and that this Association urges the appointment by the House of a Judicial Commission to examine into this whole matter." Page 127 The January meeting of the Clinical Section was held at the Vancouver General Hospital on the 26th. Cases were presented by Drs. E. J. Curtis, A. W. Bagnall, Wallace Wilson, W. L. Graham and F. N. Robertson. At the close of the meeting refreshments were served through the courtesy of the Board of Directors of the Hospital. A full report of the cases presented at this meeting will appear in a later issue. The Committee authorized at the General Meeting of the Association on January 6 th to investigate the cancer question as it affects the City of Vancouver has appointed an Executive Committee of which Dr. J. J. Mason is Chairman and Dr. A. Y. McNair, Secretary. Several meetings have been held and sub-committees formed to investigate and study the question from different angles. CLINICAL MEETING, DECEMBER 16th, 1930 Owing to the courtesy of the authorities at Shaughnessy Military Hospital we are enabled to publish the following full report of the cases presented at the meeting of the Clinical Section held at Shaughnessy on December 16th: Dr. J. Brown presented the following cases: Case 1—G.S. Brought into hospital with ordinary symptoms of hemiplegia. He could remember having no serious illness. Mother died when he was quite young. Always had good health. Served overseas and in 1919 appeared for Board at Whitley. Diagnosis D.A.H. Symptoms noted were palpitation, shortness of breath and poor exercise tolerance. Pulse 96 to 144 on exercise. A note made at that time stated there was a cardio-respiratory murmur only. After coming back to Canada was given a small pension for D.A.H. which was discontinued in about a year because of greatly improved exercise tolerance. Carried on at his own work until about July 5, 1930. Noticed during 1929 that he was not standing up to his work very well, particularly during the last six months. He complained of being tired and of shortness of breath. On the morning of July 5 th was not feeling well and decided to stay off work. Lay down on couch in the living-room, something apparently happened and the next thing he knew he was off the couch with his wife bending over him. He was not sure whether he lost consciousness or not but if so it could only have been for a few moments. That day he was brought into hospital. Routine examination showed the usual symptoms of right hemiplegia—right arm and right leg helpless. The detailed symptoms will not be gone into as we are mainly interested in the cause of the hemiplegia. On admission temperature was 99.2 and since admission has been more or less irregular, varying from 99 to 101. Heart examination revealed a distinct rough mitral murmur with moderate enlargement. B.P. 154/90. Arteries sclerosed excessively for his age which is 44. Hemiplegia cleared up quickly, practically in two or three weeks. Still had a little weakness of grip but was able to stand and walk about a little with good control. This was for testing purposes only and he was kept closely in bed. Wassermann and Kahn negative. No history of rheumatism. Examination showed some enlargement of spleen. Diagnosis made of sub-acute bacterial endocarditis Page 128 atuminF.suijjy with embolism. This diagnosis was made on the presence of a heart lesion, continued irregular temperature, embolism and enlargement of the spleen but up to date blood culture for the streptococcus viridans has been negative. Blood count on admission was W.B.C. 6,600, R.B.C. 5,100,000, hemoglobin 95. Blood count taken three days ago showed W.B.C. 9,000,000, R.B.C. 4,000,000, hemoglobin 76. This was not so important in the actual count as in showing the direction towards which the blood is tending, namely that of the usual anaemia. Mitral murmur distinctly heard, much the same as on admission last July, but no new murmurs or sounds added. Diagnosis of sub-acute bacterial endocarditis made on these four symptoms. Other symptoms frequently found were absent, such as petechiae, splinter haemorrhages, Kahn spots on the retina, and so far a negative blood culture. Regarding the treatment of these cases or rather the lack of efficient treatment, I should like to say a few words. Chemotherapy may be said to have failed. Various remedies have been tried and reported on by numerous careful observers, such as sodium cacodylate, arsphenamine, colloidal silver, mercurochrome, acriflavine, and gentian violet. These must be considered to have failed. Vaccine and serotherapy are, if possible, in a worse position. Auto-vaccine and anti-serum obtained from the blood of horses, immunized by the patient's own streptococci has failed. Similar treatment to that given in another streptococcal disease, namely scarlet fever, has also failed. Finally transfusion from immunized blood has also failed. Lib- man, who is regarded as the outstanding student, during the past 11 years, of these cases, reports six recoveries without any treatment but rest and nourishment. The cases reported by him were diagnosed on splenic enlargement, embolism, cardiac lesion, fever, petechiae, and positive blood culture for the streptococcus viridans. He also believes that in all probability a few cases spontaneously recover that are too mild to be diagnosed. In fact the only conclusion we can come to so far as results of research into various forms of treatment are concerned is that the streptococcus viridans is extremely resistant to treatment. Case 2—P. W. McD. A man 45 years of age who has always been engaged in hard work. He passed fit into the army, went overseas, and came back with a little chronic bronchitis for which he was pensioned for a short time. Did not hear from him again until he was admitted to hospital on the 1st of October, 1930, with double pneumonia. Had been ill about five days before admission, complaining of chill, cough, and pain in the chest. Routine examination showed double pneumonia with typical signs, dullness, increased fremitus, bronchial breathing over both bases, the larger area being on the left side. The morning after admission temperature was 102 and the same afternoon 102/2- Heart showed no enlargement, no murmurs, and sounds clearly cut. The morning of the third day temperature dropped to normal, with pulse still 120, in this respect differing from an ordinary crisis. Temperature remained normal for 36 hours, then went up to 100, next day 100.2, and third day 100. During these three days the chest was carefully watched for evidence of empyema, but no signs of this were discovered. On October 7th temperature dropped to normal and remained so until the 15th, the pulse still running from 96 to 118. Heart showed .a real apex beat about the nipple line and he still had some dyspnoea. On the night of the 15th temperature dropped to 96, and no higher registration than Page 129 this could be obtained by mouth, axilla, or rectum for about three days. On the afternoon of the 17th he had a very bad turn and the nurse thought he was dying. I saw him immediately and he had severe dyspnoea, very irregular pulse, pupils widely dilated. Taken down by stretcher to the X-ray room, an X-ray of the heart was taken in the horizontal position, the picture which you now see. This shows a greatly dilated pericardial sac with a typical pear-shape. He was immediately taken up to his room and I pushed a trocar into the fifth interspace about an inch from the sternum and into the pericardial sac. A thick, creamy-yellow pus began to ooze out. The suction apparatus was sent for and 18 ounces of pus aspirated with considerable relief to the patient. During aspiration the nurse, who was watching his pulse, with a hypodermic loaded with adrenalin handy, suddenly reported that his pulse was regular. At the close of the aspiration of the 18 ounces the pupils were down to normal. I do not know at what point during the process they became normal. It would have been a rather interesting physiological question to determine whether the return to regularity of the pulse and the contraction of the pupils occurred at the same time from the relief of the internal pressure. The presence of pus in the pericardium brought up, of course, the question of surgical drainage and the following morning I had Dr. Schinbein see the case and he advised no interference at the present time until his condition might improve a little. Two days after that I aspirated again, drawing off 13 ounces of pus. Dr. McKee in the meantime reported that the organism was a pneumo-coccus. The following day he had dyspnoea and the following morning Dr. Schinbein opened the pericardial sac and aspirated 60 ounces of pus. Tube and cigarette drains were inserted well to the back of the sac and irrigation twice a day carried out for about fourteen or fifteen days. Pulse dropped a little after the operation but not a great deal—still 98 to 112. Patient, however, experienced very great relief, and began to eat and sleep very much better. During this period of drainage the chest was watched closely. Signs of dullness seemed gradually mounting on the left side—a pleural rub, which had developed about ten days before, was very marked. This rub was also present on the right side. Finally about the sixteenth day the pupils dilated again. With a Potain aspirator I drew off 68 ounces of clear fluid from the left side. Dr. McKee reported this sterile. After this aspiration there was the first considerable drop in the pulse. A week later 64 ounces were aspirated and again 42 ounces on December 1st. Since then he has been able to take care of the fluid and needling this morning showed practically nil. During this period he developed phlebitis in the left leg. One morning the calf was swollen and the next morning the thigh was considerably swollen. Dr. Schinbein saw him but considered it probably an iliac phlebitis. However, under elevation it went down completely in a week and the leg has remained normal since. A few words about the capacity of the pericardium. A case reported some seventeen years ago by Osier had 2,000 cc. removed. This was clear fluid. The only experimental work regarding pericardial capacity which I have been able to find is that done in 1929 by Williamson, who states that 100 cc. could be injected without evident distention but when the quantity recahed about 655 cc the pericardium either ruptured or was torn from its reflection at the great vessels. In this case Page 130 altogether there was 91 ounces—2700 cc—of pus removed. This amount, however, was evidently not all present at once. Lilienthal, in his recent work, quotes a case reported by Matas, where a gallon of fluid had been removed from the pericardial sac. Our patient, at the present time, has gained weight, is doing well, sleeping well, getting stronger and would look to be in a very fair way to recovery. He will, of course, have an adherent pericardium and pleuro-pericardial lesions, but how far these conditions will hamper the mechanical action of the heart is questionable. His pulse is now from about 74 to 90. The apex appears to be just within the nipple line, but what his future will be is a rather interesting question. Discussion on Case 1: Dr. C. E. Brown. I think the diagnosis of sub-acute myocarditis is almost positive in this case. I do not see how the brain lesion could possibly be explained on any other basis. There were a series of cases in Toronto (these were very mild) reported to have recovered. I have never seen one recover myself. Dr. Keith. I feel I would like to thank Dr. Brown for bringing these cases up. I have nothing but agreement as far as the diagnosis of the first case is concerned. We must bear in mind that arteriosclerosis has practically nothing to do with high blood pressure. We used to associate one with the other, yet he has no breaking of the artery in the brain, but he has an embolus and in taking his blood pressure the pressure is not up very high. What a change has occurred in medicine. It is not so many years ago that aspiration of the pericardium was done to save a life in England. In this particular case it was a young man and the opening of the pericardium saved his life and he was enabled to live for many years. Dr. Vrooman. The capacity of the pericardium is of very great interest. I drew off 43 ounces of clear fluid from a case of T.B. pericarditis and then a few weeks later drew off 30 ounces. X-ray very comparable to the one shown tonight. Post mortem showed that effusion was due to T.B. pericarditis. Did not cause him very acute distress, whether because it was pus or not is a question. Dr. Gillespie. We had a very typical case about six months ago in one of the hospitals—enlargement of the spleen, embolism, etc., seen in consultation with Dr. Pearson and Dr. B. D. Gillies. We could not get the organism. Of course we gave a very doubtful prognosis, in fact all pretty well agreed that the prognosis was very bad and very little hope was held out; yet with rest and very small doses of novarsenol benzol, even with .5 and .3, she had a very decided reaction. To the surprise of all of us she got better and today she is comparatively well. I am doubtful, of course she had very good care and nursing (in one of the private nursing homes), but I have always felt that there is a possibility the novarsenol benzol had an effect because every time we gave it, even a small dose, she was decidedly better and her temperature came down to normal for about a week and then she got bad and we again administered medicine. She was in hospital about three months. Discussion on Case 2: Dr. W. Wilson. There is one point in connection with large pericardial effusions that it is well to bear in mind. When I watched that Page 131 bottle filling up to 40 and 50 I kept hoping that that man had a good heart muscle. If you have a bad heart and a pericardial effusion you may have trouble from .a cardiac standpoint. In one case a man had a great big flabby pericardium. He nearly died during the twelve hours following aspiration. He recovered from his acute symptoms, went out for some months, returned and was again tapped. A second time he nearly died. The third time he filled up he refused tapping. If you have an acute pericardial effusion where the pericardial sac is not stretched then there is not so much danger in taking off the fluid, but if a bad heart is present then there cannot be too much care taken. Dr. Appleby. I congratulate Dr. Schinbein on the result of his case. I think I have seen only three such pericardial cases operated on. (Dr. Appleby brought before the meeting the method of approach in the cases which he had seen operated on.) Dr. W. Wilson. There is the case of a boy who had a very large pericardial effusion. He was tapped or a needle was put in and out at the apex and also in the fifth and fourth space with no result. No fluid was withdrawn although he obviously had a very large collection of fluid and it appeared that the heart was pushed up against the anterior wall. The boy was in acute distress. On opening the pericardial sac, however, there was a large gush of fluid. Dr. A. B. Schinbein. Unless you can sit your man right up I do not think you will be able to get good drainage. When I opened this pericardium I was right at the bottom. You would have to sit the man up before you could drain anything. I think irrigation is to be commended in these cases. I passed a tube behind the heart and in that way I kept, I think, the posterior part of the pericardial sac empty. I irrigated every day with an irrigating can and very little pressure and washed it out until we got clear fluid. There was a lot of pus present at first. The approach was certainly very easy. I had a good big tube in behind cigarette drains placed so that it would remain open. Dr. J. Brown. I should have liked to hear some opinion expressed as to the reason for the clear serum in the pleural cavity in view of the presence of a large amount of pus on the other side of a comparatively thin wall. Dr. Vrooman. The only explanation would be a hypostatic condition due to heart weakness which is a very lame explanation. It is hardly likely to have been inflammatory or to have been infected with an empyema. It looks to me as if it was hypostatic. Dr. J. Brown. There was a pleural rub extending outside the nipple line around to the back on the left and also a pleural rub on the right with a little fluid, and these rubs corresponded with the site of the typical pneumonic signs. This would appear to militate against the idea of a hypostatic effusion. The kidney function was normal. Dr. W. A. Dobson presented the following Cases: Case 1—C.H.T. This man at the age of 35 (1915) joined the Infantry. He was then apparently very healthy, weight 165 pounds. In Calgary stood his training very well. A few months later was in France and soon complained that he could not take part in the ordinary drill and marches and was removed from the Infantry to the Labor Corps. Remained in France 1915 to 1919. Discharged in 1919. Weight then 135 pounds. Many cmoplaints but it was not considered that he had anything really disabling him and he was discharged without pension. He made a number of applications between 1919 and 1927, but nothing came of them. We have on record a number of reports from various employers in which it was always stated that although he seemed to be quite earnest and sincere he was a total failure in his work. Admitted to hospital 1927. Examined in the ordinary way and nothing organic found. He was labelled as a neurasthenic and put on a small pension. At that time some apical abscesses were discovered on X-ray and treatment carried out. Admitted again 1928, and pension raised, also in 1929, and again two months ago. During all this time his complaints were of the usual neurasthenic type—headache, dizziness, stomach trouble, insomnia and loss of weight. This time he complained of his back more than any time previously. He walked in a stiff way. X-ray showed very definite arthritis. ("Definite slight osteoarthritic change is noted throughout the lumbar spine, there being small spurs at various points. Otherwise the spine is negative.") I bring this case up hoping to have some discussion on the possibility and probability of what we have been labelling neurasthenia as being arthritis during all these years. He compained of any slight jarring in 1915 affecting the spine and making it impossible to carry out his routine work as a soldier. Now he shows a definite arthritis. Examination shows the pelvis tilted forward obliterating normal lordosis. Bends forward till finger tips reach knees—returns very slowly and carefully. Lateral and rotary movements one-third normal range. Tender on right side of notch. Straight leg raising to 45 degrees right, 80 degrees left. Towards extreme range complains of pain along back of right thigh. That is all we found on examination. DISCUSSION Dr. C. E. Brown. Does the prostate show anything? Dr. W. A. Dobson. Dr. Campbell examined him on many occasions and found it negligible. Dr. Naden. It probably would not be an arthritis in a man of 3 5 years of age, if you could not find more clinically. In a man of this age symptoms would be very acute. Dr. Schinbein. In 50% of men over 45 years of age on X-ray of spine you will find marginal lipping of the vertebra. Do not think that because you find body changes that they are causing symptoms. This whole problem of hypertrophic arthritis of the spine is unsettled and personally I do not think that because you find a few lips on the dorsal vertebrae that you should say that that man is incapacitated, because of lipping. Dr. Keith. You may have a man come in with symptoms of irritation, pain and discomfort along the spine and you have him X-rayed and you find that he has this lipping, and in a few months you see him again and you find that he has no complaints, and comes back within a few years again with the same complaint. Therefore that would favor this having started away back. Dr. Bagnall. Before the war a woman patient about 30 years old had a good deal of pain in her back, and in the last three or four Page 133 years I have seen her at intervals. At times after working hard or after a lot of strain she would have marked symptoms. Now I have no doubt that at that time she had arthritis, and as it became more or less anky- losed, the condition became better. We had her teeth all out at the time. Dr. Barker. I would like your ideas as to whether this man's arthritis was the cause of his neurasthenia. In my experience I have seen cases which are a good deal worse, where the patient grumbles a good deal, but they do not as a rule show as many symptoms of arthritis as this man. I think probably this arthritis is just a coincidence. I think neurasthenia is the main condition. Case 2:—W.H.L. This man went into eye, ear, nose and throat work. He was quite successful in that and in 1914 joined up and went overseas. Went to France from 1915 to 1919. In 1918 developed a tremor, particularly of the head and hands. A number of his associates have supplied certificates as to the onset at that time. On discharge this still bothered him, more when he attempted to do any fine work. Was on the boats for a number of years, then someone advised him to get into the open and work. He did so and worked on the P. G. E. as a labor man for a considerable time. Feels very sensitive about his condition. Applied for recognition for. this condition on many occasions, but it was considered a post-war disability and was not recognized until a few months ago when he was admitted to hospital. Age 55. Mild tremors of both hands and arms and occasionally very slight tremor of the head. These used to be much worse. Worse when meeting strangers. No tendency to exaggerate the symptoms, in fact attempts" to hide his condition. When informed that the condition was considered genuine he appeared to be very much relieved. Pupils equal. Convergence is good. Vision good with glasses. Slight presbyopia. When following page, movement left to right or right to left, there is a fine jerky movement of the eye, not present when eyes are moving in a vertical or rotary direction. No hearing defect. He has been a little concerned about his condition. After five years he began to become despondent. Has been reading text books with the idea of finding out whether he has something more serious. Much relieved when he found out that it was a functional tremor. There is nothing in this man's private life or habits that would produce a tremor. He was under terrific strain from 1915 to 1919. Was a sensitive man and felt he could not take his old place in the profession again and was naturally worried about it. He made one or two slight attempts to get recognition and treatment, but it was passed up until this year. In hospital where worries have been very much lessened, where he has had a chance to relax and treatment, there has been a very definite improvement. At rest tremor now is very slight. Can grasp a thing lightly without tremor, but if he attempts to hold anything tightly it comes on. The Patdent says: "I suppose it is easiest to explain by writing a letter. If you write a letter, you are alright for the first few words, and then whatever you do you cannot control the hand—it will shoot out so that nobody can read what is written. Same thing in moving a cup off the table^—it will spill in spite of anything you can do. When lying at rest there is no tremor at all. Only when you use some exertion it produces that. For four or five years, yes up to 1923 or 1924, I used to Page 134 ^«^ww—iprB'~-'^ ' ^w ** get, about three or four times a year, an attack of fever (not malaria) running up to 103 and 104, and staying that way for ten days, and then it would go away. That happened about every five months and lasted up to 1923 or 1924. When sleeping, would wake up with a start. No dreaming. As soon as I start to dwell on anything then it seems to affect the muscles." DISCUSSION Dr. C. E. Brown. When we start to make a diagnosis of neras- thenia on these patients we are starting at the wrong end. I think that the more experience we get the more we see these patients to have organic trouble. I think a basal ganglion condition in this case is quite a possibility. A syphilitic condition or something of that type may have something to do with this case. Dr. W. A. Dobson. The practice here is that with all our cases first on admission to hospital they go through other departments, surgical, intrenist, eye, ear, nose and throat, etc., and then they gradually drift to the neurologist. Dr. Cathcart—who spent most part of a day with him—felt that he had ruled out any organic condition entirely. Dr. Cathcart is a very thorough man. However, our neurasthenics are not started in the neurological department, but are shifted from other departments. Dr. C. E. Brown. Pathology has only just begun to be appreciated. Anyone could, however, find an organic lesion. It is only in recent years this has been found. There is no disturbance of reflex, but none the less it is an organic lesion. Dr. W. A. Dobson. A great manly of our cases ten years ago called neurasthenia have developed some other condition that may or may not be at the back of it. Being labelled neurasthenia in the department does not mean that all other examinations are ceased. Very often some organic condition would explain all the symptoms of ten years previous. Dr. A. B. Schinbein presented the following case: V. O'B., Age 48. This man is pensioned for G.S.W. head and a diagnosis of sarcoma of ilium with secondaries in chest has been made. About 12 weeks ago he complained of pain to right of spine and running down his right thigh. A few weeks later reported to doctor, who at that time could not make a diagnosis. On the 13 th of November was admitted to this hospital. At that time he had a mass about the size of a grapefruit in the posterior iliac region. X-ray showed: "In the ilium on the right side extending from the lower part of the sacro-iliac joint downward and outward there is an area nearly two inches in diameter in which destruction of bone has taken place without any evidence of bone production. The whole bone is not completely destroyed. The appearance might represent an inflammatory process or malignancy. An extreme degree of curvature in the lumbar spine is seen without evident bony change." A mass in the right iliac region could be felt, and it has increased since. He developed a mass in the left humerus, which has gone on to spontaneous fracture. About three weeks ago he began to get a swelling in the left lobe of the thyroid, which is quite firm, and in the last week his voice has become practically nothing but a whisper. A Page 13 5 few days ago I took a section from the mass in the right iliac region and had Dr. Pitts report, as follows: "Macrosc. Exam. A number of very cellular, greyish-white portions of tissue approximating to the size of a pigeon's egg. They are grossly malignant. Microsc. Exam. Sections show an extremely cellular type of growth, the cells being markedly atypical. In some areas the cells are small, spherical, very deeply-staining, with no especial arrangement. In other areas, probably the majority, the cells are polyhedral, many extremely large, frequently giant cell in type, with innumerable mitotic figures and marked hyperchromatism. Many of these cells are hydropsical in type, the cytoplasm being practically colorless. In parts there are fine trabecular fibrous strands running through the sections, giving a somewhat alveolar appearance which, in some instances almost resembles adrenal cortex, except that the cells are so atypical. Many areas of degeneration are present and the tumour is generally fairly well vascularized. Diagnosis: Metastasis from either an adrenal or pulmonary carcinoma—because of the marked anaplasia of the cells, it is almost impossible to determine which—the innumerable giant cell formations, in a sense favor an adrenal source." He also has another lesion in the upper end of the right femur and in the chest plate which I have just shown there is one in the rib. The most common malignant lesions that metastasize in bone, of course, are breast, thyroid, prostate and the suprarenal. You will have to take my word for it and also that of Dr. Campbell that this man has no enlargement of the prostate and that there is no irregularity or mass there. No evidence of any malignancy of the breast. In the thyroid, left side, there is quite a hard mass. You can feel no mass in the region of the left or right kidney. I thought that this was probably a carcinoma of the thyroid with metastasis in the bone but our section which we took from the mass in the right iliac region the day before yesterday was reported on by Dr. Pitts as I read before. I cannot tell you definitely, gentlemen, just what the primary lesion in this case is. I do know that often a very small malignant tumour in practically any part of the body may result in these metastases being of very large size. Dr. Pitts. This is extremely atypical and it certainly looks very much to me like an adrenal carcinoma. I think that we can almost certainly rule out any thyroid trouble or any carcinoma of the prostate. This picture is very, very, atypical and it is often very difficult to say from which they originate. The query about this one is, of course', whether to call this a carcinoma of the thyroid or in one of these other places. As I say I think I would be a little bit inclined to put this down as an adrenal carcinoma. Dr. Riggs. It is very interesting from a thyroid standpoint. The mass is very adherent to the thyroid cartilage or shoulder, so that it evidently has either involved the whole of the inside of the larynx already or there is a growth on both sides of the trachea involving both nerves as his voice is completely gone. I have had a number of these cases in which some have grown very rapidly and others have been of slow growth like this one, but the voice does not go until the whole of the thyroid is pretty well involved so that it presses upon the larynx. The problem is, from an adrenal tumour will you be likely to get a metastasis in the thyroid gland? It is not such a common place for it to metastasize. I do not remember ever seeing or reading of an adrenal tumour Page 136 which metastasized in the thyroid and I should judge that any such metastasis would be an extremely cellular one that would be quite soft, as you sometimes see in thyroids of very rapid-growing medullary type. This is extremely hard which is rather against an adrenal metastasis iii the thyroid. Dr. A. B. Schinbein. I should like to say that I do not think any case of pain down the leg should be considered as sciatica until every evidence of a new growth has been eliminated. I think this is a very important factor in these malignant cases. Dr. W. Wilson presented the following: pathological specimen A man in the early fifties, first seen by Dr. Schinbein in office November, 1929. Had lost some weight. Complained of indefinite gastric symptoms. Dr. Schinbein could find nothing. Gastrointestinal tract negative to X-ray. Some sense of resistance in the region of the pancreas. The man was sent into Hospital early in 1930, and he was there till his death in November. During that time we had the interesting experience of watching a carcinoma of the head of the pancreas develop. The-man continued to lose weight. He gradually developed a large mass in the right side of the abdomen going down well below the umbilicus. I must say I did not diagnose what that tumour was. I thought it was simply a cancerous mass in the abdomen. It was fairly globular, almost the size of a small cocoanut. X-ray of G.I. tract negative. The man developed very profound jaundice followed by ascites. The abdomen was aspirated. I have never seen a gall-bladder that approached this one in size. The large tumour extending down to the umbilicus was this man's gall bladder. He suffered a great deal of pain. Gall-bladder was not X-rayed. Note the tremendous size of the gallbladder and common and cystic ducts. J. McF. For diagnosis. Polycythemia—true or secondary. 57 or 58 years of age. First seen in 1926. Had very marked bronchitis with a great deal of purulent sputum with putrid odour. Could not sleep oh left side because of constant coughing and expectoration of pus. X-ray did not show much except very high diaphragm on right side and hilum shadows possibly slightly enlarged. It at that time (1926) injected some lipiodol through the cricothyroid membrane. The man complained of no particular discomfort but the lipiodol was all in the neck tissues. I had gone through the trachea. X-ray taken this month still shows a lot. of that lipiodol present. It has spread out very considerably but there is still a fair amount of lipiodol present in the man's neck. There was no inflammatory reaction following it. I have had some cases where I have injected lipiodol and got a good filling of the bronchus where I have seen it a couple of years afterwards. You must expect, according to these findings, that you will have lipiodol for some time in the spinal canal in the case of spinal canal injections. At that time I did not repeat it and the man went out of hospital shortly afterwards and went back to Dawson. He came down with shortness of breath, cough and dyspnoea several times but at no time have I any note of his colour or any increase in his red blood cells. Some intestinal distress. Vomiting. Pathological gall-bladder. About a year ago he came down from Dawson, and at that time his picture was certainly different from that on his prior dis- Page 137 ACUTE SINUSITIS may be due to 1. Vacuum—inflammatory closure of the sinus, and subsequent absorption of air; 2. Pressure of accumulated exuadate; 3. Toxic influence upon nerve terminals of pus and other inflammatory products. SUCCESS in the treatment of these cases depends upon the establishment of free drainage and ventilation. applied over the affected region will help to: 1st—Relieve the pain; 2nd—Dissipate the congestion; 3rd—Establish drainage of the diseased sinus. By virtue of its prolonged hyperaemic, osmotic and antiseptic powers, Antiphlogistine activates lymph circulation and relieves the swelling and congestion of the mucosa. 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Hg. 110 to 170. We have bled him on frequent occasions and gave him phenyl hydrazin hydrochloride. No enlargement of the spleen. No enlargement of the liver to be made out. No haemorrhages. The question is, is this a symptomatic secondary polycythemia? Very little sputum now. Purely dry cough. Certainly now has nothing like the sputum one would expect from a man with bronchiectasis. When this man came in the last time I though "here is a man with a symptomatic polycythemia due to his lung condition." Was inclined to put him to bed and treat his bronchitis and see what results I could get. No results until we started to bleed him and give him phenyl hydrazin. Increased red blood cells—marked myocarditis, bronchiectasis. This is a typical picture of ordinary polycythemia-vera. Headaches, dizziness and all the pictures that go with the polycythemia vera except enlargement of the spleen. There are three methods of treatment, but these only give temporary relief. (1) Repeated bleeding. (2) X-raying of the long bones. There is a definite risk in X-raying the long bones because you may turn the case into an aplastic anaemia where the case is then worse than when you first started. (3) Phenyl hydrazin hydrochloride by mouth in capsules. We have been treating this man with various courses of .1 gram, three times a day. Kept watching his blood count and stopped when he was between six and seven million because action of the drug is cumulative. Then gave him a rest for awhile and then bled him. Another point worthy of note in connection with the giving of phenyl hydrazin is that it apparently deliquesces if you leave it for any length of time in capsules. If you are giving large doses watch your white blood count which is often fairly high at the start; twelve, thirteen to fifteen thousand; and if you find that your white blood count starts to climb you should stop the drug for a time. DISCUSSION Dr. Montgomery. In these cases there is a symptom that to me is very marked. This patient is wearing an upper plate. If you look in his mouth where the plate is pressing you will see a pale pink area of almost natural color. If he was not wearing the plate the whole mouth would be of a darker colour. At first it looks as if it is a thing that you could not explain, but it is quite easy to explain. You will notice that the mucous membrane is red on taking the plate out of the mouth. It is a symptom that is almost pathognomonic. The reason for no congestion when wearing the plate is that the plate in pressing against that area depletes it to a pale pink. Dr. Pitts. There was a case two years ago of a woman 31 years of age. The diagnosis was polycythemia. She was given phenyl hydrazin and a short time after she suddenly died. On autopsy an aneurysm was found. (Dr. Pitts spoke a few words regarding the size of the gall-bladder at the time of removal.) Dr. Naden. In some cases where lipiodol was injected into the spinal canal neuritis resulted. The lipiodol spread down around the nerve trunks and caused it. Page 13 8 Dr. McKee. Polycythemia vera, I admit, does exist. It is, however, extremely rare. If you follow your cases for a long enough period you will usually find there is some other cause. Since the war I have seen six or seven cases which seemed to be nothing else but polycythemia. All of the others showed some other cause. A high count (red blood cells) does not mean anything more than that for a year or so you have to follow your case clinically as well as through the laboratory and see if there is not some other cause. Dr. Perry. There are characteristic eye grounds in these cases. CERTAIN CONTACTS OF MEDICINE AND THE LAW The following are. the chief points in a very able address delivered before the Vancouver Medical Association on January 6th, by the Hon. Chief Justice Morrison. A large audience paid close attention to his Lordship's remarks. At the outset Judge Morrison pointed out that the functions of the Court and of a medical man are quite distinct. The function of the doctor in ordinary life is treatment, the function of the Court is to determine liability. When the doctor comes before the Court, however, his function is to assist the Court, to which he is responsible, in arriving at the truth. It is obviously absurd for an unin- structed judge or jury to decide on medical questions. It should be remembered, however, that the medical problem in a trial is only one of many and all the facts, medical and otherwise, must be taken into account before a decision can be given. Cases coming before the Court and in which the aid of the doctor is necessary in order to enable the matter in dispute to be properly determined, are innumerable and increasing, as witness the growing number of automobile accidents, insurance cases, cases of assisted abortion, and so on. Doctors come to the aid of the Court in one of two capacities, either as assessors or as witnesses. The rules of the Court provide for the calling to the aid of the judge and jury one or more doctors as medical assessors. Whilst afcting as assessors medical men do not decide on the facts, they merely give their opinion as assistants. Their advice may be, and is, disregarded, but not often. They do not decide, that is the responsibility of the judge or the jury as the case may be. Medical men assist the Court best as witnesses in the witness box. As witnesses they appear either as witnesses of fact or as experts. As experts they give their opinion to explain the bearing which the facts may have on a particular point. When called as experts they do not, of course, pretend to depose as to the facts, but, owing to their special knowledge, they are called to aid the Court in appreciating the value or meaning of a fact not observed by them and they are permitted then to express their opinion, which a witness to the fact may not do. The medical witness must not be a partisan. He does not come to give evidence pro or con, but to aid the Court. An expert witness is called in to assist by virtue of his special knowledge. The significance of an observed fact is often only of value when judged by an expert. Page 139 The medical man who is called as a witness of the fact is often placed in a most trying and invidious position. It is, of course, needless to say he must not lend himself to the concealment of a crime nor to its commission. Secondly, there is a rule that a doctor cannot refuse to answer questions put to him, even though it affects his medical confidence. The duty of a doctor to preserve his patient's confidence is one not lightly to be set aside, but a doctor, as a witness, is there to assist the Court, he is not there to advance the interests of his patient exclusively. He is subject to cross-examination upon all matters relevant to the issues in the case. He is subject to the rulings of the Court, for it is in the public interest that he should be. In all cases where a person is charged with infanticide, assisted abortion, murder, manslaughter, concealment of birth, etc., the doctor who may have attended the patient may be called by the Crown to give evidence against his patient at the trial of the charge that is laid. In divorce trials the doctor in attendance is often called by the other side. As his position is most confidential, a delicate situation is created, and one which might, in the hands of an unscrupulous patient, be used to the detriment of the doctor by imputing a betrayal of that confidence. A medical man, when called as an expert witness, if he is not sure of a fact should say so. The Court respects such a man. One thing is certain; it is a great mistake to be cocksure and pretend to know too much. If the doctor is not sure of a fact he should say so. The medical man is not an advocate. Generally speaking the Bench and the Bar trust a medical witness, hence the doctor may face his duty with equanimity. No class of evidence is viewed more sympathetically than medical evidence, and the medical man may rely upon this feeling on the part of both judge and jury. Then we come to the great and important field of insanity. The question of insanity is approached by the medical and legal professions from different points of view. The misunderstanding, between the law and medicine as to the bearing of the criminal law towards insanity is to be deplored. The attitude of the criminal law towards insanity is the question, not the insanity per se. To begin with, the law does not define insanity. The two professions regard it from different viewpoints to some extent. The lawyer bases his view upon the clear, simple, principle of the law that everyone is presumed to be sane and to possess a sufficient degree of reason to make him responsible for his acts, until the contrary is proved to the satisfaction of the jury which is trying the case. The prosecution is not called upon to prove the sanity of the person accused, for his sanity is presumed. The onus of proving insanity, which is a matter of defense, is upon the accused. He must prove that at the material time he was afflicted with a disease of the mind to such an extent that it brought about such a defect of reason that he did not know the nature and quality of the act he was doing or if he did know what he was doing he did not know he was doing what was wrong. The material time is the time of the perpetration of the act, and this must be proved with particularity. The defence must prove first and foremost that the accused was suffering from a disease of the mind; secondly, that in consequence of that disease he was labouring under a Page 140 defect of reason; thirdly, that that defect of reason so brought about was of one of two particular kinds. That defect of reason when so found must be clearly proved to be such as either (a) to prevent him from knownig what he was doing; or (b) to prevent him from knowing that he was doing what was wrong. The defence must prove that either one of these conditions existed at the material time. The third prerequisite illustrates the difference between the point of view of the lawyer and of the doctor as to the criminal law. The doctor who ordinarily examines a patient with a view of determining as to his insanity may well come to the conclusion that his mind is diseased and that therefore he labour under a defect of reason. Having arrived so far he then decides upon the degree of medical attention and care to which his patient is to be subjected. His responsibility is to his patient. But where the patient is charged with having committed a crime the public are interested and the question arises whether he is to be excused from responsibility for what appears to be his criminal act, in which case the criminal law insists upon further inquiry, because disease of the mind alone, although a justification for treatment by the doctor, affords no defence. He must prove that that disease of the mind at the material time prevented him from knowing what he was doing when he committed the act; or prevented him from knowing that he was doing what was wrong. Of course it is consonant with the principles of the law and with common sense that he should be excused from criminal responsibility if he was at the time in such a state of unreason through a disease of the mind as not to know what he was doing. In this condition he cannot have known the nature and quality of his act. That means, as an eminent judge has put it, that he thought he was peeling an apple when in fact he was cutting a throat. In that case he did not know what he was doing. And it may also be said that though from a disease of the mind he is in such a state of unreason he knows what he is doing but he does not know that he is doing what is wrong. To illustrate this condition the learned Judge gives the case of the woman who strangled her mother-in-law, laid the dead body on the hearth rug and called in her neighbours to see how well she had done her work— saying, "It was my duty to do it, and you see I have done my duty/' In that case she knew what she was doing but did not know that what she was doing was wrong. The question of the conditions which have to be proved in order that a person may be excused from criminal responsibility is a legal question and for the courts, to be determined in accordance with the principle of the criminal law. It is submitted by some high medical authority that a person charged with a criminal offence should not be held responsible when he committed the act charged under an impulse which by mental disease he was powerless to resist. That of course raises a fundamental difference as regards the third condition, rendering it immaterial that the prisoner knew what he was about or that he knew he was doing what was wrong. He might claim immunity notwithstanding he knew what he was doing because he was acting under an impulse caused by a diseased mind which deprived him of the power to resist or desist. The Lord Chief Justice of England, in a treatise on this subject dealing with the Report of a Special Committee and the expressed views Page 141 of the British Medical Association thereupon, as set out briefly in the foregoing remarks, says that the suggestion is, the ancient and dangerous plea of the uncontrollable impulse, which in practice is so difficult to distinguish from the impulse that is not in fact controlled. The doctrine involves two propositions which are not of the same kind nor upon the same plane. The first proposition is one of fact namely that there are, as a matter of scientific imagination not of controversial speculation but of actual experience, unfortunate persons in existence who though they know what they are about and also know that they are doing wrong, are nevertheless impelled by disease and irresistible impulse to commit an apparently criminal act. The second proposition is of legislative morality or expediency, namely that these persons by reason of their number or otherwise are of such importance as to require or deserve a fundamental revision of the criminal law." Should such an alteration take place, which is not at all likely, it would do away with the necessity for objection tests now applied by judge and jury. It would do away with the necessity of considering the evidence to ascertain whether the prisoner was aware of what he was doing or that what he was doing was wrong. The test that would be left would be whether he was guided by an irresistible impulse. It can Veadily be seen the predicament of the jury called upon to try a man under these conditions—conditions which would leave them with little, if any, guidance. They would have to rely solely upon conflicting medical testimony. As to the prisoner's responsibility to the law, why have a jury—why not also leave that question shorn of its objective tests to the doctors? This doctrine of uncontrolled or uncontrollable impulse has been repeatedly rejected in this country. As one eminent Judge has said, "If an influence be so powerful as to be termed irresistible, so much the more reason is there why we should not withdraw any of the safeguards* tending to counteract it. There are three powerful restraints existing, all tending to the assistance of the person who is suffering under such an influence; the restraint of religion, of conscience and of law. But if the influence itself is to be held a legal excuse rendering crime dispunishable, you at once withdraw a most powerful restraint, that of forbidding and punishing its perpetration." This doctrine of uncontrollable impulse has been considered, is so considered today, a most dangerous one, fatal to the interests of society and the security of life. Persons tried on any charge in any of our Courts have so many safeguards thrown around him, that the chance of any miscarriage of justice is so remote as to be entirely negligible. The learned Chief Justice concluded his remarks by adding that if the law were relaxed it might well be that in cases where there has been no such evidence of mental disease antecedent to the alleged crime mental experts would be found to say that the alleged crime itself afforded evidence that it was committed under an uncontrollable impulse and that upon that ground the inference might be based that there was no mental disease. If so the result might be to transfer to a section of the medical profession the question whether a great number of ordinary criminals should be held responsible to the law. Page 142 . British Columbia Laboratory Bulletin Published irregularly in co-operation with the Vancouver Medical Association Bulletin in the interests of the Hospital Clinical and Public Health Laboratories of B. C. Edited by The Vancouver General Hospital Laboratories Financed by The British Columbia Provincial Board of Health COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital, Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster; Royal Inland Hospital, Kamloops; Tranquille Sanatorium; Kelowna General Hospital; and Vancouver General Hospital. All communications should be addressed to the Editor as above. Material for publication should reach the Editor not later than the fifteenth day of the month of publication. Vol. V. MARCH, 1931 No. 3 CONTENTS Bacteriological Diagnosis Hill Bronchomycosis Ootmar BACTERIOLOGICAL DIAGNOSIS OF GONOCOCCAL INFECTIONS By H. W. Hill, M.D. Director, Vancouver General Hospital Laboratories. This article elaborates, for the gonococcus, the general principles laid down in the preceding article; but there applied to the diphtheria bacillus. For the gonococcus, as for the diphtheria bacillus, the tests ordinarily made are those which can be made quickly—on the principle that the physician, in order to act promptly, must know almost at once what the result is; not weeks, or even days, later, but within a very few hours. Hence, ordinarily, the report of the laboratory on gonococcus, "smear positive," is based on the morphology (including staining) of the organism found, as in the case of the diphtheria bacillus, but in part also on its relationships to the epithelial or pus-cells present; the latter point being quite as weighty in arriving at a decision as the former, since the morphology of the gonococcus is not so distinctive as is that of the diphtheria bacillus, and cannot be equally trusted, by itself, for the recognition of the germ. Strictly speaking, positive reports on smears for suspected gonococci would be more logical if they read, "intracellular gram negative diplo- cocci present, having the morphology of the gonococcus." This would leave squarely to the physician, as in diphtheria, the decision as to whether these organisms are reasonably to be considered significant or not, his decision being then based, again as in diphtheria, on the actual clinical conditions the patient shows. Why cannot the laboratory be more certain of the gonococcus then as above stated? The laboratory can—but only after an expenditure of Page 143 time so great as ordinarily to make the results almost useless to both physician and patient. Why not culture the specimen, as in diphtheria? Because culturing gonococci from pus is difficult and uncertain at best; and provided they do grow, they show themselves rather as resembling staphylococci than as the typical biscuit-shaped diplococci of pus smears, i.e., they show themselves in a form less identifiable than ever. In brief, gonococci in culture lack three outstanding features by which they may be recognized promptly and fairly definitely in smears from pus—namely, their typical diplococcoid arrangement, their "biscuit" shape, and of course their relationships to epithelial or pus-cells. Hence, even if the suspected organism found in the culture were in fact the gonococcus, and if also it occurred as a pure culture, it would be less readily recognizable in such culture than in the original pus specimen. In order to demonstrate that such a slow-growing, now extracellular, and staphylococcoidal organism is in truth the gonococcus, further and very intricate tests must be made, depending upon its antigenic relationships, and requiring for conclusive results an elaboration of the laboratory work far beyond present practicabilities here. Dr. A. W. Hunter has disputed this, but it is in accord with the best literature available—Topley and Wilson—"Principles of Bacteriology and Immunology, 1929"—Vol. 1, p. 337 (see text and plates). In the supposed instances above offered, it was assumed that the culture made from the pus proved to be pure. As a matter of ordinary occurrence, pus from the urethra or the cervix, etc., or from the eye, is not unlikely to yield a mixed culture; cocci, especially of various kinds, are to be expected, some of which—e.g. Staph, aureus or albus—are likely to outgrow any gonococcus present, and to add immensely to the difficulties of the isolation of the gonococcus; which isolation must, however, be accomplished if the conclusive antigenic tests are to be employed. It will be obvious, then, that at the present time a report from a gonococcus-suspicious smear of "smear positive" means only that, so far as expert experience permits, the direct microscopical examination shows organisms indistinguishable by such tests from gonococci; at the present time here this is the only practicable method. Certainly cultural work is possible, but only as the outcome of a very considerable special lay-out and experience, and at an expense per specimen relatively very high. A positive report on a gonococcus smear, although based only on morphology (including staining) and cell relationships, would be practically conclusive of the presence of gonococci, if the pus examined originated in a clinically infflamed cervix or urethra. Even if the pus originated in the clinically inflamed eye of a patient, such a "smear positive" report would call for immediate treatment as of a case of gonorrheal ophthalmia, because delay for further cultural work might prove extremely serious. (This statement is closely parallel to that calling for the giving of antitoxin in all cases of sore throat showing "diphtheria bacilli positive," even where the clinical symptoms do not resemble those classical of diphtheria.) As in diphtheria, if the clinical symptoms are classical or even clinically suspicious, prompt treatment should be initiated, without Page 144 awaiting the laboratory report, or even if the laboratory report is nega tive. If a "smear positive" report is made for diagnosis from a urethra, a cervix or an eye showing no clinical evidence of inflammation, the question of the representativeness of the specimen submitted, already discussed under diphtheria, of course comes up. But, allowing this point, there is no reason to believe that all infections with gonorrhea necessarily yield severe clinical symptoms—indeed, gonorrheal ophthalmia is rare, compared with the number of infections of the eye with gonorrheal pus that must necessarily occur; suggesting a high degree of local immunity to gonorrhea in the average eye, except perhaps in infants. Assuming, then, that the specimen submitted is representative, this report, "smear positive," from a clinically negative eye establishes two things—first, the probable presence of trouble in some degree, since the organisms were intracellular; and second, the presence of the typical morphology and staining. The absence of obvious clinical symptoms must then be accounted for—exactly as in the case of "diphtheria bacilli positive" without sore throat, etc. Is the condition a very early or a very late one? Is the patient infected, but with non-virulent organisms? Is he infected with virulent organisms, but is also immune? Or is he carrying a Micrococcus catarrhalis, etc., indistinguishable in morphology with certainty from the gonococcus? In diphtheria the question of virulence can usually be determined in about three days; but this determination in the case of gonococci requires conditions not to be found in most laboratories, and the time required for its determiniation would make it wholly useless to the physician. Therefore the three latter questions cannot be answered in any given case promptly enough to meet the emergency. The only "safety first" procedure, then, is to assume that the organism found may be significant, and to treat promptly; after that, as in diphtheria, to await further developments. The physician should not wait for a demonstration of virulence from the development of severe lesions in the patient before instituting treatment. Even in the absence of clinical symptoms, a report of "smear positive" should call for at least prophylactic precautions, if not very active therapeutic treatment. What reliance may be placed on a gonococcus report "smear positive" for diagnosis? Once more as in diphtheria, a negative report on a gonococcus smear is reliable in proportion to (a) the representativeness of the specimen, and (b) the thoroughness of the examination in the laboratory. Only for the latter is the laboratory responsible. "The representativeness of the specimen" includes not only its origin from the proper source, but also its being taken at the proper time. As to proper source, the eye, and the male urethra in acute stages, present little difficulty. But in the female serious errors may arise. Thus vaginal smears from young female children may be representative; but from older females are useless. In the older female infected with gon- Page 145 orrhea, the organisms must be sought, not in the vagina, but in the cervix, in the urethra and its glands, and in the ducts of the various vulvar glands. In metastatic infections (blood, joints, etc.) the particular material involved must of course be securea\ As to the proper time for the taking of a specimen for gonococcus, in general the best time is at the earliest moment—certainly in acute cases. In the more chronic cases, especially those under treatment, it is sufficiently obvious that specimens must be taken from the freshest and most abundant of such discharges as may be available, and as long as possible since the last local treatment, several hours at the shortest. In smears taken for release of the patient as "cured" or "non- infective," the possible sources of error of a negative report, due to non- representativeness of the sample, are multiplied many times over the possible sources of error in the acuter stages. Hence smears for release require redoubled care in the taking, as well as in the laboratory examination. In genito-urinary smears from the male for release, account must be taken of deep prostatic infection, of gonorrheal threads, of the small numbers likely to reach the exit, of the intermittency of their escape. The same sort of factors must be considered in smears from the female for release. Urethra, cervix, ducts of vulvar glands and the deep adnexa may all have been infected. All these must be "released" individually, so to speak. Even in very young females where vaginal smears may be used, the significance of a single negative for release is almost nil, and experience shows that many negatives at considerable intervals may be interspersed with or followed by positives. Hence release of gonorrhea patients is even more time-consuming and responsible a procedure than release of diphtheria patients. Since three consecutive negatives are a minimum for reasonably accurate work in diphtheria, double the number would not be unreasonable in gonorrhea (taken from a week to a month apart.) Doubtful reports in gonococcus examinations mean, as in diphtheria, that the best the laboratory evidence offers in the case so reported is inconclusive as to presence or absence of the gonococcus. This inconclusiveness, always involved, as already reviewed, in all examinations for gonococci when restricted to ordinary smears, becomes acute if the smears yield organisms which are not definitely of the classical type. Thus, the organisms may be gram-negative and intracellular but not biscuit-shaped, or diplococcoid, or may only present these features in small proportion. They may be much smaller or much larger than usual, or be accompanied by so many extracellular forms as to confuse the picture. They may be diplococcoid and "biscuit-shaped," but not typically so. Under these circumstances, the only thing to do, from the laboratory standpoint, just as in diphtheria, is to secure another sample, hoping that in the second the picture will be more definite. The only thing to do, from the clinical standpoint, is to consider the "doubtful" report as having yielded no final information, but as a strong indication that the gonococci may be present, and that appropriate treatment should be installed, pending further evidence. Page 146 Summary 1. Definite clinically suspicious symptoms of gonorrhea, whether related to the genito-urinary apparatus or the eye, call for immediate precautionary, if not full therapeutic treatment, whether a smear be taken or not, and without regard to the results of any smear taken, whether positive, negative or doubtful. In such cases, take pus for a smear; then, without waiting for a report (unless this can be obtained within a few minutes), treat; and govern later treatment by the subsequent clinical developments as well as by the smear results. 2. Given a genito-urinary or eye condition not definitely clinically suspicious of gonorrhea, and a positive smear from it, the physician is morally bound to assume that gonorrhea probably is present, and to treat immediately on that basis. Only very strong evidence to the contrary can justify any other conclusion. 3. Negative results, as in all bacteriological work, must be heavily discounted, especially in face of good clinical evidence or even doubtful clinical evidence—and second or third examinations should be freely used. 4. Suspicious or doubtful reports from smears for diagnosis should be taken at their face value—i.e., they indicate that the result of the smear examination was not practically conclusive as to either presence or absence of the suspected organisms, and that interim treatment at least should be employed until further examinations or clinical evidence clear up the diagnosis. 5. Smears negative for release should be accepted as indicating the probable facts regarding the specimen submitted. But smear negative does not mean patient negative, still less patient permanently negative. Only the most careful collection of the specimens under the most favourable circumstances for the securing of positives, and the repetition of negative results many times, can make it reasonably safe to say that the patient is negative. This applies particularly to females of any age, and to old deep-seated infections in any one. BRONCHOMYCOSIS CASES IN B. C. By G. A. Ootmar, M.D. Director, Provincial Board of Health Laboratory Kelowna General Hospital, Kelowna, B. C. In 1913 a boy, who had been recently repatriated from the Dutch West Indies (N. America), fell ill in Holland of a disease which had all the clinical symptoms of tuberculosis. The disease ended rapidly fatal and was registered as "tub. florida" (miliary tuberculosis) though tubercle bacilli were never found in the sputum. The only fact that struck us was that the sputum contained many fungi. Some years later, 1918, in the Annates de I'lnstitut Pasteur, Besredka gave a summary of the germs in infection of the bronchi and lungs and mentioned, too, budding fungi. In 1928 we received in our Laboratory in Kelowna a specimen of sputum for examination which proved to contain many fungi—and as the patient had been for some time in Southern California and in the Page 147 literature it was mentioned that bronchomycosis was known in that part of America, we suggested that the blastomyces found in the sputum were the cause of the disease. The disease points clinically to tuberculosis. Two types are known, a mild and severe type (perhaps according to different species.) In the mild type, which may become severe, there are no physical changes in the lung,—even a Roentgenogram does not show any changes. This is in contrast with the severe type, in which all clinical symptoms and physical changes in the lung known for tuberculosis may be present. It seems to us that the above mentioned case of 1913 was an unrecognized severe case of bronchomycosis. This year we were struck by the fact, that of 126 sputa we got for examination in our Laboratory, four proved to contain yeast-like bodies; two of the specimens came from the same community, and from patients who were very nearly related. We asked for other samples. The consistent presence of the yeast-: like bodies in the sputum, with the absence of tubercle bacilli, leads us to diagnose bronchomycosis. The following interesting case is now in the Kelowna Hospital: Mr. W. H. S., 65 years, patient in Kelowna Hospital, contracted pneumonia in 1916 in the army, (temp. 104.4° on admittance to the War Hospital) and was returned as a tuberculous suspect; but sputum always negative. Had haemorrhages many times after the pneumonia. Roentgenogram 1930 showed very little change. Dr. A. S. Lamb, who examined him, was surprised to find no lesion to accord with his history. November, 1930,—sputum positive for blastomyces. Fell ill December, 1930 with severe pain in stomach; was suspected to have peritonitis; symptoms alleviated after a week's illness. January, 1931, blastomyces in stool. The organisms are Gram positive oval cells of the size of plus— minus 2 by 8 microns; they grow on agar, do not liquify gelatin and form gas in glucose, maltose, laevulose but none in xylose. They form a special group, separated from the ordinary yeast. Stokes, in the Journal of Tropical Medicine and Hygiene, August 1, 1930, mentions that MacKinney isolated 12 yeast-like strains from cultures from sputum, throat, mouth, stool and pus of human beings. Six strains proved pathogenic for guinea pigs at times, three causing death, three causing inflammatory reactions. Immune serum was prepared from all these strains and each one of them agglutinated with the majority of the sera from the other heterologous strains. When tested with immune serum from commercial yeast with a titre of 1—120 these strains failed to agglutinate in any appreciable dilution. These pathogenic strains, therefore, can be separated as a distinct immunological group from the commercial yeast strains. Whether or not our cases showing blastomyces in the sputum are due to contact infection, we do not know. All four cases proved to be mild. The isolation of the fungi from sputum and the repeated absence of tubercle bacilli, leads to the diagnosis bronchomycosis in mild form. Potassium iodide treatment may be installed, in mild cases, while in severe ones treatment with autogenous vaccine seems to be of value. Page 148 PROGRAMME OF THE 33rd ANNUAL SESSION VANCOUVER MEDICAL ASSOCIATION Founded 1898 Incorporated 1906 GENERAL MEETINGS will be held on the first Tuesday and CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m. Place of meeting will appear on the Agenda. March 3rd—General Meeting: THE OSLER LECTURE— Dr. R. E. McKechnie; "Reminiscences of Forty Years' Practice." March 17th—Clinical Meeting. April 7th—General Meeting: Speaker—Dr. C. F* Covernton; "Problems of the Primipara." April 21st—Clinical Meeting. April 28th—Annual Meeting. Massage & Medical Electricity Medical Gymnastics C. S. M. M. G., London, England C. A. M. R. G. Montreal, Canada MISS O. G. HARDING Seymour 7613 825 VANCOUVER BLOCK Vancouver, B. C. Telephone Sey. 3334 MRS. E. M. PARR Chartered Society of Massage and Medical Gymnastics, England Canadian Association of Massage and Remedial Gymnastics Office Sey. 2855 Res. Doug. 4682Y MISS BEATRICE GALLOP C. A. M. R. G. Graduate McGill University School of Massage and Remedial Exercises 419 VANCOUVER BLOCK Vancouver, B. C. Office Sey. 8683 Res. Doug. 1707R MRS. ETHLA FABER D. A. D. M. F. Copenhagen C. A. M. R. G. Montreal Physiotherapy Certified by the General Danish Association of Physicians 214-215 VANCOUVER BLOCK Vancouver, B. C. HJa0frurorth & JflBaoirmorth JItit COLLECTION SPECIALISTS Telephone Sey. 3296—3297 407 RANDALL BUILDING, 535 Georgia Street West Vancouver, B. C. 430-431 BIRKS BUILDING Vancouver, B. C. Office Doug. 908 MISS A. E. MARKHAM Chartered Masseuse, England Canadian Association of Massage and Remedial Gymnastics 924 BIRKS BUILDING Vancouver, B. C. Phone Kerr. 1520R MRS. L. H. EARLE Canadian Association of Massage and Remedial Gymnastics 6059 ELM STREET Vancouver, B. C. VANCOUVER CRYSTAL POOL BEACH AVENUE AT NICOLA STREET AN INVITATION is extended to .members of the medical profession to visit the Crystal Pool at any time, to take a sample of the water for analysis, and to investigate the rigorous standard of cleanliness and safety maintained by the management. The purified warm salt water in the Crystal Pool is passed through the filters one and a half times daily. At night, the pool is completely filled, and any sediment is removed by a vacuum cleaner. All floors, mats and dressing rooms are sterilized daily. All- wool bathing suits and towels are sterilized after use. Attendants are constantly on guard for safety. Dr. Underhill, as City Health Officer, made frequent unheralded visits to the Crystal Pool, and reported as follows: "I have always found the Crystal Pool rigorously clean and sanitary .... inspections have included not only tests of the filtered and chemically purified water in the pool itself, but unheralded visits to see the elaborate precautions taken to keep the filters, apparatus, floors, dressing rooms and laundry in perfect condition." It was further stated in a Laboratory report that: "Filtering treatment given by your plant in this case completely removes gas forming bacteria. Further, the total number of bacteria are so reduced by means of the filtering medium, that the number of colonies per cc. remaining are no higher than those .found in some samples of drinking water." OPEN EVERY DAY Weekdays, 1 p.m. to 10 p.m. Sundays, 1 p.m. to 6 p.m. For information regarding Book Tickets, Special Children's rates, etc. Phone Douglas 2376 ?^v Pfc*^ ii the BATTLE of the NUMBERS" is the expression used by a prominent biochemist who recently visited our Research Laboratory, in referring to the pseudo-scientific practice employed by many manufacturers in stating the number of "vitamin units" contained in their cod liver oil. "The problem seems to have resolved itself," he went on to explain, "into a game of 'number, number, who has the largest number,' each firm trying to outdo all others in having the largest number of units displayed on the bottle." We have refrained from entering this "battle of the numbers,'' not because Mead's Standardized Cod Liver Oil could not also be designated by large numbers,— the data at the left give proof of this—but because, as competitively used, unit numbers hold little significance. We are, therefore, holding ourselves aloof from this Don Quixotic conflict until the smoke of "battle" clears and numbers on the label of a bottle of cod liver oil really mean something. In the meantime, as from the beginning, we ask the physician's confidence in Mead's Cod Liver Oil on the basis of performance, knowing that: (1) l/4th of 1% of Mead's Cod Liver Oil in a rickets-producing diet will initiate healing of rickets in rats in 5 days. (2) l/16th of 1% of Mead's Cod Liver Oil in a xerophthalmia- producing diet will cure xerophthalmia in rats in 10 days. (3) Mead's Standardized Cod Liver Oil is so pure it needs no flavoring. There are in use at the present time at least seven arbitrary systems of designating cod liver oil by "units" of vitamin D. The size of these units varies with each system, consequently the "number" of units is small where the "unit" is large |and large where the "unit" is small. This is illustrated by the fact that if Mead's Standardized Cod Liver Oil were to be designated by one system, it would test .15 unit. By a second system, 3 units. By a third, 15- By a fourth, 40. By a fifth, 120. By a sixth, 265. And so on. In the matter of vitamin A units, while the above confused status does not exist (fortunately, due to the fact that there is a U.S.P. standard), on the other hand, there is such a wide ' latitude permitted in the interpretation of this unit, that there may be a very wide difference in "interpreted" potency between sample oils at the two extremes of the permitted latitude. The physician can find assurance in Mead's Standardized Cod Liver Oil—without units—on the basis of actual performance. ,r Supplied in 4-, 8-, and 16-oz. brown bottles in Iight- *% proof cartons. Samples and literature on request. fa MEAD JOHNSON & CO. of CANADA, LTD., Belleville, Ont. ■■■■■■■mi Newfoundland Cod Liver Oil Exclusively iiiniiiitiiiiiii ANNUAL DUES Members are reminded that March 31st is the end of the financial year of the association and in accordance with the Bylaws of the Association the name of any man whose dues are unpaid on that date must be removed from the role of the association. BILLON'S I :%Mi SULFARSENOBENZOL (Heretofore called Sulpharsphenamine) For painless subcutaneous treatment of syphilis. Perfectly tolerated, SULFARSENOBENZOL is particularly indicated for treating children or whenever the intravenous method is not practicable. It is innocuous at therapeutic doses and of great clinical activity. Offered in gradual dosages of from 0.005 gm. to 0.60 gm. LABORATORY POULENC FRERES OF CANADA LIMITED For literature and sample, apply to Canadian Distributors: ROUGIER FRERES, 350 Le Moyne St., MONTREAL MOTOR CYCLE Delivery FREE! m*~y Daily from 8 a*m* to 11 pan* Courteous - - Prompt A PLEASURE TO SERVE YOU gll Distributors H. K. MULFORD & CO. BIOLOQICALS FRAISSE'S FERRUQINONS AMPOULES Capitola Pharmacy LtcL FRED. G. BROWN Prescription Specialists Davie and Bute Sts. Phone Doug. 158 Dunbar and 27th Ave. W. Phone Bay. 3663 Rest Haven Sanitarium and Hospital MARINE DRIVE, SIDNEY, B. C, (Near Victoria) Particularly convenient and desirable for Rest—Recuperation and Convalescence. Rates are reasonable, -with meals and treatments included. Direct patients to Rest Haven from Victoria by the Vancouver Island Coach Lines, Ltd., at the Broughton Street Station. Private car will meet boats if desired. FOR RESERVATIONS AND FURTHER INFORMATION WRITE OR TELEPHONE MEDICAL SUPERINTENDENT OR MANAGER, SIDNEY 95—61L. In cardiac and respiratory crises .... when danger is great and the need urgent CORAMINE "CIBA" (pyridine—:B—carbonic acid diethylamide) stimulates the medullary centers and the heart muscle; causing an increase in respiration, blood-pressure, and the strength of cardiac contractions. AMPOULES of 1.1 cc. boxes of 5, 20 and 100 LIQUID bottles, of 15 cc. and 100 cc DOSAGE: Subcutaneously, intramuscularly or intravenously 1 to 2 ampoules Internally 1 to 2 cc with a little water. Literature and samples sent on request. CIBA COMPANY LIMITED Montreal 536 13th Avenue West Fairmont 80 Exclusive Ambulance Service FAIRMONT 80 ALL ATTENDANTS QUALIFIED IN FIRST AID "St. John's Ambulance Association" WE SPECIALIZE IN AMBULANCE SERVICE ONLY R. J. Campbell J. H. Crellin W. 1 Bertrand STEVENS' SAFETY PACKAGE STERILE GAUZE is a handy, convenient, clean commodity for the bag or the office. Supplied in one yard, five yards and twenty-five yard packages. ESTABLISHED NEARLY A fcCENTURYjg ~ B. C. STEVENS CO. Phone Seymour 698 730 Richards Street Vancouver, B. C. -f^h*- Hollywood Sanitarium LIMITED tyor the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively Inference ~ IB. Q. Q^Siedical ^Association For information apply to Medical Superintendent, New Westminster, B. C or 5 15 Birks Building, Vancouver Seymour 4183 Westminster 288 !KSW
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History of Nursing in Pacific Canada
The Vancouver Medical Association Bulletin: March, 1931 Vancouver Medical Association Mar 31, 1931
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Title | The Vancouver Medical Association Bulletin: March, 1931 |
Creator |
Vancouver Medical Association |
Publisher | Vancouver, B.C. : McBeath Spedding Limited |
Date | 1931-03 |
Date Issued | 1931-03 |
Subject |
Medicine--Periodicals. |
Genre |
Periodicals |
Type |
Text |
File Format | image/jpeg |
Language | English |
Notes | Shaughnessy clinical meeting; Medicine and the law; Laboratory bulletin. |
Identifier | W1 .VA625 VMA_Bulletin1931_03 |
Collection |
History of Nursing in Pacific Canada |
Source | Original Format: University of British Columbia. Library. Woodward Library Memorial Room |
Date Available | 2015-06-18 |
Provider | Vancouver : University of British Columbia Library |
Rights | Images provided for research and reference use only. Permission to publish, copy, or otherwise use these images must be obtained from the University of British Columbia Library. |
Catalogue Record | http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642 |
DOI | 10.14288/1.0214603 |
Aggregated Source Repository | CONTENTdm |
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