History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1942 Vancouver Medical Association Mar 31, 1942

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Full Text

 i'-jiv
LEfW»
of the
P 1SVANCOUVER
MEDICAL ASSOCIATION
Vol. XVIII.
MARCH, 1942
No. 6«
With Which Is Incorporated
Transactions of the
Victoria Medical Society
th*
Vancouver General Hospital
and
St Paul's Hospital
In This Issue:
NEWS AND NOTES 4|p S j	
CORRESPONDENCE j| SI	
INTRACRANIAL HAEMORRHAGE IN THE NEWBORN-
NEURONITIS ^B|g|B| ! M	
SACRO-ILIAC LIPOMATA %. I	
C.M.A. AND B.C.M.A^ANNUAL MEETING
JASPER J- JUNE 15-19, 1942
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GYN ERHI STIC
ACTI
between
FERROUS
IRON and
VITAMIN BI
A MOST IMPORTANT
POINT TO REMEMBER
when HAEMOGLOBIN
FERROCHLOR E.B.S. WITH VITAMIN BI
More recent investigation confirms the observation that
adequate supplies of Vitamin BI prevent achlorhydria
and achylia with their accompanying anorexia and
anaemia. When BI is combined with Ferrous Chloride, as
in Ferrochlor E.B.S. with Vitamin BI, these elements
act synergistically to correct the achlorhydria and to
regenerate the haemoglobin in anaemia accompanied by
achlorhydria. Ferrochlor E.B.S. with Vitamin BI is
of particular value in the hypochromic anaemia of
pregnancy where the extra demands of the foetus on the
mother lower her natural iron reserve and increase her
need for BI. By its synergistic activity in stimulating
the nervous system and restoring normal appetite, BI
combined with Ferrous Chloride, as in Ferrochlor E.B.S.
with Vitamin BI, is a most useful form of medication
in these conditions. Available in liquid and tablet form.
For both Ferrochlor with Vitamin BI (E.B.S.)
—and Ferrochlor (E.B.S.) plain, indications
are those conditions where an iron deficiency
exists, as in nutritional anaemias, the anaemia
of pregnancy, chlorosis, and other conditions
of iron deficiency. Ferrochlor with Vitamin BI
is suggested for routine use during the later
months of pregnancy, for prophylactic purposes. Ferrochlor is an excellent restorative
postoperatively, where blood loss has depleted
iron reserves, and it is a nutritive supplement
during convalescence.
FERROCHLOR WITH VITAMIN BI—(Liquid)
Ferrous Chloride—16 grs. per fid. oz.
Vitamin B1—2,0001. U. per fld. oz.
Dose: One teaspoonful three times daily.
FERROCHLOR E.B.S.  WITH VITAMIN  BI—(Tablets)
No. 338a.  Each tablet represents 1M fluid drachms or 75
minims    Ferrochlor    E.B.S^fk equivalent   to    2H    grains
ferrous    chloride.
must be regenerat
rapidly.
Modern medical research
repeatedly confirmed the findingJBi
anaemias due to iron deficiency are
best treated with inorganic Ferrous
Salts. Of these salts, Ferrous Chloride
has been found to give the highest
percentage of utilization of iron, in
the shortest time, with a minimum of disturbance. Ferrous
Chloride in its most palatable
and  effective  form is found
in Ferrochlor E.B.S., which
combines  ease  and  rapidity
of absorption and high utilization   of   iron   with   small
effective dosage, stability and
palatability.
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WHEN   PRESCRIBING,
Specify E.B.S. Preparations
combined with 200
I.U. Vitamin BI.
Dose: One or two
tablets three times
daily.
iilGHLORili
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JUST TO
BE SUREI
THE E. B. SHUTTLEWORTH CHEMICALHttMiTEB I
TORONTO MANUFACTURING   CHEMISTS CANADA I THE    VANCOUVER    MEDICAL    A SSOC I AfT- I ON
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Db. G. A. Davidson Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVHL
MARCH, 1942
No. 6
OFFICERS, 1941-1942
Db. C. McDiarmid Db. J. R. Neilson Db. D. F. Busteed
President Vice-President Past President
D&. W. T. Lockhabt Db. A. E. Tbites
Hon. Treasurer lion. Secretary
Additional Members of Executive: Db. Gobdon Bubke, Db. Frank Tubnbull
TRUSTEES
Db. P. Bbodie Db. J. A. Gdllespie Db. W. L. Pedlow
Auditors: Messbs. Plommeb, Whiting & Co.
SECTIONS 1
Clinical Section
Db. Ross Davidson Chairman Db. D. A. Steele Secretary
Eye, Ear, Nose and Throat
Db. A. R. Anthony Chairman Db. C. E. Davies Secretary
Pcediatrie Section
Db. G. O. Matthews Chairman Db. J. H. B. Gbant Secretary
STANDING COMMITTEES
Library:
Db. F. J. Btjlleb, Db. D. E. H. Cleveland, Db. J. R. Davies,
Db. A. Bagnall, Db. A. B. Manson, Db. B. J. Harbison
Publications:
Db. J. H. MacDermot, Db. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. H. H. Caple, Db. J. E. Habbison, Db. H. H. Hatfield,
Dr. Howard Spohn, Db. W. L. Gbaham, Db. J. C. Thomas
Credentials:
Db. A. W. Hunteb, Dr. W. L. Pedlow, Db. A. T. Henby
V. O. N. Advisory Board:
Db. W. C. Walsh, Db. Rt E. McKechnie II., Db. L. W. McNutt.
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont.
Greater Vancouver Health League Representatives:
Db. R. A. Wilson, Db. Wallace Coburn.
Representative to B. C. Medical Association: Db. D. F. Btjsteed.
Sickness and Benevolent Fund: The Pbesident—The Tbustees.
'Mi -rH\M*»*E
HVO*OCHUO*">E
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RIBOFLAVIN
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THE BETTER KNOWN FACTORS
THE LESSER KNOWN & UNIDENTIFIED FACTORS
B-PLEX
WYETH
The better known factors are present in Biological
Balance with the lesser known and unidentified.
B-Plex Wyeth supplies significant amounts of Biotin,
Choline, Inositol, Folic Acid, P-aminobenzoic Acid
and the unidentified factors as found in rice-bran
extract—a potent natural source.
S.M.A. -BIOCHEMICAL DIVISION
John Wyeth & Brother (Canada) Limited    •    Walkerville, Ontario VANCOUVER  HEALTH  DEPARTMENT
■W
STATISTICS—JANUARY, 1942
Total Population—estimated :	
Japanese Population—estimated	
fGhinese Population—estimated .	
Hindu Population—estimated	
Number
Total deaths 345
Japanese deaths 9
Chinese deaths 11
Deaths—residents only 304
272352
8,769
8,558
360
BIRTH REGISTRATIONS:
Male, 249; Female, 242	
INFANTILE  MORTALITY:
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths (not included in above).
.   491
Jan.. 1941
L: * 18
36.7
14
Rate per 1,000
Population
15.0
11.6
14.8
13.2
21.3
Jan., 1940
19
40.03
14
CASES OP COMMUNICABLE DISEASES REPORTED IN THE CITY
Dec., 1941 Jan., 1942         Feb. 1-
Cases   Deaths Case
Scarlet Fever 22           0 39
Diphtheria 0           0 0
Diphtheria Carrier 0           0 1
Chicken Pox 135           0 235
Measles 16           0 34
Rubella 11           0 12
Mumps 60           0 342
Whooping Cough     24           0 25
Typhoid Carrier 10 0
Typhoid  Fever 2           0 1
Undulant Fever 0          0 1
Poliomyelitis 2           0 0
Tuberculosis 26         18 37
Erysipelas       5           0 0
Meningococcus Meningitis 2           0 5
Pneuruococcic Meningitis 0           0 1
Flexner Dysentery 10 0
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IS
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
Syphilis	
Gonorrhoea
West North      Vane.
Burnaby   Vancr.  Richmond   Vancr.     Clinic
Not yet received
Not yet received
Hospitals &
Private Drs.
Totals
«
A DYNAMIC MENTAL AND PHYSICAL TONIC
INDICATED IN THESE DAYS OF STRESS
<< A  *'
BIOGLAN "A
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C.
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.4Hfi/llll0(/iStlM(?...always indicated in
Tonsillitis - Pharyngitis - Laryngitis - Bronchiolitis
Write for Samples ana Literature
The Denver Chemical Mfg. Co. -  153 Lagauchetiere St. W.# Montreal
Made in Canada MEASLES
Modification
»«
Prevention
In 1939 there were 197 deaths from measles in Canada.
More than 95 per cent of these were in the age-group 0-5
years.
Human serum prepared from the blood of healthy adults
so as to involve a pooling from a large number of persons
may be used effectively either for modification or prevention
of measles. Modification is often preferable in that it reduces
to a minimum the illness and hazards associated with measles,
but does not interfere with the acquiring of the active and
lasting immunity which is conferred by an attack of the
disease. On the other hand, complete prevention of an attack
of measles is frequently desirable, and can be accomplished
provided that an ample quantity of serum is administered
within five days of exposure to the disease.
For use in modification or prevention of measles, pooled
human serum is available from the Connaught Laboratories in
a concentrated form. While the recommended dose of this
pooled and concentrated human serum for purposes of prevention is ordinarily 10 cc, the most usual dose is for
purposes of modification and amounts to 5 cc. The serum is
therefore supplied in 5-cc. vials. Prices and information
relating to it will be supplied gladly upon request.
■
CONNAUGHT LABORATORIES
UNIVERSITY   OF   TORONTO
Toronto
Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. After - A HARD
9or "the Mabitually
Zired Patient"
GLYCOLIXIR
This elixir of glycocoll—the simplest of
all amino acids—exerts an appreciable
effect on the retention of creatine 'which
plays a part in muscle metabolism. Better
appetite, a higher level of general health
and well being have been reported following its use.
Dose: Adults—1 or 2 Tablespoonfuls t.i.d.
>ToT r**
\lJ Syrup w»ilf»_
arid
"'calciw PfcospW"..
9or Convalescents
and the Undernourished
NAVITOL MALT
COMPOUND
A palatable dietary supplement providing vitamins A, B, D and B Complex with dicalcium
phosphate and liver extract.
Dose:     Adults   —1 - 2 tablespoonfuls daily.
Children—1 - 3 teaspoonfuls.
For literature, write 36 Caledonia Road, Toronto
Ml:Squibb &Sons of Canada. Ltd.
MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE   1858 VANCOUVER MEDICAL ASSOCIATION
Founded 1898
Incorporated 1906
Programme of the Forty-fourth Annual Session
(Winter Session)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Papers of the evening.
1942
January   *—GENERAL MEETING.
Dr. F. N. Robertson: "A Simple Test for Cancer."
January 20—CLINICAL MEETING.
February   3—GENERAL MEETING.
Dr. J. H. MacDermot: "Epi-Sacro-Iliac Lipomata—A small cause of
much trouble."
February 17—CLINICAL MEETING.
March 3—GENERAL MEETING
Osier Lecture—Dr. D. E. H. Cleveland.
March 17—CLINICAL MEETING.
April  7—GENERAL MEETING.
Dr. L. H. Appleby: "The Use of Snake Venom in Medicine."
April 21—CLINICAL MEETING.
■<s    i;f.
and, as adjuvant to treatment:
"A GUINNESS A DAY"
(famous British health rule)
Physicians recently reported seventeen conditions
for which they use GUINNESS STOUT. They
emphasized, of course, its famous tonic properties
and its usefulness in inducing sound, natural
sleep ■without the depressing after effects of most
hypnotics.
AN ANALYSIS OF GUINNESS STOUT 100 cc.
Total solids 5.87 gms.
Etbyl alcohol   (7.9%  by volume) 6.25   gm.
Total   carbohydrates 3.86 gm.
Reducing  sugars as glucose 0.66  gm.
Protein     None
Total  nitrogen 0.10 gm.
Ash     0.28 gm.
Phosphorus 3SJ0 mg.
Calcium—. 7.00 *;.
Iron 0.072  n;.
Copper . 0.049  mg.
fuel value  61  cat.
Vitamin Bi 6 Int. Units
Vitamin G 33  Sherman Bourquin Units
A. GUINNESS, SON & CO., LIMITED
DUBLIN  and LONDON
For older people, Guinness is a stimulating and
appetizing food. The energy expense of digesting
Guinness   is   low.
Guinness is brewed from only four ingredients:
barley malt, hops, yeast and water. It is matured
over a year in oak vats and bottle. Unlike other
stouts    and    porters,    Guinness    is    unfiltered   and
unpasteurized, and thus
contains all its natural
goodness, including active yeast, a source of
vitamins B and G and
valuable   minerals.
Guinness has been
brewed in Dublin since
1759 and is the largest
selling malt beverage
in the world, foreign
Extra Guinness is obtainable through all
legal outlets. Write for
convenient 3" x 5" file
card giving complete
analysis and indications
to Representative, A.
Guinness, Son & Co.,
Limited, 501 Fifth Avenue,  N.Y.C.
Page 166 m
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....adequate Vitamin D increases the efficiency of calcium-
phosphorus medication by ensuring utilization of these minerals.
*;\
ir
^^3
ffCALCIUM A"
Bach soft gelatin
capsule contains:
Vitamin A 3500 International Unil
Vitamin D 350 International Unil
Dibasic Calcium Phosphate 560 ma
Boxes of 40 and 100 capsules
AYERST, McKENNA & HARRISON LIMITED * Biological and Pharmaceutical Chemists • MONTREAL, CANADA
974
PRESCRIBE CANADIAN MADE PRODUCTS
HELP WIN THE WAR
BUY WAR  SAVINGS CERTIFICATES EDITOR'S PAGE
During the past month, the profession of British Columbia has been very busy con-
I sideling a questionnaire sent out by the Committee on Economics of the Canadian
Medical Association. The indefatigable chairman of that Committee, Dr. Wallace Wilson
of Vancouver, has been very busy personally conducting meetings in Vancouver and
elsewhere, where this questionnaire was explained and amplified, and various members
lof the B. C. nucleus of this Committee have travelled to different parts of the province,
where keenly interested groups of medical men have met to discuss their difficulties and
propound questions.
It is not to be wondered at, we think, that there should have been some slight diffi-
Iculty in answering this questionnaire, for the man in active practice. It represents a
highly concentrated extract of several months of meetings, not only here, but in other
parts of Canada; of reams of correspondence back and forth; of very careful and prolonged discussion and study. In fact, those of us who have sat on this Committee for
quite a while, and so took part in this province-wide survey, visiting various centres,
were struck, not by the lack of understanding, but by the shrewdness and high intelligence of the questions asked, and the keen understanding interest shewn by all who
attended these meetings: and they were amazingly well attended: busy men came scores
of miles, under winter conditions of travel, and gave their time unsparingly to the consideration of these problems.
I If our long battle over Health Insurance did nothing else for us, it has created a very
alert and keenly aware mental response in all of us to problems of medical economics—
one has only to look back to the beginning to realise this. Time was, not so long ago,
when, like Gallio, the average man "cared for none of these things." Today, while our
individual views may differ, sometimes quite widely, we are all nevertheless wide awake
and united in one thing at least: our interest in these things, and our determination to
keep in touch with each other, and to do our shade towards collective action.    There
lore, and always will be, some mavericks who will not tag along with the rest of the
herd: but they are few and getting fewer: and this is as it should be.
We would humbly suggest to the powers that be—in this case, our Medical Council—
that the time has come for us to take the public into our confidence over some of our
problems—and appeal to its members to help us to solve them.
The medical profession, of B. C. as elsewhere, has been depleted rather seriously of
late, first by the active enlistment of so many members, and secondly by the fact that
few if any newcomers into the profession are starting medical practice: the younger men
are almost entirely taken up by the armed forces as they graduate. Meantime the population is growing steadily, and the situation is beginning to become somewhat difficult
for many of us. Our medical .structure is beginning to shew signs of strain—many of
us are overworked, and things are not likely to improve, for a while at least.
Under there circumstances, it might be a wise thing if, in some impersonal and quite
considerate way, we were to point this all out to the people at large, and ask them, for
their own sakes at least, as much as for ours, to carry out certain suggestions.
First, as far as possible, to curtail unnecessary calls: not to be surprised or resentful if
a doctor does not always make daily visits, as long as.everything is going satisfactorily.
Secondly, to do their best to let the doctor know early in the day that he will be
wanted to make a call at the house that day: not to put it off as long as possible.
Thirdly, whenever possible, to call at the doctor's office rather than have him call at
the house. The gradually increasing difficulties in getting gasoline are going to make it
very difficult—perhaps impossible—for the doctor to make all his calls.
This is no new idea: we were reading lately that certain other large areas were considering doing something of this kind. A well-thought-out plan of public notification
would, we think, produce results. It is difficult for the individual doctor to do this
without, perhaps, antagonising his patient, but an explanation made by the responsible
authorities would, we are sure, elicit sympathy and co-operation from the public. After
all, it is in their interest just as much as ours, to conserve their doctor's energy, and
apply it to the best advantage.
Page  16?
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NEWS    AND    NOTES
According to word received here, Capt. H. R. L. Davis, R.C.A.M.C, who is servingj
overseas, has been promoted to the rank of Major.
The profession extends sympathy to Dr. T. K. McAlpine in the loss of his wife, and
to Dr. A. O. Brown in his recent bereavement, his wife having passed away.
Dr. C. H. Hankinson of Prince Rupert has addressed several meetings of A.R.P.
workers, including a fifteen-minute talk over the local radio station, in the interests of
A.R.P. work.
M
Dr. J. H. Carson of Prince Rupert was back from Toronto for a visit and is now
away again.
Dr. D. T. R. McColl of Queen Charlotte City visited Prince Rupert recently.
Dr. and Mrs. E. D. Emery of Nanaimo are receiving congratulations upon the birth
of a daughter.
Dr. S. W. Baker has taken up practice in Ladysmith and will be associated with Dr.
D. P. Hanington.
Flight-Lieut. A. S. Underhill, formerly of Kelowna, has been moved East to take a
course of instruction in Aeronautical Medicine.
*lr
Dr. Bridgeman of Winnipeg was a visitor in Penticton recently.
Dr. W. S. Barlay and Dr. J. D. Galbraith of Coqualeetza Hospital, Sardis, have
accepted the invitation of the Chilliwack Medical Society to join the organization and to
take part in Hospital Staff discussions.   This brings the number of members to ten.
Word has been received that Capt. R. W. Patten, formerly of Chilliwack, has arrived
safely and is serving somewhere in Great Britain.
We are pleased to report that Dr. G. B. Helem of Port Alberni has recovered from
an operation and following a short holiday in Manitoba is back in practice.
Major P. S. Tennant, R.C.A.M.C, formerly of Kamloops, arrived home from England
for a short leave.    He is now posted in Canada for instructional duties.
Dr. J. P. Ellis of Lytton called at the office when in Vancouver recently.
Dr. W. E. Bavis of Port Renfrew visited the office.
Dr. Andrew Turnbull, R.C.A.M.C, radiologist, formerly at St. Joseph's Hospital, has
returned from Great Britain and is now at Esquimalt Military Hospital.
Capt. J. D. Balfour, R.C.A.M.C, at one time Pathologist at Royal Jubilee Hospital,
Victoria, has returned to this Military District and is now stationed at the Nanaimo
Military Hospital.
Page 168
w It is with keen regret that we record the fact that Dr. D. E. H. Cleveland, of the
Publication Committee of the Bulletin, and, quite apart from this, one of our most
valued friends, is ill in the Vancouver General Hospital. Latest reports (he has been
unable to see visitors) are that he is improving rapidly.
Recent visitors to B. C have included Major Geo. H. Clement, R.CA.M.C, who
has been transferred from Ottawa to a Western area; and Capt. T. Dalrymple, R.C.
A.M.C., also transferred from an Eastern Depot to an appointment somewhere in the
West.
We extent our deepest sympathy to Dr. and Mrs. A. O. Rose, of Langley, in the
recent tragic loss by accident of their son.
DR. ELMER BOLTON
Obiit Feb. 10, 1942
The sudden death of Dr. Bolton recently marks the passing of another of
our older practitioners in Vancouver. Dr. Bolton had been suffering for some
months from cardiac trouble, but he had been working steadily, and had, as we
think, a very happy and fortunate ending, as far as he was concerned himself,
though the shock must have been a severe one to his family, to whom we extend
our deepest sympathy for their heavy loss.
Dr. Bolton was a good physician. He was quiet and retiring—but friendly,
and very much liked and respected by all who knew him. He had been in
practice in Vancouver for a long time, we think thirty years at least, and had
a large circle of friends, who will miss him and mourn his passing.
DR. G. W. KNIPE
Obiit Feb. 6th, 1942.
Dr. Knipe's sudden death was a shock to all who knew him. He was apparently in perfect health, and had been scheduled to attend the Annual Meeting
of the Vancouver Dickens Society, of which he was President, on the evening
of the day he died.
Dr. Knipe, who graduated in medicine in his native land of Ireland, was
a man of many parts. A well trained physician, he was also keenly interested
in literature and the drama—was a member of the Shakespeare Society as well
as the Dickens, and a capable amateur actor—the writer of this saw him play
Falstaff in a short skit most admirably. He had all the geniality and wit
traditionally possessed by his countrymen, and was a delightful man to know.
Not very long in Vancouver, he had made for himself an abiding mark in the
cultural life of the community. We extend our deepest sympathy to his family.
Page 169
1
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*$4 DEPARTMENT OF NATIONAL WAR SERVICES
Medical Examination and Certification of Recruits
PLEASE NOTE:
(a) That in order to facilitate the payment of the doctor's examination
fee, the notice of call for Medical Examination, issued to the recruit by the
Department, should be secured by the Examining Doctor and attached to the
Medical Examination and Certificate Form, before sending both these forms in
to the Divisional Registrar.
(b) That in order to prevent duplication of medical examinations of a
recruit you are requested not to examine a recruit without some printed or
written authority from the Department of National War Services, this authority
should be secured from the recruit and attached to the Medical Examination
and Certificate Form, and send both of these at once to the Divisional Registrar.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY:
Medical Clinics of North America, Symposium on Common Skin Diseases, Chicago
Number, January, 1942.
Maude Abbott, A Memoir, 1941, H. E. MacDermot.
Behind the Mask of Medicine, 1941, by Miles Atkinson.
MICROFILM SERVICE
The Vancouver Medical Association has become a subscriber to the Microfilm Service of the Army Medical Library at Washington, D.C By this means, member's who
are desirous of reading in the original any article published in some medical journal which
is not available in our own Library, may have the article placed before them on a
microfilm.
A weekly list of medical literature available on microfilm, and classified under various headings, such as Anatomy and Histology, Anthropology and Ethnology, Medicine,
Neurology and Psychiatry, etc., is furnished.
The cost to the individual user will be 25 cents for an article not exceeding 25 pages,
and 10 cents for each succeeding 10 pages, plus American exchange. The film, wheif
obtained, becomes the property of the person ordering it, but it is expected that it will
be left on file in the Medical Library, whereby a special library of microfilm will be
accumulated. It does not seem unreasonable to expect this, in view of the convenience
offered to members by the Library, in making this service available to them, the handling and remittance of payments, etc.
Copies of the list of available literature are on hand in the Library and selection can
be made at any time with the assistance of the Librarian.
The Library Committee have carefully considered this service and obtained reports
on it from individual users, all of which are very laudatory, and the Committee feels
that it is placing a valuable addition to the sources of up-to-date medical knowledge
before the members of the Association in this way.
Page 170 Vancouver Medical  Association
A. R. P. REGISTRATION OF PHYSICIANS
Do you know that unless you are registered for Civil Protection (A.R.P.) Services—
1. You will not; be allowed to drive a car during Military Emergencies, Air Raids or
Blackouts?
2. You will not be covered by compensation if injured while on duty during such
emergencies?
Over fifty per cent of the medical men in Vancouver have not yet filled out registration forms, and they are urged to do so without delay. Forms may be obtained from
the offices of the Vancouver Medical Association or from the Information Desk at the
Vancouver General Hospital or St. Paul's Hospital.
IS;
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CORRESPONDENCE
[The Editor was greatly delighted to receive the letter published below from our old friend Roy
Huggard, who is doing sitpb good work overseas. (We may say that this remark is based, not on any
evidence supplied by Major Huggard himself, but on what has been told us by other men.)
The lofty tone and sincerity of this letter are very striking—but only what one would expect from
Roy. All who know him will know without words from anyone that he will be an asset to any unit,
and that his presence in it will add immeasurably to its efficiency and strength. We wish him. the best
of luck and a speedy return.
Anyone knowing the address of any B. C. medical man now in the Servies, who would like the
Bulletin sent, would do us a favour by telling us. We send it to all whose address we have, and would
rejoice to send it to anyone who wants it. Ed.]
Jan. 22, 1942
Base Post Office, Ottawa, Ont.
Major L. H. A. R. Huggard,, R.C.A.M.C,
"C" Group C.R.U.,
Canadian Army Overseas,
Dr. J. H. MacDermot, ill
Vancouver, British Columbia.
Dear Jack:
The above is my address^-one would be delighted to hear from any of you, anytime,
because naturally one's thoughts are frequently in the homeland, wondering what is
going on.
Naturally you folks wonder what is happening here. To begin with, the people of
this island fortress are of excellent heart and morale. They are of grim determination,
and despite many privations, the terrors of bomb attack, death, and shortage of many
comforts, they are committed in will as one man to finish it one and for good. As you
know, women are subject to conscription. Most of them (20-35) are in uniform.
From the three services, A.T.S., W.A.A.F., W.R.N.S., to the munitions workers, land
girls, conductresses and many other callings, all cheerfully discharge their duties, onerous
or taxing though they be. Gone are the days of yesteryear when the social columns
state "Mrs. X was adorned in such and such a creation," etc. The clothes (all rationed
except the services) are for warmth and service rather than style, etc. Cosmetics have
pretty well vanished and the vital tasks of war take first place. The shop girls now are
in industry, stenographers, etc., also older women now do the less taxing work, but all
by and large serve in some capacity.   I should say in conclusion that the women of this
Page 171
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island should merit the admiration of all, in the sacrifices they make willingly daily.
After all, as-mothers, wives and sweethearts, their menfolk leave for the various theatres
of war and they cheerfully bid them "Au revoir" never "Adieu."
I should like to say something of the men of the Merchant Navy. These are truly
heroes—daily their ships arrive and leave—and to those who are in these ships who cross
the submarine infested seas reckless of all dangers, our debt can never be paid. But for
they our efforts would all be in vain. After all, they are not of the fighting service—
yet they cheerfully accept their supreme responsibilities and traverse the lifelines eager
to speed their task and bring closer that day of victory.
There is little air activity by the enemy here. Sporadic solitary attacks only. Mass
raiding has ceased (at least for a season). One feels that the R.A.F. has made it too
expensive a luxury for Jerry. In fact, it is reasonable to say that the R.A.F. are lords
of the skies of Britain and indeed of those over western Europe. They have done a
mighty work and only those few well informed can really appreciate the gigantic effort
that was put forth.   "They saved Britain," someone has said.
Our fortunes in Libya are much better and there is reason to hope for a decision that
is favourable in due course.
In Malaya for the time being we suffer. Naturally there is much criticism. To
have a battle line stretching now from Canada across the Atlantic, Britain, Norway,
across Europe, India to the East Indies and sweeping across the Pacific to the U.S.A. is
astounding. Yet who are they who would suggest that here or there a point of weakness might not exist. I believe in due course our fortunes in the East will merit a
happy surprise.
Russia has shocked the world. She is steadily gaining strength and victories. The
German armies for the first time have been checked and are being hurled back. It may
be that this is the crucial hour and that from this time onward we shall be able to soften
Jerry in a preparation for his ultimate destruction.
The health of the people here and our troops is excellent. Food while rationed
is of staple character—scientific supervision is exercised and nutritional balances carefully
observed. To my knowledge there is no nutritional disease, no epidemics, and the general welfare extraordinary. The medical profession here is well organized and great credit
is due to the efficiency of its work.
London full well shows the scars of war. Many buildings of historical interest and
beauty are now stacks of rubble. Vandalism is to be seen at its worst. Whole areas of
homes have been demolished. However, this is pocketed here and there and other areas
are untouched. In fact, you can go distances in some zones and see no destruction.
Strange to say, military objectives suffered little or no damage at all. The tragedy is
that thousands lost their lives. The same applies to Liverpool and Manchester. Words
of course would beggar the description of Coventry.
Col. Leeson is doing an excellent job. He is a most efficient and popular officer.
Major Boulter is on a headquarters staff and doing excellent work. Captain H. R. L.
Davis likewise is doing well. In fact the various B.C. men all to my mind are faithfully discharging their several tasks. One's work at present is administration on a
headquarters staff. Lieut.-Col. A. Desbrisay, O.C of a field ambulance, has done excellent service. Squadron Leader D. M. Meekison, R.A.F., is doing excellent skilled work
at a famous R.A.F. orthopaedic centre. His talents are well employed, and yielding fine
results.
How soon victory will come we cannot know. The price of our liberties will be a
heavy one. All of us are at crossroads of destiny. Much sacrifice will be required and
for a while we shall have to surrender some of the more luxurious phases of our lives.
Some there are who will surrender their lives. Many will lose their fortunes, and others
will lose loved ones. But as Lincoln so ably puts it, "Let us have faith that right makes
might and let us dare to do our duty as we see it." So shall we face the future with
confidence, bending all our several efforts and wills to the supreme task and in the end
I am confident that all will be well.
Page 172 To you in the homeland, every good wish. I know you are all with us who have
gone away for a little while. I am sure you will avail yourselves of every opportunity
to ever press forward in the prosecution of the war.
I should welcome a copy of the Buletin anytime it is convenient to send one.
For you, Jack, cheerio—drop us a line sometime.
As ever,
ROY.
Dr. A. E. Trites,
Secretary,
Vancouver Medical Association.
Vancouver, B. C,
Feb. 2nd,  1942.
Dear Dr. Trites:
As many of the medical profession already know, a Vancouver branch of the
Women's Auxiliary to the R.C.A.M.C. was formed just before Christmas. It is composed of about sixty members, wives of R.CA.M.C officers and Vancouver doctors.
The purpose of the group is to provide for the needs of medical personnel in the
ranks of the Canadian Army, and to care for the welfare of the families of these men.
We have already accomplished the following:
(1) Purchased $120.00 worth of musical instruments for the 12th and 13th Field
Ambulances.
(2) Bought over $350.00 worth of wool out of which we have knitted 250 sweaters and 240 helmets.
(3) Arranged a Christmas party for the wives and children of the 12th and 13th
Field Ambulances and No. 11 Field Hygiene Section.
(4) Sent hampers to 5 needy families; made welfare calls on 3 others; and have
already met several emergency demands.
The money for these activities has been raised by cheerful voluntary contribution on
the part of the members of our Auxiliary. The ladies have given liberally of their time,
handwork and money; they have tried faithfully to help the men who are wearing the
insignia of your profession in the Canadian Army. They will continue to do so. However we realize that with the formation of the 16th Base Hospital our responsibilities
will expand beyond our ability to cope with them financially.
Therefore, in our urgent need, we appeal to members of the Vancouver Medical
Association for assistance.
May we suggest a contribution of $3.00 yearly from each of your members, until
the war is over and our work is done? We would, of course, give you an annual accounting of our expenditures, and happily return you the balance when we close our books.
Would you please give this your earnest consideration and anything that you feel
you can do for us will be greatly appreciated.
(Signed)   IDA M. LEES, President,
NAOMI DESBRISAY, Secretary,
R.CA.M.C Auxiliary,
Vancouver Branch.
Mrs. H. A. DesBrisay, | February 17th, 1942.
Secretary, R.CA.M.C Women's Auxiliary,
4998 Granville St.,
Vancouver, B. C
Dear Mrs. DesBrisay:
At the regular meeting of the Vanouver Medical Association on February 3rd, the
sum of $50.00, as an immediate token of support, was voted, as well as the proposed
contribution of $3.00 from each member of the medical profession in the city.
Page 173
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It was the opinion of the meeting that the work of your Auxiliary has been excellent, and we feel that the assistance as outlined above will be duly forthcoming.
A cheque for the initial contribution is herewith enclosed.
Yours truly,
A. E. TRITES, M.D., Honorary Secretary,
Vancouver Medical Association.
[Our old friend, Dr. D. M. Baillie of Victoria, has written to the Bulletin a letter which we gladly
publish. Dr. Baillie has long been known to us in British Columbia as a man who takes a keen interest
in the future of his profession, and holds strong views, and rather advanced ones, on the form that he
feels that future should take, if it is to be to the best interests of both the medical profession and the
public.
There is a great deal to be said for Dr. Baillie's views, which be has, before this, presented in a somewhat more detailed form in a previous number of the Bulletin. -He is a realist, and feels, we think,
that we should face facts, and follow them through to their logical end. We cannot but sympathise with
him in this, but in some ways, we are a slow profession to move: individualistic to a degree (this is determined to some extent by the very nature of our work), suspicious of regular hours and regular pay, and
very unwilling to change at all, except under the sternest of duress.
So the missionary and reformer amongst us has had a hard time. But such memoranda as this of
Dr. Baillie's are of great value: they make us think, and sow seed which later bears fruit. We thank him
for this letter. Ed-I
Victoria, B. C,
February 11, 1942.
To the Editor,
Vancouver Medical Association Bulletin.
Sir:
The medical profession has now squarely before it the question of Health Insurance
and a questionnaire is by this time in the hands of every medical man and woman in the
Province. We are told in the first paragraph that "profound changes are occurring
throughout our whole economic system and these are having their effect on our Medical
and Health Services."
In other words a revolution is taking place in our economic system and we are asked
to devise means of bringing ourselves in line with the developments as they arise. The
remedy proposed is Health Insurance. May I suggest that this remedy is already out of
date. Great Britain has had a medical insurance system for some thirty years which has
been a boon and a blessing both to the doctors and the public. The response on the part
of the medical profession of Britain to the revolutionary developments—which are similar
in most respects to our own—is an ever growing demand for State Medicine as the only
logical way out of their difficulties. Would it not be wise for us to boldly strike out for
a similar objective instead of allowing ourselves to flounder into the wilderness of Health
Insurance?
We have already gone a long way towards this objective inasmuch as some thirty
percent of the practitioners in British Columbia have already enrolled in the Air, Naval
and Military Medical Services and are being paid directly from Dominion funds. There
will, no doubt, be more of them before this trouble ends. It seems to me that the sane
and logical thing for the Government to do is to mobilize the remaining seventy percent
into a Civil Branch to look after the civil population and to act as a recruiting basis for
the Air, Naval and Military Medical Services.
This would ensure some measure of equality of sacrifice and prevent the exploitation
of the situation which is taking place, unwittingly I hope, by the men left in civil practice. Above all it would ensure a tremendously enhanced public health effort in the field
of preventive medicine by merging the present private system of medicine into the Public
Health Services of the State.
D. M. BAILLIE.
Page 174 British  Columbia  Medical  Association
(CANADIAN MEDICAL ASSOCIATION, BRITISH COLUMBIA DIVISION)
President ! Dr. C. H. Hankinson, Prince Rupert
First Vice-President Dr. A. H. Spohn, Vancouver
Second Vice-President Dr. P. A. C. Cousland, Victoria
Honorary Secretary-Treasurer Dr. A. Y. McNair, Vancouver
Immediate Past President ! Dr. Murray Blair, Vancouver
Executive Secretary 1 Dr. M. "W. Thomas, Vancouver
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CANADIAN MEDICAL ASSOCIATION
BRITISH COLUMBIA DIVISION |
.l||  ANNUAL MEETING |gj§
The British Columbia Medical Association Annual Business Meeting will be held at
Jasper on June 16th, during the Canadian Medical Association Meeting, June 15 th to
19 th, inclusive.
British Columbia has always attended its Annual Meeting, and should have a large
attendance at Jasper.
The C.N.R. office in the Hotel Vancouver will accept your bookings for accommodation at Jasper.
A special train will be provided for the party travelling from the Coast.
CANADIAN NATIONAL RAILWAY
Special All-inclusive Rates, covering Four Days' Room and Board at Jasper Park
Lodge—First-class Railway Fare and Return, including Standard Lower Berth.
From: Kamloops   $45.80
Kelowna 64.90
Nanaimo -      - 66.70
Prince Rupert 63.75
New Westminster 63.75
Vancouver =. 63.75
Victoria   ___: . 66.70
Those from the Coast may travel either going or returning by Prince Rupert on payment of $13.00, which covers meals and berth on steamer.
All double rooms equipped with twin beds. Those travelling singly are asked to
double up.    The Manager, Jasper Park Lodge, will receive reservations.
Chairman of Committee on Registration and Information—Dr. A. McGugan,
Edmonton.
The following schedule shows how the Government Railway proposes to meet the
need. You leave Vancouver on the evening train and arrive at Jasper at noon the following day.
Leave Vancouver 1 7:15 p.m.    Daily
Arrive Jasper 1:15 p.m. (next day)
Leave Jasper 12:55  p.m.       1
Arrive Vancouver  : 8:35 a.m. (next day)
Leave Jasper 2:05 p.m.    Friday
Arrive Prince Rupert 2:30 p.m.    Saturday
Leave Prince Rupert 4:00 p.m.
Arrive Vancouver 9:30 a.m.    Monday by CN.S.S.
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CANADIAN PACIFIC RAILWAY
Those wishing to avail themselves of the service may travel one or both ways by the
C.P.R., leaving the main line at Lake Louise and travelling by bus through the ice fields
to Jasper.
Vancouver 7:15 p.m.
Jasper  1:15 p.m.
Jasper 9:00 a.m.
Lv.
Ar.
Lv.
Ar. Icefield 12:00
Lv.
Ar.
Lv.
Ar.
noon
Icefield 2:30 p.m.
Lake  Louise :  6:00 p.m.
Lake  Louise 12:20 p.m.
Vancouver    8:35 a.m.
Estimated costs:
Rail—Vancouver, Jasper and Lake Louise, V;
Lower berth—Vancouver, Jasper and Lake Louise, Vancouver     11.60
Six days Jasper Park Lodge     36.00
Bus—Jasper Park to Lake Louise     14.85
Lunch at Columbia Icefield Chalet        1.25
Room and meals Chateau Lake Louise, and transfer     10.00
Sat.,   June 13th, CN.R
Sun.,
'     14th
Sat.,
"    20th Bus
Sat.,
"    20th
Sat.,
te    20th Bus
Sat.,
"    20th
Sun.,
l.    21st C.P.R.
Mon.,
\    22nd
couver   .
1   _$  34.65
Total $ 108.35
(Leave Jasper 9:00 a.m. daily by bus to arrive Lake Louise 6:00 p.m., thence C.P.R.
to Vancouver.)
Then, again, those wishing to travel by automobile may do so, over the Big Bend
Highway, or through the southern part of the province, or even through the States and
north through Windermere Valley, all of which would make a delightful trip.
Please inform the office if you intend to go to Jasper.
Our slogan for 1942 is: "ON TO JASPER IN JUNE."
HEALTH INSURANCE QUESTIONNAIRE
As you already know, it is absolutely essential that 100% returns of completed
Questionnaires must be secured if at all possible. If no form has been received by you
or if you have mislaid it, kindly secure from this office another form and complete and
return at once.
At the request of the Government, the profession of Canada has an opportunity to
sit in with the medical officers of the Department of Pensions and National Health on
the discussions of proposals bearing on the health services to the people of Canada. The
Committee of Seven appointed by the Canadian Medical Association wants your help in
drafting the bases for these conferences. This is your opportunity to present your views
and at the same time materially help this important Committee.
Eleven meetings were held in various parts of the province and were all well attended,
and it is felt that the discussions have been most helpful, not only to the members of
the profession, but in gathering opinions from doctors engaged in every phase of medical
practice. At this date large numbers of forms have been returned. You are appealed
to now to quickly make this survey 100%.
CANADIAN MEDICAL ASSOCIATION
MEMBERSHIP
By arrangement, the Canadian Medical Association will accept membership
and send the Journal to any Medical Officer in His Majesty's Forces for the
sum of $4.00.
The $4.00 may be remitted to the office, 203 Medical Dental Building,
Vancouver, B. C
Page 176 COMMITTEE ON THE STUDY OF CANCER.
CANCER OF THE BREAST
"All lumps in the breast must be removed for pathological study." How often has
that statement been made and how often have we sagely nodded our heads in agreement
with the dictum? It would seem, at last, that the medical profession has been convinced
that all lumps in the breast are to be viewed with grave suspicion and removed at the
earliest possible moment. But strangely enough there are too many far advanced lesions
being operated on that have been under the observation of a physician for too long.
Why does this occur? It occurs because one doctor's idea of what consists of a lump
worthy of attention is different from that of the doctor next door. There is no uniformity of opinion, and until the profession realizes that "all lumps" mean ALL lumps,
there are bound to be too many late cases of cancer of the breast, that first came under
observation during the stage that they appeared clinically benign. Then was the time
to remove them. We must always be aggressive in the war against cancer as with our
other war—it is later than you think.
Remember that the lump referred to in the breast may be very large and fixed, or,
again, it may be only one centimetre in diameter, perfectly smooth, without skin attachments and accompanied by several other similar lumps that appear and feel almost identical. In fact, the truly curable stage of the disease is often misleading and may tend
to lull one into a false sense of security. The early stages of the" tumour growth may
defy a positive clinical diagnosis, and it is only by excision and careful examination that
the true identity is established.
The next and obvious question is whether or not it is wise to excise all lumps immediately, or "wait and see." The answer is, that if a physician holds to the cardinal rule that
all lumps should be excised soon after being first observed, he is then in for many pleasant
surprises, as so often the most benign appearing type of tumour turns out to be malignant
and a life has been saved. It is better to be surprised by the operating room pathologist
than the post mortem pathologist.
As the skill and experience of the clinician develops he will allow himself less and
less latitude in the clinical diagnosis of pathological conditions of the breast, realizing
there is one infallible method, the all important for the patient, early diagnosis, and that
is "Biopsy early and save a life."
th:
THE REPORTING OF CANCER
Cancer, in the Province of British Columbia, is the second chief cause of death,
second only to diseases of the heart and circulatory system. Cancer and other malignant
tumours in 1939 killed 1044 persons in this Province, a rate of 135 per 100,000 population, and accounted for 13.9% of total deaths. These statistics are obtained from death
certificates signed by physicians.
Since 1931 cancer has been a Notifiable Disease. In 1939, Provincial notifications
numbered 995, 49 less than the number of deaths. Reporting of cases, therefore, has not
given a true indication of the extent of cancer. The majority of notifications have been
received from the larger centres, particularly from those Hospitals which hav active
Cancer Study Groups. Many other cases, many previously diagnosed, others not, are
never reported until their names appear on death certificates.
The Committee on the Stndy of Cancer, B. C Medical Association, has given special
consideration to this problem, realizing that lack of reporting is an obstacle in the educational approach to the problem of cancer. The Provincial Board of Health has, of
January 1, 1942, requested that physicians and Hospitals report all new cases of cancer.
Special forms have been provided for this purposes. Provision is also made for the
physicians and hospitals in the Vancouver Metropolitan Health Area to report such cases
to the Local Medical Health Officers of the respective municipalities comprising the area.
Page 177 t*J
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The ommittee has endorsed this procedure and has assisted in an educational appeal urging
that physicians report all cases early. It has been pointed out that some years ago the
physicians of the Province urged the Government to make cancer reportable, which
action led directly to the Order-in-Council of 1931 which made cancer a Notifiable
Disease in British Columbia. The machinery for reporting has been set up; valuable
information relating to diagnosis, duration of sickness, promptness or delay in seeking
medical aid may be interpreted from the reports.
The Preventive approach to the problem of cancer must be enlarged. Rporting of
cases is essential, and in this connection the value of periodic health examinations must
be emphasized if cancer is to be discovered early.
The month of January, 1942, has seen a notable increase in the number of reported
cases.    This is encouraging, so keep up the good work.
FURTHER LIST OF CONTRIBUTORS TO
BULLETIN WAR RELIEF FUND
Anonymous    - $25.00
Howard  Spohn,  Vancouver     5.00
H. J. Wasson, Victoria  25.00
MEDICAL SERVICES ASSOCIATION
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WHAT YOU GET
1. For Employees and Dependents—Medical Service.
2. For Employees and Dependents—A Daily Hospital Indemnity of $3.00.
3. For Employees and Dependents—Reimbursement for certain hospital expenses up to
a maximum of $15.00.
4. For Employees—$1000 Accidental Death, Dismemberment and Loss of Sight Insurance.
5. For Employees—An Accident and Sickness Weekly Indemnity in an amount determined by an employee's hourly wage as follows:
Class    I—Employees earning less than 45 cents per hour—$7.00 Weekly Indemnity.
Class   II—Employees earning 45   cents but less than  60  cents  pec hour—$10.00
Weekly Indemnity.
Class III—Employees earning 60 cents per hour and over—$15.00 Weekly Indemnity.
(Rules governing this form of insurance do not permit an employee to
select amounts of insurance other than those provided by his hourly wage
as indicated above.)
Your Share of the Cost—Deducted Monthly From Payroll
Class I     Class II   Class III
Single Employee   $1.12 $1.26 $1.49
Employee with Wife only.     2.59 2.73 2.96
Employee with Wife and Children     3.09 3.23 3.46
The above contributions represent one-half the cost of the total benefits at the
initial rates. In addition to assuming the balance of the cost, the Mohawk Handle
Company will pay a required registration fee of $1.50 for each employee.
Note—Further explanatory pages were included in this announcement which it is
thought unnecessary to reproduce here.
Page 171 Ninety per cent of the employees and their families of this Company are
now participating in the benefits of the Medical Services Association.
MOHAWK HANDLE COMPANY LIMITED
PLANT No.  1
Douglas   Fir  Handles  for  Brooms,   Brushes,
Mops,  Rakes, Hoes
Telephone 2707
PLANT  No.   2
Alder,  Maple Birch   Lumber   and  Furniture
Dimension  Stock
Telephone   1462
NEW WESTMINSTER, B. C.
To Our Employees:
For many months we have been considering and investigating plans by which our
employees might be relieved of a large portion of the worry and burden of the cost of
sickness to themselves and family. Accidents occurring at work are taken care of by
the Workmen's Compensation, but no provision is made for sickness or for accident
occurring away from work, nor for family care.
It is necessary to make many sacrifices today and payroll deductions for such
necessities leave little over to take care of doctor's and hospital bills, and to provide
for bread and butter during an enforced disability through sickness. Realizing this,
we have now arranged for the most complete plan of protection it is possible to secure.
The benefits will be provided by the Medical Services Association and The Travelers
Insurance Company and the plan will be available to all employees when they have
completed three months' service with us.
The cost of this plan is considerable, but the benefits are in proportion and are
of a character which you cannot purchase as individuals. Because we believe every
employee should have this protection, we are willing to pay the full charge the first
month, and thereafter so long as the plan is in effect it is our intention to pay all of
the cost over and above the employees' contribution provided 75% of our employees
are willing to take advantage of this offer—your portion of the cost will be deducted
from the payroll.
The plan is explained in detail on the following pages. It provides payment for
accidental death and dismemberment and a weekly income for disability, caused by
accidents occurring away from 'work, a weekly income for disability from sickness, the
payment of doctors' bills and a daily benefit for hospital confinement. If you are
married, it provides for doctors' bills and a similar hospital benefit for your wife and
children—you have free choice of doctor and hospital.
Under this plan, as long as you are in our employ and the present plan is continued, we are jointly providing in advance for those expenses which can so easily set
you back financially for years to come.
We hope every employee 'will make application for these benefits and complete the
attached card and either return it to the office or give it to the representative of the
Insurance Company when he interviews you.
We appreciate the loyalty of our employees and are glad to be able to express our
appreciation in what we believe to be a practical way.
kwm
MOHAWK  HANDLE  COMPANY  LIMITED
W. G. Lambert, President.
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Vancouver  General   Hospital
AN ANALYSIS OF SOME CAUSATIVE FACTORS IN
INTRACRANIAL HEMORRHAGE IN THE NEWBORN
A paper delivered before the North Pacific Pediatric Society, January, 1942.
Reginald Wilson, M.D., M.R.C.P. (London)
In the ten-year period just passed, our nation's birth rate has declined from twenty-
four to nineteenla. At present we are in a war period which will soon act to depress
this still further. These facts make it of interest and importance to study the causative
factors which are associated with our infant mortality rate. Because of the great efforts
which have already been focussed on the care of infants from one month to one year,
the infant death rate in that period has been reduced by approximately one-half in the
last twenty-five yearslb. However, the death rate from birth to one month (neonatal
death rate) and the stillbirth rates have remained practically unchanged during the same
period. Therefore, it is at the causes of death in this neonatal period that we should now
direct our most strenuous efforts. Approximately one-fourth of the infants who die
during the neonatal period do so from intracranial haemorrhage-. Moreover, the recognition of this complication as a cause of death has apparently increased at the Vancouver
General Hospital in recent years: 7 in 1936, 16 in 1937 and 26 in 1938. That th|S
apparent increase is not due entirely to more frequent autopsy examination is shown in
Table I, where it will be seen that the increased percentage of intracranial haemorrhage
has been greated than the expected increase due to the larger number of autopsies.
The other two most important causes of death in the neonatal period are fcetal malformation and anoxaemia. The former condition is, as a rule, not much influenced by
obstetric or paediatric care. It is probable, on the other hand, that the death rate due to
intracranial haemorrhage and anoxaemia could be improved by ideal obstetrical management together with the application of the recent advances in paediatric practice. (In
this connection vitamin K and its influence on haemorrhagic diseases of the newborn
appears to offer an additional means of prevention and cure of this complication3). This
whole problem assumes even greater importance when we consider also the number of
cases in which severe spastic deformity, hydrocephalus, and mental deficiency are caused
by the milder intracranial haemorrhages. The purposes of the present study, then, are
to. record some of the possible factors which might contribute to the increase of this
disease in Vancouver, and to investigate where, if possible, they might be avoided.
Material.—The autopsy records for infants at the Vancouver General Hospital for
the past five years were studied. The number of these cases in which death was due to
intracranial haemorrhage, the percentage relation of these cases to the total number of
births and the total number of autopsies is given in Table I.
The obstetric records in the mother's case in the last fifty patients were examined
and a detailed analysis of these records was made. The information derived from this
is given in Table II.
Discussion of the Results.—From the analysis of the contributing maternal and
foetal factors given in Table II it will be seen that the position of the foetus during birth
is of significance. The number of abnormal presentations of the foetus (64%) are in
excess of the natural cephalic presentations (36%). The complication of breech presentations (28%) is seen to be particularly dangerous to the foetus. Toxaemia of the
mother (present in 12%) apparently contributes to this disease and probably exerts its
deleterious effect, partially through the fact that it is a frequent cause of prematurity.
Prematurity was present in 40% of the infants which died of intracranial haemorrhage,
Page 180 although" all cases studied were born in the viable period. Multiparity of the mother
does not seem to have the beneficial effect one might expect, for 44% of the cases
occurred in multiparous women. Atelectasis is frequently (42%) an associated pathological finding, but it is likely that this is usually a terminal result of the haemorrhage.
Haemorrhage from other organs was reported in only three of the cases (6%) and this
represents the relative importance of true haemorrhagic disease of the newborn as a
contibutory cause of intracranial haemorrhage. It is mainly this group which we hope
may be influenced by vitamin K therapy. Besides these cases, however, the use of
vitamin K might increase the resistance to haemorrhage from a damaged tentorium in
!■ those patients where there was no other external evidence of a generalized haemorrhagic
tendency.
Anoxaemia rivals intracranial haemorrhage as a cause of foetal and neonatal death but
its incidence has not been investigated at this time. Into this group fall those cases in
-which there is no gross anatomical cause of death but there is general anoxaemia of the
tissues. (See Potter2 on definition of anoxaemia.) Many of the contributing causes of
intracranial haemorrhage must operate to cause anoxaemia as well; e.g., in this connection mention must be made of those patients (36%) in which maternal medication
could be considered as of causative significance in this condition. In 10% of the cases
more than six doses of barbiturates were given to the mother and this could accentuate
or cause a condition of anoxaemia in the foetus.
Pituitrin was used for the medical induction of labour in 26% of these cases and
could reasonably be supposed to contribute to both haemorrhage and anoxaemia.    This
bdrug was used frequently, of course, to induce labour in cases of toxaemia and disproportion, and in such instances its use may be justified.    However, I believe its use increases
the danger to the foetus and should always be avoided if possible.
Summary.
1. The stationary foetal and neonatal mortality rates in our nation, in the presence
of a falling birth rate, present a problem which should be attacked with redoubled efforts.
2. Intracranial haemorrhage and anoxaemia are the main causes of neonatal death
which we are likely to influence by the best obstetric and paediatric care.
3. An analysis of fifty cases of intracranial haemorrhage at the Vancouver General
Hospital indicates that the management of abnormal presentations and the prolongation
of gestation where this can possibly be accomplished are the two most important factors
to prevent this complication.
4. The use of pituitrin as a means of induction of labour is common (26%) in
cases of intracranial haemorrhage and its use should be undertaken only on the most
urgent grounds.
TABLE I.
Year  1935 1936 1937 1938 1939
Total   Births    '.  1,632 1,742 1,999 2,191 2,343
No.   of   infants   autopsied   with   death
due to intracranial haemorrhage  8 7 16 26 25
%   of total  births  .49 .49 .80 1.2 1.1
Total  autopsies  489 468 601 669 699
%  of total births !  29.9 26.9 30.1 30.5 29.8
TABLE II.
ANALYSIS OF MATERNAL AND FCETAL FACTORS IN INTRACRANIAL HEMORRHAGE
OF THE NEWBORN (50 CASES)
Total    Percentage
I.    Type of Delivery:
Natural Cephalic  18
Low Forceps  8
High Forceps   5
Breech Presentation  14
Caesarean Section  0
Version and Extraction  5
Total    Percentage
II.    Duration of Labour:
Under 6 Hours 18
6-24 Hours 25
24-36 Hours       2
36  Hours        5
III.    Maternal Medication:
Pituitrin Induction     13
Large   Doses   of   Sedative
(Barbiturates   given   in
more than 6 doses)       5
26
10
Page 181 Total    Percentage
M
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rV.    Maternal Illness:
Toxaemia-	
Infection	
Abnormality   of   Placenta
6 12
2 4
2 4
V.    Multiparous  Mothers 22 44
VI.    Primiparous   Mothers 28 56
VII.    Contributory Foetal Factors:
* Prematurity 20 40
Other   Foetal   Malformations  5 10
Infection 3 6
Atelectasis 21 42
Gross   Haemorrhage   from
other  organs 3 6
Total -Percentage
VIII.    Duration of Fcetal Life:
Stillborn  23 46
Under 1 day  11 22
1 to 2 days  7 14
2 to 3 days  4                 8
4 to 5 days  3                  6
1 week or over  2                 4
*The criteria for prematurity used were those of
Scammon. All cases classed as premature weighed
between 100 and 2499 grams or were between
3 5 and 47 cm. in length.
REFERENCES:
1. Vital Statistics of Canada, 1937—(a) Page 17;   (b) Page 22.
2. Potter, E. L., and Adair, F. L.—J. A. M. A., 1939,  112:1549.
3. Poncher, H. G., and Kato, K.—J. A. M. A, 1940, 115:14.
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NEURONITIS
Department of Neurology, Vancouver General Hospital.
By N. L. Auckland, M.D.,
Senior Resident in Neurology, Vancouver General Hospital.
A great many names have been given to this syndrome during the past century. The
first report of a case was made in 1937 by Oliver. Later$JLandry recorded several cases
in his "Note Sur Paralysie Ascendante Aigue." Thereafter, many cases of neuritis of
known and unknown etiology were presented: "Polyneuritis with Facial Diplegia," Peir-
son, 1936; "Acute Febrile Polyneuritis," Osier; "Radiculo-neuritis," Guillain, Barre and
Strohl, 1937; "Acute Infective Polyneuritis," Bradford, Bashford and Wilson, 1938; etc.
Foster Kennedy, reporting on some of the latter's cases, suggested "infective neuritis"
because of the widespread lesions. It is doubtful if there is any justification to consider
"neuronitis" as a specific entity. Nevertheless, cases exhibiting the syndrome to be
described below occur frequently enough and are distinctive enough to be conveniently
grouped together under this one name.
Attempts have been made to divide this syndrome into sub-types. Pinckney recognized three types1:
(1) A four-limb peripheral neuritis plus external ophthalmoplegia, with rapid onset
but no fever or pain.    The ophthalmoplegia may be severe and the limbs little affected.
(2) A four-limb polyneuritis with facial weakness and often slight bulbar weakness, slight fever, less rapid onset; limb paralysis may dominate facial paralysis and vice
versa.
(3) Begins with a lower limb paralysis and spreads rapidly upward to involve trunk
and muscles of respiration. This cannot be distinguished from what is generally recognized today as "Landry's paralysis."
Another example of attempted grouping or differentiation is the Guillain-Barre
syndrome and the febrile polyneuritis of Gordon Holmes2. The characteristics stressed
by the former were a diffuse polyneuritis, an albumino-cystological dissociation in the
spinal fluid and an almost invariable and complete recovery. That described by the
latter differs only in the presence of fever and the absence of hypefalbuminosis in the
spinal fluid. It is apparent that the various types are produced as a result of an overemphasis on one or two signs and that all cases really belong to the same syndrome. Any
attempt to place all cases in definite clinical subgroups usually fails.
Symptoms and Signs
Most cases occur in the autumn and winter. There is frequently a history of preceding infections, usually upper respiratory and usually mild2' 5.   (There have been case
Page 182
ti; reports of the disease following more severe infections such as bronchopneumonia,
pyelitis, etc3, 4.) The patient usually recovers from this, and then after a period of time
varying from two weeks to over a month, motor and sensory disturbances may appear.
The sensory disturbances may or may not be present. In any event, they are variable
and always less prominent than the motor phenomena. Usually, if present,, they appear
first as numbness and tingling of hands and feet. Muscular tenderness may be present.
"Glove-and-stocking" hypaesthesia may occur. Vibratory sense and even position sense
may be absent and ataxia may be marked.
The motor disturbance is characterized by widespread, frequently ascending, flaccid
paralysis or paresis, tending to affect the proximal muscles in an extremity as much as,
or more than, the distal ones. The involvement is symmetrical rather than patchy.
Usually the trunk muscles are also affected. The cranial nerves, usually the seventh,
may be involved. Sometimes the lower cranial nerves are involved but rarely the upper
ones. Bowel and bladder are rarely disturbed, and then only mildly and transiently.
Tendon reflexes are diminished or absent.    The abdominal reflexes are usually absent.
Occasionally in the early stages there may be a transient fever with corresponding
elevation in pulse rate.   Papillcedema may occur5.
Most cases occur in the young adult and early middle age although extremes of two
years and seventy-eight years have been recorded4. The onset and course of disease do
not seem influenced by age or sex of the patient.
The most constant laboratory finding is an elevated spinal fluid protein with little or
no increase in cell count (Guillain-Barre's albumino-cytological dissociation). Protein
values as high as 750 mgm. per cent have been reported4. The cases with a normal
protein value have occasionally been explained on the basis of time factor, that is, the
puncture made too soon after the onset of the disease for the protein to be elevated.
However, in an analysis of twenty-six cases of polyneuritis with facial diplegia, by
Forster, Brown and Merritt, it was concluded that the time element is of little, if any,
importance4.
Etiology.—Whether the etiology is toxic or infectious is still a matter of debate6.
Barber believes a neurotropic virus is the most probable explanation2. Some investigators
believe the damage is done by a toxin without direct invasion of the nervous system by
a living organism.    The general opinion at present probably favours the virus theory.
Pathology.—Because the great majority of patients have recovered, pathological data
are not abundant. The whole neuron is affected. There is a diffuse interstitial neuritis,
most marked at the origin of the nerve, an irregular lymphocytic infiltration and the
sheath of Schwann shows nuclear proliferation. The myelin sheath shows some evidence
of alteration with partialy fatty degeneration. Root ganglia may show similar changes.
The meninges may be oedematous. The brain is usually normal, but lesions of the cortex
have been described4' 6.
Differential Diagnosis.—There are four main diseases to be considered: anterior poliomyelitis, post-diphtheric polyneuritis, syphilis, and peripheral neuritis due to various toxic
conditions. Neuritis can usually be distinguished from these quite easily on the basis of
careful history, physical examination and laboratory findings.
Prognosis.—Recovery usually takes place although convalescence may be protracted.
Recent studies have suggested this viewpoint is erroneous and that the mortality has been
rising in the past few years4. This apparent increase in virulence may be possible evidence of virus etiology.
Treatment.—-Treatment is entirely supportive. There has been no proof as yet
regarding the value of vitamin therapy.
Physiotherapy and general orthopaedic measures to prevent contracture and aid in
the restoration of function are the basis of treatment. For cases going on to respiratory
paralysis, a respirator becomes a necessity.
Page 183
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CASE REPORT:
A twelve-year-old male was admitted to the Vancouver General Hospital on June 16, 1941, and discharged October 6, 1941.
History: Previous to May 1, 1941, the patient was perfectly well. About this time he developed an
intermittent tingling of the tips of the fingers. Other than this, he continued to be quite well until
June 7, when he complained of numbness of the fingers and numbness and tingling of the feet, some
difficulty in swallowing and some difficulty in walking due to the weakness of the legs. Two days later,
his  arms became  weak.
Examination on admission revealed temperature 99°, pulse 100, and respirations 20. The cranial
nerves were intact except that the uvula was deviated to the left. There was no wasting of the
extremities, but a generalized symmetrical weakness and flaccidity of the muscles of the limbs and trunk.
All tendon reflexes were absent. The abdominal reflexes were present. The vibratory sense was absent
in the legs and sensation to pin-prick impaired in the hands and in the legs below the knees, and absent
in the toes. The cerebro-spinal fluid protein on June 12, 1941, was 33 mgm. per cent. There were no
cells present. Blood smear showed no stippling. The cerebrospinal fluid protein on July 2 was 100 mgm.
per cent with 5 white blood cells. (More extensive laboratory investigation was hot done because of the
expense to the patient.)
Following admission, the patient developed a mild and very transient incontinence. During the next
month or so, he lost a considerable amount of weight and there was definite muscular wasting. Then
slow but progressive improvement began. The sensory disturbances were the first to disappear, followed
by a gradual return of power to the muscles.    The tendon reflexes were the last to improve.
Upon discharge from the hospital, fifteen weeks after admission, he was up and about the ward with
the aid of crutches. Sensation was normal. Power was almost normal in upper extremities and rapidly
increasing in the trunk and lower extremities. All reflexes had returned except the knee jerks and
there was even a suggestion of these.
Treatment had consisted of an overfeeding diet with extra vitamins, components of
vitamin B complex (given empirically), and physiotherapy. The physiotherapy was
commenced on admission and was to be continued at home after discharge. While the
patient was confined to bed, the usual precautions were taken to prevent foot and
wrist drop*.
Summary.
The more recent literature has been briefly reviewed, and one case of neuronitis
presented.
The condition appears to be a syndrome of unknown etiology (probably virus), characterized by a gradual or sudden onset of a symmetrical, generalized, flaccid paralysis,
with or without history of antecedent infection, and with or without preceding or
accompanying sensory changes. A transient mild fever may be present at the outset.
The only significant laboratory finding is in the protein content of the cerebro-spinal
fluid which is usually elevated, but with little or no increase in the white blood cells.
Treatment is merely supportive, physiotherapy being most important. Although the
prognosis is usually good, there is recent evidence that the virulence of the disease is
increasing.
I would like to thank Dr. F. Turnbull for his permission to report the above case.
REFERENCES:
1. Pinkney, Charles—British Med. Jour., Aug. 15, 1936.
2. Barber, H. Stuart—Lancet, 239, October, 1940.
3. Lauria and Mandelbaum—Jour. Amer. Med. Assoc, 115, October, 1940.
4. Forster, Brown and Merritt—New England Jour, of Medicine, July, 1940.
5. Moersch—Surg. Clinics of North America, October, 193 5.
6. Hecht—Jour, of Paediatrics, 2, December, 1937.
^Seen in February, 1942, and has made a complete recovery.
No. 16 GENERAL HOSPITAL
The
Officer
Commanding No.   16
General
Hospital announces
vacancies
for two
MALE
radiological technicians.
(These
will receive non-commissioned
ranks ar
id extra
technical pay.)   Apply
to Orderly Room, Vancouver
Page 184 *w
SACRO-ILIAC LIPOMATA
Read before the Vancouver Medical Association, Feb. 3, 1942, by
Dr. J. H. MacDermot
Vancouver.
Of all the problems with which we medical men have to deal, the most pressing of
solution, and often the most difficult, is that of pain. It is one that brooks no delay,
and one that ofttimes taxes all our resources of skill and ingenuity. Chiefly is this
true, of course, of acute pain, but it is also true, especially as regards the difficulty that
the problem presents, in the case of chronic pain—pain that does not completely disable,
that is more or less bearable, but pain that comes back and back again, of which we are
never really free, that takes the joy out of life, and out of other people's lives too—
pain for which the doctor can find no specific cause, and so is driven to try remedy after
remedy, operation after operation, with little or no result. We still have too many of
these pains to torment us, and beset our path; and anyone who can help us to unravel
the problem of some of them is something of a benefactor to mankind, and the "shadow
of a rock in a weary land" to us, in our endeavours to mitigate the lot of those who
suffer. So I hope that this paper tonight may be of value to some of you who may
have some of these problems to solve. There is nothing very original about what I have
to say, and many of you know far more about the subject than I do; but my hope is
that some of you may not, and that I shall be able to lighten one of your many loads
to a small extent.
Some four or five years ago, a certain Dr. Emil Ries of Chicago visited Vancouver
for the second time to give a lecture to the Vancouver Medical Association. Dr. Ries,
who has since died, was a very erninent American surgeon—was on the staff of the
Chicago Postgraduate Hospital and Medical School.
The first time I heard him lecture here, he spoke on myxomata of the appendix. This
time he gave us the result of some original work of his own. Subsequently he wrote a
paper which can be found in the American Journal of Obstetrics and Gynaecology, vol..
34, 1937, entitled Epi-Sacro-Iliac Lipomata.
He told us of the case of a woman who came to his clinic, complaining of a constant, steady backache that she had had for years. She had been through the clinic, and
had had a very thorough examination and treatment. Like the woman of whom St.
Luke tells us, she had suffered much at the hands of doctors, and like her had got little
benefit. She had had her teeth X-rayed and the bad ones removed—various of her organs
were now merely memories—she had had belts and orthopaedic supports etc. But the
pain still persisted.
If I may diverge for a moment, this is a very typical history in the condition of
which I am speaking tonight.    One gets frequently a history of a long period of disability, where thorough examination and treatment have been faithfully carried out,
|with no real relief from any of them.
Dr. Ries now proceeded to do what nobody had really done before. He went over
the back inch by inch, and found, near the sacro-iliac joint on one side, a small, elastic,
rubbery little mass, very tender, freely moveable. Manipulation of this small tumour
and pressure elicited severe pain, and this was, according to the patient, the same kind
of pain as that from which she had suffered for so long. He removed the tumour, and
obtained complete relief for the patient.    The pain did not return.
He had the tumour sectioned, and found it to be of the nature of a lipoma, but with
nerve fibrils in it.
This excited the curiosity of Ries, and he set about examining some 1000 patients
chosen at random, in various dispensaries, clinics, etc., in the city of Chicago. Of those
examined, roughly one-third had these nodules or tumours in the vicinity of the sacroiliac joint. Of this number, about a third had backaches or other pain, the pain being
sometimes a matter of complaint on the part of the patient, sometimes only elicited by
pressure on the tumour.
Page 18> m
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Ries found several other cases of pain due to these tumours, on which he operated,
with good results.  Then he modified his technique to some extent.  Before removing the
tumour, he injected it with 2% novocaine.  If this gave definite relief, he felt that he)
had been able to prove the causal relationship between the tumour and the pain.   If thej
pain remained away, as he found it did in some cases, he did nothing further—but if j
the pain returned, he removed the lump.    In his article, he records several cases of
rather dramatic success.
He was so positive of the reality of these tumours as a frequent cause of backache
that while here he offered to review all the cases of long standing backache in the Hospital, which had not yielded to treatment, and said he was willing to wager that a large
percentage of them would shew these lipomata. He did, as a matter of fact, assemble
quite.a few, and, as many of you will remember, demonstrated them to us during and
after his lecture, sitting in a row on the table, with their feet dangling over the side.
Shortly after his visit, I was fortunate enough to have in my own practice a perfect
example of this condition, conforming exactly to Ries' description, and yielding at once
to treatment.    I shall give a short summary of the case later.
This was very gratifying, of course—but I should not have felt justified in inflicting this paper on you just because I had been able to confirm Ries' findings in one case.
Nor, if all the cases I have since seen of this condition (sacro-iliac lipomata) had merely
conformed to the pattern described by Ries, with the same symptoms and signs, and the
same sort of results with the same treatment, would I have felt that any very specially
good end could be served by a mere recapitulation. You can read the paper for yourselves, and test his findings and conclusions.
But, as time has gone on, and I have been on the lookout for these lipomata, I have
come to the conclusion that the symptoms that Ries described, the location of pain, etc.,
are only part of the whole picture, only one syndrome of several that are caused by the
presence of these tender nodules.
Ries only described backaches that are caused by them. In my very limited experience, I have found at least three distinct syndromes, if we may use the word, that can
be caused by these lipomata, and cured, or at any rate very greatly relieved, by their
removal or injection.
I have found, too, that Ries' description was rather incomplete and sketchy. This is
not to detract in any way from the value and significance of these original observations
and work, which I think have a very great value and significance, and have opened up
to us a most useful method of diagnosing and treating successfully! a condition which is
far more common than most of us realise, and causes a really surprising,amount of disability and invalidism. But I think it will be of interest and even value to us to follow
this condition and the symptoms it can cause a bit further than Ries did. In so doing,
we shall find, as I believe, quite a definite and valuable addition to our armamentarium
of therapeutic measures.
I have, then, or think I have, been able to recognize three distinct types so far, of
symptoms due to the presence of these lipomata. By the way, when Ries calls them
epi-sacro-iliac lipomata, I take leave to differ a bit with him. The word epi- means
upon. These tumours are not over the joint or on it, but alongside of it, and "para"
would, perhaps, be a better word. Also they are not simply lipomata, though fat is the
bulk of the tissue, and they look and feel like lipomata. The presence of nerve fibres in
the tumour, sometimes in quite large amounts, suggests that these may be neurolipomata.
If my knowledge is correct, lipomata are not tender, while these are, very. But perhaps
the simplest term would be "sacro-iliac nodules."
The first set of symptoms, then, are those referable to the back, as described by Ries.
They are referred chiefly to the lumbar or pelvic regions, and consist of pain, not going
beyond the back proper.
This pain is often severe, even disabling at times. It has generally lasted for a long
time. It is not aggravated by work, often comes while sitting or turning over in bed.
There is no relation between this pain and the menstrual period'—it is not relieved by
Page 186 defaecation or the passage of gas—is not connected with micturition. Salicylates have
no effect, and sedatives are of little use. Examination of the feet and rectum (two
very common causes of backache, often missed by us, to our great humiliation and.
reddening of the face, when some orthopaedist discovers the former, and a careful rectal
examination by someone else shews the presence of a rectal ulcer or whatnot) reveals;
nothing to cause such severe backache. X-rays are negative, postural and occupational
causes are ruled out. Only examination of the sacro-iliac can exclude the lipomatous
nodule as the cause, and this should always be done in all cases of backache that can not
readily be cleared up by other discoveries, but will often be solved by the discovery of
these tender, elastic little nodules, which slip under your finger, give pain on pressure,
and the removal or injection of which will cause the pain, to vanish immediately.
Volumes have been written about low back pain, and there are, of course, many
causes other than the one of which I am speaking. Strain, arthritis, focal infections,,
trauma, posture—all or any of these may produce backache, and must be excluded before
we go further.
The second syndrome is characterised by the radiation of pain down one or other leg-
—sometimes both. There may or not be backache as well. In most of the cases I have'
seen associated with the presence of these nodules, the pain has not gone further than.
the knee, but occasionally it goes as far as the ankle. There is also frequently pain,
running down the front of the thigh, along the distribution of branches of the genito-
crural nerve. The pain is frequently quite crippling, and will cause limping. It is apt:
to go away completely and come back again another day, and is erratic in its appearances.
These cases are often diagnosed as sciatica, and the distribution is apt to mislead one.
There is no atrophy, however, no tingling or tenderness, and the pain is apt to stop at
the knee, suggesting some pressure on the obdurator nerve rather than involvement of
the sciatic. The radiation down the front of the thigh, too, is against sciatica as a cause.
I am beginning to suspect very strongly sciatica as a diagnosis, unless the signs are
unmistakable, and unless I am satisfied that the pain is not caused by the sacro-iliac
nodules.
I have seen several cases that fall into this group, and will describe one or two briefly
later.
The third group is in some ways the most interesting of the three—and I have seen,
several rather dramatic cases—but I think it is the least common. It should be of special,
interest to those who deal with gynaecological disorders—though it is by no means limited to the female sex.   I have seen at least two cases in men.
Lower quadrant pain on either side of the abdomen is one of the most troublesome'
problems, from a diagnostic standpoint, with which we have to deal—when, as is so-
often the case, it is vague, not clearly marked as to cause, difficult to localise, and resists;
all measures of relief. It is, of course, especially a problem in the case of women, whose-
pelvic organs are so often suspected as the fons et origo mali in most cases of pelvic pain.
The history of gynaecology has been one of a steady reduction in the list of charges;
that are laid to the door of the uterus and ovaries, particularly the latter. One can
almost always elicit some pain and tenderness in the ovary if one presses hard enough,
and the parous cervix will very often shew some infection. Yet it is hard to believe
that these organs are so hardened in their career of crime as they are often held to be,,
and it is a pleasure to be able to do something at least towards clearing them of blame,,
and restoring their good name.
It goes without saying that one must exclude pelvic disease and infection as a cause..
But when we have found no real pathology, and are still faced with a chronic, intractable pain, sometimes disabling and crippling, sometimes associated with backache—not
influenced by menstruation, not relieved by rest, not accompanied by localised abdominal
tenderness, we shall do well to examine the sacro-iliac region very carefully, and here
we shall, sometimes at least, find the cause in a tender nodule, pressure on which may
occasionally elicit the pain complained of, though I have not often found this to be the
case—but at any rate injection with novocaine will settle the diagnosis.   I am making it
' m
Page 187 ,.■ •
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i
m
a rule in my own practice to examine this region in all cases, whether I find other
trouble or not, and to record my findings on the history card.
The pain here is not intrapelvic at all, apparently, but referred along the somatic
nerves, the branches of which like the intercostal nerves, run around the patient, and|
give pain points in front, as well as at the back.
It is surprising how much disability and real crippling these things can cause. I
always find it hard to believe that they can give so much pain, till I find by injection
and subsequent removal, how complete the relief can be.
I have had several cases of this group, and some very spectacular results. I shall
describe one or two later.
In one or two particulars I have found myself compelled to differ from Ries.
In the first place, he says that these nodules are superficial, freely moveable, and
easily grasped between the fingers. In most cases this is true, except that they are not
really very superficial—but frequently I have found them quite deeply placed, and not
found without firm pressure, and careful search. Sometimes they are quite hard to find,
but we must hunt patiently for a tender spot. Injection deeply into the area helps, as
the point of the needle will often find the point of maximum tenderness more easily
than the examining finger.
Secondly, removal under local anaesthetic, which Ries says is all that is necessary, is
not always as simple as he found it to be. With some of the nodules, one has to go
fairly deep to get them, especially in stout people, and if one is going to get results, one
must be thorough. One has often to go right down to the periosteum and search for _»
offending nodule. In several cases, I have failed because of insufficient thoroughness,
and very often I have had to use general anaesthesia.
Lastly, pressure on the nodule, while producing pain, sometimes exquisite pain, does
not always evoke the particular pain of which the patient complains. So, if one does
not get this confirmation, he should not for that reason absolve the area of guilt.
Injection of tender points will tell us whether or not the pain complained of is caused
by their presence or not.
General Considerations.
1. History. This should be carefully taken. It will often extend back a long time
—in fact it is generally a long one of pain and more or less disability. The patient has
usually had long, careful and exhaustive examination—often by excellent men—radiologists, orthopaedists, urologists, etc. There is often a history of the removal of one or
more foci of infection, quite legitimately. Teeth, tonsils, gallbladder, have all been considered; often removed. X-rays have been taken and proved negative—belts prescribed,
corrective exercises, and so on. One patient of mine diagnosed her own case and went
and had all her teeth removed on her own initiative.
This very fact of a long history of pain, rather vague and unlocalised, not pointing
clearly or definitely to any one organ, is very suggestive in this condition. All causes
have been considered, sought for and excluded. All measures, medical, surgical, supportive, have been tried, and found useless, and the disability continues. These patients
are apt to receive very little sympathy from us. They are often put into the neurotic
wastebasket. As is always the case, where we are considering "neurosis" as a possible
cause, we should be very sure indeed that we have excluded everything else. I am definitely of the opinion that we have here an opportunity to limit to a great extent the
number of people to whom we must apply this rather defeatist diagnosis. As time goes
on, we are finding more and more that the word "neurosis" is very often a confession
of failure on our part, rather than a final word on the subject, and we must all rejoice
when we can fiid a genuine cause for the disability of which our patient complains.
2. Diagnosis.   This is based on two things.
(a) Finding of one or more definite nodules, in the neighbourhood of the sacro-iliac
joint, varying in size from a split-pea to a decent sized bean. Firm pressure on these
nodules causes pain. The patient winces and complains—often says that the pressure
causes the pain that has been bothering him or her.    The nodule is firm, elastic, slips
Page 188 under the fingers—generally feels as if it were quite close to the surface. It is best
found by having the patient sit up, feet over the side of the exarnining table, back easily
rounded, but not bent far over, and the patient relaxed. The nodules are most easily
found in this position.   They are in any position within an inch or two from the joint.
Sometimes one cannot find a definite, moveable nodule—but one's search will nevertheless find a very tender spot, where deep pressure will elicit marked pain. Injection
here will enable us to determine whether this spot is the source of the pain complained of.
Here the trouble appears to be due to some condition deep down near the periosteum:
.perhaps not always a nodule, but fibrositis or something similar. These cases, in my
experience at least, are relieved by injection, and sometimes permanently so.
(b) Result of injection with novocain—2% or thereabouts. Holding the lump
anchored between the thumb and forefinger of the left hand, we plunge the hypodermic
needle into it, and inject the novocain. Massage the part gently, and wait a minute,
then ask the patient to get down, and tell you how he or she feels. Very often, with an
air of surprise, the patient will say the pain is "much better," "completely gone," or
something of the sort. If no immediate relief seems to have been secured, ask the
patient to report to you the next day. Very often he or she will have considerably less
pain than usual. It is important, of course, not to promise the patient anything, but.
to ask for an exact report of what happens. Relief, if obtained, may last a long time,
or only a few hours, but if it is definite, we are justified in pursuing the matter further.
Removal is, of course, the final test, but should never be done without a preliminary
injection.
Relief is often spectacular and very complete. I am sure it is not merely a suggested relief. Apart from the fact that we should take every care to avoid suggestion,
these people are not as a rule very suggestible. They have run the gamut of treatment,
with very little if any relief, and are more apt to be very skeptical of new treatments.
Differential diagnosis. Here the onus is distinctly on our shoulders, to exclude all
other causes of three types of pain, before we ascribe them to the presence of sacro-iliac
lipomata. We should be on our guard against over-enthusiasm. Remember Ries' figures.
Roughly one-third of people have these nodules, and in about a third of this group we
find tenderness, i.e., about 10% of the population have some disability or discomfort due
to them. But we must find a nodule, it must be tender, and injection must relieve, to a
^definite degree at least, the pain complained of.
There is, of course, a long list of contenders. The feet and legs, the rectum and
pelvic organs, arthritis of various brands, trauma, rheumatism, and many other causes
must be carefully considered.    Focal infections must also be excluded.
I think the important thing is that we should get into the habit of examining this
area as a routine.   It is a very useful and helpful thing to do.
Sex incidence. I do not know if there is any definite law about this, but in my
somewhat small experience, I have found these painful nodules far more frequently in
women than in men. But- this perhaps proves very little. For one thing we have more
women patients, and they are more thorough in their history. Again, men's backaches
and whatnot are much more naturally ascribed to strain, occupation, injury, and so on,
and I cannot help feeling that we may be missing a good many cases of this condition
amongst men. Even when there has been a history of strain or injury, there may be
other reasons for an overlong continuance of the disability, and I have seen one case
particularly, a W.C.B. case, where even the unimpressionable Medical Board acknowledged the fact of pain, but where, after all methods, exercises, heat, rest, and the like,
had failed to secure any real benefit, examination of the sacro-iliac area revealed nodules.
These were injected, and up to the time of writing, he has been much better.
Cause of Pain from These Nodules.
I do not know why so much pain should arise from the presence of these small
tumours.    They are mostly freely moveable, and many people have them without any
pain.    Since, however, microscopic examination shews quite a large number of nerve
Page 189
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fibres among the fat cells, one can only conclude that they are of the nature of neuro-i
lipomata. The fact that so much relief can be obtained simply by injecting them suggests that they are neuromata, and have definite connection with pain centres themselves.!
Then they occur in a place where there is not much laxity of tissue, and they act asj
would a foreign body, e.g., a sliver. Relief that has been obtained from fasciotomy here,!
an operation which I do not think is very often done now, suggests that there is tension, \
or pressure, which are relieved thus.
The size, and indeed the degree of tenderness of these nodules is in no way propor-i
tionate to the amount of pain and disability that they can cause.   One is constantly loath
to believe, in a given case, that so much pain can arise from so insignificant a little
lump, and it is only after repeated experiences with them that one learns that here, as
elsewhere, appearances are not to be trusted.
Treatment.
Removal gives, of course, the most permanent results, and in many cases is necessary.
Rut it is by no means always necessary. The preliminary injection is often enough, and
in many other cases, two or three repetitions of this procedure will give the desired
result. If after this, there is still pain, or if the relief obtained is not adequate, removal
should be done. As said above, this must be thorough, and where the nodule is deep-
seated, the patient obese, or nervous, I think it is a mistake to attempt this with a local
anaesthetic. The incision should be adequate, the haemostasis complete, and this is hard
to secure with a conscious patient—and one has to go deep enough to reach the periosteum, as frequently the offending nodule is anything but superficial—in fact I think
the ones that cause the most trouble very seldom are.
As to the solution of novocaine used. For purposes of test, the 2% solution is best,
and if only one or two injections are to be used—but the 72 of 1% solution gives excellent results, and large amounts, up to 50 cc, can be used at a time.
Case Reports.
I should like to present, briefly, records of two or three cases of each of the types
that I have described.
First type—backache alone. D. A., unmarried, age about 16 or 17. Thin, otherwise
quite healthy. She complained bitterly of attacks of severe backache, coming on at
intervals and often crippling her.
She had had these attacks on and off for years. Gave a vague history of previous
injury due to a fall. Being on relief, had been sent to the Outpatient Department of
the V.G.H., and had been very thoroughly examined and treated by excellent men. Her
teeth and tonsils had been checked, the latter removed, her spine and pelvis X-rayed and
found negative, corsets given her, exercises prescribed. I had seen her several times, and
had given her various placebos, which had done her no more good or harm than any of
the other treatments.
One day, shortly after Ries' lecture, she came into my office in despair, declaring that
she could not stand this pain any longer, and begging me to do something. I examined
her back, and found very painful nodules in both sacro-iliac areas. Pressure on these
elicited very severe pain, of the type of which she complained. I injected them with
novocaine. The relief was immediate and very startling. She rolled off the table, stood
up, and declared that she hadn't been so free from pain for six months. I removed the
nodules, and she has been free from pain ever since.
2. Man—age 32. This man was seen not very long after the girl, and I have not
as good a record of him as of her. But he had the pain, of long standing—had tried
everything, including treatments by our good friends the chiropractors, who had done
him no more good and no less than had we. Tender nodules were found and injected
with complete relief, and removed. At last seeing, he was clear, but I have lost track
of him. I record his case, because he was one of the few men I have seen with this condition.   Within the past two weeks I have had another, a W.C.B. case, who has had bad
Page 190 and intractable backache for a long time. His case seemed so definitely one of trauma
that I had not considered the possibility of these nodules being concerned in his pain.
But since everything else has failed, some two weeks ago I explored, and found a very
tender nodule on the most painful side. I injected this, and he is still under observation.
I have not heard from him lately, and am almost afraid to ring him up—but it is quite
-possible that he may be a credit to us yet. He certainly had a great deal of relief for
the first few days following the injection.
3. Woman, Jessie H., telephone operator. History of many years of backache—
making her job at the board difficult. She had very tender nodules, which I injected
with relief. Later I removed them. This woman was that rare thing in women, a
bleeder, and a bad one. Oozing kept up for days, in fact for two weeks, and was very
hard to control—but firm pressure, etc., eventually stopped it. She has had no return
of the pain.
4. An especially stubborn case, woman of 52, widow. Here the attacks of pain
were very crippling, and made walking so painful as to be practically impossible. They
did not come on every day, but at irregular intervals. The pain was one sided, and
extended into the groin. Thorough examination revealed no pelvic disorder. She had
a very painful nodule on one side—the left.    Injection gave immediate relief, and I
farranged for removal, which I did, foolishly, under local anaesthetic. This did not work
well, and I did not do a thorough operation, I am now convinced. I did not go deep
enough, for one thing, and left some nodules behind. The result was that the pain
returned, as badly as ever.   Injection about once every week or ten days gave relief, but
|only for about that length of time. I had been using 2% novocaine—but if I gave her
more than about 2 or 3 cc. of this, it made her very jittery. So I changed to J4 of 1%,
and gradually gave up to 25 or 30 cc. at a time, with no discomfort, and eventually
very gratifying results, as after two or three of these, the pain disappeared for good, and
she has had none since  (after some fifteen or eighteen months).    The morals to be
|:drawn from this case are obvious—do a good job of removal, and use weak solutions in
large amounts, if you have to do many injections. Other cases have borne out this
latter conclusion.
Second Group. Here we have pain down thighs and legs—sometimes, but not
always, associated with backache.
First case. N.R., woman aet. 22, dressmaker, on feet all day shewing and selling
dresses. Married—childless. Came to see me about eight months ago, complaining of
severe periodic attacks of pain down the back of the left leg, going as far as the heel,
and making her limp very badly. She had been in New York for some time, and while
there had been carefully examined and X-rayed, both as regards the back and pelvis.
UU1 these were negative. She is in excellent health—teeth perfect, throat negative, pelvic
examination entirely negative. Salicylates gave no relief. Examination of her back
shewed nodules on both sides. I understood her to say, however, that the pain was only
in one leg. Injection of the nodules on the left side gave positive relief, so I removed
the nodules on that side—with complete relief for the first three days—when the pain
returned to some degree, though much less severely. Examining the wound, I found
considerable serum pent up in it. Letting this out gave relief at once, and till now, she
has been free from any return of pain on this side. (Saw her on Saturday, Jan. 31, and
she is still free of pain.)
A week later, she returned, to say that the right side was giving her the same
trouble, and that she wanted the lumps on that side removed at once. Then she said
that she had told me of this side before, and thought I would have done both sides, and
was surprised that I did not. I went ahead and removed these, with exactly the same
result as with the other side, even to the trouble caused by retention of serum in the
wound. The eagerness with which she asked me to do the second operation was, I
think, the best testimonial to the success of the first.
Page 191
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Here there was a remarkable likeness to sciatica, as far as pain distribution went,
but there was no wasting, no tenderness on pressure over the calf, no paraethesias, in|
fact, it was obviously not sciatica.
The pain caused by the presence of the serum in this case suggests that it is the
pressure on nerves caused by the lipoma, acting as would a foreign body, that has a good
deal to do with the pain.
2. Woman, aet 3 5, E. H., unmarried—telephone operator. Thin but healthy. No
history of trauma. Pain extended down to ankle, but was worst in thigh, front as well
as back. In this case, as in the other, sciatica was considered to be excluded. All symptoms were normal, and no other cause could be found until we examined the back,
and found definite and very tender nodules. This case was injected two or three times
with the weaker solution of novocaine after the first trial injection. Relief was marked,
and she has not, apparently, needed removal, though this is still a shot in our locker if
the pain returns.
3. Woman, Mrs. B., 41, stout, sedentary. This I give as one of the unsatisfactory
cases. Tender nodules were found, to account for the pain of which she complained in
her back and legs. Injection gave apparent relief, but this did not last, and later injections were unsatisfactory. She discontinued the treatment, and I tliink still has about
the same amount of pain, which was never very acute, however. I think there are
definite postural and muscular elements in this case.
Third Group—where there is iliac pain and even abdominal pain, referred to one or
other side, with or without backache.
It is in this group that I have seen the most remarkable results, and in some respects
the most gratifying.
1. Mrs. W. aet 35, multipara. I first saw her some two or three years ago with
Dr. Corry, at which time we operated on her for an ectopic pregnancy. Soon after this
she began to complain of severe pain in the lower abdomen, especially "On the left side,
coming on constantly, interfering with her work and sleep, and making her thoroughly
miserable. We examined her several times, and could not satisfy ourselves that there"
was enough of any trouble of any sort to justify operation, though we suspected torsions,
adhesions, and all the things that float out of the void into the mind of the unfortunate
doctor who is trying to find some kind of label for an obscure and troublesome pain. No
treatment by medicine, heat, douches, etc., gave more than the most transitory and superficial relief, and she was the picture of misery. I am convinced that her pain was
genuine and severe. She was one of the unfortunates that eventually find themselves in
the category of neurotics.
After Dr. Corry's death, she came to see me, in despair. The pain was still making
life miserable for her. I checked her over again, and could find nothing, till I decided to
try the sacro-iliac regions, though it seemed to me to be a pure shot in the dark. But I
found very tender nodules over the sacro-iliac joint on the side, the left, of which she
complained.
Very skeptically I injected them, and she obtained immediate relief. She has had no
pain at all since that first injection, and is a very happy woman. I did not suggest to
her in any way that I was going to cure her, and to have given this poor woman relief
after some three years of misery is one of the greatest pleasures that has happened to me
in practice.
2. Woman Mrs. S., aet. 49, multipara. This patient complained similarly to the
above, of constant pain in the left lower quadrant. She was very concerned about herself, and had been very thoroughly examined by Dr. Corry, whose patient she used to
be. Her appendix had been removed some years ago. She was X-rayed from stem to
stern. She had a mortal terror of cancer, and no step had been missed in the effort to
exclude this. She had a little stasis. Her pain was chiefly in the left lower quadrant,
and we sigmoidoscoped her, as well as giving a barium enema. All were negative,
except that rectal examination revealed quite the most tender rectal ulcer that I have
Page 192
m ever seen.    She cried with the pain, and stated that even the passage of gas sometimes
hurt her badly. (We got this relieved, but had no improvement in the backache.)
I was quite unable to find anything to account for this pain which had persisted for
so long, and made her life so miserable, until I examined the sacro-iliac area on that side,
to find, as you will all have guessed by now, tender nodules. I injected these, and she
obtained so much relief that she rang me at about seven o'clock the next morning, to
|tell me that she had had a "lovely" night, and was quite free from pain. I injected the
mass two or three times, and today she is perfectly well as far as this goes. I saw her
only last week, and she has forgotten she ever had a pain.
One more case and I have done.   This was the first of this type that I recognised.   A
woman of about 30, housewife, 2-para. Constant attacks of left lower quadrant pain,
I which interfered with her housework, and made life miserable for her.    Pelvic exam-
ination shewed some prolapse, and a somewhat tender left ovary. That ovary will probably never know what a narrow escape it had of some serious procedure, but it is still
^unharmed.   I was lucky enough to find tender nodules, injected them, obtained imme-
diate relief, removed the nodules; and the patient has been free from pain since—a
period of more than two years.
In all these cases, and many others, I need hardly say that every effort was made to
^exclude all other possible causes.   One must try not to make this thing too much of a
hobby.    But I am training myself to think always of this condition as a possible cause
of chronic, recurring pain, in the areas described, and more and more I am making a
routine of exarnining these backs carefully, even when there does not seem to be any-
t thing calling for especial notice.    I can only counsel you to go and do likewise.    You
prill have some very gratifying and satisfactory results.    Often you will be skeptical
about the possibility of such a small thing kindling so great a matter of pain and disability—but if you persevere, and try and try again, you will, I think, find, as I have
pound, that you have here quite a useful and helpful addition to your store of diagnostic
and therapeutic weapons against that most baffling and troublesome of all problems,
[chronic, unclassified pain.    You will be able to help quite a few people to keep out of
the bin labelled "neurotic," and will make it unnecessary for them to go, as a last resort
jin their real distress and misery, to quacks and irregulars.    These little lipomata may
seem trifling, even ridiculous, as a cause of any severe pain, but from even my limited
experience, I can assure you they are not trifling at all, and their recognition by Ries
was an excellent piece of work, and a very valuable contribution to our knowledge.
The more often you think of them, and look for them, the more often you will find
them, and the more often you will get results that will delight you personally, and will
do your patients a lot of good;
Mrs. E. M. Parr, of 926-927 Birks Building, wishes to announce
that Miss M. F. Coleman, who Has been in charge of the P. T. Dept. of
the R. C. Hospital, New Westminster, for eight years, is joining her in
her practice this year. The practice will remain in Mrs. Parr's name
for the present.
Page 193 •
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HPHE use of cow's milk, "water and carbohydrate mixtures represents the
-*- one system of infant feeding that consistently, for three decades, has
received universal pediatric recognition* No carbohydrate employed in this
system of infant feeding  enjoys so rich and enduring  a background of
authoritative clinical experience as Dextri-Maltose.

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