History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: August, 1941 Vancouver Medical Association Aug 31, 1941

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 fThe BULLEtriE!
of the
f/ANCOUVER
MEDICAL ASSOCIATION
vol. xvn.
AUGUST, 1941
No. !<)•
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
StMPaul's Hospital
In This Issue:
NEWS AND NOTES. S_
Page
314
PROGRAMME, ANNUAL MEETING B. C. MEDICAL ASSOCIATION—|pl8
PANEL DISCUSSION ON CHEMOTHERAPY J^€" 2|327
PROBLEM OF DWARFISM—C. E. Gould, M.D M H ^^ft 337
CONGENITAL SYPHILIS—P. C. Jeans, M.D.j|_. ^K343
BRITAIN KEEPS FIT I __. Hffi
ANNUAL MEETING BRITISH COLUMBIA MEDICAL ASSOCIATION
1941
SEPTEMBER Id, 17, 18. p? i;
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VITAMIN K CJSA
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F.
y
The Anti-Haemorrhagic Vitamin
Vitamin K has been found to be an essential link in the process of blood clotting
and, when the clotting time is abnormally long, the administration of Vitamin
K may prevent fatal haemorrhage.
Vitamin K E.B.S. is supplied for oral or parenteral (intramuscular) administration in the high potency forms described below.
Neo natal haemorrhage i
Newborn infants pass
through a period of dangerously low prothrombin concentration shortly after
birth. Many fatal haemorrhages occur for this reason.
Administration of Vitamin
K, both to the mother for
a period before delivery, and
to the infant after birth, is
of the greatest value.
INDICATIONS:
Jaundice >
The danger because of
lengthened clotting time can
be much reduced by administering Vitamin K and Bile
Salts for several days before
operation. Bile Salts are necessary for the absorption of
Vitamin K and should be
simultaneously administered,
where biliary insufficiency
may exist.
* Descriptive literature on rtauest.
Supportive treatment!
The very numerous applications include biliary fistulae*
catarrhal jaundice, moderate
liver injury, obstruction due
to carcinoma of the bile
duct, of the head of the
pancreas or of the liver.
S.C.T. No. 746 Vitamin K—25,000 Dam Units (1 mg. 2 Methyl 1:4 Naphthoquinone)
C.C.T. No. 749 Vitamin K—25.000 Dam Units (1 mg. 2 Methyl 1:4 Naphthoquinone)
and Bile Salts 5 grains
No. A-130 STERILE SOLUTION—30 cc. Vitamin K in Sesame Oil (25,000 Dam Units)
(1 mg. 2 Methyl 1:4 Naphthoquinone) per ml.
Intramuscular
il
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THE E. B. SHUTTLEWOHTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA
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SPECIFY
f. B. S.      ON
YOUR
PRESCRIPTIONS
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THE    VANCOUVER    MEDICAL     ASSOCIATION
BULLETIN
•
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
•ill]**
.'iiilit'
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
.   1  .1 *
Db. J. H. MacDermot
Dr. G. A. Davidson            Dr. D. E. H. Cleveland
'If '"i in
All communications to be addressed to the Editor at the above address.
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Vol. XVII                             AUGUST, 1941                                 No. 11
OFFICERS, 1940-1941
Dr. W. M. Paton                  Dr. 0. McDiarmid                Dr. D. F. Busteed
President                             Vice-President                       Past President
Dr. W. T. Lockhart                                Dr. R. A. Palmer
Hon. Treasurer                                      Hon. Secretary
! V
Additional Members of Executive: Dr. Gordon Burke, Dr. Frank Turnbull
TRUSTEES
' ■»
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Dr. F. Brodie             Dr. J. A. Gillespie              Dr. G. H. Clement
.'■i\'\ \IM J'l  ^  ■
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
"i^'f I'M
Clinical Section
Dr. Karl Haig   ......   Chairman           Dr. Ross Davidson ...    Secretary
Eye, Ear, Nose and Throat
Dr. J. A. McLean  ..Chairman           Dr. A. R. Anthont         Secretary
*
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Pediatric Section
Dr. R. P. Kinsman   Chairman           Dr. G. O. Matthews.    -Secretary
STANDING COMMITTEES
^   !
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Library:
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. A. Bagnall, Dr. A. B. Manson, Dr. B. J. Harrison
\'hj   ■
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
' »* a »
ii
Summer School:
Dr. H. H. Caple, Dr. W. W. Simpson, Dr. Karl Haig, Dr. J. E. Harrison,
Dr. H. H. Hatfield, Dr. Howard Spohn.
* *4               *
1  T   *i Irfrf
Credentials:
Dr. A. W. Hunter, Dr. W. L. Pedlow, Dr. A. T. Henry
11
If ill
V. 0. N. Advisory Board:
Dr. W. C. Walsh, Dr. R. E. McKechnie II., Dr. L. W. McNutt.
;  i
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Metropolitan Health Board Advisory Committee:
Dr. W< D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont.
^
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Greater Vancouver Health League Representatives:
Dr. R. A. Wilson, Dr. Wallace Coburn.
*-. :*£    h
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Representative to B. C. Medical Association: Dr. D. F. Busteed.
Sickness and Benevolent Fund: The President—The Trustees.
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IN PREGNANCY
SUGGESTED
FOR TREATMENT OF THREATENED
OR HABITUAL ABORTION DUE TO
1    VITAMIN E DEFICIENCY   '  .
FOR INCREASED
CALCIUM REQUIREMENTS
0 Each capsule contains 50 milligrams of mixed tocopherols,
equivalent in vitamin E activity
to 30 milligrams of a-tocopherol.
Tocopherex contains vitamin E
derived from vegetable oils by
molecular distillation, in a form
more concentrated, more stable
and more economical than wheat
germ oil.
For experimental use in prevention of habitual abortion (when
due to Vitamin E Deficiency): 1 to
3 capsules daily for 8^£ months.
In threatened abortion: 5 capsules
within 24 hours, possibly continued
for 1 or 2 weeks and 1 to 3 capsules
daily thereafter.
Tocopherex capsules are supplied
in bottles of 25 and 100.
% Each capsule of Viophate—D
contains 4.5 grains Dicalcium
Phosphate, 3 grains Calcium Gluconate and 330 units of Vitamin
D. The capsules are tasteless, and
contain no sugar or flavouring.
Where wafers are preferred, Vio-
phate—D  Tablets  are  available,
pleasantly flavoured with winter-
green.
One tablet is equivalent to two
capsules.
How supplied:
Capsules—Bottles of 100 and
1,000.
Tablets —Boxes of 51 and 250.
For literature, write 36 Caledonia Road, Toronto
E-R:Sojjibb & Sons of Canada. Ltd.
MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE   1858 VANCOUVER -HEALTH  DEPARTMENT
STATISTICS—JUNE, 1941
Total population—estimated ' _  272,852
Japanese population—estimated   8,769
Chinese population—estimated "'       -   ^  8,558
Hindu population—estimated -■■-—.   , g^Q
Rate per 1,000
Number       Population
Total deaths  . 250 11.2
Japanese deaths j.        4 5.6
Chinese  deaths "& ll 15.6
Deaths—residents only  208 9.3
BIRTH REGISTRATIONS:
Male, 255; Female, 270_
525
INFANTILE MORTALITY: June, 1941
Deaths under one year of age.. 8
Death rate—per 1,000 births 15.2
Stillbirths  (not ncluded in above) 11
23.5
June, 1940
5
11.8
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
May, 1941 June, 1941
Cases   Deaths   Cases   Deaths
July 1-15,1941
Cases   Deaths
Scarlet Fever  3
Diphtheria  0
Chicken  Pox  73
Measles  204
Rubella  133
Mumps	
Whooping Cough
Typhoid Fever  _
Undulant Fever
Poliomyelitis   	
Tuberculosis 	
Erysipelas
Meningococcus Meningitis
Paratyphoid Fever	
♦(Outside)
16
23
0
1
0
36
2
5
.  1
0
0
0
0
0
0
0
0
0
0
16
0
0
0
7
0
78
24
41
2
5
0
0
0
32
1
3
0
0
0
0
0
0
0
0
0
0
0
9
0
1
0
3
0
9
3
4
0
0
*1
0
0
22
1
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
Syphilis 	
Gonorrhoea
West
Burnaby
Vancr.
1
0
0
0
Richmond
1
0
North
Vancr.
0
0
Vane.
Clinic
22
47
Hospitals &
Private Drs.
16
16
Totals
40
63
A DYNAMIC MENTAL AND PHYSICAL TONIC
INDICATED IN THESE DAYS OF STRESS
BIOGLAN "A
Another Product of the Bioglan Laboratories, Hertford, England
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C.
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If doesn't hurt now!
In abrasions and other soft tissue
injuries, Antiphlogistine may be
applied warm or at room temperature. There is no sting or pain on
application. It may be used on the
most sensitive parts.
//
ANALGESIC   •   BACTERIOSTATIC   •   DECONGESTIVE   i   DETERGENT
j*
is kind to injured tissue
THE DENVER CHEMICAL MFG. CO., 153 Lagauchetiere St. W., Montreal Bo D. H. VITAMIN  PRODUCTS
AND THEIR PRINCIPAL USES
in General Practice
H
AVOLEUM (Vitamin A)
To prevent night-blindness and mucocutaneous degeneration with consequent suscepti-
biity to infection.
VITAMIN Bi B.D.H.
To maintain carbohydrate metabolism and
prevent, or relieve, neuritis, anorexia and
constipation.
NICOTINIC ACID B.D.H.
(P.P. Factor) jf     1
To correct derangements of carbohydrate
metabolism manifested by sub - pellagroid
symptoms.
ASCORBIC ACID B.D.H.
(Vitamin C)
To promote collagen formation and thus to
ensure the formation of sound bones, teeth
and blood vessels.
RADIOSTOL (Vitamin D)
For the prevention and treatment of hypo-
vitaminosis-D and consequent calcium deficiency.
PHYTOFEROL (Vitamin E)
To restore the funtioning and structure of
endocrine and myoneural tissues.
PROKAYVIT (Vitamin K)
To prevent neonatal and post - operative
haemorrhage resulting from hyporothrom-
binaemia.
RADIOSTOLEUM
(Vitamins A and D)
To correct the effects of lack of "protective" foods and to prevent respiratory and
other bacterial infections.
RADIOMULSIN
(Vitamins A, Bi, C and D)
A convenient form of supplying the vitamin
equivalents of fish-liver oil and orange juice,
as well as Vitamin Bi, to infants.
RADIO-MALT
t§(Vitamins A, Bi, B2 and D)
A dietary adjunct for children and adults.
MULTIVITE
(Vitamins A, Bi, C and D)
To correct multiple vitamin deficiencies in
children and adults.
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Slocks of B.D.H. Vitamin Products are held  by leading druggists throughout  the Dominion,
and full particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse
Toronto 2, Onr.
VitPr/C«B/418 i
V   '
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iPife
fmt2te55ive /<e5Ui
in /^etniciou5 -Anaemia
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LIVER EXTRACT (No. 499)
In one patient (male, age 60) suffering from Addisonian pernicious
anaemia, an increase in red blood eel I count from 1,075,000 to 4,475,000
and in haemoglobin from 35% to 67% followed the administration of
Ayerst Liver Extract No. 499. The average dosage was approximately
1.7 c.c. weekly during the period from March 20th to June 4th, 1941.
Further information regarding this and similar
cases as well as data on the product is available.
AYERST,   McKENNA   &  HARRISON   LIMITED,   Biological
and Pharmaceutical Chemists,       -       - MONTREAL, CANADA
935
HELP  WIN  THE   WAR   —  BUY  WAR   SAVINGS  CERTIFICATES  —  PRESCRIBE   CANADIAN-MADE  PRODUCTS When Sherman, according to tradition, said "War is hell," he said a mouthful. One
of its worst aspects is the mess it makes of all our orderly arrangements, the dislocation
of our plans and the disorganization of our carefully-built social structures. It has now
laid its disfiguring and ruthless hand on our own Medical Association. Many of our most
valued members are, temporarily as we hope, absent from our ranks—but the latest and
greatest loss is in the person of our President, Dr. W. M. Paton, who has only been in
office a matter of three months or so. But he has gone to a higher and wider sphere of
duty—and has now joined His Majesty's armed forces.
We shall miss Walter Paton sadly: he has, for some years, served us very well, and
richly earned the honour of the Presidency. But he will be back, and we all hope soon:
and will take up where he left off. Meantime, he is one of a gallant company. Perhaps
never in the history of war has the medical personnel been so vital a part of the military
structure. The M. O. has always, of course, filled a unique place—but that was because
he was a repair man—at least that was his chief function, once the enlisted man had
passed the medical Cerberus at the gate. But now, he is infinitely more—especially in
such services as the Air Service. As one reads of the work of the medical officers of the
various Air Units, one sees that a whole new field of medicine, largely preventive and
corrective, rather than remedial, has come into being. This is as it should be, of course
—and it is in this capacity, as a guardian of health rather than as a repair mechanic,
that the man of medicine reaches his highest level. One sees this even in the enlistment
depots, where so much attention is now being paid to the would-be recruit's actual fitness—not only physically, though this perhaps comes first, and is the sine qua nan of the
requirements—but also mentally and psychologically. This is good in every way, making
for a maximum of present efficiency, and a minimum of future loss and wastage, and
economic disruption—not to speak of the benefit to the man himself, due to proper
selection for the work he has to do.
In this war, too, the M. O. seems to be far more intimate with those with whom
he works—reading about the parachute troops, one is told how the medical officer accompanies them to the ground, with his kit and medical comforts, to take care of the
wounded. It seems a lot to ask of a medical man, somehow—and is a far cry from the
old horse and buggy days: but with the advent of the automobile, one's practice became
more and more widely scattered, and now the coming of the aeroplane has added still
more to the distances one has to go to keep one's patients. We can only hope that Dr.
Paton will not be called on to engage in any such adventures—and meantime, we wish
him the best of luck and a speedy return.
In this number we publish certain notices re the forthcoming B. C. Medical Association Annual Meeting: to be held September 16th, 17th and 18th. In our next number
we shall publish reports of the various Committees, the summary of the year's work.
The Bulletin, whose date of publication during the summer is more or less variable,
will be brought out in time, if we can possibly arrange it, for everyone to have his copy
well in advance of the meeting. By doing this, time and energy will be saved. Meantime, we advise our readers to take a good look at the programme which has been prepared for the meeting. We all look back at the delightful meeting which was held at
Nelson last year: and hope this one will be as enjoyable and profitable. Certainly there
is an admirable menu of speakers and addresses, and Dr. Thomas, our Executive Secretary, has put his back into the work of arrangements, and that says a good deal. There
are some important economic questions, too, to come up—and we promise full value for
his time and effort to everyone who attends this Annual Meeting.
Page  313
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NEWS    AND    NOTES
Dr. J. H. MacDermot has returned from a month's holiday at Savary Island, looking
extremely well.
* *      *      *
Dr. and Mrs. Carl M. Eaton and son, Freddie, of Vancouver, visited Dr. and Mrs.
S. P. Findlay of Fraser Lake. Dr. Eaton reported the trout fishing at Fraser Lake as good.
3fr Sf* *t 3fr
Dr. Alexander Jackson MacLachlan was married to Miss Jean Reid on July 24th.
They have the best wishes of the profession.
•I* *P 5p •**
Dr. S. Graham Elliot of Vancouver has returned from a visit to Regina.
* *      *      *
Dr. W. M. Paton, President of the Vancouver Medical Association and Honorary
Secretary-Treasurer of the British Columbia Medical Association, has entered the Naval
Medical Services.
* *      *      *
Dr. Ken L. Craig of Vancouver is in the R.C.A.M.C.
* *      *      *
Dr. V. W. Pepper of New Westminster and Dr. P. C. Lund, formerly an Interne of
the Royal Jubilee Hospital in Victoria, are in the Air Force.
* *      *      *
Squadron-Leader Norman M. Kemp is now in Edmonton.
Dr. W. B. Clarke, who has been doing the practice at Invermere since Captain F. E.
Coy entered the R.C.A.M.C., has returned to Vancouver.
Dr. A. E. Kydd is now carrying on the practice at Invermere.
*      *      *      *
Dr. Gordon A. Brown, lately of the Vancouver General Hospital, is assisting Drs.
Green and Green at Cranbrook.
* *
* *
Dr. F. W. Green of Cranbrook received the nomination and will stand as the Conservative candidate at the next provincial election.
*       * .    *       *
Dr. D. W. Graham of Victoria called at the office in July.
*c ~r
Dr. P. L. Straith of Courtenay was in Vancouver recently and is looking exceptionally
w
ell.
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Dr. and Mrs. J. J. Gibson, formerly of Tulsequah, are vacationing in Vancouver.
*       *       *       *
Dr. H. A. Macdonald has left for Surf Inlet, where he will relieve Dr. J. M. English,
who is returning to Vancouver.
Building operations for the Military Annex to the Prince Rupert General Hospital
have commenced.
Dr. D. J. M. Crawford of Trail, accompanied by Mrs. Crawford and daughter, is
holidaying at Medicine Hat, Alta.
Page 314
V* Dr. and Mrs. E. S. Hoare of Trail are spending some time in Vancouver and on
the Island.
Dr. H. R. Christie of Rossland has joined the R.C.A.F., and at present is stationed
in Regina.
Dr. H. H. Mackenzie of Nelson is moving to New Westminster, where he will be
associated with Dr. S. Cameron MacEwen. Dr. Pepper, who was assisting Dr. MacEwen,
is now with the Air Force.
Dr. M. L. Allan arrived in Nelson in the service of the Tuberculosis Division.
Dr. D. H. Williams has been vacationing in Penticton, and as it turned out it proved
to be somewhat of a busman's holiday.
Dr. and Mrs. J. R. Parmley of Penticton are receiving congratulations on the birth
of a son, July 5 th.
Dr. Wm. McCallum has been appointed Medical Health Officer and School Inspector
for Salmo and District.
Dr. G. F. Young is now practising in Alberta.
Dr. Richard Gibson of Port Washington was appointed Medical Health Officer and
School Inspector for that district.
St Sfr 55" 3fr
Dr. T. C. Holmes of Burns Lake has returned from vacation. He was relieved by
Dr. Robert McKenzie of Grantham's Landing.
Dr. D. W. Beach of McBride has returned home after a visit on the Coast.
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Dr. Roscoe Garner has returned from Toronto, having completed his D.P.H. course,
and is attached to the Tuberculosis Division.
Dr. W. J. Knox and family of Kelowna have returned from a wonderful trip in the
Cariboo.
Dr. D. J. Millar of North Vancouver was fishing in the Cariboo.  It is reported that
he got bigger and better fish and more of them.
Dr. G. B. Helem of Port Alberni has returned from a short holiday at Banff and
Lake Louise and arrived back in time for the heat wave.
*      *      *      *
Dr. and Mrs. B. T. H. Marteinsson of Port Alberni are receiving congratulations on
the birth of a daughter, July 5 th.
Dr. and Mrs. N. H. Jones of Port Alberni are receiving congratulations on the birth
of a daughter, July 15 th.
Dr. W. S. Barclay, formerly associated with the Tuberculosis Division in Saskatchewan, has been appointed Medical Superintendent of the New Hospital opened by the
Indian Affairs Branch at Sardis.
Dr. J. D. Galbraith, formerly of Bella Coola and more recently on the staff at
Tranquille, has been appointed to the staff of the new Sardis Institution.
Page   315
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Dr. J. McGilHvary Tedford, who served with the Winnipeg Hospital Overseas, had
the misfortune to be returned to Canada owing to illness. Dr. Tedford is now doing
special work with the Division of Venereal Disease Control.
Dr. W. P. Walsh, one of the Doctor sons of Dr. W. C. Walsh, is an Interne at the
Vancouver General Hospital.
*5- »«■ s£ 55*
Dr. A. L. Yates and Dr. Mary C. Luff were successful in the Spring examinations
of the Medical Council of Canada.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY
Surgical Clinics of North America—Symposium on Diseases of the Gastro-intestinal
Tract, Lahey Clinic, June, 1941.
Symposium on Infantile Paralysis—A series of six lectures delivered at Vanderbilt University on April 7th, 8th, 9th, 14th, 15th and 16th, 1941.
The Analytical Chemistry of Industrial Poisons, Hazards and Solvents, 1941, by Morris
B. Jacobs.
Outline of Syphilology, by Frank E. Cormia.
REDUCED POSTAL RATE
The Library Committee has received permission from the Post Office authorities to
use a reduced postal rate, allowed to libraries when lending books to out-of-town members, within the Province.
Under this arrangement both the outgoing and return postage is prepaid by the
Library. This amount will be repayable to the Library but as the new rate is 5c for the
first pound and lc for each additional pound or fraction of a pound in place of the
usual rate of 8c a pound, the entire amount will be considerably less than the cost of
mailing one way heretofore.
Special labels are being printed and at the time of mailing a return franked label will
be pasted on the reverse side of the wrapper. The reverse side must then be used !in
returning books to the Library, and the package will be delivered without further postage..
The Library Committee is indebted to the Post Office Department of Canada for
their courtesy and kind co-operation in completing these arrangements.
SUBSCRIPTIONS TO BULLETIN WAR RELIEF FUND
SINCE THE LAST ISSUE
July, 1941
Davis, D. W., and Huckvale, Wm. S. (Kimberley) $100.00
Dunn, J. Cecil C. (Massett)  10.00
Dyer, Harold  (North Vancouver)  20.00
McKechnie, W. B   25.00
Planche, H. H -  15.00
Wall, J. T j   10.00
Page 316 EZRA NEWTON DRIER
Obht June 27, 1941
Dr. Drier was born at Woodstock, N.B., seventy years ago. He graduated
at McGill in 1899, practised a year at Kelowna, B.C., then in Vancouver till
1915. In 1906 he took a six months' post-graduate study at Harvard and spent
1909 in studying abroad, in Vienna, London and Edinburgh, where he obtained
his F.R.C.S.
He joined the R.A.M.C. in 1915 and went overseas, when he was attached
to the Cambridge Hospital, but resigned after a year on account of ill health.
Following a sea voyage he started practice in New Zealand and continued there
for 16 years.
Then came two years travelling with wife and daughter, visiting Australia,
India, Ceylon, Japan and Europe, where he visited every state but Russia.
He finally settled in Vancouver in 1931, where he led a retired life.
In 1913 he studied the electrocardiograph in London under Lewis, and
brought to Vancouver the first electrocardiogram, which he placed in St. Paul's
Hospital.
It was a pleasure to talk to him in his retirement, and he had a fund of
information, both on professional and lay subjects, and his description of the
customs and manners, the ways of living, the various grades of sanitation in
various countries was very interesting.
Not many of the old-timers are left here but those who remain have a vivid
memory of his personality. To the younger members of the Profession here he
was only a name. We extend our sympathy to his wife and daughter in.their
loss. R. E. McK.
P. W. BARKER
Obht July 30, 1941
In the recent death of Dr. Percy W. Barker of Vancouver, at the age of
59, the medical profession of British Columbia has lost one of its most valued
members. Death came suddenly and unexpectedly to Dr. Barker, and we can
only rejoice that he was spared long disability and suffering—but to his relatives and friends, the news came as a great shock.
Dr. Barker's place in the life of his city was a high and secure one. Well-
known as a physician and internist, excellently trained, and devoted to his
work, he had the confidence and respect of his fellow-practitioners, to whom
he was always a ready reference and source of information. His special interest
was in tuberculosis, and his position as one of the leading men on the Staff of
the Tuberculosis Division of the Provincial Board of Health testified to his
pre-eminence in this specialty.
He had other interests, too—notably literary. He was a keen Shakespearean
scholar, and from time to time read papers on the subject.
Dr. Barker possessed many gifts of personality which endeared him to others,
and made him a pleasant and charming friend. Quiet of voice, gentle of manner, and of an unfailing courtesy, he displayed a ready sense of humour, and was
a welcome addition to any gathering. To his family we extend our most sincere
sympathy and condolences.
Page  317 ir-i
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British  Columbia  Medical  Association
(CANADIAN MEDICAL ASSOCIATION, BRITISH COLUMBIA DIVISION)
President Dr.  Murray  Blair, Vancouver
First Vice-President Dr. C. H. Hankinson, Prince Rupert
Second Vice-President Dr. A. H. Spohn, Vancouver
Honorary Secretary-Treasurer Dr. Walter M. Paton, Vancouver
Immediate Past President Dr. F. M. Auld, Nelson
Executive Secretary j Dr. M. W. Thomas, Vancouver
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1941   ANNUAL   MEETING
VANCOUVER
HOTEL VANCOUVER
September 16,17,18
THREE DAYS—FULL OF
FINE FEATURES
"■«' ifs
Make Your Plans and Reservations Early
SCIENTIFIC SPEAKERS
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DR. THOMAS ADDIS,  San Francisco,  Professor  of  Medicine,  Stanford University
School of Medicine.
DR. LENNOX G. BELL, Winnipeg, Associate Professor of Medicine, University of
Manitoba.
DR. GORDON S. FAHRNI, Winnipeg, Assistant Professor of Surgery, University of
Manitoba.
DR. LOUIS P. GAMBEE, Portland, Associate Clinical Professor of Surgery, University
of Oregon Medical School.
DR. C. K. P. HENRY, Montreal, Associate Professor of Surgery, McGill University.
DR. F. G. McGUINNESS, Winnipeg, Professor of Obstetrics, University of Manitoba.
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REPRESENTING CANADIAN MEDICAL ASSOCIATION
DR. GORDON S. FAHRNI, Winnipeg, President.
DR. T. C. ROUTLEY, Toronto, General Secretary.
Page 318
hi.
liitf'iP?- 12:30 p.m.
2:30 p.m.
8:00 p.m.
1941   ANNUAL  MEETING
TUESDAY, SEPTEMBER 16th
8:00 a.m.      Registration.
9:00 a.m.      1.   Dr. Louis P. Gambee—The Management of the Distended Abdomen.
2. Dr. Thomas Addis—Nephritis—Practical Methods for Diagnosis and
Treatment.
3. Dr.  F.   G. McGuinness—Maternal Deaths  occurring   in  the  2-year
Pregnancy Survey in Manitoba.
4. Dr. Lennox G. Bell—Some Common Drug Intoxication.
Official Luncheon—His Worship the Mayor, President of the Vancouver
Medical Association, Dr. Gordon S. Fahrni, and Dr.
T. C. Routley.
Clinic—St. Paul's Hospital.
Session on Medical Economics.
Speakers: Dr. T. C. Routley; Dr. S. C. MacEwen, Medical Director
of the Medical Services Association; Dr. Wallace Wilson,
Chairman of the Committee on Medical Economics, Canadian Medical Association.
(As this subject is always of considerable interest, any members having
questions are requested to submit them to the Secretary prior to September 6th.)
WEDNESDAY, SEPTEMBER 17th
8:30 a.m.      1.   Dr. F. G. McGuinness—Obstetrical Causes of Prematurity.
2. Dr. G. S. Fahrni—Parathyroid Tumours and Hyperparathyroidism.
3. Dr.  Thomas Addis—Nephritis—The  Theory  of  the Treatment  of
Bright's Disease.
4. Dr. Lennox G. Bell—The Diagnosis and Treatment of Purpura.
5. Dr.  Louis  P.  Gambee—The  Diagnosis  and  Management of  Acute
Intestinal Obstruction.
12:30 p.m.      Social Luncheon.
2:30 p.m.      Clinic and Demonstration—Vancouver General Hospital.
8:00 p.m.      Annual Meeting—College of Physicians & Surgeons of B .C.
8:30 p.m.      Annual Meeting—British Columbia Medical Association.
Report of Divisional Advisory Committee.
Present: Surgeon-Commander A. G. LaRoche, Naval
Services.
Lieutenant-Colonel   G.   C.   Kenning,   Army
: Services.
Wing-Commander E. E. Day, Air Force Services.
THURSDAY, SEPTEMBER 18th
8:30 a.m.      1.   Dr. Lennox G. Bell—Some Problems in the Diagnosis of Anaemias.
2. Dr. F. G. McGuinness—Toxaemias of Pregnancy.
3. Dr. Louis P. Gambee—Common Hand Infections.
4. Dr. Thomas Addis—Nephritis—The Results of Treatment.
5. Dr. C. K. P. Henry—Cancer of the Gastro-intestinal Tract.
12:30 p.m.      Luncheon—Board of Directors, British Columbia Medical Association*
1:30 p.m.      Golf—Jericho Golf and Country Club.
7:00 p.m.      Annual Dinner—Speaker.
Distribution of prizes.
Page   319
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SPECIAL FEATURES
The Committee on Programme offers three full days of excellent fare.
The 1941 Annual Meeting will be worthwhile.
GENERAL SESSIONS
Lectures each morning provide variety.
MEDICAL ECONOMICS
A session on Medical Economics will be held on Tuesday evening. The Committee in
charge have at this date to report that the discusion will be held by Drs. T. C. Routley,
S. Cameron MacEwen and Wallace Wilson. Owing to the growing interest on the part
of the profession it has been arranged that questions be invited from the Members. These
should be sent in to Dr. M. W. Thomas, 203 Medical-Dental Building, prior to the
meeting (before September 6th).
CLINICS
On the afternoon of the first day demonstrations will be held at the Vancouver
General Hospital. On the second day clinical features at the St. Paul's Hospital are
being arranged.
PUBLIC HEALTH
In conjunction with the above clinical features the various divisions of the Department of Health will have an opportunity to present interesting phases in their particular
departmental work.
It is proposed to hold a public meeting at which public health and preventive medicine will be dealt with by the Directors of the Divisions.
PUBLIC MEETING
A public meeting is being arranged when speakers will deal with Cancer, Maternal
Welfare, Pasteurization, Tuberculosis, Venereal disease control, and other phases of public
health and preventive medicine.
OFFICIAL LUNCHEON, TUESDAY
On the first day, Tuesday, September 16th, the Official Luncheon will be devoted
largely to the Canadian Medical Association when, following the welcomes by His Worship the Mayor and the President of the Vancouver Medical Association, Dr. Gordon S.
Fahrni, President, and Dr. T. C. Routley, General Secretary, will address the members.
This luncheon is largely attended and provision will be made for all.
SOCIAL LUNCHEON, WEDNESDAY
A Special Social Luncheon will be held on Wednesday for all members. Come ana
fraternize with your friends.
MATERNAL WELFARE
We are fortunate in having Dr. F. G. McGuinness of Winnipeg, Professor of Obstetrics at the University of Manitoba, and he will deal with the exhaustive study carried on
in the Province of Manitoba during recent years.
CANCER
£)r. C. K. P. Henry, Associate Professor of Surgery, McGill University, is admirably
fitted to deal with the question of cancer, and comes to the Annual Meeting under the
aegis of the Department of Cancer Control of the Canadian Medical Association.
Page 320 ANNUAL MEETINGS
The Annual Meetings of both bodies, the College of Physicians and Surgeons and
the British Columbia Medical Association, will be held on Wednesday evening. Important
business will be presented to the profession at both meetings. You are a Member of the
College of Physicians and Surgeons.
The Annual Meeting of the College of Physicians and Surgeons of British Columbia
is your Annual Meeting. This is for all members. Every doctor in British Columbia who
is licensed to practise is a member. In the past there has bene some misunderstanding
regarding this meeting and just who is eligible to attend. This is your Annual Meeting.
WAR MEDICAL SERVICES
Surgeon-Commander A. G. LaRoche, Senior Medical Officer, Naval Service, at
Esquimalt; Lieutenant-Colonel G. C. Kenning, District Medical Officer, M D. No. 11,
and Wing-Commander E. E. Day, Chief Medical Officer, Western Air Command, have
been invited to attend the Annual Meeting of the British Columbia Association on
Wednesday evening.
Because of the great interest in the War Medical Services it has been arranged that
questions will be submitted prior to the meeting. Please send your questions to Dr. M.
W. Thomas, 203 Medical-Dental Building, before September 6th.
ATTENTION!   CHAIRMEN OF STANDING COMMITTEES
Reports of all Committees must be handed in at the office for publication in the
Bulletin. This procedure is adopted to expedite business at the Annual Meeting.
ARRANGEMENTS FOR ANNUAL MEETING
Chairman of Committee on Programme and Arrangements—Dr. G. F. Strong.
Chairmen of Sub-committees:
Registration and Reception—Dr. H. H. Milburn.
Publicity, Press and Publication—Dr. J. H. MacDermot.
Arrangements—Dr. W. W. Simpson.
Clinical Features—Dr. R. A. Palmer.
Entertainment—Dr. J. R. Neilson.
Golf—Dr. D. F. Murray. ^^
Commercial Exhibits—Dr. Bruce Cannon.
Special Session on Economics)—Dr. W. A. Clarke.
ANNUAL DINNER
The Annual Dinner will be held in the Banquet Room in the Hotel Vancouver on
Thursday evening, September 18th.  This promises to be an outstandingly fine Dinner.
A good speaker and music will be arranged, and golf prizes will be distributed.
GOLF
The British Columbia Medical Association Trophy (presented by the Mead-Johnson
Company) will be up for competition. The past holders are: 1937, Dr. D. Fraser
Murray; 1938, Dr. G. R. F. Elliot; 1939, Dr. Neil M. McNeil; 1940, Dr. H. H. Mac-
Kenzie, Nelson.
Dr. D. Fraser Murray is Chairman of the Sub-committee on Golf and has already
made provision for play at the Jericho Golf and Country Club Course. Dr. Murray
anticipates a very heavy registration and has provided prizes for everyone (almost).
Please return the golf card indicating your desire to play.
COMMERCIAL EXHIBITS
This year our friends who deal in pharmaceuticals, electrical and X-Ray equipment
and surgical supplies are supporting our Annual Meeting in large numbers. This is
much appreciated and our members are asked to reciprocate by visiting the Exhibits.
Page  321
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i.   ■ »Mrrj-r: LADIES' PROGRAMME
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TUESDAY, SEPTEMBER 16th
All Ladies are requested to register, signifying intention of participating in the vari-1
ous features of entertainment.
4:00 p.m.—Wives of members of the Board of Directors, wives of out-of-town mem- j
bers and members of committee to be guests at Tea at the home of Mrs. I
Murray  Blair,   1215   West   32nd Ave.    Transportation  for   out-of-town
guests will be provided.
WEDNESDAY, SEPTEMBER  17th
2:00 p.m.—Drive to West Shore and British Properties for visiting ladies.
4:00 p.m.—Tea—Shaughnessy Golf Club. All ladies are asked t oregister and receive
invitations to attend this Tea as guests of the British Columbia Medical
Association.  Ladies who take in the Drive will arrive in time for the Tea.
THURSDAY, SEPTEMBER 18th
7:30 p.m.—Ladies' Dinner to be held in the Social Suite.  Tickets: $1.50.
The Ladies' Dinner has grown in popularity and is largely attended. The
above programme will give the wives an opportunity to meet and know one
another.
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nd Su
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President-
.Dr. Wallace Wilson, Vancouver
Vice-President j Dr. W. A. Clarke, New Westminster
Treasurer Dr. F. M. Bryant, Victoria
Members of Council—Dr. F. M. Auld, Nelson; Dr. F. M. Bryant, Victoria; Dr. W. A.
Clarke, New Westminster; Dr. Thomas McPherson, Victoria; Dr. H. H. Milburn,
Vancouver; Dr. Osborne Morris, Vernon; Dr. Wallace Wilson, Vancouver.
Registrar . Dr. A. J. McLachlan, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
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MEDICAL SERVICES ASSOCIATION
The First Annual General Meeting of the Medical Services Association was held at
8 p.m., July 4, 1941, in the Auditorium of the Medical-Dental Building, Vancouver, B.C.
The following Directors were elected:
Mr. F. C. Whitehead (Shell Oil Co. of B. C. Ltd.) by Employee Members;
Mr. John Young (Henry Birks & Sons (B.C.) Ltd.) by Employee Members;
Mr. J. W. G. MacKenzie (Seaboard Lumber Sales Co. Ltd.) by Employer Members;
Dr. M. W. Thomas (Executive Secretary, College of Physicians & Surgeons) by Professional Members.
At a subsequent meeting of the Directors, the following were appointed:
President—John Young; Vice-President—F. C. Whitehead.
The Provisional Directors' Report, the Balance Sheet and Financial Statement
appeared in the July issue of the Bulletin.
For the information of our mfembers who were unable to attend the meeting we are
publishing the report of the Director of Medical Services and in the next issue the highlights of the address by Dr. M. W Thomas, which was enthusiastically received by the
members.
Page 322
JW
ilH
H Member. Groups
[Agriculture, Food & Drug Division Employees.
lAsh Temple Company Ltd.
[Henry Birks & Sons (B.C.) Ltd.
I Canadian General Electric Co. Ltd.
^Dominion Income Tax Employees.
[Graham Electric Company Ltd.
[Great West Life Assurance Company.
[income Tax Specialists Ltd.
International Business Machines Company
Ltd.
Medical-Dental Building Floors 2, 9 and
14.
Metropolitan Health Committee.
! Montreal Life Insurance Company.
! Fred C. Myers Ltd.
North Vancouver General Hospital.
Port Coquitlam School Board.
Powell River Company Ltd. (Vancouver)
Seaboard Lumber Sales Company Ltd.
Shell Oil Company of B. C. Ltd. (Plant
Employees).
George Straith Ltd.
Sun Life Assurance Company of Canada.
Vancouver Board of Trade.
Victor X-Ray Corporation of Canada
Ltd.
Victoria City Hall Employees.
Western Sales Book Company Ltd.
Roy Wrigley Printing & Publishing Company Ltd.
Yorkshire & Pacific Securities Ltd.
Report of Director of Medical Services to the Annual Meeting,
July 4, 1941.
I am not here to go into the financial side of this Association, but my department has
a very vital bearing on its finances. Proper supervision means a considerable saving on
accounts, and I am sure Mr. McLellan will bear me out when I say that this has proved
to be a fact.
There have been many cases where I have not felt justified in holding to the letter
of the law. These are mostly problems which only obtain when a plan like this is first
brought into effect. Naturally these have embraced both the subscribers and the doctors.
It is easy to write into a contract that diseases known to exist previous to entry are not
covered, but it is difficult to decide each case with fairness to the member. Many plans
have been wrecked or have had to be curtailed by the number of serious cases, particularly surgical, which present themselves. This is particularly true in the first few months
or year of the plan, and, of course, is more noticeable in those plans in which choice of
physicians obtains, and where there are not many members.
To my knowledge there have been no complaints from the members or the doctors
thus far, and I feel sure with the co-operation of all concerned there will be very few.
I wish to thank all the members of the Medical Profession for their help, consideration, and fairness in all cases that I have taken up with them. One point, however, I
would like to present to them and ask their co-operation. This is the question of
authorization of all major surgery and serious cases, outside of actual emergencies. The
funds handled are those of the Association and practically all of the doctors are members
of this Association. Authorization is necessary for control of funds, and to prevent
duplication, and I shall have to insist more and more that they should keep strictly to
this part of the agreement. The profession as a whole has given overwhelrning support
to the plan by becoming members. The forms to be filled have been made as simple
as possible consistent with good record keeping and I would ask that they be filled as
completely as possible and as soon as possible. The absence of progress reports at regular
intervals simplifies the report writing we all dislike.
To the Lay Members—I would suggest that so far as possible the General Practitioner be consulted first—consultation will be allowed, as necessary, and this again
should be authorized before being carried out. At times first consultation with a
specialist is natural as in ordinary practice and these are handled in the same manner
as with the General Practitioner.
Always disclose your identity as a member of the M-S-A on the first visit. Do not
be afraid that you will receive inferior or disinterested service. The exact opposite will
be found to be the rule.
Page   323 If
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Early diagnosis is essential to good results and a visit to your doctor may prevent!
complications. We cannot allow periodic routine examinations, but when there is some-!
thing wrong, get in touch with your doctor.
Remember that the funds of this Association are your funds and its success willjj
depend on your co-operation.
The plan is being extended gradually to the whole Province and for the convenience!
of the Members, I have arranged, with the co-operation of the officers of the locals
Medical Associations, for Assistant Directors of Medical Services.  The following doctors
have consented to act:
Dr. J. S. Daly, West Kootenay.
Dr. C. H. Hankinson, Prince Rupert.
Dr. W. J. Knox, Kelowna.
Dr. E. J. Lyon, Prince George (Central Interior).
Dr. Thomas McPherson, Victoria.
Dr. T. S. Sullivan, East Kootenay.
Dr. Gordon James, Britannia Beach.
S. Cameron MacEwen, M.D.,
Tv.-. Director of Medical Services.
S. D. K.
N. L. G.
M. M.
J. R.
N. N. G.
H. S.
C. H.
N. F. W.
A. McK.
C. H.
K. S.
J. R.
J. S. R.
N. H.
W. E. A.
H. A. M.
T. D.
M. L.
D. D.
D. M.
P. F. C.
N. F. H.
E. H.
V. E. M.
F. C. W.
C. F. M.
F. M. H.
H. H. W.
L. M. C.
R. K. P.
G. L.
M. McC.
R.  S.
G. C. P.
W. W. D.
R. W. D.
S.
C A.
A. E. S.
D. C.
P. T.
J. M.
N. W. D.
Page 324
Examples of Claims Paid
From November 1, 1940, to May 31, 1941
Medical
Infected eye   $    2.50
Inflammation of the eye  8.25
Laryngitis    i  6.00
Lacerations     2.25
Septic Throat   6.75
Inflammation of middle ear  3.75
X-Ray—Vertebrae     15.00
Run-down  condition    3.75
Sliver  in nail  2.25
Ache  in  spine  7.50
Arthritis  33.50
T. B. kidney  35.00
Head injury  2.25
Cyst  46.88
Inflammation of the eye  2.25
Haemorrhoids       	
Appendix   15.00
Foreign body in the eye  3.75
Foreign body in external ear  5.50
Colic—left   renal  30.00
Pyelitis :  4.13
Threatening Hernia ~ 2.25
Tonsillitis  3.7 5
Septic throat and abscess	
Opening into  abdomen	
Skin disease  9.75
Anaemia  6.00
Influenza  6.00
Toxic goitre  13.50
Pneumonia  117.33
Tonsillectomy '. 	
Rheumatic fever   6.00
Lumbago    4.13
Measles  4.13
Sprained   ankle  8.63
High   blood   pressure  4.13
Tonsillectomy    5.50
Pleurisy  2.25
Deafness—treated  2.25
Tonsillectomy =	
Sprain  2.25
Abdominal  pain  4.13
Disease of old age  6.00
Surgical
$	
37.50
56.25
112.50
13.50
112.50
37.50
37.50
37.50
Hospital
$	
	
	
—	
80.60
3.90
95.50
33.66
61.20
	
36.10
	
12.00
64.60
20.00
14.35
	
	
22.12
	 f*
J. V. G.
A. B.
A. P. J.
B. P.
D. M.
J.  G.
O.  McA.
D. C E.
0. M. A.
N. L. R.
J. A.
R. V. D.
T. F.
K. F. B.
S. M.
E. J. H.
G. D. D.
C C.
J.  B.
S. D.
f: b.
H. J. E.
L. E. C
M. D.
L. J. H.
R. E. L.
R. E. L.
R. W. D.
1. M.
W. H.
V. W.
N. G.
R. C.
R. E. G.
D. M. P.
R. H. G.
S. D. H.
M. H. E.
F. E.
D. T.  S.
Anaemia	
Asthma   	
Glandular condition
Goitre   	
Lumbo-sacral sprain
Measles 	
Anaemia	
31
30,
4,
30,
6
2
2,
4,
7,
4,
13.
2,
50
00
50
00
75
25
25
13
50
13
13
25
112.50
26.00
87.3 5
Run-down  condition
Tumour 	
Sprained ankle 	
Skin disease 	
Neuralgia   	
Influenza  	
Tonsillectomy	
High   blood  pressure       2.25
Sprained ankle 9.00
Ulcer 15.00
Sinus          6.00
Change of life     11.25
Bronchitis          2.25
Run-down condition 16.88
Cyst
37.50
11.90
Tonsillectomy 	
Boil   	
Nasal  adhesion  	
Bronchopneumonia •	
Tonsillitis and bronchitis.
Facial Neuralgia 	
Nervous  exhaustion 	
Abdominal operation 	
Measles 	
4.13
7.50
37.50
7.50
13.00
13
13
5
Pain  1.   ovary  2
Tonsillitis     2
Bronchitis     2
Laryngitis     2
Measles   2
Gastric pain   4
Thymus  2
Appendicitis  —
Tonsillectomy    	
50
50
63
63
25
25
25
25
25
25
13
25
112.50
3.00
63.73
$707.53
112.50
37.50
$909.75
20.15
$669.16
$2,286.44
COMMITTEE ON MATERNAL WELFARE
Indications for the Induction of Labour
Part I.
The indications for induction of labour may be either maternal or foetal. The commonest maternal indication is toxaemia—nephritic, pre-eclamptic, or eclamptic.
Nephritics must be induced immediately upon discovery. In pre-eclampsia, or technical
toxaemia, treatment and observation is indicated first, to improve the maternal condition
and to increase faetal viability. If the condition becomes worse, interruption of pregnancy must be done. Induction in eclampsia is delayed until convulsions are controlled
and blood pressure recedes.
Organic diseases which may necessitate induction are: Heart trouble with decompensation—but only after compensation is restored; intractable anaemia; advancing hypertension; acute hyperthyroidism; severe pyelitis or pyelonephritis. Pregnancy was interrupted formerly in tuberculous or diabetic, or moderate hyperthyroid patients. Now it
is generally the rule to manage these cases medically until' the child is viable.
Foetal Indications Which May Necessitate Induction Are:
Premature separation of the placenta with concealed or frank haemorrhage
treatment for shock has improved the patient's status.
ift
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Placenta praevia of lateral and marginal types.   The central variety is more safely j
handled, for all concerned, by Caeserean.
Acute or excessive gradual hydramnios and demonstrable monstrasities.
Postmaturity, particularly if beginning disproportion is feared.
Early spontaneous rupture of membranes with or without cord prolapse, because the i
risk of infection of amniotic sac increases in proportion to delay.
Intrauterine death of foetus should be followed by induction within one week.
Habitual death of the foetus. A history of this condition demands careful examination of the patient, careful observation of a decrease in maternal weight, or size of
uterus, or changes in foetal movements or heart rate, denoting distress—then immediate
induction is done, particularly in nephritics or hypertensives. (In these cases quinine or
pituitrin should not be used.)
Moderate degrees of pelvic contraction were until recent years considered to be an
indication for early induction, in an attempt to procure a smaller passenger for the
smaller passage. But mistakes are common in judgment of gestation period, and size of
infant, and there is a high foetal mortality, obviously due to inabaUty of the premature
to stand normal or abnormal labour, as well. Besides this, large numbers of full time
babies are delivered successfully through small pelves—particularly the small inlet and
generally contracted types, after trial of labour. These facts, plus the improvement of
technique and results of caesarean section, have caused a diminution of this practice. It
it to be especially condemned in the case of the funnel pelvis or the absolutely contracted
pelvis.
Artificial induction is also contra-indicated in the presence of severe acute infectious
diseases, such as pneumonia or influenza, because the patient's condition may be made
worse by labour and delivery.
COMMITTEE ON THE STUDY OF CANCER
What Is This Disease Called Cancer?
"Cancer" is the Latin word for crab. Carcinoma is derived from the Greek word
"karkinos" also meaning the same animal. It may seem strange to call a disease after
such a queer animal but, as usual, there is a reason. All of the malignant tumours seen
in Grecian and Roman times were far advanced when first recognized as such, and were
causing marked local and systemic reactions. It was from the appearance of the local
reaction, according to one theory, that the term cancer was derived: "The veins are
distended and spread around like the feet of the animal called crab, whence the disease
has derived its appellation. However, some say that it is so called because it adheres
with such obstinacy to the part it seizes, that, like the crab, it cannot be separated without great difficulty" (Paulus Aegineta, IV, XXVI). Thus cancer derived its strangely
appropriate name from a description of a far advanced malignant growth.
Today we are gaining a new conception of cancer as we recognize the disease in its
earlier stages. We find that cancer starts as a cell, or group of cells, in any tissue of the
body, that for some reason unknown as yet become more embryonal than the normal
cells. They start to grow first locally, without much if any systemic reaction, then
generally with increasing effect on the body until the body is finally and inevitably overwhelmed by the now truly crab-like growth.
From this definition of cancer it can be readily seen that there are two all important
stages in the growth of cancer. Both stages should be familiar to the physician who
hopes to defeat the disease.
Stage 1—The local or the curable growth. This stage can seldom be recognized for
certain on clinical examination alone, and a biopsy is necessary in almost all cases to
prove or disprove its malignancy. There is none of the classical symptoms of anaemia,
loss of weight, strength, etc., to aid in the diagnosis.
Stage 2—The generalized growth or the incurable growth. The recognition of this
stage is so simple that the lay public often diagnoses the condition before the doctor has
Page 326 seen the case. The recognition of this stage is of interest only as far as palliation is
concerned.
Thus it is important that the physician concern himself less with Stage 2 and more
with Stage 1 of cancer. Let him view with grave suspicion all even slightly atypical
lesions throughout the body. Let him not take the life of his patient m his hand and
attempt in the glory of his own ego to define whether an early lesion is or is not
malignant.
Rather, let him recognize that even those most specialized in the diagnosis of cancer
are frequently wrong in the early cases. Let the physician biopsy fifty or even a hundred
lesions to find one positive biopsy. When he does find a positive biopsy, then and only
then can he bask in the light of accomplishment, for he has truly saved a life.
Vancouver Medical   Association
PANEL DISCUSSION ON CHEMOTHERAPY
Held during Summer School of Vancouver Medical Association, June,  1941.
Introduction by Dr. W. H. Hatefdzld:
Ladies and gentlemen, tonight we are going to try an innovation in our Summer
School. This is the first time we have had a panel discussion and tonight we have three
experts who are going to discuss Sulphonamides. The proposal is that we take a series
of questions that have been presented by a group of people and we will put these questions to our guests and ask them to answer them. They will have a maximum of four
minutes in which to answer any given question. We hope, however, that we shall have
a free discussion and that any man at this table will feel quite free to get up and disagree with the person who asked that question. He will be allowed two minutes to
disagree.
We feel that we have here tonight a group of authorities—there is one yet to come
and when he comes he will be given several of the most difficult questions that we have
—so we will start off tonight with the first question of the evening and ask Dr.
Osgood what are the general principles underlying the use of the sulphonamides for local
application.
Answer (Dr. Osgood) : In my opinion the general principles are these: The drug of
choice for local use (and Dr. Long may disagree with this) is sulphathiazole, because
this drug has proved the most effective compound. We feel that when we have a considerable local collection of pus the local use of the drug is important because large
numbers of organisms are not sterilized by any of these drugs, so where there is a local
collection of pus not due to the tubercle bacillus but due to almost any other organism,
we like to get a blood level of sulphathiazole between 5 and 8 mg. That blood concentration will take care of the small number of organisms that might be in the blood
stream or in the adjacent tissue. As soon as that level is obtained by use of sulphonamides intravenously, the local collection of pus should be drained and the pus or necrotic
tissue all washed away with saline solution saturated with sulphathiazole. That takes
about 1 gr. per litre to make this solution. Then powdered sulphathiazole is applied
locally in excess. Except in the general peritoneal cavity, or where there is a very large
absorbing surface, the amount of sulphathiazole does not make much difference, for the
reason that it is soluble only about to the amount of 1 gr. per litre.
The method of applying the local sulphathiazole depends upon the type of the infection rather than the location of the infection; e.g., a compound comminuted fracture—
rinse it with the saline saturated with the sulphathiazole, pack it with sulphathiazole and
it can be sewn up like a clean wound. In a great majority of instances it will heal by
first intention. In general peritonitis, as soon as the blood level is obtained—immediate
operation, closure of the opening, rinsing out the peritoneal cavity with saline saturated
with sulphathiazole poured in or sprinkled in with a salt cellar. After tooth extraction
we have had a considerable series of osteomyelitis of the jaw. We now simply pack the
powdered sulphathiazole into the infected socket afterward.   Or with something like a
Page   327
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brain abscess, the abscess is opened and with a catheter we rinse out the cavity with
saline saturated with sulphathiazole, put in a very heavy suspension, anywhere from 2
to 10 grs. to 20 c.c. of the saline. You have to shake it in order to maintain it in suspension. In sinuses, rinse the sinus free from pus and put in the saline suspension. In all
streptococcic throats we have been using powdered sulphathiazole with a powder blower,
blown into the throat. It is completely non-irritating. In G.C. ophthalmitis you can give
a saturated solution by a continuous drip. For those very rare cases of gonorrhoea which
do not clear up with sulphathiazole by mouth, we use sulphathiazole intra-urethrally. We
have had quite a number of cases in the male that have failed to respond to the drug
by mouth—out of a very large series—and they have cleared up with intra-urethral
administrations. In the female we use this in a contraceptive diaphragm over the cervix.
Dr. Long: This may be your last panel discussion so you might as well enjoy it!
I do disagree with Dr. Osgood in just a few minor points. When we are discussing local
use we want to discuss local use. In local use, where you have a fresh wound before six
hours has passed, it is our opinion that sulphanilamide is the drug of choice. It should
be of the consistency of table salt. You can sterilize it by heating it at 140° F. for four
hours and then sterilize it in salt shakers. It makes a very good way for applying it
locally. If you have an infected wound, use sulphathiazole. My only disagreement would
be: I would not use more than 10 grams of sulphathiazole locally, 5 grams per 50 c.c.
of exposed wound surface, not more than 10 grams in any one patient, because you will
get too high a blood level. You may get into difficulties, if you go over 10 or 11 grams,
for that is a little too much. The important think is to keep re-applying it because a
single application is not any good. If you are going to close your wound, I think for
a non-infected wound sulphanilamide is the best. Even if you were giving it by mouth
you will get better results to keep on re-applying it.
We shift to sulphapyridine if we cannot cure a case of G.C. on the fifth day of
treatment. Mahoney in the United States has reported 95% favourable results. Those
that we cannot cure we usually give local treatment and fever therapy.
Dr. Osgood: I agree with most of this except that we have found that except in the
peritoneal cavity we have not run into high blood levels from larger amounts of sulphathiazole.  I didn't get a chance to bring out the prophylactic use of the drug.
Dr. Fluhman was asked: Are the sulphonamides the drugs of choice in urinary
infection?  If so, why?
Answer: I am terribly embarrassed and I assure you that, with Dr. Long here, who
has done so much work on urinary infections, I have got to watch my step. I have never
done anything of any original nature in this problem. I wish you would ask Dr. Long
some questions about gonadotropic hormones.
I shall have to own up that I have watched all this business for four or five years
and have been terribly interested. I am all out for sulphonamides as far as genito-urinary
infections are concerned—cystitis, pyelitis and even perirenal abscess. There are a great
many things in regard to what we should use and why and so on. The answer is Yes.
We ought to use it with all the precautions. A terribly important thing in urinary tract
infection is the answer that you get from the bacteriological laboratory. We have used
both sulphanilamide and sulphathiazole. The first is certainly a good drug in urinary
tract infections due to the Basillus Coli. Where there is staphylococcus and certain types
of streptococcus, we feel that sulphathiazole is preferable. There are many things,
though. Should we or should we not limit the fluid intake? Is it terribly important
that the urine should be concentrated, or is it not? We don't limit the fluid intake of
our patients. We give them sulphathiazole now starting off on the first day with 3 or
4 grams and then continuing with 1 gram every 4 hours for five or six days.
Dr. Struthers was asked: Is a previous history of nephritis a contraindication to
the use of sulphonamides?
Answer: To give a categorical answer, I would say No. If there is evidence of renal
failure, one must use caution in using these drugs. In children, I think one could say
that the presence of nephritis, or even a past history of it, is not a contraindication.
Page 328 We have had considerable experience with the use of sulphanilamide drugs in the case of
post-nephritis. One sees a pneumonia with nephritis and we have not hesitated in the
treatment of the pneumonia with sulphanilamide. In the treatment of so-called nephrosis
in childhood, we have not hesitated to use sulphonamides in the treatment of the acute
infection, though the child has a markedly poor outlook with the urine. They should
be treated in hospital, where one is able to follow the blood level quite closely. The
drug of choice is, of course, sulphathiazole, and, I believe, sulphadiazene has been used
in the acute infections. It is of particular value in the acute crises which occur in the
presence of acute nephritis or in the presence of acute nephrosis in childhood.
Dr. Long: Dr. Henry Holmo came to Baltimore and we tested it out and I think he
is right. That is, in these kids who had had a long continued story of pyelonephritis,
P.S.P. 20% to 30%, and in whom, if you give large doses of sulphathiazole, they pile it
up in the blood, and then we get scared and quit. By giving 1/5 gr. sulphathiazole five
times a day, he has not been able to cure these kids because of their urinary tract
deficiency, but he has been able to maintain these children for months and for long
periods of time with what the urologists call a sparkling urine. They get along very
well. That is an important observation because it shows that in these children we use
these small doses and we may be able to hold down this infection and maintain a good
condition. My former chief, Dr. Longcope, for the past four years has treated all his
nephritis, acute haemorrhagic nephritis following a haemolytic streptococcic infection—he
feels quite certain that he has markedly shortened the course of their nephritis and has
reduced the morbidity rate in his adult patients by using sulphanilamide for long periods
of time in these patients who have nephritis. In nephritis, as in rheumatic fever, if a
patient comes up for a tonsillectomy or extraction of a tooth, etc., he is put on prophylactic doses of sulphanilamide, and continued on it through the day of the operation and
for three subsequent days. By doing that, we see very few of the acute flare-ups following operative procedures.
Dr. Fluhman: As far as the treatment of urinary infections is concerned, one point
has come up. Is the concentration of the sulphonamide in the urine of such terrible
importance? A great point was made on the concentration of the blood. Now, Dr.
Longcope did a very great deal of work on that point and dosage was a very important
factor. Our impressions involve so few patients that I would not like to speak
authoritatively. The concentration in the urine- is not of such vital importance. There
are two factors concerned in the use of these drugs: the tissue reaction and the blood
level. The concentration in the urine is not so important. Another factor, too, and I
hope I am right, is the reaction in people who take sulphanilamide. In these patients
who only excrete small amounts, there is a direct proportion to the kidney function
present but even with a bad kidney the infection does improve and the concentration in
the urine does not necessarily arise.
Dr. Long: Dr. Longcope really feels that without any clinical proof that you can
put up, acute haemorrhagic nephritis following haemorrhagic streptococcic infection is
of the nature of an allergic infections. It differs from rheumatic fever (which we think
is also allergic) in the fact that you can treat an acute nephritic in the acute phase with
sulphanilamide without much worry, but if you treat a rheumatic fever patient you
will have more bad effects than you have ever had before. With regard to Dr. Fluh-
man's remarks, we wrote a paper once. A year ago I would have said that you should.
have such and such a. level. It is not true. We were wrong. I will now say to Dr.
Fluhman that in our women that We have been treating for the past four years, we
are still treating them. We have these tramps in the cystoscopic clinic and they are
turned over to me for treatment. They have urethral strictures and infections. We treat
them and we clear them up, but I have never seen a woman patient who did not come
back within a year with another urinary infection. Can you cure, in the absence of
stone, urinary tract infections in adult women so that they never have it again? Because
every one that we have had before has come back with another urinary infection. You
can get a clear urine, then they will come back.  I am talking about cystitis and pyelitis.
Page   329
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I think you can do wonders with sulphanilamide and its derivatives, but I wonder if
you ever cure a lot of these women?
Dr. Fluhman: I cannot answer that, but I would like to make a couple of guesses.
Women who don't completely empty their bladder always have a little bit of stinking
urine in their bladder, which provides a good place for the bugs to grow.
Dr. Osgood: Dr. Long mentioned sulphanilamide and I wonder if he meant sulphathiazole for the urinary tract infections. It has been my opinion that sulphathiazole was
superior to sulphanilamide. I thought that for the staphylococcic and streptococcic
infections it is the best drug. None of these will work on tubercular infections in-the j
urinary tract and it is very important to be certain that there is not a suberculosis of the
kidney with a superimposed colon bacillus infection and treat the colon bacillus infection and miss the tuberculosis.
Dr. Struthers: I was interested to hear Dr. Long discussing the question of allergy
in nephritis and rheumatic fever. All these patients will give positive skin reactions.
Acute rheumatism makes them more ill. The question that I had in mind was to ask
Dr. Long if these small doses produce any changes in the blood.
Dr. Osgood was asked: Are there any incompatibilities with other drugs?
Answer: There are no important incompatibilities except with parabenzoic acid. I
used to disagree with Dr. Long on the question of magnesium sulphate, eggs, etc., but
I heard him say that he had changed his mind. The theory was, of course, that since
sulphanilamide can lead to the destruction of haemoglobin, it would be better to avoid
anything that might give rise to a sulphide. It was very sound theoretically but it
turned out to be wrong, and it is my feeling that where there is a definite indication for
other drugs in connection with the sulphonamide drugs, there is no reason why they
should not be used.
Dr. Long: One idea is that you should not X-ray a person that is getting the sulphonamides.
Dr. Long was asked: What determines the toxicity of the sulphonamides?
Answer: I can answer that in much less than four minutes by saying that I don't
know!
Question: If you don't know what determines the toxicity, what are we going to
do to prevent it?
Dr. Long: Don't give the same drug to people who have had a reaction before, and
if they have had a reaction, be careful when you give another drug.
Question: Is there anything in the prevention of toxicity in the fluid intake, etc.?
Dr. Long: We do like to keep the urinary output at 1000 c.c. or a quart, I don't
know why people react like they do. Personally, I react badly. The only thing I can
say is that when sulphadiazene is available you won't have so many worries.
Dr. Struthers was asked: Do children need higher dosages per pound than adults?
If so, why?
Answer: Children probably don't need a higher dosage per pound than adults. One
answer is that children, particularly infants, have very little chance to make their results
known. While an adult will make his complaints plain, the average infant has very
little way of making his distress known. The other answer would be that in the average
infant who is on a comparatively high fluid intake, if he be taking 2 J/2 to 3 oz. of
fluid per pound he is likely to have low blood levels and it is likely that he washes out
a great deal of his sulphonamides. We have not been particularly impressed by high
blood levels. One of the striking things in pneumonia in children is that the effervescence that has occurred in our experience appears to have little relationship to the
blood level of the sulphonamide used. I don't think that children actually require
higher levels because it is washed out more rapidly.
Dr. Osgood was asked: What effect have these drugs on the blood cells and bone
marrow?
Answer: In the concentrations that are obtained in the body we have not noted any
toxic effects in our marrow cultures of the cells.   That does not mean that we don t
Page 330 run into toxicity clinically but it means that we have not run across a marrow as yet
from a person with an idiosyncrasy, to conceal our ignorance of what is there. We are
trying to get a bone marrow from patients who have had an agranulocytosis from these
drugs and check these against a normal serum and also check the serum of persons in
the process of agranulocytosis. We have done one, but the results were not good. We
checked them with reagents and none of them seemed to do the cells any particular
harm. We speak very glibly of idiosyncrasies, but when it comes right down to knowing
why it is that some persons, with the same dose or even a much smaller dose, will get a
severe leukopenia or agranulocytosis from one of these drugs—you can give it to hundreds of others with the same concentration and they don't get it—we simply don't
know why. Undoubtedly there is a reason which we conceal under this very convenient
word of individual idiosyncrasy. We say this of the organic arsenicals. We know their
toxicity—dermatitis, etc.—and mose of the sulpharsenamides will produce many of these
symptoms. Why is it that one person will get a dermatitis and others don't get any of
these things? That is one of the most important problems with regard to drug toxicity
in general. As far as I know we have made no progress at all. If any of the rest of the
consultants has an idea, I would like to know the answer myself.
Dr. Long: I agree with Dr. Struthers. About these children, again: I agree entirely
on that pneumonia business. Some people have given children one big dose of sulphapyridine and the children got well. We say that you continue the drug for 24 to 36
hours in children. Children get well from pneumonia in a day.
In the prevention of mastoiditis, I feel that, just to be a little contrary, as far as
haemolytic streptococcal infections are concerned, or meningococcal infections, there is
quite a difference in drug level and rapidity of cure. Another factor is not so common
in adults as well as with many children who are having their first infection, while adults
have had many infections and may have some residual immunity, so you can cure that
with much less dosage than with children. It is a very good idea to have decent levels of
these drugs if you are combatting haemolytic streptococcal infections.
Question: How often should one take blood levels and how closely should blood
levels be followed?
Dr. Struthers: We have followed the teaching of others that the blood level should
be ascertained about every 48 hours and that the amount of the drug is somewhat
dependent on the blood level but also on the clinical condition of the patient. The
question of how often the drug should be administered—every four hours day and night
while the patient is febrile. After the patient is no longer seriously ill, it is Usually
given four times a day, half the dose, and omitting the night dose. But every four
hours both day and night while the infection is acute.
Dr. Osgood was asked: Should we take a white blood count regularly at certain
intervals or should we not?
Answer: From the standpoint of ideal use of these drugs, it is much safer to take
daily leukocyte counts and haemoglobins right from the start. In clinical practice, one
cannot always do what is ideal and I realize also that many persons will argue that that
is too expensive, but, while I know that many of the published articles have said that
you don't have to worry much about agranulocytosis in the first few days, I know of
one case that came in on Saturday, was started that morning on small doses, the interne
taking the initial leukocyte count. (There is one thing that I want particularly to
stress, that overwhelming infection can produce leukocytosis and can produce anaemia.
Later on you get the count and you get a leukocytosis; very likely the only way to save
the patient is to continue the drug in full doses, and if the leukocytosis were due to the
drug, the only way to save the patient is to stop the drug. I have seen patients with no
indication of their leukocyte count at the time the drug was started, and it is a very
difficult thing to judge.) The initial leukocytes in this patient were elevated. The
interne was off duty on Sunday and the other interne did not do a leukocyte count on
Sunday. On Tuesday the patient was dead. That is not very common, but my feeling
is that where it is at all feasible, a leukocyte count should be done daily at least for the
Page  331
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first two weeks, and if the drug has been stopped and then is to be started again, be sure
to get leukocyte counts again. It has been my impression that there was more toxicity
in those who had the drug for a period of time and then stopped and then re-started,
than when they were having the first start of the drug. If you have got a patient
with pneumonia 'way out in the hills, it is much better to reap the benefits of sulphathiazole in the therapy of that disease than run the very small risk of an agranulocytosis
and so on.
I do feel that these drugs carry an appreciable mortality, probably greater than general anaesthesia. I have seen about ten deaths from these drugs, and it has been my
impression that if the patient has a disease that in itself carries almost no mortality, it
is better not to give the drugs; and if the patient is not sick enough, it is better not to
give it. Many will disagree with me in this point, but if you have seen, as I have seen,
a general practitioner who delivered a girl and then later, when she was about 16, and
the mother calls up and says she has a little sore throat and he prescribes sulphanilamide
over the phone, and finally he calls me up and says she has a leukocyte count of 200,
there isn't an awful lot that I can tell him to do. So I have still some respect for the
toxicity of this group of drugs. We should weigh the risk of the disease against the risk
of the drug and the benefit that the drug is likely to give.
Dr. Struthers: I recall a patient who had the initial white count done and which
was within normal limits at death. I would like to ask Dr. Osgood at what blood level
he would consider discontinuing the use of these drugs?
Dr. Osgood: If there has previously been elevated or normal leukocyte count and
suddenly the count drops below 4,000 with an appreciable drop of the neutrophiles down
to below 20%, then the drug should be dropped instantly. With a leukopenia due to
overwhelming infection, the total percentage of neutrophiles does not drop- There may
be a marked leukopenia without the drop in the percentage of neutrophiles. I do feel
that one is justified in continuing the drugs in infections that are in themselves almost"
100% fatal in the presence of toxic manifestations that would certainly indicate discontinuance of the drug for other things; but a true agranulocytosis is always an indication for stopping the drug, because if it is not, it usually leads to a fatality. The
one important thing about agranulocytosis is to stop the drug quick enough. Transfusions, if there are enough of them, may be of some help, but it should be recognized
early, and to stop the drug is the thing.
Dr. Long: I take a little objection to what Dr. Osgood has said. There were
1,200,000 pounds of sulphanilamide sold in the United States in 1939. How many white
counts were done? Less people die from sulphanilamide than from neoarsphenamide.
It is one of the least toxic drugs we have. I agree with Dr. Osgood and Dr. Struthers
about the white counts, if you can do them. I am in the same position as you are.
When you are out in the country and you take out your white cell pipette and you
find it is plugged, what are you going to do? You give your sulphanilamide and you
go back home. Whenever you can, do .a white count. For the first time tonight I
heard of a case of agranulocytosis that died in the first 14 days of treatment. The fatal
cases fall in those days and are due to agranulocytosis. If I thought I had an infection
that I believed I could treat with these drugs, I would treat with them even if I could
not do a white count. Ask the patient how he feels and you can go a lot on that. If
we are really going to get the most out of these drugs, if you have an infection that
you think you can treat with these drugs, then treat it. The number of people that
will be saved serious complications will greatly outweigh the number who are going to
have serious damage from the drug.
Dr. Osgood: I think we really agree on this, because I said that where there is an
appreciable mortality of the disease, then treat with these drugs.
Dr. Fluhman was asked: Have these drugs any place in chronic non-venereal
pelvic infection?
Answer: Certainly; for almost five years we have given a lot of patients—women
who have had babies, who have had alarming temperatures, with urinary tract infec-
Page 332 tions—and the worst I have seen yet was a patient whose total W.B.C. dropped down
to 2,000. This question can be answered in many ways. If you are going to include
puerperal infections, the answer is yes. We have now got them from 22% down to
6%. I think that whoever asked this question was thinking of certain conditions conditions that gynaecologists have to deal with all the time, i.e., chronic parametritis and
chronic infections of the cervix. Here the answer is no. The difficulty here is that it
is no use giving these things because the patients have a pathological condition and the
damage is already done. There is infiltration of the tubes, there are rotten cysts in the
cervix, adhesions, thickened parametria. The thing is purely a mechanical thing and
that is why these patients are sick. You must approach the problem in a very different
way. In G.C. you must get the patient at the initial attack before the damage is done.
Dr. Long: My own experience in chronic endometritis is in mares and if you have a
mare that is non-fertile, by injecting sulphanilamide into the cervix you will get a
fertile animal.
Dr. Struthers was asked: Are the sulphonamides of any use in acute upper
respiratory infections?   For example, colds, sinusitis, etc.?
Answer: They have a very definite prophylactic place. We have the good fortune
of seeing a great deal of rheumatic fever in children in Montreal. It is very liable to
produce an exacerbation of the infection. We have had experience with the administration of comparatively small doses, without any estimation of blood levels, and we
have found that this administration of such small doses has been of very great prophylactic value in children.
Speaking of the minor cold, my own experience is that the administration of these
drugs has little or no effect on the course. With regard to complications of the upper
respiratory infections, it has a very definite place in the treatment. It is not our experience that it has any effect on the upper respiratory infection itself. It has no effect on
the ordinary upper respiratory infection but it has a good effect in the treatment of the
complications.
Dr. Osgood: During this last winter there was a great deal of "flu" seen and my
experience has been that there were many who felt that the sulphonamides were of great
value in the epidemic. My personal feeling was that they were of no value whatsoever.
In our 300-bed hospital we saw a great deal of "flu" this winder and we have given
very few of them sulphonamides. By the second day at the latest they had normal
temperatures. We do have to be careful about drawing conclusions. I do feel that if,
during the "flu" epidemic of 1918, we had had these drugs, the mortality would have
been reduced to practically nil instead of the enormous mortality that we had at that
time, but the mortality was not due to the "flu" but to the associated haemolytic streptococcal pneumonia, and if we should have another epidemic it would be worthwhile to
give those patients sulphathiazole, but when, as in this epidemic last year, there was not
the associated complications, I would omit the drugs.
Dr. Long: In the first five weeks of this year in the United States Army, when the
"flu" epidemic was raging, 1,100,000 men had it and there were 548 cases with pneumonia with 11 deaths. The case fatality rate during the last war was 37% and we
attribute all that drop in deaths to the sulphanilamide group of drugs. And in this
camp where they had 28,000 admissions there were only two deaths (one man was shot
and the other had a ruptured appendix which he didn't come in with). That is quite
a record.
It is the hope of the Board that next year we shall be able to set up controlled prophylactic treatment. However, there is one disease where the prophylactic use of this drug
is good and that is measles. We feel that in measles, especially if it be before the 1st
of April, it is a good thing to give small doses of these drugs in order to prevent middle
ear infection, sinusitis, bronchitis and pneumonia.
Dr. Struthers: The patient with measles is not nearly as much danger to his
community as his community is to him. I think we are probably talking about two
different tilings when we suggest the use of sulphanilamide.   We are talking about the
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haemolytic streptococcic infections and not the measles.
Dr. Long: I have just been over our experience in 1917-19. There were 200 cases
of middle ear disease following measles and I think we can cut this down to nil with
these drugs. I am talking about real measles. We feel you should start it as soon as the
diagnosis is established, and in an adult of Army age sulphanilamide, 30 to 40 grs. per
day, well distributed.
Dr. Struthers: These drugs, particularly sulphathiazole and sulphadiazene, are apparently of value at the onset of scarlet fever. They make the patient more comfortable. They produce a quicker drop in fever. The streptococcus of scarlet fever is
apparently more resistant to the sulphonamide group of drugs than are the meningococcus
and the staphylococcus. It would seem that the streptococcus is somewhat more resistant.
It has been shown that it requires a much greater concentration to produce failure of
growth of the inoculated culture than it does with the meningococcus, etc. We have
been very much struck with the failure of complications to arise in measles when small
doses of drugs as given at the onset of the disease, and it has been very striking the drop
in the number of mastoids secondary to scarlet fever. We have been in the habit of
seeing 30 to 50 mastoidectomies in one winter. This year we saw only one mastoidectomy done for mastoiditis. An acute cervical lymphadenitis is no longer fashionable for
the doctors to have. Acute cervical adenitis responds very promptly without ever the
need of surgical intervention with sulphonamide group.
(The above answer by Dr. Struthers was in answer to the question: What is the value
of sulphonamides in acute infectious disease of childhood?)
Dr. Fluhman Was asked: What are the dangers of urinary calculi formation?
Answer: I am very grateful to you for your nerve in asking this question. After all,
here is the man so I will answer what I think and let him call me a liar if he wants to.
We used to give alkalies when we used sulphanilamide. In using sulphathiazole, certainly
examination of the urine will show crystal deposits, the urine will become very cloudy,
but I still have to see a patient where there is definite evidence of large concretions,
stones in the ureter, in the bladder, that subsequently require surgical attention: maybe
we are just running away from the problem, but we are giving the patients lots of water
to drink and giving lots of sulphathiazole.
Dr. Long: In hospital, for some unknown reason, they make people void at four
o'clock in the morning.  Crystals, in the absence of anything else, do not mean anything.
Dr. Osgood: The method of choice for administration of these drugs is by mouth,
with this exception—wherever you have a very acute infection, where a matter of two
to four hours will make a difference and it is desirable to use the sodium salt of the
drug, sulphathiazole intravenously is preferable for the first dose because that gives you
your blood level immediately. It is important, when you are using the sodium salt, to be
sure that the needle is in the vein, because the sodium salts of these drugs will produce
a great deal of irritation if they don't get in the vein, but there is no essential difference
between the sodium salts and the drug once it is in the vein, because immediately it is
buffered by the blood and you have sulphathiazole in the blood stream. There are
patients who vomit so much that it is almost impossible to get a blood level by mouth.
Sometimes one can get the blood level by giving bigger doses by rectum, but usually
it is better, in my opinion, to resort to the use of sodium salts intravenously or to a
continuous drip of a saturated solution intravenously, which is another way. You can
give a suspension intramuscularly but it is not a very satisfactory way of giving it, and
one should never give the sodium salts subcutaneously or intramuscularly.
Dr. Long: I understand why that hospital has forbidden the intramuscular use of
these drugs because I saw that patient. Don't give these things any way but intravenously. In Johns Hopkins Hospital I had it figured out before I left, we have had
676 intravenous injections of the sodium salts of these drugs and the only times we
have had any difficulty was when some half-wit put them in someone they should not
have been put in. We have never given an intramuscular dose. They should not be put
in saline or glucose or blood for a transfusion. Keep it out of transfusion bottles.  Take
Page 334 fifteen minutes to give it to an adult and you have nothing to worry about. I know
another specimen in our country who gave it intrathecally in meningococcic meningitis. You are putting in a thing that is very alkaline. I saw the sections on both these
patients and you should have seen those cords. It just ruins the muscle. I have written
to the Lancet and to the British Medical Journal and they have gotten into a peck of
trouble from the intramiuscular use of the drug. That would not be permitted in the
United States.
Dr. Osgood: What does Dr. Long think about recent articles on using sodium salts
sprayed into the nose? In the J.A.M.A. there was an article recommending that therapy
and I very strongly argued against it and have a paper on it. It is just about like
spraying sodium hydroxide. I think that with the sodium salts—do not use them in
any way except intravenously.
Dr. Struthers: As far as treatment of acute infections goes, particularly meningococcus infections, we do feel that the early adrninistration should be given intravenously.
We use the sodium salts. Put in a stopcock distal to the needle and administer the
sodium salts with a syringe. As regards intramuscular administration, our experience
has been completely bad. We also have had two unfortunate experiences, due to lack of
supervision, with the intrathecal adrninistration. I would very heartily deprecate the
use of them intrathecally and intramuscularly.
Dr. Long: If you are using sulphapyridine or sulphathiazole, use one or two doses
with sodium salts intravenously. It is much easier to use the mouth dosage, 5% solution. In spite of what you say, there have been thousands of injections given in this
city and the people are still alive. I have seen some very bad results from the intramuscular administration.
Dr. Osgood: My feeling is that a leukopenia that is present before the infection is
present is no contraindication at all. A leukopenia that is due to the drug is a very
important indication for not giving any more of the drug, but a leukopenia on the basis
of etiology is no indication whatsoever.
Dr. Long: We prefer sterile distilled water every time.
Dr. Osgood was asked: What is prophylactic use and abuse?
Answer: One thing I want to particularly stress is the question of the possible
prophylactic use of these drugs as a preventative measure against subacute bacterial
endocarditis. It has been our opinion that quite a percentage of them developed following teeth extraction or some operation about the mouth and throat, and I feel that
in the case of any patient who has rheumatic heart disease or congenital heart disease,
whre such an operation is unavoidable, that it would be desirable to give both sulphathiazole and neoarsphenamine for a three-day period beginning the day before operation,
continuing on the day of the operation and for a day or so afterwards, and also to use
sulphathiazole locally in the tooth socket. We like to use sulphathiazole powder as a
prophylactic in any operation in an infection zone, in most procedures about the mouth
and throat and surgical operations about the large bowel. After tooth extraction we
simply pack sulphathiazole powder in the sacket and sew the gum over it, and even in
infected third molar extractions they get very much less discomfort, very much less
swelling and very much less complications. We also find that it is worthwhile to blow
the powder into the tonsil fossa after tonsillectomy. Where there is an operation on
the large bowel, it possibly would be worthwhile to give sulphaguanadine by mouth as
well as the powdered sulphathiazole at the site of the operation afterwards.
Dr. Long was asked: Do you consider the advent of the sulphonamides in the
therapy of G.C. has been a two-edged sword from a public health standpoint?
Answer: I Was sitting in a bar once having a drink and my table was very near
the bar and I heard one of the boys say to the others: "I am going out tonight and they
say that if you take four of these (prontylin) you are perfectly safe." The knowledge
which is prevalent throughout a large section of the public—is that a good thing or a
bad thing? We have come to the conclusion that it is a very good thing. We don't
believe in the over-counter dispensing of these drugs.
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They don't get very adequate treatment but we do know that through the result of
these drugs We feel definitely certain at the present time that we can cure 95% of all
male G.C. within ten days. Those are figures from our public health records. We
don't believe that you should ever use sulphanilamide because it is the least effective of
the drugs. You can be sure that if you treat 100 cases of male G.C. with sulphanilamide
you will get 60% cure. With sulphathiazole and sulphapyridine you can be sure that
with only the slightest toxic symptoms you can get 95% of male G.C.
What about the cases you don't cure? Don't give sulphanilamide. The 5% that
we are not curing we should treat locally or with fever therapy. We feel that of that
95 out of 100 who are going to be cured, 80 are probably non-infectious in 72 hours.
We say, Go back to work, loaf on the job. We feel that in our military and civilian
establishments, the advent of these drugs is going to save an enormous amount of man
days. If you translate that into groups and squadrons you can see what an enormous
difference we have today, and I feel that—give us the money and we shall practically
be able to eliminate G.C. from the United States. Chicago is going to spend one million dollars on G.C. for sulphathiazole.
The same seems to be pretty true of women. You can get a high percentage of
cures in women and hence there is every reason to believe that the risk is going to be
remarkably reduced within the next ten years.
The speakers were then asked if they had had any personal experiences with any of
these drugs.
Dr. Osgood: No.
Dr. Struthers: Yes, on three occasions. The first occasion was pure curiosity—
20 grs. five times a day. My curiosity was quite satisfied. The most distressing feature
was dizziness. Taking it in smaller doses, the results were not nearly as unpleasant.
The sensation of tightness in the head and dizziness, some nausea but no vomiting, is
very distressing. One thing I did learn was that a great deal of the distress was relieved
by drinking large quantities of very weak tea. Why this is so I don't know but it is
apparently a fact.
Dr. Fluhman: Yes. Three or four years ago I went to work one morning with all
the evidences of an acute cold. I met a good friend of mine, a graduate of Johns
Hopkins, and he told me to take sulphanilamide. I went home in the middle of the
afternoon and went to bed and took 5 grs. of sulphanilamide and twenty minutes later
the room started to go around. I took another 5 grs. 1 l/z hours later. Ever since then
I have taken the colds instead of the drug.
Dr. Longs Twice I have taken these poisons. At 4 o'clock I took 6 grams in one
dose and at 5 o'clock I went to a cocktail party. After two cocktails I could hardly
made my way back to the hospital. About 10 o'clock the night watchman came along
and I didn't even know he was in the room. The second time I took it for an infection
and the room went around on me and finally I was under the bed and holding on to it.
I had extreme dizziness, was quite disoriented at the time. Sulphadiazene gives practically none of these symptoms and so is greatly relished by nearly everyone.
#       *       *       *
Regarding these drugs and whether they have any effect on ulcerative colitis, Dr.
Long said: I wish I knew. I went over the records of about 200 cases in the hospital
and found that 2 out of 10 make a brilliant response to these drugs. Another 2 out of
10 you feel hopeful about and the patients feel hopeful and you have to give them
prontosil over long periods of time and finally they flare up, and the other 6 patients
don't do anything and you wonder why, and you shift around and you just don't know
anything. It is all a part of the complete confusion in our minds as to the cause of
ulcerative colitis.
Page 336 ><;'
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Hospita
A SUMMARY OF THE PROBLEM OF DWARFISM,
WITH PRESENTATION OF TWO CASES
By C. E. Gould, M.D.
Dwarfs have been known since the dawn of history, but the world repudiated the
statements of early geographers and writers of antiquity such as Homer and Herodotus,
who described races of pygmies quite accurately, and their actuality was not definitely
re-established until the latter half of the nineteenth century, and since that time extensive studies have been made of the pygmy peoples found widely in equatorial Africa, and
in lesser numbers in Madagascar and southern India.
These pygmies are all of Negroid origin.
The derivation of the word pygmy is from the Latin pygmaeus—about a foot long—
in turn derived from the Greek pugme, meaning the length of the forearm with the
fish closed.
The word dwarf is derived from the Anglo-Saxon, and means simply a diminutive
man. In ancient times dwarfs were kept by persons of rank for their amusement. The
Roman ladies kept them as domestics. In Europe the passion for dwarfs reached its
height under the reigns of Francis I and Henry II of France.
A great deal of Scandinavian mythology has to do with dwarfs, who were supposed
to have been produced as maggots in the flesh of the great giant Ymer, and the gods
gave them the form and understanding of man. They shunned the light, and lived in
the earth and rocks, and were very skilful artisans, and manufactured priceless treasures
from rare metals for the delight of the gods. The cardinal points of our present-day
compass are named after four of these Norse dwarfs, who supported the four corners
of the heavens on their shoulders, and were called North, South, East and West.
Outstanding among actual dwarfs who have become historically famous are Philitus
of Cos, a grammarian, poet and teacher of royalty; Nicholas Ferry, a court favourite of
Stanislaus, King of Poland; the brother of the great Erasmus, whose mind was as perverted as his body was stunted; and more recently General Tom Thumb, an American
by the name of Charles J. Stratton.
In the fourteenth century the great English explorer, Sir John Mandeville, brought
back tales of fabulous people whose heads grew out of their chests, etc., while in our
own time the American explorer, Martin Johnston, has brought back moving pictures
of the pygmy peoples of the African jungles.
Dwarfs have played their roles in the literature of the world from time immemorial.
In our own time brilliant psychoanalytical studies have been made by Oscar Wilde in
"Birthday of the Infanta," and by Walter de la Mare in "Memoirs of a Midget."
The great masters have painted dwarfs. Outstanding are the works of the Spanish
artist of the seventeenth century, Velasquez, twelve of whose canvases depict some of
the different types of dwarfism with unerring accuracy.
Normal Growth and Development:
There are many factors influencing the growth of a normal child, principal among
them being heredity, sex and environment. It is impossible to formulate a curve for
any individual, but in general growth shows three main cycles of rapid growth, with
slower growth between them. The first is in the first year of post-natal life, the second
has its peak in the sixth or seventh year, and the third is in the adolescent spurt. These
three "springing-up" periods represent an acceleration of skeletal growth, while the
"filling out" periods between may be termed visceral growth.
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In addition to these cyclic variations in general growth rate, there are variations in
growth rate in different parts of the skeleton. In the infant the limbs are short in
comparison to the trunk, and the normal infant measures more from symphysis to
vertex than from symphysis to soles. This is maintained until the second growth wave,
at about the time of the second dentition, or about the sixth or seventh year, and from
that time on the distance from symphysis to soles is greater than from symphysis to
vertex.
This is accounted for by the fact that the activity of the growth cartilages varies
considerably • in different sites. Each cartilage has its norm, and the activity can be
measured by the number of cartilage cells in the columns. Harris has pointed out that
the most active growth cartilages are those around the knee, and here in the distal cartilage of the femur and in the proximal cartilage of the tibia the number of cells in each
column is maximal, counts of twelve to fourteen cells being common. The growth at
the upper and lower surfaces of the vertebral bodies, however, is much slower, the
number of cartilage cells in the column being usually less than five. The rate of growth
at the upper and lower surfaces of the vertebral bodies is only from one-quarter to one-
third of that in the region of the knee. Further, growth in the tibia is faster than in
the femur for the combined activity of the two growth cartilages in the tibia exceeds
that of the cartilages of the femur. Histiological evidence thus confirms the clinical
view that during the active growth period, activity in the limb bones is greater than in
the vertebral column, and greater below the knee than above it. This accounts for the
observed fact that during the growth period, in normal children, the bodily proportions
change from those of the infant to the adult type.
In considering the structure and changes in growth cartilage during growth it is
obvious that cartilage is essentially a vegetative matrix, relatively avascular, in which
actively proliferating cells are growing in columns, and these growing cells depend for
their nutrition mainly on tissue-juice diffusion, as the vascular arrangemnets in the
spiphysis and metaphysis are only relatively effective. The vessels of the epiphysis, from
the vascular circle around th joint, and those of the metaphysis, from the meain vessels
of the shaft, have no free communication. Cartilage cells proliferate by transverse
fission, and mitotic figures can be shown by special stains. The arrangement of the cells
undergoing mitosis is in the form of a ring at the head of the bone, and from this ring,
traced centripetally to the epiphysis and centrifugally to the diaphysis, three zones of
gradually maturing cells can be found. In the zone next the ring the young cells are
arranged in columns or palisades, in the middle zone enlarged and degenerate cells with
calcified matrix occur, and in the zones farthest from the ring, those next to the
diaphysis, and in the centre of the epiphysis, osteogenesis is proceeding. Conditions of
nutrition become gradually more and more difficult for the cells removed from the ring,
and this results in calcification of the matrix. Subsequently the calcified matrix is
removed by ingress of blood vessels carrying osteogenic cells, the function of which is
to deposit bone. This is a process whereby the senescent cartilage, as a virtual foreign
body, is replaced by highly vascular bone. We thus have the arrangement of an ossification centre in the epiphysis, and an area of ossifying cells in the metaphysis, representing new bone laid down at the end of the shaft. In between and at the junction
are the young cartilage cells, which continue their activity throughout the period of
active growth. It is on these that the growth of the long bones depends. In the vertebral bodies the number of cells in the growth columns is fewer, otherwise the process
is the same.
Factors Influencing Growth:
These are many, and imprefectly understood. If the anterior pituitary is removed
from an animal it continues to live but fails to grow. However, the inherent growth
tendency present in living cells is demonstrated by their ability to growth in tissue
culture.
Undoubtedly heredity is a major factor in growth determination. It has been customary to associate racial dwarfism with pituitary activity, assuming that the endocrine
Page 338 constitution too was determined by heredity. However, Harrison has shown, in experimental work on the transplantation of limbs, that limbs and other structures from two
species of different sizes, in the same endocrine environment, will respond differently,
and grow according to their inherited growth capacity. It would seem, therefore, that
the chief factor in the production of inherited racial types would be genetic constitution.
The anterior pituitary hormone is an important factor in growth, and apparently
affects the tissues directly, and also indirectly through integration with other glands
such as thyroid, adrenals and sex glands. It has been shown by Evans that in animals
given anterior pituitary growth hormone there is a maximum growth reached, and that
no matter how much hormone is given after that point is reached, no further growth
takes place. He has also shown the most rapid normal growth has never been exceeded
by the use of the growth hormone.
Thyroid hormone, from a quantitative standpoint, stimulates growth only temporarily, but from a qualitative standpoint it is of major importance at all times.
Without it normal development and function cannot be attained, and this applied to
the growth cartilages of the skeleton as well as to other tissues.
Thymus extract is thought to have a definite influence on growth prior to puberty.
Rowntree and Hanson produced a rapid acceleration of growth in rats, that became
halted by gonadal development.
The sex hormones influence growth indirectly, insofar as they induce maturity, and
have to do with the time of fusion of the epiphysis.
External factors affecting growth are food and disease, and, to a lesser degree,
season and climate.
The role of vitamins in growth is well established experimentally, since it is possible
in rats to stop growth at will be excluding one or another vitamin from the diet.
Classdttcations of Dwarfism:
The term dwarfism may be defined as a defect in stature below the normal limits,
and may be either proportioned or disproportioned. If disproportioned the defect may
be in the spine or the long bones.  The underlying cause may be congenital or acquired.
The term infantilism refers to a more or less permanent condition in which the
physical and psychological attributes of childhood persist into adult life.   In short,
dwarfism is a defect of growth, infantilism a defect of development.   The two are not
necessarily coexistent, but are found together in a high proportion of cases.
Simple Dwarfism:
1. Simple Hereditary Dwarfism.
2. Simple dwarfism due to developmental skeletal disease:
(a) Achondroplasia, chondroosteodystrophy, and dyschondroplasia.
(b) Osteogenesis imperfecta.
3. Simple dwarfism due to acquired skeletal disease:
(a) Simple rickets and late rickets.
(b) Spinal deformities due to Pott's disease, poliomyelitis, etc.
4. Hypergonadal dwarfism.
Dwarfism and Infantilism:
1. Cachectic.
2. Cachectic infantilism associated with more specifis changes at the growth cartilages:
(a) Congenital syphilis.
(b) Scurvy.
(c) Cceliac rickets.
(d) Renal dwarfism.
3. Endocrine:
(a) Hypopituitary
(b) Hypothyroid.
(c) Hypogonadal.
Page   339
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1. Simple Hereditary Dwarfism:
This should not be regarded as a pathological state unless the term pathological i
defined in its strictest sense, as these individuals, except for their small stature, are entirely
normal. Puberty occurs at the normal age, and mental and sexual function is normal.
The racial types are exemplified by the Norwegian Lapps, the central African pygmies,
and by peoples in the Andaman Islands and Madagascar.
2. Simple Dwarfism Due to Developmental Skeletal Disease:
(a) Achondroplasia, chrondoosteodystrophy   (Morquio's disease), and dyschondro-
plasia (Ollier's disease).
It is now recognized that these three conditions are different manifestations of the
same pathological state, a dyschondroplasia probably due to a nutritional defect of the
growth cartilage. Achondroplasia represents the extreme form, i.e., an aplasia, while
the others are intermediate varieties.
In achondroplasia there is mucoid degeneration and absence of cell proliferation in
the growth cartilages. The normal palisading of the cells into columns is absent, hence
ossification and longitudinal bone growth is interfered with.
The term osteochondrodystrophy applies to several ill-understood conditions, mainly
concerned with irregular development of the metaphyses and epiphyseal ossification
centres. In Morquio's cases the epiphyseal ossification centres appeared as multiple foci
which either fused gradually or became distorted and fragmented in joints subjected to
pressure. In the vertebral column affected vertebral bodies became irregular in shape
and size, the result ©f compression from the superimposed vertebral column.
Dickson Wright in 1930 reported cases of generalized osteochondritis, in which
every epiphysis in the body became fragmented and distorted.
The term dyschondroplasia was coined by Oilier in 1899 to describe the condition
in the growth cartilage in which cartilage cell proliferation is present in excess, but
there is failure of the senescent change with ossification to occur, and as the bone
develops masses of unossified cartilage persist at the metaphysis. Hereditary deforming
dyschondroplasia is a variety of this condition, with additional features—an unmodelled
metaphysis and exostoses.
Clinically these conditions have much in common, and dwarfism is generally pronounced. The achondroplasic represents the extreme form, in which the whole skeleton
is affected and the changes are present at birth. The characteristic appearance is produced by a combination of normally sized trunk and short limbs, particularly the proximal segments, a relatively large head and small face with depressed nasal bridge and
trident hand. A lumbar lordosis usually produces a protuberant abdomen, and the gait
may be somewhat waddling. Dentition, sex and mental development are normal. The
X-ray changes in childhood and adolescence are characteristic. The space between the
epiphysis and metaphysis is smaller than normal, and the metaphysis tends to be splayed
and broadened between the joints, producing the characteristic "petunia-like" appearance, due to failure in the modelling process.
The dwarfism of chondroosteodystrophy is very similar, but the child is normal at
birth, and the head and facial changes are not found as in achondroplasia. The defects
may be in the vertebral bodies or the limb bones, or both. The X-ray shows fragmentation of the epiphyses. In some cases the condition improves as the child grows older,
but even when a satisfactory growth rate is resumed, a degree of dwarfism remains.
The clinical pictures of dyschondroplasia and hereditary deforming dyschondroplasia
are similar to the above, but the limb bones are chiefly affected, and shortening and genu
valgum are prorninent.
(b) Osteogenesis imperfecta—osteopsathyrosis or brittle-bone disease.
The greater part of the dwarfism produced by this disease is due to the multiple
fractures, but in addition the bones are actually shorter, thinner and smaller than normal, but decalcification is not prominent, nor is it the cause of the fractures, which are
due to an extreme degree of brittleness, the cause of which is unknown.   The presence
Page 340 i*
of blue-sclerae, and sometimes of other congenital abnormalities, places this condition,
for the present, in the category of an hereditary anomaly.
3.  Simple Dwarfism Resulting from Acquired Skeletal Disease:
Systemic disease in childhood has a pronounced effect on the epiphyseal cartilages,
producing a temporary arrest and calcification, which can later be seen, "travelling up
the shaft" as it were, as a thin calcified line. A quick succession of severe systemic diseases may completely arrest the epiphyseal cartilage, and there is no further growth,
resulting in a dwarf.
Aside from these cases, however, there are two types of dwarfism secondary to
acquired skeletal disease:
(a) Those due to simple and late rickets;
(b) Those due to Pott's disease or other spinal deformity.
(a) The pathological cause of rickets is a vitamin D deficiency, and the physiology
and pathology are well known, although the disease is becoming very rare, at least on
this continent. The intensity of the process is directly proportional to the rapidity of
growth, so that the non-growing animal does not develop rickets. "Late rickets," a rare
condition, is thought to be due to vitamin D deficiency in adolescence, and is usually
manifested by marked bowing of the legs, bending downward of the neck of the femur,
and slipping epiphysis.
(b) The types of hunchback dwarfism produced by tuberculosis of the spine, and,
in rarer cases, by muscular atrophy following poliomyelitis, are familiar, and need only
to be mentioned here.
4.   Hypergonadal Dwarfism.
This rare type of dwarfism is the end result of macrogenitosomia praecox of childhood. This syndrome at present is attributed to three types of tumours: those of the sex
glands themselves, those in the region of the third ventricle and pineal body, and those
of the adrenals.
In all three syndromes—genital, pineal and adrenal—the outstanding features are
skeletal, somatic and sex development inappropriate to the age of the individual and
suggestive of adulthood. Bone development is advanced correspondingly, ossification
centres appear early, and epiphyseal fusion occurs prematurely, so that the end result is
an adult dwarf. These are rare, however, as the majority of these tumours are malignant.
Dwarfism and Infantilism:
1.  Cachectic Infantilism.
The etiological factor in this is a chronic wasting disease occurring during the growth
period. This causes retardation of general development and "lines of arrest" in growth
cartilages. The skeletal and other systems of the body are affected proportionately. Any
condition of prolonged illness in childhood may produce this result, but especially important are gastro-intestinal diseases where there is a long-standing interference with
nutrition. Chronic abdominal tuberculosis and cceliac disease are the most typical
examples. The latter condition will also produce rachitic changes. Other causes of
cachectic infantilism are insanitation from underfeeding, chronic dystentery, and intestinal works. In regions where malarie and hookworm disease are in evidence, both have
been found to lead to serious delay in development.
Lorain's original description of cachectic infantilism has not been bettered: "The
physique remains feeble, and the general bodily form is small; the skeletal proportions
are normal; the genitalia appear diminutive, but are in proportion to the bodily size.
There is no defect in intelligence, but the mind remains childish. The changes of
puberty do not occur at the normal age, and may be delayed until eighteen or twenty.
Even then they may not be normally established, but, in later life fuller development
is usually reached." The only factor of significance that has been added to this description is that by the X-ray lines of arrested growth can be demonstrated in the diaphyses.
Page   341
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2. Cachectic Infantilism with more specific changes at the growth cartilages:
(a) Congenital syphilis:
In addition to general cachectic changes, there is a more specific lesion in the growth
cartilages, interfering with growth in the long bones, and producing a disproportioned
dwarfism. This lesion is a syphilids osteochondritis, a chronic inflammatory process
destroying the normal arrangement of the cartilage cell columns. Fibrous tissue of
chronic inflammation is interspersed in this area, and the margin of the newly formed
bone is irregular. By the X-ray the free edge of the ossification zone has a saw-tooth
appearance in which the teeth are irregular in size. Another differentiating feature is
that the lesion of syphilitic osteochondritis predominantly affects the slower growing
cartilages at the proximal end of the femur and the distal end of the tibia, while scurvy
and rickets are usually manifested at the fast growing cartilages around the knee.
(b) Scorbutic infantilism:
Scurvy that has persisted long enough to produce dwarfism and infantilism is more
of historical than medical interest at present. The clinical, history and findings are
diagnostic, and the X-ray shows evidence of recent or old haemorrhage around the ends
of the long bones.
(c) Coeliac rickets:
The usual picture of infantilism due to long continued coeliac disease may be complicated by the presence of rickety changes in the metaphyses of the long bones, and
produce a short limbed, disproportioned skeleton. Radiologically the metaphyses are
swollen and cupped as in rickets and the epiphyseal line becomes irregularly serrated.
Clinically, the general appearance is similar to hypopituitary infantilism, with pronounced dwarfism and delay of secondary sex characteristics. The X-ray evidence of
rickets, and a history of fatty stools, usually gives the clue to the underlying cause.
(d) Renal dwarfism:
Renal dwarfism from chronic interstitial nephritis in childhood presents a very similar picture. It differs fundamentally from the other types in being due to the action of
retention products, that is, inadequate excretion of phosphates by the kidneys, and consequent interference with calcium metabolism. The underlying renal condition is in
many cases congenital.
While in the past the renal lesion has been accepted as the primary cause, with the
phosphorus and calcium metabolism and bone changes secondary to it, there is recent
evidence in support of the view that the parathyroids are the primary seat of the lesion,
that they upset phosphorus metabolism, in turn producing renal and body lesions. This
work remains to be confirmed.
3. Endocrine Infantilism.
( a )  Hypopituitary:
The most clearly understood pathological states causing hypopituitary infantilism
are vascular lesions and tumours. Little is known of the functional exhaustion of the
anterior lobe of the pituitary. Simmonds described the syndrome bearing his name, of
infantilism, cachexia, and defective growth from ischaemic necrosis of the anterior pituitary, the result of infarction generally from infective or acute illness. Since that time
there have been characteristic cases of Simmonds' disease in which no lesion of the
anterior pituitary or any other endocrine organ was found at autopsy.
The deficiency syndromes in childhood due to compression from a tumour are those
associated with parahypophyseal and suprasellar cysts. As a rule the clinical picture is
characterized by infantilism, dwarfism and obesity, the syndrome originally described
by Froelich. This namenclature cannot be followed clinically, however, as cachexia is
sometimes found with parahypophyseal cysts, and typical cases of Froelich's syndrome
without tumour. The relationship of the various metabolic upsets in these cases, notably
those of sugar, water and salt, are imperfectly understood, and the safest classification
at present would seem to be hypopituitarism with or without tumour.
Page 342 In the absence of X-ray signs of pressure from tumour in or around the sella turcica,
the best way to diagnose hypopituitarism without tumour is to rule out, if possible, all
the other causes of dwarfism.
(b) Hypothyroid infantilism:
Since a close relationship between the pituitary and the thyroid is known to exist,
it is impossible to postulate a pure hypothyroid dwarfism. The striking picture of
cretinism is undoubtedly predominantly hypothyroid, and in this congenital type of
athyroidism the long bones are affected more than the trunk, and a disproportioned
short-limbed dwarfism results. The ossification centres are late in making their appearance in the cartilaginous epiphyses, and when they do they develop slowly. Growth may
come practically to a standstill in untreated cases, and the epiphyses may remain largely
cartilaginous till the end of life.
In post-natal hypothyroidism, the resulting skeletal defects depend to a large
extent on the age at which the thyroid defect develops. If it antedates the second dentition, and remains untreated, a disproportioned short-limbed skeleton is found. If it
post-dates the second dentition the skeletal disproportion will be less marked. Puberty in
hypothyroidism may be indefinitely delayed, and the associated mental retardation and
myxedematous skin changes help to make the characteristic picture.
(c) Hypogonadal infantilism:
Cases of this type are extremely rare. They may result from pre-pubertal castration,
in which case the etiology is fairly clear, but, if seen in adult life, presenting a picture
of eunuchoidism (from undescended testicles), infantilism and dwarfism, it is almost
impossible to tell whether the lesion is primarily gonadal or pituitary.
CONGENITAL SYPHILIS
Delivered at Summer School of Vancouver Medical Association, June, 1940.
Dr. P. C. Jeans
There has been a good deal of discussion in the past as to what term to apply to this
disease. There has been objection to each of the several names that have been given to it.
It has been spoken of a hereditary or inherited syphilis but objection has been taken to
this because it does not conform to the usual laws of heredity. The term congenital does
not necessarily imply that the parents had the disease, and sometimes it seems desirable to
have this implication. Sometimes it has been called prenatal syphilis, but there has been
objection to this.   I don't think it makes much difference what it is called.
It is of some interest, no doubt, to find out with what frequency one may expect
to encounter syphilis in childhood. It is necessary to consider briefly the frequency in
the adult because if it did not occur in the adult it would riot occur in the child. There
have been all kinds of estimates of frequency of this disease. We know that the disease
is much more frequent at lower economic levels; it varies with forms of occupation. It
is seen more in sedentary occupations than in those doing manual labour. So often the
material used in these experiments is rather highly selective. Much of this data bears
on attendance at Outpatient Clinics among people who are sick. Naturally, one expects
to find this disease more frequent in such groups, in groups of people who are sick. In
general, I think as far as the United States is concerned that at the lower economic level
one may find 10% of the male population to be syphilitic. Figures even up to 20%
have been given. Among the women of this same social level, the incidence is very much
lower, but after marriage the proportion among the women approaches that for the
men; so that one may expect figures something like 10% in this lower economic level.
As to the children in these groups at this same lower economic level, we find at Outpatient Clinics that something like 3 % of the children in the larger cities in the United
States will have syphilis.   If this figure is again subdivided according to age, we find
Page   343
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that the incidence for children under 2 years is around 5% and for over 2 years it is
around 2%, meaning that syphilis is more frequent among infants than among older
children.
At one time we undertook to survey the population of the city of St. Louis, and in
the process examined the cord bloods and placentae of rather more than'2,000 pregnancies and examined as many babies as possible after they were two months of age.
From this survey we came to the conclusion that even in the lower economic levels and
among the white people, syphilis approximated l%o%- ^n tne higher economic levels
we have a situation quite different. It is very difficult to get any accurate information,
but it seems certain that the figure for men is definitely less than 1 %; Wasserman positive in about %0 of 1%. However, it is found that some of these do. When surveys are
made of college students (as they have been in the recent past among quite a number of
the United States colleges) is is found that the real situation would be 2 for each 1000
students. Any survey made at any particular time does not represent what is going to
happen to the individuals at some later date. I recently noticed some figures given out by
the United States Public Health Service, indicating that something like 1,000,000 new
cases appeared in the United States each year. On the basis that each syphilitic man does
not infect his wife in every instance, and not in every case does a syphilitic woman give
birth to a syphilitic baby; it appears that you would not expect to get a child with syphilis
more than once in every 500 patients, and it might even be more than 500 patients.
Interesting is the means of transmission from the parent to the child. There are relatively few men who have the means to get married at the time when they have
active syphilis. Many of them have acquired the disease, the disease has become latent,
and some of them have taken the cure, and even under these circumstances syphilis has
been transmitted. How can it be done? There is evidence that the testes are involved in
every case in the male, and when examined histologically there seems to be evidence that
there is involvement of this organ. This has been decided in other ways—by examining
the semen of such a man and finding the spirochete by inoculation of animals. So we
do not believe in the germ transmission of this disease. It is our present belief that the
mothers of syphilitic children are infected in all instances and that this infection has
travelled through the placenta to the child, when the child is infected in utero. Formerly, it seemed clear that there might be maternal transmission without infection of
the mother. In approximately 90% of syphilitic children, the mothers will honestly
deny any knowledge of this infection, and because the mothers seem so free of infection
and the father admits it in many of these instances, it seems rather clear that the father
could transmit the infection directly to the child. However, this seems to be not the
case. These mothers are known to be syphilitic by various means—by the Wasserman
reaction, by exarnining the lymph nodes for spirochaetes. Mothers apparently non-
syphilitic really are. Just why it is that syphilis treats these women so kindly is not
wholly clear. It is well known that pregnancy does make a marked difference in the
course of the infection. This has been shown by the experimental animal. It is known
that pregnancy makes changes in the time between the various stages of the disease and
tends to ameliorate the infection of the disease. One seldom sees clinical neurosyphilis in
the woman who has been pregnant. There are certain hypotheses that have been advanced
as to reasons why the disease treats the women so kindly. There are a number of old
laws of rules of transmission that are still with us. They have not died wholly yet. For
example, the law which is merely an observation, to the effect that a congenital syphilitic
baby will not infect its own mother. The reason for that is perfectly obvious. You
cannot reinfect a person already.infected. The same is true in the law in which it is
stated that the syphilitic mother cannot infect her own child. There are certain exceptions to this. There has been discussion in the past as to the fate of twins but this seems
so simple that it does not seem worthy of much discussion.
The discussion of the third generation of syphilis is still with us. It seems reasonable
that it can occur, but it is difficult, perhaps impossible, to prove definitely that it ever
Page 344 does occur, for the reason that one cannot have any human being under close observation
over so long a time. One may find evidences that the disease really has been transmitted
to the third generation. I have seen a syphilitic mother who was able to give birth to
syphilitic children over a period of 20 years, having, therefore, active syphilis to the
extent of being able to transmit it, and every one of those children was syphilitic. If it
can remain active for that length of time, then it certainly should be able to be transmitted to the third generation. Even fourth and fifth generation transmission may be
possible. Even though it is theoretically possible it is relatively unimportant. It is always
recognized that syphilis is a family disease. When it is encountered in a member of the
family, it is found necessary to examine all the members of the family. The effects of
syphilis in a syphilitic family have been studied by many people and one finds a wide
variation among records. These variations depend upon the type of selection used. If the
family has been chosen for study because of a man with latent neurosyphlis, the incidence of effects of syphilis on his family is usually very small, whereas if one selects a
family orf the basis of a syphilitic child, then one finds the maximum effects so that
these figures of effects on f amilies will differ according to the manner of selection of
material for study. In our own case, we have chosen families because of the syphilitic
child, and have found that premature birth is twice as frequent in the syphilitic groups
as in the non-syphilitic; also that foetal death is twice as frequent in the syphilitic families. In the lower economic groups, 25% of all of the pregnancies of a syphilitic group
resulted in foetal death; 9% in the same economic groups where there was no syphilis.
One might assume that the difference was caused by the infection of syphilis. Does
syphilis have any effect upon sterility? In general, it would seem that it does not. No
doubt in isolated cases one might find a bearing, but on most families there has been no
effect whatever, because in these syphilitic families the number of children is much
greater. The ability to raise children is certainly not impaired in the majority of these
families.
Syphilis is very effective in producing infant mortality. Infant mortality may be
looked at from several points of view. We have found in our own material that infants,
born living, died in their early months or first year twice as frequently in syphilitic
families as in the- non-syphilitic families. It was not shown that they died of syphilis.
Another way to study them is by following syphiHtic babies who come under our care,
to see what happens to them. We have been treating syphilis now for quite a long period
of years and in the early years of treatment we had a mortality of approximately 3 3 %
among these babies. In more recent years the mortality has been smaller but even now
it approaches about 20%. Of course, one of the contributing factors is the fact that
so many of these babies come under care very late in the disease when it has become
very active.
There are various studies of the incidence of syphilis in syphilitic families. In our
own studies we have found that 70% of the living births have resulted in children
who were syphilitic, and of those who were dead at the time of the survey (and these
were excluded as not being syphilitic) even then 60% of the members of the family
were syphiHtic.
In a summary of the damage in the kind of group that we have studied, we found
that 25% of the pregnancies result in miscarriage and stillbirth; 20% result in living
births, the children later dying; 40% resulted in living births, the children having
syphilis; and only 15% resulting in non-syphilitic children. This seems highly important,
therefore, in the syphiHtic family; but when one takes this along with the population as
a whole, it is not so very important. Just what role it plays in mortaHty and morbidity
on the population as a whole, it is very difficult to say. Perhaps 1% of the infant deaths
are caused by this infection. This is an unrefiable figure, however, as so many times it
is not stated on the death certificate.
There are other factors to be considered. Dystrophies might occur. It is now the
general view that they really do not occur, that these things have been misinterpreted;
that some of the things formerly considered as syphiHtic dystrophies are not syphiHtic.
Page  345
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Repeatedly I have encountered the idea that harelip may be a syphiHtic dystrophy, but
I am quite sure that it has nothing to do with this infection. Of all the children we
have seen with congenital syphilis, I beheve we have encountered only one or two with
hareHp; so I think there can be no relationship.
As to the diagnosis of congenital syphilis, here we encounter several pecuHarities.
One would like to diagnose it at the time of birth but we are faced with quite a number
of difficulties. There is the placental examination to be considered, and we have studied
the placentae rather extensively, and it is our finding that when the placenta is found
by histological exarnination to be syphiHtic, the baby is in all instances syphiHtic. However, the placenta does not show this in a high proportion of cases. In our own cases,
this proportion is only 28%. With such a small proportion it would hardly seem worth
while to make a histological exarnination of the placenta. Dark field examination is
useful, but only for lesions that are superfiicial. The clinical examination, of course, is
highly useful, but so often one is led astray by things which may be syphiHtic but turn
out not to be syphiHtic. The behaviour of the Wasserman reaction in the case of syphiHs
is sometimes a Httle confusing. Among babies who are later shown to be syphilitic, we
find that approximately two-thirds of these babies have positive Wasserman reactions
at birth. So one cannot depend upon the Wasserman reaction from this point of view.
On the other hand, there are syphilitic mothers with a positive Wasserman reaction whc
don't transmit the infection to the baby but they do transmit the Wasserman reaction,
but the baby may not be syphilitic. I think possibly that in those which are very strongly
positive, the chances are great that the baby is syphiHtic. In the course of the first few
weeks of life, aU Wasserman reactions that have been transferred have disappeared and
all negative Wassermans in syphiHtic babies become positive, so that at two months of
age we find the whole situation cleared up. In all instances of syphiHtic babies, the
Wasserman will be positive and in non-syphilitic babies the Wasserman will be negative.
There should be no confusion. After this age of two months or so, the reaction remains
strongly positive, sometimes throughout the period of childhood and someitmes not quite
so long, so that in later childhood we find a high proportion having a strongly positive
reaction. In our own material, this is 93.3% in our older children. In the small residual
figure the reaction was negative in the children that we thought possibly might be
syphilitic. We know that syphiHs can become spontaneously cured so that perhaps in
some of these cases the cure had been spontaneous.
We have encountered two or three cases of neurosyphilis "where the spinal fluid was
positive but the Wasserman was negative. Therefore, a negative reaction in childhood
is of much greater significance than in the adults. It is my own conviction that syphilis
should not be diagnosed in a child in the presence of a negative reaction. The more cases
that are studied, the more it becomes apparent that this is not the case. We have shown
to our own satisfaction that he cases which were studied were not syphilitic. There is
some tendency at times to diagnose syphilis on the basis of the parents. There seems to
be some trouble to get a positive reaction in the baby; therefore one takes it from the
parents. By the time the baby comes under our observation, about half the fathers win
have a negative reaction. About 24% of the mothers will have a negative reaction by
the time the child comes under our observation. So that one might find syphiHtic parents
who do not transmit the infection to their children and one will find parents who give
negative Wassermans who have transmitted the infection to their children. Thus, one
canno rely on the diagnosis of the parents; it must be made on the person under consideration. It has been our own observation that if a mother has a strongly positive
Wasserman reaction, the chances are about 70% that she will give birth to a syphilitic
baby; 90% in the other direction, if she is weakly positive.
Congenital syphiHs is not so very different from the acquired syphilis of the adult.
There are just a few differences. There are the same stages of the disease except that
there is no primary stage. The initial lesion is in the placenta. The secondary stage is
represneted by infantile syphilis. The tertiary stage is represented by late syphilis in the
older child.   We find that in the child certain things happen that don't happen in the
Page 346
*L adult with syphiHs. In the infant with syphiHs, we find more extensive skin lesions.
Sometimes they occur on the face and the infiltration may be very deep and leave behind
scars. In the infant we may find a rhinitis with considerable severity at times. We find
syphiHtic changes in the bones of the infant of greater frequency than in the adult, and
certain of these changes do not have any counterpart in the adult. We do not have the
developmental changes in the adult because he is fully matured. In the cases of keratitis
we find the most common condition of late syphiHs. The most important phase of congenital syphiHs. This is quite as frequent as in the adult with acquired syphiHs and it
would seem that this fact is not fuUy appreciated. I have already spoken of the delayed
positive reaction in the Wasserman of congenital syphiHs. Early in the course of congenital syphiHs, if there is going to be neurosyphilis, there will be changes in the spinal
fluid, but the Wasserman reaction may not be positive for a period of months; whereas
in the case of the blood Wasserman, it only takes two months for it to establish itself.
It is my opinion that if there is ever going to be neurosyphilis develop, there will be
evidence of it in the nervous system in the early months of infancy, and that these
infants who have negative cerebrospinal fluids in these early months will forever have
these negative cerebrospinal fluids.
There are certain observations that perhaps might be of some Httle interest. We
have come to the conclusion, upon examination of our own material, that there is no
such condition as neurotropism, that there is no evidence of this. We have seen evidence of this in the birth of twins. One twin may have neurosyphilis and the other may
not. Everybody knows about Hutchison's triad and I am sure that you realize that this
is of no value in diagnosis because it does not occur very often, because one of the components of this triad, deafness, is relatively rare. With deafness so unusual, one would
not expect to find this condition as having any importance in diagnosis. At the present
time our methods of treatment are superior to the time of Hutchison ond children come
under care before he period of deafness.
As to the treatment of congenital syphiHs, the fundamental principles are exactly
the same as for the treatment of the adult. We have mercury, bismuth and arsenicals
and certain other adjuncts. Bitmuth is tending to replace mercury so that most of the
preparations today contain bismuth and one of the arsenicals. Of the various treatment
schemes, most of them—almost all of them—consider the treatment of the patient once
a week. This is true whether for the adult or for the child, and there can be many
schemes, of course, many combinations of the various remedies in use; but one of the
most frequently employed is the administration of one of the arsenical preparations once
a week for about ten doses, the administration of one of the bismuth preparations once
a week for about ten doses, and then alternating these for about two years. There seems
to be a good deal of difference of opinion among the practitioners as to the length of
treatment. There are many syphilologists who consider that two years of treatment is
enough for anybody and if the Wasserman stiU happens to be positive at the end of that
time, then one can disregard it. That is not our own point of view. It is our idea that
children with syphiHs should be treated until their Wasserman is negative, regardless of
how long that would take. I realize that that point of view is open to criticism. We
have practised it for many years and have no reason to regret it. The ones least amenable
to treatment are the neurosyphilis cases. I would hesitate to stop treatment at the end
of two years where the blood and cerebrospinal fluid are stiU positive. We are actuaUy
not treating the Wasserman reaction but we are treating the patient. In some few
instances this takes a rather long period of years. We have a few we have been treating
for as long as ten years before the Wasserman reaction became negative. It has been
necessary for us to develop a treatment different from that in common use. In our
institution we serve a fairly large community and some of our syphiHtic patients Hve
300 miles or so away. It is obvious we cannot treat such a group once a week, so we
were compelled to devise some system. The system we are using at the present time is
to bring these children in for care every six weeks, or every eight weeks sometimes, and
each time they come to the hospital they are given a series of five injections of old
Page   347
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Salvarsan in large doses and these doses are given 48 hours apart for a series of five.
And with the first, third and fifth injections they get an intramuscular injection of
bismuth in fuU dose again. Then we are driven to use medication by mouth and for this
purpose we have chosen mercury with arsenic, and most of the children are
reasonably faithful in taking it. Upon comparing our results, we find that our present
results are superior. Cures are accompHshed with a smaUer amount and in a shorter
period of time. So that there are advantages in the scheme as weU as one or two difficulties, inasmuch as there are rest periods, as some of the children don't take their mercury as well as they might.
It is our behef that congenital syphiHs is curable.   There is a common behef that it
is not particularly amenable to treatment.
(We had a good deal of dermatitis, so that is why we use old Salvarsan.)
Our criterion of cure is that when a patient has been treated until his Wasserman is
negative and treated for a longer period than the older child, then the treatment is
stopped and we find that the Wasserman reaction does not again become positive. We
have no assurance that aH the spirochsetes have been killed. We beheve that we can cure
all of these cases if one qualifies the meaning of the term "cured." One can arrest the
process in a great majority of infants. The few exceptions to the possibiHty of the cure
would be in those cases of neurosyphilis in which disease is rather far advanced when
the child comes under our care and some of these, of course, are not worth the effort
of cure.
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BRITAIN KEEPS FIT
The Nation's Health After the "Blitz"
By Robert Williamson
Industrial Publicity Unit, Mowbray House, London, W.C.2.
Medical authorities in Britain are everywhere expressing astonishment at the robust
state of health shown by the inhabitants of the "island fortress." After a winter of
crowding in air-raid shelters, exposure by day and night in all weathers on A.R.P. and
fire-watching duties, and subjection to a nervous tension unparalleled. in history, not
only have prophesies of epidemics and lowered vitality been confounded, but the nation's
health is in many respects better than it has been for years past.
In the first place, the winter has made quite a favourable showing in regard to the
general incidence of disease. A review made by the Ministry of Health reveals that
cases of scarlet fever in 1940 were fewer than in any year for the last ten years, while
the number of diphtheria cases was the second lowest in this period, being 6,000 below
the average. As regards influenza, the peak period has now been passed, and the total
number ojf deaths in London and the 126 great towns up to April 12 was less than half
the corresponding figure for 1940 (2,336 against 4,472). Measles remained fairly constant, and whooping cough showed a slight rise. Pneumonia, like influenza, was well
down on last winter. There were only ten deaths from typhoid fever in the first fourteen weeks of this year compared with eleven in the same period of 1940.
The only disease with a large increase was cerebrospinal meningitis, which was more
prevalent than even in the previous record year of 1915. Incidence in the services, however, was much less than a quarter of a century ago, there being one-third of the total in
1915 and only one-seventh in 1940. Moreover, the figures are steadily declining week
by week—returns for the four weeks of March were 434, 400, 370 and 330—and it
must be remembered that this disease never declines below a certain residuum—in 1940
it was one hundred cases a week.
What are the reasons for the comparatively healthy state of the Kingdom under such
trying conditions as those of last winter? For a full answer it will be necessary to await
the findings of a Ministry of Health committee of epidemiologists who are making a
Page 348
:•*-. special inquiry in the London shelters.   Nevertheless, some interesting conclusions may
be drawn from a brief review of events since the "bHtz" opened in the autumn.
It will be recalled that in the beginning there was some agitation for deep bombproof shelters. The Government, however, realising the enormous technical difficulties
of providing these in time for effective use, had decided before the war that the best
policy was dispersal of the population. Evacuation of women and children from densely
populated areas was encouraged and assisted, and for those unable to leave the big towns
the local authorities provided family steel shelters, communal shelters, street surface
shelters and compulsory refuges for all new buildings.
But as the "blitz" intensified many thousands of people crowded into the deep
underground railway stations, warehouses, and tunnels, which were not intended to be
used as shelters and were not equipped to accommodate a large number of people for
long periods. And as the dark days brought the rains, fog and snow of Britain's winter
months, these people queued up for hours each day, sometimes from early in the forenoon, clutching bundles of bedding. When, in the late afternoon, they reached their
haven, it was to be crowded together in conditions which were inevitably uncomfortable and insanitary. Everything, in fact, pointed to a plethora of epidemics such as had
never been known before.
Presented with a fait accompli, there was, inevitably, some confusion among the
various authorities, and during this period the initiative taken in particular by the
Underground railway staff to improvise sanitation for the invaders of their properties
showed a pubHc spirit which has not been sufficiently praised. The Government appointed
a special committee under Lord Horder, which endorsed the poHcy of dispersal but
recommended immediate improvements in the provisions for health and comfort in all
types of shelters. Many basements in large buildings were requisitioned and equipped as
shelters; comprehensive sanitary arrangements introduced; ventilation and fighting improved; coal stoves installed in the surface shelters; and medical aid posts instituted in
all large shelters. In January, the Ministry of Health became responsible for the interior
management of shelters.
As has already been stated, there were no "shelter" diseases as such, and no outbreak
in any shelter, and the comriiunity, as a whole, remained remarkably healthy. What are
the conclusions to be drawn?
In an admirable survey of the situation, read before the Royal Society of Arts
recently, Lord Horder has suggested, among other things, that rough and ready as some
of the improvisations were, shelter conditions may in many cases have been better than
those of the people's own homes.
Sir Wilson Jameson, Chief Medical Officer to the Ministry of Health, has proposed
other possible factors. With children's diseases, he says, dispersal must be considered a
main safeguard. It is true that measles occurs even in the most remote country districts, but it is noticeable that where children are evacuated from tenement life to
housing estate conditions, the disease, though still present, becomes a school disease,
whereas in tenement areas it affects children of pre-school age when the malady is most
fatal.
With regard to shelter conditions, Sir Wilson Jameson points out that even there,
families tend to group themselves, thus exchanging only their own family germs.
A factor which has no doubt had due weight is the poHcy of the Ministry of Health
of providing increased health education. An advertising campaign has been instituted,
consisting of the unwearying repetition of simple rules for the avoidance of infection,
posters and leaflets have been distributed in the shelters and there is already evidence that
these are forming good habits and eradicating bad ones. The importance of ventilation,
exercise, dispersal and adequate sleep is being stressed.
An important part has also been played by the emergency Public Health Laboratories set up to meet war conditions, for these have resulted in a much earlier notification of the outbreak of disease, for example, in institutions.  Doctors and nurses in the
Page   349
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shelters have been able to diagnose infectious cases quickly and have them removed to
hospital.
But there is no doubt that there are factors in the situation not directly connected
with medical science. Among his other suggestions, Sir Wilson Jameson mentioned that
people were not going to the cinema as frequently, nor congregating in other ways as
they did in peacetime. There is no doubt that the spread of infection has been much
reduced, in this way. Then, too, there are an incalculable number of office workers who
have of their own accord moved to temporary quarters in the country or on the outskirts of the large towns. There they live more or less the life of the countryman,
rising early to catch their trains and going to bed at a correspondingly early houri
"Digging for victory" in gardens old and new has no doubt induced health by the
exercise it provides as well as by making fresh vegetables available to the household.
Lastly, there is the psychological effect of the blitz itself. Those who Hve dangerously have no time to brood over ailments, and when sudden death may fall on them
at any moment there is no inducement to He defenceless on a bed of sickness.
But whatever the reasons for Britain's excellent state of health, there is no doi
that when the fuU story of the war is written, this will be one of its most interesting
chapters. At the present time, to a nation faced with the most critical six months of
its history, it may weU be a decisive factor in the situation.
Just
/
/
water
V
AN ANALYSIS OF GUINNESS STOUT  100 cc.
Total solids  j 5.87 gm.
Ethyl alcohol (7.9% by volume) 6.25 gm.
Total   carbohydrates 3.86 gm.
Reducing sugars as glucose 0.66 gm.
Protein     I \ None
Total  nitrogen 0.10 gm.
Asb        0.28 gm.
Phosphorus  38.50 mg.
Calcium 7.00 mg.
Iron     \     0.072 mg.
Copper        0.049 mg.
Fuel value , 61 col.
Vitamin   BI 6 Int. Units
Vitamin G 33 Sherman Bourquin Units
GUINNESS
Analysis is only a partial indication of the attributes of Guinness Stout. The
physical equilibrium of colloidal properties is important, and the well-nigh
perfect   balance   between   the   alcohol  and   the  malt   and   hops   constituents.
LITERALLY    thousands   of   physicians   in   Great
Britain have testified to  the value of Guinness
as   a   tonic  during  convalescence.
...   as  a  stimulating  and   appetizing  food   for
older  people.
... in the treatment of insomnia, to obviate
the depressing after-effects 'which most hypnotics
produce.
All the natural goodness is retained in Guinness
for,   unlike   other   stouts   and   porters,   Guinness   is
unfiltered and unpasteurized. The active yeast
■which thus remains is a source of Vitamin B and G.
Guinness has been brewed in Dublin since 1759,
and is the largest selling malt beverage in the
■world. It is matured over a year in oak vats and
bottle, foreign Extra. Guinness is obtainable through
all legal outlets. Write for convenient 3"x5" file
card giving complete analysis and indications to
Representative, A. Guinness, Son & Co., Limited,
501  Fifth  Avenue,  N.Y.C
A. GUINNESS, SON & CO., LIMITED
DUBLIN and LONDON
S314
Page 350

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