ssasasHESSfEEcsss. 11E^t:l*T9t.£. & tcLte- $sa**&m®x.M if0% Crtttffit ft IS VgLifig WM .■ HJWMffMff^amt —r^fothlfr r^f^fmmmvi.' MAl'o fcra M mm* VII. OCTOBER, 1930 No. 1 The Bull of the^ Vancouver Medical Ass British oJXledical (^Association Uisit Ascites ciHaematuria Tublished monthly at ^Vancouver, "33. Q., by McBEATH-CAMPBELL LIMITED "^Trice^ $1.50 per yeac-^ Patient Types: THE OBESE PATIENT is frequently in the chronic constipated class because of the factors of dietary excesses and lack of exercise. The general form of treatment calls for a regimen of exercise and diet. Petrolagar is a very important aid in the management, because, being unassimilable, it is impossible for it to increase or produce obesity. Petrolagar, a palatable emulsion of 65% (by volume) pure mineral oil emulsified with agar-agar, has many advantages over plain mineral oil. It mixes easily with bowel content, supplyihg unabsorbable moisture with less tendency to leakage. It does not interfere with digestion. Petrolagar restores normal peristalsis without causing irritation, producing a soft-formed consistency and real comfort to bowel movement. fetrot agar Petrolagar Laboratories of Canada Ltd. 907 Elliott St., Dept. V.M. 10 Windsor, Ont. Gentlemen:—Send me copy of "HABIT TIME" (of bowel movement) and specimens of Petrolagar. Dr Address THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the Interests of the Medical Profession. Offices: 203 Medical and Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Dr. J. M. Pearson Dr. J. H. MacDermot Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the abov; address. Vol. VII. OCTOBER, 1930 No. 1 OFFICERS 1929-30 Dr. G. F. Strong Dr. C. Wesley Prowd Dr. T. H. Lennie President Vice-President Past President Dr. E. M. Blair Dr. W. T. Lockhart Hon. Secretary Hon. Treasurer Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow Trustees Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson Auditors: Messrs. Shaw, Salter & Plommer SECTIONS Clinical Section Dr. S. Sievenpiper . j Chairman Dr. J. E. Harrison Secretary Eye, Ear, Nose and Throat Dr. F. W. Brydone-Jack Chairman Dr. N. E. McDougall ^Secretary Pediatric Section Dr. C. F. Covernton j Chairman Dr. G. O. Matthews Secretary STANDING COMMITTEES Library Orchestra Summer School t^t-.t-t> t-.tt>t-> Dr. W. T. Ewing Dr. D. F. Busteed Dr. J. R. Davies „ t> n v t^ t^ *, -k, t-. T u >t t~. Dr. R. P. Kinsman Dr. D. M. Meekison Dr. J. H. MacDermot ~ ™. T ~ _ __. TT TT t^-cxt-d Dr. W. L. Graham Dr. W. H. Hatfield Dr. F. N. Robertson ~ T -, _,„„„ tatac_ Dr. J- Christie Dr. C. H. Bastin Dr. J. A. Smith t-\ V- -n -d t^ „ TT »r Dr. C. E. Brown Dr. C. H. Vrooman n> -r t r> Dr. T. L. Buttars Dr. C. E. Brown Publications Hospitals Dr. J. M. Pearson Dr. j. w> Arbuckle Dinner Dr. j. H. MacDermot Dr. j. a. Gillespie Dr. L. H. Webster Dr. D. E. H. Cleveland Dr. w# C. Walsh Dr. F. W. Lees Dr. E. E. Day Credentials „nu i. . „ j V.O.N. Advisory Board T1J.J r> •-. tr j a Dr. W. S. Turnbull Dr. Isabel Day Rep. to B. C. Med. Assn. i-. a t n* t t\ -u -u r> -„ " Dr. A. J. MacLachlan Dr. H. H. Caple Dr. H. H. Milburn Dr. P. W. Barker Dr. G. O. Matthews Sickness and Benevolent Fund — The President — The Trustees VANCOUVER MEDICAL ASSOCIATION Founded 1898 Incorporated 1906 PROGRAMME OF THE 33rd ANNUAL SESSION GENERAL MEETINGS will be held on the first Tuesday and CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m. Place of meeting will appear on the Agenda. 1930 October 7th—General Meeting: Speaker—Dr. M. F. Dwyer of Seattle, "Interpretation of Gastric Symptoms," a clinical and roentgenological study of 3000 cases. October 21st—Clinical Meeting. November 4th—General Meeting: Speakers— ^j "Early Recognition Dr. J. G. McKay > and treatment of the Dr. A. L. Crease J Psychoses." November 18 th—Clinical Meeting. December 2nd—General Meeting: Speakers—Dr. E. H. Saunders; "Early Recognition of Acute Mastoiditis." Dr. N. E. MacDougall; "Treatment of the Comon Cold." December 16th—Clinical Meeting. VANCOUVER HEALTH DEPARTMENT 1929 _i 240,421 9,33 5 Rate Per 1,000 of Population STATISTICS, AUGUST Total Population (estimated) Asiatic Population (estimated) Total Deaths Asiatic Deaths Deaths—Residents only Birth Registrations , Male 155 Female 190 INFANTILE MORTALITY— Deaths under one year of age Death Rate—per 1,000 Births Stillbirths (not included in above) July, 1930 Cases Deaths Smallpox 0 0 Scarlet Fever 9 0 Diphtheria 21 1 Chicken-pox 12 0 Measles 0 0 Mumps 1 0 Whooping-cough 3 5 1 Typhoid Fever 2 0 Paratyphoid 0 0 Tuberculosis 29 17 Poliomyelitis 1 0 Meningococcus Meningitis 0 0 Erysipelas _, 7 0 167 8.18 17 21.44 152 7.44 345 16.90 16 46.38 16 August, 193 0 Cases Deaths 0 13 2 5 1 3 13 3 0 14 0 0 0 0 0 0 0 0 1 0 0 12 0 0 0 September 1 to 15, 1930 Cases Deaths 0 8 7 2 0 0 1 0 0 13 0 0 3 Pagel Doctors Have Long Hours The sign on your office door may read "9 a.m. to 5 p.m.," but frequently it's "9 p.m. to 5 a.m." as well. Frequently we can be of service to Doctor and Patient in emergencies during the night. Do not hesitate to call on us. Seymour 1050 eft© Geotfgu* Pharmacy 7 m& Granville a.tC,eor&i^ Open All Night in cystitis and pyelitis TRADE MARK PYRIDIUM Phenyl-azoalpha-alpha-diamino-pyridine hydrochloride {Manufactured by The Pyridium Corp.) For oral administration in the specific treatment of genitO'Urinary and gynecological affections* Sole distributors in Canada MERCK & CO. Limited 412 St. Sulpice St. Montreal EDITOR'S PAGE With this number, the Bulletin enters upon its seventh volume. To those of us who have been associated with its publication, it hardly seems possible that it is six years since it was launched. For the launching we have one man largely to thank, Dr. H. H. Milburn, in whose term of office as president, the idea of an Association Journal was first brought to practical fruition; in fact, it was his personal enthusiasm that supplied most of the momentum with which this rather fragile bark, to continue our metaphor of the sea, was started on the ways. What, we wonder would be the verdict today, if the Bulletin were on trial for its life? What verdict would our readers give, as to the worth and usefulness to them of the Bulletin? What would be the verdict of our contemporaries? And what is our own verdict, as an Editorial Staff? Stocktaking at intervals is a salutary check on any organization's activities, and perhaps it is time that we effected an audit on those of the Vancouver Medical Association's Bulletin. It is in the air—City, School Board, even the Hospital, have all been on trial, and, it is hoped, to the ultimate betterment of conditions in all three, and why should we not follow their example? Financially, perhaps, it is not so necessary,—we have the questionable happiness of the poor man whose accounts are hardly worth auditing, but there are many angles besides the financial one, from which we should review our position. As to our readers—they are, we find, either a very well-satisfied, or a very inarticulate body of people. We hope the former—but would suggest that even if no criticism occurs to them, a word of commendation, faute de mieux, would not be amiss. But we feel there must be some criticisms that should be voiced. We should like to receive from any of our readers, suggestions, criticisms, expressions of preference, anything that will show us that we have readers. It is a weary thing to speak into a great silence. A few catcalls, even, would be a welcome relief. For our contemporaries. We are evidently read elsewhere for we so frequently find references to articles, or other of our contents, in journals scattered all the way from the Atlantic to the Pacific. Even editorial expressions of opinion have been commented on, and this is all very cheering. And our own verdict? Are we satisfied with what we have done? Heaven forbid that we should ever be, and certainly we are not yet. Our policy as an Editorial Board has so far been to stress the scientific side of things, to secure all the material that we can, and, perhaps, to do this rather to the neglect of the human side. Perhaps this has struck others too, we do not know—but we have felt that a re-arrangement of emphasis may in many ways be a good thing. Vancouver is now, medically speaking, a city with a history. The Vancouver Medical Association shares in this history, and there is much in the past, not only of interest, but of value and encouragement, that we might do well to recall. Our Association itself is insufficiently known to its members—and we feel this a pity, not that we are boastful or self-assertive in the matter—but that there is much that we should all know, and in which we could all feel pride. So that in this volume we propose to stress a little more, the things that are not strictly utilitarian, but which are no less important for that reason. And, in the immortal, if not original, words of Tiny Tim "God Bless us All." Page OBITUARY On August 31st, the death occurred, in the Vancouver General Hospital, of Dr. Henry M. Cunningham at the age of sixty-five. Dr. Cunningham was a son of the late Thomas Cunningham, well known Government Fruit Inspector of the Province, and received part of his early education in New Westminster. Later he attended the University of Toronto, also Columbia University, New York, graduating in 1895. He entered private practice at Detour, Michigan, later doing postgraduate work at the Cleveland Eye Clinic. In 1908 he spent considerable time in Vienna and Freiburg in special post-graduate study in Eye, Ear, Nose and Throat work. He practised his specialty in Marquette, Michigan, until 1917, when he located in Vancouver. To the many warm personal friends of Dr. Cunningham it was known, but hidden from the public by characteristic modesty, that he was the possessor of musical ability and a very wonderful voice, and was also a crafstman in the working of fine silver, a maker of silver ornaments and silver instruments. The late Dr. Cunningham was a member of the American Larynological, Rhinological and Otological Society, a Fellow of the American College of Surgeons and a Past President of the Pacific Coast Oto-Ophthalmological Society. He was a contributor to numerous medical journals and delivered the Osier Lecture in 1928 before the Vancouver Medical Association. Dr. Cunningham married, in 1908, Miss Bertha Mount- ford, of Chicago, who survives him. His loss will be felt by a wide circle of friends both within and without the profession of medicine. As a man and a physician, Henry Cunningham was beloved by all who came in contact with him. Friendly and sincere, generous and kindly at heart, he never failed to respond to any appeal for help in the work in which he was so highly skilled. He specialized, within his specialty, in bronchoscopy and oesophagoscopy, and those who do this work know that more often than not, the patients needing it are hopelessly crippled and unable to pay, as cancer is so often the disease present. Yet he gave his time and used his special and expensive instruments freely and ungrudgingly in the very best traditions of his profession. The ovation given him at the close of his Osier Lecture showed in what wide and true esteem he was held. Page 3 ANNUAL DUES The Annual dues for the year 1930-1931 were payable on April 1st last and, acording to our Bylaws, if not paid before October 31, bank drafts are issued to each member in arrear. The Treasurer will be glad if members who have not yet paid up will send in their cheques as soon as possible, in order that the work of the Association may be carried on efficiently. NEWS and NOTES Dr. H. A. DesBrisay, who was on the Interne Staff of the Vancouver General Hospital in 1919 has returned to the City and opened an office in the Medical Dental Building. During his absence from Vancouver Dr. DesBrisay was for two years at the Mayo Clinic and later for three years was with the Lockwood Clinic at Toronto, of which he was one of the original members. Later Dr. DesBrisay was for five years Assistant Professor of Medicine at Dartmouth Medical School and was also engaged in private practice. The doctor's intention is to limit his practice to consulting work in Internal Medicine. Dr. A. W. Hunter went South for a holiday during the month. He is Treasurer of the Western Branch of the American Urological Association and read a paper on "Primary Tumours of the Ureter" at a meeting of the Association on September 18 and 20th, at Los Angeles. We offer our hearty congratulations to Dr. Herbert Stalker and Mrs. Stalker who were married on September 10th at the Canadian Memorial Church. Mrs. Stalker, who was Miss Irma Hyland, was a popular member of the nursing staff of the Eye, Ear, Nose and Throat Department of the Vancouver General Hospital, and Dr. Stalker has been acting for some time as Assistant to the Acting Superintendent. The honeymoon was spent in the South. Dr. George Seldon, who is quite recovered from his recent illness, attended the British Medical Association Meeting at Winnipeg. The doctor then went on to Ottawa and at the meeting of the Medical Council of Canada on September 3rd, he was elected President of that body. Dr. J. G. McKay also went on to Ottawa to attend the Annual meeting of the Dominion Medical Council as representative of the British Columbia College of Physicians and Surgeons in place of Dr. Forrest Leeder, resigned. Congratulations are in order to Dr. Stanley and Mrs. Sievenpiper on the birth of a son in Grace Hospital on September 4th. The names of a few of our members who went to Jasper to enjoy (inter-alia) the Totem Pole Golf Tournament, follow: Drs. B. D. Gillies, D. M. Meekison, W. A. Whitelaw, L. H. Appleby, H. H. Milburn, W. l! Pedlow, E. E. Day, F. Day-Smith, J. A. Milburn, G. H. Clement, N. E. McDougall and R. B. Boucher. Page 4 Dr. C. E. Brown and family have left for the East and expect to be away till the end of October. Dr. Brown will attend the Interstate Medical Association at Minneapolis on the return trip. OUR BRITISH MEDICAL VISITORS Late on the afternoon of September the fifth, the Victoria boat nosed its way through the fog bearing one hundred and fifty of the overseas visitors who had attended the splendid convention in Winnipeg. The fog lacked only the flavour of the London variety and for a brief moment the delegates fancied themselves back on their own Thames. This illusion was soon dispelled when they disembarked on the "landing- stage," by the spectacle of a brass band awaiting their arrival. The responsibility for this Mid-western touch has not yet been fixed—but a brass band there was, and, to the strains of something or other the visitors were escorted to their hotel. The experience was described later, by Mr. Bishop Harman, as unique. In the evening a truly excellent civic dinner was tendered to the Britishers and about one hundred and fifty local guests, in the Hotel Vancouver ballroom. With the aid of more than the physiological 10c.c. of spts. vini rect., and some non-vintage wine, the gathering took on a very sociable character. His Worship the Mayor, Lt.-Col. Malkin, sans uniform, presided, and in one of those witty speeches for which he is famous, welcomed the visiting medicos, introducing the principal speakers, Mr. Bishop Harman, the noted ophthalmological surgeon, and Sir James Purves-Stewart. Mr. Malkin's remark, that there was no tariff on brains coming into the country, was particularly well received. Mr. Harman, with his "hatches,, matches and despatches," and his subtly expressed, kindly jealousy of the Scottish race, gave a splendid opening to the well-known neurologist, Sir James Purves-Stewart, himself a Scot. Sir James, splendidly decked out in Stars and so forth, somewhat shading the ordinary O. B. E.'s and service medals, informed the gathering that the Scots descended upon England either for the Sassenach's money or on account of the climate. He himself lived in London for the latter reason, he declared. On Saturday there was much to divert the visitors. Mr. Eric Hamber displayed most royally the hospitality of the west, by taking a round hundred of them on a cruise to Britannia and Woodfibre. His genial entertainment was greatly appreciated both internally and external- 1 Woodfibre was visited first, where the visitors had what must have been to them the novel experience of sitting down to dinner in the employees' mess-hall. Here they were regaled with the meagre fare that is served up to the pulp and paper makers, beginning with tomato gumbo and continuing through to lemon pie and spotted dog. The latter is entirely unrelated biolgically to hot-dog, as was explained by Dr. Riggs. The visitors were then divided into small parties and taken through the plant before returning to the boat. We are very grateful to Mr. A. E. Brennan, the manager, and Dr. C. G. McLean, the medical officer at Woodfibre, for making this visit so enjoyable. At Britannia the visitors were loaded on flatcars and towed by an electric locomotive up to the top of the mill. Here they saw the Page 5 copper ore as it came in from the mine, entering the crushers, and then descending hundreds of feet of steps; observed the successive processes on the various levels until the sulphides are floated off on oil-bubbles to be carried away in scows to the smelters. A lavish tea was served on the Vencedor after leaving Britannia and Vancouver was reached at nine o'clock when Mr. Hamber was warmly thanked for the royal style of his day's entertainment. After landing the majority of the visitors returned to the hotel, but a small number were taken to the Medical-Dental Building where they inspected and marvelled at the comfortable home for books and journals and their users, as well as the auditorium on the second floor, and the compact hospital-unit on the third floor. Some elected a tour of Burrard Inlet as guests of the Harbour Board. Our port and its potentialities opened the eyes of some of our old country colleagues just a little wider. Another party, under the escort of Dr. Lennie, was taken to Fraser Mills to view the terminal operations upon the remains of the race of forest giants, for whom tree surgery arrived too late. Others toured the city while still others pursued the elusive white pill over the beautiful rolling country-side at Jericho. These latter were mostly from north of the border and little money changed hands. Many were greatly surprised at the conspicuous absence of Indians, bears, cowboys and gambling dens, while astonishingly few of the local inhabitants carried guns. They were impressed by the fact that almost the same language was spoken. Indeed, our worthy mayor was almost more English than they were. The party left on Sunday morning to return to the murk and drizzle of the tight little isle. Many of them avowed an early return. Certainly, if the contingent which paid us the brief but thoroughly enjoyable visit has anything to say about it, the 1940 B. M. A. Convention will be held in Vancouver. Although the members of the British Medical Association who visited Vancouver were only a fraction of the whole, the entertainment furnished them here must rightly have been regarded as a fitting climax to their Canadian tour, and as illuminating, and characteristic as any local colour they have seen. Although not the "farthest West," Vancouver was the last city which they visited before their return across Canada to their port of embarkation. It is fortunate, therefore, that such an efficient committee was appointed to arrange for their reception and entertainment here, and we congratulate and thank this committee for its excellent work and arrangements. CORRESPONDENCE The Editor of the Bulletin, Vancouver Medical Association, Vancouver, B. C. Dear Sir, In the September number of the Bulletin I notice an adverse comment on the sending of a patient out of the City for a condition which was diagnosed as brain tumour. The diagnosis was arrived at only after complete Hospital laboratory tests, checked by private laboratory tests, Page 6 and consultation with men of outstanding ability in the profession. Besides this, he was examined independently by other members of the profession—men of good judgment and long experience, who, I understand, acquiesced in that diagnosis. It is only fair to state that the clinic to which the case was sent, does not agree that the case is one of brain tumor, being rather of the opinion that it is one of multiple sclerosis—a serious condition, and one which could readily be confused with brain tumour, especially in one so young—21 years. However, I wish to state here that if another similar case were to occur in my practice, I would unhesitatingly call the same men in consultation. The Bulletin, while commending the newspaper for the charitable impulse in getting together the funds which enabled the patient to go, evidently considers the sending of the man as a slight on the profession here. Not at all—such was never intended. It is my opinion, often expressed, that the City of Vancouver is as well, perhaps better, served medically and surgically, than any city of its size in the world, and there are great men among us, who in their particular line, could hold their own against the world's best. May I point out however that "talent and ability in some fields at least" is an entirely different thing from skill and experience in one particular field. It may be asked how it is possible to attain or maintain skill without experience, and how experience can be gained if comparatively rare cases are sent out to some one who already has that experience. My answer is simply this—that while our patients may incidently be useful to that end, they are not primarily for that purpose. I was rather surprised to hear that the profession in Vancouver is outstanding "in the matter of brain surgery in particular." I have gone carefully trough the records of the Vancouver General Hospital to ascertain the facts, and this is what I find. The records of the Vancouver General Hospital show that during the ten years 1920-1929 inclusive, there were performed all told, 93, 988 operations, of which number 5,761 were appendectomies. During the same period, although there were in all 31 deaths from intercranial tumour, and more than that number discharged from the Hospital with the same diagnosis, the records do not show one single operation for brain tumour having been performed. In St. Pauls Hospital, as regards operations for brain tumour, practically the same situation obtains. I understand that during the past five years there was one—possibly two specimens of brain tumour examined in the laboratory, although it is not certain whether these Were ante-mortem or post-mortem tumours. Now, brain tumour is an operable condition. In regard to treatment "in the matter of brain surgery in particular," it would appear that we are not in accord with such men as Cushing and Dandy. If your premises are correct, I quite agree that "it should not be necessary to send a patient half way across the Continent to obtain proper treatment" —it should not be necessary to send him half way across the street, for, if the proper treatment consists in watchful waiting, any of us ought to be able to do that—in time. Although I have ' gone into all the available records with the greatest possible care, and have presented the case as fairly as I know how, I am still willing and anxious that any surgeon who may feel Page? that he has been overlooked, may have an opportunity of placing his position fairly before the profession. I therefore request that any such surgeon give to the Bulletin for publication, a report of all his operations for brain tumour—say during the past five years—with laboratory findings, and end results in each case. For purposes of this discussion I am not at all interested in cases such as fractures of the skull, decompressions, and operations such as trephining etc. which are done as a matter of routine by any surgeon. A propos of this discussion, you may perhaps remember the circumstances surrounding the death of Floyd Bennett, who died of pneumonia in the City of Quebec on April 25th, 1928. An eminent physician was called from the City of New York to assist with the case, and the Rockefeller Institute sent Lindbergh by air with a quantity of serum. Two gentlemen in high places, feeling that the fair name of Canada was in jeopardy, rushed to the defence of Canada in general, and the doctors of Quebec in particular. Note the similarity of argument to that of the Bulletin. (I quote from the Vancouver Daily Province of April 28, 1928) "We have physicians and surgeons who have absorbed the best science of Europe. Here we have everything that is necessary, and we do not need them to come from the United States to bring us serum. We can get along without American doctors, be they the most accomplished specialists in that country." The doctor in attendance, concerned only with the saving of the life of his patient, and not with any questions of injured dignity, said not a word, until he said the last one, and this in part is what he said:- "I think the World of Medicine has not any borderline or limit and out of charity, in the face of death or suffering, should be big enough to include the whole world, if relief can be given or obtained." The Bulletin is the official organ of the Vancouver Medical Association. May I suggest that the Bulletin, before rushing into print in ' criticism of one of its members, be careful to ascertain beforehand all the available facts, and then try to see the end from the beginning before doing so. Some things are better ignored than discussed. Yours very truly, Daniel McLellan, M.D. LIBRARY SECTION Abstracts and Reviews Conducted by The Osier Society Discussion on Amputations and their relation to the Artificial Limb. C. Max Page et al. Proc. Ry. Soc. Med., July, 1930. A fairly exhaustive review of the problems confronting the surgeon: a dissertation on the ideal stump in both upper and lower extremities; details in technique of various amputations and in general; types of artificial limbs and a comparative summary and contrast of fashions and Page 8 ideas in America and on the continent. At the outset, the general aims are set forth governing any final major amputation, namely. 1. That the stump should provide a lever of sufficient length and power for the attachment of an artificial limb suited to the level of the amputation. 2. That it should be covered closely by healthy, well-nourished skin or scar, both of which should be mobile on deeper structures. 3. That no part of the stump should be tender on pressure or abnormally sensitive. The Symes amputation, is condemned, as invariably giving trouble after a few years. The six-inch tibia stump is upheld as ideal. The stokes-Gritti operation is held to be unsatisfactory while that through a point four inches below the great trochanter is recommended. A. Rowatt Maxwell's contribution is invaluable by virtue of experience with over 10,000 upper extremity amputation cases in thirty years. This is a very frank portrayal of the whole subject and should be thoroughly persued by any surgeon doing amputations. D. M. Meekison Malaria Treatment of Paresis. Freeman, Walter. Am. Jnl. of Syphilis, v. 14; p. 326. July, 1930. Dr. Freeman in his work on a group of patients that were innocu- lated with malaria and later followed to necropsy, endeavours to explain the modus operandi of malaria in the treatment of paresis. He reached a tentative conclusion, based principally on his findings in the group that reacted favourably to the treatment, that the malaria or other febrile illness does not always annihilate the spirachaete, even though it may suppress its activity in the central nervous system. The patient is given a better chance to handle his infection elsewhere. In his paper he gives three possible ways that malaria may operate in bringing about a remission—By killing the spirochaete by the high temperature—by stimulation of the reticulo-endothelial system in the cerebral cortex—this hyperpalasia combating and controlling the tre- ponema and by forced drainage of the nervous parenchyma along the perivascular channels into the sub-arachnoid space. Treponema are rarely found in the sub-arachnoid space and spinal fluid. It is thought that the swollen hydrated brain tissue forces a current of fluid along the peri-vascular channels into the parenchyma evicting the treponema from its haunts and allowing it to be easy prey for the reticular cells in the meninges. W. L. C. Middleton. Injuries Resulting from Irradiation in Beauty Shops. Hazen, H. H. Am. Jnl. Roentgenology and Radium Therapy, v. XXIIL, 409-412. April, 1930. Hazen points out that five years ago there occurred an indiscriminate installation of X-Ray machines in beauty shops for the purpose of treating superfluous hair. This article includes case reports of ten women so treated in various shops of this sort in the East. Among these ten the following conditions have developed: telangiectasia, deep muscular atrophy, atrophy and retraction of the gums, etc., and many suffered, in addition to the disfigurment, much pain. Dr. Hazen states "In other words, Page 9 sufficient roentgen radiation to remove hair from the face or body permanently, will, in a high percentage of cases, damage the skin to a visible extent"—a conclusion with which all will agree although it is just as certain that hair removal with a slight amount of telangiectasia of the skin is acceptable to some women on areas other than the face. He concludes "It is amazing that in many communities medical practice Acts "include only the prescribers of drugs and permit any type of physiotherapist to ply his trade without let or hindrance, with a total disregard for the potential dangers of the therapeutic procedure." The above applies equally well to X-Ray examination and treatment of other parts of the body by those other than qualified medical men or properly trained technicians under adequate medical supervision. H. A. Rawlings. Mechanism of Physical Signs in Neoplastic Diseases of Lung" Chevalier Jackson, J.A.M.A. 95; 639-644. August 30, 1930. Chevalier Jackson endeavours to point out the importance of understanding the mechanism of physicial signs produced by neoplastic and other diseases of the lungs in order to interpret better their signs. His conclusions are drawn from a study of 5,000 bronchoscopies and deals entirely with bronchial obstruction. He states that for the production of abnormal physical signs, one or more of four conditions must be present. (a) Narrowing or enlargement of the lumen. (b) Swollen mucosa. (c) Projecting abnormal tissue. (d) Foreign body, or (e) Secretions. There are three types of bronchial obstruction comparable to the : three types of mechanical valves. 1. Stop valve; where there is complete obstruction resulting in atelectasis and later drowned lung. 2. By-pass valve; air passing in and out but in dimished quantity, e.g. asthma. 3. Check valve; air passing only one way, resulting in obstructive atelectasis or obstructive emphysema. The following conditions producing valvular obstruction are taken up in detail. Foreign bodies, benign growths, malignant growths, adenopathy, anomaly, inflammatory, mucosal swelling, granulations and granuloma, secretions and blood clots. The author concludes by stating that a full comprehension of the mechanism of each of the three types of bronchial obstruction is necessary for the proper interpretation of the physical signs and properly interpreted, the signs in the respective conditions become of the utmost diagnostic importance. The article is made specially clear by the schematic illustrations. W. H. Hatfield. Early Gastric Cancer. Wellbrock, W. L. A. Arch, of Pathology, v. 8; 735-743. November, 1929. A series of 100 excised and resected small gastric lesions form the subject matter of this paper. These were studied by both fresh frozen Page 10 sections stained by Unna's polych. meth. blue and fixed frozen sections with haematozylin" and eosin. The author carefully notes the histology of the chronic gastric ulcer; touches on a few of the theories of aetiology and then very carefully describes the mucosal cells in various parts of the stomach. He further states how difficult it is to prove carcinomatous change in a chronic ulcer unless one could experimentally produce a chronic ulcer and then carcinoma in the ulcer, and show that all conditions are comparable to the conditions arising in human beings The earliest changes must be sought in the lining cells of the tubules, the typical changes in shape, staining properties, etc., being described. The author feels the term "malignant or cancerous degeneration" in an ulcer is a misnomer, as cancer is biologically a defensive constructive process, though purposeless, functionless and, eventually, fatal. His conclusion is that differential clinical diagnosis of benign and malignant gastric ulcers is notoriously defective. All chronic callous gastric ulcers are suspected of being carcinomatous, and should be treated as such before and at the time of operation. The use of the microscope is the only means of mstinguishing simple chronic gastric ulcers from early gastric carcinoma. The diagnosis cannot be made by clinical means, roentgenoscopy or the appearance of the gross specimen, that is, in the small lesions. H. H. Pitts. "Read, Mark, Learn and Inwardly Digest" THE SIGNIFICANCE OF ASCITES, AND ITS TREATMENT By Dr. William Fitch Cheney I. Significance. Assuming the diagnosis made, face to face at the bedside with a case recognized to be Ascites, what does it mean? There are five possibilities of any consequence and only five. All others are rare and remote by contrast. Of these five possible causes, two are general—disease of heart and disease of kidneys; and three are local in the abdomen—cirrhosis of the liver, tuberculous peritonitis and carcinomatous peritonitis. 1. Ascites Due to Heart Disease: It is usually easy to recognize this form. The history that precedes the ascites points to the heart and the other signs of disease that are found show faulty action of the heart itself, of the lungs, of the kidneys as demonstrated by urinary tests, and of the liver as proved by its increased size and tenderness. Furthermore dropsy involving the peritoneal cavity rarely occurs first or alone; it is only a part of a more or less general dropsy. It must be remembered, however, that in ascites due to cirrhosis of the liver, swelling of the feet and ankles frequently precedes and frequently follows; and after ascites from any cause, oedema of the feet results from mechanical pressure. But it is a rule fairly trustworthy that ascites is never the only sign of dropsy due to cardiac insufficiency, as right hydrothorax may be. Delivered before the Vancouver Medical Association Summer School, June, 1930. Page 11 Gynecologically Correct! Every gynecologist knows that uterine pain, whether due to displacement, functional disorders, or inflammation, is, at times, one of the most intense that the human organism endures. Every gynecologist conversant with, the use of also knows what a larger measure of comfort can be brought to the patient by the simple insertion of a tampon prepared with this hygroscopic, thermotherapeutic agent. [n cervicitis and endocervicitis, where there is often considerable sensation of weight and bearing down in the pelvis, the ANTIPHLOGISTINE tampon, by inducing an abundant serous transudation, is considered by leading practitioners as the depletant and supportant agent of choice in the management of these conditions. Many gynecologists also find this tampon useful for the purpose of exciting pressure and giving support in the gradual replacement of a retroverted uterus. In such cases, the tampons should be small and the string to each one should be long enough to reach from the vaginal vault to a point well outside of the introitus. THE DENVER CHEMICAL MFG. CO. 153 W. Lagauchetiere Street Montreal Dera Sirs:—You may send me a complimentary copy of your booklet "Pregnancy, Its Signs and Complications" (sample of Antiphlogistine included). M.D. Address. City Prov. PUBLIC HEALTH BIOLOGICAL PRODUCTS Diphtheria Antitoxin Diphtheria Toxin for Schick Test Diphtheria Toxoid ('Anato,:ine-Ramon) Scarlet Fever Antitoxin Scarlet Fever Toxin for Dick Test Scarlet Fever Toxin Tetanus Antitoxin Anti-Meningitis Serum Anti-Pneumococcic Serum (Type 1) Anti-Anthrax Serum Normal Horse Serum Smallpox Vaccine Typhoid Vaccine Typhoid-Paratyphoid Vaccine Pertussis Vaccine Rabies Vaccine (Semple Method) INSULIN Price List Upon Request CONNAUGHT LABORATORIES University of Toronto TORONTO 5 - CANADA Depot for British Columbia MACDONALD'S PRESCRIPTIONS LIMITED Medical-Dental Building Vancouver 2. Ascites Due to Kidney Disease: Here also there are almost invariably other symptoms and signs present before ascites develops. There is a puffy oedema and a waxy pallor about the face, eyes and hands. There is more or less frequent headache, nausea and vomiting. There are urinary changes as regards both quantity and quality. Tests of blood urea show faulty elimination. Phthalein tests show faulty excretion of the dye. The blood pressure is usually high. Finally there is practically always some other evidence of dropsy and general anasarca. Rarely or never is the peritoneal cavity alone involved. 3. Ascites Due to Cirrhosis of The Liver: Ascites is a late manifestation of cirrhosis, therefore a long history usually precedes its development. This history is one of gastro-intestional disturbances such as poor appetite, dyspepsia, occasional nausea and vomiting especially on rising, flatulence, abdominal unrest, heaviness and tenderness in the epigastrium, looseness of the bowels alternating with constipation, weakness, languor, loss of weight, slight transient jaundice. Hematemesis caused by cirrhosis is usually a much earlier result than ascites, and the history frequently includes such a past event when ascites finally appears. With this background, often of years duration, ascites, when it comes, makes its onset gradually and painlessly as a rule, but it may appear quite suddenly The first complaint is of distension by gas, increasing size of the abdomen and a sense of fulness and stretching. Physical examination shows wasting of the body in marked contrast to the enlarged abdomen; sallow colour and dryness of the skin, dilated vessels on the face, often a number of dilated vessels over the lower thorax, and the distribution of enlarged veins in the abdominal wall known as the "Caput Medusae." Another interesting sign, to which Osier used to call particular attention, is "Spider Angiomata"—small red elevations over the face, neck and trunk, with radiating small vessels running out from them like the legs of a spider from its body. After tapping the abdomen and withdrawing the fluid contents for better palpation, the liver is usually found smaller than normal, but may be swollen, the spleen is palpable but not excessively large, and there are no masses found elsewhere. Frequently there is oedema of the feet and legs but no general dropsy. As regards laboratory examinations, (a) the ascitic fluid is clear, greenish or yellow in colour, its specific gravity is low (usually below 1015), there is a low albumen percentage, and the cells found are 95 per cent, endothelial (not lymphocytes); rarely is the fluid bloody; (b) the urine is scanty, highly acid, has a high specific gravity, is dark in colour and uratic, but contains no albumen, no sugar, no casts and no blood; (c) the blood shows a moderate secondary anaemia but not the degree or character shown by splenic anaemia, and there is no leucopenia; not infrequently the Wassermann reaction is positive, and this is important because the cirrhosis may be luetic and yield to specific treatment; (d) gastric analysis shows a typical chronic gastritis, with abundant mucus and complete achlorhydria; (e) the stool frequently shows occult blood; (f) the icterus index may show bilirubinaemia above normal even where there is no clinical jaundice; and the van den Bergh test may prove that the cause of this is intra-hepatic; while liver function tests after the administration of a dye may or may not prove impairment of the liver's excreting powers. Page 12 Ascites due to cirrhosis is not always a terminal event, but usually it makes a bad prognosis, with death probable in three or four months, after a few tappings. But it may disappear entirely (1) after treatment for syphilis by mercury and iodides; (2) because it was really due to some other cause, as a failing heart; (3) because adhesions form after tapping and permit the blood to return to the heart without passage through the liver, as after a successful Talma operation; (4) after the use of ammonium salts and merbaphen, even though the result is not permanent and ascites recurs slowly a few months later. 4. Ascites Due to Tuberculous Peritonitis: Here the usual history is one of pain and tenderness over the lower abdomen; but the onset may be insidious and ascites appear without any preceding symptoms. It occurs most often in young people; but not always. Almost all patients complain of enlargement of the abdomen and distension by gas as the first signs of their ascites. There may be a history of previous tuberculosis elsewhere, in lung, pleura or glands, or the disease may apparently be primary in the abdomen, even though some focus does exist. In this form of ascites the effusion is moderate, not as large as in cirrhosis or in carcinomatous peritonitis. After tapping paplable masses may be found, due to puckered omentum or enlarged mesenteric glands. Frequently there is a doughy consistency of the abdominal wall and tenderness on palpation. There is no enlargement of liver or spleen. It is important to remember, however, that cirrhosis of the liver predisposes to tuberculous peritonitis, which may occur as a complication and both conditions coincide. In women, pelvic masses may be found, due to tuberculous disease of the appendages, that act as a focus; and in men similarly a focus may be found in the testis or epidydimis. Fever usually acompanies tuberculous peritonitis, but of low grade, variable, and there may be none. The ascitic fluid due to this disease is clear as a rule but may be haemorrhagic. It is of higher specific gravity than in cirrhosis and shows more albumen. There is a preponderance of lymphocytes in the cell count. No bacilli can be found in smears from the sediment, but guinea pig inoculation may prove the nature of the trouble. The urine is not in any way characteristic unless primary tuberculosis of the urinary tract has been the focus for the peritoneal infection. The blood shows a secondary anaemia bu!t no Ieucocytosis. The stool may contain blood if there is a primary tuberculosis of the bowel and the proctoscope may demonstrate the presence of ulcers. It is always wise to secure an X-Ray plate of the chest in the search for primary tuberculosis to explain the ascites as due to tuberculous peritonitis. 5. Ascites Due to Carcinomatous Peritonitis: This form occurs most often in elderly people, because it is metastatic to the peritoneum from primary carcinoma in stomach, bowel, rectum, uterus, etc. Therfore the age incidence of one is that also of the other; and a history of the primary disease precedes the development of ascites. The effusion is large. After tapping, palpable masses are found in the abdomen or by rectum, or by vagina. The spleen is not enlarged but the liver may be, and likewise irregular and modular. More emaciation and cachexia occur than in other types of ascites. There may be visible and palpable Page 13 nodules in the abdominal wall or glands may be enlarged in the neck or the groin; and biopsy on any of these may prove the nature of the pathology. The ascitic fluid is haemorrhagic more often in this form than in any other. It has a comparatively high specific gravity and more albumen than in cirrhosis. The fluid is otherwise much like that in tuberculous peritontitis; but the cells at times are more characteristic, multinuclear and in groups. The blood shows only a secondary anaemia. The blood Wassermann should be done in every case as a routine. Gastric analysis may give information proving the existence of primary cancer of the stomach. X-ray of the gastro-intestinal tract after tapping is always indicated and may identify the source of the metastatic peritonitis causing ascites. Besides these five outstanding causes of ascites there remain only a few other possibilities, much more remote and unlikely. (6) Polyserositis, or Pick's Disease, involves not only the peritoneum but the pericardium and the pleura. It is characterized by ascites of long duration, recurring persistently after tapping. Its aetiology is unknown. It is comparatively a rare disease. (7) Solid ovarian tumours may give rise to ascites in some cases, even when they are not malignant. Pelvic examination ought to identify them. (8) Intestinal obstruction may occasionally produce ascites as a complication. II. Treatment: 1. When Ascites is Due to the Heart: The principles of management here are those for general dropsy in heart disease:—rest in bed, Karell diet, limitation of fluids; calomel and soda in broken doses followed by Epsom salts; paracentesis of the abdomen; then digitalize the patient by use of the powdered leaves according to the well-known method, a total of one decigram for each ten pounds of body weight. Instead of this plan, the longer-used pill of calomel, squills and digitalis, one grain each, one pill three times a day for four days, may act more satisfactorily. Diuretics are always indicated following digitalization, such as euphyllin of which the dose is two-tenths of one gram (3 grains) by mouth three times a day. Even more efficacious is salygran one-half cc. intravenously followed next day by one cc. intravenously and 2 cc every three or four days afterward. Or merbaphen (novasural) may be used in the same way intravenously, supplemented by ammonium nitrate by mouth, in dose of 6 to 10 grams (90 to 150 grains) daily, given in peppermint water. 2. When Ascites is Due to the Kidneys: The indications for treatment are rest, heat, limitation of fluids, low salt and low protein diet, tapping of the abdomen, purgation by salines, sweats by external heat, hot flaxseed poultices to the back over the kidneys. If diuretices are to be employed, again use ammonium nitrate by mouth and salyrgan by vein as described. Or the old-fashioned mixture of acetate of potash with infusion of digitalis sometimes acts even more satisfactorily. 3. When Ascites is Due to Cirrhosis: The plan advised here is as follows: (a)paracentesis as early as required to give comfort, for it relieves pressure on the abdominal and thoracic viscera, prevents venous Page 14 engorgement and possible hematemesis; (b) low salt and low fluid content in the diet; (c) diuretics, particularly merbaphen and ammonium nitrate given as previously described, constitute the most distinct advance in the therapy of ascites due to cirrhosis and may control it for long periods, but not indefinitely; (d) purgatives such as the hydro- gogues (elaterium, Jalap and gamboge) do harm by weakening the patient, but repeated small doses of calomel followed by Epsom salts are beneficial. Personal experience with patients subjected to the Talma operation has never been satisfactory. 4. When Ascites is Due to Tuberculous Peritonitis: The first thought only a few years ago was surgery. It was believed that by opening the abdomen and admitting air freely the tuberculosis was arrested. But in recent years it has been found that equally good results can be obtained without surgery; by keeping the patient at rest in bed for a long period, weeks or months; and by the use over the abdomen of heliotherapy or the quartz lamp or the X-ray. But any one of these must be used cautiously, beginning with brief exposure to their influence, because they may cause serious burns if emplayed injudiciously. 5. When Ascites is Due to Carcinomatous Peritonitis: The only plan to follow is paracentesis and symptomatic treatment to give relief and comfort. In any case where doubt exists as to the diagnosis, laparotomy is justifiable to settle the matter. It at least does no harm and it may reveal a condition that is not malignant after all and therefore subject to removal or at least improvement by medical treatment. HAEMATURIA By Dr. W. L. C. Middleton There are few, if any, symptoms relative to the genito-urinary tract than are more important than haematuria, and with but few exceptions it means organic disease, consequently when met with its source and its cause should be exhaustively searched for. It is the cardinal symptom of kidney tumour which is one of the four important serious conditions giving rise to haematuria—namely, tumour of the kidney, tumour of the bladder, tuberculosis and urolithiasis Haematuria may be the only symptom of tumour for a long time showing as but a few microscopic cells in the urine or as large clots. It is often intermittent and the intervals may be long. It is well to remember this tendency to intermittency, especially if a haematuria, whose source and cause is not definitely known, clears up under some treatment used. It is apt to leave both the patient and the doctor with a false sense of security in believing the condition cured. Clinical observation over long periods of time and frequent cystoscopic examinations mey be necessary in patients with a profuse haematuria before a diagnosis can be made, especially if the bleeding is the only symptom and no apparent cause for it can be demonstrated. Of ten-times a tuberculosis that evaded diagnosis on previous examinations may be demonstrated. Haematuria is the second important symp- Read before the Osier Society of Vancouver, February, 1930. Page 15 torn in urogenital tuberculosis frequency being the first. Their association is important, especially when they appear out of a clear sky. These two conditions, tumour and tuberculosis, are the most frequent causes of haematuria and it is especially in these groups that an early diagnosis must be made if a satisfactory end result is to be expected. Young, quoting Clado, Geraghty and Verhoogen, states that in 541 cases of vesical tumour, 404 or 75% gave haematuria as the initial symptom. Haemorrhage is characteristic of bladder tumours practically without exception. This is due to the very thin walls of the capillary type of vessel developing in tumours, making rupture from tranma or ulceration easy. Casper found in cystoscoping 142 cases of bladder tumour immediately after the first haematuria, that all but three were small early tumours. This is a most potent argument in favour of immediate cystoscopic investigation of all haematurias. It is probable that a good many of the cases demonstrating haematuria late, when extensive involvement has occurred, are due to a non-papillary type of tumour. Kretschmer, in a series of 23 8 cases of haematuria made an accurate diagnosis in 197. It is interesting to note the incidence of the types of lesions he found. In the kidney were found: 3 cases of tuberculosis 2 " ' trauma 2 CC ct nephritis 2 " renal carcinoma 8 cc cc renal calculus 1 " I pyonephrosis 8 cc cc hypernephroma 1 " ' movable kidney 8 cc tt colon bacillus infec 1 " ' pregnancy tion 1 " c doubtful stone 2 cc tt renal tumour 1 " ■ oxaluria 2 ct cc polycystic disease 2 tt *i diverticula 1 tt angiomata 1 Ct " polypi making a total of 74 cases. In the bladder were found: 32 cases of carcinoma 26 " " papilloma 14 I " calculus 10 " bladder tuberculosis making a total of 86 cases. In the prostate there were 12 cases of carcinoma and 13 cases of hypertrophy, making a total of 25 cases. In the ureter were found 10 cases of calculus. In the female urethra the haematuria was due to prolapse in one case and tumour in another. In analysing these cases it is seen that tumours of the bladder were responsible for bleeding 60 times or 30%. Of the 74 renal lesions tumour was found in 12 cases. In the prostate there were 25 lesions, twelve carcinoma tons and 13 benign hypertrophy. If the prostate hypertrophies are included in the new growths, then the cases of haematuria due to tumour were 99, or approximately 50% of the positive cases in this series. Tuberculosis is second in point of frequency. In the remainder of the cases, in 14 the origin was found but the cause not definitely established. In the remaining 25 neither a diagnosis Page 16 nor the origin of the bleeding could be determined, but the author stressed the point that though no diagnosis could be made in many of the latter group, they should not be classed as "essential haematuria," but that they are expressions of our present diagnostic limitations. In reviewing the literature on "essential haematuria" I have noticed a desire by many authors to get away from this term as it is rather a poor one and perhaps one that can be too readily used when a definite diagnosis cannot be made. Later in this paper I will give the opinions of some of the investigators of this condition. Though the. cystoscope and urethroscope should always be used to determine the source and cause of the bleeding some idea of its source can be gained by the examination of a three glass specimen of urine, and the constituents, visual or microscopic, of a bladder specimen. A lesion in the urethra, distal to the external sphincter, producing bleeding, will show at the meatus, independently of voiding. If the bleeding is profuse from a lesion in the urethra above the external sphincter, then the blood will flow back into the bladder and give one the impression of its having originated from the bladder or kidneys. A terminal increase in the amount of blood passed in the urine may be due to compression of a lesion in the posterior urethra by the muscles emptying the urethra, the blood of renal origin may have collected in the base of the bladder or the final contraction of the bladder muscles may squeeze some additional blood from the tumour or other lesion causing a typical "terminal haematuria," the blood being unmixed with urine and occasionally considerable in amount. This was demonstrated very well in a patient seen a short while ago who had been treated for various complaints and symptoms for some months with nothing referable to the genito-urinary system until, upon examination of the lower abdomen by her attending physician, a bladder tumour was palpated—upon catheterization a considerable amount of urine was drawn off at the end of which appeared about a cupful of blood unmixed with urine. At each subsequent voiding the urine was blood stained but that passed last was always much thicker and was often pure blood. Cystoscopy revealed a fla.t cauliflower-like growth undergoing ulceration, situated at the neck of the bladder and involving a portion of the sphincter. It is likely, owing to the position of the tumour, that the bleeding following the first catheterization was due to trauma, thus revealing a lesion that was totally unsuspected, for at no time previously had blood been noticed or found in the urine. The presence of worm-like ureteral casts are pathognomonic of bleeding above the bladder, and blood casts of bleeding from the renal parenchyma. As the introduction of a ureteral catheter sometimes causes bleeding, blood in a ureteral catheter specimen does not necessarily indicate the source of the haematuria. Observation of the jets of urine issuing from the ureteral orifices is often more valuable in determining whether the blood is from one or other side, or from both. Page 17 Microscopic examination of the urine obtained in bleeding above the vesical orifice may give one an idea as to its cause. If the urine is clear but for the .blood, the probable cause is either neoplasm, calculus or acute nephritis. If blood and pus are present, but no bacteria other than tubercle bacilli, then tuberculosis or occasional calculus must be considered. If blood, pus and bacteria are present then the condition is likely one of the above secondarily infected or cystitis. In cases of haemoglobinuria, combining the microscopical and chemical tests will give the diagnosis, a positive benzidine or guaiac test, and no red corpuseles in the urinary sediment. When are we dealing with a case of "essential haematuria?" That is a case of painless bleeding, in which the kidneys show absolutely no infectious agent, no organic changes and no clinical evidence of functional insufficiency. Bumpus, going on the assumption that the haematuria may be the result of single or multiple diseases not far enough advanced to be diagnosed at the time of examination, followed a series of 155 such patients whose haematuria dated back from 5 to 25 years and found that in only six had there developed any definite renal disease, three of which were calculi, and in the other three nephrectomy had been performed, presumably for the persistent bleeding. He has made an extensive survey of the literature on this condition and gives the views of some 20 writers, as to the cause, which briefly are the following: Chronic passive congestion resulting from scar formation from pyelonephritis, kidney abscesses which have healed, or infarcts produced by remote foci of infection. The cicatricial contraction following the healing of these conditions impedes the circulation of the adjacent vessels causing them to become varicose and rupture. Wheeler cites a case of symptomless haematuria with known bleeding from one kidney for 2 years and with negative X-rays. At exploration of the pelvis at operation no lesion could be found, the pelvis appeared normal, but upon gross examination a small papilla showed a small raised granular area about the size of the head of a black pin—this area upon microscopic examination showed dilated thin-walled capillaries and veins in large numbers close beneath the epithelium, with numerous extravasations of blood cells into adjacent tissue and in some places absence of the endothelium of the capillaries and in one spot rupture of the pelvic epithelium. It is likely that all of the above mentioned reasons for this type of haematuria may be correct to a degree, some more than others, and that "essential haematuria" may be taken, not as a haematuria due to any one specific cause, but as a group term embodying any and all causes that remain after an exhaustive and painstaking search by all means and methods available, has been made, to find the source and the cause of the bleedine. rage 18 In conclusion I would like to give a brief history of 2 cases that gave as their only symptom blood in the urine. Mr. age 67. Complaint:—Blood in the urine. The bleeding had been present for 2 weeks. Cystoscopy revealed a tumour growth, ulcerated in one portion, in front of and obscuring the right ureteral orifice. The prostate was definitely malignant and the concerous growth could be seen extending into the bladder wall. The malignancy in the prostate came as a surprise as when felt per rectum it appeared absolutely normal. X-Ray of the pelvic bones showed marked involvement with metastases. Mr. -Age 45. Complaint:—Passing of bloody urine. The haematuria was present off and on for 4 months and once about 8 months previous to that time. There had been two cystoscopic examinations, once when the urine was clear and once when only a slight amount of blood was present. The findings were negative. A final cystoscopy and psyclography showed bloody urine being ejected from the left ureteral orifice and the X-Ray showed a marked distortion of the upper two calices. Nephrectomy revealed a hypernephrome, replacing some two-thirds of the kidney with some extension into adjacent tissues. This patient demonstrates the value of examination of the patient's genito urinary system while he is showing the blood in the urine and of a complete examination, as no doubt valuable time was lost in making the diagnosis by not doing a pyelography at the previous examinations. Miss R* A* Backett, r* n. Is/lasseuse Rooms 503-504 Birks Building Phone Trinity 2004 Sun Ray with Quartz Lamp Cabinet Baths and Shower Swedish or Weir Mitchell IS/iassage Specializing in Physio-Therapy Patients may be visited in homes (Qualified Physicians invited to visit) Page 19 British Columbia Laboratory Bulletin Published irregularly in co-operation with the Vancouver Medical Association Bulletin in the interests of the Hospital, Clinical and Public Health Laboratories of B. C. Edited by A. M. Menzies, M.D., of The Vancouver General Hospital Laboratories Financed by The British Columbia Provincial Board of Health COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital, Victoria; ~St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster; Royal Inland Hospital, Kamloops; Tranquille Sanatorium; Kelowna General Hospital; and Vancouver General Hospital. All communications should be addressed to the Editor as above. Material for publication should reach the Editor not later than the seventh day of the month of publication. Vol. IV. OCTOBER, 1930 No. 8 CONTENTS Editor's Notes Local Facilities for Convalescent Measles Serum Co-operation Between the Laboratory and Physician Examination of Feces for Parasites -_ Harri rts MEASLES CONVALESCENT SERUM Some months ago the V. G. H. Laboratories announced that through the courtesy of the Provincial Board of Health, measles convalescent serum would be stocked and distributed gratis to the Profession if suitable donors-could be obtained. It was also announced that the Provincial Board of Health would pay such donors at the usual rate of $25.00 per :pint. The V. G. H. Laboratories can now announce further that at last a suitable donor has been obtained and a limited supply of measles convalescent serum is now available for use. From a study of the literature the dosage recommended is 2 to 4cc for infants under 3 years if given during the first 4 days after exposure, twice this amount during the next 2 days and 7 to 8cc if given later, given intramuscularly. As convalescent serum may entirely prevent an attack, or at least modify the disease, it is particularly useful in weakly infants or those recovering from a previous illness, etc. The passive immunity produced if the disease is entirely prevented by serum, is probably good for only a few weeks. Those who have the disease in a modified form following the adminstration of serum, probably develop a lasting immunity. It would seem, therefore, that the most ideal results would be obtained by giving the serum the 6th to 8th day after exposure, thus allowing the disease to develop in a modified form, thus ensuring the formation of antibodies which would protect the patient from further attacks probably for life. MEASLES CONVALESCENT WHOLE BLOOD In outlying districts where convalescent serum cannot easily be obtained owing to transportation difficulties, it might be well to remember Page 20 that whole blood or citrated blood, from a person who has had measles even long before, may be used with success. The usual care would need to be taken of course, to insure that the blood carry no communicable disease. The procedure in the use of whole blood is to inject about 20cc. to 50cc. intramuscularly. In a circular letter recently sent out by the Provincial Board of Health to the physicians, instructions are given for collecting and administering convalescent or inmune whole blood for the treatment of poliomyelitis. In the treatment of measles the same instructions would apply, except that one would need to be certain that the donor had previously had measles. A copy of the polio instructions follow: "Whole blood from Convalescent Patients in Place of Serum for the treatment of Poliomyelitis cases." The usual dose of convalescent Polio, blood is 50cc. It, of course, must be taken strictly aseptically and so handled before and during the injection. To prevent coagulation sodium citrate must be added in the proportion of 0.5cc of a 20% solution of sodium citrate to each 50ccs. of blood. (Of course, if the donor be handy to the patient a direct transfer of the blood may be done.) The injection is given intra-muscularly into the gluteus maximus muscle. The donor should be previously tested for any specific infection. (Wassermann and Kahn tests, etc.) Blood taken as above and citrated may be kept in an efficient icebox with safety for 24 hours, probably with no material diminution in therapeutic value. CO-OPERATION BETWEEN THE LABORATORY AND PHYSICIAN The following lines are extracts from an article in the Canadian Medical Association Journal of August, 1930, quoting Dr. A. C. Rankin, Dean of the Faculty of Medicine in the University of Alberta. Material should reach the laboratory at the earliest possible moment and be accompanied by intelligent and full information as to the nature of the examination required. The worth of the laboratory and its value to the hospital and the public and the patient rests not only with the laboratory staff but upon the co-operation of others. It is impossible to make proper distinctions in diagnosis on laboratory findings alone. While laboratory findings are necessary for accurate diagnosis and treatment, clinical medicine is still the important factor. There is a tendency to rely on laboratory findings, instead of upon the clinical findings in conjunction with laboratory findings. Dr. Rankin reminds us that the laboratory is adjuvant and can never take the place of good thorough physical examination and the investigation of disease in each case as a problem. He also believes that every physician and nurse should be familiar with the simpler essential examinations performed in a clinical laboratory and should have a good understanding of the methods of collecting samples. Page 21 EXAMINATION OF FECES FOR PARASITES R. V. Harris, BSc, V. G. H. Laboratories. Four main factors contribute to the prevention of the spread of parasitic infections in the residents of Vancouver, namely the temperate climate, the modern sanitation, the meat inspection, and the pure water supply. Nevertheless, owing to its geographic position and its desirable climate there are many temporary and permanent residents in Vancouver who have spent part of their lives in places where the incidence of this type of infection is very high. The Japanese, Chinese, or Finnish immigrant, through his habit of eating raw fish, may harbor Diphyllobothrmm latum (fish tapeworm), or Fasciola hepatica (liver fluke); the white man who has lived in India or South America, hookworm or amoebae; and sailors, black, white, yellow or brown, who have sailed the seven seas, may in their travels have collected any of the worms which may infest the human intestine. It happens, therefore, that from time to time we are asked to examine stools for evidence of parasites, and that once in a while such evidence is found. Until about sixteen months ago the method used for the discovery of ova was the brine-flotation method. In March 1929, however a new method for concentrating ova and cysts was adopted. This method, of Damaso de Rivas and Charles A. Fife, is taken from J. Am. Med. Assoc. February 23, 1929, and is as follows: "A small portion of material is first softened when necessary and suspended in an excess of 5% acetic acid solution in a test tube. After the material is thoroughly shaken it is filtered through a layer of gauze and the filtrate is collected in an ordinary centrifuge tube, so as to have the tube about one-third full. To this is added an equal volume of ether, and after the resulting emulsion has been thoroughly shaken it is centrifuged for from three to five minutes. By this procedure the mixture is separated into four layers from above down as follows:—the ethereal extract, which forms the topmost layer; the detritus plug, consisting of soap and coarser particles, which forms the second layer; the acid solution below this; and finally a scanty sediment at the bottom. The three upper layers are poured off, leaving the sediment attached to the bottom of the tube; this is * ■* * examined under the microscope as with fresh cover glass preparations." The method does not occupy an unduly large amount of time and does not involve the purchase of any special apparatus. The superiority of this new method over the old is indicated by the following records:- Period Number Examined Number Positive % Positive Year 1926 43 3 7 Year 1927 40 2 5 Latter half 35 6 17 1929 First half 34 5 14 1930 These numbers are gratifying, and indicate that the adoption of the new method was justifiable. Although a negative result from a single examination is never conclusive, we feel considerable confidence in the value of this method for detecting intestinal parasites. Page 22 'Hold Fast to That Which is Good" i tiMlSmmstm The Mead Policy that for years has proved professionally and economically valuable to physicians who feed infants also applies to Mead's Viosterol in Oil, 100 D (originally Acterol). As with Dextri-Maltose, we feel that Mead's Viosterol is a part of the physician's armamentarium, to be prescribed by him alone. Therefore, we refrain from lay advertising of Mead's Viosterol or any other Mead Product; furthermore, we do not print dosage directions on the bottle, on the carton or in a circular. "Hold fast to that which is good"—the Mead Policy, Dextri-Maltose and Mead's Viosterol (originally called Acterol). Mead Johnson & Co. of Canada, Ltd., Belleville, Ont. Rest Haven Sanitarium and Hospital MARINE DRIVE, SIDNEY, B. C. (Near Victoria) (Visited by Qualified Physicians) Rest Haven is situated amid natural beauty. Particularly convenient and desirable for Rest—Recuperation and Convalescence. There is boating, salt water fishing, and golf. < Private room accommodation $28.00 and $35.00 weekly; Semi-private $21.00 and $25.00 weekly. Direct patients to Rest Haven via the Steveston-Sidney ferry, MOTOR PRINCESS. From Victoria by the Vancouver Island Coach Lines, Ltd., at the Broughton Street Station. Private car will meet boats if desired. FOR RESERVATION AND FURTHER INFORMATION WRITE OR TELEPHONE MEDICAL SUPERINTENDENT OR MANAGER- SIDNEY 95 — 61 L. Say it with Flowers Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs, Roots, Wedding Bouquets. Florists' Supplies and Funeral Designs a Specialty Three Stores to Serve You: 48 Hastings St. E. 665 Granville St. 151 Hastings St. W. One Phone: Seymour 8033 Connecting all three stores. Brown Bros* & Co. Ltd. VANCOUVER, B. C. 536 13th Avenue West Fairmont 80 Exclusive Ambulance Service FAIRMONT 80 ALL ATTENDANTS QUALIFIED IN FIRST AID "St. John's Ambulance Association" WE SPECIALIZE IN AMBULANCE SERVICE ONLY R. J. Campbell J. H. Crellin W. L. Bertrand STEVENS' SAFETY PACKAGE STERILE GAUZE is a handy, convenient, clean commodity for the bag or the office. Supplied in one yard, five yards and twenty-five yard packages. ESTABLISHED NEARLY A ~ .CENTURY^ B. C. STEVENS CO. Phone Seymour 698 730 Richards Street Vancouver, B. C. -H®e «j*[* •i<33f-»~- » Hollywood Sanitarium LIMITED "ijor the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively Reference ~ <2B. (p. (^Medical ^Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Seymour 4183 Westminster 288 *» The Bulleti f ;rHH OF THE >/<|M|| Vancouver Medical Association £SSt Contents Health Insurance Golf Pyloric Stenosis Meetings General—Nov. 4th Clinical—Nov. 18 th Dinner—Nov. 26th ANNUAL MEETING CANADIAN MEDICAL ASSOCIATION JUNE 22—26, 1931 VANCOUVER, B. C Vol. VII NOVEMBER, 1930 No.