"CONTENTdm"@en . "http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642"@en . "History of Nursing in Pacific Canada"@en . "Vancouver Medical Association"@en . "1940-04"@en . "2015-01-29"@en . "1940-04"@en . "https://open.library.ubc.ca/collections/vma/items/1.0214396/source.json"@en . "image/jpeg"@en . " \u00E2\u0096\u00A0\nmm mmmam^mM\t\nM ED I c A Hi sit) cit fc 1\nVol. XVI.\nAPRILM940\nNom\nWith Which Is Incorporated\nTransactions of the\nVictoria MedicaJ\u00C2\u00A7Saciety\ntbt\nVancouverGeneral[Hospital\nmmd\nSt. PauTs Hospital\nIn This Issue:\nPag*\n|fl|ENDS IN ANJESTHESimrDr^^p. ^^z^'^^^^^^^^^^^^9^\nSPECIAL CORRESPONDENCE-_i^^^^^^^^^^^^^^^^^^p5.\nj||fcSE OF SUBDURAL H^MATOMA-^t^\ngifE HANDS AND INFECTION OF CLEAN WOUNDS\u00E2\u0080\u0094J, P. Henry, I^i^p98\nCASE OF POLYCYSTIC KIDNEYA^ITH^^pMPLICATlONS\u00C2\u00AB\nSIGMUND FREUD AND PSYCHOANALYSIS\u00E2\u0080\u0094Dr. D. E\u00C2\u00BB Alcorni^^^^fc04\nVANCOUVER ^AEDICAI^SSOC^ATION\nSUMMEI#CHCK>LJiuN:i^i^ TO 28th INCLM940 if THE VANCOUVER MEDICAL ASSOCIATION\nBULLETIN\nPublished Monthly under the Auspices of the Vancouver Medical Association\nin the interests of the Medical Profession.\nOffices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C.\nEDITORIAL BOARD:\nDr. J. H. MacDebmot\nDb. G. A. Davidson Db. D. B. H. Cleveland\nAll communications to be addressed to the Editor at the above address.\nVol. XVI.\nAPRIL, 1940\nNo. 7\nOFFICERS, 1939-1940\nDb. A. M. Agnew Db. D. F* Busteed Db. Lavell H. Leeson\nPresident Vice-President Past President\nDr. W. T. Lockhabt Db. W. M. Paton\nHon. Treasurer Bon. Secretary\nAdditional Members of Executive: Db. M. McC. Baibd, Db. H. A. DesBbisat.\nTRUSTEES\nDb. F. Bbodie Db. J. A. Gillespie Db. F. W. Lees\nHistorian: Db. W. L. Pedlow .\nAuditors: Messbs. Plommeb, Whiting & Co.\nSECTIONS\nClinical Section\nDb. F. Tubnbull Chairman Db. Kabl Haig Secretary\nEye, Ear, Nose and Throat\nDb. W. M. Paton \u00E2\u0080\u0094.Chairman Db. G. C. Labge Secretary\nPediatric Section\nDb. J. R. Davies Chairman Db. E. S. James Secretary\n| STANDING COMMITTEES\nLibrary:\nDb. F. J. Bulleb, Db! D. E. H. Cleveland, Db. J. R. Davies,\nDb. W. A. Bagnall, Db. T. H. Lennie, Db. J. E. Walker.\nPublications:\nDb. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson.\nSummer School:\nDb. T. H. Lennie, Db. A. Lowbie, Db. H. H. Caple, Db. Fbank Tubnbull,\nDr. W. W. Simpson, Db. Kabl Haig.\nCredentials:\nDb. A. B. Schinbein, Db. D. M. Meekison, Db. F. J. Bulleb.\nV. O. N. Advisory Board:\nDb. I. Day, Dr. G. A. Lamont, Db. S. Hobbs.\nMetropolitan Health Board Advisory Committee:\nTo be appointed by the Executive Committee.\nGreater Vancouver Health League Representatives:\nDr. W. W. Simpson, Db. W. M. Paton\nRepresentative to B. C. Medical Association: Dr. L. H. Leeson.\nSickness and Benevolent Fund: The Pbeshjent\u00E2\u0080\u0094The Trustees. in the form you prefer\n/ THIAMIN CHLORIDE Or for the Clinicians who feel\nuun it is better therapy to use the\nTablets \u00C2\u00A7 B-COMPLEX\n1 mgm. 333 I.U. B-Complex Syrup\n5 mgm. 1665 I.U. Derived from natural sources\n\u00E2\u0080\u0094containing all the recog-\njjl nized factors in the Complex.\nSupplied in\nVials 3, 6 and 12-oz. bottles.\n5 cc. 10 mgm. per cc.\n5cc. 25 mgm. per cc. j\u00C2\u00A7 B-G Capsules\n-\n5 cc. 50 mgm. per cc. contain not less than 150 In-\n,.. . . ter. units of Bx and 150 gam-\n10 cc. 10 mgm. per cc. mas Riboflavin.\nYeast Tablets\nAmpoules N.N.R.\n6 x 1 cc. p 10 mgm. jn bottles of 100, 250 and\nlOOx 1 cc. 10 mgm. 1000.\nAs we have no trade names for these products\nplease specify SQUIBB on your prescription.\nFor Literature write\nERSqjjibb &.Sons of Canada.Ltd.\nMANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858\n36 CALEDONIA ROAD, TORONTO. VANCOUVER HEALTH DEPARTMENT\nSTATISTICS, FEBRUARY, 1940\nTotal population\u00E2\u0080\u0094estimated 269,454\nJapanese population\u00E2\u0080\u0094estimated 9,094\nChinese population\u00E2\u0080\u0094estimated 8,467\nHindu population\u00E2\u0080\u0094estimated \ _ 339\nRate per 1,000\nNumber Population\nTotal deaths 244 11.4\nJapanese deaths \u00E2\u0080\u0094 6 8.3\nChinese deaths jj 10 14.9\nDeaths\u00E2\u0080\u0094residents only 206 9.6\nBIRTH REGISTRATIONS:\nMale, 185; Female, 171.-.\n. 356\nFeb., 1940\nINFANTILE MORTALITY:\nDeaths under one year of age 7\nDeath rate\u00E2\u0080\u0094per 1,000 births 19.7\nStillbirths (not included in above) 8\n16.7\nFeb., 1939\n9\n26.5\n5\nCASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY\nMarch 1st\nJanuary, 1940 February, 1940 to 15th, 1940\nCases Deaths Cases Deaths Cases Deaths\nScarlet Fever r , 10\nDiphtheria , 0\nChicken Pox 125\nMeasles 67\nRubella 1\nMumps i 16\nWhooping Cough 23\nTyphoid Fever 0\nUndulant Fever 0\nPoliomyelitis \u00E2\u0096\u00A0 0\nTuberculosis 36\nErysipelas \u00E2\u0096\u00A0 7\nEp. Cerebrospinal Meningitis 0\nParatyphoid Fever Carrier 0\nV. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH.\nDIVISION OF VENEREAL DISEASE CONTROL.\nWest North Vancr. Hospitals,\nBurnaby Vancr. Richmond Vancr. Clinic Private Drs. Totnls\nSyphilis 0 0 0 0 27 28 55\nGonorrhoea 0 0 0 1 70 35 106\n0\n6\n0\n11\n0\n0\n0\n0\n0\n0\n0\n122\n0\n77\n0\n0\n82\n0\n6\n0\n0\n9\n0\n5\n0\n0\n3\n0\n0\n0\n0\n12\n0\n13\n0\n0\n0\n0\n0\n0\n0\n1\n0\n0\n0\n0\n0\n0\n0\n0\n14\n42\n18\n4\n0\n1\n0\n2\n0\n0\n0\n0\n0\n0\n0\n1\n0\n0\n0\nBIOGLAN\nTHE SCIENTIFIC HORMONE TREATMENT\nDescriptive Literature on Request.\nA Product of the Bioglan Laboratories, Hertford, England.\nRepresented by\nSTANLEY N. BAYNE\nPhone: SEy. 4239\n1432 Medical-Dental Bldg.\n\"Ask the doctor who is using it.\"\nVancouver, B. C. ~l\nMYALQIAS of the\nEXTREMITIES\nBACK and NECK\nare almost invariably benefited by heat therapy*\nAntiphlogistine is a most useful and\nefficient form of applying prolonged\nmoist heat, plus medication, for the\nrelief of muscular aches and pains and\nassociated stiffness.\nIt is distinctly beneficial, also, as a\nsupporting measure to electro^therapy.\nSample on request\nANTIPHLOGISTINE\nTHE DENVER CHEMICAL MFG. CO.\n153 LAGAUCHETIERE ST. W.\nMade in Canada\nMONTREAL\nJ KELLOGG'S ALL -\nBRAN\nHELPS ELIMINATION AND\nIMPROVES INTESTINAL\nJ0*fcp*\nMhiram\nTONE BECAUSE IT PROVIDES\n\"BULK\" AND VITAMIN Bt\nALLBRAN\n\" T^^nTd MAIT SUSAR ANO SAIT\nMade by Kellogg's\nDUE TO DIET DEFICIENCY\nOF'BULK\"\nps\nin London, Canada\nKELLOGG COMPANY OF CAHADA.LT0a.ONDOM.ONT.\nProfessional Men appreciate\nthe Value of being well-dressed\nA Suit tailored to your measure by us is your assurance of\nQuality British Woollens, fine hand tailoring\nand correct style.\nOur new Spring patterns are now ready and your early\ninspection is invited.\nBritish Importers of Men's and Women's Wear\nMEDICAL-DENTAL BUILDING VANCOUVER, B. C. Each tablet contains:\nTheobromine - - - - 5 grams\n*Neurobarb E.B.S. - - Yt gram\nSodium Bicarbonate - 5 grams\nBeing antispasmodic and sedative in action, the ingredients of\nTheobarb E.B.S. act synergistically to relieve spasm.\nThe prompt relief following its administration greatly improves\nthe patient's mental outlook and sense of physical well-being.\nINDICATIONS: Angina. Pectoris, Arteriosclerosis, Cardiovascular Disease, Nervous Manifestations of the\nClimacteric Period, Epilepsy, Hyper Tension\nand as an Antispasmodic and Sedative.\nAlso supplied with }/\u00C2\u00A3 grain Neurobarb as C.T. No. 691A Theobarb Mild\nLiterature and sample on request.\n'Neurobarb is the E.B.S. trade name for Phenobarbital.\nTHE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED\nTORONTO\nMANUFACTURING CHEMISTS\nCANADA\nSTOCKS CARRIED AT\nWINNIPEG, MAN CAMPBELL HYMAN LTD. VANCOUVER. B. C\u00E2\u0080\u0094J. P. SOUTHCOTT & CO. LTD.\nSPECIFY E. B. S. ON YOUR PRESCRIPTIONS\nj There is an old Latin tag, \"De mortuis nil nisi bonum.\" For the benefit of any stray\nreader who may not have remembered all he learnt at school, this means \"Nothing but good\nconcerning the dead.\" Too often we act as if it read: \"Nil bonum nisi de mortuis.\" \"Nothing good except about the dead.\"\n\"We tend to take people for granted, and to abstain from gracious acts and words of\nappreciation and affection, all too often. It is the \"flegme Britannique,\" no doubt\u00E2\u0080\u0094but\nwe sometimes wonder whether a kind word now wouldn't be worth a great deal more than\nthe finest, most Periclean of orations, when we are no longer there to hear it: or when,\neven if we do hear it, we cannot say \"Thank you.\"\nAll of which longwindedness leads up to a forthcoming celebration of an anniversary\nby one of our oldest and dearest members, Dr. Robt. E. McKechnie, Senior, who has now\npassed the fiftieth milestone in his medical career. No man better deserves our affection\nand esteem: no man, we say without slightest fear of question, has a greater measure\nof it: and this esteem, this affection, are given him not only by his colleagues and professional brothers, but by men and women in every walk of life, from the highest to the lowest.\nDr. McKechnie (R.E. to everyone who knows him) is much more than a prominent\nVancouver citizen, or an eminent Vancouver surgeon. He is an international figure in\nmany ways. He has served his profession in almost every possible capacity\u00E2\u0080\u0094alike in federal, provincial and local activities, he has been ever a leader, and thus a devoted servant,\nof his fellows.\nHe has done his share in politics, has been a member of the Legislature of this province.\nIn federal medical activities he has been an active member of the Dominion Medical\nCouncil.\nHe has been an outstanding figure in educational circles: and his present position as\nChancellor of one of the leading Canadian Universities is his as long as he cares to fill it.\nHis advice and counsel have been freely sought in every walk of life: and in fact from the\nday he started his medical career, fifty years ago, he has been two things, which any man\nwould be proud to be, a good doctor and a good citizen.\nHe has been honoured in many ways, as the long string of letters after his name shows:\nby his King, by other universities, by leading educational institutions. The City of Vancouver gave him its \"Good Citizen\" medal in appreciation of his long and fathful service.\nAnd with it all, he has preserved a modesty of demeanour, a kindliness and a true friendliness which have never varied or failed\u00E2\u0080\u0094and which have made him not only a respected\nand valued member of our community, but a dearly loved friend. Every one of us will\njoin in the heartiest congratulations to him on his long and successful career: every one of\nus will from our hearts wish him \"Many, many happy returns\" of this anniversary of his.\nLong may he live and be with us, for our sakes fully as much as for his own.\nIt is with very hearty congratulations and good wishes that we record the recent\nmarriage of our Librarian (and Chief Editor of this journal, if the truth be told, as she does\n75% of the work connected with it), Miss Jessie M. Choate. There is a slight feeling of\nregret tempering this congratulatory feeling of ours\u00E2\u0080\u0094a purely selfish regret, we fear, since\nwe shall miss her badly\u00E2\u0080\u0094but the congratulations are very sincere: since we wish her all the\nhappiness in the world, and this is, for her, a step towards that end. We wish her all prosperity and a happy, peaceful life, and we know that every one of us will say the same.\nMiss Choate has been a very devoted member of our staff for some years. She was\nengaged as a Librarian, and from the beginning the Library has been her chief activity.\nMany a man owes very much to her skill and patience in this regard.\nShe has been a tower of strength to the Bulletin: both in the mechanical gathering\nand collating of material, and its proofreading, and also through her willing co-operation\nPage 185 with editor and publisher alike. What on earth we shall do without her we do not know,\nbut we cannot do anything about it, except make the best of it, and carry on. In the\nmeantime, we retain the pleasantest and most grateful memories of our association with her.\nDINNER TO DR. AMYOT\nEach member of the profession will have received a letter regarding the forthcoming\ncomplimentary Dinner being given to Dr. G. F. Amyot, our new Provincial Health Officer,\nby the B. C. Medical Association, on April 4th.\nWe hope sincerely that every medical man that can possibly do so will make it his business to be at this dinner. There are many reasons for this.\nFirst, Dr. Amyot himself. He is, we believe, the best possible choice for this position,\nand British Columbia is indeed fortunate in this appointment. Dr. Amyot has had a wide\nexperience in matters of public health; not only in Vancouver, or in Canada\u00E2\u0080\u0094but in the\nU. S. A. as well, where he has for the past two years been lecturing and studying public\nhealth matters.\nHe has it in his blood. His distinguished father, Dr. J. A. Amyot, so well known to all\nCanadian medical men, has here a worthy successor to wear the mantle he has himself now\nput aside. Dr. Gregory Amyot, our guest and colleague, has vision and ideas, and those\nwho have heard him speak on these matter, on recent occasions, have testified to the breadth\nand statesmanship of his vision.\nDr. Amyot has always considered the whole of the medical profession, and not merely\none branch of it.* Just before he left Vancouver he had been working on a scheme to\ninclude the practitioner of medicine in the preventive and health forces of the community:\nto utilise the services of the theraputic side to reinforce the preventive side. This, we\nunderstand, is still his hope and plan\u00E2\u0080\u0094and we should help him with this, and show our\nwillingness to do so. There is, and should be, only one medical profession. It has two main\nduties: the first, to prevent and forestall disease: the second, to treat and heal it when it\ncomes. There should be no sharp division between the two branches: they should work\ntogether and in the utmost harmony and understanding. This is another reason why, when\nwe have an opportunity, as we shall here, to bring the two branches together, and maintain and fortify friendly relations, we should do so.\nThe dinner should be a very large one, and should be an outstanding event. So we urge\neveryone to come on Wednesday, April 4th, and give Dr. Amyot a real and hearty welcome.\nNEWS AND NOTES\nDINNER\nGuest of Honour:\nDR. G. F. AMYOT\nProvincial Health Officer.\nThe President and Board of Directors of the British Columbia Medical\nAssociation request that you attend this Dinner in compliment to Dr.\nAmyot on his appointment to this important position in\nBritish Columbia Medicine.\nPlace HOTEL VANCOUVER, BANQUET ROOM (1st floor)\nDate THURSDAY, APRIL 4th.\nHour RECEPTION AT 7:30\u00E2\u0080\u0094DINNER AT .8:00.\nDress Optional, FORMAL PREFERRED.\nCharge $2.00. Please secure tickets beforehand.\nPage 186 We offer our congratulations to Dr. and Mrs. Douglas Telford on the birth of a son on\nMarch 9, 1940.\nDr. G. A. Davidson has left for the East, where he will attend the meeting of the\nAmerican College of Physicians in Cleveland. He will visit New York and Toronto before\nreturning about the end of April.\nDr. and Mrs. J. A. MacLean are receiving congratulations upon the birth of a son on\nMarch 1, 1940.\nThe marriage took place on March 23rd of Miss Margaret E. Milburn, eldest daughter\nof Dr. H. H. Milburn, to Dr. Frederick O. R. Garner. Dr. and Mrs. Garner will make their\nhome in Kamloops. We offer them our heartiest congratulations and best wishes for their\nfuture.\nDr. Gerald Baker of Quesnel visited on the Lower Mainland and on Vancouver Island\nand enjoyed a well-earned vacation. He had his fishing-rod\u00E2\u0080\u0094took a steelhead out of the\nVedder River\u00E2\u0080\u0094and spent several days at Fisherman's Lodge, Oyster River, on Vancouver\nIsland, luring lusty trout.\nDr. G. D. Oliver, who was associated with Dr. Baker at Quesnel, is still in Great Britain.\nDr. Baker reports that Dr. Oliver secured the F.R.C.S. (Edin.) in the recent examinations.\nCongratulations to Dr. Oliver.\nDr. D. W. Davis of Kimberley has been visiting in Vancouver.\nDr. H. H. Mackenzie of Nelson was in Vancouver for a few days.\nDr. N. J. Paul of Squamish called at the office.\nDr. Andrew Turnbull of Victoria was in Vancouver on March 11th, and attended the\nmeeting of the Committee on Cancer of the British Columbia Medical Association.\nCol. A. L. Jones, D.M.O., M.D. No. 11, spent several days in Vancouver. On March\n11th Colonel Jones went to Prince Rupert.\nMajor W. Allan Fraser of Victoria is doing special work under Military Headquarters\nin setting up arrangements for the care of venereal disease.\nCaptain and Mrs. G. C. Large of Vancouver made the round trip to Stewart during\nhis leave.\nDr. W. T. Kergin, formerly of Prince Rupert, now residing in Vancouver, visited the\nSkeena riding during the election campaign in support of Mr. Olaf Hansen, the Liberal\ncandidate.\nDr. and Mrs. C. A. Armstrong of Port Simpson are receiving congratulations on the\nbirth of a son on March 5th in Prince Rupert General Hospital.\nDr. W. H. (Bill) White of Penticton has sufficiently recovered from his recent operation to be holidaying in Spokane.\nDr. J. Vernon Murray of Creston was in Vancouver recently and called at the office.\nPage 187 Dr. H. F. P. Grafton was called to Belleville, Ont. The profession extends sympathy\nto Dr. Grafton in the loss of his mother.\nThe profession regrets the passing of Mrs. R. F. Greer and extends sympathy to Dr.\nGreer in his bereavement.\nDr. and Mrs. J. L. Murray Anderson of Victoria are receiving congratulations on the\nbirth of a son.\nDr. G. F. Amyot, Provincial Health Officer, has been elected to membership in the\nVictoria Medical Society.\nLIBRARY NOTES\nJournals in the Library.\nThe attention of the members is drawn to the complete list of Journals which are\nreceived in the Library, which has now been prepared and may be found on the Reading\nRoom table for reference. As will be seen from the list, many of those received are sent\nfree of charge, or as exchange copies for the Vancouver Medical Association Bulletin.\nIn order to accommodate the increased number of journals in the Reading Room, the\nLibrary Committee has authorized the construction of a new magazine stand, which will\nmatch the one already in use. When this is installed there will probably be some rearrangement of the order in which the journals are to be found on the shelves, and a plan will be\nput up which will make the location of any journal a simple matter.\nItems from the Journals.\nDiagnosis of Polycythemia\u00E2\u0080\u0094Annals of Internal Medicine, February, 1940, p. 1136.\nStudies in Peripheral Vascular Disease. No. 1: Intravenous calcium in occlusive vascular\ndisease.\u00E2\u0080\u0094Annals of Internal Medicine, January, 1940, p. 1150.\nInfectious mononucleosis\u00E2\u0080\u0094Medicine, February, 1940, p. 85.\nSymposium on Traumatic Surgery\u00E2\u0080\u0094Amer. Jour, of Surgery, February, 1940.\nSymposium on Peripheral Vascular Diseases\u00E2\u0080\u0094Arch, of Surgery, February, 1940.\nSymposium on Intervertebral Disks\u00E2\u0080\u0094Arch, of Surgery, March, 1940.\nSymposium on Surgery of the Aged\u00E2\u0080\u0094Surg. Clin, of North America, February, 1940:\nSurgery of the Aged: Indications and Contraindications, by Dr. George de Tarnowsky.\nTreatment of Intestinal Obstruction, by Dr. Albert H. Montgomery.\nTreatment of Carcinoma of Rectum and Colon, by Dr. Guy V. Pontius.\nSurgery of Thyroid Gland in Aged, by Drs. Bernard Poris and Harold A. Roth.\nSurgery of Liver, Gallbladder and Bile Ducts in Aged, by Dr. Warren H. Cole.\nUrologic Surgery in Aged, by Dr. Herman L. Kretschmer.\nManagement of Fractures of Neck of Femur by Operative Fixation, by Dr. Kellogg\nSpeed.\nOsteochondritis of Knee in Aged Patients, by Dr. Elven J. Berkheiser.\nAppendicitis in Aged, by Dr. Edwin M. Miller.\nSenile Changes of Vulva, by Dr. Ralph A. Reis.\nDiagnosis and Management of Cancerous and Precancerous Lesions in Aged, by Dr.\nCleveland J. White.\n(There are 13 other Clinics in this number in addition to the Symposium.)\nThe 69th Annual Meeting of the American Public Health Association will be held in\nDetroit, Michigan, October 8-11, with the Book-Cadillac Hotel as headquarters.\nThe Michigan Public Health Association, the American School Health Association, the\nInternational Society of Medical Health Officers, the Association of Women in Public\nHealth, and a number of other allied and related organizations will meet in conjunction\nwith the Association.\nThe Michigan Committee on Arrangements is headed by Mr. Abner Larned of Detroit.\n\u00E2\u0096\u00A0Dr. Henry F. Vaughan, Health Commissioner of Detroit, is Executive Secretary.\nPage 188 The Annual Meeting of the American Public Health Association is the largest and\nmost important health convention held on this continent. It will bring 3500 health officials to Detroit for a series of scientific meetings covering all phases of health protection\nand promotion. A Health Exhibit will be held in connection with the meeting and an\nInstitute on Health Education is scheduled prior to the official opening.\nDr. Reginald M. Atwater is Executive Secretary of the American Public Health Association, with offices at 50 West 50 th Street, New York City.\nThe following were recently elected to membership in the Vancouver Medical Association: Dr. Thomas Dalrymple, Dr. R. S. Manson and Dr. R. A. Wilson. Dr. D. J. Bell\nwas elected a Life Member of the Association.\nThe next general meeting will be held in the Auditorium of the Medical-Dental Building on April 2nd, when Dr. H. H. Boucher will give the paper of the evening, on \"Low\nBack Pain.\"\nANNUAL MEETING\nThe Annual Meeting of the Vancouver Medical Association will be held on April 23 rd,\n1940. The meeting will follow a dinner, details of which will be announced later.\nMembers are reminded that nominations for officers of the Association must be posted,\nbefore the meeting, in the Library.\nVANCOUVER MEDICAL ASSOCIATION\nSUMMER SCHOOL CLINICS\nDates\u00E2\u0080\u0094June 25th to 28th, incL, 1940.\nPlace\u00E2\u0080\u0094Hotel Vancouver, Vancouver, B. C.\nPlans are almost completed for the Annual Summer School, to be held in the Hotel\nVancouver in June from the 25 th to the 28 th, inclusive.\nThe Committee feels that it will have a most varied and interesting programme, and\nhas kept in mind the interests of the General Practitioner and the Specialist. While as yet\nthe final decision has not been made as to all topics, the list of speakers who have definitely\npromised to be here is as follows:\nDr. A. W. Farmer, Department of Surgery, University of Toronto Medical School,\nToronto. Dr. Farmer will speak on Children's Surgery.\nDr. P. C. Jeans, Professor of Paediatrics, University of Iowa, Iowa City, who will discuss\nchildren's diseases.\nDr. William Magner, of the Department of Pathology, St. Michael's Hospital, Toronto.\nDr. Magner will speak on Jaundice and Anaemia, from both pathological and clinical\nstandpoints.\nDr. Wm. S. Middleton, Professor and Dean of the University of Wisconsin Medical\nSchool, Madison, Wis. Dr. Middleton's lectures will be on some phases of Internal\nMedicine.\nCANADIAN MEDICAL PROTECTIVE ASSOCIATION\nThe protection afforded by the Canadian Medical Protective Association has proven\nsatisfactory to a large number of our members.\nSome members of the practising profession in British Columbia have not secured membership and this protection.\nBe advised.\nPage 189 TRENDS IN ANESTHESIA\nDr. D. D. Freeze.\nGiven before Vancouver Medical Association, March 5, 1940.\nWhat I have to say tonight is not in any sense a scientific dissertation on the subject of\nanaesthesia, nor am I going to trouble you with statistical data. My paper will be devoted\nto what might be termed a meditative consideration of the drastic changes which have\noccurred within recent years. It is pretty definite that the practice of medicine in general\nis subject to what might be termed \"vogues.\" What is heterodox today may be orthodox\ntomorrow. We have all seen new ideas eagerly taken up, popularised for a time, and then\nslowly forgotten. This is natural, it is dynamic, it is characteristic of growth and life.\nJust to mention an instance, it is a far cry from the time when inhalations of ether for the\ntreatment of respiratory diseases was orthodox practice, to our present feeling toward it\nin this regard. If I am not mistaken it would seem that we are about to see the replacement\nof catgut by the non-absorbable suture for many uses in surgical practice: this, after\nuntold labour and expense in producing an absorbable suture to replace the then orthodox\nnon-absorbable one. And so in the field of anaesthesia during the past two decades there\nhave been modifications and additions, which, while on the whole improving the scope of\nanaesthesia, have also complicated an otherwise pretty clear picture. In reality there have\nactually been no new methods introduced. Intravenous and rectal anaesthesia are described\nas far back as 1910, but in both instances ether was the drug used and its intravenous use\nnever passed the experimental stage. Rectal ether, both in vapour form and mixed with oil,\nhas had a certain popularity to within recent times. In fact, at one time the rectal administration of ether was the only non-inhalation method available in general anaesthesia. The\nrectal use of ether and oil even yet has its advocates for certain conditions.\nForms of local anaesthesia, including splanchnic block and sacral and parasacral block,\nwere quite popular a few years ago. Spinal anaesthesia has been used since before the turn of\nthe century, but not ony of these methods threatened the position of inhalation anaesthesia.\nThese, briefly, summarize practically all the methods for invoking anaesthesia in use today,\nso that the great changes and developments in its practice have been along the lines of new\nmaterials and improved technique, these having revived old methods previously unsatisfactory. In practically every instance the revival of an old method has been through the\ndiscovery of a new drug.\nIntravenous\nLet us consider the intravenous method. This type of anaesthesia had not been used up\nto the discovery of sodium amytal, a barbituric acid derivative. With the finding that this\ndrug would create complete loss of consciousness when introduced into the blood stream,\nwithout any initial restlessness or unpleasant sensations, and would permit operative procedures with comparative safety, the barbiturates were launched on a wave of anaesthetic\npopularity that for a time threatened all other methods. So rapidly did the gospel of its\nefficacy disseminate that it assumed the proportions of a crusade. Many of you may recall\nan article appearing in one of our papers, vivid and idealistic, describing an operation in a\nhome for the extraction of teeth under amytal. It read like a page from the Arabian Nights.\nA number of apparently satisfactory major surgical procedures were accomplished with\namytal only, but after its initial enthusiasm had dwindled it was apparent that large doses\nnecessary for surgical procedures were not exactly safe, and likewise the stormy post-operative period requiring free use of narcotics and sometimes actual restraint led to its use in\nsmaller doses for hypnotic effect only. In reality this drug was never routinely satisfactory\nfor surgical anaesthesia. Product, however, followed product, until today there are two\ndrugs, pentothal sodium (Abbott) and evipal (Winthrop), which are being used more or\nless routinely for surgical procedures of moderate duration. Just now it would appear that\npentothal has outstripped its competitor in popularity, chiefly from its control of reflexes,\nalthough it is not considered quite as safe a drug as evipal. Pentothal has been vised by a\nnumber of surgeons for intra-abdominal surgery, including long operations, but in nearly\nevery instance where a series of cases has been reported there appears a warning against its\nroutine use for major surgical procedures.\nMy personal experience with both these drugs has been, generally speaking, satisfac-\nPage 190 tory, but they have only been used in minor cases or where inhalation or spinal anaesthesia\ncould not be made available. The longest instance I can personally report was a recent case\nof an hour's duration. This was an operation on the face involving laceration of both nose\nand mouth, thus precluding an inhalation anaesthetic. The use of pentothal here proved a\nhappy choice. The patient was placid throughout and made an uneventful recovery. On\nthe other hand, I would like to' submit the report of a case of a young boy with an oral\ngrowth. The operation was for the insertion of radium needles. Pentothal was chosen,\nand. even after the administration of a full gram the patient reacted so strongly to any\noperative procedure that it was necessary to use a supplemental inhalation anaesthesia. As it\nturned out, this was not a good procedure, and for a time the patient developed rather\nalarming symptoms.\nRectal\nIn rectal methods for general anaesthesia, not taking into consideration the use of paraldehyde, the use of ether in oil has been pretty well abandoned, though one sees the method\noccasionally mentioned in recent writings. Replacing it is avertin, a bromine derivative,\nwhich, while an excellent hypnotic and much favoured for pre-operative administration,\nis of little value per se for even minor operations. It enjoys a well-earned reputation in\nmany quarters, but opinion regarding its safety is strongly divided, more so, I would say,\nover this drug than over any of the other modern ones. This is particularly true both among\nsurgeons and obstetricians. Where used, it has borne the brunt of criticism for nearly every\nform of post-operative complication. It is considered by some in obstetrics to increase\nrespiratory depression in the newborn* with delayed resuscitation, but, on the other hand,\nhas not delayed resuscitation occurred after every type of delivery, when where anaesthesia\nhas only been used to the degree of analgesia? And so, obstetrically speaking, there are the\nBoffkins and the Slearys\u00E2\u0080\u0094\"and year by year, in pious patience, vengeful Mrs. Boffkin sits\nwaiting for the Sleary babies to develop Sleary fits.\" For caesarian sections, I am a Sleary.\nIn my opinion, avertin in an excellent and most satisfactory drug for pre-operative\nmedication. It is difficult for one to place one's finger on a single instance of pre-operative\nor post-operative complication that could be directly attributed to Avertin, or that could\nnot or has not occurred in anaesthesia without its use. One is naturally suspicious of its use\nin hepatic disease, but case after case has been reported of its use in the presence of jaundice\nwithout complication. An interesting instance of its non-toxic effect occurred a few\nmonths ago, when through an error in transcribing the weight of a child the avertin dosage\nof 100 mgm. per kilogram was based on a weight of 71 lbs. instead of 41 lbs. This worked\nout at the unheard-of dosage of 175 mgm. per kilogram. The anaesthetist, not knowing of\nthe error, reported the operation, an encephalogram, as the \"slickest\" avertin he had seen.\nThe patient's condition was good throughout; there were no untoward symptoms; the child\nawoke 4 hours after the administration of the drug, and 24 hours later his condition had\ncontinued good and his kidneys were functioning well. The average dose as used today lies\nsomewhere between 80 and 100 mgm. per kilogram. Here it would appear that ample\nmargin of safety exists.\nEvipal has also been prepared for rectal use, but it has never been extensively used by\nthis method.\nSpinals.\nAnother method of anaesthesia which has become extremely popular in recent years is\nspinal block. Here again it has been pretty much a matter of new drugs, and there is still\nroom for improvement. I mean by that that those drugs which can be used satisfactorily\nfor short operations tend to produce discomfort, restlessness, pallor, nausea and shock,\nwhile on the other hand those which have not shock-producing proclivities do not lend\nthemselves to short anaesthetics. Specifically, novocain crystals\u00E2\u0080\u0094most satisfactory from\nan anaesthetic point of view for operations up to an hour, but tending to produce severe\ndepression with the symtoms just previously mentioned. Pontocain, an essentially long-\nacting drug, while leaving the patient with a better sense of well-being and much more\nplacid, does not act with any certainty in diminishing doses- Its freedom from the unsatisfactory immediate complications as seen with Novocain is a curious phenomenon. Would\nI be going too far in suggesting that the sympathetic system would appear to be less affected\nwith pontocain than with novocain? Generally speaking, drugs for spinal anaesthesia may\nPage 191 be grouped under those in a solution lighter than spinal fluid, those in solution heavier than\nspinal fluid, and those essentially isotonic. Each group has its advocates, but among those\nwho have adopted spinal anaesthesia more recently the isotonic form is best liked. In this\ngroup the height of anaesthesia is obtained through barbitage, that is, the drug is forced the\nrequired distance up the canal by means of re-injected spinal fluid. Spinal anaesthesia is\nbest suited for operations below the diaphragm, and intra-abdominally is more successful\nin lower abdominal operations than in the upper abdomen.\nIn perusing reports of clinics where spinal anaesthesia was the anaesthetic of choice it is\nto be noted that in upper abdominal operations supplemental anaesthesia is frequently resorted to either for the control of pain or for improved relaxation. As an anaesthetic of\nchoice, while kindly disposed towards it, I do feel that it is essentially an anaesthetic for\nthe physically fit. On the other hand, it does lend itself satisfactorily to extra-abdominal\noperations in elderly people. Laparotomies in infants for pyloric stenosis are reported under\nspinal with success. Opinion is divided regarding pre-operative medication, and varies from\na desire for complete basal narcosis to a modest dose of morphia. There does not appear to\nbe any contra-ihdication one way or the other, though halfway measures, where the patient\nis drowsy but restless and uncooperative, are most unsatisfactory. Here it is difficult\nsometimes to tell whether the patient's behaviour is the result of pain from the site of\nthe operation or merely the drunken effect of his pre-medication. To know definitely that\nthe spinal anaesthetic is efficient is a great help in deciding on the necessity or otherwise\nof some supplemental anaesthesia, so that it seems to me that the anaesthetic first and medication following is the more rational procedure.\nI would like to mention a point in regard to the use of the high-tension unit under\nspinal anaesthesia. Is the flow of electrical potential through tissues capable of exciting reflex\naction? It is interesting to note that two cases of coronary attack, clinically, occurred\nunder spinal with the high-tension unit. It would seem safer to keep the cardiac area away\nfrom the electric flow; that is, the metal pad under the hips for operations below the\ndiaphragm, and between the shoulders for operations above the chest.\nGas.\nNow let us consider the remaining group of anaesthetics, within which are harboured\nnearly all anaesthetic villains, namely, the inhalation group: what has been done in this\ngroup, and should their use be continued except where necessary. Without a doubt the\ngreatest advances of recent years have been in the field of gaseous anaesthetics. Here gases\nof relatively increasing power for producing satisfactory anaesthesia have been added, but\nwith increasing toxic dangers and explosive hazards. One must, I suppose, believe in an\nAladdin's lamp to imagine a completely innocuous substance capable at the same time of\nproducing profound unconsciousness with muscular paralysis. It really doesn't seem\nreasonable. Do you recall some fifteen years ago when ethylene appeared, more powerful,\nused with a higher oxygen content\u00E2\u0080\u0094both advantages over nitrous oxide\u00E2\u0080\u0094but highly\nexplosive, nevertheless in the final analysis requiring some ether for the production of complete muscular paralysis?\nMay I digress here a moment to give my view in regard to muscular relaxation? When,\nto a substance inherently incapable of producing muscular relaxation, is added one capable\nof so doing, and relaxation is obtained, it would seem that it must have come from the\nlatter. It is all very well, for instance, to talk of supplementing nitrous oxide with a little\nether for relaxation. If ether is to produce relaxation it is going to do so in a certain blood\nconcentration, and whether that blood concentration has been reached through nitrous\noxide as a vehicle, or air, the amount of ether in the blood stream is the same. There are possibly those among us tonight who have in the past worked with nitrous oxide when it was so\npopular for general surgery, and they must recall the diverse methods in use for introducing\nsufficient ether for relaxation. The best gas anaesthetist unquestionably was the one with\nthe most tricks up his sleeve. Did not a patient lose her life at Montreal during a meeting\nthere of the American College of Surgeons in 1920 directly due to this effort to introduce\nsufficient ether with nitrous oxide for relaxation\u00E2\u0080\u0094and this in the hands of an exceptionally\nexperienced anaesthetist? It could have happened to anyone in those days. Literally dozens\nof ridiculously risky anaesthetics were administered in those seemingly far-off days with\nPage 192 nitrous oxide, in the name of safety, and it is to be hoped that the pendulum of time in its\ninexorable swing will never again pass within the orbit of a period as fraught with discomfort, dissatisfaction and danger. What a friend ethylene must have been to those who were\nusing nitrous oxide almost exclusively; with its greater potency and higher oxygen content.\nYet ether was still necessary for good relaxation, and that necessity, added to its inflammable character, militated against its adoption in many places, including Vancouver. As\nyou are aware, it has never been used here, and now that it has been supplanted by\nanother gaseous substance, cyclopropane, I think one can honestly say that it really has\nnever been missed.\nWith the introduction of cyclopropane for surgical use in 1932, together with the\ncarbon dioxide adsorption technique for the administration of gases, a real advance in\ngaseous anaesthetics occurred. Here is a substance with real potency, capable of producing\nmoderate relaxation in low strength, thus permitting the use of oxygen to an almost unlimited degree. Exhilaration and secretion are negligible; recovery is rapid; nausea, while\noccurring, particularly after the deeper anaesthesias, is usually of short duration. Is there\nany blemish on the escutcheon of so ideal a material? Generally speaking, it may be said\nthat the element of safety diminishes directly as the increase in potency. Here is a gas\nwhich is comparable to chloroform, in that it has real coma-producing qualities with\nintense action on medullary centres, and, clinically at least, acting directly on heart muscle\nto the end that variations in pulse rate may occur quickly, and a persistent tachycardia be\na real cause of anxiety. It, too, is inflammable within anaesthetic ranges. However, its\nvirtues far outweigh its faults, and it is being used increasingly, and in some places to the\nexclusion of all other inhalants.\nLet it be noted, however, that the recorded successes of the gases in major surgery are\nintimately bound up with the free exhibition of narcotics or hypnotics prior to operation,\nand I mean free. At that, relaxation can never reach the profundity of that obtainable with\nether or spinal block.\nAnother comparatively new comer among the inhalants, and concerning which I am\nbut vaguely familiar, is vinthene or vinyl ether, a derivative of the ethylene series. Its\nchief recommendations are: a rapidity of action, relaxation under analgesia, and rapid\nrecovery. Its faults, salivation and rapid deterioration.\nHappily, as I see it, the old guard of inhalants are still with us, and should be given a\nlittle more than the \"passing tribute of a sigh.\"\nThere are those who in their enthusiasm for modern trends would give to ether and its\nassociates that relation which old Dobbin once bore to the enthusiastic motorist in other\ndays\u00E2\u0080\u0094a nuisance on the highway, but \"a refuge and a strength; a very present help in\ntrouble!\" ^\nEther is probably yet the most widely used single drug in anaesthesia, and is likely to\ncontinue so for some time. What a tradition it possesses! The first in the field, and still\nthe big brother to all the newer ones after the lapse of nearly a century. It is stable; like\none of its close cousins it actually improves with age, and it is the most versatile of them\nall, in that it can lend itself to all situations. It is, in reality, the centre of the anaesthetic\nsolar system, about which its satellites revolve. True, it possesses faults aplenty, but most of\nthese are surmountable, and a well-conducted ether anaesthetic gives a pretty satisfying\npicture. Its being a fat solvent is one of its greatest faults, permitting the useless storing\nof ether in the tissues, which must be later eliminated, leading to a long-drawn-out,\nnauseated recovery period. It is pungent and irritating to the larynx, but if coughing in\nthe initial stages bears any relation to subsequent respiratory conditions, why shouldn't\nthose tearing, heart-rending spasms, frequently heard in the hospital corridors, due to the\ninhalation of a laryngeal irritant, be conducive of more acute respiratory trouble?\nAdmitted that it appears to disadvantage in upper abdominal operations, yet I was\nimpressed with a recent statement made to the effect that respiratory complications in\nupper abdominal operations under spinal are no greater than with ether. Why are there\nhot more acute respiratory conditions following tonsillectomy under ether, where the\ntract is so much more subjected to abuse, and aspiration is shown to be inevitable? Lung\nabscess? Admitted! but never the acute respiratory flare-up of the laparotomy. The sen-\nPage 193 sitive and susceptible respiratory tract of the infant has been subjected to the vapor of\nether without respiratory complication times without number. It will give complete\nrelaxation, placid, effortless respiration, with little or no circulatory disturbance, over long\nperiods of time, which, after all, are accomplishments not to be overlooked in any anaesthetic.\nBesides its tendency to respiratory complications there exists one really formidable\ncomplication which is causing growing concern and for which a satisfactory explanation\nhas not been found. I refer to the appearance of convulsions or clonic movements under\nether anaesthesia, fortunately seen only occasionally. They seem to be associated only with\nether and the background is much as follows: young person in the teens or early twenties,\nin good physical condition, with an acute illness\u00E2\u0080\u0094often appendicitis\u00E2\u0080\u0094associated with\npyrexia and leucocytosis.\nThere does not appear to be any warning of their advent, appearing in an anaesthetic\nwell under way, and well organized\u00E2\u0080\u0094anoxemia does not appear to be a factor; they commence as circum oral or orbital twitchings, spreading rapidly downwards over the chest\nand extremities, interfering with respiration and presenting a truly alarming picture. Fatal\nterminations have occurred, and one wonders whether the cardia is sometimes involved\nin a similar way. A good deal has been published in recent years on the subject, and diverse\nexplanations offered, but the last word has certainly not yet been written.\nKemp\u00E2\u0080\u0094our Kemp\u00E2\u0080\u0094published a paper on the subject, attributing the probable cause\nto an alkalosis\u00E2\u0080\u0094and recommended carbon dioxide inhalation as a remedy. In some cases,\nbut only in some, will carbon dioxide help; in others it intensifies the condition. This would\nsuggest a more complicated origin. Deeper anaesthesia makes matters worse.\nTwo of the more recent suggested causes are: (1) The presence of a neurotropic\norganism, and (2) a physiological or biochemical disturbance.\nSuggested treatment involves withdrawal of drug, maintenance of oxygenation, and\nsedation. The barbiturate evipal has been successfully used in some cases.\nDown through the years I have seen convulsions cease sometimes with the withdrawal\nof ether, sometimes with the use of drop chloroform, and sometimes with carbon dioxide\ninhalations, and treatment was instituted in that order. Today an intravenous injection of\nevipal or pentothal sodium would be indicated early.\nOf the other inhalants I will only make mention. Opinion continues sharply divided\non the use of both ethyl chloride and chloroform for general anaesthesia, but they continue\nto maintain the noiseless tenor of their way; doing good work for those who still maintain\nan abiding faith in their virtues.\nTo summarize, these newer methods for creating anaesthesia have certainly broadened\nthe field and offered quite a wonderful range of choice. At the same time certain complicating factors have been introduced, as in some cases combinations of the various methods\nhave been necessary to complete an operation; a spinal anaesthetic possibly passing through\nthe stages of gas and ether, or if near the finish, the intravenous type. Just what ?oes\non under these circumstances is far from clear, but I admit a profound respect for an\nintravenous barbiturate followed by ether; both pulse and respiration can be disorganized\nand one's confidence decidedly undermined. In attempting to estimate the anaesthetic\nvalues of these hypnotic drugs, more of which will undoubtedly appear, some datum, or\nassumed base, on which to appraise their qualities is necessary. While the method I am about\nto mention will probably not stand the searching light of truth, it is a help both in teaching\nand in selecting an anaesthetic.\nBriefly it is this: Unconsciousness is represented as a baseline, the extremities of which\nrepresent natural sleep and coma. The anaesthetics of the intoxicating type, such as ether,\nchloroform and cyclopropane, are essentially coma-producers, and the coma-producers are\nthe real paralyzing anaesthetics. One, therefore, can place somewhere on this baseline the\nrelative value of a certain drug in proportion as its effect is merely an artificial sleep, or a\ncoma. A recent article from the Lahey Clinic, where spinal is used routinely for upper\nabdominal operations, distinguishes between the barbiturates and ether for supplemental\nanaesthesia as to whether relief from discomfort is required or actual relaxation. This points\nto the likelihood of the modern hypnotics in use as not producing true relaxation.\nPage 194 An interesting point in this regard occurs with vinethene, where, under what would\nappear to be very light anaesthesia, the lid and eye reflexes being active, there may occur\ncomplete relaxation of the extremities. This must not be confused with the true muscle\nparalysis necessary for laparotomies. It would seem, then, for the time being, that the real\nfield of major anaesthesia must be distributed\u00E2\u0080\u0094other than local methods\u00E2\u0080\u0094between spinal\nand inhalation methods. With the gaseous forms of inhalation out-popularizing ether\nwhere feasible. |^i\nWhat does the future hold? Who can say? Certainly loss of consciousness as a mode\nof controlling pain will always be in demand, irrespective as to how unconsciousness may\nbe induced. Up to the present the intoxicating group of drugs still holds the high water\nmark for profound anaesthesia, and it would seem that where such is required it will not be\none for the mere sleep producers, but for the coma producers capable of doing a man's job.\nI would just like to say a word on the more recent trends of post-operative pulmonary\nventilation. Here is a clear example of what I term a \"vogue\" in the early part of the\npaper. The use of carbon dioxide, and oxygen, post-operatively, was hailed as the greatest\ninnovation for the prevention of respiratory complications. Now, after several years of\nits successful application, such a mixture has been shown not only to be of no help but a\npossible source of trouble. The reason behind this is simple. The natural pulmonary ventilation is done with an atmosphere of which approximately 80% is an inert non-absorbable\ngas. When such is replaced artificially by a completely absorbable atmosphere pulmonary\ncollapse may ensue. It is therefore now considered that ordinary air with a small amount\nof carbon dioxide added is more advantageous than oxygen and CO2.\nCORRESPONDENCE\nThe Editor,\nThe Vancouver Medical Association Bulletin,\nVancouver, B. C.\nSin-\nIn the editorial column of the March, 1940, issue you have made certain comments\nabout the excellent review of sixty-eight cases of brain tumour, which was compiled from\nrecords of the Vancouver General Hospital, covering the years 1934-1938, by Drs. D. P.\nRobertson and C. E. Gould. As all but one or two of the forty-two cases which were\noperated upon were mine, I may be excused for recording a few thoughts which were\nstimulated by your editorial.\nYou state: \"It is doubtful if more than two or three men in Vancouver realize that\nthere had been sixty-eight cases of brain tumour in this city in these five years.\" May I\nsuggest, sir, that you should have gone further, and deplored the fact that there are so few\ncases in this series from the largest hospital in the Province.\nI am informed by the records department at St. Paul's Hospital in this citv that during\nthis same period of 1934-38 nineteen cases of brain tumour were admitted to that institution, of which six were verified by operation or post-mortem. Outside of the Vancouver\nGeneral Hospital and St. Paul's Hospital, there are no specialized neurosurgical services in\nthis province, and I doubt whether during this period more than five or ten cases were\ntreated surgically at other hospitals. In other words, approximately ninety-seven cases of\nbrain tumour in B. C. during the period 1934-38 received presumably adequate neurosurgical care. The number of patients who die from brain tumour can be conservatively\nestimated as 1.34 per cent of the total mortality. (Garland, H., and Armitage, G.: Jour.\nPath. & Bad., 1933, 37:461.) In B. C, that works out to an average of eighty-four cases\nPage 195 per year, or four hundred and ten cases during 1934-38. The discrepancy between ninety\nseven treated cases and three hundred and thirteen untreated cases is too great.\nI am, Sir, yours faithfully,\nFrank Turnbull, b.a., m.d.\n913 Medical-Dental Building,\nVancouver, B. C.\nMarch 7, 1940.\n[Dr. Turnbull's letter is an important comment, not only for the facts it contains, but as showing\nthe immense value of specially directed, competent, attention to diagnosis. We confess to being quite\nsurprised by what he says about the number of undiagnosed and untreated cases of brain tumour that\nmust exist at all times. Perhaps on some future occasion Dr. Turnbull and his colleagues would go\nfurther into this matter, and give to the profession of B. C. at large a lead in the recognition and\nadequate care of these unfortunates. Many must be curable, and all should be given a better chance\nthan they apparently now have. The criteria of diagnosis: the signs and symptoms that should\narouse our suspicion, all these should be better known, and this rather twilit area of our medical\nknowledge should have more light let in on it. We are very grateful to Dr. Turnbull for this\nnote of his.\u00E2\u0080\u0094Ed.]\nBritish Columbia Medical Association\n(Canadian Medical Association, British Columbia Division)\nPresident. Dr. F. M. Auld, Nelson\nFirst Vice-President Dr. E. Murray Blair, Vancouver\nSecond Vice-President^\u00E2\u0080\u0094. Dr. C. H. Hankinson, Prince Rupert\nHonorary Secretary-Treasurer X)r. A. H. Spohn, Vancouver\nImmediate Past President Dr. D. E. H. Cleveland, Vancouver\nExecutive Secretary Dr. M. W. Thomas, Vancouver\nCHAIRMEN OF STANDING COMMITTEES\nConstitution and Bylaws: Dr. H. H. Mil-\nburn.\nProgramme and Finance: Dr. G. F. Strong.\nLegislation: Dr. G. C. Kenning.\nMedical Education: Dr. D. M. Meekison.\nArchives: Dr. M. McC. Baird.\nMaternal Welfare: Dr. C. T. Hilton.\nPublic Health: Dr. A. H. Spohn.\nEthics and Credentials Dr. S. A. Wallace.\nEconomics: Dr. W. A. Clarke.\nPharmacy: Dr. C. H. Vrooman.\nHospital Service: Dr. W. S. Turnbull.\nCancer: Dr. Roy Huggard.\nEditorial Board: Dr. J. H. MacDermot.\nThe Committee on the Study of Cancer held a meeting on March 11th, which was\nattended by sixteen members. Dr. Amyot flew over from Victoria to be present and discuss with the Committee the whole question of the development of a Biopsy Service which\nwould make it possible for the practising profession to have this aid to diagnosis made more\neasily available.\nPage 196 ancouver\nleneral\nHospital\nCASE OF SUBDURAL HEMATOMA\nDr. T. F. H. Armitage\nA white male, aged 64, was admitted to the service of Dr. F. N. Robertson (Vancouver\nGeneral Hospital) on August 19, 1939. Two days previously he had complained of a pain\nin his head, and said he did not feel well. The next day his right arm and right leg gradually\nbecame weak, and then he became unconscious. No further history was obtainable.\nPhysical Examination: Temperature 98.2, pulse 66, respirations 20.\nThe patient was restless, drowsy and unable to speak.\nCranial Nerves: Both fundi showed moderate arteriosclerosis but no papillcedema. The\npupils were equal in size and reacted to light. The corneal reflexes were present and equal.\nRight lower facial weakness was present. The tongue protruded to the right side.\nMotor System: There was a flaccid right hemiplegia and slight weakness and slight\nspasticity of the left arm and leg.\nSensory: Though sensation to pin prick seemed normal throughout, the patient's cooperation was too poor for adequate sensory examination.\nReflexes: These were increased on the left side -|\u00E2\u0080\u0094\-, and there was normal activity on\nthe right side. There was a bilateral extensor plantar response.\nThe blood pressure was 150/90.\nA diagnosis of thrombosis in the left internal capsule was made at this time.\nProgress: For the week following admission his condition remained the same. At times\nhe was very difficult to arouse and he had difficulty in swallowing. At other times he was\nable to co-operate to a slight extent. His temperature ranged from 98.2\u00C2\u00B0 F. to 102.6\u00C2\u00B0 F.\nAt the end of the first week we obtained from his wife a history of head injury ten\nweeks previously, with subsequent headaches. The.patient was seen-by Dr. F. Turnbull of\nthe subdepartment of neurosurgery, who reported aS \"follows: \"Cerebral thrombosis is the\nmost likely diagnosis in this case, but in view of the history of recent head injury, he should\nhave an exploratory trephine of his skull.\" >*TSH'-\nX-ray of the skull showed no evidence of fracture.\nThe report of the operation by Dr. F. Turnbull, which was done on the morning of\nAugust 31, is as follows:\n\"Under local anaesthesia, burr holes were-made over the upper anterior parietal region\non both sides. On the right side this was negative, but on the left side a typical subdural\nhaematoma was encountered.\n\"The burr holes were enlarged to about 1%' in diameter and the outer capsule of the\nhaematoma, which was about Ys in thickness, was incised in cruciate fashion. The brain\nwas about Yz depressed from the dura, and by inserting a soft catheter it was found that\nthe haematoma extended forward over the frontal pole and laterally over the temporal pole\n\u00E2\u0080\u0094posteriorly about l\" from the site of trephine. The contents seemed to be entirely liquefied, and were washed out with saline. The brain seemed to expand very little, even though\nthe patient coughed a great deal.\n\"Tight closure was made in the usual manner, leaving a Penrose drain leading out\nthrough stab wounds in adjacent skin margins from the subdural space.\"\nIn the afternoon of the day of operation the patient was talking, but was confused at\ntimes. He continued to improve and gradually regained the use of his right arm and leg.\nOn the tenth post-operative day the patient began to complain of dizziness and headache\nand his right arm and leg again became weak. He was taken to the operating room and\nthe report of the second operation performed by Dr. F. Turnbull is as follows:\nPage 197 \"Under local anaesthesia, a burr hole was made about 1J4\" anterior to the site of\nprevious drainage on the left side. The subdural haematoma was opened into and the brain\nwas found to have not completely expanded, being about Ya\" to Y2\"- away from the dura\nstill. A number of adhesions of semi-solid old blood clot were scooped out from the lateral\nmargins of the haematoma cavity, and the cavity thoroughly washed out.\nFollowing this procedure the brain had practically expanded to the dura. A drain was\ninserted and closure made in the usual manner.\"\nFrom this time onward the patient improved steadily and was discharged from hospital thirty-seven days after admission. At this time his speech was normal and there was\nonly slight weakness of his right arm and leg.\nThe history obtained from the patient himself after recovery, which was not fully\navailable from his relatives, was that, while doing carpentering on June 25, he fell about\ntwelve feet to the ground, striking his head. He was unconscious about ten minutes, and\nthen complained of headache, dizziness and weakness, but went on and finished his day's\nwork three hours later. He stayed home four days but was up and around, with complaints of dizziness and headache. He went back to work for five days and finished bis\njob. He stayed around home and did light work for eight weeks, although he did not feel\nwell. On August 18, the day before admission, the patient states he \"thought he was going\noff his head.\" The patient did not recall anything that happened from this time until September 4, seventeen days later. This was three days after his first operation.\nThe patient was seen two months after discharge from hospital; he was feeling well,\nwas back to work and had regained complete use of his right arm and leg.\nThis case represents the essential value of a complete history; also the value of an\nexploratory trephine of the skull, which can be done under local anaesthesia with very little\ndisturbance to the patient, in cases where there is any history of head injury suggesting the\npossibility of subdural hxmatoma.\nTHE HANDS AND INFECTION OF CLEAN WOUNDS\nBy J. P. Henry, M.B.\nClean wounds can derive infection from several sources4 112. Only the role of the\nhands will be considered in this brief review. The recent contributions of Devenish ,\nPrice15 16lT and Gillespie8 have clarified many issues. What follows is for the most part\nbased on their conclusions.\nIn 1861, Semmelweis21 first demonstrated that the shocking mortality prevailing in\nlying-in hospitals was due to septic materials on the hands. During the ensuing years great\nstrides were made in the development of an antiseptic, then of the aseptic technique. So\ngreat have been the advances of the past forty yars that it is a temptation to assume our\npresent methods to be not only correct in principle but also adequately effective in practice.\nThus Meleney states that a hospital conference considered an estimate of 2% to be high\nfor the incidence of clean operative wound infections12. It was with a shock that they\nrealized the true figure to be nearly 15%.\nAll authorities agree that it is impossible to sterilize the hands3 9 10, and that even a\nfew minutes after scrubbing fresh hordes of organisms pour up onto the surface of the\nsKin\ns\nThe misconception that these are harmless and that only hands that have come into\ncontact with infected wounds are liable to infect the operative field19 has been disproved3 .\nJust as in infectious diseases, the healthy carrier is a more important disseminator of infection than the patient himself, so the hands may frequently be infested with dangerous\norganisms which do not originate from septic cases, and since only \"transient\" organisms\nnot indigenous to the skin can with certainty be eradicated, the inherent dangers of the\nsituation may readily be appreciated.\nSource of Transient Organisms\nThe transient population of the hands consists of harmless mould spores and non-pathogenic saprophytes20, but a varying number of dangerous organisms such as Streptococcus\nhaemolyticus are also found. The latter usually derive from breeding grounds in the nose\nPage 198 and throat8 2, The percentage of a hospital staff carrying Streptococcus haemolyticus in\nthe throat varies from 5% to 30%2. This figure increases during periods of epidemic\ninfection. It is estimated that nobody can escape being a carrier of these organisms at\nsome time or other.\nRemoval of Transients\nRidding the hands of transients is a comparatively simple matter. The healthy skin,\nwhen washed and freed from grease, will entirely rid itself of subsequently inoculated\norganisms such as Streptococcus haemolyticus or B. coli, etc., within a few hours20 3. The\nmechanism by which this is accomplished is unknown. The power resides in the stratum\ncorneum and vanishes when the latter is injured14. This adds force to the arguments of\nthose who maintain that the greatest care should be taken to avoid chafing the skin during\nits preparation5 '. In carriers it is, however, necessary to remove transient organisms more\nrapidly, for the hands are being constantly re-infected from the reservoirs in the nose and\nthroat3.\nFortunately plain soap solution in standard concentrations will kill Streptococcus\nhaemolyticus, etc., in less than three minutes when applied to previously cleansed but not\nspecially prepared hands3. If, after washing and drying, a dram of Dettol 30% cream is\nmassaged into the hands until it evaporates, they will be entirely freed from transients and\nwill resist infestation for a further period of several hours3. 70% alcohol may be substituted for Dettol, although it is not so effective. It should be rubbed in with a gauze sponge\nfor at least two minutes to allow time for action1'. The rubbing is important, as it increases\ncontact with the more deeply lying bacteria17. If mercury perchloride is used, it should,\naccording to Price15, be used after the alcohol and not before, since it relies for its effect on\nthe precipitation of a sterile coating of complex mercurial albuminoids, which inhibit the\naction of the alcohol by preventing access to the bacteria beneath. To sum up\u00E2\u0080\u0094soap and\nwater for three minutes, applied to previously cleansed hands, followed either by Dettol or\n70% alcohol with mercuric chloride to follow, will reduce transient infestation to a point\nwhere it would be safe to operate even without rubber gloves, were they the only organisms\nto be feared9 10 19.\nSources of Resident Organisms\nFreeing the hands from indigenous residents presents a very different problem. The\ncommonest organisms to be found are Staphylococcus albus and aureus, but Micrococcus\ntetragenes, B. proteus, B. coli, B. subtilis, and Diphtheroids, are all frequently recovered20.\nAll of these have been proved responsible for wound infection of varying severity12 \\nwhich, in areas of low resistance, have even terminated fatally1. The majority of infections of clean wounds have been proved to be due to Staphylococci12, and it has been shown\nrecently that pathogenic strains (i.e., producing coagulase and Alpha haemolysin8 22 n)\ncan be found on the hands of 15 % of a hospital staff8. On one-third of these carriers the\norganisms are true residents and cannot be eradicated by the usual pre-operative scrub\nroutine (soap solution followed by alcohol). Their source appears to be the nasal vestibule,\nfor in most skin carriers a heavy nasal infestation by the same serological strain was demonstrable11 8. Chronic nasal catarrh and sinus infection increase the liability to a carrier state.\nIt was estimated that a high percentage of the staff of an operating theatre become, at\nsome time in their career, temporarily infested with these pathogenss. Such skin carriers\nwill, whenever they perspire, excrete organisms into their gloves . It has been found that\nafter an operation 15 % of the new gloves used by skilful operators have in them minute\nperforations through which bacteria-laden perspiration can be expressed in quantities\nsufficient to initiate an infection4.\nRemoval of Resident Organisms\nThe results of the usual preparatory routine are interesting. After scrubbing for six\nminutes, the resident organisms are reduced by one-half only, and this halving, with every\nsix minutes of scrubbing, continues until patience is exhausted and an irreducible minimum\nattained16. The remaining organisms will double themselves every forty minutes under\nrubber gloves16. The average number of permanent residents is eight million. They cannot\nbe reduced below about two hundred thousand16. In unhealthy rough hands, a higher\npercentage of these organisms are pathogens, showing that scrubbing is not only disap-\nPage 199 pointing in its results, but can be dangerous if carried to the point of chafing the hands.\nMost authorities advise a soft brush and practically confine its use to the nail sulci and the\npalms of the hands5 7 3 19 13.\nEthyl alcohol is effective only when used in a dilution of exactly 70% by weight in\nwater . Slight deviations greatly diminish its powers for a reason which is not understood.\nRubbing with an alcohol sponge reduces the residents by 50% for each minute it is\nemployed. Alcohol is particularly effective against staphylococci17. The 70% solution\nis not a fat solvent and its value in the preparation of the skin probably rests on its germicidal action alone17.\nDettol Cream 30% is a valuable agent but it cannot destroy staphylococci with the\nsame rapidity and certainty that it can streptococci3. Mercuric chloride 1-1000 requires\na full twenty minutes to kill staphylococci at room temperature in vitro. It is thought that\nthe secret of its undoubted efficacy, even as a rinse for the skin, may be that a complex mercury protein derivative is instantly precipitated, which acts as though it were a tough\nsterile coating, through which the underlying bacteria cannot escape15. It requires twenty\nminutes of scrubbing to wear away this film15. There is danger, however, because underneath this shield the bacteria breed at an increased rate, due in part to the stimulating\neffect of the mercury20 -18, and if the barrier should break down during the operation\nnumbers of virulent organisms could be liberated. The film also inhibits the autolytic\npower of the skin. Pathogenic transients imprisoned under it may thus succeed in forming\ncolonies and become residents. This theory of the mode of action of mercurials is derived\nfrom circumstantial evidence and further enquiry is necessary to substantiate it. It is not\nknown exactly how impermeable the barrier is, but even if it should prove fully effective,\nthe use of mercurials will continue to be limited by their injurious effect on some skins.\nHowever carefully a deep staphylococcal skin carrier prepares his hands, by the current\nroutine of scrubbing and alcohol, they remain a potential danger3. Comparison by Devenish\nof the post-operative figures of two surgeons of equal skill, one a deep carrier and the other\nfree from pathogens, shows how high these dangers may become8.\nSuggested Improvements\nPlentiful powdering of the hands and avoidance of hot water and vigorous scrubbing,\nby diminishing the subsequent accumulation of fluid perspiration within the gloves19 10,\ndecreases the number of organisms which can escape from a perforation. Finally, the\nchances of perforation are greatly decreased by handling needles and tissues with instruments only, wherever possible4.\nSurgery has extended into regions of the body which have little or no ability to combat\norganisms, even those hitherto regarded as non-pathogenic1. This must be remembered,\nas well as the percentage among us who are unwitting carriers of ineradicable though\nhighly virulent organisms. A review of the scrub technique in representative hospitals\nshowed a count reduction of some 10 to 50% only16. Some improvement could be effected\nby shortening the time spent with the scrubbing brush and devoting it to rubbing the\nhands with an alcohol sponge16. When the transient population has been removed, soap\nsolution is of little value, as it is not lethal to staphylococci3. This leaves only the gradual\ndetergent action of the brush16. 70% alcohol with its affinity for staphylococci3 will\nachieve in two minutes as much bacterial reduction as twelve minutes of assiduous scrubbing17. Dettol is of great value in obstetrics, which is most concerned with streptococcal\ninfections3. Mercurials find a place in surgery for the temporary immobilization of the\norganisms which always remain. It remains to be seen whether it is wise to use them\nrepeatedly; the consensus of opinion appears to reserve them for the occasional and for the\nbare-handed operator, and finally for rough, heavily contaminated hands5 19 15.\nSummary\n1. Frequency of transient streptococcal and persistent staphylococcal infestation of the\nhands.\n2. The easy removal of transients and the difficulty of eradicating residents.\n3. Suggested modifications in technique.\nPage 200 REFERENCES:\nCairns: Lancet, 1:1193, May, 1939.\nColebrook: B.M.J., 2:723, Oct. 21, 1933.\nColebrook: Jour. Obstet. & Gyntec. B. E.,\n40:966, 1933.\nDevenish & Miles: Lancet, 1:1993, May 13,\n1939.\nDoderlein: Oper. Gyntec, Leipzig, 1924.\nErnst: Problem des Haiti. Inf., Copenhagen,\n1937.\nGarrod & Keynes: B.M.J., 2:1233, 1937.\nGillespie: Lancet, 2:890, Oct. 21, 1939.\nKocher: Oper. Surg., 1903.\nMcDonald: S. G. & O., 21:82, 1915.\nMcFarlane: B.M.J., 2:939, Nov. 5, 1939.\n20.\nMeleney: S. G. & O., 60:264, 1935.\nMoynihan: Brti. J. Surg., 8:27, 1920.\nPijoan: Arch. Surg., 34:590, 1937.\nPrice: S. G. # O., 69:595, 1939.\nPrice: J.A.M.A., 111:1993, Nov. 26, 1938.\nPrice: Arch. Surg., 38:528, 1937.\nProc. Roy. Soc. of Brit., 120:147, 1936.\nTheobald: Jour. Obstet. & Gyntec. of the B.\nE., 31:54, 1924.\nTopley & Wilson: Principles Bacteria and Immunology, 1936.\nSemmelweis: Pest. Wein., 1861.\nBigger: B.M.J., 2:836, Oct. 23, 1937.\nCASE OF POLYCYSTIC KIDNEYS WITH COMPLICATIONS\nEarle R. Hall, M.D.\n(Presented at Clinical Meeting of Vancouver Medical Association, April, 1939.)\nThis case for presentation is interesting because of several factors involved. Diagnosis\nis usually of prime consideration in any medical problem, and in this instance plays an\nextremely important part. Treatment, the aim of which is generally to produce complete\nrecovery or the greatest possible degree of improvement and restoration to normal, required\ndeliberation and some degree of precision. In this respect the role of conservatism had to\nbe ever foremost. Prognosis and surveillance of future treatment are worthy of considerable thought and speculation.\nThe following is a case history and summary of progress reports and findings: J. T.,\nmale, age 38 years, married, first came under supervision on July 8, 1936, with the following history:\nPrevious Illnesses: Negative.\nPrevious Venereal: Denied.\nPrevious Kahn: Negative report, few months previously.\nFamily History: Father died age 36\u00E2\u0080\u0094cause unknown to him, but stated that he had\nhad \"kidney trouble,\" and had had two operations on one of the kidneys. Mother died\nresult of carcinoma of uterus. Otherwise negative.\nComplaints Presented: (1) Pain in the left lumbar area; (2) fever.\nOnset and Course: About six months previously, following a chill, he felt out of sorts\nfor a few days, and then noticed that the urine appeared to have blood\u00E2\u0080\u0094well mixed. He\ndeveloped a fever, temperature ranging from 101 to 103. He received medical attention,\nand urine examinations were reported positive for hematuria and pyuria. He remained\nin bed for about a month with gradual improvement, temperature returning to normal.\nAt this time he had no dysuria and apparently very little frequency. He stated that micturition was a little slower in starting. Following this illness he was in good health until\na few days later, when he developed a pain in the left lumbar area, this coming on for no\napparent reason. The pain was described as a dull aching type, did not radiate. He had no\nurinary distress. A flat X-ray of the renal tract was taken with negative report. The pain\nbecame more severe and radiated anteriorly downward to the left lower quadrant. His temperature rose to 102 degrees and he was admitted to St. Paul's Hospital, July 8, 1936.\nExamination at Hospital: Patient did not appear acutely ill, temperature 102, pulse 98.\nAbdomen showed some tenderness at the left renal area and the lower pole of the left\nPage 201 kidney was palpable, tenderness extending downward toward the left anterior quadrant.\nOtherwise negative.\nUrine: S.G. 1022, acid, albumen -j\u00E2\u0080\u0094j-, sugar 0;\nMicroscopic: pus -j-, bacteria -)\u00E2\u0080\u0094|\u00E2\u0080\u0094|\u00E2\u0080\u0094|-.\nN.P.N.: 36 mgs. Haemo.: 87%. R.B.C. 4,750,000; W.B.C. 8,500.\nBlood Pressure: 140/80.\nCystoscopy and Pyelography\u00E2\u0080\u0094July 9, 1936\u00E2\u0080\u0094S.P.H. = Urine obtained from bladder\nwas clear; bladder was negative; both ureteral orifices were negative. Catheters passed up\nboth ureters without obstruction. Urine from the right kidney was clear; urine from the\nleft kidney was thick and showed many flakes of pus. Pyelograms were made; the urine\nsent for examination. A large ureteral catheter was inserted within the left ureter to the\nrenal pelvis as a retention catheter for drainage.\nX-Ray Report of Pyelograms: \"Bi-lateral enlargement of kidneys, with large pelves and\ncalices\u00E2\u0080\u0094probably congenital.\"\nReport of Urines: The urine from the left kidney showed 39,425 w.b.c. per c.mm. The\nright ureter showed 12.5 cells per c.mm. Direct urine smears were negative for tbc. Urine\nwas sent for animal inoculation.\nCulture of Urine showed Haemo. Staph, from both kidneys.\nThe ureteral catheter was removed from the left kidney after 72 hours. At this time\nit was draining freely, and his temperature, which had dropped to 100 degrees after its\ninsertion, had been ranging from 99 to 100. Twenty-four hours after removal of catheter,\ntemperature was 99, and he was feeling much improved and refused to stay in hospital any\nlonger. He was discharged July 14, 1936.\nFollowing his discharge from hospital he was well for one week, when he had return of\nfever\u00E2\u0080\u0094his temperature being normal in the morning but rising to 101 to 102 at night.\nI was called to see him at his residence on the evening of July 25th, at which time his temperature was 103, and he appeared to be slightly irrational. He was admitted to Vancouver\nGeneral Hospital the same night, and diagnosis of left pyonephrosis was made.\nOperative Treatment\u00E2\u0080\u0094July 26, 1936, V.G.H., under general anaesthesia\u00E2\u0080\u0094Left\nNephrostomy: The left kidney was exposed through the usual left lateral lumbar incision,\nand it was found to be about four times normal size, and its surface was studded with\nmultiple cysts, these varying from the size of a pea to larger than a hen's egg\u00E2\u0080\u0094this was\na typical polycystic kidney. With considerable difficulty the kidney was freed as fast as\npossible, numerous adhesions being removed near the hilus in order to reach suitable area\nfor nephrotomy. In the region of the hilus near the pelvis, the kidney was incised and a\nfree flow of pus obtained, and a drain tube inserted. This was inserted down to the renal\npelvis and brought out through the lower angle of the wound. Many of the larger cysts\nwere punctured, and thin sero-purulent fluid obtained. Swabs were sent to the Laboratory\nfor culture.\nHe sustained this operation well and his post-operative course was uneventful. Cultures of pus from kidney and cysts after ninety hours showed no growth.\nUrine Report: Urine smears showed colon bacilli, negative for tbc. Urine specimen\nvoided after operation showed pyuria varying from -j- 2 to -(-4.\nN.P.N, two days ofter operation was 40 mg.\nN.P.N, one week after operation was 3 0 mg.\nN.P.N, two weeks after operation was 3 0 mg.\nAugust 16th patient was discharged from hospital, wound well healed.\nAugust 24th, report of animal inoculation (urine obtained at first cystoscopy, July\n9th) : Right kidney, negative. Left kidney, positive for tbc.\nAugust 24th, admitted to V.G.H. for cystoscopy and obtaining of urine for further\nstudy.\nSeptember 26th, report of animal inoculation was negative for tbc. Urine was sent to\nthe Laboratory which first reported presence of tbc. from left kidney. This report was\nreceived on November 16th and animal inoculation was now reported negative.\nDuring the next three months the patient made steady improvement, and urine examinations varied from a few w.b.c. to pyuria -f-1 and at times -\-2. Urine examination\nPage 202 showed presence of B. coli and he received various mandelic acid preparations which would\nclear the urine for limited periods. Rectal examination showed a prostate that was somewhat enlarged and the prostatic strippings showed presence of pus. Stained smear showed\npresence of B. coli and staphylococci. The diagnosis of chronic prostatitis\u00E2\u0080\u0094non-specific\nwas added and he was placed on treatment directed to the eradication of the infection in\nthe prostate.\nThe patient was not seen for a period of about six months, but during this time he\nmade steady improvement, put on weight, and micturition was normal. Urine examination showed pyuria -j-2. A recheck of his pyelograms was advised.\nDecember 19, 1938\u00E2\u0080\u0094V.G.H.\u00E2\u0080\u0094Cystoscopy and Pyelography. Urines were also sent\nfor animal inoculation.\n Report of Pyelogramss \"The general outline of both kidneys appears greatly enlarged\nwithout any localized deformity of the excretory system\u00E2\u0080\u0094possibly a polycystic condition\nof both kidneys.\"\nFebruary 7, 1939\u00E2\u0080\u0094report of guinea pig inoculation: Guinea pigs inoculated separately\nwith urine from right kidney, left kidney and bladder urine were all negative for any\nevidence of tbc.\nThe patient continued treatment for prostatitis during 1939 and showed gradual\nimprovement in his general health. Last examination of the patient was in March, 1940,\nat which time he was feeling well, although the urine still showed a few pus cells. Micturition was apparently normal. Nocturia about once each night. Examination of the prostate still showed presence of pus in the strippings, and he was advised to continue therapy\nfor this.\nFinal Diagnosis: 1. Bilateral Polycystic Kidneys. 2. Acute Left Pyelonephritis\u00E2\u0080\u0094Pyonephrosis. 3. Chronic Prostatitis, Non-specific. 4. Sub-acute Pyelonephritis.\nSummary: At the first contact with this case it was not difficult to make a tentative\ndiagnosis of renal infection with possible presence of a calculus. This being based upon\nthe fever, pyuria and associated pain, together with previous history of haematuria. Following cystoscopy and pyelography the possibility of a stone was ruled out, and the X-rays\nshowed typical pyelograms as produced by polycystic kidneys. The presence of pus and\nextremely high cell count in the urine from the left kidney indicated a severe infection of\nthis organ. This condition was undoubtedly a pyelonephritis, which on account of inadequate drainage went on to a pyonephrosis requiring nephrostomy for relief. This operation\nverified the existence of a polycystic kidney.\nThe first report of animal inoculation being positive for tbc. in the left kidney produced a problem. It is extremely rare to find tuberculosis involving polycystic kidneys\nwhich are usually bi-lateral and congenital in origin. It was felt that the report of\ntbc. was an error and that more urines should be studied. Subsequently there were three\noccasions when animal inoculation was carried out and these reports were all definite in\ntheir negative findings. These examinations were at different laboratories, and the one first\nreporting positive tbc. later reported a completely negative guinea pig autopsy.\nA definite pyogenic prostatitis of non-specific origin was found to be present and I\nconsider that this was probably the source of the renal infection, the latter being the result\nof an ascending infection. The same organisms, i.e., colon bacillus and staphylococcus,\nwere present in the prostatic strippings and in direct urine smears.\nPage 20} Victoria Medical Society\nOfficers, 1938-39.\nPresident : Dr. W. A. Fraser\nVice-President Dr. A. B. Nash\nHon. Secretary Dr. E. H. W. Elkington\nHon. Treasurer Dr. C. A. Watson\nSIGMUND FREUD AND PSYCHOANALYSIS\nD. E. Alcorn, M.D.\nVictoria, B. C.\nThe death, last year in London, of Sigmund Freud removed one who, perhaps more than\nany other physician, has left the impress of his genius upon the thought of our times. For\nwe find his influence extended beyond the field of psychiatry and psychology into that of\nart, ethics, and even religion. Modern art, especially of the surrealist variety, is filled with\ndream symbolism; ethics has begun to consider seriously psychological factors; and even\nreligion has studied them.\nIt has, therefore, been a source of considerable difficulty to many to know why physicians in general, and psychiatrists in particular, have been so slow in accepting psychoanalysis. Myerson1, in a recent survey, found only 25 out of 179 psychiatrists, 5 out of\n75 neurologists, and 2 out of physologists and other workers in allied fields, who accepted\npsychoanalysis more or less wholeheartedly, although there were many others who accepted\nsome of his teaching, with more or less reservation. Some have felt that this was simply\nmedical conservatism, and that the doctors would come around in time. But nearly half a\ncentury has elapsed since Freud began his first teaching: half a century which has been\ncharacterized by such advances as the introduction of diphtheria antitoxin and insulin,\nwhich are now fully accepted by the medical profession.\nEven more puzzling is this situation to those who use the term \"psychoanalysis\" as\nsynonymous with \"psychiatry\" and psychotherapy.\" The term \"psychoanalysis\" should\nbe reserved for the technique and theory originated by Sigmund Freud, and should not be\napplied even to the closely allied systems of Jung and Adler.\nTechnique and Theory.\n(a) Technique. Freud, early in his investigations, elaborated a technique, the essentials\nof which have not been greatly modified since. Briefly, it is as follows: One hour a day is\nreserved in advance for the patient, for six days a week; the treatment extending from several months to several years2. This should be paid for in advance. Treatment unpaid has\nnot been generally satisfactory, as the patient tends to stop at convenient points in the\nanalysis and thus defeat the purpose of the treatment. For the poor, a very different kind\nof therapy is required; namely, financial assistance. Incidentally, the role which finances\nplay in the neuroses is not so well recognized by many of his followers*\nDuring the treatment, the patient usually reclines on a couch. Freud's own instructions\nare as follows: \"Before I can say anything to you, please tell me what you know about\nyourself. One thing more before you begin: your talk with me must differ in one respect\nfrom an ordinary conversation. Whereas, usually, you rightly keep the threads of your\nstory together and exclude all intruding associations and side issues, so as not to wander too\nfar from the point, here you must proceed differently. You will notice that, as you relate,\n1. Myerson, A.: The attitude of neurologists, psychiatrists and psychologists towards psychoanalysis.\nAm. J. Psycb., 96:623, 1939.\n2. Freud, S.: Further recommendations in the technique of psychoanalysis. Collected Papers, 11:31, 1913. various ideas will occur to you, which you feel inclined to put aside with certain criticisms\nand objections. You will be tempted to say to your 'this or that has no connection here,'\nor 'it is quite unimportant' or 'it is nonsensical' so that 'it cannot be necessary to mention\nit.' Never give in to these objections, but mention it even if you feel a disinclination against\nit, or indeed just because of this. Later on, you will perceive and learn to understand the\nreason for this injunction, which is really the only one you have to follow. So say whatever\ngoes through your mind. Act as if you were sitting at the window of a railway train, and\ndescribe to someone behind the changing views you see outside. Finally, never forget you\nhave promised absolute honesty, and never leave anything unsaid because, for any reason,\nit is unpleasant to say it.\" This is the free association method by which unconscious\nmaterial is brought to light3.\nRegarding the physician, according to Freud4, \"he must bend his own unconscious,\nlike a receptive organ, toward the emerging unconscious of the patient. The physician's\nunconscious mind must be able to reconstruct the patient's unconscious, which has directed\nhis associations from communications derived from it.\" One of the rules by which this is\naccomplished is: \"One has simply to listen and not try to remember anything in particular.\"\n(b) Unconscious. Freud uses a large number of technical terms in describing his\ntheories. First, there is his system of consciousness, etc.\n(1) The conscious, including the perceptual consciousness;\n(2) The unconscious (formerly vailed the subconscious), which applied to \"any mental process the existence of which we are obliged to assume, because we infer it\nfrom its effects\"\u00E2\u0080\u0094such as dreams, hallucinations, slips of the tongue, recall by\nassociation, etc.\u00E2\u0080\u0094\"but of which we are not directly aware.\" From this he differentiated the preconscious, to be applied to that \"which is transformed into conscious material easily,\" reserving the unconscious for the rest.\nOne might add to this scheme of things, although I do not know that Freud ever did so,\na third concerned with physiological processes outside of consciousness altogether.\n(c) Conflict. The mental apparatus of the individual Freud divided into three regions:\n(1) The ego, which \"in popular language\" \"stands for reason and circumspection\";\n(2) The id, which \"stands for untamed passions\"7;\n(3 ) The super-ego, which is roughly equivalent to the conscience8.\nThe ego and super-ego might be either conscious or unconscious; the id is unconscious.\nThe ego also contains the perceptual consciousness and the preconscious9.\nFreud at first divided the instincts into two groups:\n(1) The ego-instincts, under which he'placed \"everything that had to do with the\npreservation, maintenance and advancement of the individual\";\n(2) The sexual instincts, to which he \"ascribed the rich content implied in infantile\nand perverse sexual life\"10.\nFreud's \"investigation of the neuroses led him to regard the ego as the restricting and\nrepressing force, and the sexual impulses as the restricted and repressed ones.\" Thus\nwe have here the element of conflict which is central to the Freudian conception. However,\nas time went on, he found it increasingly difficult to separate the two, and he was finally\nfaced, as Jung had been before him, with the alternative of \"either dropping the term\nlibido (sexual energy) altogether, or using it as meaning the same as psychic energy in\ngeneral.\" He did not keep to this long, however, and presented another pair\n(1) \"The sexual instincts in the widest sense of the word\" and\n3. Freud, S.: Ibid.\n4. Freud, S.: Recommendations for physicians on the psychoanalytical method of treatment. Collected\nPapers, 11:29, 1912.\n5. Freud, S.: New Introductory Lectures on Psychoanalysis (1937), trans, w\". H. Sprott. Hogarth Press,\np. 94.\n6. Freud, S.: Ibid, p. 95.\n7. Freud, S.: Ibid, p. 102.\n8. Freud, S.: Ibid, p. 87.\n9. Freud, S.: Ibid, p. 105.\n10. Freud, S.: Ibid, p. 125.\nPage 205 (2) \"The aggressive instincts, whose aim is destruction.\"11\nTo these two, the terms life and death instincts are sometimes applied. Freud's explanation\nof the origin of this \"death\" instinct is interesting: \"If it is true that once, in an inconceivably remote past, and in some unimaginable way, life arose out of inanimate matter, then,\nin accordance with our hypothesis, an instinct must at that time have come into being\nwhose aim it was to abolish life once more, and to re-establish the inorganic state of things.\"\n\"He goes on to say \"the question whether all instincts without exception do not possess a\nconservative character, whether the erotic instincts do not seek a reinstatement of an\nearlier state of things, when they strive towards the synthesis of living substance into larger\nwholes . . . must be left unanswered.\"12\n(d) Neuroses. Freud13 at first divided neuroses into four groups:\n(1) Pure neurasthenia which he believed to be due to excessive masturbation, numerous spontaneous emissions, etc.\n(2) Anxiety states, characterized by irritability, worry, tachycardia, dyspnoea, tremor,\nparaesthesias, apprehensiveness, etc., and which he attributed to failure to secure\nadequate sexual gratification in the presence of stimulation. These he regarded as\nphysiological in origin.\n(3) Hysteria due to sexual traumata during early childhood, of a passive character.\nInfantile sexuality plays, an important role, and consists in seeking stimulation\nand thereby satisfaction of various portions of the body; namely, in order, (a)\nthe oral, (b) the anal (which is associated with sadistic trends), (c) the phallic\n(penis.and clitoris), and (d) the genital, which he regarded as being established\nabter puberty14. It is at this time (the infantile sexual period) that there occurs\nthat love of mother, fear of father and castration by him, and finally the internalization of the father's threats to form the super-ego, that make up the Oedipus\nComplex.\n(4) Obsessional Neuroses are also due to infantile sexual traumata, but in this case\nactive or at least pleasurable, so that there is the added feeling of guilt, which\nmanifests itself in the ceremonials, etc., of the patient.\nHis doctrine of infantile sexuality brought Freud into violent conflict with his confreres, and most psychiatrists have continued to this day skeptical of these traumata. In\nconnection wtih this, the following experience of Freud is of interest: \"At the time when\nmy main interest was directed on to the discovery of infantile sexual traumas, almost all\nmy female patients told me that they had been seduced by their fathers. Eventually I was\nforced to the conclusion that these stories were false, and thus I came to understand that\nhysterical symptoms spring from phantasies and not from real events.\"10 Freud's views of\nthe neuroses have undergone many changes since, too complex to enter into here.\nPrepsychoanalytic Technique and Theory.\nIt is perhaps of interest to enquire as to how much of this elaborate system actually\noriginated with Freud, in an attempt to differentiate psychoanalysis from other forms of\npsychotherapy. This can be answered best by reference to the ideas current before the\nappearance of Freud's first article on psychiatry in 1892.\n(a) Therapy. Regarding therapy, the most important agency then used was hypnosis,\nwhich had been known for nearly a century, and its relationship to hysteria known for\nabout half a century. One of the most commonly accepted explanations of hypnosis was\nthat it was due to hysteria, a view which was supported by Charcot's discovery that he\ncould produce hysterical symptoms by hypnosis. In 1881 Breuer told Freud of a case which\nhe had cured by recalling apparently forgotten unpleasant memories by means of hypnosis.\nIn 1886 we find Freud with Charcot, and again in 1889 with Bernheim, who developed\nsuggestion as a therapeutic technique, as well as teaching hypnosis.\nIbid, p. 133-134.\nIbid, p. 138, 140.\nHeredity and the Aetiology of the Neuroses. Collected Papers, 1:8, 1896.\nNew Introductory Lectures of Psychoanalysis, p. 128.\nIbid, p. 159.\nPage 206\n11.\nFreud,\nS.:\n12.\nFreud,\nS.:\n13.\nFreud,\nS.:\n14.\nFreud,\nS.:\n15.\nFreud,\nS.: (b) Unconscious. Among the many theories presented to explain hypnosis, one of the\nmost widely accepted (Myers16, Beaunis1' , Carpenter18, etc.) was that there were other\nforms of consciousness, besides that of the normal waking self. Jung traced the doctrine\nof the unconscious back to the early 1880's19 to Carus.\nDr. Paul Carus's system20 is of particular interest. He refers to the following levels.\n(1) Conscious central neural activity;\n(2) Subconscious peripheral neural activity indirectly connected with central consciousness, \"so that we have a dim idea of its proceedings.\" This he connected not\nonly with hypnosis but also with dreams. \"The ego of the dream possesses a chain\nof memories of its own, which perhaps has never been connected with the memory\nchain of the conscious ego in the waking state,\" and goes on to suggest that the\ncontent of the dream might be recalled by an accidental association.\n(3) Unconscious neural activity, such as reflexes, etc.\nAs Carus was an oriental scholar, I feel almost certain that he was influenced by ancient\nHindu concepts. The Mandukyophanishat21 mentions four states of the self (Jivatma):\n(a) The waking self (Jagrat) ;\n(2) The dreaming self (Svapna) ;\n(3) The well-sleeping (dreamless sleep) self (Sushuptih) ;\n(4) In which the self is united with Brahma;\nthe elaboration and explanation of which, here and elsewhere in the Hindu scriptures,\nreminds me very much of Carus.\nOf course there were many other similar concepts in the West. Spinoza refers to unconscious instinctive motivation22. The old Egyptian concept of the ka, or double, is suggestive.\n(c) Conflict. The conflict between \"untamed passions\" and \"conscience\" for the\n\"self\"\u00E2\u0080\u0094between the \"flesh\" (sarx) and the \"spirit\" {pneumo) for the \"soul\" (psyche)2*\n\u00E2\u0080\u0094between the Hindu \"mind\" (manas), dominated by \"desire\" (kama), and the \"enlightenment\" (buddhi) for the \"ego\" (ahamkara)\u00E2\u0080\u0094has formed the subject of innumerable\nsermons since the beginning of ethical religion.\nThe importance of sex in relationship to human behaviour was not neglected in the\n1880's, and was regarded as the principal manifestation of the activity of the \"flesh.\" Carus\nremarks that \"human soul-life may be compared to an elipse. It is determined and regulated from two centres: one of which is in consciousness, the other the sexual instinct.\"\nFreud mentions three instances in which the importance of sex was stressed to him by his\nteachers, one of which (Chrobak's suggestion that a neurosis in a particular case might be\ndue to sexual abstinence) is significant. Masturbation was regarded as the cause of a vast\nnumber of things, of which depression, anxiety, lethargy, neurasthenia, are the most frequently mentioned.\n(d) Neuroses. Whyt, in 1765, differentiated between neurasthenia, hysteria and\nhypochondriasis. Obsessions and phobias (by which were known what we now call anxiety\nstates, at least in many instances) were also well known.\nBut, if Freud did not originate these ideas, at least he clarified them, gave them names\nfree from religious or philosophical connotations, and supported them with a vast mass of\nclinical observations.\nT>\n24.\n.25.\nMyers, F. W. H.: The Subliminal Consciousness. Proc. Soc. Psychical Research, 8: p. 298.\nBeaunis, H: Le somnambilisme provoque. Paris, 1887.\nCarpenter, W. B.: Principles of Mental Physiology. London, 1881.\nJung, C. G.: Modern Man in Search of a Soul. New York, 1933, p. 1.\nCarus, P.: The Soul of Man. Open Court Pub. Co., Chicago, 1891.\nMandukya Upanishad, v. 3-12, trans, by R. E. Hume: The Thirteen Principal Upanishads. Ovford\nUniv. Press, 1921, p. 391.\nSpinoza, B.: Ethica, pt. Ill, Prop, ix, schol. Modern Student's Lib. Scribner, p. 217.\nAlcorn, D. E.: New Testament Psychology. Brit. J. Med. Psychology, v. 16, p. 270, 1937.\nFreud, S.: Historv of the Psychoanalytic Movement, The Basic Writings of Sigmund Freud. Modern\nLibrary, New York, 193 8, p. 93 8.\nSpitzka, E C: Insanity. Cycloptedia of the Diseases of Children. J. M. Keating, Lippincott, Philadelphia, 1891, p. 1047.\nHenderson, D. K., and Gillespie, R. D.: A Text Book of Psychiatry, p. 404.\n201 Present Non-Psychoanalytical Technique and Theory.\nStill I feel that most of the important advances in psychiatry since the 1890's have\nbeen made by workers outside the field of psychoanalysis. Kraepelin's differentiation\nbetween the manic depressive and dementia praecox disorders; Pavlov's experimentation\nwith conditioned reflexes; Havelock Ellis's monumental work on the Psychology of Sex\n(although Freud influenced him in his last volume); the establishment of the definite\nrelationship between lues and general paresis\u00E2\u0080\u0094to mention four\u00E2\u0080\u0094are such advances, most\nof which came out before Freud was widely known. And since then, the use of malaria\nand insulin has changed the prognosis of two of the most serious mental disorders known.\nBut, confining ourselves to the neuroses, what is the situation today?\n(a) Technique. Today we have other means, less expensive, less lengthy, and, most of\nus feel, more effective than psychoanalysis. Psychoanalysis is not only limited by the conditions which it can treat (hysteria, obsessions, phobias) 21, but also by the financial status,\nintelligence, age, and co-operation of the patient2S. One of the most widely used forms of\npsychotherapy (\"exploration\" or \"analysis\" as opposed to \"psychoanalysis\") begins with\nthe systematic study of the individual, his background, environment, and physical condition, and then treating his personality problems by treating him by endeavouring to\ncorrect what is unhealthy\u00E2\u0080\u0094be it foci of infection, financial uncertainty, his sex life, or\ninhibitions. Thus, besides advice, instruction, re-education and suggestion, the social service worker, the surgeon, the club or church may be called in; things that are not done by\neither the psychoanalyst or the hypnotist. It may not be possible to deal with all the factors, but often enough can be attended to, to enable the individual to adjust himself, which\nis, after all, the object of therapy. One other thing I would like to stress is that, while past\nevents are important in conditioning the individual, his neurosis occurs in response to a\npresent situation, and will continue until this situation can be dealt with satisfactorily, and\nwill recur when a new situation demands it, whether he has been psychoanalysed or treated\nby any other form of psychotherapy or not. This method was elaborated by Adolph Meyer,\nHavelock Ellis, and many others.\n(b) ..Unconscious. In the so-called unconscious, we see today not only the mass of\nunverbalized experiences, unperceived sensations, unremembered memories, and unrealized\ndesires, but also many forces outside the individual, such as the form of our social customs.\nIn this respect we tend to be closer to Carus's conception than to Freud's.\n(c) Conflict. We have given up almost entirely the long-established concept of\ninstinct, and see it now more as a tendency to establish an equilibrium between a vast mass\nof forces, no longer divided into two definite opposing camps. These forces are made up\nof stimuli from the environment, the machinery needed to react to these stimuli, the conditioning reflex arcs or rather complexes, etc. Indeed, instinct is more closely related to the\nphysical capacity to react to a given stimulus than to anything else.\n(d) Neuroses. These are no longer regarded as clear-cut entities. Our ideas regarding\ntheir aetiology have tended, if anything, to drift away from the sexual. Masturbation, for\ninstance, is now regarded more as a symptom than a cause.\nIn short, we are drifting steadily further and further away from the idea of a mind\nsplit up into separate entities or faculties, and have come to look upon them more as patterns or systems, alterable according to the circumstances. In this process the Gestalt\nschool has made valuable contributions.\nConclusion.\nFreud's greatest contribution lies not so much in what he said as in how he said it. His\nvery extremism, his force of language, the stirring way in which he presented his material,\nhas gained popular attention, and some measure of popular support. By proclaiming the\nimportance of sex, he has made it possible for us to discuss sex freely. By proclaiming the\nfunction of the unconscious, he has made it possible for us to point out unrecognized motivation. But, even greater than these, he has, by proclaiming the unconscious hypocrisy of\nthose who think pleasure sin, advanced immeasurably man's right to enjoy pleasure\u00E2\u0080\u0094\npleasure, not only in sex, but in life itself, and the right of all men and women to it.\n27. Freud, S.: New Introductory Lectures, p. 199.\n28. Freud, S.: Psychotherapy. Collected Papers, 1:12, 1904.\nPage 208 Milk Is Good...\n*s**4\nkm- 4 *'\n\u00C2\u00A5'\n*!\u00C2\u00BBt\n. . . BUT the public do not drink ENOUGH\n| MILK for their own GOOD. 1\nWe wish to take this opportunity of thanking\nthe medical profession for their efforts in\nbringing the merits of milk to the attention\nof the consuming public.\nLIMITED\nSS^^V\nJ\u00E2\u0082\u00ACRf\u00E2\u0082\u00ACY QUALITY\nMILK CREAM BUTTERMILK gg^jg^^\nHEMATINIC PLASTULES\nRepeated tests prove that the iron in Hematinic Plastules remains in\na semi-fluid soluble ferrous state indefinitely because the capsule is\nhermetically sealed. This is an important advantage of Hematinic\nPlastules as it assures maximum absorption and assimilation of the\niron medication.\nThe small daily dose of three Hematinic Plastules Plain is usually sufficient to prompt optimal hemoglobin rise, in cases of iron\ndeficiency anemia.\nFor good results in instances of chronic \u00C2\u00AB*&$\u00C2\u00AE^m**\nblood loss, the anemias of pregnancy, or\nfor general debility, prescribe Hematinic\nPlastules \u00E2\u0080\u0094 modern iron therapy. A\nHematinic Plastules Plain\n\u00E2\u0080\u0094Supplied tn bottles of 75's\nHematinic Plastules with Liver Concentrate\n\u00E2\u0080\u0094Supplied in bottles of 50's\nJohn Wyeth & Brother (Canada) Limited\nWALKERVILLE, ONTARIO\n\u00C2\u00AB*JU*\nWmm\nTftfii\nW$m\ UVOCEN\nLivogen is rich in ai! the members of the Vitamin B complex and in liver principles which are\nactive in red blood cell regeneration. Deficiencies of members of the Vitamin B complex are, in\nmost instances, manifested by various neurological derangements in both the early and late stages.\nBriefly, the following are the specific neurological symptoms of deficiencies:\u00E2\u0080\u0094\nVITAMIN Bi\u00E2\u0080\u0094Neuritis\nVITAMIN B2 (lactoflavine)\u00E2\u0080\u0094Degeneration of medullary sheaths and axis cylinders of the\ncord and of peripheral nerves.\nP. P. FACTOR (nicotinic acid)\u00E2\u0080\u0094Psychoses and, in severe cases, dementia and hallucinations.\nVITAMIN Be\u00E2\u0080\u0094Acrodynia, particularly the peripheral nervous hypersensitivity.\nAny or all of the symptoms attributable to a marked deficiency of any of the members of the\nVitamin B complex are commonly present in subclinical intensity either in patients whose intake is\nin some degree below the normal requirement, or during times of mental or emotional exertion\nand stress.\nThe serious, though ill-defined, nervous debility resulting from such minor deficiencies or nervous\nstrain rapidly responds to Livogen treatment and the development of more serious deficiency\nstates is prevented.\nStocks of Livogen are held by leading druggists throughout the Dominion,\nand full particulars are obtainable from:\nTHE BRITISH DRUG HOUSES (CANADA) LTD.\nTerminal Warehouse Toronto 2, Ont.\nLgn/Can/404\nFor Complete :. .\nPRINTING\nOF\nEvery\nDescription\nA phone call will bring\nimmediate attention.\nSey. 6606\nRoy Wrigley Printing\nand Publishing Co. Ltd.\n300 West Pender St.\nVancouver, B. C.\nARTHRITIS and ECZEMA\nof endogenous origin\nclaimed to be allergic, may be\nfavored or induced by calcium and\nsulphur deficiency, impaired cell\naction, and imperfect elimination\nof toxic waste.\nLYXANTHINE ASTIER\nadministered per os, brings about\nimproved cell nutrition and activity, increased elimination, resulting symptom relief, and general functional improvement.\nCanadian Distributors\nROUGIER FRERES\n350 Le Moyne Street, Montreal flDount pleasant TUnbettaking Co. %tb.\nKINGS WAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.\nR. P. HARRISON W. R. REYNOLDS\n13 th Ave. and Heather St.\nExclusive Ambulance Service\nFAIR. 0080\nPRIVATE AMBULANCES AND INVALID COACHES\nWE SPECIALIZE IN AMBULANCE SERVICE ONLY\nJ. H. CRELLIN\nW. L. BERTRAND Nutttt $c\n2559 Cambie Street\nVancouver, B. C.\nColonic\nIrrigation\nInstitute\nSuperintendent:\nE. M. 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VAc^JL--^ r1-\n898 \"It must be EFFICIENT. DEPENDABLE, and PORTABLE\"\n\u00E2\u0080\u00A2 That's what the Nootka Mission\nHospital required in its x-ray equipment, and the G-E Model F-3 Unit was\nselected because it met every need.\nEfficiency and ease of operation were\nimportant. The hospital, located in\nisolated Ceepeecee on the west coast\nof Vancouver Island off the British\nColumbia mainland, serves 1500\npersons who live along a 100-mile\nstretch of coastline. And most of the\n1500 are engaged in hazardous work\n\u00E2\u0080\u0094mining, logging, millwork, fishing\u00E2\u0080\u0094\nwork that produces a large number of\nemergency cases. .\nThere could be no question about\ndependability. It's a long, hard trip to\nCeepeecee from the mainland. Mail\nboats make it every 10 days. Nootka's\nstaff demanded a unit that \"could take\nit,\" a unit that would require an absolute minimum of servicing\u00E2\u0080\u0094and the\nF-3 filled the bill.\nTrue portability was necessary. Transportation on Vancouver Island is a\nreal problem. There are no roads; all\ntravel is by air and water, and there's\nno room for \"excess baggage.\"\nTo every medical man who does not\nhave adequate roentgenological service readily available, and who realizes\na need for a compact, efficient, dependable portable x-ray unit, G-E makes\nthis suggestion: Protect your investment, investigate the G-E Model F-3\nbefore you invest in any x-ray unit.\nFor complete information and an\ninteresting demonstration, send your\nrequest to Dept. A204.\nVICTOR X-RAY CORPORATION of CANADA, Ltd.\nnsniHiTORS ran Gweui &X9 afcmc hay cotrotAnON\nTOKONTO. 30 lloor St. w VANCOUVER! MoMtTtm. Mb. 570 Dimm* St\nMONTWAli 400 Mtdkol Art. !\u00C2\u00AB\u00C2\u00BB*!\u00C2\u00BB WMNPECi Wl\u00C2\u00ABlll Art. tuldixg Serums, Vaccines, Hormones\nAND\nRelated Biological Products\nAnti-Anthrax Serum\nAnti-Meningococcus Serum\nAnti-Pneumococcus Serums\nDiphtheria Antitoxin\nDiphtheria Toxin for Schick Test\nDiphtheria Toxoid\nOld Tuberculin\nPerfringens Antitoxin\nPertussis Vaccine\nVaccine Virus\nPneumococcus Typing-Sera\nRabies Vaccine\nScarlet Fever Antitoxin\nScarlet Fever Toxin\nStaphylococcus Antitoxin\nStaphylococcus Toxoid\nTetanus Antitoxin\nTetanus Toxoid\nTyphoid Vaccines\n(Smallpox Vaccine)\nAdrenal Cortical Extract\nEpinephrine Hydrochloride Solution (1:1000)\nEpinephrine Hydrochloride Inhalant (1:100)\nEpinephrine in Oil (1:500)\nHeparin\nSolution of Heparin\nInsulin\nProtamine Zinc Insulin\nLiver Extract (Oral)\nLiver Extract (Intramuscular)\nPituitary Extract (posterior lobe)\nPrices and information relating to these preparations will be\nsupplied gladly upon request.\nCONNAUGHT LABORATORIES\nUNIVERSITY OF TORONTO\nToronto 5\nCanada\n\"Depot for British Columbia\nMacdonald's Prescriptions Limited\nMEDICAL-DENTAL BUILDING, VANCOUVER, B. C Igfour Azr/neff\nfor 30\u00C2\u00A7odd ^fe^s\nDay or Night\nMArine4161\nFree City Delivery till 10 p.m.\nGeorgia Pharmacy is\nproud of if s Ipngf^^^nate\nconnecfen with the Doc^rs\nof this city and \u00C2\u00A3tov1jlce.\nve^4^^.Jc/emcLiAjon\nGEORGIA PHARMACY\nu i vt i y v o\n\u00C2\u00ABOR\u00C2\u00ABIA\n9TRSBT\n{htatx^Mwxm^^\nESTABLISHED 1t\u00C2\u00ABS\nVANCOUVi^P C.\nNorth Vancouver, B. C.\nPowell River, B. C. Hollywood Sanitarium\nLimited\nI!\nglPW the treatment of\nAlcoholic*Ner^ps and Psychopath%rCases\npSxclusiyely\n. Reference\u00E2\u0080\u0094Bi^rMedieal Association\nFofjtnformation appl^^j\nMedical Superintende|ll|^^ C.\nor 515 Birks Building, Vancouver.\nSEymoub 4183\nWestminster 288\nrov wmouty imuntinq\nft PUBLISHING CO. LTD."@en . "Periodicals"@en . "W1 .VA625"@en . "W1_VA625_1940_04"@en . "10.14288/1.0214396"@en . "English"@en . "Vancouver : University of British Columbia Library"@en . "Vancouver, B.C. : McBeath Spedding Limited"@en . "Images provided for research and reference use only. Permission to publish, copy, or otherwise use these images must be obtained from the Digitization Centre: http://digitize.library.ubc.ca/"@en . "Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625"@en . "Medicine--Periodicals"@en . "The Vancouver Medical Association Bulletin: April, 1940"@en . "Text"@en . ""@en .