"CONTENTdm"@en . "http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642"@en . "History of Nursing in Pacific Canada"@en . "Vancouver Medical Association"@en . "1940-05"@en . "2015-01-29"@en . "1940-05"@en . "https://open.library.ubc.ca/collections/vma/items/1.0214420/source.json"@en . "image/jpeg"@en . " 0\nTteBllJL\nof the\nVol. XVI.\nMAYj|l940\nNo\u00C2\u00BB\nWith Which Is Incorporated\nTransactions of the\n$i^\nth*\nVaiuzGw\nand\nSt.\u00C2\u00A7^t^s: Hospital\n. Iii This Issue:\nPage\nPROGRAMME Vi^^^UMMER. SOHKJ^L-j^^;. SSt ij|||||fi|\nllbMPLIMEN^^\nREPORTS\u00E2\u0080\u0094ANNUAI&EETING^pM.;^^^^^^^^^^^^^^^^\nMEDrcip|SERVIGES A^OnfA^T^M-'^^^^^^^^^^^^^^^^^g\nTHE DTAf^OS^^SYPT^^^li^^^^fel;ami^^^P^\"- ^^^^^^g\nTHE WHOLE SET-UI^I WRONG4Wr; D. ifeaifc____^K-_-^^^K'242 In Acute\nQenito^urinary Inflammations\nthe use of Antiphlogistine constitutes a rational aid to the treatment.\nIts heat and medication tend to\nexert a modifying influence on the\ninflammatory phenomena.\nAs a local adjuvant to other\ntherapeutfif measures* it |p\u00C2\u00A3 often\nbeneficial.\nSample on request\nANTIPHLOGISTINE\nHypertrophic prostate.\nW^Accretions (\"prostatic pearls?).\nsp& Overgrowth of connective tissue.\nTHE DENVER CHEMICAL MFG. CO.\nPP? Lagauchetiere SjiifW., Montreal\nMade in Canada 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:\nDe. J. H. MacDebmot\nDb. G. A. Davidson Db. D. E. H. Cleveland\nAll communications to be addressed to the Editor at the above address.\nVol. XVI.\nMAY, 1940\nNo. 8\nOFFICERS, 1939-1940\nDb. D. F. Btjsteed Db. W. M. Paton Db. A. M. Agnew\nPresident Vice-President Past President\nDb. W. T. Lockhabt Db. Mubbat Baibd\nHon. Treasurer Hon. Secretary\nAdditional Members of Executive: Db. C. McDiabmid, Db. L. W. McNutt.\nTRUSTEES\nDb. F. Bbodie Db. J. A. Gillespie Db. F. W. Less\nAuditors: Messes. Plommee, Whiting & Co.\nSECTIONS\nClinical Section\nDb. Kabl Haig. Chairman Db. Ross Davidson Secretary\nEye, Ear, Nose and Throat\nDb. W. M. Paton Chairman Db. G. C Laege Secretary\nPediatric Section\nDb. R. P. Kinsman Chairman De. G. O. Matthews Secretary\nSTANDING COMMITTEES\nLibrary:\nDe. F. J. Bullee, Db. D. E. H. Cleveland, Db. J. R. Davies,\nDe. W. A. Bagnall, Db. T. H. Lennie, De. J. E. Walkeb.\nPublications:\nDb. J. H. MacDebmot, De. D. E. H. Cleveland, De. G. A. Davidson.\nSummer School:\nDe. T. H. Lennie, De. A. Loweie, Db. H. H. Caple, Db. Feank Tubnbull,\nDe. W. W. Simpson, Db. Kabl Haig.\nCredentials:\nDe. A. W. Hunteb, De. W. T. Ewing, De. A. E. Tbites.\nV. O. N. Advisory Board:\nDe. C E. Riggs, Db. T. M. Jones, De. R. E. McKechnie II.\nMetropolitan Health Board Advisory Committee:\nDb. H. Spohn, De. F. J. Bullee, Db. W. T. Ewing.\nGreater Vancouver Health League Representatives:\nDb. G. O. Matthews, De. M. W. Simpson\nRepresentative to B. C. Medical Association: Db. A. M. Agnew.\nSickness and Benevolent Fund: The Pbesident\u00E2\u0080\u0094The Tbustees. Endocrine Therapy\nAMNIOTIN (N. N. R.)\u00E2\u0080\u0094Squibb estrogenic substance.\nThe established indications for this A.M.A. Council-accepted product are\nvasomotor symptoms of the natural or artificial menopause; gonorrheal\nvaginitis in children; senile vaginitis. There are also other conditions\nwhere its value is under investigation.\nAmniotin is a highly purified preparation of naturally occurring estrogenic\nsubstances, derived from natural sources. It is available in oil in ampules,\nin pessaries, in capsules; for administration hypodermically, intrava-\nginally, or orally; according to the condition being treated and the\nindividual patient.\nANTERIOR PITUITARY EXTRACT SQUIBB is indicated for its\ngrowth-promoting effect in pituitary types of dwarfism, in diabetic children\nwhere there is pronounced failure of growth, and in Simmond's disease.\nAnterior Pituitary Extract Squibb is available in 20 cc. vials, each containing 200 growth units, for intramuscular injection.\nFOLLUTEIN (chorionic gonadotropin) \u00E2\u0080\u0094 anterior pituitary-like sex hormone Squibb.\nIn cases of undescended testes, satisfactory results have been obtained\nthrough the use of Follutein.\nFollutein is supplied in glycerin solution with sterile distilled water\ndiluent; mixture 5 cc.\u00E2\u0080\u0094500 International Units; 10 cc\u00E2\u0080\u00941,000 I.U.;\n5 cc\u00E2\u0080\u00945,000 I.U. Administered by intramuscular injection.\nTHYROID SQUIBB\u00E2\u0080\u0094thyroid glands dessicated. The product is standardized with respect to its iodine content, and also biologically assayed\nto assure specific therapeutic activity.\nThese Squibb Thyroid Tablets enable accurate and controlled dosage in\nhypo-thyroid states, including subnormal metabolism as in myxedema\nand cretinism, mental retardation associated with thyroid deficiency,\nsome cases of obesity and of gonadal insufficiency in women.\nThyroid Squibb is supplied in plain or enteric-coated tablets, 1/10, 1/4,\n1/2,1, 2, and 3 grains, in bottles of 100,1,000, 5,000. Also 5-grain tablets\nenteric-coated.\nFor further information write 36 Caledonia Rd., Toronto\n^/RjScgjibb & Sons of Canada, Ltd.\nNUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858\n\ VANCOUVER HEALTH DEPARTMENT\nSTATISTICS, MARCH, 1940\nTotal population\u00E2\u0080\u0094estimated\t\nJapanese population\u00E2\u0080\u0094estimated :\t\nChinese population\u00E2\u0080\u0094estimated\t\nHindu population\u00E2\u0080\u0094estimated\t\nNumber\nTotal deaths 263\nJapanese deaths 6\nChinese deaths 8\nDeaths\u00E2\u0080\u0094residents only 229\nBIRTH REGISTRATIONS\nMale, 202; Female, 17L\n373\nINFANTILE MORTALITY: March, 1940\nDeaths under one year of age 9\nDeath rate\u00E2\u0080\u0094per 1,000 births :-\u00E2\u0080\u0094! 24.1\nStillbirths (not included in above) 8\n 269,454\n 9,094\n.__ 8,467\n 339\nRate per 1,000\nPopulation\n11.5\n7.8\n11.2\n10.0\n16.4\nMarch, 1939\n14\n36.7\n8\nCASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY\nApril 1st\nFebruary, 1940 March, 1940 to 15th, 1940\nCases Deaths Cases Deaths Cases Deaths\nScarlet Fever 6 0 18 0 6 0\nDiphtheria 0 0 0 0 0 0\nChicken Pox 122 0 122 0 0 0\nMeasles 82 0 10 0 14 0\nRubella 9 0 7 0 10\nMumps 3 0 0 0 3 0\nWhooping Cough 12 0 22 0 4 0\nTyphoid Fever 0 0 0 0 0 0\nUndulant Fever 10 10 0 0\nPoliomyelitis . 0 0 0 0 0 0\nTuberculosis 42 18 26 14 15\nErysipelas 10 4 0 2 0\nEp. Cerebrospinal Meningitis 0 0 0 0 0 0\nParatyphoid Fever Carrier 10 10 0 0\nV. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,\nDIVISION OF VENEREAL DISEASE CONTROL.\nWest\nBurnaby Vancr.\nSyphilis 0 0\nGonorrhoea 0 0\nNorth Vancr.\nRichmond Vancr. Clinic\n2 0 24\n1 0 55\nHospitals,\nPrivate Drs.\n24\n9\nTotals\n50\n65\nIBIOGLAN\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.\nPage 209 Professional 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.\nTENDERS\nWill be received by the undersigned up to Noon, Thursday,\nMay 23 rd, 1940, for the purchase of one McCarthy Double\nCatheterising Cystoscope, with electric cord, located at\n2700 Laurel St., Vancouver, B. C.\nFor further information apply to Dr. D. H. Williams, 2700\nLaurel St., Vancouver, B. C.\nThe highest or any tender not necessarily accepted.\nParliament Bldgs.,\nVictoria, B. C,\nApril 24th, 1940.\nA. V. HAMILTON,\nPurchasing Agent. SUMMER SHOOL, 1940\nVANCOUVER MEDICAL ASSOCIATION\nHOTEL VANCOUVER |\nJune 25th, 26th, 27th and 28th, 1940\nPROGRAMME\nTuesday, June 25 th\n9.00 a.m.\u00E2\u0080\u0094Dr. Magner: \"Pathogenesis of Jaundice.\"\n10.00 a.m.\u00E2\u0080\u0094Dr. Jeans: \"Recent Advances in the Diagnosis and Treatment of Nephritis\nand Nephrosis.\"\n11.00 a.m.\u00E2\u0080\u0094Dr. Reichert: \"Lymphcedema in Man.\"\n12.30 p.m.\u00E2\u0080\u0094LUNCHEON, Cafe Room Hotel Vancouver.\nSpeaker: Dr. W. S. Middleton: \"Some Lay Contributions to Medicine.\"\n(Illustrated by Slides.)\n3.00 p.m.\u00E2\u0080\u0094CLINIC: Vancouver General Hospital.\nDr. P. C. Jeans: Pediatric Clinic.\n8.00 p.m.\u00E2\u0080\u0094Dr. Wm. S. Middleton: \"Idiopathic Hypertension.\"\n9.00 p.m.\u00E2\u0080\u0094Dr. Farmer: \"Burns and Their Treatment.\"\nWednesday, June 26th\n9.00 a.m.\u00E2\u0080\u0094Dr. Reichert: \"Neuralgias of the Head and Face.\"\n10.00 a.m.\u00E2\u0080\u0094Dr. Middleton: \"Protection of the Circulation in Surgery.\"\n11.00 a.m.\u00E2\u0080\u0094Dr. Farmer: \"Emergency Abdominal Surgery in Childhood.\"\n2.30 p.m.\u00E2\u0080\u0094CLINIC: St. Paul's Hospital.\nDr. Reichert: Surgical Clinic.\n8.00 p.m.\u00E2\u0080\u0094Dr. Magner: \"Clinical Aspects of Jaundice.\"\n9.00 p.m.\u00E2\u0080\u0094Dr. Jeans: \"Nutritional Requirements of the Growing Child.\"\nThursday, June 27 th\n9.00 a.m.\u00E2\u0080\u0094Dr. Magner: \"Pathogenesis of Anaemia.\"\n10.00 a.m.\u00E2\u0080\u0094Dr. Jeans: \"Calcium and Vitamin D Needs of the Child, with Reference\nto Dental Cares.\"\n11.00 a.m.\u00E2\u0080\u0094Dr. Reichert: \"Anterior Scalenus Syndrome.\"\nAFTERNOON\u00E2\u0080\u0094GOLF TOURNAMENT.\n8.00 p.m.\u00E2\u0080\u0094Dr. Farmer: \"Treatment of Avulsed Skin Flaps and Treatment of Angiomata.\"\n9.00 p.m.\u00E2\u0080\u0094Dr. Middleton: \"Post-operative Pulmonary Complications.\"\nFriday, June 28 th\n9.00 a.m.\u00E2\u0080\u0094Dr. Middleton: 'Rationalized Therapeutic Experiences.\"\n10.00 a.m.\u00E2\u0080\u0094Dr. Farmer: \"Acute Osteomyelitis.\"\n11.00 a.m.\u00E2\u0080\u0094Dr. Jeans: 'Congenital Syphilis.\"\n2.30 p.m.\u00E2\u0080\u0094CLINIC: Vancouver General Hospital.\nDr. Middleton: Clinic on Internal Medicine.\n8.00 p.m.\u00E2\u0080\u0094Dr. Magner: \"Some Clinical Aspects of Anaemia.\"\n9.00 p.m.\u00E2\u0080\u0094Dr. Reichert: \"Regional Ileitis and Other Localized Lesions of the Small\nBowel.\"\nPage 210 Each tablet contains:\nTheobromine - - - - 5 grams\n*Neurobarb E.B.S. - - J4 grain\nSodium Bicarbonate - 5 grains\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 x/i grain Neurobarb as C.T. No. 691A Theobarb Mild\nLiterature and sample on request\n\u00E2\u0080\u00A2Neurobarb is the E.B.S. trade name for Phenobarbital.\nTHE L 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\n\u00E2\u0096\u00A0t EDITOR'S PAGE\nWe would call our readers' attention to certain things in this issue of the Bulletin,\nwhich will be of interest to all medical men, and are deserving of some mention. Those\nwho read Collier's Magazine will have noticed the running commentary on prospective\nstories, articles, etc., and the obiter dicta suggested by contributors, writers, and subscribers, which constitute a regular feature on the first page of the journal. Some such\nidea would, we think, be a good one for any publication, as it gives an introduction to its\ncontents and provides a foretaste of good things to come.\nWe publish at last in this number Dr. Gee's report on the Aschheim-Zondek test as it\nhas been used in the Vancouver General Hospital for the past eight or nine years. We\nwould again suggest that this is a very fine piece of work, and well worth recording. It\nrequired a great deal of editing by Dr. Gee before it could be published, hence the delay.\nVictoria sends us, as part of its contribution for the month, a paper read by Dr. D.\nM. Baillie, dealing, not with scientific matters, but with a far more important thing, one's\ndaily life. Most of us, in these days of stress and strain, these days, too, of transition\u00E2\u0080\u0094for\nMedicine is undergoing one of its periodical new births, emerging from the general practitioner age, where all were equal, all were surgeons and obstetricians, urologists and\nneurologists, and the medical man was an intense individualist\u00E2\u0080\u0094most of us, we say again,\nhave lost sight of the necessity for living a full and abundant life, if we are to be happy\nand productive. Where are the Osiers, and the Moynihans, and the Cushings, and the\nJohn McCraes, and the Tait McKenzies? men to whom their medical work, important\nand pre-eminent as it always was, meant yet only a part of their life? They read, they\nconversed, they thought, they spoke, they lived: and they made contributions of a creative\norder to the life of their times. We have had them too. John Mawer Pearson, when alive,\nhad his hobbies. Sculpture and poetry gave to him happiness\u00E2\u0080\u0094surcease from daily care,\na spiritual.uplift. Banting of Toronto (of Canada?), paints pictures in his spare time, of\na high order of merit. Kidd, of Vancouver, by his patient, arduous efforts, has contributed\nmuch to the knowledge of today on Canadian history, gleaned from his explorations of\nthe past. And there are many others, no doubt.\nThere should be more of this, and we should get away more, far more than we do, from\nour daily grind, and escape into freer and purer airs. Only so can we avoid becoming hopelessly narrow and selfish, out of touch with realities, out of sympathy with human needs.\nThe fact is that we, of all men, should be in least danger of so getting out of touch\u00E2\u0080\u0094but\nthere are many signs that we are not as aware as we should be of modern trends, of modern\ndevelopments, of the inevitably inescapable changes that are coming, and must come, to\nmeet modern conditions, and this strange new world that is slowly emerging from the\nruins of the old world we knew.\nWe feel that such papers as that of Dr. Baillie, while they deal only with one aspect of\nthe case, are of great and timely value. Let us make no mistake\u00E2\u0080\u0094times are changing\u00E2\u0080\u0094\ntempora mutantur. Can we say \"et nos in Hits\"? \"And we with them\"? We rather doubt\nit. There is altogether too reactionary an attitude amongst medical men\u00E2\u0080\u0094a tendency to\ncling to old things merely because they are old things, and we are used to them\u00E2\u0080\u0094to deprecate change\u00E2\u0080\u0094to refuse any alteration or modification of our traditions and habits.\nThis is dangerous-\u00E2\u0080\u0094because, if we do not ourselves welcome and direct, and even\ninitiate, many of these changes and modifications that are inevitable, and often long overdue, we are going to find that someone else will do it.\nSo we suggest a careful reading of Dr. BailhVs paper. With much of it, many of us\nmay disagree in detail\u00E2\u0080\u0094but if it makes us think, arouses us to suggesting our own ideas,\nwe venture to say that it will have served its author's purpose.\nPage 211 As a proof that there are others who have constructive ideas, and that there is yet life\nin the old dog, we are glad to publish in this issue a brief display representation of the work\nof the M.S.A. (the Medical Services Association) which is now in existence, and is gradually, but with ever-increasing rapidity, accumulating an imposing list of prospective\nmembers.\nThis organization is endorsed by the British Columbia Medical Association, and will,\nwhen it has been fully developed, solve a real public need, and represent a real contribution\nto the common good.\nWe rejoice to see that this Association intends to proceed gradually, in safe stages, and\non grounds as safe as human foresight can ensure. The actuarial basis of the scheme has a\nwide margin of safety\u00E2\u0080\u0094which is as it should be.\nFull details of the scheme in all its aspects cannot, of course, be given here, but we are\nsure that the secretary and organiser, Mr. McLellan, will gladly give any particulars and\ninformation desired.\nNEWS AND INOTES\nDr. G. A. Davidson, Dr. Russell Palmer and Dr. S. C. Turvey attended the meeting\nof the American College of Physicians, which was held in Cleveland, Ohio, during the\nfirst week in April.\n*\nOur congratulations are offered to Dr. R. K. Brynildsen, who was married on March\n26th to Miss Dorothy Rider, of this city, formerly of Regina, Sask. The marriage took\nplace in Christ Church Park Avenue Cathedral in New York. After a honeymoon in\nthe South Dr. and Mrs. Brynildsen will make their home in Vancouver.\n*\nDr. A. L. Lynch has recently returned from Carmel, where he and his family enjoyed\na month's vacation.\n* * * *\nDr. A. E. Trites has left for a short, but well-earned vacation in the South.\n* * * *\nDr. W. Turnbull has returned from spending three weeks' holiday in the South.\n* * * *\nOur deepest sympathy is offered to Dr. B. D. Gillies on the death of his wife, who\npassed away on March 26th.\n*\u00C2\u00A3 \u00E2\u0080\u00A2*. *!. \u00C2\u00ABt\n*C \u00E2\u0080\u00A2** \u00C2\u00BBF *r\nThe following delegation from British Columbia attended the Winter Course of the\nOregon School of Medicine, Eye, Ear, Nose and Throat Convention held in April: Drs.\nR. B. Boucher, Colin Graham, W. M. Paton, R. Grant Lawrence, J. A. Smith, J. A.\nMacLean, J. A. Montgomery and C. E. Davies, from Vancouver; Dr. W. Laishley from\nNelson, and Dr. B. H. Cragg of New Westminster.\nC;v \u00E2\u0096\u00A0''\"* ;' : \u00E2\u0096\u00A0'.*\u00E2\u0096\u00A0'* ;-;:4\n^r *T *T *F\nThe Canadians were complimented on their excellent representation.\nThe speakers for the course were Dr. Marion Jones of New York City and Dr.\nMeyer Weiner of St. Louis, Mo.\n* * * *\nDr. and Mrs. W. F. Anderson of Kelowna are receiving congratulations on the birth,\non March 9th, of a daughter.\n\u00E2\u0080\u00A2*. *t *fc *t\n\u00E2\u0080\u00A2P \u00C2\u00BBr \u00C2\u00BBr *r\nDr. R. J. Wride of Princeton has returned after two months in the East, where he did\npost-graduate work in Boston, New York City and at Rochester, Minn.\nPage 212 Dr. Wilfrid Laishley of Nelson attended the Annual Meeting and Dinner of the Eye,\nEar, Nose and Throat Section and then travelled to Portland to attend a special course in\nEye, Ear, Nose and Throat.\n4L. *&. \u00C2\u00ABi. *t-\nDr. E. E. Topliff is in the Mater Misericordiae Hospital, Rossland, making satisfactory recovery from a recent illness.\n* * * *\nCapt. P. S. Tennant, R.C.A.M.C., formerly of Kamloops, now on active service with\nNo. 8 Field Ambulance at Calgary, was home in Kamloops for a few days.\nCapt. W. Bramley-Moore, R.C.A.M.C., formerly of Blue River and Kamloops, now on\nactive service, was in Kamloops on a visit.\nDr. W. D. Higgs, formerly of Port Alberni, is relieving Dr. T. C. Harold at Ladysmith\nduring the latter's absence in the East doing post-graduate work.\nDr. C. C. Browne of Nanaimo is impatiently waiting a favourable opportunity to go\ndown to Victoria and bring back his new sloop.\nDr. and Mrs. R. Scott-Moncrieff of Victoria are receiving congratulations on the birth\nof a son.\nsj- if- jj. sj.\nDr. and Mrs. R. C. Newby of Victoria are receiving congratulations on the birth of\na daughter.\n* * * *\nDrs. G. A. McCurdy and D. B. Roxburgh of Victoria attended the meeting of the\nPacific North-West Society of Pathologists in Portland. Dr. McCurdy contributed a paper\non Tumours of the Synovial Membranes and Bursae.\n* * * *\nDr. R. A. Hunter of Victoria attended the Annual Meeting of the American College\nof Physicians and visited various centres in the East, including New York.\n*\u00C2\u00A3 *t *$\u00E2\u0096\u00A0 H\"\nDr. G. F. Amyot gave a very interesting address before the last meeting of the Victoria\nMedical Society. The paper was entitled \"The Practice of Medicine and Public Health.\"\nThe Eye, Ear, Nose and Throat Section of the British Columbia Medical Association\nheld its Annual Meeting and Dinner in the Hotel Vancouver on March 3 Oth.\nDr. Meyer Wiener, Clinical Professor of Ophthalmology, Washington University, St.\nLouis, was the guest speaker, his subject being \"Some of the Newer Methods and Treatments of Glaucoma.\"\nDr. E. F. Raynor of Victoria gave a paper on \"The Treatment of Lachrymal Duct\nStenosis.\"\nThe attendance was large and the programme was good.\nDr. M. J. Keys, President of the Eye, Ear, Nose and Throat Association, presided.\n* * * *\nWe are pleased to learn that Dr. R. W. Garner of Port Alberni is now improving,\nhaving been seriously ill with pneumonia.\n* * * *\nDr. J. Bain Thorn of Trail visited on the Coast at both Vancouver and Victoria during\ntwo weeks in March.\n* * * *\nDr. B. T. H. Marteinsson of Port Alberni, who is associated with Dr. C. T. Hilton,\ncalled at the office while in Vancouver.\nThe Penticton Hospital has just installed additional X-ray equipment and a new\nmetabolism machine. All the doctors require now is a new hospital building.\nPage 213 The wedding is announced of Dr. G. A. B. Hall of Nanaimo to Miss Charlotte Annable,\nR.N., of Nelson. Dr. and Mrs. Hall are at present motoring in the Southern States.\nDr. J. K. Kelley of Zeballos is away doing post-graduate work.\nDr. and Mrs. John U. Coleman of Duncan are receiving congratulations on the birth,\non April 23rd, of a son.\nI CORRESPONDENCE\nEditor The Bulletin:\nDear Doctor:\nIn your last issue of the Bulletin I read what I wished I had written referring to our\nbeloved friend R. E. McKechnie, and his services to this Province during half a century.\nWithout consultation, I would like to add, on behalf of his confreres in the interior in\nthis neck of the woods (of which he has viewed many), a tribute to his personality. It has\nbeen my fortunate experience to call this man my friend. And those who do not know him\nas I do have missed something which cannot be recaptured in these times of stress and\ncompetition.\nWith his wonderful God-given gift of kindness, surgical skill and meeting S.O.S.\nsituations under most trying circumstances he has no equal.\nHis delightful personality, which everyone with whom he has come in contact admits\nhas been a beacon and an inspiration, will never change.\nMay he long continue as he is, and if he meets all the lame dogs he has helped over the\nstile it will keep him from starting Golf.\nYours sincerely,\nPenticton, B. C. R. B. White.\nDR. GEORGE S. GORDON\nObiit April 16, 1940.\nWith the passing of George Gordon a few days ago, goes another of a race of\nmedical men that is now well-nigh extinct\u00E2\u0080\u0094one of the \"old school.\" The present\ngeneration of medical men in Vancouver hardly knew his name, for it is many\nyears since ill-health forced his retirement into inactivity\u00E2\u0080\u0094but the writer knew\nhim well, and liked and admired him greatly.\nToday medicine has become one of the high-pressure professions\u00E2\u0080\u0094it is\nbecoming an exact science, with little or no room or time for the leisurely, rather\ndesultory attitude of the older days\u00E2\u0080\u0094when a doctor was not so much a scientific\nprofessional man as a guide, counsellor and friend of the family, a kindly\nphilosopher, cheery and optimistic, and achieving, results, perhaps, more through\nhis personality than through exact precision. We do not feel that the change is\nanything but for the better, but sometimes we rather regret certain of the\ninevitable discards that have accompanied it.\nGeorge Gordon was a well-trained, up-to-the-minute practitioner of his\nspecialty, urology: but he retained many of the traditions and habits of the older\nschool of which we speak, and was a punctilious observer of a most rigid ethical\ncode. He was honour itself in his dealings with his fellows\u00E2\u0080\u0094and his courtesy and\nconsideration for them were unfailing: he gave generously and without any stint,\nof his superior knowledge and skill, where any of his brethren needed these. To\nconsult with George Gordon, to meet him on a case, was ever a delight, and one\nknew that one was meeting and consulting with an honourable gentleman.\nA warm-hearted friend, a loyal colleague, a genial host, a fine citizen in every\nway, was George Gordon, and we salute his passing.\nPage 214 DR. ALFRED THOMPSON\nObht April 20, 1940.\nThompson of the Yukon died suddenly, in harness, doing his job, on April\n20th, and his death was a profound shock to many of the medical profession in\nthis city. The day before his death, he had been in the hospital, cheery and active\nas ever, and one can hardly believe that we shall not again meet that tall, erect\nfigure, and receive from him, in answer to one's greeting, that charming smile\nand friendly recognition that he gave to all whom he knew.\nThere are politicians and politicians, and Alfred Thompson was one of the\nhighest order. Of scrupulous honesty and the highest integrity of character himself, he gave full credit for these in others, and gave every man the full right to\nhold his own views and beliefs. One cannot remember, in a long knowledge of\nDr. Thompson, ever hearing him speak slightingly or unkindly of any political\nopponent. His own opinions were clear-cut and strongly held, and he was a loyal\nparty man\u00E2\u0080\u0094but he respected every other man's opinions, and gave him credit\nfor sincerity and honesty. A gentle, kindly humour was his, and he was a perfect loser, with no alibis, and no blame for anyone.\nHe had a huge acquaintance, and a vast number of friends and admirers\u00E2\u0080\u0094all\nover Canada\u00E2\u0080\u0094for he was a national figure in politics, and had been a doughty\nfighter for many years in the rough-and-tumble of Canadian political life. He\nwas one of the many medical men who have embraced a political career, and by\ntheir methods and actions have brought honour to their profession, and made a\ncontribution to the true welfare of their country.\nAs a medical man, Dr. Thompson was popular and well known, and his work\nwas excellent. Latterly, one could see he felt the strain, and there can be little\ndoubt that the circumstances of his last call, where he turned out on foot, late\nat night, to give help to a dying woman, had much to do with his sudden demise.\nBut we can only envy him this ending, and deem him happy to have died waging\n\"one more fight, the best and the last,\" dying with his boots on, alive to the last\nminute, in full possession of all his faculties. Our memories of him will be\nfragrant and pleasant ones. To his family we extend our sincerest sympathy and\ncondolences.\nMcKECHNIE DINNER\nThis has been a month of Dinners. The Amyot Dinner has been referred to elsewhere,\nand another Dinner held on April 26th was also outstanding.\nIt was a Complimentary Dinner given by the Graduates' Society of McGill, in collaboration with the B. C. Medical Association, to our beloved Dr. R. E. McKechnie, O.B.E.,\nLL.D., F.R.C.S.(Can.), M.D., CM. (etc.), whose list of titles and positions and achievements is far beyond our power to publish in the room at our disposal.\nFifty years of medical practice, and seventy-nine years of life, are among his achievements to date, and the Dinner given last week is merely in the nature of a progress report.\nIt was a big and an imposing function. There must have been three hundred guests or\nmore, and the Banquet Room of the Hotel Vancouver was an imposing sight, with McGill\nemblems flanking the British and American flags (for we had many Americans as guests),\nand supported by Varsity and Queens' colours.\nMedical men, of course, formed the great majority of the audience, and there were\nrepresentatives of all parts of Btriish. Columbia. Dr. F. M. Auld, President of the B. C.\nMedical Association, sat at the left of Dr. C. F. Covernton, President of the Graduates'\nMedical Society of McGill, and spoke for the B. C. Medical Association. Lt.-Col. A. L.\nJones, D.M.O. of M.D. XI, was there, and there were many others representing public\nbodies of various kinds, gathered to do honour to this man, who has done honour to us all.\nThe University of British Columbia, of which Dr. McKechnie has been Chancellor for\nmany years, sent a strong contingent, among others Dr. Buchanan of the Faculty of\nArts and Sciences, who gave a characteristically witty speech, in toasting sister Universi-\nPage 215 ties; Dean Finlayson, of the Faculty of Science; Prof. Lemuel Robertson, Mr. Wm. Powell,\nerstwhile Professor in the Faculty of Science, and several others.\nThe Vancouver General Hospital Board of Directors, too, was represented by Mr. J.\nH. McVety, Treasurer; Mr. Norman Cull, President; Mr. Frank J. Burd, Dr. A. K. Haywood, Medical Superintendent, and many besides.\nThe Dinner was a very enjoyable one. There were few speakers, and they were very\ngood. As has been said, Dean Buchanan delighted us all by his speech, and was answered\nby Dr. Wallace A. Wilson, whose reply was a thing of art. He had to work hard to find in\nthe McGill accent a parallel to the Oxford accent, but then Toronto men have to learn to\nwork hard anyway to get what they are after (no slurs on Toronto are intended here) and\nhe did very well, and everyone enjoyed his speech.\nDr. P. A. McLennan introduced the guest of the evening, Dr. McKechnie, in a speech\nwhich could not well have been bettered in style and material. Dr. McLennan has a\nliterary taste and skill based on wide reading and keen appreciation of the masters of\nEnglish, especially the translators of the English Bible\u00E2\u0080\u0094and what he says, especially if\nhe allows himself to speak extempore, fairly boils over with apposite quotations and\nallusions. The present writer was close and could hear him\u00E2\u0080\u0094but it is a matter of regret\nthat the microphone did not work well for parts of his address.\nThen Dr. McKechnie rose, and the walls of Jericho fell down, and he took us all over.\nModest, unassuming, gentle, he told a few simple anecdotes of the Clan McKechnie, from\nwhich he comes, and to which he does honour\u00E2\u0080\u0094and said nothing of himself. We do not\nknow the motto of the McKechnie Clan, but perhaps it is \"Acta, non verba,\" and in any\ncase that would be a good motto for them.\nIt was a heartfelt tribute of affection and esteem on the part of his fellows and those\nwho know him best, to a man who never sought fame or much reward, but merely has\ndone what he could: and has \"stood by the day's work.\" As someone, we think Dr.\nMcLennan, said, he is not of any University, but of all Universities, and he belongs\nto us all.\nDrs. Osborne Morris of Vernon and Frank McEown of Vancouver as fellow graduates\nof the class of McGill '90 were associated as honoured guests.\nDrs. Frank Horsfall, Otis Lamson and Donald Trueblood of Seattle, H. Whitacre of\nTacoma, Hiram E. Cleveland of Burlington and several others were present.\nOther members who had come to Vancouver on this occasion were: Lieut.-Col. A. L.\nJones, D.M.O., M.D. No. 11; Drs. R. B. White of Penticton, J. S. Burris of Kamloops,\nW. F. Drysdale of Nanaimo, H. M. Robertson of Victoria, all of whom graduated in the\nNineties; Drs. Thomas McPherson, M. J. Keys, George W. Hall, A. C. Sinclair, and Lieut.-\nCol. G. C. Kenning of Victoria; Drs. R. W. Irving of Kamloops, Robert McCaffrey and\nW. E. Henderson of Chilliwack, E. Howard McEwen and W. A. Clarke of New Westminster, G. K. McNaughton of Cumberland, G. E. Darby of Bella Coola, D. J. Millar of\nNorth Vancouver and Norman J. Paul of Squamish.\nAMYOT DINNER\nThe Dinner given to Dr. G. F. Amyot, Provincial Health Officer, by the British\nColumbia Medical Association, on April 4th, was in many ways a quite unique function.\nTo begin with, considered as a Dinner, it was a great success\u00E2\u0080\u0094most enjoyable in every\nway. While formal dress was the general rule, there was no formality or ceremony about\nthe function\u00E2\u0080\u0094and the atmosphere was one of quiet, friendly cordiality. The arrangement\nof the tables had much to do with this, but even more, perhaps, it was due to the excellent\nstage management, if one may use the phrase, of the Committee in charge of arrangements\n\u00E2\u0080\u0094and particularly one must acknowledge the staff work of Dr. M. W. Thomas, the\nExecutive Secretary, who spent most of his waking hours at the hotel for the day of the\ndinner, making sure of exactness of detail.\nThen, as a complimentary Dinner, it was a very great success. Everyone was unfeign-\nedly glad to see Dr. Amyot, and he must have felt, or we hope he felt, a warm sensation\nin his praecordial region, when he looked on the big gathering, drawn from all parts of\nthe Province, and assembled for one purpose only, to greet him and wish him all the luck\nin the world, and to assure him^that we will help, to the best of our ability, to ensure that\nin his new work he will be prosperous and successful.\nAfter a preliminary cocktail or so, in the big lounge of the Banquet Room (what a\nPage 216 beautiful place the new Hotel Vancouver is!) we moved into the Dinner proper. At the\nHead Table, Dr. F. M. Auld, President of the B. C. Medical Association, was flanked by\nvarious eminent members of the profession. Our guest, of course, Dr. Amyot, who probably enjoyed the dinner far less than we could have wished\u00E2\u0080\u0094since he had a speech ahead\nof him: then Dr. Alexander Primrose, erstwhile Dean of Medicine at Toronto University,\nwell-known (and favourably) to every man whose Alma Mater bears the title of Varsity.\nThen on the other side of the President, Lieut.-Col. A. L. Jones, O.B.E., M.C., D.M.O.\nM.D. XI, Dr. A. L. Crease, Director of Mental Hygiene for the Province, Dr. C. E. Dolman, Director of Provincial Laboratories, and many others. Representatives of Medical\nElectoral Districts were present.\nThe President read many telegrams from many members of the B. C. Medical Association unable to attend\u00E2\u0080\u0094for this was no local affair, but a Dinner given by all the men of\nthe Province: and this was one of the elements that made the mixture so unique. It was,\nas Dr. Appleby said in his remarks as President of the Council of the College of Physicians\nand Surgeons, a family gathering, not merely a medical dinner. He remarked, too, that in\nfew places could such a united and harmonious meeting be called of all sorts and conditions\nof men. The Dinner was further unique in its composition. All branches of the medical\nprofession met on equal ground, in the greatest amity, and in a spirit of pure fellowship.\nThe therapeutic lamb lay down with the preventive lion, and all was happy, with no signs\nof indigestion on either side. This was, we maintain, one of the finest things we have seen\nin our time. No longer should there be any division or dichotomy between these two:\nthey should each study not only their own problems, but also each other's: and should\ntogether, and in full agreement, settle both. There is, as Dry Amyot said in his short speech\nof reply, no problem that cannot be solved by agreement and a true spirit of give and take.\nDr. Auld made an admirable Chairman and Toastmaster, and introduced each speaker\nbriefly. The representatives of local medical societies each spoke briefly and cordially, and\neach had some contribution to make. Lt.-Col. Jones made a short and witty speech; Dr.\nAgnew, for the Vancouver Medical Association, also spoke; Dr. W. A. Clarke referred\nto the immense importance of the Public Health Department to the general practitioner\nof medicine. Dr. McGregor of Penticton referred especially to the problems of rural\nand small town areas, where conditions are so different from those in a large city. Dr.\nDaly invited us all most cordially to go to Nelson in September for the Annual Meeting\nof the B. C. Medical Association.\nDr. Primrose referred to the late Dr. J. A. Amyot, father of Dr. G. F. Amyot, who\nwas such a distinguished ornament to his specialty of Public Health, and who achieved\nan international fame through his work in the war.\nThe guest speaker was introduced by Dr. A. L. Crease, and everyone knows who Dr.\nCrease is, or he ought to, and probably will some day if he doesn't know now. Dr. Crease\nspoke in terms of warm admiration and respect for Dr. Amyot, and bespoke the support\nof all medical men in the province in his future work.\nDr. Amyot, in replying to the toast given in his honour, was obviously much moved\nby the sincerity and warmth of the applause that greeted his rising. He expressed it as his\nmost sincere ambition that as time went on there should come to be a closer and closer\nco-operation and harmony between all departments of medicine in British Columbia. He\nfelt that neither therapeutic nor preventive medicine could go very far or very fast\nwithout the other\u00E2\u0080\u0094that there could be no problem or difficulty arising which could not\nbe solved or removed by goodwill, consultation and discussion in a spirit of give and take.\nHe suggested that a consultative group be formed, perhaps as a direct motion on the\npart of the B. C. Medical Association, which could function constantly\u00E2\u0080\u0094with which he\nmight meet periodically, and to which problems arising from either side could be referred\nfor discussion and adjustment. This seems to us to be a splendid suggestion, and one that\nmust not be allowed to be forgotten.\nDr. Amyot spoke warmly of the personnel of his Department, and felt that with their\nloyal backing, and with the support and sympathy of the medical profession as a whole,\nthe years should bring to B. C. ever-increasing harmony and efficiency in the promotion of\nhealth, the prevention of disease, and thus the assurance of longer, better, and happier lives\nto all who live in this Province of ours.\nPage 217 Vancouver Medical Association\nANNUAL MEETING\nThe Annual Meeting of the Vancouver Medical Association was held on Tuesday,\nApril 23 rd, in the Auditorium of the Medical-Dental Building.\nWe present in this issue most of the Reports\u00E2\u0080\u0094and only what might be called the\n\"negative\" reports, where there was nothing to report, are omitted.\nIt had been hoped to hold a Dinner to mark this Annual Meeting, but, as it happened,\nthere have been two Dinners during the month, the one given to Dr. G. F. Amyot and\nthat to Dr. R. E. McKechnie later. Wisely, we think, the V. M. A. Executive decided to\nwaive its own claims.\nHowever, we were not left hungry in every sense of the word. Rather, the Executive\nis to be congratulated warmly on its choice of a speaker for the evening, in the person of\nProfessor F. H. Soward, of the Faculty of Arts and Sciences of the University of B. C.\nDr. Soward gave us a talk on \"The Background of the Second World War\" whcih\nwill not soon be forgotten by those who were fortunate enough to hear it. It was a masterly address by a man who not only knows history, but, more invaluable still, has the\nhistorian's mind. Just to know the facts and sequences of history is a small achievement and\nof small value. It is like knowing anatomy backwards, but having no knowledge of physiology and being ignorant of the uses and functions and results of action on the part of\nthe structures concerned.\nProfessor Soward knows the facts, but he can also philosophise on them, see their connection with each other, and with past and future events. This is what we, who read the\npapers and read of facts and happenings, need most of all. We need the sane and considered opinion of a man whose wide knowledge of history, and intimate understanding of\nits philosophy, can make for us a clear and connected picture, looking at which we shall\nunderstand the why and the wherefore of the present struggle.\nHe has, too, the gift of dispassionateness. Nobody can doubt where his sympathies\nlie\u00E2\u0080\u0094but he allowed no prejudice or passion to cloud his mind, and so confuse his utterance\n\u00E2\u0080\u0094and this is as it should be.\nAltogether, it was an excellent and an inspiring address.\nWe congratulate the new officers, and especially Dr. Dan Busteed, our new President.\nDr. Busteed has worked long and hard for the Association, and in every way deserves this\nrecognition. He will do honour to the position.\nThe thanks of the Association are due to last year's Executive, which has done outstanding work, and left a good record.\nFollowing the address the business of the meeting proceeded, with the election of\nOfficers and the presenting of Reports. Names of Officers for the coming year will be\nfound on the first page of the Bulletin, and the Reports of Standing Committees and\nOfficers are given below.\nReports of the Clinical Section, by Dr. Karl Haig; the Eye, Ear, Nose and Throat\nSection, by Dr. W. M. Paton, and the Pediatric Section, by Dr. E. S. James, were presented\nand showed well-attended meetings and keen interest in the work of individual sections.\nREPORT OF THE HONOURARY SECRETARY, 1939-1940\nSeven general meetings were held during the year. One special meeting was held on\nJanuary 3rd, to consider the Vancouver School Teachers' Medical Services Scheme.\nMembership.\u00E2\u0080\u0094Total membership of the Association, including applications for membership which are pending, is 303. This number is made up as follows: Life Members, 10;\nActive Members, 246; Associate Members, 42; Privileged Member, 5.\nPage 218 Thirteen new members were elected during the year.\nThe Association has lost three members since the last Annual Meeting: Dr. G. E.\nGordon, who was a Life Member; Dr. F. G. Logie; Dr. Alfred Thompson.\nThe average attendance at General Meetings during the year was 55, this being a decrease of 25 from the average attendance of last year. This may be accounted for partly\nby the fact that no dinner meeting was held.\nThe Executive Committee held 14 meetings throughout the year.\nRespectfully submitted,\nW. M. Paton, M.D., Hon. Secretary.\nHON. TREASURER'S REPORT, 1939-1940\nMr. President and Members of the Vancouver Medical Association:\nI have the honour to report as follows:\nI present the Auditor's report, which I shall move be taken as read. It is quite a lengthy\nand intricate document and will be available in the Library for perusal by members at\ntheir leisure.\nOur trust accounts are all in healthy condition.\nThe Historical and Ultra-Scientific Fund shows an accumulation of interest of $491.64, which is available to the Librray Board for expenditure.\nThe Stephen Memorial Fund has accumulated interest of $85.61, also available for expenditure by the\nLibrary Board.\nThe Sickness and Benevolent Fund Grants during the year amounted to $825.00\nReturned by a Grantee 450.00\nBalance outstanding T\u00E2\u0080\u0094$375.00\nBond interest for the year 155.66\nNet depletion of fund $219.34\nThe Sickness and Benevolent Endowment Fund $ 700.00\nThe John Mawer Pearson Lecture Fund $3,063.52\nSummer School Fund balance $3,366.49\nEntertainment Fund balance $ 103.68\nIncome for the year consisting of:\nMembers annual dues ($100 less than 1938) $4,3 88.75\nInterest on Securities __ 197.81\nRelief Administration allowance 600.00\nProfit on Bulletin 355.08\nTotal Expenditure, including Depreciation\t\nExcess of Income over Expenditure\t\nAll of which is respectfully submitted.\nI move the adoption of this report.\n$5,521.64\n. 4,402.66\n.$1,118.9*\nJ. W. Lockhart, Hon. Treasurer.\nREPORT OF TRUSTEES\nThe President, Vancouver Medical Association.\nDear Sir:\nThe following is the annual report of the Trustees, in which is included the report of\nthe Sickness and Benevolent Fund Committee. Both bodies met at irregular intervals as\nrequired throughout the year. Up to the end of the Association's fiscal year there was\ndisbursed from the Sickness and Benevolent Fund the sum of $825.00 and up to the present\ndate $900.00. Of this sum $450.00 has been refunded, which leaves an expenditure for the\nfiscal year of $375.00.\nThe Sickness and Benevolent Endowment Fund has been augmented by a donation of\n$200.00 from Dr. J. A. Gillespie. This has been invested in Dominion of Canada bonds.\nThe Committee wishes to record its appreciation of this munificence and expresses the hope\nthat it will act as an incentive to others to do likewise.\nPage 219 The disbursements during the year have practically exhausted all current assets of the\nSickness and Benevolent Fund, and should any further expenditure be required in the near\nfuture some of the principal sum will have to be liquidated to meet the expense. It would\ntherefore appear that at the present time more than at any other over a long period, the\nSickness and Benevolent Fund is in need of augmentation. The Trustees once more would\npoint out to the Association that if reasonable assistance is to be given necessitous members\nthere will have to be collections made for that purpose. The Trustees would again suggest\nto the Executive that steps be taken to accomplish this.\nAll of which is respectfully submitted.\nSigned on behalf of the Trustees,\nFred M. Brodbe, Chairman.\nREPORT OF THE LIBRARY COMMITTEE, 1939-1940\nBooks Added to the Library.\nGeneral Collection:\n57 new books at a cost of\t\n37 gifts (including old books in library, not previously catalogued).\nNicholson Collection:\n6 books added at a cost of\t\n.$ 375.55\n18.88\nTotal of 100 books added at a cost of - $ 394.43\nNicholson Fund:\nbooks purchased at a cost of $18.88, leaving a balance in this fund of $129.90.\nMedical Journals:\n69 Journals are subscribed to at a cost of $ 604.52\n35 Journals are received as gifts.\n104 total number of Journals received in the Library.\n94 volumes were bound at a cost of 286.47\nOther Expenses:\nSubscriptions to Medical Library Association 15.00\nBoxes for storing books 13.12\nTotal expenditure-\n.$1,314.04\nThe Committee is indebted to Drs. Frank Turnbull, D. E. H. Cleveland, E. Trapp,\nTchaperoff and others for gifts of books and journals during the year.\nLists of new books have been published in the Bulletin from time to time.\nA new rack for journals in the Reading Room was made necessary by the increased\nnumber of journals received.\nA list of journals was prepared and kept in the Reading Room for reference.\nThe'meetings of the Library Committee have been well attended throughout the year.\nBefore closing this report I want to express, on behalf of the Committee, our very\ngreat regret at the resignation of our Librarian. As Miss Choate, she has given long and\nmost efficient service to the Library\u00E2\u0080\u0094most cheerfully and unstintingly\u00E2\u0080\u0094and I can assure\nher this has been most thoroughly appreciated. As she has taken unto herself a new name\n\u00E2\u0080\u0094and other, and probably more important duties and responsibilities\u00E2\u0080\u0094we wish to assure\nMrs. Van der Burg of our most sincere good wishes.\nHer place is not an easy one to fill and we would bespeak on behalf of her successor,\nMrs. Craig, as much patience, tolerance and helpfulness as possible, until she has familiarized herself with this work, which is decidedly different from the usual office or Library\nwork.\nF. J. Buller, M.D., Chairman.\nREPORT OF PUBLICATIONS COMMITTEE, 1939-1940\nThe past year of work on the Bulletin has been one of quiet progness\u00E2\u0080\u0094there has been\nno change in the policy or makeup of the Journal worthy of report: but on the whole, we\nfeel that the standards of publication have been maintained, and perhaps in some cases\nadvanced.\nFrom a financial point of view, we have rather more than held our own. Advertising\nhas been, on the whole, satisfactory. World conditions have made the going hard for some\nPage 220 of our advertisers\u00E2\u0080\u0094but the great majority have renewed their contracts with us as they\nelapsed. Mr. McDonald, our publisher, tells us that we are in a fortunate position in this\nregard.\nOur balance sheet for the year shows a profit. Last year we had a deficit of some $250\nnet. This year we are some $355 ahead, so that we can, in the two years, show a clear profit\nof some $105. This has, of course, been a source of great satisfaction to us.\nDuring the year the Bulletin acted as editorial centre for two publications: the\nSummer School Supplement, containing the papers read before the V. M. A. Summer School\nin June, 1939, and the Supplement containing the papers read at the Annual Meeting of\nthe British Columbia Medical Association in September, 1939. Strictly speaking, the latter\nis not a supplement to the Bulletin at all but the independent publication of the B. C.\nMedical Association. We were, however, very glad to be of service in this regard and the\nname of the Bulletin appears as publisher on the cover of the issue.\nThe Summer School Committee, wisely as we think, adopted the policy of limiting the\ncirculation of their printed issue to those who had bought tickets for the Summer School.\nThis will undoubtedly be their permanent policy. We hope to be able to extend the editorial services of the Bulletin again this year to the Summer School Committee for 1940.\nAn idea of the necessity for editing and concentration may be gathered from the statement\nthat the wordage of these papers before editing amounted to some 110,000 words\u00E2\u0080\u0094we had\nto cut this down to about 80,000, without doing any harm to the papers. Some of them,\nwe feel, rather benefited by curtailment.\nIt may be of interest, as showing that our publications do reach readers, to tell you\nthat only a fortnight ago we had a request from the editor of a fairly prominent journal\nin the southern part of the U.S.A., asking our permission to reprint one of the articles\npublished in one of these supplements\u00E2\u0080\u0094this is by no means an isolated instance.\nTwo people particularly deserve our thanks at this juncture, for the indispensable and\nmost valuable help they have given us.\nFirst of all is our Librarian, Miss Jessie Choate, now, alas, happily married, and therefore about to leave us. No words of mine can express our debt to this lady. To begin with,\nher interest in the Bulletin has been a personal one\u00E2\u0080\u0094she has taken the keenest possible\ninterest in its welfare, has given of her time, and of her overtime, freely and ungrudgingly,\nin collection of items, proofreading, arranging, and so on. And personally, I do not know\nhow we are going to get along without her help: and especially without her enthusiasm\nand friendly interest. One always knew that one could depend unfailingly on her help.\nBut we must bite on the bullet, and meantime we wish her, as must all who know her, the\ngreatest happiness and prosperity.\nAs publisher, Mr. Macdonald, of the Roy Wrigley Printing & Publishing Co., has also\nbeen a tower of strength. He has been absolutely dependable, and has guarded our interests\nas if they were his own. The service and devotion he has given to the Bulletin are quite\nbeyond any ordinary business requirements, and are, we feel, due to a pride and interest\nwhich he, too, feels in our Bulletin.\nWe are very grateful, tod, to Dr. M. W. Thomas, Executive Secretary of the B. C.\nMedical Association. He has, each month, rounded up the News and Notes from the whole\nProvince; and has been most generous with help and contributions of material.\nI should like to say a good deal more about the Bulletin, but must not, yet we feel\nthat we have by no means attained the full stature to which we have every right to aspire.\nOur Board feels that we must investigate, during the coming year, some new paths. For\ninstance, illustrations would greatly enhance the value of our publications, and we are now\nexploring that possibility. Again, our ambitious publisher, Mr. Macdonald, feels that we\nshould consider ways and means of increasing circulation, and so increasing advertising\npossibilities! This brings us back to a most alluring, if somewhat over-ambitious, idea that\nmany of us have toyed with at times\u00E2\u0080\u0094the question of expansion into wider fields. This is\nby far too big a subject to deal with now, especially as it is no more than a faint cloud, the\nsize of a man's hand, on the far horizon, but we can assure you that no step will be taken\nwithout the most careful and scrupulous scrutiny and investigation, and without your\nfullest knowledge and endorsement.\nPage 221 In conclusion, I should like to add my personal thanks to Drs. Cleveland and Davidson,\nmy colleagues on the Editorial Board, for their loyal help and counsel.\nJ. H. MacDermot, Editor.\nREPORT OF THE CREDENTIALS COMMITTEE, 1939-1940\nMr. President:\nSixteen applications for membership were sent to your Committee for consideration.\nOf these, five have been elected, three for active membership and two for Associate membership. The remaining eleven have not yet completed their one year of practice in British\nColumbia.\nA. B. Schinbein, M.D., Chairman.\nREPORT OF THE RELIEF ADMINISTRATION COMMITTEE, 1939-1940\nYour Committee wishes to draw to the attention of this Association the following\nitems, viz.: that the number of people on relief in March, 1939, was approximately 10,000\nand in 1940 about 9,000, yet the relief accounts have continued to soar.\nThe gross accounts in 1938 amounted to $162,422.00; in 1939, $166,295.00; in 1940,\n$174,450.00. In September, October and December, 1939, 45% was paid on accounts\nreceived and in the other months the percentage ranged from 30 to 42%.\nFor these reasons a resolution was passed at the last meeting of the Relief Administration Committee reducing the maximum amount to be paid on any one account from\n$100.00 to $75.00.\nThe total net accounts for the year were $151,532.28; the total amount paid to\ndebtors, $58,364.59; cost of administration, $1,523.00 or 3%; balance in bank, $143.28.\nIn addition to the above $3,5 88 was paid for maternity relief, $2,388 being paid to\nthe doctors in charge of cases and $1,200 to the Victorian Order of Nurses.\nOwing to military duties Dr. Roy Mustard was obliged to resign from the Committee\nin September and Dr. A. O. Brown was appointed to succeed him. Your committee wishes\nto express its hearty appreciation of Dr. Mustard's good work on the Committee.\nThe Committee now consists of: Dr. W. T. Lockhart, Chairman; Dr. J. A. Sutherland,\nVice-Chairman; Dr. Colin McDiarmid, Dr. J. R. Davies, Dr. A. O. Brown, Dr. L. W.\nMcNutt, Dr. D. F. Busteed.\nAll of which is respectfully submitted,\nJ. A. Sutherland, Secretary pro-tem.\nREPORT OF REPRESENTATIVES OF V. M. A. TO\nB. C. MEDICAL ASSOCIATION\nMr. President and Gentlemen:\nThe report of your representative to the Executive of the B. C. Medical Association is\nnot lengthy, but it contains a few items of particular interest to our members.\nThree meetings have been held with representatives from the sections of British\nColumbia. In the past year the two large contracts, viz., the B. C. Electric Railway Employees and the B. C. Telephone Employees sick benefit associations have functioned satisfactorily. There does not seem to be any reason why the profession should be wary of contracts which seem to have worked out to the benefit of the medical practitioners. This\nyear saw a third large group, viz., the Teachers of the Greater Vancouver area, embraced\nin a medical scheme under the same type of contract as the two previous associations. The\nEconomics Committee of the College of Physicians and Surgeons, working with the B. C.\nMedical Association executive, have worked hard in the interests of the profession.\nSeveral members of our Association have joined His Majesty's forces and at present a\ncommittee is enquiring if it is possible, in some manner, to hold in part the practices of\nthese officers. The B. C. Medical Association has discussed the matter at length and a committee made up of members of the Vancouver Medical Association, the B. C. Medical\nAssociation and the District Advisory Committee of the Canadian Medical Association, is\nseeking knowledge in the preparation of a report which will be presented later in the year.\nPage 222 There are some matters which may be brought to the attention of this organization in\nthe future, as it has been expressed that the Vancouver Medical Association is the \"voice-\npiece\" of the profession in this area, and at times we are asked to consider and approve or\ndisapprove of certain measures which may have a bearing upon the health of this community, it might be better if more doctors in the metropolitan area were members of the\nVancouver Medical Association and so swell the \"voice\" which must speak with authority\non occasions.\nSome of the matters that have been discussed at length are: (1) The preparation of\nmilk and the methods of handling; (2) The pollution of na:vigable waters inside the city\nlimits and the proposed use of some of these areas for sea products.\nL. H. Leeson, Chairman.\nBritish Columbia Medical Association\n(Canadian Medical Association, British Columbia Division)\nPresident j Dr. F. M. Auld, Nelson\nFirst Vice-President Dr. E. Murray Blair, Vancouver\nSecond Vice-President Dr. C. H. Hankinson, Prince Rupert\nHonorary Secretary-Treasurer Dr. A. H. Spohn, Vancouver\nImmediate Past President ._Dr. D. E. H. Cleveland, Vancouver\nExecutive Secretary Dr. M. W. Thomas, Vancouver\nThe Board of Directors of the British Columbia Medical Association held its regular\nmeeting following Dinner at the Hotel Georgia on Wednesday, April 3rd, 1940.\nThe following attended: Dr. F. M. Auld, of Nelson, President; Drs. W. E. Ainley,\nMurray McC. Baird, Murray Blair, W. A. Clarke of New Westminster, D. E. H. Cleveland, P. A. C. Cousland of Victoria, J. Stuart Daly of Trail, Major Allan Fraser of Victoria, Captain Roy Huggard, L. H. Leeson, J. H. MacDermot, H. McGregor of Penticton,\nD. M. Meekison, H. H. Milburn, P. L. Straith of Courtenay, G. F. Strong, Stewart A.\nWallace of Kamloops, George T. Wilson of New Westminster, Wallace Wilson, A. H.\nSpohn and M. W. Thomas.\nThe Dinner held on April 4th, in honor of Dr. G. F. Amyot, Provincial Health Officer,\nwas largely attended by members of the profession from many parts of the Province and\nwas representative of all phases of medical practice. The Banquet Room of the Hotel\nVancouver provided a suitable setting and under the able Chairmanship of Dr. F. M. Auld\nof Nelson, President, the whole affair proved to be a very happy feature.\nTelegrams brought greetings and assurance of goodwill from Drs. G. E. L. MacKinnon\nof Cranbrook, E. J. Lyon of Prince George, F. W. Green of Cranbrook, C. H. Hankinson\nof Prince Rupert and W. J. Knox of Kelowna.\nLieut.-Col. A. L. Jones, D.M.O., M.D. No. 11, and Major E. E. Day, Chief Medical\nOfficer of the Western Air Command, travelled from Victoria ot attend the Dinner. Both\nColonel Jones and Major Day briefly addressed the gathering.\nThe following representatives of organized medicine spoke briefly:\nDr. L. H. Appleby, as President of the Council of the College of Physicians and Surgeons;\nMajor Allan Fraser, President of the Victoria Medical Society, on behalf of Medical Electoral District No. 1;\nDr. W. A. Clarke of New Westminster, member of Council from Medical District No. 2\nand President of the Fraser Valley Medical Society;\nDr. A. M. Agnew, President of the Vancouver Medical Association for Electoral Ditrict\nNo. 3;\nPage 223 Dr. H. McGregor of Penticton, President of No. 4 District Medical Association;\nDr. J. Stuart Daly of Trail, President of the West Kootenay Medical Association for\nMedical District No. 5.\nDr. Alexander Primrose of Toronto was visiting in Vancouver and was present at the\nDinner. Dr. Auld introduced Dr. Primrose, who spoke brieky of his associations with Dr.\nAmyot's father.\nDr. A. L. Crease, Director of Mental Hygiene in the Province of British Columbia,\nintroduced the Guest of Honour, Dr. G. F. Amyot.\nIn responding, Dr. Amot conveyed to the Association his appreciation of this overwhelming expression of goodwill from his fellow members. At the close of his very interesting discussion of the responsibilities and possibilities of the Department of Public\nHealth, Dr. Amyot announced that he was considering a plan by which he could have the\ncounsel of the profession in developing the Public Health Services in this Province.\nOther members from outside points were: Drs. M. G. Archibald of Kamloops, Wr E.\nHenderson of Chilliwack, R. McCaffrey of Chilliwack, P. L. Straith of Courtenay, P. A.\nC. Cousland of Victoria, C. T. Hilton of Port Alberni, J.JV. Taylor of Abbotsford, L.\nChipperfield of Coquitlam, G. S. Purvis, W. R. Brewster, J. T. Lawson of New Westminster, J. R. Parmley of Penticton, Richard Felton of Victoria, N. J. Paul of Squamish,\nW. G. Saunders of North Vancouver.\nA REPORT OF 2069 ASCHHEIM-ZONDEK TESTS\nM I (FRIEDMAN MODIFICATION)\nJULY, 1932, TO JANUARY, 1940* *\nEvelyn M. Gee, M.D.\nDorothy E. Wylte, M.A.\nFollowing the basic work of Smith, Evans, Long, Simpson, Aschheim, Zondek and\nothers, the Aschheim-Zondek test for pregnancy and the Friedman Modification have been\nwidely used in diagnosis and recommended by authorities for universal adoption. Therefore\njustification of this test is no longer necessary.\nThe work of P. E. Smith and Leonard3 4, Evans and Associates, Brosius and Schaefer,\nCollip5 and others in the isolation of the responsible hormone and its identification from\nthose of anterior pituitary origin is generally accepted6 8. The name chorionic gonadotropic\nhormone7, indicating the origin in living chorionic tissue, appears well chosen.\nSince, however, these tests are not tests for pregnancy per ses 9, being quantitative\nrather than qualitative in type, many problems arise in their interpretation. To date many\nthousands of tests have been reported and several investigators have reviewed them. Possibly\nthe only justification for a report of our tests at this time lies in a discussion of the so-called\nproblem cases, all of which are matched in the literature. We wish to thank the physicians\ninvolved whose co-operation has made this possible. This report is actually written for the\ndoctors who have sent us these tests, asked us reasonable questions about them and listened\nto our halting explanations during the past seven and one-half years.\nThe tests, except the first 25 which were done for training, have been strictly utilitarian\nrather than experimental. In all of these the clinical diagnosis was in doubt. The adoption\nof the Friedman Modification rather than the original Aschheim-Zondek test is advised by\nmost authorities10 1 for laboratores with like demands and facilities and by many11 8 as\nthe more useful of the two. Several other simple tests reported as useful, notably the Davis,\nKonikov and Walker pupillary reaction and the Visscher-Bowman Chemical test have been\ntried in duplicate and found inaccurate. At the present time, the only accurate test, apart\nfrom the Aschheim-Zondek and Friedman, appears to be the test reported from South\n* From the Laboratory of the Vancouver General Hospital under the direction of Dr. H. H. Pitts. We\nalso gratefully acknowledge the help of other members of the laboratory staff, particularly Mr. Shearer, Mrs.\nCox, Miss Nicholson.\nPage 224 Africa in 193 5 by Shapiro and Zwarenstein using female South African claw-toed frogs,\nXenopus Laevis. This test is excellent, but the frogs are obtainable only in South Africa,\nbecome useless after one month, and six are used for each test, necessitating a continuous\nfresh supply, which renders it locally impracticable1 6.\nTechnique.\nOur technique has been altered slightly since 1932 and is actually a modification of the\noriginal Friedman. In its present form it is used with occasional variations in many laboratories.\nSummary of Technique:\n1. Rabbits used\u00E2\u0080\u0094ordinary, mature, domestic, females weighing 4 lbs. plus.\n2. Isolation in individual cages. Used for Friedman tests only, no bacteriology discards.\n3. Use in tests\u00E2\u0080\u0094\nNot less than one month from date obtained.\nNot less than one month following negative test.\nNot less than two months following positive test.\n4. Specimen requested\u00E2\u0080\u0094first morning urine, delivered as early as possible to the Laboratory\u00E2\u0080\u0094fluids\nrestricted previous evening\u00E2\u0080\u0094preferably not within two weeks of missed but expected menstrual period unless\nactual date of impregnation known.\n5. Specimens sent from a distance\u00E2\u0080\u0094preservative\u00E2\u0080\u00941 drop of concentrated carbolic per ounce\u00E2\u0080\u00942 ounces\nrequested.\n6. Treatment\u00E2\u0080\u0094kept in refrigerator\u00E2\u0080\u0094filtered if turbid\u00E2\u0080\u0094tested for acidity, if alkaline made acid by\naddition of acetic acid.\n7. Injection\u00E2\u0080\u009410 plus ccs. intravenously immediately and on following day (use of large amount of\nurine does not lead to false positive-\").\nOne rabbit only used for each test.\n8. Operation\u00E2\u0080\u009448 hours21 from first injection\u00E2\u0080\u0094posterior approach\u00E2\u0080\u0094examination of both ovaries in all\nnegative or doubtful reactions. Ether anaesthetic. %\u00C2\u00A5&\n9.\u00E2\u0080\u0094Diagnosis\u00E2\u0080\u0094gross only.\nPositive reaction\u00E2\u0080\u0094presence of bulging haemorrhagic follicles.\nNegative reaction\u00E2\u0080\u0094normal ovary with follicles small or large, clear and colourless.\nDoubtful reaction\u00E2\u0080\u0094recheck requested.\nUnsatisfactory ovaries\u00E2\u0080\u0094fibrotic without follicles or embedded in scar tissue. Rabbit discarded.\nMarked congestion of follicles\u00E2\u0080\u0094pink colour\u00E2\u0080\u0094no true haemorrhage.\nLarge black degenerating follicles only.\nReferences\u00E2\u0080\u0094Laboratories using the same or slightly different technique12 13 14 ten test conditions\ndescribed2 lx 15.\nSome investigators report excellent results with single 25 cc. injections, but on the\nwhole the experience of men working with hormone reactions in lower animals appears to\nbe that frequent small injections are more effective. As suggested by Mack and Agnew8,\nthe uniformly good results reported seem to indicate that the many slight variations in\ntechnique are of little significance in determining the accuracy of the test. By using one\nrabbit only we have saved at least 2353 rabbits, and the repetition of doubtful reactions\ndue to the condition of the rabbits' ovaries has caused little inconvenience. In spite of the\nabove suggestion attention should be paid to details of technique, and, in view of its quantitative nature, the test repeated whenever there is any question as to interpretation in the\nlaboratory or clinically.\nTable I.\nGENERAL SUMMARY OF COMPLETED TESTS\nImpossible to confirm\t\nConfirmed as correct\t\nConfirmed as incorrect\t\n% accuracy in confirmed cases-\n% error in confirmed cases.\nPositive\nNegative\nReactions\nReactions\nTotal\n85\n87\n172\n984\n1057\n2041\n12\n16\n28\n98.8\n98.6\n98.7\n1.2\n1.4\n1.3\n48.1\n51.9\n100\n% distribution of positive and negative tests\t\nUncompleted tests: 112.\nThe tests in Table I were done for a large group of physicians and include both normal\nand problem cases. Confirmation was obtained by conversation with the doctors involved\nand in part by circularization. As this is a test for hormone produced from living chorionic\ntissue in connection with the blood stream, death of such tissue soon leads to failure of\nproduction. Negative tests in such cases cannot properly be described as false. Workers\nPage 225 in recent years8 16 refuse to classify them as errors and Aschheim and Zondek calculate only\nthe false reactions obtained from the urine specimens of patients known definitely to have\nbeen normally pregnant or not pregnant. In our series we have elected to call some tests\nfalse in which no other information was obtainable. If the clinical data were available they\nwould possibly be more correctly classified as true.\nThe number of uncompleted tests is too low, as these were not always recorded. In 56\nof these cases the rabbit died before completion of the test. The toxicity of the urine was\napparently due in most cases to old specimens kept at room temperature and to specimens\nsent from a distance without preservative. Alkalinity of the urine accounted for a few,\nthe second rabbit being saved by acidifying the urine with glacial acetic acid. Medication\nincluding quinine and arsenic possibly accounted for several deaths and a diabetic urine\nshowing 4 plus acetone for one, but the various illnesses encountered in the patients were\ngenerally not significant, as the test, except in a few instances, was successfully carried out\nlater. Twelve male rabbits were injected by mistake.\nThis number also includes tests which required recheck. These specimens were not\nrcorded in the early years, which is unfortunate, as a doubtful reaction is sometimes significant. Our list includes a patient showing persistent brownish discharge two months after\ncurettage in which the tissue was not examined and which later proved to be an old ectopic\npregnancy, several in the menopause and abortions, one day after degenerated placental\ntissue had been passed, one from a recheck of a hydatidiform mole passed 1 month previously, and several from cases of early pregnancy in which a sufficient time interval had\nnot elapsed. One test taken 10 days from possible impregnation, no period having been\nmissed, gave a doubtful positive reaction and was later checked and confirmed as positive.\nImproper collection of specimens was blamed for other doubtful reactions.\nIncluded in Table I are 198 tests done on. specimens sent from a distance containing\npreservative. Of these, 80 were positive including 1 false as confirmed, 82 negative including 1 false negative, and 3 6 were impossible to confirm. The percentage accuracy of these\ntests corresponds favourably with that listed above.\nThe physician is requested when sending in a specimen to state the age of the patient,\nthe date of the last menstrual period or first missed but expected one and any other detail\nof the clinical history he thinks might be of help in the interpretation of the test. In 590\ncases the gae of the patient was given; these are presented in Table II in the manner of\nCrew10.\nTable II.\nAGE DISTRIBUTION IN POSITIVE TESTS CONFIRMED AS CORRECT.\nTotal: 291 tests.\nAge of patient 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32\nNo. of tests 4 3 6 7 10 15 22 16 17 12 16 16 9 8 5 5 12\n33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49\n9887582 14 12 74343 121\nAGE DISTRIBUTION IN NEGATIVE TESTS CONFIRMED AS CORREST\nAge 13 14 15 16 17 18 19- 20 21 22 23 24 25 26 27 28 29\nTests 3 021533332 13 12 99776\n30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46\n22 5 3 4 3 13 6 5 5 6 13 10 17 10 7 17 9\n47 48 49 50 51 52 53\n9 18 4 6 4 3 2\nTotal: 299 tests.\nThis list also includes all types of case. In one negative aged 13, pregnancy was suggested by a spiritualist. These ages may possibly be some indication of the high percentage\nof complicated cases. Probably few average normal cases are included and in these diagnosis\nof very early pregnancy was desired.\nIn 352 of these cases duration of pregnancy as related to the missed period is recorded.\nWhere the date of the last menstrual period only was given tabulation was made by adding\n28 days. All of our false negatives are placed in this table to demonstrate their position as\nregards duration of gestation. The percentage of accuracy is therefore valueless.\nPage 226 Table III.\nNORMAL PREGNANCIES INCLUDING NO HISTORY CASES AS REGARDS DISTRIBUTION\nINTO PERIOD OF GESTATION.\nInterval from Correct\nmissed period positive\nUnknown 53 0\nNo missed periods 26\nPeriods irregular 2\n1 day 1\n2 days 1\n4 days 2\n5 days 2\n6 days 2\n7 days 13\n8 days 4\n9 days 5\n10 days 11\n11 days 3\n12 days 4\n13 days 3\n2 weeks 59\nInterval from\nmissed period\n3 weeks\t\n4 weeks\t\n5 weeks\t\n6 weeks\t\n7 weeks\t\n8 weeks\t\n9 weeks \t\n10 weeks\t\n3 months\t\n4 months\t\n5 months ,\n6 months\t\n7 months\t\n8 months\t\n9 months\t\nTotal, interval known..\nTotals\t\nCorrect\nFalse\npositive\nnegative\n43\n**,'\n68\n1\n16\n0\n22\nr0\n3\n0\n38\n*,o.':\n1\n['&\"\n2\n0\n8\nl\n3\n|l|i\n1\n0\n1\ni\n'.'~3;f\n0\nn\n0\n4\n0\n352\n11\n882\n16\nA positive reaction can only be obtained after the trophoblast has been opened and the\nmaternal circulation and exchange of material between it and the circulating blood resulted9. This must be considered a limitation of the test15. The earliest date reported for a\npositive reaction to occur following a known date of conception is 10 days. This was not\ndefinitely established when we commenced use of the test and in an attempt to find this\nearliest date we record several cases, included in the above series, in which the only possible\ndate of conception is known. We obtained a doubtful positive in 10 days which later\nbecame positive, a false negative in 11 days, and true positives at 14 days, 18 days, 20 days\nand 21 days respectively. These tests were recorded before a period was missed. Our success\nin this group, however, Table III, is due to the fact that we consider and advise that negative reports made on specimens taken less than 2 weeks from the first missed but expected\nperiod are unreliable unless the last possible date of impregnation is known or the case is of\na certain problem variety.\nIn the largest group where the date is known, 1 period only is missed, that is up to 4\nweeks from the first missed period. From this point onwards the reason for the test changes,\nbecoming less a diagnosis of pregnancy before the clinical diagnosis becomes clear and\nmore a matter of differential diagnosis. Four false negative reactions are present in the\nlast group.\nIn 1937 Evans, Kohls and Wondre17 made a report on quantitative estimations of the\ngonadotropic hormone in the blood and urine in pregnancy, disproving most previous\nideas6, and pointing out as erroneous the charts presented by Zondek, Frank, and Mazer and\nGoldstein. Occasional figures reported by various authors fitted into their correct chart\nand many discrepancies were explained. Their charts show the actual quantitative content\nof the urine in gonadotropic hormone at various times throughout six normal pregnancies.\nThey show the invariable existence of an exceedingly steep and high hormone peak at a time\nwhich is quite accurately one month from the beginning of the first expected but missed\nmenstruation. From the time of its first appearance the increase in concentration of\ngonadotropic hormone is rapid, the peak being reached between the 20th and 50th days,\nusually about the 30th, and the fall is equally spectacular, the concentration in rat units\nper litre generally below 10,000 by the 56th day and continuously at this level until the\ntermination of pregnancy. At the peak their cases fell into two groups, one in which the\ntotal unitage per day was between 75,000 and 150,000 rat units and another in which it\n.was between 750,000 and 1,000,000 units. This normal transient hormone concentration\nexceeds that reported in hydatidiform mole and chorionepithelioma. It is interesting to\nnote that the patients with the higher concentrations experienced none of the minor disturbances of early pregnancy, and those with the lower concentrations many of them. It\nwas also no indication of the sex of the foetus nor found more commonly in multiparae\nPage 227 than primiparae. In view of the above findings of Evans et al, the false negatives occurring\nin the third, f ourtlr and sixth months are more readily understood. Interesting in this connection is the finding, not recorded in these tables, of many doubtful positive reactions\nobtained in our training period at the commencement of these tests, when our known positives consisted of specimens from the labour rooms.\nTable IV.\nNON-PREGNANT CASES INCLUDING NO HISTORY CASES.\nCorrect negative\nNo history\t\nAmenorrhcea only recorded\t\nAmenorrhcea, anaemia\t\nMenopause\t\nPseudocyesis\t\nObesity\t\nPossible ectopic\t\nSalpingitis\t\nOvarian abscess\t\nAcute appendicitis\t\nFibroids \t\nOvarian cysts (all types)\t\nPapillary Ca. ovary, with cysts\t\nFor Sterilization Court\t\nSterilization previously performed.\nAssault\t\nPre-biopsy of endometrium-!\t\nNormal male\t\nNephritis ]\t\nCervicitis\t\nOther serious illness\t\nCases with history\t\nTotal \t\n557\n211\n1\n99\n2\n1\n37\n2\n2\n2\n20\n11\n2\n9\n2\n6\n2\n2\n1\n1\n0\n413\n970\nFalse positive\n1\n2\n4\n0\n0\n0\no\n0\n3\n1\n0\n0\n0\n0\n0\n1\n11\n12\nIn Table IV are listed various conditions in which negative reactions were obtained and\nconfirmed as correct. Similar reports have been made by many workers. As regards the\nfalse positive reaction, most of these workers emphasize the possibility of early unrecognized abortion and criminal abortion. The false positive of the menopause is probably\nexplained by the increase of a follicle stimulating gonadotropic hormone from the hypophysis. If the technician is in the least doubt as to the reading of the test, recheck should\nbe advised, preferably after an interval of 1 to 2 weeks. In this time if early pregnancy is\npresent a true positive reaction should be obtained, and a second doubtful reading should\nagain be viewed with suspicion. False positives in cases of ovarian cyst and ovarian carcinoma are also regarded as of this source, the same hypophyseal stimulation, which gives the\nreaction in the rabbit's ovary, possibly accounting for the formation of the cysts. In our\nseries several types of cyst are encountered, the \"correct negatives\" including serous cysts,\none cystadenoma papilliferum benignum, as diagnosed in our own laboratory, and one\nhasmorrhagic cyst diagnosed elsewhere. The false positives similarly include 1 cystadenoma\npapilliferum benignum, 1 hasmorrhagic ovarian cyst and 1 serous cyst. The \"false positive\"\nmalignancy was a papillary adenocarcinoma of the ovaries and the correct negative ones\nalso papillary carcinoma.\nAs a diagnostic aid the Friedman test is of value both in the diagnosis of pregnancy in\nthe menopause and differential diagnosis between pregnancy and ovarian tumours. In the\nlatter instances, also, the operator should exert extreme care in the reading of the test.\nSince many of these cases are hidden, in our series, within the bulk of no history cases, this\nstatement applies, of course, to all tests. Since, however, many other workers in well-\nequipped laboratories report similar failures it should emphasize to the physician the value\nof indicating such clinical possibilities in his requisition. These cases should actually be\nplaced in the group described below as problem cases, and our inclusion of our total of false\npositives in this short series is for demonstration of the above points only. The percentage\nof error in this series is also valueless.\nBelow \"possible ectopic pregnancy\" with a negative confirmed result have been placed\nsalpingitis, ovarian abscess and appendicitis. These were also cases of suspected ectopic\ngestation. Others, if the history were known, could possibly be similarly grouped. How-\nPage 228 ever, it should seem that some of these possible ectopics with amenorrhcea and negative\nFriedman tests later confirmed as correct with the return of normal menstruation, could be\ndead or completely separated extra-uterine pregnancies. With the separation of the chorionic tissue the production of hormone would cease9, and the invasion and erosion of the\nfallopian tubes would cease and the symptoms and eventually the physical findings would\ndisappear. In several instances amenorrhcea of three months duration, pain, the presence of\na tender mass and irregular spotting are recorded, but as no operation was performed the\nfinal diagnosis is obscured. The above cases are included in the series of ectopic pregnancies\nlisted below.\nProblem Cases\nIt is observed18 that uniform accuracy in the same laboratory may vary with the proportion of problem cases. Regardless of its source, death of the ovum and its elements soon\nleads to failure of hormone production and a negative test. A positive test in these cases\nsignifies a continuance of the biologic connection between living foetal elements and the\nmaternal circulation8. Positive or negative reactions are significant and should not be considered incorrect. We have, whenever possible, challenged our own readings by analyzing\nthe pathological reports on tissue specimens received from these patients in our own\nlaboratory.\nEctopic Pregnancy.\u00E2\u0080\u0094In 14 cases of ectopic pregnancy reported by Crew10, specimens\nwere taken within 8 hours after operation and thereafter daily for 7 days. A definite negative was invariably obtained 72 hours after the removal of the embryo. A positive reaction\nin these cases, therefore, indicates that live chorionic tissue is present, or has been in existence within the last 72 hours; a negative, that the chorionic tissue is dead or that the hormone concentration is insufficient. Aschheim9 differentiates thus between the \"living and\ngrowing\" and \"dying or dead\" extra-uterine pregnancy, contending that in the latter \"the\nfoetus no longer lives, the villi no longer grow and the uterine vessels can no longer be\neroded.\" It would also seem possible that chorionic tissue attached in only a small area\nmight continue to invade the wall and cause bleeding, although insufficient to produce\nenough gonadotropic hormone to give a positive Friedman test. This is possibly the answer\nto at least one of our false negatives in which the tube ruptured \"a few weeks\" after our\nreport was received. We therefore consider it essential to inform the physician of this\npossibility when making negative reports if we know that ectopic pregnancy is suspected.\nTable V.\nSUSPECTED ECTOPIC PREGNANCIES.\nConfirmed correct.\n{No tissue (with tissue Total False Corrected\nsection) section) correct report % error\nPositive test 14 15 29 2 6.4%\nNegative test_ 37 10 47 2 4.0%\nincluding\novarian abscess 2\nsalpingitis 2\nAppendicitis 2\ndeg. plac. tissue 4\nTotal confirmed tests 51 26 76 4 5.0%\nUncorrected error in negative tests 12.2%\nIn the above series the tests in the first column were marked \"suspect ectopic\" on requisition and later confirmed as correct without clinical data. In the second column tissue\nwas sectioned in our laboratory in all instances. Although there is no way of estimating\nthe morphological criteria, the actual activity of chorionic villi19, it may at least be said\nthat in the 10 positive tests the villi and frequently the foetus were well preserved, while\nin the four true ectopics included in the 10 suspect confirmed negatives, the villi were\ndegenerated or necrotic and the foetus macerated. In one the structure was separated\nfrom the tube by a thick mat of blood clot and showed degeneration microscopically. These\nwe have elected to place in the confirmed class as true negative reactions. The uncorrected\nerror, considering these tests false, is also reported. There is possibly less chance of rupture\nin these cases and, as indicated in another section, similar pathology may be present in some\nof the 37 in the first column upon whom operation may not have been performed. In the\nPage 229 two false positives ovarian cysts were found. The confirmed positives include: 4 taken\nbefore a period wasjnissed, one 7 days from the missed period, one 1 month, one 5 weeks,\nthree 6 weeks, one 7 weeks and one in which a 3 34-months foetus was found in the tube.\nThe 2 false negative tests include one which, according to the attending physician, ruptured a few weeks after the test was performed, no further data being supplied, and one\nfrom another city which later came to operation and proved to be \"an ectopic pregnancy\";\nno tissue was saved for examination.\nAbortions\nIn interrupted uterine pregnancy, as in extra-uterine pregnancy, the result of the\nFriedman test should be interpreted with the clinical findings. Once pregnancy is established the result will remain positive as long as live chorionic issue is in biologic contact\nwith the mother15.\nTable VI.\nUSE OF TEST IN ABORTION CASES\nTotals Positive Negative\nFor Therapeutic Abortion 19 19\nTherapeutic Abortion: 2 weeks previous 1 1\n4 weeks previous ; 1 1\n6 weeks previous 1 1\nThreatened Abortion 7 4 3\nIncomplete Abortion:\u00E2\u0080\u0094\nRetain, well preserved placental tissue 2 2\nRetain, degenerated placental tissue '. 2 2\nSeptic Abortion, for diagnosis 2 2\nComplete Abortion: 2 days previous 1 1\n10 days previous 3 3\n21 days previous ! 1 1\n3 months 1 1\nNo history of date ' 2 2\nMissed Abortion:\u00E2\u0080\u0094\n(a) Before 4th month 18 4 14\nIrregular Bleeding, for diagnosis 4 4\n(b) After 4th month:\nLiving foetus 2 2\n3 mos. foetus dead 6 mos. 2 2\n6 mos. foetus dead 2 wekes 4 4\nTotals 73 40 33\nIn Table VI the various problems are considered in their clinical grouping. In those\npatients requiring early therapeutic abortion, the problem is a relatively simple one, that of\ndiagnosing pregnancy at the earliest possible date. In those next listed, in whom the\nefficacy of the therapeutic abortion is in question, we list one positive test obtained after\n4 weeks. In this case the laboratory worker is required to supply the information as\nregards complete abortion fisted below, and the clinician to investigate the case as regards\npossible incomplete abortion, extra-uterine pregnancy of hydatidiform mole. In some\nplaces where therapeutic abortion is performed by radiotherapy Friedman tests are done\nat weekly intervals and a persistence of a positive reaction taken as an indication for further\nradiation2. In threatened abortion the fundamental principles of the test must be kept\nclearly in mind. The positive test indicates the presence or recent presence of viable chorion\nand does not indicate whether the foetus is alive or dead. In come cases it may be concluded\nthat when the reaction disappears after having previously been positive, the biologic contact between ovum and mother has been interrupted and the ovum has died. In cases of\nclinically verified pregnancy in which the hormone test has been made only once, and has\nbeen found negative, repeated examinations should be done9 and all clinical findings carefully considered. Cases are reported13 where a positive reaction was obtained which became\nnegative when the patient started to bleed and became positive subsequently when the\nbleeding had stopped. Here the factor which caused the bleeding could have prevented the\nproduction of sufficient hormone to give the test; untreated, this might have resulted in\nabortion. A negative test in any pregnancy in conflict with the clinical evidence should\npossibly be taken as evidence of a threatened abortion and the patient treated accordingly.\nIn the incomplete abortion the problem is simpler, the presence of viable chorionic\ntissue being indicated by a positive test. Here again the negative test does not exclude the\nPage 230 presence of degenerated placental tissue. Had the tests been negative in the two instances\nof septic abortion, curettage might have been necessary to establish the diagnosis.\nUnder complete abortion we have listed negative tests occurring in 2, 10, 21 days and\n3 months respectively. It is possibly safe to say that 24 to 72 hours after delivery either a\nnegative or positive reaction may be expected13. Aschheim9, however, states that although\nthe positive reaction usually ends by the 10th day it was be found as late as the 16 th, and\nother writers emphasize this persistence in elimination of the hormone8. We have had one\ncase of a positive reaction obtained 17 days after tissue had been passed by the patient. This\ntissue was fortunately saved and recently obtained by the laboratory, having been placed in\nformalin by the attending doctor. As it proved to be what was apparently a complete\ndecidual cast of the uterus and no chorionic tissue was present it cannot properly be included amongst the abortions. There appears to be a definite possibility that this was a case\nof tubal pregnancy or tubal abortion. It serves, however, to emphasize the value of establishing final diagnosis by tissue section and clinical findings rather than by the Friedman\ntest in these cases.\nThe cases of Missed Abortion to be investigated by the Friedman test are best divided\ninto two classes, those occurring before the 4th month of pregnancy and those occurring\nafter the 4th month13. After the 4th month death of the foetus may take place independent\nof damage to the placenta or its hormone capacity and positive tests are recorded up to 30\ndays after foetal death at 6 or 7 months. Foetal death has been reported where a positive\nFriedman test was obtained with l/40th of the normal test dose and curettings revealed\nwell preserved placental tissue19. Two cases listed above, in which we have fairly complete\nclinical data, are here reported in brief:\nCase R\u00E2\u0080\u0094Age 28, L.M.P. July 29, 1938. Clinical note\u00E2\u0080\u0094no evidence of pregnancy in\nuterus\u00E2\u0080\u0094nipples show changes, patient's weight r55 lbs., November, 193 8, weight of\npatient only 123 pounds, indicating illness; April 13, 1939, Friedman test No. 165 doubtful positive, patient's weight 151 pounds; April 17, 1939, Friedman test No. 168 positive;\nJuly 18, 1939, Friedman test No. 306 positive! September 13, 1939, Friedman No. 387\nnegative. September 27, 1939, uterus was emptied; our pathological report S-39-3781\u00E2\u0080\u0094\nLithopedian 3 months.\nIn this case a positive reaction persisted after normal term but the possibility of a new\npregnancy had to be considered. Actually the foetus had apparently died during the illness\nwhich accounted for the weight loss noted in November, 1938.\nCase S\u00E2\u0080\u0094Age 20, L.M.P. February, 1938. May, 1938, pains with little bleeding (death\nof foetus\u00E2\u0080\u0094missed abortion 2l/z months; note made in report sent in later by attending\ndoctor). November 7, 1938, uterus size of 2% to 3 months pregnancy retro verted and\nretroflexed. November 8, 1938, Friedman test No. 407 positive\u00E2\u0080\u0094nine months amenorrhoea.\nPatient was watched 3 weeks, no enlargement observed so abortion induced. Pathological\nreport December 2, 1938, our S-38-4220, degenerated foetus 1.5 cm. in length; placenta,\nmicroscopically, showed degenerated tissue with calcareous deposits and interspersed\nislands of viable tissue.\nBefore the 4th month more negatives were obtained owing to the death of the chorionic\ntissue.\nTo summarize this review it may be stated that a positive test does not indicate whether\nthe foetus is alive or dead and that the test will remain positive as long as viable chorion is\nattached to the uterine wall.\nTable VII.\nCHORIONEPITHELIOMA\u00E2\u0080\u00946 cases.\nNote: Pos. & Neg. \u00E2\u0080\u0094 Friedman Reaction. C. = Confirmed clinically. OS. = Confirmed by\ntissue section. Chorio. = Chorionepithelioma. H.Mole = Hydatidiform mole.\nMcG.\u00E2\u0080\u0094July 2, '32\u00E2\u0080\u00944 mos. foetus delivered with H.mole, Chorio, OS.; March 13, '33\u00E2\u0080\u0094Pos. C; June 26, '33,\nPos. O; July 24, '33, Autopsy: Chorio with extensive metastases.\nS.\u00E2\u0080\u0094Outside Hosp.\u00E2\u0080\u0094no date\u00E2\u0080\u0094Chorio. C.S.\u00E2\u0080\u0094April 24, 33\u00E2\u0080\u0094Pos. C.\nR.\u00E2\u0080\u0094Chorio. (Early change in H.mole); Neg. C. 5 days later; Neg. C. 8 days later; Neg. C. 8 days later;\nNeg. C. 1 month later.\nP.M.\u00E2\u0080\u0094Feb. 22, '36, Chorio. C.S. (no history V.G.H.); Feb. 22, '36, Pos. C.S.; Aug. 25, '36, Pos. C, rather\nweak reaction; Jan. 7, '37; Hysterectomy; Oct. 8, '38, Neg. C.\nPage 231 R. McV.\u00E2\u0080\u0094Jan. 29, '38, Curettings, Chorio change in H.mole; Feb. 3, '3 8 (2 ccs. only) Pos. OS.; Feb. 3, '38,\nHysterectomy:.Ohorio change in H.mole; Feb. 15, '38, 2 ccs. only, Neg. C; April 11, '38, full test,\nNeg. C.\nN.T.\u00E2\u0080\u0094July 27, '38, H.mole, OS.; Aug. 16, '38, Chorio change in H.mole, OS.; Oct. 18, '38, Pos. OS.;\nNov. 28, '38, Neg. C. (using Radium for Chorio but bleeding); Feb. 11, '39, Neg. O; Nov. 20, '39,\nNeg. C. (Has had Radium implants).\nPositive tests\u00E2\u0080\u00947 (including 1 dilution, l/lO). Negative tests\u00E2\u0080\u00948 (including 1 dilution, 1/10).\nPossible Chorionepithelioma\u00E2\u0080\u00942 cases. Neg. confirmed.\nMuch has been written as to the value of the Friedman test in investigation of cases of\nchorionepithelioma and hydatidiform mole, especially as regards the value of dilution tests.\nWhile some investigators have reported excellent results8 9, others have been less successful.\nThese discrepancies18, which chiefly arise in the original diagnosis of the condition, can\nundoubtedly be explained by the occurrence in normal early pregnancy of Evans' peak\nphenomenon17 of excretion of hormone, noted above. Also there is always the possibility\nof one of these growths in its early stages, or a small or degenerated hydatidiform mole,\nyielding a relatively small amount of hormone9. In at least two of our cases an extremely\ndoubtful reaction was obtained, although one later proved to show clearly chorionepi-\ntheliomatous change. Table VII and Table VIII have been prepared chiefly as a check of\nour own tests and the clinical notes appended were reported to us. As a possible useful\ncourse in the investigation of these cases we suggest that the Friedman test in dilution is\nnot a safe basis for final diagnosis where there is a possibility of early pregnancy, and similarly that a weak reaction does not rule out the possibility of these conditions. Once the\ndiagnosis is established by other means an estimation of the dose level required to produce\na positive reaction should be determined. This will then form a useful basis for further\nobservation of the case. The persistence of a positive test in the same or greater dilution\nwill indicate continued chorionic proliferation. The gradual dinainution of the amount of\nhormone excreted may be estimated by further dilution tests. The recurrence of a positive\nreaction after a negative reaction may be taken to indicate the presence of metastases. In\none of our cases the test became negative following radium therapy; the paitent is apparently free of recurrence. In all cases the most careful clinical observation is necessary and\nclinical findings must not be treated lightly because of negative or doubtful Friedman tests.\nHydatidiform Mole.\nTable VIII.\nHYDATIDIFORM MOLE\u00E2\u0080\u009420 cases.\nFor abbreviations see Table VII.\nMcG.\u00E2\u0080\u00944 months foetus, delivered with H.mole, OS.; July 2, '32, Pos. C.S.\nM.\u00E2\u0080\u0094May, '32, Hmole, OS.; 3 months later, Neg. OS.; Dec. 1, '39, Neg. C.\nP.B.\u00E2\u0080\u0094April 11, '34, Curetted: H.mole OS.; April 14, '34, Pos. OS.\nE.W.\u00E2\u0080\u0094H.mole, OS.; 3 months later, Pos. OS.; 5 weeks later, Pos C.\nK.\u00E2\u0080\u0094Passed H.mole; 4 weeks later, April 18, '33, Pos. OS.; April 20, '33, Panhysterectomy: early Chorio\nchange in H.mole; one year later, Neg. C.\n/.\u00E2\u0080\u0094Passed \"Frog Spawn\"; 1 month later, doubtful Pos. OS.; 4 days later, Neg. C.\nC.\u00E2\u0080\u0094H.mole passed 2 weeks previous. Pos. C.\nD.J.S.\u00E2\u0080\u0094Jan. 3, '35, passed H.mole, OS.; 5 weeks later, Neg. O; 10 weeks, Neg. O; 4 months, Neg. O;\n6 months, Neg. C.\nH.J.\u00E2\u0080\u0094Pos. C.\nWM.\u00E2\u0080\u0094July 3, '35\u00E2\u0080\u0094H.mole, OS.; 3 weeks, Neg. O; 10 weeks, Neg. C.\nW.L.\u00E2\u0080\u0094193 6, passed H.mole; Sept. 7, '3 6, Pos. OS.; Sept. 14, '36, Pos. OS.; Sept.\" 18, '36, curettage persistent decidual rection following H.mole; hyperplastic endometritis, only shadowy Hmole structures\nseen; Oct. 5, '36, Pos. O; Dec. 31, '36, Neg. C; Mar. 4, '37, Neg. O; Oct. 6, '37, Neg. C; Oct. 24, '39,\nNeg. C.\nf.L.N.\u00E2\u0080\u0094July 23, '36, Pregnant; Aug. 23, '36, abdominal pain; recovery; Oct. '36, Flow profuse; Dec. 14,\n'3, therapeutic abortion. Flowed until Jan. 31, '37; Feb. 20, '37, Pos. O; March '37, Curettage: 6H.mole\n(N. Westminster); Curettings sent to V.G.H.: Glandular hyperplasia; March 29, '37, Hysterectomy:\nglandular hyperplasia; retained degenerated tissue, decidual or placental; May 18, '3 8, Pos.\nA.K.\u00E2\u0080\u0094Feb. 23, '36, Pos. O; March 24, '36, Hmole, OS. Outside Laboratory; April 19, '36, Pos. C.\nY.\u00E2\u0080\u0094May 20, '38, H.mole; June 4, '38, Neg. OS.; July 7, '38, curettage; Aug. 9, '38, Neg. OS.; Jan. 4, '39,\nNeg. O; May 11, '39, Neg. C.\nK.\u00E2\u0080\u0094June 2, 538, H.mole; July 7, '38, Neg. O; April 8, '39, Neg. O\nE.S.\u00E2\u0080\u0094Oct. 23, '3 8, H.mole, OS.; Nov. 14, '38, Neg. O; Dec. 19, '38, Neg. C.\nH.\u00E2\u0080\u0094Dec. 9, '38, H.mole; Jan. 9, '39, Neg. O; Jan. 23, '39, Neg. OS.; Curettage: Glandular hyperplasia.\nr>.\u00E2\u0080\u0094Feb. 14, '39, H.mole, OS.; Feb. 11, '39, Pos. OS.; Feb. 28, '39, Pos. O; March 13, '39, Neg. C; April\n15, '39, Pos. OS.; April 26, '39, Hysterectomy: Chorio.; Aug. 30, '39, Neg. C.\nPage 232 P.W.\u00E2\u0080\u0094June 17, '39, passed Hmole; June 20, '39, Pos. OS.; Aug. 15, '39, Neg. O; Sept. 28, '39, Neg. C.\nO.L.\u00E2\u0080\u0094Aug. 17, '39, H.mole, OS.; June, '39, Pos. OS.\nPositive tests\u00E2\u0080\u009421.\nNegative tests\u00E2\u0080\u009427.\nPossible Hydatidiform mole\u00E2\u0080\u00949 cases, Negative, confirmed.\nPossible Hydatidiform mole\u00E2\u0080\u00945 cases, Positive, confirmed.\nMost of the points emphasized in the discussoin of chorionepithelioma may be repeated\nin a consideration of hydatidiform mole. Philipp9 reports a case in which a mole was isolated\nfrom the uterine circulation by a fibrinous coating and from which no gonadotropic\nreaction could be obtained from the urine although the tissue of the mole itself was effective on implantation. Here, also, the peak phenomenon must be recognized in all attempts\nto relate high hormone levels with this condition. Once the diagnosis is established by\nother means, monthly and later bimonthly Friedman tests with dilution tests will be found\nof use in following cases as regards recurrence or malignant (chorionepitheliomatous)\nchange. Here also clinical signs even in the absence of a positive Friedman test must be\ninvestigated.\nReview of the cases in Table VIII demonstrates that negative reactions can occasionally\nbe obtained as early as 2 weeks after evacution of the mole and negative reactions in 1\nweek are reported. It is also reported10 that cases most frequently become negative in about\nthree months, and the same authority reports a case in which a doubtful positive reaction\nwas obtained 1 year later. With the exception of the 5 cases at the bottom of the table, in\nwhich no history was obtainable and in which confirmation of the test does not necessarily\nmean a final diagnosis of hydatidiform mole, the tests in our series have been done in\ninvestigation of proven cases, as have also those in Table VII. Five of the nine negative\ncases were also investigated, by means of dilution tests, the smallest amount of urine giving\na positive test being 1/10 of the average dose; this was a case of incomplete abortion.\nTesticular Tumours\nTable LX.\nTotal Positive Negative\nMalignant Teratoma of Testicle:\n(a) Showing Chorio carcinomatous change 1 1\n(b) Embryonal adenocarcinomatous type showing choriomatous\ndifferentiation ; 1 1\n(c) Possible teratoma. No surgical specimen 1 1\nPossible Malignant Teratoma\u00E2\u0080\u0094No surgical specimen 7 7\nMalignant Teratoma\u00E2\u0080\u0094By tissue section 7 7\nMalignant Teratoma, Embryonal Ca.\u00E2\u0080\u0094By tissue section 2 2\nTuberculous Epididymitis 1 1\nGumma of Testicle : 2 2\nTotal 22 3 19\nIn Table LX are listed the various tumours investigated in the male. The final diagnosis\nof these tumours was made histologically in all instances, except those specified. As indicated, 2 tumours, both showing chorionic epithelial constituents, have a positive test.\nWhen these cases came to autopsy extensive metastasis was found. The third, which was\nnot confirmed histologically in our laboratory, is grouped with them. No such differentiation was noted in any of the other tumours examined. Although negative reactions do\nnot differentiate between neoplastic and inflammatory processes, nor serve to rule out\nmalignancy, the Friedman test has a definite field of usefulness in tumours of the testicle;\nan occasional positive reaction will be obtained in some few growths of a type which may\nbe termed chorionepithelioma testis. Once this diagnosis is established by a positive test or\nby histological section, the use of the test in following the course of the patient is the same\nas in chorionepithelioma in the female.\nThe remaining problem cases form a miscellaneous group, as listed in Table X. After\nparturition gonadotropic substance disappears from the urine within 3 to 5 days9 1T, and\nour early tests done on urine from the labour rooms gave frequent doubtful reactions.\nDiagnosis of pregnancy during post-partum amenorrhcea is therefore complicated only by\nthe frequent impossibility of determining the date of possible impregnation and repeated\ntests may be necessary. Ovulation without menstruation is also the problem factor in cases\nof assault before menstruation has commenced.\nPage 233 Table X.\nOTHER PROBLEM CASES.\nTotal Positive Negative\nPregnancy in Postpartum Amenorrhoea ? 13 3 10\nContinued Menstruation in Pregnancy ? at 6 months 3 12\nAssault 7 16\nRetroverted Uterus or Pregnancy 1 1\nFractured Pelvis with Pregnancy 1 1\nPregnancy with fibroids 2 2\nMare's Urine 1 1\nGlaucoma\u00E2\u0080\u0094Tumour Anterior Pituitary 1 doubtful\nTotals 29 9 19\n(1 doubtful)\nIn cases of continued menstruation during pregnancy false negative reactions are\nreported, which are explained as due to hormonal-imbalance. In the cases listed above the\npatients for whom negative tests were obtained were not pregnant.\nThe only problem in the next three headings listed is possibly that of missed abortion.\nHere the problems are chiefly clinical.\nIt has been found impossible to obtain a Friedman positive reaction from mare's urine\nduring pregnancy. Positive tests may, however, be obtained from pregnancy mare serum4 7\nbetween the 45th and 150th days of gestation. Equine gonadotropic hormone, though\napparently formed in the placenta, differs from the human variety, exhibiting the properties of both anterior pituitary and chorionic hormones.\nThe possible tumour of the anterior pituitary gland gave a doubtful positive reaction of\nthe type occasionally found during the menopause and mistaken for a true positive, then\npossibly due to hyperplasia of the same organ. In summary of this complete section may\nwe again state that, especially in problem cases, the Friedman test should assist, not supplant, the usual diagnostic technique.\nTable XI.\n12 FALSE POSITIVES.\nREVIEW.\nCase Age\nNo. 768 No data.\nNo. 169 45 Menopause.\nNo. 39-222 4 weeks after missed period. (Test positive.) Patient near menopause.\nNo. 216 45 J4 1 month amenorrhcea (test positive). Curetted 3 weeks after test. Cervix hard.\nFibroid size of 2l/z months pregnancy present.\nNo. 37-93 45 Normal menstrual period every 21 days. Test done 10 days after missed period (test\npositive). 3 weeks after test, menstruation resumed\u00E2\u0080\u0094Doctor now thinks this was\na possible missed complete abortion and considers test possibly correct.\nNo. 307 Possible conception 33 days previous to test. Patient had serious illness at time\nof test.\nNo. 3 8-137 27 Test done 11 days after missed period.\nNo. 38-352 28 1 month after missed period, patient clinically pregnant (test positive). At 7\nmonths, returned to doctor stating she felt movement. Uterus found to be size of\n3 months pregnancy. Amenorrhcea for 7 months. (Test negative.) Tissue section\nobtained by complete curettage negative. History obtained of slight bleeding in\nmonth first test was taken. One doctor thinks missed abortion; another, a false test.\nNo. 682 Possible ectopic pregnancy (test positive). Operation at St. Paul's Hospital. Patho\nlogical report medium-sized follicular cyst and larger cyst which shows some blood\nclot. Microscopic examination: Sections show corpus luteum with simple cyst formation. Is3^\nNo. 37-170 Possible ectopic pregnancy (test positive). Operation: Cystadenoma papilliferum\nbenignum of ovaries.\nNo. 465 35 Periods regular. Dysmenorrhoea. Uterus size of 4 months pregnancy (test posi\ntive). Test negative 6 days later. Operation 8 days after second test showed a serous\ncyst of ovary.\nNo. 37-126 50 (Test positive)\u00E2\u0080\u0094Autopsy 2 months later: Bilateral papillary adenocarcinoma of\novaries with metastases.\nA complete summary of our false positive tests is given in Table XI. Duplicate cases\nare reported in the literature20 10. The recorded information was supplied by attending\nphysician or physicians in all instances, generally after the test was proven false. As regards\nthe first case listed no comment is possible. The second, third and fourth cases are false\npositives of the menopause. Wnile these false positives are a reflection on the skill of the\nPage 234 laboratory worker, the clinician should acquaint the laboratory of the patient's age, at\nleast when accepting a positive report in this group, but, of course, preferably before the\nrabbit's ovaries are examined. While he may be inconvenienced by more requests for repetition of the test the end result should be more trustworthy.\nCase No. 37-93 was also grouped with this series until recent discussion with the\nattending doctor suggested the possibility of early unrecognized abortion. The information received in Case No. 307 suggests a similar explanation.\nIn case No. 37-137 no clinical data can be offered in explanation. It was suggested by\nthe laboratory that this case possibly fell in the group of patients by whom pregnancy is\ngreatly feared. The incorrectness of a positive result in this group strongly suggests that\nabortion has taken place. This could not be confirmed clinically. The doctor was also\nquestioned regarding the possibility of early unrecognized abortion but could obtain no\nhistory.\nTest No. 38-3 52 may also possibly be classed as an unrecognized spontaneous abortion.\nThe duration of amenorrhcea in this case, however, also suggests some hormonal imbalance.\nIn case No. 682 two possible explanations are suggested. The presence of a corpus\nluteum suggests the possibility of pregnancy, possibly intra-uterine, with spontaneous\nabortion, missed in the signs which causes suspicion of ectopic pregnancy. The other possibility is that the reaction was due to increased gonadotropic hormone from the pituitary,\nwhich also may have been a factor in the production of the cysts. The laboratory favors\nthe former explanation.\nCase No. 37-170 falls under the latter explanation, as does also the first test done, No.\n465, on the next case fisted. These reactions are those of the false menopausal type and\nshould not occur; practically all large series, however, include them.\nCase No. 37-126 must also be grouped with these cases.\nFrom the above discussion it will be realized that in 4 of these cases we consider the\nexplanation of the reaction adequate and do not actually consider these tests false. In 6\ncases we consider the test truly false and, although similar cases are reported in the literature, feel that they should h-Tc L>een identified in our laboratory as doubtful rather than\nas positive tests. Of the remaining two cases one cannot be analyzed and for the other\npossible explanations were discarded by the attending physician.\nCase\nNo. 39\nNo. 38-154\nCondition\nof specimen\nTable XII.\n16 FALSE NEGATIVES\nTime from\nmissed period\nNo. 38-96\n19 days\nNo. 38-103\n21 days\nNo. 37-146\nMenstruation\nirregular\nNo. 412\nNo. 74\nUrine\n4 days old.\nNot k\nept on\nice.\nREVIEW\nAge No data.\nPossible ectopic pregnancy. Confirmed at operation.\nUrine sent from a distance in preservative. Surgical\nspecimen not obtained.\nSuspected tubal pregnancy. Ruptured ectopic few\nweeks after report. No other data. No surgical specimen obtained.\nNausea and vomiting 3 months. Negative test. Two\ndays later, operation for subacute appendix. 4 months\npregnancy noted. Fibromyoma uteri with red degeneration. Chronic productive appendicitis; 2 days later, test\npositive.\nBleeding 2 days after missed period, with intermitetnt\npain, left side.\nPatient withheld fluids evening previous to test\u00E2\u0080\u009415 cc.\ninjected x 2.\n8 months from missed period, delivered 5-lb. baby\nwhich lived 23 hours.\nRapid growth of mass. Operation showed a 3 months\npregnancy. Delivered at term.\nOne doctor states test false. One doctor states \"speci-\n25 men may have been substituted from another source, as\npatient unmarried and anxious to have an operation.\"\nPregnancy confirmed.\nNo other data.\nNormal delivery.\nPage 235 No. 521\nNo. 270\nNo. 37-5 8\nNo. 780\nNo. 39-70\nNo. 39-396\nNo. 39-140\nPossib. 6 mos.\npreg. Menses\nalways irreg.\nLast bleeding\n2 mos. prev.\nNo missed period, 11 days\nfrom possible\nimpregnation\n12 days\n14 days\n22 days\n26 days\n63 days preg.\nby delivery date\n34\n24\n41\n32\n32\n26\nPositive 26 days from possible impregnation.\nPositive 3 3 days from missed period.\nPositive 3 6 days from missed period.\nPositive 42 days after missed period.\nPositive 40 days after missed period.\nDelivery apparently'normal in every way and course of\npregnancy normal.\nIn the false negative tests listed in Table XII different explanations can be made. In\ncase No. 39 no comment is, of course, possible, and also the following two ectopic pregnancies must be listed as false negatives, failing histological section although the chorionic\ntissue in them was probably dead or separated from the wall of the tube by blood clot.\nThese serve to emphasize the value to the clinician of the uncorrected percentage of error\nin diagnosis of ectopian pregnancy by the Friedman test, and this may be termed the\nclinical error. By correction, the false positives in the ectopic list could also have been\nremoved, as these reactions, though false, were given by another process. It does emphasize\nthe fact that the Friedman test is not one for pregnancy per se but merely a reaction to\nthe presence of a certain amount of gonadotropic hormone present in the injected urine.\nThe fourth case, No. 38-273, is of interest as possibly indicating a threatened abortion\nin the presence of a degenrating fibroid. Two days after the removal of this fibroid the\ntest was positive.\nIn case No. 38-96, taken with its recheck, No. 38-103, in which a definite attempt to\nobtain a positive reaction was made without avail, the possibility of hormonal imbalance\nmust be considered. That the baby lived only 23 hours after delivery may be significant in\nthis respect. The low hormone content in the early part of pregnancy, however, may have\nbeen associated with pathology of which the bleeding was another symptom. In other\nwords, at the time of the test the diagnosis may have been threatened abortion.\nThe \"irregular menstruation\" noted in Case No. 37-146 is more suggestive of hormonal\nimbalance as an explanation.\nCase No. 412 may be as indicated an example of a certain type of case which appears\nin all reports of large series and always offers difficulties of classification. The false result\nappears in most cases as a false positive. Here, failing to menstruate, the patient requests\na pregnancy test and after receiving a positive report has menstruation re-established. She\nthen either disappears, leaving a report impossible to confirm, or returns for a negative\nreport, making the first one appear false. When the history supports this explanation the\nresult should be regarded as correct.\nCase No. 74. This result is no doubt due to the condition of the specimen. It is unusual\nand unfortunate that it did not kill the test animal before the test was completed. In case\nNo. 521 two factors must be considered: the possibility of hormonal imbalance as evidenced by irregular mentsruation with persistence during pregnancy, and the factor of\nactual quantitative excretion of chorionic gonadotropic hormone during normal pregnancy\nas indicated by Evans. In the sixth month of pregnancy the normal excretion is relatively\nlow compared with that indicated by the peak phenomenon in the first 65 days.\nCase No. 279 is an example of a false negative due to insufficient duration of pregnancy\nand Case No. 5 8 may be classed in the same group. In this case a specimen obtained 3 weeks\nlater was correctly positive. Similarly case No. 780 should be placed in this group allowing\nsome discrepancy of normal menstruation. Many of these cases, as reported, are dated from\nthe last menstrual period, and the actual date of the missed but expected period is not\ndefinitely known. In this case, also, a positive test was obtained 3 weeks later.\nThe last three cases cannot be classified on this basis. All apparently conform with the\nrequirements of the test. There is always a possibility that the specimen was dilute.\nAlthough we urgently advocate that only first morning specimens be submitted, when\nPage 236 these were not available we have accepted others. This possibility was not accepted by the\nattending doctor. Technical flaws were not admitted by the laboratory. Similar cases are\nreported in the literature15, where the test remained negative until the 4th or 6th month\nof pregnancy. The explanation made was in the form of a suggestion that the hormone\nproduction did not occur to the usual extent or else the eliminative threshold of the kidney\nwas different from that usually found. As these tests were all obtained under ideal conditions, we have no better explanation to offer.\nIt will be recognized from this discussion that we suggest that all negative tests are\nfundamentally correct and significant. The fundamental limitations of the test must be\nconsidered, and technical flaws such as acceptance by the laboratory of results from\nunsatisfactory test animals must be ruled out.\nWe beg to quote a classic case in closing. In this case, in which we reported a negative\nreaction, considerable consternation was encountered. The doctor knew the patient was\npregnant. The patient knew she was pregnant, and it only remained for a positive Friedman\nto establish the diagnosis. On final analysis it was learned that the patient, instead of\nboiling the bottle, had boiled the specimen. The result we elected to place in the list of\nconfirmed correct negatives as experimental.\nIn conclusion, we would emphasize again the fact that is not a test for pregnancy per se\nbut a demonstration of the hormonal response within the body to the presence of living\nfoetal elements. The practitioner must understand the hormonal significance of the reaction and, in the last analysis, must depend upon his clinical judgment in evaluating the\nlaboratory findings in abnormal cases.\nREFERENCES:\n1. Weisman, A. I.: Am. J. Obs. 6 Gyn., 35:354, 193 8.\n2. Spielman: Am. J. Obs. 2? Gyn., 27:448, 1934.\n3. Smith, P. E.: J.A.M.A., 104:7, p. 548, 1935.\n4. Smith, P. E.: J.AM.A., 104:7, p. 55 3 (Feb. 16), 193 5.\n5. Collip, J. P.: J.AM.A., 104:7, p. 556, 1935.\n6. Crew, F. A. E.: Brit. M. J., 2:1092, 1936.\n7. Fluhmann, C. F.: Menstrual disorders, W. B. Saunders Co.\n8. Mack, H. O, and Agnew, G. H: Am. J. Obs. 6? Gyn., 27:232, 1934.\n9. Aschheim, S.: J.A.M.A., 104:15, p. 1324 (April 13), 1935.\n10. Crew, F. A. E.: Am. J. Obs. & Gyn., 3:989, 1937.\n11. Friedman, M. H, and Lapham, M. E.:Am. /. Obs. tf Gyn., 21:405, 1931.\n12. Young, A. M.: /. Lab. & Clin. Med., 19:1224, 1934.\n13. Feresten, M.: Endocrinology, vol. 21, 1937.\n14. Kelly, G. L., and Woods, E. B.: /.A.M.A., 108:615, 1937.\n15. King: Am. J. Lab. & Clin. Med., 19:1033, 1934.\n16. Best, C. H., and McHenry, E. W.: C.M.A.]., 28:599, 1933.\n17. Evans, H. M., Kohls, C. L., and Wonder, D. H.: J.A.M.A., 108:287, 1937.\n18. Davy, L., and Sevringhaus, E. L.: Am. J. Obs. tf Gyn., 28:888, 1934.\n19. Goldberger, M. A., Salmon, U. J., and Frank, R. T.: J.A.M.A., 103, p. 1211, 1934.\n20. Mull, J. W., and Underwood, H. D.: A. J. Obs. & Gyn., 33:850, 1937.\n21. Ware, H., and Maine, R. J.: J. Lab. 8 Clin. Med., 18:254, 1932.\nThe Reports of the Annual Meeting of the Vancouver Medical Association are contained in this issue. These, together with editorial matter already accumulated, make it\nnecessary for us to defer publication of the following important articles now in our possession. These will be published in our next issue: Low Back Pain: Dr. H. H. Boucher;\nDiagnosis and Treatment of Glaucoma: Dr. Wiener; A Case of Unusual Menses: Dr. J.\nW. Arbuckle; Lipoma of the Colon: Drs. G. E. Seldon, W. A. Whitelaw, W. A. Morton.\n\u00E2\u0080\u0094Ed.\nPage 237 O\nH\n\n4->\nrt .\n> ^\n1 \u00C2\u00AB\nCm o\n\u00C2\u00B013\n\ns J\nCO 4-\u00C2\u00BB\ncu rt\nM G \u00C2\u00B0*\n\u00C2\u00A3 .2 **-\u00C2\u00AB\n\" \u00E2\u0080\u00A2 iM *^\nCO 4-> O\nrt\na\nG\n3\no\ncu CJ\net\no\nrt\n4->\nCU\n\"* co\nu\nCO\nw\nG\n\u00C2\u00A3\nrt\nX\ncu\nG 5 rt o\nC O 2 5\nCO\nG\nO\n* *H\n4->\nrt\nG\na\n\u00C2\u00A3\nrt\nX\n4>\ncu\nG\n\u00E2\u0080\u00A2 \u00E2\u0080\u0094H\n4->\n3\no\nu\n>s\nCU\nrt\nSi\ncu\nG\ncu\n4->\nrt\ncu\nu\n*T3\nG\nco aj\nco G\n\u00C2\u00B0 tl\n\u00C2\u00A7> 8\nrt 4->\n\u00C2\u00A3 \nrt -G\nQ<^>\u00C2\u00AB\u00C2\u00ABcJ5wO\n* \u00C2\u00A3\n>s *h T3\n5 LX AT\nw\npet\nU\nH-l\nu\nO\nC/3\nrt\nO\nj-i\n^G\nT3\n>\u00C2\u00BB G\nSi rt\ncu\nW) \u00C2\u00AB\n5h\nG\nCO\nco\nO\nG\nrt\ncu\nG\ncu\no\nrt\ncu\nciT\nu\ncu\n00\nS-l\n3\nCO\n\"rt\nG\n'a,\nCO\nG\nrt\ni-i\n\nb CU\nt-l\ncu\n00\nki\n3\nCO\nU\nrt\nPQ\nOi tuO\nO O\no ^\n.G\nCO i-i\nCO\nrt $c>\nbO <\nO '\nG\no\nbd\n5-1\n3\ni\ni-i\nG\nrt\nO\nO\nC w \u00C2\u00ABo\nO g -G\ncu Jd ^\ncu\n\"\u00C2\u00AB\nrt\nU\n'rt\nrt\nG\ni\nCO\no\nPi\nO\n\u00C2\u00A3\ncu\nu -G\nJ? *3\nO -Q ^\ncu \"T3 *-i\nU --< CU\nrt \"G ,+->\nO rt\n*T3-a\nG \u00C2\u00AB\nrt\nG\n. cu\n-a\nCo\nO\nHH\nH\n 2\nsh i-i G G\nn -,\nUQOOi\nco\n4->\nb0\nO\n.2 5b\n*3 G\nco n\n\u00C2\u00AB o *c\nS\"8 \u00C2\u00AB\ncu 3 co\n5^o\nbO\nO\n3 \u00C2\u00A3\nrt\n-G\n<->\n-G\nO\n\u00E2\u0080\u0094H CO\no ^\nb0.2\nG \"T3\n\u00C2\u00AB &-\no w-g -a\nbO\nO\nCO\ni->\nCO\n[rt\n\"o\nw Cm\n-< co\nG \"<\n5 bo\ncu O\n\u00E2\u0080\u00A2 rt N ^^\n000phP,p^^5\nS-l\n4->\nrt\n\u00E2\u0080\u00A2 \u00C2\u00ABH1\n-G\ncj\nCO\nH\nQ\no\nrt\nG co\nO cu\nT! -G\nrt\na, ~\n3 co\ny cu\nO 'u\ni\nrt\nCO\nG\ncU\na,\nI\n0\nG\ncu\nSh\n\u00E2\u0096\u00A0*-\u00E2\u0080\u00A2 O\ni\nS-l\ncu\nCO\nO ca\nu\nO\n-Q\nrt\n-o\ncu\nrt\nCJ\n4->\nCO\no\nG\nCA\nO\nO\n<\nCO\ncu\nrt\nO\nCO\n\u00C2\u00A3\nCU\n-G\nu\no\nG\n3\n\u00C2\u00B0 \u00C2\u00AB\nco\ncu\nCO\nO\nG\nbO\nrt\n\"5 ^\n8 2\nCO\ncu\nCO\n\u00C2\u00AB pq >< 5 5\nN bo\n^3.2\n^^\nG G\nrt c\u00C2\u00AB\n43\nco co\nCU\nH\nW\neet\nH\nQ\n<<\nW\nu\nS-l\nrt\nG\ncu\nu ^\nO 3\nG\nO\no\nCU ^<4\n-G <\n** G\niT >^.2\nS-i\ncu O\no S\n-G -a\nrt\ncu\nS-i\ncu\nCJ\nIG >H\n<+5 i-i\nrt \u00C2\u00BBH\nrt rt\n+J O\nG >\u00C2\u00BB\nCU\n\u00C2\u00A3 \u00C2\u00B0\n2 o\nE bo\nrt\nO\n-G\nS-l\n3\nO\n-a o\nG CO\nrt *>.\nS-l\nO\ncu <_.\ny y\n\u00E2\u0080\u00A2s 5\ns -o\nT3 S\nG\nrt cu\ncu3 \u00C2\u00AB\n\u00C2\u00AB \u00C2\u00AB,y\n^ 3 o\nrt\n>\nQ\nCm\nG cu\n\u00C2\u00A7 \u00C2\u00B0\nrt\ncu\nG\ncu\n\u00C2\u00A3\n4-1\nrt\ncu\nS-i\n\u00C2\u00A3\n3\nCO \"4\n4->\nG\ncu\n\u00C2\u00A3\n4-1\nrt\ncu\niH\nrt\n S-i\nU H \u00C2\u00AB I\nH S Oh X\n0* M\n.a 5\n^ cu\n^g\nc\u00C2\u00AB .5\n'S\no o\n\u00C2\u00AB\u00C2\u00BB\u00C2\u00BB o\nO fl\na \u00C2\u00AB\n1^\nii\n \u00C2\u00B0\na* ^3 fl\n\u00C2\u00A5 \u00C2\u00AB3 cu\nQ o s\nu\n4>\n* rt\no <0\nK -c\nu\no\nON\nB)\nu\nV\nO cu\nfl-4\n3Hfl\n$i\nH\nbo\no\nM\n60\n\u00C2\u00AB4H\no\no\nNO\n<\nQ\nw\nHi\no\n\u00C2\u00AB ^\n\u00C2\u00A9 8\ncu\n>% CU\na \u00C2\u00B0\n\u00C2\u00AB fl\n^. \u00C2\u00AB\nCN\nM\n8*2\nm rt\n\u00C2\u00B0o\nM O\nw\n60 \u00C2\u00A9\nrt o\nP4\nT3\ncu\nu\nfl\n4)\nSh\nrt\nu\nV^\n8 s\n6s M\nO 4>\n\"El's\nS v\nw it\nS\nrt\nCm\n1?\nfl \u00E2\u0096\u00A0\u00C2\u00BB\nrt C\nK*0\nCU VM\nrt\nQ\n8\n8\ncu\nQ\ns>\no\nCN \u00C2\u00AB-^\n\"ft.\ns\nte\nHJ\n*3\nrt\n8\nM\no\nfl\no\nCD\nw\n\u00E2\u0096\u00A0ft.\nu\n8\n\u00E2\u0080\u00A2\u00C2\u00AB\nc\n8\n(J\noil\n4>\nM\nrt\nU\nrt s.\nft (fi\n\u00C2\u00BB\nE c\nrt]\nca ~\nv *G\nC5 O\nH^ U\n6s\n_ rt\nU\n-H T3\n\u00C2\u00AB S *\no \u00C2\u00AB c\n60 m .3\nm rt ol\n3 \u00C2\u00B0 \u00E2\u0080\u00A2-\n-T \u00C2\u00ABsH M\n\u00E2\u0096\u00A0** M \u00E2\u0080\u0094 \"H\n\" \u00C2\u00AB rt\n*5 ^\ncu $\nS Sgj\n\u00E2\u0080\u00A2\u00C2\u00AB fl\n4) CU\n** JZ\nfl\nS.-< cu\n6\n\"J\n\u00E2\u0080\u00A2> Jm\nCU h>\n41\nO\n6\n'>\nO\nT3 Oi\nrt\nCA\nU\n0\nw\ny\n5\n4)\ns-\ncu\nJ3\n5\u00C2\u00AB\nrt\noi at\nfl 8\n6\ncu\nfl\nrt\n>\n*<*2\n4\u00C2\u00BB 8\n*\u00C2\u00BB rt\nrt <\u00C2\u00AB^\n4t\nu to\nrt\n41\nA rt\no\n8\nrt\na> .\nrt *\u00C2\u00A3$\n4) 41\n4) ?\nfl 8\nrt\n49\ns\n*> \u00E2\u0080\u00A2-\n4\u00C2\u00BB \u00C2\u00AB\n4\u00C2\u00BB \"3\n11\n<\nM\n o\n111 i* \u00C2\u00AB\n4) fl O 8\nr rt \u00E2\u0080\u0094| .-\no *8 6 4\u00C2\u00BB\nCrt \u00C2\u00AB J M\nP<*\u00C2\u00A3* 23 X [Our good friend Dr. D. H. Williams, who is ever on the watch for a chance to help\nthe man in practice, has handed us an admirable summary entitled \"The Diagnosis of\nSyphilis by the General Practitioner.\"\nIssued by the United States Public Health Service, under the aegis of Dr. Thomas\nParran, Surgeon General, of the United States Public Health Service, this is a wholly\ncommendable little volume. It is short (36 pages) and contains excellent tables, and\ncondensed statements, given in aphoristic form.\nWe are glad to publish this in instalment form\u00E2\u0080\u0094and suggest that our readers keep\nthe numbers containing these instalments collected together in some convenient way,\nfor ready reference.\u00E2\u0080\u0094Ed.]\nFOREWORD\nFor modern syphilology the years 1905 to 1910 was the great period of discovery.\nWithin that brief span we discovered the organism, the complement fixation test, arsphenamine. In the years which followed, the still more sensitive flocculation tests were\nintroduced and bismuth replaced mercury in the scheme of treatment. With these new\ninstruments physicians developed the technics of diagnosis and treatment.\nThe last decade has been an equally notable period of analysis and consolidation.\nCo-operative Clinical Group studies have compared the various regimens of treatment,\ngleaning their data from 75,000 case histories; for no other serious disease is there so\nsatisfactory and so specific a treatment as those studies developed for early and latent\nsyphilis. The Committee on Evaluation of Serodiagnostic Tests has demonstrated that\n100 per cent specificity and a sensitivity of 80 per cent are routinely obtainable objectives. Neurosyphilis, cardiovascular syphilis, prenatal syphilis have been subjected to\nsimilarly searching inquiry. Public health administration is offering new aids to the\nphysician in dealing with the disease.\nWe are proud of the part the United States Health Service has played in this development. But our job is not finished when the data are filed. These instrumentalities have\nbeen created for use. We hope that this little volume of Doctor Moore's own diagnosis,\nand one simultaneously issued on modern treatment, may effectively serve to synthesize\nthese advances for the busy clinician who holds the front line against disease.\nIt is fitting that this series of technical monographs should begin with diagnosis. It\nis the first clinical problem. In a society where even physicians have sometimes been\nreluctant to face syphilis, and with a disease of so many disguises, it requires emphasis.\nHalf a million early cases, 600,000 advanced cases of syphilis go to physicians for the\nfirst time each year. The advanced cases suggest that our \"index of suspicion\" for the\nearlier diagnosis has been too low.\n\"But I see an incredulous look on some faces and I hear the whispered comment\u00E2\u0080\u0094'tis\nheard often enough! 'Where is all this syphilis? I does not come my way.' Yes it does.\nThe syphilis we see, but do not recognize, everywhere awaits diagnosis, so protean are\nits manifestations.\" Sir William Osier's warning to the Medical Society of London, like\nany unlearned lesson, bears repeating. 1\nR. A. VONDERLEHR,\nAssistant Surgeon General.\nTHE DIAGNOSIS OF SYPHILIS\nGeneral Considerations\nThe physician's share of the syphilis control programme hinges on two major points\u00E2\u0080\u0094\ncase-finding and case-treatment. They are inextricably interwoven. It will do little\ngood to bring under treatment a million patients if the treatment given them is ineffi-\nPage 239 cient. On the other hand, treatment, no matter how efficient, will not solve the problem\nunless patients are actually recognized and provided with its benefits.\nOn the whole, experience has convinced me that in spite of all present-day shortcomings, the treatment element is better performed than case-finding. Bad as it often\nis, the treatment of those patients actually submitted to it does accomplish a great deal.\nThat a decrease in the incidence of syphilis is not yet apparent is due, I believe, largely\nto the fact that so many syphilitic patients pass completely unrecognized until the\ndamage of infection of others or the ultimate breakdown of the individual has already\noccurred.\nWTiat are the reasons for this failure? Case-finding involves two elements \u00E2\u0080\u0094 the\ncorrect diagnosis by the physician of patients with actual lesions of syphilis, and organized\neffort to search out the patient who has no lesions. In which of these two elements does\nthe medical profession fail? I believe it fails in both, and for three reasons.\n1. The Doctor's Puritanical State of Mind\nToo many doctors still believe that nobody has syphilis except Negroes, prostitutes,\nand criminals. Their own patients, failing to fall into one of these classes, are too well\nborn, too moral, too well educated, too well to do to be infected. Too many doctors,\nsurprising as it seems, still think of syphilis as a disgrace, not as a disease, and hesitate to\nsuggest the necessary steps for diagnosis lest the patient's feelings be wounded. Too\nmany, even if they do recognize syphilis, still think of it as well-earned punishment for\nsin, and do less than their part in administering or arranging for proper treatment.\n2. Fadlure to Realize the Prevalence of Syphdlis\nSuch statements as \"10 per cent of the adult population is infected\" fall on uncomprehending ears, and are as difficult to interpret in terms of personal experience as the\nbillions of the national debt. Even if the facts of 500,000 fresh infections each year\nand a total of some 10,000,000 syphilitic adults in the country are accepted, there is no\nappreciation of the fact that all social classes, not only the lowest, are to some extent\ninvolved.\nThese two reasons combine to produce in the minds of many physicians what Stokes\nso neatly calls a 'low index of suspicion.\" The possibility of syphilis is dismissed as\nincredible. That syphilis can occur in the clientele of the family doctor, who has known\nhis patients for a lifetime, is beyond belief. It is likewise incredible that the specialist's\npatients, well educated and relatively well to do, can be infected with a disease which he\nbelieves to be limited to social groups with which he does not deal.\nThe medical profession's attitude of mind must be remedied before case-finding in\nsyphilis is adequately successful.\n3. Inaccurate Diagnosis of Syphilis\nThe third and most important reason for failure in case-finding lies not in the confusion of morals and medicine, but in the diagnostic inaccuracies of medicine itself. So\nfar as syphilis is concerned, there is still too great reliance on clinical acumen; too little\nappreciation of the fact that syphilis can so imitate or be imitated by other diseases that\nclinical diagnosis is sometimes literally impossible; too little awareness that the possible\nlesions of syphilis are so diverse that in these complicated days few physicians can be\nexpected to recognize them all.\nThe teaching of syphilis in medical schools is sometimes scattered through all general\nand special departments, is sometimes centralized in special clinics, and is sometimes\ncarried on in both fashions. Whichever method is used, there is usually far too much\ndetail. The student is expected to learn expertness in the diagnostic differentiation of\ngenital lesions, or skin rashes, of ocular lesions, of cardiac disorders, of neuropsychiatric\ndiseases. He is expected, as part of his general training, to acquire knowledge in special\nfields to which the several experts in these fields have devoted lifetimes. If he makes use\nof special text books devoted to syphilis, he is faced with the same difficulty in concentrated form. There is a tendency to require that he know the differential diagnostic\npoints between, for example, pityriasis rosea and the macular syphilide, between hepatic\nPage 240 syphilis and cholecystitis, between tabes dorsalis and subacute combined sclerosis. The\ndetails of these and similar points are insisted upon to the exclusion of the far simpler\nprinciples which ought to govern diagnosis. The forest is lost in contemplation of the\ntrees.\nThe Complaints of the Syphdlitic Patient\nIn history taking, every medical student is taught, as the first step, to record the\npatient's complaint in his own words. If the syphilitic person complains at all, of what\ndoes he complain, and how valuable is his complaint in arousing suspicion of syphilis?\nAlmost never does he say \"I have syphilis.\" Instead, he says he has a sore on the penis,\na skin rash, a sore mouth or throat, sore eyes, falling hair, malaise, fever, headache,\nrheumatism, pain in the abdomen, nausea and vomiting, constipation, shortness of breath,\nweakness, difficulty in urination, pains in his legs\u00E2\u0080\u0094in short, the same complaints that\ngreet the doctor every day among his non-syphilitic patients.\nWho is Concerned With Diagnosis?\nTo what physician does the patient go with these complaints? First and foremost,\nof course, to the family doctor, the general practitioner. If he thinks himself wise enough\nto choose his own specialist, or if he goes to a polyclinic hospital, his original contact is\nwith one or another specialist (rarely the syphilologist). Patients with primary or secondary syphilis gravitate to the urologist, gynecologist, dermatologist, ophthalmologist,\nlaryngologist, orthopedist, or even the neurosurgeon. The same group of specialists\nencounter the patient with late syphilis. The pediatrician struggles with the problems\nof congenital syphilis bequeathed to him by careless obstetrics. In short, no special\nbranch of medicine unless it be the allergist (and even he would find syphilis if he deliberately searched for it) is exempt from having to decide, not infrequently but often,\nwhether his patient has syphilis or some other disease.\nCan the family physician, the general practitioner, have the clinical knowledge of\nall these branches of medicine adequate to permit him to recognize syphilis when he sees\nit? To ask the question is to answer it. Can the urologist or dermatologist have sufficient knowledge of internal medicine, neurology, psychiatry, and ophthalmology to enable\nhim to deal properly with late syphilis? Can any physician lacking special training in\ndermatology recognize clinically all or even a fair proportion of patients with syphilitic\nskin lesions? To ask these questions is to answer them, too.\nWho Must Diagnose Syphilis?\nIt is obviously impossible to expect of the general practitioner expertness in diagnostic differentiation in all the special branches of medicine in which the lesions of\nsyphilis may fall, and likewise impossible to exact of the specialist an adequate knowledge\nof general medicine and of all other special branches than his own as well. How then\nis the problem of diagnosis to be solved? Not by the creation of a special group of\nsyphilologists, whose function in this domain is presently described, but by leaving the\ndiagnosis of syphilis precisely where it is, in the hands of every physician no matter what\nhis special training.\nIf this is to prove successful in the case-finding element of the control programme,\nthere must, however, be less insistence on details of clinical diagnosis and more on fundamental principles. I am convinced that the average medical student, general practitioner, and specialist can be taught all that is necessary for him to know of the clinical\nmanifestations of syphilis and their recognition (outside his own special field) in far\nsimpler fashion than is the present custom, in far less time than the medical curriculum\nusually devotes, and in far less space of printed matter than is expended by current\ntexts on syphilis.\nThe Role of the Syphilologist in Diagnosis\nSyphilology as a diagnostic specialty does not and cannot exist. While it is true\nthat the syphilologist, if he is competent, is a well-trained internist with added knowledge\nadequate to his special field of the particular specialties of dermatology, ophthalmology,\nneurology, and psychiatry, he is far more often called upon to apply this knowledge to\nPage 241 the problems of treatment than to those of diagnosis. In the latter respect he serves\nonly as a consultant, and rarely at that. His patients come to him for the most part\nalready diagnosed as syphilitic by another physician. His job is to find out what kind\nof syphilis, what structures have been damaged by syphilis (and other diseases as well)\nand to what extent, and to estimate the effect of this damage in planning treatment.\nThe Fundamental Princdples of Diagnosis of Syphilis\nConsidering the disease as a whole, these are only three:\n1. Raise the index of suspicion of the doctor. Let him realize that syphilis is the\nmost prevalent of all the major infections, and that some of his own patients\nmay be infected.\n2. Emphasize repeatedly that syphilis is often difficult to diagnose clinically, even for\nthe expert; that clinical suspicion is easier to arouse than is clinical certainty to\ndeterrnine.\n3. Emphasize still more repeatedly that clinical suspicion, once aroused, can in most\ninstances be accurately resolved into certainty by the serologic test. In untreated\nsyphilis, the serologic test is 95 per cent efficient.\n(To be continued)\nVictoria 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\nA clinical meeting was held on Friday, March 1, 1940, at the Royal Jubilee Hospital,\nunder the chairmanship of Dr. H. H. Murphy.\nA paper was read by Dr. D. M. Baillie, entitled: \"The Whole 'Set-Up' Is Wrong.\"\nThis paper was followed by an interesting discussion, in which Dr. J. L. Gay ton gave\nhis experiences as a Public Health officer in the district of Trail, where the medical services are organized on a co-operative basis. He commented upon the great advantages to\nbe secured from the public health; point of view. He also emphasized the tremendous\nbenefits derived for the individual doctors concerned in the matters of opportunities for\nspecialization and for the increased amount of leisure that is enjoyed by them.\nTHE WHOLE \u00C2\u00ABSET-UP\" IS WRONG\nBy Dr. D. M. Baillie.\nVictoria, B. C.\nRead before Clinical Meeting at Jubilee Hospital, Victoria, B. C, March 1, 1940.\nWe were \"chewing the rag\" in the Doctors' Room at the Hospital on a recent Sunday\nmorning, and Dr. X was complaining bitterly about the night work he had had to do\nduring the week. Said he, \"I've been up every night but one\u00E2\u0080\u0094mostly about 2 or 3 in the\nmorning. Just had a bad streak, I guess, with those midders.\" X has a big practice; and\nefficiently carries out the functions of general surgeon, obstetrician, gynaecologist, paediatrician and general practitioner, with an occasional excursion into the tonsil and adenoid\nbusiness. He does a great deal of midwifery and, all told, puts in a steady twelve to fourteen hours' work a day, not counting the work done during the hours he is supposed to\nsleep. How he stands the racket, I don't know.\nPage 242 A week before this, Dr. Y had told me, wearily, that he had been pulled out every night\nfor a week. He, also, tries to spread himself thin in the practice of surgery, obstetrics, ear,\nnose and throat, and general medicine, and rarely finishes his day's work before ten o'clock\nat night.\nIn this Province, particularly in the cities, one could multiply these examples by scores,\nif not by hundreds. No doubt the war, which has plucked some of the younger men from\ntheir practices into the army, has increased the burden of those who are left. Possibly so,\nbut even without this qualification the whole business spells out to bad medical organization.\nToday, my task is to endeavour to tell you why I think the whole medical \"set-up\" as\nwe have it in Victoria is wrong. These remarks will apply to the rest of Canada to a great\nextent as well.\nA Local Survey.\nIt is a good thing to sit down quietly and take stock of any situation, because the\nhuman animal, even the medical variety, is inclined to take so much for granted. So far as\nI know, no serious attempt has been made an analyse the medical situation from the general\nwide public health point of view in this city and district. I take it you will agree with me\nthat our primary function should be the safeguarding of the health of the people of our\ncommunity. Unfortunately for this point of view, the first consideration forced upon us\nis that of making a living for ourselves and families, with the added hope of being able to\nsave enough to provide us with a competence in old age, if we ever reach that period. The\neconomic factor forever obtrudes itself upon those of us who are in private practice of\nmedicine and brings in many considerations that militate against a scientific approach tc\nour work: but more about this later.\nIn surveying the medical scene here one is first of all struck by the confused disorderli-\nness of it\u00E2\u0080\u0094manifested in the variety of agencies involved and by the mixture of functions\ncarried by the individuals concerned. These weave and intertwine in the most extraordinary fashion and the situation is, at present, still more involved by war conditions and the\nmedical necessities thereof.\nIn a short paper to the Vancouver Medical Association Bulletin, of April, 1939, I\nmade a very sketchy survey of the activities of the medical practitioners of this city, and\nstated that I found some 57% were in receipt of funds from public sources as well as from\ntheir private practices. Since then I find that I was grossly underestimating the number,\nas I had omitted any mention of relief appropriations, which I suppose all of us in private\npractice share in, if only, to a modest degree. In fact, we are forced to the conclusion that\nwe are. all giving services to the State (Dominion, Provincial and Municipal) for benefits\nreceived, and that we really have State Medicine without, perhaps, knowing it.\nReferring to the telephone directory and other sources, I find that there are 75 medical\npractitioners in the city and immediate district giving medical or health services in one\nform or another. Twenty-five, or 33%$%5 of these, are simon-pure specialists\u00E2\u0080\u0094confining\ntheir work to a single specialty. Another fifteen, or 20%, are what one might call pseudo-\nspecialists: in other words, they are general practitioners who have a long suit, such as\nsurgery, internal medicine, and so on. Adding these together, we find forty men, out of\nseventy-five, specializing\u00E2\u0080\u0094more or less\u00E2\u0080\u0094making 53%$%. Of general practitioners, we\nhave twenty-four, or 32%, most of whom do their own surgery and obstetrics. Of full-\ntime salaried men, we have eleven, or 15%. Some of these men do the radiology and\npathology at our hospitals, two are in the Chest Clinic, and one is the Medical Superintendent of the Jubilee Hospital. There are two other full-time salaried men in the city\u00E2\u0080\u0094\nthe Medical Officer of Health and the School Medical Officer. There is also the Medical\nOfficer of Health for Saanich. Part-time public health work is done by three men in the\ndistrict; two of whom are specialists in other fields.\nAll this seems very confusing, but there is worse to come. We have to reckon up the\nnumber of men who are working more or less part-time for the Dominion and Provincial\nGovernments. It is difficult to get the exact figures, but a superficial survey gives me\ntwelve for the Dominion and eight for the Provincial Governments. Then, we are nearly\nall working for the City and Saanich Municipalities by doing their relief work, and thus\ngetting small accretions to our individual incomes. Finally, there is the Workmen's Com-\nPage 243 pensaton Board, which paid out in 1936 the sum of $595,894 to the medical profession of\nBritish Columbia.\nYou will see, then, that the medical situation in this community is one of some complexity. That would not matter so much, perhaps, if we could honestly claim to be efficient. I would like to put the question to you: Are we, as a profession, collectively and\nindividually, as efficient as we ought to be? For answer, I could refer you to the large number of quacks and irregular practitioners in the city, not to mention the amount of self-\nmedication that goes on all the time. Perhaps we are better off in this respect than most\nother cities in this country, because I feel that, despite our faults, we do give in this city a\nbetter than average medical service. But you will admit with me that most of us are daily\ndoing things medical and surgically that would be better done by other more qualified\npractitioners. We can't afford to refer the work. Particularly is this so in the field of surgery. It is most difficult for the young man in practice to get the necessary experience to\ndo surgical work under our present arrangements, particularly when he has to struggle to\nmake a living at general practice. The same can be said of obstetrics and gynaecology,\nis done by the general practitioner and pseudospecialist, largely because they feel they\ncan't afford to refer the work and also because such a small percentage of our people can\nafford to pay specialist fees. We badly need orthopedic and skin specialists in this city, but\ndo you think the men generally would refer their fractures and skin conditions to them?\nMost certainly not, because they would lose money by it.\nSpecialists.\nIn recent years we have witnessed the rise of the specialist. An increasing number of\npractitioners are confining themselves to the practice of an increasing number of specialties. This, to my way of thinking, is a natural and obvious result of our unscientific way\nof managing and co-ordinating our daily medical work. In a manner of speaking, it is a\ncompensatory mechanism, and indicates a period of transition. One perhaps can say that\nthe specialist is the practitioner who is trying to escape, or has escaped, from what he considers to be the intolerable drudgery of general practice. And I think we would be prepared\nto admit that the specialist, in good standing, has escaped to a sphere in which he has economic security, restricted hours of work (an eight-hour day), and the time and opportunity to really develop and do his work in a scientific manner. He has also, by virtue of\nthese privileges, an increased allowance of that form of wealth called leisure, in which he\ncan develop the cultural side of his life and enjoy reading about other worlds besides that\nof Medicine. It is interesting to observe that twenty years ago the only specialists in this\ncity were three Eye, Ear, Nose and Throat men and one Radiologist. Since then, as I have\npointed out, their numbers have increased considerably.\nAn interesting new development has been observed also and that is that many of these\nspecialists seem to revolve in a solar system of their own and refer cases to each other\nwithout reference to the general practitioner.\nI suppose, in this community, all the surgical work could be most efficiently done by\nfive senior and five junior men, excluding the Ear, Nose, Throat, and Eye men. Instead,\nwe find that quite half the men dabble in surgery to a greater or lesser extent.\nAnd so on, throughout the whole field of Medicine, we find a lack of balance. The\nmore popular minority over-worked; the majority getting by, not so much because of\npoor qualifications, but because they have not had the opportunity to apply their gifts to\none particular branch of Medicine. They have grown up into Medicine as individuals, got\nchained to their practices, and have not had the opportunity to develop along certain\nspecialized lines.\nPreventive Medicine\nPerhaps the most serious indictment against our methods of doing \"Medicine\" is our\nattitude towards Preventive Medicine. A great deal of work has been done, not by us\nbut by the State, which has, in most cases against our active resistance and hostility, made\nthis field peculiarly its own. A well-known New York professor of Surgery recently\nquoted in American Medicine writes: \"It is well known that the doctors have persistently\nopposed every measure that has been conceived and dedicated to increasing the health and\nlongevity of the community. We opposed the establishment of boards of health, we\nPage 244 opposed the reporting of communicable diseases, and we have opposed practically every\nstep along the arduous course of the public health movement. We are not unlike the\nweavers in the great industrial centres in England who organized mob parties to go in and\ndestrop the newly-made machines. They argued that one machine, run by one man, can\nproduce an output equal to the labour of ten men. Therefore, nine men must obviously\nbe through out of work. History records that this assumption was fallacious.\"\nIn truth, this is the crisis of the medical profession today; and we have, so far, failed\nto tackle the problem in a scientific way. We are practicing therapeutic medicine like the\ndoctors of past generations, and doing the minimum of preventive work. It really ought\nto be the other way around, if we were applying scientific principles. Thirty years ago,\nwhen I qualified in Medicine, epidemic disease was rife and constituted a great proportion\nof the maladies we treated. Also, a large percentage of our patients were children. Today,\na very small proportion of our patients are children, and this fact is associated with a great\nincrease in the expectancy of life. We are now mostly concerned with treating the\ndegenerative conditions of middle life and advanced age; e.g., arterio-sclerosis, in all its\nmanifestations; and trying to deal with the cancer problem. How much of our time is\nfilled up in gently wafting people over Jordan!\nBetween the fields of Preventive and Therapeutic Medicine there is still a great gulf\nfixed with tenuous strands of inter-communication. The former is run by the State; the\nlatter by private medicine. The practitioners of the former are paid by salary; those of\nthe latter on a basis of fees for services rendered. It is high time that, in the interests of\neconomy, these fields of endeavour should be merged into one, so that a scientific, co-operative, and planned medical economy should be obtained for the benefit of our pople.\nSocial Consciousness\nAnother great drawback to our Medical \"set-up\" is that, as a profession, we have not\ndeveloped anything like a social consciousness. We do not fully realize that, besides being\ndoctors, we are citizens and members of the community. There has always been the\ntendency for us to shut ourselves off as individuals from active social endeavour and, as a\nprofession, from the pressing social and economic problems that must be solved. We have,\ntoo long, taken the attitude that these things are none of our business. They are very much\nour business, and the public are looking to us for leadership.\nSigerist, Professor of History of Medicine in Johns Hopkins University, has some very\npertinent things to say about this. In his book \"Socialized Medicine in the Soviet Union\"\nhe states: \"In all Western countries there is a great deal of unrest in the medical world.\nThe causes of this unrest are easy to find. Society has undergone a profound change in the\nlast hundred years. We live in a highly industrialized, highly specialized, society. At the\nsame time, medical science has become revolutionized, has become highly specialized, and\nhighly technical also. Science and technology are the driving forces that transformed both\nsociety and medicine. It is obvious that a new medicine in a new society calls for new\nforms of medical service. Instead of recognizing this, instead of taking advantage of all\nthe weapons that modern medicine puts into our hands, we oppose the development and\ntry by all means available to preserve the old traditional forms of medical service adapted\nto conditions that no longer exist. We know what should be done in medicine. We all\nknow that slums breed tuberculosis; that unemployment leads to prostitution and to the\nspread of venereal disease; that undernourishment cripples children. We all know that,\nand yet we are helpless under the present system.\n\"We hear complaints everywhere as to the number of physicians. There are too many\nphysicians to guarantee the individual doctors a decent income, under the present system;\nthere are not too many so far as the population is concerned. Great medical tasks have\nbarely been undertaken yet. Medicine is still in its first stage\u00E2\u0080\u0094that of therapy. Something\nhas been done in the prevention of communicable diseases, but very little in preventing\nindividual persons from developing diseases.\n\"There is unrest in medical education because we are not quite sure as to the type of\nphysician that is required by our modern society. We do not know it or do not want to\nPage 245 know it. There is widespread fear among the doctors of state interference in medical\nmatters, and\"yet the same doctors call for the state to take care of the unprofitable cases;\nthe indigents, the mentally ill, the unemployed, the chronically sick people.\"\nThe Economic Problem\nWe are all only too well aware of the fact that modern medical service has become an\never-increasing burden on our patients as well as on ourselves. Modern medical technique,\nincluding X-ray, pathological and specialist investigation, has become very expensive. We\nhear a good deal\u00E2\u0080\u0094both from doctors and patients\u00E2\u0080\u0094about X-ray and operating room\ncharges, despite the fact that our hospitals are mostly in debt and are carrying on with the\ngreatest difficulty. We know only too well that a lengthy illness is a calamity to all but\na small proportion of our patients who are fortunate in being well-to-do. Our style is\noften cramped severely because we are forced to consider the effect of these expensive\ndiagnostic aids on the pocketbooks of our patients. We can't forget, too, that the rate of\nwhat we may call \"medical indigency\" is very high in Canada and has been conservatively\nestimated to be 25% of our population.\nMedical Indigents in Canada, 1936\nIndividuals affected by unemployment 894,000\nDependents on State (Blind, Old Age Pensions, etc.) 444,436\nWage-earners and dependents incapable of defraying\nmedical costs 1,399,227\nTotal 2,737,663\nIn America, the figure is given as 30%.\nYou know, as well as I do, that these people are receiving very inadequate medical\nservice, and this fact is borne out by the high morbidity rate in this class as compared to\nthe better-to-do. It may surprise you to know that a large number of people die in Canada\nevery year without any medical attention. The Dominion Bureau of Statistics gives an\ninteresting table showing that, in 1936, of 107,050 people dying in that year, 10,505 had\nno medical attention whatever. It is also of interest ot note that 45% of all wage-earning\nfamilies in Canada have a yearly income of less than $950.00, or less than $79.00 a month.\nIt is not surprising, then, to find that some 45 to 60% of hospital and medical bills\nremain unpaid, and that the average medical income in Canada is very low. This has been\nparticularly marked since the \"Great Slump\" of 1929, and the signs are not particularly\nhopeful for any appreciable improvement.\nSome new method of financing medical and hospital services has got to be found.\nOur Methods Are Wasteful\nThis is particularly true in our cities, where we have to pay rent for separate offices\nand salaries to our office nurses. I suppose any of us is lucky if our annual expenses in\nrunning our offices are less than $2000 a year. There is, also, a tremendous amount of overlapping and duplication of work involved in the inco-ordinated shifting of patients-jfrom\ndoctor to doctor\u00E2\u0080\u0094necessitating more X-ray and pathological investigations, which haVe\nalready been done on many occasions. The time is long overdue when competitive mediA\ncine should give way to co-operative medicine. The old idea that salaried men are inade-\\nquate, inefficient, and shiftless should surely now have no protagonists. The status of the\nsalaried men on our Staff here is an object lesson to us as to wn&tcan be/achieved in this\nrespect.\nSome day, if you'll ask me, I would like to suggest to you a projected scheme for the\nmedical organization of this city and district.\nIn conclusion, I would recommend to all of you younger men to continue with general\npractice. Be sure, however, to develop a \"long suit,\" and some time, before you're thirty-\nfive, shut your office up, get away for at least one year's intensive study in your chosen\nsubject, and return as a specialist. The day of the general practitioner, in my opinion, is\nrapidly coming to an end. Conditions have changed and are rapidly continuing to change.\nThe old shibboleths no longer ring true, and a New Era is coming for Medicine, in which\nmoney will be the least of all values.\nPage 246 B. D. H. PRODUCTS\nOF OUTSTANDING VALUE\nANACARDONE\nAn efficacious cardiac and respiratory stimulant with low toxicity. It is of value in all\ncases of cardiac and respiratory embarrassment.\nOESTROFORM\nThe natural cestrogenic hormone. Issued for\nthe treatment of menopausal symptoms, delayed puberty, oligorrienorrhcea, amenorrhcea,\nsterility and dysmenorrhoea due to uterine\nhypoplasia.\nMERSALYL\nThe officially-recognised mercurial diuretic\n(Mersalyl B.P.). Mersalyl is issued for parenteral, rectal and oral administration.\nIODATOL\nFor use in radiography, particularly for visualisation of the bronchial tree, uterus, spinal\ncolumn and Fallopian tubes.\nPROGESTIN\nThe natural luteal hormone. Issued for the\ntreatment of menorrhagia, threatened abortion, dysmenorrhoea, pregnancy toxaemias,\nmetrorrhagia and tonic uterine contraction.\nDEHYDROCHOLIC ACID\nA powerful stimulator of bile secretion.\nDehydrocholic Acid also stimulates pancreatic\nsecretion and assists the absorption of fats.\nStocks of B.D.H. Medical Products are held by leading druggists\nthroughout the Dominion, and full particulars are obtainable from :\nTHE BRITISH DRUG HOUSES (CANADA) LTD.\nTerminal Warehouse Toronto 2, Ont.\n-Omn/Can/405\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.\nlyxanthinFastier\nadministered per os, brings about\nimproved cell nutrition and activity, increased elimination, resulting symptom relief, and general functional improvement.\nSince the best evidence is clinical\nevidence, write for literature and\nsample.\nL-17\nCanadian Distributors\nROUGIER FRERES\n350 Le Moyne Street, Montreal 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 In the Treatment of\nTRICHOMONAL\nVAGINITIS\n\"Stovarsol\" Vaginal Compound\nis especially indicated in leucorrhoeal conditions\nresulting from or associated with the Trichomonas\nVaginalis which, although not generally serious in\nthemselves, are usually extremely chronic in character and resistant to ordinary antiseptic treatment.\nIt is also indicated in cases where the leucorrhoea\nmay be the result of mixed and non-specific infections of the vagina.\nSTOVAGINAL contains Stovarsol, Boric Acid and\na special carbohydrate base, and is presented as\nfollows:\nVaginal tablets to be inserted in the vagina\u00E2\u0080\u0094boxes\nof 20 and 100 tablets.\nDry powder for use by insufflation\u00E2\u0080\u0094bottles of 30\ngm. and 200 gm.\nInterested physicians are invited to request booklet with\ncomplete information about Stovaginal in the treatment\nof Trichomona! Vaginitis.\nJLaMxruttxnjj I cmlenjc j*i\u00C2\u00A3A\u00C2\u00A3/s\nOF CANADA llMITID-MOWr\u00C2\u00ABf^i \u00E2\u0080\u00A2J\nWHEN milk is delivered to a Carnation evaporating plant, every dairyman's quota is kept separate for individual\ntesting\u00E2\u0080\u0094for freshness, cleanness, coolness,\nrichness. Here a can from \"77\" has passed\ninspection and is ready to move on through\nthe channels of scientific processing\u00E2\u0080\u0094\nevaporation, irradiation, homogenization,\nand sterilization\u00E2\u0080\u0094which finally result in a\nmilk of unsurpassed usefulness in the field\nof infant feeding. With Irradiated\nCarnation Milk, the physician is assured of\npurity, uniformity in composition and vitamin D potency, and ready digestibility.\nA BOOKLET FOR PHYSICIANS\n\u00E2\u0080\u0094 Write for \"Simplified Infant\nFeeding\", an authoritative publication treating of the use of Irradiated\nCarnation Milk in normal and difficult feeding cases . . . Carnation\nCompany, Ltd., Toronto, Ontario.\nCl IRRADIATED \"X JT gf\narnation JVlilk\nA CANADIAN PRODUCT \u00E2\u0080\u0094 \"from contented cows \u00E2\u0096\u00A0\n\u00E2\u0096\u00A0\nSS\u00C2\u00BB\nm\n\u00E2\u0096\u00A0H\nHi\nov:o\nft\n**?>\n\"W\nJHSMBI\n^\nt^\n^^:\ny*\n^\nJL\n\u00E2\u0096\u00A0\n\"\u00C2\u00A5\nI\nm\nm\nvsms\nmm\n^* "Periodicals"@en . "W1 .VA625"@en . "W1_VA625_1940_05"@en . "10.14288/1.0214420"@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: May, 1940"@en . "Text"@en . ""@en .