"CONTENTdm"@en . "http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642"@en . "History of Nursing in Pacific Canada"@en . "Vancouver Medical Association"@en . "1939-08"@en . "2015-01-29"@en . "1939-08"@en . "https://open.library.ubc.ca/collections/vma/items/1.0214426/source.json"@en . "image/jpeg"@en . " The BULLETIN\nof the\nI VANCOUVER\nMEDICAL ASSOCIATION\n-Vol. XV.\nAUGUST, 1939\nNo. 10\nWith Which Is Incorporated\nTransactions of the\nVictoria Medical Society\nthe\nVancouver General Hospital\n\u00E2\u0080\u00A2ni\nSt Paul's Hospital\nIn This Issue:\nCOMPULSORY PASTEURIZATION\nOF MILK :^|\nNEWS AND NOTES\nBRITISH COLUMBIA MEDICAL ASSOCIATION\nANNUAL MEETING, SEPTEMBER 18, 19, 20, 21 > '\n\u00E2\u0096\u00A0 I'M-\nMl\nc 1\nBULKETTS\n(With Cascara and Bile Salts)\n. . FOR . .\nChronic Habitual\nConstipation\nBULKETTS POSSESS ENORMOUS BULK\nPRODUCING PROPERTIES AND BEING\nPROCESSED WITH CASCARA AND\nBILE SALTS PRODUCE BULK WITH\nMOTILITY.ll\nWE WILL BE PLEASED TO PROVIDE\nORIGINAL CONTAINERS FOR TRIAL\nON REQUEST.\nWestern Wholesale Drug\n(1928) Limited\n456 BROADWAY WEST\nVANCOUVER - BRITISH COLUMBIA\n(Or \u00C2\u00ABt oil Vancouver Drag Co. Stores)\n_feftk\nI ' THE VANCOUVER MEDICAL ASSOCIATION\nBULLETIN\nPublished Monthly under the Auspices of the Vancouver Medical Association\nin the interests of the Medical Profession.\nOffices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C.\nEDITORIAL BOARD:\nDr. J. H. MacDebmot\nDr. G. A. Davidson Dr. D. E. H. Cleveland\nAll communications to be addressed to the Editor at the above address.\nVol. XV.\nAUGUST, 1939\nNo. 11\nOFFICERS, 1939-1940\nDr. A. M. Agnew\nPresident\nDr. D. F., Busteed\nVice-President\nDr. W. T. Lock hart\nHon. Treasurer\nDr. Lavell H. Leeson\nPast President\nDr. W. M. Paton\nHon. Secretary\nAdditional Members of Executive: Dr. M. McC. Baird, Dr. H. A. DesBrisay.\nTRUSTEES\nDr. F. Brodie Dr. J. A. Gillespie Dr. F. W. Lees\nHistorian: Dr. W. L. Pedlow\nAuditors: Messrs. Plommer, Whiting & Co.\nSECTIONS\nClinical Section\nDr. W. W. Simpson Chairman Dr. Frank Turnbull Secretary\nEye, Ear, Nose and Throat\nDr. W. M. Paton Chairman Dr. G. C. Large Secretary\nPcediatric Section\nDr. J. R. Davies Chairman Dr. E. S. James -Secretary\nSTANDING COMMITTEES\nLibrary:\nDr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,\nDr. W. A. Bagnall, Dr. T. H. Lennie, Dr. J. E. Walker.\nPublications:\nDr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.\nSummer School:\nDr. A. B. Schinbein, Dr. H. H. Caple, Dr. T. H. Lennie,\nDr. Frank Turnbull, Dr. W. W. Simpson, Dr. Karl Haig.\nCredentials:\nDr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J, Buller.\nV. O. N. Advisory Board:\nDr. I. Day, Dr. G. A. Lamont, Dr. S. Hobbs.\nMetropolitan Health Board Advisory Committee:\nTo be appointed by the Executive Committee.\nGreater Vancouver Health League Representatives:\nDr. W. W. Simpson, Dr. W. M. Paton\nRepresentative to B. C. Medical Association: Dr. L. H. Leeson.\nSickness and Benevolent Fund: The President\u00E2\u0080\u0094The Trustees. Calcium\n\u00E2\u0080\u00A2 \u00E2\u0080\u00A2. particularly important daring\nthe physiologic crisis of pregnancy and lactation\nAN increased supply of calcium and phosphorus is particularly important during pregnancy and lactation since,\nin addition to her own requirements, the mother must\nsupport the demands of the fetus for these elements.\nSince food preferences are often accentuated during pregnancy, calcium intake may be deficient. The addition of calcium\nalone, however, is not enough. It has been demonstrated that\nthree factors\u00E2\u0080\u0094calcium, phosphorus, and Vitamin D\u00E2\u0080\u0094must be\nsupplied in proper ratio to secure best results. Many physicians\nprescribe Viophate D, Dicalcium Phosphate Compound with\nViosterol Squibb because it provides these three factors in therapeutically effective quantities. It is supplied in both tablet and\ncapsule forms.\nOne pleasantly flavored tablet, or two capsules, contains\n9 grains dicalcium phosphate, 6 grains calcium gluconate, and\n660 Int. units of Vitamin D. The capsules are useful as an alternative dosage form. Capsules are available in bottles of 100 and\n1000; tablets in boxes of 51 and 250.\nFor Literature, write\nE-R:Sqijibb&Sons of Canada, Ltd.\nMANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858\nProfessional Service Department, 36 Caledonia Road, Toronto. VANCOUVER HEALTH DEPARTMENT\nSTATISTICS, JUNE, 1939\nTotal population\u00E2\u0080\u0094estimated\t\nJapanese population\u00E2\u0080\u0094estimated\nChinese population\u00E2\u0080\u0094estimated\t\nHindu population\u00E2\u0080\u0094estimated\t\n263,074\n8,891\n7,728\n389\nNumber\nTotal deaths 228\nJapanese deaths 6\nChinese deaths 9\nDeaths\u00E2\u0080\u0094Residents only 194\nBIRTH REGISTRATIONS:\nMale, 2 06; Female, 184\t\n390\nINFANTILE MORTALITY:\nDeaths under one year of age\t\nDeath Rate\u00E2\u0080\u0094per 1,000 deaths.\nStillbirths (not included in above).\nJune, 1939\n 5\n 12.8\n 9\nRate per 1,000\nPopulation\n10.5\n8.2\n14.2\n8.9\n18.0\nJune, 193 8\n10\n29.3\n3\nCASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY\nMay, 1939\nCases Deaths\nScarlet Fever 10 0\nDiptheria 0 0\nChicken Pox 61 0\nMeasles 7 0\nRubella 1 0\nMumps 27 0\nWhooping Cough 112 0\nTyphoid Fever 0 0\nUndulant Fever 0 0\nPoliomyelitis 0 0\nTuberculosis 37 15\nErysipelas . 3 0\nEp. Cerebrospinal 0 0\nJune, 1939\nCases Deaths\nJuly 1st\nto 15th, 1939\nCases Deaths\n19\n0\n28\n3\n0\n21\n86\n0\n1\n0\n30\n1\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n18\n0\n0\n3\n0\n9\n1\n1\n4\n19\n0\n0\n0\n11\n1\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\nV. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,\nDIVISION OF VENEREAL DISEASE CONTROL.\nBurnaby\nSyphilis 0\nGonorrhoea 0\nWest\nVancr.\n0\n0\nNorth\nRichmond Vaucr.\nVancr. Hospitals,\nClinic Private Drs. Totals\n0\n0\n58\n84\n58\n84\nBIOGLAN|\nTHE SCIENTIFIC HORMONE TREATMENT\nDescriptive Literature on Request.\nA Product of the Bioglan Laboratories, Hertford, England.\nRepresented by\nSTANLEY N. BAYNE\nPhone: SEy. 4239\nPage 311\n1432 Medical-Dental Bldg.\n\"Ash the doctor who is using it.'\nVancouver, B. C. ALL\nthe VITAMINES\nfrom\nA foG\nYOUR patient gets all six vitamines in a single tablet\nwhen you prescribe PAN VITA. This remarkable concentrate has proved extremely valuable in treatment of\nconditions due to multiple vitamine deficiency.\nFor quick correction of such deficiencies you can depend\non Panvita Tablets. They provide an assured and standardized intake of Vitamines A, B (B,), C, D, \u00C2\u00A3 and G (B2).\nThe vitamines in this potent concentrate are obtained\nas follows: Vitamine A from carotine, B (Bj) and G (B2)\nfrom activated extract of yeast, C from chlorophyl, D from\nirradiated ergosterol, and \u00C2\u00A3 from extract of wheat germ.\nIt is well recognized that patients receiving an adequate\nintake of all six vitamines respond much more readily to all\nforms of therapy. Authorities therefore recommend the\nuse of vitamine concentrates wherever partial deficiency\nmay be a disturbing factor.\nDOSAGE: The average dose is 2 to 6 tablets daily,\naccording to the severity of the deficiency. In cases of\npronounced deficiency much larger doses may be used.\nThere are no contra-indications. For young children the\ntablets should be crushed and dissolved in a lukewarm\nliquid.\nSUPPLIED: In bottles of 40 tablets, 100, 300 and 1,000.\nPANVITA Tablets\na concentrate of all six vitamines\nANGLO-TRENCH DRUG- COMPANY\n354 St. Catherine Street, Bast\nMontreal, Quebec.\nGentlemen: Please send me complimentary sample of Panvita\nTablets for clinical trial.\n \u00E2\u0080\u009E M.D.\n Street ^_ .U. .- City Iii Complications Following Vaccination\naids phagocytosis and absorption of toxic debris; it stimulates the local reparative forces and hastens resolution. \u00E2\u0080\u00A2 It is an ideal surgical dressing for\ndirect application to wounds, ulcers, burns, broken, raw and torn skin surfaces.\nSample on request\nTHE DENVER CHEMICAL MANUFACTURING COMPANY\n153 Lagauchetiere St. W., Montreal Made in Canada\n^\u00E2\u0080\u0094\u00E2\u0080\u0094\u00E2\u0080\u0094\u00E2\u0080\u0094T\u00E2\u0080\u00941\u00E2\u0080\u0094ll\u00E2\u0080\u0094^^Mf U1WB\u00C2\u00BBHHI\u00C2\u00ABIIMM| |i\u00E2\u0080\u0094 \u00E2\u0080\u0094 II Il\u00E2\u0080\u0094I if\u00E2\u0080\u0094' \"\u00E2\u0080\u0094\u00E2\u0080\u0094 'I any pathological\nlesion which may bring on a convulsion is more likely to do so in a child than in the corresponding adult. Certain authors regard this view as paradoxical, but they, I think, fail\nto distinguish between convulsions and susceptibility to convulsions. They feel, apparently, that this question of increased susceptibility in early life was partially solved by\nthe finding of an extremely high incidence of birth injury with some slight cerebral\nhaemorrhage, as pointed out by Ylppo and Swhartz, as well as more recently by Howard\nSmith of Portland.\nPage 322 It is quite true, then, that this work on birth injury cleared up the cause of a goodly\nnumber of infantile convulsions that has been obscure, but at the same time this fact of\na high susceptibility in childhood cannot be solved by merely pointing out a new high\nincidence of one type of organic lesion.\nThis point is well summarized by Peterman, who says: \"A convulsion at any age is a\npathological episode; but in young children, because of the late and slow development of\ntheir central nervous systems, there exists a physiological predisposition which makes it\neasier for a convulsion to appear in response to a given cause.\"\nIt does also happen that the infant and young child are subject, because of their age,\nto a great many diseases which in themselves are or can be the exciting factor of a convulsion. When this age period is past, the incidence of convulsions is greatly lowered.\nTo me, then, there must be two definite and distinct factors. First, an increased susceptibility, and, second, a greater number of possible exciting factors. Certainly it is not alone\nthe incidence of infections or febrile diseases, as later in life no convulsions accompany\nthem. As to why febrile diseases cause seizures, Peterman feels, and no one else has expressed\nany diverse opinion, so it may be said to be unanimous, that thse convulsions are probably\ndue to a response of the patient to an invasion of the blood stream or meninges by microorganisms, or to an upset in the water balance which so many infections produce (this\nmight cause the initiating cerebral cedema).\nSo much for the cause of convulsions. To repeat: The cerebral pathology prior to and\nduring the seizure is pretty well known and the exciting factors can be enumerated, but\nit can only truly be said that a child is such an easy prey to a seizure just because he is a child.\nConvulsions can be best classified under two main groups.\nFirst: Convulsions of organic origin such as occur in acute or chronic disease of the\ncentral nervous system.\nSecond: Symptomatic convulsions\u00E2\u0080\u0094and this group must be subdivided into two\ndivisions: (a) Incidental or functional seizures such as accompany febrile diseases or such\nas psychogenic seizures (here I mean seizures in psychopathic children from very little\ncause); (b), convulsive diseases, namely, idiopathic epilepsy or tetany.\nPeterman in 1934 gave us a very practical study on the cause and types of convulsions\nin childhood. He carefully analyzed five hundred cases. First of all, he took a very careful history, paying particular attention to the birth and to the new-born period, and to\nany familial incidence of seizures in other members of the family.\nHis cases were all hospitalized and thoroughly investigated. All had Kahns done, blood\ncalcium and phosphorus estimated, X-rays taken of the skull, and stool and urine examination, plus, of course, a careful physical examination. Spinal fluid was examined in all\nexcept those of definite spasmophilia. Encephalograms were done in doubtful cases.\nThe most striking part of this study to me was the fact that he made a definite diagnosis in 94% of all his cases. He also found that there are certain diseases peculiar to child-\nrood that are the cause of most of the convulsions (measles, streptococcic infections).\nWhile he found that certain children may be said to be particularly susceptible to seizures,\nthere is usually a physical basis for this susceptibility (such as a lowered blood calcium)\nand one which may be amenable to treatment.\nEvery convulsion produces a certain amount of cerebral injury, and Peterman thinks\nthat one seizure increases the child's susceptibility. This I heartily agree with, and for\nthis reason I feel that each individual convulsion must be given a very painstaking and\ncareful study in order to prevent a recurrence if possible. Only such a course is adequate\ntreatment.\nIt is unfortunate that even today one finds occasionally an older physician who considers convulsions a more or less necessary evil of childhood, and who merely advises the\nparents that the child will outgrow his tendency. Such a child probably will, but just as\na succession of blows spoils the sharp edge of a knife so a succession of convulsive seizures\nmay irreparably impair a child's mental alertness. Although such trivial things as worms\nor teething may set off a seizure, they are never the real basic cause, as in all oases some\nunderlying factor such as a mild spasmophilia can be proven to exist if searched for. The\nthymus, whatever it may do, never causes convulsions.\nPage 323 Convulsions in childhood are just as serious as in adults and there is no justification in\nminimizing the symptom because of age, or in believing that time alone will remove the\ncause.\nI give you herewith a short abbreviation of Peterman's classification of his 500 cases:\nIdiopathic Epilepsy 34.4%\nAcute Infections 21.4%\nSpasmophila or Tetany 16.0%\nCerebral Birth Injury or Sequela; 13.1%\nCause unknown 6.7'%\nPerhaps hyper-or hypo-glycxmia, perhaps allergy\nwith a resultant brain oedema.\nMiscellaneous 8.4%\nAcute Gastro Enteritis.\nTraumatic Brain Injury.\nPertussis \"with slight cerebral hemorrhage.\nNaturally this percentage classification will vary greatly in the different age groups.\nFor example: From birth to 1 month, over 50% of seizures were due to birth injury or\nhemorrhagic disease; from 1 month to 6 months, only 20% were due or incidental to\nbirth, 30% were infectious and 16% spasmophilia; from 6 months to 36 months, infections accounted for 30%, spasmophilia 23%, and epilepsy was now the cause of 20%;\nfrom 3 years to 10 years, epilepsy was the cause of 60%.\nIt is to be remembered that some time, may elapse, months or even years, before a case\nof birth injury will have its first seizure, but such convulsions will often be of the localized Jacksonian type and a careful history of the new-born period will give valuable\ndiagnostic help. Very often, too, as you know, these babies will haye other signs of birth\ninjury.\nIdiopathic Epilepsy\nThis is a convulsive disease, the essential feature of which is its gradual but persistent\nprogressiveness to which exceptions are rare. Once an epileptic, always an epileptic, is\npractically true. The onset very often occurs in early childhood. There are statistics that\nshow from one-third to one-half of all adult epileptics suffered from convulsive seizures in\ntheir first year of life. On the other hand, Peterman's series showed'only a mere 5% under\n2 years that were true epileptics, and I think this work carries a great deal of weight. It\nis, however, fair to say that idiopathic epilepsy is no great rarity in early childhood, but\ncertainly no convulsive seizure in a child under four should be labelled epilepsy without a\nmost painstaking and thorough search for a more likely cause.\nThere are, of course, the two types of seizures\u00E2\u0080\u0094grand mal, with or without aura,\ninjury during the fall, biting of the tongue and fixation of the pupils, and the minor petit\nmal attacks which, as you know, are mere lapses lasting only a few seconds.\nSometimes various forms of seizures occur in the same patient; for example, after a\ngrand mal attack the child may go for months with merely a few petit mal spells, or vice-\nversa, but in general petit mal attacks will come more frequently than grand 7nal, and the\ngreat majority of petit mal cases will, if untreated, and unfortunately all too often even\nif treated, be replaced eventually by typical grand mal seizures.\nAttacks can and often do occur at night when the patient sleeps, and so are often\nmissed or misinterpreted. Perhaps certain older children who had been quite trained and\nthen begin to wet the bed periodically may in reality be epileptic, and the bed wetting\nincidental to the seizure.\nFindings on physical examination are meagre. In fact, if there are any positive neurological signs they probably rule out epilepsy as the diagnosis. A small group of children\nhave been reported to have periodic recurrences of nightmare. These children would awake\nscreaming and in a confused state, and the so-called nightmares were gradually replaced\nby typical epileptic seizures.\nI do not for one minute mean to imply that many of our bed wetters, or children\nhaving nightmares, are epileptics, but only that, when such histories are related to you,\nepilepsy should at least be thought of.\nThe mental deterioration suffered by epileptic children depends a great deal more on\nPage 324 the frequency of the attacks than on their severity. In fact, mentality is only slightly\naffected unless the seizures are quite frequent.\nThe prognosis of epilepsy in a child is, of course, very grave; and the nature of the\nattacks is no measure of the course it may take. Indeed, the outlook for true petit mal is\njust as bad as for grand mal, and an optimistic outlook, no matter what -the type, and no\nmatter what the treatment, is unwise.\nHowever, although it is true that no other convulsive state has such a poor outlook,\nit is also and equally true that there is no other condition where errors of diagnosis can so\neasily be made. In the worst age group only 60% of all convulsions can be epileptic.\nSymptomatic Convulsions\nHere we are dealing with seizures that are similar to grand mal epileptic attacks and\nwhich occur in connection with many causative factors, but which never lead to a true\nepileptic state, and which at most may reappear due to the original cause or a similar one.\nThe most frequent and common convulsions of this type are those which precede or\naccompany the onset of an acute infectious disease. As these convulsions so often occur at\nthe beginning of the prodromal period, their significance is often obscure for several days.\nJust what the exact mechanism of these initial convulsions may be is not known. Many\nof them, of course, are tetanic in origin, the metabolic changes that occur as a result of\nthe illness being sufficient to change a latent tetany phase into a manifest one. We know\nhow easily this can be done, as so often we find a blood calcium of 8 or even 9 in a child\nthat has suffered a series of seizures from some comparably minor ailment. Such a blood\ncalcium is not greatly lowered, but it is down sufficiently to give a lowered convulsive\nthreshold and almost any upset may start them off. It is this type of thing that Peterman\nstresses so strongly and which he found present in the great majority of his series that had\nconvulsions from such initiating factors are worms, constipation, teething ,etc.\nApparently a rise of fever, as such is not the exciting factor, as many children will have\na full-sized convulsion with moderate fever, and then, a week or two later, no seizure\naccompanying a much higher fever. During the course of febrile conditions, such as\npyelitis or influenza, convulsions may occur, but not nearly so frequently as at the onset\nof the infectious diseases or lobar pneumonia. In pertussis, also, convulsions occur, but\nhere they are seldom purely symptomatic or tetanic, but more often caused by minute\ncerebral hemorrhages due to spasmodic coughing. Terminal convulsions in young children\noften occur a few hours before death, usually accompanied by hyperpyrexia. In these cases,\nat autopsy little is found except cerebral cedema, and only perhaps something such as a\nsmall bronchial pneumonia, or even nothing, to account for the fever. I have lately had\ntwo cases that died within twenty-four hours of the onset of their illness\u00E2\u0080\u0094both had fever\nof 109\u00C2\u00B0 towards the end, and had convulsion succeeding convulsion right up to their death.\nTheir postmortem examinations were almost identical. Well-nourished, well-developed.\nbabies with minute signs of early bronchial pneumonia and extreme brain cedema. Their\ninfection was very overpowering, but later I hope to point out how somewhat different\ntreatment might have helped put out even these two wild fires.\nDifferential Diagnosis of Convulsions\nNo matter what the age, it must first be decided whether the seizure is organic or\nsymptomatic. In the first few days of life, even in the first few weeks, the great majority\nof convulsions are, of course, organic, from birth injury or hemorrhagic disease. After\nthis new-born period, the age group is of only relative help.\nSeizures of the Jacksonian type are, of course, organic and relatively simple of diagnosing, but, in my own experience, seizures of this type in early childhood are extremely\nrare. I may be open to correction, but I feel that, in( young children, even the definitely\nlocalized lesion is more apt to give a generalized seizure than a true Jacksonian one, perhaps\nbecause of the diffuse oedema that is usually present.\nTetany is uncommon under 6 months, although it may even occur in the new-born.\nAs the child becomes older, the percentage of seizures that are epileptic increases and\nat puberty that percentage reaches its maximum of 60%. I wish again to stress the\nimportant fact that at no time in childhood can the stigma of epilepsy be attached to more\nthan half of all children having even periodic convulsions.\nPage 325 However, a history of recurrent seizures during both summer and winter in a child\non good dietary regime, whether or not there is any family history of epilepsy, makes one\nvery suspicious, and if the attacks last for four years, or if they cease only to recur after an\ninterval of years, in all probability that child is epileptic. It may also help if it is remembered that in true epileptic seizures the pupils are fixed and widely dilated and that the\nattacks often occur during sleep.\nThere is also, of course, the defective child\u00E2\u0080\u0094the Mongol, the microcephalic idiot, the\nlow-grade moron\u00E2\u0080\u0094or perhaps merely the child with an extremely low intelligence\nquotient. These children have convulsive seizures very, very easily, but even here the\nattack needs some trigger to start them off. Mild fever, severe scoldings, even frustration\nmay be sufficient cause, as, although not due directly to the psychopathic state, such children have an extremely low convulsive threshold. Such children! can be spoken of as a\nprimitive type and are inclined to respond to their surroundings by explosive reactions,\nbecause they lack entirely or in part the power of thoughtful or deliberate reasoning. To\na lesser degree the so-called neurotic child, living in all probability in a high tension atmosphere, is so likely to explode into a temper tantrum or even a convulsion from very little\ncause. Fortunately, such types as a rule are easily recognized, and as these neurotic youngsters have a lowered blood calcium so much more often than the normal, placid child who\nis in tune with his surroundings, calcium therapy is sometimes helpful.\nThere is little that is new in the treatment of convulsions. Its fundamental basis is\nthreefold:\n1. Prevent harm to the patient.\n2. Stop the seizure.\n3. Find the cause and prevent a recurrence.\nA convulsion is always, in the eyes of the family, an immediate and urgent emergency.\nThere is nothing that will upset and frighten the ordinary family more than a real generalized convulsive seizure. Usually they come out of a more or less clear sky without\nwarning, and although we know that most convulsions will cease by themselves in a comparatively short time, advice and orders that are clear and didactic, and that will keep all\nthe members of the family busy as well as prevent injury to the patient, must be given\nover the telephone. Don't forget the stick between the teeth. This telephone advice must,\nas I have said, prevent further harm to the patient, but it really won't help very much in\nterminating the seizure. The usual things, such as the hot bath, perhaps with mustard,\nand the enema, do no harm, and it is good to keep everyone busy until you arrive fifteen\nor twenty minutes later. As soon as the seizure has ceased, its cause must be determined\nand, of course, further convulsions prevented.\nIn my opinion the one drug of choice for this purpose is phenobarbital; give it freely\nin large doses, by mouth if possible, or if necessary by hypo in the form of the sodium salt.\nIt will usually work. I have had no occasion to use thei bromides, paraldehyde or chloral\nhydrate, as, if luminal won't work, neither likely will they.\nMagnesium sulphate, of course, is very valuable. It may be used in various dilutions\nintramuscularly, has a strong depressing action, and will perhaps in some cases work faster\nand more surely even than phenobarbital. It must be always remembered, however, that\nmagnesium sulphate should not be used in conjunction with sulphanilamide therapy.\nIf a convulsion does not, however, subside within a short time\u00E2\u0080\u0094say thirty minutes\u00E2\u0080\u0094\nI feel that chloroform should be resorted to more often than is customary, for two reasons:\nFirst, the longer the seizure the more possibly cerebral damage will result; and secondly,\nand perhaps more important, until the seizure is terminated its cause can hardly be diagnosed, and it is also equally difficult to treat the fundamental cause adequately during a\nconvulsive state.\nAs previously stated, it has been my recent experience to find at autopsy, in several\nchildren dying soon after severe convulsive seizures, an almost unbelievable amount of\ncerebral cedema. They were in all cases children with high fever, but the cerebral cedema\nwas practically the only autopsy finding. They had not been ill long, and undoubtedly\nsuffered from an overwhelming infection of some sort, and it may well be that this cedema\nresulted from the infection and was the initiating cause of the seizures and the hyperpyrexia rather than the result of them. I am not satisfied however, that had I controlled\nPage 326 the convulsions quicker (and they were either uncontrollable or very slow in being controlled with drugs, as can always be done almost immediately with chloroform), and then\ninstituted hypertonic intravenous therapy, at least a percentage of these children might\nnot have lived. Therefore, in future, I intend to use chloroform much sooner than I\nhave done in the past and, where diagnosis is obscure, follow its quick sedative action with\nhypertonic intravenous therapy.\nOf all our diagnostic aids I resort last to the lumbar puncture. The history and type\nof convulsions will usually tell whether or not it is indicated, and it is seldom of much\nvalue in merely controlling the seizures. If time is taken for lumbar puncture, valuable\ntime may be lost in doing other things. Certainly I do not now feel, as I once did, that all\nconvulsive cases must have or need an early lumbar puncture either for diagnosis or for\ntreatment. This applies most particularly, perhaps, to the new-born baby who is twitching, but to older children as well. Instead of running for the lumbar puncture needle in\nthese new-borns, run for the blood syringe. This opinion is far from unanimous, early\ndrainage, etc., but I think the less handling the better\u00E2\u0080\u0094sedatives. Later, in two or three\ndays, if the baby is still alive and your bleeding has stopped, is the proper time, in my\nopinion, to do the lumbar or cisternal taps.\nAs the treatment of epilepsy, I wish merely to emphasize one or two points. Here,\nagain, I feel that phenobarbital is the drug of choice. It needs to be given in big doses,\nsufficient to control the seizures, and continued over a long period of time. The child must\nbe kept free from infections and there must be no dietary excesses. They should lead a\ncalm and regular life, free from excitement and all over-stimulation. Children's parties\nand movies are much less suitable for the epileptic than for the normal child. In my own\nlimited experience, phenobarbital is more effective in preventing grand mal attacks than\npetit mal lapses. I have no experience of mebaral, which is supposed to be as effective as\nluminal and not so stupefying. The ketogenic diet is unquestionably of great value, but\noutside of hospital is extremely difficult to maintain. Not only is it expensive, but in my\nfew attempts with it I have had to contend with gastro-intestinal upsets from its high\nfat content. When it is used, it must always be preceded by a two to three-day starvation\nperiod and fluids must be limited to 1000 cc. per days.\nIn ordinary practice the epileptic is well handled if the following rules are followed:\nFirst: Restrict carbohydrate and protein somewhat and give as much fat as the child\nand parents' pocketbook will stand. Second: Limit fluids to 1000 cc. per day. Third:\nPhenobarbital in sufficient dosage to control seizures.\nLastly, a paper such as this should not omit mentioning the fact that certain poisons\nmay in children set off convulsions. Such substances as santonin, atropine, strychnine, oil\nof chenopodium, camphor, bad mushrooms, phosphorus, lead, and lastly, arsenic, can all\ninitiate severe and lasting seizures. I remember very vividly ,a child that had extremely\nsevere and prolonged convulsions from arsenic, which was being given in the course of\nanti-luetic treatment. The child was aged seven, and syphilis was only suspected because\nof keratitis, so I feel sure that the seizures were due to the treatment and not to the disease.\nThese convulsions were finally and dramatically relieved by the intravenous use of sodium-\nthio-sulphate, but not before I was gravely worried for the life of the child. Lead is the\nonly other poison that I have had any experience with, and convulsions from it as well as\nfrom arsenic are probably due to encephalitis. The above case showed a few blood cells in\nthe spinal fluid, and is mentioned in Jean's book as an unusual complication of arsenic\ntherapy and called encephalitis hemorrhagica arsenicalis. His cases all died, but he advocated the use in future of sodium-thio-sulphate, and it certainly worked in my one case.\nIt was also interesting that further arsenical therapy was made possible by the giving of\nsodium-thio-sulphate by mouth during its further courses of treatment.\n1. Kennedy and Foster\u00E2\u0080\u0094Epilepsy and the Convulsive States. Baltimore, Williams and Wilk-\nins, 1931.\n2. Hill, Leonard\u00E2\u0080\u0094The Physiology and Pathology of the cerebral circulation. London,\nChurchill, 1896.\n3. Dandy, W. E.\u00E2\u0080\u0094Am. J. Psychial: 6:519, 1927.\n4. Wilder, R. M.\u00E2\u0080\u0094Mayo Clinic Bull. 2:307, 1921.\n5. Peterman, M. G.\u00E2\u0080\u0094J.A.M.A. 99:546, 193 2.\nPeterman, M. G.\u00E2\u0080\u0094J.A.M.A. 102:1729, 193 4.\nPage 327 PRINCIPLES OF POST-OPERATIVE TREATMENT\nDr. T. H. Lennie\n[We publish the attached lecture by Dr. T. H. Lennie as an example of the type and\nstandard of lectures given to the Internes at the Vancouver General Hospital.\u00E2\u0080\u0094Ed.]\nThis sub jet covers a very large field and is one in which I find great difficulty in preparing subject matter which would be of sufficient authority to designate as a lecture.\nThere is a remarkable diversity of opinion and practise among surgeons of equal competence with little variation in their results. It should be.inferred from this that the rules\nof convalescence should be flexible and adopted to the individual patient. In other words,\none should not feel that his school has said the last word, but should approach each problem\nwith an open mind. For myself, I find as age increases the less dogmatic I become.\nIt seems to me that the first principle of post-operative care is a careful and adequate\npreoperative preparation. The handling of hyperthyroid cases is the outstanding example\nof this, and I feel that, apart from immediate emergencies, many of the means applied in\nthis connection might with advantage be used in surgery generally. I refer particularly\nto adequate rest, the instilling of confidence in the patient regarding this major epoch in\nhis or her life, and I would like to emphasize this point, and the bolstering of resistance to\na surgical attack by adequate fluid and carbohydrate intake.\nIt has been said that every surgeon should undergo an operation, as only in this way\ncan he appreciate the pain and suffering which an operation entails. It is true that memory\nfor pain and physical discomfort in the average individual is short, but I can recall that\nmy first thought after coming out of the anaesthetic some twenty years ago following a\nsimple appendectomy was that I had opened my last abdomen.\nAs was said before, the individual patient must be studied. No two people are entirely\nalike, and the ability to withstand pain varies in races and sexes. The frail little woman\nwill often put the robust male to shame. Post-operative comfort is therefore all important.\nAs to dressings, it is probably sufficient to say that they should adequately protect the\nwound from contamination and irritation. In addition, the dressing should lend support\nto the abdominal wall, but this does not mean the application of large strips of adhesive so\ntightly as to interfere with abdominal respiration and thereby add to the risk of pulmonary\ncomplications.\nAs a rule, a clean wound does not require dressing until the stitches are removed. If,\nhowever, there is the escape of blood or serum, the dressings become uncomfortable and\nshould be renewed. The modern tendency is away from all but necessary drainage, but I\nwould qualify that by saying that when! in doubt, drain. By all means one must drain\nwhen frank pus is encountered. It naturally follows that when drainage is instituted\ndressings must be changed frequently. Just a word about the escape of infected material\non the abdominal wall. The skin may be protected by sterilized vaseline, but, better still,\nif bowel contents are escaping, a paste made up of egg albumin and cornstarch makes a\nvery satisfactory protection.\nThe immediate post-operative orders should provide for: (1) Quiet and relief of pain;\n(2) stimulation if necessary, and (3) the administration of fluids.\nMorphine, unless there is some idiosyncrasy for this drug, is by all means the narcotic\nof choice. This should be given in doses large enough to assure rest, and if the respirations\nare depressed should be combined with atropine. My choice is % morphine and Vl50 atropine, repeated in four hours.\nStimulants, except in long and severe operations, are seldom necessary. Caffeine sodium\nbenzoate 3-5 grains does very well.\nFluids, either by mouth, rectum, interstitially or intravenously. We seem to have\nadopted the intravenous method of giving normal saline and glucose, as this gives the\nquickest response. It has been estimated that within four hours after a major procedure\nthe patient loses 1000 cc. of water and that the average adult requires from 3000 to 4000\ncc. of fluids in 24 hours. One word of warning about salines. The above amounts of\nfluids, if given in this form, would be far in excess of the normal daily requirement, and\n\"pushing\" normal salines may actually do harm by imposing an impossible load on the\nkidneys. Thus it is wise to give some of the fluids in the form of 5% glucose.\nPage 328 Nausea and vomiting may be due to the anaesthetic. The more skilful the anaesthetist\nthe less likely is the patient to vomit. The proper preHminary preparation and absence of\ntrauma during operation will lesson the amount of nausea and vomiting. Of course\nindividual susceptibility varies. Warm water with the addition of small amounts of soda\nwill often serve as a natural lavage. In protracted cases the stomach tube may be necessary. I believe it was one of the Mayo Brothers who remarked that an interne should carry\na stomach tube around his neck rather than a stethoscope.\nDistention may occur after any operation, but is more likely to follow abdominal\nsurgery, particuarly in the upper quadrant. It may vary from a few gas pains to a fatal\ncomplication. It may be avoided largely by gentle handling of the abdominal contents.\nDistension usually manifests itself on the second post-operative day. Loosening of the\nbandage will frequently give relief. The passage of a rectal tube and enemas, with the\npossible addition of heat to the abdomen, will usually suffice.\nBy the third day the patient should be on the road to recovery. He should be on a\nfull liquid diet and possibly some softs. A cathartic is usually given on the night of the\nthird day and he should be returned to his normal diet as soon as possible.\nComplications\nThe average surgical case gets by with remarkable smoothness. It may with some\ntruth be said that the operator's skill may be measured to a large extent by the absence\nof post-operative complications. The majority of complications develop as a result of\npathology in some system or organ not actually concerned in the original disease process;\nbut some serious complications may ensue as a direct result of the operation itself.\nInfection: Leaving out the ordinary wound infections one must always recognize\nthe possibility of septicaemia developing either from the original infection or from infections introduced by a break in the surgical technique. Here one must increase the fluid\nintake, particularly by giving glucose intravenously, and, if there is an accompanying\nblood destruction, blood transfusion. The new drug, Sulphanilamide, will likely prove\na potent addition to our armamentarium.\nCardio-renal and pulmonary complications may be looked upon as medical and, therefore, will not come within the purview of this paper.\nAbdominal Complications: The most important of these are ileus of whatever type\nand acute dilatation of the stomach. Lewis states that \"paralytic ileus has almost disappeared as a post-operative complication due to the perfection of aseptic technique.\"\nTo this can be added the importance of gentle handling of tissues. Any abdominal distension after operation may be regarded as a mild grade of ileus. It is common after\nsurgery of the biliary tract, less likely to follow stomach operations. Large ventral hernia\nrepairs are prone to be followed by distension of a serious nature, but it may also follow\na simple appendectomy. Early recognition is imperative and treatment should be instituted immediately. It is important but difficult to differentiate between paralytic and\nobstructive ileus. In the former peristalsis should be stimulated, in the latter this may\nprove fatal.\nIn paralytic ileus the following measures may be employed: enemas, hot turpentine\nstupes, pituitrin by intramuscular injections, hypertonic salines, acetylcholine, continuous\nsuction and possibly jejunostomy. Spectacular results have been reported following the\nadministration of a spinal anaesthetic. In paralytic ileus, due to general peritonitis, one\nshould not stimulate peristalsis\u00E2\u0080\u0094jejunostomy is the procedure of choice.\nAcute dilatation of the stomach also requires early recognition, and treatment. No\npatient should die from this condition. Gastric lavage is the treatment. In fact I believe\nthe more routine use of continuous suction has in several instances prevented the development of these two distressing conditions. One need hardly point out the rapid development of a grave toxaemia which develops in all obstructive lesions. The object of continuous suction, of course, is to rid the intestines of the toxic material which rapidly\ncollects therein. It is extremely important that the chlorides lost be replaced by normal\nsaline immediately.\nHiccoughs'. This distressing condition is most likely to follow upon extensive operations of the gastro-intestinal tract where large peritoneal surfaces are involved. Next in\nPage 329 order are operations upon the brain and spinal cord. Thus it is difficult to explain the\netiology. The actual mechanism, however, is a spasm of the diaphragm. Lasting for more\nthan a few days it should be looked upon as a very serious complication and} may end\nfatally. Practically every drug in the pharmacopoeia has been advocated for the treatment\nof this condition. This alone would indicate their ineffectiveness. The usual attack is\nself-limited, so that the drug last used gets the credit for the cure. An anti-spasmodic\nsuch as atropine is indicated. In protracted cases gastric lavage followed by large doses\nof morphine should be given and this repeated at intervals. The rest thus obtained is very\nbeneficial.\nInhalations of carbon dioxide have also been advocated. Blocking of the phrenic nerve\nwith alcohol may occasionally be indicated.\nShock: I shall not attempt to define this condition. There is no unanimity of opinion\nas to the exact changes which occur in producing and maintaining shock. It is generally\nrecognized now that this condition depends upon a dilatation of the smallest channels in\nthe arterio-venous tree, thus normal arterial pressure cannot be maintained.\nThe symptoms and signs are subnormal temperature; irregular, rapid and compressible\npulse; cold, pallid, clammy skin; shallow and irregular respirations; consciousness maintained at a low ebb and mentality weak. The sphincters are relaxed. There may be marked\nrestlessness or even delirium. The onset is always rapid. Treatment should include the\nfollowing: heat to the entire body, elevation of the lower part of the body and lowering\nof the head, bandaging the lower extremities, adrenaline for its temporary effect. Blood\nvolume must be increased immediately. Transfusions of whole blood, if available, are by\nfar the most efficacious. As a substitute slightly hypertonic solutions should be used,\npreferably glucose.\nNaturally I realize in this short paper the subject of post-operative care has been very\ninadequately covered. Abdominal conditions have been stressed, as it was felt that the\nsurgery of the specialties could be discussed much more effectively by representatives\nfrom these departments.\nSTREPTOCOCCIC MENINGITIS\nin the Vancouver General Hospital\nDr. T. F. H. Armitage\nStreptococcic meningitis is not a common disease, only thirty-three cases occurring\nin this Hospital in the seven year period, 1932 to 1938, diagnosed by positive culture from\nthe spinal fluid. The disease up until two years ago was almost universally fatal. The\nmajority of these cases have arisen from mastoiditis.\nThere was thought to be a relationship between the incidence of scarlet fever and the\nincidence of mastoiditis, but the statistics on the whole do not bear out this relationship.\nThere were twenty-five cases of mastoiditis in the seventeen hundred and ten cases of\nscarlet fever in the period 1932 to November, 1938.\nThe following figures show the concurrence of these diseases and the results of the\ntreatment of streptococcic meningitis with sulphanilamide. There were no cases up to\nthe beginning of 1937 treated with sulphanilamide, and all cases since that time have\nbeen treated with sulphanilamide either in the form of prontosil or prontylin or both.\nNumber of reported cases of\nScarlet Fever with Mastoiditis\n1932\t\n193 3\t\n1934\t\n193 5\t\n193 6\t\n1937\t\nNov., 1938.\nTotaL.\number of\ncases\nof\nScarlet F\never\n110\n280\n595\n190\n173\n167\n185\n1\n0\n9\n1\n8\n5\n1\n1710\n25\nPage 330 No. of Cases of\nMastoiditis and No. of Cases of\nMastoiditis with Streptococcic Mortality.\nOtitis Media Meningitis d. %\n1932 84 3 3 100%\n193 3 : 137 1 1100%\n1934 ^ 114 1 1 100%\n193 5 108 4 4100%\n193 6 213 11 10 91%\n1937 220 10 7 70%\n1938, Nov 82 3 3 100%\nTotals 958 33 29\nIn 1936 there were 11 cases of streptococcic meningitis, 3 male and 8 female, their\nages ranging from 11/4 to 28 years. The original sources of the infection were as follows:\nOtitis media and mastoid 5 cases\nStreptococcic pharyngitis 1 case\nBronchopneumonia . 1 case\nNot stated . 4 cases\n11 cases\nTen died and one was discharged well. Mortality rate 91%. This case that recovered\nwas a male Chinese, age 10, treated with scarlet fever antitoxin and acriflavine intravenously. None of these was treated with sulphanilamide.\nIn 1937 there were ten cases of streptococcic meningitis, 4 male and 6 female, their\nages ranging from 7 to 78 years. The original sources of infection were as follows:\nOtitis media and mastoid 2 cases\nScarlet Fever \L 1 case\nNot stated 1 case\n10 cases\nSeven died and three were discharged well. All these cases were treated with sulphanilamide.\nUp to November, 1938, there have been only three cases of streptococcic meningitis,\n2 female, ages 1 and 7 years, and 1 male, age 62 years. The original sources of infection\nwere:\nOtitis media and mastoid /\"'* ' 2 cases\nStreptococcic pharyngitis 1 case\n3 cases\nAll these patients died.\nThese thirty-three cases in the Vancouver General Hospital constitute a series in\nwhich there is no selection and the analysis of which does not take into consideration the\ncondition of the patient when treatment was started. In such a group as this, individual\ncases should be studied in considering the final results. For instance:\nCase 1. Reported in November, 1938: Female, age 7 years, had had definite signs of\nmeningitis ten days previous to admission and improved slowly for three days on treatment with sulphanilamide, but died with a bronchopneumonia.\nCase 2. Female, age 1 year, admitted April 4, 1938. Patient's condition was poor\non admission; there were frequent convulsions and twitchings. Patient was treated with\nscarlet fever antitoxn and prontosil but developed bronchopneumonia and died May 5,\n1938. Source of infection was bilateral suppurative otitis media.\nCase 3. Male, age 62 year, admitted September 9, 1938. Patient had chronic otitis\nmedia and condition on admission was poor. Prontosil was given but condition became\nworse and patient died September 11, 1938.\nUp until the time that the use of sulphanilamide in the treatment of streptococcic\nmeningitis became general this disease was almost 100% fatal but now a definite number\nPage 331 can be cured, a great deal depending on the early diagnosis and early treatment. In a\ncomparative series of seventeen cases treated with sulphanilamide by Neal and Appelbowan\nin New York, four of the seventeen cases died and thirteen recovered, the mortality rate\nbeing 24%.\nREPORT ON CASES OF PERNICIOUS ANAEMIA TREATED\nIN THE OUT-PATIENT DEPARTMENT ;^^;\nR. D. MacLaren and B. M. Fahrni\nAt a recent staff meeting of the Vancouver General Hosptal a review of cases from\nthe pernicious anaemia clinic of the out-patient department was presented by Drs. J. E.\nWalker, S. H. Sievenpiper, E. F. Christopherson, R. D. MacLaren and R. M. Fahrni.\nOnly those cases attending since November, 1936, were considered, this date coinciding\nwith the appearance of the more concentrated liver extracts. It was found that there were\nthirty-eight cases which we could conclusively prove were! pernicious anaemia. The data\nobtained was from these thirty-eight proved cases and the conclusions drawn, as well as\nparts of the data which we feel would be of value to the general practitioner, will be given\nbelow:\nDiagnosis: The importance of satisfactorily establishing the diagnosis of pernicious\nanaemia in a new patient by ruling out the other causes of macrocytic anaemia cannot be\noverestimated. The inconvenience, expense and psychic trauma caused by committing a\npatient, especially a relatively young patient, to the sentence of weekly or bi-weekly liver\ninjections for the remainder of his life, are not to- be treated lightly.\nNo symptoms are in themselves diagnostic, but the history of sore tongue, weakness,\nand such neurological symptoms as numbness, tingling of exremites and difficulty in\nwalking, are always suggestive. These cases demonstrating the triad of achlorhydria,\ntypical blood picture, and subacute combined secerosis of course present no difficulty.\nTwenty per cent, of our cases showed no neurological signs or symptoms on admission.\nThe following procedures were carried out, as a routine, in all cases:\n1. Full blood count and colour index.\n2. Gastric analysis for free HC1. with histamine preceding the test in cases of doubt,\nbearing in mind the danger of the use of this drug in elderly patients.\n3. Gastro-intestinal X-Ray\u00E2\u0080\u0094three cases of gastric carcinoma have been picked up\nduring the past eight years, one of which was under treatment with liver extract\nfor two years before admission.\n4. Stool examined for occult blood\u00E2\u0080\u0094this helps in the diagnosis of malignancy and\nless serious causes of chronic blood loss.\n5. Examination of stool for parasites\u00E2\u0080\u0094in the last eight years there has been one case\nof tapeworm infestation picked up at our clinic.\n6. Van den Bergh may be done as further confirmatory evidence, though it is not of\nspecific value.\n7. Sternal puncture as a rule is unnecessary, unless one is in considerable doubt as to\nthe diagnosis, and especially where aleukaemia may be considered a possibility.\nAnother reason why we labour the point of adequate investigation when the case is\nfirst seen is because we not infrequently admit patients who have been on liver treatment\nfor varying lengths of time, and who have had little or no initial investigation, sometimes\nnot even a blood count. In such a case, liver treatment has obscured the original blood\npicture and the only way left to make a definite diagnosis of pernicious anaemia may be\nto discontinue liver therapy and allow the patient to relapse.\nMaintenance Dosage: The majority of those who attend our out-patient department are maintenance cases, those who relapse being hospitalized. As with insulin in\ndiabetes, there is no standard dosage of liver in pernicious anaemia. Our cases were maintained on from 1 to 5 cc. of concentrated liver extract weekly injected intramuscularly,\nthe dose in most cases being 2 cc. per week, although 2 cc. every two weeks was sufficient\nfor many cases (1 cc. of the extract used is equivalent to 100 grams of fresh liver1 (3).\nPage 332 The importance of keeping the red cell count well up to the normal figure, both to prevent the development of neurological lesious, and more especially in those cases where\nsigns of postero-lateral sclerosis are already present, is well recognized. This is demon-\nstread by the fact that two of our cases developed these signs after irregular treatment.\nFour million red blood cells per cubic millimetre and 80% haemoglobin is not sufficient.\nThe figures of five million red blood cells and 95% to 100% haemoglobin should be aimed\nat in every male case, with the count slightly lower in women. It is inexcusable for any\npatient to develop serious incapacitating neurological signs while under treatment for\npernicious anaemia; it means simply that insufficient liver was given\u00E2\u0080\u0094the count was not\nmaintained at sufficiently high level.\nTo cases were satisfactorily maintained on autolyzed liver extract by mouth, the doses\nbeing drs. 1, t.i.d., and q.i.d.\nInhibiting Factors: The amount of liver required to maintain the red cell count at\nnormal level is greater in the presence of any condition to which inhibits haemopoiesis. In\nour patients, as might be expected in their age group, the commonest of these factors\nwas general arteriosclerosis. Second to this cause was infection, most commonly in the\noral activity or respiratory tract, such as carious teeth, septic tonsils, or chronic bronchitis. The presence of diabetes, heart f aliure, duodenal ulcer, pulmonary T. B., and menopausal symptoms, also appeared to act as inhibiting factors.\nCases in Relapse: (These findings were based in indoor patients). The object of the\nreview of these cases was to decide whjat constitutes a satisfactory dosage of liver in this\nstage of the disease. During the past twenty months, twenty-three cases were found suitable for study, the remainder having had insufficient investigation for us to be sure of\nthe diagnosis, or insufficient data to enable the course of recovery to be closely followed.\nThe cases were divided into three groups, depending upon the blood count on admission:\ngroup one constitutes cases below one million, group two between one and two million,\nand group three between two and three million. The complicated and uncomplicated\ncases of each group were separated.\nGroup I: According to Osgood, a satisfactory response in group one entails a reticulocyte count peak of 20% to 70%, with an average of 40%, and according to Minot,\na R. B. C. rise of one million in two weeks. In this group were two uncomplicated cases.\nLiver Dosage up to time of Retic Increase of R.B.C. (millions)\npeak of reticulocyte count Response and time recorded\n1 1 cc. daily for 3 doses 3 0% .95 in 2 weeks\n14 cc. in 1 dose - 20% \u00C2\u00AB94 in 2 weeks\nThe remaining four cases were complicated by arteriosclerosis, active lues, or pneumonia, and larger doses of liver than those stated above gave poorer responses.\nObservations: A total dosage of more than 3 or 4 cc. of concentrated liver extract (\u00C2\u00A3)\nshould apparently be given in cases in this group and daily doses appear more satisfactory\nthan a single larger dose.\nGroup II: Theoretically, in this group, a satisfactory response entails a reticulocyte\npeak of 10% to 60% with an average of 25%, a red cell of one million in two and a half\nweeks. Six cases were uncomplicated and are listed below:\nLiver Dosage up to time of Retic Increase of R.B.C. (millions)\npeak of reticulocyte count Response and time after starting treat\n*4 cc. in one dose 17% .91 on 16th day\n1 2 cc. daily for 2 days 27% .90 on 10th day\n1 3 cc. daily for 5 days 39% .73 on 15th day\n2 2 cc. in one dose 30% 1.21 on 20th dya\n3 5 cc. daily for 5 days 25% 1.3 on 15th day\n4 5 cc. daily for 5 days \ 26% 2.2 on 15th day\nThe four complicated cases in this group suffered from arteriosclerosis, cardiac decompensation, peripheral neuritis, and pneumonia, and responded similarly to the complicated\ncases of Group I.\nObservations: The length of hospitalization necessary in Group II varied but little,\nwhile dosages varied as much as 400%. From the results it would seem that the largest\nPage 333 dose, 15 cc. (1) appeared to do little but increase expense, while the smallest single dose,\n4 cc. (2), was hardly sufficient, and again daily smaller doses gave a better response.\nGroup III: Here a satisfactory response ranges from 5% to 33% reticulocytes with\nan average of 11%. Four uncomplicated cases comprise this group and are recorded as\nin Group II.\n1 1 cc. twice 10.8% 1.0 on 20th day\n1 2 cc. twice 11. % .3 on 5 th day\n1 2 cc. daily for 5 days 17. %\n2 4 cc. once _'_- 8.2% .61 on 27th day\nThe complicated cases responded as in other groups. Complications here were arter-\nioslcerosis, chronic nephritis and essential hypertension.\nObservations: In this group the smallest dose, 2 cc. (1), given evoked a satisfactory\nresponse.\nGeneral Observations: Following the reticulocyte peak in these cases it was found\nbi-weekly injections caused a continued satisfactory response up to the stage where maintenance dosage was commenced. In regard to the complicated cases the necessary dosage\nwas noticeably larger, and to some extent dependent on the severity of the complication.\nAccessory Treatment: After reviewing the results of the accessory treatment given\nour out-patient department cases of pernicious anaemia, we find our views much the same\nas those stated by some of the eastern clinics, i.e., in regard to the use of iron, hydrochloric acid, transfusions, and vitamin B.\nIron: It is believed that in pernicious anaemia the breakdown products of red cells\nare stored in the body, and are available at once for the manufacture of haemoglobin,\nshould normal blood formation recur as the result of a natural remission or liver therapy.\nIn the patient who presents himself with a one million red cell count, it is not uncommon\nfor the colour index to fall below one, temporarily, during the rapid rise expected from\nadequate liver therapy, i.e., for the red cell rise to be greater in proportion than the rise\nin haemoglobin. But it is usual that following this initial rapid rise the colour index again\nbecomes greater than 1.0. However, in a few cases the iron storage may not be sufficiently\ngreat to prevent the C.I. from remaining below 1.0 for a considerable period, as the\nblood count rises. Under such circumstances we feel that iron is indicated. In three of\nour cases we noticed almost specific effects from iron when given in addition to liver\ntherapy. For example, one case of ours, who, when first seen, had a count of 1.5 million,\nimproved as expected on liver therapy until a count of 3.3 million was reached. No\nfurther increase was noted, even though 6 ccs. of concentrated liver extract were given\neach week. Iron and ammonium citrate (90 grs. a day) was then started and the count\nrapidly rose to 5 million, where it has remained, the patient requiring 2 cc. of liver\nextract a week to maintain her count at this level. In 5 0 % of our cases iron was not used\nand in 40% of the remainder was of no apparent benefit, so we conclude that the average\ncase of pernicious anaemia does not require iron, with the exception of the above stated\nconditions, or when the case is complicated by haemorrhage from any cause. Previously\nlarge doses of iron were thought to benefit neurological symptoms, but this has been\nshown many times not to be the case, and certainly caused no improvement in our cases.\nHydrochloric Acid: In regard to hydrochloric acid we consider the only indication\nin pernicious anaemia to be in the treatment of digestive disturbances\u00E2\u0080\u0094certainly some\ncases of dyspepsia which are not alleviated by specific liver therapy are kept well in check\nby the use of l/z to 1 drs. of dilute hydrochloric acid taken with meals. Among our cases\nthe incidence of those given hydrochloric acid for the control of gastro-intestinal symptoms was just below 25%. Two cases obtained more relief when pepsin was added. The\nachlorhydria of pernicious anaemia does not appear to greatly affect the absorption of iron\nfrom the gastro-intestinal tract.\nArsenic: None of our patients in this series received Fowler's Solution; it is generally\nagreed that arsenic is of no benefit in the treatment of pernicious anaemia.\nTransfusions: While formerly transfusions were frequently given to pernicious\nanaemia patients with haemoglobin of 30% or less, it is now felt that unless the patient is\nsuffering from the effects of insufficient oxygen carriage, at bed rest, this procedure is\nPage 334 not indicated. Transfusion has no beneficial effect on blood production in pernicious\nanaeemia and it has been shown that giving 500 cc. of citrated blood affects very little in\nthe end the time required to bring the count of a patient from one to four million, when\nadequate liver therapy is given. In contrast to hypochromic anaemia there is an added\ndeficiency element often not relieved by elevating the blood1 count alone, and frequently\ndo not disappear until some of the deficiency factor in the form of liver is supplied. Since\nclinical improvement in our cases began three to four days after injection of liver, and\nin two of our cases no improvement in symptoms was noticed following transfusion, we\nbelieve that liver extract rather than blood is always the primary need. It must not be\nforgotten also that serious transfusion reactions are more apt to occur in the severely\nanaemic patient than in one with a haemoglobin of 60%. So we consider the chief indications for transfusion to be the following:\n1. In the presence of some severe inhibiting factor, such as infection (notably pneumonia), or arteriosclerosis.\n2. Where surgery is contemplated, several transfusions may be given in addition to\nliver therapy to repidly elevate the blood level.\n3. Where there is definite doubt as to the diagnosis, a small transfusion is the safe\nand conservative course.\n4. Where the case is complicated by haemorrhage from any cause.\nVitamin B: The role of vitamin B in the treatment of pernicious anaemia is at present\nuncertain. In 1932, Castle believed that the extrinsic factor deficient in this anaemia was\nvitamin B.2, but this has been shown not to be so. With the recent flair for vitamin B.l\nin medical treatment, it was suggested that all cases of pernicious anaemia with sensory\nchanges in the extremities be given this vitamin. Consequently, six of our cases were\nput on what was considered adequate dosage of vitamin B. 1 with improvement in paraes-\nthesias in only one case. The few cases reported improved in the literature were uncontrolled, and like our cases do not constitute significant evidence that vitamin B is of any\nvalue in the treatment of pernicious anaemia.\nLegend'.\n1 Lederle's Concentrated - Anahaemin \u00E2\u0080\u00A2\u00C2\u00BB Ccnnaught \"* Campolon\nUPPER ISLAND MEDICAL ASSOCIATION\nThe members of the Upper Island District Medical Association gathered for a Dinner\nMeeting at Qualicum on Wednesday, June 21st. While not as largely attended as the\nAnnual Meeting, which takes place in the Fall, it/ was not lacking in enthusiasm.\nThose present included: Dr. P. L. Straith, Courtenay, the President; Dr. T. L. Briggs,\nCourtenay, Secretary; Dr. G. K. MacNaughton, Cumberland; Doctors C. T. Hilton and\nR. W. Garner of Port Alberni; Doctors C. C. Browne, W. F. Drysdale, S. L. Williams and\nE. D. Emery of Nanaimo; Doctors J. McKee and H. A. L. Mooney of Courtenay; Doctors\nH. A. DesBrisay and M. W. Thomas, Executive Secretary, visiting from Vancouver.\nA short business session preceded the papers of the evening.\nDr. C. C. Browne of Nanaimo dealt with Separation of the Tibial Tuberosity, discussing fully etiology and treatment, proving that the general outlook in these cases was\ngood. He was able to show a series of interesting ^ilms illustrating case reports.\nDr. H. A. DesBrisay of Vancouver presented in a very interesting way a Review of\nNewer Trends in Modern Medicine, stressing particularly recent therapeutic advances\nand showing wherein they were very practicable and based soundly on our knowledge of\nchanges in disease. He told of useful tips in diagnosis which could be easily used outside\nof hospital practice.\nDr. M. W. Thomas, Executive Secretary, told the members of the work in the office\nof the College of Physicians and Surgeons and finally reminded all of the excellent programme being prepared for the Annual Meeting to be held in September.\nDoctors Hilton and MacNaughton presented a vote of thanks to those who had\nprovided the programme and such an interesting meeting.\nPage 335 POSSIBILITY OF FAULTY DIAGNOSIS OF DIABETES\nIN PATIENTS TAKING THIAMIN CHLORIDE\nRuth S. Hart, M.D., and Louis E. Wise, Ph.D,, Winter Park, Florida\nReprinted from J.A.M.A. Feb. 4, 1939, p. 423.\nThe first morning specimen of urine collected from the patient, Mr. L. W., showed\nvery marked reduction of Benedict's solution. The following morning the fasting blood\nsugar content was determined and found to be 90 mg. per hundred cubic centimetres.\nThe following day, after a breakfast high in carbohydrates, the urine was again examined\nand showed no reduction. At intervals thereafter, with a continued daily dose of 4 mg. of\nthiamin chloride, the urine either showed traces of reducing substances or no. reduction\nwhatever. The medication of the patient, begun a month prior to the first examination,\nwas two tablets of thiamin chloride prior to each meal (i.e 6 mg. a day), three 1 l/z grain\n(0.1 Gm) tablets, of theophylline with ethylenediamine and 3 grains (0.2 Gm) of phenobarbital daily. Neither theophylline with ethylenediamine nor phenobarbtal reduced\nBenedict's solution.\nOn the other hand, 10 mg. of pure thiamin chloride in 1 cc. of distilled water reduced\nBenedict's solution only slightly, giving an atypical yellow precipitate.\nWhether or not thiamin chloride alone was responsible for the reducing substance\nfound in the urine originally examined still is problematical.\nMorning specimens from three other patients who were on at least 6 mg. of thiamin\nchloride daily were examined and showed no reduction of Benedict's solution. Of these,\none patient was taking in addition to thiamin chloride an uncertain amount of morphine.\nOne other was taking 40 grains (2.5 Gm) of acetylsalicylic acid daily.\nThe following possibilities in this case must be considered:\n(a) Storage of thiamin chloride with marked elimination at intervals.\n(b) Elimination of oxidizable degradation products of thiamin chloride.\n(c) Elimination of oxidizable degradation products of theophylline with ethylenediamine or phenobarbital or both.\n(4) Lowering of the renal threshold to dextrose through the agency of thiamin\nchloride.\nThe question arises of the accuracy of Benedict's test for measuring dosage of insulin\nwith patients taking thiamin chloride.\nConclusions\n1. Pure thiamin chloride will reduce Benedict's solution in vitro.\n2. Urine of one patient receiving 6 mg. daily of thiamin chloride reduced Benedict's\nsolution despite a blood sugar of 90 mg. per hundred cubic centimetres of blood.\n[We reprint this as what we consider rather an important item, in these days of extensive use of vitamin B. Our attention was drawn to the matter by Dr. Hebb of the medical\nstaff of the Vancouver General Hospital who, quite independently, had made the discovery that the administration of thiamin chloride, in two cases, led to reduction of Benedict's solution by the urine of the people concerned, though neither was diabetic. One\nlarge manufacturing firm assured him his ideas were nonsensical, but another, perhaps\nmore up-to-date, was able to locate for him the short article reproduced above, of which\nDr. Hebb knew nothing. We feel that this constitutes an important warning in the treatment of diabetes and others, and thank Dr. Hebb for letting us know about it.\u00E2\u0080\u0094Ed.]\nPage 336\nmMmi St Paul's Hospita\nREPORT OF A CASE OF PRIMARY CANCER\n| OF THE LIVER \u00C2\u00A7 ;|\nBy C. H. Vrooman and A. Y. McNair\nThose who attended the clinic of Doctor Holman at St. Paul's Hospital during the\nSummer School session will remember the case of a Chinaman with large haemorrhagic\nascites, in which the diagnosis was discussed but nothing definite arrived at. We are now\nable to present the post mortem report.\nHISTORY\nChinese cook, aged 48, seen first on April 13th, 1939, complaining of lumbago.\nNothing was noted in the abdominal examination at that time. He was seen a second time\non May 26th when he complained of acute swelling of the abdomen of only two weeks'\nduration. The abdomen was greatly distended, and the patient was sent to St. Paul's\nHospital, where about 1000 cc. of blood was aspirated. Even after aspiration the liver\ncould not be well defined, though it was thought it had slightly roughened edges. The\nman was again aspirated at the clinic, and pure blood Was again found. He gradually\ngot worse, and died on June 9 th.\nDoctor McNair did a post mortem, and reported as follows:\nPost mortem examination of Chew Lee, age 39. Apparent age of this Chinaman was 45,\nfairly well developed and poorly nourished. Two small trocar holes, from which bloody,\nperitoneal fluid exuded, were seen in the lower abdomen, which was markedly discolored\nfrom subcutaneous extravasation of blood. No marks of violence were seen on the body.\nPeritoneal cavity contained approximately one quart of blood, with some increase in\nperitoneal fluid. Liver was enlarged, particularly the right lobe. Stomach was small and\ncontained some \"coffee-ground\" material. Spleen, esophagus, and gastric wall were negative. Gall bladder and cystic duct were negative except for some biliary sand. Duodenum\nwas normal. Ampulla of Vater and pancreas were normal. Kidneys were negative except\nfor mild arteriosclerotic changes. Intestines from end to end showed nothing remarkable.\nLiver showed many adhesions to surrounding structures, weighed approximately 1800\ngrams, with a very marked enlargement of the right lobe. On section there was a very\nlarge tumour mass involving right lobe and practically replacing three-quarters of it, with\nnumerous other smaller areas of malignancy scattered through the left central portion.\nPortal vein and splenic vein were opened in situ. These two vessels were filled with\nmalignant thrombi throughout with the large tumour growth in the liver. In the liver\nthese thrombi were fairly firm, and very densely adherent to the vessel walls. Tumour in\nthe liver on section was grayish-yellow in colour, very soft, and central portions undergoing liquefaction.\nNo secondary growths were found anywhere in the body. Lungs showed terminal\nbroncho pneumonia. Heart was rather small, very lean, and had the appearance of a heart\nof starvation.\nMicroscopically, the chief point of interest was the liver. Sections of the liver show\nvery definite cirrhosis of the unilobular type, with very heavy, fibrous trabeculi separating\nthis into small islands of various sizes, and containing from one to three lobules. Portal\nareas show a good deal of round cell infiltration, and many bile ducts compressed and\nscarred. Liver cells themselves stain rather diffusely, and their cell margins are indistinct.\nCentral vein areas are moderately engorged. Tumour varies considerably in density, with\nmany areas of softening and degeneration, and other areas show growth to be the outstanding feature. In many respects these cells have the appearance of liver cells. Many of\nthem are arranged in cords, are quite hyperchromatic and hyperplastic. Many tumor giant\ncells are seen, with active mitoses, and complete loss of normal lobular arrangement.\nPage 337 Tumour is quite vascular and in places tumour cells line venous sinuses. Extravasation of\nblood into the tumour mass is quite marked. Search for parasites in the liver and duodenum\nwas negative.\nThis is a malignant hepatoma, and has been superimposed on a liver showing moderately well advanced cirrhosis, with malignant thrombus formation filling portal and\nsplenic veins, with terminal broncho pneumonia and concealed hemorrhage.\nCANADIAN MEDICAL ASSOCIATION\nThe Seventieth Annual Meeting has passed into history and Montreal excelled itself\nboth in weather and the success of the convention. 1085 registrants enjoyed a fine\nprogramme.\nDr. T. H. Leggett, Chairman of General Council presided, with an attendance of 8 8.\nThe Council adopted the consolidated Constitution and By-Laws for which a Committee\nwith Dr. R. I. Harris as chairman, is to be commended.\nFederation: New Brunswick has applied for status as a Division and it now remains\nfor Manitoba to take similar action arising out of its Annual Meeting in September to\nbring the nine provinces into Federation.\nArising from recommendations in the splendid report of the Committee on Economics, of which Dr. Wallace Wilson of Vancouver is chairman, Mr. Hugh H. Wolfenden\nhas been engaged as consultant to assist the committee in its work during the coming year.\nTen Senior Members were elected and included Doctors Harvey Smith of Winnipeg,\nR. D. Rudolf of Toronto, W. C. Galbraith of Lethbridge and I. Glen Campbell of Vancouver.\nIn 1940 the Annual Meeting will be held in Toronto and in Winnipeg in 1941. In\n1942 the meeting will come west to Alberta. There is a suggestion that it may be held\nat Banff or Jasper, in which case the British Columbia Medical Association would be asked\nto hold its meeting at that time.\nThe needs of refugee doctors and their admission to practice in Canada were sympathetically studied. It was felt, however, that more than sufficient doctors are graduating\nfrom Canadian Medical Schools to provide for the needs of the Dominion.\nAmong the distinguished visitors to the meeting were Sir Arthur MacNalty, Chief\nMedical Officer, Ministry of Health for Great Britain, London, England; Professor Edward\nProven Cathcart, Professor of Physiology, University of Glasgow; Dr. Thomas S. Cullen\nof Baltimore, fraternal delegate of the American Medical Association; Dr. Allen O.\nWhipple of Columbia University, New York, who gave the Lister Lecture.\nMontreal did herself well.\nDr. G. F. Strong of Vancouver was elected to the Executive Committee of the\nCanadian Medical Association as representative from British Columbia, which position\nwas capably filled by Dr. Gordon Kenning of Victoria during last year.\nIMPRESSIONS OF THE ANNUAL MEETING OF THE\nCANADIAN MEDICAL ASSOCIATION, JUNE 19, 1939\nF. Sidney Hobbs, M.D.\nWas the Annual Meeting of the Canadian Medical Association, held in Montreal, a\nsuccess? Emphatically yes. From the time the first committee meetings were held until\nthe final wind-up with the Golf Tournament and Golf Dinner, there was never a dlill\nmoment. If any criticism was to be made it would be that there were too many good things\non at the same time, so that often one had to miss lectures which one would like to have\nheard.\nThe programme began with the meeting of the General Council on Monday morning.\nDrs. Wallace Wilson and G. F. Strong flew to Montreal to be present. Tuesday was set\naside for meetings of the General Council and the Council were guests in the evening\nat a dinner given by the Montreal Medical Chirguical Society and La Societe Medical de\nMontreal. The dinner was very well attended and by that time a great many of the\nPage 338 doctors were present who had come for the general meetings, so it was pleasant to renew\nold acquaintances among teachers, classmates and friends.\nThe scientific programme got underway on Wednesday and was without a doubt one\nof the best that has ever been presented. The round table conferences were well attended,\nbut what a struggle it was to be on time at 8:30 a.m. when one had been well, perhaps, too\nwell entertained the night before! To give a detailed account of each meeting is out of\nthe question but mention should be made of the papers presented by the doctors from\nBritish Columbia. Dr. D. E. H. Cleveland gave a well received paper on \"The place of\nAllergy in the diagnosis of skin conditions,\" and Dr. Kinsman spoke on \"Some aspects\nof intra-cranial birth injuries.\"\nOne of the best events of the meeting was the Lister Oration, presented by Dr. Allen\nO. Whipple of New York. His subject was \"A consideration of recent advances in surgery\nin the light of Lord Lister's studies.\" Other professors from outside of Canada were Professor E. P. Cathcart from Glasgow and Dr. Norman Miller of Ann Arbor, Michigan.\nThe latter gave a particularly good talk on treatment of dysmenorrhcea, which suggested\nmany new angles of attack on this problem-\nBritish Columbia was honoured by the election of Dr. Glen Campbell to Senior Membership in the Association.\nThe scientific exhibits were well arranged and well attended. Dr. Norman Kemp was\nbusy at the Ayerst, Harrison and McKenna booth, describing all the latest hormones that\nhis company have brought out. He forgot business however, when he suggested a trip to\nroom 704, where with glass in hand, he asked all about his old friends in Vancouver. It\nwasn't hard to see that his thoughts often strayed back to Vancouver.\nAnd what of the entertainment provided? To say the least, it was excellent. The dance\nheld at the Chalet on Mount Royal was a great treat, as was; the dance held' on the Nor-\nmandie Roof of the Mount Royal. The golf dinner on Friday night wound up the meeting.\nThe ladies' entertainment was well looked after\u00E2\u0080\u0094one doesn't need to worry about entertaining one's wife at such a meeting\u00E2\u0080\u0094that is all looked after. How hard it must be for the\nladies to come down to ordinary living after being entertained at Beaconsfield and Mount\nBruno!\nThe weather man was kind to us, too, the only rain being on the afternoon of the\ngolf tournament.\nAnd so, on Saturday morning the hotel lobby was deserted, and the medical profession\nof Canada was returning home, but with happy feeling of having learned a little, and\nrenewed a great many old friendships. One and all resolved that when next year rolls\naround, instead of buying tickets for Montreal, they will be for Toronto, where just as\nmany old friends will be on hand to greet us again.\nThe officers of the Canadian Medical Association elected for the coming year are:\nPresident\u00E2\u0080\u0094Dr. F. S. Patch, Montreal.\nChairman of Council\u00E2\u0080\u0094Dr. T. H. Leggett, Ottawa.\nHonorary Treasurer\u00E2\u0080\u0094Dr. D. Sclater Lewis, Montreal.\nEditor\u00E2\u0080\u0094Dr. A. G. Nicholls.\nGeneral Secretary\u00E2\u0080\u0094Dr. T. C. Routley.\nAssociate Secretary\u00E2\u0080\u0094Dr. G. Harvey Agnew.\nPresident-elect\u00E2\u0080\u0094Dr. D. Graham.\nJOHN SIMON GUGGENHEIM MEMORIAL FELLOWSHIPS\n\u00C2\u00A7 \"^f\" FOR CANADA :\u00C2\u00A7M\nAnnouncement has been made that the Fellowships of the John Simon Guggenheim\nMemorial Foundation have been extended to Canada and Newfoundland. These Fellowships were established in 1925 by the former U. S. Senator and Mrs. Simon Guggenheim\nin memory of a son John Simon Guggenheim. By them during the past 15 years, 840\nartists, poets, novelists, composers of music* biologists, physicists, economists and workers\nPage 339 in all fields of the mind and spirit have been assisted, and now six stipends, normally fixed\nat $2,500 a year will be awarded annually to assist scholars and artists from Canada and\nNewfoundland to go to the United States to do research and creative work in their\nvarious fields.\nFor information please write to Henry Allen Moe, Secretary General, John Simon\nGuggenheim Memorial Foundation, 551 Fifth Avenue, New York City, U.S.A.\nA circular regarding the above is now in the library, which gives some further information and also gives a list of those scholars of Canadian origin who have already been\nawarded one of these scholarships.\ns.\nBOWELL\n&\nSON\nDistinctive Funeral\nService\nPhone 993\n66 SIXTH STREET I\nSTEW WESTMINSTER, B. C.\nmm,\nBreaks th^/icibusfprcle of perverted\nmenstrual function in cases of amenorrhea,\ntardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic\nrelief bj)|\u00C2\u00A7timulati||g the5|hnervation^ the\nuterus and stabilizing tBe tone of its\nmusculature. Contr||s thelutero-ovarian\ncirculation and thereby encourages a\nnormal menstrual cycle. ,f|i\u00C2\u00A7\np\nIP\n\u00E2\u0080\u00A2 MARTIN H. SMITH COMPANY\nISO IAFATCTTI STRUT. NEW YORK. N. V.\n^H\nFull formula and descriptive\nliterature on request\nDosage: l to 2 capsules\n3 or 4 times daily. Supplied\nin packages of 20.\nEthical protective mark MHS\nembossed on inside of each\ncapsule, visible only when capsule is cut in half at seam.\n1\nPage 340 oo,\nayt^\na\nhow long does it take you to add\nP. D. &CO. to your prescriptions?\nAssure for your patients the quality of medicinal agents made possible by\nseventy-three years of scientific research and manufacturing experience THE MENOPAUSAL SYNDROME\nPOST-MENOPAUSAL CONDITIONS\nINHIBITION OF LACTATION\n\u00C2\u00A3-5 ttolren e\nIdentifies the Ayerst products prepared from diethyl stilboestrol, a\nsynthetic compound known to have powerful oestrogenic properties\nfollowing either oral or intramuscular administration. Available in\ncapsule and ampoule form as follows:\nFor oral use\n\"Estrobene\" (diethyl stilboestrol in oil)\nSoft Gelatin Capsules\nNo. 233 0/2 mg.)\u00E2\u0080\u0094boxes of 25 and 50\nNo. 234 (1 mg.)\u00E2\u0080\u0094boxes of 25 and 50\nNo. 235 B| mg.)\u00E2\u0080\u0094boxes of 12 and 25\nFor parenteral use\n\"Estrobene D.P.\" (diethyl stilboestrol dipropionate in oil)\n1 cc. ampoules\nNo. 479 (1 mg.)\u00E2\u0080\u0094boxes of 10 and 25\nNo. 480 (5 mg.)\u00E2\u0080\u0094boxes of 10 and 25\nDue to variations in the potencies of different forms of diethyl stilboestrol (amorphous as\nopposed to crystalline forms), the Ayerst brand is made available under the trade name\n\"Estrobene\" as a guarantee of uniformity.\nAYERST, McKENNA & HARRISON LIMITED\nBiological and Pharmaceutical Chemists\n879 MONTREAL \u00E2\u0080\u00A2 CANADA NEUTRASIL\n(Hydrated Magnesium Triscilicate B.D.H.)\nNeutrasil is pre-eminent among antacids. Within the range of pH encountered in\ngastric hyperacidity and at body temperature, Neutrasil is partly decomposed immediately upon administration, but the process continues over a considerable period.\nIncomplete immediate decomposition eliminates all danger of excessive alkalinity,\nfurther secretion of acid effecting the delayed release of free alkali as it is required.\nThe silica gel produced concurrently forms a protective layer over inflamed areas;\nthus it absorbs acid which may have escaped neutralisation, further it absorbs toxic\nproducts, inactivating them until they are eliminated.\nNeutrasil is indicated, therefore, in all cases of gastric hyperacidity, in gastric and\nduodenal ulcer and in toxic intestinal derangements.\nStocks of Neutrasil are held by leading druggists throughout the Dominion,\nand full particulars are obtainable from\nTHE BRITISH DRUG HOUSES (CANADA) LTD.\nTerminal Warehouse Toronto 2, Ont.\n NEU/CAN/398\nMount pleasant TUnbertaking Co. %tb\nKINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.\nR. F. HARRISON W. R. REYNOLDS The New Synthetic Antispasmodic\nTrasentin \"Ciba\"\n(Diphenylacetyldiethylaminoethanolester-hydrochloride)\nSUPPRESSES SPASMS OF THE GASTRO-INTESTINAL\nTRACT, GENITOURINARY SYSTEM AND\nOTHER SMOOTH MUSCLE ORGANS\nTablets\u00E2\u0080\u0094bottles of 20 and 100. Ampoules\u00E2\u0080\u0094boxes of 5 and 20.\n1 tablet or 1 ampoule contains 0.075 grm,\nof the active substance.\nCIBA COMPANY LIMITED\nMONTREAL\n13 th Ave. and Heather St.\nExclusive Ambulance Service\nFAIRMONT 80\nPRIVATE AMBULANCES AND INVALID COACHES\nWE SPECIALIZE IN AMBULANCE SERVICE ONLY\nJ. H. CRELLIN\nW. L. BERTRAND Protecting Children . . .\nNOW that schools are about to reopen,\nphysicians are again reminding parents\nto have their children given the benefit of\nspecific protection against certain communicable diseases. This protection is highly\nI \u00E2\u0084\u00A2 \u00C2\u00AB\nimportant both for school children and for\nyounger children and infants.\nDIPHTHERIA\nThe administration of three doses of diptheria toxoid has been found to\nbe most effective in affording protection against diptheria. Active immunity\nto this disease is established in well over ninety per cent of those receiving\nthe three injections.\nSMALLPOX\nModern technique and vaccine virus of assured potency make possible a\nmaximum number of \"takes\" with a minimum of reactions and scars.\nSCARLET FEVER\nProtection as evidenced by the Dick Test can be demonstrated in the\ncase of more than seventy per cent of children following their receiving five\ndoses of scarlet fever streptococcus toxin.\nWHOOPING COUGH\nInjections of a vaccine made from freshly isolated strains of H. pertussis\nhave given most promising results in prevention of whooping cough. This\ndisease provides an outstanding illustration of the importance of immunizing children before their attaining of school age. Often, as in the case of\nwhooping cough, it is among the younger children and infants that illness,\nsequelae and death occasioned by communicable diseases are most notable.\nCONNAUGHT LABORATORIES\nUNIVERSITY OF TORONTO\nToronto 5\nCanada\nDepot for British Columbia\nMacdonald'S Prescriptions Limited\nMEDICAL-DENTAL BUILDING, VANCOUVER, B. C. t\n2559 Cambie Street\nancouver\n1B. C.\nColonic\nIrrigation\nInstitute\nSup erint endent:\nE. M. LEONARD, R.N.\nPost Graduate Mayo Bros.\nUp-to-date treatment rooms;\nscientific care for cases such as\nColitis, Constipation, Worms,\nGastro-intestinal Disturbances,\nDiarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.\nIndividual Treatment $ 2.50\nEntire Course $10.00\nMedication (if necessary)\n$1 to $3 Extra\n1119 Vancouver Block\nVANCOUVER, B. C.\nPhone: Sey. 2443\n506-7 CAMPBELL BUILDING\nVICTORIA, B.C.\nPhone: Empire 2721\nThe Purified\nACTIVE PRINCIPLE\nOF\nSANDALWOOD OIL\niU\u00C2\u00AB^ ECONOMICAL\nDosage Form\nDoctor, why use ordinary sandalwood\noil when you can just as easily administer the active principle of the oil\nwith the irritating and therapeutically\ninert matter removed\u00E2\u0080\u0094and at a cost\nto your patients of only a very few\npennies more?\nYou can do this by prescribing' the\nnew, economical 50-centigram capsules of\nARHEOL\n(ASTIER)\nnow obtainable in bottles of 12, 24 and\n100 capsules at $1.00, $1.75 and $6.00\na bottle respectively.\nARHEOL. is the purified active principle of sandalwood oil. It is a uniform, standardized product with which\nprompt and dependable results may\nbe expected. Undesirable sequelae\noften associated with sandalwood therapy are either absent or reduced to a\nnegligible degree.\nA3-BVMA\nROUGIER FRERES, Agents\n350 Le Moyne Street, Montreal.\nPlease send me a sample of\nARHEOL (Astier) in the new\neconomical dosage form.\n M.D.\nStreet\t\nCity Prov.\n^tQ^^KMli^i^s::S t r e e t, M o n t r e a I Kellogg's ALL-BRAN\nprovides iron and\nVitamin Bi as well as\nLAXATIVE BULK\nMade by Kellogg's\n\u00E2\u0096\u00A0\u00E2\u0080\u009E W1TH MALT SUGAR AND SALT\nDUE TO DIET DEFICIENCY\nOF-BULK\"\nKELLOGG COMPANY Or CAHADA.LTD4.0ND0N.0NT.\nin London, Canada\nA PRESCRIPTION SERVICE . . .\nConducted in accord with the ethics of the Medical\nProfession and maintained to the standard suggested by\nour slogan:\nPharmaceutical Excellence\nMcGi SOrmr,\nLIMITED X*\u00E2\u0080\u0094^\nFORT STREET (opp. Times)\nPhone Garden 1196\nVICTORIA, B. C.\nMEMBERS of THE GUILD\nof PRESCRIPTION OPTICIANS of AMERICA\nAlways Maintain the\nEthical Principles of\nthe Medical Profession\nGuilder aft Opticians\n430 Birks Bldg. Phone Sey. 9000\nVancouver, Canada. A Word of Thanks...\nTo the Medical Profession for their assistance\nto the dairy industry in making known to the\nconsuming public the important part dairy\nproducts play in promoting health.\nIT PAYS TO BE SURE OF YOUR MILK SUPPLY\nMILK CREAM BUTTERMILK MEAQJSfBKWERpEH\nAT NO INCREASED COST TO THE PATIENT\n\u00E2\u0080\u00A2 MEAD'S BREWERS YEAST TABLETS\nVitamin Bi potency increased from 25 to 50 International units per gram. Vitamin G (riboflavin) potency\nincreased from 42 to 50 Sherman units per gram. Each\ntablet now supplies approximately 20 units each of\nthese vitamins, so that dosage may be calculated\nreadily in round numbers by the physician. Supplied\nin bottles containing 250 and 1,000 6-grain tablets..\n\u00E2\u0080\u00A2 MEAD'S BREWERS YEAST POWDER\nis also thus increased in potency per gram. In addition,\nit is now improved in texture so that it mixes more\nreadily with various vehicles the physician may specify\nin infant feeding. Supplied in botiles containing 6 ozs.\nMEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ontario\nZtkicaUtf, Marketed\njta Mte. futMUc Confident Accuracy\nTHE EXPERIENCE OF 30 YEARS'\nPRESCRIPTION WORK MAKES\nDOUBLE - CHECKED ACCURACY\nA CERTAINTY.\nFree City Delivery until 12 p.m.\nSEymour\n2263\n.\nc\u00C2\u00A3\u00C2\u00A7*UJL ^.JtktooleAAori\nGEORGIA PHARMACY\nl_ PM I T E D\nOIOR\u00C2\u00ABIA\nfTMIT\nDay or\nNight\ntitenfrr $c ISjatma ffiti\nEstablitbtd 1993\nVANCOUVER, B. C.\nNorth Vancouver, B. C. Powell River, B. C.\nagn.u^aacau.:'isi:s-!rjmK,;K<.-<7\u00E2\u0080\u009En- -in \u00E2\u0080\u00A2\u00C2\u00BB\u00E2\u0096\u00A0\u00E2\u0096\u00A0 w;rr-^gnumnw Hollywood Sanitarium\nLimited\nFor the treatment of\nAlcoholic, Nervous and Psychopathic Cases\nExclusively\nReference\u00E2\u0080\u0094B. O. Medical Association\nFor information apply to\nMedical Superintendent, New Westminster, B. C.\nor 515 Birks Building, Vancouver\nSeymour 4183\nWestminster 288\nROY WRiaLKY PRINTING u*|\u00C2\u00A3:=SS\u00C2\u00BB>ft PUBLISHING CO. LTD\n' ."@en . "Periodicals"@en . "W1 .VA625"@en . "W1_VA625_1939_08"@en . "10.14288/1.0214426"@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: August, 1939"@en . "Text"@en . ""@en .