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History of Nursing in Pacific Canada
Vancouver Medical Association
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mm the BULL of the I VANCOUVER MEDICAL ASSOCIATION â Vol. XVI SEPTEMBER, 1940 No. 12- With Which Is Incorporated Transactions of the Victoria Medical Society the Vancouver General Hospital and St. Paul's Hospital "Â«p" In This IssueS Page NEWS AND NOTES^g || ^---^p . S ^^^R 345 B. C. MEDICAL ASSOCIATION REPORTS ..A ijjlfe â â ':â :. '^^fll^ *49 A SUMMARY OF THE PROBLEM OF JAUNDICEâBy C. E. Gould, MJX 355 THE BLOOD SEDIMENTATION TEST AND THE WELTMANN REACTIONâBy J. P. Henry, M.DJp:;. JK| ~^fe ^^^Â»361 NEW WING ADDED TO ST. PAUL'S HOSPITAL Jg'366 BRITISH COLUMBIA MEDICAL ASSOCIATION ANNUAL MEETINGâNELSONâSEPT. 9, 10, 11. A useful adjuvant in treating: Tonsillitis Pharyngitis Laryngitis Coughs and other inflammations of the respiratory tract. Antiphlogistine âis always indicated wherever the effects of prolonged moist heat are desired, plus the medication of its ingredients. It contains: 45% cp. glycerine, small quantities of iodine, boric and salicylic acids, essential oils, in a vehicle of dehydrated silicate of aluminum. Sample on request THE DENVER CHEMICAL MFG. CO. 153 Lagauchetiere St. W. Montreal Made in Canada â¢^â ^r-.j^.,-i3jfcÂ» THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C. EDITORIAL BOARD: Dr. J. H. MacDebmot Dr. G. A. Davidson Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XVI SEPTEMBER, 1940 No. 12 OFFICERS, 1939-1940 Dr. D. F; Busteed Dr. W. M. Paton Dr. A. M. Agnew President Vice-President Past President Dr. W. T. Lockhart Dr. Murray Baird Hon. Treasurer Hon. Secretary Additional Members of Executive: Dr. C. McDiarmid, Dr. L. W. McNutt. TRUSTEES Dr. F. Brodie Dr. J. A. Gillespie Dr. F. W. Lees Auditors: Messrs. Plommer, Whiting & Co. SECTIONS Clinical Section Dr. Karl Haig Chairman .Dr. Ross Davidson Secretary Eye, Ear, Nose and Throat Dr. W. M. Paton Chairman Dr. G. C. Large Secretary Pediatric Section Dr. R. P. Kinsman Chairman Dr. G. O. Matthews Secretary STANDING COMMITTEES Library: Dr. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies, Db. W. A. Bagnall, Db. T. H. Lennie, Db. J. E. Walkeb. Publications: Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson. Summer School: Db. T. H. Lennie, Dr. A. Lowrie, Db. H. H. Caple, Db. Feank Tubnbull, Db. W. W. Simpson, Db. Kabl Haig. Credentials: Db. A. W. Hunteb, Db. W. T. Ewing, Db. A. E. Tbites. V. O. N. Advisory Board: Db. C. E. Riggs, De. T. M. Jones, Db. R. E. McKechnie II. Metropolitan nealth Board Advisory Committee: Db. H. Spohn, Db. F. J. Bulleb, Db. W. T. Ewing. Greater Vancouver Health League Representatives: Db. G. O. Matthews, De. M. W. Simpson Representative to B. C. Medical Association: De. A. M. Agnew. Sickness and Benevolent Fund: The PbesidentâThe Tbustees. !|- UUv I UKâhere are Vitamin A and D products to suit your requirements Small dosage and high potency, Q.E.D. economy for your patients Teaspoonful dosageâSquibb Cod Liver Oil N.N.R. (plain or mint flavoured), so rich one teaspoonful supplies a daily dose of 6,660 I.U. of vitamin A and 960 I.U. of vitamin D. Seventy-two days' supply (12 oz.) costs your patient only one dollar. âSquibb 10D Cod Liver Oil where additional vitamin D appears desirable. Half-teaspoonful dosageâHal-Cod-01, this highly potent combination of Squibb cod and halibut liver oils supplies 6,900 I.U. of vitamin A and 690 I.U. of vitamin D in the half-teaspoonful dose. DrOp Dosageâ10 drops of Navitol, Squibb natural vitamin oil, supply 9,400 I.U. of vitamin A and 1,700 I.U. of vitamin D. Two months' supply (10 cc-) for sixty-five cents. ^Capsule formâeach capsule of Navitol supplies 9,400 I.U. of vitamin A and 1,700 I.U. of vitamin D in natural form. TabletsâAdexâeach tablet supplies in stable form 3,300 I.U. of vitamin A and 660 I.U. of vitamin D. Supplied in bottles of 80 and 250. The recognized preference for vitamins A and D from natural sources if available in sufficient potency for therapy as well as prophylaxis is satisfied by these Squibb products. All are biologically standardized, with their high potency stabilized by Squibb methods of preparation and packaging. For samples write 36 Caledonia Rd., Toronto, ERiSojjibb &Sons of Canada.Ltd. MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858 VANCOUVER HEALTH DEPARTMENT STATISTICSâJULY, 1940 Total Populationâestimated â Japanese Populationâestimated Chinese Populationâestimated ^. Hindu Populationâestimated Number Total deaths 266 Japanese deaths 5 Chinese Deaths . % 11 Deathsâresidents only 236 BIRTH REGISTRATIONS: Male, 250; Female, 218_ 468 INFANTILE MORTALITY : July, 1940 Deaths under one year of age_ 12 Death rateâper 1,000 births 25.6 Stillbirths (not included in above) 5 269,454 9,094 8,467 339 Rate per 1,000 Population 11.7 6.5 15.3 10.3 20.5 July, 1939 6 17.0 6 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY June, 1940 Cases Deaths July, 1940 Cases Deaths Aug. 1-16,1940 Cases Deaths Scarlet Fever â ; 5 0 4 0 0 Diphtheria t 0 0 0 0 0 Chicken Pox 157 0 17 0 8 Measles 181 0 45 0 8 Rubella 0 0 0 0 1 Mumps 3 0 10 1 Whooping Cough 4 0 4 0 2 Typhoid Fever 0 0 0 0 0 Undulant Fever 0 0 0 0 0 Poliomyelitis 0 0 0 0 0 Tuberculosis 32 15 .24 18 8 Erysipelas __ 3 0 2 0 1 Meningococcus Meningitis 0 0 0 0 0 Paratyphoid Fever | 10 10 0 V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH, DIVISION OF VENEREAL DISEASE CONTROL. West Burnaby Vancr. Syphilis 0 0 Gonorrhoea 0 0 North Richmond Vancr. 1 1 0 0 Vancr. Clinic Hospitals, Private Drs. Totals BIOGLAN THE SCIENTIFIC HORMONE TREATMENT Bioglan products differ in that they are derived from original material. A Product of the Bioglan Laboratories, Hertford, England. ||ff Represented by STANLEY N. BAYNE Phone: MAr. 4027 1432 Medical-Dental Bldg. Descriptive Literature on Request Vancouver, B. C. Page 342 Each tablet contains: Theobromine - - - - 5 grams *Neurobarb E.B.S. - - H gram Sodium Bicarbonate - 5 grains Being antispasmodic and sedative in action, the ingredients of Theobarb E.B.S. act synergistically to relieve spasm. The prompt relief following its administration greatly improves the patient's mental outlook and sense of physical well-being. INDICATIONS: Angina Pectoris, Arteriosclerosis, Cardiovascular Disease, Nervous Manifestations of the Climacteric Period, Epilepsy, Hyper Tension and as an Antispasmodic and Sedative. Also supplied with yi grain Neurobarb as C.T. No. 691A Theobarb Mild Literature and sample on request 'Neurobarb is the E.B.S. trade name for Phenobarbital. THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED TORONTO MANUFACTURING CHEMISTS CANADA SPECIFY E B. S. ON YOUR PRESCRIPTIONS THE EDITOR'S! PAGE >tiil Dear Doctor: We have in the Editorial Office papers presented at the Summer School held in June last. Many Members of the Profession have asked for printed copies. If sufficient funds for this purpose are secured, a Supplement containing the following lectures will be printed. Dr. Magner "Pathogenesis of Jaundice" "Clinical Aspects of Jaundice" "Pathogenesis of Anaemia" "Some Clinical Aspects of Anaemia" Dr. Reichert "Lymphoedema in Man" "Neuralgias of the Head and Face" "Anterior Scalenus Syndrome" "Regional Ileitis and Other Localized Lesions of the Small Bowel" Dr. W. S Middleton "Some Lay Contributions to Medicine" "Idiopathic Hypertension" "Protection of the Circulation in Surgery" "Post-operative Pulmonary Complications" "Clinic on Internal Medicine" Dr. p. C. Jeans^ "Paediatric Clinic" "Nutritional Requirements of the Growing Child" 1 "Congenital Syphilis" Dr. Farmer - "Burns and their Treatment" "Emergency Abdominal Surgery in Childhood" "Acute Osteomyelitis" If you desire a copy, you will greatly assist us by returning the following information to: "The Library, 204 Medical Dental Bldg., Vancouver, B.C." please mail me a copy of the Summer School Supplement, together with an invoice for fl.00 to cover cost of printing. Name Address In this number of the Bulletin we wish to pay tribute to an institution which is one of* the oldest and most valuable, speaking from a civic point of view, of all the institutions of Vancouver. For some forty years or more, St. Paul's Hospital has been a landmark. It has been much more than this: it has been a haven of refuge, a centre of healing and mercy for the sick and afflicted of this Province. Unobtrusively, with no tuck of drum or flourish of trumpets, the Sisters of Providence have maintained and developed a hospital which at all times has been well up to the standards of its day, and is now an outstanding example of what a really good hospital can be. One looks back over some thirty-five years or so to the day when we first saw St. Paul's Hospitalâa small wooden building, which did a land-office business in the care of Page 343 If I I 1 the sickâbut with not a very great pecuniary reward. The loggers and miners of that day, up and down the B. C. Coast, had no hospital of their own, no hospital ships, no doctors and nurses. If sick or hurt, they had only one thing between them and worse trouble, a long trip to town, in a slow tub of a boat, in weather often very prejudicial to the future of an acute appendix, or a broken legâand most of them went to St. Paul's. It was near the docks, and most of them had a hospital ticket for that institution, peddled by agents in the camps and woods: costing ten dollars a year, and entitling them to hospital care. This constituted a form of health insurance that has since fallen into disuseâbut was a godsend to these men, who found sanctuary and the best of care in St. Paul's Hospital. From a doctor's point of view it lacked some conveniences: and there was a certain pessimism about the place. A large text, "Nearer, my God, to Thee," hanging at the foot of the main stairway, hardly seemed any more encouraging to the new inmate than the "Abandon hope, all ye who enter here" of Dante. And if one arrived late at night for a maternity case (for some reason best known to hospital authorities, the case room is always on the top floor), there was a long climb to the topâbut we were young then, and a maternity case was worth a long climb. But St. Paul's filled a real want in the community, and filled it well: and, as it has always done since, it developed and grew and kept pace with the needs of the city, with the advances in scientific treatment, and modern equipment, and so came to its own in late years as an Al hospital. And the opening of the new south wing this summer, with its magnificent equipment, and its last-word arrangement and construction, is merely the logical last step of a steady upward progress by a hospital that has never been content to be anything but the best of its kind and size. As one has watched the patient but steady accretion of one department after another, planned far ahead, each designed with thorough care by experts in its line, one cannot but be proud of St. Paul's Hospital. Its X-ray department is the equal of anyâits laboratory facilities are compact, complete, and would meet the needs of an institution twice its sizeâits surgical suites are models of convenienceâand now a new paediatric department, a new physiotherapy department, new private wards, have been addedâwith many other minor departmentsâso that we have now a complete hospital under one roof: a masterly piece of work, only made possible by the vision of its administrative beads, who have built to a plan which in its conception was of surpassing excellence. We present in this number some brief descriptions of the new wing, and a short historical sketch of the hospital. These are of interest, too; but one cannot but regret that so many of the old-timers that were so loyal and faithful to St. Paul's, and did so much for it, are not here today to see this culmination of their unselfish work. Dr. F. J. McPhillips, for instance, who was the head and front of the old St. Paul's, and whose surgical skill meant so much to its work; Dr. Robert Boyle, another surgeon who did so much work here; old "Jerry" Curtin, one of its earliest anaesthetists, an unforgettable figure in the hospital's history, a trusted and loyal member of its staff; Neil McDougall, whose wise, calm counsel was always so helpful and valuable; and many other names flit down the corridor of memory: men who "builded better than they knew" as they worked day by day in St. Paul's. Many of these old-timers are still with us, and take their place as leaders in the new, complete Hospital. W. D. Keith, W. D. Kennedy, E. J. Gray, H. H. Milburn, are only a few of the men who have given many years of devotion to the hospital that has served them so well. There are many things one could say about St. Paul's, all favourable and all true. But there is one thing chiefly that, as we look back over the years, has marked St. Paul's more than anything else. Up-to-date equipment, scientific thoroughness, magnificent X-ray laboratories and operating rooms are all very wellâbut they are not all, or nearly all. But above and beyond all of these, there is the atmosphere of kindliness and friendliness, of solicitude for the comfort and happiness of its patients, that all who know St. Paul's will agree is the unf ailing characteristic of this hospital. Its patients are its children, its wards, its friends: and their welfare is its first consideration. Its. nurses reflect Page 344 this tone, and give kindly and generous service to those in their care. The closing sentence of one of the paragraphs written about the opening of its new wing could hardly have been written except by those who add to science and skill the love and affection which are as potent in healing as "all the poppies and mandragora" of the most highly skilled healer. We wish St. Paul's Hospital the success and prosperity it has deserved in the past and will always, we know, deserve in the future. NEWS AND NOTES Dr. A. W. Hunter of Vancouver was elected to the Executive of the American Urological Association at the recent meeting of the Association in Buffalo, N. Y. Congratulations are extended to Dr. and Mrs. R. D. A. Bisson on the birth on August 6th of a daughter. Dr. and Mrs. R. H. Fraser are receiving congratulations on the birth on August 3rd of a daughter. Sp Sp Sp Sp We offer congratulations to Captain A. C. Gardner Frost upon his marriage to Miss Gertrude Griffin of Vancouver. The wedding took place on August 12th at Brandon, Man. The marriage took place at Shilo, Man., on August 13 th of Lieut. John A. MacMillan and Miss Beatrice Merritt of Vancouver. Congratulations are extended to them. Sp jp jp jp Dr. William Leonard of Trail again distinguished himself in the field of skeet and trap shooting, when he carried off four trophies at the recent Kimberley meet. Dr. and Mrs. E. S. Hoare of Trail have returned from a holiday spent at Banff, Calgary and the Big Bend country. Sp Sp Sp Â»p Major Fred Wrigglesworth, 2nd Canadian Base Hospital Unit, Montreal, paid a short visit to his parents in Penticton before going overseas. â¢5. *t *t 55. j Dr. H. B. Wright of Calgary has been visiting at Summerland and Penticton. Sp Sp Sp Sp Dr. R. B. White of Penticton has been away on a fishing trip. ?Â£â sÂ£Â» sÂ£Â» S5Â» Dr. and Mrs. R. J. Wride of Princeton attended the Kelowna Regatta. sp Sp sp Sp . Dr. and Mrs. J. R. Parmley and family of Penticton returned recently from a motor trip over the Big Bend to Banff. Â»Â», *Â«, *'â Â»Â»â Dr. R. W. Irving of Kamloops travelled by motor to Lethbridge to meet an old college mate, Dr. Dave Smith of Stratford, Ontario, who arrived by Trans-Canada Plane. They intend to motor to Vancouver over the Big Bend Highway. It is reported Dr. A. N. Johanson has left Salmon Arm to join the C.A.S.F. Page 345 r We regret to record that Dr. C. M. Bennett of Nelson was accidentally drowned in Kootenay Lake on July 29 th. Dr. W. M. Toone, late of Kimberley, has taken over Dr. Bennett's practice. Dr. R. B. Shaw of Nelson has returned from holiday at the coast. Dr. J. M. Crawford of Trail is at present on holiday. # * Dr. and Mrs. G. L. Watson of Revelstoke are receiving congratulations on the birth on August 14th of a daughter. Dr. C. A. Armstrong of Port Simpson has moved to Ocean Falls and will be associated with Dr. G. D. Saxton in the practice there. Dr. J. E. Whiting of Hazelton is moving to Port Simpson. Dr. and Mrs. R. Geddes Large of Prince Rupert are motoring to Nelson. Dr. Carl Ewert of Prince George is holidaying in Vancouver. Â«â¢ Â«â *- * Dr. E. J. Lyon of Prince George is leaving for Vancouver, September 1st, to attend his daughter's wedding. â¢Â£. *t *4. *t 5p Sp 5p~- *p Dr. John C. Poole and Mrs. Poole (formerly Dr. Lois F. Stephens) are now in Revelstoke, having recently moved from Wells. Doctor Poole is associated with Dr. G. L. Watson. *t *t **â¢ *% Dr. Donald M. Black will be remembered by graduates of the University of Manitoba. He graduated in 1924. During the fifteen years since 1925 Doctor Black has served with the United Church in Northern Manchuria. He was stationed for some years at Lungchintsun. He has returned to the Province and is now commencing practice in Kelowna. *t. *^ *<. *t. Dr. and Mrs. W. R. Patten have returned to Chilliwack after spending a two weeks' vacation up Coast. *r *c "f *>, We offer congratulations to Dr. J. B. Roberts of Victoria uponi his marriage to Miss Bertha Margaret Lind on August 10th . Â»H. *Â». **!. *$. Doctors E. H. W. Elkington, S. G. Kenning, of Victoria; G. W. C. Bissett of Duncan; A. B. Nash, L. W. Bassett, N. C. Cook, W. H. Moore, O. C. Lucas, G. B. Buffam and D. E. Alcorn of Victoria have become medical officers of the newly-formed N.P. A.M. Unit, No. 13 Field Ambulance, R.C.A.M.C., which is under the command of Lt. Col. G. C. Kenning. A Duncan company, under the command of Capt. G. W. C. Bissett, has been formed, the other officers being Doctors D. S. McHaffie and C. H. Beevor-Potts. Present indications are to the effect that Victoria will he well represented at the Nelson meeting of the British Columbia Medical Association. At least a dozen local men have expressed their intention of attending. Others who would like to go are likely to be prevented by military duties. The importance and value of this annual event is fully appreciated by members of the Victoria Medical Society . Page 346 Major W. M. Carr and Capt. A. Turnbull, Radiologists of Victoria, both have recently left for overseas on service with the R.C.A.M.C. Dr. T. M. Jones, until recently of Vancouver, has opened offices in Victoria, with practice limited to surgery. Dr. S. Janowsky, who has for two years been on the Resident Staff of St. Joseph's Hospital, Victoria, has entered general practice with offices in the Scollard Building, 1209 Douglas Street. ** s5Â» The addition to the Royal Jubilee Hospital is rapidly approaching completion and will represent a most necessary and valuable adjunct to the hospital facilities of the Lower Island. The directors plan a campaign to augment the building fund shortly and have announced the forthcoming opening of a new and completely modern Isolation Unit, the plan of which conforms to the most recently accepted authoritative opinions regarding the disposition and treatment of all forms of Infectious Disease. Dr. Christina Fraser of the Department of Radiology of the Vancouver General Hospital spent a short holiday on the Island. Dr. N. H. Jones of Port Alberni returned from his holiday in the Okanagan and at Banff and Jasper. Dr. B. T. HÂ« Marteinsson of Port Alberni is now on holidayâa hiking trip from Great Central Lake west to the Coast. Dr. John A. McLean of Vancouver spent a holiday at Qualicum and Campbell Fiver. Dr. and Mrs. Alan Hall of Nanaimo spent a fortnight's holiday at the new summer camp at Ratrever Beach. Dr. and Mrs. E. D. Emery of Nanaimo left for Jasper and Edmonton on vacation at the end of August. Dr. C. E. Davies of Vancouver is now getting a nice sunburn on a week's cruise in Island waters. He stopped off en route to pay Nanaimo a visit. Dr. H. A. W. Brown of Fort St. John is holidaying at the Coast following a trip over the Big Bend. He called in at the office and looks unusually well. Page 347 SPECIAL LIBRARY NOTICE Following is a list of books which have been taken from the Library, and for which the Librarian has no Doctors' signatures: Index of Differential Diagnosis, 5th ed. Edited by Herbert French, (Reading Room Copy.) Caesarian Section (25-A-31), Marshall, C. Mel. Alcohol (36-Z-4), Strecker & Chambers. Lancet, vol. I, 1939. Journal of the American Medical Association, v. 113, Sept.-Dec, 1939. American Journal of Obstetrics and Gynaecology, v. 37, 1939. American Journal of Surgery, v. 44, April to June, 1939. Annals of Internal Medicine, v. 12, Jan. to June, 1939. Journal of Infectious Diseases, Nov.-Dec. number, 1939. Canadian Medical Association Journal, v. 36, 1937. Lancet, Jan. 6th and Feb. 3rd, 1940. As these books have been out for some length of time, varying from a month to a year, it is requested that they be returned to the Library at once. DR. C. M. BENNETT An Appreciation The profession in British Columbia has lost one of its younger members in the person of Dr. Clare M. Bennett of Nelson, by a tragic drowning accident which occurred July 29 th. Dr. Bennett was born at Creighton Mine in the Algoma district of Ontario, where his father, the late Dr. J. H. Bennett, was in practice. Later, the family moved to Copper Cliff, where Clare1 received his elementary education, his father being with the International Nickel Company as a surgeon. In 1923 Dr. Bennett removed again, this time bringing his family to Nelson, B.C., where he continued in practice until his decease some three and one-half years ago. Clare pursued his high school education in Nelson, where he passed his junior and senior matriculation. Under the stimulus of the strong influence which the father exerted, who to the youth was the ideal practitioner, Clare chose a career in medicine. He entered the University of Toronto, his father's school, and after the completion of a very successful undergraduate course received his degree in 1933. He then interned in the Toronto General Hospital for a year. On conclusion of his interne year, he came West to join his father as junior partner. After the demise of Dr. Bennett, Senior, Clare continued the practice as sole partner except for a period when Dr. W. K. Blair was associated with him. Dr. Clare Bennett's untimely death leaves a grief-stricken mother, a young widow and two small children, to whom the profession extends its sincere sympathy. Dr. Bennett had a definite leaning towards surgery, and was gifted with the manual dexterity which is such an important asset tot one who follows this branch of medical practice. Dr. Bennett's capacity for making friends was very definitely evidenced by the large numbers who assembled on the day of the funeral to pay their last token of respect. Page 348 British Columbia Medical Association (Canadian Medical Association, British Columbia Division) "President '. Dr. F. M. Auld, Nelson First Vice-President | Dr. E. Murray Blair, Vancouver Second Vice-President Dr. C. H. Hankinson, Prince Rupert Honorary Secretary-Treasurer X)r. A. H. Spohn, Vancouver Immediate Past President '. Dr. D. E. H. Cleveland, Vancouver Executive Secretary Dr. M. W. Thomas, Vancouver REPORTS OF STANDING COMMITTEES Please note: It is requested that all members read these reports, and thus expedite the proceedings of the Annual Meeting in Nelson. REPORT OF THE COMMITTEE ON CONSTITUTION AND BY-LAWS During the past year there was no occasion for much activity of our Committee. Although there are some very minor changes that might be made in our present Constitution and By-laws, it was not deemed wise to make them at this time. Our present Constitution and By-laws is sufficiently comprehensive and elastic to make it comparatively easy to conduct all the business of the Association without difficuty. It was, therefore, our opinion that no amlendments be submitted this year. All of which is respectfully submitted. H. H. Milburn, Chairman, Committee on Constitution and By-laws. REPORT OF THE COMMITTEE ON PROGRAMME AND FINANCE Programme'. The work of your Programme Committee falls into two main divisions: 1. The arrangements for the Annual Meeting are started six months or more before the date of the meeting, and entail a considerable volume of correspondence and a number of meetings of the Committee to settle details of arrangement. Your Committee is happy to be able to report that the programme for this meeting is well up to the standard maintained at previous meetings, and we feel satisfied that the lectures should prove of value to every man attending the meeting. 2. Tours throughout the Province were arranged during the past year as follows: (a) October 5th, 1939âDrs. D. E. H. Cleveland and S. A. McFetridge addressed the Annual Meeting of District No. 4 Medical Association in Kamloops. It was arranged that Drs. D. H. Williams and E. R. Hall would also attend) the meeting, but through inadvertence they were forced to make a last-minute cancellation. (b) November 30th, 1939âDrs. D. E. H. Cleveland and S. G. Baldwin addressed the Annual Meeting of the Upper Â« Island Medical Association, held at the Casa del Mar Hotel. (c) June 20th, 1940âDr. W. Norman Kemp addressed the Spring Meeting of the Upper Island Medical Association at the Qualicum Beach Hotel. Finance: Your Association continues to operate on a budget of approximately $2500.00, which is granted to us as required by the Council of the College of Physicians and Surgeons. Page 349 During the past twelve months we have succeeded in carrying on our activities with only $2250.00. The detailed expenditures are included in the Auditor's Report. In concluding this report, I wish to take this occasion to thank the members of my Committee, and particularly Dr. Auld and Dr. Daly and the members of the local group in Nelson, for their very excellent assistance in arranging for this Annual Meeting. I should also like to point out that our Executive Secretary, Dr. Thomas, is of inestimable value to our Committee in the constant assistance that he is able to give us. All of which is respectfully submitted. Committee on Programme and Finance. G. F. Strong, Chairman, COMMITTEE ON MATERNAL WELFARE The Nucleus Committee has met regularly in Vancouver during the past year and has also received valuable advice from some of the outside members. The Maternal Record Card, which was approved by the last Annual Meeting of the British Columbia Medical Association, was put into operation at the beginning of the year with the help and co-operation of the B. C. Provincial Board of Health. The assistance of the Board, without which the scheme could not have been put into effect, and which has been freely and cheerfuly given, is acknowledged with grateful thanks. The response from the Doctors in the Province has not been all that the Committee had hoped f or,, up to date. It may be that some Doctors are holding their records until the end of the year and then intend' to send in a number at one time. If so, we would ask them to please send in a few at a time as it is easier for the Statistical Department to handle them, and they will be returned sooner. Some Doctors, notably those of the Trail Clinic, have responded 100%, and the late Dr. J. P. Bilodeau was one of the first and most regular in his records. The maternal death rate for the Province, which has always been one of the best in Canada, showed decline in 1939. The breakdown into causes has not yet been received, but before 1939 the greater number of cases were due to sepsis in some form and it is probable that the improvement shown is due to the new chemo-therapy. But there are still some other causes that may be improved by more careful pre-natal work and less unnecessary interference. It had been hoped to start the publication in the Bulletin of short articles on Maternal Welfare subjects, but the authors have not yet supplied them. It is hoped that the next Committee will soon be able to get enough articles on hand to start with regular monthly articles. It is recommended to the incoming committee that they consider the causes of maternal deaths with a view to making a recommendation re the computing of the maternal death rate, which is at present on a very unsatisfactory basis. It is expected that they will shortly be in a position to investigate, with the help of he Provincial Board of Health, all maternal deaths in the Province with a view to being in a position to give some advice in what manner the mortality may* be lowered. All of which is respectfully submitted. C. T. Hilton, Chairman, Committee on Maternal Welfare. * * *?â * REPORT OF THE COMMITTEE ON PUBLIC HEALTH Your Committee on Public Health and Nutrition has been active throughout the year, although not many meetings have been held. General matters of Public Health have come before the Committee and the endea- vaurs towards uniform pasteurization of milk have been continued. This year the Com- Page 350 mittee co-operated with the Greater Vancouver Health League in an effort to have universal pasteurization of milk receive the endorsation of the Metropolitan Board of Health for Greater Vancouver. The fight for pasteurization still continues, although progress will be slow both with the lay public and important legislative bodies. Certain features of Well Baby Clinics as conducted in Greater Vancouver by the Metropolitan Board of Health have not met with universal medical approval. The Paediatric Section of the British Columbia Medical Association has held several conferences with the Committee and conferences have taken place between the Greater Vancouver Medical group and the Paediatric Section. Several points of difference exist and no satisfactory solution has yet been reached. This year, matters concerning Nutrition were referred to the Committee on Public Health. The New Canadian Medical Association Committee on Nutrition has been very active and your Committee has co-operated with this Committee in furnishing information and suggestions. The book, "Food and Health" was published and distributed during the year by the Canadian Medical Association Committee on Nutrition and this publication met with universal approval. It is expected that matters of great national importance will be considered by the National Committee on Nutrition throughout the War and duties of the Committee on Public Health and Nutrition will be greatly increased. All of which is respectfully submitted. A. H. Spohn, Chairman, Committee on Public Health. COMMITTEE ON THE STUDY OF ECONOMICS During the past year the principal question before the Committee of the British Columbia Medical Association revolved around the development of a pre-payment Medical Service Plan, the outline of which was presented at the Annual Meeting of the College of Physicians and Surgeons in 1939. Instruction was given that the Committee on Economics of the Council proceed with a view to placing the plan in operation. Incorporation of the Medical Services Association was completed in April, 1940. Mr. A. L. McLellan has done much valuable work in introducing the Plan to employee groups. Much interest has been shown by employees and at this time the Medical Services Association is preparing to enroll membership. Our members have been informed from time to time of the nature and extent of the service offered under this Plan. It is felt that the service should; be comprehensive and free from those restrictions which only lead to controversy and embarrassment. Under this Plan small groups of employees may join co-operatively as members of the Medical Services Association and avail themselves of privileges otherwise only possible with larger groups of employees. At the present time the British Columbia Telephone Employees' Sick Benefit Association, the British Columbia Electric Railway Company Office Employees' Medical Aid Society and the Vancouver School Teachers' Medical Services Association are operating similar plans which provide for two fundamental principles in medical practice; namely, free choice of doctor, and payment for services rendered on the basis of the Schedule of Fees of the College of Physicians and Surgeons. Under these plans all doctors are included and enjoy equal privilege. The Medical Services Association has its own Board of Directors consisting of representatives of employees, employers and the medical profession. Dr. S. Cameron MacEwen, well known to us all, has been appointed Director of Medical Services, and we bespeak for him the confidence and support of the profession. I may say that a growing interest has been shown by employees in the development of some plan whereby they may budget against the expense of illness or accident, especially for the protection of their family. Under this Plan they are allowed to contribute, by deduction from their payroll for their own membership in the Association, $1.00 per Page 351 I month for medical and surgical care. Where hospitalization is included, $1.50 per month would be required. Among groups of employees, in order that families may be included, a census would be taken so that a flat rate might be applied to the man with the greater number of dependants. In some groups the employer would contribute and in this way a lower rate could be arranged for the man with the larger family. If there is a demand for a system of medical practice, which permits employees to make regular monthly payment for medical services, your Committee feels that the medical profession should give direction, in that it is best fitted to give leadership in the development of any satisfactory plan. W. A. Clarke, Chairman, Committee on the Study of Economics. COMMITTEE ON THE STUDY OF CANCER This Committee has carried on under the enthusiastic Chairmanship of Major Roy Huggard for the past two years. In May of this year, owing to rnilitary duties, Major Huggard resigned and I was asked to complete his term of office. The following report is the result of his very efficient stewardship. Since the Annual Meeting in September, 1939, seven regular meetings of the Committee have been held, all of which were largely attended. Major Huggard travelled through the northern part of the Povince last Fall as one of a lecture team and was able to enlist greater interest by presenting the question of Cancer to special meetings in such centres as Prince George and Prince Rupert. Previously, in the same manner he visited New Westminster, Chilliwack, Lytton, Kelowna, Penticton, Trail, Nelson, Creston, Cranbrook and Revelstoke, attending the Annual Meetings of the District Associations at Kelowna, Trail and Cranbrook, While on these tours Major Huggard addressed evening and luncheon meetings at the various centres, speaking on behalf of the Canadian Society for the Control of Cancer. Public meetings were held at both Prince Rupert and Prince George. Major Huggard represented the Committee on a Cancer Council for British Columbia, the objective of which is to correlate Cancer activities within the Province. The Committee has supported strongly the Department of Cancer Control of the Canadian Medical Association in encouraging the use of Cancer Record Forms. The development of this service was placed in the hands of a sub-committee of which Surgeon-Lieutenant H. H. Caple has been the Chairman. Record Forms were distributed to seventeen reporting centres and follow-up work has been done to stimulate their widespread use. A report submitted by this Committee stated that 794 cases had been reported. These were for the most part hospital patients. It is hoped that this work will be further developed in the ensuing year. The Committee has attempted to establish a Biopsy Service using existing laboratories, in an effort to serve all sections of the Province. This has been studied by a subcommittee composed of Drs. FL H. Pitts and A. Y. McNair. A questionnaire has been circulated to the whole profession to which there has been a large response, indicating that the profession wishes such a service. A conference of the sub-committee was arranged and the question discussed with Dr. G. F. Amyot, Deputy Minister of Health in British Columbia. Subsequently a large meeting of the Committee was attended by Dr. Amyot, and his attitude would suggest his willingness to co-operate in developing a Biopsy Service. While a universal biopsy service has not yet been obtained, it is felt that a lot of useful spade work has been accomplished ana one'hopes that another year will see the fruition of our efforts. The Committee studied the question propounded by the Department of Cancer Control of the Canadian Medical Association regarding the principle of centralization for treatment of cancer and placed itsef on record in favour of this principle. Arising out Page 3 52 of this discussion, the Committee asked the Department of Cancer Control, Canadian Medical Association, to set up minimum requirements for "well-equipped institutions." An Editorial Committee has been appointed to prepare and supervise material for publication on the question of Cancer. An effort has been made to secure presentation of cases of Cancer on the programme at clinical meetings throughout the Province. The Committee has been supported by the Committee on Programme of the Provincial Association by the inclusion in post-graduate tour courses of a speaker on Cancer. The Library Committee of the Vancouver Medical Association has provided the American Journal of Cancer at the request of the Committee. The Committee hs strongly supported the British Columbia Branch of the Canadian Society for the Control of Cancer in its development and programme. The Speakers' Bureau, under the aegis of the Committee and with Dr. M. W. Thomas as Chairman, has successfully undertaken to provide medical speakers for lay audiences on fifty-seven occasions. The acquisition recently of Cancer films by the British Columbia Branch of the Canadian Society for the Control of Cancer will assist materially in creating greater interest in public meetings and will also be very helpful in placing this question of Cancer before the members of the profession. Those of the films suitable for lay audiences are to be shown at several public meetings in September and together with the scientific ones will be shown to members of the Association at their Annual Meeting in Nelson. Respectfully submitted on behalf of the Committee. Ethlyn Trapp, Chairman, Committee on the Study of Cancer. EDITORIAL BOARD September, 1940. After the Annual Meeting of the British Columbia Medical Association in September, 1939, this Committee collected the papers read at that meeting, and published them in a Supplement which was sent to all members of the profession throughout B. C. In view of the cost of such a supplement, somewhere between $350.00 and $400.00, we do not know whether the Association will see fit to authorize the publication this year of the papers read at the 1940 Annual Meeting, but we propose to secure them if possible for future disposal. The Greater Vancouver Health League approached us recently with a view to securing the co-operation and endorsation of the British Columbia Medical Association in regard to a Health Supplement which the Vancouver Daily Province proposes to publish at an early date. The Greater Vancouver Health League would be co-sponsor with us, and the keynote of the number would be preventive medicine. At a meeting of the Board of Directors of the British Columbia Medical Association, your Committee was instructed to inform the Greater Vancouver Health League that the British Columbia Medical Association would endorse this number, and act as co-sponsor, on the definite understanding that the following steps be taken:â 1. All material for publication to be submitted to the Committee on Publications of the British Columbia Medical Association for censorship and approval. 2. All advertising to be similarly subject to censorship. 3. No articles appearing were to be signed by the writers, if the latter are in any way engaged in private practice. Page 3 53 1 Dr. M. W. Thomas, Executive Secretary of the British Columbia Medical Association, has kindly consented to act with the Committee as a member of this body. All of which is respectfully submitted. J. H. MacDermot, Chairman, Editorial Board. SPECIAL COMMITTEE ON BENEVOLENT FUND The Special Committee appointed by the Board of Directors of the British Columbia Medical Association to study the advisability of developing and maintaining a Benevolent Fund for the benefit of the members, wishes to report that much preliminary work has been done and the Committee is ready to proceed with a very definite educational and collection campaign. The Committee recommended to the Board of Directors that owing to present unsettled conditions due to the War situation that no further action be taken at this time. When the time appears more opportune ,the Committee will make further representations and will be prepared, under instruction, to proceed with its task. This report is submitted for the information of the membership. W. E. Ainley, Chairman, Special Committee on Benevolent Fund. British Columbia Medical Association. CANADIAN RED CROSS SOCIETYâB. C. DIVISION NEWS NOTES RED CROSS CO-OPERATES WITH WOMEN'S INSTITUTES The Provincial Red Cross is taking a lead in a food conservation project and is extending a special invitation for co-operation to the Women's Institutes in the agricultural districts, the membership being largely farm womenâpartners of the men who produce the country's food supply. It is intended that food conserved under this scheme should be donations of surplus food products which might otherwise go to waste. This canned food will be distributed by the Red Cross, as the need arises, to Canadians on Overseas service, refugees in England and evacuees in Canada, and to the needy in any emergency. NO RED CROSS SUPPLIES GO TO ENEMY-OCCUPIED COUNTRIES All Canadian Red Cross supplies shipped Overseas are going to Britain as it is impossible for the Canadian or British Red Cross Societies to make shipments to Europe. Blankets collected for suffering refugees and wounded sodiers in France have not been sent to that country as the Red Cross could not take a chance on their falling into German hands. The first shipment authorized before the French armistice was diverted to England, where they will be stored until needed. The remainder, about 60,000, will be held in Canada. Already the Dominion Government has asked for the loan of a quantity of them to equip colonist cars carrying Overseas children to their destinations in Canada. RED CROSS WILL MEET B. C. GUEST CHILDREN If British Columbians expecting Overseas children would notify Provincial Red Cross Headquarters, 213 Marine Building, Vancouver, every effort will be made through the Nova Scotia and Quebec Red Cross Divisions to see that these children are met and looked after at the ports of Halifax and Montreal. Page 354 ancouver enera Hosplta A SUMMARY OF THE PROBLEM OF JAUNDICE By C. E. Gould, M.D. The study of the liver dates back at least to the sixth century B.C., and earlier. Prognosis, with both the Assyrians and the Babylonians, was largely based upon inspection of the liver, terra cotta models of which, at least three thousand years old, have been found, divided into squares, and studded with prophetic inscriptions. The Book of Ezekiel, chapter 21, verse 21, says: "For the King of Babylon stood at the parting of the ways, at the head of the two ways of divination; he made his arrows bright, he consulted with images, he looked in the liver." From the clay tablets of King Assurbanipal of Assyria, now in the British Museum, we know that the Assyrians practised hepatoscopy, and that the art of prognosis was largely based upon inspection of the liver. Garrison states that the Babylonian clay models of the liver are better specimens of anatomical illustration than the five-lobed mediaeval figures. Similar models of the liver have been found on ancient Hittite sites in Asia Minor, and Etruscan livers in bronze, dating from the third century B.C. have been found. The liver, as the source of blood, was regarded by the ancients as the seat of the soul and, as the god identified himself with the sacrificial animal, to inspect the liver Was to see into the soul of the animal and the mind of the god. It is safe to say that this is "a consummation devoutedly to be wished" by many a modern internist. Classification of Jaundice. While in the past jaundice has been described as an hepatogenous, haemohepatogenous, extrahepatic, haemolytic, polycholic, acholuric, pigmentary, infective toxic, and other named forms, the present-day tendency is to simplify the problem and now we have two classifications in general use, those of McNee and Rich, the former more adequate clinically, the latter more accurate scientifically. McNee's classification has three divisions: 1. Obstructive; 2. Haemolytic; 3. Toxic-infective; while Rich's has but two: 1. Retention; 2. Regurgitation. Since the physiological and biochemical principles of jaundice production have been synthesized by Rich more clearly than by anyone else to date, in his publication in 1930, it is proposed to follow his classification here, and outline the physiological principle that he propounded. Physiology. Bile pigmentâ^bilirubinâis made outside the epithelial liver cells, is carried to them by the blood stream, and is excreted by them into the bile canaliculi. Bile pigment is manufactured mainly within the bone marrow, liver and spleen. The reticulo-endothelial system is responsible for its production. The only known source is haemoglobin from broken down red cells. Haemoglobin taken from the blood stream by phagocytic reticulo-endothelial cells anchored within the capillaries of the bone marrow, spleen, and liver is split, within these cells, into bilirubin and a colourless iron-containing residue. Both substances are then discharged into the blood stream. Bilirubin, as it passes through the capillaries of the liver, is selectively taken out of the blood by the epithelial hepatic cells, and is secreted, somewhat as a threshold substance, into the bile canaliculi, whence it flows, mixed with the rest of the bile, into the duodenum. Page 355 Although bilirubin can be absorbed from the intestine back into the blood stream, most of the pigment reaching the intestine is reduced there to urobilin by the action of bacteria. Some of the urobilin so formed is excreted with the faeces, and some is absorbed into the blood, where it is removed by the liver, to be excreted in the bile, or â¢ to be conserved for unknown purposes. Under certain conditions the liver cannot remove it efficiently from the blood stream, and quite large amounts may pass from the blood to the urine. Considering now the possible mechanics of non-obstructive jaundice, there are several possible causes. Since, to prevent jaundice, the liver cells have to excrete the bilirubin brought to them by the blood streams, jaundice would occur: 1. If the liver threshold for bilirubin became raised. 2. If bilirubin were produced faster than the fiver cells could excrete it. 3. If the excretory mechanism of the liver were so disturbed that the amount of bilirubin normally produced could not be satisfactorily removed from the blood. 4. Combinations of the above conditions. No. 1 is hypothetical and a poor explanation. No. 2 is rarely the cause of jaundice because the normal excretory power of the liver is far above the necessary. Bollman and Mann have shown that 5 per cent of liver tissue left in a hepatectomized dog will prevent jaundice. Many pathological conditions of liver cells do not cause jaundice. Rich states that there is no known pathological condition which impairs the function of living hepatic cells to the point where they are unable to prevent jaundice by excreting the amount of bilirubin normally formed. Necrosis and cellular damage, however, will reduce the excretion capacity of the fiver to the point of jaundice, as in acute yellow atrophy, yellow fever, chloroform poisoning, etc. The common cause of non-obstructive jaundice, then, is No. 4âa combination of No. 2 and No. 3âdue to the fact that conditions which are responsible for an increased production of bile pigment are almost always associated with conditions which depress the excretory function of the fiver. The analysis of jaundice, then, involves the following three fundamentals: 1. The physical state of bilirubin in the blood. 2. The chemical state of bilirubin in the urine. 3. The quantity of pigment in the stool, blood and urine. 1. The physical state of bilirubin in the blood: The physical state of bilirubin in the blood is deterrnined by the Van den Bergh reaction, which involves Ehrlich's diazo reaction as a test for bilirubin in the blood. It is both quantitative and qualitative. Quantitatively it indicates the amount of bilirubin in the plasma. Qualitatively it indicates whether bilirubin is: (a) that which the liver has failed to remove from the blood; (b) that which has passed through the fiver cells and into the bile canaliculi, but which has subsequently found its way back into the blood stream because of obstruction of the ducts or necrosis of the liver cells. Applied to (a), bilirubin which has not yet passed through the liver cells, it gives the indirect reaction. Applied to (b), bilirubin taken from the bile ducts, gall-bladder, or that regurgitated into the blood from the bile canaliculi, it gives the direct reaction. The difference in reaction depends upon the medium in which the bilirubin is, and the work of E. S. Barron clarified this. He showed that: 1. pure bilirubin at blood pH = direct reaction. 2. pure bilirubin at blood pH -j- normal plasma = indirect reaction. If, however, substances which can lower surface tension are added to the plasma first, Page 356 and then bilirubin added, the reaction will be direct, and the reason for this is that substances which lower surface tension are adsorbed by plasma proteins more readily than is bilirubin. Barron then showed that both bile salts and cholesterol are potent in preventing adsorption of bilirubin by plasma proteins. Both these substances are present in whole bile, and occur in increased amounts in the various forms of jaundice in which the blood bilirubin gives the direct reaction. The direct reaction indicates, therefore, that whole bile, containing bile salts and cholesterol as well as bifirubin, has been regurgitated into the blood stream, either by obstruction of the ducts or by necrosis of liver cells, as these are the conditions which permit whole bile to escape from the canaliculi into the blood. The indirect reaction indicates that the bilirubin in the examined plasma has not been regurgitated into the blood from the canaliculi, but that it represents bilirubin which the liver has not yet been able to remove from the blood stream. The diphasic reaction indicates in plasma varying amounts of both direct and indirect reacting types of bilirubin. In the direct reaction, where there is regurgitation of whole bile into the blood stream, there is also bilirubin and bile salts in the urine. In the indirect reaction, where there is neither obstruction nor necrosis of liver cells, there is neither bilirubin nor bile salts in the urine, but there is present an excess of the reduced form of bilirubinâurobilin. The explanation of this is clear in the light of Barron's work, mentioned above. In the indirect reaction, where there has been no regurgitation of whole bile with bile salts and cholesterol back into the blood, the bilirubin has not been displaced by these from the plasma proteins, is still in a state of physical adsorption with them, and, as Boyd has pointed out, the plasma proteinâbilirubin molecule is too large to pass the renal filter, so that there is no bilirubin or bile salts in the urine, whilej in the direct reaction, the bilirubin is split away from the plasma protein molecule by the regurgitated bile salts and cholesterol, which adsorb to the protein, leaving the bilirubin as a free uncombined molecule, and small enough to pass the renal filter, and hence its appearance in the urine. The urobilin present in the urine, in the indirect Van den Bergh, is due to the fact that the amount of bilirubin excreted into the intestines is greater than normal, and being reduced in the intestines to urobilin, a greater amount of urobilin is available for adsorption into the blood stream, and hence appears in the kidneys, and faecal urobilin is increased in the same way. Rich's classification, then, is: I. Retention jaundice: the liver is functionally unable to free the blood from bilirubin produced in excess, usually by haemolytic processes. II. Regurgitation jaundice: is the result of escape of whole bile from the canaliculi into the blood stream, either because of obstruction to the outflow through the ducts, or because of necrosis of liver cells. I. Retention Jaundice: (1) Indirect Van den Berghânever having passed through the liver cells, and being therefore unmixed with the constituents of the bile. (2) Stoolsâincreased urobilin, because in the face of the increased production of bilirubin the liver is excreting more of the pigment than normally, even though it cannot excrete enough of the excess to prevent jaundice. (3) Urineâincreased urobilin for the same reason that it is increased in the stool, and the urine is free of bile salts, as these are formed in the liver, and are absent in the urine unless they have been poured into the blood by the escape of whole bile from the canaliculi into the blood stream, and for the same reason bilirubin is still adsorbed on the plasma proteins, and also does not appear in the urine. The pathology of Retention Jaundice consists of: (a) The aetiological factor, the commonest of which are: Pernicious anaemia, haemo- Page 3 57 lytic jaundice, mismatched transfusions, haemolytic septicaemias, malaria, icterus neonatorum, etc. (b) The liver cells may show cloudy swelling or atrophy, but (c) There is no widespread necrosis. (d) The bile ducts are patent. II. Regurgitation Jaundice: (1) Direct Van den Bergh. (2) Stoolâless urobilin than normally, because passage of bilirubin to the intestine is interfered with either by obstruction of the ducts, or by necrosis associated with ruptures of oanaliculi which allow bile to leak into the blood stream. (3) Urineâcontains bilirubin, since direct reacting bilirubin escapes into the urine. The pathology of Regurgitation Jaundice consists of: (a) The aetiological factors, either those causing necrosis, such as acute or subacute yellow atrophy, from whatever cause, or those causing obstruction of the bile ducts, either by plugging, stricture or pressure from without. Tests Used in the Diagnosis of Jaundice. (a) The Icterus indexâdevised by Meulengracht, is a simple index of the amount of bilirubin in the blood. The index represents the number of times that a given serum has to be diluted to match in color a one-ten-thousandth solution of potassium dichro- mate. A necessary precaution is that haemolysis be not allowed to occur during the collection of the blood and prior to separation of cells and serum in the centrifuge. Rarely carotin must be eliminated as a factor in a false reading. The test is simple, efficient and reasonably accurate. Manufacturers put out a device with a graduated scale and coloured slips of glass for the practitioner who wishes to do his own. (b) The Van den Berghâconsists always of two testsâthe quantitative or indirect, and the qualitative or direct. Since all bilirubin, either direct or indirect, is measured in the quantitative indirect Van den Bergh reaction, the result represents the absolute total, and is expressed as milligrams per one hundred cubic centimetres. Next the qualitative or direct is done; this test depends on graded colour changes, and is expressed as: immediate, delayed, biphasic and negative direct reaction. If the reaction is immediate, it signifies that nearly or probably all of the blirubin in the quantitative test was of the direct variety. If the direct test is negative, it signifies that all of the bilirubin in the quantitative test was of the indirect variety. With regard to the intermediate formsâthe delayed and the biphasicâit is customary to accept the delayed as equivalent to a negative reaction, and the biphasic as equivalent to an immediate or positive reaction. Some laboratories are now reporting the direct Van den Bergh as being either positive or negative. As has been pointed out by Boyd, the icterus index and a test for bilirubin in the urine is a clinical substitute for the Van den Bergh. The icterus; index is equivalent to the quantitative Van den Bergh, and the test for bilirubin in the urine equivalent to the qualitative Van den Bergh, as only the direct type of bilirubin passes the renal filter. (c) Bilirubin in the urineâyellow foam on shaking is a gross test, but a more accurate and simple method is the Gmelin testâlayering concentrated nitric acid on urine, producing definite colour changes. (d) Urobilin in urineâWatson test. (e) Urobilin in stoolsâWatson test. Clinical Diagnosis. With the above armamentarium we now approach the problem of clinical diagnosis. Rather than waste time with the majority of cases, in which the diagnosis can be made clinically on the basis of the history and the physical findings, and any laboratory tests are merely confirmatory, let us approach the smaller group of cases which are the bug- Page 358 bear of diagnosisâthe so-called "painless jaundice." To postulate the most difficult type of case, a patient within the cancer age group comes to a doctor early in the onset of a deepening jaundice; there may be a little anorexia, there may or not be a slight weight loss. A fruitless history and a negative physical examination have given absolutely no clues. The differential diagnosis narrows down to an important triadâ catarrhal jaundice (now known to be due to a variable degree of liver! necrosis), silent stone, and malignancy. Too frequently the management of these cases consists of a perfunctionary estimation of the degree of jaundice by an icterus index, an X-ray examination of the gall-bladder region to rule out stone, and then watchful waiting. If the jaundice clears up, the diagnosis was catarrhal jaundice. If it continues to deepen, we wait for the post-mortem, with the fingers crossed in the hope that a stone was not missed by the X-ray. It is in this type of case, the very type where the most help is needed, that Rich's classification falls down, as all three conditionsâcatarrhal jaundice, silent stone, and obstruction by malignancyâfall under Rich's Regurgitation type, and all three will have a direct Van den Bergh, bilirubin in the urine, and decreased stool urobilin. But early diagnosis is imperative in this predicament, considering the differences in treatment and prognosis entailed by these three conditions. The diagnostic attack in this type of case is directed into three channels, none of which are clinical. It is by a carefully planned campaign of laboratory procedures that the earliest possible diagnosis can be reached. The three procedures, in the order of their diagnostic importance," are: (1) Estimation of the urobilin in the stool. (2) Estimation of the bilirubin in the blood. (3) Estimation of the blood cholesterol. (1) Stool urobilin.âIt is well established that obstruction of the biliary tract b? catarrhal jaundice is rarely complete, and that, if it is complete, almost never for morÂ« than two to three days. It is also established that obstruction by stone is only inter mittently complete, almost never continuously complete, whereas the obstruction b} neoplasm is progressive, and when it becomes complete, almost never fails to remain so If one accepts these postulates, it becomes apparent that the study of the faecal urobilin is of paramount importance. This study, to be of real value, must be continuous. An easy and inexpensive way of doing this is to insert the gloved finger into the rectum daily, and smear a particle of faecal material on a piece of white paper. Daily comparison by this method affords a reasonably accurate estimation of variations in the amount of faecal urobilin. More recently C. J. Watson has devised a method far more accurate than the above. Employing an improved quantitative method of determining faecal urobilin, he found that the average normal daily output varies between 40 and 280 milligrams. He found, however, that the excretion of urobilin in the faeces in patients with obstruction due to stone differed strikingly from those with obstruction due to neoplasm. In the former the level was frequently within normal limits, varying from 10 up to 250 mg. daily, while in the latter the level was usually very low or absent, varying from zero up to 5 mg. daily. The test is done on a four-day stool specimen. His published series consisted of 135 cases. (2) Blood bilirubin.âThe importance of blood bilirubin estimations in these difficult cases is in direct proportion to their frequency. To be of greatest value they should be done daily. The icterus index is the easiest method of doing this. While there is no absolute correlation between the icterus index and the quantitative Van den Bergh, ten units of the former correspond roughly to one milligram of the latter, that is, an icterus index of 25 is equivalent to a Van den Bergh of 2.5 mg. per 100 cc. (3) Blood cholesterol.âIt is becoming increasingly apparent that blood cholesterol estimations can be of great value in the diagnosis of jaundice. Ottenberg and others have pointed out the marked elevationâfrom 300 to 400 mg. percentageâin the blood cholesterol occurring in complete obstruction of the bile ducts, while with partial or intermittent obstruction the blood cholesterol is only moderately elevated, whereas in Page 359 hepatic degenerative processes the blood cholesterol level is depressed, and in severe degenerative processes reaches very low levels. In emphasizing the above methods of diagnosis, it should be stressed that they are not intended to be used to the exclusion of other procedures. Evidence of stone should be sought by X-ray examination, but since stones are found in about one-third of cases of malignancy of the biliary trust, the established presence of stone does not necessarily rule out malignncy. The bowel should be investigated if there is any question of primary neoplasm arising there. Treatment. With the diagnosis established, treatment resolves itself either into the removal of obstruction by surgery, or into the medical management of damaged liver tissue. It is safe to say that this latter therapy is purely empirical, and this includes the less important group of retention jaundices, in which there are instances of more specific, but still empirical, therapy, such as quinine in malaria, splenectomy in congenital haemolytic jaundice, and others. Leaving the surgical management in the hands of the surgeon, mention should be made of the use of Vitamin K and bile salts in the reduction of the prothrombin time, and the lessening of the dangers of haemorrhage during and after operation. The present trends in medical management are outlined by Ottenberg, and consist of: (1) Protection of the liver. (2) Reduction of metabolic work to a minimum. (a) Diet should be a high carbohydrate dietâ 300 to 500 gm. of carbohydrate per twenty-four hours, mainly in the form of fruit juices, lactose, and dextrose. Starches are permitted unless pancreatic insufficiency is suspectedâas in obstruction near the papilla of Vater. If the patient does not take food well it is advisable to give intravenous glucose. The diet should be fat-free. Fat is not necessarily harmful, but is useless. It is not necessary, therefore, to go to the extreme of refusing the patient all butter, cream and eggs. Since a large part of the work of the liver has to do with protein metabolism, spare the protein as much as possibleâgive the minimal amount of protein that the body requiresâ0.7 to 0.1 gm. per kilogram of body weight per dayâusually 40 to 50 gm. per day for the average person. Meat should be avoided because of its suspected toxic effect. Protein is best given as leguminous foods, and milk, cheese and egg white. Since the liver uses glycine as a detoxicating agent, with a combination of glycine and benzoic acid excreted by the kidney as hippuric acid, Ottenberg suggests the use of glycine containing proteins, such as gelatine. From 5 to 10 gm. of gelatine per day can be given as sweetened desserts or powder. (b) Drugs.âGive as few drugs as possible. Not recommended (for protective reasons): (i) Catharsis with calomel, Carlsbad or epsom salts; (ii) duodenal lavage with magnesium sulphate to relax the gall-bladder sphincter. Food should be a sufficient stimulus. (c) General.âComplete mental and physical rest. Page 360 THE BLOOD SEDIMENTATION TEST AND THE WELTMANN REACTION W .jK| By J. P. Henry, M.B. In spite of over a thousand publications since the introduction of the sedimentation test by Fahreus in 19182, little has been found that fails to confirm the conclusions of this master, and in spite of a dozen complicating modifications, the simple bedside method introduced in 1920 by his colleague Westergren36 is still considered the most reliable and accurate so far available8. It may be used in the attempt to estimate the trend and severity of any disease characterized by tissue destruction for it gives an evaluation of the extent of the morbid process by supplying a measure of the inflammatory reaction with which the body attempts to counter every such injury. On the body surface, the progress of an inflammation can often be estimated by inspection and palpation; but the majority of the viscera cannot be so observed, and the struggle must be followed by the interpretation of symptoms, and of disturbances of temperature, pulse and weightâall of which may be absent in the presence of considerable hidden activity. It is in these apyrexial, asymptomatic cases that the test is most often of value. In 1920, Whipple^, in a series of convincing experiments, showed that in response to every inflammation there is an outpouring of fibrinogen from the liver. This is utilized in clot formation, and as a scaffold for repair. This outpouring is closely proportioned to the amount of tissue damage1. An index of blood fibrinogen would thus be a measure of the trend and severity of the lesion. It is believed that in the majority of cases this holds true for the sedimentation test. The mechanism by which this may occur can be outlined as follows: S â Si V (N.B. g f g â gravity J S â specific gravity, cell I Si â specific gravity, fluid |_ u â viscosity J 9 u This hydrodynamic equation applies only to the fall of single spheres through fluid media.) g-> A single corpuscle falling through plasma would do so at a uniform velocity- (V). This is dictated by the drag on its surface according to Stokes' law2: It is found that in blood variations in u, S, and Si, are negligible compared with that of r2, and the equation may therefore be written: V = C . r2 (where r is radius, and C is a constant) 10 Thus the rate of sedimentation of a solitary corpuscle is proportional to the square of its radius. This is so small that a suspension of corpuscles in saline will fall only one millimetre (1 mm.) in an hour5. The phenomenon responsible for the more rapid fall in blood is aggregation of the cells into irregular clumps or rouleaux. This enormously increases the square of the radius (r2) and hence the rate of fall. The sedimentation rate of blood is thus largely an expression of the degree of aggregation of the red corpuscles10' !J* 5. It is probable that the electronic charge carried by the red cells in the colloidal sol that constitutes blood plasma is a potent factor controlling aggregation. The greater it is, the more strongly they repel each other, and anything decreasing the charge will facilitate their cohesion in irregular clumps. The mass of these varies as r3, the retarding friction on their surface as r2, so the bigger the aggregate, the faster the sedimentation rate3. Fahreus and other workers have shown that one of the most important factors decreasing cell charge is the fibrinogen content of the plasma2' 3'18'19, and they believe that it is due to this that the sedimentation rate is directly proportional to the fibrinogen content17. In congenital absence of fibrinogen the sedimentation rate is practically zero15. Where the fibrinogen varies, the blood sedimentation rate will be found to vary with it39. It is true that globulin is believed to facilitate aggregation and a fall in the albumin-globulin ratio often results in a raised sedimentation rate, due in part to the increased globulin16, but in part also to the concident rise in the fibrinogen level itself, for fibrinogen is a protein of globulin type and a rise in fibrinogen is a well Page 361 â marked feature of the nephrotic syndrome22. It is also said that lecithin inhibits aggregation, and that cholesterol promotes it. Therefore before the sedimentation rate is used as an index of fibrinogen content, the possibility of an abnormality of these factors should be considered21, but this does not often occur in those cases where the sedimentation rate is of most value, namely, the asymptomatic, apyrexial, ambulatory types. Further, in acute infections, the albuniin-globulin ratio does not usually change23, and cholesterol and other lipoids usually decrease23. Lipoids are markedly abnormal in conditions such as hypothyroidism, diabetes, and heptic damage, but in these, the sedimentation test is rarely employed22' 23. It is worth noting that in pregnancy, the fibrinogen is raised22'37, and that with it goes a constant increase in the blood sedimentation rate2. The anticoagulant used in the sedimentation test is of great importance. Soluitons often involve diluting the plasma by one-fifth. This results in a decrease in the concentration of the charge reducing factors, and it may be due to this that aggregation is lessened and that, therefore, in spite of dilution, the sedimentation rate is slower8'14. Inorganic salts, such as sodium citrate and fluoride, slow the sedimentation rate. It is believed that they are adsorbed onto the surface of the cells, increasing their charge, and that hence by increasing mutual repulsion, they diminish aggregation14. Oxalated blood is most unreliable, especially if kept standing for more than an hour24, for aggregation then diminishes greatly, and estimation of the sedimentation rate gives readings that are from 50% to 200% too slow. Sodium citrate, 3.8% (0.2 cc. to every 0.8 cc. of blood) will slow the sedimentation rate by two-thirds24' 3>14. However, unlike oxalate, this effect is constant and unaltered by delays of up to five hours in setting up the blood26. Studies of aggregation show that, although continuing for some hours, most of it occurs during the first fifteen minutes5. It is regarded desirable to end this period of increasing sedimentation rate due to clumping as soon as possible, as the rate at which the clumps form is not so closely related to the fibrinogen level as the final steady velocity of fall. From this point of view, heparin and hirudin are inferior to citrate, since, although they have no effect on the final rate of fall, the time taken to reach it is, with them, more variable and prolonged14,18'13. A practical test must take minimal amounts of blood, yet the column of blood must be high to avoid packing, which introduces a disturbance varying with the degree of anaemia. This packing of the aggregates decreases the distance between them, and begins to cause deviations from Stokes' law (V = C . r2), when they have fallen half the total length of the tube. Thereafter, the increasing frictional losses rapidly slow the rate of fall to zero. In the 50 mm. Cutler tube, this starts at 25 mm., but in the 200 mm. Westergren, a blood must drop 100 mm. in the first hour to give rise to this effect8. As Bannick4 and others5, 6Â» 7> 8 point out, by using this longer tube, the disturbing effect of this variation, which depends on total cell volume, is avoided in almost all cases, and a correcting factor for anaemia is unnecessary. Since only 2 cc. can with reason be taken repeatedly, the column must be a narrow one3. In practice, 2.5 mm. is the diameter used. Even with this the sedimentation rate is 20% slower than with 3 mm. tubes, showing that it is important to employ tubes of the same bore in consecutive tests3. Below this diameter the aggregates adhere to the walls, making the cell plasma division indefinite. Slight tilting of these narrow tubes gives false high readings by leading to down-streaming of the corpuscles on the lower side and up-streaming of the displaced plasma, on the principle of the angle centrifuge. As little as 3 degrees tilt will make a 30% difference in the result3'14. In this respect, the newly introduced suspended Westergrens may prove an advance, since they cannot be inadvertently placed at a slant6' 23. Heating of the sedimenting blood by exposure to sunlight, or standing near a radiator, will increase the rate about 30% for a 10Â° C. rise. The Westergren method, using citrate, and taking a single reading at the end of one hour, is now regarded, after twenty years of attempts to improve on it, to be the most practical, as well as the best indicator of fibrinogen content9, 8. Hambledon9, Osgood2' and others8' 4' 24 point out that graphic methods do not repay the time consumed by giving any extra information of value. In the first fifteen minutes during which the Page 362 aggregates are forming, readings are less reliable than those taken at one hour, when the steady fall of the aggregates formed has been so great as to greatly outweigh the variable initial period of slower fall. If used at all, oxalated blood must be set up at once or the results will be grossly misleading24. What is the significance of the results obtained? In cardiac decompensation, in cachexia, and other conditions causing liver damage, fibrinogen production is diminished15, and the blood sedimentation rate is often low, for fibrinogen production is a liver function1' 22' 23. On the first day of acute infections, there is no rise, possibly because the liver has not yet had tmie to react to the sudden drain with an increased output of fibrinogen. In appendicitis, before there is much peritoneal reaction, that is, during the early stages previous to rupture, the sedimentation rate is low. In salpingitis, there is much fibrinous exudation, and Bannick and Gregg4 point out that this may prove of value in the differential diagnosis of the two conditions. In pulmonary tuberculosis, though usually of great value2 'n, the sedimentation test may occasionally29 be of no index as to the patient's progress. Thus, a favourable pneumothorax may have a consistently high sedimentation rate, whilst a sputum-positive, cavitating case may remain deceptively low30' 31, 32. It is possible that the reason for this is that a fibrinous pleural reaction, calling for increased fibrin output, may occur even in favourable pneumothoraces. Also, a fibrotic cavity may have around it so little tissue destruction that there is but slight stimulus to fibrinogen production. In rheumatic fever, the sedimentation rate follows the fibrinogen level, and Ernstene20 considers that it forms a reliable guide to progress. In nephritis, as mentioned, the disturbance of the albumin- globulin ratio is accompanied by a rise in the globulin fraction, including fibrinogen, which is paralleled by the sedimentation rate22. Bannick4, Cutler5, n, and others7'8, consider that anaemia, associated with a rapid sedimentation rate, has underlying it, in all probability, some tissue destructive process, because in itself it does not materially affect the sedimentation rate. Most authori- agree that there is no need to "correct" sedimentation rates for anaemia. ties 4 7, 9.32 This is because in anaemic, and in normal bloods, the aggregates are not so closely packed that the rate at which the plasma streams through the chinks between them is so high as to interfere with the application of Stokes' law. In polycythaemia, on the other hand, the fibrinogen level is depressed38, especially when there is little infection. The aggregates are, therefore, small, and the rate may be deceptively slow. This is because the distance between them is reduced to a point where the lines of flow through the chinks are broken by eddies behind each aggregate, and the frictional drag on them considerably increased thereby. In such cases correction factors may have to be applied9. The sedimentation test is most valuable as an index of the activity of a hidden disease process in the chronic and asymptomatic stages, but it must be read with discrimination. Only changes of some 30 to 40.% can be regarded as significant. It will, on occasion, fail to give a true picture. It may remain raised when, as a matter of fact, the processes are pre-eminently those of repair. It may be deceptively low when, because of liver damage, tissue destruction is unaccompanied by fibrin outpouring38. Increase in lipoids, or other substances inhibiting aggregation, may also depress it in spite of considerable disease activity. It is only after following the sedimentation rate for some weeks that an idea can be gained as to whether the processes of repair or those of destruction have the upper hand. Even then, the results are often equivocal. It would be of value to have a test by which the relative predominance of the exudative or fibrotic processes at any particular moment might be estimated. Especially in the gravely ill, the recently developed Weltmann reaction may prove a more reliable index than the sedimentation test. The basis of the Weltmann test is the empirical observation that the concentration or calcium chloride required to complete heat precipitation of the serum proteins varies with the clinical condition of the subject. Of its intimate mechanism nothing is known, save that it does not appear to follow the fibrinogen, albumin-globulin ratio, hydrogen- ion concentration, or serum calcium. So far no explanation has been advanced. Page 363 U In carrying out the test, 0.1 cc. of serum is diluted with 5 cc. of calcium chloride solution of strengths varying from 0.1% to 0.01%, and heated at 100Â° C. for 20 minutes. Ten solutions are used. Concentrations of Calcium ChlorideâPercent. 0.1% 0.09% 0.08% 0.07% 0.06% 0.05% 0.04% 0.03% 0.02% 0.01% Tube No. 1 (left) ~4~ Exudative Lobar pneumonia Miliary tuberculosis Tuberculous bronchopneumonia Acute rheumatic carditis Exudative pleurisy Exudative tuberculosis 6 Normal 8 10 (right) Fibrotic |p| Fibrotic tuberculosis Peritoneal carcinoma Cirrhosis of the liver Endocarditis lenta Fibrotic pleurisy 35 According to Levinson33' 34, Klein, and Rosenblum30, who have recently, published the results of work on over twelve hundred subjects with this test, if flocculation occurs in the first six tubes, the reaction is to be regarded as normal. If in more than six, it is suggested that the changes are likely to be fibrotic When less than six tubes flocculate, they state that the condition is often of an exudative nature. They regard the amount of shift as a measure of the intensity of the process. Thus, in catarrhal conditions such as bronchitis, they find it normal, but in pneumonia they report it as often greatly shifted to the left, and they feel that this point may /prove of value in the differential diagnosis of respiratory tract infection. In fibrotic tuberculosis or pleurisy the shift is often to the right. They admit that the Weltmann is often equivocal34, and it is suggested that this is because the lesions are, in such cases, partly exudative and extending, and in part healing and fibrotic. It is claimed by Klein35 that it follows the patient's condition more closely than the sedimentation test, which may stay elevated in spite of improvement, and remain normal in the very ill. They believe that it also forms a better prognostic guide and that the sedimentation test often gives readings whose significance it is hard to correlate with the other clinical findings. They consider that a shift from the fibrotic to the exudative in rheumatic fever (110 cases examined) may presage carditis, and also that a fibrotic reaction in tuberculosis (100 cases examined) suggests a good prognosis, whilst a shift to the exudative may predict a relapse. It is possible that it may prove of value where the sedimentation rate fails to drop, and the rest of the clinical picture is confused. In the question of liver damage it may prove of value, since cirrhosis gives a strongly fibrotic reaction. Levinson33 states that in pyrexia of unknown origin, miliary tuberculosis may be regarded as improbable if the reaction is not exudative; if it is, that typhoid fever and malaria are then unlikely. It is also claimed that it is of some value in the distinction between rheumatic carditis and endocarditis lenta, since in the former the reaction is exudative, whilst in the latter it remains normal. It has found many adherents in Europe during the past ten years, but so far, in spite of the favourable reports of those few who have used it here, it has not yet been given the really extensive and searching appraisal that it merits34. Summary: 1. Mechanism of the sedimentation test. 2. Significance of the results obtained. 3. Technique of the Weltmann reaction and the advantages claimed for it. l. 2. Page 364 REFERENCES: G. H. WhippleâAmer. Jour. Phys., 58:391, Jan., 1922. R. FahreusâPhys. Rev., 9:241, 1929. T. HamâMedicine, 17:447, 1938. E. Bannick and R. Greggâ/. A. M. A., 109:1257, Oct., 1937. T. W. CutlerâAmer. Jour. Med. Sc, 195:734, June, 193 8. C. H. SmithâAmer. Jour. Dis. Child., 56:511, Sept., 1938. L. W. Diggs and J. BibbâJ. A. M. A., 112:695, Feb., 1939. A. HambletonâAmer. Jour. Med. Sc, 198:177, Aug., 1939. D. W. Crombie and A. HambletonâCan. Med. Assn. Jour., 39:163, Aug., 193! A. B. RobinsâAmer. Rev. Tub., 35:762, June, 1937. J. W. CutlerâAmer. Rev. Tub., 19:544, May, 1929. D. Rourke and A. ErnsteneâJour. Clin. Invest., 8:556, June, 1930. C. R. WaltonâJour. Lab. & Clin. Med., 7:711, April, 1933. D. Rourke and E. PlassâJour. Clin. Invest., 7:365, Aug., 1929. W. OakleyâLancet, .1:312, Feb., 193 8. StruthersâCan. Med. Assn. Jour., 603, Dec, 1934. S. Lucia and T. BlumbergâAmer. Jour. Med. Sc, 192:179, Aug., 1936. W. PayneâLancet, 1:75, Jan., 1932. E. Gresheimer and J. A. MyersâAmer. Rev. Tub., 16:344, Sept., 1927. C. ErnsteneâAmer. Jour. Med. Sc, 180:12, Jan., 1935. T. H. HamâJour. Clin. Invest., 16:681, July, 1937. Peters and Van SlykeâQuant. Clin. Chem., Vol. 1, 1932: Bailie re, London. CanterowâClin Biochemistry^ Saunders, 1939. S. BergâJoÂ»r. Lab. & Clin. Med., 24:757, April, 1939. H. D. FurnissâJour. A. M. A., 114:756, March, 1940. F. Boerner and H. FlippinâJour. Lab. & Clin. Med., 20:583, March, 1935. E. Osgood and H. HaskinsâJour. Lab. tf Clin Med., 5:486, Feb., 1931. Beaumont and DoddsâRecent Advances in Medicine: Churchill, London, 193 ( T. Cecio and B. ElwoodâAmer. Rev. Tub., 39:748, June, 1939. H. Pesser and A. HurstâAmer. Rev. Tub., 3 8:491, Oct., 1938. L. E. HoughtonâTubercle, 17:51, Nov., 193 5. H. BuntingâAmer. Jour. Med. Sc, 198:191, Aug., 1939. S. A. LevinsonâJour. Lab. & Clin. Med., 23:53, Oct., 1927. S. A. LevinsonâAmer. Rev. Tub., 200:37, Feb., 1938. B. I. Klein and P. RosenblumâAmer. Jour. Dis. Child., 59:49, Jan., 1940. A. WestergrenâAmer. Rev. Tub., 14:94, July, 1926. D. P. FosterâArch. Int. Med., 34:301, 1924. T. H HamâMedicine, 17:413, Dec, 193 8. RED CROSS RAFFLES All Red Cross Branches have been instructed that no individual has the right to sponsor a Red Cros raffle in his or her own nameâwith part proceeds going to the Red Cross. All Red Cross raffes must be under complete control of the branches, with full proceeds going to the local branch. Branches have also been advised to consult and get permission from local police authorities before starting them. RED CROSS HELPS PRISONERS OF WAR Families or next of kin of Canadians serving with the Royal Air Force or other units of British Forces are asked to communicate particulars to Canadian Red Cross Headquarters, Toronto. The Canadian Red Cross is now receiving from the International Red Cross names of Canadians who, serving with the Imperial Forces, are now prisoners of war in Germany. If men are not on Red Cross lists it is impossible to advise relatives of receipt of parcels or convey Red Cross information concerning them. Page 365 St. Pauls Hospita NEW WING ADDED TO ST. PAUL'S HOSPITAL Invitations were extended to representatives of the Provincial Government, the City Council, and a number of officials and friends for the opening of the new wing of St. Paul's Hospital, which was blessed by His Excellency, Archbishop Duke, and formally opened by Hon. George Weir, Minister of Education, on Sunday, June 30th, the Feast of the Commemoration of St. Paul, at 2:30 p.m. The new wing completes the large and splendidly equipped modern St. Paul's Hospital fronting on Burrard Street and occupying one block on Comox Street and one on Pendrell, nad now having a capacity of over 600 beds. The main building stands on the original site purchased by the Sisters of Charity of Providence in 1894. From then until 1907 there were no nurses but the Sisters. Now there is an accredited School of Nursing for 220 student nurses. The present imposing edifice is the result of hard work and far sightedness, and the amount of sacrifice and thought entailed in its gradual rise to its present imposing dimensions will never be calculated. As one Superior succeeded another some characteristic of each has been woven into the glorious structure which now stands. The new wing, facing on Pendrell Street, has a total frontage of 246 feet by 45 feet in width, and in design, so far as the exterior is concerned only, very similar to the North wing. On entering, the visitor will immediately be impressed with the cheerful atmosphere that is noticeable on all floors, the spaciousness of all the wards, together with the modern decorative scheme and homelike furnishings. One of the important features adopted in this new wing, so far as it affects the patients' comfort, is the type of sound deadening suspended ceilings installed throughout, to eliminate as much as possible all noise and sound travel. The new wing contains seven floors, the first floor being given over to maintenance departments, Ladies' Auxiliary, Pharmacy storage, store rooms, etc., and in addition will be found the splendidly equipped cafeteria for the male and female help, apart from the nursing staff. This cafeteria measures 79 feet by 42 feet, and is fitted out with the very latest in cafeteria design and equipment, all finished in stainless steel, together with kitchen, wash up rooms, etc., making this department one that will be greatly appreciated by the Hospital employees. The main floor is entered from an imposing entrance on Pendrell Street, opposite the Comox Street entrance. On this floor is placed the new Physio-Therapy Department, which is considerably enlarged and moved over from the centre wing. This department has been given very careful study and is strictly modern in every respect for the treatment of patients. Special provision has been provided for the Internes on this floor, having their own individual rooms, together with large lounge and library, the balance of this floor being taken up with Pharmacy storage, guests' rooms apart from the Hospital floors, and in addition will be found the Sisters' dining room, measuring 40 feet by 42 feet, with large pantry, kitchen, etc., adjoining. The second, fourth and fifth floors are typical. These floors contain single, double and four-bed wards, each ward having its own individual locker room, lavatory and bath accommodation, all fitted with the latest nurses' call system, lighting, etc., each ward having a different scheme of wall decoration. At both the East and West elevation on each floor is provided a large solarium for the use of convalescent patients. Page 366 1 The third floor is given over entirely to the Pediatric or Children's Department. Special care has beer^taken in the designing of this unit to provide ample light, ventilar tion, and to take full advantage of sunshine. Here the visitor and nurses have complete vision and supervision over each ward and patient, the corridor walls being provided with large plate glass windows, with glass panel in each cubicle partition, and each cubicle is a complete unit, having hot water service to each, with special ventilation, lighting, sun and violet ray equipment. A special Children's Separating Unit is also provided on this floor, which is completely shut off from the rest of the patients. This Isolation Department is practically a small Hospital in itself, complete with all necessary facilities for the safe and proper care of any suspected case. Provision for the accommodation of older children is also provided, together with special rooms where the parent of any patient may live in the Hospital, if necessary. Two large play rooms, one at each end of this third floor, are provided for, where full advantage can be taken of fresh air and sunshine. The sixth floor is given over entirely to the Sisters' quarters, and is a complete dormitory. Provision has been made in this new wing to take full advantage of the roof space for patients. The passenger elevator lands right up at this roof level, where an uninterrupted view of the city can be had and the patient can take full advantage of the fresh air and sunshine. It can safely by stated that this new South wing is as complete and up-to-date a Hospital wing as can be found anywhere. There are no unnecessary expensive frills to be found, the interior is finished off in complete good taste, the one thought being to provide complete efficiency for the care and treatment of the sick first, and in this regard a complete co-ordination between the other departments in the older part of the Hospital has been carefully considered, to enable the St. Paul's Hospital to work smoothly on as a complete unit. New car parking facility has been provided on the Hospital property for the doctors' use, which will be greatly appreciated. St. Paul's Hospital until now had a bed capacity of 357 with 48 bassinettes. The present Superior, the Rev. Sister Mary Philip, f .c.s.p., R.N., came to Vancouver in September, 1938, having been formerly Superior at Olympia, Wash., and at Mount St. Vincent, Seattle. Historical Sketch of St. Paul's Hospital. May 16th, 1894âA wooden building comprising 20 rooms with a bed capacity of 25. It was situated on the corner of Burrard and Pendrell. Sister Fredric was the first Superior, replaced by Mother Praxedes in 1900, who is at present the Superior general of the institute. The Sisters personally took care of the patients. During the first year of its existence 120 patients were admitted to the hospital. 1904âAddition of a new south wing on Pendrell street took place while Mother Praxedes was still here as Superior. The bed capacity was raised to 120, consisting of 3 3 private rooms, 7 semi-private and 11 wards, also two surgeries and an X-ray. From 1894 to 1904, 5823 patients had been admitted. Dec. 8, 1913, marked the opening, under Mother Wenceslaus, of the modern fireproof unit, constituting the main section of the present hospital. It had accommodation for 200 patients. A new surgical department and an X-ray were installed on the fifth floor. The south wing of 1904 remained as an annex to this structure but the original foundation was destroyed. October, 1931âOpening of the North Wing. It faces Comox Street and has a frontage of 233 feet with a depth of 45. It provides for 200 bedsâis 6 storeys in height with full basement as well. It is fireproof throughoutâhas terrazzo floors everywhere and special sterilizing, heating, ventilating and signal systems installed. The whole top floor comprises the surgical department with 11 operating rooms and adjoining modern scrub rooms and work rooms. The first floor is reserved entirely for the X-ray and laboratory departments, which are destined to accommodate a growing institution. Page 368 The south wing built in 1904 remained as an annex until this date, when it was transferred to the rear on Pendrell Street and is now being used as accommodation for the male employees. New South WingâJune 14th, 1939 (a) Blessing of the grounds by Archbishop Duke, D.D. (b) Building commencedâArchitects: Gardiner, F. G., & Mercer; Contractors: Armstrong & Monteith. The new wing of St. Paul's Hospital will fill a long-felt want for more hospital bed accommodation in Vancouver and the Sisters of Charity are to be congratulated for their courage in providing for its citizens this splendid and up-to-date addition. [For a large amount of this information, we are indebted to the columns of the B. C. Catholic, and make grateful acknowledgment therefor.âEd.] m 4 if gNiiijga^gpgL â "os.*"**. *f't'i !?"-j!wÂ«?>&?5??5v^^w^: An exterior view of the new wing recently added to St. Paul's Hospital. Page 369 THE DIAGNOSIS OF SYPHILIS BY THE GENERAL PRACTITIONER By Joseph Earle Moore, M.D. From the Syphilis Division of the Medical Clinic, the Johns Hopkins Medical School and Hospital. Reprinted from Supplement No. 5, United States Public Health Service. {Continued from August issue) Ocular Lesions The common ocular lesions of secondary syphilis are iritis (incidence about 5 per cent) and neuroretinitis (incidence about 1 per cent). Except in the case of iritis papulosa, there is nothing distinctively syphilitic about the appearance of either of these. The most expert ophthalmologist cannot differentiate them clinically from iritis (fig. 12) or neuroretinitis due to other causes. Since syphilis is responsible for from 10 to 70 per cent of all cases of iritis (depending on the type of clientele) and about 30 per cent of all cases of neuroretinitis, the only safe rules for the family physician and ophthalmologist are, in all such cases: Figure 12. THE IRITIS OF EARLY SYPHILIS Cannot be Clinically Distinguished from Iritis due to Four Other Causes, as Follows: Focal infection Tuberculosis Gonorrhoea Rheumatic fever EXAMINE SKIN AND MUCOUS MEMBRANES DO A BLOOD SEROLOGIC TEST 1. Suspect syphilis. 2. Examine immediately the skin and mucosae for other lesions of early syphilis. 3. Whether or not such lesions are present, do a blood serologic test at once. These steps should be the first, not the last part of the diagnostic study. When they are omitted, many an unfortunate syphilitic patient has been subjected to useless removal of teeth and tonsils, to prostatic massage, gall-bladder drainage, even to brain operations without benefit, but with possible detriment to his eyes, and with danger to the operator and the community. Lesions of Bones and Joints Involvement of the bones and joints in early syphilis is far more common than is generally supposed. Symptoms are more important than signs. The usual manifestations are: 1. Osteocopic pains, often nocturnal, involving the shafts of all the long bones. Localized tender area may be present on palpation though no other abnormalities are obvious. 2. Arthralgia. Dull aching and stiffness of the joints, large and small, worse at night or in the morning. There are no objective or X-ray changes. 3. Hydroarthrosis, usually involving the knees and ankles. No X-ray changes. 4. Actual acute periostitis (commonest in the tibia) in which, owing to its acute - ness, X-ray changes are at first absent. There is nothing about the first three of these manifestations to differentiate them from a variety of other conditions, and in fact the mistaken diagnosis of "neuritis," "rheumatism," and "infectious arthritis" (acute, subacute, or chronic) are commonly Page 370 made. These mistakes can be avoided only if the family physician and the orthopaedist will, in all cases: 1. Suspect syphilis. 2. As the first step in checking suspicion, strip the patient and look for other lesions of secondary syphilis on skin and mucosae. 3. Whether or not such lesions are present, do a serologic test, since the bone and joint symptoms may be the sole clinical evidence of early syphilis. As in ocular syphilis, these steps should be the first, not the last of the diagnostic procedures adopted. Only in this way will grave error be avoided and some patients spared the useless extirpation of foci of infection. Summary of Diagnosis in Early Syphilis The above description is conspicuous for its lack of clinical detail. No stress whatever has been laid on a history of syphilis, since this is often either lacking or confusing. Nothing has been said of generalized lymphadenopathy, or of the "tout ensemble" of the clinical picture. No attempt has been made to describe or to illustrate the differential diagnostic points of lesions. These are matters for the expertâfor the syphilologist, dermatologist, urologist, gynaecologist, laryngologist, ophthalmologist, and orthopaedistâand are not to be learned by reading textbook descriptions or studying photographs. Instead, every stress has been laid on the facts that primary syphilis causes genital or extragenital sores; that secondary syphilis causes generalized skin eruptions, mucosal lesions, loss of hair, iritis and neuroretinitis, and bone and joint symptoms; that these syphilitic lesions are readily confused with many other diseases, often by the general practitioner, sometimes even by the appropriate specialist; that in the presence of any of the diseases with which syphilis might be confused, syphilis should be suspected; and that this suspicion may be at once and accurately checked by a dark-field and serologic test. If every medical student and every physician learns so much and no more of the diagnosis of early syphilis, 95 per cent of delayed and missed diagnoses will disappear. Diagnosis vs. Case-Finding in Early Syphilis Both from the public health standpoint and from that of the individual patient, however, it does not suffice that the physician recognize the lesions of early syphilis when he is consulted. Too many freshly infected patients do not consult the physician at all, because of ignorance or negligence, or because infection may either be actually symptomless or the symptoms so trivial that the patient is unaware of his disease. These patients must be sought out; they must be found instead of diagnosed. (To Be Continued) MEMBERS of THE GUILD Â§Â§ of PRESCRIPTION OPTICIANS of AMERICA Always Maintain the Ethical Principles of the Medical Profession Guildcraft Opticians 430 Birks Bldg1. Phone Sey. 9000 Vancouver, Canada. Page 371 â 1 """"V*"-^v"*"" â :;; â¢_--; v -.vv- â¢ v.-â¢- Take along PABLUM ... so easy to prepare Whether or not there is a baby in your family Pablum is a convenient, nutritious food to include in the vacation kit. This unique cereal can be served in an instant... almost anywhere, any time. No cooking is required. All that's needed is to add water or milk of any temperature. As a physician you will appreciate the advantage that Pablum, unlike so many camp rations which tend to be concentrated carbohydrate lacking in minerals and vitamins, supplies generous amounts of calcium, phosphorus, iron and vitamins Bi and B2 (riboflavin). Packed without water, Pablum is light and easy to carry, yet its iron and calcium content is far higher than that of bulky, perishable vegetables. Pablum consists of wheatmeal (farina), oatmeal, wheat germ, corn- meal, beef bone, alfalfa, yeast, sodium chloride and reduced iron. MEAD JOHNSON & CO. OF CANADA, LTD., â¢ BELLEVILLE, ONTARIO INDEX TO VOLUME XVI, V.M.A. BULLETIN, 1939-1940 A AGNEW, A. M.âThe cervix a focus of infection 117, 302 ALCORN, D. E.âSigmund Freud and psychoanalysis 204 ANAESTHESIA, TRENDS INâD. D. Freeze 190 ANDERSON, J. L. MURRAYâActive immunization in general practice 295 ANTHONY, A. R.âFever therapy in retro-bulbar neuritis 115 APPLEBY, LYON H.âCongenital polycystic disease of the liver 114 ARMITAGE, T. F. H.âCatastrophe due to suphanilamide 326 ASCHHEIM-ZONDEK TESTâFriedman ModificationâH. H. Pitts 48 ASCHHEIM-ZONDEK TEST (Friedman Modification) Report of 2069 testsâE. A. Gee 224 B BAILLIE, D. M.âThe whole "set-up" is wrong 242 BIOPSY OF BONE MARROW IN BLOOD DYSCRASIASâG. A. McCurdy 27 BLOOD SEDIMENTATION TEST AND THE WELTMANN REACTIONâJ. P. Henry.... 361 BOUCHER, H. H.âLow back pain 252 BRAIN TUMOUR CASES, VERIFIEDâD. P. Robertson and C. E. Gould 174 BRIGHT'S DISEASE AT THE VANCOUVER GENERAL HOSPITALâGillean McKinnon 24 .BRITISH COLUMBIA CANCER INSTITUTEâ A Summary of the first year of operationâA. Maxwell Evans 66, 306 BRITISH COLUMBIA MEDICAL ASSOCIATIONâ Annual meeting, 1939 11 Annual meeting of No. 4 District Medical Association, 1939 65 Medical service to indigents 162 Annual meeting, 1940 285, 314 Annual reports for 1939-40 .^.; 349 BROWN, EDGAR N. and WILLIAMS, DONALD H.âPrevalence of Venereal disease infection in Vancouver _ 180 BRYANT, F. M.âDiverticulosis and diverticulitis 82 C CAMPBELL, C. G.âA few notes on peptic ulcer 1 143 CANADIAN MEDICAL ASSOCIATIONâ Annual meeting, 1940 284 CANCER, SOME POINTS REGARDINGâF. N. Robertson 307 CERVIX, A FOCUS OF INFECTIONâA. M. Agnew 117, 302 CLARK, R. H., CORBOULD, IRIS and McKECHNIE, R. E. II,âIntravenous feedings of amino acids 182 CLARKE, WALTERâThe five day treatment of syphilis 323 CLEVELAND, D. E. H.âEctodermosis erosiva pluriorificialis 110 CLOUSTON, H. R.âDoctor and Priest 146 COLLEGE OF PHYSICIANS AND SURGEONSâ Medical Service Plans 163 Medical Service Association 319 CORBOULD, IRIS, CLARK, R. H. and McKECHNIE, R. E. IIâIntravenous feeding of amino acids 182 CUSHING, DR. HARVEY, (Biography)âWilliam Carleton Gibson 84 DOCTOR AND PRIESTâH. R. Clouston 146 D DIVERTICULOSIS and DIVERTICULITISâF. M. Bryant 82 DOBSON, WILLIAM A.âEarly diagnosis of schizophrenia 59 E ECTODERMOSIS EROSIVA PLURIORIFICIALISâD. E. H. Cleveland 110 EVANS, A. MAXWELLâSummary of first year of operationâB. C. Cancer Institute.... 66 P FEVER THERAPY IN RETRO-BULBAR NEURITISâA. R. Anthony . 115 FRACTURES, SOME SUGGESTIONS FOR MANAGEMENTâD. M. Meekison s 276 FREEZE, D. D.âTrends in anaesthesia 190 FREUD AND PSYCHOANALYSISâD. E. Alcorn 204 G- GEE, EVELYN A. and WYLIE, DOROTHY E.âReport of 2069 Aschheim-Zondek Tests (Friedman Modification) 224 GLAUCOMA, DIAGNOSIS AND TREATMENTâMeyer Wiener 264 GIBSON, WILLIAM CARLETONâDr. Harvey Cushing, Biography 84 GOULD, C. E.âSummary of the problem of jaundice 355 GOULD, C. E. and ROBERTSON, D. P.âVerified brain tumour casesâV.G.H. 1934-1938.. 174 H HALL, EARLE R.âCase of polycystic kidneys with complications 201 Urethral discharge 130 HENRY, J. P.âThe hands and infection of clean wounds 198 Blood sedimentation test and the Weltmann reaction 361 X ILEITIS, REGIONALâW L. Pedlow 69 IMMUNIZATION, ACTIVE, IN GENERAL PRACTICEâJ. L. Murray Anderson 295 INCOME TAX INFORMATION 135 INFECTION OF CLEAN WOUNDS AND THE HANDSâJ. P. Henry 198 INTRAVENOUS FEEDING OF AMINO ACIDSâIris Corbould, R. H. Clark and R. E. McKechnie II lg2 JACKSON, J. M.âThe schizophrenic problem and some recent advances 60 JAUNDICE, SUMMARY OF THE PROBLEMâC. E. Gould 355 X KEMP, W. N.âIncreased nutritional requirements of pregnancy and lactation 50 INDEXâContinued LABORATORY PROCEDURESâH. H. Pitts. 159 LIVER ABSCESS DUE TO ENTAMOEBA HYSTOLYTICAâH. H. Milburn.... 78 LOW BACK PAINâH. H. Boucher .<. 252 M MEEKISON, D. M.âSome suggestions for management of common fractures 276' MENSTRUAL DISORDERS, TREATMENTâA. E. Trites.... 97 MILBURN, H. H.âLiver abscess due to entamoeba hystolytica 78 MAC. McCURDY, G. A.âBiopsy of bone marrow in blood dyscrasias 27 Affections of the synovial membrane 334 McKECHNIE, R. E., II, CORBOULD, IRIS and CLARK, R. H.âIntravenous feeding of amino acids 182 MacKINNON, GILLEANâBright's disease at the Vancouver General Hospital 24 MacLAREN, R. D.âReview of 316 cases of peptic ulcer 139 N NUTRITIONAL REQUIREMENTS OF PREGNANCY AND LACTATIONâW. N. Kemp.... 50 OBITUARIESâ O Dr. Benjamin Butler Marr 36 Dr. H. C. Wrinch 36 Dr. H. E. Young - 37 Dr. J. W. Mcintosh 52 Dr. Thomas Curtin 57 Dr. C. A. Drummond .. _ 95 Dr. Campbell Davidson 157 Dr. Paul Ewert 157 Dr. John Amyot 158 Dr. George S. Gordon 214 Dr. Alfred Thompson 215 Dr. J. P. Bilodeau 1 320 Dr. C. M. Bennett - ' 348 P PAEDIATRIC PRACTICE IN EUROPEâHoward Spohn 38 PEDLOW, W. L.âRegional Ileitis 69 PEPTIC ULCER, REVIEW OF 316 CASESâR. D. MacLaren 139 PEPTIC ULCER, NOTES ONâC. G. Campbell 143 PETERSON, S. C.âNotes on latent syphylis 74 PHYSICIAN AS A WITNESS (Extract)âC. O. Sappington 8 PITTS, H. H.âAschheim-Zondek Test (Friedman Modification) , 48 Brief discussion of some newer laboratory procedures 159 POLYCYSTIC DISEASE OF THE LIVER, CONGENITALâLyon H. Appleby 114 POLYCYSTIC KIDNEYS WITH COMPLICATIONSâEarle R. Hall 201 PROSTITUTIONâFACTS AND FALLACIESâD. H. Williams ~ 107 R. ROBERTSON, D. P. and GOULD, C. E.âVerified brain tumour case 174 ROBERTSON, F. N.âInvestigation into some points with regard to cancer 307 S ST. PAUL'S HOSPITAL SECTION : 80, 182, 291 New Wing â â 366 SAPPINGTON, C. O.âThe physician as a witness (Extract) 8 SCHIZOPHRENIA, EARLY DIAGNOSISâWilliam A. Dobson 59 SCHIZOPHRENIC PROBLEMâRECENT ADVANCESâJ. M. Jackson 60 SPOHN, HOWARDâPaediatric practice in Europe 38 SULPHANILAMIDE, CATASTROPHE!âT. F. H. Armitage 326 SULPHANILAMIDE AND DERIVATIVES, CHEMOTHERAPYâJ. H. W. Willard 164 SYNOVIAL MEMBRANE, AFFECTIONS OFâG. A. McCurdy 334 SYPHILIS, DIAGNOSIS'âU. S. Public Health Service 239, 273, 308, 339, 370 SYPHILIS, LATENTâNOTESâS. C. Peterson 74 SYPHILIS, FIVE DAY TREATMENTâWalter Clarke 323 TRITES, A. E.âTreatment of functional menstrual disorders. 97 URETHRAL DISCHARGE!âEarle Hall 130 U. S. PUBLIC HEALTH SERVICEâDiagnosis of syphilis by the medical practitioner 239, -273, 308, 339, 370 V VANCOUVER GENERAL HOSPITALâ Case reports 69, 71, 159, 197, 260, 270, 287, 288, 326, 330 VANCOUVER MEDICAL ASSOCIATIONâAnnual meeting, 1940 218 VENERE1AL DISEASE IN VANCOUVERâEdgar N. Brown and Donald H. Williams.... 180 VICTORIA MEDICAL SOCIETY SECTION 27, 45, 82, 117, 204, 242, 276, 295, 334 VITAMIN DEFICIENCY STATES, RECOGNITION AND TREATMENTâDwight L. Wilbur ". 14. "W WHOLE "SET-UP" IS WRONGâD. M. Baillie 242 WIENER, MEYERâDiagnosis and treatment of glaucoma 264 WILBUR, DWIGHT L.âVitamin deficiency statesâRecognition and treatment 14 WILLARD, J. H. W.âChemotherapy of sulphanilamide and derivatives 164 WILLIAMS, DONALD H.âProstitutionâfacts and fallacies 107 WILLIAMS, DONALD H. and BROWN, EDGAR N.âVenereal disease infections in Vancouver 180 WYLIE, DOROTHY E. and GEE, EVELYN A.âReport of 2069 Aschheim-Zondek Tests.. 224 Page 2 yyt^H ounce ol pAeuertti&n rr One of the most effective methods of preventing untoward menopausal symptoms is through the early use of "Emmenin". As Hawkinson* has suggested, "Patients at the menopause who are still menstruating may be more difficult to control . . . Oral therapy in the form of emmenin is best suited to these cases." *Hawkinson, L. F.: J.A.M.A. 111:392 (July 20) 1938. "EMMENIN" â the orally-active, oestrogenic placental hormone â is supplied in LIQUID form (120 Collip day-oral units per teaspoonful) and in TABLET form (120 Collip day-oral units per tablet). McKENNA & HARRISON LIMITED Biolo^ccd and PUatomtu&tt&cai (Zkemidti HONTREN PRESCRIBE CANADIAN MADE PRODUCTS HELP WIN THE WAR CANADA BUY WAR SAVINGS CERTIFICATES Professional Men appreciate the Value of being well-dressed A Suit tailored to your measure by us is your assurance of Quality British Woollens, fine hand tailoring and correct style. Our new Spring patterns are now ready and your early inspection is invited. British Importers of Men's and Women's Wear MEDICAL-DENTAL BUILDING VANCOUVER, B. C. Nlttttt Sc 2559 Cambie Street Vancouver, B. C. Colonic Irrigation Institute Superintendent: B. M. LEONABD, B.N. Post Graduate Mayo Bros. Up-to-date treatment rooms; scientific care for cases such as Colitis, Constipation, Worms, Oastro-Xntestlnal Disturbances, Diarrhoea, Diverticulitis, Bheu- xnatism, Arthritis, Acne. Individual Treatment 9 2.50 Entire Course $10.00 Medication (if necessary) $1 to $3 Extra 1119 Vancouver Block VANCOUVER, B. C. Phone: MArine 3723 Three B.D.H. Products of Outstanding Value ANACARDONE Diethylnicotinamide 6.D.H., an analeptic characterised by its high activity and low toxicity, is available as Anacardone; it is indicated in collapse and shock following operation, injury or acute infectious disease and in cardiac and respiratory embarrassment during convalescence. IODATOL Iodised vgeetable oil has won an established place as a contrast medium for X ray diagnosis and has received official recognition in that it is included in the Addendum 1936 to the British Pharmacopoeia 1932. A British product, conforming with all the pharmocopoeial specifications, is available as lodatol (Oleum lodisatum B.P.). LIVOGEN Debility, lassitude, "nervousness" and many minor digestive derangements are early signs of deficiency of various members of the Vitamin B complex which are essential for the maintenance of oxidation-reduction processes of the body. These processes are intimately concerned with carbohydrate metabolism and therefore with the maintenance of normal nerve function and the health of all body cells. Livogen supplies all the members of the Vitamin B complex and thus it may be described as the "rational tonic." Further, the blood-regenerating properties of the liver contained in Livogen ensure an adequate supply of oxygen for the re-invigorated tissues. Stocks of B.D.H. Medical Products are held by leading druggists throughout the Dominion, and full particulars are obtainable from: THE BRITISH DRUG HOUSES (CANADA) LTD. Terminal Warehouse Toronto, 2, Ont. Omn/Can/409 ii ieraims, Vaccines, Hoimones AND Related Biological Products Anti-Anthrax Serum Anti-Meningococcus Serum Anti-Pneumococcus Serums Diphtheria Antitoxin Diphtheria Toxin for Schick Test Diphtheria Toxoid Old Tuberculin Perfringens Antitoxin Pertussis Vaccine Vaccine Virus Pneumococcus Typing-Sera Rabies Vaccine Scarlet Fever Antitoxin Scarlet Fever Toxin Staphylococcus Antitoxin Staphylococcus Toxoid Tetanus Antitoxin Tetanus Toxoid Typhoid Vaccines (Smallpox Vaccine) Adrenal Cortical Extract Epinephrine Hydrochloride Solution (1:1000) Epinephrine Hydrochloride Inhalant (1:100) Epinephrine in Oil (1:500) Heparin Solution of Heparin Insulin Protamine Zinc Insulin Liver Extract (Oral) Liver Extract (Intramuscular) Pituitary Extract (posterior lobe) Prices and information relating to these preparations will be supplied gladly upon request, CONNAUGHT LABORATORIES UNIVERSITY OF TORONTO Toronto 5 Canada Depot for British Columbia MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. Check Every Feature of this EFFICIENT, COMPACT, FLEXIBLE, Combination X-Ray Unit IsMiM HUHl You can depend on the G-E Model D3-38, with its wide range of service, its refined, simplified control, its flexible tilt-table with built-in Bucky, to produce routinelyâ and duplicate accuratelyâ end results of uniformly high diagnostic quality. Completely self-contained and unusually compact, it needs but little floor space. BEFORE you invest in: any x-ray unit, you owe it to yourself to check, every feature of the G-E Model D3-38. Moderately priced, it offers you more value for your x-ray dollar than any comparable equipment. Designed and built to meet your need; incorporating the many valuable suggestions you have made, the D3-38's unusual worth will be recognized readily by medical men with a keen sense of value. Start checking, today. Use the coupon to request your copy of the D3-38 catalog. f â â CHECK, SIGN, AND MAIL â HI VICTOR X-RAY CORPORATION of CANADA, Ltd. OOTtlftUTOAS FOB GENBLU ifflGj) ELECTX K-KAV CORPORATION TORONTO: 30 Bloor St, W VANCOUVER: Motor Troiu. 6ldg., 570 Dunsmuif St MONTREAL: MO Medical Acts Building WINNIPEG: Medical Am Bvildiao Please Bend me my copy of the G-E Model |âI D3-38 catalog and include full information about this modern, combination X-ray unit. A209 Name Address. (Please Print) City. ilM flfoount pleasant XHnoertahinG Co. %to. Telephone Fairmont 58 VANCOUVER, B. C. KINGS WAY at 11th AVE. R. F. HARRISON W. R. REYNOLDS 13 th Ave. and Heather St. Exclusive Ambulance Service FAIR. 0080 PRIVATE AMBULANCES AND INVALID COACHES WE SPECIALIZE IN AMBULANCE SERVICE ONLY J. H. CRBLLIN W. L. BE3RTRAND RESTFUL SLEEP REFRESHED AWAKENING Soneryl is a specially valuable hypnotic by reason of the fact that in varying dosage it can produce a result ranging from mildly sedative to powerfully hypnotic. Whether the stimulus preventing sleep be some painful condition or an over-active or over-anxious mind, Soneryl proves quickly effective. Each tablet contains 1 V% grs. of Soneryl (butyl-ethyl-malonyl- urea). Adult doseâ1 to 3 tablets half an hour before retiring. '?sa Â£2?1S'S Z&e&sZSZ** Â«W "*M / Hf"/,.. fRres Fso*t, '&Â«<* fÂ£fcr Rectal administration of Soneryl is to be preferred in young children, in cases where there is nausea and vomiting, and postoperatively to tide the patient over the first few hours after the effects of a general anaesthesia has passed off. Each suppository contains three grains Soneryl (butyl-ethyl-mal- onylurea) and three grains camphor in a cocoa-butter base. Adult doseâOne suppository. Children 7 to 12 years oldâ half a suppository. LI fVllTWU-MONTREAL Breaks the vicious circle of perverted menstrual function in cases of amenorrhea, f tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic relief by stimulating the innervation of the I uterus and stabilizing the tone of its a musculature. Controls the utero-ovarian normal menstrual cycle. 1 â¢ MARTIN H. SMITH COMPANY ^i ISO. lAfATiTTI STMET. NEW TO*K. N. Y Full formula and descriptive literature on request Dosage: l to 2 capsules 3 or 4 times daily. Supplied in packages of 20. Ethical protective mark MHS embossed on inside of each capsule, visible only when capsule is cut in half at seam. A new "Ciba" product, which exhibits, according to the dose, a sedative- antispasmodic effect of a central and peripheral nature, or acts as a mild soporificâ NEURO-TRASENTIN (Trasentin--phenylethylbarbituric acid) FOR THE TREATMENT OF NEURO-VEGETATIVE DISTURBANCES Neuro-Trasentin should undoubtedly be of great value in the following conditions:â Excitability, states of agitation, cardiac neurosis, angina pectoris, vascular spasms, hypertonia, nervous dyspepsia, ulcer pains, climacteric disturbances, dysmenorrhoea, pruritus, hyperthyreosis, etc. Issued: Tablets, in bottles of 30 and 100; also 500 for hospital use. CIBA COMPANY LIMITED MONTREAL HIM ATI NIC PLASTULES FOR IRON DEFICIENCIES Easy to take Because. | Easy to Swallowâ Hematinic Plastules are small gelatin capsules. Rapid Hemoglobin IncreaseâWell toleratedâless likelihood of gastric upset. One After Each Meal is Sufficient â The suggested daily dose is three Hematinic Plastules Plain. Tasteless, Odorless â The medication is hermetically sealed. This assures uniform potency. of ferrous iron and consistently good results. John Wyeth & Brother (Canada) Limited WALKEfWILLE, ONTARIO ^v&ult/u^ but the SPHYGMOMETER" A VISITING physician, observing the elaborate system of scientific tests employed in a Carnation Milk evaporating plant, remarked: "You seem to have everything but the sphygmometer!" . . . This appreciative jest emphasizes the extreme care practised in all Carnation plants. An exacting routine rejects milk for excess acidity, sediment, or "off" odor. It insures uniformity in composition and vitamin D potency. It guarantees complete steriliza tionâ for ready digestibility and perfect safety.... All Irradiated Carnation Milk, regardless of when or where it may be purchased, carries with it this same trustworthy assurance of uniform, dependable quality. A BOOKLET FOR PHYSICIANS â Write for "Simplified Infant Feeding", an authoritative publication treating of the use of Irradiated Carnation Milk in normal and difficult feeding cases . . . Carnation Company, Ltd., Toronto, Ontario. Cl IRRADIATED 1 r 1^ arnation JVLilk A CANADIAN PRODUCT- "from contented cows Responsibility 1. Day or Night MArine 4161 Free City Delivery till 10 p.m. Trained pharmacists, plus the invaluable experience of thirty odd years in filling Doctors' prescriptions â these are the ingredients of responsibility. c&aujL ^.Jaimde/iAoYA GEORGIA PHARMACY LIMITED OIOR9IA 9TMIT dtetiter & Sfattna Utit ESTABLISHED 1893 VANCOUVER, B. C. North Vancouver, B. C. Powell River, B. C. Hollywood Sanitarium Limited For the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively ReferenceâB. C. Medical Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver. SEymoub 4183 Westminster 288 ROY WRIOUTY PRINTING >ft PUBLISHING CO. LTD.
Periodicals
W1 .VA625
English
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: September, 1940
Text