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History of Nursing in Pacific Canada
Vancouver Medical Association
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t wHir of the MEDli^IMS«wB)N Vol. XX. OCTOBER, 1943 No*^ With Whu%$£ Incorporated ■ Transactions of the Victoria Med^^^mocie^ the Vanemiverpeneral^o and- St Pc^mH0S^S'\--: In This Issue: NEWS AND KOTES PROVlJg^LAL BOARD CS^EAjgpl_........'.' ^^^P^JJSIQ^^^^^^ - ----- THE SEX STEROID^ifiGENE^H^MEDl<|Ki^(tW^C 19 Diethyl-stilboestrol diproplonate, A synthetic oestrogen for oral administration Diethyl - stllboestrol diproplonate It proving especially valuable In the treatment of Prostatic ffeopfasms. Under Its definitely an tl-androgenic Influence, prostatic growths ^often and diminish In size, urinary retention decreases, and patients report easing of pain. ORESTOL C.B.S. is available in bottles of 100 or 500. C.C.T, §530—0,5 mg. C.C.T. §531 —1.0 mg. C.C.T. §532 — 5.0 mg. ORESTOL E.B.S., the dipropionate of diethyl- stilboestrol, has been found to be less toxic, and to give effective relief, for longer periods, than the parent compound, diethyl-stilboestrol. (Freed, Eisin, and Greenhill, J.A.M.A., Vol. 119, No. 17, p. 1412-1414). The Council on Pharmacy and Chemistry of the American Medical Association accepted, over a year ago, *(JA.MA., June 20,1942) the use of diethyl-stilboestrol, for the following conditions: Senile Vaginitis Kraurosis Vulvae Gonorrhoeal Vaginitis ^Infantilism in Women Menopausal Symptoms •Since the above report was published, extensive research, in U.SJL particularly, is corroborating the findings of earlier investigators that the oral administration of diethyl-stilboestrol and its derivatives is of definite value in treating: Suppression of lactation, breast engorgement, dysmenorrhoea, amenorrhoea, habitual abortion, hypersexuality in the male, and prostatic neoplasms. Wh*n Prescribing SjMctfy E.B.S. THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED TOPONfO MANUFACTURING CHEMISTS CANADA BRITISH liovi 43 THE VANCOUVER MEDICAL A S jjOCXA T I O N BULLETIN Published Monthly under the Auspices of the Vancouver Medical Asociation in the interests of the Medical Profession. Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C. EDITORIAL BOARD: Db. J. H. MacDermot Dr. 6. A. Davidson Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XX. OCTOBER, 1943 No. 1 OFFICERS, 1943-1944 Db. A. E. Thites Db. H. H. Pitts Db. J. R. Neilson President Vice-President Past President Db. Gobdon Bubke Db. J. A. McLean Hon. Treasurer Hon. Secretary Additional Members of Executive: Db. J. R. Davies, Db. Fbank Tubnbull TRUSTEES Db. F. Bbodie Db. J. A. Gillespie Db. W. T. Lockhabt Auditors: Messbs. Plommeb, Whiting & Co. SECTIONS Clinical Section Db. J. W. Milleb Chairman Db. Keith Bubwell Secretary Eye, Ear, Nose and Throat Db. C. E. Davies Chairman Db. Leith Websteb Secretary Pediatric Section Db. J. H. B. Gbant Chairman Db. John Pitebs Secretary STANDING COMMITTEES Library: Db. A. Bagnall, Chairman; Db. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies, Db. J. R. Neilson, Db. S. E. C. Tubvey Publications^: Db. J. H. MacDebmot, Chairman; Db. D. E. H. Cleveland, Db. G. A. Davidson Summer School: Db. J. C. Thomas, Chairman; Db. J. E. Harbison, Db. G. A. Davidson, Db. R. A. Gilchbist, Db. Howabd Spohn, Db. W. L. Gbaham Credentials: Db. D. E. H. Cleveland, Chairman; Db. E. A. Campbell, Db. D. D. Fbeeze V. O. N. Advisory Board: Dr. L. W. MacNutt, Db. G. E. Seldon, Db. Isabel Day Metropolitan Health Board Advisory Committee: Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont Representative to B. C. Medical Association: Db. J. R. Nehson Sickness and Benevolent Fund: The Pbesident—The Trustees MULTIVITE Registered Trade Mark (Vitamins A, Bi, C and D) Multivite, the B.D.H. preparation of the four vitamins, A,~Blf C and D, in the form of chocolate coated pellets, provides an acceptable means of correcting the most commonly-occurring dietary vitamin deficiencies. Two pellets, taken daily, will provide sufficient of these four vitamins to prevent the appearance of deficiency symptoms in an otherwise normal person whose diet is completely lacking in these vitamins. Taken, therefore, in addition to an average diet, two pellets of Multivite daily will not only provide the full amount of these vitamins necessary for the maintenance of normal health, but will provide also a reserve with which special temporary extra demands can be met. As examples, the increased needs imposed by a period of pyrexial infection or unwonted physical exertion (causing increased metabolic rate) will be met by the content of Vitamins Bi and C of two Multivite pellets, as will the Vitamin D deficiency which may result from a period of night work. It will be seen that the possible applications of Multivite in general war-time practice are numerous and that the frequent prescribing of Multivite can be an important factor in maintaining the highest standard of health and efficiency in adverse circumstances. Stocks of Multivite are held by leading druggists throughout the Dominion, and full particulars are obtainable from THE BRITISH Toronto DRUG HOUSES (CANADA) LTD. Canada -Mlvt/Can/4310 VANCOUVER HEALTH DEPARTMENT STATISTICS—AUGUST, 1943 Total Population—Estimated _ Japanese Population Chinese Population—Estimated Hindu Population Total deaths Japanese deaths Chinese deaths Deaths—residents only BIRTH REGISTRATIONS: Male, 331; Female, 316. Number _ 282 16 . 227 . 647 INFANTILE MORTALITY— Aug., 1943 Deaths under one year of age 19 Death rate—per 1,000 births 29.4 Stillbirths (not included above) 10 288,541 Evacuated 5,541 301 Rate per 1,000 Population 11.5 Population evacuated 34.0 9.3 26.4 Aug., 1942 11 18.7 15 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY July, Cases 16 0 Scarlet Fever Diphtheria J Diphtheria Carrier 0 Chicken Pox 28 Measles , 2 5 Rubella - I ; 2 Mumps , 0 Whooping Cough . 13 Typhoid Fever Undulant Fever Poliomyelitis Tuberculosis Erysipelas 0 42 1 Meningococcus Meningitis , . 1 1943 Deaths 0 0 0 0 0 0 0 0 0 0 0 17 0 0 August, 1943 Cases Deaths 19 0 0 18 7 1 18 17 37 1 1 0 0 0 0 0 1 0 0 0 23 Sept. 1- Cases 10 4 5 15,1943 Deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Syphilis. Gonorrhoea. V, D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH DIVISION OF VENEREAL DISEASE CONTROL West North Vane. Burnaby Vane. Richmond Vane. Clinic Figures not yet available Hospitals & Private Drs. Totals BIOGLAN-A I The most effective therapy for waning mental and physical energy, deficient concentration and memory, reduced resistance to infection, muscular weakness and debility, neurasthenia and premature senility. The efficacy of this very potent endocrine tonic has been confirmed by the clinical evidence of many thousands of cases treated since 1943. Phone MA. 4027 Stanley N. Bayne, Representative 1432 MEDICAL-DENTAL BUILDING Descriptive Literature on Request THE SCIENTIFIC HORMONE TREATMENT Vancouver, B. C. Page One LIVER EXTRACT INJECTABLE Purified and Concentrated 15 U.S.P. UNITS PER CC. The best therapeutic measure at present available for the treatment of pernicious anaemia is the intramuscular injection of a potent, concentrated, and purified liver extract. The concentrated extract prepared by the Connaught Laboratories has the following advantages:— A SSI IRFD POTFNK^Y ^ac^ 'ot is testeclcZmica%for therapeutic activity. The potency is 15 U.S.P. units per cc. PURITY The extract is a clear, light brown solution, containing less than 100 mg. solids per cc- SMALL DOSAGE In most cases initial treatment with one cc. per week is sufficient — for maintenance, one cc. at less frequent intervals is generally adequate. LIVER EXTRACT INJECTABLE is supplied by these Laboratories in 4-cc. rubber-stoppered vials, and in 12-cc. vials for hospital use. CONNAUGHT LABORATORIES University of Toronto Toronto, Canada DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. VANCOUVER MEDICAL ASSOCIATION FOUNDED 1898 :: INCORPORATED 1906 PROGRAMME OF THE FORTY-SIXTH ANNUAL SESSION (WINTER SESSION) GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m. These meetings are to be amalgamated with the clinical staff meetings of the various hospitals for the coming year. Place of meeting will appear on the agenda. General meetings will conform to the following order: 8:00 p.m. Business as per Agenda. 9:00 p.m. Paper of the evening. November 16—COMBINED CLINICAL MEETING and CLINICAL STAFF MEETING at ST. PAUL'S HOSPITAL. 13 th Ave. and Heather St. Exclusive Ambulance Service FAirmont 0080 PRIVATE AMBULANCES AND INVALID COACHES WE SPECIALIZE IN AMBULANCE SERVICE ONLY J. H. CREL.LIN W. Li. BERTRAND Nuttn Sc 3lj0mjs0tt t 2559 Cambie Street arte ouver ,B.C Page Two EDITOR'S PAGE It is some months now since Vancouver accepted the ruling of the Dominion Public Health authorities, that the water supply of the city and its neighbours, North Vancouver and New Westminster, be chlorinated, as a war measure. Recently this has been put into effect: and it has certainly stirred up a hornet's nest. One had thought that everything had been said about this matter—and that we had all accepted it, if not entirely with enthusiasm, at least as the wisest step under all the circumstances. Our leading health authorities were unanimous in their support of the scheme—and surely they are best qualified to judge. If we cannot trust these experts, who devote their lives and energies to the study of epidemiology and public health, whom can we trust? There is, however, a considerable amount of public opposition and dislike of the scheme, and there is certainly a state of public anxiety, amounting to a real fear of the dangers of chlorinated water. Daily we read in the newspapers, and hear over the telephone, tales of sickness and disability, supposedly caused by the drinking of chlorinated water. These, we verily believe, are entirely groundless—but the public is gradually developing, to an ever-increasing degree, a genuine fear of chlorniated water, and a marked hostility to this measure, and to those who are responsible for it. We feel strongly that this is a case in which measures should be taken to allay this anxiety, and to dispel this fear. This can only be done, in our opinion, by the Public Health authorities, either Provincial or Federal, or better still, both. They owe it, we think, to the public to take steps to do these things. They have the knowledge and the facts, and should make a careful, categorical, public statement. Most people are reasonable and intelligent, and if the facts are dispassionately and simply placed before them, they will, we are sure, accept and believe them: and a great deal of anxiety and worry will be removed. We must not adopt an Olympian attitude of detached superiority: this will not do, and is neither fair nor safe. People are entitled to be told, clearly and fully, all the facts. They should be told, again, of the need for chlorination—and of its harmlessness and safety. They might be told that all the big cities from here to Montreal, and from here to San Diego, are drinking chlorinated water and have done so for a long time, without any ill effects. In many cases, the water in these cities requires far more chlorine to make it safe than does ours—and yet the inhabitants remain healthy, and drink the water without any harm. Here every cold, every sore throat, every attack of diarrhoea in children, is being blamed on the chlorine in the water. xOf course, we know that this is not a reasonable view to take—but we cannot expect the average man to know this, especially when he reads all these letters and statements in print. We hope that the Public Health people will take this under advisement. It would, we sincerely believe, be a public service, and would do a great deal of good. From our point of view as practitioners of therapeutic medicine, it would be of very great help to us, who have to spend a great deal of time explaining to individuals what could most easily be explained, once and for all, to the whole public. As for us—our duty is, we feel, a clear one. We should support and endorse the action of our colleagues in the Public Health service. They are the experts, their action is impersonal, and based only on their scientific knowledge and judgment—and we should back them up. The Vancouver Medical Association formally passed a resolution endorsing chlorination, and stating that we believed it should be done, and we should stand by that. In this connection, we greatly deplore the attitude of certain members of the City Council towards the Medical Health Officer. These members seem to feel that they are entitled to the "support" of Dr. Murray in this matter. Dr. Murray is a doctor, and a medical health officer. His duty, and we need not say so to him, is to give his medical opinion honestly and without any consideration other than what is based on the best and most up-to-date scientific and medical knowledge. The wishes of any person on earth, pro or con, cannot influence his opinion in any degree. We, on our part, should hold up his hands and support him to the best of our ability. Page Three ■KB pHBjnai MJHn NEWS AND NOTES BIRTHS To Dr. and Mrs. W. F. Anderson, Kelowna; a daughter. To Dr. and Mrs. H. J. Alexander, Vernon; a daughter. To Dr. and Mrs. C. E. Davies, Vancouver, a daughter. To Dr. and Mrs. W. L. Turnbull, Vancouver; a son. To F/L. and Mrs. H. G. Cooper; a son. To F/O. and Mrs. J. W. Whitelaw; a son. To S/L. and Mrs. E. T. W. Nash; a daughter. OTHER NEW ARRIVALS Dr. Maitland Young in Victoria, from Iroquois Falls, Ont.' Dr. W. A. McElmoyle in Victoria, from Winnipeg. NIMRODS AND PISCATORS Dr. Wm. Leonard, Trail; at Vernon. Object: Pheasants. Drs. R. A. Hunter and R. B. Robertson, Victoria; on Mainland. Object: Unspecified and several. Dr. D. J. Millar, North Vancouver; in Cariboo. Object: Fish. STEPS Major S. L. Williams, Nanaimo. Major W. H. Moore, Victoria. MOVES Dr. C. E. McRae; Kamloops to Salmon Arm. VISITS Capt. F. L. Wilson, in Trail. Capt. W. J. Endicott, in Trail. Dr. J. S. Burris of Kamloops, in Montreal and Nova Scotia. Dr. H. F. P. Grafton of Kamloops, in Quebec and Ontario. Dr. R. V. McCarley of North Vancouver, in Kingston. Dr. C. M. R. Onhauser of West Vancouver, in eastern Canada. Dr. J. W. Lang of West Vancouver, in New York. Dr. J. R. Naden, Vancouver. Dr. M. G. Archibald, Kamloops. Dr. L. W. Cromwell, Victoria. Dr. H. Dyer, North Vancouver. CONVALESCENT At the recent Annual Meeting of the Victoria Medical Society, the following were elected to the executive for the ensuing year: President, Dr. J. W. Lennox; Vice-President, Dr. J. H. Moore; Honorary Secretary, Dr. T. M. Jones; Honorary Treasurer, Dr. P. A. C. Cousland. Page Four The following non-profit plans, operating among employees, who have formed their own association, have been approved by the Council of the College of Physicians and Surgeons of B. C: Medical Services Association Telephone Employees' Sick Benefit B. C. Electric Railway Co. Ltd. Office Employees' Medical Aid Society B. C. School Teachers' Medical Services Association Vancouver School Teachers' Medical Services Association Cunningham-Western Drug Sick Benefit Association Yarrow's Employees Health Association West Kootenay Power & Light Company. LIBRARY NOTES RECENT ACCESSIONS: Surgical Clinics of North America, Symposium on Orthopedic Surgery, Mayo Clinic Number, August, 1943. Studies of the Eighth Nerve, 1937, Research Study Club of Los Angeles (Gift of the publisher, The Laryngoscope Press). Resources of the Pacific Northwest Libraries, 1943, John VanMale. Exploring the Dangerous Trades, 1943, The Autobiography of Alice Hamilton. First Aid, Surgical and Medical, 2nd ed., Warren H. Cole and Charles B. Poestow. Psychosomatic Medicine, 1943, Edward Weiss and O. Spurgeon English. PACIFIC NORTHWEST BIBLIOGRAPHIC CENTRE Recently the Library Committee was approached with reference to participation in a bibliographic centre which was being organized by Mr. John VanMale at the University of Washington Library for the purpose of extending and expediting inter-library loans. The Committee expressed its willingness to co-operate, and is now an active member. It will be seen that this arrangement will extend our library facilities greatly, as it will give us access, through inter-library loans, to the medical libraries of the King County Medical Society in Seattle, the University of Washington, Seattle, and the University of Oregon Medical School at Portland. Moreover, the time factor will be greatly reduced, as the Centre will have accurate and detailed information of the various library holdings. The Centre also includes most of the law and technical libraries as well as college and public libraries in Washington, Oregon, Idaho, Montana and British Columbia. To supplement this service Mr. VanMale has published a book, which the Library has recently acquired, entitled "Resources of the Pacific Northwest Libraries." It lists the participating libraries, and gives a general outline of the resources of each. It contains an interesting account of library backgrounds and the history of libraries in the Pacific Northwest, as well. Page Five wi9V9|K^V4BaHPBWMHnM*WBp HnMaannn <mmmr*mmm HSBSSIGH SgHgHS ^n BOOK REVIEW MANUAL OF DERMATOLOGY: Donald M. Pillsbury, M.D., Marion B. Sulzberger, M.D., and Clarence S. Livingood, M.D. Philadelphia and London: W. B. Saunders Company, 1942. This is a small manual of less than 400 pages designed by a group of dermatologists of eminence, at present commissioned officers in the armed forces of the United States, for the instruction of medical officers serving in those forces. In the preface it is stated that in the United States Army (1940) skin diseases produce 9.80% of all sick list admissions, and 10.41% of all days lost. Venereal diseases (exclusive of gonorrhoea) produced an additional 3% of all admissions. In the United States Navy during the last 10 years, the picture was almost exactly the same. It is emphasized that these are peace-time figures, and that this class of diseases has always shown a rapid relative increase under conditions of military expansion and warfare. Beyond this it is estimated as a conservative figure tljat 20 to 25% of all diseases in the armed forces become the object of dermatosyphilologic management. The necessity for a small compact manual instructing in the diagnosis and management of the commoner skin diseases is obvious. This need has been met by the authors of this book in a most satisfactory manner. The book is one which every general practitioner in or out of military life would do well to keep at his right hand, or in his pocket. Clarity has at no time been sacrificed to brevity. Tabular presentations of symptoms and procedures have been freely and advantageously used. The photographs are excellent and unlike many in larger text$, they really do illustrate. They are accompanied by captions which extend their usefulness. A most valuable feature is the manner in which photographs of different parts of the body have been grouped together, presenting the different lesions which may be encountered in those parts. This gives a most graphic presentation in many cases of differential diagnosis. Principles of local treatment are well shown in photographs, of which the only criticism is that a few more might well be added. The fact that this is a military manual is never lost sight of, and while investigation and treatment under field or ambulant conditions is given the largest consideration, hospital or sick-bay methods are dealt with adequately. The Formulary which is appended is not cumbersome, but sufficient, containing less than 90 formulae. The volume is small and compact, and an admirable piece of book production. ADVANCE NOTICE MEDICAL SERVICES ASSOCIATION M-S-A ANNUAL MEETING FRIDAY, NOVEMBER 26th, 1943 8:00 p.m. MEDICAL-DENTAL BUILDING AUDITORIUM VANCOUVER, B. C. Page Six PROVINCIAL BOARD OF HEALTH Division of Venereal Disease Control Dr. J. H. MacDermot, Editor, Vancouver Medical Association Bulletin, Daer Dr. MacDermot: Some misunderstanding exists concerning the matter of certificates of freedom from venereal disease as was evidenced by a letter from a medical practitioner in the Province a short time ago. This doctor stated he understood the medical profession had been instructed that under no circumstances were certificates of freedom from venereal disease to be issued by doctors. A difficulty arose therefore from the fact that the Army requires all young men contemplating matrimony to produce a certificate to the effect that the proposed bride is free of venereal disease. In addition to this since a venereally- infected soldier is always asked to name the source of his venereal infection, if possible, and this is followed by the alleged source being required to apply for an examination to confirm that she has an infection and bring her under treatment, or on the other hand to clear her of the suspicion of venereal disease, what is the doctor to do in case he finds no evidence of infection in the alleged source? The following states in brief the principles to be observed in such a situation: "The strictures upon giving certificates of freedom from venereal disease were specifically aimed at giving such statements to prostitutes. "A certificate stating that the woman whom a soldier proposes to marry has been examined and shows no evidence of venereal infection is quite in order. In fact under the legislation re premarital examinations, which has been enacted but which has not yet been put into force, this is exactly what a doctor is required to do. This is a certificate for a specific purpose and should be carefully worded to the effect that examination has revealed no signs of venereal disease. Examination should of course include laboratory as well as clinical findings although in the case of a woman who shows no suspicious discharges one is not expected to take smears or material for culture for gonococci. When all clinical and laboratory findings are negative then one may be morally certain that the patient has not a venereal infection. Nevertheless in the case of a statement in writing it is better to say that the patient shows no evidence upon examination rather than to state unequivocally that the patient has no venereal disease. "Where a girl has been named as a source of disease a certificate of lack of evidence of venereal infection is not given to the girl. If she is negative on both clinical and laboratory examination a statement to that effect should be furnished the Division of Venereal Disease Control but not given to the patient. If a girl has been named by two or more as a source of disease it is probable that she is prostituting herself and the question to be decided is whether she should be treated or not. Establishing her freedom from infection probably establishes completely her non-infectivity. No patient should be treated for syphilis until the diagnosis is positive beyond all peradventure. Such a case, if the allegation by the soldier appears to have been made in good faith, and unquestionably if the allegation has been made by two or more, should be re-examined again in three months at the most. In the case of gonorrhoea there are three criteria for diagnosis: a suspicious clinical history including being named as a source of gonor- rhceal infection, a suspicious discharge and positive laboratory findings. If any two of the three are present this should be sufficient grounds to require a woman to take treatment." It has been requested that the information given to this doctor should receive wider circulation to all members of the profession in the Province through the medium of the Bulletin. This is therefore submitted to you for publication. Yours truly, D. E. H. Cleveland, Acting Director, Venereal Disease Control. Page Seven t REGULAR MEETING OF THE VANCOUVER MEDICAL ASSOCIATION October 5, 1943. This was the first meeting of the 1943-4 Session, and was presided over by Dr. A. E. Trites, President. The chief items of the business part of the meeting were the Reports of the Executive Meetings during the summer, and the Report of the Summer School Committee. We publish these below—and add our sincere congratulations to the many so well- deserved laudatory comments received by those in charge of the Summer School. Nominations were made of the following gentlemen, first for active membership, as follows: Drs. Gordon S. Hutton, Gordon F. Kincade, Webster T. Maguire, Mackenzie Morrison; second for associate membership: Dr. Arnold Francis, New Denver, B. C; Dr. J. C. Kovach, Quesnel. These will be voted on at the next regular meeting. Dr. S. E. C. Turvey then read the paper of the evning: "Epilepsy as a Problem in the Community." This excellent paper, presented by one whom we may rightly regard as a leading authority on the subject in Western Canada, is published elsewhere in this number. A very good discussion followed the paper, led by Dr. Frank Turnbull of Vancouver and Dr. A. M^ Gee of the Essondale Mental Hospital's medical staff. REPORT OF THE SUMMER SCHOOL COMMITTEE FOR THE 1942-43 SESSION The twenty-first Annual Summer School was held in the Hotel Vancouver, June 22 nd to 25 th, inclusive. The total registration this year set an all-time-record at 400. Of this number 156 were members of the Armed Services and 25 were hospital internes. Comparison of these figures with those of last year is interesting. The number of hospital internes is approximately the same, but there is a tremendous increase in the number of men in the Services from 32. Surely this is due to the fact that the Summer School is recognized as a desirable refresher course by the Senior Medical Officers in the Services. The number of paid admissions rose from 183 to 216. The fee was increased to $6.00 this year. The Committee Was fortunate in receiving help from the R.C.A.M.C. in providing three speakers. Because our Summer School coincided with that of the B. C. Pharmacists, we shared one of their speakers who was sponsored by John Wyeth & Brothers for their meeting. The hearty thanks of the Committee have already been tendered on behalf of the Association. The total receipts amounted to $1,475.00 Total disbursements 1,520.80 Leaving a deficit of $ 45.80 It should be pointed out here that payment of expenses for Dr. Foster Kennedy had to be made in U. S. funds, and the exchange on this was over $60.00. The attendance at the luncheon was 186, a big increase over last year. The address delivered by Dr. Foster Kennedy has been published in a recent issue of the Journal of the Canadian Medical Association. Page Eight The usual Thursday golf tournament was played at Point Grey. On that evening the Round Table on Thyroid Disease was held. This year an extra clinic was held, making use of material at Shaughnessy Hospital. The clinics were all well attended, with more than 175 at each one. The success of the 1943 Summer School may be taken as a mandate from the profession at large to continue holding these meetings in war-time, in spite of the added difficulties in obtaining speakers encountered each year. The Chairman and members of the Committee wish to take this opportunity to thank teh staffs of Shaughnessy, St. Paul's and the General Hospitals for their courtesy in providing cases and accommodation for the afternoon clinics. Respectfully submitted, J. C. Thomas, Chairman. * * * * REPORT OF EXECUTIVE COMMITTEE MEETINGS DURING SUMMER MONTHS, 1943 X.' Regular meetings were held as usual during the Summer. The question of fees for medical service to dependents of members of the Armed Forces again came up for discussion, following a complaint from one of our members. As this had previously been referred to the British Columbia Medical Association for action, they were again written, with a request for a reply. Subsequently they informed the Executive Committee that the schedule of rates was being revised and it was expected that the new tariff would be higher than the average rates of the Workmen's Compensation Board. The subscription to War Medicine, donated to Camp Nanaimo, was renewed. The matter of a classified listing of doctors' names in the telephone directory was taken up, and a form letter was sent out to all members of the Vancouver Medical Association advising them of the Committee's motion: "That the whole matter be left in abeyance until such time as the official classification of specialists by the Royal College of Physicians and Surgeons of Canada be received." A joint meeting with members of the Publications Committee was held, to discuss the affairs of the Bulletin, and later a special meeting of the two committees was held, at which time suggestions for changes and additions to the Bulletin set-up were discussed. It was decided that in future lectures given at the Annual Meeting and the Osier Lectures should be specially bound and kept in the Library. Arrangements for the Fall and Winter programme for general and clinical meetings are being completed. J. A. McLean, Hon. Secretary. GOLF The 1943 golf tournament finished at Capilano on Thursday, October 7th. Thirty- six players took part in the final play. At dinner the prizes for the season were presented to the following winners: The Bilodeau Memorial Trophy awarded to the low gross score of the third game of the season was won by Dr. Leith Webster. The Worthington Cup, donated by Dr. George Worthington, was won by Dr. George Seldon, with the low net score for the third game of the season. The Ram's Horn Trophy, donated by Dr. Daniel McLellan for the low net in two of the three games of the season was won by Dr. S. C. Peterson. The Macdonald Trophy, donated by Macdonald's Prescriptions, Limited, for the low Page Nine mB^m ngmnnBMB Hnmnn^ni gross in two out of three games for the season was won by-Dr. J. E. Harrison. The handsome sweater donated by George Straith Limited was won by Dr. T. R. Harmon for the second low net on the day's play, while the set of club covers was won by Dr. T. A. Johnston with the second low gross of the day. The prize for the long drive was won by Dr. Jack Millar, while the prize for the closest to the pin was won by Dr. Tom Nelles. Dr. Leith Webster was elected Captain for 1944, with Dr. J. W. Millar as Vice- Captain. Dr. J. C. Thomas was elected as a non-playing member of the Committee for 1944, to act in an executive capacity. The retiring Captain, Dr. A. E. Trites, is to be congratulated on the successful season under his guidance. No. 4 DISTRICT MEDICAL ASSOCIATION I § ANNUAL MEETING The annual meeting of No. 4 District Medical Association was held in Vernon on September 30th. A large attendance rewarded the Executive Committee for its effort in providing a very full programme, commencing at 2.00 o'clock and finishing at 10.30 p.m. This included an afternoon clinical session, a social hour followed by dinner, and a discussion on Health Insurance and other economic problems which was participated in freely by a number of members. Doctor P. A. C. Coulsand, President of the British Columbia Medical Association, was in attendance and opened the discussion. He was followed by Doctor M. W. Thomas, Executive Secretary of the College, and other speakers who contributed to the discussion were: Doctors W. J. Knox, Kelowna; R. W. Irving and C. J. M. Willoughby of Kamloops; H. I. Campbell-Brown of Vernon.* Doctor J. E. Harvey, President, presided over all sessions and was ably assisted by the Honorary Secretary-Treasurer, Doctor H. J. Alexander. Doctor H. A. DesBrisay gave two lectures and Col. Lavell H. Leeson one lecture at the afternoon session. Doctor W. B. McKechnie of Armstrong was in attendance and moved a vote of thanks to these gentlemen who had come to Vernon as guest speakers under the aegis of the Committee on Programme of the British Columbia Medical Association. The election of officers resulted as follows: Doctors L. A. C. Panton, Kelowna, President; C. J. M. Willoughby, Kamloops, Vice-President; W. F. Anderson, Kelowna, Honorary Secretary-Treasurer. Doctor L. A. C. Panton was appointed representative to the Board of Directors of the British Columbia Medical Association. The members decided that the next annual meeting would be held in Kelowna and this was agreeable to the members from that place. Those present at the meeting included Doctors H. S. Stalker, E. A. Gee, H. A. Jones and R. H. Irish of Tranquille; G. E. Wride, Creston; A. F. Gillis, Merritt; W. A. Drum- mond and S. Z. Bennett of Salmon Arm; W. B. McKechnie and R. Haugen of Armstrong; J. H. Kope, Enderby; B. de F. Boyce, W. J. Knox, L. A. C. Panton, W. F. Anderson of Kelowna; A. L. Jones of Revelstoke; R. W. Irving, C. J. M. Willoughby of Kamloops; L. F. Brogden, G. C. Paine, R. B. White of Penticton; Capt. W. R. Walker, formerly of Penticton; J. E. Harvey, H. J. Alexander, H. I. Campbell-Brown, F. E. Pettman, N. W. Strong of Vernon. From Vernon Camp the following were in attendance: Lt.-Col. G. A. Bird, Major Hamilton, Captains C. G. G. Maclean, D. W. Moffatt, Govan and G. McL. Wilson. Lt.-Cl. R. L. Miller of Headquarters was in the area and attended the dinner. Others in attendance included Doctors P. A. C. Cousland of Victoria, H. A. DesBrisay, Lavell H. Leeson and M. W. Thomas. Page Ten THE PROBLEM OF EPILEPSY IN THE COMMUNITY S. E. C. Turvey, M.D. (Read before the Vancouver Medical Association, October 5, 1943) In this twentieth century, the empire of medicine has been extended to frontiers beyond the dreams of optimists of three decades ago. Yet there remains a common affliction about which the majority of practitioners have the general conception of twenty to fifty years ago and the average layman of one to two centuries ago. Epilepsy, so common that in Canada there are probably over fifty thousand persons subject to it, and two thousand of these in Vancouver, still puzzles laity and physicians almost as much as it did in the time of Hippocrates. It is as common as tuberculosis or diabetes. Epileptics occupy ten per cent of the beds in hospitals devoted to nervous and mental diseases. In 1940, in the armed forces of the United States, epilepsy ranked next to schizophrenia as the most common cause of discharge. For every epileptic, there are about twenty citizens who are predisposed to it. I propose to outline some of the reasons why our profession is not coping with this problem adequately and to suggest a rough pattern for the future. The idea that epilepsy is being inadequately handled is not original, for neurologists the world over have been repeating it for over four decades. The International League Against Epilepsy was formed in 1909 in Budapest, with Dr. J. J. Muskens of Amsterdam as the prime mover, and has branches in five countries. Needless to say, it has had to be suspended for the duration of the war, but Dr. William Lennox of Boston remains President and is still active on this continent. The League publishes a journal, "Epilepsia." On this continent there are the Section on Convulsive Disorders of the American Psychiatric Association, the American League Against Epilepsy, and the Laymen's League Against Epilepsy. All these organizations are cognizant of the tragic need for a change in the methods of medicine and of society in dealing with epilepsy. At the present time, there are only two methods of handling the epileptics, and .these in a way are at opposite extremes. On the one hand, they may be cared for in the home, and in a majority of cases this is far from satisfactory. Parents rarely have the special skill to teach these patients discipline, to give them the self-confidence to meet the world, or even to understand their problems of personality and adjustment. Oftentimes the parent is as horrified by the seizure as the veriest aborigine, and they impart this attitude to the patient, as well as to the other members of he family and the public. On the other hand, there is only the recourse of committing them to hospitals for the insane or feeble-minded, a sorry alternative. The great majority of epileptics are not congenitally defective, the potentialities of good citizenship are present, and they are a very valuable group to be salvaged for the community. If the seizures can be eliminated, either by medicine or surgery, the resulting individual is a social and economic asset. Also, the majority of epileptics are normal except for very short periods of time, and the majority do not deteriorate mentally with adequate treatment. Even aside from the obvious humanitarian aspects of the issue, the economic aspects alone would be worthy of consideration. In the last three years, out of a total of four hundred and ten epileptics, I have records of eighty-six who are carrying on successfully in full-time remunerative jobs at union rates of pay. Admittedly, this has been possible only under the conditions of war, but they still can do their job and could in peace time if given a chance. I would hesitate to divulge some of the subterfuges, to which I am forced, to help them past the personnel manager or the suspicious employer, but in no instance has any catastrophe resulted. However, the em- ployability and the employment of epileptics is a very sore subject to any thoughtful physician. The main reason for employers refusing to employ epileptics is a law which makes the employer liable for injuries which employees may sustain while at work. As a member of our local Compensation Board recently stated to me in private conversation, "an employer takes a man with all his disabilities." This is extremely unfair to the employer and still more unfair to the epileptic, who is thus condemned to idleness all his life. It should be possible for an epileptic to waive his right to compensation if thfi Page Eleven injury results from a seizure while at work. As a consequence of these conditions, a person who has seizures must conceal his disability, which means that neither he nor the employer are able to use safeguards against injury which might be used if the true state of affairs was known. A remedy for this unhappy situation has been taken in seven states in the United States but in Canada we have no such provision. I should add that many of my epileptic patients who are working are doing so for employers who are fully cognizant of their illness and they are kept on their jobs and their rare seizures are ignored because of special abilities and because they are good workers. A more general employment of epileptics is urgently needed, as it is estimated conservatively that approximately seventy per cent of all epileptics are found to be employable in industry. From the viewpoint of clinical and laboratory research on humans, there is no more fertile field than the epileptic. Usually they give excellent co-operation, they even seem pathetically^ anxious to be the subject of any experiment or new cure. Researches so far have yielded invaluable data on the influence of the acid-base equilibrium, of the fluid-balance of the body, of the oxygen tension in the blood, and on concentration of certain chemicals in the blood on the frequency of seizures. The electroencephalogram is in its infancy but has already given a practical basis to a classification of epilepsy and is useful in diagnosis. The normal brain exhibits rhythmic changes of potential, which, after being led off from the scalp and stepped up by radio amplifiers, are recorded in ink on a moving strip of paper. There are two main rhythms, the alpha waves from the occipital region (10 per second) and beta waves from the frontal regions (22 per second). The rhythms are very irregular in epileptics, and not only during the seizure. Three types of abnormality have been found: I. Grand mal—high voltage, fast waves. II. Petit mal—fast wave and spike, or slow wave and spike. III. Psychomotor seizures—high voltage, square and six per second waves. The two thousand epileptics in Vancouver should be utilized by a properly organized team to further such researches. A frequent point of misunderstanding between the physician and the epileptic is the belief on the part of each that neither is very interested in the other. All of us have these patients who come to us once or thrice, and then disappear. The fault lies at our doorstep. The principal mail order house for the treatment of epileptics is run by Doctor James in Chicago, and he is an M.D. who graduated with honors from a Grade A medical school. I venture to guess that he asks the patient more questions than the average physician does, that he gives them fairly "adequate" drug therapy, that the amount of real investigation is about the same in each instance. We must do more for these people than ask questions and give prescriptions, or we shall never hold them as patients, rarely cure them, and we shall be fighting a losing battle with the quacks and proprietary medicine-men. It costs a patient about five to eight dollars monthly to receive Doctor James' advice and medicines, and I am amazed at the numbers of patients from Vancouver who have turned to him, and turned in desperation because our advice did not serve to control their seizures as well as his advice. A smaller number of patients get their medicines from England from a similar source and for the same money. It is rare for a patient to come to the Outpatient Department of the Vancouver General who has not attended at least three physicians, and it is much rarer that one of them has received adequate investigation or treatment. What are the reasons for this? The chief reason is economic, but lesser ones are lack of education of the public, of the patients, of the physicians, and in many instances, lack of technical facilities. We must not tell parents not to worry because their child "will grow out of the little faints," that they should use as little "drugs" as possible "because it slows up the brain and is habit-forming," or that "no cure is known for fits," that fits are a sure sign the brain is permanently damaged, that he is teething, that his stomach is upset, that he has worms, that his diet is wrong, that he needs a tonic. These are a few of the dangerous fallacies we hear every month. Nor must the public be Page Twelve allowed to consider epilepsy a family disgrace, as syphilis now is and as cancer and tuberculosis used to be. The general attitude of defeat surrounding epileptics must be enlightened. The epileptic can, in all but a few cases, be cured insofar as he can become a useful citizen, economically self-supporting. The economic barrier for an epileptic who seeks adequate medical attention is a serious one. A thorough investigation requires the following: (1) History—birth, development, past, present, family, and psychiatric (including level of intelligence). (2) Physical and Neurological Examinations—including, if possible, observation of a fit. (Sometimes a fit should be induced for observation.) (3) Haemoglobin, leukocyte count, Kahn, sedimentation rate, urine. (4) Spinal puncture, always with measurement of the pressure, and examination of the fluid for: Cells; Kahn; Protein, Colloidal Gold. (5) X-ray of the skull—two views; and not infrequently encephalography. (6) Occasionally: (a) electroencephalogram, (b) arteriography following injection of a radio-opaque substance. It must be emphasized that epilepsy is not a "disease entity" but a symptom due to one or several etiological elements, and hence its accurate diagnosis can be very difficult. The necessity for the first three of these investigations is obvious, but too often a spinal puncture and X-ray of the skull are omitted from the examination. About ten per cent of our epileptics have abnormalities of the skull, demonstrable by the roentgenogram. One girl had seven physicians over a period of nine years without a spinal puncture or X-ray, and then the X-ray showed a calcified tumour. This is not an isolated instance by any means. Another man attended four physicians for three mild seizures or "strokes" in five years, from all of which he recovered, yet never had a spinal puncture, evidently because his blood Kahn was always negative, though the spinal Kahn finally proved to be positive. I do not cite these instances to prove any superior skill of specialists, but rather to point out two facts. The first is that no one or two or even three specialists can perform all those six investigations. The second is that the cost of these investigations ranges from a minimum of one hundred dollars to over two hundred dollars. Is it any wonder that so few epileptics are ever properly investigated? Add to this the cost of daily medication over months or years, as well as regular visits to the physician, and the burden becomes almost unbearable to most families. The monthly cost of medicines varies from two dollars to eighteen dollars, and there are many patients who have had to stop the treatment because they could not afford that much. The treatment of idiopathic epilepsy remains largely medicinal but, as both Mallory and Lennox have insisted, the vast majority of epileptics can be cured if they are treated early enough, long enough, and with enough medicines. Frequently the physician is asked "Can you cure epilepsy?" The answer is "Yes" and hopefully "Yes" except in a very few instances. We can cure it in the sense that epileptics can be made to carry on useful and successful lives, that they can be made to be proud of carrying on in spite of their handicap, that they can be trained to think of themselves as people who are the same as all other people. They can be cured by medicines which reduce the number and severity of their attacks to the point where the seizures do not interfere with normal activity and business. These medicines are not "drugs," they are not "dope," they are not "stupefying," they do not poison the system, they do not form a drug habit, they do not cause mental deterioration. They only keep the electrical waves of the brain in their usual slow and rhythmical beat. They must be given in adequate doses, and most epileptics are so foolishly frightened, of them that they are taking inadequate doses. I know one boy of fourteen who has taken ten tablets a day for six years, and yet he leads his class at school, has a very high intelligence quotient, and is a good athlete. I know a lady of fifty who has taken Page Thirteen nine grains of phenobarbital a day for twenty-two years "and is a brilliant clubwoman and a good mother. I must emphasize: Don't be afraid of the medicines; don't prescribe too little and too late; remember that under-treatment is the rule and the curse of epilepsy. You may ask "Should every child who has a seizure be considered to be an epileptic?" I think not. The child with a sudden illness and high fever who has a seizure may have no more all his life. Two seizures should be viewed with grave suspicion, and the worried parents should not be reassured too completely until prolonged observation has rendered recurrence unlikely. More than two seizures is very likely to be epilepsy. About twenty per cent of patients whose seizures began at puberty or later had an isolated convulsion in infancy. The portion of the adult population which has epilepsy is about one-tenth of the proportion of children who have had one or more convulsions (0.5 pet cent against 5 per cent). Physicians are asked frequently by their epileptic patients concerning the advisability of marriage and having children. The Committee of the American Neurological Association for the Investigation of Eugenical Sterilization, of which Abraham Myerson was chairman, published their report in 1936 and they stated that "there was some constitutional etiologic basis, but that it was not proved to be of hereditary origin." They referred to the Boston group of workers, Lennox, Gibbs and Gibbs, who thought that it undoubtedly had an hereditary basis, and based this opinion on a study of the brain waves. However, they also quoted the works of Finley and Dynes, which tended to contradict the finality of studies based on brain waves. They finally said that "the most that as yet can be said as to its relationship to heredity is that some individuals and familial groups are more liable to it." I usually adopt the attitude that, if the patient's seizures have been completely controlled for two or three years, and if they come of a good family stock which is not heavily tainted with epilepsy, and if they marry a normal person who has had no fits and whose family history is clear, then there is no bar to their marriage or procreation. I would concur in any programme that advocated the eugenic sterilization of feeble-minded epileptics. The drugs most commonly used are four—bromides, phenobarbital, dilantin and mebaral. The bromides are much less used nowadays because they are not as effective as the others as a rule, they frquently cause cutaneous lesions, they are more depressant to the mental activity, and they may accumulate in the body to cause a toxic psychosis. Its use should be restricted for the occasional patient who cannot take the other three because of sensitivity or whose seizures are not controlled by them. Phenobarbital is a more effective drug and rarely causes toxic manifestations. If large doses are necessary, mental slowing may result, but this is easily abolished by the additional exhibition of benzedrene or caffeine before breakfast and lunch. Neither of these drugs increase the incidence of seizures, nor are they toxic when administered judiciously even over years. Nine grains of phenobarbital daily may rarely be necessary. Sodium phenobarbital is available for intramuscular or intravenous injections or for use in liquid prescriptions, but it contains ten per cent less phenobarbital than does phenobarbital itself. Dilantin is a relatively new drug and an invaluable adjunct. It has high anticonvulsive power combined with a minimum of hypnotic effect or mental dulling. Four to nine grains may be given daily to an adult. It is more liable to cause toxic phenomena than phenobarbital but these are rarely serious. If it causes gastric distress, it should be taken midway during a meal or with milk. It may cause nystagmus, diplopia, blurring vision, pupillary dilatation, dizziness or staggering gait, and these may pass off in a few days, or the drug may have to be discontinued. Rarely it causes fever and dermatitis. It commonly causes hyperplasia of the gums, but the mechanism of this is unknown, and if the oral hygiene is good and the gums be massaged frequently, it is rarely necessary to discontinue the drug. It should be noted that dilantin is of least effectiveness in petit mal, and of most in psychomotor seizures (so-called psychic variants or motor automatism) which are little influenced by phenobarbital or bromides. Page Fourteen Mebaral is usually used if phenobarbital or dilantin fail. It is relatively non-toxic, produces little hypnotic or toxic effects, and as much as sixteen grains a day may be given. It is much less widely used than either dilantin or phenobarbital but is still useful at times. Successful treatment frequently involves tedious and painstaking trial. The drugs must be changed, the dosage varied, the hours of administration made to suit the activities of the individual and, above all, unwearying patience and encouragement are essential. The patient and the parents must be seen frequently until the seizures are controlled, and preferably seen by the one who institutes the treatment. Neurologic consultations are frequently obtained, the diagnosis is confirmed, the particular medicine recommended, and the patient sent back to his physician. When the patient continues to have seizures, he moves on to a third physician, who is apt to send him to another neurologist. This is actually occurring time after time in Vancouver. This is not the treatment of epilepsy. I should very imperfectly execute the task which I have undertaken if I did not offer some solution of the vast problem of the epileptic in our community. There is a need and an opportunity, and, fortunately, the means at hand. A co-ordinated programme is possible because of the relatively small number of investigators involved, but the scope of the programme must be wide enough to include the patient, his family, the public, the physicians, the specialists, and serious social and economic questions. If epilepsy were infectious, this programme would have been inaugurated years ago. And any programme must be sustained over many years by a persisting group truly interested in epilepsy, a group driven by an inner compulsion rather than drawn by a chance to spend a grant. In Table I, I have outlined such a tentative programme. Table I. Division of Control of Epilepsy (Chairman at Head) Committee of Neuropsychiatrists Business Management Publicity Endowments and Donations Research Group Investigation and Treatment Neuropsychiatrists Neurosurgeon Internists X-ray and E.E.G. Laboratory Drugs Epileptic colony Mental hospital Social Service Home Conditions Follow-Up and Attendance Employment Marriage Educational Supervision Ordinary Schools Special Classes Handicraft Artisan Trade or Profession Recreations Social Adaptation Public and Parents To implement this proposed scheme, I would like to see the usual procedure in medicine reversed. In the past, whenever we as a group of physicians failed to solve a problem in medicine, it has been taken over by the state. This is epitomized in dealing with the insane, the tuberculous, those with venereal disease, those with cancer, and in Page Fifteen a portion of the field of diagnosis by laboratory measures? Could we not launch this programme ourselves? The problem of a director of the unit should not be difficult and he should be chosen by you for his organizing abilities, his zeal and his professional skill. He should be responsible to you for the success of his unit. For the rest of the personnel, there is no dearth of skill in British Columbia but there should be a flexibility of membership to allow for substitution if a change of technique is required. Though the unit should have resting place in a hospital, where patients, operating rooms, diagnostic facilities and a pharmacy are available, it should possess mobility and be prepared to "set up" in some other institution (epileptic colony, school laboratory or other hospital) if conditions or opportunities make this advisable. One of the researchers might go from centre to centre, not only in the province but to other countries to centres where epilepsy is being studied. And, though this is controversial, X-rays, laboratory studies and drugs should be available to this group of patients at near-cost, or free for those who cannot afford them. It is interesting to note that the province of Quebec leads Canada in agitating at the present time for a colony for epileptics. The problem of finance is difficult but not insurmountable. Grants-in-aid could go to research students attached to some organization such as one of our excellent service clubs. The Welfare Federation might not be aloof. Some patients can pay and should within their means. Endowments for medicine in this province are shockingly small, and we have some wonderfully public-spirited citizens. If a wealthy family would only oblige by begetting a child with seizures, it would help a great deal, just as an afflicted scion of royalty in England was responsible for Queen Square. Our established provincial institutions would surely make available their X-ray and laboratory facilities. Now would be the time to bespeak two or three beds for epileptics in the projected new psychiatric wing at the Vancouver General Hospital. Our government might well make a grant to start and help maintain such a programme, for, though the cost of epilepsy falls on the individual and the family affected, it is a heavy burden on the community. And for every epileptic that is kept out of a state institution, the saving is large. The cost of one aeroplane would be an ample yearly budget. Lastly, our medical society could afford to help financially, even if it were a small amount. A more difficult question would be the solution of the ultimate relationship between the general practitioner and this group for the treatment of epilepsy. It would have to be understood that the group is not trying to steal business or patients from the individual physician. Let the group treat only referred patients if you wish, let the group de all the investigation and research, let the group "stabilize" the treatment satisfactorily, then that group would be only too pleased to have the physician carry on. But if the patient lapses from treatment, or if the seizures recur for any reason, the group would wish to be informed so that their social service could reclaim the lost one; and the privilege of follow-up studies would be an inherent privilege for the benefit of research and teaching. The remuneration of the specialists concerned would, of necessity, be nominal in the early years of such a programme. In conclusion, the following three objectives are proposed: For the patient—adequate investigation and treatment, cure, rehabilitation. For society—awareness of the magnitude of the problem, of the present neglect of .incipient cases, of their duty to help the epileptic. For us physicians—a wider diffusion of present knowledge, more research, more will to work together towards the common end, which is the final eradication of epilepsy. (Slides were shown illustrating various methods of investigation, Table I, and the electroencephalogram.) 1. Cortical calcification in Stiirge-Weber's disease. The patient was an epileptic idiot with a large port wine naevus on the right side of the scalp—the same side as the calcification in the cortex. At first it was thought to be a calcified angioma but one can see the gyri and also the microgyria. 2. Calcified frontal tumour—a history of epilepsy for six years. 3. Aneurysm of Circle of Willis, using thorotrast. Epilepsy began six months after an episode of spontaneous subarachnoid hemorrhage. Page Sixteen 4. Aneurysm of the anterior communicating artery. Epilepsy of many years duration, then more recent headaches and visual field defects. 5. Calcified wall of an arterial aneurysm, known as "Albl's ring." 6. A large temporal meningioma shown by thorotrast injection. There is much distortion of the normal direction of the middle cerebral artery. This patient had homonymous hemianopia, uncinate fits, and some mental impairment. The tumour was removed "almost entirely" in two stages. 7. Cysticercosis of thigh muscles from a patient with epilepsy due to cerebral cysticercosis. 8. Patient was a girl eighteen years of age who attended seven physicians over a period of nine years for uncontrollable epilepsy. Patient has now had no seizures for nine months and is at work. REFERENCES: Lennox, W. G.: The Campaign Against Epilepsy, A. J. Psychiatry, Vol. 94, No. 2, September, 1937. Ibid: The Problem of Epilepsy, Epilepsia, May, 1937. Gibbs, Gibbs and Lennox: Epilepsy: a paroxysmal cerebral Dysrythmia. No. XXV, Studies in Epilepsy. McEachern, Donald: Epilepsy, Can. Med. J., 45, 106-111, 1941. Lennox, W. G.: Metabolism in Epilepsy, Arch. Neur. & Psych., July, 1928, Vol. 20, 155. Lennox, W. G.: Science and Seizures, Harper and Bros., 1941. Putnam, J. J.: Convulsive Seizures, J. B. Lippincott Co., 1943. Myerson, A.: Eugenic Sterilization, Annals Int. Med., Vol. 18, 4, April, 1943. Lennox, W. G., and Cobb, S.: Employment of Epileptics, Industrial Medicine, December, 1942. Eugenical Sterilization: By the Committee of the American Neurological Association for the Investigation of Eugenical Sterilization, 1936, The McMillan Co., New York. Lennox, W. G, Gibbs, E. L., and Gibbs, F. A.: The Inheritance of Epilepsy as Inherited by the Electroencephalograph, /. Am. Med. Assoc., 1939, CXHI, 1002. Finley, Knox H., and Dynes, John B.: Electrc-encephalographic Studies in Epilepsy, Trans. Am. Neurol. Assoc, 1942, William Byrd Press, Richmond. WEST KOOTENAY MEDICAL ASSOCIATION ANNUAL MEETING The West Kootenay Medical Association held its annual meeting at Nelson on September 25th, 1943. Doctor N. E. Morrison of Nelson, President, and Doctor W. Laish- ley, Secretary, had made provision for the comfort of those who attended and excellent appointments for the various sessions of the meeting. Doctor P. A. C. Cousland of Victoria, President of the British Columbia Medical Association, was in attendance and contributed a paper to the afternoon programme, which was devoted to clinical features. Doctor W. K. Massey dealt with the newer surgery of the chest, and Doctors Daly, Krause and Hoare of Trail rounded out a very full programme, which was followed by motion pictures shown by Doctor Laishley. A social hour preceded the dinner, following which the annual business session was held. The elections resulted in placing the following in office: Dr. C. M. Kingston of Grand Forks, Honorary President; Dr. E. E. Topliff of Rossland, President; Dr. J. Vernon Murray of Creston, Vice-President; and Dr. Wilfrid Laishley of Nelson, Honorary Secretary-Treasurer. Doctor E. E. Topliff, the new President, will be the representative from the West Kootenay on the Board of Directors of the British Columbia Medical Association. It was reported that Doctor Kingston, Honorary President, was ill and the secretary was asked to send him flowers with the good wishes of the Society. Doctors Cousland, F. M. Auld, J. S. Daly, Arnold Francis and others discussed the present status of Health Insurance legislation at Ottawa. Doctor M. W. Thomas, Executive Secretary of the College, was also present and discussed several items of interest to the profession at this time. A Committee was appointed to study Health Insurance and be prepared to report to the Association on those features upon which the profession in general will be asked to voice an opinion, with particular, reference to such questions as administration, standards, methods of remuneration and income limits. The meeting was attended by Doctors Morrison, President; W. Laishley, Honorary Secretary; W. A. Coghlin, M. E. Krause, J. S. Daly, D. J. M. Crawford, E. S. Hoare from Trail; E. E. Topliff of Rossland; W. H. Ormond of Slocan; V. B. Goresky of Castlegar; Arnold Francis of New Denver; Soldier-interne G. R. Collbeck of Nelson; F. M. Auld, R. B. Brummitt, G. R. Barrett, R. B. Shaw of Nelson; P. A. C. Cousland of Victoria, and M. W. Thomas, Vancouver. Doctor W. O. Green of Cranbrook, President of the East Kootenay Medical Association, and Doctor D. W. Davis of Kimberley, travelled to Nelson and participated in the annual meeting of the West Kootenay Medical Association. Page Seventeen British Columbia Medical Association (Canadian Medical Association, British Columbia Division) President Dr. P. A. C. Cousland, Victoria First Vice-President Dr. A. Y. McNair, Vancouver Second Vice-President Dr. A. H. Meneely, Nanaimo Honorary Secretary-Treasurer Dr. G. O. Matthews, Vancouver Immediate Past President Dr. A. H. Spohn, Vancouver Executive Secretary : Dr. M. W. Thomas, Vancouver Dr. K. D. Panton, Chairman of the Committee on Medical Education, gave an excellent report at the Annual Meeting of the B. C. Medical Association. Shortage of space forbids its publication in full,, unfortunately: but the original report can be seen and read at the Library. Meantime here are the highUghts. The pre-medical work at the University of B. C. is not yet satisfactory from the standpoint of the student who wishes to go to an Eastern university. These have varied requirements, and it is often very difficult, owing to lack of accommodation in their entrance classes, and the need for competitive examinations, for a student from B. C. to secure a place. The post-graduate work in B. C. Hospitals is not satisfactory—the teaching of internes is often poor or non-existent. So the hospitals find it very difficult to secure internes. "The obvious solution of these difficulties," states Dr. Panton, "is to form a medical faculty at U.B.C." He shews how this could be done—the Rockefeller Foundation has offered to subscribe $500,000 on condition that B. C. puts up an equal amount. He shews that approximately 150 men a year leave B. C. to study medicine: and these men could be accommodated here. The University, however, lacks buildings and equipment at present. Clinical material of high value is available to a satisfactory degree. The writer points out the urgent need, growing yearly, for more graduates in Medicine—and refers to the estimate of increased need that will follow the introduction of Health Insurance. He makes recommendations with a view to expediting the formation of a Medical Faculty. We heartily agree with him and hope the B. C. Medical Association will take steps to implement this report. —Ed. In presenting Dr. Strong's report of the Committee on Economics, we would suggest that our readers give this careful study. This Committee has been very active, and its Chairman, Dr. Strong, has been also a member of the Committee of Seven, appointed by the Canadian Medical Association to meet the Government of Canada and discuss Health Insurance from the profession's point of view. This report is therefore of special interest. The Bulletin hopes at an early date to be able to give a summary of the Round Table Discussion held at the B.C.M.A. meeting. Page Eighteen ANNUAL REPORT COMMITTEE ON ECONOMICS B. C. DIVISION OF CANADIAN MEDICAL ASSOCIATION September 8, 1943 (By Dr. G. F. Strong, Chairman) Your committee has been more than usually busy in the past year because of the action of the Dorninion authorities in connection with Health Insurance. After our last annual meeting at Jasper we learned that this legislation might be introduced at the 1942-43 session of parliament. At that time there were many decisions that still had to be reached by the medical profession, one of the first being to define our own attitude toward the subject of Health Insurance in general. This was done at a special meeting of the General Council of the Canadian Medical Association held in Ottawa on January 18th and 19th. Proceding this meeting, and in an effort to secure the views of organized medicine in B. C, an important meeting of key men from all over the province was held in Vancouver on January 7th. Present at. that time, in addition to members of the Council of the College of Physicians and Surgeons, were the members of the Board of Directors of the B. C. Medical Association, the Committee on Economics of both the College and the B. C. Medical Association, the Health Insurance Committee and the President and Secretary of each district society. After a full discussion the following resolution was unanimously passed: "As part of a Canadian post-war reconstruction programme, which would also include adequate provisions to prevent and relieve want and idleness, to furnish adequate housing, to overcome inadequate nutrition, and to attack similar problems, the British Columbia Division of the Canadian Medical Association is in favor of an adequate Health Insurance, provided that the service offered, is complete, including full preventive and Public Health measures as well as a complete plan of curative medicine, both domiciliary and institutional." The same meeting endorsed the principle of the capitation method of remuneration for general practitioners under the scheme. You are all now f amiliar with the action of the Council of the Canadian Medical Association in endorsing the principle of Health Insurance and favouring a plan which would secure the highest standard of health services. After the introduction of the proposed Health Insurance, it was referred to a special committee on Social Security which proceeded to hold a series of meetings in order to secure the views of various interested organizations. The Committee of Seven of the Canadian Medical Association was instructed to prepare a brief for submission to this Committee on Social Security and asked for comments and suggestions for that brief from the various divisions. We would take this occasion to commend this action as an indication of the earnest effort of the Canadian Medical Association to be an organization truly representative of opinion throughout the Dominion. The first submission was made on April 6, 1943, and is familiar to all since it was distributed in booklet form to every doctor in Canada. A second submission was made on June 22nd and emphasized among other things, the need of bursaries for training in clinical medicine, and grants for postgraduate education; safeguards for clinical teaching; comments regarding the financial structure. The difficulty in obtaining a considered medical opinion during the war with so many of our profession in uniform was also pointed out, as was the unfairness of starting such a scheme with 30% of medical men away from their usual civilian work. In order to keep members of the profession in B. C. informed, an abstract of those portions of the Dominion and Provincial Acts that are of direct concern to medical men has been prepared, as well as a digest of the proceedings and evidence submitted to the metings of the Committee on Social Seecurity. Page Nineteen Your committee is convinced that the profession must proceed forthwith to make up its mind regarding many of the controversial aspects of this whole subject. We can not afford to present a divided house in our dealings with the government. Granted that complete unanimity is impossible, we must secure the considered majority viewpoint and agree to unite on that. It is hoped that the round table conference arranged for tomorrow night will go a long way toward settling some of the contentious points. The whole question of the costs of this scheme must be more closely studied. Your committee is convinced that we, either of the Canadian Medical Association, or the B. C. Division itself, should secure the services of some thoroughly competent authority to assist us in this work. As medical mien we know only in a general way the financial implications of this scheme. It is of interest that the advocates of Health Insurance stress the large amount of medical work that is not being secured by the public under our present system and yet when these same advocates attempt to ascertain the cost of Health Insurance, they take the total costs expended on present health services. In other words, while admitting that the present coverage is inadequate, they use that service as the basis for estimating cost. Also it is to be pointed out that in this method of ascertaining costs, no account is taken of the large amount of free medical care rendered under the present system. The free service rendered every year in our medical schools alone is of normous value, and even greater is the value of the free medical work given to the indigent and low income groups both in and out of hospitals all over the Do- minnin. There is, of course, in addition, a great deal of medical work that is not done as charity but for which no payment is ever received. The sum total of all these free services would considerably augment the figure used, from which the estimate of $26.00 per year per capita was secured. Offsetting these factors, it is recognized that the principle of compulsory universal insurance will permit a saving in unit cost. In conclusion, therefore, your committee wishes to make two recommendations which it would urge that you endorse: 1. That we attempt immediately to crystallize our views re Health Insurance in order to present a united front; 2. That we obtain the services of a statistician, actuary, or business adviser to assist us in obtaining our own estimate of the costs of an adequate Health Insurance. All of which is respectfully submitted. G. F. Strong, Chairman. OBIIT DR. JOHN A. WEST October 22, 1943. Dr. West was well known in British Columbia, since he practised in Prince Rupert and Vancouver, over a period of 23 years: of which he spent 15 in Vancouver. His professional ability was of a high order, and he was a very skilful and able surgeon. Latterly, since an attack of illness he had a year or more ago, it required much courage for him to carry on, as he was obviously far from well. As a man, he had a charming personality—and his friendly, courteous manner endeared him to all who knew him. We extend our sincerest sympathy to his wife and family. Page Twenty THE SEX STEROIDS IN GENERAL MEDICAL PRACTICE By Max M. Cantor, B.Sc, M.D., F.A.C.P. Assistant Professor of Biochemistry, University of Alberta. Paper read at the Summer School Session of the Vancouver Medical Association, Vancouver, June 22nd, 1943. It is impossible to give anything but the highlights of the subject announced. For that reason, this paper will be limited to a discussion of the sex steroids—a group of pure substances which have been isolated from the ovary and testis and which have all been synthesized. It will be further limited to a discussion of the use to which these can be put in general practice. The sex steroids are conveniently classified into three groups depending upon their natural source: the androgens, substances like testosterone, which is the primary hormone of the testes and which produces the same physiological effect; oestrogens, which imitate the action of oestradiol, the primary ovarian follicular hormone, and progestogens, the activity of which resembles in effect that produced by progesterone, the natural secretion of the corpus luteum. Table I presents the classification and summarizes their action. Table I. NOMENCLATURE, SOURCE AND ACTION OF SEX STEROIDS Name Androgens: 1. Androsterone 2. Dehydroandrosterone 3. Anhydro-iso-androsterone 4. Testosterone Testo, propionate Methyl testosterone Oestrogens: 1. Oestrone (Theelin) 2. Oestriol (Theelol) 3. Conjugated oestrogens 4. tf-cestradiol ^-oestradiol benzoate tf-cestradiol dipr'opionate Description Excretory product of Testosterone Intermediate in the metabolism of Testosterone Excretory product closely related to sex steroids True testis hormone Synthetic derivatives Source Male urine and synthetic Male urine and synthetic Adrenal cortex and synthetic Male urine and synthetic Synthetic Essential Action In the male: Normal development of the reproductive tract, maintenance of secondary sex characters and male pattern be- aviour. In the female: Suppression of rhythmic men- archial phenomena General—both sexes: Increase in skeletal growth and in weight in cases of endocrine underdevelopment except when due to hypothyroidism. Cardiac and vascular tonic. Excretory product | Urine of tf-oestradiol Excretory product of a-cestradiol Water-soluble glycuronides True follicular hormone Synthetic Pregnancy urine and placenta Pregnant mares' urine Ovary and pregnancy urine. Synthetic Initiate and control functional activity of female, produce the proliferative phase in vaginal mucosa and endometrium, cause increase in secretion of uterine serous glands, enhance myometrial .activity and promote activity of the mammary duct system. Progestogens: I. Progesterone 2. Pregneninolone True corpus luteum hormone Anhydro- hydroxy- progesterone (Ethinyl- testosterone) Corpus luteum of ovary and synthetic Synthetic Converts vascular proliferated endometrium into secretary, type, produce myometrial relaxation, stimulate acinar development in breast, nullify oestrogen action (convert active oestradiol into relatively inactive oestriol). Page Twenty-one Metabolism of the Sex Steroids Testosterone produced by the testis or injected therapeutically produces its characteristic effect and is altered to dehydroandrosterone, and excreted as androsterone in the urine. In this process it loses much of its activity although it can produce some effect. Oestradiol in the same way is metabolized to oestrone (theelin) and excreted both as oestrone and as oestriol (theelol). This conversion is effected by the corpus luteum hormone progesterone and occurs only in the presence of a functioning endometrium. In the process of conversion oestradiol loses nearly all of its activity. This is an important process physiologically, since oestradiol inactivation (to oestriol) renders the uterus quiescent so that the secretory phase of endometrial change can take place and pregnancy is stabilized. Progesterone undergoes similar inactivation and its excretory product pregnandiol is completely-inactive physiologically. In all three cases, then, the primary hormone possesses the greatest physiological activity. This is illustrated in Table II. Table II. STANDARDIZATION OF SEX STEROIDS AND COMPARISON OF ACTION I:U:/ntgm. Other units used Abbreviated definition of stand Name per mgm. ard international unit Androgens: Activity of 0.1 mg. of andro Testosterone 100 70-100 capon U. sterone as measured by a specific Androsterone 10 10 capon U. biologic test such as Capons D ehydrondrosterone 10 Comb growth or seminal vesicle response in rat (castrate). Anhydro-iso-androsterone 4 Specific oestrus-producing activ Oestrogens: ity in 0.0001 mgm. standard d-cestradiol 120,000? 12,000 R.U. oestrone. » Benzoate standard—specific oes a-oestradiol benzoate 10,000 B.U. 10,000 R.U. trus-producing activity in 0.0001 mgm. of oestradiol monoben- <r-cestradiol dipropionate 10,000 B.U. 18,000 R.U. zoate. oestrone (theelin) 10,000 1,000 R.U. The activity present in 1 mgm. or one unit of these is not the oestriol (theelol) 1,500 150 R.U. same. Conjugated cestrog. (orally) 4,000 400 R.U. The Allen-Doisy method commonly employed. Progestogens: • Progesterone 1 1 Corner-Allen The I.U. is defined as the spe Rabbit unit cific activity of 1 mgm. of in 2 Clauberg U. ternational standard progesterone 4 European U using Clauberg's rabbit method Pregneninolone 0.25 quantitatively determined by McPhail on the rabbit's uterus. Pregnandiol inactive It may be noted here that chemical manipulation has improved on nature. It was found that if testosterone and oestradiol were combined with acetic acid, benzoic acid or propionic acid, the intensity and duration of their action was enhanced. Thus esteri- fication of testosterone with propionic acid increases its effect seven times and doubles the duration of its action. In the same way oestradiol dipropionate possesses double the intensity of action of oestradiol and its effect lasts six times as long. Esterification also increases their solubility in oil, so that greater concentration may be obtained in small volume for injection. All in all, this provides greater comfort and economy for the patient when therapy is continued for long periods. Page Twenty-two Route of Administration and Choice of Material The primary sex steroids are active orally, by inunction and intramuscularly. The intensity and duration of effect varies, however, with the route chosen. Testosterone propionate intramuscularly is the material and route of choice. For purposes of inunction or oral administration, methyl testosterone is more economical but the dose must be four times as great by the oral route and twelve times as great by inunction as the intramuscular dose to produce the same effect. Quite commonly, the propionate intramuscularly is supplemented by therapy either orally or by inunction. Progesterone is not effective orally or by inunction. It should be given by intramuscular injection. Supplementary therapy with pregneninolone (oral progesterone) is a good procedure and if used early in six times the intramuscular dose can replace progesterone by injection. Oestrone is effective by all three routes, but its low solubility precludes the possibility of its use in adequate dosage and makes it unsuitable and uneconomical for prolonged therapy. The recent introduction of aqueous suspensions of oestrone overcomes this drawback but does not overcome its low comparative potency. Oestriol is effective orally only, and in the form of the water soluble conjugated glycuronide it has about three times the activity of oestrone. Oestradiol is active by all three routes, 1 mg. intramuscularly producing the effect of 12 mg. orally or 6 mg. by inunction or 3 mg. by vaginal insertion. The chief value of the esterified form, especially the dipropionate as in intramuscular injection or by inunction. This is illustrated in Table III and Table IV. By all criteria, oestradiol dipropionate is the most potent oestrogen known. Table IK. ACTIVITY OF ONE MILLIGRAM BY VARIOUS ROUTES AND IN VARIOUS VEHICLES (OESTROGENS) Substance Oestrone (oil) Oestrone (water) - Oestradiol (oil) Oestradiol (tablets) _._ Oestradiol in prop, glycol 1,000 Oestradiol benzoate (oil) 2,000 Oestradiol Dipropionate (oil) • 6,000 Oestradiol Dipropionate in prop, glycol 8,000 Conjugated Oestrogen 3,000 Oral progesterone is about one quarter as effective as by the intramuscular route. Methyl testosterone by mouth is above one-tenth as effective as by the intramuscular route. Table IV. COMPARING THE ACTTVTTY OF 50 GAMMA (0.005 MGM.) OF VARIOUS OESTROGENS IN WATER AND OIL INJECTED INTRAMUSCULARLY IN RATS Oral Intramusct dar Inunction Sublingual R.U. R.U. R.U. R.U. 50 1,000 160 ? 100 2,000 000 ? 1,000 8,000 2,500 ? 1,000 10,000 18,000 4,000 3,000 6,000 12,000 Substance Oestrone Oestrone Oestradiol Oestradiol benzoate Oestradiol dipropionate Conjugated oestradiol . Vehicle Duration of Effect water 2 days oil 4 days oil 7 days oil 14 days oil 42 days tablets 2 days oral Human dose equivalent for one month 60-70 mgm. in 18 doses 30-35 mgm. in 12 doses 26 mgm. in 8 doses 8 mgm. in 4 doses 4 mgm. in 2 doses 3 5 mgm. in 90 doses Diagnostic Methods The diagnosis of thyroid dysfunction is based on the history and physical examination of the patient, the degree of dysfunction is measured by the metabolic rate. Symp- tome and signs suggest the diagnosis of diabetes mellitus, the glucose tolerance curve estimates the degree of insulin deficiency. In both cases, laboratory techniques confirm diagnosis and provide a mathematical index of the severity of disturbed function. The same procedures are used in following the effects of treatment. The symptoms and signs associated with impaired gonadal function, especially those related to ovarian disease, are very difficult to assess, unless fully detailed menarchial his- \ Page Twenty-three 4 tory is obtained. Evaluation of the degree of ovarian function may be obtained from several sources: hormone excretion studies, endometrial biopsy, and the vaginal smear. Hormone excretion studies are complicated procedures which are time-consuming and expensive. They need to be carried out frequently and except for investigational purposes are not feasible. Endometrial biopsy involves histological section and study and is a procedure for the expert. The vaginal smear, taken at frequent intervals, is an, excellent reflection of ovarian activity. It is simple to perform and is readily interpreted, especially if the smears are prepared with Shorr's Trichrome Stain. By this method it is a relatively simple matter to differentiate the proliferative from the secretory phase of the cycle and detennine approximately the period of the cycle. In the early part of the cycle the smear is composed of leucocytes, debris and a few cornified cells which stain blue. When full cornification sets in (full oestrogenic effect) the cells are colored an intense red, and no leucocytes are present. This is the mid-point of the cycle. Reappearance of leucocytes and change in staining of the cornified cells to green indicates the early luteal phase. The cells then degenerate and appearance of red cells among" the debris herald menstruation. Atrophic spheroidal cells which stain blue or lavender are common in the menopause and indicate oestrogenic deficiency. The response to adequate therapy is indicated by the appearance of well formed cornified cells and the disappearance of lucocytes. The vaginal smear provides a simple and accurate method for controlling the therapeutic use of sex hormones. It has special value in differentiating between symptoms due to ovarian deficiency of the menopause and those of non-menopausal origin. The latter will persist even when enough hormone has been given to produce full cornification. In amenorrhcea, replacement therapy with oestrogens or stimulative therapy with gonadotropins will transform the smear so that the small-blue-green cells with large nuclei are replaced by the deep red flat cornified cells with small nuclei. Androgens cause the disappearance of the red cornified cells and their replacement by small, round or oval blue-green cells with large nuclei. Clinical Application of Sex Steroids in General Practice The symptoms of female sex endocrine disorders which we meet most commonly in general practice are concerned with: I Irregularities in menstrual flow II Dysmenorrhea a III Menopause IV Threatened or Habitual Abortion. I. Functional irregularities of uterine bleeding. The differentiation of an irregularity which is significant, from a minor variation in the normal, is difficult. The use of certain terms like amenorrhcea, oligomenorrhcea, metrorrhagia, etc., in the literature tend to confuse the issue since they do nothing but describe the duration, quantity and cyclicity of bleeding. A recent practical classification tends to qualify these terms by relating them to ovarian function. Thus menstruation is bleeding from a progestational endometrium which has been preceded by ovulation—it terminates a fertile cycle. Menorrhagia is excessive bleeding of the same type. Metrorrhagia is oestrogenic bleeding. A. Progestational {menstrual type) bleeding 1. Normal menstruation 2. Infrequent bleeding 3. Too frequent bleeding 4. Prolonged bleeding 5. Excessive bleeding B. Oestrogenic (interval type) bleeding 1. Cyclic bleeding 2. Infrequent bleeding 3. Too frequent bleeding Page Twenty-four 4. Prolonged bleeding 5. Excessive bleeding C. Non-occurrence of Heeding amenorrhcea). To use such a classification the diagnosis has to be established before therapy is begun. This is possible by obtaining a biopsy specimen of the endometrium within 12 to 18 hours from the onset of bleeding or vaginal smears at three-day intervals during the asymptomatic period. A. Progestational Irregular Bleeding In these cases some progestational effect is generally present. Where bleeding is more frequent than normal this is usually from an immature progestational endometrium and treatment should either substitute for the deficiency in corpus luteum activity or attempt to prolong the luteal phase by ovarian stimulation. Substitution may be accomplished with progesterone, 5 mg. every other day together with l/z mg. oestradiol dipropionate every alternate dose. This procedure is carried out for 10-12 days commencing about the mid-interval of the cycle. Where the symptoms are mild pregneninolone daily by mouth will produce the desired result. Infrequent progestational bleeding (delayed menstruation) is never of much consequence unless hypothyroidism is associated with it. Where the thyroid is not involved prostigrnine 1 mg. daily by intramuscular injection for 2 or 3 days will usually bring on menstruation. Incidentally this is a nice means of differentiating between delayed menstruation and early pregnancy—the latter condition is not affected-. Prolonged bleeding of the progestational type is nearly always due to endometrial pathology and responds best to thorough curettage. Where there is an endocrine basis for the disorder, testosterone propionate in doses of 25-50 mg. daily for three or four days is of definite value. B. Oestrogenic bleeding This bleeding is interval in type and comes from an oestrogenic endometrium. It is commonly associated with severe flowing and/or sterility. The bleeding may occur in cycles and may be associated with sterility. In these cases the evidence for oestrogenic failure is not marked. The ovaries are refractive and do not produce the full response. This type of refractivity is seen in climacteric women due to aging and treatment is not effective. An attempt may be made to stimulate the ovaries with charionic gonadotropins (F.S.H.), 500 I.U. daily for 10 days followed by daily therapy with 500 I.U. charionic gonadotropins (L.H.) for the next ten days. The appearance of a progestational endometrium or characteristic vaginal smear is indicative that a specific response has been obtained. It is our opinion that prolonged therapy of this type is not justified by the results and its use should be limited to those cases in whom it is desired to secure pregnancies. Infrequent oestrogenic bleeding, unless it is associated with hypothyroidism or produces sterility, does not require treatment since there are no symptoms. The administration of thyroid to these patients even in the face of a normal B.M.R. will frequently bring the character of the bleeding to normal proportions and render it progestational in type. If thyroid substance is not effective, a trial with gonadotropins by the procedure outlined is justified. Frequent and prolonged oestrogenic bleeding which is acyclic in character generally produces a severe secondary anaemia and is associated with sterility. Curettage may effect temporary haemostasis but does not cure the condition. The only effective therapy is found in the use of sex steroids. Large doses of oestradiol benzoate will produce hasmostasis. Introduction of progesterone in addition will subsequently re-establish normal rhythm and bleeding. The procedure will vary with the degree of symptoms and is usually as follows: Oestradiol benzoate (Ben ovocylin) 5-10 mg. daily until bleeding stops. Then Daily injection oestradiol benzoate 2 mg. for 10 days followed by combining this with 5 mg. progesterone (Lutocylol) every day or every alternate day for the next ten Page Twenty-five days. If bleeding starts during the second phase of treatment, therapy is discontinued and resumed again at the end of 4 or 5 days. Three such courses generally suffice to produce a progestational phase in the cycle and quite frequently cyclic bleeding continues thereafter. Where sterility is an associated complication, gonadotropins may be tried after the cycles are established. The use of stilboestrol in the control of this type of bleeding is in my opinion contraphysiological since it does not produce a progestational effect. In large doses orally or by intra-cervical injection, stilboestrol will produce haemostosis but it does not salvage endocrine ovarian function. Endocrine therapy for excessive and prolonged bleeding of the oestrogenic type in the menopausal woman is not justified until a diagnostic curettage is first performed to rule out malignancy. Even where malignancy is ruled out, it is more economical to negate ovarian function with a little radium and treat these patients with small weekly or bimonthly injections of oestradiol dipropionate (diovocylin) for four or six months. C. Non-occurrence of bleeding—amenorrhcea Amenorrhcea is more frequently a symptom of organic disease elsewhere in the body than it is an indication of ovarian failure. Treatment is indicated only where it is associated with Sterility. Even if hypothyroidism is ruled out completely, small doses of thyroid extract are occasionally efficacious and should in any event be used as an adjunct to sex hormone therapy. Adequate therapy consists in complete replacement by this procedure. Day: 1 5 9 11 13 17 21 25 Diovocylin : mg. 1.0 2.5 2.5 5.0 5.0 2.5 1.0 Equine Gonadotrop (F.S.H J.U. 0 0 500 500 500 0 0 0 A.P.L. (L.H.) 0 0 0 0 100 100 0 0 Lutocylin 0 0 0 0 0 5 10 5.0, Such a cyclic routine builds up the endometrium and provides stimulative therapy to the ovary. The substitution of synergistic preparations of gonadotropins such as syna- poidin for F.S.H. and L.H. factors simplifies the procedure. Quite frequently uterine- refractivity is the major factor in the aetiology and normal cycles may be re-established without recourse to gonadotropins at all. The use of testosterone propionate in the control of excessive bleeding is not contra- physiologic in our opinion. The normal female produces androgenic substances and there is a good body of evidence to suggest that these play an essential role in the phenomena of menstruation. In doses of 25-50 mg., testosterone propionate is extremely useful in the immediate treatment of uterine bleeding no matter what the cause. II. Dysmenorrhea is a term used to denote the exaggeration of pelvic discomfort associated with menstruation. It may be functional or organic. There are three theories with regard to the aetiology of functional dysmenorrhcea: (a) Deficiency of progesterone permitting unopposed oestrogen action on uterine muscle. (b) Excessive oestrogen production causing hypermotility of uterine muscle. (c) Excessive progesterone activity. None of these theories can boast of adequate support, but therapy is based on all three. Progesterone and more commonly testosterone propionate are used for their oestrogen- antagonistic effect. It has also been suggested that dysmenorrhcea represents an androgen deficiency and results in the unopposed action of ovarian hormones. Our experience with the use of testosterone propionate (perandren—Ciba) has been quite satisfactory. Relief is generally prompt and complete. Our practice is to administer between 10 and 25 mgm. of perandren daily or on alternate days for 2 to 4 doses commencing a day or two before the usual expected onset of pain. The use of methyl testosterone (metan- dren) 10 mg. twice or three times daily is quite frequently a useful procedure in milder cases. We are not in favour of using androgens throughout the entire period and prefer Page Twenty-six total monthly dosage not to exceed 200 mg. This is well below the amount which may produce masculinization phenomena and will not produce an oestrogen deficiency. We have had no experience with the use of oestrogens in dysmenorrhcea. The effect produced by them is parasympatheticomimetic and is mediated by the inhibition of acetylcholine esterase. This produces a blocking effect on the sympathetic component of dysmenorrhcea. The total doses commonly used by proponents of this theory vary from 6 to 20 mg. of oestrogen administered over ten days in the first half of the cycle. The material of choice is oestradiol diproprionate (diovocylin) although good results are also shown with the oral preparations. m. Menopausal Symptoms. The severity of the symptoms in this condition varies with the degree of ovarian failure or oestrogen deficiency. This is well indicated by hormone excretion studies and the appearance of the vaginal smear. From what is known of the autonomic influence of oestrogens it seems more than likely that hot flushes are part and parcel of the same syndrome and not as is commonly suggested evidence of a psychic disturbance. The value of oestrogens in the therapy of menopause is well established, but there is still some question as to the material to be used and the frequency of administration. Thyroid extract definitely has a place in the routine if the B.M.R. is not greater than plus 15. We are firmly of the conviction that the great majority of menopausal patients benefit from small doses of thyroid and suggest no less than 1 gr. a day for six weeks, followed by a rest period of three weeks and the course repeated. With regard to oestrogens we prefer the long acting diovocylin since it reduces the number of injections necessary. When menorrhagia is not prominent, 5 mg. at weekly intervals for three or four weeks is followed by smaller doses, 1 to 2 mg. at weekly or 10-day intervals. The dose is reduced gradually and the interval between injection lengthened until 1 mg. at monthly intervals controls the symptoms. Frequent vaginal smears should be taken as a gauge of the effectiveness of treatment and sufficient oestrogens should be provided to maintain it in a cornified state. Usually subjective symptoms are relieved within 24 hours and cornification of the vaginal epithelium is complete in about six days. Symptoms referable to the vaginal tract, atrophic vaginitis and pruritus, also disappear with this form of therapy but some assistance is afforded by the use of vaginal suppositories containing 0.4 mg. oestradiol every alternate night until symptoms are controlled. The effect produced in the mucosa by this procedure is often very dramatic. Occasionally patients are encountered who do not respond to oestrogens. Failure to improve after three weeks' trial with adequate dosage is an indication for a change in tactics. These patients usually complain of excessive bleeding and best results are obtaind with testosterone proprionate (perandren) 10 to 25 mg. or more at weekly intervals, the total monthly dose not exceeding 200 mg. With control of symptoms, the dose is decreased and the interval between injections lengthened. When symptoms are moderate, control may be effected by oral oestradiol (ovocylin) or conjugated glycuronides of oestriol (premarim). IV. Threatened or Recurrent Abortion. The causes of spontaneous abortion are many. We are concerned here only with those of endocrine origin. In these the fault is of three types: (a) Faulty development of the chorio-placental system. This is generally due to an incomplete progestational effect associated with a deficient functioning corpus luteum. There is a deficiency of progesterone produced. This failure is in greatest evidence in the initial stages of pregnancy and the embryo is lost because the process of nidation is inadequate Page Twenty-seven (b) Failure of the placenta to take on the function of the corpus luteum. This normally occurs about the third month. When the placenta is at fault in this respect, insufficient progesterone is available for the metabolism of oestradiol. This produces an irritable uterus and results in loss of the embryo. Such a deficiency is usually seen at about the third lunar month. (c) Abortion late in pregnancy, or premature labour, is associated with failure in progesterone production and consequent relative increase in "active" oestrogen. The best measure of progesterone production is in the measurement of its excretory product pregnandiol. The method of estimation is not easily performed outside of a laboratory. Where facilities are available it is an excellent aid in diagnosis and prognosis. Therapy in all these cases is with progesterone (lutocylin). Successful therapy depends upon anticipating the crises or in early and adequate therapy. It is of no value after the os is dilated. Doses from 20 mg. daily to 2 to 3 times a day are necessary in the severe types, supplemented with 10 mg. three times a day by mouth. Milder cases may be controlled by 10 mg. a day orally commencing two or three days before the expected missed period and continuing through the interval. We make a practice of giving thyroid extract in small dosage to all such patients. Our own experience is not very extensive, but large clinics which follow this procedure report more than 80% salvage in large series of cases. Indications and Contraindications The intelligent application of sex hormones demands a precise knowledge of the agent used, and its pharmacological and physiological effects. An essential antecedent is clear understanding of the nature of the sex cycle. The steroids are pure chemical substances and should contain no contaminants. Pain following injection of the oily material can be avoided if the outside of the neeVlle is wiped clean of oil with some sterile gauze. Oestrogens suppress pituitary function and assist in the closure of un-united epiphyses. There is a danger of stunted growth. They also cause retention of water and electrolytes such as sodium. This may cause an increase in weight and complicate cardio-renal failure. Oestrogens may produce bleeding, especially in overtreatment for the menopause. Poor results from oestrogen therapy in the conditions in which it is indicated are most frequently due to ineffective dosage. Like oestrogens, progesterone may produce oedema and depress pituitary function. Given in the middle of the period it may induce intermenstrual bleeding and may aggravate flow if given during a period of bleeding. Overdosage is precluded by the cost of the preparations. Ineffective dosage is the rule and commonest cause of poor results. Testosterone is a pituitary depressant and it also has a retention effect for sodium and water. In addition it produces a positive nitrogen balance and promotes somatic growth. This property makes it useful in the treatment of some types of dwarfism. Overdosage with testosterone is common and produces abnormal sexual development. More than 300 mg. a month may produce masculinization in women. Testosterone is of value in stimulating libido in males but it is contraindicated in male sterility since it depresses spermatogenesis. I have left out of this discussion the very controversial subject of the treatment of sterility in both males and females as well as the discussion of other uses to which the sex steroids have been put. The use of androgens in the male climacteric, in prostatism and in coronary heart disease is still in the experimental stage. As more information regarding their pharmacological action becomes available it appears possible that the sex steroids will assume a larger sphere of usefulness. Until that time their use should be limited in practice to those conditions in which their action is definitely known. Such rational and judicious use will yield desrable therapeutic salvage. Empiricism may be followed by irreparable damage to the physiologic economy of the patient. Page Twenty-eight (jU00t 11 MOID THAT UN* Soon the infectious diseases of Winter will again threaten Canada's health line and extra supplies of vitamins A and D will be needed to supplement deficient diets, "Alphamettes" and "Alphamette" Liquid—standardized, concentrated cod liver oil, fortified with irradiated ergosterol—will be found effective media for the administration of these important vitamins. AIlFH Al*! E'JL'l'ES " For adults and older children.—Each gelatin 077 capsule contains 5,000 International Units of vitamin A and 1,750 of vitamin D. U ALPH AMETTE" LIQUID For infants and young children. Each drop contains approximately 1,500 International Units of vitamin A and 300 of vitamin D. AYERST, McKENNA & HARRISON LIMITED | Biological and Paaimaceutical Chemists ■ MONTREAL, CANADA 169 New quick, simplified URINE-SUGAR TEST CLINITEST URINE-SUGAR ANALYSIS TABLETS NOTE THESE PRACTICAL ADVANTAGES A test can be made in less than 1 minute. No complicated equipment. No heating. No liquids or powder to spill. Small, compact, portable in pocket or bag. And Clinitest is Reliable The chemistry underlying the Clinitest Tablet Method is essentially the same as that involved in the well- known copper reduction methods of Fehling and Benedict. It retains the familiar progression of colors from blue through green to orange, and indicating sugar (glucose) at 0%, H%, XA%, ZA%, 1% and 2% plus. ' Economical Complete set (with tablets for 50 tests) costs patient only $2.00. Tablet Refill (for 75 tests) $2.00. Write for full descriptive literature. Available through your surgical house or prescription pharmacy. 5 drops urine plus 10 drops water. Drop in tablet. © Allow for reaction, and compare with color scale. EFFERVESCENT PRODUCTS INC. 3 FRED. J. Sale Canadian Distributors WHITLOW & CO., LTD., 187 DUFFERIN STREET, TORONTO WINTHROP CHEMICAL COMPANY, INC Genera/office* ^Professional service office: Dominion Square Bldg., Montreal, Que. WINDSOR, ONT. 1930 Tisd^ F- F- Drake, T. G. H.. and Brown, A.: A new cereal mixture containing vitamins and mineral elements. Am. J. Dis. Child. 40:791-799, Oct. 1930. iQli Tisdalli F. P.: Dietary factors and x:'JX health. Soc. Tr., Am. J. Dis. Child. 42:1490, Dec. 1931. 1932 Summerfeldt, P.: The value of an in- creased supply of vitamin Bt and iron in the diet of children. Am. J. Dis. Child. 43:284-290. Feb. 1932. • Morse. J. L.: Fads and fancies in present day pediatrics, Pennsylvania M. J. 35:280-285, Feb. 1932. Hen- ricke, S. G.: The vitamin B complex: Its role in infant feeding in the light of our present knowledge. Northwest Med. 31:165-169, April 1932. -Langhorst, ,H. P.: Vitamins: Their role in the prevention and treatment of disease. M. J. & Rec. 135:326-329. April 6, 1932. Crimm, P. D.: Dietary of Childhood Tuberculosis: Cereal as a source of added mineral and vitamin elements; preliminary report. J. Indiana M. A. 25:205-206, May 1932. Troutt, L.: Quality studies of therapeutic diets: I. The ulcer diet; a committee report, J. Am. Dietet. A. 8:25-32. May 1932. Summerfeldt. P., Tisdall, F. F., and Brown. A.: The curative effects of cereals and biscuits on experimental anaemias, Canad. M.A.J. 26:666-669, June 1932. Sneed,' W.: Ununited and delayed union of fractures, Kentucky M. J. 30:363-370. July 1932. Silverman, A. C: Celiac disease. New York State J. Med. 32:1055-1061, Sept. 15, 1932. von Meysenbug, L.: Infant feeding with especial reference to some of its problems during the first year, Texas State J. Med. 28:543-547, Dec 1932. 1933 Sampler. F. J., and Forbes, J. C: Cal- cium and phosphorus metabolism in a case of celiac disease. South. M. J. 26:555- 558, June 1933. Brown, A., and Tisdall, F. F.: The role of minerals and vitamins in growth and resistance to infection, Brit. M. J. 1:55-57, Jan. 14, 1933; Effect of vitamins Orleans M. & S. J. 87:738-743. May 1935. Tarr. E. M., and McNeile, O.: Relation of vitamin B deficiency to metabolic disturbances during pregnancy and lactation. Am. J. Obst. & Gynec. 29:811-818, June 1935. Blatt, M. L., and Schapiro, I. E.: Influence of a special cereal mixture on infant development. Am. J. Dis. Child. 50:324-336. Aug. 1935. Coward, N. B.: Infant feeding. Nova Scotia M. Bull. 14:525-532, Oct. 1935. Tisdall, F. F.: Inadequacy of present dietary standards.-Tr. Sect. Pediat.. A.M.A., 1935: Canad. M. A. J. 33:624-628. Dec. 1935. Marriott, W. McK.: Infant Nutrition, second edition, C. V. Mosby Co., St. Louis, 1935. p. 202. Summerfeldt, P.: Iron and its availability in foods, Tr. Sect. Pediat.. A.M.A. 1935. pp. 214-220. 1936 Dafoe, A. R.: Further history of the care and feeding of the Dionne quintuplets, Canad. M. A. J. 34:26-32. Jan. 1936. Conn. L. C. Vant, J. R., and Malone, M. M.: Some aspects of maternal nutrition, Surg., Gynec. & Obst. 62:377-383. Feb. 15. 1936. Ross, J. R., and Summerfeldt. P.: Haemoglobin of normal children and certain factors influencing its formation, Canad. M. A. J. 34:155-15X, Feb. 1936. Smyth, F. S.: Allergic diseases, J. Pediat. 8:500-515, April 1936. Lemmon, J. R.: Problems of the crying infant. Southwestern Med. 20:24S-250, July 1936. Rice. C. V.: The success of treating celiac disease from a standpoint of vitamin deficiency. Arch. Pediat. 53:626629, Sept. 1936. Smith, C. H.: Management of nutritional anemia in infancy, M. Clin. North America 20:933-950. Nov. 1936. Strong. R. A., editor: Nutritional anemia of infants, Orleans Parish M. Soc. Bull., pp. 6-9. Nov. 9. 1936. Jeans. P. C: Specific factors in nutrition. Round Table discussion, J. Pediat. 9*93-698, Nov. 1936. Young. J. &.: Meeting the requirements for proper nutrition in infancy. Texas State J. Med. 32:531- 533, Dec. 1936. 1Q37 Stearns, G., and Stinger, D.: Iron re- tention in infancy, J. Nutrition 13:127- ner, B., and Gruehj, H. L.: Anaphylactogenic .properties of certain cereal foods and bread- stuffs: Am. J. Dis. Child. 57:739-758. April 1939. Monypenny, D.: Early introduction of solid foods in the infant diet, Soc. Tr., Am. J. Dis. Child. 58:1144-1145, Nov. 1939. Brown. A., and Tisdall. F. F. Common Procedures in the practice of paediatrics, third edition, McClelland & Stewart, Ltd., Toronto, 1939, pp. 77-79. 1940 McDougal, L. L., Jr.: Feeding a nor- mal infant. Mississippi Doctor 17:437- 442. Jan. 1940. Monypenny. D.: The early introduction of solid foods in the infant diet, Canad. M. A. J. 42:137-140. Feb. 1940. Robinson, E. C: A study of two hundred and forty breast-fed and artificially fed infants in the St. Louis area. Am. J. Dis. Child. 58:816- 827, April 1940. Ratner, B.: Round Table discussion On food allergy, J. Pediat. 16:653- 672. May 1940. Rosenbaum, I., Jr.: The management of the allergic child, Kentucky M. J. 38:199-203. May 1940. Barondes. R. de R.: Report of a case of pellagroid, M. Rec. 151:376-380. June 5. 1940. Brown. A.: The fourth Blackader lecture on a decade of paediatric progress, Canad. M. A. J. 43:305- 313. Oct: 1940. Drueck. C. J.. Vitamin therapy in colon and rectal disease, Illinois M. J. 78:337-341, Oct. 1940. Swift. F. L.: Infant feeding, Lackawanna Co. M. Soc. Reporter, 33:16-18, Nov. 1940. B.ogert. L. J., and Porter, M. T.: Dietetics Simplified, ed. 2, Macmillan Co., New York, 1940, p. 181. Davison, W. C.: The Compleat Pediatrician, third edition, Duke University Press, Durham. N. C, 1940, No. 216. Hawley. E. E., and Maurer-Mast. E. E.: The Fundamentals of Nutrition. C. C. Thomas. Springfield, 111., 1940. pp. 296. 456. Kugel- mass, I. N.: The Newer Nutrition in Pediatric Practice, J. B. Lippincott Co., Philadelphia, 1940, p. 372. Leaman, W. G.. Jr.: Management of the Cardiac Patient. J. B. Lippincott Co.. Phila.. 1940. p. 549. Paterson, D., in Index of Treatment, edited 4iy R. Hutchison, ed. 12, revised, Williams & Wilkins Co.. Baltimore. 1940. p. 491. Thomas. G. SCIENTIFIC BACKGROUND Mead's Cereal was introduced in 1930, and Pablum in 1932, by Mead Johnson & Company. Since then, the growing literature indicates early recognition and continued acceptance of these products and the important pioneer principles they represent. and the inorganic elements on growth and resistance to disease in children. Ann. Int. Med. 7:342-3527 Sept. 1933. Crimm. P. D.. Raphael, I. J., and Schnute, L. F.: Diet of tuberculous and non-tuberculous children: Effect of increased supply of vitamin B concentrate and minerals. Am. J. Dis. Child. 46:751-756. Oct. 1933.. Smith, A. D.: Consideration of various infants' foods. Pacific Coast J. Homeop. 44:463-465. Sept.-Dec. 1933. 1 Q"\ A Somers, R., Rotton, G. C, and Rown- tree, J. I.: Possibilities of improving dental structures, Soc. Tr., Bull. King Co. M. Soc. 13:6, Jan. 15, 1934. Blatt, M. L.: Development of infants on a diet of a special cereal mixture, Soc. Tr., Am. J. Dis. Child. 47:918. April 1934. Rice, C. V.: Anemia of infancy and early childhood, J. Oklahoma M. A. 27:125-129. April 1934. Hawk. W. A.: A few of the commoner feeding problems in infancy. Univ. Toronto M. J. 11218-229, May 1934. Ross. J. R., and Burrill, L. M.: The effect of cooking on the digestibility of cereals. J. Pediat. 4:654-659, May 1934. Rice. C. V.: Sauerkraut juice for the acidification of evaporated milk in infant feeding, Arch. Pediat. 51:390-395. June 1934. Eder. H. L.: Iron therapy: A routine procedure during infancy. Arch. Pediat. 51:701-713, Nov. 1934. Lynch, H. D.: Fundamentals of infant feeding, J. Indiana M. A. 27:571- 574, Dec 1934. Chaney, M. S.. and Ahl- born, M.: Nutrition, Houghton Mifflin Co., Boston, 1934, p. 323. 1935 Bailey, C. W.: Anemia in infants and young children, J. South Carolina M. A. 31:54-58, March 1935. S Kugelmass, I. N.: The recent advances, in treatment, of nutritional disturbances in infancy and'childhood, M. Comment 17:5-13, March 1, 1935. Ross, J. R., and Summerfeldt, P.: Value of increased supply of vitamin Bt and iron in the diet of children: Paper II, Am. J. Dis. Child. 49:1185-1188. May 1935. von Meysenbug, L.: Breast feeding with especial reference to some of its problems. New 141. Feb. 1937. Strong. R. A.: Nutritional anemia, Mississippi Doctor 15:13-16, Aug. 1937. Smith, C. H.: Prevention and treatment of nutritional anemia in infancy. Preventive Med. 7:115-124, Aug. 1937. Saxl, N. T.: Pediatrics, in Dietetics for the Clinician, edited by M. A. Bridges, third edition. Lea & Febiger, Philadelphia, 1937. pp. 637- 639. Boyd. J. D.: Nutrition of the Infant and Child. National Medical Book Co., Inc., New York, 1937, p. 110. Brennemann, J.: ' Practice of Pediatrics, W. F. Prior Co., Inc., Hagerstown. Md.. 1937, Vol. 1. Ch. 25, p. 19. Griffith. J. P. C, and Mitchell. A. G.: The Diseases of Infants and Children, second edition, W. B. Saunders Co., Philadelphia, 1937. pj>. 106, 111. Saxl, N. T.: Pediatric Dietetics, Lea & Febiger, Philadelphia, 1937, pp. 131-133. 1938 Hoffman' s- J- Greenhill, J. P., and . Lundeen, E. C: A premature infant weighing 735 grams and surviving, J.A.M.A. 110:283-285.. Jan. 22. 1938. Krasnow. F.: Nutritional influence on teeth. Am. J. Pub. Health 28:325-333. March 1938. Ratner, B.: Round Table discussion on asthma and hay fever in children, J. Pediat. 12:399-413, March 1938. Ratner, B.: Panel discussion on the role of allergy in pediatric practice, J. Pediat. 13:582-604, Oct. 1938. Snelling, C. E.: Nutritional anaemia. Bull. Acad. Med. Toronto 12:710, Oct. 1938.. Dauphinee. J. A.: The iron requirement in normal nutrition, Canad. M.A.J. 39:483-486. Nov. 1938. Summerfeldt, P., and Ross, J. R.: Value of an increased supply of vitamin Bi and iron in the diet of children. Paper III, Am. J. Dis. Child. 56:985-988, Nov. 1938. Tisdall, F. F., and Drake, T. G. H.: The utilization of calcium, J. Nutrition 16:613- 620. Dec. 1938. Drake, T. G. H.: Introduction of solid foods into the diets of children. Canad. M. A. J. 39:578-580, Dec. 1938. 1939 Strong, R. A.: The most frequent causes of vomiting in infancy, Texas State J Med 34:665-670, Feb. 1939. Rat- I.: Dietary of Health and Disease, ed. 3, revised. Lea & Febiger. Phila.. 1940, pp. 171. IQ^l Gipson, A. C: The role of allergy in pediatric practice, J. M. A. Alabama 10:272-274. Feb. 1941. Ross. J. R, Monypenny, D., and Jackson, S. H.: II. The effect of cooking on the digestibility of cereals, J. Pediat. 18:395-398. March 1941. Kennedy, A. S., Snider, O., Hazen, J. S., and McLean, C: The dietary management of intestinal tuberculosis, Canad. M. A. J. 44:380-385, April 1941. McAlpine, K. L.: Management of the nutritional anaemia of infancy, Canad. M. A. J. 44:386-390. April 1941. Patek, A. J., Jr., and Post. J.: Treatment of cirrhosis of the liver by a nutritious diet and supplements rich in .vitamin B complex..J. Clin. Investigation 20:481-505. Sept. 1941. Bercovitz, Z.. and Johnson, H. J.: Ulcerative Colitis, in Dietetics for the Clinician, by M. A. Bridges, fourth edition, revised. Lea & Febiger, Phila., 1941. p..295. Bridges, M. A.: Dietetics for the Clinician, fourth edition, revised. Lea & Febiger, Phila., 1941, pp. 727, 751. 809. Griffith, J. P. C, and Mitchell. A. G.: Textbook of Pediatrics, ed. 3, revised, W. B. Saunders Co., Phila.. 1941. pp. 87, 91. Rowe, A. H.: Elimination Diets and the Patient's Allergies, Lea & Febiger, Phila., 1941, p. 230. Twiss, J. R.: Gall-bladder Disease, in Dietetics for the Clinician, by M. A. Bridges, fourth edition, revised. Lea & Febiger, Phila., 1941, p. 401. 1Q42 Gleich, M.: The premature infant. ^ Part II, Arch. Pediat.59:99-135. Feb. 1942. Part IV, Arch. Pediat. 59:241-263. April 1942. Brown, A., and Robertson, E. C: Factors to be considered in the construction of the diet of the older child, J. KansasM.Soc. 43:237-244. June 1942. Porter, L-, and Carter, W. E.: Management of the Sick Infant and Child, ed. 6, C. V. Mosby Co., St. Louis, 1942. p. 125. Proudfit, F. T.: 1 Nutrition and Diet Therapy, ed. 8, Macmillan Co., New York. 1942, p. 515. Willard, J. H.: Digestive Diseases in General Practice, F. A. Davis Co., Phila.. 1942. p. 147. ARTHRITIS and ECZEMA of endogenous origin claimed to be allergic, may be favored or induced by calcium and sulphur deficiency, impaired cell action, and imperfect elimination of toxic waste. LYXANTHINE ASTIER administered per os, brings about improved cell nutrition and activity, increased elimination, re- suiting symptom relief, and general functional improvement. Since the best evidence is clinical •evidence, write for literature and ■camnle. Canadian Distributors ROUGIER FRERES 350 Le Moyne Street, Montreal Colonic and Physiotherapy Centre Up-to-date Scientific Treatments COLONIC IRRIGATIONS, SHORTWAVE DIATHERMY, SIN NEW AVE GALVIN- ISM, IONIZATION, ULTRA VIOLET RAY, STEAM BATHS AND SHOWERS Medical and Swedish Massage Physical Culture Exercises STAFF OF GRADUATE NURSES Superintendent: E. M. LEONARD, R.N. Post Graduate Mayo Bros. 1119 Vancouver Block MArine 3723 Vancouver, B.C. Results of Extensive Studies of Research on the Use of Bran X- ray^ of barium meal m the colon where laxative effect is primarily exerted. Observations indicate that KELLOGG'S ALL-BRAN does not interfere with normal digestive processes in the stomach or small intestines. R, .ECENTLY reported developments in research as to the mode of laxative operation of ALL-BRAN added to unrestricted and uncontrolled diets are of considerable interest. Evaluations by the use of measuring methods that have been found consistently reliable indicate that: • When bran is added to the diet a desirable change takes place in the waste material- it becomes bulkier and softer.1 • Bran exerts its laxative effect primarily in the colon; it does not interfere with normal processes of digestion in the stomach or small intestine.2 • Bran has little effect on the emptying time of the colon when this emptying time is as it should be. But among subjects with a delayed emptying time, bran has a distinct accelerating effect.2 • It is not necessary to control rigidly the quantity of bran eaten, as 2 ounces (double the usual cereal serving) eaten daily does not result in a corresponding increase in laxation.3 • Bran eaten every day for an extended period of time has no adverse effects on normal intestines; its continued use does not lessen or increase its laxative effect.3 1 "Mode of Action of Bran," Journal of Laboratory and Clinical Medicine, August, 1941. 2 "Roentgen Study of Intestinal Motility as Influenced by Bran," The Journal of the American Medical Association, February 3, 1940. 3 "Effect of Long-Continued Consumption of Bran by Normal Men," Journal of American Dietetic Association, April, 1942. • Any or all of these reports are available. Requests for reprints relative to the action of KELLOGG'S ALL-BRAN should be made to KELLOGG COMPANY OF CANADA LIMITED, London, Ont. flDount pleasant Xttnbertahing Co. 5ltb. KINGS WAY at 11th AYE. Telephone FAirmont 0058 VANCOUVER, B. C R. F. HARRISON W. E. REYNOLDS Jfead Cold* Checked J § { WITH 3 DROPS IN EACH NOSTRIL . . . PRIVINE"Ciba" (1:1000 solution of 2—(naphthyl—1-^methyl)—imidazoline hydrochloride) NASAL DROPS! Clinical investigations on Privine Nasal Drops have proved that they are excellently suited for the treatment of all forms of nasopharyngeal affections. In head colds, a few moments after the instillation of 3 drops of Privine in each nostril, the headache and sensation of heaviness in the head disappear, while the nasal respiration becomes easier, the watering of the eyes stops, the voice regains its normal tone and the sense of smell is restored. ISSUED: In bottles of Vi ounce with dropper, and bottles of 4 ounces. CIBA COMPANY LTD. Montreal GRATIFYING RELIEF at diUrefolna bumhtamA ity CYSTITIS PYELONEPHRITIS PROSTATITIS URETHRITIS /T^HE prompt symptomatic relief provided by ^ Pyridium is extremely gratifying to the patient suffering with distressing urinary symptoms such as painful, urgent, and frequent urination, tenesmus, and perineal irritability. Conveniently administered perorally in the average dosage of 2 tablets t.i.d., Pyridium possesses a combination of advantages. It is relatively nontoxic, is-effective in the presence of either acid or alkaline urine, is well tolerated, and has a local analgesic effect on the urogenital mucosa. Literature en request PYRIDIUM REG. U. S. PAT. OFF. (Phenylaxo-alpha-alpha-diamino- pyridine mono-hydrochloride) More thai decade vore man a of service in urogenitaHhfettions Li MERCK & CO. Limited <Ma*iu<factuKiny 9£Aemtit4 Montreal and Toronto IIIMII1IIIIIIIIIIIII1IMIII11IIIIII.I .iiiiuiuimmiiiituiiiiiiiiiiitiiiiiiiiiiiiiii I'm off the bottle- but I'm sticking with Carnation! When, along toward the tenth month, your Carnation feeding formula prescribes a whole-milk dilution, there is no need to change to any other form of milk—and many good reasons for "sticking with Carnation." These are the same reasons that have made Irradiated Carnation Milk a preferred milk for infant feeding—and the added reasons of established taste-habit and digestive acceptance. JLhysicians are invited to write for "Continuing After Weaning With Irradiated Carnation Evaporated Milk" Address Carnation Company limited, Toronto, Ont. IRRADIATED Carnation I y'jIRRADlMED Utonatiffl1 \» fim. C..t~lrJ ft" "FROM CONTENTED COWS" Milk A Canadian Product ^Prescription Specialists » That phrase has been the Keynote of Georgia Pharmacy for 35 years. The war has. reduced our staff of registered pharmacists^but it hasn't lessened our skill nor the quality and accuracy of our dispensary. Phone MArine 416 ,JL*^^.JU*d*4**\ GEORGIA PHARMACY I. I V I T ^nter^c2|anttalltb ISTABLISHED 1891 VANCOUVER, B. C. North Vancouver, B. C. Powell River, B. C. Ji ^ttff (So. Ctmttf & New Westminster, B..C. For the treatment of NEUROPSYCHIATRIC DISORDERS Reference—B. C. Medical Association For information apply, lif* Medical Supekintenden^New Westminster, B.^i^ or 721 Mewcal-De^^IBuilding, Vancouver, B.:^ PAcific^7823 Westminster 288 >S7
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: October, 1943
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