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History of Nursing in Pacific Canada
Vancouver Medical Association
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an.■■-' "''l-!i.'JJ- ".W The BULLETIN' of the jj I VANCOUVER MEDICAL ASSOCIATION Vol. XVI. DECEMBER, 1939 No. 3 With Which Is Incorporated Transactions of the Victoria Medical Society tit Vancouver General Hospital and St. Paul's Hospital In This Issue: SCHIZOPHRENIA DR. HARVEY CUSHING SYPHILIS NEWS AND NOTES VANCOUVER MEDICAL ASSOCIATION NEW TELEPHONE NUMBER—MARINE 4622 BULKETTS (With Cascara and Bile Salts) . . FOR . . Chronic Habitual Constipation BULKETTS POSSESS ENORMOUS BULK PRODUCING PROPERTIES AND BEING PROCESSEll WITH CASCARA AND Bn-EIJSALTS PRODUC^BULK WITH MOTILITY^ WE WILL BE PLEASED TO PROVIDE ORIGINAL CONTAINERS FOR TRIAL ON REQUEST. Western Wholesale DrugM (1928) Limited 456 BROADWAy|wEST VANCOUVER|. BRITISH COLUMBIA (Or at all Vancouver Drug Co. Stent) THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C. EDITORIAL BOARD: Db. J. H. MacDebmot Db. G. A. Davidson- Db. D. B. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XVI. DECEMBER, 1939 OFFICERS, 1939-1940 Db. A. M. Agnew Db. D. F„ Busteed President Vice-President Db. W. T. Lockhabt Hon. Treasurer Additional Menibers of Executive; Db. M. McC. Baibd, Db. H. A. DesBbisat Db. F. Bbodie Db. F. Tubnbull. TRUSTEES Db. J. A. Gillespie Db. F. W. Lees Historian: Db. W. L. Pedlow Auditors: Messbs. Plommeb, Whiting & Co. SECTIONS Clinical Section .Chairman Db. Kabl Haig Eye, Ear, Nose and Throat Db. W. M. Paton Chairman Db. G. C. Labge Secretary Pcediatric Section Db. J. R. Davies Chairman Db. E. S. James Secretary STANDING COMMITTEES Library: Db. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies, Db. W. A. Bagnall, Db. T. H. Lennie, Db. J. E. Walkeb. Publications: Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson. Summer School: Db. T. H. Lennie, Db. A. Lowbie, Db. H. H. Caple, Db. Feank Tubnbull, Db. W. W. Simpson, Db. Kabl Haig. Credentials: Db. A. B. Schinbein, Db. D. M. Meekison, Db. F. J. Bulleb. V. 0. N. Advisory Board: Db. I. Day, Db. G. A. Lamont, Db. S. Hobbs. Metropolitan Health Board Advisory Committee: To be appointed by the Executive Committee. Or eater Vancouver Health League Representatives: Db. W. W. Simpson, Db. W. M. Paton Representative to B. C. Medical Association: Db. L. H. Leeson. Sickness and Benevolent Fund: The Pbesident—The Trustees. VITAMIN B ~- COMPLEX SYRUP If the diet is deficient in Vitamin Bx it is logical for the Physician to assume it is deficient in many of the other factors of the B-Complex. In treating: VOMITING IX PREGNANCY POLYNEURITIS ANOREXIA CHRONIC CONSTIPATION by prescribing Squibb Vitamin B-Complex Syrup the Physician assures his patient adequate amounts of Vitamin B1 and all the other recognized factors in the B-Complex. AVERAGE DOSE: 3 teaspoonfuls T.I.D. plain or mixed with milk, tomato juice or similar vehicle. Supplied in 3, 6 and 12-oz. bottles and 10-lb. containers. For literature and samples write: E-RiSqpibb & Sons of Canada, Ltd. MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858 Professional Service Depanrtment, 36 Caledonia Road, Toronto. VANCOUVER HEALTH DEPARTMENT STATISTICS, OCTOBER, 1939 Total population—estimated \ 263,974 Japanese population—estimated 8,891 Chinese population—estimated 7,728 Hindu population—estimated 389 Rate per 1,000 Number Population Deaths—residents only 207 9.2 Total deaths. 246 11.0 Japanese deaths 6 7.9 Chinese deaths 16 24.4 BIRTH REGISTRATIONS: Male, 177; Female, 191 , 368 16.4 INFANTILE MORTALITY: October, 1939 October, 1938 Deaths under one year of age 11 8 Death Rate—per 1,000 births. 29.9 20.6 Stillbirths (not included in above) 9 6 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY November 1st September, 1939 October, 1939 to 15th, 1939 Scarlet Fever 12 0 40 0 19 0 Diphtheria 2* 0 0 0 0 0 Chicken Pox 7 0 46 0 53 0 Measles 3 0 3 0 10 Rubella ! 10 0 0 2 0 Mumps 17 0 8 0 2 0 Whooping Cough 7 0 13 0 7 0 Typhoid Fever 0 0 0 0 0 0 Undulant Fever 0 0 0 0 0 0 Poliomyelitis Ij 0 0 0 0 0 0 Tuberculosis I 32 14 26 23 8 Erysipelas £*_ 2 0 3 0 2 0 Ep. Cerebrospinal Meningitis 0 0 0 0 0 0 * Carriers. V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH, DIVISION OF VENEREAL DISEASE CONTROL. West North Vancr. Hospitals, Burnaby Vancr. Richmond Vancr. Clinic Private Drs. Totals Syphilis 1 0 0 1 42 25 69 Gonorrhoea 1 0 0 0 75 38 114 .BIOGLAN THE SCIENTIFIC HORMONE TREATMENT Descriptive Literature on Request. A Product of the Bioglan Laboratories, Hertford, England. Represented by STANLEY N. BAYNE Phone: SEy. 4239 Page 53 1432 Medical-Dental Bldg. "Ask the doctor who is using it." Vancouver, B. C !SSgMKKJ-i?gSSf i? i m WHEN PROLONGED MOIST HEAT IS INDICATED IN THE LOCAL TREATMENT OF LUMBAGO • MUSCULAR RHEUMATISM OSTEO ARTHRITIS • RHEUMATOID ARTHRITIS I FIBROSITIS •PLEURODYNIA* it is best applied by means of Antiphlogistine, which maintains its heat for many hours without devitalizing or rendering the tissues sodden. It is an aid to improving the circulation through the parts, encouraging dissipation of the inflammatory deposits and reducing the pain. Modi e in Antiphlogistine Canada THE DENVER CHEMICAL MANUFACTURING COMPANY 153 Lagauchetiere St. W. MONTREAL VANCOUVER MEDICAL ASSOCIATION Founded 1898 :: Incorporated 1906 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. 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. 1939. Programme of the 42nd Annual Session October 3—General Meeting. Dr. Howard Spohn: "Some observations on Pediatric practice in Europe." October 17—Clinical Meeting. November 7—General Meeting. Dr. W. A. Dobson: "Diagnosis of early Schizophrenia." Dr. J. M. Jackson: "Treatment of early Schizophrenia." November 21—Clinical Meeting. December 5—General Meeting. Dr. A. E. Trites: "Treatment of functional Menstrual Disorders." December 19—Clinical Meeting. 1940 January 2—Dr. Earle Hall: "Urethral Discharge." January 16—Clinical Meeting. February 6—Dr. H. H Pitts: "Symposium on Laboratory Methods." February 20—Clinical Meeting. March 5—Osier Lecture. March 19—Clinical Meeting. April 2—Dr. H. H. Boucher: April 16—Clinical Meeting. April 23—Annual Meeting. Subject not yet chosen. The New Synthetic Antispasmodic Trasentin "Ciba" (Diphenylacetyldiethylaminoethanolester-hydrochloride) SUPPRESSES SPASMS OF THE GASTRO-INTESTINAL TRACT, GENITO-URINARY SYSTEM AND OTHER SMOOTH MUSCLE ORGANS Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20. 1 tablet or 1 ampoule contains 0.075 grm. of the active substance. CIBA COMPANY LIMITED MONTREAL Page 54 HYPOBYN E.B.S. Each fluid ounce contains: Calcium Hypophosphite 12 grs. Sodium Hypophosphite | 8 grs. Iron Hypophosphite 2 grs. Manganese Hypophosphite ....... i gr. Potassium Hypophosphite ....... 1 gr. Quinine Hypophosphite J4 gr. Strychnine Hypophosphite 1/16 gr. With Vitamin A—4900 int. units Vitamin D— 800 int. units Malt 25% An excellent reconstructive and nutritive tonic. Dose—One-half to two fluid drachms. CCT. No. 466 MINEROVITE E.B.S. Each tablet contains: 1500 international units of Vitamin A 60 international units of Vitamin B i 35 micrograms Vitamin Ba 200 international units of Vitamin C 400 international units of Vitamin D 20 units Vitamin K 5 mgm. Nicotinic Acid and Vitamin E, combined with salts of the following mineral elements: Iron, manganese, copper, calcium and phosphorus. Dose—Three or four tablets daily. CT. No. 501 NEUROVIT E.B.S. Each tablet contains: 50 international units of Vitamin Bi 0.1 mgm. Nicotinic Acid 0.001 mgm. Riboflavin Vitamin Bi is the antineuritic vitamin. Nicotinic Acid is a preventive and corrective of subclinical pellagra, and Riboflavin is essential to carbohydrate metabolism and muscle tonicity. Dose—One tablet three times a day. THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED TORONTO MANUFACTURING CHEMISTS CANADA 3g& STOCKS CARRIED AT WINNIPEG, MAN.—CAMPBELL HYMAN LTD. VANCOUVER. B. C—J. P. SOUTHCOTT & CO. LTD. SPECIFY E. B. S. ON YOUR PRESCRIPTIONS . . | ..'JaMBHMHMH THE EDITOR'S PAGE In the first place, may we wish all our readers a Merry Christmas and all that goes with it. It is not, perhaps, as easy this year to present an unruffled and serene exterior to the world as it has been at other times—but it is even more necessary. The Scotch, speaking in that remarkable dialect of theirs, have a phrase that seems to us especially apt at this juncture: "A stoot hert hae a stey brae." While it does seem remarkable that anyone should talk like that, if they don't have to, nevertheless the meaning of the phrase is clear, and the courage and sound philosophy of it are appealing, just now more than ever. We can have no real cause for fear or doubt. The eternal verities cannot be changed or overthrown—honour, good faith, freedom to think and say and do the things one's conscience demands of one, cannot perish from the earth. But they can only be had at a price, and We seem, as a race, to have been in some danger of forgetting this. They are not ours by inherent right, and we have allowed the bill to accumulate over long and become over large, so that it is rather an appallingly large one. But who can doubt that we shall pay it in full, and recapture for the world some real security andl decency and right to be free? So, though "the foundations of the world" seem to be "cast down," we can face the future calmly and courageously, secure in the knowledge that the right must and will prevail, as it has always done in the end—and this need not be at all a gloomy season, even if it cannot be a carefree one. The response to the questionnare sent out by the Provincial Advisory Committee has been very good indeed, more than 650 cards having been returned, but there are still many men to hear from. There can be no good reason, that we can think of, why any man should hesitate to send these in: all information is confidential, there is no obligation imposed or sought to be imposed on any person, and it is merely an effort to secure an accurate composite picture of our resources and capabilities as a profession, to meet the national emergency, as and when occasion arises. As we pointed out last month, it is rather more than this: it is an opportunity given to us to show our sincerity and good faith. We constantly claim, as a profession, the right to speak for5 ourselves, to be consulted, to determine our own future and destiny. But, in the words of Thomas a Kempis, "no man is fit to govern others unless he hath first learned to obey," and we cannot logically expect governments and bodies of authority to trust us unreservedly, and commit to our control matters of vital national importance, until and unless we can show that we can safely be so trusted. There are some few who seem to think; it beneath their dignity to fill out this card; there are others who, apparently, are loath to confide in others to the extent of giving the information asked for; there are yet others who do not want to play, and will not come in with the rest of us. Tq all such, we address a request to reconsider, and see whether they cannot alter their minds. There must, in any social organization, be always compromise, give-and-take, and no one person or individual can ever hope, nor has he the right to demand, that he be allowed always to have things his own way—no matter how right he thinks that way to be. Now, more than ever, unity and harmony are essential—and we feel it only fair to say that they exist in far greater measure than ever before in our history. More and more we are learning to pull together, and act as a unit. The few jarring notes that are occasionally struck do not alter this inherent soundness of construction and unity of organization. We are learning, slowly, but surely, in the words of Kipling, that prince of phrase-makers, that rtThe game is more than the players of the game And the ship is more than the crew." Au revoir! Merry Christmas! Page J 5 ' NEWS AND NOTES Dr. W. K. Massey of Ashcroft has been appointed Medical Health Officer for Ashcroft and District and School Health Inspector, replacing Dr. C. A. Drummond, who resigned owing to ill health. Dr. N. J. Ball of Oliver has been on a hunting trip—it's great to live where the birds are. Dr. F. P. McNamee of Kamloops was a visitor in Penticton and attended the Gyro Installation and Ball. Sf* Sf> *'- 3|a Dr. F. W. Andrew of Summerland has been on holiday. Dr. H. McGregor of Penticton, as President of No. 4 District Medical Association, attended the meeting of the Board of Directors of the British Columbia Medical Association in Vancouver. Dr. B. J. Harrison and his son Jack motored through the Okanagan recently. Dr. W. E. M. Mitchell of Victoria has arrived in England, where he hopes to join the R. A. M C. as a surgeon specialist. *5. *t *t *t n> *r »s* *r Lieutenant-Colonels Gordon Kenning, Thomas McPherson and J. A. Stewart; Majors W. A. Fraser, R. L. Miller, Thomas Miller and C. A. Watson, and Captains Lloyd Bassett, M. R. Caverhill, J. S. McCannell and R. Scott-Moncrieff are among those who have already entered service with the Royal Canadian Army Medical Corps at Victoria. Dr. Everett F. Raynor, who was well-known at the Vancouver General Hospital as an interne during several years, where he latterly majored in the specialty of Eye, Ear, Nose and Throat, after doing two years' special post-graduate work in New York has returned to British Columbia, and is now associated in practice with Dr. M. J. Keys of Victoria. Dr. A. S. Underhill has been elected President of the Kelowna Gyro Club for the coming year. We offer congratulations to Dr. Neil Duncan Clyde MacKinnon of Trail upon his marriage to Miss Jean Robson Gourley of Toronto. The weldding took place on November 4th in Cranbrook. Dr. and Mrs. N. M. Morrison of Nelson paid a visit to Greenwood. *t A sfc sf» Dr. George More of Shawnigan Lake has taken over the offices of Dr. J. U. Coleman of Duncan during the latter's absence on military duties. *K. at at a% Dr. H. F. Tyerman of Nakusp is leaving for his vacation in the Sunny South. * s:- * # Dr. E. C. Hart of Victoria called at the office during a visit to Vancouver. Major R. L. Miller was in Vancouver in connection with Medical Boards. Dr. Walter J. Elliot is ship surgeon on the Empress of Canada. Page 56 Dr. R. R. Laird is on the Empress of Russia. Dr. and Mrs. H Burris of Kamloops and their two sonst visited the Cariboo, staying at Quesnel, Wells and Prince George, at which latter point Dr. Burris visited the local doctors and the Hospital. Dr. and Mrs. E. D. Emery of Nanaimo motored to San Francisco for a short holiday. We are glad to learn that Dr. G. A. B. Hall of Nanaimo is showing improvement following a serious attack of influenza. The North Pacific Surgical Society met in Victoria on the 17th and 18 th of November. Vancouver members of the society who attended Were: Drs. Pedlow, McLennan, Brodie, Riggs, R. E. McKechnie, G. E. Gillies, Schinbein, Lennie, H. H. Boucher, A. J. MacLachlan, Lee Smith, W. S. Turnbull and J. R. Neilson. DR. THOMAS CURTIN Died November 9, 1939. In the recent death of Dr. Thos. Curtin, at a comparatively early age, the Vancouver medical profession has lost a picturesque figure, as well as a most popular and well-liked colleague. "Jerry" Curtin, as he was called by everyone who had known him for an hour or two (we always feel that this immediate adoption of the first name, especially when it is in the nature of a nickname, is evidence of a more than normally friendly and lovable personality), had been a familiar figure round St. Paul's Hospital for a long time: first as an interne and anaesthetist, the latter for many years; later as member of the visiting staff of the hospital. We all liked him, and liked to sit down and have a chat with him. Somewhat rough and ready in his ways, he was nevertheless very competent in the things he undertook. He was fond of sport, keenly interested in athletics, and very much addicted to attending wrestling matches andi boxing exhibitions, and he even backed a horse occasionally. He enjoyed living, and his friendliness and kindly personality contributed to the enjoyment and happiness of others. COMMON PROCEDURES IN PEDIATRICS By Alan Brown, M.D., and Frederick Tisdall, M.D., Hospital for Sick Children, Toronto. This is undoubtedly a book that every general practitioner of medicine will welcome and use constantly. It is not a text-book on diseases of children, but, as its title shows, a guide to the diagnosis and handling of these. It points the way to the solution and understanding of the innumerable problems that the child presents to the family physician, and gives short, but full, directions for his guidance. The names of the authors are guarantees of the sterling quality of the material contained in the book. They have deemed nothing too small or unimportant to include in their list of ailments and problems of childhood. Thus infant feeding receives minute attention, the care of the bowels, the treatment of intestinal parasites, the care of burns, questions of immunization against infectious disease, all these and many other details are fully investigated and described. Laboratory procedures, bedside nursing, the preparation of foods, all receive careful attention. Two excellent chapters on behaviour problems, and difficulties in diagnosis, are especially worthy of mention. Directions as to various procedures are short, concise, but clear and simple, to follow. Altogether, this book is a vade mecum which each of us would do well to have within constant reach. —J. H. M. Page 57 ancouver ca Association EARLY DIAGNOSIS OF SCHIZOPHRENIA William A. Dobson, M.D. "Schizophrenia" was suggested by Bleuler about a quarter of a century ago as a more logical term to cover those mental abnormalities commonly known as Dementia Praecox. The older term implies a dementia that is not always apparent, and a period of life, the precocious years, which may be equally misleading. "Schizophrenia," meaning a splitting of the mind, is descriptive of the condition and is applicable to any age, and it is well known that this morbid mental disorder may present itself in the later, as well as in the earlier, years of life. Schizophrenia has aroused much interest all through the ages, but until more recent years it has constituted a diagnosis that we all tried to postpone as long as possible, because so little by way of active treatment was at our command for those cases. Institutional care, to safeguard the patient from endangering himself and others, general medical <atten- tion and occupational therapy, covered the treatment in a large majority of cases. A diagnosis of dementia prascox usually carried with it a prognosis as hopeless as that in advanced carcinoma. Strecker, in his "Clinical Psychiatry," states that of the 250,000 patients in mental hospitals in the United States 40% are cases of dementia praecox anctj that out of 50,000 new yearly admissions 25% are diagnosed dementia praecox. Because of our attitude towards Schizophrenia in the past, the disease probably enjoys a worse reputation than it deserves. Statistics have been based on those serious cases that required certification; the milder ones that recovered were undiagnosed as such, or placed in a category more acceptable than dementia praecox, which has carried with it a picture of almost utter hopelessness. In.many chests we find the scars of undiagnosed and unsuspected tuberculosis, and so in many minds, if correct histories could be obtained, we should find much evidence of old schizoid assaults, with recovery, that would create a trend towards a more hopeful view of this disease. The number of "cures" would be so increased that the percentage of favourable results would swing into higher figures. It is because of that picture we have, been inclined, in the past, to cMay the diagnosis as long as possible. Recent developments in treatment, however, have offered so much promise, for cure, improvement or even the halting of the disease, that a recognition of early features is being urged and that a cautious study of the individual be made. I suggest "cautious" advisedly, for so much harm could be caused by paying1 undue attention to idiosyncrasies that might occur in a sensitive youth, who, because of benign episodes, was to become the object of too much sheltering and a consequent victim of introspection and a possible and unnecessary neurotic future. What is schizophrenia? Mapother, of Maudsley Hospital, presents the answer concisely in the following quotation: "Logical thought, appropriate feeling, and expedient action are dependent on a conscious synthesis of present impressions, past experience and future aims. The synthesis must be comprehensive and also selective. In schizophrenia there is a reduction of the tendency to such comprehensive and selective synthesis. Association tends to be unduly determined by isolated and superficial rather than by numerous and complex associations. The transient emotion, of any kind, aroused by some passing event provokes disproportionate response, or the influence of one remote episode of an emotional character may affect the reactions of the present with abnormal frequency and intensity. The most characteristic feature of all is the 'splitting of the mind'—the occurrence of mental processes which are not connected by conscious links, with the rest of the patient's thoughts and actions." Page 58 It has been said that the connecting link between different cases of schizophrenia consists In the very disconnection of mental processes observable in all. There is a disjointed quality with regard to thoughts, feeling and action—there is absence of correlation between these. Causes of Schizophrenia. The apparent success of present-rday treatment makes one hesitate to discuss etiological factors. Much has been said and written from different angles, but the causes are not yet, by any means, clear. Early symptoms that should give rise to careful consideration. Dr. Ewen Cameron, in the American Journal of Psychiatry, November, 1938, reported on 100 first admissions to Worcester State Hospital as follows: Of these, 50 were discharged as recovered or in social remission at the end of the first year; 50 were still in hospital at the end of the second yelar. Early manifestations in adolescents and adults. Earliest non-specific symptoms. Antedating the clinically recognizable symptoms there is a group of behaviour changes which we refer to as non-specific—they can, it is obvious, be found preceding disorders other than schizophrenia. Elements of a hyperactive pattern: Nervousness (restless and tense), sleeplessness, worried (uneasy and apprehensive), nightmares, hypochondriasis, somatic complaints, moodiness, impatience, tantrums, fault finding, moralizing. Hypoactive pattern'. Seclusiveness (withdrawn, quiet), daydreaming, preoccupation, loss of friends, irritability, loss of interest (of ambition), depression, lack of energy (slump in work), lack of concentration, fatigue, poor appetite. Many of these symptoms occur in normal children, and grownups should approach them with a measure of restraint, but when there is persistence or when many features are present it is well that advice be sought. Too often it is that patients are brought to the doctor, not because of troublesome behaviour but because the behaviour has become so troublesome that management at home is no longer possible. Those early reactions may be noted in the schoolroom, the playground or in the home, and it is then, when adjustment is first beginning to be an effort, that pretention of a possible breakdown of the youthful forces should be given careful and studied attention. These non-specific symptoms may be present for weeks or years and are usually noted only in introspection. Early specific symptoms.—Less varied than non-specific symptoms. Two groups: First major group (largely ideational in nature): Fears of being watched, fears of being talked about; that those around them are unfriendly; fear of poison, of dope, of violence; ideas of guilt and disgrace and a vindication with identification with the Deity; hallucinations. Second group—Symptoms indicative of abnormal somatic experience: Dazed, dizzy; confused; organs not right; environment has lost its feeling of familiarity; abnormal somatic responses; giggling spells; tantrums; impulsiveness; refusal to co-operate (eating, speaking, acting). Detection and Early Hospitalization. In physical illness the patient himself recognizes early warnings, but that insight is not often found in mental diseases. Friends and relatives, it was thought, might be educated to early recognition of signs, etc., and they would take action. They do recognize, but they do not take action. They are unwilling to send their relatives to hospital until an emergency occurs and they send the patient to hospital then, not because he is mentally ill, but because he is unmanageable. The pattern in schizophrenia is fairly well developed when we recognize: Loss of interest, of affection, of ambition; tendency to phantasy; morbid religiosity, ecstasies; pondering over philosophic problems, without serious attempts at study; dabbling in mysticism and spiritualism; unproductive absorption in art, music, poetry; loss of moral control. Page 59 It is when those reactions are first apparent that so much help can be afforded by employment of the "shock treatments" that have been showing rather amazing results throughout the world. Something has been accomplished in our approach to a successful attack on that disease that was hitherto considered so hopeless, so chronic and progressive. A great deal yet has to be learned, but it does seem that we are on the threshold of something more constructive than the most optimistic would have dared dream of in other years. THE SCHIZOPHRENIC PROBLEM AND SOME RECENT ADVANCES IN THE WAR AGAINST IT By Dr. J. M. Jackson Provincial Mental Hospital, Essondale, B. C. The medical, economic and sociologic problem of the treatment and care of this group of mental patients is more staggering than most of us know. In Canada there are in hospital over 12,400 patients so classified. The annual cost to the community at $1.00 per day is $4,402,000.00. New cases annually increase this burden by $238,560.00. Of all the hospital beds in Canada—general, tuberculosis, sanatoria, mental hospitals, etc.—one bed in every five is occupied by a schizophrenic. New cases of schizophrenia make up 2 3 % of total admissions each year to mental hospitals. The morbidity is so great, however, that re-admissions added to these account for 50% of the annual increase in population. The average hospitalization of these patients ultimately discharged is, in Canada, 2.02 years. The average cost to the state in this case is $900.00. The average stay of the patient who dies in the hospital is 12.2 years and the cost $4,260.00. Deutsch, in his "Mentally 111 in America," states that the recovery rate in 1924 was only 6%. The above figures give some idea of the staggering economic burden of this type of illness. I wish it were in my power to picture as graphically the cost in human misery. The sufferers are almost entirely young men and women at the beginning of their careers. The progress of the disease is often so slow as to go unrecognized for years, for this reason proving to be a positive menace to the mental health of those well people who have to live with them. There is no other disease afflicting man that is so diabolical. It doeis noti shorten life, and owing to their sheltered existence5 these people live longer than they otherwise might. Many hospitals in Canada, fifty or sixty years old, are still caring for some of the original patients of this type. In view of the magnitude of the* problem, woefully little has been spent on research. The profession and laymen alike have come to look at it as hopeless. There are, however, certain features which cause one to disagree with this attitude. The clinical course is often a slow one, interrupted by remissions; in acute stages, remissions for a few hours or days demonstrate that the patient still retains, undamaged, the mechanism for normal thinking, if the disease process could be terminated. We occasionally see a dramatic clearing of this mental fog just before death, in very old cases. The names schizophrenia and dementia praecox are necessarily only descriptive, because the cause of the disorder is not known. Certain forms of treatment have been found to bring about remissions of varying duration, the most successful of which have many features in common with hypoglycaemic shock therapy. Researches in the fields of pathology, psychopathology and genetics have as yet failed to demonstrate a clear cause, nor have they found any reason for discouragement. An empirical therapy recently developed has given more practical and spectacular results than any so far devised. The hope of those using it is that from this tangible beginning research may work back to the cause, as has been the case in medical history of other conditions. Page 60 As far back as 1926, and in the intervening years, insulin was used in the treatment of psychotic patients with the object of improving their appetite, but always combined with the administration of food soon after injection. Hypoglycaemic coma was observed, but feared and never deliberately induced. Several writers, when reporting good results in cases of malnutrition, also mentioned transitory improvement in the mental health of their patient, but no one followed up this lead. Dr. Manfred Sakel, of the University Clinic in Vienna, was the first to introduce hypoglycaemic shock as a therapeutic principle. He devised a relatively safe procedure for its management, and was the first to elaborate a successful method of treatment on that basis. In 1928 Dr. Sakel was working with morphine addiction, and searching for some new treatment to allay the withdrawal symptoms which are so troublesome. He found that such cases constantly showed an abnormally high adrenalin output. It was previously known that insulin and adrenalin had a neutralizing or antagonistic effect upon one aother. On this premise he began the administration of insulin. The experiment proved encouraging and was persisted in. Many of these patients showed mental abnormality as well, and Sakel was quick to note improvement in these symptoms also. Due to the wide variation in the individual tolerance to high doses of insulin, some of these patients went into coma, and an even more striking improvement was noted in the mental condition following. Sakel, unlike his predecessors, and without knowledge of their previous reports, followed up this lead and began to experiment with frank psychotic cases of the most stubborn and hopeless variety—namely, schizophrenics. He worked carefully, and elaborated a relatively safe technique, for the management of a deliberately induced hypoglycaemic shock, and after five years' work he first reported his method in November, 1933. He called it "A New Treatment for Schizophrenia," and since that time its use has. spread rapidly, until it is being carried out in practically all of the so-called civilized countries of the world. Early in 1936 Cameron and Hoskins, at Worcester State Hospital in Massachusetts, treated the first case on this continent. During the same year several workers in the east also started to use the method, and the Mental Hygiene Commission of New York State decided to give it a trial in some eighteen of their State Hospitals. Dr. Sakel came to America, and later personally conducted a course of instruction in his technique at Harlem Valley State Hospital, New York. The Hospital and State Commission kindly extended an invitation to men in United States and Canada to come there for training during 1937. There is as yet no proven theory of how hypoglycaemic coma produces its striking therapeutic effect on schizophrenia. The technique is therefore woefully devoid of hard and fast rules, and must be based on judgment gained by experience. The conduct is therefore much more an art than a science at the present time. The so-called "therapeutic" shocks take one of two forms: (1) Coma of varying depth, with, as a rule, profuse sweating; (2) epileptiform seizures. Within these two general groups there is an infinite variety of reaction in each individual. The coma-producing dose of insulin has to be established for each patient by trial. We usually begin with 20 units, given intramuscularly at 7 a.m. to a fasting patient. He is allowed to remain without food for about four hours, and is then given simple syrup with orange juice to drink. About one to one and a half gm. of sugar for each unit of insulin is given. This dose is as a rule increased by ten units daily until the coma dose is established. This may take anywhere from a few days to two weeks. During this period the patient usually shows drowsiness for the first hour followed by restlessness, with occasionally acute activity and shouting, as one sees in a delirium. After a day or so, most patients perspire freely during the morning. Many patients, during this first stage, show considerable change mentally. They become more approachable and friendly, and appear less worried, and more cheerful. Often the mute patient begins to hold conversation, especially just after he has drunk the sugar solution. When a comt dose is reached it is repeated each day, six days a week, so long as the reaction each day is satisfactory. Fairly deep coma with sweating is the most generally desirable reaction. Page 61 Coma is a rather difficult state to define, but for our purpose we think of a patient who is not responsive to external stimulation as being in coma. He may have his eyes open and appear to be awake. A second look, however, will tell one that he does not see, and has lost the power to fix his gaze. In a moderate coma, the pupils often appear to be floating from side to side as the eyeballs rotate laterally. Clonic switchings and jerkings of the muscles, particularly of the face and limbs, are common. These sometimes last ten or twenty minutes, and then subside into a quiet deep coma. Sometimes, without warning, a major epileptiform seizure may develop. This reaction seems to have an exceptionally beneficial effect in certain cases. Seizures, especially when occurring late in the morning, are looked upon by Sakel as an indication for rapid interruption of coma by intravenous glucose injection. Ordinarily, the coma is interrupted by nasal feeding of simple syrup, which requires about 20 to 30 rninutes for the patient to become responsive. One has personally seen nothing more dramatic in medical experience than the response of a hypoglycaemic patient to the administration of sugar. This is especially true when glucose is given intravenously. A patient may be in deep coma, with loss of reflexes, or with a spasm of the larynx, and in a matter of a few seconds, often before one has time to inject rapidly more than 100 cc, he will regain control of his facial expression and speech, and in response to questioning will say he is feeling fine. During the hypoglycaemic period, from injection until after the patient wakes up and is able to take a meal, he must be critically watched at all times by the physician in charge. No two patients react exactly alike, and a slightly different technique is required for each. This also may have to be changed from time to time during the course of treatment. It is obviously putting a considerable strain on the human body to subject it deliberately to such physiological insults over a considerable period of time. Fortunately most schizophrenics are young. They must be carefully examined before treatment for any pathology in cardiovascular, pulmonary and renal systems. Plates of the chest are taken and blood sugar and N.P.N, tests are done. Cases with abnormality of these systems, or current infection, are not subjected to treatment. Another important requirement is accessible veins, as the sheet anchor in case of emergency is the injection of intravenous glucose. These requirements all have to be met before it can be considered safe to administer the treatment. Using present methods, it is the unanimous opinion of workers in America and Europe that treatment must be instituted early in the course of the disease. It is felt that 60% to 80% of cases treated in the first year respond Veil. Many of those cases who do not become well are, nevertheless, improved to such an extent that the nursing problem becomes very much lighter. Even though they are physically normal, and are apparently good subjects for treatment, some cases show signs of cardiac failure on doses of insulin, and depth of coma short of the optimum. In such instances, one has to work carefully, stopping short of dangerous reactions, and hoping that some benefit may be derived. Other individuals seem to have a peculiar resistance to insulin, or to the process by which coma is produced. Some of these will not go into satisfactory coma on doses as high as 200 units and more daily. Others may have an optimum reaction on as little as 10 to 20 units. A treatment ward with capacity of twenty patients was opened at our hospital in December, 1937. It has accommodation for ten male and ten female patients. The time required varies from 30 to 100 treatment days, that is, exclusive of rest days. Very careful and efficient nursing is imperative. Ordinarily one nurse to two patients is about adequate; with a picked and experienced staff one to about 3 or 3 l/z can be managed. Usually one doctor should not try to manage more than about ten patients, but here again a high quality of staff assistance and adequte experience makes it possible to handle more. It must be emphasized that from 8 a.m. until all patients are up and around again, each patient must be constantly watched by both nurses and doctor. It may be likened to having twenty patients under general anaesthesia, which is slowly progressing in depth. Unlike any anaesthetic case, however, each requires something positive to be done in order Page 62 that he may wake up. The decision as to the best time to interrupt the coma is based on experience with other cases, and the previous reactions of the patient in hand. Except late in the course of treatment, most patients are at their best just after they have been roused from coma. The asocial ones become friendly and interested. Those who are hallucinatory admit the fact, and appear to be temporarily free from these hallucinations. This well period lasts for a varying length of time during the afternoon. It is often noted that this period becomes a little longer each day, until it finally carries through the whole twenty-four hours. Some patients, when they are becoming well, seem to reverse this order, and show their psychotic behaviour only in what might be termed the drunken period, just after interruption of hypoglycaemia. Some of what might be called the by-products of this treatment are fortuitous. The effect on general nutrition is probably the most fortunate. Practically all patients gain weight early in the course of treatment. Some gain very rapidly. They usually have an abnormal appetite, due to'insulin, which makes it easy to see that they get adequate starches, to guard against secondary shock later in the day. With this gain in weight the general health improves. The patient sees himself looking better, and this has a profound psychological effect, even before he has gained insight into his mental illness. Another fortunate thing is the amnesia for most of the period of treatment each day. Events occurring before he lapses into into coma, until he is almost awake, are not recalled to memory. One is convinced that from the early days of treatment onward, most patients feel a decided satisfaction from the treatment. Very few patients protest against it except on the first few days. Those who appear to have trying experiences during the awakening period often say it is terrible, but worth it, and do not complain. In the majority of cases improvement is evident before thirty days. Some, however, have not begun to clear till after sixty days or more. If any improvement is note, one continues treatment so long as it is progressive. As mentioned earlier, epileptiform seizures are not infrequent during hypoglycaemic coma. In certain instances these episodes are of profound benefit. It has been our own observation that those patient least prone to seizures during their course often derive most benefit from one when it happens. Seizures cannot be induced! at will with insulin. When it is felt that this reaction would be a benefit, we indued a seizure during light coma' by the method of Meduna. This is accomplished by the rapid intravenous injection of metra- zol. This compound is a cardio-respiratory stimulant, but a convulsant in high dosage. It is found that the dosage of this compound required during hypoglycaemia is much lower than otherwise. Many patients complain of a terrifying aura just before a metrazol-induced convulsion. When used in conjunction with hypoglycaemia, the patient is spared this experience. Except for its use combined with insulin I have had no personal experience with Von Meduna's treatment. It consists simply in a series of induced convulsions, at two or three-day intervals. It is reported to give good results in early cases, and one is forced to think that, whatever the essential action is, it must have a lot in common with hypoglycaemic shock. One feature of hypoglycaemic therapy, however, is its flexibility. The technique is capable of almost infinite variation, to suit the problem presented. This latitude is not possible with metrazol. On its side, the convulsant therapy has simplicity. It requires little time, not a big staff, and little equipment. For this reason it is possible to carry it out in the psychopathic ward of the general hospital, or nursing home: this is hardly practicable in the case of hypoglycaemic therapy. The theories as to the mechanism of improvement from either of these treatment methods are many. At least eleven have been offered, but as yet none is capable of proof. The biggest single factor in prognosis is the duration of the illness prior to treatment. If given within the first six months, good recovery can be expected in about 80% of cases. The material that we, at a provincial hospital, have to work with is relatively chronic, averaging two to three years' duration, even in our group selected for treatment with insulin. Our own experience is that half of the patients treated may be discharged as apparently well, and resume their former place in society; while an additional 15% are improved Page 63 enough for parole to their families, and} some of these continue to improve after leaving the hospital. Of the former group we have sixty who have been out of hospital for varying periods up to two years, with only four relapsing. The ultimate durability of the cure, only time will tell. The treatment as now conducted is empirical. We apply it because it benefits a relatively high percentage of cases. It is our hope that it may be a beginning: that as more is learned about its action new vistas of research may be opened up, and so give some clue to the etiology of this terrible disability. It is not universal in its application to schizophrenics, and is not a 100% panacea for mental illness. It has been dramatized by all the newspapers and magazines, because it lends itself to the art of the feature writer. Much more time is required before the final verdict, but we at least seem to be on a promising lead. It is a stimulating xperience to be able to work hard and see at least some patients react in an almost miraculous manner. The best results are obtained in early cases, and especially those in which the onset is acute and dramatic. It usually follows that such cases have been fairly well adjusted before the illness, and therefore have something to come back to. The best we can hope for from any therapy is a return to the pre-psychotic level. Nothing can make a man into what he never was. A jeweller cannot make a Waltham out of an Ingersoll. Discussion Dr. Geo. A. Davidson opened the discussion, congratulated both speakers on the papers presented, and remarked that he was glad to know that the Medical Society was prepared to give an evening to the discussion of Mental Disorders. He stressed particularly the question of making a diagnosis of schizophrenia early in childhood, and felt that every medical man should be f amiliar with those things that may lead to schizophrenia. He said that Williams had remarked that for ten to fifteen years before the actual breakdown occurred there were features that might be regarded as danger signals. In discussing the early treatment, he felt that metrazol shock had much to offer. While the reports in the literature give more favorable results with insulin shock, he felt that an early case was definitely benefited by metrazol shock. In considering all types treated, and not only schizophrenia, it was felt that the percentage of good' results in the early cases was high. He pointed out that he was aware of the danger reported from metrazol, but stated that in his own cases he had had no bad results, although he had given some seven hundred treatments. He did not feel that the dangers were serious enough to withhold this type of treatment. Dr. Ernest Campbell, of the Provincial Mental Hospital staff, spoke of the use of metrazol in patients with more chronic types of disorder. In his experience, he said, he felt that there was definite improvement in about 40% of cases. He thought that many patients who had had disorders for years showed much more interest in their surroundings, looked after themselves better, were tidier, and much more useful than they had been before receiving metrazol shock. Dr. S. E. C. Turvey stated that he was very favourably impressed with the use of metrazol in early cases, and felt that a large number of his cases had benefited markedly. He said that he had discussed the question of fractures with Dr. Alexander Gibson, Professor of Orthopaedics at the University of Manitoba, and that Dr. Gibson felt that there was no contra-indication to the use of metrazol because of the type of fracture that had been reported. These fractures are practically all in the upper thoracic region, and involve the bodies of the vertebrae. The number of cases of compression of the spinal cord recorded is extremely small. He congratulated the speakers on the excellence of their presentations. Dr. Jackson, in reply, thanked the members for their attention. He stated that he was gratified to know that the profession was interested enough to devote so much time to the discussion of such a problem. He stated that he had not used metrazol, except in conjunction with insulin shock, and that most of his experience was with the insulin; shock treatment. He agreed that although they had one fractured, vertebra, this was not sufficient reason for discontinuing the use of metrazol. Page 64 British Columbia Medical Association (Canadian Medical Association, British Columbia Division) President _ Dr. F. M. Auld, Nelson First Vice-President Dr. E. Murray Blair, Vancouver Second Vice-President Dr. C. H. Hankinson, Prince Rupert Honorary Secretary-Treasurer Dr. A. H. Spohn, Vancouver Immediate Past President Dr. D. E. H. Cleveland, Vancouver Executive Secretary Dr. M. W. Thomas, Vancouver The Board of Directors of the British Columbia Medical Association held its regular meeting following dinner at the Hotel Georgia on November 8th, 1939. Those present included the following members from throughout the Province: Dr. Fred M. Auld, President, of Nelson; Doctors Stewart "A. Wallace of Kamloops, C. T. Hilton of Port Alberni, Herbert McGregor of Penticton, W. Allan Fraser and P. A. Clyde Cousland of Victoria, William A. Clarke of New Westminster and R. V. McCarley of North Vancouver. The local members included: Dr. E. Murray Blair, Chairman of the Board of Directors; Doctors William E. Ainley, Lyon H. Appleby, Murray McC. Baird, Donald E. H. Cleveland, Anson C. Frost, Lavell H. Leeson, John H. MacDermot, Harry H. Milburn, George F. Strong, Walter S. Turnbull, Charles H. Vrooman, A. Howard Spohn, Honorary Secretary, and M. W. Thomas, Executive Secretary. Re Survey:—At this date 695 completed cards are returned to the Canadian Medical Association. British Columbia is rapidly reaching the 100% response to this questionnaire. Cancer Councils—Dr. Murray Blair reported that the newly formed Cancer Council had met and was planning its approach to the whole question of cancer in British Columbia. Four representatives have been appointed from each of the three groups interested in the various phases of the problem: The British Columbia Branch of the Canadian Society for the Control of Cancer, the British Columbia Cancer Foundation and the British Columbia Medical Association. The representatives from the British Columbia Medical Association are: Dr. Murray Blair, Chairman of the Board of Directors; Captain Roy Huggard, Chairman of the 0>mmittee on the Study of Cancer; Major W. Allan Fraser of Victoria, and Dr. George T. Wilson of New Westminster. ANNUAL MEETING OF No. 4 DISTRICT MEDICAL ASSOCIATION The Annual Meeting of District No. 4 Medical Association was held in Kamloops, at the Plaza Hotel, on Thursday, October 5th, 1939. The meeting consisted of afternoon and evening sessions, with dinner intervening. Several papers were read. Dr. D. E. H. Cleveland, dermatologist, of Vancouver, gave two papers, one entitled: "Applications Used in the Treatment of Diseases of the Skin," and the other, "Allergic Skin Diseases." Dr. S. A. McFetridge of the Provincial Board of Health, Division of Venereal Disease Control, of Vancouver, addressed the meeting on "Gonorrhoea in the Female." Dr. Gibbons, of the Dominion Department of Health at Kamloops, gave a short talk on two items of interest from the entomological point of view, namely, "The Discovery of the Organism of Rocky Mountain Spotted Fever in the Ticks in the Kelowna District" and "The Organism of Bubonic Plague among the Rodents of Alberta." Dr. A. H. Jones, Assistant Superintendent of Tranquille Sanatorium, gave an address on "Collapse Therapy of Pulmonary Tuberculosis," illustrated with radiographs. Dr. M. W. Thomas of Vancouver spoke to the meeting on matters of interest to the profession of the Province generally, emphasizing the good response to the questionnaire Page 65 on willingness to enroll for military service which had just been circulated. He noted the .increasing interest in medical meetings sponsored by the British Columbia Medical Association. He said it was pleasing to see the passing of the individualist and the increasing tendency of the profession to act co-operatively. He expressed his regret that two of the speakers originally announced as coming had been unable to attend owing to last-minute complications. He made a plea for more news items for the Bulletin. It was decided to hold the next meeting in Penticton, according to the usual rotation. The following officers were duly elected for the year 1940: President, Dr. H. McGregor (Sr.); Secretary-Treasurer, Dr. J. R. Parmley; reporter to Bulletin, Dr. Parmley; both of Penticton; Representative to the Board of Directors of the British Columbia Medical Association, D. W. J. Knox of Kelowna. The secretary was instructed to write letters of sympathy to the widows of the two members of the District Association who had died during the year, Dr. Stuart Beech of Salmon Arm and Dr. G. A. Ootmar. J. A. Ireland, Secretary-Treasurer. THE BRITISH COLUMBIA CANCER INSTITUTE 685 West 11th Avenue, Vancouver, B. C. A Summary of the First Year of Operation. November 7, 193 8, to November 7, 1939. By A. Maxwell Evans, M.D., Medical Superintendent. [We believe that our readers will be greatly interested in the following summary of the first year's work of the B. C Cancer Institute. Certain facts are of especial interest. Thus 176 indigent patients received accurate, scientific care. This alone justifies the existence of the Institute. There is for the first time in British Columbia an opportunity for accurate recording and observation of the effects of treatment. This cannot but be of value. We are very glad to publish the report.—Ed.] The British Columbia Cancer Foundation was formed on June 15, 1935, through the initiative of the B. C. Medical Association, the Vancouver Board of Trade and the Greater Vancouver Health League. The primary object of this organization was to increase the facuities for the diagnosis and treatment of those patients suffering from cancer who were unable to pay for treatment. The first step in the programme was undertaken in March, 1936, when 3 l/z grams of radium were purchased with the backing of the Government of the Province of British Columbia. In May, 1938, a public-spirited anonymous donor gave $50,000 to the Cancer Foundation for the setting up of an Institute where patients could receive radium treatment. Since that time, large donations have been received from the Lions Gate Riding and Polo Club and the Rotary Club. With the generous assistance of the Vancouver General Hospital, which now provides various essential services free, the Board of Directors were able to obtain a house at 685 West 11th Avenue, to serve the purpose of an Institute. One gram of the 3 J4 grams of radium was sent to Belgium for processing, to provide radium needles and tubes of the type used in radium work. His Honour the Lieutenant-Governor officially opened the British Columbia Cancer Institute on November 5, 1938, and the first patient was admitted to the Clinic on November 7, 193 8. Since that date, 288 patients have come to the Institute. Of this number, 176 patients had cancer and 126 received radium treatment. All treatment, apart from radium therapy, is carried out either by the patient's private physician or at the Vancouver General Hospital and St. Paul's Hospital. The facilities, Page 66 therefore, of the Cancer Institute are limited entirely to radium therapy, but it is hoped that as further funds become available, additional equipment such as an X-ray therapy machine and beds will be added, so that all forms of treatment of cancer can be carried out at the Institute. The medical staff of the Institute consists of a medical superintendent and 17 consultants, who are specialists practising in the City of Vancouver. In addition, there is an Honorary Medical Staff of 29 doctors chosen from the medical profession throughout the Province. Patients come to the Institute from all over British Columbia, but the majority are from Vancouver. No patient is accepted for diagnosis or treatment unless he is referred by a doctor or some accredited body. This stipulation is necessary in order that the function of the Institute—the treatment of cancer—be not curtailed by unnecessary examinations. No patient is refused treatment. Those who are able are expected to pay what they can. To co-ordinate the fight against Cancer in this Province, there has been formed recently by the B. C. Medical Association a Cancer Council consisting of 12 members, both lay and medical, to which four members each have been appointed by the B. C. Medical Association, the Canadian Society for the Control of Cancer, and the British Columbia Cancer Foundation. Clinical Statistics Number of cases admitted (Males, 123; Females, 165) 288 Number of cases having cancer 176 Number of non-malignant cases 91 Number of cases having no demonstrable disease 21 Number of biopsies performed 185 Types of malignancy'. Squamous cell carcinoma of skin 22 Basal cell carcinoma of skin 22 Melanotic carcinoma of skin 1 Adenocarcinoma of sweat gland 1 Squamous cell carcinoma of upper lip 2 Basal cell carcinoma of upper lip 1 Squamous cell carcinoma of lower lip 14 tongue 6 soft palate 2 epiglottis 1 floor of mouth.. 3 tonsil 1 buccal mucous membrane 6 " larynx 1 Mixed parotid tumour 1 Patients were treated by the following methods: Radium treatment only : 73 X-ray treatment only 40 Radium treatment and x-ray treatment 44 Radium treatment and surgery 6 X-ray treatment and surgery 6 Surgical treatment only 42 Radium, x-ray and surgical treatment 3 Number of patients requiring hospitalization (including malignant and non-malignant cases) 94 Number of deaths 23 Status of cases: Private ■■ 112 Individuals 79 Department of Pensions and National Health 15 Municipalities 5 Provincial Welfare 13 Indigent 176 Patients came from the following districts: City of Vancouver 156 Cranbrook District 3 J Carcinoma of nasopharynx ; . 2 " antrum 3 " oesophagus 3 " stomach 1 " bronchus 1 " breast 20 Squamous cell carcinoma of cervix uteri 35 Adenocarcinoma of cervix uteri 1 Adenocarcinoma of body of uterus '$%$* Squamous cell carcinoma of vagina Lymphoblastoma of mucous membrane of upper jaw Squamous cell carcinoma of vulva Carcinoma of ovary i 2 Adenocarcinoma of rectum 12 Fibrosarcoma of leg 2 Medical treatment 6 No treatment, for the following reasons 68 1. No disease demonstrated. 2. Treated elsewhere; patient returning for observation only. 3. Incurable case. 4. Patient refused treatment. 1 3 Lower Mainland (Burnaby, New Westminster, North Vancouver, etc.) 48 Nelson-Creston District- Grand Forks District Page 67 Vancouver Island—_: 19 Fraser Valley 14 Lillooet District 4 Okanagan Valley 17 Kamloops District 2 Salmon Arm District 6 Revelstoke District 1 Fernie District 1 Rossland-Trail District 1 Cariboo District 3 Prince George District: 3 Prince Rupert District 2 Peace River District 1 Calgary 1 Los Angeles J 1 An analysis of the 176 cases of cancer reveals the following facts, and these should be interpreted on the basis of the one-year period during which the Institute has been in operation: 1. 23 patients died. 2. In 40 patients, the growth disappeared following treatmentl and there were no signs of recurrence at the last examination of the patients. 3. 29 patients have been apparently improved, although it is too early to say definitely. 4. 30 patients are in the process of having treatment. 5. In 24 patients, treatment was given as a palliative measure. 6. 17 patients showed improvement following treatment, but still show signs of disease. 7. 13 patients were not treated and are still alive. 8. 24% of the cases had cancer of the skin; 23% of the cases had cancer of the uterus; 10% of the cases had cancer of the breast; 9% of the cases had cancer of the Up; 6% of the cases had cancer of the rectum. CANADIAN MEDICAL ASSOCIATION MEMBERSHIP 1940 1940 FEE OF $8.00 INCLUDES JOURNAL OF C M. A. TO BE PAID THROUGH THE OFFICE OF REGISTRAR COLLEGE DUES FOR 1940 ........ C. M. A. MEMBERSHIP, 1940 $15.00 8.00 THIS WILL MAKE YOUR CHEQUE TOTAL FOR 1940 $23.00 New Members are reminded that prompt response will assure receipt of the January number of the Journal. Please Note: College Dues have been reduced from $18.00 to $15.00 for 1940. British Columbia as a Division of the Canadian Medical Association has secured a reduction in Membership Fee—from $10.00 to $8.00. THE C. M. A. MEMBERSHIP FEE INCLUDES THE JOURNAL. Page 68 V ancouver G enerai Hospital REGIONAL ILEITIS By Dr. W. L. Pedlow. M. T, age 16, Japanese schoolboy. Admitted January 13, 1939. Chief complaint: Crampy right lower quadrant pain two days. Present illness: The patient was in his usual good health until January 10, 1939. January 10, 1939: While at school developed a headache and generalized abdominal pain, for which he was sent home. Nausea accompanied this abdominal pain but there was no vomiting. At home, an enema was1 given and the boy put to bed. January 11, 1939: He stayed in bed and the abdominal pain became somewhat less. January 12 and 13, 1939: The abdominal pain became mora severe and localized in the right lower quadrant, becoming crampy in character with a ten to fifteen-minute time interval. This pain was aggravated by micturition. January 13, 1939: He was admitted to hospital. Personal History, Family History and Past Illnesses, and Functional Enquiry: Not significant. Physical Examination: General: Patient is a boy appearing acutely ill. Head and Neck, Chest, about fifteen years of age, lying comfortably in bed, not Cardiovascular System, Nervous System, etc., essentially negative. Abdomen: (a) Inspection: Abdominal respiratory movements normal. (b) Palpation: No hyperaesthesia found. Marked right rectus rigidity present. Marked tenderness present over McBurney's; point on deep pressure. Rebound tenderness also present. (c) Percussion: Normal. (d) Auscultation: Normal peristaltic sounds heard. Rectal Examination: No abnormal tenderness on either side. On Admission: Temperature 99.6; pulse 84; respirations 20. White blood count, 11,700 (53 Polys., 21 Staff., 18 Lymph., 8 Disintegrating). Urine negative. Operation, January 13, 1939. A right rectus incision was made. The terminal six inches of the ileum was found dilated, congested and boggy. The appendix also was congested, cedematous and evidently involved in the same type of general inflammation. The caecum and lower third of the ascending colon were similarly reddened, congested, and the walls apparently thickened. The para-ileal lymph glands were enlarged and inflamed. A f aecolith was present in the proximal third of the appendix. To sum up: It was evident that this was not merely an acute appendicitis. This whole region of bowel, namely, terminal ileum, appendix, caecum, lower third of ascending colon, with their mesentery and lymph glands, were all involved in a uniformly diffuse inflammatory process and the appendiceal inflammation and faecolith were but incidental factors. The appendix was removed in the usual manner and the abdomen closed without drainage. Cultures: Cultures were taken aseptically at the time of operation from the intramural region of the appendix and resulted in growth of B. coli and streptococci. Progress Notes: January 16, 1939: Patient continued to run a mild fever, around 99.6, and was put on Neoprontosil, no cause outside of the ileitis being found for the continued temperature. Subjectively he felt well. January 18, 1939: Neoprontosil discontinued. January 19, 1939: Temperature rose to 101.2. Throat, chest, abdomen and costoverte- Page 69 bral angles thoroughly checked for any evidence of infection and all found negative. Neoprontosil treatment repeated. January 22, 1939: Temperature falling in response to Neoprontosil. January 24, 1939: Patient passed blood in the stools, for which no explanation can be found other than the regional ileitis. January 25, 1939: Urine shows a few red and white cells, but no albumin. Head, neck, chest all rechecked and found negative. There is generalized tenderness over the right lower quadrant, probably due to the ileitis, with fairly marked right rectus rigidity. X-ray report, G. I. series: "Five hours after the ingestion of barium the stomach was empty. The stomach showed no evidence of filling, defect or irregularity. The patient was examined hourly after the ingestion of barium, and the fourth and fifth hours part of the ascending colon and the small intestine were filled, but a portion of the terminal ileum showed a string-like appearance, indicative of an inflammatory condition in this region such as occurs in terminal ileitis." January 27, 1939: Right rectus rigidity still present. Patient, however, feels subjectively fine and was discharged from hospital. February 21, 1939: X-ray report, G. I. series: "The stomach was examined and hourly plates in relation to the small intestine revealed no irregularity in relation to the terminal ileum and caecum as shown in previous examination." February 27, 1939: Right rectus rigidity was still present, with the suggestion of a mass in the right lower quadrant. Pathological Findings: Appendix .(Summary). Macroscopic examination: Serosa is diffusely but moderately congested, the mucosa rather hyperplastic and patchily congested, but no gross ulceration in distal third. Faecolith present in proximal portion. Microscopic examination: No definite polymorph infiltration in mucosa, but there are a considerable number of plasma cells here with a few in the submucosa and muscularis. Subserosa shows a few polymorphs. "This is not a definitely acute process in general," but sections through f aecolith impaction area show more definite evidence of an acute process. Diagnosis: Acute exudative appendicitis. Pathogenesis: A generalized inflammation developed involving terminal ileum, caecum, appendix and ascending colon, with swelling, congestion and cedema. This inflammation resulted in increased pressure oru the already present faecolith, which led to a more acute process in the wall of the appendix immediately otverlying the f aecolith. Thus, an acute exudative type of appendicitis was present over the f aecolith together with a generalized so-called "Regional Ileitis." This continued fever and persisting right lower quadrant pain, also the melaena, were due to the persisting regional ileitis. This case is of interest in that it presents one or two new features. Regional ileitis is now recognized as a well-defined clinical entity. It frequently runs a subacute or chronic course until such time as partial obstruction!—fistula—or abscess formation complicates the picture. In the chronic condition the physical examination and the X-ray findings are fairly constant. Treatment of such a condition will depend upon the complications present and usually involves an ileocolostomy with resection of the involved area often in one or more stages. In this case, as Dr. Kovach has pointed out, there was an indefinite subacute history until the third day, when the local symptoms became more definite. The operative findings were decidedly unusual. Approximately six to eight inches of the terminal ileum, the ileo- caecal valve, the appendix and a portion of the first part of the ascending colon were involved. The parts were unif ormly hyperaemic, thickened and cedematous. The mesentery was similarly involved and the mesenteric glands palpably enlarged. The appendix appeared to be involved in the general inflammatory process, suggesting an associated or incidental involvement rather than separate acute or primary infection. During the past few years numerous articles on Ileitis have appeared in surgical journals. Recently Rockey published an account of four cases in children which presented the picture of acute appendicitis. In each, operation disclosed a thickened inflamed ileum, Page 70 masses of enlarged, hyperplastic nodes in the mesentery and a normal appendix. At each operation Rockey removed the appendix but felt that he could do nothing for the ileitis —yet all children recovered. It seems, therefore, it is by no means certain that every ileitis runs a chronic course. An interesting suggestion has been proposed in explanation of why the terminal ileum seems to be the site of predilection for regional inflammations, viz., that it may possibly be on account of its functional and anatomic peculiarities. Normally the flow of contents is retarded at the valve, which necessarily leads to some stagnation in the terminal ileum. Furthermore, the lymphatic tissue in the mucosa and submucosa is here more abundant than in other segments, and this would favour the absorption of micro-organisms. I could find only a few references to report of cultures taken at the time of operation. These stressed the virulence of the infection even in the more chronic cases. Cultures were taken in this case from the appendix, and were reported as showing B. coli and streptococci. An interesting observation at this point was that on the first post-operative day Neoprontosil was started and continued for four to five days. It was then discontinued, as the temperature was normal. Within forty-eight hours, however, the temperature had risen to 101 without any reasonable explanation, only to subside promptly when Neoprontosil was resumed. To summarize: A case of Regional Ileitis in an early subacute stage. An associated appendiceal involvement due to enlarged f aecolith possibly with necrosis developing in lumen of appendix in the area surrounding the f aecolith. Culture from appendix show B. coli and streptococci. Only active treatment was the administration of Neoprontosil—a secondary rise of temperature occurring when discontinued on the fifth day, promptly relieved on resuming treatment. 1. 2. 3. 4. CASE OF MULTIPLE MENINGIOMATA Dr. T. F. H. Armitage W. H. M., an unemployed Chinese male, age 49, admitted to the department of Nuerol- ogy, service of Dr. S. E. C. Turvey, July 27, 1939. Complaints on admission: (1) Pain in the back of the neck; (2) mental confusion and loss of memory; (3) constipation and pain in the rectum; (4) weakness of the legs. History of present illness (by interpreter) : Two months previous to admission the patient complained of vague pain in the back of his neck; also he began to show mental confusion and loss of memory. Thus, when given some medicine by his physician he took the whole bottle at once; he forgot the names of his friends; he seemed very much amused at everything going on around him. Further complaints were constipation and pain in the recrum causing sleeplessness. For three weeks previous to admission he complained of weakness of his legs, with difficulty in walking and a staggering gait. Past history: Gonorrhoea, 1929. His diet has included fresh vegetables, meat and rice. Examination: T, P., R., 98°, 74, 20. Patient, well-developed and nourished, appears younger than the stated age of 49 years. He is cheerful and co-operates! fairly well but attention is difficult to maintain. He frequently voids and passes faeces on the floor of his room and in his bed. Neurological examination: (Tests not carried out imply lack of co-operation of the patient or language difficulty.) Cranial nerves negative. Fundi normal. Motor System: Some weakness of both legs (-] f-); strength in the arms normal. There is rigidity of the neck (-| 1-) and Kernig's sign is positive. No wasting present. Fine tremor of the extended right arm and forearm, intermittent and increased on intention. Gait is shuffling in character and the patient tends to stagger. Sensory: Though sensation to pin prick seems normal throughout, his co-operation was too poor for adequate sensory examination. General physical examination is negative except for marked dental caries and pyorrhoea. Page 71 Cerebrospinal fluid: Initial pressure 300 mm. of C. S. F. The Queckenstedt test was positive. About 10 cc. of clear straw-coloured fluid were withdrawn and the final pressure was 152 mm. of C. S. F. Cells, 120 lymphocytes per cu, mm.; chlorides, 736 mg. per 100 cc; protein, 333 mg. per 100 cc; Kahn test, negative; colloidal gold reaction, 0344554433; culture, no growth. Succeeding spinal punctures revealed similar findings in the spinal fluid. There was marked predominance of lymphocytes in the fluid each time. Discussion: The tentative diagnosis at this time, in view of the mental changes, the high cell count in the spinal fluid, the neck rigidity and positive Kernig's sign, was a low- grade encephalitis or meningitis. On August 5, 1939 (nine days after admission), there was not much! change in the patient's general condition. However, early papillcedema of the optic discs was noted at this time. On August 11, 1939 (fifteen days after admissions), his general condition remained the same but the papillcedema had increased and numerous recent retinal haemorrhages were present iri both eyes. Treatment: On August 14, 1939, under avertin and local anaesthesia, with the patient on his face, burr holes were made over the anterior poles of both lateral ventricles. After several attempts it was found impossible to locate the left ventricle. The right ventricle was entered readily and approximately 60 cc. of clear fluid poured out under greatly increased pressure. This was replaced with about 45 cc of air. The X-ray report after this procedure was as follows: "Practically no air was seen in the left ventricle. The whole of the right ventricle is grossly enlarged and displaced to the right side, carrying with it the third ventricle, which is! of relatively small size. The displacement and the enlargement involves the whole of the body and the upper part of the descending horn." From the above findings on clinical and X-ray examination a diagnosis of left frontal brain tumour was made. Operation was performed in the afternoon of August 14 by Dr. F. Turnbull. The operative report reads as follows: "The patient had not regained consciousness since the morning. His general condition was not very good. The right pupil was very small and the left pupil dilated. His color was cyanotic "A moderate-sized left frontal bone flap was turned down without difficulty, using a concealed incision, the medial arm of which included the; left ventricle wound. Several times before opening the dura the right ventricle was tapped and fluid and air under pressure released. The bone and meninges were excessively vascular. "On reflecting the dura the tumour was encountered in the Sylvian fissure region, which was adherent to the overlying dura, very vascular and quite firm and nodular— apparently a meningioma. The cortex at this stage was greatly swollen, bluish, and in order to give an adequate decompression a portion of this was resected down for a distance of about \l/z inches up to the margin of the tumour. The tumour was then gradually resected piecemeal, during the course of which considerable blood was lost. "The dura was tacked back loosely, bone flap laid in place and scalp closed in the usual manner, leaving a Penrose drain leading out through a stab wound in the adjacent skin margin. "At the conclusion of the operation the patient appeared to be moderately shocked and was given a transfusion of 500 cc. of blood." The day after operation the patient became restless but at no time did he regain consciousness and he died on the second post-operative day. The autopsy report by Dr. H. H. Pitts is as follows: There is nothing of note in the respiratory, cardiovascular, gastro-intestinal or genitourinary systems. "The brain weighs 1620 grms. It was removed with, considerable difficulty from the base of the skull and it was found to be slightly adherent at the tip and inferior aspect of the right frontal lobe and also in the medial fossa on the left side. In the former area, a large filbert nut-sized tumour mass is found adherent to the dura and producing a small Page 72 depression in the inferior aspect of the right temporal lobe. The brain tissue in the inferior aspect of the left temporal lobe is quite cedematoust and rather soft and a cellular tumour mass is found adherent to the dura in the left middle fossa. On section of the brain a tumour mass the size of a medium-sized hien's egg is found in the left frontal lobe in an inferior aspect. It is surrounded by cedematous, rather softened brain tissue, and appears to infiltrate slightly; this tumour mass has a cellular, rather pinkish-grey appearance and shows considerable cystic change and areas of degeneration. It is not in communication with the area from which the tumour mass was removed in the left frontal region. Both lateral ventricles, but especially the right, contain ja considerable amount of blood and the posterior horn of the right ventricle is almost entirely filled with both fluid and clotted blood. There is no particular accentuation of the depression on the inferior aspect of the cerebellar lobe which would suggest a herniation into the foramen magnum. "In the posterior aspect of the brain on the dura there are several small barley grain- sized soft, apparently tumour-like areas, lateral to the areas of the Pacchionian Bodies, which suggest the possibility of tumour implantations, and these apparently extend through the dura and are seen on the cortical aspect of the brain in these areas. "Microscopical examination of the tumour mass removed from the frontal area show it to be of a rather cellular meningioma type, but the tumour in the left frontal lobe noted at autopsy suggests a more cellular type and possibly a glioblastoma multiforme. This will, however, have to be decided by microscopic examination. The, tumour mass in the inferior aspect of the right temporal lobe appears to be of a meningioma type. "Microscopic findings: Tumour left frontal lobe, inferior aspect: This tumour grossly suggested, by reason of its much softer, more cellular and degenerated appearance, a different type of growth to the one removed from the superior aspect of the frontal lobe but it also arose apparently from the dural meninges of the) left anterior fossa, and microscopically appears to be also of meningioma type but of the very cellular variety. It consists of, in places, dense fibrous-like tissue, well vascularized and showing whorl-like aggregations of very markedly pleomorphic and polymorphic cells, some almost ganglion-like in form. They vary greatly in size and shape. There are large areas of degenerative change, areas of cystic change as well, some areas of haemorrhagic extravasation and, with the extensive fibrous-like stroma, the apparent origin from the meninges, and the presence of the other tumours of meningioma-like structure, it seems more reasonable to suppose that this is also of a similar type rather than that there are present two distinct and different types of tumour growth. This, however, I believe one of the very cellular types of meningioma. "Sections through the growth in the right temporal lobe inferiorly and from the growth in the superior aspect of the right frontal lobe removed at the time of operation, show the typical meningioma structure, this also being somewhat cellular and in the former an occasional psammoma body is found. 'The sections through the small implantation-like areas in the posterior aspect of the brain,, measured grossly, also show the meningioma type of structure. "Diagnosis: Multiple meningiomata (cellular type) of brain." According to Cushing and Eisenhardt, in cases of this type three conditions must be differentiated: (1) Von Recklinghausen's disease (this patient had no evidence of this disease either on ante-mortem or post-mortem examination); (2) Multiple meningiomas, indicating more than one meningioma and something less than a diffusion of them; ( 3 ) Meningiomatosis. It was considered, inView of the clinical and autopsy findings, that this was a case of multiple meningiomata. REFERENCES* Cushing and Eisenhardt—Meningiomas. Boyd—Textbook of Pathology. McCrae—Osier's Principles and Practice of Medicine. Page 73 NOTES ON LATENT SYPHILIS S. C. Peterson, M.D. [The following "Notes on Latent Syphilis," kindly furnished by Dr. S. C. Peterson, formerly Director of the Venereal Diseases Division of the B. G. Provincial Health Department, will, we feel, be of both interest and value to readers of the Bulletin. It is well for us to have constant reminders from those especially devoted to the treatment of syphilis, of the immense importance of constant, unremitting wakefulness and care over details. The recognized necessity for lumbar puncture in every syphilitic, the need for completeness in treatment, for careful follow-up and so on, are well brought out in this short article.—Ed.] These notes are an attempt to describe the changed conception of that period of syphilis between the termination of the secondary stage and the beginning of the tertiary stage. The terms primary, secondary and tertiary were found to be untenable, as they failed to take into account that long period of quiescence which belonged neither to the second nor to the third stage. The newer nomenclature classifies syphilis rather as early, latent, and late syphilis. Latent syphilis may be defined as that period of the disease when neither clinical signs nor symptoms are present. It may also be thought of as dormant, concealed, occult or sub-clinical syphilis. The superficial, early lesions of syphilis are of tremendous importance from the standpoint of the public health. They have no more clinical significance to the patient's health than the rose spots scattered on the skin of the abdomen of the typhoid fever patient. Long before the early lesions appear the virus of syphilis has been widely disserninated through the body. Spirochaetes have been demonstrated in the spleen and bone marrow before the appearance of the chancre. As a matter of fact, there may be no initial lesion and the early signs may be so insignificant as to escape notice. Approximately one out of every three syphiHtic patients seen by the general practitioner will be in the latent stage of the disease. In Turner's study of ten thousand clinic patients, one-third of all males and nearly one-half of all females presenting themselves for treatment had no physical evidence of the disease. Half of all patients with late syphilis gave no history of the infection. The biological course of syphilis infection is quite orderly; the introduction of the virus; its multiplication at the site of inoculation; its dessimination by way of the lymphatics and blood stream; the development of the chancre; the inguinal adenitis; and then the cutaneous, mucosal and constitutional symptoms of early syphilis. Even though the patient is untreated, the lesions of the secondary outbreak heal spontaneously after a variable period of time ranging from a few days to many months. The next few years are marked by their uneventfulness. Either the individual shows no obvious physical evidence of syphilitic infection, or, in a relatively small proportion of cases, relapses of the secondary type may appear, usually insignificant, transitory, and, in most cases, limited to the mucosae. Finally, even these cease to occur, and a period of complete quiescence ensues. The patient has entered the stage of latency. A clinical diagnosis of latent syphilis assumes that no lesions attributable to the disease have been revealed after the most searching physical examination and that the diagnosis rests either on: (1) A positive serological rest, or (2) a clear-cut history of infection inadequately treated, or (3) on the birth of a) syphilitic child. The best definition, then, that can be given of latency is "clinically unrecognizable disease." Two exceptions must be made: (1) Cases with abnormalities in the spinal fluid; (2) those with demonstrable cardiac lesions. If the spinal fluid examination reveals increased cells and protein, a positive Kahn or Wassermann test, and an abnormal celloidal curve, it indicates not only invasion of the central nervous system by the treponoma but actual tissue involvement, even though there may be no clinical evidence of neurological damage. The importance of routine lumbar puncture and the absolute necessity of carrying this out in every patient with syphilis, early or late, is apparent from the fact that spinal fluid abnormalities antedate the appearance of obvious clinical damage in the nervous system by many years. The potential paretic or tabetic patient is recognizable within the first year of the infection. Page 74 As the latent syphilitic can only be recognized by means of the routine blood test, so can the latent neurosyphiHtic only be discovered by means of routine spinal fluid studies. The physician who omits to perform a routine spinal puncture in every patient diagnosis as syphilis is* guilty of gross negligence. Cardiovascular syphilis is essentially an aortitis. In the syphiHtic clinic at Johns Hopkins University it is thought that uncomplicated syphilitic aortitis (without aortic regurgitation of aneurysm) may be diagnosed with reasonable assurance if, in a patient with a positive blood test and without disease of the mitral valve, any four of the following seven criteria are fulfilled: 1. X-ray evidence of aortic dilatation; 2. Increased retrosternal dullness; 3. A history of circulatory embarrassment; 4. Accentuated tympanitic second aortic sound; 5. Substernal discomfort. 6. Paroxysmal dyspnoea; 7. Progressive cardiac failure. But, taken singly, each of these criteria, or even several of them in combination, may be produced by other conditions, notably essential hypertension. The presence of only one or two of them in the patient with supposedly latent syphilis can only suggest the possibility of the diagnosis of cardiovascular syphilis, and does not permit it to be made definitely. History shows a remarkable evolution in the virulence of the disease since the great European pandemic in the 15thl Century. L. W. Harrison expresses the opinion that the tendency of syphilis is to become latent so far as outward manifestations are concerned. Animal experiments have taught us that syphilitic infection is latent from the first in a definite proportion of cases. A study of the pathology of latent syphilis gives a key to the mystery. Griffith Evans believes that "it lies in the increasing power of the body to confine the virus to the lymphatic system, whence, however, it may emerge to attack the host, with the production of either temporary or permanent disability." The peribronchial and mediastinal glands become reservoirs for the storage of spirochaetes. Klotz writes: "It is from the two main lymphatic drainage beds, the thoracic and the abdominal, that the) syphilitic virus comes to be distributed to particular segments of the aorta." Carey Coombs summed up the lymphatic hyothesis in these words: "The peri-aortic origin of syphilitic! aortitis is recognized. The cellular infiltration that is its distinctive mark wells out of the mediastinal lymphatics in the direction of the aorta and is piled up on the outer surface of the adventitial' Griffith Evans further suggests that: "It may not be unreasonable on pathological evidence to attribute nervous dysphagia, nervous dyspepsia, spastic colon, chronic abdominal pain, and the like, in some instance at least, to syphilitic infiltration of the sympathetic nervous system." Kilduffe says: "The latent syphilitic is as likely as not to seek medical advice for symptoms not at all suggestive of syphilis on their face value; for stomach trouble, vague and ambulatory pains, high blood pressure, etc., and all too often he receives treatment for just that of which he complains." Stokes and Brown give details of 200 syphilitics whose main complaint was stomach trouble, with the classical tale of heartburn, belching, pain, nausea and indigestion. Thirty-five of these had undergone needless operation. More significant is their statement that during the period of their investigation fifty per cent of the patients admitted to the clinic with a diagnosis of neurosis of the stomach or functional stomach proved to be latent syphilitics. Other organs also may act as storehouses for the Treponema. Warthin found spirochaetes in large numbers in the testicle, liver and aorta of latent syphilitics. Recent studies have shown that half the liver structure may be destroyed by syphilis before any symptoms of disfunction appear. The only possible method of approach to the question of the natural evolution of untreated syphilis is to follow over a period of many years a large series of patients who have never received any treatment. Page 75 This has been done by Bruusgaard, whose results may be summarized. Between the years 1891 and 1916, 2181 patients, diagnosed as primary or secondary syphilis, were admitted to the Oslo Clinic Many of them received no treatment. Some received a little mercury by mouth, or potassium iodide, or both, but for al! practical purposes it can be said that these patients were untreated. In the years 1925 to 1927 Bruusgaard was successful in following 473 of the original 2181 patients. Three hundred and nine were living and each of these were completely re-examined physically, with special emphasis on the cardiovascular and nervous systems. One hundred and sixty-four were dead. Most of these had died in the Oslo Hospital, the cause of death being known; in 40 necropsies had been obtained. The majority of the patients were re-examined or had died more than twenty years after infection. Thirty-seven per cent of the total number had developed active lesions of late syphilis; 22 per cent had died of some unrelated cause, and nearly half of this group lived for twenty years or more after infection without developing any lesions. In 14 per cent the only evidence of infection was a persistently positive blood reaction; in 27 per cent "clinical arrest" or "cure" seemed to have occurred in spite of the absence of treatment. Syphilis does not always maim or kill; so far as anyone can tell from clinical study the treponema may in certain persons be a perfectly harmless saprophyte. The results achievable by nature can be materially improved upon by adequate treatment, but due consideration must be given to this natural defense mechanism of the individual in planning treatment, particularly the treatment of latent syphilis. The material of the Co-operative Clinic Group revealed that progression or relapse in treated patients occurred in less than 5 per cent of those studied. This was interpreted as due partly to the degree of development of the patient's own resistance, partly to the added protection afforded by treatment. It indicates that a patient with latent syphilis may be assured with reasonable certainty that, if he submits to a moderate regime of treatment, he may be promised nineteen chances out of twenty of freedom from clinical evidence of disease in the future, and that if lesions do develop they will rarely be incapacitating. It is possible that the natural immunity of the patient is fully established by the end of the fourth year of the infection. A more or less arbitrary line has been drawn, therefore, at this point, to distinguish between early and late latency. This distinction is of great significance because the two most important factors to be considered in planning treatment in latent syphilitics are the age of the patient and the duration of the infecion. We must ask ourselves what we hope to accomplish and how to achieve the maximum good with the minimum harm. The late E. W. Karacher remarked: "Our decision must rest on a critical evaluation of the factors presented in the individual case, and not on the simple and too frequently used formula: the patient's blood test is positive, that means he has syphilis and the treatment for syphilis is arsphenamine. The probability of cure diminishes with the passage of time, and after an indefinite period of about four years biological cure its rarely achieved. This being so, we can, in those cases where latency has been established, temper our therapeutic attack to conform to the indications present. If we can prevent infection in others and maintain a state of latency throughout a long and uneventful life, even though at autopsy the pathologist finds a few spirochaetal nests, we have accomplished all that is possible with our present knowledge. In latency Wassermann fastness is not of grave significance. Relapse and progression are no more frequent among Wassermann fast patients than in those with more easily reversible tests. As a rule the blood tests revert to normal spontaneously after treatment has been discontinued. The treatment of early latent syphilis is essentially the same as the treatment recommended for secondary syphilis. The guiding rule in the treatment of late latent syphilis is that treatment should begin with small doses of one of the less potent drugs, namely mercury or bismuth, and that the dosage should be increased gradually. This preparatory treatment should be continued for Page 76 two or three months at least before the arsphenamines are even con/sidered. If it is then decided to employ them, the same rule as to dosage should apply. This rule, to be sure, is broken frequently and in a vast majority of cases, without any serious trouble ensuing, but serious accidents, including death, doubtless occur with more frequency than we can know, as they are not generally proclaimed. They must be guarded against, since they are in a large part preventable, and adherence to the rule will do much. The ultimate therapeutic benefit in late latency is obtained by the administration of 20 to 30 injections of the arsphenamines or mapharsen together with 60 to 100 injections of mercury or bismuth, extended over a period of three to four years or longer. Intermissions are allowable and form part of the plan. The length of the treatment periods is to be gradually lessened and the length of the rest periods gradually extended. The iodides are extremely beneficial in late latency. They are best given in fifteen-grain doses, three times a day, well diluted. A useful plan is to give the drug month on and month off during the first year and thereafter for a month at a time, two or three times a year. If the patient has had syphilis for 15 years or more it is questionable if treatment will accomplish more than the natural defense mechanism of the body has already accomplished. But repeated courses of bismuth and potassium iodide, yearly or bi-yearly, do seem to produce a general improvement in the patient's well-being, both physical and mental. This self-voiced expression of betterment is heard repeatedly in actual practice. Summary and Conclusions , 1. An entirely new conception of a period of syphilitic infection known as latency has been introduced in the last decade. 2. It represents at least a third of all cases of syphilis seen by the clinician. 3. The condition requires clear definition and classification by exclusion. 4. The prognosis is extremely favourable. 5. Serological reversal is of minor importance. 6. Treatment must be modified according to the duration of the infection, the sex and the age of the individual. CANADIAN MEDICAL ASSOCIATION 1940 MEMBERSHIP 1940 FEE OF $8.00 INCLUDES JOURNAL OF C M. A. TO BE PAID THROUGH THE OFFICE OF REGISTRAR COLLEGE DUES FOR 1940 C M. A. MEMBERSHIP, 1940 $15.00 8.00 THIS WILL MAKE YOUR CHEQUE TOTAL FOR 1940 $23.00 New Members are reminded that prompt response ■will assure receipt of the January number of the Journal. Please Note: College Dues have been reduced from $18.00 to $15.00 for 1940. British Columbia as a Division of the Canadian Medical Association has secured a reduction in Membership Fee—from $10.00 to $8.00. THE C. M. A. MEMBERSHIP FEE INCLUDES THE JOURNAL. Page 77 LIVER ABSCESS DUE TO ENTAMOEBA HYSTOLYTICA H. H. Milburn, M.D. Mr. McC, age 25, British subject, sailor on a grain boat. Environment was that of a dust-laden atmosphere. Had previously been well, and had been at sea several years. During this time had visited various European ports, Australia, England, Central and South America. He was on shore very little of this time, approximately two weeks in Central American ports. While on the boat, drinking water was protected by chemical treatment, which the sailors very much disliked, and took every advantage of getting water from other sources. There was no history of any intestinal infection, acute or chronic diarrhoea, etc Appetite and health good till two weeks prior to admission to hospital on July 21st, 1939. At that time he complained of general malaise, non-productive hacking cough, loss of appetite, and pain in upper right quadrant over the gfall bladder. He was sick approximately 10 days prior to reaching this port. This was six weeks following the ship's visit to Central American ports. Physical examination on July 21st revealed a somewhat emaciated man of 25, fairly well developed. Moderate pallor; slight icteric tinge to the sclera, pupils somewhat dilated and equal, react to light and distance. Rather an anxious expression' to the face. Respirations 34 per minute. Teeth discoloured, marked degree of pyorrhoea, breath foul. Neck was negative. A few moist rales at the base of the right lung. Slight cardiac enlargement. Visible p.m.i. at 6th interspace in the mid-clavicular line; no murmurs were present. Blood pressure 110/70. No adventitious sounds. Abdomen showed a generalized tympanites with slight general tenderness. Marked tenderness over the right hypochondrium. Muscle rigidity over the! gall-bladder area was quite marked. No definite increase in liver dullness. Genito-urinary system negative. Reflexes hyperactive and symmetrical. Genitalia negative. Otherwise his condition showed nothing remarkable. His condition appeared to present one of probable pulmonary tuberculosis, on account of loss of strength and weight, dry hacking cough, septic temperature, dyspnoea and abdominal distention. Pain in right lower chest was aggravated by respiratory movement. Repeated sputum examinations were negative for T.B. Repeated stool examinations for amoeba and parasites were negative. Blood showed a marked secondary anaemia, which was progressive with practically a normal white blood count. Repeated examinations of this man, particularly his chest and heart, showed intermittent attacks of rough cardiac murmurs and friction rubs, which at times would entirely disappear. Pain in right lower chest persisted. Patient developed chills and fever, became more jaundiced and progressively more anaemic Heart was enlarged and diagnosis of possible liver abscess or subphrenic abscess was made, and an unsuccessful attempt to explore and aspirate this area was made. His general condition continued septic, and rapidly became worse, and he died on August 18th, 1939. X-ray results: July 26th—(1) Minor degree of cardiac enlargement; (2) pneumonic process right base. Aug. 3rd—(1) Liver shadow increased moderately. Negative for abscess. Aug. 8th—(1) Heart borders markedly enlarged; (2) increased density base right lung; (3) no evidence of sub-diaphragmatic abscess. Laboratory results: July 24th—W.B.C., 7400; Polys 76%; Lymphs 24%. Aug. 3rd—Haemo. 43%, R.B.C. 2,170,000, W.B.C. 5200, P. 70%, L. 29%, Eos. 1%. Aug. 10th—Haemo. 42%, R.B.C. 1,970,000, W.B.C. 6,700, P. 70%, L. 29%. Page 78 Red cells show marked anisocytosis, achromia and poikilocytosis. Stool: Repeatedly negative for amoeba or parasites or occult blood. Culture, negative for typhoid,group. Blood culture: Negative. Sputum: Negative for T.B. repeatedly, or type pneumococcus. Culture: Non-haemolytic streptococcus, non-haemolytic staphylococcus and Staphylococcus albus. Direct smear: Bac. fusiformis plus 2; Spirilla (Vincent) plus 2; pus cells plus 2. Negative for ova, amoeba, or fungus. Kahn: Negative. Widal: Negative—Typhoid, dysentery and B. abortus. Blood group: Group A. Urine: Acid. Sp. Gr. 1020-1030. Albumin plus 2. Sugar neg. Micro: Pus cells plus 1; granular casts plus 1; hyaline casts plus 1; few red blood cells. Post-Mortem Performed Nine Hours After Death. Body was that of a well developed, rather thin, adult white male, apparent age 25. Abdomen was distended, particularly the upper half. There were no marks of external violence. Hair was dark, pupils measured .5 cm. in diameter, were regular. There was some cedema of the lower extremities. On opening the abdomen, it was found to contain approximately* three quarts of dark, clear amber fluid. Liver was enlarged, right lobe rather firmer than usual, rubbery in consistency. Edges were round, and mottled dark blue and brown in colour. Gall bladder was small and normal. Stomach was small, contained a moderate amount of gas. Duodenum was contracted and firm, was negative. Small intestine was negative. Large bowel contained a small amount of solid and semi-solid faeces, with moderate amount of gas. There was no ulceration, no glandular enlargement. Mucosa was not thickened. There was no evidence, as far as could be determined, of previous colitis. Spleen was slightly enlarged, soft and pulpy. Pancreas was normal. Kidneys were large, swollen, cedematous, and right kidney showed multiple small areas of thrombosis which extended through the medulla and cortex into the sub-capsular area. These were small areas and numbered approximately ten to twelve. Cortex was quite thickened, and indistinguishable from the medulla. There were no inflammatory changes in the pelvis, and ureters were normal. Both suprarenal glands were negative. Thorax: Precordial dullness was markedly increased, measured 18 J4 cm. at its greatest width. Anterior leaflet of the middle and lower lobes of the right and left sides were adherent to the pericardium by fibrinous purulent exudate. There was relatively little fluid in either pleural cavity, and lungs appeared to be comparatively dry. There was no mediastinal tumour and no enlargement of the hilar lymph lodes. On opening the pericardial .cavity, pericardium was very thick, measured approximately 2 cm., contained approximately five ounces of dirty, pinkish-yellow, fibrinous purulent material. Heart was covered with the same type of material. It was not adherent to the parietal pericardium. This is a marked empyema of the pericardial cavity. On examining this closer, on the lower aspect on the surface of the diaphragm, at the centre there Was a small, pinpoint opening which communicated with a large abscess in the liver. Heart was removed. Valves appeared to be competent. Heart was not enlarged, muscle was relatively soft. Coronary vessels were normal. Aorta was small, very elastic and healthy. There was no endocarditis. Inflammatory change on the surface of the heart extended for approximately %e inch into the muscle. Lungs showed some slight cedema and congestion. Bronchi were clear and left lower lobe somewhat collapsed. Liver and diaphragm were removed and examined. There was a large abscess in the upper left portion of the right lobe toward1 the centre of the diaphragm, which communicated through a small opening with pericardial cavity. This opening was very small. Cavity contained five to six ounces of dirty, stringy pus. Wall was whitish-gray in colour, very fibrotic and very irregular and shaggy. Some of the pus was removed for culture, which showed haemolytic Staphylococcus Aureus. Areas of the liver surrounding this showed many small abscesses from the size of a grain of wheat to 1 cm. in diameter. Many Page 79 of the bile ducts contained pus, and there were numerous areas of thrombus in the veins of the liver, producing a condition where the liver was very dark in colour, markedly engorged, and slightly softer than normal liver tissue. Left lobe was healthy and character, and greater portion of the right lobe was perfectly healthy. Examination of the pus removed from the abscess showed presence of amoeba typical of entamoeba histolytica. Anatomical diagnosis: (1) Amoebic abscess of the liver with secondary empyema of the pericardium; (2) epicarditis and pericarditis; (3) myocardial degeneration. Microscopic: Section of lymph gland shows very marked degree of hyperplasia, congestion, infiltration with endothelial cells and plasma cells and a few polymorphs. Other areas show evidence of early breaking down. Kidneys show little or nothing abnormal apart from cloudy swelling of the proximal tubular epithelium with few scattered areas of inflarnmatory reaction with round cell infiltration. Spleen shows diffuse increase in connective tissue with some hyaline deposit in the centre of the Malpighian corpuscles, and general increase in splenic pulp. Liver shows marked hepatitis with deep engorgement, cloudy swelling and fatty degeneration of very extensive areas of the lobules. Toward the inflarnmatory area extensive areas of liver tissue have been destroyed, bile ducts still persist. Abscess in the liver shows extensive areas of necrosis without definite walling off, edge of the abscess being represented by tiny liver cords and connective tissue. Central portion shows degenerating cells, polymorphs, round cells and some plasma cells. Anatomical diagnosis is confirmed. This case is of interest for several reasons: 1. Absence of any history or evidence of colon infection; 2. Amoebic infections in this latitude are rare; 3. Short history of probable date of infection; 4. Massive involvement of liver and pericardium; 5. Difficulty in diagnosis. Staff Meeting, October 18th, 1939. DYSTROPHIA-ADIPOSO-GENITALIS Paper presented by Dr. Meth, courtesy Dr. O. De Muth. This patient is being presented this evening for the purpose of demonstrating a familiar form of pituitary dysfunction. He is a white male, 24 years old, single, a truck driver; he was admitted to hospital following an injury to his left ankle which was diagnosed as a sprain. X-ray negative for fracture or other lesion. History: Apparently up to the age of 12 the patient developed quite normally, but at puberty, at about 12 or 13 years, bis mother noticed an increasing obesity. He states that the development of his genitals had remained retarded and in the state at which they appear now since the age of puberty. He has periods of lassitude, and claims that he can easily fall asleep anywhere and at any time, given the opportunity. Appetite good. Gastro-intestinal, cardiovascular, respiratory and neurological functions have all been normal. Family history revealed nothing significant. Father and mother, one sister and one brother are all in good health and do not show any abnormalities. His past history revealed that he had mild rheumatic fever at the age of 5, chicken-pox, whooping cough, measles and scarlet fever. Tonsils were removed in childhood. A recent injury to the left cornea, from burn, completely recovered. Physical examination revealed an obese male, 6 ft. 2 in. in height, weight 210 lbs., with distribution of fat generally of the female type. Head—Eyes: Pupils react to accommodation and light. No nystagmus. Both fundi appear to be normal. There is no sign of papillcedema, and fields of vision are quite normal. Nose and Ears; Essentially negative. Mouth: Teeth only fair. Slight pharyngeal injection. Otherwise negative. Neck—There appears to be no palpable enlargement of the thyroid. No cervical adenopthy. No abnormal pulsations. Page 80 Chest inspection.—Expansion good. Female distribution of fat, especially noticed in the mammary region. Nipples surrounded by a feminine type of areola. No evidence of any hair except in the axilla, which definitely has a female type of distribution. Lungs and heart clear. No evidence of any murmurs. Rhythm regular. Rate 72. Abdomen—Obese. No tenderness. Liver and spleen not palpated. Other findings negative. Genitals—Pubic hair distribution of the female type. Small hypoplastic genitals. Testes are descended, appear small and underdeveloped. Extremities—Except for the injury to the left ankle, which shows some hematoma over the lateral aspect, leading up to the anterior portion of the leg, essentially negative. Neurological examination proved to be negative. Additional points—His voice has never changed. Apparently has no libido. Laboratory investigation— B.M.R. +14 ~4; blood calcium 11.2 mgm.; blood phosphorus 4.2 mgm.; blood Kahn negative; haemoglobin 94%; R.B.C. 4,470,000; W.B.C. 8,700; differential: Eosinophiles 1, lymphocytes 36, polymorphs 63. X-ray of the Sella Turcica: Negative. Diagnosis: Dystrophia-adiposo-genitalis or Frdlich's syndrome. Discussion of Dr. Meth's Paper by Dr. C. E. Brown. The case which Dr. Meth has presented is rather typical of one of pre-puberal gonadal deficiency, probably of pituitary origin. In these cases developing before puberty, retardation of the ossification of the epiphyses of the long bones leads to enlargement of stature. There is also adiposity tending to the female type of distribution. The larynx fails to develop and the voice remains high-pitched. The hair on the head is usually plentiful; on the body it tends to the female type of distribution. The penis, testicles and prostate fail to develop, and sexual feeling is suppressed. The pituitary gonadotropic hormones in the blood and urine may be greatly increased in amount. On the other hand, the testicular hormones, the" androgens, are small in output as compared to the normal individual. Treatment of these heretofore has been with gonadotropic-like hormones such as Antuitrin-S therapy and dieting. The results in many cases have been indifferent. Testicular extracts and grafts had been used with rather indifferent results. Since the introduction of a synthetic crystalline preparation, similar in action to the androgenic type of hormone, which is called testosterone propionate, the treatment of these pre-puberal gonadal deficiencies has shown marked improvement. The preparation is presented under the trade name of Perandren "Ciba" or Oreton "Schering." With two to three injections weekly of 10 to 25 mgm. of testosterone propionate, there has been a definite response in many cases in regard to stimulation of the male sexual functions, including libido and potency, with a definite growth of the accessory organs such as the penis and testicles. The larynx grows and voice becomes lower. There are many improvements in the mental and psychic state with relief of nervous and sexual symptoms. The treatment is apparently a replacement therapy. CANADIAN MEDICAL ASSOCIATION 1940 MEMBERSHIP 1940 FEE OF $8.00 INCLUDES JOURNAL OF C. M. A. TO BE PAID THROUGH THE OFFICE OF REGISTRAR COLLEGE DUES FOR 1940 $15.00 C. M. A. MEMBERSHIP, 1940 8.00 THIS WILL MAKE YOUR CHEQUE TOTAL FOR 1940 . $23.00 New Members are reminded that prompt response will assure receipt of the January number of the Journal. Please Note: College Dues have been reduced from $18.00 to $15.00 for 1940. British Columbia as a Division of the Canadian Medical Association has secured a reduction in Membership Fee—from $10.00/to $8.00. THE C. M. A. MEMBERSHIP FEE INCLUDES THE JOURNAL. Page 81 Victoria Medical Society Officers, 1938-39. President : Dr. W. A. Fraser Vice-President Dr. A. B. Nash Hon. Secretary Dr. E. H. W. Elkington Hon. Treasurer Dr. C. A. Watson PATHOLOGICAL CONFERENCE: DIVERTICULOSIS AND DIVERTICULITIS A Pathological Conference was held at the Royal Jubilee Hospital, Victoria, on Friday, October 13th, 1939, at 12 noon, under the chairmanship of Dr. G. A. McCurdy. Dr. F. M. Bryant presented the following paper on "Diverticulosis and Diverticulitis." It has long been known to anatomists and pathologists that abnormal hollow pouches may be found in the different parts of the alimentary canal. Craveilhier in 1849 gave a good description of multiple pouches in the large intestine; later others described this condition. Moynihan in 1901 published a report of cases he had seen. Radiology has proved that diverticula are far more common than had been thought, the incidence being about 10% in routine colon examination. The existence of pouches should be called diverticulosis, the term diverticulitis being applied to the inflammation of these pouches, intestinal wall and later surrounding structures. Multiple diverticula of the large intestine are usually small, occur in rows along the intestine between the taeniae, and are often found where the blood vessels and lymphatics pierce the muscle wall. Three stages of diverticulosis of the colon can be recognized: (1) The pre-diverticular state; (2) established diverticulosis; (3) diverticulitis. 1. In 192 0 O. A. Marxer noted that at times a part of the wall of the large intestine showed small shallow concave impressions deforming haustration or replacing it by a closely serrated outline, and that small diverticula were -often near such an area. Upon rechecking these patients a year or two later, diverticula were present where the fine corrugation had previously been observed. Among 564 consecutive cases of diverticulosis, the pre-diverticular state had been found in 132, or 23%. That there is a degenerative element in a diverticulosis is suggested by the fact that it arises as a rule in middle and later life, rarely in the young. It is thought that there is some previous inflammatory state which disorganizes the function or structure of the circulatory muscle, apparently dividing it up into bundles, separated by areas of weakness, which allows the projections or pouches to be easily formed. A fine irregularity of the peritoneal surface can be seen by the naked! eye, ascribed to bunching of the circular muscle fibres and sometimes separation of their bundles. On microscopic examination there has been evidence of mild chronic inflammation and of recent inflammation of the mucosa and sub-mucosa. It has been suggested that constipation and obesity are causes, but this has not been proven. The occurrence of inflammation gives rise to symptoms such as pain, discomfort and flatulence and in areas of extensive involvement symptoms of obstruction develop, due to spasm of the bowel. Page 82 r 2. The stage of diverticulosis: The pouches may be quiescent for years if the openings into the colon are wide, and inflammatory change is improbable. Many individuals with such diverticula are free from symptoms. In about half of the cases there be flatulence, pain or discomfort, irregular motions, or pain with defaecation. The diagnosis is made by X-ray. 3. Diverticulitis: When the openings of the pouches are narrow, and faecal matter cannot easily pass in and out, obstruction may occur. Inflammation tends to arise at the stretched neck of the sac or pouch, the blood supply is interfered with and bacteria pass through the wall into the surrounding tissues, which undergo inflammatory thickening. This is the beginning of diverticulitis. As the process continues, the necks become elongated and the sacs1 involved in the induration. The disease may extend over a large area of bowel without symptoms, but sooner or later symptoms may arise which are referable to involvement of the mucous lining, muscular or peritoneal coat, or all three. The clinical features are those of a low-grade inflarnmatory process usually involving the pelvic colon, which may spread to adjacent structures and usually runs an intermittent course with free intervals of weeks or months. Pain and discomfort are present below the navel. This may be associated with headache, malaise, fever, leucocytosis—the condition simulating a mild left-sided appendicitis. Constipation or a sense of incomplete evacuation or sometimes diarrhoea may occur. Palpation may reveal a sausage-like tender mass. Haemorrhage is not infrequent. Bladder symptoms are quite frequent and perforation into the bladder is not unknown. Abscesses may form around the affected areas. There may be a decided difference in symptoms, depending on whether the peritoneum or mucous membrane is first involved. There may be inflammatory cedema of the mucosal folds without involvement of the other layers, which may lead to some degree of obstruction. On examination a tender swollen colon may be palpated. There may be tenesmus. These cases may be relieved easily by saline enemata. There are cases that develop polypus with haemorrhage. Chronic inflammation of all the layers of the bowel may be present in the mild form of diverticulitis, with little or no obstructive symptoms, and the disease may be very advanced and extensive without either severe constipation or dilatation of the bowel above. Then there are the subacute cases, a tumour is palpable and the symptoms are intermittent, they respond well to medical treatment. In a small group of cases obstruction develops with little warning. In others there is an increasing constipation. These may be treated by warm olive oil enemata. Perforation, either acute or chronic, may develop as a complication. The former may occur in the stage of diverticulosis from a rupture of a sac or may occur from a rupture of a sac after diverticulitis has become well established, and cannot be diagnosed from a perforation of any other abdominal viscus. Inflammatory reaction with later abscess formation may follow. Diagnosis: The long history, the wellbeing of the patient, and the situation of the tumour, are often distinctive. X-ray in invaluable. It can usually be differentiated from carcinoma by means of the X-ray plus the sigmoidoscope. Prognosis: The pre-diverticular state and diverticulosis carry little risk, except in rare instances when a diverticulum ruptures. After diverticulitis has developed, danger may be avoided by suitable and appropriate treatment. Colostomy is necessary in some cases of obstruction and is followed by a cure of the inflammation, so that the bowel may be restored. Treatment Pre-diverticular state: Saline douches, a little mineral oil daily, and removal of all foci of infection. Diverticulosis: The body, the alimentary canal and especially the mouth and colon should be kept as healthy and clean as possible. All possible foci of sepsis should be removed. A small dose of liquid paraffin, night and morning, the development of a proper habit Page 83 BIOGRAPHY OF DR. HARVEY CUSHING Mrs. Cushing has requested me to prepare a biography of her husband, and I should be most grateful to anyone who wishes to make letters, anecdotes, or other memorabilia available. Copies of all letters, no matter how brief, are desired, and if dates are omitted it is hoped that, when possible, these may be supplied (e.g., from the postmark). If original letters or other documents are submitted, they will be copied and returned promptly. A new Medical Library building is being erected at the Yale University School of Medicine to receive Dr. Cushing's library and collections, including his letters, diaries and manuscripts. Any of his friends who wish, now or later, to present correspondence, photographs or other memorabilia for permanent preservation among the Cushing papers will receive the appreciative thanks of the University. John F. Fulton, M.D., Yale University School of Medicine, 333 Cedar Street, New Haven, Conn. DR. HARVEY CUSHING 1869-1939 By William Carleton Gibson, D.Phil. (Oxon.) Dr. Harvey Cushing was born in Cleveland, Ohio, seventy years ago last April 8 th. He was one of nine children, as was Osier. Hisj great-grandfather practiced medicine in Massachusetts, his grandfather in Cleveland, and his father became Professor of Obstetrics and Gynaecology in Western Reserve Medical School. Cushing's undergraduate life at Yale was characterized principally by his interest in baseball. He followed his brother Edward to the Harvard Medical School, and graduated with the degrees of M.A. and M.D. in 1895. He served an interneship in the Massachusetts General Hospital, where, as he has said, "surgery was done by the clock" and dressings were so neatly done that few had the heart to take them down to observe what was happening beneath them. In his time in Boston he saw only one operation on the brain, and it proved to be a complete failure. His interest was aroused by a small X-ray tube which Professor Warren brought back from Europe in 1896. The same year Cushing went to Johns Hopkins Hospital in Baltimore to serve his apprenticeship under Osier's colleague, Halsted. There he learned of such refinements in surgery as rubber gloves, fine silk sutures, and the handling of tissues with great gentleness. Cushing lived at 3 West Franklin Street, and became one of the "latch-keyers" of Osier's house next door. He took the first X-ray photographs which Johns Hopkins had seen, with a very small tube and "with the aid of a decrepit and perverse static machine as big as a hurdy-gurdy." His first paper1 concerned this X-ray of a bullet lodged in the spine of a patient, and proved to be his introduction to neurology. Each day he mapped the areas of anaesthesia as the patient recovered. In 1900 Cushing crossed the Atlantic with Osier and Thomas McCrae, probably with the inteniton of working under Victor Horsley. However, he went on to Berne, in Switzerland, where he was able to study and carry on research with Kocher and Kronecker on intracranial pressure. After a short stay in Italy, he went to Liverpool to work with the already famous Sherrington on the delineation of the motor cortex of anthropoids. Returning to Johns Hopkins Hospital in 1902 to do "neurosurgery," Cushing found his chief skeptical of such a venture and he was sent to work in the orthopaedic wards. At this time Cushing married and took up residence again at 3 West Franklin Street. His paper published in 19022 marks the introduction into American hospitals of routine blood pressure readings at the bedside, and of general BMR'S. He offered a course Page 84 in surgical anatomy in animals, and gradually came to the conclusion that surgeons in the future would not be made in the dissecting room, but in the experimental surgical laboratory. In 1908 he published a paper on the surgery of the heart valves3 and in 1912 brought out his well-known study on "The Pituitary Body and Its Disorders."4 Harvard University elected Cushing Professor of Surgery in 1912, and Surgeon-in- Chief of the Peter Brent Brigham Hospital in Boston. There, for twenty years, Cushing was to develop a neurosurgical clinic and school unrivalled in the world. He changed neurosurgery in that time into something more than brain carpentry; and while Horsley—a neurologist who took up surgery—left few pupils, Cushing left a veritable host of disciples. They are to be found in every corner of the world. To mention only three of them: Wilder Penfield, Director of the Neurological Institute; Hugh Cairns, the Nuffield Professor of Surgery at Oxford; and Herbert Olivecrona, in Stockholm. As a Harvard professor and internationally famous surgeon, Cushing spent strenuous days in long operations, often followed by tennis. Nothing recalls' this so much as to see Penfield playing squash; or Cairns, tennis; or Olivecrona, a hard game of golf—after operating. The University of Toronto, in 1922, awarded Cushing the Charles Mickle Fellowship, as the man who had "done most during the previous ten years to advance sound knowledge of a practical kind in medical art or science." Cushing returned the $1000 prize, which went with the Fellowship, to the University of Toronto, with the request that they send one of the best young graduates to him for training in neurosurgery. This was typical of his generosity, and he often paid from his own pocket for the blood transfusions which indigent neurosurgical patients needed. Many Canadians today remember with gratitude the surgery and help of Harvey Cushing. Cushing accompanied the Harvard Ambulance Unit to France in 1915, and in 1917 was intrumental in taking over further units. At the battle of Passchendaele he operated for sixteen hours a day. He was on duty when Revere Osier was brought in mortally wounded, and did his best to save him. On the backs of X-ray reports and temperature charts Dr. Cushing kept his monumental war diary, which finally totalled over a million words and is now bound in nine volumes—excerpts having been published in the Atlantic Monthly and in his "From a Surgeotfs Journal"^ Working wearily at this absorbing record long into the night, he declared "the writing centre is not in the angular gyrus, it's in the gastric mucosa." He is at his best in his description of the great day on which a steel splinter from an obus was extracted from the depths of a soldier's brain, with the help of a magnet and a six-inch nail. From all around, doctors came to see the performance, and, after the third attempt had failed, they left. Cushing was not to be beaten and went back, and on the" fourth attempt succeeded in extracting the piece of metal. How well he could say, with Walt Whitman, "The marrow of the tragedy is concentrated in the hospitals!" Cushing was honoured by the British Government with the order of Commander of the Bath; by the United States with the Distinguished Service Medal; while France made him an Officer of the Legion of Honour. After trying in vain to get the Allied governments to centralize all their neurological cases for study and treatment, Cushing returned to the United States, suffering from perpiheral neuritis. He was glad to be able to plunge into the work of compiling the vast quantities of material, dealing with the recently deceased Sir William Osier, which poured in from the four corners of the world. I venture to say that Harvey Cushing's name will be remembered longest for his unsurpassed biography of "The Great Canadian." With characteristic foresight, he dedicated the "Life of Sir William Osier"6 "To medical students, in the hope that something of Osier's spirit may be conveyed to those of a generation that has not known him; and particularly to those in America, lest it be forgotten who it was that made it possible for them to work at the bedside in the wards." It took five years to write this monumental work, sorting out mountains of material and dictating at every spare moment of the day. The Oxford University Press in 1925 published the work in two volumes; it had originally run to three volumes. This stimulating and unforgettable biography was awarded the Pulitzer Prize of 1926. Cushing's association with Osier was a long and happy one, brought together as they were by a common interest in books, in the history of medicine, and the training of the Page 85 profession. The following is a message' written by Osier in Naples to Harvey Cushing in 1909: "Thus far on the trip. Glorious place. Glorious weather. I wish you were mit. I dreamt of you last night—operating on Hughlings Jackson. The great principle, you said, in cerebral surgery was to create a commotion by which the association paths were restored. You took off the scalp, like a p.m. incision—made a big hole over the cerebellum and put in a Christ Church—whipped cream—wooden instrument and rotated it rapidly. Then put back the bone and sewed him up. You said he would never have a fit again. I said solemnly, I am not surprised. Hughlings Jackson seemed very comfortable after the operation and bought three oranges from a small Neapolitan who strolled into the Queen- Square amphitheatre! I have been studying my dreams lately and have come to the conclusion that just one-third of my time is spent in an asylum—or should be!" Dr. Cushing possessed one of the finest collections of medical books in America, including the almost complete works of Vesalius. While he was not, to quote his own phrase, "exophthalmic with hyperbiblioism," he nevertheless gravitated to anything concerned with books. How truly he wrote: "The soul of an institution that makes pretence to learning comes to reside in its library, no less than does the soul of a profession or of an individual!" Never interested in "institutional dinosaurs," Dr. Cushing loved to retail the story of the Librarian at Yale who, at the entrance to their mammoth new edifice, placed a sign which read: "This is*not the Yale Library. The Yale Library is inside." As a speaker at university or medical gatherings, Dr. Cushing had few equals in making a subject live. He shunned platitudes as the plague, and was gifted with a sparkling originality. In bis paper7 on "Dr. Garth, the Kit-Kat Poet" (1661-1718), he relates Johnson's story of Garth reading the funeral oration at the burial of John Dryden, from the top of a barrel, and of the lid falling in! In his highly entertaining description of Garth and his friend Dick Steele, Dr. Cushing does not forget to mention the fact that Garth, in 1696, raised subscriptions for the opening of a dispensary for the poor of London, where drugs could be obtained at cost. Just as Steele said in dedicating his play, "The Lover," to Garth, so might we say of Dr. Cushing: "The pitiful artifices which empirics are guilty of to drain cash out of valetudinarians, are the abhorrence of your generous mind." 1926 saw the publication of his well-known work on the classification of the gliomas8. It was graciously dedicated to Ramon y Cajal and the Spanish school of neuro-histologists. The year was marred by the death of his son William, who was killed in an accident at Yale. The Lister Centenary Committee invited Dr. Cushing to give a Memorial Oration in Edinburg in 1927, and this well-known speech "Emancipators" has been published along with many other brilliant papers in "Consecratio Medici."7 Rounding out twenty busy years at Harvard, Dr. Cushing, in 1932, published the famous work "Intracranial Tumours"9, describing two thousand verified cases from bis service. In 1932 he was able to report a mortality rate of only 5 %. The book is dedicated "In affection and gratitude to my successive co-workers and assistants in neurosurgery." In the same year he published a work on "Peptic Ulcers and the Interbrain"10, and a monograph on "Pituitary Basophilism"11 which has come to be known as "Cushing's syndrome." Retiring from Harvard at the age of sixty-four, he was invited to the newly created Sterling Professorship in Neurology at Yale, his former alma mater. With Dr. Louise Eisenhardt, he set to work to organize a brain tumour registry, which has brought together in New Haven most of the tumours of the nervous system which are known today. Without the burden of formal teaching, Dr. Cushing was able to work at his books and historical essays, and to attend such pathological conferences as this for which we have assembled today. I well remember one of these conferences, to which he took me in 1934. In true Oslerian fashion, he put his arms around the students as they strolled through' the halls in the New Haven Hospital on their way to the meeting. At the meeting, he was altogether too alert for some of the internes who became bogged in endless pathological verbiage, and an occasional quip interjected at the right moment sent the meeting into gales of laughter. In the autumn of 1934 Dr. Cushing gave the foundation address in neurosurgery12 Page 86 at the opening of the Montreal Neurological Institute, where his name has been inscribed in the Hall of Fame. An amusing incident is related by one of his hosts there, who, knowing that Dr. Cushing because of a painful disease of the feet was unable to walk far, took a wheel chair from the Hospital to meet him at the railway station. While his hosts searched the train for him, a dear old lady of enormous size spied the wheel chair, and promptly had a porter push her away in it. When Dr. Cushing appeared at the door of the train and saw no wheel chair in evidence, he hailed the baggage truck and rode triumphantly out of the station on top of a mound of luggage. His lightheartedness occasionally got him into amusing predicaments, as on the day when he came by the office of the Superintendent of Nurses in a large hospital, and found two probationer nurses waiting for a chastising from the Superintendent. He shouted to them at the top of his voice—"Don't take anything off her—life's too short!" Late in 1934 Dr. Cushing delivered the Presidential address to the History of Science Society in Washington, on the subject "The Humanizing of Science"13, a few paragraphs of which will serve to illustrate the elasticity of mind and the broad humanity of the man at the age of 65: "People in general are unquestionably becoming more socially minded—that it, more 'humanistic' in its broader sense. . . . "Among those who call themselves pure scientists, whatever their particular field, there are many who feel that they would demean ^themselves' and lose caste among their fellows should they engage in researches that obviously point to some utilitarian purpose. This I have always regarded as an academic pose; for in the disinterested pursuit of knowledge, to stumble, as did Roentgen or the Curies or Banting, on something not only of great scientific importance but which at the same time was immediately applicable to human welfare is certainly nothing to be ashamed of. "So let us hope that when some future student of this confused and disconcerting period in our history comes to tell of it, he will be able to say: That at the very time when such progress in their subjects was being made as never before, with one discovery following on the heels of another, the scientists and the engineers of the country temporarily abandoned the investigations dear to their hearts in order to concentrate on problems the most difficult of all to solve—those that have to do wtih the social well-being of the community at large. Thus, under a quickly spreading Religion of Humanity, there began a new era—one in which scientists took a commanding position in a rapidly changing world and through their well-planned and executed experiments a new and rational science of society came into being and made its first.great forward movement." Cushing's growing concern that men of science should more and more endeavour to understand the society in which they live was in a very real sense the thing which endeared him most to the present generation of medical students. I remember with what feeling and conviction he addressed them when he introduced Professor Henry Sigerist's series of lectures at'Yale in December, 1934. It was with the greatest satisfaction that his young admirers saw him receive the Gold Medal of the National Institute of Social Science in 1935. He was greatly concerned for the safety of the many world-renowned neurologists in Madrid during the Spanish war, and he was gratified to see some of Cajal's and Rio Hortega's pupils finally re-established in Mexico. In 1936 Dr. Cushing published a brief tribute to Ivan Pavlov14, and in 193 8 he brought out what has been called "his greatest clinical monograph," "The Meningiomas"15. Oxford University, in the same year, gave him the honorary degree of Doctor ol Science, his twenty-second honorary doctorate. On April 8 th of this year, his seventieth birthday was celebrated at New Haven by pupils and admirers from all over the continent. The Yale Journal of Biology and Medicine published a special Cushing number containing papers read by his former pupils at a special meeting of the Harvey Cushing Society. You will be interested to know that the first paper in the volume was presented by Dr. Frank Turnbull of Vancouver. Professor John Fulton told me that over one thousand testimonial letters arrived for the occasion, and that a group of twenty-five Swedish doctors sent a bound volume of specially prepared papers. Page 87 On October 4th Dr. Cushing suffered a coronary thrombosis, and he was carried off in the early morning of October 7, 1939. We must all feel that his loss leaves a great void in the medical world. Wherever one went—whether in Madrid, or Moscow, or Mexico City—one heard the same questions: "How is Dr. Cushing? What is he writing now?" Passing as did Osier, in his seventieth year, Dr. Cushing has been' saved a war that would have broken his spirit, as the last war broke Osier's. To Yale goes the honour of perpetuating the life and work of Harvey Cushing: the Medical Library is being enlarged to house the extensive and valuable collection of books which Dr. Cushing has willed to it; and Dr. John Fulton, the Sterling Professor of Surgery, is writing his biography. BIBLIOGRAPHY: 1. Haematomyelia from gunshot wounds of the spine. A report of two cases, with recovery following symptoms of hemilesion of the cord. Am. J. Med. Sci., June, 1898, 115:654-683. 2. On routine determinations of arterial tension in operating room and clinic. Boston Med. Surg. J., March 5, 1903, 148:250-256. 3. Experimental and clinical notes on chronic valvular lesions in the dog and their possible relation to a future surgery of the cardiac values. (With J. R. B. Branch.) /. Med. Res., Feb., 1908, n.s. 12:471-486. 4. The Pituitary Body and Its Disorders. Philadelphia and London: J. B. Lippincott Co., 1912, 8vo, 341pp. 4. From a Surgeon's Journal, 1915-191S. Boston: Little, Brown & Co., 1936. 8vo., 534 pp. 6. The Life of Sir William Osier. Oxford: At the Clarendon Press, 1925. 8vo., 2 vols, 685pp. and 728 pp. 7. Consecratio Medici and Other Papers. Boston: Little, Brown & Co., 1928. 8vo., 276 pp. 8. A classification of the tumours of the glioma group on a histogenic basis with a correlated study of prognosis. (With P. Bailey.) Philadelphia: J. B. Lippincott Co., 1926. 8vo., 175 pp., 10 8 figures. 9. Intracranial Tumours. Springfield, 111.: Charles C. Thomas, 1932. 8vo., 150 pp., Ill figures. 10. Peptic Ulcers and the Interbrian. Surg., Gynec. & Obstet., July, 1932. 55:1-34. 11. The Basophil adenomas of the pituitary body and their clinical manifestations (pituitary basophilism). Johns Hopk. Hosp. Buil., March, 1932. 50:137-195. 12. Psychiatrists, Neurologists and Neurosurgeons. Yale J. Biol. Med., Jan., 1937, 7:191-207. Also in Neurological Biographies and Addresses. London: Oxford University Press, 1936, 178 pp. 13. The Humanizing of Science. Science, Feb. 8, 1935, 81:137-143. 14. Ivan Pavlov. Soviet Russia Today, April, 1936, p. 9. 15. The Meningiomas (With Louise Eisenhardt). Springfield, 111.: Charles C. Thomas, 1938. Large 8vo., 785 pp., 685 figures. IT SIMPLIFIES THE PROBLEMS OF CONVALESCENCE ~^$#~ /f>4 'wh vp~^ Ovaltine contains these essentials: Proteins, Carbohydrates, Calcium, Phosphorus, Iron and Vitamins A, B, D and G. Once the crisis of an illness is past the problem generally becomes that of building new strength on a restricted diet, a diet that the weakened patient is able to tolerate and digest. Here Ovaltine is definitely helpful. Ovaltine has long been used as an aid to the solving of this problem. Ovaltine combines in easily digested form the proteins and carbohydrates required to rebuild wasted tissues and restores energy. Its rich vitamin and mineral values give it high rank as a "protective" food. It has the property of aiding the digestibility of milk and making it acceptable to patients who ordinarily cannot tolerate milk. In addition it is a pleasant drugless aid to sound, natural sleep. Why not recommend it to your patients? They will enjoy its appetizing flavour. OV4LXINE TONIC FOOD BEVERAGE Manufactured in Canada by A. WANDER LIMITED, Peterborough, Ontario. Page 88 In Obstetrics and Surgery . . . "DETTOL" FILLS A NEED "'DETTOL'—In contrast to its very low toxicity for skin and mucous membranes, its effect on the bacteria with which we are concerned in puerperal fever is high. Streptococcus pyogenes and B. Coli, even in the presence of pus, are killed within two minutes by a two per cent solution." Journal of Obstetrics and Gynaecology of the British Empire, Vol. 40, No. 6, 1935 The properties of 'Dettol'—demonstrated in actual practice —are quickly winning recognition with the medical profession of Canada. For 'Dettol' Antiseptic is a vast improvement over old type carbolic and cresylic germicides in that it is non-poisonous, gentle to human tissues, persistent in action, stainless, pleasant to use, and can be applied at highly effective strengths. 'DETTOL' is available through your regular druggist or surgical supply house. Literature and clinical sample available on request. Reckitts (Over Sea) Limited, Pharmaceutical Department, 1000 Amherst St., Montreal, P. Q. DETTOL The Modern, Non-Poisonous Antiseptic In Addition to laxative bulk Kellogg's ALL-BRAN contains vitamin Bi said by many authorities to help intestinal tone Made by Kellogg's DUE TO DIET DEFICIENCY OF"BUlK" KEU0GG COMPANY OF CMU0A.tni4ANDOH.OMt in London, Canada Serums. Vaccines. Hormones AND Related Biological Products Anti-Anthrax Serum Anti-Meningococcus Serum Anti-Pneumococcus Serums Diphtheria Antitoxin Diphtheria Toxin for Schick Test Diphtheria Toxoid Old Tuberculin Perfringens Antitoxin Pertussis Vaccine Vaccine Virus ( Pneumococcus Typing-Sera Rabies Vaccine Scarlet Fever Antitoxin Scarlet Fever Toxin Staphylococcus Antitoxin Staphylococcus Toxoid Tetanus Antitoxin Tetanus Toxoid Typhoid Vaccines Smallpox Vaccine) Adrenal Cortical Extract Epinephrine Hydrochloride Solution (1:1000) Epinephrine Hydrochloride Inhalant (1:100) Epinephrine in Oil (1:500) Heparin Solution of Heparin Insulin Protamine Zinc Insulin Liver Extract (Oral) Liver Extract (Intramuscular) Pituitary Extract (posterior lobe) 'Prices and information relating to these preparations will be supplied gladly upon request. CONNAUGHT LABORATORIES UNIVERSITY OF TORONTO Toronto 5 Canada Depot for British Columbia Macdonald's Prescriptions Limited MEDICAL-DENTAL BUILDING, VANCOUVER, B. C t 2559 Cambie Street a nc ouver. Colonic Irrigation Institute Superintendent: . B. M. LEONARD, R.N. Post Graduate Mayo Bros. Up-to-date treatment rooms; scientific care for cases such as Colitis, Constipation, Worms, Gastro-intestinal Disturbances, Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne. Individual Treatment 9 2.50 Entire Course . $10.00 Medication (if necessary) $1 to $3 Extra 1119 Vancouver Block VANCOUVER, B. C. Phone: Sey. 2443 506-7 CAMPBELL BUILDING VICTORIA, B. C Phone: Empire 2721 Canadian Distributors ROUGIER FRERES 350 Le Moyne Street, Montreal MPHAMETTES H m y &m \ V J£i A A*t ^AlpJi&mette"a dau, jjfMun how- u+vtil Mom "ALPHAMETTES" build resistance to colds and infections. Each capsule contains 10,000 International Units of Vitamin A and 1,750 International Units Of Vitamin D. AYERST, McKENNA & HARRISON LIMITED Biological and Pharmaceutical Chemists MONTREAL, CANADA Exclusive Ambulance Service FAIR. 0080 PRIVATE AMBULANCES AND INVALID COACHES WE SPECIALIZE IN AMBULANCE SERVICE ONLY J. H. CRELLIN W. L. BERTRAND Indications and Dosage For B. D. H. Vitamin Products Vitamin Specific Deficiency Disease and Hypovita- minotic Symptoms B.D.H. Product Indicated Form 1 Daily Dose A Night blindness Susceptibility to bacterial infection Rickets Dental caries AVOLEUM Liquid Capsules 3 drops to 1 teaspoonful 1 to 3 capsules D RADIOSTOLEUM (A and D) PHYTOFEROL Liquid Capsules 6 to 15 drops (prophylactic) 15 drops to 2 teaspoonfuls (therapeutic) 1 to 3 capsules E Abortion (habitual or threatened) ; Pregnancy toxaemia; Vulvo-vaginitis; Deficient lactation; Sterility Capsules 1 to 6 capsules Bi Beriberi Neuritis; Intestinal atony; Anorexia VITAMIN Bi B.D.H. Tablets Ampoules 1 mg. to 10 mg. P.P. factor Pellagra Glossitis; Diarrhoea; Dermatoses; Psychoses NICOTINIC ACID B.D.H. ASCORBIC ACID B.D.H. Tablets 60 mg. to 1200 mg. C Scurvy Anaemia; All pyrexial states; Cataract; Peptic ulceration Tablets Ampoules 25 mg. to 250 mg. In the commonly occurring states of general hypovitaminosis which cannot be classified as specific diseasie entities the two B.D.H. products Radio-Malt (Vitamins A, Bi, B2 and D) and Multivite (Vitamins A, Bi, C and D) are indicated. Stocks of B.D.H. Vitamin Products are held by leading druggists throughout the Dominion, and full particulars are obtainable front: THE BRITISH DRUG HOUSES (CANADA) LTD. Terminal Warehouse Toronto 2, Ont. VP/Can/3911 m®m>m?M% Breaks the vicious circle of perverted menstrual function in cases of amenorrhea, tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic relief by stimulating the innervation of the uterus and stabilizing the tone of its musculature. Controls the utero-ovarian i circulation and thereby encourages a , Ik normal menstrual cycle. V • MARTIN H. SMITH COMPANY ■^ 150 lAMYITTt ST«lit. NEW YORK. N. T. Full formula and descriptive literature on request Dosage: l to 2 capsules 3 or 4 times daily. Supplied in packages of 20. Ethical protective mark MHS embossed on inside of each capsule, visible only when capsule is cut in half at seam. A Word of Thanks... htm 2 *% 8 W P^-M:1 ^1 To the Medical Profession for their assistance to the dairy industry in making known to the consuming public the important part dairy products play in promoting health. IT PAYS TO BE SURE OF YOUR MILK SUPPLY "Ar<C^y^?« LIMITED fffor J€Rf€Y QUALITY MILK CREAM BUTTERMILK Here t^*^?*^*-: Ml Example of severe rickets in a sunny clime* Iest we forget—we who are of the j vitamin D era—severe rickets is not yet eradicated, and moderate and mild rickets are still prevalent. Here is a white child, supposedly well fed, if judged by weight alone, a farm child apparently living out of doors a good deal. This boy was reared in a section having a latitude between 37° and 42°, where the average amount of fall and winter sunshine is greater than that in the major portion of Canada. And yet such stigmata of rickets as genu varum and the quadratic head are plain evidence that rickets does occur under these conditions. How much more likely, then, that rickets will develop among city-bred children who live under a smokepall for a large part of each year. True, vitamin D is more or less routinely prescribed nowadays for infants. But is the antiricketic routinely administered in the home? Does the child refuse it? Is it given in some unstandardized form, purchased from a false sense of economy because the physician did not specify the kind? A uniformly potent source of vitamin D such as Oleum Percomorphum, administered regularly in proper dosage, can do more than protect against the gross visible deformities of rickets. It may prevent hidden but nonetheless serious malformations of the chest and the pelvis and will aid in promoting good dentition. Because the dosage is measured in drops. Oleum Percomorphum is well taken and well tolerated by infants and growing children. Rigid bioassays assure a uniform potency —100 times the vitamins A and D content of cod liver oil*. Oleum Percomorphum, moreover, is a natural product in which the vitamins are in the same ratio as in cod liver oil*. Oleum Percomorphum offers not less than 60,000 vitamin A units and 8,500 vitamin D units (International) per gram. Supplied in 10 and 50 c. c brown bottles, also in 10-drop soluble gelatin capsules, each offering not less than 13,300 vitamin A unto and 1,850 vitamin D unto. In boxes of 25 and 100. *U.S.P. Minimum Standard MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ont. enclose professional card when requesting sample* of Mead Johnson products to co-operate in preventing their reaching unauthorized persons. 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Periodicals
W1 .VA625
English
Vancouver : University of British Columbia Library
Vancouver, B.C. : McBeath Spedding Limited
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Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: December, 1939
Text