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History of Nursing in Pacific Canada
Vancouver Medical Association
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ll( The BULLETIN of the VANCOUVER MEDICAL ASSOCIATIO Vol. XV. MARCH, 1^9 #«-, x 19 Q Wm With Which Is Incorporate^ Transactions of the o Victoria Medical Society the Vancouver General Hospital and St. Paul's Hospital ^^s^ Jn TAis Issue: NEWS AND NOTES "RHEUMATISM" POINTS IN PHYSICAL ANTHROPOLOGY No. 6 V. M. A. SUMMER SCHOOL, JUNE 6-9, 1939, INCL. BULKETTS (With Cascara and Bile Salts) . . FOR . . Chronic Habitual Constipation BULKETTS POSSESS ENORMOUS BULK PRODUCING PROPERTIES AND BEING PROCESSED WITH CASCARA AND BILE SALTS PRODUCE BULK WITH MOTILITY. WE WILL BE PLEASED TO PROVIDE ORIGINAL CONTAINERS FOR TRIAL ON REQUEST^ Western Wholesale Drug (1928) Limited 456 BROADWAY WEST VANCOUVER - BRITISH COLUMBIA (Or at all Vancouver Drug Co. Stores) THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical-Dental Building, Georgia Street, Vancouver,'B. C. Editorial Board: Dr. J. H. MacDebmot Dr. M. McC. Baird Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XV. MARCH, 1939 No. 6 OFFICERS 1938-1939 Dr. Lavell H. Leeson Dr. A. M. Agnew President Vice-President Dr. W. T. Lockhart Hon. Treasurer Dr. G. H. Clement Past President Dr. D. F. Busteed Hon. Secretary Additional Members of Executive: Dr. J. P. Bilodeau, Dr. J. W. Arbuckle. Dr. F. Brodie TRUSTEES: Dr. J. A. Gillespie Historian: Dr. W. D. Keith Auditors: Messrs. Shaw, Salter & Plommer Dr. Nell McDougall SECTIONS Clinical Section Dr. W. W. Simpson Chairman Dr. F. Turnbull Secretary Eye, Ear, Nose and Throat Dr. S. G. Elliott Chairman Dr. W. M. Paton Secretary Pediatric Section Dr. G. A. Lamont Chairman Dr. J. R. Davies. Secretary Cancer Section Dr. B. J. Harrison Chairman Dr. Roy Huggard— —Secretary STANDING COMMITTEES Library: Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland, Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davies. Publications: Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird. Summer School: Dr. A. B. Scheinbein, Dr. H. Caple, Dr. T. H. Lennje, Dr. Frank Turnbull, Dr. W. W. Simpson, Dr. Karl Haig. Credentials: Dr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J. Buller. V. 0. N. Advisory Board: Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell. Metropolitan Health Board Advisory Committee: Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller. Greater Vancouver Health League Representatives: Dr. W. W. Simpson, Dr. W. N. Paton. Representative to B. C. Medical Association: Dr. G. H. Clement. Sickness and Benevolent Fund: The President—The Trustees. I' i n EMMIQTIN (Squibb Estrogenic Substance) SPECIAL PACKAGES AVAILABLE FOR USE IN Amniotin has a regenerative effect on the type of nasal mucosa seen in atrophic rhinitis ... an effect that has been found useful in the treatment of this condition. Amniotin in Oil for Intranasal Administration by the physician is provided in 5-cc. screw-cap vials containing 10,000 International Units per 1 cc... . may be applied to nasal mucosa on cotton pledgets or by means of an atomizer. The insert accompanying this package outlines procedure for treatment. Amniotin in Oil with Nasal Atomizer—An atomizer package for home use under the direction of the physician. It contains a total of 20,000 International Units of Amniotin in 30 cc of specially purified corn oil. It provides for continuous treatment during the intervals between periodic visits to the physician's office or to the clinic. No printed matter accompanies this package. Amniotin in Oil for Intranasal use is also supplied without atomizer in 30-cc bottles {total potency 20,000 International Units). For literature write Professional Service Dept., 3 6 Caledonia Rd., Toronto E-RiSqjjibb&Sons of Canada, Ltd. MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858 (. t,7 VANCOUVER HEALTH DEPARTMENT STATISTICS, JANUARY, 1939 Total population—estimated . 263 974 Japanese population—estimated 8891 Chinese population—estimated . 7728 Hindu population—estimated '359 Number Total deaths 248 Japanese deaths 6 Chinese deaths p 12 Deaths—residents only 222 BIRTH REGISTRATIONS: Male, 192; Female, 164 INFANTILE MORTALITY: Deaths under one year of age Death rate—per 1,000 births Stillbirths (not included in above) - 356 Jan., 1939 9 25.3 8 Rate per 1,000 Population 11.1 8.0 18.3 9.6 15.9 Jan., 1938 8 24.0 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY February December, 1938 Cases Deaths January, 1939 Cases Deaths Scarlet Fever 39 0 27 0 20 Diphtheria : -- 0 0 0 0 0 Chicken Pox - 105 0 145 0 60 Measles 2 1 3 0 1 Rubella 2 1 6 0 2 Mumps 5 0 7 0 6 Whooping Cough 31 0 96 0 39 Typhoid Fever 10 10 1 Undulant Fever 0 0 0 0 0 Poliomyelitis 0 0 0 0 0 Tuberculosis 43 16 44 13 14 Erysipelas 3 0 2 0 2 Ep. Cerebrospinal Meningitis 0 0 0 0 0 V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH, DIVISION OF VENEREAL DISEASE CONTROL. 1st to 15th, 1939 Cases Deaths 20 0 Burnaby Syphilis 0 Gonorrhoea 0 Richmond 0 1 North Vancr. 0 0 Vancr. Clinic 43 92 Hospitals, Private Drs. 33 25 Totals 76 118 § BIOGLAN} THE SCIENTIFIC HORMONE TREATMENT Descriptive Literature on Request. A Product of the Bioglan Laboratories, Hertford, England. Represented by STANLEY N. BAYNE 143 2 MEDICAL-DENTAL BUILDING "Ask the Doctor Who Is Using It" Phone: SEYMOUR 4239 VANCOUVER, B. C. Page 151 f w A NEW TREATMENT FOR HYPERTENSION HEADACHE HYPOTENSYL is a synergistic combination of Viscum album extract (European mistletoe) with hepatic and insuline-free pancreatic extracts. Especially indicated for headache ,and dizziness associated with essential hypertension, fibrotic kidney and elevated blood pressure accompanying pregnancy. The dose is 3 to 6 tablets daily, one-half hour before meals. For literature and samples write to: ANGLO-FRENCH DRUG CO., 3 54 Ste. Catherine E., MONTREAL HYPOTENSYL FOR RELIEF OF HIGH BLOOD PRESSURE. VANCOUVER MEDICAL ASSOCIATION Founded 1898 Incorporated 1906. GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m. Place of meeting will appear on the Agenda. General meetings will conform to the following order: 8 p.m.—Business as per Agenda. 9 p.m.—Papers of the evening. Programme of the 41st Annual Session (Winter Session) 1939 March 7th—OSLER LECTURE: Dr. J. H. MacDermot: "The Layman and the Doctors." March 21st—CLINICAL MEETING. April 4th—GENERAL MEETING. Canadian Society for the Control of Cancer. April 18th—CLINICAL MEETING. April 25th—ANNUAL MEETING. ADIONULS1N (Radiostoleum Emulsion with Vitamins B^ and C) During infancy and childhood the most urgently-needed vitamins are A, B1} C and D. Of these, Vitamins A and D have hitherto been administered in the form of fish-liver oils or of Radiostoleum, and Vitamin C as orange juice or tomato juice. Vitamin Bj is present in human milk and in cows' milk, but in variable and, generally, inadequate amounts. The administration of supplementary amounts of Vitamin Bj is, therefore, particularly essential, especially since the other dietary sources of this vitamin are not suitable for infants. The administration of Radiomulsin is a simple means of giving Vitamins A, Bi, C and D in accurately-standardised quantities in suitable proportions. Radiomulsin may be given direct from a spoon or mixed with the feeds; it is available from the principal drug stores in bottles of 4 fl. oz. and of 16 fl. oz. Stocks of Radiomulsin are held by leading druggists throughout the Dominion, and full particulars are obtainable from: THE BRITISH DRUG HOUSES (CANADA) LTD. Terminal Warehouse Toronto 2, Ont. Etmul/Can/393 Page 152 EDITOR'S PAGE A certain happening in this city a few weeks ago is worth recording, and its implications worthy of close consideration, since they are, we think, vitally important, not only from our particular point of view, since we were in this case the one whose ox was gored, but as affecting every citizen of our country. A campaign is on foot in Vancouver to lessen the incidence, and mitigate the evil effects, of venereal disease. This campaign has the endorsation and support of provincial and municipal health departments. The Greater Vancouver Health League, in co-operation with these departments, arranged for a public meeting, at which were present Dr. G. M. Weir, Minister of Health for B. C, the Mayor of Vancouver, Dr. J. Lyle Telford, and others, so that it may be regarded as quite respectable. The Crystal Ballroom of the Hotel Vancouver was packed to bursting, and many hundreds were turned away. Dr. Williams, Director of the Venereal Diseases Division of the Provincial Health Department, was the chief speaker. His message was timely, important to everyone in B. C, calculated to promote health, to prevent premature death, chronic disease and suffering and immense monetary loss. It was felt by all concerned that this should be broadcast, so that everyone could hear it, young and old. The power to grant or refuse this rests with the authorities of the Canadian Broadcasting Corporation in Ottawa: a very proper restriction if rightly used. The president of the League, Dr. Strong, and others, made every attempt to get permission, but it was refused, unless the words promiscuous and promiscuity were substituted for prostitute and prostitution, and the words brothel and bawdy house omitted from Dr. Williams' speech, which had been submitted for review. This would perhaps impress one at first as merely silly prudery and a curious species of bowdlerism, and there is no doubt that this enters into the situation to some extent. But there is far more to it than that. The final power to accept or reject lies with Dr. J. J. Haegerty, whose name appears on certain government publications, and who occupies the position of advisor to the C.B.C. His objection, as stated to Dr. Strong, over the telephone, was that "he did not agree" with Dr. Williams' opinions as to the cause of venereal disease. He believed that promiscuity, not prostitution, was the chief cause of the spread of venereal disease, and so he used his power to control what must be said by competent men over the air. And we talk of Hitlerism! Leaving out the relative values of the opinion of Dr. Haegerty, who is not, we believe, in active practice, and that of an expert such as Dr. Williams, there is the much deeper question of the danger that exists, that a solitary man can say, from his personal opinion, what is, and what is not, to be said over the air. It was not the fact that Dr. Williams was discussing venereal disease that earned the rejection: it was that Dr. Haegerty did not agree with the opinions expressed. We leave it to our readers to think out for themselves to what this may lead. We feel that no stone should be left unturned till such a dangerous autocracy is overthrown. And there is one more point. If Dr. Haegerty is going to make himself responsible for what is said over the air, he must admit responsibility for the dangerous and misleading advertisements that are allowed over the air, of quack remedies, of proprietary medicines, of painkillers and alkalizers and all the other tripe that is daily dispensed via the radio, advising tablets for pain, pills for "all the deficiencies that you or any of your family may suffer from," and so on. Does Dr. Haegerty agree with these? If so, he is not a safe man for censor; if not, why does he not stop them? He cannot have it both ways. We hope that our provincial and federal medical organizations will take up this challenge, and carry the fight to a finish. It is a matter too vital to our fundamental liberties to be left where it is. Who was it that said "1 do not agree with a word you say, but I will fight to the death for your right to say it"? We all agree that safeguards to broadcasting are right and necessary things: but they must not be left to any one man to impose. Omitted from February, 1939, Issue The name of Dr. H. H. Pitts, of the Vancouver General Hospital, Vancouver, B. C, was omitted as author of the article "Blood Sedimentation Tests," page 148, Feb. issue. Page 153 NEWS AND NOTES News comes from Whitehorse, Y.T., that on January 23rd Dr. Neil Stewart and 1000 pounds of supplies were flown from there to Aishikik Lake, where sixty Indians were reported starving in icy weather that cut off their usual food sources. Congratulations are extended to Dr. and Mrs. F. S. Hobbs on the birth of a daughter on January 21st, 1939. * & | * The sympathy of all members of the Vancouver Medical Association will go out to Dr. J. P. Bilodeau on the death of his mother, Mrs. O. P. Bilodeau, of New Westminster. Dr. G. F. Strong will leave early in March for San Francisco, where he will attend a meeting of the Pacific Interurban Club. Following this he will attend the meeting of the American College of Physicians, of which he is a Fellow, in New Orleans. Dr. Murray McC. Baird attended the Spring meeting of the North Pacific Society of Internal Medicine in Tacoma on February 25 th. Dr. D. A. Tompsett has left for California, where he will spend a three or four weeks' holiday. | * * * Puget Sound Surgical Society. Dr. D. M. Meekison will attend the meeting of the Puget Sound Surgical Society in Seattle on March 10th and 11th. Clinics at this meeting will be held in the morning, and there will be an evening meeting which will take the form of an informal dinner, at which the guest of honour will be Dr. Phillip Wilson, Surgeoh-in-Chief of the Ruptured and Crippled Children's Hospital of New York. Dr. Wilson will address the meeting, and will answer questions. If Dr. Wilson accepts the invitation extended to him to address the members of the Vancouver Medical Association on March 13 th, he will motor up from Seattle With Dr. Meekison. | | * * Dr. Wallace Wilson will leave on March 9th for Toronto, to attend a meeting of the Executive Committee of the Canadian Medical Association, at which he will present his report as Chairman of the Committee on Economics of the Canadian Medical Association. Dr. Walter S. Turnbull. A very pleasant little ceremony, including a dinner, was held at Shaughnessy Golf Club on January 7th, when the Gynaecological and Obstetrical Staff of the Vancouver Medical Society marked the retirement of Dr. Walter S. Turnbull from the active attending staff of the Hospital. Dr. Turnbull has been Chief of Staff in Gynaecology and Obstetrics for some years, and it is with unfeigned regret we see him relinquish this position, which he has filled so admirably. His work as surgeon was only part of his duties, which included administration of this department, the teaching of internes and nurses, and so on. He did it all well. The dinner was organized by Dr. J. P. Bilodeau, and that one statement is guarantee that it was a nice, quite orderly, and quite respectable affair. Everything went off very tranquilly. (There were a few regrettable exceptions, perhaps, but Joe was not to blame.) There were some speeches (sparkling and witty, as one would expect from an obstetrical concourse) and a few toasts were drunk. (We were assured that it was not the quantity, but the quality.) The evening ended very happily with the presentation of a large silver platter to Dr. Turnbull, as a memento of the cordial and friendly relations that have always existed between him and his staff. Dr. Turnbull responded suitably, and the evening closed with bridge and other parlour games. Page 154 nm Dr. George Paine has received the appointment as Indian Medical Officer for the Penticton district. Dr. W. H. White was a visitor to Vancouver over the February 10th week-end, attending the Graduate Nurses' Dance and renewing acquaintances about the General Hospital and Medical-Dental Building. The members of the Penticton Medical Society are still attempting to reach a mutually satisfactory relief arrangement with the local council. The Sub-Committee on hospital affairs is busy drawing up a list of new equipment, etc., with the co-operation of the hospital board. The Kelowna medical men are also interested in the relief problem and are corresponding with the Penticton group for their mutual benefit. Dr. and Mrs. C. C. Browne of Nanaimo are receiving congratulations on the birth of a son. Dr. W. J. Elliot is now at Chemainus with Dr. R. N. Dick. Dr. W. J. Knox of Kelowna called at the office while in Vancouver last week. Dr. J. J. Gillis of Merritt was in Vancouver last week. Dr. Alan Beech of Salmon Arm visited the office last week. at. *(• *?• A Dr. W. Allan Fraser, Dr. Arthur B. Nash, Dr. R. A. Hunter and Dr. Glenn Simpson of Victoria came to Vancouver for a Conference on Treatment of the Division of Venereal Disease Control. Dr. Harvey Agnew of the Canadian Medical Association, in the Department of Hospital Service, met the local members of the Committee on Hospital Service of the British Columbia Medical Association while in Vancouver. Dr. Agnew was in Seattle attending a convention of the Western Hospitals Association. He is President of the American Hospital Association. Dr. Walter S. Turnbull, Chairman of the British Columbia Committee, conferred with Dr. Agnew. *r "■(• *r *c Dr. Osborne Morris of Vernon and Dr. J. Bain Thorn of Trail, who represent No. 4 and No. 5 Districts, respectively, were in Vancouver on February 16th to attend a session of the Medical Council. Dr. Thomas McPherson and Dr. Gordon C. Kenning of Victoria, who represent District No. 1, and Dr. S. Cameron MacEwen of New Westminster, who represents District No. 2, also attended this all-day session of the Medical Council, along with Dr. W. E. Ainley and Dr. L. H. Appleby of Vancouver, representatives of District No. 3. •*" 'i* »r *f Dr. H. F. Tyerman of Nakusp called at the office en route home after an extended holiday in California from which he has received much benefit. Dr. George F. Young relieved Dr. Tyerman in the practice at Nakusp. MAYO FOUNDATION A special programme of lectures and demonstrations in surgery and medicine will be held under the direction of The Mayo Foundation from April 11 to 15, inclusive. Mornings will be devoted to surgical and medical clinics. In the afternoons and evenings presentations of various surgical subjects will be made and symposiums will be conducted on heart disease, arthritis, gynaecology, gastro-enterology, oxygen therapy, pneumonia and bronchial asthma. Visiting physicians are invited to attend. Page 155 LIBRARY NOTES Publication of Member Pulmonary Embolism: Dr. G. F. Strong. CM.A.J., February, 1939. Items from the Journals. Problem of Rheumatism and Arthritis: Review of American and English Liteurature. Ann. of Internal Medicine, February, 1939, p. 1005. Neonatal Mortality at the Philadelphia Lying-in Hospital: R. M. Tyson, M.D. Amer. Jl. Obstet. & Gynaec, February, 1939, p. 241.' Symposium on Cancer, Surg., Gynaec. & Obstet., February, 1939. Whooping-cough—New phases of the work on immunization and prophylaxis: L. W. Sauer, M.D. J.A.M.A., January 28, 1939, p. 305. Estimation of Disability after Injuries to Bones and Joints: W. G. Stern, M.D. J.A.M.A., January 28, 1939, p. 293. Peripheral Vasctdar Disease: A. Ochsner and M. De Bakey. J.A.M.A., January 12, 1939, p. 230. Journals in the Library. Following is a list of Journals and Proceedings in the Library which deal with General Medicine. American Journal of Digestive Diseases. Journal of Infectious Diseases. American Journal of Medical Science. Annals of Internal Medicine. Archives of Internal Medicine. Bulletin Johns Hopkins Hospital. British Medical Journal. Canadian Medical Journal. Clinical Science. Endocrinology. Guy's Hospital Reports. Indian Journal of Medical Research. Journal of Allergy. Journal of Clinical Investigation. Journal of Immunology. Quarterly Journal of Medicine. Journal of Laboratory and Clinical Medicine. Journal of Royal Army Medical College, Journal of Tropical Medicine. Lancet. Medical Journal of Australia. Medical Research Council Reports. Medicine. New England Journal of Medicine. Post Graduate Medical Journal (English). Practitioner. Proceedings of Staff oj Mayo Clinic. Proceedings of Royal Society of Medicine. Candian Society for the Control of Cancer Formal notice has been received in Canada that His Majesty King George VI has been pleased to extend his patronage to the Canadian Society for the Control of Cancer. AMERICAN PHYSICIANS' ART ASSOCIATION The American Physicians' Art Association, composed of members in the United States, Canada and Hawaii, will hold its second Art Exhibit in the City Art Museum of St. Louis, May 14-20, 1939, during the annual session of the American Medical Association. Art pieces will be accepted for this art show in the following classifications: (1) Oils, both (a) portrait and (b) landscape; (2) water colours; (3) sculpture; (4) photographic art; (5) etchings; (6) ceramics; (7) pastels; (8) charcoal drawings; (9) book-binding; (10) wood carving; (11) metal work (jewelry). Practically all pieces sent in will be accepted. There will be over sixty valuable prize awards. For details of membership in this Association and rules of the Exhibit, kindly write to Max Thorek, M.D., Secretary, 850 Irving Park Blvd., Chicago, 111., or F. H. Redewill, M.D., President, 521-536 Flood Bldg., San Francisco, Calif. Page 156 DR. STUART ECCLES BEECH The profession in British Columbia has sustained a serious loss in the passing, on the 29th of January last, of Dr. Stuart Beech, who practised in Salmon Arm during 14 years. Those who knew him were shocked at the premature closing of a useful life. "Free from self-seeking, envy, low design, I have never found a whiter soul than thine." His friends would describe him thus. A sorrowing community mourns the loss of a doctor and friend. The funeral services were largely attended. The late Dr. Beech was born in India, where his father served as Colonel in the I.M.S. In 1895 the family moved to Canada. After attending St. John's College, where he secured his B.A. in 1905, Dr. Beech proceeded to Oxford as Rhodes Scholar in that year, where he majored in Physiology, obtaining the Arts degree. Subsequently he was a student at Middlesex Hospital. He decided to complete his medical education in Canada and graduated in Medicine from the University of Manitoba in 1911. He returned to England to be married and then came to British Columbia in November, 1911. He first practised in Nanaimo and Parksville and was associated for a time with the late Dr. Ingham. He served during the war with the rank of Major from 1915 to 1919, when he returned to take up practice in Ashcrof t, whence he moved to Salmon Arm in 1924. His brother, Dr. Alan Beech, soon joined him, and these two happily served together during several years. Our late colleague leaves to mourn his passing a widow, a daughter and four sons, to all of whom the profession extends its sincere sympathy in their sorrow. Vancouver Medical Association OSLER DINNER Plans are all made for the annual Osier Dinner and Lecture, which is to be held in the Oval Room of the Vancouver Hotel on March 7th at 7:15 p.m. Dr. J. H. MacDermot, the Lecturer for 1939, has chosen as his subject "The Layman and the Doctors." A loudspeaker will be installed for the occasion, which will ensure good reception in all parts of the room. The dinner will be formal, price $1.25. Dr. Philip Wilson, Clinical Professor of Orthopaedic Surgery at Columbia University School of Medicine, who will be in the west in March, has been invited to speak as a guest of the Vancouver Medical Association at a special meeting on Monday, March 13 th, in the Auditorium of the Medical-Dental Building. While definite word has not yet been received from Dr. Wilson, it is more than probable that he will be here, and members are requested to keep this date in mind, until further notice. Dr. Wilson is Surgeon-in-Chief of the Ruptured and Crippled Children's' Hospital in New York City and was formerly Surgeon- in-Chief of the Massachusetts General in Boston. He has just recently published a book reviewing 4390 Fractures and Dislocations. Dr. H. A. DesBrisay has announced his intention of spending a month in the East and Southern States and will therefore not be able to speak to the Association at the regular meeting in April. Page 157 mm The Programme Committee is pleased to announce that the Chairman of the Canadian Society for the Control of Cancer, B. C. Branch, Dr. A. Y. McNair, has been asked to arrange the programme for the general meeting April 4th, and that he has agreed to do so. Nominations for officers of the Association and members of Committees for the year 1939-1940 will be received after the first of March. Voluntary Hospital Insurance. A committee has been appointed by the Executive Committee of the Vancouver Medical Association, consisting of Drs. Wallace Wilson, G. F. Strong, L. H. Appleby, L. H. Hodgins and A. M. Agnew, to study plans of Voluntary Hospital Insurance. This Committee will meet with representatives who have been appointed from the Vancouver General Hospital and St. Paul's Hospital at a date to be arranged in the near future. SUMMER SCHOOL CLINICS June 6th to 9th, Incl., 1939 Plans are rapidly taking definite shape for the programme for Summer School to be held in June of this year. The School will be held in the new hotel, where the management has promised good lecture-room facilities. There is no question as to the quality of the fare to be provided, either in variety or interest. At the time of going to press the following lecturers have promised to be there: Dr. L. C. Conn, Professor of Obstetrics and Gynecology, University of Alberta. Dr. Conn is a graduate of McGill University of the year 1909. He is no stranger to British Columbia medical profession, as he gave two excellent papers at the 1934 Annual Meeting of the British Columbia Medical Association. Dr. Emil Holman, Professor of Surgery, Stanford University School of Medicine. He is a graduate of Johns Hopkins University, 1918, and is at present head of the Department of Surgery at the Lane and Stanford University Hospitals. Dr. Charles P. L. Mathe, Urologist, is a graduate of the University of California, 1916. He is Urologist-in-Chief of St. Mary's and Southern Pacific Hospitals. He is a linguist, contributing to English and American journals and also to French and Spanish medical publications. He is reported to be an excellent lecturer. Dr. Dwight L. Wilbur, Associate Clinical Professor of Medicine at Stanford University. English by birth (he was born at Harrow-on-the-Hill), he graduated from University of Pennsylvania in 1926. He spent eight years at the Mayo Clinic before going to Stanford. He is also a consistent contributor to the best of medical journals dealing with Internal Medicine. COMMITTEE ON ECONOMICS OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF BRITISH COLUMBIA. IMPORTANT NOTICE APPOINTMENTS AND CONTRACTS Members of the College of Physicians and Surgeons of British Columbia are reminded by the Committee on Economics of the Council that they SHOULD NOT APPLY for any APPOINTMENTS or enter into negotiation with reference to any CONTRACT without having first communicated with either or both: Dr. A. J. MacLachlan, Registrar, College of Physicians and Surgeons of B. C. or/and Dr. M. W. Thomas, Executive Secretary, College of Physicians and Surgeons of B. C. 158 POINTS IN PHYSICAL ANTHROPOLOGY Geo. E. Kidd, M.D., F.R.C.S. (Read before the Vancouver Medical Association February 7th, 1939) A few years ago I had the pleasure of spending an evening with the late Dr. Davidson Black, then on the staff of the Rockefeller Foundation Medical School of Peking. He was returning to China from a convention of anthropologists which had been held in Sweden. In the pocket of a belt which was strapped to his body underneath his clothing, he carried a molar tooth. It had been found by workmen during excavations some 20 miles from Peking in a soil formation laid down during early Pleistocene times, several thousand years ago. Dr. Black insisted that the tooth was human, and he had made the trip to Sweden to have his opinion verified. Later, on his return to China, he arranged to continue the excavations, under his own supervision, and as you know, his faith was rewarded by the finding of the skull of the Peking Man, or Sinanthropus. Dr. Black, who was an unassuming young man from Western Ontario, and a graduate of Toronto Medical School, found himself world-famous, with unlimited funds of the Rockefeller Foundation at his disposal, and the world as his field of operation for research. This episode is what Sir Elliot Smith called the "Great Romance of Anthropological Discovery," for while other important finds, such as the Java and Piltdown man, have been accidental, we owe the Peking Man to Dr. Black's persistence in following a clue supplied by a single tooth. Since we cannot all have China or Java as our fields of investigation, we must of necessity deal with what material we have at hand. British Columbia is a fertile enough field for an enquiring mind, and I wish to deal briefly with a few of the features which it presents. The Mongolian Spot.—Those of you who have had occasion to do obstetrical work among the Chinese or Japanese of this city, will probably have noted on most newborn babies a darkly pigmented area on the sacral or lumbar areas of the back. It is fairly constant, being present in 98 per cent of Chinese, and in 90 per cent of Japanese babies. When first described by Bealz, working in Japan in 18 8 5, he considered it a characteristic limited to the Mongolian races, and named it the Mongolian spot. Some time ago I asked Dr. Darby, superintendent of the R. W. Large Memorial Hospital at Bella Bella, to check on the Indian children of the Coast for this spot, as evidence of their Mongoloid affinities. His report was as follows: "This spot is very noticeable in newborn babies, whether fullblooded or hybrid. As a rule the discoloration is over the sacrum, just at the top of the natal cleft. Sometimes it is quite distinct, varying in size from one-half to two inches. Such a spot is quite blue, and resembles very much the mark left after a blow or bruise. Often it is not quite so distinct and is spread over a larger area, perhaps the dorsal surface of the sacrum, or down over the buttock. Occasionally it will cover the whole lumbar region. In one case there was evidence of it over the back of the upper arm. "I found no spot that I could be sure of in any child over three years of age, but saw signs of it in two-year- :-oldj "1 think that to call it a 'black and blue mark' describes it as well as anything. In fact an old Indian told me, when I asked him if they had any reason to ascribe for it, that they thought it was due to the final punch that the midwife gave the youngster, when she thought it was time for it make its debut into the world." Dr. Darby's report conforms to others which have since been made in regard to the spot, found among Eskimos and the Nahavo and Cree Indians; so it may be assumed that it is widely spread among the aboriginal tribes of this continent. Although originally considered a characteristic confined to Mongoloid races, it has more recently been found to occur sporadically in the more darkly pigmented European peoples. It is found in Spain and Portugal. There is a l/z% occurrence in Italy, and) a slightly higher one in the Balkan countries and in Austria. Here it is thought to be a relic of the Mongolian conquests of the fifth and thirteenth centuries. Page 159 Its significance is not known. When it occurs in white children, it is thought to be a spontaneous atavism, a remnant of a wider ancestral pigmentation. Skeletal Remains of B. C. Indians.—I recently had the opportunity of studying a group of eighty-one aboriginal skulls, taken, some from the Indian shell heaps at Point Roberts, but mostly from the shell mound at Marpole, known to anthropologists all over the continent as the "Great Eburne Shell Mound." Skeletal remains taken from the latter1 are estimated to be between 750 and 2000 years old. As most of the findings have already been published, I shall refer only to two or three more interesting features. There were found in the mound two distinct types of skulls. One group, by far the more numerous, were round, having a high cephalic index. All skulls of this group were more or less deformed by a flattening of the posterior surface, immediately to the right or to the left of the mid-line. Not being the symmetrical deformity which was practiced in more recent times, I feel that it was unintentional, and was probably due to the child being strapped to the cradleboard during infancy, with the head turned slightly to the right or to the left to facilitate nursing. A small percentage of the skulls were not so deformed, and were much longer, with a cephalic index of slightly over 80, other measurements also differing from the larger group. These long skulls have caused considerable discussion, both in Canada and by members of American expeditions who have worked on the mound. Many theories of origin have been advanced, even to their being Eskimos, who at one time lived this far south. The measurements, however, precluded the acceptance of this theory. Six months ago a skull was brought to me from just north of Lytton, which had been excavated from 12 feet below the surface of a gravel bed during placer mining. Its measurements were almost identical with the longer skulls found in the Eburne mound, and I have no doubt that the latter were the heads of prisoners who had been brought to the Coast during raiding expeditions on inland tribes, i.e., those living on the Thompson and Upper Fraser rivers. The teeth of these Precolumbian people met in an edge to edge bite, as contrasted with the overlapping, or scissors bite, of the modern white man. Cameron, late of Dalhousie, found that this condition was universal in Anglo-Saxon England before the Norman conquest. A thousand years later only 2 % of Britishers have it. Keith is of the opinion that the retraction of the lower jaw is due to the changes in diet which resulted in the discontinuance of the act of biting as contrasted with that of chewing. Man is the only mammal to possess a chin, and its development may not be due so much to a pushing forward of the mental protuberance to give freer play to the tongue, as suggested by some, as to retraction of the alveolaf border carrying the incisor teeth. This retraction is accompanied in modern man by a deepening of the arch of the hard palate, and by a crowding of the teeth, so that there is a tendency towards non-eruption of the third molars. Fragments of some 200 skeletons were removed from the Eburne mound and measurements of the long bones pointed to these people being shorter in stature than the Eastern Indians, as indeed are the modern Coast tribes. I have frequently heard it stated that the present generation of native born British Columbians is decidedly taller than their immediate ancestors born elsewhere. Even Dr. Basin, on his recent visit, is reported by the newspapers to have said that he expected to find a taller, more vigorous race of native sons west of the mountains. While the province is much too young to rely on statistics, some such are available through the kindness of Dr. Brandon, medical examiner for the students of the University of British Columbia. Students constitute an excellent cross-section of the present generation of B. C, in that the great majority are native born or have been raised in the province. Dr. Brandon's figures comprise a group of 3 51 present first term, first year male students, with an average height of 5 ft. %l/z ins.; and 218 females, averaging 5 ft. 4 ins. Measurements of last terms, group were approximately the same. A slight correction is necessary in that 16% of the male and 19% of the female students were in their seventeenth year. Growth Page 160 during and after that year averages 4 Cm., so the average height would be brought up % inch, giving 5 ft. 8 % ins. for the males. Davenport published in 1917 average heights for European peoples. The highest were the Fiighland Scotch at 5 ft. 10% ins. English soldiers average 5 ft. 7V4 ins. Unfortunately, no statistics for Eastern Canada or the United States are available. The average of 5 ft. 8 % ins. for the B. C. student is good by the above comparison, but he is far from equalling the Highlander, nor do I think that he exceeds the average of his parents, especially those born in Eastern Canada. So many factors enter into the process of growth that it is almost impossible to formulate rules regarding it. We know that it is controlled by growth hormones, but these are regulated by the growth genes, which are in turn fixed in the germ cells by inheritance. Growth therefore can be modified only by environment of which there are two factors: food and climate. The Jersey cow is small due to lack of certain chemicals in the soil in its native island. The smallness of the Shetland pony is probably due to the rigors of the climate in which it lives. Our B. C. climate should be conducive to growth, but, then, the warm climate of Italy produces a people whose height averages only 5 ft. 5 ins. Nor can our food be a factor, as it comes from the four quarters of the globe, milk and seasonable fruits and vegetables alone being constant B. C. products. Although Galton contends that there is very little evidence to prove it, I believe that unfavourable environment, such as non-nutritious food, may stunt growth temporarily, with the result that a following generation, more fortunately placed, may shoot up inches above their parents. Such conditions are not likely to prevail in Canada, especially among those of the social environment of a student group. Stature is, I feel, a matter of inheritance, and while it may be modified by forces acting from without, such changes are slow. While anthropology may be largely a system of hypotheses, there are many questions of interest to Medical Science, which I think can be answered only by reference to morphology, and to Man's evolution through the lower orders of animal life, which he recapitulates during the short period of his embryonic existence. For example, why is man the only animal which is not ambidextrous? Why in left-handed individuals is the frontal area speech centre transferred to the right side of the brain? What is the relation between speech and right-handedness, and why are stammering and nervousness liable to be induced in a left-handed child who has right-handedness forced upon him? What, too, is the explanation of blood groups, a condition which exists among the lower primates? Then, again, I feel that morphology alone can explain the origin of such deformities as hare lip and cleft palate, imperforate anus, hypospadias, congenital dislocation of the hip, etc. Most embryologists agree that they are all due to arrested development. The child born with a cleft palate is reverting to a condition which prevailed among the higher vertebrates who lived 250 million years ago. Broom and Watson of London have traced the evolution of the palatine plates from mere side ledges, as they were in the amphibian, till they meet in the midline of the roof of the mouth to form a complete bony palate, as seen in the mammal. This evolution of the palate, which occupied seons of time, is repeated in the course of ten days in the face of the human foetus. Imperforate anus and congenital hip are also arrested in the reptilian stage. The normal human body is a museum of relics which, having lost their usefulness, have been discarded as man passed through the stages represented by the lower forms of animal life. Thompson cited 85 of these vestigial organs, some constant and some occasional. Usually they are harmless, but may give rise to pathological conditions . Man as a plantigrade animal: When man first decided to stand on his hind legs and walk without the aid of his hands, he made the most important step in his whole history towards that development which led eventually to his dominance over the entire world. The development of the human foot, enabling man to stand erect with his hands free, was responsible for all those changes incident on the erect posture. The chest became barrel-shaped, and the heart came to rest on the diaphragm. New mesenteric adhesions were necessary to support the intestinal canal. The muscles of the tail were modified to form a hammock to support the pelvic organs, and as the brain increased in size, the pelvis became widened and its outlet rounded to permit passage of the enlarged head. The whole spinal column Page 161 and its muscles were also altered to meet the new postural conditions. If man gained immensely by assuming the upright position, he also paid heavily for it. To the assumption of this posture may be attributed such afflictions as varicose veins and haemorrhoids, visceroptosis and prolapse of the pelvic organs. The abdominal viscera, which in pronagrade animals are slung in a hammock formed by the abdominal muscles, are in man supported partly by the mesenteries and accessory ligaments, and partly by the front- to-back pressure of the anterior abdominal wall. This greatly increases the intra-abdominal pressure and is probably the chief cause of hernia, a condition practically unknown in lower animals. Inguinal and femoral hernias are human characteristics, and their frequency is largely due to changes in the pubofemoral region as a result of the assumption of the upright position. This, along with the great increase in the size of the human head, requires an enlarged pelvic outlet and a widened anterior abdominal wall. This, in turn, resulted in a shifting of the muscular attachments about the crest of the ilium and the ileopectineal line, weakening the wall in that region. Poupart's ligament is a structure peculiar to man. Let us return to the effect of the assumption of the upright position on the development of the human brain. I repeat that the most important factor in this development was the freeing of the hand. The human hand has retained a highly generalized structure, in contrast with that of other mammals such as the horse, whose foot has become highly specialized, thereby losing much of its general usefulness. Man's hand retains that primitive arrangement of structures peculiar to the earliest mammals, and to the reptiles from which they are derived. Thus in the human hand may be seen the same bones, with almost the same arrangement, as are seen in the foot of the tortoise or lizard. The effect of the freeing of the hand, together with the many advantages of the upright position, must have been great. It may be asked, what would the brain have been if neither hand nor foot had made its appearance. The brain of an animal with hoofs or flippers responds only to the requirements of these specialized organs. The brain is that of an ungulate or swimming animal. That is, the brain of an animal of restricted behaviour limited in its intelligence to the amplitude of its adjustments to life. It is peculiarly deficient in that one great brain division which is the hallmark of animals possessing hands, viz., the frontal lobe. Now, the brain began as five expansions at the anterior end of the neural tube, called cerebral vesicles, each of which had its own special function. This was the setup in the lowest vertebrates, viz., the cyclostomes, and holds good for all fishes. In the amphibians the ear appeared, with a new sensory pathway leading to the brain; and this in turn created a need for an additional development in the brain, seen as the earliest cortex. This primitive cortex, first seen in reptiles, leads to the next great step taken by mammals, the predominance of the end brain, or most anterior of the five cerebral vesicles. Here, then, in the lowly reptile was introduced the first detail of brain perfection. New and larger areas of cerebral hemispheres came into existence, to form the new matter of the neocortex (or neopallium, as named by Elliot Smith) . In it millions of new cells were added to the brain. Of the various parts of the neopallium, the frontal lobe is often referred to as the silent area of the brain. It is, however, to be credited with the function of speech, and with such functions as are connected with the higher faculties; and the development of personality. As Tilney remarks, "The brain had not only set on foot the age of man, but made possible the age of the frontal lobe." Origins of Modern Man. Between 10 and 2 5 million years ago, the progenitors of the human race split off from a common anthropoid stock, and the two great branches of the sub-order parted company. Thereafter each developed independently of the other. The first branch from the common stem gave rise to the human species. From the second arose the anthropoid apes. The common stem from which they mutually arose is represented today in the little tarsier, or tree shrew, no bigger than a kitten, which lives in the trees in Borneo. Of the human stock, or Homidae, our own species is the only one of several to reach modern times. Others, such as the Pekin Man and Neanderthal Man, etc., in spite of being well supplied with a highly developed frontal lobe and the faculty of speech, all fell by the wayside, finding the going too difficult. Homo Sapiens alone persevered. Page 162 These few prehistoric men, whose remains have been found, whom we must consider human but not of our species, were probably representatives of more numerous genera which were spread all over the Eastern Hemisphere during early Pleistocene times. Gates has recently advanced a theory, which has been accepted by Keith and some others, that living man is the product of a fusion of at least three other species of men. Homo Sapiens was represented at the dawn of history by the four great races which exist today. But in prehistoric times there may have been many more. At least 12 extinct races are known, of which Cromagnon Man is a good example. It was evidently a factor in Nature's great experimental laboratory for the evolving of the highest type of race. What of Man of the future? It has frequently been said that he will have a large head, a small body, and be fed on peptonated tabloids. It is significant that our own species lived in Europe forty thousand years ago, and that his cranial capacity was equal to our own. Keith answered the question very fully in his presidential address to the British Association in 1934. He said: "In the struggle for existence of primitive man, wits were of more use than strength. So nature gave him a big brain that he might solve his problems and have dominion over all the world. But no purely intelligent form of humanity could last long. Nature evidently recognised the dangers of intellect, and saw that if the animal in us should be suppressed, the human race would soon cease to exist. Life's pleasures come to us from the animal which nature has left in us. No race can endure without an abounding zest for life, and all outlets for human emotions. Most of us have ten times as much brain power as we are ever likely to use, so why increase the size of the brain? There is no limit to the progress man can yet make. Intellectually he has scarcely scratched the limit of his possibilities. In closing, let me say that the more recent work in the field of Anthropology deals largely with a phase of the subject which is beyond the scope of this paper. It is the question of Racial Cultural Efficiency, which has been stimulated largely by obsessions of racial superiority which exist in the modern world. There is, so far, no consensus of opinion as to the possibility of predicting mental capacities from physical data. Hooten and Boaz, in America, both claim that potentially there is no such thing as racial superiority. Fleure, in his Huxley lecture of 1937, sums up the British attitude by saying, "We nearly all feel that there is some linkage between physical characteristics and mental features, but attempts to study them are still in their infancy." II SOME REMARKS ABOUT "RHEUMATISM" Murray McC. Baird, B.M.(Oxon.), M.R.C.P.(Lond.) (Read before a meeting of the Vancouver Medical Association, February 7, 1939.) The word rheumatism can hardly be considered an exact medical term, in fact, it is used by the lay public and the physician alike to describe many vastly different conditions, whose only common ground is that they are characterized by aches and pains in various parts of the body. Strictly speaking, the word rheumatism should be limited to mean acute rheumatism or rheumatic fever. However, its use is sanctioned by ancient custom and is supported by the fact that it is frequently impossible, at any rate in the early stages, to fit the patient's complaints into any pigeonhole more accurate than this all-inclusive term. It is interesting to note that a great deal of work is being done with regard to the classification of rheumatic diseases, but it is very difficult for the various committees working in different countries to arrive at anything like an international classification at the present time. A commission of the International League Against Rheumatism has already collected more than sixty different nomenclatures, and it is unlikely that a standard classification will be reached until the pathology of rheumatic diseases is clarified; but it is necessary in speaking of any condition to have some idea of what is included and I have therefore adopted the standard American classification, which includes all the known varieties of joint diseases: Classification of "Rheumatism" 1. Diseases of joints related to trauma. 2. Diseases of joints due to infections of known type. (a) Gonorrheal arthritis; (b) Tuberculous arthritis; Page 163 ') —«r (c) "Tuberculous rheumatism"; (d) Pneumococcal arthritis; (e) Scarlatinal arthritis; (f) Syphilitic diseases of joints, Charcot joints; (g) Undulant fever; (h) Septic (purulent) arthritis; (i) Arthritis of subacute bacterial endocarditis; (j) Meningococcal arthritis. 3. Rheumatic fever. 4. Chronic arthritis of unknown aetiology. (a) Atrophic (rheumatoid, proliferative, infectious); (b) Hypertrophic (osteo-, degenerative, senescent); (c) Backache and sciatica; (d) Spondylitis—1. Atrophic or ankylosing; 2. Hypertrophic. 5. Gout and gouty arthritis. 6. Ha:mophilic arthritis. 7. Psoriatic arthritis. 8. "Allergic," "metabolic" and "endocrine" arthritis. 9. Diseases of muscles and fibrous tissues. "Fibrositis" of the English, also variously labelled myositis, myofascitis, "Muscular rheumatism." In general, this agrees fairly well with the English classification, but there are certain differences, under the heading of atrophic arthritis particularly. In the United States, all cases of this type of whatever age or sex are grouped under one heading—atrophic, rheumatoid or infectious arthritis. Many English authorities, however, regard rheumatoid arthritis as a disease of separate etiology, occurring only in women of child-bearing age and having nothing to do with infection. These cases they call primary rheumatoid arthritis, whereas other cases of similar type in other persons are referred to as chronic infective arthritis. The English have also popularized the term fibrositis, meaning an inflammation of fibrous tissue in any situation, even within the substance of a nerve, and including all the conditions usually referred to as muscular rheumatism or myofascitis. Some Conditions Which May Simulate "Rheumatism" Vascular—Periarteritis nodosa; Buerger's disease; peripheral arteriosclerosis; Raynaud's disease. Bone—Acute osteomyelitis; syphilitic or tuberculous dactylitis. Defiiciency—Beri-beri—Vitamin B; scurvy—Vitamin C; rickets and osteomalacia—Vitamin D. Glandular—Hypothyroidism; hyperparathyroidism; acromegaly. Nervous—Herpes zoster; cervical rib; peripheral neuritis; secondary carcinoma in spine; "lightning pains" of tabes; leprosy. Miscellaneous—Pleurisy; acute leukasmia; posture; foot strain. When a patient consults his doctor regarding pain in any situation, it is decidedly unwise to assume that it is of rheumatic nature without at least a thorough physical examination, because there are many conditions of entirely different etiology and significance which, in their beginnings, may disguise themselves as a little "rheumatism" or a little "neuritis." I have made a list of a few of the common ones, some of which/have impressed themselves upon me as a result of too hasty judgment on my own part. I have no doubt that many other conditions could be added to this list. I wish particularly to mention Buerger's disease and arteriosclerosis in the lower limbs leading to pains1 in the feet and legs. It is usual for these patients to spend at least a year or two in having foot treatments and arch supports before the diagnosis is made. Another condition which will give rise to pains and aches of a most widespread character is hypo-thyroidism. It has been impressed upon me recently that it is by no means uncommon to find this explanation in quite young subjects, either male or female. A typical case is that of a young woman of twenty-five whose complaint was of aching in the left shoulder, both wrists, and in her toes. Her temperature was normal, but never went above 98. Her pulse range was from 54 to 74. Red cells were 4 million. Hemoglobin 80%. White cells 4,600. Polys. 72%. Lymphs 27%. Eosinophiles 1%. The B.M.R. was —17%. The sedimentation rate was normal. Clinically, the pains resembled those of mild rheumatic fever, but did not react to salicylate. The patient was given Vitamin B, iron and thyroid, grains x B. & W. daily. Her pains were relieved and she has been well for nearly four years. Another condition which I should like to emphasize particularly is pleurisy. A low-grade type of pain in the back, especially in young women, should not be diagnosed as muscular rheumatism, pleurodynia or intercostal neuralgia until every effort has been made to rule out the insidious onset of Page 164 sero-fibrinous pleurisy. Patients who develop pleurisy with effusion frequently give a history of such pain in the chest for several months before the onset of chest symptoms. A negative chest plate and a normal sedimentation rate are frequently found, but in spite of this, I have seen several such patients develop pleural effusion. The answer is that if the patient's general condition warrants, that is, if she is tired and undernourished, she should be made to rest as a precaution. Another type of pleurisy which may mislead is that which originates from the diaphragm, either from abdominal or thoracic disease. The pain in this case may be referred to the shoulder and the condition diagnosed as myositis or fibrositis. Finally, I should like to mention posture as a cause of pain in the back found particularly in young sedentary workers who take insufficient exercise of the right sort, and pains in the hip and thigh which may be brought about by foot strain. I have seen several puzzling cases of pain in the thigh of a radiating character with no complint about the feet and no apparent flattening of the arches, where proper strapping of the feet brought about immediate relief. These cases are quite familiar to most orthopaedic surgeons. Incidence of "Rheumatism" Public Health Survey (U.S.A.) 193 3: Calculated incidence of "chronic arthritis and rheumatic diseases" 22.18 per 1,000 Tuberculosis in all forms, including suspects 4.72 per 1,000 120,000,000 total population; 2.2% 2,700,000 people are affected by rheumatic diseases; 1.0% 1,230,000 are "disabled"; 0.85% 1,020,000 are "bedridden". Massachusetts Survey (1933): 3.2% or 3,264,000 persons in the U.S.A. suffer from chronic rheumatism. Annual work loss (estimated) 7,000,000 weeks Economic value 200,000,000 dollars Rheumatic diseases affect more persons than heart disease, cancer and tuberculosis combined— (Hench). I give you herewith a table showing the incidence of rheumatic diseases in the United States. The figures are, of course, approximate, but the views of those who compiled them indicate that they are on the conservative side. It will be seen that about 1% of the population is either bedridden or so crippled as to be economically useless. The immensity of this problem from an economic point of view can hardly be overemphasized, especially as rheumatism itself has a very small mortality and these patients drag on for years as an economic deadweight. It is stated by authorities such as Pemberton that a good result should be expected in about 70% of cases of rheumatoid arthritis, which is probably responsible for most of the crippling, provided that the patient receives the benefits of modern treatment during the first two years of the disease. If this is so, it would seem that there are a great number of patients in this country who are not receiving either early or adequate treatment. This is due in part to the attitude of patients themselves, who frequently will listen to a quack rather than take sound medical advice, and to the cost of adequate treatment, but it is also due in no small measure to lack of early diagnosis, lack of up-to-date information, and lack of definite advice and a clean-cut plan of campaign on the part of the average doctor. I feel that when the political powers realize how much rheumatism is costing the country every year, its treatment will probably be made a matter of state medicine, as is happening in the case of tuberculosis and of cancer. Possibly the best solution of this problem is the establishment of rheumatism centres, where all moderri facilities will be available and the staff will be specially interested in this type of work. Rheumatic Fever. I do not wish in a paper of this type to burden you with the clinical manifestations of rheumatic fever, which are numerous and extremely varied. From the point of view of the joints this disease is comparatively unimportant, since it is now generally agreed that it never leaves any permanent after effects. Rheumatic fever may be an illness of extreme seriousness, with hyperpyrexia and serious cardiac damage. On the other hand, it may be of such mildness that its manifestations are regarded merely as fibrositic in nature and the necessity for rest may be entirely overlooked. I am convinced that in Vancouver rheumatic fever is a comparatively mild disease, but although mild, it is often very persistent. The sedimentation rate is so sensitive as an index of this condition that it should be adopted as a routine office procedure in any patient complaining of aches and pains, and Page 165 especially if the patient is young. Frequently, when the temperature is negligible and the pains are very slight and transient, the degree of alteration in the sedimentation rate will be quite surprising, and I do not see how any doctor can give sound advice regarding a rheumatic child without frequent use of this test, which is at least as? simple as doing a haemoglobin estimation. Rheumatic fever is associated with respiratory infection in many ways. The first attack frequently follows, within two weeks, an attack of tonsillitis, but this is not always the case. Relapses are also frequently, but by no means always, initiated by a cold or nasopharyngeal infection. Most authorities now consider that the preceding infection is nonspecific and is merely the match supplied to the powder keg, so to speak. Rheumatic fever, however, can be precipitated by other provocative agents, such as vaccination or inoculation, injuries, surgical operations and the exanthemata. Blood cultures of rheumatic fever patients do not show any consistent results and it may be stated that, up to the present, no one has been able to demonstrate bacteria, either in the blood or joints, which could be causally related to the condition. Occasionally, haemolytic streptococci or other bacteria may be recovered from the blood by using special technique, but this is also true of normal persons and especially persons whose resistance is lowered by serious illness. Direct evidence from cultures has not been able to prove that rheumatic fever is a streptococcal infection in the ordinary sense. The fact that sulphanilamide is useless in treatment also lends no support, to say the least, to this idea. There is a certain amount of indirect evidence, however, that streptococci are involved in the production of rheumatic fever. This evidence consists of the fact that positive skin reactions to streptococci are present in rheumatic children in 75% to 80% of cases and in only 25% to 30% in controls. Also, there is certain evidence to be obtained from the serum of these patients with regard to the development of streptococcal antibodies in association with the rheumatic attack, and it is thought by Coburn that the rheumatic subject who develops an attack has an abnormal, that is, delayed, immune reaction to streptococci. There is, at the present time, no evidence that a virus is involved in the production of the disease, though much research has been done with the object of locating one. In the treatment of rheumatic fever, there is very little that is new, and the most important point that needs to be emphasized is that a patient with even the mildest attack should be kept in bed until all symptoms have disappeared, the pulse rate is normal, and the sedimentation rate has become normal. It is very difficult to convince patients and relatives that a disease is still there when there is no temperature, no pain and no external and visible signs. There is now a sufficient body of evidence that the sedimentation rate is the most delicate indication we have of activity in rheumatic fever. The equipment to do the test costs about $1.50, and I think that every general practitioner should familiarize himself with it, if for no other reason than that the public will listen to a test but frequently turn a deaf ear to a doctor's advice. In cases where the heart is involved, it is essential that the resting pulse rate be normal, and this is likely to require six or more months, rather than weeks. Some authorities believe that heart lesions may progress even after the sedimentation rate becomes normal, and it would therefore appear to be wise to see that the resting pulse rate and the sedimentation rate are both normal before allowing any activity to these patients. One has the impression that many doctors suffer from the delusion that removing a child's tonsils after an attack of rheumatic fever will render him immune from further trouble. This is quite contrary to the conclusion reached by Kaiser in a consideration of 48,000 rheumatic children. The incidence of recurrence is not influenced by tonsillectomy done either before or after the initial attack. Tonsillectomy does not prevent either recurrence or primary attacks of rheumatic fever. The only evidence of benefit derived from tonsillectomy was that the mortality in children with tonsils at the time of the initial attack was nearly twice as high as among children whose tonsils had been removed. The tonsils should therefore be removed in rheumatic children on exactly the same grounds as they are removed in other children, but it is foolish to imagine that by doing so we are going to influence their rheumatic disease to any great extent. Page 166 A newer idea in the treatment of rheumatic fever is the administration of vitamin C, since it has been found that many rheumatic patients have a low blood concentration of this vitamin. Experiments conducted by several observers show that the course of the disease is not influenced by giving vitamin C intravenously daily, nor by giving orange juice daily, nor by giving vitamin C by mouth. Also, ascorbic acid given daily for several months to rheumatic patients apparently did not lower the incidence of recurrence. It is therefore very doubtful whether deficiency of vitamin C has any real significance in this condition. Rheumatoid Arthritis. This disease probably existed in the time of the Pharaohs and is one of the most tragic which can affect any young adult. Its onset may be slow and insidious, marked by anaemia, flitting pains in the smaller joints and excessive fatigue for months before definite signs appear. Or it may begin acutely, with fever and leucocytosis and the most intense pain in many joints with marked fluid effusion. In the latter case it may be difficult to distinguish from gonococcal arthritis, acute polyarticular gout and particularly from rheumatic fever, especially as sometimes pleurisy and cardiac lesions do occur. The old distinction that rheumatis fever responds as to pain and fever to adequate doses of salicylate and never leaves permanent joint changes still holds. The blood of patients with rheumatoid arthritis in 75% to 80% of cases shows the presence of antibodies to haemolytic streptococci, but these are different from those found in rheumatic fever, and this is the most scientific method of distinguishing the two conditions. The course of rheumatoid arthritis, if neglected and untreated, as it so often is, is downward by a series of relapses and remissions, until, after a variable period of years, it burns itself out. In the meantime, after too late trial of many cures, the patient has often become prematurely aged, a mere caricature of her former self, dependent and depressed, deformed and disillusioned. Etiology. It cannot be stated too definitely that, at the present time, the cause of rheumatoid arthritis is still quite unknown. The infective theory is still only a theory. The relationship of focal infection to this condition is still unproven. Nevertheless, there is a great deal of evidence of an indirect nature, both clinical, pathological and bacteriological, that bacteria are concerned. It is impossible here to enter into a detailed argument, which was well summarised by Hench both for and against the infective theory at the Bicentenary of the Royal Mineral Water Hospital at Bath last year. It is sufficient to say that the exponents of the microbic theory have been compelled to abandon the bacteriaemic conception advocated by Cecil, Nicolls and Stainsby about ten years ago, not because the organisms were not present, but because bacteriaemia can be demonstrated by special methods even in healthy persons and especially in any morbid state. The theory of bacterial toxaemia may also be said to have been fairly well abandoned for lack of evidence. The organism now most universally blamed is the haemolytic streptococcus and the current theory may be called one of bacterial allergy, by which is meant an abnormal immunological reaction of certain tissues to the products of bacterial action. This reaction, once set up, evidently si irreversible and proceeds by its own momentum, very much as is the case in a chronic nephritis. The exponents of this idea are having some difficulty in explaining the ineffectiveness of sulphanilamide both in rheumatic fever and in rheumatic arthritis. In addition to the microbic theory, there are many influences which have been thought to be responsible or adjuvant factors. These may be listed briefly as follows: Virus infection, circulatory disturbance (vaso-constriction), disturbance of carbohydrate metabolism (lowered sugar tolerance), disturbance of calcium metabolism, of sulphur metabolism, hepatic deficiency (indoluria), vitamin B, C or D deficiency, food allergy, intestinal intoxication, endocrine abnormalities, trophic (autonomic) disturbances. None of these factors can be shown at the present time to have other than secondary importance in the production of the disease. Treatment of Atrophic Arthritis REST IN BED . . . With splinting of joints. Physiotherapy. Removal of foci of infection. Drugs . . . Aspirin, cincophen. Page 167 1. 2. 3. 4. "T 5. General Measures—Calorie intake, Vitamines, Anaimia, Constipation. 6. Psychotherapy (for both doctor and patient): Restrained optimism, patience, a plan of campaign. 7. Gold therapy. 8. ? Vaccine therapy. Other treatments used with reported benefit: Sulphur, bee venom, histamine, choline, vitamin D, staphylococcus toxoid, radiotherapy, bone puncture, colonic irrigation, intestinal antiseptics, special diets, insulin, fever therapy. The doctor is hampered a great deal in treatment by the fact that even experts do not agree as to what should be done. New medical methods only partially tried radiate like waves from authoritative sources and the practitioner relies upon them often after they have been already discarded by their originators. I believe that there are certain principles of treatment which have had sufficient trial for them to be followed in the majority of cases. 1. Bed rest. I believe that one of the most important therapeutic measures in arthritis is bed rest. It has been repeatedly pointed out that the arthritic patient is a tired patient and it is perfectly obvious from a consideration of the patient's condition that he is suffering from a severely toxic process of some kind. I believe that it is as important to put such a patient to bed as it is in the case of a tuberculous infection, nor do I see any logical reason for allowing him out of bed until the disease is arrested. But rest should be adopted at the very earliest date upon which it is possible to make a definite diagnosis and here the sedimentation rate, though not infallible, is of great assistance. I have seen patients who were encouraged by their friends, families and even their doctors to keep moving, because if they remained in bed their joints would become stiff and they would be unable to move. I believe that this idea is probably responsible for more crippling than any other single factor. The usual result of this method is that the patient insists upon walking about on inflamed joints and suffers agony for five or six years, at the end of which time he is forced to take to his bed with joints badly damaged, possibly beyond repair. He stays in bed because he can do nothing else and his joints become ankylosed anyway, just as predicted if he did not move about. It is illogical to use and especially to take weight on an inflamed joint merely because we do not know the cause of the inflammation. Destruction of cartilage and ankylosis of knees and hips in flexion are the main cause of total immobility in arthritis, and I think that if we were sufficiently forcible in selling this point to our patients there would be fewer bedridden people in the community. Local rest to inflamed joints by splinting is also most important in the acute stage. The patient should be instructed to lie flat in bed and to turn on the face if possible for part of the time, and should not be allowed to sit humped up in bed with flexed knees, hips and spine. As soon as the acute stage is over, gentle active and passive movements should be begun and should be carried out daily up to the point of causing increased pain, heat or swelling. Active exercise of the fingers is most important, as also is the prevention of flexion of the wrist. A nice balance between rest and exercise must be maintained and should certainly be supervised by a physician and not by a relative, or, worst of all, by a quack physiotherapist. 2. The next important feature of treatment is physiotherapy, which all authorities agree is probably second in importance to rest. It is common to see arthritic patients hobbling downtown in order to obtain some variety of "electrical treatment" on their acutely inflamed joints. This is quite ridiculous, as the exertion of getting there and getting back more than counteracts any benefits which may result from the treatment. When joints are acutely inflamed, the treatment must be brought to the patient, not the patient to the treatment. For this reason, the medical profession should make a study of simple home physiotherapy which can be applied by an intelligent relative or a practical nurse. Such treatment is outlined by J. S. Coulter in the Journal of Laboratory and Clinical Medicine, 1936. It is estimated that in the United States arthritic patients pay some $105,000,000 per annum to irregular practitioners for physiotherapy of various types. The presumption is that they are buying something which they find of value and which is not being supplied adequately by the medical profession. A consideration of our own patients would probably lead to the conclusion that the same conditions apply in Vancouver. 3. Removal of foci of infection. Although there is very great difference of opinion regarding removal of foci of infection, as practical medical men it is probably wise for us Page 168 to do so whether we believe in the infectious theory or not. Some caution in the amount of work that is done on a patient at any one time must be exercised and I have known patients who had no apparent arthritis at all until some focus was too rudely tampered with. The removal of infected teeth is particularly liable to cause a flare-up and probably not more than two should be removed at once. From a consideration of the literature, it is probable that the tonsils, the teeth, nasal sinuses, prostate and cervix constitute the more important foci and all should be examined with care in any arthritic patient. Any case of atrophic arthritis may improve temporarily after an operation such as tonsillectomy but often the improvement is very temporary indeed. I should like to emphasize that no doctor should now delude himself or his patient into the belief that the removal of any focus of infection is sufficient treatment for atrophic arthritis. It may constitute a good beginning, but frequently it is a very small part of the treatment and one suffers from a feeling that the interest of many doctors wanes as soon as the operative work is over. 4. Drugs. Of the drugs used there are probably only two which are really useful, the first being aspirin and the second cincophen. Cincophen is a dangerous drug and many physicians will not use it at all except in gout. Snyder of New York, however, uses cincophen in doses of 3 0 grains a day over long periods with apparent safety. I do not believe that it should be administered except when the patient is closely supervised. 5. General measures. The improvement of the patient's general condition is most important if it can be brought about. For this purpose the diet should be so arranged that a patient receives a sufficient, but not excessive, calorie intake. There is no agreement that any special diet is of value. Undernourished patients should have a high calorie, high vitamin diet. Those who are overweight should be reduced by the reduction of carbohydrate intake. The hygiene of the bowel should be attended to without drastic purging. Anaemia of severe degree is frequently present and should be rteated with large doses of iron, vitamin B and even by blood transfusion if practicable. 6. Psychotherapy. I believe that the time has come when the medical profession should take the treatment of arthritis out of the hands of amateur doctors, quacks and well- meaning friends. To this end, they should make every effort to secure an early diagnosis, and, having done so, they should explain the condition to the patient, admitting that there is no royal road to recovery, but at the same time refusing to adopt a defeatist attitude, which drives the patient to seek help from the dozens of misguided sources who are ready to proffer advice and to take his moneyi I feel that at the present time we are justified in being reasonably optimistic with regard to securing an arrest of the disease, provided the diagnosis is early, the patient will co-operate, and some economic ammunition is available. 7. Gold Therapy. Since the introduction of gold as treatment by Forrestier of France in 1928, and the subsequent publications of Hartf all and Garland of England, many papers have appeared on this subject. The Americans appear to have received therapeutic as opposed to commercial gold with great skepticism, chiefly owing to its supposed dangers. It is true that gold in large doses such as used for tuberculosis can produce a very unpleasant nephritis or dermatitis. However, if the individual dose does not exceed .1 gram and the total for a course does not exceed 1 gram, it appears to be reasonably safe. I have used Solganol B Oleosum is only ten cases in private practice and in eight of them there was decided improvement after other methods had failed. In the other two cases there was marked destruction of cartilage which even gold will not repair. I believe that in some cases gold is spectacular in bringing about a remission, and for my own part, it has entirely replaced vaccines, in which my confidence has waned, no matter how they are prepared or from what source they are obtained. There are many other treatments which are used in rheumatoid arthritis and which may be of help in individual cases, but I believe the ones I have enumerated are the most useful. Fibrositis. I wish to conclude this paper with some reference to fibrositis, which is probably the commonest of all forms of rheumatism. This condition has much more substance as a clinical entity than as a pathological one. It is characterized by slight fever, possibly a mild chill and acute pain and tenderness usually located in a muscle or about a joint. Some Page 169 authors include acute bursitis under the same head as fibrositis. The condition may recover rapidly, it may recur or it may become chronic. It accounts for many cases of lumbago and sciatica and is common around the shoulder joint and the chest wall. Sometimes exquisitely tender nodules can be felt under the examining finger and the only pathological picture we have of these nodules is that of Stockman, who in 1920 described swelling of interstitial fibrous tissue without any leucocytic infiltration. The American school inclined to view fibrositis somewhat askance as having no secure pathological foundation. However, I am certain that any physician who searches carefully a patient with an attack of acute muscular rheumatism will find that often he can roll under his finger a nodule of extreme sensitiveness from which the pain radiates. The diagnosis of fibrositis can very often be made only by a process of exclusion. Some of these patients who have what appears to be fibrositis should be classified as abarticular gout, as it is not uncommon to find, in men particularly, that a tendency to recurrent lumbago or olecranon or acromion bursitis is accompanied by a high blood uric acid and responds to the appropriate regime for gout. I can recall three cases of lumbago, three acutely painful shoulders and one bilateral tendo Achillis bursitis where the blood uric acid was 5 milligrams or more and the condition cleared up miraculously with colchicum or atophan. The majority of cases of fibrositis, however, are not of this nature and it can only be said that the cause is at present entirely unknown. Various authors ascribe the condition to fatigue, chill, focal infection, dietary indiscretions and inability to handle oxalates. The treatment, after accurate differentiation from gout, osteo-arthritis and rheumatoid arthritis, in the acute stage, consists of massage and physiotherapy, by which is meant the application of some form of heat. This heat may be applied by simple or complicated means and massage should be applied to the tender spots, since many authorities agree that this course, though painful, is often most effective. Foci of infection should be searched for and removed. When the condition is chronic, physiotherapy, manipulation and the regulation of the patient's' hygiene of living offer the best hope of success. This condition covers many cases where the proper use of manipulation as practiced by bone setters, chiropractors and osteopaths undoubtedly brings about marked benefit. I feel that this measure is one which is probably too much neglected by the medical profession as a whole, in fact its existence seems hardly to be recognized except by certain orthopaedic surgeons. Conclusions : 1. The rheumatic diseases constitute what is probably the most important medical- economic problem of the day. 2. Early diagnosis and adequate treatment should be the aim of the medical profession, who should take more responsibility for these patients and who should take the lead in instructing the public as to the proper course to pursue. 3. In rheumatic fever and atrophic arthritis there are certain well recognized principles of treatment which should be applied early and persisted in with the object of preventing crippled hearts and joints. These are the two great causes of death and disability. 4. Fibrositis is a clinical entity of rheumatic nature, the importance of which is that it is very common and that it may be mistaken for arthritis as well as many other non- rheumatic conditions. Its treatment, which has been briefly outlined, should be under the control of the medical profession. COLLEGE OF PHYSICIANS AND SURGEONS OF B. C. INCOME TAX J Provincial returns from doctors must be filed on or before MARCH 3 1st. Dominion returns should be filed on or before APRIL 3 0th. Information regarding the preparation of Dominion returns is published below for your help. No printed instructions are issued by the Provincial Offices. The following information may be helpful: Depreciation—5 % is allowed on Instruments and Office Equipment. If and when such equipment requires to be replaced, an appraisal at the full value less the depreciation Page 170 already deducted will be accepted. Automobile Depreciation—20% annually (Less 25% for private use =■ 15%). It has been the practice of the Assessors to deduct 25% for private use. Expenses—Cost of license, insurance, oil, gasoline, grease, tires, washing, garage and repairs. In City practice: Where the cost of operating automobile exceeds $500.00 per year, a claim supported by proof of unusual wear and tear and heavy mileage would receive consideration. In Country practice: Where Doctors are travelling on country roads, $600.00 per annum is allowed. Where expenses exceed this amount, as stated above, claim for greater allowance must be substantially supported by proof of cost of operation. Members are urged to study the details of expenses in the Dominion memorandum so that all will be included. DOMINION INCOME TAX Memorandum Regarding Returns of Members of Medical Profession Income 1. There should be maintained by the Doctor an accurate record of income received, both as fees from his profession and by way of investment income. The record should be clear and capable of being readily checked against the return filed. It may be maintained on cards or in books kept for the purpose. Expenses 2. Under the heading of expenses the following accounts should be maintained and records kept available for checking purposes in support of charges made: (a) Medical, surgical and like supplies; (b) Office help, nurse, maid and book-keeper; laundry and malpractice insurance premiums. (It is to be noted that the Income War Tax Act does not allow as a as a deduction a salary paid by a husband to a wife or vice versa. Such amount, if paid, is to be added back to the income); (c) Telephone expenses; (d) Assistants' fees; The names and addresses to whom fees are paid should be furnished. This information is to be given on or before the last day of February in each year on Income Tax Form known as Form T.4, obtainable from the Inspector of Income • Tax. (Do not confuse with individual return of income, Form T. 1, to be filed on or before 30th April in each year) ; (e) Rentals paid; The name and address of the owner (preferably) or agent of the rented premises should be furnished. (See (j)); (f) Postage and stationery; (g) Depreciation on medical equipment; The following rates will be allowed provided the total depreciation already charged off has not already extinguished the asset valuer— Instruments—Instruments costing $50 or under may be taken as an expense and charged off in the year of purchase; Instruments costing over $50 are not to be charged off as an expense in the year of purchase but are to be capitalized and charged off rateably over the estimated life of the instruments at depreciation rates of 15 per cent to 25 per cent, as may be determined between the practitioner and the Division according to the character of the instrument, but whatever rate is determined upon will be consistently adhered to; Page 171 The residual value of instruments not heretofore fully depreciated win. be depreciated along with instruments costing over $60 purchased subsequently; Office furniture and fixtures—10 per cent per annum; Library—The residual value of library not heretofore fully depreciated will continue to be depreciated at 10 per cent per annum for the years 1932, 1933 and 1934 as well as charging off the actual cost of books purchased in those years. After 1934 only the cost of new books will be allowed as a charge. (h) Depreciation on motor cars on cost; Twenty per cent 1st year; Twenty per cent 2nd year; Twenty per cent 3rd year; Twenty per cent 4th year; Twenty per cent 5th year; The allowance is restricted to the car used in professional practice and does not apply to cars for personal use. (i) Automobile Expense; (one car). This account will include cost of licence, oil, gasoline, grease, insurance, washing, garage charges and repairs; (Alternative to (h) and (i)—In lieu of all the foregoing expenses, including depreciation, there may be allowed a charge of 8 cents a mile for mileage covered in the performance of professional duties.) If chauffeur is employed so that in the result he is substantially used for business purposes (although incidentally used for personal or family use) the expense will be allowed. (j) Proportional expenses of doctors practising from their residence— (a) owned by the doctor; (b) rented by the doctor. (a) Where a doctor practises from a house which he owns and as well resides in, a proportionate allowance of house expenses will be given for the study, laboratory, office and waiting room space, on the basis that this space bears to the total space of the residence. The charges cover taxes, light, heat, insurance, repairs, depreciation and interest on mortgage (name and address of mortgagee to be stated); (b) Rented premises—The rent only will be apportioned inasmuch as the owner of the premises takes care of all other expenses. The above allowances will not exceed one-third of the total house expenses or rental unless it can be shown that a greater allowance should be made for professional purposes. (k) Sundry expenses (not otherwise classified) — The expenses charged to this account should be capable of analysis and supported by records. Claims for donations paid to charitable organizations will be allowed up to 10 per cent of the net income upon submission of receipts to the Inspector of Income Tax. (This is provided for in the Act.) The annual dues paid to governing bodies under which authority to practise is issued and membership association fees not exceeding $100, to be recorded on the return, will be admitted as a charge. The cost of attending post-graduate courses or medical conventions will not be allowed. (Continued on page 173) Page 172 Preventive Medi cine Secti on THE TREATMENT OF EARLY SYPHILIS Part II. Donald H. Williams, M.D. Director, Division of Venereal Disease Control, Provincial Board of Health. Early syphilis includes primary, secondary and all cases of latent syphilis less than four years in duration. Routine treatment can be given with few exceptions. The following rules, if followed, will make treatment easy for the patient and result in closer co-operation with the physician: 1. The meal before and after an intravenous injection should be light; 2. Sterile distilled water must be used as a solvent; 3. The intravenous needle, 25 standard gauge, must be sharp; 4. The intravenous injection must be given slowly, at a rate of 0.1 grams neoarsphenamine in 30 seconds, or 0.6 grams in 3 minutes. The following schedule is recommended:— 1. Continuous weekly injections until a total of 40 neoarsphenamine and 42 bismuth has been received. Dosage: Neoarsphenamine 0.3 to 0.6 grams, insoluble bismuth 1 to 2 cc. 2. The injections are divided into 5 courses of neoarsphenamine and 6 courses of bismuth. 3. These courses are arranged in the following manner: 8486888888 rest 8 Neo Bis Neo Bis Neo Bis Neo Bis Neo Bis 4 weeks Bis 4. In primary or secondary syphilis the first 3 injections of neoarsphenamine are given on the first, third and fifth days respectively and thereafter once weekly. 5. In seronegative primary syphilis, if the blood serodiagnostic test and the cerebrospinal fluid examination are negative throughout, the final course of neoarsphenamine and bismuth outlined in section 3 is not given. (Continued on page 174) DOMINION INCOME TAX (Continued from page 172) (1) Carrying charges; The charges for interest paid on money borrowed against securities pledged as collateral security may only be charged against the income from investments and not against professional income, (m) Business tax will be allowed as an expense, but Dominion, Provincial or Municipal income tax will not be allowed. Professional Men under Salary Contract 3. The salary of professional men will be taxed without any deduction therefrom except as hereunder provided, unless the individual is under contract which requires of him, in order to maintain his contractual position, to operate a motor car of his own, in which case if the principal does not pay the upkeep, running expenses and depreciation, the individual will be allowed to reduce the salary by such expenses as the use of the car in the earning of his income may cost, on the same basis as above provided for, i.e., expenses and depreciation or alternatively 8 cents a mile for mileage covered in the performance of professional duties. The annual dues paid to governing bodies under which authority to practise is issue, and membership association fees, not exceeding $100, to be recorded on the return, will be admitted. Page 173 i'"^r 6. The blood serodiagnostic test (Kahn) is taken routinely at the time of the second injection of each course of neoarsphenamine. 7. The lumbar puncture is done during the third course of neoarsphenamine in all patients with primary or secondary syphilis. In those patients with early latent syphilis the lumbar puncture is done at the time of admission. A second lumbar puncture is performed when the prescribed treatment has been completed. (To Be Continued) A PRELIMINARY REPORT ON 452 CASES OF NEUROSYPHILIS By Dr. S. E. C. Turvey of the Provincial {Vancouver) Clinic. Two years have elapsed since the Neurological section of the Vancouver Clinc of the Division of Venereal Disease Control was started, and though it is too early to report the end-results of treatment, it seems timely to make a preliminary survey of this work. The profession should know the scope of the work and how cases which they refer to the clinic are being treated. There are four hundred and fifty-two (452) cases in the neurological clinic at present, and three hundred and sixty of these are males. They have been diagnosed according to the classification accepted by the Co-operative Clinics in the United States, and sanctioned by the Committee of the League of Nations. By "early neurosyphilis" is meant involvement after this four-year period. Sex and age of these patients is listed in Table I: Table I. Males 360 In the third decade 52 In the fourth decade 108 In the fifth decade 12 3 Females 92 In the sixth decade 127 In the seventh decade 3 6 Over seventy 1 The incidence of each neurological condition has been listed for convenience in Table II, dividing the cases into early and late neurosyphilis. Table II. DIAGNOSES OF 452 CASES OF NEUROSYPHILIS Total number of cases 452' Late 414 Tabes 154 General paresis 73 Tabo paresis 32 Asymptomatic . 109 Meningeal 3 Vascular 8 Meningovascular 3 5 Optic Atrophy 25 Neurorecurrences 1 Early Asymptomatic 31 Meningeal 5 Tabes 2 All these cases have had a carefully taken history, including the original date of their infection, the number of contacts, and the amount of previous treatment; a detailed neurological examination and general physical examination; in about half of them a cardiac examination (X-ray, electrocardiogram, fluroscope and cardiac consultations are performed by Doctors Hatfield and Palmer); urinalysis, haemoglobin estimation, red cell count, leucocyte count, and cerebrospinal fluid (almost all have had more than one spinal puncture, and most of them have had several). The mental status is carefully chcked in those cases in which such examination is indicated, and the eyes are checked most carefully in all cases. Every case is re-examined once a year, and though this may not seem very frequent, it is the only practical proceeding in a clinic of this size. Each patient is seen before every treatment, and if not feeling well or improving, examined immediately. Page 174 The high incidence of tabes, general paresis, and the other symptomatic forms of late neurosyphilis is to be expected in a community where an adequate anti-luetic programme has been in progress for only two years. Nevertheless, treatment of this group is far from being wasted effort, for, as will be shown in a later analysis, the majority of these patients are being kept fit for the labour market, many others are being kept out of beds for incurables, and still others are being kept out of the Provincial Mental Hospital. The encouraging group is the "asymptomatic" neurosyphilis, both early and late. These are patients who have no symptoms or signs, and in whom neurosyphilis can only be diagnosed by an examination of the spinal fluid. In Table III is listed a summary of the salient facts about asymptomatic neurosyphilis. Table III. ASYMPTOMATIC NEUROSYPHILIS 1. Is the earliest manifestation of neurosyphilis. 2. Responds well to treatment. 3. Requires intensification and specialization of treatment. 4. Is the precursor of tabes and general paresis. 5. Can only be diagnosed by early and routine lumbar puncture. 6. The lumbar punctures must be repeated to check treatment and "cure.'* The are 146 of these cases in the series, and proper treatment yields a high percentage (about 94%) of "cures." Our hope in the future is to have the asymptomatic group increase and the symptomatic decrease, and this can only be accomplished if early syphilis is adequately treated and lumbar punctures are performed as a routine in every case of syphilis. The other syphilitic diagnoses in this series of cases are outlined in Table IV. Table IV. OTHER SYPHILITIC DIAGNOSES Cardiovascular 13 Chorio-retinitis : 9 Interstitial keratitis 2 Osseous , . 4 Cutaneous 1 Join t : 2 Epilepsy '. 4 Visceral . . 1 Meniere's syndrome , 1 The apparently low incidence of cardiovascular disease (which usually is 6 -10%) in our series) is due to the fact that all cases have not yet had a cardiac investigation. Whenever another organ or structure in the body is affected by the syphilitic processes, it is treated by whatever measures are required, or the antiluetic measures are modified so that both conditions can be treated simultaneously. There have been remarkably few deaths in this series, but in a group of patients of this size, this can only be fortuitous. The elapsed time has not been sufficient. The known causes of death are listed in Table V. Table V. CAUSES OF DEATHS Carcinoma of stomach 1 Bed sores, pyelonephritis, cystitis ' ;,ty ? 1 Under treatment or due to treatment 0 The treatment of neurosyphilis is not pertinent to this report, but may be briefly stated as follows: 1. Neoarspheanmine and bismuth in early asymptomatic neurosyphilis and optic atrophy. 2. Tryparsamide and bismuth for all early cases that do not respond to neoarsphenamine, and in all late cases except optic atrophy. 3. Malaria for cases that do not respond to chemical treatment and for early optic atrophy. A summary of the treatment of this series of cases is listed in Table VI. Fage 175 Table VI. 1. Treated with tryparsamide 341 Nausea and vomiting after each tryparsamide injection 16 Ocular complications due to tryparsamide 12 Objective and subjective signs 7 Subjective signs only 4 Objective signs only 1 Permanent ocular damage due to tryparsamide 2 (Percentage—0.5 8 %) 2. Treated with malaria 200 Treated with artificial fever 1 Deaths ' '. . 0 The administration of tryparsamide requires special care because it may damage the retina and optic nerves. Stokes says that, even with the most careful precautions; 1-2% is the irreducible minimum of patients to whom it will cause permanent ocular damage. We have been fortunate in keeping our percentage down to 0.58%, though we do take elaborate care before every injection. The drug is given weekly, one gram intravenously the first dose, two grams the second dose, and three grams for eight subsequent doses, and bismuth is given concurrently. Then the patient is given a resting period of two months and this routine is repeated until a total of one hundred injections of tryparsamide has been administered, and this usually constitutes adequate treatment. Before each injection the patient is asked whether he has had any ocular symptoms— dimming of vision, grayness, "groundglass" effect, "dazzling," an appearance of clouds or "waves" approaching from the periphery of the visual field, flashes of fight, or "specks." Then the visual acuity is checked and the visual fields are tested by confrontation of each eye with a 4 mm. red object. Examination of the optic discs is of little value, because changes in the colour of the nerve-head are a late phenomenon. If the drug is discontinued as soon as subjective symptoms appear there will be no permanent damage in the great majority of cases. In one of our cases the patient became blind after the fifteenth inject- tion, though there were no subjective or objective warnings; in the only other case the typical constriction of the peripheral margins of the fields of vision occurred, but useful vision has been retained. In seven cases this same peripheral constriction occurred but eventually disappeared entirely. Malarial therapy has been given to two hundred patients and no fatalities have occurred. They are examined carefully before receiving it, are cared for by a specially trained nursing staff, and are not allowed to become dangerously ill. Eight to ten rigors are sufficient. The technique has been described in a previous paper. A point that cannot be over-emphasized is the fallibility of reliance on the Kahn test of the blood alone. As shown in Table VII,, ninety-three of these patients had negative Kahn tests of the blood while their spinal fluid showed all the changes of neurosyphilis. In every case of syphilis, and examination of the spinal fiuid is essential. Table VII. Negative Blood Kahn on Admission 93 Negative Spinal Fluids at Present 152 Discharged 11 To private phyisicians 3 6 "Cured" 28 To other Clinics: England 1 China 2 Scotland 1 U. S. A. 1 Alberta 2 Montreal 1 About one-third of the series has negative fluids at present. When the word "cured" is used, it is always with a reservation, and usually means that the patient is over sixty-five years of age, has had his infection for twenty-five or thirty years, or has had a negative blood and spinal fluid for five years. Wherever possible, the patient is referred back to his private physician for treatments. If the physician desires, we do any or all of the following for him: Page 176 1. Neurological examination. 2. Lumbar puncture. 3. Examination of the eyes each week before the physician administers tryparsamide. 4. Either give the course of malarial chills, or consult with the physician while he gives the malarial course. 5. Supply all drugs necessary. It is not our policy to treat patients who can afford to pay their physician. In conclusion, I would like to thank Doctor S. C. Peterson, who has supervised the treatment of these cases and whose advice has been invaluable, and the Superintendent of the Vancouver General Hospital, who has made possible the malarial treatments. DISCUSSION. Dr. D. Williams: I think Dr. Turvey is to be congratulated upon the care with which he has prepared this large number of cases. It is probably safe to say that there are not very many other large groups of cases of which treatment records, etc., are being kept. These cases are going to provide a tremendous amount of very valuable material from the standpoint of statistics. The figures brought out a great many practical points, which Dr. Turvey covered very well. One of the first is the incidence of neurosyphilis in women. Syphilis is always milder in women than in men, and it is milder in women who have been pregnant. One sees less neurosyphilis in a group who have had pregnancies than in those who have not. The dangers of tryparsamide were well brought out. The subjective symptoms appear several weeks before the objective ones appear. The objective symptoms are irreversible. One should question the patient carefully regarding the subjective symptoms, and thus avoid getting into difficulties. The good results obtained in the 200 cases of malaria therapy were materially due to selection of cases and to the excellent nursing care and the care of the consultant. They are using less chills now; ten is considered enough, whereas fifteen were considered the proper number some years ago. Immediately untoward symptoms appear one stops at once. It is just as important to do a spinal puncture in the case of the juvenile or pre-natal syphilitic as in the case of the adult. The necessity of doing routine spinal puncture has been well pointed out this evening. Views have changed regarding neurosyphilis—the basis is laid down in the first weeks of infection. In most cases we can determine neurosyphilis in the quiescent stage by spinal fluid diagnosis and treatment can then be instituted. A similar situation not as easily diagnosed clinically is cardio-vascular syphilis. . . . There is no reason why we should not have a cardiac clinic almost as large as the neurological clinic. We hope to build up this group. The value of treatment in a group as large as this reported tonight to community and taxpayers cannot be estimated. When you consider what it costs to keep these cases in Essondale, etc., one can realize what a saving to the taxpayers and people of British Columbia a clinic such as Dr. Turvey has described means. Dr. Strong congratulated Dr. Turvey and remarked on the large number of young people who had neurosyphilis. Dr. Hodgins admitted that for many years he had been under the impression that there was a routine treatment for neurosyphilis, and he was of the opinion that many other doctors had the same idea. However, this paper by Dr. Turvey had shown that it was impossible to "routine" this type of treatment and that each case must be considered on its own merits, taking into consideration the age of the patient, the duration of infection, the general health of the patient and the presence of complications. The amount of work that an analysis of 452 cases involved was tremendous, and it was this type of paper which advanced clinical medicine to the best degree. He sounded a warning concerning tryparsamide in private practice, because one had only to produce blindness in one or two patients to be in serious trouble. Personally he did not think he would like to administer such a drug unless he were skilled in testing eyes. (Concluded page 178) Page 177 ctoria Medical Society Officers, 1938-39. President Dr. P. A. C. Cousland Vice-President Dr. W. Allan Fraser Hon. Secretary T Dr. W. H. Moore Hon. Treasurer ^ Dr. C. A. Watson CORONARY THROMBOSIS AND CARDIAC INFARCTION Clinical Conference A clinical conference was held at the Royal Jubilee Hospital on Friday, December 9th, 1938, at 12 noon. In the absence of Dr. H. H. Murphy, Dr. J. B. Roberts acted as chairman. Dr. S .G. Kenning was introduced and presented a paper, by means of slides, on ''Coronary Thombosis and Cardiac Infarction." Dr. Kenning stated that he hesitated to discuss coronary thrombosis and cadiac infarction at such a gathering, as it is almost quite commonplace, so much so that the typical dramatic picture of coronary thrombosis is now so generally well known that even the layman is making the diagnosis of a clot in one of the arteries of his heart. Nevertheless, most of us realize that there is still much to be learned concerning many phases of coronary thrombosis and cardiac infarction. It is widely recognized that the clinical picture, though generally clear cut, may be simulated by other conditions and when atypical may be missed or overlooked. Confusion occasionally arises as to whether the patient has a rather prolonged attack or whether a thrombosis has taken place. Other thrombotic attacks are masked by the presence of a diffuse pulmonary cedema, again there is the ever present differential diagnosis between coronary (Continued an page 179) A PRELIMINARY REPORT ON NEUROSYPHILIS (Continued from page 177) Dr. G. A. Davidson said he was glad to know cases are being so excellently handled in this clinic. "This is good evidence that they are getting every care and consideration that we know that they need." Dr. Turvey has stressed the importance of the early spinal fluid examination, and has shown the need of continued check-ups in these cases. "In Alberta they have been routinely examining the spinal fluid of all syphilitics over a period of about fourteen years now—all the cases that showed positive spinal fluid were sent to the Provincial Mental Hospital for malarial treatment. In spite of that, however, there has been nobody energetic enough to work out the details as they have been presented this evening. Congratulations to the Department and to Dr. Turvey." Dr. Frank Turnbull remarked that some of the problems of diagnosis are quite puzzling and asked Dr. Turvey if he had encountered cases, who, although having never received any antiluetic treatment, showed a negative Kahn test of the blood and a positive test of the spinal fluid. He also asked concerning the effectiveness of sympathectomy of the carotid artery in cases of optic atrophy. The reason for this operation, which had been devised by Leriche, is to produce an increased blood supply to the retina. In reply, Dr. Turvey thanked the various speakers for their courteous reception. He was sorry that he did not have accurate figures to answer Dr. TurnbulPs first question, but there were several cases at least in this series who had had a negative Kahn test of the blood and a positive Kahn test of the spinal fluid, though they had had no antiluetic treatment. Concerning the carotid sympathectomy in optic atrophy, Doctor Charles Davies had been doing some work recently on the intra-ocular tension in primary optic atrophy. He also was of the opinion that in these cases there was a low systolic blood pressure with consequent anemia of the retina which aggravated the atrophic processes. In this clinic no sympathectomies have been done but it might well bear investigation. Page 178 •^^^bwpohs thrombosis and the acute gall bladder attack and, lastly, the so-called "Silent Thrombosis," in which there is no apparent severe attack of pain and diagnosed chiefly by electrocardiographic findings. The latter type falls into that group sometimes referred to as "Occult Heart Disease," in which case there may be no obvious cardiac manifestations until a very exhaustive study is made from the cardio-vascular standpoint. There is a great deal of truth in the axiom that we diagnose the conditions we think of and miss those which are not taken into consideration while deliberating on a differential diagnosis. Etiology: 1. Primary etiological factor: (a) Majority of cases—Coronary arteriosclerosis; (b) In younger individuals—Coronary arteritis. 2. Precipitating factors—often obscure: Related to some acute general infection; food allergy (Werley): oesophageal irritation or spasm: over-eating, etc.; trauma due to severe mental or physical stress and strain. Mortality—Mode of death in 79 cases of coronary thrombosis: 1. Severe heart failure 26 2. Heart failure plus shock 13 3. Severe shock 7 4. Embolism 15 5. Sudden death 9 6. Pneumonia 3 7. Miscellaneous (Diabetic coma, uraemia, etc.) 6 Prognosis—50% sudden death or before medical aid available; 12.5% complete recovery and return to work; 12.5% some remaining disability; 25% die in a few years congestive heart failure. The usual mortality rate has been cited as about 5 0 % and even in late years has varied as quoted by different authors from as high as 60% to 70% down to 10%. Diagram as reported in 1936 by Dr. G. F. Strong. Recent records, however, indicate the probable rate lies between 2 0 % and 30%. Factors in Prognosis—In occlusion of the coronary arteries practically every symptom and sign and every factor contributing to the incidence is a valuable aid in prognosis. 1. Age—Increasing number of cases under 50 years or even under 40 years. Prognosis for the attack is best in younger and poorest in older age groups. Master reports— 21 attacks in individuals of 40 years of age or younger. Two died. 62 attacks in individuals between 40 and 50 years. Eight died. Mortality rate rose steadily with increasing years to 22%. Outlook for attack better in the young, but thrombosis at 40 years means life span shorter than if had first attack at 50 or 60 years. Average period of survival for youth 4.3 years and at all ages 2.4 years. 2. Sex—Ratio of males to females about 3 or 4 to 1. Classical picture less apt to appear in women. Mortality rate for both sexes about the same in spite of the fact when found in women is more often associated with diabetes or hypertension. 3. Factor of number of attacks— (a) Previous attacks have occurred n about half the cases; (b) Prognosis much better in initial attack than in later ones; (c) Mortality rate in first attack 11%, second attack 22% and third attack 50%. Series as reported by Master Joffe and Dock. 4. Importance of early diagnosis— (a) Early correct treatment is essential for recovery; (b) Importance of differential diagnosis—angina, etc.; (c) Until diagnosis is certain, patient should be put to bed at complete rest. 5. Pain— (a) Severity and degree of pain not of great significance except indirectly, i.e., severe pain lasting over long period of time—prognosis not so good, as probably indicates extensive infarction; (b) Pain may not necessarily be present. Page 179 6. Shock— (a) Present in about half of all hospital cases; (b) With its presence mortality rate about six times as great; (c) A large percentage of cases with shock show evidence of heart failure. 7— Dyspnoea—One of the earliest and most reliable signs of heart failure. Therefore its presence and orthopnea is serious. Respiratory rate more than 28 per minute prolonged —poorer outlook. 8. Pulmonary Oedema—May be the first and in fact the main indication of an occlusion. When present, cedema usually associated with hypertension and enlarged heart. When present, mortality rate (in most series of cases) is 50%. 9. Cyanosis—When really present is accompanied by a mortality rate of 30%. Must not be confused with the ashen-gray colour usually present in thrombosis. 10. Pulse Rate—Valuable information as to what the patient is going to do. A rate of 100 or over, especially if persistent, adds to a poor prognosis, 120-140. Tachycardia not necessarily associated with thrombosis but with heart failure. Slow regular rate of approximately 80 a very good sign. Irregularities add to the gravity of the prognosis. 11. Arrhythmias—In a series of 300 cases at Mt. Sinai Hospital, women were twice as prone as men to cardiac irregularities. Premature beats were found in one-fourth of the patients and other arrhythmias found in 14% of all patients. Of these—auricular fibrillation comprised one-half; auricular flutter occurred in three; ventricular tachycardia in one; auricular or nodal tachycardia in eight; complete heart block in five; partial heart block in three. Arrhythymias usually carried a mortality rate of 39% as compared to 22% for normal sinus rhythm. One-half of the patients with auricular fibrillation or flutter and complete heart block, died. Rarely, however, is the arrhythmia itself the cause of death. The heart rate, regardless of rhythm, is the significant factor in the outcome. 12. Blood Pressure—Most significant is a pulse pressure of 20 mm. hg. or less. Therefore watch for a marked drop in blood pressure; with a pulse pressure of 20 mm. of less, mortality 60%. Previous high blood pressure only N. B. as an added causative factor for heart failure. Blood pressure should be checked carefully early, while waiting for morphine to take effect, as by the time the patient arrives in hospital he is more or less in a state of shock and blood pressure has already fallen. 13. Heart Sounds—Usually diminished, when markedly so plus gallop rhythm the sign is more serious. Pericardial rub—its presence or absence is of little importance. 14. Cardiac Enlargement—Because of its associations with heart failure, adds to to the seriousness. At autopsy most cases show enlarged hearts. Conversely an attack of occlusion with a normal-sized heart has a better outlook. 15. Fever—Temperature 101 or higher continuing for more than a week significant. 16. Leucocytosis—A high percentage of immature cells after the fourth day suggests a large infarction. A count of 15,000 to 20,000 shows a severe lesion. Less than one per cent Eosinophils not a good sign. 17. Sedimentation Rate—Normal for first two days, then rises gradually from the fourth to the twelfth day. Rapid early rise to high level, evidence of large infarction. Slow rise and gradual decline more favourable, duration six weeks to three months. When rate returns to normal, or ceases to fall, this may be used as a guide as to the time of permitting patient up. 18. Non Protein Nitrogen—Steinberg first showed a rising and persistently high N.P.N., of grave prognosis. He demonstrated it was due to circulatory disturbances and occurs without the presence of chronic nephritis. Location of Infarct—Posterior occlusions (right coronary) warrant better prognosis than anterior. When both anterior and posterior surfaces are damages the prognosis is unfavourable. Electrocardiograph—of importance in diagnosis, especially anterior and posterior infarctions. Only prognostic value is in taking serial tracings. Page 180 The following six cases are cited as examples with brief notes also as to blood pressure and present disability: ^_Day N.P.N. B.P. Result Disability at present Mr. J. C— Age 71 years 1st 190/130 Cerebral embolism 25% 2nd 60 mgs. 140/90 8th day. 4th 50 mgs. 120/85 8th 46 mgs. 140/90 13th 37.5 mgs 142/90 Mrs. F. C.— Age 60 years_ 1st 120/85 to 100/85 Recovered. Broken compensation and 2nd 33 mgs. 96/60 to 120/90 fibrillation. 40% to 50% 4th 36 mgs. 120/84 5th 39 mgs. 120/80 Mr. A. S.— Age 46 years* 1st 170/116 Slow recovery. Having anginal pain. 2nd attack..' 3rd 0 mgs. 114/90 50% to 2 5% 4th 42.5 mgs. 150/96 5th 43 mgs. 110/78 Mr. C. E.— Age 46 years.. 1st 115/65 Slow recovery. 25% 2nd 66.6 mgs. 116/68 3rd 50 mgs. 120/68 6th 23 mgs. 120/70 Mr. H. N. W\— Ace 66 years 1st 110/90 to 96/78 Died 6th day. Severe attack. Shocked. 2nd 60 mgs. 94/86 Considerable amount of 4th 80 mgs. 92/70 arterio-sclerosis. Then 6th 90.9 mgs. 85/70 acute auricular fibrilla- Mr. W. G.— tion- Age 72 years 1st 120/80 Died 13th day. (Old arterio sclerotic) 2nd 60 mgs. 10 5/82 5th 87 mgs. 100/82 7:h 120 mgs. 100/80 Complications—Geo. Blumer states 50% of cases show mural thrombi. About 14% of cases of coronary infarction have embolism. Embolism most likely to occur in first ten days. Prognosis, of course, depends on site of lesion. Site of Emboli as shown by autopsy: Authors Limb Mes'y P.M. Lungs Brain Kidneys Spleen Vessels Aorta Artery Meakins and Eakin._ 62 47 4 14 9 11 2 0 Parkinson and Bedford... 83 7 1 9 8 2 1 3 Wolff and White 19 0 2 6 2 0 0 1 Total 164 54 7 29 19 13 3 4 Site of Emboli as observed clinically: Authors No. of Emboli Lung Brain Kidney Spleen Extremity Periphery Aorta Blumer 35 16 9 1 0 6 3 0 Gordinier 4 2 110 0 0 0 Howard 17 9 3 2 1 2 1 0 Levine _. 17 5 7 1 1 0 2 1 Parkinson and Bedford 8 3 3 110 0 0 Total- 81 35 23 6 3 8 6 1 Conclusions—Prognosis in coronary occlusion has definitely improved. Factor chiefly responsible for improvement is more accurate diagnosis, thus permitting early and correct treatment. The ones who survive the initial shock do not die of coronary thrombosis but because of the resulting cardiac infarction and its effect on the myocardium. The majority who die show evidence of previous arterial or myocardial involvement; i.e., arterio sclerosis, hypertension, cardiac enlargement, etc. Dr. Roberts, on behalf of the staff and those present, thanked Dr. Kenning for his interesting presentation. The meeting was then thrown open to discussion. Page 181 V ancouver enera ospita SCABIES—A NEW METHOD OF TREATMENT D. E. H. Cleveland, M.D. The method of treatment of scabies to be described has been in use in the Outpatient Department for the past two years. Thirty cases are recorded of its use in the Skin Clinic, but this actually represents many more persons treated, for the reason that nearly every case seen at the clinic has one or more relatives at home who were also treated. It is axiomatic that in scabies each person living in the home, unless there is positive assurance that there has been no intimate contact with the patient or his clothing, should receive complete treatment synchronously with the original patient. A small and unrecorded number of cases have been treated in the public wards. In addition to these, the author has treated about thirty-five cases in private practice. There is no record of any case treated in the Dispensary or in private practice, where instructions have been followed, in which a cure has not resulted from this treatment. The method was first described by Ravaut and Mahieu. For this reason the method has commonly been referred to as the "Ravaut Method." Two years later Kulchar and Meininger of San Francisco2 reported their experience with the method. They treated fifty patients, ranging in age from one year to seventy-three years, with 100% success. The treatment depends upon the precipitation of colloidal sulphur on the skin by the interaction of sodium thiosulphate and hydrochloric acid. The patient is given two bottles, one containing four ounces of a 40% solution of sodium thiosulphate, which is marked Solution No. 1, and the other containing four ounces of 4% hydrochloric acid, marked Solution No. 2. He is instructed in the following routine: Take a hot soap and water bath, scrubbing well and giving particular attention to the interdigital webs, front of the wrists, points of elbows, the breasts, axillae, abdomen, buttocks and external genitalia, but neglecting no part of the body from neck down. When thoroughly dry, the body is rubbed over in the same manner with Solution No. 1. Fifteen minutes later this is followed in the same manner by Solution No. 2. In an hour the two solutions are used again as before. On the following day exactly the same routine is followed except that the bath is omitted. On the third day the patient bathes again and changes to fresh clothing. All recently used bed-linen, night-clothing and underwear is sterilized by boiling for ten minutes or by dry heat. Outer clothing, such as may be worn in contact with the skin of some parts such as hands, wrists, arms and thighs may be sterilized by dry cleaning and hot pressing. The method has numerous advantages. It gives a higher proportion of cures than the commonly used sulphur ointment, or the "Danish" ointment. In a limited series of cases such as reported herein 100% of cures have been obtained. It seldom produces a sulphur dermatitis, and this is extremely mild, even when, contrary to advice, the patient has continued to apply the treatment over a much longer period than the two days necessary. The general discomfort due to having the body greased over and the offensiveness due to the smell of sulphur is avoided. These are serious matters to patients the least degree fastidious, and often interfere with treatment. It is an important advantage that the entire treatment lasts only three days and need not interfere in any way with business or social activities. The cost of the remedy to the hospital has been inquired into, and we are informed that it is approximately the same as an adequate supply of sulphur ointment, and considerably less than that of the "Danish" ointment. 1. Bulletin de le Soc. franc, de Dermat et Syph., Jan., 1934, p. 13 5. 2. Archives of Dermatology, Aug., 1936, p. 218. Page 182 CYST OF THE SEPTUM PELLUCIDUM AND EPILEPSY Frank Turnbull, M.D. Mr. A. D., age 23, was admitted to the Vancouver General Hospital on October 24th, 1938, to determine the cause of epileptic seizures which had occurred during the previous year. He had suffered from mild attacks of scarlet fever, mumps, and pneumonia in childhood. When 16 years of age he was trampled by a horse but did not receive any injury of his head. The family history did not reveal anything significant. He began to suffer from attacks of a peculiar nature in the fall of 1937. He did not lose consciousness in the early attacks but merely felt "giddy" for two or three minutes and noted that "things went black" before his eyes. After such an occurrence he would suffer a slight bi-temporal headache and feel nauseated for a few minutes. These seizures occurred without warning about three times a month. During the month before admission he had a dozen attacks and three of these were characterized by loss of consciousness following a few seconds of giddiness. After awakening from these severe attacks he complained of paresthesias of his hands and feet, severe bi-temporal headaches, nausea, occasionally vomiting, weakness, and marked diaphoresis. These symptoms lasted three to four hours. His mother had noted a change in his personality during the year. He had become unruly, restless, argumentative, and subject to fits of temper. He was a well developed and well nourished young man. General physical examination was negative. Neurological examination was completely negative apart from a slight deafness of 'nerve' type in the right ear. Roentgen plates of his skull showed slight flattening of the sella turcica. Dr. S. E. C. Turvey reported that one week prior to his admission lumbar puncture had been done and showed an initial pressure of 260 mm. of water. Lumbar puncture was repeated after his admission and showed an initial pressure of 280 mm. of water. The cerebrospinal fluid was clear, contained no cells, and had a negative Kahn. Blood Kahn was likewise negative. A provisional diagnosis of unlegalized brain tumour was made and it was decided to do ventriculography to obtain further information. This procedure, rather than encephalography, was chosen because of the evidence of raised intracranial pressure. Ventriculography was performed on October 30th under local anesthesia with the patient in a sitting position. Burr holes were made over the occipital poles of both lateral ventricles and brain needles inserted into the ventricles without difficulty. A total of 60 cc. of fluid was removed from the two sides and this was replaced by 40 cc. of air, injected into the right ventricle, as well as air which aspirated into) the left ventricle by negative pressure at the commencement. Shortly after fluid commenced to drain from the right ventricle the patient's pulse rate dropped down from 85 to 55 per minute. About this time he had a mild epileptic seizure. During the conclusion of the operation he remained in a stuporous condition. The pulse rate rose to 8 5 before he was transferred to the X-ray department. Ventriculographic films showed moderately large ventricles, well filled with air. In the antero-posterior view the walls of the septum pellucidum appeared to be separated about 1.5 cm. In the lateral view definite outline of the air-filled cavity in the septum pellucidum was seen. This measured 6.5 x 2.5 cm. It was obvious that the patient had a cyst of the septum pellucidum and, because it was filled with air, that it communicated with the lateral ventricles. No further operation was indicated. After ventriculography he had severe headaches for several days. Air was aspirated from the ventricles on one occasion with great relief of pain. Thereafter he made uneventful progress. On November 8th he still had a slight headache and lumbar puncture showed a pressure of 224 mm. of water. To ensure that the opening from the cyst into the ventricles had remained patent encephalography was done under local anesthesia on November 12th. 110 cc. of cerebrospinal fluid were removed and replaced with an equal amount of oxygen. Subsequent roentgen plates showed that the cyst was well filled with the gas. He was discharged free of symptoms on November 16th with instructions to take phenobarbital gr. 1 twice daily. Page 183 He has reported back at the Out-Patients' Clinic periodically and has remained free of epileptic seizures and of all other complaints. The last examination was made on February 7th, 1939. DISCUSSION. The septum pellucidum is a thin, triangular, two-leaved membrane which separates in a vertical plane the anterior mid-portion of the two lateral ventricles. If these two thin membranous plates are not in perfect apposition a cavity results. The most posterior extension of the septum, pellucidum is known anatomically as the cavum vergae and hence cysts in this region are generally called cysts of the cavum vergae rather than cysts of the septum pellucidum. A cavity of usually insignificant dimensions is present in an uncertain percentage of "normal" brains. Figures range from 4 to 60 per cent and it is said to be a constant finding in brains of the newborn or of the foetus. Rarely the cavity enlarges to become a sizeable cyst and then causes symptoms identical with a similarly placed tumour. The source of fluid in the cysts is probably embryonic rests of pia-arachnoid on the inner walls of the septum. Dilations of the cavity of the septum pellucidum and cavum vergae may be of three types: (1) The non-communicating type in which the walls are intact and a closed cyst results; (2) The communicating type in which there is communication with the adjoining lateral or third ventricle as a result of rupture due to pressure within the cyst; (3) Secondary dilation of the communicating type associated with a later developing or superimposed hydrocephalus from various causes. Non-communicating dilatations of the septum pellucidum may cause marked symptoms such as headache, epileptic seizures, and mental disturbances. Dandy first called attention to the possibility of diagnosis in these cases by ventriculography. Communicating dilatations do not produce clinical symptoms. It appears to me that in the case reported above there was a non-communicating dilatation of the septum pellucidum which accounted for the patient's history of epileptic seizures and mental changes, and the finding of increased intracranial pressure. During ventriculography, pressure in the adjacent lateral ventricles was suddenly released and in consequence the cyst ruptured spontaneously into one of the lateral ventricles. It then became a communicating dilatation. This state of affairs was verified by the subsequent encephalogram. Van Wagenen and Aird had an identical experience after encephalography and mentioned that Stokey had previously reported a similar occurrence. In a brief survey of the literature I have not encountered any other reports of such an experience in a case of cyst of the septum pellucidum. Reference: Van Wagenen, W. P., and Ai>"d, R. B., Amer. J. Cancer, 1934, 20, 5 39. COMMON RECTAL CONDITIONS Dr. A. Taylor Henry I have been asked to review concisely a few of the common rectal conditions which are found in general practice, and their treatment. It is a regrettable fact that so much neglect has in the past been given to irregularities in this zone, both by the patient and also the physician, due chiefly in the first place to sensitiveness of the patient in undergoing an examination, and, unfortunately, also to the physician who may disregard this part of the anatomy. As a student, I remember hearing very little about diseases of the rectum beyond "piles" and cancer, and yet it is amazing how much trouble arises in this area and how needlessly advanced many of these conditions become due to neglect. From the standpoint of treatment, there is no area where, under proper diagnosis and treatment, quicker and better results can be obtained. Let us consider some of the common symptoms, such as pain, bleeding and bowel irregularity and consider the differential diagnosis. When a patient comes to one's office with these symptoms, let us not be satisfied by saying "Oh, yes, you have piles," and give some ointment and send them on their way. It may be necessary, if they are not well prepared, to have them go home and, by the use of a laxative that night and an enema on the Page 184 following morning, have them return for a complete examination. This should not only require exploration with a gloved finger, but also the use of a proctoscope. The first condition which I will discuss is simple proctitis. Probably a better term to use would be cryptitis. This may be due to trauma of a foreign body, such as a fish bone, scratching the wall of the anal canal or to hardened faecal matter tearing the base of some of the crypts and allowing infection to develop. When the infection becomes more chronic, there is a tendency for the papillae to become enlarged and cedematous and to harbor organisms at their bases. The condition then becomes a vicious circle and, as a result, although the inflammation may subside, the papillae do not reduce greatly in size. Thus it may occur that, while under the routine treatment of mild irrigations to the rectum and the use of heat such as Sitz baths, these cases may clear up temporarily, many are prone to recurrence unless these enlarged papillae are snipped off. With the proper instruments, this can easily be done in the office. Better results aire gained if, in addition t6 these irrigations, the crypts are individually cleansed with a swab, using some disinfectant solution such as metaphen. The use of suppositories inserted at night before going to bed is also of considerable value in certain cases. In their use, it is important that the patient be told not to push the suppository right into the rectum, but to hold it in the anal canal until it dissolves at least partially. These cases, generally speaking, have a good deal of anal spasm due to the irritability of the canal and may present signs of a fissure in this respect. Let us, then, consider the differential diagnosis. Anal fissure, which is a very common condition, consisting of a small ulcer which forms on the muco-cutaneous junction and practically always in the posterior quadrant, gives severe pain at defaecation, persisting usually for a variable time afterwards and then, as a rule, unless it be very advanced, the patient has comparative comfort until the bowels move again. There is usually, along with this, intermittent bleeding at the time of defaecation, whereas, in simple cryptitis, bleeding is not very common. Both conditions give severe sphincter spasm, but, in the case of fissure, it is more easily detected. Without even inserting the finger into the rectum, if one spreads the posterior anal margin apart, one can practically always see the ulcerated area. This ulcer starts at the muco-cutaneous junction and usually extends up about one centimetre into the anal canal. If, with a lubricated glove, one then inserts a finger and rotates it posteriorly, the roughened surface can quite easily be felt. In many of these cases, there is a so-called sentinel pile on the cutaneous margin. This is usually a small, papillary-like projection and, when the stool passes through the canal, it tends to tear the base of this projecting tag and keep the ulcer from healing. Conservative treatment of these fissures is unsatisfactory. Anaesthetic ointments tend to give little or no relief. The local application of caustics, such as silver nitrate, while it tends to relieve the symptoms temporarily, is insufficient to produce permanent cure. Briefly, the treatment of these cases depends on excision of the ulcer and any tags that may be present. This is best done under local anaesthesia. A spinal anaesthetic is ideal for all rectal operations. I might mention here the great advantage of spinal or sacral anaesthesia over general anaesthesia. To produce sufficient relaxation of the sphincter muscle requires deep ether anaesthesia, which is hard to control, whereas, with spinal anaesthesia, the relaxation is complete and allows one much more freedom in manipulations. I might, before leaving this subject, mention treatment by subcutaneous injections of various substances. In small fissures, which have not eaten into the underlying muscle, I have seen good results obtained by injecting about 5 cc. of proctocaine (Allen & Hanbury). This must also be injected into the sphincter muscle itself. In these minor cases, they usually do get instant relief from the anaesthetic solution and will thus heal up. Most fissures, however, have gone too far by the time they are first seen to be able to react to such treatment. Let us now consider briefly the treatment of haemorrhoids. For simplification, we will divide them into three classes: (a) internal; (b) internal and external; (c) prolapsing. Although I still think the best and quickest cure for haemorrhoids is surgical, there are a great many cases of the internal variety causing both haemorrhage and some prolapse, which, for various reasons, are unable to have an operation. This may be due to inability to leave their work and, perhaps more often, to lack' of financial means to pay for hospitalization as well as doctor's bills. Many of these cases get very good results from injection Page 185 treatment. This is done by using various types of reagents, probably the best known being quinine and urea. Others used are phenol in oil, and sodium morrhuate. Personally, I have had the best satisfaction with the quinine compound and have come back to its use after trying the others. The amount used varies with the case, the injection being given by a fine needle on the end of an elongator, inserted sub-mucously into the prominent pile area. Care must be taken not to go too deep so as to run into the muscular coat, or, as sometimes occurs, to go through the pile in two places so that the end of the needle lies behind the pile and empties the fluid into the rectum. The amount injected varies; 4 cc. of quinine given slowly is a good average dose. If the point of insertion of the needle suddenly turns white, you know you are not sufficiently deep or have given enough. Caution has often been advised not to inject enough to cause a slough. I can see no reason for this, as a slough insures destruction of the pile and surely cannot be more dangerous than the radical methods of cutting or cauterization. It takes a week to ten days for the slough to separate, when a little bleeding may occur, but, as thrombosis takes place, it is extremely seldom that severe haemorrhage results. While more than one area may be injected at a time, it is customary to do only one segment at a time, with weekly intervals between. Where there is a degree of prolapse of the mucous membrane, one can often run in beneath this redundant mucosa, disassociated from the pile itself, a varying amount of this solution which will permeate around a segment of the wall and set up sufficient inflammatory reaction to hold it up. External haemorrhoids should never be treated by injection. The resulting pain and swelling cannot be borne by the patient and an external slough makes a nasty mess as a complication. These cases must be treated by the usual haemorrhoidectomy. In severe cases of haemorrhoids, both internal and external, with a lot of redundant skin and prolapse, one can, on chosen cases, get a very good result by a modification of the old Whitehead method surgically. By this method, the redundant peri-anal skin is removed along with the protruding mucous membrane of the anal canal. By interrupted sutures, the mucous membrane is brought down and sutured deeply to the sphincter muscle and a raw ring left between it and the cut skin margin. On no account must the mucous membrane be sutured to the skin and, if the technique is properly carried out, the formation of stricture or eversion of the mucous membrane, which put the old operation into disrepute, will not occur. Before finishing with haemorrhoids, I might mention the treatment of acute thrombosis as is so often seen with the characteristic blue, painful swelling. It has been the practice of some, and I must admit of myself on occasions, to incise and remove the clots for the relief of pain. This practice I do not feel justifies the result. Aside from producing a painful incision, and some oozing and often infection, I find that the swelling usually recurs and is, if anything, more painful. These cases are best treated conservatively with rest in bed, hot fomentations and sitz baths. The thrombosis itself acts as a cure in the same way as the injections already referred to. Another common condition often improperly treated is fistula-in-ano. Briefly, these cases result from infection arising in a fissure or a cryptitis breaking through the rectal wall and forming a peri-rectal abscess. This extends usually into the soft tissues and comes to a head on either side of the anal opening, appearing as a boil. The patient sees his doctor, who lances the "boil," and following this it either continues to drain or temporarily heals up and reforms and has to be opened again. The tract thus formed may be either inside or outside the sphincter muscle and wherever it is must be opened up throughout its entire course to gain a cure. Fistulae used to be considered tuberculous in origin much more than they are now. While it is true that some of them are and that we run into them not infrequently in tuberculous patients, the great majority of them are non-tuberculous. The tract may be very tortuous and have several openings. The worst case I have ever seen was thirty-five years in duration and involved the whole circumference of the canal with five external openings. The secret of cure is the excision of all its branches. As is well known, of course, when the tract runs external to the sphincter, the muscle must be cut through. At times, when there is a large abscess cavity outside the sphincter, which may allow the sphincter to spread dangerously apart, the old French Seton method can be used. Here a non-absorbable suture is tied around the sphincter until the abscessed cavity has Page 186 granulated in, thus holding the sphincter together, when it may be cut through at a second sitting and the tract then allowed to fill in by keeping it packed. Pruritus ani is a frequent and miserable condition causing its sufferers must grief. When present, it is always worse in bed at night and produces sleeplessness and nervous debility. Its causes are many and varied and I can only discuss herd a few of the commoner ones. Certain are due to fungus infection, so that one must rule out its transmission from other sources such as "athlete's foot." These cases usually react well to Whitfield's paste, keeping the parts dry with a dusting powder and also cleansed by washing at least twice a day with soap and water and thoroughly drying afterwards. Other cases appear due to infection travelling subcutaneously from fissures, infected crypts, etc., in which case the causes must be removed. Even this may not relieve the irritation, which produces that typical, washed leather appearance. In prolonged cases, good results are attained by the use of alcohol injections. Several methods are used with varying percentages of alcohol. Personally, I have been stepping up its amount until now I am using 80% alcohol, injecting the whole area by multiple injections and using 3 or 4 minims at each site about 1 centimetre apart. Too much alcohol produces sloughing which is slow to heal up, but with experience, and being sure that the alcohol is below the skin surface, good anaesthesia is obtained. It ias amazing how improved the skin appears within a few days. I have used Proctocaine in my office in milder cases with gratifying results. The use of x-rays generally I have not found nearly so satisfactory, although there is a group of selected cases, perhaps 15% to 20%, who get prolonged and sometimes permanent relief. The majority of cases get a temporary relief of some weeks by the use of x-ray, only] to relapse into their former state. There is much to suggest an endocrine cause for some of these cases, particularly in women, and already various firms are suggesting follicular hormone treatments. I think, from what little I have seen of it, that there is a future for it. In conclusion, I might say that space does not allow of my discussing other conditions, such as ulceration in the rectum associated with colitis, or benign polyps and other growths met with. Suffice it to say that, when such conditions are met with, examination by the sigmoidoscope is always indicated. Ulcerative colitis starts in the rectum and sigmoid and polyps may be sentinels of multiple polypi further up. Some authorities suggest that 40% of polyps become malignant. Their removal by cautery is simple. I have seen and locally removed polypoid growths no larger than a pea, which, microscopically, were malignant. It is a real tragedy that earlier malignancy of the rectum is not diagnosed when treatment is so simple. MEMBERS of THE GUILD of PRESCRIPTION OPTICIANS of AMERICA Always Maintain the Ethical Principles of the Medical Profession Guildcraft Opticians 430 Birks Bid?. Phone Sey. 9000 Vancouver, Canada. Page 187 fFf PLUMMER VINSON SYNDROME Dr. C. E. Brown The Plummer Vinson syndrome is an interesting triad of hypochromic anemia, achlorhydria, and oesophageal spasm and is probably represented by the following case: Mrs. H., a widow of about 52, seen with Dr. Charles Walsh, gave a history of difficulty in swallowing solids, increasing pallor and weakness, but very little disturbance of digestion except for some gas. The blood count revealed a severe grade of hypochromic microcytic anaemia, the haemoglobin percentage being 23, and the red cell count approximately 2,000,000.. A careful search for a source of haemorrhage being negative, and X~rays of the gastrointestinal tract revealing no evidence of ulcer or malignancy, a Fractional Gastric Analysis was suggested and revealed an achlorhydria with the ordinary gruel meal without any histamine injection. There was.great difficulty with the Rehfuss tube' the Levine tube passed with some delay. The treatment outlined is that for a severe secondary anaemia with the addition of liver in liberal amounts, this being one type of microcytic anemia that responds better to the combined exhibition of iron and liver. Dram doses of dilute acid hydrochloric were suggested, to be taken well diluted as a beverage with each meal. REGIONAL OBESITY—PROBABLE CUSHING'S SYNDROME Dr. C. E. Brown Two cases of marked obesity of a regional type are reported, their interest lying in the many symptoms each shows which suggest their inclusion in the group of cases designated as Cushing's syndrome, or as originally suggested in 1932 by Cushing as being associated with basophilic adenomata in the anterior lobe of the pituitary gland. Mrs. McK., aged 49 Mr. S., aged 69. Regional obesity + + Hypertension 210/140 210/104 Hypertrichosis Cheek No Genital dyscrasia | | Loss of Libido Loss of Libido Asthenia Marked Marked Well marked Plethora j + Hemoglobin 95% Purplish Striae None None Osteoporosis Not definite + Spine Kyphosis, dorsal _•_ Present Well marked Mrs. McK., referred by Dr. Adam Beattie, showed a fairly rapid development of her obesity. At 24 years of age she weighed 150 pounds and was well developed. Nine years ago she weighed about 200 pounds and at that time had a pelvic operation with removal of the uterus, but she is not certain as to the removal of the ovaries. During the following five years the weight increased to 314 pounds. She shows the girdle type of adiposity with heavy chest and prominent abdomen. There is considerable pain in the back of the head and neck. Her chief complaint is exhaustion. B.M.R. is within normal limts. Mr. S., whose top weight has been 325 pounds, has doubled in weight since the third decade, having increased rapidly after typhoid fever at 3 0 years of age. He has continued a fairly active life as a consulting construction engineer, but has been very short of breath, easily exhausted, and subject to arthritic pains. His lumbar vertebral bodies show definite Page 188 biconcavity and there is a definite dorsal kyphosis. The fasting blood sugar and glucose curve are elevated. The fasting cholesterol is 150 mgs. (normal). The type of obesity in this patient is typical girdle distribution with marked deposits on, the trunk, neck, face, and a large pendulous abdomen; the buttocks and lower extremities are fairly free. B.M.R. is within normal limits. The recent reports of Evelyn Anderson, Haymaker and Joseph of the University of California on the Hormone and Electrolyte studies of patients with Hyperadrenocortical Syndrome (Cushing's Syndrome) indicates an excessive production of cortin resulting from hyperplasia of the adrenal cortex as the underlying cause of the syndrome rather than the presence of basophilic adenomata of the anterior pituitary. Presence of Cortin-like substance in the blood and urine of patients with Adrencortical Syndrome. Extracts of the blood and urine of patients with Cushing's syndrome, prepared by a method used for extracting adrenal cortical hormone from adrenal tissue, have been shown by Anderson and Haymaker to prolong the lives of adrenalectomized rats beyond the survival of untreated controls. The cortin-effect of 1 cc. of blood was equivalent to 4-6 gm. of fresh adrenal tissue. The extract of urine of one of these patients showed a similar effect. It was estimated that a 24-hour urine specimen contained the equivalent of 400 gm. of adrenal gland. It has been found that the AGH (adrenal cortical hormone) is a controlling influence in maintaining plasma electrolyte balance. It has been shown that in Addison's Disease, where the cortin production is deficient, that the sodium electrolytes are decreased and the potassium increased, whereas in Cushing's syndrome, where there is an increased production in cortin, the reverse is found, the sodium is increased and the potassium is decreased. On the other hand, the urinary secretion of sodium was below normal, whereas the potassium excretion was elevated. Treatment On the supposition that Cusing's syndrome is the opposite of Addison's Disease, Anderson and Haymaker have given patients with Cushing's syndrome a daily dose of 5 to 10 gms. of potassium, either as chloride or acetate, and a diet low in sodium content. In addition, the adrenals have been exposed to therapeutic doses of X-ray in most of the cases. The results, they state, have been quite gratifying, with a resultant drop in hypertension, loss of weight, and improvement in many of the symptoms such as headache, pains, menstrual disturbances, etc. Although these two patients are by no means typical cases of adrenocortical syndrome, it is felt that they have sufficient characteristics to warrant at least a trial of the above mentioned treatment, giving at first the potassium acetate and a high potassium and low sodium diet, which includes the reduction of table salt with the exhibition of milk, eggs, green vegetables, sea foods, whole wheat, and dried fruits. Reference'. New International Clinics, Vol. iv, Series 48. A review of the Syndromes Arising from Hyperfunction of the Adrenal Cortex: The Adrenogenital and Cushing's Syndromes. By Webb Haymaker and Evelyn Anderson, University of California. A PRESCRIPTION SERVICE . . . Conducted in accord with the ethics of the Medical Profession and maintained to the standard suggested by our slogan: Pharmaceutical Excellence AAcGiI 6 Otfmr, LIMITED V—' FORT STREET (opp. Times) Phone Garden 1196 VICTORIA, B. C. Page 189 Out orm Daily at this time of the year many physicians are called upon to alleviate the symptoms of certain infections of the upper respiratory tract and thus to help the patient "ride out the storm." One of the commonest and most distressing symptoms of such infections is inability to breathe properly through the nose. For prompt, effective relief of this symptom Neo-Synephrin Hydrochloride is recommended. NEO-SYNEPHRIN HYDROCHLORIDE |jt is a vasoconstrictor which exerts a more prolonged effect than ephedrine or epinephrine and, in therapeutic dosage, is less toxic than either. When used as recommended, Neo-Synephrin Hydrochloride constitutes a highly efficient agent for reducing nasal congestion. EMULSION %% (1-oz. bottle with dropper) SOLUTION *% J0* dro.pPer,or spray 1-oz. bottle. 1% for resistant cases \ JELLY -/2% (in collapsible tubes with applicator) EMULSION Sill SOLUTION W& m? JELLY Literature and professional sample on request. Frederick Stearns & Company of Canada/ Ltd, WINDSOR ONTARIO Makers of Kasagra. Detroit, Mich. New York, N.Y. Kansas City, Mo. San Francisco, Calif. Sydney, Australia. (M&B 693) PNEUMOCOCCAL 3 INFECTIONS Controlled clinical trials have demonstrated that DAGENAN exercises a very favourable influence in these conditions, resulting in a great reduction in the mortality rate. GONOCOCCAL INFECTIONS Early encouraging reports have been amply confirmed by later investigations of DAGENAN in the treatment of gonorrhoea and its complications. For complete information about Dagenan write to LABORATORY POULENC FRERES OF CANADA LIMITED 204 YOUVILLE SQUARE - - MONTREAL HOW SUPPLIED: Tablets each containing 0.5 gramme of the active substance in bottles of 20. 100 and 1000 tablets. You CAN Take It With You V HERE'S a portable x-ray unit that is powerful, efficient, and unusually compact. It is so light in weight that you can easily take it with you on your calls. It's the G-E Model F-3, a unit you can rely on for satisfactory, dependable x-ray performance within its range — in your office or at the patient's bedside —wherever adequate roentgenological service is not already available. The simplified, refined control unit of the F-3 is easy-to-operate, requires no complicated manipulation; and the unit's full flexibility expedites and simplifies positioning with minimum patient discomfort. Think what a valuable assistant this fine unit would be! It's easy to own, too. As a matter of fact, its total cost is surprisingly low and requires an initial investment of no more than is necessary for an ordinary small x-ray unit. So that you may decide for yourself the worth of the F-3 to you in your practice, and its merit as a dependable, economic investment, let us arrange an interesting working demonstration in your office at your convenience. Then you can actually use and operate the unit just as you would in your daily practice; to do this will cost you nothing and incur you no obligation. Just sign and mail the handy coupon today. VICTOR X-RAY CORPORATION of CANADA, Ltd. DISTRIBUTORS FOR GENERAL fc i ELECTRIC X-RAY CORPORATION TORONTO: 30 Bloor St., W VANCOUVER: Motor Trans. Bldo., 570 Dunsmuir Si MONTREAL) 600 Medical Arts Building WINNIPEG: Medical Arts Building I am interested in seeing and operating the G-E Model F-3 X-Ray Unit in my office. A203 Name Address^. Protection Against Typhoid Typhoid and Typhoid-Paratyphoid Vaccines Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly in rural and unorganized areas. This is borne out by the fact that during the years 1931-1935 there were reported, in the Dominion, 12,073 cases and 1,616 deaths due to these infections. The preventive values of typhoid vaccine and typhoid- paratyphoid vaccine have been well established by military and civil experience. In order to ensure that these values be maximum, it is essential that the vaccines be prepared in accordance with the findings of recent laboratory studies concerning strains, cultural conditions and dosage. This essential is observed in production of the vaccines which are available from the Connaught Laboratories. Residents of areas where danger of typhoid exists and any one planning vacations or travel should have their attention directed to the protection afforded by vaccination. Information and prices relating to Typhoid Vaccine and to Typhoid-Paratyphoid Vaccine will be supplied gladly upon request. CONNAUGHT LABORATORIES UNIVERSITY OFItORONTO Toronto 5 Canada Depot for British Columbia Macdonald's Prescriptions Limited MEDICAL-DENTAL BUILDING, VANCOUVER, B. C Wm HI * j* i Jv Hematinic Plastules Effective in Small Dosage J The daily dose of three Hematinic Plastules Plain yields gratifying results in the average case of hypochromic anaemia. Each Hematinic Plastule Plain contains 5 grains of ferrous iron in a well tolerated, easily assimilated form. Two types of Hematinic Plastules are now available on your prescription—Plain, in bottles of seventy-five; with Liver Concentrate, in bottles of fifty. Your patients will find the cost of this medication well within their means. ■ • JOHN WYETH & BROTHER INCORPORATED WALKERVILLE - - ONTARIO STEVENS' SAFETY PACKAGE STERILE GAUZE is a handy, convenient, clean commodity for the bag or the office. Supplied in one yard, five yards and twenty-five yard packages. ESTABLISHED NEARLY A ^CENTURY.* B. C. STEVENS CO. Phone Seymour 698 73 0 Richards St., Vancouver, B. C. ... BOWELL & SON s. Distinctive Funeral Plinnr* 001 Service 66 SIXTH STREET I ^EW WESTMINSTER, B. C. '■V5$t^.px&yiffiy.$<tf&:& >'•//*?'.% I 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-ovarisi||| circulation and thereby encourages a normal menstrual cycle. F p Sort ft • MARTIN H. SMITH COMPANY M£ ISO lAFAYITTt STRUT. NEW YORK. N. V. w 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. m m 2559 Cambie Street Vancouver, B. C. Colonic Irrigation Institute Superintendent: E. M. LEONARD, B.N. Post Graduate Mayo Bros. Up-to-date treatment rooms; scientific care for cases such as Colitis, Constipation, Worms, O astro-Intestinal Disturbances, Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne. Individual Treatment $ 2.50 Entire Course $10.00 Medication (if necessary) $1 to S3 Extra Suite 115, Hotel Vancouver VANCOUVER, B. C. Phone: Sey. 2443 506-7 CAMPBELL BUILDING VICTORIA, B. C. Phone: Empire 2721 The Purified ACTIVE PRINCIPLE OF SANDALWOOD OIL §»**»» ECONOMICAL Dosage Form Doctor, why use ordinary sandalwood oil when you can just as easily administer the active principle of the oil with the irritating and therapeutically inert matter removed—and at a cost to your patients of only a very few pennies more? You can do this by prescribing the new, economical 50-centigram capsules of ARHEOL (ASTIER) now obtainable in bottles of 12, 24 and 100 capsules at $1.00, $1.75 and $6.00 a bottle respectively. ARHEOL is the purified active principle of sandalwood oil. It is a uniform, standardized product with which prompt and dependable results may be expected. Undesirable sequelae often associated with sandalwood therapy are either absent or reduced to a negligible degree. A^-BVMA "Pharmaceutical Specialties of DR. P. ASTIER 350 Le Moyne Street, Montreal. Please send me a sample of ARHBOLi (Astier) in the new economical dosage form. .M.D. Street City Prov. Pharmaceutical Specialties of DR. P. ASf IER 350 Le Moyne Street, Montreal _yv bio It -standardized w-sianaaraizea pw of etoen tlal ult j am ins avid minerals "Alphamin" is recommended as a valuable dietary supplement particularly during pregnancy and lactation, throughout adolescence, during convalescence and for patients on reducing or other restricted diets. Available in convenient form for easy administration. • • • For scientific reasons, the fat-soluble Vitamins A, D and E are presented in soluble gelatin capsules and in a natural oil base, separate from the minerals and water-soluble vitamins; the water-soluble Vitamins Bi and C are contained with the minerals in "Comprills". "Each Capsule contains: Vitamin A 10,000 International Units Vitamin D 1,750 International Units Vitamin £ As contained in 21/2 ounces oi whole wheat Each "Comprill" contains: Vitamin Bi (Thiamin Chloride) 200 International Units (.67 mg.) Vitamin C (Cevitamic Acid) 300 International Units ( 15 mg.) Ferrous Sulphate Exsiccated I1/2 grains (100 mg.) Acid Calcium Phosphate 11/2 grains (100 mg.) also traces oi copper, manganese and iodine. DOSE:—As a dietary supplement—One capsule and one "Comprill" daily, preferably taken before dinner. AYERST, McKENNA & HARRISON LIMITED Biological and Pharmaceutical Chemists No. 869 MONTREAL, CANADA Doctors- YOUR PRESCRIPTION AND RECOMMENDATION Is Our Guide Always-- OUR MECHANICAL and SCIENTIFIC ORTHOPAEDIC EQUIPMENT Is At Your Service Avail Yourselves of our experience in last making to aid correction in Minor Foot Ailments. PHONE Pierre Paris FOOT CLINIC Sey. 3778 51 W. Hastings mmlttKmm liliiiiliiil 558!!; i «s ARTHRITIS <WCHRONIC RHEUMATISM Lyxanthine Astier makes it practical to administer, per os, the indicated synergists: sulphur, calcium and iodine, together with lysidin bitartrate, a powerful solvent and eliminant of metabolic waste, in one combination and in one dose. These agents bring about rapid disappearance of periarticular infiiltra- tion, subsidence of swelling, stiffness and numbness, relief of pain, increased articular motility. Lyxanthine Astier is non-toxic, non- irritant ; in usual dose, cholagogue, in larger dose, laxative. Makes it possible gradually to discard the use of salicylates, aspirin or other anal- resics. LYXANTHINE ASTIER Pharmaceutical Specialties of DR. P. |STIE R 350 Le Moyne Street, Montreal ! Pbarmace utical Specialties of i DR. F. ASTIER ! 350 Le Moyne Stre et, Montrc sal. ■Please ■Lyxam send li ;hine As terat >tier. ure and s< imp le of : Dr ■ Address ' : City ..-Prov L14- BVMA 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 grrm. of the active substance. CIBA COMPANY LIMITED MONTREAL MMMwHW 13 th Ave. and Heather St. Exclusive Ambulance Service FAIRMONT 80 PRIVATE AMBULANCES AND INVALID COACHES WE SPECIALIZE IN AMBULANCE SERVICE ONLY J. H. CRELLIN W. L. BERTRAND TRIPLE ///CHECK THE uniform vitamin D potency of Irradiated Carnation Milk is, first, assured by exact scientific processing . . . second, verified at the Carnation central laboratory by rat-feeding tests and bio-assays . . . third, confirmed by the Wisconsin Alumni Research Foundation, which regularly receives control shipments from all Carnation plants . . , The uniform quality of Irradiated Carnation Milk makes it a most dependable food for infants —a pure, nourishing, readily digestible, convenient, economical, and universally available milk that has won unique acceptance in this field. A BOOKLET FOR PHYSICIANS —Write for "Simplified Infant Feeding", an authoritative publication treating of the use of Irradiated Carnation Milk in normal and difficult feeding cases . . . Carnation Company Ltd., Toronto, Ontario. CI IRRADIATED arnation Milfi A CANADIAN PRODUCT — "Aoxn contented cows For Mothers and Mothers to Be Ovaltine is a food supplement concentrating the nutritive values of fresh milk, eggs and a special barley malt extract, lightly flavoured with cocoa. It helps expectant mothers maintain their vitality and so aids in bringing better babies into the world. Ovaltine has these outstanding advantages as a tonic food beverage used during the period of pregnancy and lactation: 1. It is a delicious tonic food beverage. 2. It contributes essential vitamins and minerals. 3. It adds extra nourishment. Ovaltine contains these Essentials: Proteins and Carbohydrates Vitamin A Calcium Vitamin B Phosphorus Vitamin D Iron Vitamin G Your patients will find the flavour of Ovaltine appetizing and delightful. OVALTINE TONIC FOOD BEVERAGE Manufactured by A. WANDER LIMITED, Peterborough, Canada. Also factories in Switzerland, England, France and the United States. flDount pleasant XHnbertakinQ Co. %tb. KINGS WAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C. R. F. HARRISON W. R. REYNOLDS In Bronchitis Influenza Cough is always indicated. It stimulates the capillary network of the thorax, and hence improves the local metabolism. It eases the constriction in the chest and helps to loosen the cough. Made in Canada. THE DENVER CHEMICAL MANUFACTURING CO. 153 Lagauchetiere St. W. Montreal OLEUM PERCOMORPHUM (Liquid) 10 and 50 cc. brown bottles in light-proof cartons. Not less than 60,000 vitamin A units, 8,500 vitamin D units (International) per gram. 100 times cod liver oil* in vitamins A and D. OLEUM PERCOMORPHUM (Capsules) Especially convenient when prescribing vitamins A and D for older children and adults. As pregnancy and lactation increase the need for vitamin D but may be accompanied by aversion to large amounts of fats, Mead's Capsules of Oleum Percomorphum offer maximum vitamin content without overtaxing the digestive system. 25 and 100 10-drop soluble gelatin capsules in cardboard box. Not less than 13,300 vitamin A units, 1,850 vitamin D units (International) per capsule. Capsules have a vitamin content greater than minimum requirements for prophylactic use, in order to allow a margin of safety for exceptional cases. FOR GREATER ECONOMY, the 50 cc. size of Oleum Percomorphum is now supplied with Mead's patented Vacap- Dropper. It keeps out dust and light, is spill-proof, unbreakable, and delivers a uniform drop. The 10 cc. size of Oleum Per- comorphum is still offered with- the regulation type dropper. LJSQS ' For the prevention and treatment of rickets, tetany, and selected cases of osteomalacia; to prevent poor dentition due to vitamin D deficiency; for pregnant and lactating women; to aid in the control of calcium-phosphorus metabolism; to promote growth in infants and children; to aid in building general resistance lowered by vitamin A deficiency; for invalids, convalescents, and persons on restricted diets; for the prevention and treatment of vitamin A deficiency states including xerophthalmia; and wherever cod liver oil is indicated. *U.S.P. Minimum Standard MEAD JOHNSON & CO. OF CANADA, LTD. Belleville, Ont. ETHICALLY MARKETED "We purposefully selected for these products classic names which are unfamiliar to the laity, or at least not easy to popularize. No effort is made by us to "merchandise" them by means of public displays, or over the counter. They are advertised only to the medical profession and are supplied without dosage directions on labels or package inserts. Samples are furnished only upon request of physicians. // You Approve This Policy Specify MEAD'S Please enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized person*. Exactly as You Order It Every prescription is filled exactly as you order it. Free City Delivery Phone: SEYMOUR 2263 Open All Night OMMAU MICMT GEORGIA PHARMACY M I T E D W.OIORttlA STREET (&mtn $c larota Stib Establitbtd 1893 VANCOUVER, B. C. North Vancouver, B. C. Powell River, B. C. Hollywood Sanitarium Limited For the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively Reference—B. 0. Medical Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Seymour 4188 Westminster 288 ROY WRIGLEY PRINTING a PUBLISHING CO. LTD.
Periodicals
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: March, 1939
Text