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History of Nursing in Pacific Canada
Vancouver Medical Association
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The .1 . bullet rev of the .. .8 VANCOUVER M Ed|cAL ASSOCIATION _*o_ With Which Is Incorporated Transactions of the VICTORIA MEDICAL SOCIETY the VANCOUVER GENERAL HOSPITAL and ST. PAUL'S HOSPITAL In This Issue: Page CARCINOMA OF THE CERVIX By Dri|_thlyn Trapp :--lf— SyBKlWll UROLOGICAL COMPLICATIONS IN CARCINOMA OF THE CERVIX—By Dr. 1^ A. Williams 128 LATE MANIFESTATIONS OF CARCINOMA Dr. A. T. H*wfT "^j^fe^^S MS^^MS|LM PAIN ASSOCIATED WITH CARCINOMA OF g*HE CERVIX—By Dr. R^pjurnbull '-_f&33 AN UNUSUAL CASE OF PULMONARY HAEMORRHAGE—By Dr. Elliott Harrison 135 NEWS AND KoAsfi 111 __j8|l :-jfe^ 137 ANNUAL SUMMER SCHOOL VANCOUVER MEDICAL ASSOCIATION May 29th to June 1st, 1945 (in^ft Hotel Vancouver VOL XXI NO. 5 February. 1945 • The blood film tells what to do for anaemic patientstM When red cells are small and the unstained central portion abnormally large, Ferrochlor E.B.S. will bring rapid improvement. Ordinarily, iron medication presents two difficulties. Firstly, ferric iron precipitate, proteins, thus interfering with digestion. Secondly, many ordinarily used .salts, such as ferrous carbonate, react with and use up hydrochloric acid in the stomach—a serious matter in the condition of archlorhydria so frequently concomitant with anaemia. • In FERROCHLOR E.B.S., the use of ferrous chloride overcomes both difficulties. Being a ferrous salt, it does not precipitate proteins; being a chloride, it cannot combine with the hydrochloric acid of the stomach. The addition of Vitamin BI improves the muscular tone of the patient, making him feel better jst| a big help in suc||] cessful therapy. E. B. S. chemists have, moreover, successfully attacked the problem of keeping an aqueous solution of ferrous chloride from oxidizing t4|p,he ferric forms. Samples from production runs of over four years ago still show no trace of ferric ions. Ferrochlor, E. B. S. is indicated in all cases of hypochromic microcytic anaemia. There is a growing feeling, too, that it should be administered almost routinely during late pregnancy to ensure that babies will be born with a reserve of iron sufficient to prevent the drop of haemoglobin that: so often occurs during the first year of life. Illlil_ll_____31I jHHJBI 3__l_t_gl%^^_ft>^-nrim_MwP^g, >-gi FERROCHLOR E.B.S. with vitamin B! i|| Available in liquid or Tablet Form J| Liquid: Contains 16 grains of ferrous chloride and 2,000 International units of Vitamin BI per fluid ounce. Supplied in one pound bottles, Winchesters and gallons. Tablets: Each tablet represents 2^_ grains of ferrous chloride combined with 200 International units of Vitamin BI. Supplied in bottles of 100, 500 and||o00 tablets. FERROCHLOR liquid or tablets without the Vitamin BI are also available in similar package sizes to those mentioned above. Specify E.B.S. when prescribing E.B.S. is wholly Canadian, and Established in 1879 L-i tHfffiilSHUtTLEM TORONTO MANUFACTURING CHEMISTS CANADA ■;S5Ssssa« -\ THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Pulished 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: De. J. H. MacDermot Db. G. A. Davidson Db. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XXI. FEBRUARY, 1945 No. 5 OFFICERS, 1944 - 1945 Db. H. H. Pitts Db. Fbank Tubnbull Db. A. E. Tbites President Vice-President fig Past President Db. Gobdon Bubke Db. J. A. McLean Hon. Treasurer Hon. Secretary Additional Members of Executive: Db. G. A. Davidson, Db. J. R. Davies TRUSTEES Db. P. Bbodie Db. J. A. Gillespie Db. W. T. Lockhabt Auditors: Messes. Plommee, Whiting & Co. SECTIONS Clinical Section Db. W. D. Keith Chairman Db. S. E. Tubvey Secretary Eye, Ear,'Nose and Throat Db. Leith Websteb Chairman Db. Gbant Laweence Secretary Pediatric Section Db. John Pitebs Chairman Db. Habey Bakes Secretary STANDING COMMITTEES Library: Db. S. E. C. Tubvey, Chairman; Db. F. J. Bulleb, Db. W. J. Dobbance, Db. R. P. Kinsman, Db. J. R. Neison, Db. D. E. H. Cleveland Publications: Db. J. H. MacDermot, Chairman; Db. D. E. H. Cleveland, Db. G. A. Davidson, Db. J. H. B. Gbant, Db. W. D. Keith, Db. L. H. Websteb Summer School: Dr. G. A. Davidson, Chairman; Db. J. C. Thomas, Db. R. A. Ghchbist, Db. A. M. Agnew, Dr. L. H. Leeson, Db. L. G. Wood Credentials: Db. D. E. H. Cleveland, Chairman; Db. E. A. Campbell, Db. D. D. Fbeeze. V. O. N. Advisory Board: Db. Isabel Day, Db. J. H. B. Gbant, Db. G. F. Stbong Metropolitan Health Board Advisory Committee: Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont Representative to B. C. Medical Association: Db. A. E. Tbites Sickness and Benevolent Fund: The Pbesident—The Trustees COMBAT NUTRITIVE FAILURE TUi^Mfid&m t/Jaif SqeiJ& || IfKiti Ykaam Fwwsk 1 f« *xj* «n# »*U««r IW <W_fW Rwy>Jn?»rJ« —_»■M-?.pfa* | }m „^_£_[wwi! • Since reliance on diet alone is uncertain and slow, polyvitamin therapy is often indicated. Such therapy should be based on multiples of the new nutritional yardstick—the daily Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. This formula represents the combined judgment of "more than 50 persons qualified to express an opinion on the subject."* One capsule daily of Squibb Special \fitamin Formula supplies the Recommended . Dietary Allowances for a 70 Kg. man. 6* «»•*•«-*** _ 5000 Units 800 Units 3^9- 20 ^9 ita«n»n Vitamin nomine iboflay"} iacinamV _ _ _ ttydi ide rochlorid* 75 ^9- *° ^rbic Add Squibb Special Vitamin Formula capsules are supplied to druggists in bulk. Generally dispensed on prescription for 7 or 8 cents per capsule, in any quantity designated. Combat nutritive failure this modern way, by using Squibb Special Vitamin Formula Capsules. % For Therapy • Diet Supplement in Health • Diet Supplement in Convalescence ♦National Research Council, Reprint and Circular Series No. 115, Jan. 1943. For literature write E. R. Squibb & Sons of Canada, Ltd. 36-48 Caledonia Rd., Toronto, Ont. ERiSqjjibb 5. Sons Iof Canada, Ltd. manufacturing chemists to the medical profession since 1858 VANCOUVER HEALTH DEPARTMENT STATISTICS—DECEMBER, 1944 Total Population—Estimated 299,460 Japanese Population—Estimated Evacuated Chinese Population—Estimated 5,728 Hindu Population—Estimated 227 Rate per 1,000 Number Population Total deaths 318 12.5 Japanese deaths — Population Evacuated Chinese deaths 19 39.2 Deaths—residents only 267 10.5 BIRTH REGISTRATIONS: Male, 277; Female, 253 530 20.9 INFANT MORTALITY Dec, 1944 Dec, 1943 Deaths under one year of age \ 16 12 Death rate—per 1,000 births 30.2 22.2 Stillbirths (not included above) . 3 11 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY Nov., 1944 Dec, 1944 Jan. 1-15, 1945 Cases Deaths Cases Deaths Cases Deaths Scarlet Fever 50 0 49 0 20 0 Diphtheria 10 10 0 0 Diphtheria Carrier 0 0 0 0 0 0 Chicken Pox . 43 0- 87 0 87 0 Measles 153 0 128 0 169 0 Rubella 9 0 4 0 6 0 Mumps ; 0 0 15 0 15 0 Whooping Cough 37 0 14 0 16 0 Typhoid Fever (Carrier) 0 0 10 0 0 Undulant Fever ! ' 0 0 0 0 0 0 Poliomyelitis i 0 0 0 0 0^0 Tuberculosis 53 18 46 10 Erysipelas 10 4 0 2 0 Meningococcus Meningitis 0 » 0 0 0 0 0 Paratyphoid Fever (Carrier) 0 0 10 0 0 Infectious Jaundice 0 0 2 0 2 0 Typhi-murium (Carrier) 0 0 0 0 0 0 Dysentery 0 0 0 0 0 0 V.D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH DIVISION OF VENEREAL DISEASE CONTROL , Rich- North West Vancouver Richmond North Van. Burnaby West Van. Syphilis . 66 — — _— — Gonorrhoea 119 3 — — — BIOGLAN-A The most effective therapy for waning mental and physical energy, deficient concentration and memory, reduced resistance to infection, muscular -weakness and debility, neurasthenia and premature senility. The efficacy of this very potent endocrine tonic has been confirmed by the clinical evidence of many thousands of cases treated during 1932-1943. Stanley N. Bayne, Representative Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C. Descriptive Literature on Request THE SCIENTIFIC HORMONE TREATMENT Page One Hundred and Fifteen Happen Here EH» Example of severe rickets in a sunny clime. Lest we forget—we who are of the j vitamin D era—severe rickets is not yet eradicated, and moderate and mild rickets are still prevalent. Here is a white child, supposedly well fed, if judged by weight alone, a farm child apparently living out of doors a good deal. This boy was reared in a section having a latitude between 37° and 42°, where the average amount of fall and winter sunshine is greater than that in the major portion of Canada. And yet such stigmata of rickets as genu varum and the quadratic head are plain evidence that rickets does occur under these conditions. How much more likely* then, that rickets will develop among city-bred children who live under a smokepall for a large part of each year. True, vitamin D is more or less routinely prescribed nowadays for infants. But is the antiricketic routinely administered in the home? Does the child refuse it? Is it given in some unstandardized form, purchased from a false sense of economy because the physician did not specify the kind? A uniformly potent source of vitamin D such as Oleum Percomorphum, administered regularly in proper dosage, can do more than protect against the gross visible deformities of rickets. It may prevent hidden but nonetheless serious malformations of the chest and the pelvis and will aid in promoting good dentition. Because the dosage is measured in drops, Oleum Percomorphum is well taken and well tolerated by infants and growing children. EXIGENCY OF WAR: Oleum Percomorphum 50% is now known as Oleum Percomorphum with other Fish-liver Oils and Viosterol. The potency remains the same; namely, 60,000 vitamin A units and 8,500 vitamin D units per gram. It consists o lthe liver oils of percomorph fishes, viosterol and fish-liver oils, a source of vitamins A and D in which not more than 50% of the vitamin D Content is furnished by viosteroL-- .-4: Supplied in 10 cc and 50 cc bottles; and as capsules in bottles containing 50 and 250. MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ont. Please enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized aersons. VANCOUVER MEDICAL ASSOCIATION FOUNDED 1898 r: INCORPORATED 1906 * * * * PROGRAMME OF THE FORTY-SEVENTH ANNUAL SESSION GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m. These meetings will continue to be amalgamated with the clinical staff meetings of the various hospitals for the coming year. Place of meeting will appear on the agenda. General meetings will conform to the following order: 8:00 p.m. Business as per agenda. 9:00 p.m. Paper of the evening. April 3—GENERAL MEETING: "Activities of a Field Surgical Unit." Lieut.-Colonel Rocke Robertson, R.C.A.M.C. April 17—COMBINED CLINICAL MEETING AND STAFF MEETING AT ST. PAUL'S HOSPITAL. May ' 1—ANNUAL MEETING: "Plastics." Professor R. H. Clark, Head, Department of Chemistry, U.B.C. FOR SALE HARMONY HALL at 1655 West Broadway SUITABLE FOR MEDICAL CLINIC, OR DOCTORS' AND DENTISTS' OFFICES. Apply to G. L CAMPBELL LTD. 525 Seymour Street Phone PA. 8645 (K?nfrr&^antta10tfr ESTABLISHED 1893 VANCOUVER, B. C. North Vancouver, B. C. Powell River, B. C. Page One Hundred and Sixteen ': STAPHYLOCOCCUS TOXOID FOR TREATMENT OF LOCALIZED STAPHYLOCOCCAL INFECTIONS Staphylococcus Toxoid is a specific antigen for use in the prevention or treatment of certain types of localized staphylococcal infections such as boils, styes, pustular acne and recurrent migratory staphylococcal abscesses of soft tissues, and bone .Staphylococcus toxoid may be administered in 8 subcutaneous doses at intervals of from five to seven days. NEW PACKAGE Staphylococcus Toxoid is now supplied by the Connaught Laboratories in packages containing a 2-cc. vial of diluted toxoid (Strength A) and a 2-cc. vial of undiluted toxoid (Strength B). Strength A is a l-in-4 dilution of Strength B and is intended for use in the four initial doses. Together, the tioo vials contain sufficient material for the series of 8 injections. CONVENIENCE IN ADMINISTRATION The new package replaces a package in which was provided a 2-cc. vial of undiluted toxoid and a vial of sterile diluent for preparing various dilutions. Since the material in the new package is ready for use without further dilution, it will be found more convenient by the physician. Laboratory studies have demonstrated that the diluted toxoid in this package remains stable and potent. CONNAUGHT LABORATORIES University of To ron to Toronto 5, Canada DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. The present sitting of the British Columbia Legislature has been characterized by the presentation of a statesmanlike programme for progress along the lines of education and public health, by the Premier of the Province, the Hon. J. Hart. The Premier announced that a considerable sum of money was reserved for expansion of the work of the University of British Columbia. Buildings are to be erected, additional grants provided, and so on. This is all excellent, and most necessary. But there are two very important matters about which we are not clear—and they are both vitally and urgently important. First about hospital construction in the Province. This has become a dangerous problem to us all, and cries for solution. Probbaly every hospital in B .C. is suffering from overcrowding, difficulties in obtaining staff, in obtaining materials and so on. Much of this cannot, perhaps, be remedied just now. But if we can find money for erecting university buildings, we can do so for hospital accommodation, and the latter is just as urgently needed as the former. Things are coming to an intolerable condition. We hear that the Royal Columbian Hospital had to refuse admission to two dangerously'ill children, unless their parents could provide cribs. These were brought in and set up in the already overcrowded ward, and as the announcement said, added further to the burdens of an overcrowded staff. But the hospital could not find a crib for these children from its own resources. When the Greenhill Park took fire in Vancouver harbour, most fortunately the list of casualties was very small, and our hospitals could take them. If, as happened in Halifax once, a ship loaded with explosives had blown up in Vancouver harbour, and thousands • of casualties had resulted, as was the case then, no possible juggling of beds could have prevented a very tragic condition. As it is, even a couple of hundred would pretty nearly wreck our hospital system, where hospitals are already filled to 101 per cent to 105 per cent of their capacity. We know well that those who administer the hospitals are perfectly aware of this and are doing all they can to urge expansions and growth. But this is not a matter for individual hospital organizations. It is a provincial matter, and should be the care of the Provincial Government. The latter should be formulating a provincial programme, studying the whole question from a provincial angle, and laying plans for a comprehensive programme of hospital construction, to extend years into the future. As we have said before, some sort of Hospitals Commission might well be set up, to study the proper location of hospitals, etc., and a start cannot be made too soon. We are years behind already. The second question is that of a Medical Faculty in the University of British Columbia. This has apparently reached the stage of practical politics, and we have undoubtedly made a small start in the direction of its establishment. But it is not definitely certain yet whether it will be started soon, and on what scale. Meantime, the need for it is growing more urgent daily. Each one of us, as medical men, should be doing his share toward creating in the public mind a clear understanding of the real need that exists for such a means of training medical men, so badly needed, not for our sakes at all, but for the sake of the people of this country. When the public understands and appreciates the reality of this need, we shall have a demand for it, based not on our wishes and hopes, but upon an enlightened public opinion, to which the government will readily accede, as it always has done, when the people of the province back the demand. Page One Hundred and Seventeen LIBRARY NOTES RECENT ACCESSIONS TO THE LIBRARY: Surgery of the Hand, 1944, by Sterling Bunnell. Internal Medicine in General Practice, 1944, by Robert P. McCombs. Surgical Clinics of North America, Recent Advances in Surgery, Philadelphia Number, October, 1944. Narco-Analysis, 1943, by John Stephen Horsley. The Marihuana Problem in the City of New York, 1944, Published by the Mayor's Conunittee on Marihuana (Gift of Publisher). Pre-Eclamptic and Eclamptic Toxaemia of Pregnancy, 1941, by Lewis Dixter and Soma Weiss. Through the courtesy of the Northwestern University Medical School this Library is now receiving their Quarterly Bulletin. Our file will commence with No. 1, vol. 19, 1945, and listed below is an outline of the contents of this issue: Founders Day Address— The Good Doctor paul B. Magnuson Scientific Contributions— Helpful Hints in the Diagnosis of Abdominal Pain Walter C. Alvarez The Management and Treatment of Cranio-Cerebral Injuries Loyal Davis A Study of Hallux Valgus: Its Cause and Operative Management, Part III Robert T. McElvenny A Study in Stateness in Students.—- Frederick T. Jung and Lillian E. Cisler The Effect of Aloes and Podophyllum (Resin) (Carter's Little Liver Pills) on the Output of Bilirubin and Cholic Acid in Human Duodenal Drainage Fluid. Andrew C. Ivy, Morton I. Grossman and Martin Gutmann Application of High Frequency Phenomena in Medicine —.Harold J. Holmquest General Contributions— Evolution of the Edinburgh Medical School J. Gordon Wilson Medical Aspects of Socialized Medicine .Walter H. Judd Twenty-five Years of Physical Medicine at Northwestern University. J. R. FRANCKUM, M.D. Obiit Dec. 12th, 1944 With the passing of the well beloved physician Dr. James Franckum of Blaine, Wash., U.S.A., on Dec. 12th, 1944, the communities on both sides of the international border suffered a great loss. He was held in the highest esteem by Americans and Canadians alike, not only for his untiring work as doctor, but for his friendliness, sympathy and understanding. His life was spent in the spreading of good will, good health, and good cheer wherever he could. He was well known in Vancouver, where he practised for some time. Dr. Franckum was born in Halifax, Nova Scotia. He was a member of the Pharmaceutical Association of the Province of Quebec, graduating in 1898. Later he attended Bishop's College, Montreal, where he obtained his degree in Medicine, and was gold medallist in 1908. After graduation he made several trips on the Cunard liners as medical officer. He then married and took up practice in Alberta, Canada, in 1910. From there he moved to Blaine, Washington, where he continued to practice until his death. Page One Hundred and Eighteen CARCINOMA OF THE CERVIX By Dr. Ethlyn Trapp Read before Vancouver Medical Association Feb. 6, 1945 Mr. President, Members of the Vancouver Medical Association, may I first tell you how conscious I am of the honour in being asked to prepare a paper for this Association, and also of the responsibility. I remember so well my first meeting of the Association— it was a symposium on cancer in the early days of your Cancer Committee, under the active chairmanship of the late Dr. Mason. I wondered at the time if I should ever have the courage or the opportunity to address such a gathering and decided in the negative on both scores. Now with some trepidation, I find myself in this enviable, yet difficult position and so I thank you and at the same time ask for your indulgence. In 1931 the Provincial Government made cancer a reportable disease at the instigation of this Association, and at the same time an attempt was made to interest every member by a regional study of the disease, each doctor being asked to participate in the section which interested him most. A special cancer meeting was held each month and there was an average attendance of fifty during the first year. After some three years of enthusiastic work the Cancer section was merged with the clinical section and so lost its identity in the larger body. Now we seem to be too preoccupied with the war to give thought to other problems, yet the threat of cancer cannot be denied and its prevention and cure are one of the most distressing problems of our time. The last few decades have seen a decline in the incidence of most of the chronic diseases, tuberculosis and syphilis are being dealt with on a comprehensive scale, diabetes and pernicious anaemia can be •successfully held in check for years by comparatively simple methods of treatment, chemotherapy has revolutionized the treatment of the infections—as Doctor MacDermot remarked the other day, "The internist is really becoming quite a cheerful fellow now that he knows that he is not going to be faced with a fatal disease in every other patient." Yet cancer goes on its inexorable and baffling course; Rous has called this problem the last stronghold of metaphysics in medicine. To come to the specific problem of cancer of the uterine cervix, in trying to review the current literature I have been appalled by the number and magnitude of articles on the subject, reviews of these articles and reviews of reviews. Most of you have read them and they are all available for your now too infrequent leisure periods, so all I propose to do this evening is to outline the subject under the conventional headings, briefly review cases treated during this last 6-year period, and touch on the current controversy on a return to surgery for very early cases. This will leave time for a consideration of the late manifestations with which we are all only too familiar. Carcinoma of the cervix is the most common form of malignant disease of the female genital tract; statistics go to show that it is almost exclusively a disease of married women, nearly all of whom have conceived. Lazarus Riverius mentions it as early as 1678 in one of his seventeen volumes which deals with the diseases of women: in the preface to it he says, "These are called Women's diseases which are proper to them only and come from the defect of that part which is distinct in them from men, viz: the womb, of which Democritus in his letter to Hippocrates said that it was the cause of six hundred miseries and innumerable calamities, all of which diseases we shall speak of in as few words as the dignity of the matter will permit." The historical approach is fascinating and bypaths have a way of being more enticing than the main highway, but for the moment, suffice it to say that the treatment of the disease has passed through several stages—the first being surgical. This method held the field, becoming more and more radical in its approach, until the discovery of X-ray and Page One Hundred and Nineteen radium during the 1890's. Through the next decades radiological treatment itself progressed through successive stages. At first radium was used alone as a local application; it was soon found that it was not effective beyond a fairly narrow radius of its position and so was curative for early cases only. The addition of deep X-ray therapy proved to be a further advance in the efficiency of treatment. The latest advance in radiological treatment might be termed the biophysical approach to the problem, i.e., the attempt to accurately assess the dose of irradiation in terms of physical measurement. This became urgent with the realization of the dangers of irradiation when delivered in too small or too large dosage, and then became possible with the growing knowledge of the physical and biological laws governing irradiation.. The international adoption of the "roentgen" as the unit of measurement for both radium and X-rays further simplified the dosage problem, until now an accurate amount of irradiation either from X-rays or radium can be delivered to the desired spot and so a cancer lethal dose may be determined, and what is equally important, the tolerance of normal tissues estimated. An added advantage of precise measurement is the possibility of comparing nothods of treatment, and this has been done by the recognized clinics of Europe and America and has helped materially to make the radiological treatment of cancer of the cervix one of the most successful chapters in the field of cancer therapy. The League of Nations must be given the credit for the original groundwork that made this possible. The Cancer Commission of its Health Committee was set up in 1924. In 1928 it was asked to make an international study of the radiotherapy of cancer. It was decided to begin with cancer of the uterine cervix, since in this site the effectiveness of radiotherapeutic methods had already been established. With this object in view, a sub-commission of radiotherapists and gynaecologists was set up under the chairmanship of Professor Regaud of Paris. The investigations were at first confined to the three European clinics that had had their treatment sufficiently long established to be of statistical value. After rules of procedure had been adopted, annual reports of methods of treatment and survival rates we're published, the last of these being in 1939. Sixteen radiotherapeutic centres were then participating and 9,061 patients were included in the last report. The war has prevented the publication of further reports, but the foundation has been laid and the value of this international effort established. The Committee also, prepared an Atlas for the guidance of clinics participating in this study. It divided cancer of the cervix into four stages according to the anatomical extent of the growth, defining the stages and describing in detail those to be included in each stage. This method of staging is widely used and forms the basis of our own clinical reports, so I should like to indicate these ranges to you by showing you a few of the diagrams. STAGE 1—Carcinoma confined to the cervix. Page One Hundred and Twenty. STAGE 2—Carcinoma infiltrates the parametrium but has not invaded the pelvic wall. STAGE 3—Carcinomatous infiltration of the parametrium has invaded the pelvic wall on one or both sides. ;re*x»« a* ;W STAGE A—Carcinomatous involvement of bladder or rectum, or distant spread. Page One Hundred and Twenty-one Carcinoma of the cervix is a curable disease in its early stages, later it is inevitably fatal, yet early diagnosis is the exception, largely because in the beginning cancer in this site is a silent disease—the typjcal discharge and bleeding do not appear until the disease is well advanced and pain is a very late symptom indeed. When irregular bleeding does appear it is so often disregarded that the great majority of cervical cancers present themselves in an advanced stage of the disease. Shintz of Zurich has described four stages of delay—first the clinically latent period, the only means of reducing this is by routine pelvic examination. In the second stage of delay the patient neglects having medical consultation owing to poverty, anxiety or to natural indolence. In a further stage the first consulted practitioner gives merely symptomatic treatment, without forming a definite diagnosis—a very common delay in cervix cancers, which occur so frequently at the menopause and may be so easily mistaken for its irregularities. Finally there is the delay in instituting treatment after a definite diagnosis has been made. All these stages could be materially reduced by means of medical and lay education. Schiller has demonstrated that the painting of the cervix with an iodine stain, the so-called "Schiller test," is a useful adjunct to routine pelvic examination. This is not a diagnostic procedure but it demonstrates areas of pathology, and is a useful indication of the site from which a biopsy should be taken. Now Papanicolaou advocates the study of the vaginal smear as a means of even earlier diagnosis, i.e. in the preinvasive or intracellular stage. The superficial epithelium of cancer as well as of the vagina undergoes continuous desquamation and to the initiated the cells from cancer are quite characteristic; the distinctive feature is the structural abnormality of the cell which consists mainly in the atypical form of its nucleus. This method of diagnosis has also been tried out at the Massachusetts General Hospital and Meigs advocates its widespread use, stating, however, that confirmatory biopsies of the cervix and endometrium are essential. It is obvious that interpretation of the smears requires an expert knowledge of cytology, but having such an expert available the simplicity of the method of obtaining the material makes the technique suitable to office and out-patient practice. Before going on to the methods of treatment, may I bring in the subject of prevention. It is equally important and would save many more lives, yet how much attention have we given to this aspect of the problem? From the research point of view, it is interesting to note that cancer of the cervix has been produced in mice by the administration of oestrogens; one cannot, of course, translate the results of animal experimentation to the study of human cancer, but they do give one pause for thought. In reviewing the possibility of relationship between hormones and cancer, Twombley and Pack in New York conclude by saying, "Their etiological relationship to cancer is obscure and has been demonstrated only in laboratory animals. While we have no proof that any such connection exists in man between hormones and the formation of cancer, the possibility that such could be the case rests so strongly in the mind that one finds oneself prescribing oestrogenic therapy less and less frequently and then only in cases where their use can be controlled in amount and the patient followed and examined from time to time for the possible presence of cancer in the breast or uterus. It is surprising how many seem to get along just as Well with mild sedatives and suggestion as with potent and possibly cancer-producing hormones." Does the gynaecologist realize his unique opportunity in this matter of prevention? Would the more widespread treatment of chronic cervicitis reduce the incidence of cervical cancer? Cashman of Pittsburg reviewed 10,000 cases that had been treated over a 25-year period with deep cauterization; in this long series only two patients subsequently developed cancer. Healy of the Memorial Hospital in a recent address reminds us that the gynaecologist has brought many of his patients into the world, his special training must have made him alert to the danger signals of cancer and also made him competent to deal with the conditions of the female genital tract that may precede it. He is also more familiar than his colleagues in the other specialties with the physiology, pathology and endocrinology of the female genital tract. Speaking of the importance of routine examination as an aid to prevention, he concludes: Page One Hundred and Twenty-two "I like to speak, not of the possibility of finding that a cancer has established itself since the preceding visit but of identifying and curing any and all of the conditions which, if neglected, may lead to illness or possibly even to cancer; in other words, to keep the patient in such good health that it would be very improbable that cancer would occur." To consider methods of treatment: Originally radium alone was used and this form of treatment has been practised in Europe since 1906, though few clinics had adequate supplies of radium before 1913. The Stockholm and Paris clinics were the first to stabilize their methods of treatment and to assess their results. The whole situation was reviewed at the first international Radiological Congress held in London in 1925. At that time it was found that these two clinics held the leadership in this type of work and that there was little to choose between their results. Regaud advocated continuous radiation at low intensity; Heyman, divided doses at relatively high intensity, delivered in two or three applications. Both the Paris and Stockholm schools still carry on with their original methods and practically the whole medical world follows one or the other; but it must be remembered that they are adaptable clinical procedures rather than fixed techniques. Manchester has combined the two, that is the low intensity factor from Paris with the divided but protracted over-all period of treatment from Stockholm. The League of Nations' work and also more recent reviews have demonstrated that no one of these methods has been shown to have a definite superiority over any other. However, all the well established clinics have improved their results over the years, partly by the skill learned through practise and partly by the addition of deep X-ray therapy. May 1 now describe the procedure we follow at the British Columbia Cancer Institute, which is based on the Stockholm method. After the patient is admitted to the Institute on recommendation of her physician, the history is taken and routine physical examination carried out—this includes a blood count, a Kahn test, and when indicated cystoscopic and proctoscopic examinations. The pelvic examination is done in consultation with one of the gynaecologists of the Honorary Attending Staffs. This reveals the anatomical extent of the disease. The clinical stage is then noted. If there is any doubt of the diagnosis a biopsy is taken; if not, in order to avoid unnecessary manipulation, this procedure is postponed until the first radium application. If the cancer has progressed to Stage III or IV, or is of an anaplastic type, or if gross infection is present, deep X-ray therapy is begun prior to radium treatment; if not, the first radium treatment is given. After removal of the radium the patient is given a douche and an enema and is encouraged to get out of bed the day after treatment in order to facilitate drainage. She is usually kept in hospital until the second radium application, which takes place a week after the first. The second) is substantially the same as the first though a different arrangement of the radium is desirable—even between these two treatments there may be very definite modification of the growth. The third treatment is a repetition of the other two and is carried out two to three weeks after the second. Reaction begins about two weeks following the first treatment and consists of a white membranous film extending over the cervix and vaginal vault. This subsides in two or three weeks following the third treatment and reappears during the course of deep X-ray therapy. The dividing of the radium dosage in this way gives several distinct advantages— . therevis less danger of complications from pelvic infections, while the dangers of hypostatic pneumonia, and of .injury to the intestines, are practically eUminated. Another important advantage is the slu-inking of the cancer between treatments, thus allowing a more effective applicaiton of the radium. There are practically no contraindications to treatment, palliation at least is nearly always possible. Chronic salpingitis is not a contraindication: if an acute flare-up occurs immediate operation is indicated. The important thing is to know when to stop; treatment should never be repeated within the first year if the maximum dose has already been given. In the few cases in' which, because of advancing disease, we have succumbed to the temptation to do this we have gained nothing and, we suspect, added to the patient's discomfort. Page One Hundred and Twenty-three If deep X-ray therapy has not been given prior to radium it is begun in a week or two following the last application; its object is to destroy cancer cells which may have . spread into the parametria or the pelvic glands. The disease is thus attacked both from within and from without and the improvement which all clinics have noted on combining these two modes of irradiation treatment demonstrates that such extension must often be present, even when not discovered on pelvic examination. In the curing of the disease we must not lose sight of the patient herself. Both the effect of the disease and the effect of treatment must be taken into account. Early cancer of the cervix is symptomless and the disease is far advanced before it has any appreciable effect on the general well-being of the patient. After the diagnosis has been established, how often do we hear "But, doctor, I have been feeling so well, I did not think I could possibly have cancer." In all cases the mental outlook of the patient is of great importance and should be dealt with. This includes the problem of whether or not to tell her that she has cancer. My own experience has been that those who know accept much more cheerfully the long and difficult treatment, than those one attempts to deceive. Actually such attempted deception is rarely successful—in these days of widespread publicity no intelligent woman can have radium and X-ray treatments without suspecting the presence of cancer. My rule has been to discuss the situation frankly with the patient before any treatment is undertaken and with an occasional exception I am convinced that this is the wisest procedure. Again many patients feel that there is some stigma attached to the disease, this idea must be eradicated. Contagion is another bugbear, and the fear of it, usually on the part of the family, has added greatly to the misery of many" cancer victims. One has taken it for granted that if radiological treatment is worthwhile, it is also worthwhile doing everything possible to improve the general condition of the patient. Early cases are becoming more frequent but they are still the exception, and only too often patients appear after months of bleeding with a pelvis full of infection as well as cancer and the general debility which is the result of such a condition. In such cases radiological treatment should be delayed for a week or two while infection is cleaned up by local means and the patient's condition improved by rest, diet, and any supportive measures that may be necessary. If anaemia is marked, transfusions should be given. While the course of X-ray therapy is under way, one may have irradiation sickness to deal with, though since I have used Vitamin "B" routinely through treatment, this has rarely been troublesome. For some patients mild sedatives are useful. A high caloric diet is advisable with sweetened fruit drinks, preceding or following treatment. Dilute hydrochloric acid occasionally does wonders when other measures have failed. Diarrhoea may become troublesome, though proper adjustment of treatment fields should obviate this. Daily rectal irrigation with saline solution throughout treatment is a useful prophylactic measure, ensuring as it does that treatment is given through a clean rectal wall. Skin reactions, except in obese women, are not severe enough to cause trouble. Ointments should be reserved for use after the completion of treatment; during treatment they only aggravate the reaction. Fatigue is always present to some degree and may be very distressing. The patient should be warned to expect it. A six-year period of clinical work has recently been completed at the British Columbia Cancer Institute. During that time we have seen and treated 230 cases of cancer of the cervix; in addition we have admitted 25 who have been treated elsewhere and have been referred to us because of recurrence or for check-up examination. The first treatments were done by Doctor Evans, the Medical Director, who is now on active service overseas; for the last four years they have been done by Doctor Caple and myself with the assistance of Doctor Sadler and more recently of Doctor Hardie. Most of the work of reviewing these clinical records has,been undertaken by the nursing staff of the Institute and it has been a painstaking and time-consuming task. In working over such charts the difficulty of arriving at accurate clinical statistics becomes apparent and one Page One Hundred and Twenty-four wonders how much even the best of them can convey to those not associated with the work. There are, however, rich compensations for the reviewer. The numbers in our series are not great enough for the statistics to be of any real value but one gets some perverse satisfaction in computing percentages, and it is interesting to note that our trends are similar to those in other clinics, for example, the percentage of early cases is small—only 22% are Stage I. Over half are well advanced, i.e., Stages III and IV. About one-half have occurred before or during the menopause, 4% have had co-incident syphilis; these incidentally are prone to have complications during treatment and the disease seems to advance more rapidly, only one of our is living. Levin of New York reports the same percentage with syphilis and states that it is three times as frequent as in women with cancer in other sites. German clinics have reported 12 to 15%. As has been noted in other places, the first stage of delay is commonly long, that is the delay between the onset of symptoms and the first consultation. In 39% this was over six months, in some cases being more than 2 years. It is generally agreed that the pathological grade of disease has no effect on its curability by radiation. It is, however, of surgical importance—anaplastic growths, viz: Grade 3 and 4, are prone to rapid and widespread dissemination following surgery. On the other hand, whether the growth is an adenocarcinoma or a squamous-cell seems to be of great importance. Th eformer are very much in the minority, only 3 % in our series, but they are all dead under two years. Other clinics report the same situation. We have had 8 cases of carcinoma of the cervical stump. Available histories do not reveal if cancer were present at the time of operation. These are difficult to treat. The uterus •ordinarily forms a convenient spot for the placement of radium sources and also serves to maintain the necessary distance of these sources from the intestines. The most recent of these cases had had a subtotal hysterectomy for the removal of fibroids only two months before admission. In order to prevent such unhappy situations arising, Haber recommends routine biopsy of the cervix before sub-total hysterectomy. In substantiation he quotes a report by Schmitz on the discovery of 15 silent cancers in the routine , examination of cervices amputated for extensive cervicitis between 1915 and 1931. Of patients treated in 1939 we have a 36% 5-year survival, which is comparable to other places. Of those treated in '39, '40 and '41, a total of 107 cases, 40.1% have lived 3 years or more. The great majority of recurrences have been during the first two years following treatment. This recurence usually takes the form of an extension into the parametria and is seldom found at the original site of the disease. Other clinics report similar observations. Beheny and Howson of Philadelphia have adopted the unconventional approach of reporting the dead instead of the living. This method has obvious advantages in dealing with a disease in which so many cases are treated for palliative purposes only and so never come witiiin range of 5-year survivals. It is also important to be able to estimate the value of such palliative treatment. Does it prolong life, and if so are these few added months worthwhile or has treatment merely increased the sum total of suffering? In assessing our own cases from this aspect we find that 97 or 42% are dead. These have had an average survival of 12.7 months. Of 30 Stage IV cases 3 were untreated and died within a month of admission. The 27 who were treated lived an average of 7*_ months, 6 of these lived over a year and 2 over two years; approximately one-half died within three months-of the completion of treatment, several within a few weeks. Undoubtedly some would have lived as long and been more comfortable with less treatment, and looking back I think we have erred on the side of giving too much treatment to these Stage IV cases. Deep X-ray therapy alone will usually clear up the discharge and help the pain, and only in an occasional case has the addition of radium done more. To go to the other end of the scale, viz: Stage I cases, is it possible that too much treatment is also given here? In this connection it is interesting to note the trend back to radium alone in the treatment of very early cases. In Manchester it is now used exclusively in both Stage I and II, and Dr. Tod is satisfied that the results judged by survival rates are at least as good as with the combined radiological treatment and from Page One Hundred and Twenty-five the point of view of complications, superior. The late Elizabeth Hurdon of the Marie Curie Hospital in London reported an 80% 5-year survival in Stage I cases treated before 1933, i.e., before deep X-ray therapy had been installed. In my own limited experience a review of cases has revealed that those Stage I cases whom practical considerations have prevented from having deep X-ray therapy have done just as well as those who had the complete course of irradiation. This is of tremendous practical importance, for while a pelvic series of deep X-ray therapy is at best a trying endurance test, at worst it can be the cause of as great a morbidity as a major operation; the application of radium, on the other hand, is a relatively simple procedure. In these early cases the patient may be up and out of hospital the day after the radium is removed and comfortably carrying on with routine household duties in between treatments. There have been several recent articles advocating a return to surgery for these early Stage I cases, notably that from the Barnard Free Skin and Cancer Hospital in St. Louis, published in the October Surgical Clinics of North America. On the basis of their own statistics, viz: 83% 5-year survival for surgery as against 60% for irradiation, this would appear reasonable, but one must remember that it was the brilliant surgery of Taussig that made these surgical results possible and also that the radiological results from this clinic were not so good as those of other outstanding clinics. One should not accept such a radical reversal of approved treatment without reviewing the evidence closely. For some years now radium and X-ray have been accepted almost without exception as the treatment of choice for cancer of the cervix in all stages. This view has been supported by adequate statistics from cancer institutes both in Europe and in America. After reviewing cases treated at Johns Hopkins between 1927 and 193 8 and comparing surgical and radiological results in Stage I cases, the authors state: "It has therefore been concluded that as a practical therapeutic procedure for early carcinoma of the cervix, panhysterectomy is an unsatisfactory method of therapy, irradiation is the treatment of choice." Behney and Howson, reviewing over one thousand cases from the Philadelphia General Hospital, came to the same conclusion. Crossen in his book on "Operative Gynaecology" says that he expects to retain a description of the radical operation because of its historical importance, but as a method of choice as opposed to irradiation it is a back number. O'Brien of Boston quotes Bonney himself as saying that surgery has reached its peak and that radium and X-ray therapy have surpassed it, yet he, Bonney, hopes that the Wertheim operation will not fall into disuse, not because it is a cure for cancer, but because by doing it one obtains a knowledge of the pelvis which can be had in no other way. Meigs of Boston is said to be also advocating a return to surgery. This is not quite the case. He, himself, in a personal communication to Buschke of Seattle, says "I have no argument with those who wish to use radium. I personally believe that there is nothing better at the present time. However, in early cases I feel that an attempt should be made to see whether or not surgery could be made as safe and sure as radiation." Meigs has based his arguments largely on the failures of radiation therapy, but like so many in comparing these two methods of treatment, he speaks of radiation results from a large hospital X-ray department and compares them with his own individual results. It would seem reasonable to suppose that the skill of radiation therapists varies as much as does that of surgeons. Buschke of Seattle, in speaking on the subject in Chicago last September, pointed out the dangers of a swing back to surgery and made a plea for improved irradiation instead. As he has said, Meigs's requirements are very strict—the patient should be thin, young and in good health and have an early carcinoma; with elaborate pre- and postoperative care, Meigs operated on 65 such patients with no primary mortality; there was, however, serious operative morbidity: cystitis, dilated ureters and hydronephrosis were the rule, a common complication was injury to the sympathetic and parasympathetic nerves with consequent difficulty in voiding. There were ureteral ftstulae in 10.6% of cases, these required nephrectomy. Meigs' operation included the Taussig dissection of pelvic glands with the radical Wertheim removal of the uterus. It is open to question Page One Hundred and Twenty-six whether such a major procedure is justifiable when at least as good results can be obtained by the use of radium alone which in such a selected group of cases has neither operative mortality nor morbidity. The only possible justification is the salvage of an occasional case with an unsuspected involvement of the pelvic lymph nodes. Inthis connectiorr one might mention Morton's recent work in San Francisco: in reporting on his own and Lynch's operative series he says that the results with improved roentgen techniques indicate that pelvic lymph nodes can be sterilized by deep X-ray therapy, quoting 39.3% involvement of pelvic nodes for those without such pre-operative therapy as against 11.4% for those who had it. Buschke, after analyzing Meigs' cases and also those treated by irradiation at the Swedish Hospital in Seattle, says that the survey of their own material has shown that more cases were not controlled by irradiation because of some avoidable inadequacies of treatment than would have been saved by surgery. He believes that improvement of radiation therapy by more careful attention to details of technique, by the elimination of inadequate procedures of the past and by a careful adaptation of the procedure to the individual requirements would save more patients than a return to surgery. Whatever opinion one may hold, such controversies are useful and this one should have the salutary effect of stimulating radiation therapists to improvement of their own techniques. Clinical research must eventually solve the problem. Meanwhile, can we do better than follow Thomas Huxley's frequently quoted admonition? "Sit down before fact as a little child, be prepared to give up every preconceived notion, follow humbly wherever and to whatever abysses nature leads, or you shall learn nothing. BIBLIOGROPHY 1. League of Nations Health Organization Reports, Geneva, June 1929, Sept. 1934, July 1937, Aug. 193 8, Aug. 1939. Atlas—Illustrating the division of Cancer of the Uterine Cervix into Four Stages—P. A. Norstedt & Soner, Stockholm, 1938. 2. Behney, Chas. A., and Howson, John Y.: Am. J. Obst. & Gynec, 47:506, 1944. 3. Bonney, V.: J. Obst. & Gynaec Brit. Emp., 48:421, 1941. 4. Buschke, Franz: Radiological Meeting, Chicago, Sept., 1944. (Not yet published). 5. Cashman, B. Z.: Am. J. Obst. & Gynec, 41:216, 1941. 6. Cramer, William: S. Clin. North America, 24:1255, 1944. 7. Crossen, H.: Am. J. Surg., 27:389, 1935. 8. Emmert, Frederick V., and Clarke, Harold M.: S. Clin. North America, 24:1185, 1944. 9. Haber, Josef F.: Am. J. Surg., 67:68, 1945. 10. Healy, William P.: Am. J. Roentgenol., 49:1, 1943. U- Heyman, J.: Acta radiol, 16: 129, 193 5. 12. Ffurdon, Elizabeth: Cancer of the Uterus, Oxford Medical Publications, 1942. 13. Jones, H. W., and Jones, G. E. Seegar: J.A.M.A., 122:930, 1943. 14. Lacassaque, A.: Brit. M. J., 2:912, 1932. 15. Levin, M. J.: Am. J. Pub. Health, June, 1944. 16. Meigs, Joe V.: New England J. Med., 230:577 and 607. 17. Meigs, Joe V.: Surg., Gynec. & Obst., 78:195, 1944. 18. Morton, Daniel G.: Am. J. Obst. & Gynec, 49:19, 1945. 19. Neary, G. J.: Brit. J. Radiol., 16:225 and 263, 1943. 20. Papanicolaou, N., and Marchetti, A. A.: Am. J. Obst. & Gynec, 46:421, 1943. 21. O'Brien, F. W.: Radiology, 40:445, 1943 (Discussion). 2.2. Sandler, B.: Brit. J. Radiol., 16:331, 1943. 23. Scheffey, L. C: Radiology, 40:436, 1943. 24. Schiller, Walter: Surg., Gynec & Obst., 56:210, 1933. 25. Taussig, F. J.: Am. J. Obst. & Gynec, 45:733, 1943. 26. Tod, Margaret C, and Meredith, W. J.: Brit. J. Radiol., 11:809; 1938. 27. Tod, Margaret C: Brit. J. Radiol., 14:23, 1941, and Personal Communication. 28. Trapp, Ethlyn: Canad. M. A. J., 46:173, 1942. 29. Twombly, Gray H., and Pack, George T.: Surgery, 16:1, 1944. Page One Hundred and Twenty-seven UROLOGICAL COMPLICATIONS IN CARCINOMA OF THE CERVIX By Dr. L. A. Williams It has for many years been recognized that patients with carcinoma of the cervix develop complications through involvement of the urological tract. As early as 1896 Dumon in the Bordeau Bulletin of the Society of Physiology and Anatomy reported in detail a case of cancer of the uterus who died from the consequences of uraemia, attendant upon obliteration of the ureters with growth. Chavaunas in 1899 and Gaus in 1904 investigated and remarked upon anuria and its causes in carcinoma of the cervix, and since then an increasing number of reports have entered the literature. In 1920, Hnry Schmidt reported on the autopsy of a patient who showed marked urinary complications due to progressive fibrosis in the parametrium obliterating the ureters. This fibrosis was due to radium irradiation. Since this time there have been many reports on clinical and experimental work investigating the results of irradiation, especially radium on the bladder and the lower ends of the ureters. Thus the complications as we now understand them are the involvement of two urological organs; the first being the involvement of the bladder, and the second, and more important and f requeatn, the involvement of the lower ends of the ureters in thei parametrium. This involvement may be one of three things— 1. Direct involvement by growth; 2. Involvement as the result of irradiation; or 3. Infection as the result of lowered resistance through the presence of either of the above. Of the complications in the bladder, direct involvement by growth is one of the later complications. The most frequent cystoscopic finding here is an elevation of the bladder floor by the enlarged cervix even though the bladder floor may not as yet be involved in growth. As the cancer advances the mucosa becomes reddened and covered with dilated vessels and punctate haemorrhages. As the wall becomes more involved there is interference with lymphatic drainage, and bullous oedema occurs. The terminal changes follow, with first the formation of nodules and papillary proliferations and later ulcers which coalesce. With further loss of tissue from necrosis vesico-vaginal fistulae develop. Following irradiation the reactions seen in the bladder are three-fold: 1. Primary erythema occurring within twenty-four hours. If inflammation were present before the beginning of radiation treatment then an increase of the symptom present usually occurred. 2. Secondary erythematous reaction seen in three to four weeks' time accompanied . by frequency and dysuria. This is the so-called "radiation cystitis." - 3. A tertiary reaction is seen after nine to twelve months and frequently after as much as two or three years. In these cases there is an insidious onset with a feeling of discomfort deep in the pelvis. Gradually there is some discomfort on urination which incrases until dysuria and frequency are extreme. Cystoscopically in the early stages the mucosa is white and glistening, is fissured and has a sparse blood supply. The posterior bladder wall is fixed, scarred and inelastic and because of this fixation and fibrosis the bladder tolerance is much diminished, producing the polyuria. Small indolent ulcers tend to form, often become encrusted with salts, and with further necrosis of the indurated area fistula: may form. This condition is due to the development of interference with th eblood supply from endarteritis obliterans and is similar to radiation necrosis of the skin. Differentiation from a carcinomatous process is often difficult in the terminal stages. In the ureters and kidneys complications may be produced as the result of infection, from direct growth involvement of the ureters, and as a result of irradiation. 1. Infections such as para and perimetritis and cystitis may by ascension produce ureteritis, pyelitis and even pyelonephritis. This is especially true when the bladder Page One Hundred and Twenty-eight resistance and that of the lower end of the ureter is lowered by irradiation or by the direct extension of the growth into the walls. 2. An active carcinoma spreading from the cervix along the lymphatics in the parametrium comes into direct contact with the lower and of the ureter, and there are many authenticated cases in which this growth by invasion of the ureter has produced obstruction and in many cases obliterations of its lumen with resultant hydroureter, hydronephrosis and in the presence of infection, pyonephrosis.. 3. Irradiation per se can cause obliteration of the ureteral lumen. C. L. Martin in 1926, experimenting on dogs, produced complete obstruction of the ureters in 16 days by using 75 mgm. hours of radium placed in needles alongside of the ureters. In humans this does not happen unless there is faulty technique, but radium placed in the vault of the lateral vaginal f ornices has nothing but the vaginal mucosa between it and the lower ends of the ureters and if it were not properly screened could and in some cases has produced ureteral stricture within a short while after treatment. In most cases, however, the ureteral obstruction is due to fibrosis which follows upon the irradiation and occurs months to years after the initial treatment. The local lesion may be a gradual constriction and narrowing of the lumen as the fibrous tissue in the parametrium contracts or it may be an obstruction through kinking of the ureter or ureters as the fibrous tissue pulls upon them. As a result of this obstruction hydroureter and hydronephrosis develops and the kidney is gradually destroyed. Clinically the main symptom is a dull ache in the affected side. This pain usually is referred to the loin or pelvis but may radiate into the buttocks or thigh and simulate sciatica, or may radiate into the hip or upwards into the kidney region. There may be nausea and vomiting present but often nothing more than the pain is complained of and frequently there are no urinary disturbances. Ureteral catheterization and pyelography render the diagnosis positive. In these cases metastases into the nerve sheaths, the spine and pelvic bones must be differentiated. This obliteration of the ureteral lumen in the parametrium has been highlighted more and more in the past few years. One report has stated that in Grade IV cervical carcinomas 75% to 80% of the deaths are due to uraemia. E. E. Mansur, reporting in the Journal of Radiology for August, 1944, upon "Ureteral Involvement in Pelvic Irradiation," comes to three rather impressive .conclusions: a. Ureteral involvement after heavy irradiation is a frequent involvement. b. Ureteral involvement is more serious and more frequent than bowel or bladder damage. c. Preservation of ureteral patency may .improve the statistics of cures. This will require patient and general practitioner co-operation. In view of these reports it was decided that a review of our own cases might prove of interest. I do not wish to bore you with a lot of tables but I would like to bring some significant statistics and conclusions to your attention. 1. In our total survey for approximately six years there were 255 patients including 25 referred here after treatment for follow-up. 2. Of this number there were 104 patients or 41% who complained of symptoms which might be referable to the urological tract; 85% of these patients with urological symptoms were Grade HT or IV, i.e. Broder's grading, and 67.5% or two-thirds were in clinical Stages III and IV. 3. Under treatment we find that 86% had combined radium and X-ray with only 9% having radium alone and 4% X-ray alone. Here are more significant figures: 4. Of the patients complaining of urological symptoms there were only 36 cystoscopies—that is, 34.6%, or one-third, and these were mostly done after treatment. 5. Of the total number cystoscoped, 22 or 61.1% of the 36 had positive findings. 6. The number of patients out of the 104 we investigated who were autopsied was 14 or 13.5%. Page One Hundred and Twenty-nine 7. The number who had cystoscopies and then autopsies later so that the cystoscopy findings could be confirmed was 3. From these findings we can draw some definite conclusions. We can agree with the literature that in patients with carcinoma of the cervix there are a large number who develop urological complications, especially those with Stage and Grade HI and IV carcinoma, and very likely may die from the complications rather than the disease. However, what is much more glaringly apparent is that there have not been by far enough cystoscopies and urological examinations carried out on these patients. And what is more apparent and shocking than this has been the lack of autopsies. Now, the cystoscopies are our department and we are instituting a programme to take care of this. The autopsies are in very great measure the responsibility of the general practitioner, for the patients are referred back to bis care after treatment, and he usually attends them in their last illness, and often at home rather than in hospital. It must be apparent that if we are to progress in treatment and learn where modifications are required we must have autopsies to correlate with our clinical findings. For this reason we humbly beg for your co-operation in the programme which we are instituting. A programme has been prepared for this piece of clinical research—time is too short for its consideration tonight but it will be published in the Bulletin, and we hope you will give it your careful consideration and co-operate with us in helping to put the proposals into effect. UROLOGICAL PROGRAMME IN CARCINOMA 'WR OF CERVIX CASES % Dr. L. R. Williams 1. All patients in admission history to be questioned with particular reference to the urological tract—the questions are outlined below. 2. All patients to be cystoscoped before treatment. This includes bilateral ureteral catheterization with measurement of the kidney pelvis contents. All cases in which pathology is demonstrated to be admitted to hospital and thoroughly investigated including retrograde, pyelograms and pertinent function tests and blood chemistry. 3. All patients to be cystoscoped 3-6 months after treatment with procedure as above. 4. All patients on return check-up visits to be questioned particularly as to urinary symptoms. 5. All patients after the 6-month cystoscopy who on subsequent visits report symptoms or signs indicating possible urinary tract involvement to be cystoscoped with procedure as above. 6. A programme of treatment for complications—the treatment will be indicated by the lesion present, the status of the original carcinomatous lesion and the general condition of the patient. It will include: 1. Further deep X-ray therapy in some cases. 2. Surgery— I. ureteral dilatation. II. ureteral transplantation to bowel or skin. HI. Nephro ureterectomy for pyo or hydronephrosis. 7. Post-mortem examination of all patients with special attention being paid to the ureters and broad ligaments to ascertain: 1. Whether or not all the carcinomatous tissue has been destroyed. 2. Whether or not the ureters are occluded and if so, the cause of the occlusion. 8. A special endeavour to encourage the co-operation of the general practitioner in obtaining these post-mortem examinations. This could perhaps be done by including with the report on the patient which is sent to the referring doctor a small circular explaining that we are carrying out an investigation of carcinoma of the cervix cases and require his co-operation and assistance Page One Hundred and Thirty in getting the patient in for rechecks and in obtaining a post-mortem examination ni the event of her death. Purpose of the Programme: 1. To detect as early as possible in the course of the disease and treatment any involvement of the urinary tract. 2. To treat these lesions as adequately as possible in order to prolong the life of the patient and reduce the alarming number of deaths from urological complications. 3. To determine where possible the exact cause of the complication, whether due to extension of the disease or to stricture or kinking of the ureters as a result of cicatrization following treatment. 4. To determine in tbe light of the findings in (3) what modifications may or may not be indicated in the treatment of carcinoma of the cervix. Questions to be asked the patient in reference to the Urological tract: 1. Do you have any pain or does it move? Pain in the back or perineum radiating to the hip or down the leg is significant. 2. Question concerning painful micturition. 3. Question regarding diurnal and nocturnal frequency. 4. Question concerning haematuria. 5. Question concerning thirst. REFERENCES 1. Bugbie, H. G.—Ureteral Occlusion Following Radium Implantation in the Cervix, Journal of Urology, 1934, Vol. II, 439-448. 2. Chavannez—Anurie par cancer de Puterus, Gaz. Rebd. de med., 1899, 4, 437. 3. Dean, Archie L., Jr.—Injury of the Urinary Bladder Following Irradiation of the Uterus, American Journal of Ohstet. 8? Gyn., May, 1933, X__V, 667. 4. Mansur, E. E.—Ureteral Involvement in Pelvic Irradiation, Journal of Radiology, August, 1944. 5. Martin, C. L., and Rogers, F. L.—Broad Ligament Extension in Carcinoma of the Cervix, American J. Roent. & Rad. Therapy, Aprli, 1926, 336-344. 6. Martin, C. L., and Rogers, F. L.—Effect of Irradiation on the Ureter, American Journal of Roent. _? Rad. Therapy, Sept., 1926, 215-218. 7. Schmitz, Henry—Complications in the Urinary Tract due to Carcinoma of the Cervix or Radiation Therapy—American Journal of Roent. S? Rad. Therapy, July, 1930, 47-53. LATE MANIFESTATIONS OF CARCINOMA (LOWER BOWEL AND RECTUM) Dr. A. T. Henry Reaction of the bowel, chiefly the lower sigmoid and rectum, to irritation is not an uncommon feature to be dealt with. It is not only a worrisome complication to the doctor but also upsetting to the patient, both psychologically as Well as causing, in the more severe type, much discomfort and misery. Aldridge, in the American Journal of Obstetrics and Gynaecology, 1942, reports 16.9% of bowel injuries in a group of cases that he studied following treatment for carcinoma of the cervix. A good deal has already been written on this subject and published in various journals so that the condition can well be accepted now as an entity of its own. Carcinoma of this region is, as a rule, a serious and active growing type and naturally requires a rather radical and powerful attack to produce destruction of growth, hence it naturally follows that one must expect a certain number of cases to develop symptoms such as we are about to discuss. Our experience has been of two separate types of reaction: Firstly, the immediate reaction which starts within a week or two and may last a few weeks following the insertion of the radium or the use of the X-rays, while this may be severe, in general, it is not so and consists chiefly of a hyperaemia of the micosa with at times some diarrhoea and passage of blood and mucus. These people may have other reactions of so-called "irradiation sickness" including severe rectal pain, tenesmus and even nausea and vomiting. The appearance of the mucosa of the bowel at this stage Page One Hundred and Thirty-one is one of congestion and oedema with sometimes petechial haemorrhagic spots which weep blood easily on being touched. It is our feeling that the reaction is more the result of the X-rays rather than that of radium, which is more localized. Pathologically, it has been suggested that the primary cause of this condition is an ischaemia, the result of thrombosis of the small terminal branches of the hacmorrhoidal vessels. Bowel spasm, the result of the irritability, is also given a place as an adjunct in reducing blood supply. Of course, overdoses in treatment may lead to a massive reaction with further impairment of the mucosa and necrosis and gross ulceration resulting. The second reaction, or shall we say secondary phase, peculiarly results months later, from on the average 6 months or a year after treatment. This may occur without having had any or very little primary reaction. In my experience these people have a much worse time than the primary or immediate group. They seldom have any general upset, such as nausea or vomiting, but may have a lot of severe tenesmus, diarrhoea and lose a lot of blood. Proctoscopic examination in these cases tends to show much more reaction and ulceration and it is in this group that we find the beginning or the formation of structure and fistula;. The picture in many cases appears like an infiltration of the actual cancer process with the formation of granulating masses or of large deep ulcer craters with heaped-up borders. Biopsy alone must be used to distinguish some of these advanced cases. Remember, of course, this is not the general rule for the condition need not arise or can be very mild such as in the primary stages. Pathologically I am not quite certain as to why there is usually this latent period between reactions, as one would suspect that the thrombosis originally would slowly lead on steadily to the second stage. It seems that the first reaction sets up a fibrosis and pelvic inflammation which, shall we say, gradually catches up with a larger blood supply and finally produces a gross necrotic change. I have opened up a few of these cases and found abundant inflammatory adhesions between the lower sigmoid and the base of the womb. I recall one case in particular of a woman who had much bleeding and marked anaemia requiring transfusions. The adhesions present were full of blood vessels attached to the bowel. These I removed, with immediate cessation of her bleeding and no recurrence. The treatment of these cases varies and has caused a good deal of controversy between conservative measures and surgery. A recent excellent article by Harriett Mcintosh and John Hutton of New York, published in the American Journal of Roentgenology and Radium Thrapy, discusses this problem well. They uphold the management of most of these cases by medical regime although admitting the necessity for surgery inj properly chosen cases. We adhere to these views and in general for the earlier primary groups restrict their diet to a bland type, if necessary, and it is seldom, so order bed rest and mineral oil. Occasionally enemata consisting of the infusion of 2 or 3 ounces of cod liver oil or irrigation of a mild AGN03 have been used with some help. With severe tenesmus, belladonna or trasentin are a questionable aid. For pain and restlessness the phenobarbiturates and aspirin with codeine in small doses usually are sufficient. In the secondary phase, again, we often have to deal with a mild form and similar treatment, but with the more advanced conditions we may be faced with the need of more radical masures. With or without gross destruction and ulceration a fibrous change may result in a constriction of the bowel lumen or stricture formation. This may vary to almost complete obstruction and the symptoms may vary considerably. I have seen X-ray pictures in which the area seemed almost completely obstructed, with very slight symptoms requiring no treatment. Recently I saw a woman 5 years after treatment with a defintie stricture of the sigmoid and relatively little discomfort beyond a diarrhoea of 5 - 6 movements a day. This diarrhoea, I suppose, is due to a mild colitis above the site of stricture, but her condition is otherwise excellent. Of course, obstruction, on the other hand, can be complete, but when so is more liable to be due to small bowel rather than large; particularly is this so in cases who have had a previous operation and liable to Page One Hundred and Thirty-two adhesions between the small bowel and uterus. In these cases the reaction may well involve the small bowel and cause swelling and kinking of it. Flat plates may aid in distinguishing this condition by small bowel patterns. These cases call for special consideration. Such suggestions have been made that a laparotomy be performed ahead of time to rule them out, for obviously X-rays cannot be depended upon. Insufflation, intra-abdominally, also would not be dependable. A laparotomy even with separation of adhesions, as was stated in this paper, would not preclude that further adhesions would reform. It has been suggested in these cases that radium be not followed by other irradiation therapy for fear of these complications resulting. One further suggestion has been made: that in early cases with previous abdominal operations surgery be used rather than radium. This, I think, has some merit. Perforation and peritonitis or pericolic abscess have all been reported, but so far I have been fortunate not to have run into this complication. On one occasion I did a colostomy on a woman with the largest single ulcer I have seen, measuring roughly the size of a fifty-cent piece with large heaped-up borders. There was a question of whether this ulcer perforated at the time of operation, but I think not. She developed a paralytic ileus with a resulting peritonitis. This was some years ago, and I did a jejunostomy about the ninth or tenth day, but she subsequently died. Post mortem was not obtained. Recto-vaginal fistulae have occurred. I have dealt with several of these and they are of course horrible complications and call for permanent colostomy. The first of these was a case in which the rectal upper ampulla contained a large fungating mass with negative biopsy. It was amazing how within several months following colostomy this condition subsided and left a large perforation between the. rectum and vagina through which one could put their thumb. Recently I had a somewhat similar case in which there was stricture involvement as well and in which, although relieved by the colostomy, her condition is deteriorating, I take it from secondary invasion. Fatal haemorrhage from the rectum is reported even where a colostomy has already been established. To meet this problem it has been suggested by some that actual resec- | tion should be undertaken; however, this seems too radical treatment for people who have gone through so much and in which the chances of the haemorrhage becoming fatal are such a gamble. How is one going to choose such a case? I suppose that indication for such measures would be intermittent moderate bleeding rather than following a massive haemorrhage in which the patient's condition would be poor for radical excision. PAIN ASSOCIATED WITH CARCINOMA OF THE CERVIX ;|P§ Abridged remarks By Dr. F. A. Turnbull Carcinoma of the cervix often is associated with intractable pain in the late stages of the disease. It is my impression that no other form of cancer is such a frequent cause for intolerable pain in the lower trunk and legs. To relieve these terrific pains there is an operation which may be of great value in selected cases. This is the operation of cordotomy, which consists in cutting the tracts in the spinal cord. Since the opening of the B. C. Cancer Institute we have had a number of cases in which this operation has proven its value. In retrospect, in almost every case, we were sorry that we had not operated earlier, and saved the patient from many more months of pain. That is the crux of the whole matter. We have hitherto been unable to say with certainty about a patient in the early stages of malignant disease whether or not that patient would at a later stage develop intractable pain. If we could make an accurae prognosis we could operate earlier when the patient is in much better shape to undergo the operation and spare the long months of suffering until a final decision about operation is forced. Page One Hundred and Thirty-three We have studied a group of patients suffering froiri carcinoma, chiefly carcinoma of the cervix, at a special Pain Clinic in the B. C. Cancer Institute. Our observations will have to be carried on for eight or ten years before any significant statistical data can be obtained. But in the meantime our experience has developed certain general impressions about how to deal with intractable pain associated with cancer of the cervix. We feel that if a patient presents herself with a high grade of malignancy and an invasive tumour, and develops, either during or after treatment, a persistent pain in the region of the bladder or hips, that the danger signals have all been posted. There is no point in debating in that case about whether or not the pain is due to invasion deep into the pelvis. The pain is established, it is intractable and it needs radical treatment, i.e., cordotomy, if the patient is going to be spared from months of useless suffering. CORRESPONDENCE THE VANCOUVER GENERAL HOSPITAL February 19th, 1945. Dr. J. H. MacDermot, 925 Georgia St. W., Vancouver, B. C. Dear Doctor: I am enclosing a notice which we are posting for our attending doctors which is more or less self-explanatory. I think it would be a help to the profession and to the hospital if some mention of this was made in the Bulletin. For your information patients ordinarily can be committed to Essondale on the completion of the regular committal forms. As soon as these forms are completed the patient can be sent out with them direct to Essondale. As you know the Provincial Hospital for Mental Diseases is overcrowded and they are getting a number of senile patients definitely committable but whom they thought could be handled in nursing homes. These patients were old, confused, had mental deterioration but on the whole gave very little trouble. To meet this situation the Government devised a regulation prohibiting the sending of patients of six years and under or 70 years and over direct to Essondale. They require that the committal papers be sent in advance and that the patient be not sent until instructed to do so by the Superintendent of the Provincial Mental Hospital. This has resulted in the "backing-up" of a lot of these cases and at the present time we have six senile patients on Ward X and eight on Heather St. Annex, all waiting for vacancies at Essondale. This backing up has made it necessary for us to refuse such senile patients. It is difficult enough for us to handle all requests for admission of acute mentally ill patients and those undergoing therapeutic treatment. I know it may be a hardship in some families who cannot make hospital arrangements but there is a limit to what this hospital can do with our limited accommodation. Yours sincerely, R. A. Seymour, M.D., Asst. Superintendent. February 16th, 1945. NOTICE The Hospital is unable to admit senile patients (70 years of age or over) for mental observation or for committal to the Provincial Hospital for Mental Diseases. This notice is necessary because of the lack of accommodation here and the fact that the Provincial Mental Hospital at Essondale is not accepting these patients direct. It is unfortunate and regrettable that the Hospital must take this stand. A. K. Haywood, M.D., General Superintendent. Page One Hundred and Thirty-four AN UNUSUAL CASE OF PULMONARY HEMORRHAGE By Dr. Elliott Harrison Mr. J. K., age 43. Admitted April 4, 1944. Complaints—Haemoptysis intermittently for 19 years, did not date from any particular event as far as known. During this time patient had had many severe haemorrhages but after lying up for a few weeks she would be able to do her own work again. During this time she had four full term pregnancies. It was particularly noted that she never had a haemoptysis during pregnancy. Since January of this year the bleeding has been more severe and has made an almost complete invalid of her. She could not ascribe the onset of any attack to any particular cause, or relate it to menstruation or infection. Personal History—She had mild childhood diseases including measles and whooping cough, pneumonia age 18, thyroidectomy 7 years ago. Family History—Father died from wounds last war. Mother died from stroke—age 62. Four brothers alive and well. Two sisters alive and well. One sister died—age 32— childbirth. There is no history of tuberculosis in family or tuberculosis in any contact. Other Symptoms—She had no complaints except cough and expectoration. Physical Examination—General examination was quite negative except that she looked somewhat pale, and had an annoying cough. Temperature 99.2. Pulse 100. Dr. Day did a bronschoscopy shortly after admission and determined the blood was all 'coming from the left lower lobe. Her blood showed R.B.C. 2,240,000 Hg. 49%. She received blood transfusion. , X-ray at Chest Clinic—Flat plate showed heavy markings in left base. Following lipiodol injection, a bronchiectasis of left lower lobe was demonstrated. In view of the bronschoscopic and X-ray findings, she was advised to have a left lower lobectomy which was done May 1, 1944. She stood the operation well. The pathological report is of interest: Macrosc. Exam.: The lower lobe of the left lung, which is completely atelectatic in appearance, and on opening the lower bronchus there is seen to be a dilated portion, quite thick-walled, in which an irregular hard brownish-yellow structure about the size of a large wheat grain lies. This is just about 1 cm. from the cut hilar end of the bronchus. Miscrosc. Exam.: A number of sections were taken through the wall of the dilated bronchus mentioned above and there is seen to be complete loss of the mucosa by ulceration and very massive infiltration with all types of inflammatory cells in the underlying bronchial wall. Many new capillary channels are present. There is a great deal of old blood pigment in macrophage cells and a few scattered giant cells, apparently of foreign body type as they are not within tubercle formations. There is well marked fibrosis in the immediately surrounding tissue and considerable atelectasis of the alveolar structures surrounding this area and in these as well considerable inflammatory cell infiltration is present. Sections taken through the small hard structure removed from the bronchus show after decalcification a few irregular, elongated structures which appear to be degenerated osseous tissue surrounded by an organized degenerated, semi-calcified material. It would appear that this is a definite foreign body and probably is the cause of the more or less localized bronchiectasis above described. Unfortunately she developed infection in the stump of the lobe and died of asphyxiation from a severe secondary haemorrhage on June 9, 1944. Complete autopsy was done, the final diagnosis being: Page One Hundred and Thirty-five "Asphyxia due to haemorrhage into left lower bronchus from an infected operative site following lobectomy for chronic haemorrhage due to bronchiectasis of left lower lobe due to foreign body in one of the small bronchi. Beginning bronchopneumonia." The case is presented becausevof the: 1. Very long history of repeated attacks of haemoptysis with intervals fo good health between. 2. The unexpected explanation of her repeated haemorrhages. The diagnosis would appear to be an ulcerating bronchiectasis caused by either an aspirated piece of bone or a broncholith, with the latter appearing to be the most likely. Broncholiths are almost identical with bone as far as their chemical makeup is concerned. Thd are often associated with broncheictases or lung abscess. One may be expectorated with complete and permanent relief of symptoms or many may be expectorated at intervals with recurring symptoms. They are seldom seen bronchoscopically. Cause is unknown. NOTICE I NO MEMBER OF THE COLLEGE WHO IS IN ARREARS WITH HIS ANNUAL DUES OR ANY PART THEREOF, SHALL BE ENTITLED TO VOTE AT ELECTIONS FOR MEMBERS OF THE COUNCIL. A. J. MacLachlan, Registrar. NEWS OF GENERAL INTEREST The Third Western Canada Conference on Venereal Disease Control was held in Regina, November 21 and 22, 1944. Seventy-one delegates attended, representing the western province sof Canada, the Armed Forces, Federal Division of V.D. Control, etc. Major J. A. LerOux, Director of V.D. Control for Ontario, was the chief speaker, reporting on the St. Louis Conference. He stated that the 1943 syphilis rate for Sweden was 14 per 100,000, while in one typical Canadian province it was 175 per 100,000. Rapid-treatment methods, rehabilitation centres, education in schools about V.D., laboratory problems and techniques ,penicillin in the treatment of V.D., the problems of those who control hotels, were among the subjects discussed-. Among those from B. C. were Dr. J. F. Amyot, Provincial Medical Health Officer for B. C. Discussing DDT, the amazing insect destroyer, Lt.-Col. A. L. Ahnfeldt, Director of the Sanitation and Hygiene Division, Preventive Medicine Division of the United States Army, gave facts and figures to show the great service performed by this remedy in the saving of thousands of American servicemen's lives, especially in Italy, where typhus was raging when the Americans entered. We quote excerpts from a radio address by Lt.-Col. A. L. Ahnfeldt, Director of the Sanitation and Hygiene Division, Preventive Medicine Service, of the U. S. Army. He says: "Servicemen know that DDT is one of their biggest protections from those dread diseases, typhus and malaria. In the last war typhus fever caused three million deaths among civilians in Europe. "When our men were going into Naples, a typhus epidemic was starting in the city. . . . We set up forty-two delousing stations and also went down into the caves beneath the city where people took shelter against bombing, to dust them with DDT powder. . . . We treated several million people in Naples in a few months and smashed the epidemic:. As a result, not one American soldier died of typhus." Page One Hundred and Thirty-six NEWS AND NOTES We regret to record the loss of two members of the profession recently: Dr. Forrest B. Leeder of Victoria, who practised in the Province for many years, and Dr. H. C, McKenzie of Williams Lake, who died on March 2nd. Sympathy is extended to Dr. L. L. Giroux of Dawson Creek in the passing of his wife. Congratulations are being received by the following on the birth of daughters: Surgeon-Lieut. Cmdr. and Mrs. Murdo McRitchie, Captain and Mrs. Peter Spohn, Dr. and Mrs. Frank A. Turnbull of Vancouver, and Dr. and Mrs. H. V. Gale of Vancouver. Among those who were honoured at an investiture in Government House, Victoria, was Surgen Commander R. H. Ruttan, who received the O.B.E. A/Major G. E. Langley, R.C.A.M.C, of Vancouver, and Capt. Noel B. Hall, R.C. A.M.C., formerly of Campbell River, were listed among the walking wounded returned to Canada recently. We hear that Capt. A. J. Stewart, R.C.A.M.C, is much better following a serious illness in Italy, where he has been stationed for some time. Capt. Stewart interned at the Vancouver General Hospital prior to enlisting in the Services. Lieut.-Col. D. H. Williams, R.CA.M.C, has returned to civilian life, and is resuming his practice in Vancouver. t ** ** ? ■* Dr. C. H. Ployart is now with the Workmen's Compensation Board in Vancouver in the Rehabilitation Department. Major Ployart had served in the R.CA.M.C since the beginning of the war. Squadron-Leader G. A. Lawson, formerly of Port Alice, who has served in the Air Force for over three years, has now returned to civilian life. Following his discharge Doctor Lawson took post-graduate training in physical medicine in the Eastern States. He is now Director of the Department of Physical Medicine in the new Colonel Belcher Hospital, a Department of Veterans' Affairs Hospital in Calgary, Alta. Lieut.-Col. H. C Davis, R.CA.M.C, has returned to civilian life and to his former practice in San Francisco. Dr. W. P. Walsh is now at Beattie Anchorage in the Queen Charlotte Islands. " Capt. J. M. Mackenzie, R.CA.M.C, formerly an interne at the Vancouver General Hospital, called at the office when in Vancouver recently.. Dr. G. E. Darby of Bella Coola spent a short holiday in Vancouver. Dr. J. S. Daly of Trail was in Vancouver recently for a few days. Dr. Colin W. Graham of Victoria called at the office when in Vancouver last week. Dr. P. A. C. Cousland of Victoria, representative from B. C, attended the meeting of the Executive Committee of the Canadian Medical Association on March 4th and 5 th. Page One Hundred and Thirty-seven Dr. Murray Blair attended the meeting of the Canadian Medical Procurement and Assignment Board held in Ottawa recently. Dr. J. L. Coltart of Kamloops called in at the office when in Vancouver. Dr. M. J. Keys of Victoria, who has been confined to hospital for some weeks, is reported much improved, and it is hoped that he will be about again soon. Two Victoria doctors who have recently had operations, Drs. W. E. Scott-Moncrieff and W. H. Moore, have had a good convalescence. Cnsiderable progress has been made in the construction of the new Maternity Pavilion at the Royal Jubilee Hospital, Victoria, and it is hoped that it will be ready for occupancy before long. Great strides are being made in the packaging and processing of food and other commodities, and research laboratories are being set up in Canada, notably by the American Can Company, to study better methods still. The use of paper for milk containers is one example. Again, the so-called "Blair Process" by which vegetables are packaged so as to retain nearly all their feshness and colour, is one result of their research. Bacon, butter, meat stews, etc., are all canned today, and the armed forces are especially benefited thereby. The American College of Surgeons has deferred for the time being its 1945 series of War Sessions. Our readers will remember the one that was held here in 1944. But transportation difficulties are insurmountable at present. We have received an Interim Report of the Conunittee on Medicine and the changing order of the New York Academy of Medicine. It is available in the Library, and covers an enormous field, both in Therapeutic and Preventive Medicine, also in Dentistry, Nursing, Medical Research, Medical Education and Hospital Affairs, as well as Medical Economics, and Medical Legislation. Each subject is dealt with in a separate monograph. We regret to report the illness of Dr. D. J. Sweeney of Vancouver. We all hope for his early recovery and return to our midst. Dr. F. N. Robertson of Vancouver has recently returned from a prolonged visit to the States, where he did post-graduate work. Dr. Robertson, we all rejoice to see, has apparently completely recovered from his serious illness last year, and looks in the best of health. ^ *C •_■ 9fr We regret deeply to record the death overseas on duty of F/L Robert A. Haywood, R.CA.F., son of Dr. A. K. Haywood, Medical Superintendent of the Vancouver General Hospital. His wife and parents have the sympathy of all. Dr. G. E. Kidd of Vancouver, who is well known as an extremely competent archaeologist in addition to his capabilities as a surgeon, has recently been honoured by election as a Fellow of the Royal Anthropological Institute of Great Britain and Ireland. The honour was bestowed in recognition of his researches into the skeletal characteristics of the Indians of British Columbia. We congratulate Dr. Kidd sincerely on this well deserved recognition of his work. Many will remember the excellent address years ago on the Fraser Midden. Nor does Dr. Kidd live only in the distant past. He is the archivist of the Vancouver Medical Association, and is compiling a history of that body, whch we hope to publish some day in the Bulletin. Page One Hundred and Thirty-eight ••*•••••*•*" « IHIIHimTBW HliFS 20 ARSENICAL" Never let a patient lapse from treatment for early syphilis till he has had a minimum of 20 intravenous injections of arsenical. More than "20 arsenical" is advisable as a rule, less than "20 arsenical" never! Arsenical controls communicability. SYPHILIS AND PREGNANCY BECAUSE: (1) During pregnancy active lesions of syphilis are rarely seen; and (2) A history of a previously known primary lesion is rarely obtained; THEREFORE: Diagnosis can be made ONLY by repeated blood tests. "Blood Tests for Every Expectant Mother Before the Fifth Month." Pelouze—H . . in line with the march of progress" The time is here when we must hasten to erase past faults, and get ourselves in line with the march of progress. None of us is too good to treat gonorrhoea and none is justified in treating it by the old haphazard ways still so commonly held. The same society that looked down upon gonorrhoea as a just reward for what it called "sin" is being rapidly awakened to the enormity of this problem, and the time is here when every physician should know more about the disease itself and what it means to society than about its purely therapeutic aspects. "FIND V. D. CONTACTS — REPORT V. D. CASES" Huttn Sc Sljflmafltt t 2559 Cambie Street ancouver , B. C. Page One Hundred and Thirty-nine ii i/ STOVAGINAL Stovaginal is especially indicated in pathological conditions of the vaginal mucosa resulting from or associated with the Trichomonas Vaginalis. It is also indicated in cases where the leucorrhoea may be the result of mixed and non-specific infections of the vagina. Vaginal Tablets in Bottles of 20, 100 and 500 Vaginal Powder in Jars of 30 gm. and 200 gm. Physicians are invited to request clinical sample. mk b o mmmm.it y wl6^B^Si mmfi^ 204 YOUVILLE SQUARE MONTREAL *jM ike iLAievwfoaM&e "SORROW" A study by Aristide Maillol; reprtflj duced from the Hyperion Press art book "Maiilol". All patients, Wi#i|ier severe or mjp the^^^__iptoms, '$t$00$ke tippled effectively with these orally-actwe natural oestro|pi_$.^fVemarin" (No. 866) for the most severe symptoms; tlfeilea? Half-Strength "Premarin" (No. 867) when symp- Mns are moderately severe; "Emmenin" for mild symptoms and maintenance. iBEMAflIN"a»/tMMEBlir conjugated oestrogens {equine) Tablets No. 866; Tablets No. 867 conjugated oestrogens, {placental) Tablets No. 7.1; liquid No. 927 NATURALLY OCCURRING • WATER SOLUBLE A? WELL TOLERATED ESSENTIALLY SAFE •iliMPARt A. FEELING OF WELL-BEING V (No. 867) A new potency for those patients whose symptoms, though severe, do not require the intensive therapy provided by "Premarin" full strength. Bottles of 20 and 100 tablets. AYERST, McKENNA & HARRISON LIMITED _ _ Biological and Pharmaceutical Chemists -._... MONTREAL CANADA 0h£d4 M A STEP FORWARD IN MENOPAUSAL THERAPY »*»» *i,lt mi inn.j §t texn eunei to it «to cur it ei cm ik[ mscuMtca or i ntiiKUM ,S*.■f<»*,8l l!§||3 . HffiTAL A SYNTHETIC ESTROGEN COMBINED WITH A SEDATIVE 84 i^Sw^w* In the modern treatment of the menopause, Hexital represents a distinct therapeutic advance. Combining, as it does, the new synthetic estrogen of low toxicity—hexestrol—together with a time-honored sedative, phenobarbital, Hexital provides an effective, simple and economical oral therapy in menopausal manifestations that offers more complete control of symptomatology than obtainable with hexestrol alone. w vJSi DOSAGE: Each Hexital tablet contains 3 mg. hexestrol and 20 mg. phenobarbital. In the average menopausal case, 1 tablet daily, preferably taken at night is the recommended dose. In more severe cases, two or three tablets a day may be prescribed. In mild cases, V_ tablet nightly should suffice. HOW SUPPLIED: Hexital is supplied in bottles of 100 and 1000 scored tablets. Each tablet contains 3 mg. of hexestrol and 20 mg. of phenobarbital. ORTHOgPRODUgS... OF CANADA LIMITED "^^-^ TORONTO n n V-/ \^ oyola MOHlSION Of SOYBHANOIL BIOIOCICAUY . STABILIZED A NEW FOOD PRODUCT £oi* _%« faea,£m0n.t off INFANTILE ECZEMA *—*l nnffl»»t_ii_ n_w«By — IW»YD_* ■*_•—Inn.- tk—.i •f*>o_.„ **-_«<_ SHAKg wag. *^¥2_25_Jgwma -WWNit .*__• «*&_*» C1^j ix This new treatment provides, in Soybean Oil, a rich supply of essential unsaturated fatty acids along with the protective antioxidants present in Rice Bran Concentrate. Each 100 Cm. Soyola contains 65 Cm. Soybean Oil and 5 Gm. Rice Bran Concentrate. A palatable emulsion in 16-fluid oz. bottles. JOHN WYETH & BROTHER (CANADA) LIMITED, NUTRITIONAL DIVISION, WALKERVILLE, ONTARIO -l>ount pleasant XHnbertaking Co. %tb. KINGSWAY at 11th AVE. Telephone FAirmont 0058 VANCOUVER, B. C. R. F. HARRISON W. E. REYNOLDS f Breaks the vicious circle of perverted menstrual function in cases of amenorrhea, tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic relief by stimulating the innervation of the uterus and stabilizing- the tone of its musculature. Controls the utero-ovarian k circulation and thereby encourages a , " normal menstrual cycle. L_ • MARTIN H. SMITH COMPANY & ISO MMTITTI SHUT. NiW TO«K. N. T. Full formula and descriptive literature on request (^P Dosage! 1 to 2 capsules 3 or 4 timet daily. Supplied in package* of 20* Ethical protective mark MHS embossed on inside of each capsule, visible only when capsule is cut in half at seam. MULTIVITE * Trade Mark Presenting Vitamins ABC and D in a single pellet In vitamin therapy the most satisfactory results are obtained when the vitarrijtps are administered in a group. The rational explanation for this is basedTupon the following facts— 1 Uncomplicated deficiencies of a single vitamin are rare. 2 The effects of incorrect ratios in the amounts of vitamins ingested are second only in seriousness to those of marked deficiencies. 3 Efficient utilisation of individual vitamins is in many cases dependent upon the presence of other vitamins in adequate amounts. It is recommended therefore that Multiyite should be given for the prevention of vitamin deficiency generally and that when deficiency symptoms attributable to lack of a specific vitamin are present, that particular vitamin should be given in curative doses together with Multivite, in order to prevent the appearance of further symptoms and to maintain more or less norma! ratios in the amounts of vitamins ingested. Multivite pellets are the original preparation in which fat-soluble and water-soluble vitamins were combined in one compact and palatable product. Each pellet contains— Vitamin A 3000 international units Vitamin Bx 200 international units Vitamin C 12.5 milligrams Vitamin D 600 international units Stocks of Multivite are held by leading druggists throughout the Dominion, and full particulars are obtainable from THE BRITISH Toronto DRUG HOUSES (CANADA) LTD. Canada .MIvt/Can/452 WOMEN WHO STAND ALONE They stand alone in sadness and disappointment...women whose hopes have been blighted by repeated spontaneous abortions due to corpus luteum hormone deficiency. BUT THEY NEKD NOT STAND ALONE. Their uncertain pregnancies can be protected, and safe-carriage to term assured with Phollton and Phanone, pure crystalline preparations for corpus luteum hormone therapy. PROLUTON (pure crystalline progesterone) for intramuscular injection, ampules containing 1,2,5 and 10 mg. PRANONE (anhydrohydroxy- progesterone) for oral use, tablets of 5 and 10 mg. Rfe _H 1 _________ SCHERING CORPORATION LIMITED 137 ST PETER STREET, MONTREAL Up ANALGESIC SPASMOLYTIC % SEDATIVE \ CtfNs->CrC00C2Hs .CHj rHE analgesic effect appears to be between that of morphine and codeine, and it persists for from three , to six hours. ethyl 1-meth.yl-4-phen.yl- pi per idi ne • 4 • car boxy 1- ate hydrochloride Demerol hydrochloride Demerol has many indications in medicine, surgery and obstetrics. Before prescribing, physicians should read carefully the booklet on Demerol hydrochloride (sent free on request). Prescriptions are subject to Canadian narcotic regulations. Supplied for oral use, tablets of 50 mg.; for injection, ampuls of 2 cc. (100 mg.). WINTHROP Trademirk Ice U. S. Fat. Off. * C-n*_a HYDROCHLORIDE Brand of MEPERIDINE HYDROCHLORIDE (Isonipecaine) // LET'S LOOK AT THE RECORD // fli"[|| K^*-**1 •Ml l_ji_iii»ji_! _U_J A study of the literature shows that NUPERCAINE has been used in these types of local anaesthesia—surface, infiltration, regional, sacral, parasacral, paravertebral and spinal. We have, then, in NUPERCAINE, a local anaesthetic of sustained action with a wide field of usefulness. It has effect in relatively high dilutions. The effect of NUPERCAINE is considerably more intense than that of the usual local anaesthetics, novocain, etc., but it can be used safely if the directions suggested are followed. Whenever a product is found which is so universally used, little need be said further about its merits. NUPERCAINE (a-butyloxycinchoninic acid diethylethylenediamide hydrochloride) has stood the best test a product can experience . . . time. NUPERCAINE Trade Mark Reg'd. POWDER • TABLETS • AMPOULES • SOLUTION FOR TOPICAL APPLICATION cs " GF MflNTHI MONTREAL, CANADA HIGHLY EFFICIENT ANTISEPTIC at letKtvt&zjUtf lota cadt Bottle of 4 FLUIDOUNCES ixaAet 4 GALLONS less than 24 cents per gallon I Cost of customarily used Aqueous- Dilutions of Zephiran Chloride: 1:1000—per gallon, less than 24 cents. 1:5000—per gallon, less than 5 cents. 1:20,000—per gallon, about 1 cent. Zephiran Chloride Stainless Tincture 1:1000 can be prepared from the Concentrate 12.8 per cent Aqueous Solution at correspondingly low cost. Detailed formula on request. ft ntiseptic costs can be radically reduced by the use of Zephiran Chloride Concentrate 12.8 per cent Aqueous Solution . . . The various dilutions customarily employed are made with ease by the hospital pharmacist . . . Zephiran Chloride dilutions possess not only a potent antiseptic action but also a desirable detergent property. Zephiran Chloride Concentrate 12.8 per cent (Aqueous Solution) is supplied in bottles of 4 ounces and 1 gallon. WINTHROP CHEMICAL COMPANY, INC. Pharmaceuticals of -merit for the physician GENERAL OFFICES: WINDSOR, ONTARIO Quebec Professional Service Office: Dominion Square Bldg. Montreal, Quebec ZEPHIRAN Trademark Reg. U. S. Pat. OS. & Canada CHLORIDE BENZALKONIUM CHLORIDE REFINED CONCENTRATE 12.8% Bottle of 1 GALLON 128 GALLONS *fe__i ' GfttcruiZe U^____ i"»o __ ■ ^ tfooor_| AQUEOUS SOLUTION ^jRjlv^^-^^ FATHERS OF CANADIAN MEDICINE *ONE OF A SERIES m m^ m __ __.«a4*a!_f5 Hi BART., C.B., G.C.M.G., M.D., LL.D. PHYSICIAN AND STATESMAN (1821-1915) fOURAGE, boundless optimism and breadth of vision characterized the distinguished career of Sir Charles Tupper. Despite the .demands of public office, he maintained an active interest in all matters concerning the medical profession. Tupper was born at Amherst, N.S., July .2nd, 1821. He studied medicine at Edinburgh University where he received the degrees of M.D. and L.R.C.S. in 1843. Of medium height, erect, and vigorous, Charles Tupper had an abundance of nervous energy which contributed to alertness and ceaseless mental activity. His manner was hearty and genial and he had a broad grasp of most topics. in 1862 Tupper was appointed a Governor of Dalhousie College, Halifax, where he initiated a medical course which reached full fruition in 1870. It was largely due to his persistence that in 1867 the Victoria General Hospital began its existence in Halifax as a provincial and city institution. When the Canadian Medical Association was formed in 1867 he was elected President. 1856-1945 The year 1855 marked the beginning of Tupper's political career. It is said that history will record the four years of his administration as Premier of the Province of Nova Scotia as the greatest era in Tupper's life—an era in which he achieved the most striking personal success. Against strong opposition he established a system of free schools for Nova Scotia. Tupper was the apostle of Confederation and played an important part in the passage of the British North America Act. He actively supported efforts to establish a Federal Department of Health which, after much missionary work, became a reality in 1919. He was made a Baronet in 1888. For two different periods he held the position of High Commissioner for the Dominion in London and in 1896, was made Prime Minister of Canada. Sir Charles died at "The Mount", Bexley Heath, England, on October 30th, 1915. The record of his life is a challenge to the medical profession and inspires William R. Warner & Company in their policy of Therapeutic Exactness . . . Pharmaceutical Excellence. ^UlAMR. \ t COMPANY LTD. JIM stmioi or FKAtMAC-UTICAt* niAtt>SM-o is j* MANUFACTURING PHARMACEUTISTS • 727-733 KING ST. WEST, TORONTO lis '^tch w*m tivo tea. £z?* « Kh\ **nin Ni oQz e# Jacii, **a. yd r°chl SuPply Of,rJe yrid Caic oxiq V*** P eft yd B enate Ui and 'tam era. >tt 'Ude, Rested lntake ***** fa ' • 10°oo St*** 14400 % ***** Wot* «« fo 8 to 4 und gamin a tea in n^tea\8po°^ls rice b van (8 e*tr, to 16 •)d aily or act. as An aqueous extract of rice bran—one of nature's richest sources of the B-Complex—balanced by the addition of crystalline B factors. MOST PALATABLE • ECONOMICAL BALANCED POTENCY JOHN WYETH & BROTHER (CANADA) LIMITED Nutritional Division WALKERVILLE, Ontario ARTHRITIS and ECZEMA of endogenous origin claimed to be allergic, may bo favored or induced by eatelum and sulphur deficiency, impaired cell action, and imperfect elimination of toxic watte. / LYXAMTHINE ASTIER administered per as, brings about Improved cell nutrition and activity, increased oiiminatlon, re- sulting symptom relief, and general functional Improvement. Write for Information L-17 Cituiidittn Distributors ROUGIER FRERES 350 Le Moyne Street, Montreal Colonic and Physiotherapy Centre Up-to-date Scientific Treatments COLONIC IRRIGATIONS, SHORTWAVE DIATHERMY, SINNEWAVE GALVIN- ISM, IONIZATION, ULTRA VIOLET RAY, STEAM BATHS AND SHOWERS Medical and Swedish Massage Physical Culture Exercises STAFF OF GRADUATE NURSES Superintendent: E. M. LEONARD, R.N. Post Graduate Mayo Bros. 1119 Vancouver Block MArine 3723 Vancouver, B.C. Tests Show Cereal's Reliable Bulk Forming Effect Recent dietary experiments conducted by a Mid-western U.S. university showed wide variations in relative digestibility of crude fibre from various nutritional sources. Kellogg's All-Bran was found more effective in bulk forming properties and laxative action than most of the fruits and vegetables studied—a fact of interest to doctors in treating cases of constipation due to lack of dietary bulk. ALL-BRAN Food-Type Laxmtive FREE! HELPFUL SCIENTIFIC MATERIAL including details of experiments. Simply fill in coupon and mail to: Kellogg Company of Canada, Ltd., London, Ont. Name. Street. City. .Province. the busy physician will appreciate these important advantages of PVRIDIUm • Prompt, gratifying relief of distressing urinary symptoms O Ease and convenience of administration % Safety—lack of toxicity Increasing numbers of busy physicians are finding Pyridium to be a thoroughly dependbale chemo- therapetuic agent upon which they may rely for prompt, gratifying relief for the distressing symptoms encountered in cystitis, prostatitis, pyelonephritis, and urethritis. Clinical experience extending over more than a decade, as reported in the published literature on Pyridium, testifies to its prompt and effective action and its freedom from narcotic or irritant effects. ptPifM TRADE MA RK (Phenylazo-Alpha-Alpha-Diomino- Pyridine Mono-Hydrochloride) A decade of service in urogenital infectiom MERCK & CO.- Limited dhnu/ac6e*£np ^ —-»MONTREAL, TORONTO niiiiniiiiiiiiiiiitiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiuiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiuiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiini Nutrition's Importance in prenatal care "In the 216 cases considered in this study, all stillborn infants, all infants who died within a few days of birth except one, most infants who had marked congenital defects, all premature, and all functionally immature infants were born to mothers whose diets during pregnancy were very inadequate."—Burke, B. S., Beat, V. A,, Kirkwood, S. B., and Stuart, H. C; J. Nutrition, 26:569, Dec. 1943. R, .eporting a "statistically significant relationship ... between the diet of the mother during pregnancy and the condition of her infant at birth and within the first 2 weeks of life," the authors of the study quoted above conclude that if the mother's diet is good or excellent, "her infant will in all probability be in good or excellent physical condition." Carnation Evaporated Milk is a valuable constituent of an adequate prenatal diet. It is especially important as a supplier of calcium and phosphorus, and as a dependable automatic source of vitamin D, needed to promote proper utilization of those minerals. With its doubled percentages of all milk solids, undiluted Carnation Milk greatly facilitates the inclusion in the diet of optimal amounts of milk, through the medium of easily prepared and appetizing milk-rich main dishes and desserts. CARNATION CO. LIMITED, TORONTO, ONT Carnation 'FROM CONTENTED COWS' Milk A Canadian Product mill We Have Closed Our 36thm¥ear Since 1908, through World War One, through depression and boom, and now nearly through World Wa^|itwo, OUr Pharmacy has grown steadily. Today we look forward to another year in which to serve the medical profession in many ways better than before. Phone MArine 4161 \4hAl ^.JUnJ^i»r\ GEORGIA PHARMACY ••»**<>y 13 th Ave. and Heather St. Exclusive Ambulance Service FAirmont 0080 PRIVATE AMBULANCES AND INVALID COACHES WE SPECIALIZE IN AMBULANCE SERVICE ONLY I H. CRELLfN W.;_. BERTRAND a* HH| New Westminster^ B. C. For the treatment of NEUROPSYCHIATRIC DISORDERS Reference—B. C. Medical Association For information apply to Medical Superintjenden^]N[ew Westminster, B. C. New Westminster 288 or 721 Medical-Dental Building, Vancouver, B. C. PAcific 7823 PAcific 8036 >_7
Periodicals
W1 .VA625
English
Vancouver : University of British Columbia Library
Vancouver, B.C. : McBeath Spedding Limited
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Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: February, 1945
Text