CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
'Laboratory findings ; News and notes ; Colitis.' -- Title page
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S3 S3 S3 S3 S3 S3 S3 S3 THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published monthly at Vancouver, B. C. (Laboratory findings U^(ews and J^gtes Colitis JULY, 1925 Tublished by eMc'^Beaih Spedding Limited, IJancouver, <25. Q. 0/ PT> CX ex ex ex ex ex ex ex 0/ m PHONE SEYMOUR 2487 McBeath Spedding Ltd* Vancouver, B. C. PRESCRIPTIONS filled exactly as written Phones: Seymour 1050 -1051 Day and Night Service Qeorgia Pharmacy Ltd. Qeorgia and Qranville Sts. Vancouver, B. C. Page Two THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the Interests of the Medical Profession. Offices: 529-30-31 Birks Building, 718 Granville St., Vancouver, B. C. Editorial Board: Dr. J. M. Pearson Dr. J. H. MacDermot Dr. Stanley Paulin All communications to be addressed to the Editor at the above address. VOL. I. JULY 1st, 1925 No. 10 OFFICERS, 1925-26 President Dr. J. A. Gillespie Secretary Dr. G. H. Clement Past President Dr. H. H. Milburn Vice-President Dr. A. W. Hunter Treasurer Dr. A. b. Schinbein Dr. w. f. Coy TRUSTEES Dr. W. B. Burnett Representative to B. C. Medical Association Dr. A. J. MacLachlan Dr. J. M. Pearson Auditor Dr. A. C. Frost SECTIONS Clinical Section DR. W. L. PEDLOW - Dr. F. N. Robertson Physiological and Pathological Section Dr. G. F. Strong - Dr. C. H. Bastin Eye, Ear, Nose and Throat Section Dr. Colin Graham ..--.. Dr. E. H. Saunders Geniio-Urinary Section Dr. g. S. Gordon .... Dr. J. A. E. Campbell - Chairman Secretary Chairman Secretary Chairman Secretary Chairman Secretary COMMITTEES Library Committee Dr. Wallace Wilson Dr. a. w. Bagnall Dr. W. D. Keith Dr. W. F. McKay Orchestra Committee Dr. F. N. Robertson Dr. J. A. Smith Dr. l. Macmillan Dr. A. M. Warner Dinner Committee Dr. N. E. MacDougall Dr. A. W. Hunter Dr. f. N. Robertson Credit Bureau Committee Dr. Lachlan Macmillan Dr. J. W. Welch Dr. G. A. Lamont Credentials Committee Dr. Lyall Hodgins Dr. R. Crosby Dr. j. A. Sutherland Summer School Committee Dr. Alison Cumming Dr. Howard Spohn Dr. g. S. Gordon Dr. Murray Blair Dr. W. D. Keith Dr. G. F. Strong Page Three VANCOUVER MEDICAL ASSOCIATION. Founded 1898. Incorporated 1906. 28th Annual Session GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m. Place of meeting will appear on Agenda. GENERAL MEETINGS will conform to the following order: 8 p.m.—Business as per Agenda. 9 p.m.—Paper of Evening. The regular work of this Session will commence on Tuesday, Oct. 6, 1925. Programmes to be announced later. HEALTH DEPARTMENT STATISTICS. MAY, 1925. Total Population (estimated) 126,747 Asiatic Population (estimated) 9,960 Rate per 1000 of Pop. per annum 9.1 13.0 6.4 Total Deaths 98 Asiatic Deaths f 11 Deaths—Residents only 69 Total Births—Male, 147 Female, 116 263 Stillbirths—not included in above 14 Infantile Mortality— Deaths under 1 year of age 8 Death rate per 1000 births 30.4 24.4 CASES OF CONTAGIOUS DISEASES REPORTED. June May. to \5th. Cases. Deaths. Cases. April. Cases. Deaths. Smallpox 30 0 10 0 Scarlet Fever 29 0 49 0 Diphtheria 15 0 9 0 Chicken Pox 77 0 42 0 Measles 10 0 0 Mumps 15 0 21 0 Erysipelas 0 0 4 0 Tuberculosis 7 0 34 11 Whooping Cough . 4 0 25 0 Typhoid Fever 3 0 10 Ep. Cerebro-Spinal Meningitis 11 0 0 (Cases from outside City included in above.) Diphtheria 10 10 Smallpox 0 0 10 Scarlet Fever 3 0 7 0 5 17 4 10 1 7 0 1 20 2 0 1 0 2 Page Four Saai SKSj^dlb^li; a@sH~ Petrolagar (Trade Mark) cA palatable, non-irritating emulsion of pure mineral oil and agar-agar In PETROLAGAR the physician is afforded a preparation in which mineral oil and agar-agar are combined in a pleasant-tasting and efficient product for the treatment of constipation. The agar is specially prepared so as to yield on incubation in the intestinal tract very many times its original bulk, forming a bland, gelatinous mass which gives the bulk necessary for the healthy peristaltic action of the bowel muscle, without irritation. The mineral oil is so finely diffused with the agar-agar that it thoroughly mixes with the fecal matter, gives full lubrication and thus eliminates the annoyance of leakage accompanying the use of oil in the older forms. The pharmaceutical methods by which PETROLAGAR is prepared are such that there is no taste of oil whatever. In fact, this elegant pharmaceutical product has the appearance and taste of pudding sauce and can be taken by even the most fastidious patient without any objection or danger of eructation. The action of PETROLAGAR, being entirely mechanical, does not interfere with any other medication which may be administered at the same time. PETROLAGAR is issued as follows: PETROLAGAR (Plain) ; PETROLAGAR (with Phenolphthalein) ; PETROLAGAR (Alkaline) ; and PETROLAGAR Unsweetened (no sugar) . PETROLAGAR has been accepted for New and Non-Official Remedies by the Council on Pharmacy and Chemistry of the American Medical Association. Write for clinical trial specimen and literature to Deshell Laboratories of Canada Ltd. DEPT. V. 245 CARLAW AVE., TORONTO London, Eng. Los Angeles Chicago Brooklyn ;»©y> Page Five EDITOR'S PAGE. It is now the "open" season for medical golf, if one may judge by the schedules of tournaments and invitations to journey elsewhere for playing purposes which are decorating the bulletin boards in places where medical men may be expected to congregate. Golf has become, for members of the medical profession, as for thousands in other walks of life, an important interest and means of recreation. Recreation in some form may be regarded as a necessary factor in our civilization. Intensive and prolonged application to any occupation, if it does not lead to physical deterioration, results in mental staleness. Even for those fortunate few to whom the beginning of each day's work is an exhilarating adventure, sooner or later zest is lessened and enthusiasm diminished. We require change, and change is synonymous with recreation. Some make holiday from a sense of duty, feeling that general experience has shown that to tear oneself away from even the most absorbing occupations for a time, results in increased keenness. With others the holiday and the ability to provide for it is the chief aim and interest of their work. Many doctors find the necessary recreation in travelling to more or less distant parts to watch their colleagues at work and to talk of difficulties with others from the observer's detached standpoint. This combination of business with pleasure, of leisurely acquirement under novel conditions has long been a recognized variety of holiday to which many great names in our profession have been devoted. Some, on the other hand, feel that they must get away from anything which pertains to or suggests the regular routine of their daily life. These may betake themselves to the wilds, fishing, hunting or what not, finding in the contact with nature, and the complete alteration in their circumstances, the necessary means of mental and bodily recreation. To still others the desired relaxation comes by means of games, such as golf—if indeed such a profane term may still be employed towards so solemn a rite. Perhaps, indeed golf as a recreation more properly comes under the head of change of occupation. To work hard and to play hard seems to be the order of the day. But all recreation should indeed be "re-creation." If it sends us back to our work with renewed interest and increased capacity, the result is beneficial no matter what form the holiday may have assumed. Of this each individual must be his or her own judge. After all we must remember that work, the regular occupation in which we find the means of livelihood, be it congenial or otherwise, is the most satisfactory discovery that life has given to us. Occupations regarded as the supreme good, recreation then falls into the secondary position as a means to prolong our capacity for work. A voluntary abstention which makes the subsequent indulgence more satisfying. The first volume of THE BULLETIN will be completed in September.. For those of our readers who are desirous of keeping Page Six the various issues, we have arranged a suitable binder for this purpose. The cost of this binder, into which the papers may be inserted, will be $1.25 post free, providing a sufficient number is ordered. The cover will be suitably inscribed in gold letters. Orders may be sent to the Editorial Office of THE BULLETIN/ Rooms 529-31, Birks Building, Vancouver, B. C. These we shall be glad to receive as soon as possible. By the time this issue is off the press the Summer School of the Vancouver Medical Association will be close at hand. We feel sure that the medical men of this province will rally to the support of the committee, which has used every endeavour to make this meeting equal or surpass its predecessors. The better the attendance the better the meetings, both present and to come. NEWS AND NOTES. We are glad to announce that Dr. Alison Cumming is somewhat improved after his illness of the past three months. He still expects to take some time to completely recuperate, and is still confined to the house. Owing to his illness, Dr. A. S. Monro is unable to attend the meeting of the Pacific Northwest Medical Association, of which he is President this year. Dr. Monro has been confined to bed for some time from an attack of acute sciatica, but we hope he will soon be sufficiently recovered to resume practice. After spending four months in New York City and two months in Boston in the women's hospitals, Dr. Walter S. Turn- bull has returned to Vancouver, where he has resumed practice which will be restricted to obstetrics and gynaecology. Dr. Daniel McLellan is at present in the East, having left to visit his brother, who is ill in Ontario. While East he expects to visit New York and other cities, for post graduate work. Drs. J. A. Smith and J. C. Farish returned on June 6th from New York City, where they attended the New York and Manhattan Eye and Ear Hospital. They were much pleased with their "Round America" cruise via the Panama. On June 10th, Dr. W. C. Walsh returned in fine fettle after having spent the previous three and a half months doing post graduate work in New York City, Chicago and Rochester, Minn. Dr. Walsh reports having had an interesting and instructive course. On June 11th, 31 Seattle medical men came to Vancouver to play the return game in the Tri-City Golf Contest. The games were played on Shaughnessy links in foursomes. The result in points was: Seattle, 48; Vancouver, 33. In the evening the usual Page Seven dinner was given, in which about 70 participated, and everybody appeared to have had a most enjoyable day. His many friends will be interested to hear of the birth of a son to Dr. and Mrs. D. J. Millar on May 30th, at Vancouver General Hospital. We also have to congratulate Dr. G. A. Upham on the birth of a son on May 29th, at the Vancouver General Hospital. LIBRARY NOTES. Book Reviews. "The Principles of Psychotherapy'," by Pierre Janet. Cloth, $3.00. 1924. Macmillan. A considerable portion of this book is given to the history of the development of Psychotherapy from Ancient religions and magic practices to hypnotism, Mesmerism, Eddyism, osteopathy and psychoanalysis. His account of the life work of that hysterical paraplegic who was promptly cured at the age of forty by P. P. Quinby, the clever, observant watchmaker, who for years had been dabbling in various forms of drugless healing, is an interesting review of the development of what is now known as Christian Science. When the author urges that in some of the neuroses the liquidation of traumatic memories is essential if relief from symptoms is to be obtained and later on finds little of value in psychoanalysis, it is difficult to find him consistent, for how can those experiences be brought to the surface except by recourse to some.degree of mental analysis. The value of rest in nervous conditions is emphasized and considerable mention is made of treatments, such as the Weir Mitchell. Intensive suggestion in the form of hypnotism is applicable, the author claims, to a very large percentage of neurotic cases. If we keep in mind the suggestibility of the French we will be more tolerant towards Janet's conclusions. As mentioned before the first portion of this work is inter esting. -W.A.D. Practical Electrotherapeutics and Diathermy. G. Betton Massey, M.D., Fellow and former President American Electrotherapeu- tic Association. Author of "Electricity in the Diseases of Women," "Conservative Gynaecology and Electrotherapeutics," etc. Octavo of 400 pages, with 157 illustrations. Cloth $5.00. The Macmillan Company. 1924. Page Eight The author of this work is one of the pioneers in the field of Electrotherapy and is considered one of the leading authorities on this subject. In the preface, Dr. Massey says: 'The present work is designed to furnish students, surgeons and general practitioners with a basis for a practical understanding of the application of electric power as received from the street main&, in the treatment of their patients, the aim being orderly simplicity as well as comprehensiveness in the consideration of the subject." The language is lucid and the subject is covered in a satisfactory manner. The author properly emphasizes the fact that electrotherapy should not be regarded as a specialty in practice, but as a mode of therapy which may be employed in general medicine and surgery and in the specialties. A chapter is devoted to each of the following subjects: Electricity and Diathermy in General Surgery, Electricity in Industrial Surgery, Electricity in New Growths, Electricity in Gynaecology, Electricity in Urology and Proctology, Electricity in the Nose and Throat, and Electricity in Ophthalmology. It is an authoritative and thoroughly practical treatise on this branch of Physiotherapy, and well merits its popularity amongst works of this character. H A. B. "International Clinics." Vol. IV, Dec. 1924. $2.00, J. B. Lippin- cott Co. To those interested in semi-tropical medicine this issue presents articles on "Bacillary Carriers," "The Value of the Noguchi Serum and Vaccine in the Treatment and Prevention of Yellow Fever," "The Importance of Infection as Well as Food in the Causation of Pellagra," and the wider application of Blastomycosis implantation in relation to Chronic Sinuses and the interesting association of Erythema Multiformae and Vincent's Angina. The paper on "Congenital Heart Disease," by so well-known an authority on the subject as Maude Abbott, should appeal to those interested in General Practice and Pediatrics. The subject is comprehensively covered and well illustrated. E. L. Eliason and Drury Hinton, in their paper on the "Internal Fixation of Fractures," have gone to considerable trouble in collecting data and views from a number of men who are specializing in this branch of surgery, and although there is little new as far as advancement is concerned, the value of the article lies in the definiteness of their conclusions. Periodic Health Examinations—though not a new subject, is one which should carry a very important lesson to all medical practitioners. Life insurance companies, health boards and soci- Page Nine eties, along with a few medical men interested, have made considerable advances along these lines. This article should bring to the minds of all the importance of the opportunity that we as individuals are not accepting. The application of the principles contained in this article by every doctor in his practice would help to establish the profession in the confidence of the public at large and of the individual patient. The article should be read by all— its application is general. For those doing general work and those who come more closely in contact with the subject of Goitre, it would be time well spent to renew our acquaintance with the subject of "Syphilis of the Thyroid Gland," by reading Ernest Schulmann's article in this issue. BOOK REVIEWS "Modern Methods in Abnormal and Difficult Labour," by a group of well-known authorities, is the first series of extra numbers by the English medical periodical, The Lancet. It is primarily written as a guide to the physician who, summoned by a midwife to attend an obstetrical complication. Some of the articles seem to be written for the midwife's instruction, while others appear to be for medical digestion. From the physician's standpoint, the articles that are very commendable are: Munro Kerr's on "Bony Deformities of the Pelvis"; "Occipito-posterior Presentations," by W. Gilliatt; "Breech Presentations," by Eardley Holland; and "Injuries to Birth Canal," by Victor Bonney. Much is wanting in some of the other articles to make them fully authoritative. All through this series the authors seem to be writing for the midwife rather than for the mature physician. The last article of the series, by M. Olive Haydon, a registered midwife, urging the widening of the midwife's field, will not be looked upon favourably by Canadian physicians. J. J. M. "Symptoms of Visceral Disease." By Dr. Francis M. Pottenger. Second Edition. 1923. C V. Mosby Co. $5.50. It must be very gratifying to Dr. Pottenger to have a second edition of this most interesting work called for in such a short time. In this book Dr. Pottenger has compiled the most recent work on the anatomy and physiology of the vegetative nervous system. Theories of the various physiologists are quoted at length and the student is presented with a complete summary of the modern conception of the anatomy and physiology of the vegetative nervous system. The main part of the work is devoted to the discussion of the relationship between the vegetative nervous system and the varying symptoms of visceral disease. The late Sir James Mac- Kenzie's dictum that most symptoms are due to disturbances of reflexes, is accepted and amplified by Dr. Pottenger. Dr. Pottenger states: "In as much as most symptoms of disease are disturbances Page Ten in the normal physiological control, therefore most symptoms are due to the altered nerve and endocrine activity." All the various systems of the body are taken in order, and the various sympathetic and parasympathetic reflexes are discussed and the relation between these reflexes and the various clinical symptoms. This work is well worth reading by all practitioners. It is pased on broad scientific knowledge, combined with sound clinical observation. At times one may be inclined to be sceptical of the more speculative conclusions, yet every month almost is bringing to light some new facts which tend to confirm the proved principles laid down in this work. The illustrations and diagrams are exceptionally good, and we would recommend all practitioners who would keep abreast *of the times in regard to the vegetative nervous system, to read this work. C. H. V. B. C MEDICAL ASSOCIATION NEWS ITEMS. Dr. John Henry Wright, of Alexis Creek, Chilcotin, B. C, died in Vancouver on June 1st, at the age of 73. Dr. Wright was a native of Scotland, a graduate of Edinburgh, and came to this province eleven years ago. He leaves a wife and a son, William, to whom our deepest sympathy is extended. Dr. Wm. T. Kergin, of Prince Rupert, recently left on a trip to Europe. He expects to return about August 1st. Owing to the closing down of the mill at Buckley Bay, Dr. G. F. Palmer has relinquished his practice at that place. He is at present enjoying a holiday in Vancouver. Dr. A. A. King, of Ladner, is leaving on June 15 th for three months' post-graduate work in Eastern cities. His practice will be cared for by Dr. H. C. McKenzie. At the annual meeting of the B. C. Medical Association to be held on July 3rd, there will be a dinner at which an address will be given by Sir Henry Gray, Surgeon in Chief of the Royal Victoria Hospital, Montreal. It is expected that quite a number of out of town doctors will be present on that occasion. An interesting wedding took place in Victoria on June 1st, when Dorothea, third daughter of the late Sir Richard McBride and Lady McBride, became the bride of Dr. J. H. Moore, South- gate Street, Victoria. Dr. Moore is the genial and indefatigable Hon. Secretary-Treasurer of the Victoria Medical Society, and it is interesting to note that conspicuous among a number of very beautiful presents was an engraved silver tray and silver tea and coffee service, the gift of the Victoria Medical Society. Page Eleven Dr. W. A. Dobson, of Vancouver, on May 11th, gave an address before the Victoria Medical Society on the subject of "Treatment of the Neuroses." There was an excellent attendance of medical men, and the consensus of opinion was that it was one of the best talks the Society had had for some time. The address was given under the auspices of the B. C. Medical Association. Dr. G. A. Lamont, of Vancouver, will be the speaker at the Victoria Medical Society's meeting to be held on June 6th. He will speak on "Baby Problems." Quite a number of the Victoria profession are proposing to attend the Annual Meeting of the Canadian Medical Association at Regina, this month, and they will take with them a very cordial invitation for that organization to hold its 1926 meeting in Victoria. In the event of its acceptance, no effort will be spared to ensure a successful and pleasurable time. The scenic beauties surrounding Victoria are well known, whilst its golf courses, ideal motor roads and other phases of amusements, etc., are unsurpassed. The Annual Meeting of the No. 4 District Medical Society (Okanagan Branch of the B. C. Medical Association) will be held at Merritt, B. O, about the middle of September. Practically every member of the Society has already signified his intention of being present, and there is every prospect of a record attendance. The annual visit of the Executive Secretary to places along the coast, Vancouver to Anyox, resulted in 100% paid-up membership, and a keen interest in the work of the Association was shewn by all the men visited. It is with regret that we record the sudden death of Miss Jean Warrender, a nurse on the staff of Shaughnessy Military Hospital. Miss Warrender went overseas from Kingston, Ontario, early in 1916. After a short time at Taplow, Miss War- render went with No. 7 General Hospital to France and served there till the end of the war. She was one of the last nursing sisters to leave France in 1919. Her death occurred from heart trouble (for which she was in receipt of a small pension) while serving tea to the patients in Shaughnessy Hospital. Miss War- render was an old country graduate from Aberdeen. She was buried with full military honours on June 6th. The Pacific Coast Oto-Ophthalmological Society meeting, June 18th, 19th and 20th, is expected to be a record one. Already a large number of men from south of the line have signified their intention of being present. Dr. H. M. Cunningham, of Vancouver, is the president this year. Among the speakers are: Dr. Gordon B. New, Dr. H. V. Wurdemann, Dr. G. Piness, Dr. Chase, Dr. Edward Jackson (of Denver), Dr. L. Klemptner. Dr. M. J. Keys, and others. Dr. H. A. Spohn and Dr. R. E. Coleman, of Vancouver, will give a paper on "Some Metabolic Observations in Herter's Disease," before the North West Pacific Paediatric Association at Portland, Ore., on June 29th. Page Twelve EXAMINATION OF URINE FOR BACILLUS TUBERCULOSIS. From the Laboratories of the Vancouver General Hospital. DR. R. E. COLEMAN, Acting Director. A clinician recently remarked that the laboratory was of no assistance in the diagnosis of tuberculosis of the kidney, since it never found the bacillus of tuberculosis in any of his cases. An examination of the records for the last four years failed to reveal any such examination made for him. However, the investigation yielded the following very interesting figures: Of the 641 examinations of urine for acid fast bacilli, by direct smear, 40 were positive, or 6.6%. Of these 40 positive reports only one was negative at the first examination, and that one was positive in the thrid and fourth examinations. One was negative in the voided specimen, but the organisms were found in a later ureter catheter specimen. This bears out the statement of the clinician who sent in the second largest number of specimens for examination. He said that the laboratory had reported positive at the first examination on all his cases, which had clinically proved to be tuberculosis of the kidney.. The measure of benefit from guinea pig inoculation can be determined by the fact that of 33 guinea pigs inoculated for tuberculosis, only three developed the disease which had been negative by previous direct smear examination. In addition to the failure to find the organism, considerable value can be attached to the absence of leukocytes in the urine. Of 30 specimens in which the organisms were found, only one reported no white blood cells in the smear. In this connection physicians could improve the interpretive value of this determination if they would notify the laboratory of any case which, after a negative laboratory report, turns out to be undoubtedly tuberculosis of the kidney. Number of Specimens Examined During Four Years. Ordinary Voided Right Left Specimen. Ureter. Ureter. Neg. 401 Pos. 27 Neg. 76 Neg. 76 Pos. 6 Total negatives, 601. Total positives, 40. Bladder. Neg. Pos. 48 5 Total, 641. Page Thirteen CHRONIC COLITIS. By Dr. C. E. Hagyard, Seattle, Wash. Read before the Vancouver Medical Association A survey of the literature gives the impression that the term "chronic colitis" suggests no definite clinical picture, but rather, refers to many disturbances, nervous or inflammatory in origin, affecting the colon. The most common conception of this condition, I believe, is based upon description of the following conditions:— Mucous Colitis. Irritable Colon. Ulcerative Colitis. Certain chronic gastrointestinal cases, classified as ulcerative colitis, in which the X-ray reveals tubular or deformed colons. In order to attempt to clarify the subject, I will briefly refer to these conditions. 1. Mucous Colitis was first described in this country by Mason Good in 1825. In 1904, Nothnagel offered much evidence to prove his opinion that mucous colitis was largely of nervous origin, and that there were no marked inflammatory changes in the colon. His conclusions have been largely accepted, and to indicate that this opinion still holds, I quote from Lord Dawson, who in the annual oration before the Medical Society of London, May, 1921, on mucous colitis, states that he is not referring to any condition associated with organic disease of the colon. In my experience, sigmoidoscopic examination of even longstanding cases of mucous colitis shows little or no evidence of chronic inflammatory changes. 2. Irritable Colon. Procto-sigmoidoscopic study of these cases, with careful examination of the mucous or muco-pus, obtained from the colon, indicates that they are relatively early stages of chronic colitis. 3. Ulcerative Colilis should refer, I believe, to a definite group in which, practically from the beginning, there is a tendency to multiple ulceration. These will not be discussed in this paper. In another group chronic ulceration is a rather late development of chronic colitis, and to these I will refer later. 4. In 1904, Swartz reported that in certain cases of chronic ulcerative colitis, he found on X-ray examination, that the colon had to a considerable extent lost its haustrations, and become a smooth, thick-walled tube, and in more advanced cases, showed marked contraction and deformity. Since then, in this country, Logan, McMahbn and Carmen, and Yeomens, have made, oimilar reports. Observation of a considerable number of cases showing these characteristic changes, indicates that in many of them ulceration is Page Fourteen not present, or, if so, is not a dominating condition. I therefore consider these changes as characteristic of advanced or terminal stages of chronic colitis and believe the ulceration, when present, to be incidental. Introduction. This study is based upon a series of 230 cases, giving a history of chronic illness, having definite chronic inflammatory changes in the colon, demonstrated by sigmoidoscopy. In this series I have excluded cases of mucous colitis, specific ulcerative colitis, tubercular or syphilitic infections, and those caused by animal parasites. Etiology. No specific organism has been demonstrated as causing this condition, which is manifestly the result of bacterial infection. A large amount of work has been done on the bacterial flora of the intestines, in health and disease, but unfortunately has not resulted in much light on the etiology of these inflammations. Bacterial study was made on a considerable number of these cases, in some a vaccine was developed that elicited marked skin reactions, but I am not convinced that much has been learned from the study of the enormous flora of the intestinal lumen. In the absence of laboratory evidence, I am satisfied, from clinical observation, that the infection is probably focal in origin and most likely due to a streptococcus, which causes chronic progressive changes in the wall of the bowel. In support of this belief, I point to the following observations: 1. Frequent history of onset following tonsillitis or respiratory infection. 2. Onset usually in early adult life when respiratory infections are common. 3. Repeated observation of exacerbations following a cold or sore throat. 4. Similarity of pathology and course with that of chronic cholecystitis. In this series of 230 cases about 50% had large and infected tonsils or pyorrhoea. A co-existence of chronic colitis and chronic cholecystitis occurred in 59 cases in this series. Age incidence in all cases was as follows: to 30, 47; 30 to 40, 93; 40 to 50, 47; 50 70, 7; 70 to 80, 2. With a history of illness having existed for five to twenty years, it places the onset in most cases in the early years of adult life. Cases have been described in infants, and more reports on the incidence in young people would be interesting. Sex was as follows: Males, 82; females, 148. Constipation has been considered a common cause of colitis. Most patients with colitis give a history of chronic constipation, but it is difficult to determine how long the constipation preceded the colitis, or how much of the trouble has been due to a longstanding mild colitis. Methods used to overcome the constipation 10 to 20, 6; 20 to 60, 28; 60 to Page Fifteen such as giving cathartics, and coarse foods, cause enough irritation to predispose to infection, or to increase an existing colitis and insure its chronicity. Amoebic colitis, bacillary dysentery, and acute enterocolitis, may be followed by chronic colitis. Pathology. In general it may be said that chronic colitis is a slow proliferative inflammation, affecting all the walls of the colon. It begins in the rectum and sigmoid, and slowly extends upward until the entire colon, and at times a portion of the terminal ilium, is involved. Early, there is much injection with infiltration of round cells and in the mucosa and submucosa, later, proliferation of fibrous tissue in the submucosa, atrophy of the mucosa and gradual thickening, contraction and deformity of the bowel. Ulceration, stricture, or perforation may occur. The pathologic picture of the various stages as I have seen it, with the use of the sigmoidoscope, will be discussed later. Symptoms. An acute onset with an attack of dysentery is not the rule, but does occur. I have seen a number of men who had such an onset while in France, and, although the dysentery cleared up, they did not regain their health, and have since run a course of chronic gastro-intestinal invalidism. I have also noted the frequent onset after an attack of tonsillitis or grippe. Usually the onset is gradual. In the early stages there may be no symptoms to call attention to the colon. Many report feeling dull and tired. They are unable to maintain mental effort and are fatigued by moderate physical exertion. A dull headache develops during the day. Lack of appetite, constipation and gradual loss of weight is common. Not infrequently they run a low afternoon fever. Constipation is the rule in this stage, but there may be periods when the stools are rather soft. Or a hard, constipated stool may be followed by a soft stool, or a spurt of liquid or gas. A well-developed case, in addition to marked impairment of the general health, as loss of weight, anaemia, weakness and nervousness, has usually developed marked abdominal discomfort. Pain is not usually so acute as in mucous colitis, but is more likely to be dull, aching, often referred to the back. It is brought on or increased with acute exacerbations of the trouble which occurs periodically. There is poor appetite, furred tongue, eructation of gas, bad taste in the mouth. Rumbling and gurgling of gas in the bowels is the rule, and usually much gas is expelled. A daily rise of one-half to one degree of temperature is common, and may continue over a long period of time. Patients may maintain their daily activity for many years, with a gradual increase in the severity of the symptoms. Others have become chronic invalids, thinking constantly of their troubles and continually Seeking new sources for relief. The general symptoms, such as apathy, weakness, loss of weight, anaemia, dull headache, are due, I believe, to the low grade infection, which may with exacerbation and remission, last over a Page Sixteen period of many years. Many of these patients have been told that their ill health was due to auto-intoxication, secondary to intestinal stasis or enteroptosis. Much work has been done tending to prove that "auto-intoxication" is more theory than fact. I believe that so long as the mucous membrane is normal, the amount of absorption of toxins from the intestinal contents is negligible. Mummery, after a long experience, states: "I feel sure that too much attention is being paid to intestinal stasis as the cause of auto-intoxication. Most extreme cases of colon stasis have no toxic symptoms. To my mind, it is clear that it is not the stasis which is the cause of the trouble, but the fact that some change has occurred in the walls of the bowel which allows toxin generation in the intestine to be absorbed direct into the blood stream." Alvarez, in the Physiological Review for July, 1924, exhaustively reviews the work done on "Auto-intoxication," and concludes as follows: "It seems that under normal conditions, the intestinal mucosa prevents the absorption of toxins and usually form an efficient barrier to the passage of bacteria. Under unusual conditions, this defensive mechanism breaks down." However, when the intestinal wall becomes the seat of chronic infection, not only do we get absorption from the inflammatory process, but probably from the abnormal intestinal contents. It has been noticeable in studying these cases, that during an interval in which there was a tendency to constipation, the patient felt better, and with a return of abdominal soreness and looseness of the bowels there was a marked increase in toxic symptoms. This indicates that not stasis, but increased inflammation was the principal factor in increasing toxic absorption. Pain and Tenderness. In the early stages there may be little pain. Gradually there develops a sense of abdominal discomfort, or peristaltic unrest, with occasional minor cramp-like pains here and there. Even in well-advanced cases, acute colic, so common in mucous colitis, is not present. A dull aching across the upper abdomen, radiating around both sides to the back, is often one of the most constant complaints. Pain is most often in the lower left side of the abdomen, next in frequency in the flexures, splenic and hepatic, and then in the cecal region. Pain is most common in the morning. It is often increased by taking food, occurs at irregular times after eating, and a common complaint is of sickening ache or a sensation of emptiness or nausea, following a bowel movement or while taking an enema. Taking an enema is usually painful and difficult on account of spasm. Hershall refers to the pain after eating, or bowel movement, as follows: "As these natural movements are increased after the ingestion of food, and before and after a passage of the bowel, an explanation of why a patient suffers at these times is at hand. The formation in the intestines of the irritating products of fermentation and putrefaction increases the peristalsis of the unnaturally irritable intestine with a concomitant exacerbation in the patient's Page Seventeen 1 sensations. In fact, a very characteristic symptom is the occurrence of pain referred to the umbilicus, immediately after food. On account of this time relation to food, this pain is often considered to be of gastric origin. In reality, it is due to peristalsis in the tender colon, excited by the entrance of food into the stomach." A dull headache is very common and some will complain of general aching and soreness. Tenderness, more or less general over the abdomen, is very common. Gastro-intestinal Symptoms. Early, there may be little or nothing to call attention to the gastro-intestinal system. The symptoms are rather those of a low grade infection or toxemia, and are often considered to be neurasthenic. These may be: poor appetite, furred tongue, bad taste in the mouth, or sense of nausea. These so-called symptoms of biliousness have been ascribed by Alvarez to irregular or reversed peristalsis, and certainly in these cases the abnormal irritability, gas distension, etc., are sufficient to profoundly change the normal gradient action. Vomiting, eructation of gas, sour stomach, and pylorospasm, are not common to colitis, and when present I begin to think of a concomitant involvement of the gall bladder, stomach or duodenum. A common complaint is "gas in the bowels," referring to the sense of gurgling and rumbling due to irregular peristalsis. Passage of large quantities of gas is common. Nausea is a prominent symptom, often in the form of a dull sickening sensation referred to the umbilicus or epigastrium, and most noticeable after a bowel movement or enema. It may be accompanied by palpitation, dyspnoea, and a sense of great weakness and depression. Bowels. Early there is constipation, and this may last for years. It is due to spasticity. The stools are usually hard, round balls, dark in color, and may have a thin coat of mucous. Measures taken to overcome the constipation, such as physics, bran or very coarse food, increases the irritation and inflammation in the mucous membrane, and really aggravate the condition. A little later, the constipated movement is followed by a soft, mushy stool, or even a spurt of liquid, or a mixture of liquid and gas. Later the stools are large, rather soft, having a mushy or frothy consistency and appearance, due to the admixture of mucous. At this time a patient, when asked about the bowels, often says that they are all right, but on close questioning admits he has three or four or more soft movements daily. They think that, so long as they are not constipated, they are all right; in fact, often take pride in the fact that they have several movements daily. In later stages, when the bowel becomes more rigid and less spastic, a certain degree of dysentery develops. Free passage of mucous, and at times mucous and blood, is not uncommon in advanced cases, but it is remarkable how many patients will state that they have not noticed mucous. On passing the sigmoidoscope, Page Eighteen _J after an enema, however, several ounces of clear or cloudy mucous flows through the tube, or is seen in the rectum. Severe degrees of dysentery are uncommon, unless considerable ulceration is present. Mucous in the form of a membrane is not common. Pruritis. Many patients complain of pruritis, and especially coming on with exacerbation of abdominal symptoms. It starts with a sense of moisture about the anus, followed by irritation and thickening of the skin, with much burning and iitching. Examination of these cases shows marked injection of the mucosa of the rectum, and the pruritis is evidently due to extension of the inflammation or to the irritating discharge from the rectum. Nervous Symptoms. As in any long continued illness, nervous and mental symptoms are common, but I have felt that these symptoms were not the neurotic or neurasthenic manifestations so common in mucous colitis, but rather those associated with weakness and chronic toxemia. Insomuch as these patients have gone from one physician or sanatorium to another, and have often submitted to surgical procedures without relief, they are naturally concerned about their condition, and often hopeless and depressed. On the other hand, I have found many, in spite of their serious condition, to be hopeful and optimistic. Headache is common, usually dull and more or less constant. Backache, pain in limbs, numbness, burning and tingling are common. Impaired memory and inability to concentrate are present in more severe cases. A number of patients have described a sense of great weakness and depression with dyspnoea and palpitation of the heart, coming on more or less regularly in the morning. Not a few of such symptoms have been considered to be due to hyperthyroidism. These same sensations, with marked prostration, may come on and last for several hours following a bowel movement or enema. Cardio-vascular System. Cardio-vascular asthenia is often present, as manifested by rapid, weak pulse, cold extremities, and exhaustion. Definite paroxysms of palpitation, extreme weakness with nausea and dyspnoea, may come on daily. I have observed a number of cases of hypertension for which no cause had been found. In some instances they were taking magnesium sulphate or other laxative daily for the hypertension. Examination showed a colitis which undoubtedly was being kept active by the cathartics. Urinary Symptoms. Considerable work has been done showing that there is a definite connection between infection of the intestinal tract with that of the urinary tract. A small group of this series had recurrent infection of the urinary tract, and were sent to me by urologists. Treatment of an existing colitis in not a few of these resulted in clearing up the urinary disturbance. Diagnosis and Physical Examination. A carefully elicited history is of greatest importance in making a diagnosis. Early, a history of obstinate constipation with some impairment of general health, is suggestive. A history of several soft stools daily, passing of mucous, of soreness, or discomfort in the abdomen, calls for investigation of the colon. In a case with long-continued gas- Page Nineteen tro-intestinal distress, of weakness, anaemia, and nervousness, and especially if they have had numerous operations without relief, think of colitis and not of prolapse of the stomach or adhesions. Palpation of the abdomen is of greatest value with the patient in a comfortable position, with muscles relaxed, it is often possible in these cases to palpate the greater part of the colon. In general, or localized tenderness of the abdomen, careful palpation may determine that the soreness is really limited to the colon. Proctosigmoidoscopy is our most valuable diagnostic method and by its use we are able, in practically all cases, to determine the presence or absence of a colitis and to judge of the type or degree of the inflammatory process. Proctoscopic Examination. 1. Early Stages. In an early case the mucosa is deep red, apparently thickened and thrown into folds. It is rarely uniform. Certain areas being deeply injected and others paler. Scattered over the surface are numerous rounded elevations that are gray and appear edematous or tanslucent. These swollen follicles may be topped by a small erosion or superficial ulcer. 2. Later or hypertrophic stage. Later a characteristic appearance is a pale, grayish, or ivory colored, thickened mucous membrane apparently much swollen and edematous. It is irregularly lobulated by the reticulated blood vessels, many of which are dilated. The entire surface resembles that of the pancreas, and is usually covered with a free secretion of mucous or muco pus. 3. Granular Stage. In this stage the surface has the appearance of small, deep red granulations. The mucosa is thickened and infiltration of the submuscosa causes a roughness of the surface. The granulations are rather firm and bleed very easily when touched. Mucous, often tinged with blood, or brown in color, is more or less abundant. Often in this stage, linear cracks or small ulcers can be seen. 4. Atrophic Form. The appearance in this stage is very characteristic. The mucous membrane is very thin and almost transparent. The secreting elements have, to a large extent, been destroyed and the surface is dry and glazed, often finely granular. The marked increase in fibrous tissue in the submucosa gives the surface a whitish or ivory parchment-like appearance, traversed by a network of blood vessels which stand out prominently. There is no distinct dividing line between the above mentioned stages and the various pictures described may be seen in one bowel. Islands of red, granular type, may be seen here and there, in a pale, swollen edematous surface, or there may be areas of granulation and atrophy scattered here and there. Ulceration. Small superficial erosions or ulcers may be seen early. Follicular ulceration; small red rounds may top a few or very many of the swollen solitary follicles. Linear cracks may occur in the granular or atrophic membrane, or Page Twenty Large, shallow, gray, indolent, ulcers may be seen. In the chronic ulceration type, irregularly shaped and deeper ulcers are scattered over the surface, usually surrounded by or adjacent to, white scarred areas. The surface is often covered with thick, bloody mucous or muco pus. Stools. The stools vary as to consistency and appearance. During a period of constipation, they are hard and often are formed of small balls; again they are often moderately soft, and then, a portion, if examined between two slides, will be translucent from a high mucous content. Much free mucous or muco pus is usually present, and not infrequently, blood. Hemorrhoids and Rstulae should be looked for. Examination of the stools or of the mucous or pus obtained through the sigmoidoscope should always be done. Repeated smears should be made if necessary. Search should be made for focal infection, as tonsils, appendices, abscesses, pyorrhoea, or infected sinuses. In all cases, investigation should be made for possible co-existing disease of the gall bladder, stomach, duodenum, and appendix. Blood examination usually shows some degree of secondary anaemia. In three cases, I have seen a very severe type, with some characteristics of primary anaemia. Leucocytosis is not marked as a rule. Gastric acidity was found in most cases to be within normal limits. X-Ray. The X-Ray examination is not the most valuable method of diagnosis in this condition, because the characteristic picture is shown only when the chronic inflammation has resulted in thickening, contraction and deformity of the colon. In this series, this picture was seen in less than ten per cent, of the cases. Early, the colon is spastic and barium may be retained in the form of round, separate balls. There may be seen definite areas, where, for some distance, there was marked contraction of the bowel walls. The picture has led to suspicion of organic diseases with partial obstruction. In one case, over a period of years, many X-Ray examinations had been made, showing much narrowing of the descending colon and a partial colectomy had been recommended. However, on one examination, after giving atropin, I saw this open up to practically normal size. A most valuable method of examination is careful palpation of the abdomen, with the aid of the fluoroscope, and a barium enema. In what seems to be general abdominal tenderness, it can frequently be demonstrated in this way that the soreness is limited to the colon. Especially is this procedure useful in differentiating the tenderness of the transverse colon, or hepatic flexure from that of the gall bladder. In the spastic stage, the barium meal is usually slow to pass through the colon, and there is some degree of stasis in the cecum and terminal ilium. Where much ulceration is present, the meal is usually hurried through. In more advanced cases, where considerable interstitial changes have taken place in the walls of the bowel, more characteristic Page Twenty-one II 1 1 ■fi ll kP ' X-Ray pictures are seen. The peristaltic waves become slow, shallow and prolonged. Later, there is marked loss of haustration. The picture presented is that of a smooth, barrelled tube, so called "garden hose" appearance. This change is practically always most marked in the sigmoid and descending colon, but gradually progresses until the entire colon becomes a small, smooth tube. More advanced cases show permanent contractions and deformities. However, a patient may have a marked colitis over a period of years before characteristic pictures are seen. Incompetence of the ileocecal valve is so common as to be the rule in these cases. Points of persistent or repeated spasm may indicate the position of an ulcer. Occasionally an ulcer crater may be shown. Differential Diagnosis. In this series, fifty had been operated on during the course of their illness for chronic appendicitis, and in all one hundred sixty-one operations had been performed. Most of them, with the hope of relieving their abdominal symptoms, <?nd usually without the desired results. Some of the conditions that should be differentiated are as follows: Cholecystitis. To determine whether or not the cholecystitis is also present with an inflamed colon, is often difficult. An analysis of symptoms is of much use. Pylorospasm, eructation of gas, and vomiting, are, in my experience, not common to colitis, though frequent in cholecystitis. X-Ray study is often of great value, and especially careful palpation with the colon visualized by means of the barium enema. Appendicitis. In this series, fifty gave a history of having had appendectomies. In the majority of these, the operation was done for chronic abdominal symptoms, which were not relieved. In the remaining 180 cases, only ten gave evidence, such as a history of acute attacks and evidence of a fixed or deformed appendix which was especially tender, leading to a diagnosis of appendicitis. Exophthalmic Goitre. Some of these cases offer a definite opportunity for confusion with colitis. In both, nervousness, sleeplessness, and often tachycardia, dyspnoea, and signs of toxemia. In some colitis cases running a low fever, the basal metabolic rate is also above normal. Five of these cases had had thyroidectomies. Two received considerable improvement, and probably had both conditions. Chronicity of the gastro-intestinal symptoms is in favor of colitis, as diarrhoea, and vomiting in hyper-thyroidism usually occurs only at the height of a toxic crisis. Pelvic Inflammation. Many women in poor health, with backache and evidences of chronic infection, have been advised to have a pelvic operation, because bimnual examination showed considerable tenderness, when really the tenderness and infection were in the pelvic colon. Gastric and Duodenal Ulcer. Colitis may simulate these cases in that there is distress after eating. Careful X-Ray and sigmoid- oscopic examination will usually allow a differentiation to be made. Page Twenty-two Gastric Neurosis. I am convinced that fewer diagnoses of gastric neurosis would be made if the sigmoidoscope were used more frequently. Tuberculosis. Long standing cases with symptoms of a low grade infection run a course very similar to that of tuberculosis, and several of these cases had spent a certain amount of time in tuberculosis sanatoria. Often, only careful observation and repeated examination will lead to a correct diagnosis. Tuberculosis of the colon is secondary to pulmonary tuberculosis, usually starts in the cecum and slowly extends to other parts of the colon, whereas chronic colitis starts in the pelvic colon and extends upward, involving the cecal region last. Amebic dysentery is recognized by the proctoscopic appearance and finding of the organism, Enteroptosis and Intestinal Stasis. In a considerable number of these cases, enteroptosis was also present, often, I believe, secondary to the loss of weight and muscle tone. I am convinced that the train of toxic symptoms ascribed to intestinal stasis are often due to a definite colitis. So long as the mucous membrane is normal, I believe, that there is little absorption of toxins through it. Treatment. Observation of invalidism due to chronic infection in the colon and disappointment in the results of treating well-advanced cases, causes us to search for methods of prevention. Dietary deficiency as a cause has not been entirely accepted, but unquestionably, it is important to see that our children have a balanced diet. It is also important to see that they develop healthful and hygenic habits, particularly with the object of avoiding constipation. At this point, I want to say that my experience leads me to the belief that practically all so-called simple chronic constipation is of the spastic type, even when occurring in asthenic and enterop- totic individuals, and that the great majority of these have, as a basis, some degree of general inflammation in the colon. If this is true, it is evident that many cases of constipation are not rationally treated, and I believe the results obtained, by minimizing irritation, are added proof of the contention. Early removal of possible foci of infection, such as infected tonsils, pyorrhoea, infected teeth, sinuses, etc., is necessary. More attention should be given to the study of causes of constipation, so that rational treatment may be instituted. Detection and elimination of intestinal parasites should be kept in mind. In general, the treatment of a case of colitis may require the institution of some of the above measures, especially the removal of foci of infection. In relatively early cases, the interdiction of cathartics and elimination from the diet of bran and other roughage, may be all that is necessary to bring relief or even a cure. In Page Twenty-three serious cases or during acute exacerbations, rest may be essential, but realizing the impossibility of getting complete colonic rest and the tendency of these patients to introspection and invalidism, I have been slow to recommend a rest cure in the average chronic case, but rather recommend that, as near as possible, they keep up their normal activities and interests. Regulation of the diet is of the utmost importance. In most cases, this simply means the elimination of coarse, cellulose-containing foods and substitution of a bland diet. Changing the type of the intestinal flora is quite possible by dieting, but in general has not been of great value. In certain ulcerative cases, a largely pro- teid diet has been very useful. Elimination of active cathartics is absolutely necessary. Olive oil, petroleum oil, agar agar, are good substitutes. Enemas are of great value in treatment. I have followed the suggestion of Logan and have used plain hot water, systematically, with excellent results. The natural tendency to add antiseptic substances gets one into troubles, as the colon in these cases is extremely sensitive, and irritation and aggravation of the inflammation follows. Neutral acri flavine solution has been recommended recently as being non-irritative. Oil enemas, using washed olive or cotton seed oil, or petroleum oil, are invaluable, especially in the constipated cases. Drugs give little aid. When dysentery exists, opium, bismuth, or certain stringents may help. Benzyl benzoate, atropin, or other antispasmatics will help in certain cases. Bile salts have been advocated to simulate the bile flow. Drinking quantities of warm water, when the stomach is empty, stimulates as free a flow of bile, as does the introduction of mag- nes'ium sulphate solution through the duodenal tube, and supplies more bile salts than you can put in many capsules. Surgical Treatment. In considering the surgical treatment, we may first consider the removal of possible foci' of infection. In the case of infection about the nose and throat, we may with some confidence recommend the proper surgical treatment for their removal, but with evidence of a co-existing infection in the gall bladder or appendix, we have a more serious problem. A considerable number of the cases here analyzed had had the appendices removed and usually without improving their condition. However, there is undobutedly a small proportion in which removal of the appendix results in improvement of the colitis. Again, indiscriminate removal of the gall bladder, even when we are reasonably satisfied that a cholecystitis is present, will often result in disappointment. Only after a very careful study of each case, and failure to get results otherwise, will lead us to advise surgical removal of possible intraabdominal foci. In those unfortunate patients, who have become chronic invalids with contracted, deformed, or ulcerated colons, there is a distinct indication for surgical treatment. Appendecostomy or cecos- tomy is the simpler procedure used, and, in many cases, give great relief. In a smaller number of cases a cure is obtained. I have repeatedly observed, following a cecostomy, an irritability and spasticity so great that the irrigating fluid was two or three hours Page Twenty-four in passing through. A week or ten days later, several gallons of water could be used several times daily with no discomfort. Ileosto'my is indicated in serious cases. It certainly results in great relief and marked gain in general health. It has disagreeable features and there is no certain way of determining when it may be safely closed. Mummery quotes Sir George Makins, who has performed the operation in six cases and has given as his opinion, that if the opening cannot be closed in eight or nine months, it will subsequently become impossible to close it on account of the contraction which occurs in the disused colon, and the patient must be prepared for the probability that the opening will be a permanent one. Colectomy has been performed where other methods have failed, but as these cases stand operation poorly, the mortality is necessarily high, and information as to the ultimate results is meagre. Conclusion. Chronic colitis is a relatively common condition in which it is possible to demonstrate progressive inflammatory changes in the walls of the colon, and inflammatory secretion from the mucous membrane. The bacterial causes have not been determined, but there is evidence suggesting that as in chronic inflammatory conditions of the stomach, duodenum, gall bladder and appendix, hematogenous infection with a streptococcus is likely. This low grade infection which alters the motor function of the colon, and impairs the protective barrier of the mucous membrane, causes not only many inflammatory symptoms, but probably accounts for many cases of chronic constipation and for many symptoms attributed to "auto intoxication" and intestinal stasis. Patients having long standing constipation, unexplained abdominal pain and soreness, or obscure gastrointestinal symptoms, are entitled to a proctosigmoidoscopic examination, before treatment is recommended. Page Twenty-five 09©" Our ^Advertisers Use this journal for the purpose of procuring business from the Medical Profession. 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Medicine--Periodicals
The Vancouver Medical Association Bulletin: July, 1925
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