History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1948 Vancouver Medical Association Nov 30, 1948

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Full Text

 THE
BULLETIN
Published By
The Vancouver Medical Association
EDITOR:
dr. j. h. MacDermot
EDITORIAL BOARD
DR. D. E. H. CLEVELAND
DR. H. A. DesBRISAY
Editorial and Business Office
203 Medical-Dental Building
Vancouver, B. C.
DR. J. H. B. GRANT
DR. D. A. STEELE
Publisher and Advertising Manager
W. E. G. MACDONALD
Vol. XXV
NOVEMBER, 1948
No. 2
OFFICERS,  1948-49
Db. Gobdox C. Johnston
President
De. Gobdon Bubke
Hon. Treasurer
Db. W. J. Dobbance        Db. G. A. Davidson
Vice-President Past President
Db. Henby Scott
Hon. Secretary
Additional Members of Executive:
Db. A. S. McConkey, Db. Rocke Robebtson
Db. A. M. Agnew
TRUSTEES
Db. G. H. Clement
Db. A. C. Fbost
Auditors: Messbs. Plommeb, Whiting & Co.
SECTIONS
Clinical
Db. B. B. Tbowbbidge Chairman Db. J. A. Ganshobn Secretary
Eye, Ear, Nose and Throat
Db. G. H. Fbancis Chairman Db. J. F. Minnes Secretory
Paediatric
Db. G. O. MATHEWs_._Chairman Dr. A. F. Habdyment.—Secretory
Orthopaedic and Traumatic Surgery
Db. H. H. Boucheb____Chairman Db. Bbtjce Reed Secretory
Neurology and Psychiatry
Db. A. E. Davidson Chairman Db. G. H. Gundby Secretary
Radiology
Db. Andbew Tubnbuix—Chairman Db. Mabvin R. Dickey—Secretary
STANDING COMMITTEES
Library:
Db. F. S. Hobbs, Chairman; Db. R. H. Palmeb, Secretary; De. R. P. Kinsman;
De. S. E. C. Tubvey; Db. J. E. WAlkeb and Db. E. F. Wobd.
Summer School:
Db. A. B. Manson, Chairman: Db. E. A. Campbell, De. J. A. Ganshobn,
Db. D. S. Munboe, Db. D A. Steele, Db. G. C. Labge.
Credentials:
Db. H. A. DesBbisay, Db. Fbank Tubnbull, Db. G. A. Davidson.
Representative to B. C. Medical Association: Db. G. A. Davidson.
Representative to V. O. N.: De. Isabel Day.
Representative to Greater Vancouver Health League: Db. J. W. Shieb.
m I!
■ ••(It
If
TABLETS
SOLUBLE
TABLETS
TABLETS FOR
PEDIATRIC
USE
THROAT
LOZENGES
OINTMENT
  Practical
PENICILLIN
II
Developments
'r / . J '
M. he  great amount  of clinical work that
,/ I . . / /
followed the introduction of /penicillin has
resulted in the employment/ of this antibiotic
/
for localized as^well^as systemic infections.
To conform with these increased indications,
new forms and strengths of Ayerst penicillin
have been developed. The variety of these
products,   offered   under   the   trade   name
Cillenta'% facilitates   treatment  for  both
physician and patient.
<.<.
0he*&t
"CILLENTA"
Ayerst brand,of penicillin
AYERST, McKENNA & HARRISON LIMITED • ..   Bh,°^°' '™*       | MONTREAL, CANADA
Pharmaceutical Chemists '
524 VANCOUVER   MEDICAL   ASSOCIATION
Founded 1898     :   :    Incorporated  1906
PROGRAMME FOR FIFTY-FIRST ANNUAL SESSION
(Spring Session) '
January    4.    GENERAL MEETING—
"Experiences in Cleft Palate Repair"—Dr. J. R. Neilson.
"Radiology in Abdominal Pain in Children"—Dr. Wallace Boyd.
January 18.    CLINICAL MEETING—Vancouver General Hospital.
February    1.    GENERAL MEETING—
"The Management of Pregnancy in cas*es of Hypertension and
Toxemia"—Dr. E. B. Trowbridge.
"Hypertension and Cardiac Complications in Pregnancy"—Dr.
J. Caldwell.
(February 15.    CLINICAL MEETING—St. Paul's Hospital.
JMarch    1.    OSLER DINNER AND LECTURE—Hotel Vancouver (Mayfair Room)
Osier Lecturer—Dr. Murray Baird.
jMarch 15.    CLINICAL MEETING—Shaughnessy Hospital.
I April    5.    GENERAL MEETING—
"Prostatism"—Dr. L. G. Wood.
jApril 19.    CLINICAL MEETING—Place of meeting to be announced.
iMay^3.    ANNUAL MEETING—Auditorium, Medical-Dental Building.
1.1'
'■,
■
m
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian
circulation and thereby encourages a
normal menstrual cycle.
k A
% MARTIN H. SMITH COMPANY
^       iso unnra nm, mm tmk. m. t .
Full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is  cut in  half  at  seam.
HI
in
ii
m\
i
Page 29 I!
nti
r—
sinusitis
§11111111111
it .«•'
if
Neo-Synephrine
hydrochloride—the
reliable, long-acting vasoconstrictor—
promotes aeration and aids
free drainage of mucopurulent secretions in sinusitis.
By opening occluded ostia, it clears the way for
effective penicillin therapy.
neo
♦
rine
®
with
CRYSTALLINE   PENICILLIN
New Yo»n 13, n. Y.    WMoso*. Ont.
Supplied on prescription as a freshly prepared
buffered solution containing Neo-Synephrine
hydrochloride 0.25% and Penicillin G Sodium
1600 units per cc, in 15 cc. bottles.
Neo-Synephrine, trademark reg. U S. & Canada, brand of phenylephrine.
1019 Elliott Street West, Windsor, Ont.
423 Ontario Street East, Montreal, P   Q VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
CITY
STATISTICS—OCTOBER, 1948
Total Population—Estimated -— - - 1 354,045
Chinese Population—Estimated 1 :       7,979
Hind u Population—Estimated  2^ 5
Rate Per 1000
%7v£. Number Population :§d|||
Total  deaths       360 12.0
Chinese deaths 2t|i- fe —      M 22-2
Deaths, residents only_ -|I 325 10.8
BIRTH REGISTRATIONS:
Male       376
Female       385
761
25.4
INFANT MORTALITY: Oct., 1948
Deaths under 1 year of age ^fe;        11
Death rate per 1000 live births       20.2
Stillbirths  (not included above) '_  8
Oct., 1947
15
21.1
10
CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY
Number Rate Per 1,000 Population
October, 1948 November, 1948
Cases    Deaths       Cases     Deaths
Scarlet Fever --^t^ft
Diphtheria	
Diphtheria Carrier-
Chicken Pox	
Measles:	
Rubella-
Mumps	
Whooping Cough g * ' _  .___
t»-;K
 ._ __
Typhoid Fever (Carriers)
Undulant Fever
Poliomyelitis	
Tuberculosis jjl5
Erysipelas _	
Meningococcus   (Meningitis)
Infectious Jaundice
Salmonellosis	
Salmonellosis   (Carrier)
Dysentery
mm
_____ _____
Dysenterv  (Carrier) ':^^^^0
TetanusJ 1 _,	
Syphilis -.J
Gonorrhoea	
Cancer (Reportable):
Resident .—— 	
Non-Resident 	
9
0
8
0
0
0
0
0
0
0
0
0
110
0
306
0
15
0
61
0
4
0
10
0
7
0
17
0
0
0
0
0
0
0
2
0
1
0
0
0
6
0
2
0
42
13
0
0
5
0
1
0
1
0
1
1
0
0
0
0
1
0
1
0
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
30
3
0
0
149
0
0
0
77
0
77
0
15
0
42
0
Page 30
■
m
■ Three to Four-Day Blood Levels . . . J|
PROCAINE PENICILLIN G IN OIL
With Aluminium Monostearate, 2%
t
The inclusion of aluminium monostearate in crystalline procaine penicillin G
in oil, together with other improvements in the method of preparation, now makes it
possible to prolong the absorption of penicillin and to maintain therapeutic penicillin
blood levels for three or even four days in the great majority of patients.
The recommended dosage of 1 cc. (300,000 units) every 48 hours has been
found to be adequate in most cases, thus overcoming the necessity of injections once or
twice every 24 hours with other forms of prolonged-acting penicillin.
HOW SUPPLIED
1-cc. cartridges, each containing 300,000 International Units of Procaine
Penicillin C in Oil, for use with B-D* disposable plastic syringes or as replacements for B-D* metal cartridge syringes.
10-cc. vials, each containing 3,000,000 International Units.
*T.M. Reg. Becton, Dickinson & Co.
\&%
m
CONNAUGHT MEDICAL RESEARCH LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S  PRESCRIPTIONS  LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. 7<&e ££Uo>& Paae.
This being the Christmas season, with a New Year in the offing, we extend to all
our readers all the good wishes appropriate to these festivals. May nineteen hundred and
forty-nine bring to us all peace, prosperity and happiness.
It will be a significant year to us of the medical profession in British Columbia,
since it brings with it the first definite step that has been taken towards socialised medicine in the province—free hospitalization. We confess that we look forward with some
trepidation to the inception of this programme—though we feel that a step has been
taken in the right direction, and that for this reason its success is not only to be hoped
for, but is a thing to realize which we ourselves must do our best. The fact that there
are many difficulties in the way, some visible and some that have not yet appeared,
should not daunt us unduly. We shall probably all find* the going heavy at first, and
there is bound to be some confusion and a good deal of trouble in adjusting ourselves to
it— but if we keep our heads, and are patient, we should be able to iron out the creases
and get things running smoothly. Above all, we must do our best to avoid unfairness and
inequalities, and to ensure that everyone concerned gets his fair share. We are assured
by the authorities that everything possible will be done to increase hospital accommodation as rapidly as this can be done, but at the best it will not be possible for some time to
do anything much to relieve conditions.
The public will need, too, to be patient, and to play fair with the scheme, and it will
be our duty, as far as in us lies, to help them to do this. We fell sure that a great many
people are quite sure that as soon as the New Year begins, they will be able to get all
sorts of service, other than hospital accommodation, free—and we are going to have a
good deal of troujble explaining to them the real facts of the case. In its publicity on the
matter, the Hospital Commission has been doing its best to explain, and to state categorically what the plan implies—but those who practise medicine, and so come in direct
contact with patients, know that a great many of them have not at all grasped the real
meaning of what has been said and they are going to suffer quite a shock when the cold
grey light of dawn reveals the actual facts: and this is quite apart from the actual difficulties connected with hospital bed shortage. It has to do with X-rays and laboratory examinations and so on—and from our own personal knowledge, we can testify to the fact that
quite a good-sized section of the public is not at all clear on this subject.
There seems to be a certain lack of definiteness about the scheme—as far as we can
tell, there is still a good deal to be done in the way of regulations etc. We were not
consulted in the drawing up of the Act, so can look on with a certain feeling of freedom
from responsibility. But unfortunately it is through us that the Act has to be made
operative. We can only undertake to do our best. The authorities in charge of the administration of the Act have shown themselves anxious to work with us, and between us all
it should be possible to make the scheme effective.
The Jubilee Dinner of the Vancouver Medical Association, which was held at the
Hotel Vancouver, on December 7th was a very successful affair. There was a very good
attendance indeed, the banquet hall being well filled.
Dr. Gordon Johnston, our President, made some very apt opening remarks about the
Jubilee Dinner, and asked Dr. W. D. Keith to speak on the subject of Dr. J. Mawer
Pearson, one of the pioneers of medicine in Vancouver, who had played a most active part
in the organization of the Association and its Library. Dr. Keith gave a short review of
Pearson's life and work, and it is hoped that his speech will be available for publication
in the Bulletin at an early date.   Dr. Keith himself is one of the chief founders of the
Page 31 Association and Library, and his work, especially in regard to the latter, has placed us
all under a considerable obligation to him. He was in correspondence with Sir William |
Osier, who was a strong supporter of the Library, as he was of all Libraries, and contributed to its inception.
Dr. A. E. Grauer then introduced the Pearson Memorial Lecturer, Dr. J. S. L.
Browne, Professor of Clinical Research at McGill University.   Dr. Browne's lecture set
a very high standard for future Pearson Lectures.   It was a monumental piece of work!
that he presented to us.  Its title "The Response of the Adrenal Cortex to Disease andi
Injury" gives some idea of the complexity of his subject—but the paper, while not at all!
an easy one to follow, was copiously illustrated by graphs and slides, which showed us
some of the mysteries of the research laboratory, and linked up the remarks of the speaker, j
to make a chain of evidence. As Dr. Murray Baird said, thanking the speaker at the endj
of the lecture, it is a good thing for the practising physician to be given an occasional]
glimpse of the work of the research men—and to realise just how much is being done,
with often very little acknowledgment or recognition from us, to open to us new fields
of treatment of disease.
Dr. Browne has promised us a copy of his paper, with illustrations suitable for
reproduction and the Bulletin is looking forward to publishing this at an early date.
Library   Notes
H HOURS I
Monday, Wednesday, Friday 9.00 a.m. to 9.30 p.m.
Tuesday and Thursday-: 9.00 a.m. to 5.00 p.m.
Saturday » 9.00 a.m. to 1.00 p.m.
RECENT ACCESSIONS TO THE LIBRARY      •     j~
Clinical Laboratory Methods and Diagnosis, 4th edition, 1948, by R. B. H. Gradwohl.
Diseases of the Chest, 2nd edition, 1948, by R. Coope.
Gray's Anatomy of the Human Body, 25th edition, 1948, edited by C. M. Goss.
Handbook of Physiology and Biochemistry, 39th edition, 1946, by R. J. S. McDowall
Health Progress 1936 — 1945, 1948, by L. I. Dublin.
Intracranial Tumors, 2nd edition, 1948, by P. Bailey
Maladie de Famine (Le Ghetto de Varsovie, 1942), 1946, by E. Apfelbaum.
Neurology of the Ocular Muscles, 1948, by D. G. Cogan.
Symposium on Recent Advances in Gynecology  and Obstetrics,   1948, Philadelphia
Number, Medical Clinics of North America.
RE: APPOINTMENTS TO STAFF
WORLD HEALTH ORGANIZATION
Dear Doctor:
Through the Department of External Affairs I have received the following message
from the Director-General of the World Health Organization at Geneva, Switzerland:
"Because there will be a moderate increase in the staff of the WHO during 1949
and because up to now the geographical distribution has not been satisfactory, may
I request that well-qualified individuals in your country be informed of the possibilities of appointment to the staff of the World Health Organization during the
coming one or two years?
While it is not possible at this time to state exactly what positions may be open,
Page 32 there will probably be a need for specialists in maternal and child health, tuberculosis, malaria, venereal disease control, nutrition, environmental hygiene, sanitation,
etc. Of course, almost all of these positions will be at salaries ranging from about
U.S. $5,000 to $7,000 a year. There may be one or two positions for highly qualified and more senior individuals on Director or Assistant-Director level. There
will also be a very few positions for doctors well qualified in general public health
and a few in non-medical administrative and financial services.
It should be understood that very few, if any, of these appointments will be made
in the immediate future but that some at least will be completed during the first
half of 1949.
Article 35 of the Constitution of the WHO should be noted. It reads, in particular .. . 'The paramount consideration in the employment of the staff shall be to
assure that the efficiency, integrity and internationally representative character of
the Secretariat shall be maintained at the highest level. Due regard shall be paid
also to the importance of recruiting the staff on as wide a geographical basis as
possible.'
I should be grateful for any assistance you may be able to give me in this very
difficult problem of finding the best available in the world in each special field, for
appointment to the staff of the WHO."        Wm
Those interested in employment with this United Nations agency should get in
touch with World Health Organization offices in the Empire State Building, New York
City, from which application forms and further information may be obtained.
Yours very truly,
G. D. W. CAMERON, M.D., D.P.H.,
Deputy Minister oi National Health.
■
M
ATTENTION
A member of the profession was a witness to an automobile accident
which took place at the intersection of 25 th Avenue and Heather Street in
Vancouver, on the 15 th September, 1948, at about 6 p.m. One of the parties
injured in the accident was Dr. Peter Beaconsfield, presently on the Vancouver
General Hospital Staff. Dr. Beaconsfield's passenger at the time was a Miss
Laurel A. Raymond, who was seriously injured.
Anyone having any idea as to the identity of the member of the profession
who was a witness to this accident, please get in touch immediately with Dr.
Beaconsfield at the General Hospital, or with D. M. Owen, Solicitor, Pacific
Building, Vancouver, TAtlow 2511.
In his late thirties or early forties.
Height:   approximately 5 ft. 10 ins.
Weight:   approximately 170 lbs.
Dark complexioned; clean shaven.
Wearing grey trench coat.
■
Page 33 ■ I
■ ...
British Columbia Medical Association
President . j ? Dr. Frank M. Bryant, Victoria
President-Elect 1 Dr. J. C Thomas, Vancouver
Vice-President Dr. Stewart A. Wallace, Kamlopos
Honorary Secretary-Treasurer . . Dr. J. A. Ganshorn, Vancouver
Immediate Past President - . Dr. L. H. Leeson, Vancouver
CHEST PAIN OF VISCERAL AND SOMATIC ORIGIN
By R. A. PALMER, M.D.
The diagnosis of chest pain is one of the common tasks of medical practice, and
involves the assessment of a symptom which may indicate grave underlying disease
on the one hand, or on the other hand, no disease at all.
As the thorax contains several organs vital to the individual, the development of a
pain in the region, and especially a pain which persists or recurs, gives rise to justifiable
apprehension. With growing lay interest in matters of health, including heart disease
and cancer, and with the oft repeated emphasis for the need of "early diagnosis," patients
are inclined to seek advice increasingly early in the history of a symptom. This means
that physical signs and laboratory evidence will often be minimal, placing special responsibility on the investigative skill and clinical judgment of the physician. On the
one hand, he is anxious to detect an early indication of serious disease—on the other
hand, it is equally his duty to relieve needless fears about an unimportant symptom.
In determining the origin of  the  symptoms,  one must really consider  all the
seperate structures of the thorax and its contents, the spine, and adjacent organs below
the diaphragm.   These potential sources may be divided into two broad groups,   (a)
visceral sources, and (b) somatic or skeletal sources.
SOURCES OF PAIN IN CHEST
a. Visceral? i. above   the   diaphtagni:—heart   and   great   vessels,   pleuro-pulmonfcry,
^p£ esophageal, other mediastinal structures.
ii. below the diaphragm:—stomach and duodenum, pancreas, gall bladder,
liver, spleen.
b. Somatic {or Skeletal): soft tissues—muscles, fascia, nerves,—bony structures such as \
ribs, cartilage, spine.
i. without associated visceral disease.
ii. associated with visceral disease—
a. casually related,
b. not casually related.
(both i and ii may be also associated with psychoneuroisis)
The visceral group includes nearly all the potentially serious disease, while the
somatic comprises in the main considerably less serious, and often no really significant,
disease. Although the somatic origins of pain are most often isolated entities, they
may occur in association with visceral disease or with psychoneuroses. At times, visceral and somatic origins of pain appear to have some causal relationship, as will be seen
later.
The diagnosis may be relatively easy in the presence of pathognomonic history,
physical findings, and laboratory evidence, and this is probably most often true of acute
Page 34 \fONS
vac us —••••*> I
PHRENIC
r'pii *« iT" "" '?'^".zaQ——-
CAAOIAeul    /'rJ_._.Q_._	
SMOULDER   aqca
ARM
M/lMONAllS  z
o
O
O
o
o
o
o
6
o
thoracic
CAOC
POSTERIOR
CM EST ANO
AtOOM E N
AFFERENT     PATHWAYS    FROM  THE  THORAX   AND   ITS   CONTENTS-
°^'; (AFT CO DASMUSSEN)
problems. In contrast, the extreme difficulty presented by many cases is notorious.
This difficulty is enhanced in some degree by the fact that many of the viscera above
and below the diaphragm are served by the same afferent nerves, and some of these
visceral afferents (phrenic and sympathetic) carry impulses to spinal pathways common
also to somatic sensory nerves; as a result of the latter the phenomenon of "referred
pain" frequently results. Fig. 1 illustrates these points, and indicates some of the pathways by which referred pain may result, e.g.:
(a) Phrenic nerve (C4)—sensory impulses from the central diaphragm may be felt
as pain in the region of the shoulder.
(b) Sympathetic cardiac and pulmonary plexuses, and spinal segments
Dl-5—cardiac pain is often referred to the shoulder and arm via Dl-2.
(c) Somatic sensory D6-12—carry impulses from the peripheral diaphragm which may
be experienced as painful sensations over the corresponding cutaneous distribution
(lower chest, abdomen).
TO    CEREBRUM
1 !
1   YfSCERAL
a SOMAT I c
3 SOMAT IC
AFFERENT
EFFERENT
AFFERENT
HEART
MUSCLE
fig- 2-
MECHANISM    OF SOMATIC- RESPONSES   TO   VISCERAL     STIMULI*
(after  wicgeps, IN LEVY, diseases of coronary arteries aho cardiac pain)
Page 35
ii i.'f
(d) Somatic sensory D 1-6—pain of root origin may be referred anywhere in the
distribution of the affected nerve, from the back to the front of the chest.
Fortunately, most afferent impulses from the chest are fairly well localized to the
general area of origin, e.g., the pleural pain is usually at the site of disease, the main
cardiac pain is usually substernal, the pain of deep lung disease (when present) is
localized as to side and approximate level; frequently one is impressed by the accuracy
with which a patient will indicate the level of an esophageal obstruction. However,
because most of the important thoracic contents are grouped in the mediastinum, this
rough quality of localization is obviously of limited differential value.
The Diagnosis of Visceral Disease Causing Chest Pain
It is not the present intention to consider in detail the recognition of the various
deep origins of chest pain. Their ordinary clinical attributes are too well known. One
must emphasize again/ftg extreme importance of the history of the pain, with the^care-
ful description ~by the patient of its more and time of_onset, its character, intensity,
duration, and perhaps most important of all, its relation to the various body functions,
and its association or lack of association with the other symptoms. What was the
patient doing at the time of onset of the pain and how was it related to, or did it
affect, his various functional activities? The relation of cardiac pain to exertion, pleural
pain to respiration, esophageal pain to swallowing, root pain to posture, are classic and
oft repeated examples too familiar for detailed discussion here. One must be prepared
to recognize frequent variations in the pattern of these syndromes, especially in the
character and site of pain, but as a rule these important relationships pertain. One is
surprised at the frequency with which examiners will neglect to establish this simple
but essential clinical data clearly. In such instances the clinical management begins
in confusion and is likely to end in confusion. A careful clinical description is always
important, will frequently indicate the diagnosis, and sometimes is the only basis on
which a diagnosis can be made; the diagnosis of "angina of effort" (angina pectoris,
coronary insufficiency) which must sometimes be made in the complete absence of
confirmatory objective evidence is the classical example of this last.
A meticulous physical examination, with particular_refereace to_the thoracic
cage and the spine, the thoracic inlet and the abdomen, is also essential. One-examines
with carethe lung fields, cardiac, and mediastinal areas, but it is usually true_jthat in
early disease of these structures, the demonstrable objective signs are within normal
limits. Itis now generally accepted, therefore, that the~investigation of possible chest
disease requires X-ray study, and this should be done no matter how trivial the problem
appears to be. A negative finding, along with the essential clinical data, will at least
permit authoritative reassurance of the patient.
In this regard, one can comment briefly on the relative merits of the X-ray plate of
the chest and the fluoroscopic examination. Although it is strictly true that these
methods of examination are complementary to one another, it is frequently the case
that, from the standpoint of convenience or expense, one must resort to either one or
the other as a primary "screen," or exclusion, of intrathoracic disease. Each has its
advantages and limitations but, if I had to select one alone, I would choose the fluoro-
scope which permits visualization in all positions, in all phases of respiration, and offers
excellent visualization of the mediastinal contents, including the esophagus; in the
examination of the size and contours of the heart and aorta, it is definitely superior.
It is my practice to use it as a primary screen in all cases in the office, and to take
plates only for permanent record in "positive" cases, or rarely when there is doubt as to
the fluoroscopic findings. It is a method of examination that every practitioner can,
and I think should, make available to himself, though he should obtain the necessary
instruction in its. operation, uses, limitations and risks.
We have not the time to discuss the employment of the other diagnostic aids.
Usually this history and the examination will indicate whether one should obtain
additional tests, such as E.C.G., a barium swallow, bronchoscopy, X-ray of the spine,
Page 36
f lumbar puncture, gastrointestinal or biliary tract study. In patients over 40 with
chest pain, one is almost forced to take an E.C.G. to complete the examination and to
reassure the patient, unless the cardiovascular system seems reasonably well excluded on
clinical grounds and some other definite cause for the pain is found. Here, too, one
must have a clear knowledge of the limitations of the instrument in detecting significant disease; and sometimes negative findings must be accepted with reservations, often
unexpressed to the patient.
The Diagnosis of Somatic {Skeletal) Sources of Chest Vain
Strictly speaking, this group includes the bony thorax and spine as well as the
soft tissues of the thoracic cage. Usually root pain from disease in the spine or spinal
cord can be recognized by the general methods discussed above. Diseases of the ribs,
sternum, and costal cartilages are very rare causes of pain, and can usually be detected
in a suitably careful examination.
Much more frequent, and therefore relatively more important, are the pains which
arise in the soft tissues of the chest wall, principally the muscles and fascia. Their
cause or causes are unknown; at various times they have been called myositis, fibrositis,
neuritis, fascial herniations, fatty dystrophy—but no constant local tissue change has
ever been satisfactorily demonstrated. It is suspected by many observers, including myself, that, in the main, they are not due to real structural change, but probably are
due to soft tissue strain, chiefly of muscles, sometimes with local spasms. They appear
to be aggravated by fatigue and by general states of tension. We are all familiar with
fatigue aches in muscles or ligaments, examples of which may be induced at will by
holding an extremity in a fixed position for a few minutes. Similar aches may be
induced in the chest by maintaining an inspiratory phase and breathing shallowly at this
level. This is the sort of thing that many people with tension appear to be doing.
However, although one may suspect the* cause, it seems best to apply some such designation as "thoracic cage pain" which does not pretend to settle the hypothetical
origin.
The pain is often described as severe, often confirmed to one area, and brings to the
mind of the subject the possibility of serious underlying disease. This possibility
usually increases the resulting distress in both normal and psychoneurotic individuals.
This type of pain as certain well known characteristics. It is usually lancinating and
intermittent, of momentary duration. However, it may be persistent, aching, constricting, and it has been demonstrated repeatedly in the past ten years that skeletal
pain may closely simulate serious visceral disease, such as angina of effort, coronary
occlusion, peptic ulcer, cholecystitis (3, 4, 5, 6, 7, 8). It may occur in any part of the
thoracic cage and is frequently in a pectoral region; when left-sided, it is more disturbing by implication. It is frequently related to function of a regional muscle.
In most instances a soft tissue tender_point can be discovered in the_area_and manual
pressure on this point may reduplicate the pain described. Search for such tender points
must carefully cover the entire chest, bearing in mind the segmental distribution of
die somatic nerves, and" the theory of referred pain. The point is usually isolated but
may he multiple.
As-indicated in the classification, somatic pain may occur alone, or in association
with underlying visceral disease, and psychoneurosis may be a complicating factor.
When it occurs in the healthy individual, its only real importance lies in its clear
recognition by the doctor and the patient. At the same time the presence of this
obvious source of pain does not exclude the possibility of more important underlying
disease which must be ruled out with reasonable care.
Skeletal pain does indeed occur with some frequency in association with visceral
disease. In many instances there appears to be no causal relationship, but naturally the
presence of the pain is an additional source of apprehension to both patient and doctor.
In such cases the recognition of a simple origin for some of his pain is of great importance, and will relieve the patient of much unnecessary apprehension.   Again, this in
Page 37
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no way releases either patient or doctor from the proper management of the underlying
major disease.
In some cases there appears to be a definite causative relationship between visceral
and somatic disease. Lewis and Kellgren (3) showed that stimuli arising from viscera
could produce definite muscle spasm. It is usually supposed that this effect is produced
by a spinal cord reflex (Fig. 2); e.g. afferent impulses from viscera such as the heart,
overflow at the first spinal cord synapse and stimulate efferent nerves to somatic
structures via adjacent cord segments (via "internuncial nerves").
In this way active heart disease may produce painful muscle spasm in the chest.
Furthermore, it is believed by some (6), (7), (8), that such muscle spasms may set up
self-sustaining reflex arcs ultimately independent of the original precipitating visceral*
stimulus. An acceptable example of somatic responses to serious visceral disease is the
"shoulder-hand" syndrome that sometimes occurs after myocardial infarct or severe
recurring angina, later the hand becomes swollen, painful, engorged, often clammy.
It is believed that the deep visceral stimulus produces a painful reflex muscle spasm
about the shoulder and later the sympathetic supply to the extremity is abnormally
stimulated (either from the original visceral stimulus, the resulting somatic focus, or
both) with resulting disturbance in the vascularity of the hand and limb.
Psychoneurosis in its various forms may be associated with any form of chest
pain, which is likely to produce considerably more anxiety and generalized "functional"
disturbance than in normally adjusted individuals. Sometimes the pain itself is the
cause of an acute anxiety state of superficial type which may be quickly removed by
the proper assessment of the origin and significance of the pain.
Cases Illustrating Skeletal Pain in Various Clinical Situations
1. Skeletal pain in good health. Businessman, 38, overly active at his work and
in community affairs, felt generally well but had a recurring ache and occasional sharp
pain in the left pectoral region. It was not related to effort or associated with dyspnoea
and not disabling in any way, but in th ecourse of a year he had become increasingly
concerned about the possibility of heart disease. A tender point in left pectoral muscle
reduplicated the pain and detailed examination was otherwise entirely normal. It was
not considered necessary to do an electrocardiogram in this instance. The origin and
significance of the pain was discussed and he continued in full normal activity. Two
years later he was asked about the pain and stated he did not feel it any more or only
had an occasional minor twinge similar to those in various other parts of his body.
2. Skeletal pain associated with hypertensive cardiovascular disease and angina of
effort—but not causally related. Female, 65, B.P. 170/100. Myocardial infarct a year
previous and mild angina of effort since. Also a recurring, severe, lancinating pain in
left pectoral region not related to exertion, which kept her in a constant state of anxiety.
A tender point reduplicated this pain and its origin was discussed with the patient. She
continued to follow the general advice required for her own cardio-vascular disease
and a year later stated that she had only noticed an occasional minor twinge in the left
chest which did not bother her any more.
3. Skeletal pain associated with visceral {heart) disease—causally related. Male,
60. Suffered a severe acute myocardial infarction and had a history of one preceding
attack. While convalescing from the last, he suffered sharp pain about the left
shoulder aggravated by postural movements and developed a "frozen shoulder." A few
weeks later his hand became swollen, reddened, stiffened, gradually subsiding over many
weeks and leaving a stiffened hand and shoulder despite physiotherapy. At the end of six
months he died suddenly with a third myocardial infarct.
Management of Skeletal Vain
The main need is to recognize clearly the origin of the pain and in most instances
the elucidation of this is all the treatment that is required in both the healthy person
and those with serious visceral disease. A simple demonstration of fatigue aches in
Page 38
HA muscles may be used to illustrate the fact that pain is frequently a normal event. Any
associated visceral disease must be carefully assessed and treated. The presence of an
unimportant symptom does not in any way relieve one of the responsibility of managing serious underlying disease.
In persistent forms of skeletal pain additional measures may be required, such as
local heat, carefully graded movements and massage, and the relief of some persistent
source of strain. In recent years much has been written about the use of such measures
as novocain injection and ethyl chloride spray to the tender areas (trigger points).
In my experience they are more useful in diagnosis than in treatment but may be used
in persistent cases. They are most likely to be helpful in the cases causally related to
underlying visceral disease and may in fact ameliorate a symptom complex that is
aggravating the visceral disease itself.
Summary and Conclusions
1. In the assessment of chest pain it is as important to exclude serious visceral disease
as it is to detect it. For this reason, it is essential to recognize the exact origin or
origins of pain about the chest (or any other part of the body).
2. In the diagnosis of chest pain, the most important aid is a clear, accurate, detailed
history of the pain. Without this, the case begins in confusion and is likely to end
in confusion. Then comes a careful examination, including a detailed scrutiny of
the general region of the pain; this must include, of course, the thoracic cage. An
X-ray of the chest is essential, but other special procedures may be selected according to the clinical indication. In dealing with psychoneurosis, the investigation
should be thorough to remove any elements of doubt in the diagnosis.
3. "Thoracic cage pain" of skeletal origin, unknown in cause, may be recognized frequently is a source of chest pain. Somatic tender points may be found which reduplicate in whole, or in part, the pain described. Skeletal pain of this type may
be found in the perfectly normal individual, or may be found in association with
visceral disease; in some of the latter, it appears to be causally related, presumably
by reflex stimulation of the skeletal structure (muscle) by the underlying visceral
origin.
4. In treatment of skeletal pain, simple elucidation and reassurance is sufficient in the
vast majority of cases. In severe or resistant cases, special forms of local therapy
may be required, particularly in the cases which are causally related to underlying
visceral disease; in some of these, the skeletal pain appears to be an aggravating
factor.
5. The recognition and treatment of the skeletal pain in no way removes the responsibility of detecting *and managing any underlying important visceral disease.
Lecture given at the Shaughnessy Hospital Postgraduate Course of Evening Lectures,
3rd November, 1948.
References
1. Da Costa, J.M.: On Irritable Heart; a Clinical Study of a Form of functional
Cardiac Disorder and its Consequences.   A.J.M. Sc. 61: 17, (Jan)   1871.
2. Herrick, J. B.: On Mistaking Other Diseases for Acute Coronary Thrombosis.
Ann. Int. Med. 11: 2079 (June)  1948.
3. Lewis, T. & Kellgren, J. H.: Observations Relating to Referred Pain, Visceromotor Reflexes, and other Associated Phenomena. Clin. Science. 4: 47 (5 June)
1939.
4. Kellgren, J. H.: Somatic Simulating Visceral Pain. Clin. Science. 4: 303 (30 Oct.)
1940.
5. Wood, Paul: Da Costa's Syndrome (or Effort Syndrome). B.M.J. 1: 767 (24 May)
1941.
Page 39 6. Young, D.: The Effects of Novocain Injections on Sinuilated Visceral Pain. Ann.
Int. Med. 19: 749 (Nov.) 1943.
7. Rinzler, S. H. & Travell, J.: Therapy Directed at the Somatic Component of
Cardiac Pain.   Am. Herat J. 35: 248  (Feb.)   1948.
8. Travell, J. & Rinzler, S. H.: Pain Syndromes of the Chest Muscles; Resemblance
to Effort Angina and Myocardial Infarction and Relief by Local Block. Can.
M.A.J. 59:  333   (Oct.)   1948.
9. Rasmusen, A. T.: The Principal Nervous Pathways, 2nd Ed. The MacMillan
Co., New York, 1943.
10. Levy, R. L.: Diseases of the Coronary Arteries and Cardiac Pain.   The MacMillan
Co., New York, 1936
11. Conference on Therapy: Treatment of Painful Disorders of Skeletal Muscle.   New
York State Journal of Medicine. 48: 2050  (Sept. 15)   1948.
L*:i
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RECENT ADVANCES IN GYNAECOLOGY
Dr. F. S. Hobbs
Staff Clinical Weekly—Nove. 23, 1948.
The subject of this lecture to-night is Recent Advances in Gynaecology. Gynaecology has been recognized as a special branch of medicine for a great many years, and
like all other branches of medicine it has made great advances in recent years. Perhaps
these are not as spectacular as certain medical discoveries, such as insulin for diabetes,
liver for pernicious anaemia, and the antibiotics, but nevertheless gynaecology has
progressed tremendously, particularly in the past twenty years. Perhaps we do not
realize that things we take for granted now have only been developed in this century—
for example, the use of the vaginal speculum we now take for granted, yet in a book
by Acton on Urinary and Generative Organs, published in 1853, controversy over the
use of the speculum is rather interesting. Its universal use was far from accepted in those
days—"Let us suppose that in a case of vaginal or uterine infection the employment of
the speculum is determined upon. The young surgeon commencing practice will naturally
ask how he is to proceed to obtain the acquiescence of the female. The consulting surgeon
in London finds no great difficulty. Many females understand the examination to mean
one made with the finger, and it may be advisable to be at first content with this, which
will of course teach the surgeon little more than the position of the os uteri or the
existence of an ulcer or granular condition of the neck of the womb, and the patient
may then be delicately told that an ulcer exists which it is impossible to reach without
an instrument, and if she be a sensible person, seeing the necessity, she will submit with
reluctance, which the surgeon may readily overcome by telling her that this necessary
examination is as repugnant to his feelings as it can be to hers, but that no other course
is left to him should she be desirous of a cure. When the patient consents the examination had better be made at once. There is no good in delaying it, and once done, your
patient will submit a second time without more ado." Little do we realize that such a
commonplace procedure as a speculum examination was a formidable procedure less than
one hundred years ago. The thought of asking our patients for their consent for a
vaginal examination is something of which we never think.
To cover all the advances made in gynaecology in the space of this paper is an
impossibility, so I have selected a few subjects and have tried to do this on the basis of
frequency of occurrence and practical aspects of treatment.
Page 40 First let us discuss the latest advances in the diagnosis of cancer of the female genital
tract. We all know that if malignancy of any tissue could be detected in its early stages,
the mortality from malignancy could be greatly reduced. In no region of the body does
this apply more than in cancer of the uterine cervix. Plate I is a diagram showing where
practically all cervical cancers originate, that is, at the junction of the columnar and
squamous epithelium.
The recent work by Papanicalou, Trout and Ayre in the smear diagnosis of cancer,
bases the method of diagnosis on finding cancer cells in the vaginal or cervical discharge.
The method of taking the smears is very easy. Plate II shows the type of pipette and the
wooden or metal cervical scraper which is advocated in this method. The principle is
that a small amount of the secretion from the vagina is taken up in the pipette and then
smeared on a glass slide as indicated in Plate III. It is then immediately dropped into
a jar containing equal parts of 95% alcohol and ether. If the scraper is used, it is inserted in the cervical os and a complete circle of the whole region of the junction between
the columnar and squamous epithelium is made. The material thus picked up on the
scraper is smeared on a glass slide and then fixed as before. So far anyone can do this.
Now, however, the question arises about the cytological diagnosis of these smears after
they have been fixed. This is where the great controversy at the present time is taking
place. At the Canadian Medical Convention in Toronto in June of this year Dr. Ayre
of Montreal gave a paper on this subject. Anyone who has listened to Dr. Ayre and
seen his beautiful colored photographs and colored movies on this subject, and heard
Dr. Ayre speak, must be impressed with what he has to say. However, his paper was
very severely criticized by several well known pathologists, such as Dr. Cameron, who
is in charge of all the biopsy clinics for the province of Ontario, and Dr. Boyd, professor
of pathology at Toronto, also was critical of this method of diagnosis.
It comes down to the fundamental criterion for the diagnosis of malignancy. In
this method the diagnosis is made on the appearance of a single cell. This the older
pathologist finds difficult to accept. Up to the present time one of the basic criteria of
malignancy was invasion through the basement membrane. It is believed that frequently
the carcinoma, when found by the cervical scraping method, is in such an early stage
that it is still intraepithelial. This does not fit in with the accepted criteria for malignancy. This is one of the big points it is hard to reconcile with this new method of
diagnosis. Proponents of this cervical smear technique admit that a great many hours
must be spent in the examination of some of the slides to be able to say definitely
whether the cells are malignant or otherwise. They also are advocating this procedure in
all routine examinations of women, some going so far as to say that the procedure should
be -done every three months. If this method of diagnosis was to become universal,
who would have the time to examine these thousands of slides? Dr. Ayre contends that
trained technicians can be used to screen out the ones which have no suggestion of
malignancy is present or not. This to me seems rather a dangerous step, to be placing
in the hnads of a technician a diagnosis of such great import as whether the patient has
or has not cancer. I feel very definitely that the cytological smear technique has an
increasingly important place in the diagnosis of cancer of the cervix and uterine cancer,
but I do feel that it can not, at the present time, be accepted as a substitute for biopsy
or curettage, and is only of use as a complementary method of diagnosis for the purpose
of discovering early cancer before the signs and symptoms commonly associated with
the disease have developed. I am quite sure that we shall hear more and more of the
smear technique for the diagnosis of malignancy not only of the generative organs but
of gastro intestinal, bladder, buccal and pulmonary systems as time goes on. I am quite
convinced in my own mind that it is an important step, but I think it should be tempered with a good deal of caution before it is universally accepted.
The next subject is trichomonas vaginitis. I have no hesitation in saying that in
my opinion trichomonas vaginitis is definitely on the increase. Why this is I am unable to
say, but I think most gynaecologists will agree that they are seeing this condition much
Page 41
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more frequently now than they did ten years ago. The diagnosis of this condition is
very easy; a small amount of the secretion is taken on a swab, put into a test tube containing five cubic centimeters of normal saline, and a drop of the mixture then being
examined under the microscope will soon show the organism if it is present. They are
motile organisms about twice the size of a while blood cell. The clinical signs you are
all familiar with—profuse, yellow, frothy, vaginal discharge with intense irritation,
which is worse in the summer months. On speculum examination one finds a patchy,
so called strawberry type of inflammation throughout the vagina and cervix. Finding
the organisms makes the diagnosis, although in most cases it can be done from clinical
symptoms alone. At one time it was believed that trichomonas vaginitis was caused by
the organism getting from the rectum into the vagina. The latest work, which was
published in the Journal of Parasitology of June, 1947, shows that this theory is incorrect.
There are three distinct species of trichomonads. Trichomonas vaginitis is one organism
which can be transplanted to the vagina of female monkeys but not to any other cavity
of the body. Trichomonas tenax is a second form of trichomonad which can only be
found in the mouth of monkeys, dogs and cats, and not in the vagina or intestine of
other mammals. The third is trichomonas hominis, which is present in the human intestine but is distinct from the trichomonas tenax. How, therefore, has the condition become
so widespread in the female population at present? I wish I knew the answer to this
question. The old idea of the organism getting from the rectum to the vagina sounded;
very logical, but now that this has been disproved, what are we to tell our patients as
to the origin of the condition? The first thing is to reassure the patient that the disease
is not gonorrhoea. The second is that it can usually be cleared up fairly readily, though
it has a very marked tendency to recur. I often wonder if trichomonas is not disseminated through bath tubs. We saw a great deal of it in the female personnel in the Armed
Forces, where very often they were using a common bath tub. Could it be that the
infected person taking a bath left some of the organisms in a wet soap dish, or in a
wash cloth that they left in the bath, or perhaps in a little water still in the bath tub
which did not drain? This to me seems to be a very logical explanation. From the
patient's point of view the important thing is the cure. There are a great many different
preparations on the market at the present time for the treatment of trichomonas vaginitis. All of these, I think, are effective. The one that I use routinely in practice is
De vegan. The reasons I use this are that it is an inexpensive drug, it is used in a tablet
form, no douches are necessary, it causes no staining from the vagina such as you get with
picric acid suppositories or some of the other forms of treatment. In my experience
Devegan has been particularly effective. I always order twenty-four tablets instructing
the patient to use one in the vagina night and morning for six days and nights. If by
then she is not menstruating she is instructed to save the remaining twelve tablets and
use them as soon as menstrution begins, one tablet night and morning all through the
priod. Unless this is done the rate of recurrence is very high. Whatever treatment is
used, I think the secret of success is to use it during the period, as it is usually immediately following the period that recurrence takes place. What do I offer if the condition
does recur? Then I usually repeat the course for another month in the same manner.
If again the condition relapses, then I bring the patient in two weeks before her period
and give her daily insufflations in the vagina with Aldarsone powder, then have her use
the Devegan through the period. She then returns immediately after the period and I
continue the daily insufflations for several days. Plate IV shows the sources of reinfection in trichomonas vaginitis. The male must be considered as a possible source of
infection. The regions in which the condition may be harboured in the male are the
prepuce, the bladder and urethra, and the prostrate. In the female, the sources of chronic
infection to be thought of are the bladder and urethra, Skene's ducts, Bartholin glands,
digital contamination, bed pan contamination and enema contamination. The gynaecologist will occasionally be faced with a recurrent case of trichomonas which, despite all
treatment, will go on month after month, and will tax the ingenuity of each of us to
Page 42
\h\ effect a cure. p||
And now what is new in the diagnosis and treatment of gonorrhoea? Gonorrhoea
i is one of the two great causes of pelvic inflammation with the usual resulting sterility
and chronic pain. The other common cause of pelvic inflammation is induced or sometimes spontaneous abortions.
We know that penicillin in the dosage of two hundred thousand units, in two
doses of one hundred thousand units each, three hours apart, will cure at least 90.95%
of gonorrhoea. The remaining five to ten percent it either fails to cure, or has actually
cured the one infection and then the patient has contracted a second of gonorrhoea. One
would think that with such short and effective treatment, gonorrhoea would soon be
compleley eradicated from the population. However, such is not the case, although there
tre some encouraging steps in that direction. Reported cases of venereal disease in the
province continue to decline. Syphilis in particular has shown a decrease of 53.6% in
the third quarter of this year compared with the corresponding period of last year.
Gonorrhoea has also declined but only to the extent of 17.2% in a comparable time.
In the past, the approach to venereal diseases has been on case finding, and then proving
the diagnosis. This concept is changing considerably now. The control problem, which
is being recognized now, is that of epidemiology. Under this heading are the two main
activities of case finding and case holding.
The problem of bacteriological diagnosis of gonorrhoea is frequently difficult. Van
Slyke and his associates found a wide variation among three excellent laboratories examining the same culture positive material. Spreads of cervical and urethral secretions
from one hundred and forty culture positive patients were submitted to three capable
microscopists. Working with identical material these examiners reported eighty-eight,
forty-seven and forty positive spreads among the one hundred and forty positive cases.
These same examiners reported seventy-six, thirteen, and four positive spreads among
five hundred and twenty-four cases with negative cultures.
It is well known that repeated cultures will not demonstrate the gonococcus in many
female patients in whom infectiousness has been demonstrated. On epidemiological
grounds many competent urologists and public health departments now believe that
microscopic examinations of stained spreads are of little value in establishing a diagnosis
of gonorrhoea in the male, and is almost worthless in females without supporting epidemiological evidence. With this in mind, we who are diagnosing and treating cases of
gonorrhoea in the Division of Venereal Disease Control base our diagnosis of gonorrhoea
less and less on bacteriology and more and more on epidemiology. At the Division of
Venereal Disease Control in Vancouver, six public health nurses and one male worker
are engaged in epidemiology. To insure effective epidemiology, emphasis is placed on cases
which are the most significant to the health of the public. First attention is given to
contacts and cases of the early contagious form of syphilis, namely primary and secondary
syphilis. Larger priority is also given to syphilis in pregnancy. In April, 1947, the
revised Venereal Disease Suppression Act was passed. This Act makes provision for
compelling persons to submit to examination and regular reporting for treatment. This
Act has been of great assistance in carrying out the programme of epideniology. The Act
also provides for compulsory examination and treatment of persons in custody or awaiting trial. At the present time all women in custody are examined for venereal disease
and in the near future this is to be extended to include men as well. These examinations
are carried out each morning before court convenes by a public health nurse from the
Division of Venereal Disease Control. From May 1st, 1947, to April 30, 1948, eight
hundred and sixty-four persons were examined at this centre, 37% of these had one
form or another of Venereal Disease.
Another method of epidemiological follow up is through the confidential laboratory
list. All tests for venereal disease done in the Provincial Laboratory are reported to the
Division of Venereal Disease Control, names of patients having positive tests are checked
against the central index, and those who are not already known to the Division are
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brought to the attention of the physician concerned. I have no hesitation in saying that
the decrease in incidence in cases of pelvic inflammatory disease is largely due to the
decrease in gonococcal infections. Pelvic inflammatory disease will probably always be
with us, but if we could rule out gonococcal infections the incidence would certainly
drop tremendously.
There is little new in the treatment of pelvic inflammatory disease once the condition is established. Penicillin has been a tremendous step in the treatment and cure in
most early cases of gonococcal urethritis and salpingitis. If all cases of gonorrhoea showing early involvement of the tubes could be hospitalized before the first menstrual period
begins after contracting the infection, and these patients were treated with two million
units of penicillin then I think few would go on to the chronic stage of the disease.
With our limited bed capacity at the present time, this is a physical impossibility. However, I do think that most of the infections of the tubes occur during a menstrual period.
The next subject is that of gynaecological endoctrinology. This is a very wide subject
and one on which there is a great deal of difference of opinion. Certain hormones have
definitely been isolated, others will be isolated in the near future. I am quite sure that
some of the next great advances in the subject of gynaecology will be along hormonal
lines. At the present time we have three known hormones produced from the follicle.
They are oestradiol, oestrone and oestriol. There is some question of whether these are
three distinct hormones or whether they are one and the same hormone in different forms.
Progesterone is the other hormone produced by the ovary. The pituitary hormones have
still to be isolated. Oestradiol is the substance secreted by the follicle, the degeneration
products oestrone and oestradiol are found in the urine and placenta respectively. Die-
thylstilboestrol or stilboestrol is the synthetic hormone. In 1934, Butenandt succeeded
in isolating progesterone in crystaline form, and now this can be produced synthetically
from the inert sterol of the soya bean. The excretion product of progesterone is pregnandiol, found in the urine.
Research on the hormone activity of the pituitary gland is showing it to be of almost
unbelievable complexity. The comparatively simple oxytocic and pressor substances of
the posterior lobe have long been known but during the last twenty years the functions
of the anterior lobe have been explored with the result that over a dozen different hor-
activities have been described. The situation is becoming further iompliratet by the
suggestion of anti-hormones and the possible relationship of the vitamines to the hormone activities have been described. The situation is becoming further complicated by the
least fourteen other hormonal effects by substances which may be specific for each effect
or multiple in their actions. Attempts to isolate the gonadotropic hormones from the
anterior pituitary have met with little success. However, a hormone with similar action
has been prepared from the urine of pregnant women at about the third of fourth month
of pregnancy, and from the serum of the pregnant mare. This is called Antuitrin S,
A.P.L., etc.
What now are the practical applications of the sex hormones? (1) Inhibition of lactation. Stilboestrol or oestradiol will definitely prevent the formation of milk in the
breasts of a newly delivered patient, provided it is begun within the first twenty-four
to forty-eight hours post partum. It is used very extensively for this purpose and I
have yet to hear of any complication from its use. I doubt if it is of any value in inhibiting lactation once a normal flow of milk has been established. However, I usually
use it, as the patients have learned to expect to take pills now for drying up their
breasts, and will suggest it to you if you fail to get in the suggestion first.
(2) Menopause. Oestrogens are now frequently used in treating menopausal symptoms. They are very useful for the symptoms of hot flushes. Here, however, one must
be careful to assess the patient and to order oestrogens only if necessary; many women
can be tided over the menopausal symptoms with small doses of phenobarb, and I think
oestrogens should be used only in those cases that phenobarb will not control.
Page 44 (3) Threatened abortion. A considerable amount of work has been done on the
treatment of threatened abortion by the use of progesterone. Unfortunately the drug
houses have, I think, got ahead of well authenticated work and have tried to teach the
medical profession how these hormones should be used. There are remarkably few
articles on this subject in the obstetrical and gynaecological literature. In my opinion
there is, at the present time, no scientific basis for the use of progesterone in the treatment of threatened or habitual abortion. Until we have biological assays of the ovarian
hormones and know definitely whether there is or is not a progesterone deficiency, then
the giving of five, ten, twenty-five or one hundred milligrams of progesterone is on
entirely empirical grounds.
(4) Menorrhagia. This is one of the commonest conditions seen, not only in gynaecological practice, but in general medicine as well. In a young individual complaining
of menorrhagia, where nothing abnormal is found in physical examination, then a diagnosis of functional menorrhagia is usually made. In the older age groups, unless you can
be quite sure in your own mind that the condition is functional, it is wiser to do a
dilitation and curettage to rule out malignancy. This will also show whether the endometrium is responding to the normal hormonal stimulus.
Are endocrine preparations of value in the treatment of functional menorrhagia?
I believe that thyroid is of some value in these cases and this is the therapy with which
I usually commence treatment. The use of oestrogens, given in the two weeks following
the period, may be of value. I am always very skeptical of my results of treatment in
these cases. Some patients do apparently respond to this therapy, but I wonder how many
would have spontaneously got better without treatment. I think if one hundred patients
were given no treatment and one hundred were given endocrine treatment that the end-
results of such methods of treatment would probably show very similar results. The
other drug which maye give some results in the anterior pituitary—like hormone, A.P.L.
or Antuitrin S. In order to get any real effect from these I think they should be given
daily, the value of them when given once or twice a week is, I think, questionable.
Another disadvantage of these hormones is their expense—a ten cubic centimetre vial
of A.P.L., one thousand strength, costing about fifteen dollars. Until we have the
ovarian and placental hormones brought to the same scientific level as insulin for diabetes,
I think the use of them is based largely on empirical grounds.
(5) Secondary amenorrhoea. This is the condition where the patient has begun
menstruating, then for reasons other than pregnancy, the periods have stopped. In most
of these cases the secondary sexual characteristics are present, the breasts have developed,
public hair is present, etc., but the natient does not menstruate. How are we to treat
such a case? Here again I usually try thyroid first. If after a trial of six months there
is no period then other measures must be tried. A.P.L. given in adequate dosage is the
next drug that I suggest. This should be carried over at least three months if the patient
can afford it. If this fails, then a combination of oestrogen and progesterone, mixed
together in the same syringe, may betried. This is given for two successive days. This
may produce uterine bleeding, but it is doubtful if this is a true menstrual period. If all
other methods fail, I think that stimulation of the pituitary by x-rays is to be considered.
Ira Kaplan of New York has used this in quite a large series of cases and reports excellent
results. When done by a competent radiologist I think there is little danger in this
method.
And now what is new in the treatment of sterility? Advances in the diagnosis and
treatment of this condition are making some headway. What should be our approach
to the woman who comes to us complaining of inability to become pregnant? First of
all a careful history should be taken. This should include the previous diseases that the
female has had, particularly mumps after puberty, history of pelvic infection, regularity
of periods, etc., frequency of intercourse and whether or not it is normal. A complete
physical examination is then done, preferably including a B.M.R., blood counts, etc. In
my experience one of the commonest reasons for sterility is chronic cervicitis.   These
Page 45
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also are the most favorable cases from a treatment point of view. If no obvious cause is
found for sterility, then I have the patient return about one week following her period
for a Rubin's and Huener's tests. The Rubin's test is an office procedure and will tell
whether the tubes are open or closed, if more accurate information is desired an x-ray
visualization of the tubes may be done. Huener's test is done by aspirating some of the
cervical mucus and examining it under the microscope for the presence of motile sperms.
If the tubes are open and active sperms are present, what is the next procedure? Naturally, if no sperms can be found in the vagina within two hours of intercouse, the husband
should be investigated, as probably the male is at fault in at least one third of the cases
of sterility^
What other measures c^n be used to overcome sterility? (1) Time of ovulation.
Plate V shows how, in theory at least, the ovulation time of a women can be determined,
by noting the increase in the basal temperature. At the time of ovulation the temperature should increase about one degree, then continue at an elevated rate until the next
period approaches, then drops to a lower level at the onset of the period. Why does the
basal temperature go up? Israel and Schnelb, at the meeting of the American Society
for the Study of Sterility, in Chicago in June, 1948, reported a series of observations
on this point. Their work showed that oestrogen lowered and progesterone raised the
basal body temperature. This work was done by injecting a series of castrates with
progesterone and oestrin and observing the results.
(2) Drugs. I believe thyroid should be given to both the man and wife in doses
up to a grain or a grain and a half a day. Stilboestrol has been recommended in small
doses of one tenth of a grain daily.
The use of Nutra Ortho has been widely advocated by the Ortho Company for
this condition. It is a carbohydrate that is used as a douche about one half hour before
intrecourse, the theory being that the substance peps the sperms up so that they will
cause fertilization. I have tried this in a number of cases but have yet to see the patient
where I felt the Nutra Ortho was the factor which overcame the sterility.
(3) Surgical Reconstruction of the Tubes, where they have been obstructed by
inflammation has been done with a small degree of success.
So far I have been discussing non operative gynaecology. Great strides have also
been taken in improving pelvic surgery. Operative gynaecology is passing more and
more into the hands of gynaecologists and I think that this is as it should be. None
of us will argue that general surgeons cannot remove a uterus as well as many gnae-
cologists, but the reasons behind such removal, I think, are probably better understood
by a gynaecologist. Conservative surgery should always be in our thoughts. If a young
individual has a fibroid, an attempt should be made to do a myomectomy and save the
uterus. Similarly with ovarian cysts, frequently some portion of the ovary could be
preserved. Total hysterectomy is being increasingly performed; subtotal hysterectomy
leaves in a cervix which is the site of potential malignancy, about three percent of
these becoming carcinomatous. As long as the operation is done correctly the vault
should be as well supported as in the subtotal operation. The removal of the ovaries at
the time of hysterectomy is a moot point. My own feeling is that the ovaries are. better
removed in a patient over forty-five years of age at the time of doing a hysterectomy.
It is believed that the ovaries will completely cease functioning within two years of
doing a hysterectomy. This may be due to a still unknown hormonal relationship between the uterus and the ovaries. In the last two years I have seen two patients develop
cancer of the ovary within two years following a hysterectomy—one of these has been
a headache to me and make me certainly wish for no repetition of the same.
Vaginal hysterectomy has a variable vogue; several years ago it was a popular
operation, then in most hospitals it fell into disrepute. Now there is a wave of enthusiasm for it again. I feel that there is a definite place for this operation; my indications
are a small uterus, along with a marked degree of prolapse and cystocele, in an elderly
patient past the menopause.
Page 46 Operations for urinary incontinence are many, and each one claims remarkable
results. I wish to mention briefly an operation that several members of our staff have been
using with good results. This is shown in plate VI. The principle is that, usually in
childbirth, the muscle is torn. This is reconstructed at the operation as is indicated. My
results in this operation are very gratifying.
What are we to do in the cases that have had one or two operations for cure of
urinary incontinence and they still continue to dribble urine to the extent of being
social outcasts? Plate VII shows a method that has been devised, using a strip of fascia
off the rectus muscle. I have not used this operation as yet but am on the outlook
for a suitable case. The subject was discussed recently at the meeting of the Canadian
Obstetrical and Gynaecological Society in Niagara Falls, and has been tried on some cases
in Montreal and Toronto. Operators who have tried this operation are enthusiastic
| about the results.
This paper has skipped from one thought to another. I hope I have been able to
j show you in the limited time available that gynaecology has made recent advances. We
are far from the days of Aristotle, whose treatment of prolapse consisted of "opening a
vein, purge with pil Hieracum, mollify the swelling with oil of Liblus and sweet
almonds. If the stomach be oppressed with crudities, unburden it with vomiting.
Sudorificial decoctions of Lignum Sanctum and Sasafras, taken twenty days together, dries
up the superfluous moisture and consequently suppresseth the cause of the disease. Abstain from dancing, leaping and sneezing, and from all motion both of body and mind,
eat sparingly, drink not much, sleep moderately."
RECENT ADVANCES IN THE DIAGNOSIS AND
TREATMENT OF EPILEPSY JK;
By R. L. WHITMAN, B.Sc., M.D.C.M., D.P.M., R.C.P.S.E.
Few physicians are aware that the incidence of clinical epilepsy is roughly that of
tuberculosis Or diabetes—namely, one out of every two hundred of the general population.
Although man has known of this disorder since the earliest recorded history, he
remained ignorant of its etiology and could offer no useful treatment until the end of the
last century. A scientific understanding came with the advance in neuro-physiology in
the nineteenth century. Advance in treatment can be related to the introduction of
bromides in 1857, phenobarbital in 1912, and dilantin in 1938.
Classification of Seizures
Most of us were taught at Medical School to classify epilepsy as symptomatic or
idiopathic. If some underlying lesion, such as a brain tumour or some physiological disturbance, such as results from a adenoma of the pancreas, could be demonstrated, the
epilepsy was referred to as symptomatic. In the absence of any such recognized pathology the condition was labeled idiopathic.
The virtue of this classification was that is early focused one's attention on certain factors which played a role in the etiology of convulsive seizures. These factors
must, of course, always be sought for and if possible eliminated. Its defect is to be
found in the fact that the lesion itself is not the sole cause of the seizure, To put that
another way, not every patient with a brain tumour is subject to seizures. There must be
a concomitant physiological disturbance—in all probability the same physiological disturbance responsible for seizures when no demonstrable pathology is evident.
Most of us find it more convenient to classify epilepsy into three groups according
to the physical manifestations which accompany an attack.  These three groups are:
1.   Petit Mai.
jMi Page 47
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2. Grand Mai, including Jacksonian seizures.
3. Psychic equivalent or psychomotor attacks.
Petit Mai:
These are more common in childhood and tend to become less frequent as the
patient grows older. They are accompanied by a transient clouding of consciousness
lasting only a few seconds, with or without minor movements of the head, eyes, and
extremities, and loss of muscular tone.
Grand Mai:
The phenomena associated with a Grand Mai attack may be quite varied. There
may be an aura or warning, but more often there is not. As a rule, the attacks are ushered
in by a sudden loss of consciousness with tonic-clonic spasm of the musculature, with or
without tongue biting and urinary incontinence.
Psychis Equivalent or Psychomotor Attacks:
These are terms used to describe an heterogenous group of epileptic form disturbances which do not conform to the classic Grand Mai Petit May type of seizure. The
milder psychomotor attacks are often confused with Petit Mai attacks, but they differ
from the latter in that the duration of mental cloudiness is greater and the range of
muscular movements much more widespread. They differ from Grand Mai in that the
patient does not fall to the ground in a clonic-tonic seizure with complete loss of consciousness.
There is a scientific basis for this method of classification. Gibbs and Lennox have
demonstrated that there are electroencephalographic changes characteristic of each of
thes three types of seizures.
Diagnosis:
There are few conditions which are more difficult to define, but for practical
clinical purposes we may define epilepsy as a paroxysmal impairment of consciousness.
There are two questions that we must answer:
1. What other conditions do we need to differentiate from Epilepsy?
2. What is the etiology of a particular patient's seizures?
1. We need to differentiate Epilepsy from hysterical attacks. We attack this
problem from two directions:
(a) By excluding physical disease (namely Epilepsy).
(b) By finding positive evidence of hysteria such as
i—Hysterical   personality—emotionally  immature,   self  centred,   suggestible
individual,
ii—By demonstrating that the seizures enable the individual to escape some
unpleasant duty or gain some desired advantage.
The answer to the second question will come from a thorough investigation of
the individual case.  We proceed with such an investigation in this manner:
1. Secure a careful and detailed history. This means objective description of an
attack or attacks, if possible, and a reasonably thorough assessment of the patient's
personality.
2. A thorough physical and neurological examination.
3. X-ray studies of the skull.
4. Electroencephalogram.
5. In selected cases, where ther is evidence of a localizing lesion, pneumoencephalo-
grams.
An investigation of this magnitude will uncover any pathology of etiological
significance.  Several generalizations may be made at this time:
1. Seizures which first make their appearance at adolescence are usually idiopathic.
2. Where Epilepsy begins between 21 and 55 an expanding intracranial lesion must
be excluded.
Page 48 3. Seizures beginning after age 55 usually arise on an arteriosclerotic basis.
4. Epilepsy associated with definite brain pathology is usually more refractory to
treatment.
Treatment
The problem of an epileptic and his illness should be attacked from three
directions:
1. The correction, if possible, of any underlying pathology. For example, the
surgical removal of a brain tumour.
2. Mental hygiene—As soon as the diagnosis has been accurately determined, sit
down and have a heart to heart talk with your patient. Explain that you can stop the
attacks—that's the least of all your problems. What is far more difficult to treat is his
or her reaction to the illness. If he or she is going to be filled with ideas of guilt or fear
or anger or shame, symptoms will appear which are far more difficult to treat than the
attacks themselves. Explain that while there are a few prohibitions—they shouldn't
drive cars or operate heavy machinery—apart from that they are to go ahead and live
a normal life.
3. Elevating the convulsive threshold by the use of suitable anti-convulsants. The
type of drug and the amount used is determined by the nature of the frequency of the
attacks. One may be used alone, or two or more may be used in combination. The doses
given below are for adults—children require smaller doses—but much more than
would be given if calculated on a basis of body weight.
Grand Mai Seizures
Dilantin and phenobarbital are our most effective drugs. If the attacks are infrequent and mild, phenobarb, beginning with 1 grain or \l/z grains in the evening, increasing after one week to morning and evening, may be sufficient. If the attacks are
frequent and severe, dilantin is the drug of choice. As a rule, it is advisable to start
with a small dose and increase to grs iss four times a day. Dilantin is somewhat of an
excitant, and frequently better results are secured if it is used in combination with
phenobarbital.
A skin rash appearing in the first or second week is occasionally seen where dilantin
has been used. Should this appear it is wise to withdraw the medication and recommence after two or three weeks.. Should the rash reappear the medication is better
withdrawn permanently.
An hypertrophic gingivitis is not infrequent, and the only thing we have to offer
is good dental hygiene.
Where seizures are refractory to a combination .of phenobarbital and dilantin, one
or the other may be withdrawn and mesantoin substituted.
Psychomotor Attacks
These are much more refractory to treatment than the Grand Mai seizures. The
best we have to offer is dilantin and phenobarbital in relatively large doses.
Petit Mai Seizures
Until the introduction of tredeme a few years ago we had no satisfactory treatment
for this type of seizure. In the majority of cases this drug produces a very marked
improvement, usually within the first week. Beginning with one capsule three times a
day the dosage may be increased to two capsules four times a day.
Unfortunately, this drug is not without its toxic effects. Skin rashes and visual
disturbances are not infrequent, and fatal cases of agranulocytosis have been reported.
The exhibition of this drug is only indicated if the attacks are frequent and disabling. Petit Mai attacks are more frequent in children and fortunately they tolerate the
drug reasonably well. In any case, the patient must be followed with weekly blood
counts for the first month and monthly counts thereafter.
We may at this time make one further observation. Each patient must be told that
in some illnesses it doesn't make very much difference if he does miss a dose of his
Page 49 medicine—but this isn't one of them.   He must take his medicine regularly and above
all never discontinue it suddenly.
Treatment of Status Epilepticus
Good results can sometimes be obtained by anaesthetizing the patient, but usually
better results are obtained by the use of sodium phenobarbital intravenously. One mistake frequently made is not to give an adequate initial dose.
Merritt recommends 6-12 grains intravenously in distilled water, or alternatively
3-6 c.c. of paraldehyde intravenously.
Great advances have been made in the diagnosis and treatment of Epilepsy. The
great majority of the patients can be made healthy and useful citizens if they receive
adequate treatment.
H. Houston Merritt, N.Y. State J.M. 46: 26, 29; 1946.
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"NEPHROPTOSIS"
EARLE R. HALL, M.D.
Read Before B. C. Surgical Society, March 18, 1948
My remarks on this subject are pertaining to acquired renal dystopia, or probably
better known simply as movable kidney. In my experience, the majority of these cases,
in order to obtain permanent relief from the distressing symptomatology, have required
treatment by operative procedure. From a review of my histories during the past fifteen
years, I find that I have performed nephropexy in eighteen instances. In follow-up
records of nearly all, complete relief had been obtained in each case. This has served
to strengthen my belief that operation, in selected cases, is the only treatment worthy
of consideration. The operation, of course, must be of judicious selection, and in its
performance a technique both meticulous and adequate must be used to obtain the
desired effect.
I wish to emphasize very clearly my belief that not every person with a movable
kidney requires an operation, but when the condition is productive of constant and increasing symptoms, relief can only be obtained by a surgical procedure.
TYPES OF RENAL DYSTOPIA
1. Lax Abdominal Muscles.
This type occurs when the abdominal muscles have grown slack, as after pregnancy,
after removal of large abdominal tumors, after the cutting at operation, of nerves which
supply the abdominal wall, or simply from lack of exercise. This type seldom requires
operation.
2. The Ectopic or XJnose ended Kidney of the Congenital Type.
This is due to a failure of the kidney to ascend into its proper position during fetal
life. It is often associated with abnormalities of the blood supply, and with hydronephrosis. I merely mention this type in passing, as it does not belong to acquired renal
dystopia.
3. This group contains the majority of cases complaining of symptoms. Many of
these have strong abdominal muscles, so that in them the support provided by the intraabdominal pressure is not at fault. They do not suffer from pelvic prolapse, nor from a
general visceroptosis. It is a type that has so far not received a satisfactory explanation
on which all can agree. It is this type of case where operative measures are usually
indicated and productive of good results.
Clinical Consideration
It is interesting to note that of the eighteen cases I have recorded, all were women.
Fourteen were married, and four single.    The youngest age was 21, the oldest 52, the
average age being 36.
Page 50
,f .'II Backache was the chief complaint in all cases, and in three was the only complaint.
It was usually of a steady dull type, often relieved by lying down, and aggravated by
standing. The pain at times would be more severe, and usually became more frequent,
so that it was of daily occurrence. At times it would be sharp, almost knife-like, and
of colicky nature, simulating somewhat an attack of renal colic. Patients finally complained of being "worn out," and unable to attend their various duties on account of
the steady and increasing persistence oi this pain. About one-third had varying degrees
of pain present anteriorly—at times near the epigastrium and usually radiating to the
lower abdominal quadrant.1l Many had gastro-intestinal disturbances, that became so
aggravating in some instances that they had been examined for derangement of the
gastro-intestinal tract as a primary consideration.
Urinary symptoms were not marked, and examination of urine in the majority of
cases was negative. Frequency was present in about half, usually occurring at intervals,
the duration being from a few hours to a few days at a time. Three cases having persistent pyuria gave a history of several previous attacks of pyelonephritis. These also
showed hydronephrosis which had apparently developed following infection and with the
increasing mobility of the kidney.
Nearly all cases experienced considerable loss in weight, which in about 70%, was
one of the chief complaints, and the remainder also gave affirmative replies when questioned.    Many noticed onset of their symptoms following this definite loss in weight.
Diagnosis can usually be made by abdominal palpation, aided by X-ray findings obtained at urography, with exposures also in the upright position. Other abdominal lesions
and a general visceroptosis must be excluded.
Operative Intereference
When it comes to the question of treatment, palliative measures should, as a general
rule, be tried before the question of operation is considered. I recall a few cases when,
following change in habits, diet, and with rest and gaining weight, each had relief from
symptoms without operation.
To insure success in operating for movable kidney, there are some essential features
which I will outline briefly as follops:
1. Care must have been exercised to pick a suitable case—the symptoms must be
definitely renal, and not merely neurasthenic or due to general splanchnoptosis. The
cases can only be picked by means of pyelography.
2. The incision should be as small as possible, and as far as possible split muscles,
rather than cut through them.    The 12th dorsal, the ilio-hypogastric and ilio-inguinal
nerves should be avoided in cutting and suturing.
3. All the perinephritic fat should be stripped off the back of the renal vessels and
upper end of the ureter so as to partially denervate these structures.
4. All the perinephritic fat lying behind the kidney must be removed so as to leave a
firm smooth bed of muscles to which the new alhesions can become firmly attached.
5. The pelvis and upper end of the ureter should be stripped clean and minutely
inspected so as not to miss abnormalities of the renal blood vessels which may be obstructing the pretero-pelvic junction, fixed kinks of the ureter or cases of true congenital hydronephrosis. All binding adhesions must be freed, such as tend to be aggregated
round the lower pole of the kidney, or which fix the ureter independently of the kidney
and cause kinks.
6. The true fibrous capsule of the kidney must be removed from the greater portion
of its posterior surface so that firm adhesions may form between the muscles of the
posterior abdominal wall and the kidney substance.
7. Sutures must be placed through portions of the fibrous capsule and not carried
through the renal substance itself.
8. Sutures in the posterior abdominal wall should be well up above the external
arcuate ligament and also above the 12th rib.
Page 51
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9. Generally, when the sutures have been tied, two-thirds of the kidney should be'
out of sight above the level of the 12th rib, otherwise the kidney has been fixed too low.
It is .hardly necessary to mention that infection, if present, should be eradicated before
nephropexy is attempted.
I do not propose to outline any definite technical procedure. Several writers during
the past few years, have described various types of nephropexy, but I believe good results
will be obtained if the principles above are embodied in whatever operation is performed.
I think it is important for the surgeon to remember that he is operating for the
"relief of pain" and not merely to "anchor a movable kidney." For this reason, it is
of prime importance to know that this pain is entirely due to movable position of the
kidney.
In the course of some other operation such as repair of hydronephrosis, the freeing
of partial obstruction at the uretero-pelvic junction, the relief of upper ureteral kinks,
or pyelotomy for stone, I have not infrequently also suspended a kidney found to be more
mobile than usual. However, the eighteen cases I have mentioned herein, were operated
upon only for correction of position. In other words they were typical examples of a
suspension procedure instituted for no other reason than replacement and fixation of a
movable kidney, which had been the sole cause of the symptoms in each case.
Nephropexy is an operation that has received a great deal of criticism, even to the
point where some state it should never be done. Probably in the largest percentage of
instances, condemnation has been justified, and a careful survey would reveal that many
of these did not fall into the group of "selected cases." Technical error, in justified
cases, has also been responsible for poor results.
In my opinion this operation does have a definite place in surgery, and one should
not hesitate to use it in a suitable case, if the necessary principles are followed. This
insures a successful result, proving completely satisfactory in every way, and obtainable
only by operation.
MILK AND FOOD SANITATION PRACTICE
H. S. ADAMS, B.Sc.
Chief,   Bureau   of  Env.   Hygiene,  Minneapolis,   and
Lecturer, University of Minneapolis
This publication may be considered as a reference handbook, designed primarily for
use of public health workers at all levels. It is written in a very readable style, made
possible by the author's apparent knowledge of public health principles and public
health administration and by his experience in the practical application of the former.
The book is not highly technical but the subjects are presented in a well organized
and thorough manner, by the common method of listing, point to point, items requiring
the attention of the health worker. What the book lacks in detail, is well augmented
by the numerous references to film titles, regulations, books and pamphlets, that are
lsited. Education of the public and of foodhandlers in health principals is stressed
through the publication.
ki||- Milk production and processing and restaurant sanitation are the chief subjects
treated. These are rounded out by adding sections on insect control, food poisoning,
outline of tests for purity, quality, etc. Special chapters that will be of interest deal
with the training of food handlers, the argument for pasteurized milk, and food poisoning.
Because  the   information   and   statistics   given   are  up-to-date   and   because   the
standards suggested might well be acceptable to any organized Health Department—
this book should serve as a useful reference text for some time to come.
Page 52 REPORT ON THE CHILDREN'S HOSPITAL
TRAVELLING CLINIC
The highlights of the natural trend of development of an institution like the
Children's Hospital are always interesting. When one of the factors of development is
an experiment slightly off the beaten path, the interest is even greater.
In September, 1947, the first travelling clinic from the Children's Hospital took a
trip into the Okanagan Valley. It was composed of an orthopedic specialist and a paediatrician. They were accompanied by a representative of the hospital staff to act as liaison
officer. The prime purpose was to see staff patients in the area covered. That is, children
who had been staff patients in the hospital. It had become increasingly evident that
many of the children discharged from the hospital needed better follow up. They could
not come to the hospital so it was decided to bring some of the hospital facilities to
them. These children's hospital charts and old x-rays were taken on the trip and the
consultation in the children's home area was treated as a regular hospital consultation.
It was decided to cover the Okanagan by stopping in four centres—Kamloops, Vernon,
Kelowna and Penticton.
A lay representative of the hospital visited the area first and discussed our problem
with the doctors in the individual centres. Most of the patients had come to the Children's Hospital from these doctors. Their reception of the idea was good. It must be
remembered that most of these children were crippled, many of them could not come
to the hospital because of financial reasons. Others because it was difficult for them to
travel because of their infirmities.
Arrangements were made for accomodation of the clinic. In all four centres the hospital concerned, very generously gave consent as to space and facilities. The Provincial
Public Health Department were eager to provide what help they could, including transportation for the patients coming in from long distances. The College of Physicians and
Surgeons of British Columbia gave their consent readily for the venture, and needless to
say the medical staff of Children's Hospital was behind it to a man and the necessary
members volunteered to give of their time and energy gratis.
The first trip took one week. It went off very well indeed, considering that it was
purely experimental. In fact, it wnt off without any real hitch. Occasionally there
were mild misunderstandings. These were readily ironed out when the purposes of the
trip was stressed. It was not the purpose of the clinic to bring specialized consultation
to private patients. These could come to the city through the regular channels. Occas -
ionally one was asked to see acutely ill patients in their home or local hospital bed. One
could not refuse. They were seen after the clinic was over and clinic patients' wants
attended.
Seventy-six patients were seen.
From all points of view the first travelling clinic of the Children's Hospital was a
complete success. Since then the Okanagan has been covered again. The Kootenays
have been covered twice the Cariboo once.
In all situations where there is a deviation from the beaten path, where misunderstandings can arise, there is bound to be criticism. This is no exception. The prime
purpose of the travelling clinics from the Children's Hospital is to follow up staff patients
of the Hospital and the only other patients that will be examined at these clinics are
indigent or near indigent patients referred by the local doctor.
Mi
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POEM OF A GRATEFUL PATIENT
Well! I've been through the Mayo Clinic
I've seen what there is to see;
I'll be homeward bound on the C.P.R.
And it's quite all right with me.
I've stood in line at the window;
I've sat with the waiting throng,
And a man from Maine has explained to me
About his spine which he thought was wrong.
Strangers have spoken of cancer and tumors
And bowels that wouldn't work
Of livers and lights and bladders
And knees that refused to jerk.
And a woman from Oklahoma revealed some
things so broad
That I certainly hope they are only known
To her, myself and God.
I have had both sizes of bottles,
I've saved with a miser's zest
I've toted them proudly around with me
And compared them with the best.
I've draped myself in a linen sheet,
I've doffed my clothes and then
I've draped myself in a little cape
And donned my clothes again.
I have never changed my clothes so much
At least, not to the skin
Since the days my mother dressed me
With a single safety pin.
They have punctured and probed and prodded,
They have diagnosed my heart
They couldn't know more about me
If they'd taken me all apart.
I have lain in bed at St. Mary's
Where they termed me "an interesting case"
And they stood around and discussed me
As though I was not in the place.
I have fought with the dietitian,
For the food had no salt worth the name,
And they fed me on spinach and carrots
And my friends with the gout got the same.
A nurse stayed with me each hour
For five or six nights or more
Which I'm here to assert is going some
For a man of sixty-four.
I furnished unaccountable pressure
I furnished a very good heart
Bui we all knew as much at the finish
As most of us knew at the start.
Yes, I've been through the Mayo Clinic,
I am ready to go and get packed
I'll be homeward bound on the C.P.R.
Thank God, I am still intact.
—J. Fitzsimmons.
Page 54

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