History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1928 Vancouver Medical Association Jan 31, 1928

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 JANUARY, 1928
The Bulletin
ofthe^
Vancouver Medical Mz£
^Abdominal humours
fyCollylvood Sanitarium
Melv 'Books
^Published monthly atTJancouver, ^B.Q., by
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Page 98
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I THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association in  the
Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718  Granville St., Vancouver, B.C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
Volume 4 JANUARY, 1928 No. 4
OFFICERS, 1927 - 28
Dr. W. S. Turnbull Dr. A. B. Schinbein Dr. A. W. Hunter
Vice-President President Past President
Dr. G. F. Strong Dr. A. C. Frost
Secretary Treasurer
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Auditors:    Messers. Price, Waterhouse & Co.
SECTIONS
Clinical Section
Dr. Gordon Burke Chairman
Dr. L. H. Appleby  Secretary
Physiological and Pathological Section
Dr. J. E. Campbell _ Chairman
Dr. F. J. Buller | Secretary
Bye, Ear, Nose and Throat Section
Dr. E. H. Saunders Chairman
Dr. W. E. Ainley Secretary
Genito-XJrinary Section
Dr. G. S. Gordon  Chairman
Dr. J. E. Campbell Secretary
Physiotherapy Section
Dr. H. R. Ross Chairman
Dr. J. W. Welch Secretary
STANDING COMMITTEES
Library Rep. to B. C. Med. Association
Dr. C. H. Bastin Dr. C. H. Vrooman
Dr. W. C. Walsh Credentials
Dr. W. A. Bagnaix tjr. F. W. Lees
Dr. D. F. Busteed Dr. e. J. Gray
Orchestra Dr- w- F. McKay
Dr. J. A. Smith Summer   School
Dr. H. A. Barrett Dr. H. R. Storrs
Dr. L. Macmillan Dr. B. D. Gillies
Dr. H. C. Powell Dr. L. H. Appleby
Dinner Dr. W. T. Ewing
Dr. D. D. Freeze Dr. J. Christie
Dr. C. H. C. Bell Dr. J. T. Wall
Dr. T. H. Lennie Hospitals
Credit Bureau Dr. H. H. Milburn
Dr. L. Macmillan Dr. F. C. Brodie
Dr. J. W. Arbuckle Dr. A. W. Hunter
Dr. N. McNeill Dr. H. H. Planche VANCOUVER MEDICAL ASSOCIATION
Founded 1898. Incorporated 1906.
PROGRAMME OF THE 30th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on Agenda.
lE'n'ft
1927
Dec.
1928
Jan.
Jan.
Feb.
6th—General Meeting:
Papers—Dr. Chas. Edwin Sears, of Portland, Ore., "Some
Aspects of Splenic Disease."
Dr.   Karl   Henry   Martzloff,   of   Portland,   Ore.,
"Carcinoma of the Cervix Uteri."
3rd—General Meeting:
Paper—Dr. H. H. Pitts, "On the Pathology of the Thyroid
Gland."
Dr. T. H. Lennie, "Surgery of the Toxic Goitre."
17th—Clinical Meeting.
7th—General Meeting:
Papers—Dr. R. E. Coleman
and
Dr. H. Macmillan
"Relation of
Carbohydrate Metabolism
to Major Operations."
Feb.       21st—Clinical Meeting.
March     6th—General Meeting:
Paper—Osier Lecture, Dr. C. H. Vrooman.
March 20 th—Clinical Meeting.
April      3rd—General Meeting:
Paper—Programme to be arranged.
April     17th—Annual Meeting.
Page 100 Why Do Many Leading Physicians and Hospitals in
Foreign Countries Buy Victor X-Ray Equipment?
Dr. A. Mayoral, Ponce,
Porto Rico.
IN every civilized portion of this ^
great, wide world, you are sure
to find a group of men outstanding in their respective professions, because they are inspired
in their aim to render fellow men
a service eminently better than
the generally accepted standard.
Where could such a high motive
register greater benefits to humanity than through the physician in
his community, clinic or hospital ?
The physician so inspired will invariably prove to be one who
insists on having the best that
science and research offer in
drugs, instruments and equipment
that comprise his armamentarium.
Why is Victor equipment found
in use in all parts of the world,
notwithstanding the fact that foreign manufactured equipment can
be bought at prices considerably
lower? The answer seems obvious
enough. There is always a sufficient number of physicians and
institutions who appreciate the
advantages in having the best
equipment available for their
individual work, to justify the investment in a research and manufacturing organization that make
possible this super-quality.
It is of more than passing interest to add that this class of
business has made Victor X-Ray
Corporation the largest organization in the world specializing in
the manufacture of X-Ray and
Physical Therapeutic apparatus.
World-wide Victor Service is
available through 48 service
organizations established in 34
different countries, in addition
to the 40 located in the. principal cities of the United States
and Canada.
2012 Jackson Boulevard   VICTOR X-RAY CORPORATION
^   XrRAY
Diagnostic and Deep Therapy
Apparatus. Also manufacturers
^      of the Coolidge Tube ,j
Vancouver Branch:   Motor Transportation Bldg., 570 Dunsmuir St EDITOR'S PAGE
The Editorial Staff desires to tender to all patrons of the Bulletin,
readers and advertisers alike, its best wishes for a Happy and Prosperous
New Year.
Periodically, for the visitation has a distinctly seasonal aspect, the
"detail" men descend upon the doctor. They appear to come, as we have
indicated, in groups, as if a sudden inspiration had mutually affected the
houses they represent. At times scarcely a day will pass for a week or
more without its appointed visitant, followed by a quiescent period during which the appearance of the familiar figure with the familiar bag
will almost fade from memory.
Always they are, at all events, faintly welcome, if only with the welcome of relief in finding that the unknown visitor, even though he is not
the valued patient we had hoped to find, at all events has no gold bricks
to sell. In his presence at least we have not that peculiar incarcerated
feeling we experience when the well-known, high-pressure salesman fixes
us with his glittering eye and defies us to move until or unless we weakly
acquiesce in the mandate which bids us "sign here." Assured, then, with
relief that we shall not be called upon to exhibit pusillanimous hesitation
in getting in on the ground floor of an oil well after the manner of Mr.
Rockefeller, and with the same assured results, or on the top storey of a
gold mine, following the example of Mr. Guggenheim, with the certainty of a similar reward, or to feebly jeopardize our present success and
future salvation by an uncertainty in the wisdom of purchasing the entire
knowledge of the world in 24 volumes, illustrated with coloured plates
and in a variety of bindings, samples of which by an incomparable sleight
of hand are whipped out from some remote recess in the person of the
tormentor and exhibited to our astonished gaze; assured we have nothing
to. fear, we can even smile benevolently on the "detail" man. Is he so
named because he is detailed to call particularly upon us, or is it that he
agrees to enter into details with regard to the products he recommends to
our attention, or is it, perish the thought, that interviewing us is, after
all, a mere detail in his daily round?
The method of approach is variable. Some come with regularity over
such a length of time as to have almost a personal interest in us. Their
products are, it is taken for granted, widely known and freely used, their
house, for this recent continent, is already verging upon antiquity. The
greeting is mutually that of long-parted friends and conversation is brisk
from the onset. Then we have the essentially business type who "represent so-and-so" and would "like to call our attention to such-and-such
a product," samples of which and "literature" (where do they gather the
odd shapes, size and colours of their pamphlets and blotters?) are placed
upon the desk, and leave is taken. The evidently scientific knowledge
exhibited by some of these visitants would confound the very elect. Is
the subject a preparation, say, adjuvant to the treatment of diabetes; in
a peculiarly flattering way we, of course, are presumed to be an individual
to whom the latest biochemical jargon is A B C, while the few facts in
Page 102 the case are suitably bridged with yards of plausible theory. And so,
more samples, more blotters, a cordial pressure of the hand, and away.
Somehow the office feels empty. We are left staring at the collection of
small bottles, boxes and literature, while the presence which animated
them has gone. The samples seem to shrink in value and the waste-paper
basket yawns. We have wondered, when these drug houses manufacture
such nice lines of perfumes, soaps, shaving creams and so on, whether a
selection of these articles might not leave with the doctor a more lasting
impression.
The detail man is quite human, he has a family and a home and joys
and troubles. He has curious information about all sorts of doctors in
all sorts of places and is quite interesting on the subject of his travels if
his professional talk bores one. As an institution, he seems to be permanent,
to be accepted with suitable resignation.
NEWS AND NOTES
The December General Meeting of the Vancouver Medical Association was held in the Auditorium on Tuesday, the 6th. Seventy-three
members were present and the president, Dr. A. B. Schinbein, occupied the
chair. After the minutes of the special meeting on November 29th had
been read and adopted, Drs. G. O. Matthews and E. J. Curtis were unanimously elected to membership. As there was no further business, the
■ president introduced the speakers of the evening, Drs. Chas. E. Sears and
Karl Henry Martzloff, of Portland, Ore.
Dr. Sears gave an address on "Some Aspects of Splenic Disease." He
presented a highly instructive and intensive study of the known facts
with regard to the histology and physiology of that interesting organ, the
spleen. He then correlated these findings with the clinical picture presented in the various diseases in which the spleen is involved. He mentioned particularly the important relation that the spleen bears to haem-
olytic jaundice, and later showed some interesting photographs and micro-
photographs of spleens that had been removed. In the lecturer's hands,
splenectomy has given splendid results, and the whole tone of his address
went to show that this procedure is not the bugaboo it has been hitherto
considered.
Dr. Martzloff dealt with surgical treatment of cancer of the cervix
uteri and the criteria for prognosis following operation and, gave a resume
of an interesting study of 387 cases from the records of the Johns Hopkins Hospital. Dr. Martzloff classifies cervical cancer according to the
predominating variety of cell found. These 387 cases were thus divided
into three large groups. Dr. Martzloff's lecture was based on 146 of these
cases because they fulfilled the following conditions:
1. The patients were all operated on.
2. They all survived operation and left hospital cured.
3. Their present status is known (except in the case of some
who were lost track of after being traced for five years. These
are included in the five-year cures).
Page 103
«■■ ■ 'r;.. if I
'
Classification according.to predominating variety of cell:
1. Spinal'cell cancer 30
(Predominating cells characterizing this yariety are morphor
logically similar to cells seen in the superficial zone of the
stratum mucosum of the normal stratified epithelium.)
2. Transitional cell cancer _ -^ ^—^90
(Predominating cells resemble those of the cervical epithelium
forming a well-defined zone of cells, limited above by the
characteristic spinal cell layer and below by the distinctive
single-celled basal layer.)
3. Spindle cell cancer l 17
(The deeply stained nuclei here seen are closely placed and
separated by only a small quantity of cytoplasm.)
4. Adenocarcinoma    9
Regarding prognosis, Dr. Martzloff stated the factors that influence
the chances of an operative cure are: (1) Extension or metastasis when
demonstrable in either the regional lymph nodes, adnexa, bladder, rectum
or pericervical tissues, render ultimate operative cure impossible. (2)
Extension of the cancer to the corpus uteri without extension elsewhere
impairs the chances of ultimate cure but by no means obviates it in
spinal celled cancer. (3) Extension to the vagina in otherwise operable
patients is more serious than uterine extension. (4) Duration of symptoms beyond eight months is sufficient to put the patient outside the scope
of an operation. Regarding the eight months' time limit. In the case of
spinal celled cancer this is probably too arbitrary, and certainly no such
arbitrary duration can be fixed for the adenocarcinoma. Curettage for
diagnosis several days before operation does not affect the prognosis in the
opinion of the lecturer. Of epidermoid cancers the spinal celled variety
offers the most favourable prospect and Dr. Martzloff showed cures in
63.6 per cent, of operable cases. In the transitional cell type this is reduced
to 46 per cent., while with spindle celled cancer it is as low as 14 per cent.
The adenocarcinoma are the most hopeful, cures being obtained in 75 per
cent, of the cases.
At the close of the addresses a hearty vote of thanks to the speakers
for their kindness in coming to Vancouver and attending the meeting of
the Association was carried unanimously.
A PRACTICAL APPLICATION OF THE TRANSVERSE
ABDOMINAL INCISION
Communicated by Dr. H. Wackenroder.
Among recent medical visitors to the city was Dr. Bakes, Primarius
of the Surgical Clinic at Brunn, Czecho-Slovakia. On request, Dr. Bakes
kindly consented to perform an operation at the Vancouver General
Hospital.
The case was one of a pyloric lesion in a man, where it was thought
that a gastro-enterostomy would be a suitable procedure. Like many or
most surgeons on the European Continent, this, operation is seldom con-
Page 104 sidered necessary by Dr. Bakes. Where the English or American surgeon
employs gastro-enterostomy, the European surgeon usually prefers resection. In this instance, owing to the limited time at his disposal and
to the fact of the absence of the special instruments used in the operation,
Dr. Bakes intended, if circumstances permitted, to perform a gastroenterostomy. However, on exposure of the lesion, a mass, apparently carcinoma, was found, and Dr. Bakes considered a resection imperative. The
type of operation selected was Bilroth 1 as being the most applicable, although the operator as a rule preferred other methods. The resection
was difficult and tedious but not otherwise remarkable. Silk was used
throughout and the omentum sutured over the line of incision. An interesting feature was the skin incision used by Dr. Bakes, which was a horizontal one. This incision is preferred for the following reasons: (a) it
gives unexcelled exposure for gastric work, (b) it is never followed by
hernia, (c) it may be termed a physiological incision in that no muscles
are severed and the aponeurosis, of which the fibres run transversely, are
cut with the grain and not across, as in the usual vertical incision. The
importance of this incision, in which the rectus muscle is mobilized, and
displaced outwards, is that when the patient strains the natural tendency
of the wound is to close.
Dr. Bakes' visit to Canada was primarily concerned with big-game
hunting, and it is satisfactory to know that the doctor was able to secure
a few specimens to add to his already large collection.
A SATISFACTORY METHOD OF OBTAINING
URINE FROM MALE INFANTS
Dr. W. T. Ewing.
Some time ago I was called to see a baby boy of two years of age
whose symptoms indicated a probable pyelitis. The usual difficulty in
getting a sample of urine was present. The baby always "wet his napkins."
I described to the mother the test tube and adhesive plaster method of
obtaining the specimen and she agreed to try it. However, at the two
following visits I was always told that something or other interfered
and resulted in a failure to get the test tube. I then pointed out the
seriousness of the situation and the urgent necessity of getting the sample.
She finally informed me that the difficulties and discomfort of the test
tube method, as well as her own hesitation in proposing the following alternative, had, in reality, been responsible for the delay. The method
suggested was the use of a rubber condom instead of the hard glass test
tube. I agreed at once and the results certainly proved that this is a
very simple, efficient way of obtaining such specimens. The following
morning the sample in its rubber container, flattened out like a miniature
hot-water bottle, lay on the dresser, and the microscopic examination
confirmed the diagnosis.
Page 10%: HOLLYWOOD SANITARIUM
We are constantly reminded that mental disease is on the increase in
British Columbia as elsewhere. The tendency of today is to regard mental
disease as being analogous to physical disease, and to get away from the
old idea that there is something disgraceful or humiliating about mental
sickness. In line with this our hospital system of treatment for diseased
minds is constantly being improved, institutions are more comfortable
and are designed with a view to promoting that happiness and contentment of mind which are so essential in aiding speedy recovery.
Many families in which there is a sufferer from mental disease are
loath to commit the invalid to publicly-owned institutions, as unfortunately they feel that a stigma attaches to anyone who has been in what is
usually known as an Asylum. To meet the needs of people who can afford to pay within reason for the care of afflicted members of their family, private hospitals are growing up all over the country. B. C. is
fortunate in possessing a very modern and up-to-date private hospital for
the care of mental cases in Hollywood Sanitarium, of which Dr. J. G. McKay is medical superintendent.
Every medical man in Vancouver and its environs knows of Hollywood Sanitarium, but it is perhaps not sufficiently known to other members of the profession throughout Western Canada, though it draws its
patients from a wide field. The Sanitarium has recently been very much
enlarged and a great deal of modern equipment has been added, so that it
The Lounge
Page 106 Sun Porch
is now in a position to take care of 40 patients, and provides for all the
modern therapeutic methods deemed necessary and useful by advanced
alienists. In fact we are informed that there is no private institution
west of Ontario which is as large and fully equipped.
The building is beautifully situated in large grounds. Entering the
institution one sees large comfortable sitting rooms, with fireplaces, where
patients are sitting smoking and reading or engaged in conversation. On
this floor we find a large sun room heated and available at any time of the
year, a billiard room with standard table, and what is of greater impor-
trance, a room specially designed for occupational therapy, which is becoming a very prominent feature in the treatment of mental cases.
In the older section of the building are some very luxurious suites for
private patients, with fireplaces and separate bathrooms. The newer part
of the building is two stories in height and the floors are exactly similar
so that a description of one will suffice. One notices everywhere the
tendency to depart from the old wire gratings and the restrictive type of
building. In place of the steel mesh that used to darken the windows and
exclude light, one finds thick plate-glass panes in steel sashes, which are
almost equally unbreakable but do not convey the idea of restraint. On
each side of the building are long verandahs, screened in and heated by
steam radiators, which allow of exercise and fresh air in winter and provide comfortable sitting-out places for the summer. The effect of sunlight
in the treatment of mental trouble is well known.
Page 107 M
On each floor are special arrangements for hydrotherapy and physiotherapy. There are bath rooms fitted up with special devices for continuous warm baths, known as the finest remedy for excited or maniacal patients. Here, too, are showers and various forms of baths. In other rooms
are quartz-light apparatus, the light being used as both a sedative and a
tonic, the latter especially inj depressed and melancholic cases. Electric
bed baths where patients may be treated in the recumbent position, occupy other rooms.
The details of building have been very carefully worked out, and
every precaution has been taken to guard against danger from fire. Escapes are provided in the form of chutes whereby patients can be lowered
rapidly and safely without fear of accident or mishap. The ventilation
is forced, and can be maintained at perfect efficiency if the room is tightly
closed. The heating is by steam, and is maintained by a furnace which we
were informed by the engineer is the only one of its type on this side of
the line. It is especially efficient and keeps the entire building piping hot
with 2 ozs. of steam to the square inch. This is done by the Hoffman
Vacuum device. The basement in fact is a very interesting part of the
building as here one finds a gymnasium, small but fully equipped to provide exercise and recreation for the patients who are able to avail themselves of it, and also a workshop.
The kitchen arrangements are similarly very complete. A large Frig-
idaire room has been installed for the preservation of perishable supplies
and the kitchen itself is well equipped with all modern apparatus.   A 450-
A Standard Bedroom
Page 108 Physiotherapy Room
gallon tank supplies hot water for all the floors. In addition to the main
kitchen, a small diet kitchen has been equipped upstairs for special dietetic
purposes. Those patients who are not necessarily confined to their rooms
meet at meals in the large dining room furnished with separate small
tables, and have at their disposal large comfortable sitting rooms on each
floor, brightened with big windows and big fireplaces.
The whole institution conveys a very homelike impression to the
visitor and is not at all suggestive of a hospital. There are one or two
suites specially equipped with separate sitting rooms and bath rooms where
patients who have indulged in alcoholic excess may spend a few quiet
days in perfect privacy recovering from the ill effects of their indiscretion.
The staff of the hospital in addition to the medical superintendent
consists of ten nurses at whose head is Miss Best as matron. The latter is
particularly delighted with the new additions and with the careful attention that has been shown in the detail of what may be ca.-ed the housekeeping side of the institution. The floors, for instance, are covered with
a neutral-tinted linoleum which is particularly easy to keep clean. The
cupboard space and household arrangements in general are ample and very
convenient and reflect considerable credit on the ability of Dr. McKay
who designed the building himself.
We would suggest to any of our readers they pay a visit themselves
to this sanitarium where they will receive a cordial welcome and see for
themselves what a complete and practical institution it is. B. C. MEDICAL ASSOCIATION NEWS
The Executive of the B. C. Medical Association takes this opportunity of wishing all its members a very Happy Christmas and all Prosperity
in the New Year.
Our Executive Secretary, Mr. C. J. Fletcher, has unfortunately been
absent from duty for the past three or four weeks suffering from a mild
attack of rheumatism. It has given him much pain and prevented him
from coming to the office. We are glad to report that he is almost well
and will soon be on duty again.   He has been greatly missed in the office.
Dr. W. A. Coburn, of Nanaimo, has been acting as a "locum" at
Lake Cowichan for Dr. E. L. Garner, of Duncan.
It is with great pleasure that the Executive has learned that a third
grant of $30,000 has been made to the Canadian Medical Association for
extra-mural, post-graduate medical education by the Sun Life Assurance
Company.
This company merits our warmest gratitude for its generosity, which
has been expressed in so sensible and practical a fashion. Following the
plans of last year we are working together with the Vancouver Summer
School Committee to arrange a tour of speakers under this scheme which
will coincide with the meeting of the Summer School in Vancouver in
1928. Our Secretary, Dr. Theo. H. Lennie, has written to Dr. Routley,
Secretary of the C. M. A., asking him to include Kamloops, Victoria and
Nanaimo in the itinerary.
We are hoping further to have an Autumn tour on similar lines but
with more time spent at each place. The large attendance at each of the
meetings this year shows the value attached to this work by the members
of the various towns which were visited.
Dr. and Mrs. G. S. Purvis, of New Westminster, are to be congratulated on the birth of a daughter.
#        «• *
The regular monthly meetings of the Fraser Valley Medical Society
have been well attended this Fall, and a good deal of interest taken in
both the lectures and the clinics. On November 8th, Dr. J. Christie gave
an address on the subject of "Skin Diseases in General Practice." On November 22nd, the evening was devoted to "A Study of the Kidney, Its
Anatomy, Physiology and Pathology," with a discussion of the later renal
function tests and differential diagnosis of nephritis and nephrosis.
The Clinic was in charge of Dr. E. H. McEwen, of New Westminster.
Dr. Theo. H. Lennie, of Vancouver, took as his subject "Toxic Goitre" at
the meeting held on December 6th.
Dr. F. P. MacNamee, who has recently been in charge of Dr. Keyes'
practice during the latter's absence in Vienna, will be associated with the
Kamloops Clinic on or about the 1st of January, 1928.
Page 110 The following letter was received by the B. C. Medical Association
from the Secretary of the British Columbia Hospitals Association:
"At the 1927 Convention of the British Columbia Hospitals Association, held in Victoria, the following resolution was presented and carried
unanimously, and I take pleasure in advising you of the same as directed.
"It having come to the observation of this Association of the kindness and prompt attention afforded by the physicians and surgeons of this
province in the hospitals and in the out-lying districts in rendering aid to
the sick without consideration as to remuneration, that this Association
goes on record as expressing their deep appreciation of the services
rendered, and that a copy of this resolution be sent to the British Columbia Medical Association."
Ill
We extend our congratulations to Dr. R. C. and Mrs. Weldon on the
birth of a son on December 7th.
LIBRARY NOTES
The Library is situated in 529-531 Birks Building, Granville Street,
Vancouver, B. C.
Librarian:    Miss Firmin
Hours:   10 to 1, 2 to 6
SOME RECENT ADDITIONS TO THE LIBRARY
"U. S. History of the War," Vol. II.    Administration.    1927.
"Early Diagnosis of the Acute Abdomen," Cope.    4th Edition.    1927.
"Treatment of the Acute Abdomen," Cope.    1926.
"Medical Clinics of North America," Vol. XL   No. 2.   St. Louis number.
"Diseases of the Eye," Swanzy.    13th Edition.    1925.
"Clinical Interpretation of Blood Chemistry," Kilduffe.    1927.
"Birth Injuries of the Central Nervous System," Crothers & Putnam.
1927.
"Surgical Clinics of North America," Vol. 7.    No. 24.
"Clinical Disorders of the Heart Beat," Lewis.    1925.
"Recent Advances in Hematology," Piney.    1927.
"Regional Diagnosis in Affections of Brain and Spinal Cord," Bing. 1927.
"Respiratory Function of the Blood," Barcroft.    1925.
"School of Hygiene & Public Health," Johns Hopkins.   Vol. VIII.    1927.
"T. B. Disease of the Hip Joint," Perkins.    1926.
"Surgical Clinics North America." Vol. 7. No. 3., Pacific Coast number.   October, 1927.
"Medical Clinics North America." Vol. XL No. 3. Tulane University
number.    November, 1927.
"International Clinics."   September, 1927.
"Urography," Braasch.    1927.
"Diagnosis and Treatment of Diseases of the Stomach," Rehfuss.
"Periodic Health Examinations," Fisk & Crawford.
"Medico-Legal Injuries," McKendrick.    1927.
"Jervis on Coroners," Danford Thomas.    1927.
"Infections of the Hand," Fifield.    1926
Page 111 :H*
In 3 vol-
"Recent Advances in Ophthalmology," Duke-Elder.    1927.
"On Hernia," Sir Astley Cooper.    1844.
"A System of Anatomy and Physiology." Alexander Monro.
umes.   Published in 1795.
"A Course of Chirurgical Operations Demonstrated in the Royal Garden
at Paris." by Monsieur Dionis. Trans, from the Paris Ed.     1733.
REVIEWS
"Infections of the Hand," Lionel R. Fifield, F.R.C.S., Eng., Surgical
Registrar, London Hospital.   H. K. Lewis & Co., London.   9/—.
This small book is by the same author as "Minor Surgery," a copy of
which is in our library.
Mr. Fifield, who has had many years' experience in the accident room
of the great London hospital, is well qualified to write such a book The
book is much smaller than Kanavel's classic monograph and is designed
for use by students, house surgeons and practitioners. It is, though small,
wonderfully complete and carefully written, the arrangement being particularly good. The first 40 pages are devoted to the anatomy of the
hand and fingers, with over 20 diagrams and reproduced dissections. The
various ismpler infections are dealt with and the more serious developments of palmar abscess, tendon sheath infections, osteomyelitis and
lymphatic infections, fully covered and illustrated. The chapter on prognosis is very concise and useful, and withal this little book will be found
very useful and does the author no small credit. It is well bound, on
good paper and carefully indexed, and is highly recommended to the profession, containing, as it does, all of the essentials.—L. H. A.
"International Clinics," 37th Series, Vol. III., September, 1927. J. B.
Lippincott Co., Montreal.
"International Clinics is one of our most valuable medical journals. Its editorial board, composed of medical authorities of international
note, is sufficient to guarantee authoritative and valuable articles. The
main part of this number is devoted to diagnosis and treatment.
Wilson, in an article on the electrocardiographic study of the various
forms of heart block, shows that by this means any type of block may
be demonstrated, the type specified and the amount of myocarditis determined. It is only by such means that one can outline a systematic
course of treatment or anything like a definite prognosis be given.
Colitis is clearly and concisely described by Brown of Johns Hopkins.
He emphasizes the necessity of studying each case individually in an endeavour to arrive at an etiological diagnosis. His classification will aid
to this end. There are two great subdivisions, namely, catarrhal and ulcerative colitis; the former divided into that due to drugs; to alimentary
irritants; to endocrine disturbances; to exogenous infections; to intestinal
parasites; colitis of gastric origin; colitis of pancreatic origin; post-operative colitis and the so-caLed mucous colitis where psychogenic factors
play a major role. Ulcerative colitis has four subdivisions; the dysenteric,
bacillary and amoebic; the malignant; the tuberculous and the so-called
non-specific ulcerative colitis. The last named is the one of which we
know the least.   Many theories prevail; there are as many modes of treat-
(Continued on Page 117)
Page 112 The
British Columbia Laboratory Bulletin
Published monthly  September  to  April inclusive  in   co-operation  with  the  Vancouver
Medical Association Bulletin, in the interests of the Hospital  Clinical and
Public Health Laboratories of B. C.
Edited by
Donna E. Kerr, m.a., of The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbia Hospital, New Westminster;
Royal Inland Hospital,  Kamloops;   Tranquille  Sanatorium;  Kelowna  General  Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.   Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Volume 2
JANUARY, 1928
No. 4
CONTENTS
A Chech on the Accuracy of Blood Counts Pottinger
The Clinical Value of the Glucose Curve Kerr
Comparison of Immediate and Delayed Plating on Milk Counts—Dowsley
Cross Aggulation 1 Kerr
Editor's Note
Christmas and New Year is the time of giving. We hope that some
of our collaborators will be inspired and give a little contribution to the
B. C. Laboratory Bulletin. During the past year at the Vancouver General Hospital Laboratories conditions (due to lack of space, volume of
work, and changes and ill-health of the staff) have not been conducive
to the production of suitable material for the Bulletin, but we feel that
the rest of the hospital laboratories must have some material that will
make up for this deficiency.
A CHECK ON THE ACCURACY OF BLOOD COUNTS
W. Pottinger, V. G. H. Laboratories.
In conformity with our general policy of using every possible check
on sources of error in this laboratory, we have come to rely upon the
blood smear examination as a check on the technical errors inherent in cell
counts and haemoglobin estimations. Assuming that the errors of the apparatus are insignificant because of our method of standardization, there
still remains the unavoidable potential errors of inexperienced workers,
and fatigue. We, therefore, make it a practice of holding all blood smears
for examination by a single experienced worker. In this way gross errors
are detected, and if there is an apparent discrepancy between the blood
count and the smear, the count and the smear are repeated.
With the red count and hxmoglobin a more detailed examination of
the smear is required. First, the size of the reds is actually measured
with a micrometer, also the shape and staining are noted. Normal staining indicates that the cells contain the normal proportion of hxmog'obin.
A normal red count, therefore, would yield a smear showing cells of
Page 113 IIII I
li
\m
normal size, shape and staining, and the colour index would be one, or
close to one. On the other hand, a case of pernicious anaemia with a low
red count and high colour index would show the red cells irregular in size
and shape and many of the reds would be macrocytes, i. e., 10 microns
and over. The count with the low colour index (e. g., 4,000,000 red
cells and haemoglobin 50%) would have pale staining and some under
sized reds, usually found in the chlorotic type of anaemia.
In some of the secondary anaemias the colour index may be normal;
the cell count and haemoglobin both being correspondingly low or the
index may even be slightly high, though most commonly the index is low.
There is also an irregularity in the size of the red cells in any anaemia.
By this method of checking the chances of a gross error in blood
counts are eliminated.
THE CLINICAL VALUE OF A GLUCOSE CURVE
Donna Kerr, M.A., V. G. H. Laboratories.
The following is a re-examination of the 102 Glucose Curves recorded in this laboratory between January 1, 1926, and November 1,
1927, for the purpose of reviewing their clinical interpretation.
At present it is usually possible from the glucose curve to confirm
the diagnosis in mild cases of diabetes, to diagnose potential diabetes and
establish cases of renal glycosuria.
In cases of suspected diabetes it is only necessary to do a blood sugar
curve in those showing a normal fasting blood sugar. In this series, nine
curves were done, in which the fasting blood sugar was markedly increased. In such cases we consider the inconvenience and expense to the
patient exceeds any value from the curve. When consulted by the physician prior to the arrival of the patient in the laboratories, we run
through the fasting specimen and if this blood sugar is not sufficiently
high to make a diagnosis, we complete the glucose curve. The extra
time and inconvenience of this to the laboratory is more than offset by
the soundness of the principle.
Twenty-three or 22.5% of the total curves proved to be diabetic,
according to our interpretation of the curve, and in all of these the fasting
specimen was normal, or very nearly normal. The characteristic feature
of the curves so diagnosed is that they fail to return to the normal fasting
level two hours after the ingestion of the glucose. This is a more important point than the height of the curve.
Eight cases were classed by us as potential diabetes. In these the
blood sugar rose above 180 mg. per 100 cc. blood three-quarters of an
hour after the glucose. We consider that these cases should be watched
very closely for any clinical signs of diabetes. When associated with
clinical symptoms of "rheumatic" pains or persistent infection, restriction of the carbohydrates frequently improves the condition.
In this series of curves we diagnosed fourteen as renal glycosuria;
that is, they showed a normal blood sugar curve and yet excreted sugar
in the urine. Four showed less than 0.1% of sugar, while the other ten
showed up to 2.5%. In one curve the fasting blood sugar was 78
mg., and the highest value after the glucose was 80 mg., yet sugar was
excreted in the urine in as high concentration as 2.5%.    These cases
Page 114 showed no marked clinical signs of diabetes, and for the most part were
examined because they showed sugar in routine urine analysis for life
insurance.
Summary.—The glucose curves are useful in diagnosing mild
diabetes, potential diabetes and renal glycosuria, especially in the accidental finding of glycosuria in routine urine examinations.
3fr S{* #
COMPARISON OF IMMEDIATE AND DELAYED PLATING ON
MILK  COUNTS
Gertrude O. Dowsley, B.A., V.G.H. Laboratories.
Our routine method of plating milk samples includes a period of
several (4-5) hours, during which the sample stands in the water dilution
bottles or in the milk can at ice-box temperature, before plating. In the
case of the hospital milk samples, they are delivered to the hospital
refrigerator room about 8 a.m. and kept in this cold room until 1 p.m.,
when a sample is taken and plated. In the case of the city milk, the
samples are brought to the laboratory between 9 and 10 a.m. and are
immediately diluted in water dilution bottles and placed in the ice-box
until about 2 p.m., when they are plated. To determine whether the
keeping of the milk in the dilution bottles or in the can at ice-box temperature made any significant difference to the final counts, as contrasted
with immediate dilution and plating, the following experiments on the
hospital milk were carried out.
One sample was taken from the milk can at 8 a.m. and placed in
a water dilution bottle. The first set of plates were then made, after
which the dilution bottle was placed in the ice-box. At 1 p.m. a second
sample was taken from the same milk can in the refrigerator room, diluted
and plated. At the same time a third set of plates was made from the
dilution bottle remaining from sample one, which had been, as noted,
in the laboratory ice-box since 8 a.m.
The following are the results after the usual 48 hours incubation.
The table shows that in some cases the counts were higher in the second
and third sets than in the first, while in others they were lower. The
variations, however, were small in consideration of the inherent errors
of the method, and therefore the factors described above do not appreciably affect the final milk count.
Date.
Sept. 14, 1927 ..
Sept. 21, 1927-
Sept. 28, 1927 1
Oct. 5, 1927-
Oct. 12, 1927-
Oct. 19, 1927-
Oct. 26, 1927 -
Nov. 1, 1927.
Nov. 9, 1927-
Nov. 16, 1927-
Set 1. Samples
Taken at 8 a.m.
Plated at 8 a.m.
36,000
35,000
80,000
21,400
10,600
15,700
13,300
10,500
5,400
10,200
Set  2.   Samples
Taken at 1 p.m.
Plated at 1 p.m.
38,400
780,000
82,000
11,800
6,400
6,500
13,900
11,200
7,800
9,300 CROSS  AGGLUTINATION
Donna Kerr, M.A., V.G.H. Laboratories
The routine procedure in this laboratory when supplying a suitable donor is to obtain an individual in the same group as the recipient
and test out the donor's cells with the patient's serum, and the patient's
cells with the donor's serum. This test is done in duplicate, one set
being put in the ice-box and the other at room temperature for one
hour, and if there is no agglutination of cells the donor is used. The
incidence of such agglutinations within the group was calculated in 23 8
cases and found to be only 13, or 5.5%. The majority of these occurred
in group 3, and, considering the small number in group 3, by far the
highest percent., that is, in 28 cases, 7 or 25% showed agglutination.
The table shows the usual distribution in the groups. Group 4
has the largest number, with group 2 running a close second. A few
are in group 3, and only an occasional in group 1. There seems to
be no difference in the distribution according to sex except that a
greater number of females occurred in group 4, i.e., 53.6%, while only
49.5% of the total males fall in group 4; this is a negligible difference.
In this series, taken from this year's records, there were no cases
in which it was impossible to obtain a suitable donor. In one case four
donors were tried before a suitable one was found. Only once, since
this technique of cross agglutination has been adopted, have we been
unable to supply a donor. This was for a case of pernicious anaemia.
Twelve donors were tried, and more would have been tried if the patient
had remained in hospital.
From these figures it would appear that a donor in the same group
might be used, in an emergency, without a cross agglutination, with
only 5.5% risk, and thus save at least V/2 hours.
Group I. Group II.
Cross Cross Cross Cross
Satisfactory.      Unsatisfactory.        Satisfactory.        Unsatisfactory.
Female          6 ' 1 29 1
Male    .       1 0 38 0
Baby         1 0 12 0
Total        8 1 79 1
Group III. Group IV.
Cross Cross Cross Cross
Satisfactory. Unsatisfactory. Satisfactory. Unsatisfactory.
Female          7 2 52 0
Male          9 5 48 4
Baby         5 0 16 0
Total      21 7 116 4
Page 116 {Continued from Page 112)
ment. The Mayo Clinic reports favourably on a mixed vaccine made
from Burgen's diplococcus and a bacillus often found in conjunction
with it, but at Johns Hopkins the results have been discouraging. At this
clinic they have found that in severe cases surgery offers a better chance
than non-surgical treatment, this view also being held by Boas and
Schmidt. Very favourable results are obtained in most cases of the other
types where the diagnosis can be reached and the above classification will
point to the treatment necessary.
Wm. A. Steel of Philadelphia gives a short but complete differential
diagnosis of thrombo-angeitis obliterans or Buerger's disease with accompanying illustrations in colours. The conditions most apt to be confused
with it are varicose veins, senile sclerosis, symmetrical anaemia and diabetic
anaemia; the three cardinal symptoms of Buerger's disease being intermittent claudication, erythromelalgia and the absence of pulse. The main
part of the article is taken up with the intravenous sodium citrate treatment with results obtained in one hundred cases. This treatment combined with local heat and potassium iodide seem to have given favourable
results in the hands of the writer, although Ginsburg and others have
found little satisfaction it it.
There is an excellent article by Held and Gray of New York on differential diagnosis and treatment of gall bladder disease. The subject is
taken up fully and although the article is long, it is full of information.
The main portion considers in detail the differential diagnosis with some
useful points on X-ray examination both with and without the aid of
dyes. The treatment is taken up more from a medical than a surgical
standpoint.
Phillips describes in a very clear way the treatment of peptic ulcer as
carried out at the Cleveland Clinic. The dietary regime is outlined in
detail with emphasis on the fact that treatment must be modified according to the indications of the individual case.
Goldstein makes a very thorough review of the literature on the subject of pneumococcus meningitis and endocarditis. The article is a lenghty
one, mainly due to twenty case reports given in full. He concludes that
it is possible with early diagnosis and prompt and active treatment to
save some of the cases of pneumococcus meningitis. Early repeated spinal
and internal lavage and drainage, with the injection of serum or antibody
solution and the joint use of ethylhydrocuprein hydrochloride injections
will probably bring the best results.
There are other interesting articles in this number by competent
men. There is always a small section devoted to medical history, a subject of interest to all medical men, the particular one in this issue being
devoted to Greek medicine.—W. H. H.
THE DIAGNOSIS OF ABDOMINAL TUMOURS
Being an address delivered before the Summer School of the Vancouver Medical Association by Dr. H. C. Moffitt, Professor of Clinical Medicine, University of California.
Either general or local symptoms may awaken suspicion of intra- abdominal malignancy which is the condition with which we have most fre-
(Continued on Page 120)
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Page 119 {Continued from Page 117)
quently to deal. Abdominal pain always means something—it may be the.
first hint of malignancy. Its interpretation may be difficult but an explanation should be carefully sought. From the nature of abdominal innervation we must not be surprised to meet with distantly referred sensations, or to be obliged to explain many vague discomforts rather than
acute pain. Abrupt change in well-established habits of body should be'
given due attention. Loss of or queer changes in appetite, with vague distress after eating, is often the first and most valuable symptom of gastric
carcinoma. Constipation may mark the begining of colon irritation or
stenosis of a growth; unaccountable diarrhoea may be the earliest hint of
pancreatic carcinoma. It is remarkable how often tenesmus with mucous
and bloody stools may be disregarded by the patient or be unrecognized
by the physician.
Unusual weakness, malaise, apathy, inertia in an active individual or
definite loss of weight should demand explanation. Dyspncea on exertion,
a rapid pulse, slight ankle oedema and other signs of myocardial insufficiency may misdirect attention to the heart which has been weakened by
the toxemia or anxmia of malignant disease. Execpt in lymphoblastoma,
fever is not usually an inaugural symptom of abdominal tumours, although common enough in later stages. In a remarkable case of retroperitoneal lipoma which eventually caused death, the onset and each recurrence after three operations was ushered in by malaise and temperature.
Unusual pallor, actual cachexia, more rarely pigmentation, may attract
attention of a patient or his friends to something unusual going on.
Thrombosis in any vein, but most often in the femoral without evident
cause, has been regarded with suspicion of distant malignancy since the
description by Trousseau, who was to find it later in himself as an early
indication of his stomach cancer. More dramatic events—unconsciousness
from large haemorrhage, sudden obstruction of the bowel, perforation of
stomach or colon may occasionally usher in the event.
A good history can rarely be assembled at the first sitting. Due attention must be given to the patient's description of local as well as general symptoms. Certain leads must be followed to a satisfactory explanation. Rarely the patient may himself have found the tumour. Usually,
however, we shall be concerned chiefly in helping him to describe more
clearly disturbances in function.
Although the history may at once direct attention to some particular
region of the abdomen or to involvement of a definite organ, it is a wise
rule to precede the local by a careful general examination. There is often
a peculiar f acies in abdominal disease—indicative usually of loss of weight
and suffering—cachexia can hardly be misinterpreted nor unusual pallor
overlooked. Pigmentation suggests intra-abdominal disease but does not
localize it—it may be a feature of chronic tuberculosis or of liver or
spleen affections as well as of adrenal involvement. We see it marked in
some cases of hypernephroma. In a man some years ago gradual development of deep general pigmentation, of pain in the left flank and later of
an irregular tumour in the kidney region led to diagnosis of an adrenal
tumour or hypernephroma, until fully a year later enlargement of the left
testicle showed we were dealing with a teratoma of the testicle with
Page 120 metastases in the lumbar glands. There is a peculiar vivid reddish-purple
hue of the entire body sometimes seen in hypernephromata. Two years
ago remarkable colouring of this kind was seen in a young woman with
amenorrhcea, hypertension and abdominal pain. At autopsy a remarkable
growth of the pancreas was found, instead of the suspected cortical adrenal tumour.
Certain phenomena in veins should attract attention. Slow-growing
tumours even without abdominal distension may lead to dilatation of
lateral veins in the abdominal wall. Retroperitoneal growths may cause
enlargement of small veins of the back. Regional dilated veins, particularly in right or left lower quadrants are more apt to mark underlying
inflammatory masses than tumour, and not infrequently the neighbouring
skin will show heat and turgidity. The caput medusae may arise from
tumour as well as from cirrhosis. Thrombosis of superficial veins has already been mentioned and successive involvement of many veins may occur. Thrombosis of deep veins may be shown by oedema of one or both
legs and by ascites. Both oedema and ascites may be shifting phenomena
even with complete cava block so that they may evade an occasional examination. Invasion of the renal veins by hypernephroma, with extension
into the cava and even upward to the right auricle, is frequent. Remarkable clinical pictures may result, as in a series of cases which have
come to autopsy in the University Hospital, San Francisco, in the last
five years. Death may be caused by anuria due to blocking of both renal
veins. The onset of symptoms may be absolutely abrupt as occurred in
a streetsweeper of 46, who was apparently perfectly well until 2 weeks
before entry, when he noted marked dyspnoea on exertion. A few days
later the right hand swelled, then the right side of the face. Oedema
completely disappeared three weeks after rest in hospital, but nosebleeds,
petechial and haematuria became striking symptoms. Superficial veins
were dilated over the upper part of the chest and there was intense cyanosis of the face. Signs in both lungs suggested miliary tuberculosis.
Ascites slowly developed. A tumour was never palpated, but autopsy
showed a hypernephroma of the left kidney with invasion of renal vein, ■
cava, right auricle and ventricle and multiple nodules in the lungs. In
two cases slow accumulation of ascites due to thrombosis of the cava had
pushed down inguinal herniae and probably filled the sacs. Operations
had been done in other hospitals for relief of the herniae without recognition of the hypernephroma. With complete block of the cava and hepatic
veins, sudden tender enlargement of the liver may be noted with development of dilated right lateral thoracic veins and a caput medusae. This
syndrome of Craven Moore was seen in an Italian with a huge left-sided
hypernephroma. Jacobson and Goodpasture in an article giving the literature of inferior caval occlusion, have described a case of hypernephroma
with sudden enlargement of the liver and death within 24 hours from
acidosis. A marked varicocele, most commonly on the left side, should,
of course, always suggest the possibility of a kidney or other retroperitoneal tumour—particularly a hypernephroma.
: Abdominal, like pulmonary tumours, may remain wholly latent
until metastases occur. Search for neighbourhood or distant metastases
should always be made as they may clinch a doubtfful diagnosis or decide
Page 121 iSl, ti
the question of an operation. I have seen cases of stomach carcinoma
about to be operated upon when unmistakable signs pointed to secondary
brain invasion. I have also seen patients prepared for removal of a testicle
growth when inspection showed a huge mass of metastatic glands in the
upper abdomen. Small nodules should be looked for in the skin, particularly in the neighbourhood of the umbilicus. Virchow's gland may be felt
in the right as well as the left supraclavicular fossa. Inguinal or axillary
gland invasion is not infrequent. Biopsies on glands or skin nodules may
give decisive evidence. Massive enlargement of mesenteric or retroperitoneal glands may mask the primary tumour. Examination of the rectal
shelf for nodules should never be neglected. Extraordinary invasion of
the lungs may occur without symptoms, even without signs, except to
X-ray. The importance of bone metastases must be emphasized. Cancers
of the prostate, of stomach or pancreas frequently metastasize to bones
and this tendency of hypernephromata is proverbial. The lesions in bones
may give symptoms long before the primary tumour—years before, in a
few cases of hypernephroma. This was so in a man with a tumour in the
sternum noted two years before the occurrence of haematuria. Bone as
well as other metastases of hypernephroma may pulsate strongly and simulate aneurism or sarcoma. Invasion of vertebrae by metastatic growths
not infrequently results in paraplegia. Liver metastases are particularly
frequent and often overshadow the primary growth. Jaundice, ascites,
leg oedema, partial bowel obstruction, dilatation of stomach or duodenum
may result from extensions of the growth or invasion of distant glands.
Remarkable clinical pictures result from the peculiar metastases of neurocytoma or neuroblastoma in infants or young children. A number of
these tumours have been seen both clinically and at autopsy. Robert
Hutchinson in 1907 first brought the subject to the attention of clinicians
by the publication of a series of cases with extraordinary metastases to
skull and orbits. His illustrations and those in the paper of Carter show
well the characteristics of this type of metastases known as the Hutchinson type. In the Pepper type there is great enlargement of the liver due
to multiple small nodules. Both types, however, may be seen together.
In a female negro infant of 9 months there was exophthalmos and numerous nodules were felt in the skull, some of them 7x8 cms. in size. The
liver, kidneys and adrenals formed a mass weighing 1000 grams. In an
infant boy 21 months old an enormous growth filled the entire left half
and two-thirds of the right half of the abdomen.
Extraordinary disturbances in other ductless glands together with
entire transformation of the body habitus and of the individual's personality may be caused by tumours of the adrenal glands—either benign or
malignant. Precocious development of the gonads in young children,
transformation of the sex type in adult women may be the first symptoms
attracting attention to the adrenals. Holmes, in the Quarterly Journal of
Medicine for 1925, reported the case of a young woman of 24, in whom
menstruation ceased abruptly seven years before. Excessive growth of
hair and gradual change of body to the male type began at 19. The
uterus was atrophied, the clitoris much enlarged. Pain in the right abdomen was a recent symptom and this led to discovery of a tumour in the
right flank.   This was successfully removed and proved to be a benign
Page 122 adenoma of the suprarenal cortex. Menstruation returned 36 days after
operation and continued to be normal during the nine years that have
elapsed. Abnormal hair entirely disappeared, the clitoris was reduced in
size and the feminine type of body was completely restored. These are
tumours of the adrenal cortex and, like hypernephromata, they may run a
benign or a malignant course.
On January 11, 1926, an Italian woman of 38 entered the University
Hospital. She had married at 24 and had four daughters, 12, 10, 8 and 5.
Two years previously weight was 165, on entrance it was 135. Pain had
been felt in the right lumbar region off and on for two years. Hypertrichosis had developed rapidly in the last fifteen months. Periods, until
then regular, had ceased in May, 1925. During the last three months pain
had grown worse and there was loss of appetite, weight and strength.
A rounded, somewhat reniform, elastic, irregular mass as big as an orange
was felt in the right upper abdomen. The liver was pushed downward
and tilted forward so that its rounded surface was felt. The left liver
lobe and stomach formed a prominent mass in the epigastrium, the stomach being obviously shifted to the left. The tumour moved down with
the liver and could be shifted forward and to the left. It lay above and
was apparently fused with the right kidney. A pyelogram showed the
right kidney low, the pelvis large and the upper calyces flattened. Cholecystography showed a thin small gall bladder displaced inward by a
tumour mass. Phthalein output was only 30% in two hours. An operation February 4, 1926, attempted removal of the tumour but was interrupted by haemorrhage. Death occurred the same day. Autopsy by Dr.
Rusk showed the following: The tumour with its adjacent kidney weighs
1400 grams. The kidney is normal in size. Its upper pole is compressed
and flattened by the tumour mass above it. There is no growth of tumour
tissue into the kidney substance. The two bodies are separated by the
fibrous capsule of each and intermediate loose areolar connective tissue.
The kidney is normal, except for the above-mentioned deformity. There
is no apparent dilatation of the kidney pelvis. Instead of a single renal
artery, the blood supply comes by way of several vessels. The tumour
mass itself is spherical in shape and measures 12 cm. in diameter. It is
surrounded by a thick capsule, adherent to which on the upper and anterior surface is a thin covering of the liver tissue, which remained attached
when the tumour was removed. The tumour shows prominent veins
over its surface. The surface is roughened with many fibrous tags. There
are many purplish ecchymotic areas over it in its connective tissue covering. It is closely bound to the inferior cava by what may be a thick blood
vessel. On its lower posterior border is an ear-like flap of yellowish brown
adrenal tissue, the attaching borders of which gradually thin out and
blend with the capsule of the tumour. Section of the mass shows a central cavity, about 4 cm. in diameter, which contains a yellowish-brown
fluid. The substance is divided into lobules of varying sizes, a soft, coagu-
lative necrosis and purplish areas suggesting haemorrhage. Vascular markings are not numerous. Section through the tumour and vena cava at
their attachment shows an infiltration of friable, cord-like masses which
completely occlude the lumen of the vena cava. The vena cava is blocked
along its whole extent from the diaphragm to the iliac vessels.
Page 123 Microscopic description. Tumour.—The structure consists of large,
fairly compact vascular masses or sheets of granular and fatty cells divided into lobules by connective tissue septa. The cells are large in size
and polymorphous. In some regions there is a suggestion of the arrangement seen in the zona fasciculata of the adrenals. Areas of necrosis as
well as areas of haemorrhage are common. Mitotic figures are numerous.
Best's carmine stain for glycogen showed this present in typical granular
form, distributed regionally and not diffusely as might have been expected.
Special stains for fat showed this present in abundant amounts throughout
the sections. Ovary.—The epithelial covering of the ovary varies. In
some places there is a loss of continuity which seems probly due to artefacts. Sometimes the epithelial cells are high cuboidal in type but in
other places they appear more flattened. In the routine section taken, no
follicles could be demonstrated. Corpora albicantia were common. One
such corpus reached a diameter of 4 mm., and by central softening formed
a simple cystic structure. Serial sections were made of a block of tissue.
Examination of a series of thirty-five of these showed the presence of very
occasional small Graafian follicles typical in structure. Only four such
follicles were demonstrated. Uterus.—The endometrium is swollen and
has the structure of a marked pseudodecidual reaction. It differs from
the true decidua in the absence of the hyperplastic spongy layer, and in
the congestion of the compacta which is here present but does not occur
in the ordinary decidua. In addition there are numerous foci of necrosis
surrounded by leucoccytic infiltrations in the compacta. These are present near the surface and ulcerate into the lumen. Adrenal.—In the left
gland there is a small adenomatous structure in the cortical tissue.
Profound anaemia may be caused by tumours of the gastrointestinal
tract but it is rarely difficult to differentiate this from pernicious anaemia.
Marked Ieucocytosis may be a feature of certain sarcomata but it usually
indicates a tumour of inflammatory origin or a complicating infection.
In a case of hypernephroma reported many years ago the terminal blood
picture was that of lymphocytic leukaemia. Ecsinophilia should suggest
lymphoblastoma. There is little need of emphasizing the importance of
macrospic and microscopic examinations of stomach content or of stools
or of establishing definitely the source of microscopic or macroscopic
blood in the urine. X-ray examinations should be estimated at their just
merit. Conditions to be carefully looked for should be pointed out to
the roentgenologist and the results of the examination discussed with him.
The clinician should be familiar with the interpretation of films himself.
Plain abdominal films may show many things of interest, may outline
liver, spleen and kidneys, may show the tumour itself, or calcification in
tumours, glands or veins. Not only are X-ray gastrointestinal examinations of supreme importance in diagnosis of tumours of the tract, but
they serve to show its relations to other abdominal growths and may prove
a valuable help in localization. Injection of C02 may assist in outlining
deep-seated tumours. Cholecystography and pyelography are valuable
methods if their limitations are kept in mind.
We come now to consideration of the tumour itself. We may find
palpation difficult by reason of pain, meteorism, fat or ascites. Examinations of the abdomen must often be made repeatedly, at different times of
Page 124 day, with varying degrees of stomach or bowel distension, j Both patient
and physician must be as comfortable as possible. Poultices or hot baths
may help to relax, abdominal- muscles. Shifting positions may bring hidden tumours to light. Peristalsis may be seen best toward the end of the
day. Tender areas, localized muscle rigidity, crepitus or friction must be
noted. .Itsgoes without saying that vaginal and rectal examinations must
.be insisted upon and that proctoscopy must frequently be done. The
abdomen must be explored for multiple masses. These may prove to be
the.multiple tumours of. lymphoblastoma (and here enlargement of the
spleen may-give, a useful hint) or they may be multiple gland or peritoneal metastases or multiple liver nodules from a primary source. It is
well to remember that benign pelvic tumours, especially fibroids, are common, and will not infrequently be found confusing colon neoplasms or
metastasis to ovaries or the pelvic shelf. Fxcal masses above a segment of
partially obstructed bowel may be taken for multiple tumours or may
magnify the size of the primary growth. It is by no means easy always
to distinguish tumours from masses of inflammatory exudate. Large,
stony, hard masses may form in right or left iliac fossae from the slow
extension of appendix or diverticula inflammation. Irregular hard tumours
under the liver may be due to matted masses of omentum or bowel about
an inflamed gall bladder or result from the slow perforation of a gastric
or duodenal ulcer. We have seen cases of osteomyelitis of the pelvic bones
with huge hard masses indistinguishable from retroperitoneal sarcoma
even at operation. Pott's disease may give rise to tumours of queer shape
and situation liable to be taken for retroperitoneal growths with invasion
of vertebrae. The irregular masses in the mesentery and omentum, in the
dry form of tuberculous peritonitis, may readily be misinterpreted. We
have seen some most unusual syphilitic tumours in mesentery and omentum as well as in stomach, spleen and liver.
Localization in abdominal as in brain tumours is more accurate in
the early stages before neighbouring tissues have been invaded, with resulting confusing symptoms of pressure or disturbed function. Repeated
palpation with careful records of the size, shape, consistency and mobility
of the tumour will help greatly in localization and in determination of its
nature. Relationship to other organs must be established and the way
these organs may be displaced or otherwise modified by the advancing
growth must be borne in mind. X-ray and laboratory examinations may,
as already indicated, be of great service in localization as well as in the
discovery of the tumour.
Tumours of the spleen and left kidney are still too frequently com^
founded. It must be remembered that a hypernephroma may run a benign course of many years before malignant degeneration takes place. A
Swiss, 58, had noted a tumour in the left hypochondrium for 8 years before metastases to lungs, bones, and blocking of the vena cava marked the
onset of malignancy. In two cases of sarcoma of the spleen rotation of
the spleen forward had presented a rounded surface instead of an edge for
palpation. Tongue shaped invasion of the kidney by hypernephroma may
simulate closely a notched edge of the spleen. Both splenic and renal
tumours move on respiration and a plump mass of the spleen may be felt
in the flank and may be moved plainly by ballottement.  Careful repeated
Page 125 examinations will usually decide correctly. As already noted, special X-ray
investigations may help. At times enlargement of the spleen from other
causes in combination with unusual symptoms may lead judgment astray.
A man of 21, thirteen months before hospital entry, had cough and fever
for some weeks. Six months later pain in the left lumbar region became
severe. An irregular mass in the left hypochondrium was thought to be a
kidney tumour. This idea was strengthened by the appearance of a mass
above the left clavicle (which decreased after Coley toxins) and by the
partial destruction of the seventh cervical and first and second dorsal
vertebrae and of the second and third ribs. A pyelogram showed deformity of the upper calyces of the left kidney. Fever was moderate, irregular
but constant. Phthalein output was only 15% in two hours. Autopsy
showed an extraordinary number of tuberculous vertebral abscesses. The
spleen, enlarged from a combination of amyloid and sepsis, lay with a
deep rounded mass in the lumbar region. A deep groove due to rib pressure had partially separated an anterior tongue-like mass much like a
kidney in shape. The spleen may be mobilized by a hypernephroma or
kidney tumour and lie attached to the mass, forming queer agglomerates
of rounded portions and definite edges. Retroperitoneal tumours are, in
experience, not as infrequent as the literature would indicate. Benign
growths may progress very slowly and for a long time cause very indefinite discomfort or queer distortion of stomach or duodenum. There
may be marked distension of the upper abdomen resembling a pancreatic
cyst, or tremendous general enlargement of the whole abdomen much like
ascites. Nodular masses may be taken for tuberculosis or lymphosarcoma.
Pressure on the cave ar aorta may give confusing symptoms. Retroperitoneal haematomata, traumatic or apparently spontaneous about the
kidneys, or the result of slow leakage from abdominal aneurisms may be
mistaken for tumour. The previous history and rapid development of
marked anaemia may put us on the right track.
In my experience tumours of the body and cardiac end of the stomach are frequently overlooked. Even X-ray may find difficulty in demonstrating carcinoma near the cardia. Slow perforation with septic temperature and Ieucocytosis has occurred in several cases in hospital without the
real cause being found—even after X-ray investigation. We still make
mistakes in labelling inflammatory masses in various parts of the abdomen
as malignant disease. We still see tumours where even continued investigation will leave us in doubt as to the possibility of removal. The
exploratory laparotomy is, therefore, still justifiable. In a man seen four
years ago with Dr. Hammond of Stockton, it seemed impossible to believe that the massive tumours in the liver was anything but a carcinoma
and yet operation showed an enormous infected cyst-like cavity, probably
the result of old amoebiasis. To supplant careful clinical investigation by
premature exploration is, however, as deplorable as to place sole reliance
in diagnosis of gastrointestinal lesions upon the x-ray examination. Both
are inimical to the cultivation of proper clinical methods. The diagnosis
of abdominal tumours must rest, after all, on a solid basis of good history
taking, knowledge of pathology, careful repeated examinations, correlation with laboratory findings and above all upon sound straight clinical
thinking.   The ending of Osier's little book has always strongly appealed
Page 126 to me in the light of many operations or post mortems on abdominal
tumours. He describes Traube in reviewing some error as observing:
"Have we carefully observed all the facts in the case? Yes. Did the art
permit of a judgment on the facts under consideration? Yes. Did we
reason correctly upon the data before us? No. Wit haben nicht richtig
gedacht.  (We have not thought correctly).
Gentlemen, let us take time in the midst of hospital and private
practice detail which threatens to overwhelm us, to think.
VANCOUVER HEALTH DEPARTMENT
STATISTICS, NOVEMBER, 1927
Total Population (Estimated)   137,197
Asiatic Population (Estimated)   10,576
Rate per 1000 of Population
Total Deaths      126 11.18
Asiatic Deaths          18 20.71
Deaths—Residents only        94 8.34
TOTAL BIRTHS      261 23.15
Male     150
Female 111
Stillbirths—not included in above        15
INFANTILE MORTALITY—
Deaths under one year of age         9
Death Rate per 1000 Births        34.48
CASES OF INFECTIOUS DISEASES REPORTED IN CITY
October, 1827
Cases Deaths
Smallpox   0 0
Scarlet Fever  2 0
Diphtheria  26 2
Chicken-pox   63 0
Measles     4 0
Mumps    18 0
Whooping Cough  12 0
Typhoid Fever   0 0
Tuberculosis   16 11
Erysipelas  6 1
Cerebro-spinal
Meningitis   0 0
November, 1927
Cases Deaths
December 1
to 15, 1927
Cases Deaths
1
7
26
86
1
39
8
0
15
6
1
0
0
1
0
0
0
0
0
17
1
0
0
1
14
33
1
29
3
2
3
3
0
0
1
0
0
0
0
1
Diphtheria	
Scarlet Fever
Poliomyelitis
Cases from outside city—included in above
5 1 4 0
10 2 0
5 1 0 0
4
0
0
0
2
1
Page 127 536 13th Avenue West Fairmont 80
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell J. H. Crellin W. L. Bertrand
May we take this opportunity to greet the members of th
B. C. Medical Association, with
t&he Compliments of the Season
and ^Heartiest Qood Irishes
for a bountiful 1928
ESTABLISHED NEARLY A
B. C. STEVENS CO.
730 Richards Street
Vancouver
£'SH££2tIAVES'Ma"^
C. PREVOST
E. S. EVERTON
Page 12% Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
Phones Sey. 988 and 672
Phones Sey. 9513 and 1391
Phone Sey. 1370
Brown Bros* & Co. Ltd.
VANCOUVER, B. C.
PRESCRIPTIONS
filled exactly as written
Phones: Seymour 1050 -1051
Day and Night Service
Qeorgia Pharmacy Ltd.
Qeorgia and Qranville Sts. Vancouver, B. C.
Page 129
1
I ADRENALIN
INHALANT
For Rapid Relief in Cases of
Nose  and  Throat  Infection
t -r 7-hen the nose is blocked and the accessory sinuses
yy are closed by pathogenic organisms and the resulting inflammatory exudate, Adrenalin Inhalant usually
affords the patient immediate relief and aids the healing
process by maintaining drainage through its tonic,
astringent effect on the tissues and blood vessels.
Adrenalin Inhalant is also of value in the control of
hemorrhage from accessible mucous membranes. It may
be applied directly to the bleeding surface on cotton or
in the form of a spray.
In rhinitis, pharyngitis, tonsillitis, laryngitis, angina,
hay fever, etc., Adrenalin Inhalant is very useful. It
likewise promptly controls certain forms of bronchial
irritation attended with coughing.
Adrenalin Inhalant is supplied in
1-0%. bottles only.
Parke, Davis & Company
ADRENALIN INHALANT HAS BEEN ACCEPTED FOR INCLUSION IN N. N. R. BT
THB COUNCIL ON PHARMACT AND CHEMISTRY OF THB
AMERICAN MEDICAL ASSOCIATION
se-^^i^r&c
Page 130
=fft
Tif^> Emergency Service
Given all Medical Men
Knowing how essential the automobile is to the Doctor, we
go out of our way to give the Doctor's damaged car
preference.
BODY FENDER WHEEL REPAIRS
Quick touching-up with Duco Finish
Complete Painting—Duco or Varnish
Tupper and Steele Ltd*
1669 3rd Avenue West
BAYVIEW 138-139
McBeath-     ^
Campbell
Limited
'Printers and
Tublishers
Vancouver, B.C.
The Oirl Drug
Co., Ltd. -•-We
sSfe
==*^s§i^s«
*^^^ax im.
Hollywood Sanitarium
":'*j"'m0'     ''.' '    ' LIMITED
'Star the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference ^ M Q. (Medical <£\ssociat
ion
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183 Westminster 288
vesxr
Page 132
V

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