History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1925 Vancouver Medical Association Oct 31, 1925

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Published monthly at Vancouver, B. C.
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Qoronary Sclerosis
<Ey T>r. J. Q. Carr
OCTOBER,  1925
^Published by
dM.d&eath Spedding Limited, TJancoUVer, <23. Q.
r#v Petrolagar
Reg. U. S. Pat. Office
Some Questions cfAnstvered
Many physicians have asked us the following questions
about PETROLAGAR. For the purpose of general information, we wish to broadcast these answers :
1. How much mineral oil does PETROLAGAR contain?
Ans.:     Sixty-five   per   cent,  pure   mineral   oil   of   high
2. What   is   the   bulk-giving   constituent   of   PETROLAGAR?
Ans.:    The only bulk-giving constituent is agar-agar.
3. Is PETROLAGAR an ethical preparation?
Ans.: Every possible effort is made to keep PETROLAGAR strictly a prescription product. It is not
advertised to the public. We do not allow druggists
to make window displays of it.
It has been passed for New and Non-Official Remedies
by the Council on Pharmacy and Chemistry of the American
Medical Association.
The Deshell Laboratories do not manufacture any product which is advertised to the public in any way.
PETROLAGAR is issued as follows: PETROLAGAR
(Plain); PETROLAGAR (with Phenolphthalein); PETROLAGAR (Alkaline); and PETROLAGAR (Unsweetened, no
Send this  coupon for an interesting treatise, "Habit Time"
Deshell Laboratories of Canada Ltd.
Kindly send me without obligation, a copy of the treatise,
"Habit Time."
Dr I v...
e<@|i^■^——■■— ——ii»^^—^^^—. ,lia>J
Published Monthly under the Auspices of the Vancouver Medical Association
in the Interests of the Medical Profession.
529-30-31 Birks Building, 718 Granville St., Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
VOL. 2.
OCT. 1st, 1925
No. 1
OFFICERS, 1925-26
Dr. J. A. Gillespie
Dr. G. H. Clement
Dr. A. w. Hunter
Dr. A. b. Schinbein
Past President
Dr. H. h. Milburn
Dr. W. F. Coy Dr. W. B. Burnett
Representative to B. C. Medical Association
Dr. A. J. MacLachlan
Clinical Section
DR.   W.   L.   PEDLOW        ------
Dr. F. N. Robertson     -        -
Physiological and Pathological Section
Dr. G. f. Strong -
Dr. C. H. Bastin	
Eye, Ear, Nose and Throat Section
Dr. Colin Graham       -        -        -     ||||
Dr. E. H. Saunders       - -        -
Genito-Urinary Section
Dr. G. s. Gordon ......
E>r. J. A. E. Campbell	
Dr. J. M. Pearson
Dr. A. C. Frost
Library Committee
allace Wilson
w. Bagnall
. D. Keith
. F. McKay
Orchestra  Committee
N. Robertson
A. Smith
M. Warner
Dinner  Committee
E. MacDougall
W. Hunter
N. Robertson
Credit   Bureau   Committee
Dr. Lachlan Macmillan
Dr. J. W. Welch
Dr. G. A. Lamont
Credentials Committee
Dr. Lyall Hodgins
Dr. R. Crosby
Dr. J. A. Sutherland
Summer School Committee
Dr. Alison Cumming
Dr. Howard Spohn
Dr. G. S. Gordon
Dr. Murray Blair
Dr. W. D. Keith
Dr. G. F. Strong
Founded  1898. Incorporated  1906.
Programme of the 28th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
H 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of Meeting will appear on Agenda.
General Meetings will conform  to  the  following order:—
8.00   p.m.—Business  as  per  Agenda.
9.00  p.m.—Paper of Evening.
Dr. J. A. Gillespie.
and Future of Medicine."
General Meeting.
Paper:     DR. HlBBERT WlNSLOW HlLL.
art  Played  by  the  Laboratory  in  Clinical
Clinical Meeting.
FEBRUARY  16 th—
MARCH 2nd—
MARCH  16 th—
APRIL  6th—     .
APRIL 20th
General Meeting.
"Intravenous Therapy."
Clinical Meeting.
General Meeting.
Paper:     DR.  G. F. STRONG.
"Cardiac   Pain."
Clinical Meeting.
General Meeting.
Papers:     Dr. J. TATE MASON, of the Mason Clinic,
"Surgical Treatment of Thyroid Diseases."
DR. LESTER J. PALMER, of the Mason Clinic.
"Some  Phases  of  the  Diabetic  Situation."
DR. MASON will probably give a Clinic at the V.G.H.
on the morning of Feb. 2nd.
Clinical Meeting.
General Meeting.
Clinical Meeting.
Dr. e. D. Carder.
General Meeting.
Urological   Evening.    DRS.   J.   A.   CAMPBELL.   B.   H.
Champion, G. H. Clement, g. s. Gordon,
and A. W.  HUNTER, on
"Problems in Urological Diseases."
Page Four Ofefitt
Constipation, Ptosis, Paralysis and Atrophy indicate the use of the Wantz Multiple
Wave Qenerator — a New Physiotherapy Unit
Built to Physiological Specifications
Another Milestone in Standardized Physiotherapy Is Reached
When we say that the Wantz Multiple Wave Generator is "different," we mean radically different from
any apparatus hitherto used for the administration of
sinusoidal and galvanic currents in physiotherapy.
Never before has it been possible for the physiotherapist to so perfectly control the form and frequency
of the sinusoidal wave, and the intensity of both sinusoidal and galvanic currents. The extraordinary flexibility, the simplicity of control, and the true quality
of currents delivered by the Wantz Multiple Wave
Generator, prove conclusively that another milestone
in standardized physiotherapy has been reached.
Physicians who are not familiar with the nature of
these currents and their value in the treatment of
many conditions encountered in everyday practice*
may avail themselves of reprints of authentic articles,
issued by our Biophysical Research Department explaining the physiological effects and quoting clinical
experiences in the use of sinusoidal and galvanic currents. Simply fill out the coupon below.
VICTOR X-RAY CORPORATION, 2012 Jackson Blvd., Chicago, 111.
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High Frequency, Ultra-Violet,
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VICTOR X-Ray CORPORATION, Publication Bureau, 2012 Jackson Blvd., Chicago
Please send me reprinted articles explaining the clinical value of sinusoidal and galvanic currents, together with description of the Wantz Multiple Wave Generator.
.A-232-A 'I
Medical schools the country over are completing their arrangements for the coming session. Once again their portals will be
assailed by young men and women anxious to devote themselves
to the business of attending the sick or searching out the secrets of
Nature. Doubtless in many a lecture hall the sentiments of the
old Edinburgh professor will be appreciated, if not uttered, by his
modern successors. Surveying the crowded benches at his opening
lecture, this good man, being struck with the apparent multitude,
was moved to exclaim, "Good God, gentlemen! what is going to
become of you all?" The overcrowding of the ranks of the medical profession has been for long a theme of lament and of prophecy
for disaster. Yet somehow the survivors of the ever-increasingly
strenuous period of preparation are absorbed into the existing state
of affairs and the gloomy anticipations are deferred to an unstated
future. The facts appear to be that if the signs of medical development are read aright, and if what we consider the correct meaning
be attached to the word, the profession has never been overcrowded, is not overcrowded to-day, and will never be overcrowded.
For our purposes, which are the care of the sick and the investigation of disease, to say that the number of workers has been, or
ever will be, even adequate to the proper prosecution of these pursuits, is, we think, incorrect. There may be justification for the
use of the word "overcrowded" in the sense of a situation being
produced where difficulty in making a living is discovered. It is
also true that the latter consideration governs the former; but to
maintain that the application and progress of medicine is to be
regulated exclusively by questions of economy, is unthinkable. In
clinical medicine two things stand out very clearly to-day, and
these are the length of time and the very considerable mental exertion required for any but the very obvious type of case in order
that our conclusions may have a justifiable basis. The doom of
the numerically large individual practice is at hand, we opine—
not the doom of those supposed to threaten to overcrowd the
Where one has been thought to suffice, four will not be too
many. In the interests of medicine alone the profession is understaffed rather than overcrowded. If this increase is necessary, who
then is to pay? In part the individual patient. We conclude that
a proportion, probably the majority, of the people are willing,
as they undoubtedly are able, to pay higher for more complete
work.    In the main, people appreciate value rather than amount.
For the unable moiety some form of State direction seems
inevitable. It is the duty, as it is also the interest of the medical
profession, to make it very clear to all concerned that more and
more time and work will be required for the individual case, and
that fewer and iewer patients can be properly cared for by any
one doctor. That in each case the cost will inevitably tend to
increase, and that individually and collectively, the necessity for
this increased cost must be recognized. Viewed thus, the recurring
bogey of overcrowding assumes small proportions, and even addi-
Page Six tional schools may be contemplated with complacency.    We need
more doctors, not fewer.
Dr. A. B. Schinbein, Treasurer of the Vancouver Medical
Association, has requested us to draw the attention of members
who have not yet paid their dues for the current Association year,
to By-Law No. 5 of the Constitution, which provides that bank
drafts shall be presented to delinquent members whose dues are
unpaid by October 31st. In accordance with this by-law, the
Treasurer will draw on such members on November 1st next.
Drs. A. W. Hunter and C. W. Prowd have recently been
enjoying a hunting trip in the neighbourhood of Quesnel, B. O
Dr. B. D. Gillies has been doing some mountaineering in the
neighbourhood of Mount Robson.
Dr. A. B. Schinbein and family are at present holidaying in
Eastern Canada. They are expected back about the middle of
Dr. H. H. Planche recently reteurned from a visit to Ottawa,
Montreal and his home town of Cookshire.
Miss K. Ellis, the popular Superintendent of Nurses of the
Vancouver General Hospital, has been absent from her duties for
the past month on account of illness.
Tenders are being received for the erection of the new Infectious Diseases Wing of the General Hospital. This is to be built
on the block bounded by Heather and Willow Streets and Twelfth
and Thirteenth Avenues. Some of the old buildings on this site
are now being demolished.
The University of B. C. having vacated the buildings on the
block between Tenth and Twelfth Avenues, these buildings revert
to the General Hospital. A Committee of the Board is now taking up with the Provincial Government the question of remodelling the stone building which formerly housed the University
It is hoped the Association will be able to make arrangements
for the use of one of the vacated University buildings for its regular meetings.
Members are reminded that the agenda papers for the monthly
general meetings are enclosed in THE BULLETIN.
Vancouver, B. C.
Total Population  (estimated)  .
Asiatic Population  (estimated)
g  126,747
Rate per 100 of
Pop. per Annum
Total   Deaths       122
Asiatic Deaths ___I      17
Deaths—Residents only      96
Total Births—Male,      151
Female,  137       ... 288
Stillbirths—not included in above        9
Infantile Mortality—
Deaths under 1 year of age        9
Death Rate per 1000 Births .._. 31.3
Cases of Contagious Diseases Reported.
July. August.   Sept. 1st to \5th
Cases. Deaths. Cases. Deaths. Cases. Deaths
Smallpox        8
Scarlet Fever      9
Diphtheria      11
Chicken-pox      6
Measles      0
Mumps        3
Erysipelas  .     5
Tuberculosis      9
Whooping Cough     24
Typhoid Fever        2
(Cases from Outside
Diphtheria     4
Smallpox     0
Scarlet  Fever    0
Typhoid Fever   2
in above
By R. H. Clark and K. B. Gillie.
From the Department of Chemistry, University of British Columbia.
Rhamnus Purshiana is found widely distributed on the western slope of the Cascade range of mountains in southern British
Columbia, Washington, Oregon and northern California. A mild,
moist climate and a slightly sandy soil are necessary for the abundant growth and large size of the tree.
The aborigines of the regions in which the tree is found are
said to have used the bark for medicinal purposes in the early part
of the nineteenth century. It was not until 1877, however, that it
was introduced to the medical profession by Dr. J. H. Bundy, of
Colusa, Cal., as a valuable remedy in the treatment of constipation.
In the following year Parke, Davis & Company made the first
pharmaceutical preparation and brought it to the attention of physicians and pharmacists. Since that time its use has become worldwide, from 1000 to 2000 tons of the bark being consumed annually in the manufacture of various laxative preparations. The
result of this popularity and of the restricted area in which the tree
grows, has caused the greater portion of the easily accessible trees
to be cut. The cascara dealers have been predicting for many years
that the supply would soon be exhausted. The average price of
the bark in New York for 1901, was five cents per pound: for
1911, eight cents per pound. The present price, 1924, is from
twenty-three to twenty-five cents according to the length of time
the bark has been aged.
Various opinions have been expressed as to the natural reforesting of cut-over areas. Some have stated that a new growth
always springs up, providing the bark is not removed from the
stump; others claim that sprouts seldom spring up from stumps,
because the trees are usually cut while the sap is running. Mr.
Hope, a landowner in the Fraser Valley, who has been interested
in this industry for many years, states that the stumps of trees
which are sufficiently exposed to sunlight will send up shoots,
which will, in the course of time, develop into trees of commercial
dimensions. In those locations which are not exposed to the direct
rays of the sun, as is generally the case, he claims that the stumps
will die.
The active principle contained in the bark has never been
isolated, nor is much known regarding its true character, in spite
of the numerous investigations in this direction.
Objects of the Present Investigation.
This investigation was undertaken with the following objects in view:
To determine whether or not an extract made from the wood
of the cascara tree will have sufficient activity to make it a commercial source of this laxative.
To examine the extent of the griping action which is claimed
Reprinted from   the American Journal of Pharmacy,  June,   19 24.
Page Nine to be characteristic of extracts made from fresh bark, and to find a
means of eliminating the griping action by curing the extracts
chemically in order to obviate the necessity of holding the bark for
a period of one to three years before extracting, as now directed
by the pharmacopoeia.
To note differences in the activity of extracts due to the
varying ages and habitats of the trees from which the bark was
To determine whether or not the active principle is a gluco-
To find some physical or chemical property of exartcts which
might be used in judging with some degree of accuracy, the comparative concentrations of the active constituent.
Method of Procedure.
The extracts from the bark were made in accordance with the
details for the manufacture of Fluid Extract of Cascara Sagrada
(U. S. P. IX, page 179), using Type Process D (U. S. P. IX,
page 176) for percolation. In the case of extracts from the wood,
the only change consisted in substituting an equal weight of pulverized wood for the bark. The wood was reduced to a powder by
planing across the grain with a power planer and then rubbing the
dry shavings between the hands. One gram of wood or bark made
1 cc. of extract containing 25 per cent, alcohol by volume. Since it
is the common belief that extracts made from freshly gathered bark
have a more or less severe griping action on the patients to whom
it is administered, an attempt was made to cure the extracts chemically in order to overcome this action and thus avoid the present
practice of holding the bark for a period of from one to three years
before use. An unexpected difficulty arose in this connection, in
the fact that from all the samples examined, only two trees, growing close together, were found which produced such a griping effect for a certainty. This led to the preparation of extracts from
the bark of trees which were in a diseased condition, from trees
that had been ringed and from trees growing in widely varying
localities, without, however, other cases of griping being found.
Since the most likely change taking place in the bark on aging is
oxidation, the proposed chemical treatment of the griping extracts
consisted in adding one pound of 3 per cent, hydrogen peroxide to
500 cc. of the extract and evaporation to the original volume.
It was also highly desirable to find some physical or chemical
property of the extracts which would have some direct relationship
to their physiological activity. If such could be found, it would
serve as a more or less easy method for determining the relative
activity of the extracts. For this purpose the following properties,
as utilized by the Inland Revenue Department, at Ottawa, were
( 1) Specific Gravity. The specific gravity was determined
by means of ,a specific gravity bottle at room temperature (20
degrees C.).
(2s) Total Solids. The total solids were determined by #the
evaporation of  10 cc.  of extract at  100 degrees C.  to constant
Page Ten weight, after dessication over calcium chloride.   The percentage of
solids was calculated from the formula W
V X Specific Gravity
X 100 = % solids, where W is the weight of the residue in grame
and V is the volume of the extract taken.
(3) Ash. The percentage of ash was found by igniting and
calcining the residue from procedure No. (2) to constant weight,
using the following expression for the percentage calculation:
Wl  X  100
V X Specific Gravity = % Ash,
where Wl is the weight of ash in grams.
(4) The amount of manganese present in the ash from procedure No. (3) was determined colorimetrically. The ash was
leached with 10 cc. of one to one nitric acid and the residue washed
with 10 cc. of distilled water; the wash water was then added to
the nitric acid solution. The characteristic permanganate color was
developed by oxidizing the solution with ammonium persulphate,
using a silver nitrate solution as a catalyst. These solutions were
then compared colorimetrically with a standard potassium permanganate solution which had been reduced and oxidized again by the
same method as the nitric acid solutions in order to bring them to
the same state of oxidation. The manganese member is given by
the following expression:
W2 X 100.000
V X Specific Gravity = Manganese Number,
where W2 is the weight of the manganese in grams.
(5) The percentage of Reducing Sugars before Hydrolysis—
was determined as dextrose using Fehling's solution, together with
the volumetric permanganate method for determining the cuprous
oxide, and also Allihn's Tables for the determination of dextrose.
(6) The percentage of Reducing Sugars after Hydrolysis,
was determined by hydrolysing 2.5 cc. of extract by boiling it with
a drop of concentrated hydrochloric acid for five minutes, and
analysing as in procedure No.  (5).
There is no definite information concerning the nature of the
active ingredient of cascara extracts. Dohme and Englehardt claim
that it is a glucoside, H. A. D. Jowett states that there is no satisfactory experimental evidence for such a claim. If the active principle were a glucoside, complete hydrolysis should destroy its
activity. In order to test out this point, two samples of bark were
extracted and the percolate in each case divided into two parts.
One-half was hydrolysed by boiling with a known quantity of
hydrochloric acid and then neutralized with sodium bicarbonate;
the other half was used as a check in comparing the laxative effects
of the hydrolysed and unhydrolysed extracts. (See Samples Nos.
11 and 12;   36 and 41.)
The physiological tests were made at the Vancouver General
Hospital under proper supervision. One cubic centimeter was administered to patients, only when a laxative was required by them.
Account was kept of the doses given and of the results obtained.
The efficiency was calculated by dividing the number of doses given
into .the number of times the dose was effectual.
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Page Thirteen Conclusion.
1. The results of the experiments compiled in Table I show
that the wood contains sufficient of the active constituents to make
it a source of commercial extracts. The physiological tests of extracts from the wood gave an average efficiency of 38 per cent.,
while that of extracts from the bark was 53 per cent., or the extracts from the wood were 71 per cent, as effectual as those from
the bark. The percentage efficiency of the wood extracts shows a
wide variation, ranging from zero in samples 21 and 29 up to 78
per cent, in sample D. E. Cabanes states that the active principles
of carcara bark are located in the layers of bast immediately adjoining the cambium, and in the medullary rays traversing these layers.
Experiments B, C and D show that there is a considerable amount
of the active principles all through the wood. If the wood extracts
were made two or three times as concentrated as those from the
bark, they would, in all probability, be just as effective.
2. All of the extracts used in this investigation were made
from freshly cut bark or wood and tested at the hospital as soon
after preparation as was found possible. From a careful study of
the griping action produced by such extracts, it was found that
this effect is far from common. Only in the case of two trees, was
the evidence considered sufficient to warrant any degree of certainty
that the extracts griped. These two trees, numbers 5 and 6, were
collected from a lot within the city limits; the trees had had a
rapid growth and the bark throughout was darker than usual.
Experiment No. 7 was carried out to see if the griping action
produced by tree No. 6 might not be overcome by oxidizing the
extract with hydrogen peroxide. Such oxidation, as far as this one
case was concerned, produced the desired result; it has been impossible, however, to confirm this point, owing to our inability to
find other trees whose bark had undoubtedly a griping effect.
3. The influence of habitat and the season's rainfall on the
activity is apparently quite marked; the average efficiencies of the
extracts made from the bark and wood collected at the end of
August, 1922, at Yennadon (numbers 21 to 41) were 44 and 29
per cent, respectively, while the average.for all other extracts were
61 per cent, for the bark and 48 per cent, for the wood. This difference was undoubtedly due to the abnormal hot and dry conditions prevailing during the summer of 1 922. The difference could
not have been due to the lateness of the season at which the samples
were collected, as those collected from October to November, 1921
(numbers A to 7) show a much higher average efficiency.
4. The age of the tree, from which the bark extracts were
made, appears to have little influence on the activity, in the case of
the wood, however, the activity shows a decrease with age.
5. Extract No. 1 3 was made with absolute alcohol as a men-
strum and finally diluted with water to the same extent as prescribed by the U. S. P.; the object being to see if a more active
extract would be obtained when hydrolysis was retarded. The
activity was little affected, the extract, however, caused considerable nausea and griping.
Page Fourteen 6. The results of experiments 11 and 12, 36 and 41, show
that complete hydrolysis does not destroy the activity of the extract. Consequently the active principle would not appear to be a
glucoside, although it might be the hydrolytic product of one.
7. None of the physical or chemical properties determined
can be said to show any close relationship to the activity of the
extracts. The values for each of the determined properties show a
wide fluctuation. (Compare Inland Revenue Department, Ottawa,
Bulletin No. 386.) The following are the average values obtained
for the extracts from bark and wood, respectively:
Bark Wood
Specific  Gravity       1.072 0.985
Total  Solids   27.4 % 4.69   %
Ash    •_      L.08 % 0.27  %
Reducing  Sugars  before  Hydrolysis     5.15 % 0.947%
Reducing Sugars after Hydrolysis      6.88 % 1.5     %
Manganese Numbers  340. 201.
*        *        *
Dr. M. Fox, recently of the V. G. H, left Vancouver on
September 20th for Atlin, B. O, where he will take care of the
practice of Dr. C. M. Eaton.
Dr. J. W. Lang, late of Hutton, B .O, is now practising at
West Vancouver, B. C.
Dr. Gerald R. Baker, of Quesnel, Is taking a month's well-
earned vacation, as from September 10th. His practice will be
taken care of by Dr. L. G. C. d'Easum.
A meeting of the Executive of the B. C. Medical Association
was held on September 1st, when several important matters were
dealt with. It was decided to continue the periodical luncheons
during the fall and winter months, and it is hoped that we may
secure one of the eminent speakers, visiting Vancouver in connection with the opening of the University, to give an address
at the first luncheon to be held about the middle of October. The
plans of the Chairmen of the various Standing Committees indicate a busy time for all concerned, particularly the Publicity and
Educational, and Industrial Service Committees.
The semi-annual meeting of the No. 6 District Medical
Society was held at Nanaimo on September 25th. Addresses were
given by Drs. W. A. Dobson and Howard Spohn.
Dr. J. W. Arbuckle, who has recently returned from Europe,
has given up practice at Vernon and intends specializing in Gynaecology and Obstetrics in Vancouver.
The hearty congratulations of their many friends are extended to three of the younger members of the profession in B. C.:
Dr. O. van Ettar, of New Westminster;   Dr. L. G. d'Easum, of
Page Fifteen Vancouver;   and Dr. M. Fox, of Atlin, B. C, on the occasion of
their recent marriage.
The University of B. C has begun its year's work at its new
and permanent home in Point Grey. The ceremonies connected
with the official opening of the new buildings will be held on
October 15th and 16th, and the B. C. Medical Association has
been invited to send representatives on this occasion. Dr. H. H.
Murphy, the President, will be there, as well as the following:
Dr. Vrooman, Past President; Dr. W. A. Clarke, Vice-President;
Drs. J. A. Gillespie and G. H. Clement, President and Secretary
of the Vancouver Medical Association; and Dr. J. H. MacDermot,
Secretary-Treasurer of the B. C. Medical Association.
The Annual Meeting of No. 4 District Medical Society
(Okanagan Branch) was held at Merritt on September 21st. The
speakers on clinical subjects were: Dr. F. P. Patterson, Dr. Geo.
E. Seldon, and Dr. Lyall Hodgins, of Vancouver. Dr. H. H.
Murphy and Dr. C. H. Vrooman, President and Past President
of the B. C. Medical Association, spoke on medico-political matters.
By James G. Carr, Chicago, 111.
A discussion of coronary sclerosis cannot be limited to the
changes which affect the vessels of the coronary circulation. The
nature of the process implies impairment of the cardiac blood supply, a heart muscle poorly supplied with blood, and eventually
myocardial degeneration. Anatomically, coronary sclerosis means
arteriosclerosis of the coronary vessels and myocardial fibrosis, the
result of the disturbance of the local circulation. It may be added
that a similar pathological process may develop in a reverse manner. Myocardial fibrosis, subsequent to an acute infective process
of the myocardium, may ultimately produce coronary obliteration.
The pathological physiology of coronary sclerosis is readily
understood in the light of the statements just made. The outstanding disturbance of function is the impoverished nutrition
dependent upon impairment of the blood supply. Secondarily, we
find myocardial degeneration with fibrosis, essentially the picture
of sclerosis with interstitial change so often met in the degenerative
diseases of parenchymatous organs. In consequence of the impaired nutrition and the alteration of structure, the cardiac reserve
is lessened and the recuperative powers of the cardiac muscle are
weakened. To properly appreciate the condition of an arterioscler-
etic heart, these facts must be kept in mind. Both prognosis and
treatment are to be guided by these two factors, impaired cardiac
reserve and lessened recuperative power. As a general rule the
arterioscleretic heart responds less promptly and less permanently
Page Sixteen to treatment than does the rheumatic heart in the earlier attacks
of decompensation. This is not alone due to the cardiac change;
rarely is the individual with symptoms of coronary sclerosis afflicted with this local disease alone; his cardiac disease is part of a
generalized condition which may be more or less latent yet must
be taken into consideration, particularly in making a prognosis.
Here it may be mentioned that our inability to correlate demonstrable cardiac change with manifest cardiac symptomatology constitutes one of the great problems in the diagnosis of coronary
sclerosis; by no means does it happen that anatomical and functional disturbance are equally obvious.
From the clinical standpoint, coronary sclerosis may be classified as latent and manifest. The latter group may be subdivided
into three: (1) cases with the usual signs of decompensation,
(2) cases in which the outstanding feature is the presence of cardiac pain, (3) a miscellaneous group of cases in which certain
less common symptoms are found, as acute edema of the lungs,
paroxysmal tachycardia or severe dyspnoea without paint.
The latent cases are of particular interest. To the surgeon,
called upon to operate upon an elderly patient, the condition of
the coronary circulation may be of great importance though it
may be far from obvious. It is not unlikely that the condition
of the coronary circulation is an important factor in the high
mortality which attends pneumonia in the aged. We commonly
associate impaired vitality with our conception of arteriosclerosis.
The sclerosis of the coronary arteries may far outstrip the demonstrable sclerosis of the peripheral vessels, without offering evidence
in the way of physical signs which point to cardiac involvement.
Several years ago, LeCount called attention to this latent
group of coronary disease in a review of some autopsy records.
He discussed sixty deaths from difficulties with the circulation of
the blood in the coronary arteries or with lesions generally regarded as caused by such difficulty. There were 34 deaths from
fibrous myocarditis with sclerosis of the coronary arteries. "Of
these only four were in a hospital for any time and ill with the
symptoms of heart disease; one for eight hours, diagnosed acute
dilatation; one for eight and one-half hours, diagnosed pulmonary tuberculosis; one for seventeen hours, diagnosed asthma; and
one for twenty-seven hours, diagnosed delirium tremens." Three
had died suddenly while convalescent from other disease. One
had been ill for three days, unable to retain anything on his stomach, but also unable to attribute this to any dietary indiscretion.
"Eight died on the way to the hospital. Eighteen were found
dead. In five of the 34 hearts the scars were of such size in the
heart muscle that pouching outward had taken place, the so-called
parietal aneurisms. In a few the scars replaced so little of the
myocardium that, in addition to other examinations, a chemical
examination was made for poisons. In four of the 34 bodies
gross indications of syphilis were found; in four others there was
pulmonary  emphysema  of the  hypertrophic  type;    in  two  the
Page Seventeen :■
• 1
kidneys were markedly diseased, 'small, red, granular kidneys.'
There was some anasarca, hydrops or both in eight of the 34
cases, obesity in one, and two hearts showed anomalies, a bi-cuspid
aortic outlet in one and the absence of a circumflex branch of the
right coronary in the other, the corresponding branch of the left
coronary being large."
Willius and Brown have recently reported a study of coronary sclerosis based upon autopsy records of 86 cases. 'Thirty-
four of these patients did not present sufficient subjective or objective evidence of cardiac disease to permit the diagnosis of coronary disease; their condition is referred to as the occult type of
coronary disease. Osier emphasizes this observation in his statement that a large proportion of all patients with angina pectoris
have clear-cut heart sounds and a good pulse and no obvious signs
of cardiac disease, yet the coronary arteries may be extensively diseased." After listing the diseases with which these patients were
obviously afflicted, they remark, "It is evident that a considerable
degree of coronary sclerosis may exist with but few clinical signs,
and it is important, therefore, always carefully to consider the
possibility of occult coronary disease in patients in middle and
later life."    In seven of these 34 cases sudden death occurred.
Of the three groups classified as "manifest" coronary disease,
the first may be dismissed with few words. Where coronary
sclerosis has caused myocardial weakness to such a degree that
decompensation, as the term is ordinarily employed, has occurred,
the treatment is identical with cardiac decompensation in general.
The course of the disease is that of decompensation, often of progressive myocardial failure without response to treatment. The
decompensated heart which has supervened upon changes in the
coronary circulation is characterized by poor recuperative power,
with difficulty in restoring and maintaining even a fair degree of
In entering upon a discussion of the cases characterized by
pain, we may easily lose ourselves in fruitless discussions as to the
exact exciting cause of the pain. Suffice it to say that two principal theories as to the cause of the pain are prevalent. Sir Clifford
Allbutt has presented with great skill and plausibility the view
that the pain of angina pectoris is the result of distention of the
aorta, and his views have been widely accepted. On the other
hand, the view that angina is definitely related to coronary disease
is an old one for which much may be said. In the paper just referred to, LeCount discussed 26 cases which had developed obstruction of the coronary arteries; in the course of this discussion he
makes this statement: 'These 26 deaths from more or less acute
obstruction of the coronary arteries are the only ones of 175 deaths
from heart disease with which I found associated symptoms suggestive of angina pectoris." The force of Sir Clifford Allbutt's
arguments is not to be denied, and the fact that not every case of
angina pectoris has shown coronary disease is not to be disregarded,
Page Eighteen yet my own opinion is still in favor of the view which connects
angina pectoris with disease of the coronary arteries.
The clinical picture of angina pectoris is too well known to
necessitate any lengthy description here. The paroxysmal pain,
the intensity of the pain, the reference along the left arm or to the
neck or the right arm, the terrible sense of substernal pain, are all.
unfortunately, too often met with in daily practice to need repetition. Certain manifestations of the disease may bear discussion.
The diagnosis is not always simple. We may refer again to the
observation of Osier, quoted by Willius and Brown. The absence
of demonstrable cardiac disease does not warrant a statement that
angina is not present. In individuals past middle life who present
a fairly typical history of anginal attacks, the physician should be
very careful about denying the possibility of angina pectoris, because the heart seems normal upon physical examination. It is
better to provide the patient with nitroglycerin and test the effect
of this drug in relieving the attack. I know of no pain save the
pain of angina which responds to nitroglycerin. Not even , the
age of the patient permits a positive diagnosis. In Osier's textbook there is the story of a young man under thirty who was
regarded as suffering from a cardiac neurosis until he died in one
of the attacks. Every new method of diagnosis should be welcomed here, and the electrocardiograph may show evidence of
cardiac disease, of myocardial degeneration, which has eluded the
usual methods of physical examination. This has only a positive
value. In the presence of suggestive symptoms, such a finding
adds to the probability that the condition is angina pectoris; the
absence of such positive evidence is not to be interpreted as disproving the presence of this clinical entity.
Angina pectoris may manifest itself under the picture ol
abdominal disease. Doubtless angina pectoris has been the real
cause of death in many instances in which "acute indigestion" has
been assigned as the cause. Confusion with gall-stone disease,
with acute indigestion, gastric crises and other conditions may be
avoided by careful attention to the history of the attack. Not
long since, I knew of a patient, whom I had seen with attacks of
pain beginning in the epigastrium, submitting to an operation for
gall-stones which were not found. The patient had described the
pain as beginning in the epigastrium, it is true, but he had also
stated that "it chokes me," and described the latter part of the
attack as associated with pain under the sternum: moreover, the
pain was relieved promptly by the use of nitroglycerin, which
does not relieve gall-stone colic.
Some reference must be made to the recent attempts to relieve
the attacks of angina by resection of the left cervical sympathetic.
To quote briefly from the article of Brown and Coffey: "Cutting
the left superior cardiac branch of the cervical sympathetic and the
main trunk below the ganglion has relieved the main condition in
anginal attacks and apparently the one from which the patients
Page Nineteen die in the attacks. In a few cases referred pains are not entirely
relieved." .... "The operation may have to be bilateral to relieve completely all pain. Only in the event of further investigation can the limits be defined. In the meantime sixteen more cases
of relief by removal of the superior ganglion are herewith reported,
including our own, with two deaths, and fourteen with relief of
the main symptom." There is, as yet, no unanimity of opinion
as to the exact surgical procedure necessary to accomplish the relief
of pain; into a discussion as to the part of the cervical sympathetic
which must be cut or removed for this purpose, we will not enter
here. In the one case which I have happened to see, the result was
satisfactory. I would like to remark in connection with an a
priori objection to the operation which has been offered to the
effect that, in stopping the pain, we interfere with a protective
warning process; that there are other warning symptoms besides
the pain, as, for instance, dyspnoea, which convey to the patient
intimations that his heart is not right and force him to a certain
degree of quiet. Pain is often not present in the ordinary decompensation, and is not expected, yet the patient has learned before
the physician tells him, that there are certain limits beyond which
he must not go. Moreover, in angina pectoris it is likely that pain
kills, the pain is of such intensity that it must be regarded as capable of taking life, and in judging of the operation under consideration, the relief of pain in itself is a protective procedure.
There remains for discussion one of the most dramatic and
rapidly fatal of cardiac diseases, acute obstruction of the coronary
vessels. There is pain of fairly sudden onset, though not always
with the very rapid onset of an attack of angina pectoris, gradually
increasing in intensity until it becomes most intense, equalling
in severity any pain to which mankind is liable. The patient who
has had angina knows that this pain is different. The pain may
be continuous or there may be exacerbations and remissions,
though this latter course of the pain is often attributed to numerous
attacks of angina rather than to true obstruction. There may,
however, be such remissions with closure of a coronary vessel.
The pain may be thoracic with the characteristic reference of an^
ginal pain, or it may be abdominal; in the latter case the long
duration of the attack may lead to the diagnosis of an upper abdominal condition; often such cases have been subjected to operation. Of 26 cases with more or less acute coronary obstruction.
LeCount lists the clinical diagnosis in eleven cases. Angina pectoris was diagnosed twice; acute dilatation of the heart, twice;
edema of the lungs, once; lobar pneumonia, twice; and pulmonary tuberculosis, acute gastritis, intestinal obstruction and carcinoma of the stomach, each once. One of these cases of acute
coronary obstruction occurred in a man whose condition two
months previously had been diagnosed as due to gall-stones. There
were no gall-stones. There is fever and leucocytosis. A pericardial friction rub develops and, if heard, is of great diagnostic value,
but it does not persist long and is frequently missed. The rub is
only present when the infarcted area reaches to the pericardium.
Page Twenty The electrocardiograph may be of considerable value, since experimentally and clinically there has been demonstrated a characteristic electrocardiogram of obstruction of the descending branch
of the left coronary vessel, which is the particular vessel most often
affected. The mortality is high, but many cases recover, the intense pain subsiding, under the influence of morphine, usually in
large doses, after 24 to 72 hours. Recovery is slow and there is
likely to be evidence of permanent myocardial damage. Rind-
fieisch has lately summarized the course of the disease. "In the
typical case the first phase of the disease is characterized by very
pronounced stenocardia, which either exhausts itself in a single
insult of tremendous severity or persists for a time in the form of
a status anginosus. The second phase, which is important for the
clinical diagnosis, gets its stamp from the pericarditis, which develops over the necrotic cardiac muscle; under favorable conditions
one may demonstrate pericardial rubs. These are frequently
missed, for they are usually to be demonstrated only for a few
hours and over a limited area, and then disappear permanently.
This pericardial stage is further characterized by a moderate fever
which may continue for a long time, and can be dependent upon
the inflammatory process of the serosa. The third phase, that of
latency, which may last for months or years. From this period
there usually develops gradually the fourth and last stage, that of
chronic cardiac insufficiency, which is characterized by frequent
emboli in the greater and lesser circulation, and otherwise is not
different from other cardiac muscular disease."
The third group of cases of manifest coronary disease will
be dismissed briefly. Edema of the lungs, which may be the chief
manifestation of coronary disease, usually occurs with hypertension, and rarely occurs alone with coronary disease. It may be a
terminal process. Paroxysmal tachycardia in an older person, especially if associated with pain, is strongly suggestive of coronary
disease, while the severe dyspnoea without pain, mentioned earlier,
really offers no definite basis for diagnosis.
{The Library is situated in 529-531, Birks Building, Granville Street, Vancouver. Librarian: Miss Firmin. Hours: 10
to I, 2 to 6.)
Orations and Addresses. By Sir John Bland Sutton. William Heineman, Ltd., London.
To the host of medical men who admire and enjoy the writings of Sir John Bland Sutton, this book is welcome indeed, presenting as it does in a compact way an even dozen of his most
interesting addresses.
An evening with this book by the fireside surely must be an
ideal way of spending an evening. Sir John writes to capture
the imagination and his subjects range from those of purely medi-
Page  Twenty-one cal interest to some which everybody may read, enjoy and understand.
The first three pages concern the life, times and work of the
immortal John Hunter, and one can well imagine what old cronies
these two would have been had they lived in the same period.
A splendid description is given of the collection in the war
pathological section of the Royal College of Surgeons. Probably
the one of most lively interest is the description of the "shrunk
heads," ear plugs and labrets of the Amazonians, Araguans and
Botocudos. Sir John made a special trip up the Amazon to obtain for himself some of these gruesome specimens.
Other pages are of great embryological interest and deal with
the development of the cave of Meckel, choroid plexuses, psam-
momata, dermoids, etc.
Probably the most interesting book in the Library.
L. H. A.
William Crawford Gorgas, His Life and Work. By Marie
D. Gorgas and Burton J. Hendrick. 1924. Doubleday, Page
8 Co.    $5.00.
No wife hould ever write the biography of her husband, particularly if the latter has reached his niche in the hall of fame.
This remark is especially apropos of the volume under consideration. One picks it up in eager anticipation that, like Mr. Hen-
drick's earlier work, "The Life and Letters of Walter Hines Page,"
it will be a historical essay on the life and works of a truly great
medical man. However, one lays the book aside with the feeling
of disappointment in that it is merely an eulogy of a very good
The book as a whole is a description of Dr. Gorgas' fight
against yellow fever, a task for which he was eminently fitted,
having been rendered immune by an attack of the disease early in
his army career. The ignorance concerning yellow fever and the
horror of it are well brought out, and the description of the out-
bread in Philadelphia in 1793 is very graphic and vivid.
It is often thought that Dr. Gorgas had something to do with
the discovery of the cause of yellow fever, namely, the Stegomyia.
This, however, was entirely due to the work of Walter Reed and
his associates, and even after Reed had proved his point Gorgas'
attitude was one of scepticism. He simply said, "If yellow fever
is caused by the Stegomyia, let us destroy this mosquito." This
he proceeded to do.
Dr. Gorgas' greatest achievement was the making possible the
building of the Panama Canal, and thus changing the future history of the world. The old French company had failed in this
effort completely owing entirely to the ravages of yellow fever and
malaria amongst its laborers. After having proved in Havana
that the eradication of the Stegomyia prevented yellow fever,
Gorgas' next task was to impress his views upon a hostile and
ignorant bureaucracy in Washington. This proved an almost
impossible task, and Gorgas with his ideas about mosquitoes was
looked upon by the governing powers as an imbecile.     Finally
Page Twenty-two Theodore Roosevelt, who was then President, sent for his personal
physician, Dr. Lambert of New York, and at a momentous conference at Oyster Bay, when the fate of the canal hung in the balance, Dr. Lambert finally persuaded the President to stand behind
Gorgas and his views. Thus we may say that if it had not been
for Dr. Lambert the American company would have gone the way
of the French and the building of the canal at least been delayed
many years.
The concluding chapters of the book relate of General Gorgas'
activities as surgeon general of the army during the late war, his
visits to various parts of the world on health matters, particularly
his visit to South Africa at the request of the Chamber of Mines
for the eradication of pneumonia among the native workers, and
finally of his death in England one month after being created
Knight Commander of the Most Distinguished Order of St. Michael and St. George, by the King, on a personal bedside visit.
The book for the most part appears to have been written by
Mrs. Gorgas, and is a familiar and intimate narrative of a man
who became really famous by being able to put into practical application the discoveries of Walter Reed and Sir Ronald Ross.
H. R. S.
Some Recent Additions to the Library.
Medical Annual.    1925.
American Medical Directory.     1925.
A Guide to- the Examination of the Blood. GULLAND AND
Goodall.    1925.
Surgical Clinics of North America. April, June, August,
Life of William Crawford Gorgas. GORGAS AND HENDRICK.
Medical Clinics of North America.    May and July,  1925.
International Clinics.    March,  1925.
Surgical Pathology.    W. BOYD.
Report of Henry Phipps Institute.    1925.
Appendix to Gyn. and Obstet. Monographs.    1925.
Chemical Aspects of Immunity.    H. G. WELLS.
Modern Operative Surgery.    H. W. CARSON.
Reports of School of Hygiene and Public Health, Johns Hopkins University.    Vol. VI.     1925.
Arteriosclerosis.    Sir CLIFFORD Allbutt.
Common Disorders of Female Urethra and Cervix. FRANK
KlDD.     1924.
Physical Diagnosis of Chest Diseases. BUSHNELL AND
Pratt.    1925.
Advance of Orthopaedic Surgery.    A. H. TUBBY.
History of the C. A. M. C. in the Great War. Sir ANDREW
Medical Dictionary.    DORLAND.     13th Ed.     1925.
Crippled Hand and Arm.    CARL BECK.    1925.
Page Tiretitii-ih'ree w
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You may select what you like from lines sent to you
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