History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1927 Vancouver Medical Association Sep 30, 1927

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Published monthly at Vancouver, B. C.
Subscription $1.50 per year
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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. 3
SEPTEMBER 1st, 1927
OFFICERS, 1927 - 28
Dr. W. S. Turnbull
Dr. G. F. Strong
Dr. A. B. Schinbein
Dr. A. W. Hunter
Past President
Dr. A. C. Frost
Dr. J. M. Pearson
Dr. W. F. Coy Dr. W. B. Burnett
Representative  to  B.C.  Medical  Association
Dr. C. H. Vrooman
Clinical Section
Gordon Burke , , '. j . ' ; I L__H1_Chairman
L. H. Appleby 9 - i Secretary
Physiological and Pathological Section
J. E. Campbell 1   Chairman
F. J. Buller : Lill . . Secretary
Eye, Ear, Nose and Throat Section
E. H. Saunders Chairman
W. E. Ainley 1 -1 -..Secretary
Genito-Urinary Section
G. S. Gordon i - Chairman
J. E. Campbell " . Secretary
Physiotherapy Section  .
H. R. Ross - ; Chairman
J. W. Welch _ j i : Secretary
Library Committee
C. H. Bastin
W. C. Walsh
W. A. Bagnall
D. F. Busteed
Orchestra   Committee
J. A. Smith
H. A. Barrett
L. Macmillan
H. C. Powell
Dinner Committee
D. D. Freeze
C. H. C. Bell
T. H. Lennie
Credit Bureau Committee
Dr. D. McLellan
DR. L. Macmillan
Dr. J. W. Arbuckle
Credentials   Committee
Dr. F. W. Lees
Dr. E. J. Gray
Dr. W. F. McKay
Summer School Committee
Dr. G. F. Strong
Dr. W. D. Keith
Dr. H. R. Storrs
Dr. R. Crosby
Dr. B. D. Gillies
Founded 1898. Incorporated 1906.
GENERAL MEETINGS will be held on the first Tuesday of the
month at 8 p.m., from October to April.
CLINICAL MEETINGS will be held on the third Tuesday of the
month at 8 p.m., from October to April.
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.
+ * *
Total Population  (Estimated)   137,197
Asiatic Population (Estimated)    10,576
Rate per 1000 of Population
Total Deaths      139 11.87
Asiatic   Deaths           14 16.9
Deaths—Residents only       91 7.11
TOTAL BIRTHS      272 20.26
Male       144
Female  128
Stillbirths—not included in above         14
Deaths under one year of age '_.      11
Death Rate per 1000 births        45.52
August 1
to 15,  1927
Cases Deaths
June,  1927
Cases Deaths
July, 1927
Cases Deaths
Scarlet Fever  	
Whooping Cough.
Typhoid Fever ...
Epid. Cerebrospinal Meningitis.
■ -.4.
Cases from outside city—included in above
Scarlet  Fever  	
Typhoid Fever __.
Epid. Cerebrospinal Meningitis .
Page 3 68
0 Section of X-Ray Department, Montreal General Hospital. Installation by
Montreal Branch of Victor X-Ray Cotporation of Canada, Ltd.
Victor Service in Canada
' I HE Victor X-Ray Corporation has assumed a respon-
sibility to the medical profession which does not
end with developing and manufacturing X-Ray and
Physical Therapy apparatus of the most approved type.
It is a tenet of the Victor code that the operator of a
Victor machine has the right to receive technical aid
when he needs it.
So, a nation-wide Victor Service Department was
organized years ago and direct branches established in
the principal cities of the United States and Canada,
where Victor trained men are always available. No
matter where a Victor machine may be installed Victor
service stands ready, on request, to inspect it or to
render such technical assistance as  may be  required.
Victor alone maintains so comprehensive a Service
Victor X-Ray Corporation of Canada, Ltd,
524 Medical Arts Building, Montreal
2 College Street, Toronto
Motor Transportation Bldg., Vancouver
Medical Arts Bldg., Winnipeg
Victor is as old as the X-Ray. Adequate service can be rendered only
by an organization of proved stability and performance. Whether
your X-Ray needs are small or large,
for limited office work or for the
specialized laboratory, Victor Service
can help you in the selection of
equipment best suited for the desired
range of service.
Diagnostic and Deep Therapy
Apparatus. Also manufacturers
m^      of the Coolidge Twbe ^
High Frequency, Ultra-VioIet,
Sinusoidal, Galvanic and
Phototherapy Apparatus      ^,
Vancouver Branch:   Motor Transportation Bldg., 570 Dunsmuir St.
Biographies of medical men are becoming more numerous. Lister,
Paget, Osier, Horsley, to mention some of those which come readily to
the memory, and now the late Sir James Mackenzie has found, if not his
Boswell or Trevellyan, certainly his admirer anxious to emphasize and
perpetuate the lessons which may be drawn from his life.
We may say at once that a very readable and interesting book has
been produced. The title of "The Beloved Physician" is perhaps a trifle
fulsome; the matter of the work less so than the title might lead one to
fear. Indeed, considerable reticence is shown in the account of the purely
personal and private life of Mackenzie. The author has before him, we
take it, always the view, which he considers this man's great ability, powers of observation, experience, clearness of vision and logical attitude of
mind, gave him of the science and the art of medicine, and the conclusions to which they led him. The work is evidently intended for popular
or, at all events, lay consumption, and the familiar description or translation into a sort of "lingua franca" of the more technical part of Mackenzie's work on the heart must have cost the author an amount of application which one would would think the results will hardly repay.
Nevertheless, as it is done, we must say that it is well done, and the popularization in no way detracts from its readability by the professional
We suppose that most of us will agree that a very great mind was
lost to medicine when Mackenzie passed away as the result of an ailment
affecting that part of the human body which his own work had done
so much to illuminate. Probably posterity will acclaim his as one of
the great and original minds working in his chosen field. A mind groping after something imagined but found difficult of expression.
This imposing edifice of modern medicine, these gorgeous towers
and cloud-capped pinnacles of bacteriology, of pathology, of surgery, of
electrical science, of biochemistry and biophysics, was it, is it sound at
the foundation? Mackenzie early in his carrer asked some pertinent
questions of the leading inhabitants of this edifice and received what
seemed to him very ambiguous answers. Particularly he wanted information about the heart and and specifically about the heart in pregnancy.
Little was forthcoming and that little mainly concerned with the accepted views of the significance of murmurs. Doubtless, also, he encountered, as he might easily encounter today, the same vagueness of
information concerning very ordinary and commonplace signs and symptoms in other fields of enquiry. At any rate, failing this assistance, he
set himself the task of observing and elucidating phenomena about the
heart, not, we take it, because he found here a very special field of enquiry, but because it offered a concrete and readily available opportunity
for such work. Possibly at first he did not consciously realize that he
was using these observations on the heart as an example of what might
and should be applied to other organs and other diseases but he certainly
had not travelled far along the road before he realized that much of re-
Page 370 search in medicine consisted in trying to sustain an isolated brick of fact
in mid-air, without a satisfactory wall either below it or on either side.
Finally, Mackenzie recognized that in a sense it was his misfortune
to have accomplished this epochal work concerning the heart. The
world of science, the world of medicine, the popular world dubbed him
"eminent cardiologist" but lost sight of, indeed, mainly never realized,
that all his work was merely as the demonstration of a principle and of a
Doubtless many, as the experience of years has accumulated, have
felt vaguely that, despite all the brilliancy of discovery in and out of the
laboratories of medicine, all is not right with our method, when to possibly more than one half of the complaints for which we are consulted,
we are unable to give even a name and in more than one-half of the remainder a name only which characterizes some prominent symptom.
But, with the lassitude of years, the problem is handed on to a younger
generation still under the spell of the text book and the mechanical
part of the craft and so quite unable, for the most part, to appreciate
that there is a problem, much less to attempt its solution.
Not so Mackenzie. When he realized the position, gathering up
his remaining energy, he deliberately renounced his eminence, his leadership and his ease, and set himself once again to the task. And what was
the task? To elucidate the meaning of the early symptoms in the diseases
common among the people. To enforce his belief that the bedside is the
real laboratory, the general practitioner the real research worker, the beginning, not the end of disease the problem, continuity of progress the
result of maintained observation, and the true aim of medicine the anticipation of the advanced results which fill our hospitals and on which so
much of the energy and enthusiasm of physician and surgeon is now
Dr. Charles L. Scudder, of Boston, who was one of the lecturers at
the Washington University Extension course in Seattle, stopped over in
Vancouver on his way home and gave a very interesting address before
the Association at a special meeting on Monday, July 25 th. Dr. Scud-
der's subject was "The Operative Treatment of Fractures."
Dr. J. Bakes, Primarius of the Surgical Clinic at Brunn, Czechoslovakia, has been staying in Vancouver on his way to Northern B.C.
on a big game hunting expedition. While in the city Dr. Bakes spent
considerable time at the Vancouver General Hospital and gave an interesting talk on some phases of gall bladder disease.
A joint luncheon meeting of the B.C. Medical and Vancouver Medical Associations was held at the Hotel Georgia on Monday, August 15 th,
when the Hon. Dr. J. H. King was the guest of honour.    At the close of the luncheon Dr. King gave an address on the activities of the Federal
Department of Health, a report of which appears in another column 6f
this issue.
Dr. A. Primrose and Dr. Duncan Graham, who are touring British
Columbia this Fall under the Canadian Medical Association's scheme for
extra-mural post-graduate instruction, are expected to arrive in Vancouver on September 7th. Special meetings will be arranged for that
date to hear addresses by the visitors, of which due notice will be given.
Columbia University, New York, announces special eight-week
courses for medical graduates in general medicine, dermatology, pediatrics,
gynaecology, neurology, ophthalmology, pathology, surgery, and bacteriology, to be given at the Mount Sinai Hospital from October 17th to
December 10th.
Dr. A. C. Frost, Treasurer of the Vancouver Medical Association,
wishes to draw the attention of members to the fact that the annual
dues for the current Association year were payable on April 1st, 1927.
Will those members who have not yet paid up send cheques as soon as
possible in order to avoid the issue of drafts, as provided for in the bylaws
of the Association.
The Trustees are still hoping for replies from a large number of
members to their letter of June last on behalf of the Sickness and Benevolent Fund.
Dr. Gordon Burke, who has been engaged in post-graduate work in
Eastern centres for the past two months, returned to Vancouver on
August 20th, and has resumed practice.
Drs. A. C. Frost and W. T. Ewing, with Dr. W. A. Clarke of New
Westminster, left at the end of August for Chicago and Rochester, and
expect to be away about a month.
Dr. Robert Crosby, who has spent several months in Europe returned home on August 21st and has resumed practice.
Dr. W. J. S. Millar has returned to the city after three months
post-graduate study and has resumed practice.
The Library is situated in 529-531 Birks Building, Granville Street,
Vancouver, B.C.
Librarian: Miss Firmin
Hours: 10 to 1,2 to 6
The tradition of giving to the library is gradually being built up.
The first large gift of books the library ever received was from the New
Page 372 York Academy of Medicine. Then Sir T. Lauder Brunton gave us a great
number of volumes. Sir Wm. Osier sent us a one-hundred-dollar cheque
as a contribution towards a library building, and the other day Dr. H. C.
Moffitt presented the library with a one-hundred-and-fifty-dollar cheque
—being the whole of his expenses, travelling, etc., in connection with the
Summer School. That the Library Committee is elated over this
thoughtful contribution, goes without saying. The example of Dr. Mof-
fitt's gift and the interest that it indicates in medical education here
should stimulate every member of our Association to take a vital interest
in the library and its development.
Not content with merely giving, Dr. Moffitt must look over the
library, so on June 25 th, at nine o'clock, Doctors Bagnall, Busteed and
Keith were on hand to meet him and showed him over the library. The
arrangement of the books and Journals in our limited space seemed to appeal to him and the relegation of the older tomes to the storage warehouse
was commended. Dr. Moffitt, like all those interested in medical libraries
and medical education, brought up the question of having our own building for library and meeting purposes. He thought our immediate efforts
should be to secure a building near the General Hospital, as probably the
most central location for the library, an old thought with all those who
have been associated with the library and the abortive efforts made by
our Association in this direction in the past. I think this suggestion of
Moffitt's is most timely and our library committee and executive should
take initial steps at once in this matter.
A shade of the late Doctor William Osier will probably arise one of
these days and ask us what happened to the contribution he gave us for
our library building.
Dr. Moffitt said of medical education here, knowing that there was
some talk of establishing professorships for the primary subjects before
a complete medical curriculum was introduced in our University: "Why
not begin on the clinical end first?—clinics could be given at the hospital right away. Get to work with the material you have at hand and
the rest will come in due time."
This, I personally feel, could be done under the jegis of our Association at once.—W. D. Keith.
"Certified Milk."   Proceedings of the 19th and 20th Annual Conferences
of American Association of Medical Milk Commissions.
"History of Medicine."   Greene Cumston.
"History Taking and Case Recording."   Corscaden.
"Massage."   J. B. Mennell.
"Abnormal Psychology."   MacDougall.
"Surgical Clinics of North America."   Feb., 1927.    Cancer number (1).
"Surgical Clinics of North America."   April, 1927. Cancer number (2).
"Treatment of Fractures.^    Scudder.    10th Edition revised.    1926.
"Pediatrics.    Abt.    In eight volumes 1921-1927).
Page 373 I II
"Transactions of the Ophthalmological Society of the U.K.    Vol. 46.
'Applied Refraction."   Homer E. Smith.    1927.
'Medical Clinics of North America."    March, 1927.    Boston number.
'Medical Clinics of North America."   May, 1927.    Heart number.
'Public Health Reports."    U.S.A.    Part II. for 1926.    Vol. 41.
'Clinical Neurology."    I. Wechsler.    1927.
'History of Med. Dept. of U.S. Army in the World War."    Vol. XI.
'Cancer Control."    Report of International Symposium (1926).    1927.
'Medical Annual."    1927.
'Diseases of Hip, Knee and Ankle Joint."    Hugh Owen Thomas.    2nd
Edition.    1876.
'Dental Education in United States and Canada."    Carnegie Foundation.
'Mayo Clinic Volume" (1926).    1927.
'Report of Henry Phipps Inst.," 1927.
'International Clinics," June, 1927.
'Surg. Clinics N. America," June, 1927.
'Symptom Diagnosis," Barton & Yater, 1927.
'A Guide for Diabetics," Campbell & Porter.
'Primer for Diabetic Patients," Russell Wilder, 3rd ed.
'Food, Nutrition and Health," McCollum & Simmonds.
'Meaning of Disease," W. A. White, 1926.
'Pneumoconiosis," Pancoast & Pendergrass, 1926.
'Kidney Disease," Floyd,  1926. ..;■■ .
'Cavernous Sinus Thrombophlebitis," Eagleton. nu
'Diseases of Women," Crossen, 6th ed., 1926.
■Surgical Technique," Printy.
'The Mind and Its Disorders," Stoddart.
'Forensic Psychiatry," East.
'Some Famous Medical Trials, Parry. «|
'The Ego and the Id.," Sig. Freud.
'Epidemic Diseases of the Central Nervous System," McNalty.
An Address to the Summer School of the Vancouver Medical Association, June 24th, 1927, by Dr. Wm. Boyd, Prof, of Pathology, University
of Manitoba.
I shall confine myself, in this lecture, to two topics, the structural
changes produced in the gall bladder in disease, and the mechanism by
which gall stones come to be formed. I shall, however, be unable to refrain from making at least a passing allusion to the function of the organ
under consideration.
Structural changes.—Before we can hope to form any conception of
the pathological gall bladder we must first gain some idea of its normal
Page 374
EH appearance.    To my mind by far the most satisfactory method of attaining this end is to look at the mucosal surface under water by means
of a low-power binocular dissecting microscope, using the brilliant light
of an arc lamp as an illuminant.    The picture disclosed to our eyes is a
remarkable   and   beautiful   one,   the   entire   mucosal   surface   is   divided
into polygonal spaces by tall, graceful membranes, delicate as gossamer,
and   swaying   with   every   movement   of   the   water.     Compare   such
a   picture   with   the   flat,   featureless   prairie   presented   by   the   inner
surface of the urinary bladder.    On morphological grounds alone it is
at once evident that the latter is a mere reservoir, whilst in the former
an active interchange of substances must take place through the lining
membrane.    This view is confirmed by a  consideration of histological
sections of the normal gall bladder,  which show what appear to be a
number of delicate villi, really mucosal folds cut on edge, each villus
covered by columnar epithelium with the scantiest of stroma containing
blood vessels and lymphatics, a structure evidently designed for secretion
or absorption.     The pathologist  is  dependent on  the kindness  of   the
surgeon for normal specimens of this kind, for in autopsy specimens the
villi appear as mere scraggy scarecrows denuded of epithelium.    For many
years it was thought that the interchange through the villi was in the
nature of a secretion, and that cholesterol in particular was poured into
the bile by the gall bladder epithelium.    In 1921, however, the work of
Peyton Rous and McMaster showed in the most convincing way that the
chief function of the gall bladder was one of absorption and concentration of the bile which it contained.    My own work in 1923  seemed to
suggest that cholesterol was one of the principal substances absorbed, a
similar  conclusion  being  reached  by  Torinoumi  working  in  Aschoff's
laboratory in the following year.
Before leaving the subject of the normal gall bladder, I must refer
to the interesting work of Boyden on the alteration of the mucosal pattern as the organ passes from distension to collapse. In complete collapse, produced by feeding an animal on a diet rich in fat, the lumen
becomes nearly filled with large fungiform projections showing a peculiar
globular distension, a condition much more favourable to absorption than
is the state of dilatation.
When we study the pathological gall bladder under the dissecting
microscope we find a picture very different from the normal. The most
extreme change is seen in hydrops of the gall bladder, where the organ
becomes greatly distended as the result of blocking of the cystic duct by
a calculus. Here we find an absolutely flat, featureless surface, devoid
of a single elevation. It is evident that in such an organ absorption must
be seriously impaired, may, indeed, be entirely abolished.
In an ordinary chronic cholecystitis the folds are enormously thickened. The cause of this thickening is revealed by histological examination. It is due in part to cedema, in part to great collections of inflammatory cells and proliferated connective tissue cells, and in part to wide
dilatation of the lymphatics which is a feature of at least the earlier
stages.    These inflammatory changes are by no means confined to the
Page 375 mucosa, but are also evident in the fibromuscular and in the subserous
coats, changes which lead to a general thickening of the gall bladder
wall In an. acute inflammation the entire wall is diffusely infiltrated
with inflammatory cells. In the more subacute form plasma cells may
form a striking feature of the picture, just as they do in the appendix.
In the chronic cases the cells in the deeper layers are more focal in their
arrangement, being collected into little groups. In these cases active
fibroblastic proliferation may be going on, with the subsequent formation of dense fibrous tissue. In course of time this scarring may become
so extreme that the mucosa is entirely replaced by a network of interlacing trabecular.
Despite statements to the contrary the normal gall bladder does not
possess true glands. The furrows between the ridges may, however, be
so deep as to suggest a simple tubular gland, an appearance known as the
Luschka crypts. In chronic inflammation these invaginations of mucous
membrane may become very pronounced, so marked, indeed, that glandlike structures may be found in the depths of the muscular coat, and
may be mistaken by the unwary for an adenocarcinoma. I have noticed
that the epithelial cells lining these deeper formations differ from those
covering the surface in that they are quite clear as if they contained
mucin. It may be that such structures behave like true glands and produce an abundance of mucus when the wall is inflamed.
For the purpose of gaining an insight into some of the fundamental
features of gall bladder pathology, I have found a study of the condition
known as the strawberry gall bladder of peculiar value. The name is
rather an objectionable one; it should rather be termed the lipoid gall
bladder or liposis of the gall bladder. With the naked eye small yellow
granules, not unlike the seeds of a strawberry, can be seen scattered over
the mucosal surface, but it is under the dissecting microscope that the
true picture is revealed. In severe cases the fragile folds of mucosa are
loaded down by dense yellow material, much as the branches of a delicate birch tree may be weighed down by a load of snow. In the milder
cases only a fold here and there is picked out, like a mountain ridge retaining but an occasional patch of the winter's snow. This yellow material can be shown by microchemical methods to be an ester of cholesterol, a lipoid which forms the most important constituent of the vast
majority of biliary calculi.
The distribution of this lipoid can be studied by a variety of methods, of which the two most useful are the polarizing microscope and the
use of a fat stain such as Scharlach R. or osmic acid. The polarizing
microscope serves to distinguish between cholesterol and neutral fat, for
the former is doubly refractive and, therefore, appears as brilliant particles, shining with a silvery radiance which is accentuated by the surrounding darkness, when viewed under crossed Nicol's prisms, whereas
neutral fat, often present in large amount in the deeper layers of the gall
bladder, remains invisible. It must be remembered, however, that all
that glitters is not cholesterol, and fibrous tissue may appear faintly
white, though not brilliant.
Page 376 For a study of the finer distribution of the lipoid the use of a fat
stain is necessary. The bright red globules and granules are found principally in the epithelial cells of the surface and in the underlying stroma
of the folds or villi. These deposits are sometimes extraordinarily heavy.
In a few of my preparations I have been able to demonstrate the lipoid
within connective tissue cells of inflammatory origin in the deep layers
of the wall. From a consideration of this distribution of the cholesterol
it is hard to believe that it is in process of excretion. The conclusion
is forced upon one that it is being absorbed, probably by the lymphatics,
a conclusion which is confirmed by experimental evidence.
The amount of cholesterol which may collect in the strawberry gall
bladder is remarkable. In a series of quantitative estimations I found
that the lipoid was increased 40, 50, and even 60 times. Fowweather
and Collinson in a recent number of the British Journal of Surgery
found an increase in the cholesterol of the gall bladder wall in 45 per
cent, of calculus cases. This brings up the point that the lipoid increase
is by no means confined to the strawberry gall bladder. I have found at
least some traces of lipoid microscopically in about half of the cases of
chronic cholecystitis.
When we enquire, what causes this remarkable deposition of cholesterol, we find ourselves taking the difficult step between structure and
function. I think myself that it must depend on the presence of inflammation in the gall bladder wall. In every case which I have examined
there has been at least some evidence of inflammation, although often
very slight. Indeed, I have hardly ever found lipoid deposits in a gall
bladder showing very marked inflammation. Long-standing inflammation leads to obstruction of the lymphatics, which, in turn, must interfere with the process of absorption. Apparently, when the inflammation
reaches a certain grade the cholesterol simply disappears. In one of our
cases the greater part of the gall bladder was thickened and had evidently
been inflamed for some time. No lipoid could be seen with the dissecting
microscope. The remaining part was much thinner, the mucosa was
comparatively unaltered, and it contained heavy deposits of cholesterol.
In addition to the factor of inflammation it is extremely probable
that an increase in the blood cholesterol and, therefore, the bile cholesterol has something to do with these lipoid deposits. Fowweather and
Collinson found a high blood cholesterol in 47 per cent, of their cases
of cholecystitis and calculus. We must remember, however, that a high
blood cholesterol is often only a transitory phenomenon, so that it may
no longer be present when the gall stones are discovered. Of this transitory increase, pregnancy is a good example. A second is convalescence
after typhoid fever. A third is rapid loss of fat in a stout subject. The
fat, female, forty person is in danger of an occasional high blood cholesterol.
Reviewing our knowledge of the morbid anatomy of the inflamed
gall bladder, we find that we may recognize three principal conditions.
First, acute cholecystitis, characterized by infiltration of the entire wall
with acute inflammatory cells and the outpouring of a purulent exudate
Page 377 into the cavity of the viscus. Second, chronic cholecystitis, in which the
wall is again infiltrated with inflammatory cells, this time of a chronic
character, with fibroblastic proliferation, subsequent fibrosis, and serious
interference with the delicate absorbing mechanism of the organ. And,
third, the condition we may term the lipoid gall bladder, also dependent
in part upon chronic inflammation, although of a slighter nature, and
distinguished by deposits of cholesterol in the mucous membrane and to
a lesser extent in the deeper layers of the bladder wall.
You will notice that I have avoided all discussion of the question
of the etiology of cholecystitis. This is because once I started I would
hot be able to stop. If, however, I could have engaged in such a discussion. I would arrive at the following conclusions. First, that streptococci of low virulence are the most common cause of cholecystitis.
Second, it is probable that bacteria reach the gall bladder both by the
blood and the lymph stream, sometimes by one path, sometimes by the
other. When they travel by the lymphatics they may come from the
liver, from the first part of the duodenum, or from the appendix. The
work of Prof. Evarts Graham has shown us the importance of lymph
spread infection from the liver.
Origin of gall stones.—Let us turn now to the second of my topics,
the origin of gall stones. The first and in some ways the most important
step is a recognition of the fact that there are several different kinds of
calculi, which have quite different methods of origin. For a full realization of the importance of distinguishing between the different kinds of
calculi we are indebted especially to the work of Aschoff and Bacmeister.
Two main types of stone may be recognized, the metabolic or aseptic
stone, and the inflammatory or septic stone.
The metabolic stone is large, oval, single, white, composed entirely
of cholesterol, and, therefore, known as the cholesterol solitaire. Aschoff
calls this a metabolic stone because it is apparently formed solely as the
result of disordered liver metabolism. Cholesterol is kept in solution
by the bile acids, but the solubility is dependent not only on the amount
but on the relative proportion of the acids. Any disturbance in the
acids, any increase in the cholesterol, may be followed by precipitation
of the latter. The stone is distinguished by its radiate structure, as opposed to the concentric structure of the septic or inflammatory stone.
Frequently it gives rise to no symptoms, and is only found by accident
at autopsy. It is a silent stone, and, as a rule, the gall bladder shows no
evidence of inflammation. It may, however, become impacted in the
neck of the gall bladder, and the acute stasis which results is apt to be
followed by infection. Should the stone then roll back into the bladder
and allow the bile to reenter, a deposit of bilirubin calcium is laid down
upon the cholesterol solitaire, with the result that what is termed a combination stone is formed, a combination of the metabolic and the inflammatory types. There is this great difference between a pure cholesterol stone and a combination stone; the pure stone is solitary whilst the
combination stone, being partly infective in origin, is nearly always associated with the septic type of multiple calculi. The formation of a
pure cholesterol stone is favoured by such factors as high blood choles-
Page 378 terol (and, therefore, high bile cholesterol), and by stasis in the gall
bladder. We have seen, however, that although a high blood cholesterol
conduces to the formation of a cholesterol solitaire, yet it by no means
follows that it will be high at the time the stone is removed.
Before leaving the subject of the metabolic stone, mention must be
made of another variety, much less common and more difficult to understand. I refer to the pure pigment stone. These are multiple, about the
size of a grain of rice, black in colour and of a hard brittle consistence.
They contain no cholesterol. These are the stones which so frequently
complicate hemolytic jaundice, but other factors concerned in their
origin are, as far as I am aware, still unknown.
We come now to the commonest variety, the infective or septic
stone. These are the facetted, cholesterol-pigment-calcium stones which
on section present not a radiate but a characteristic concentric arrangement of laminaj. All the stones of one family are about the same size,
but there may be two and sometimes even three families. In addition,
there may be one or more large combination stones. If the crystalline
material is removed by means of chloroform or ether, a protein framework is left which shows the same concentric lamellation as the stone.
This is never seen in the pure cholesterol stone. It is evident, therefore,
that they are formed in a medium rich in protein, whilst the cholesterol
stone is formed in a medium poor in protein. This provides us with a
clue to the way in which these stones originate. As the result of inflammation of the gall bladder, a mixture of pus, mucus, bacteria, and
epithelial debris is poured out. During an acute attack the gall bladder
is more or less a closed cavity, but as the swelling at the neck subsides
bile again enters, and around the little nuclei of organic matter are deposited layers of cholesterol and bilirubin calcium. In this manner the
family of facetted septic stones is formed.
There is, however, another way in which we may study the formation of stones. So far we have only considered the contents of the gall
bladder; we have still to consider its wall. If a series of lipoid gall bladders are examined by means of frozen sections and the Scharlach R stain,
masses of cholesterol will occasionally be found which so heavily weigh
down the villi that the latter appear to be attached by a mere pedicle to
the surface of the mucosa. Should one of these masses become detached
it will form an ideal nucleus for the formation of a stone. It is possible,
indeed likely, that at least some stones may be formed in this way.
Chauffard in his book on biliary lithiasis agrees with this suggestion, and
thinks that multiple-facetted stones usually originate in the mucosa.
At the time of operation the gall bladder wall may no longer present a
strawberry appearance, but this, as we have seen, tends to disappear as
the wall becomes more extensively fibrosed and thickened.
In conclusion, brief reference must be made to the condition known
as the stasis gall bladder, the Stauungsblase of the Germans. It is a fact
well known to surgeons that a patient with gall bladder symptoms may
be found at operation to have neither cholecystitis nor calculi. These
cases have been studied by Continental workers, more particularly by
Aschoff, Berg, and Westphal.    Atonic and hypertonic varieties have been
Page 379 described. In the atonic variety the gall bladder wall is thin and lax,
in the hypertonic it is thick and the bladder is distended. In both there
is stasis of bile and a tendency to the formation of stones. Westphal has
shown that the hypertonic, or, as he calls it, the hyperkinetic variety,
is due to vagal spasm of the neck of the gall bladder and the sphincter
of Oddi, a condition which is frequently present in the early stages of
pregnancy. This may be a factor of importance in determining the
formation of calculi in pregnant women.
Notes of an address by Dr. J. G. Fitzgerald, Director of the Con-
naught Laboratories, Toronto, delivered before the Summer School of
the Vancouver Medical Association, June 23rd, 1927.
Dr. Fitzgerald said that he grouped the known sera into four classes:
(1) True antitoxic sera of which there were five used in the treatment of diphtheria, tetanus, scarlet fever, botulism and more lately erysipelas. These sera contained substances directly antagonistic to the toxin
produced by the infecting organism in the case.
(2) Bactericidal sera, the best known of which was the anti-men-
inococcic, the serum produced from the pneumococcus Tl and the antityphoid serum of Chantemesse.
(3) The anti-virus sera of which the anti-poliomyelitis is the best
(4) A doubtful and questionable category containing the antistreptococcic and anti- staphylococcic sera.
The action of bacterial vaccines is very uncertain and it is exceedingly difficult to demonstrate their effect, if any, scientifically. It was
also impossible to give the proper indications for their use and, while
not definitely discountenancing the employment of vaccines, the lecturer
deprecated their indiscriminate application.
Anti-diphtheritic serum was the first discussed. Though actually
introduced by von Behring, the first large clinical test was made by
Roux (who is still living and active) in 1894. There are a few general
principles concerning its application. One of the most important is
that of early employment. It is still the practice of some to wait two,
three or more days for a laboratory report before beginning treatment
and still many patients died on account of this delay. It is to be remembered that the laboratory does not make the diagnosis, that is a
clinical matter.
If there is reason to suspect the presence of diphtheria, the course
is clear—serum treatment must be begun at once. It is to be remembered
that the mortality in cases where the treatment is commenced on the
fourth day is six times that when it is begun on the first day of the
disease.    Prior to the introduction of antitoxin, out of every three cases
(Continued on Page 385)
Page 3 80 The
British Columbia Laboratory Bulletin
Published  monthly  September   fo   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
No. 1
Eykman Water Test Ootmar
Resistant Spores in Milk Plates Kilpatrick
Temperature of Dilution Water for Milk Counts Dowsley
Difference in Function of the Two Kidneys R. E. C.
G. A. Ootmar, M.D., Kelowna, General Hospital Laboratories.
One danger of infection with the organisms of cholera, typhoid
fever, dysentery, etc., lies in using water which is contaminated with
excreta from diseased persons or carriers.
We know how difficult it is to look for microorganisms in the
water, also that a negative report may mean nothing. For years attempts
have been made to find ?.n easy method of determining the contamination of water and other liquids with excreta.
Bacillus coli communis is held to be an indicator—the presence of
this organism being a reliable test for contaminated water. Such water
must be considered dangerous on account of the possibility of an associated infection with the above-mentioned pathogens (not mentioning
the possibility that B. coli itself or related strains, might also be dangerous
to health).
Freudenreich (in the Centralblatt fur Bakteriol: Bd. XVIII, page
114) found that pure water contains no B. Coli while contaminated
water carries appreciable numbers.
Contaminated water inoculated into lactose broth and incubated at
37°, gives strong fermentation within 12-24 hours. This fermentation
does not occur with bacteria ordinarily found in the water, even if
Proteus vulgaris is present.
Page 3 81 In this way, he was able to trace Bacillus coli communis in 0.00,001
cc. of canal water, while in 100 cc. of pure water they were not found.
Petruschky and Pusch (Zeitschrift f. Hyg: und Infectionskunde: Bd.
XLIII, page 304) added equal parts of water to peptone broth and incubated at 37° C. When the mixture remained clear there were no
B. coli communis present; if it became milky, B. coli could be isolated in
a plate culture.
Still the difficulty remained, however, that there are many bacilli
related to B. coli which do not originate in the intestines; thus the reactions of B. coli alone could not be used as an indication that the water
had been contaminated with excreta (feces, etc.).
Eykman made use of the fact that B. coli still grows at a temperature of 46° C. and ferments glucose, producing indol in sugar-free
media containing peptone. He mixed 8 parts of the water with 1 part
of a sterile solution made up of glucose, 10% peptone and 5% NaCl,
and put the mixture in a sterile U-tube with one end closed. Usually
after 24 hours, but certainly after 48 hours, the mixture will become
cloudy, and gas forms if B. coli, originating from the bowel, are present.
(Indol is not formed on account of the presence of glucose.)
In the microscopical examination of the contents of the fermentation tube, we find non-motile bacilli, some with slight motility; and
cocci; and when plated, we find for example butyric-acid-producing
From a scientific point of view, one cannot say that B. coli is the
only bacillus originating from the intestines which ferments glucose at
46° C. because there are many others which do the same; but hundreds
and hundreds of tests prove that water contaminated with feces always
shows a positive fermentation at 46°; while pure water does not. Besides, the other bacteria which cause fermentation at this temperature
are nearly always found to belong to the intestinal flora.
Rainwater always gives a negative result, even when it has been
taken from a gutter.
At 37° O, the special media described above may also show fermentation, mostly after 24 hours. In this case bacteria belonging to the colon
group are found which lack the property of growing at 46° C. and
which belong to a strain which does not originate in the intestines.
Other experimentors, as Bulin from the Hyg. in Prague, modifies Eykman's test by using mannite instead of glucose, but from a
practical point of view, as the Eykman test is so easy to perform and as
it is verified by the many tests made in Dutch East India (where it is a
standard method) we may consider it a very valuable test in tracing
water contaminated with feces.
M. Kilpatrick, M.A., Vancouver General Hospital Laboratories.
History.—Spores were first noticed in the milk plates May 19, 1927.
These spores reappeared on June 14th, and persisted for a period of three
Page 3 82 Source.—Since the spores were only found in the agar, the other
media being quite free from them, we were forced to conclude that the
spores came from the crude agar.
Utensils used to make agar are used for this purpose only. This
explains why the other media had not been contaminated. The aluminum
pot in which the agar is boiled was thoroughly cleaned and sterilized in
the autoclave for 30 minutes at 15 lbs. pressure. Swabs were then taken
from the pot and planted.    Abundant spores were present in 48 hours.
It was thought that if a new tin of crude agar were used the difficulty
might be solved.
A new tin of Bacto agar was opened; a supply of Bacto agar from
the University of B.C. was obtained. Parallel tests were then made from
three sources.
6 tubes of sterile broth inoculated with U.B.C. agar.
6 tubes of sterile broth inoculated with Old V.G.H. agar.
6 tubes of sterile broth inoculated with New V.G.H. agar.
These tubes were sterilized for 20 minutes at 15 lbs. and then incubated.    In 24 hours there were spores present in every tube.
Resistance of Spores to Heat.—Agar slant cultures of spores were
made and these were sterilized in duplicate at:
(a) 15 lbs. pressure for 20 minutes.
Result:    Growth in 24 hours in both tubes.
(b) 15 lbs. pressure for 30 minutes.
Result:    No growth in 48 hours.
(c) 15 lbs. pressure for 45 minutes.
Result:    No growth in 48 hours.
(d) 15 lbs. pressure for 60 minutes.
Result:    No growth in 48 hours.
Numerous other tests were then made on crude agar, from the three
sources, and on the utensils used. It was found that half an hour at 15
lbs. pressure killed all spores except, occasionally, those from the agar
which originated the trouble. These resistant spores were, however, killed
in three-quarters of an hour.
Present Procedure.—All utensils and test tubes are sterilized for 20
minutes at 15 lbs. pressure. The crude agar is also sterilized for one hour
at the same pressure. After the spores have been eliminated by the above
procedure, the media itself is sterilized completely by 15 lbs. pressure for
20 minutes.    This technique has been, so far, completely successful.
Gertrude Dowsley, B.A., Vancouver General Hospital Laboratories.
It was suggested that high milk counts obtained during the summer might be due to the use of water dilution bottles kept at room
temperature and that the use of dilution bottles kept at ice-box temperature would appreciably lower the counts.    To determine the importance
Page 3 83 of this factor, a series of counts have been made. A sample of milk
was placed in a dilution bottle at ice-box temperature and a similar sample
of the same milk placed in a dilution bottle at room temperature. Both
bottles were then placed in the ice box and plated 4 or 5 hours later.
The accompanying results show that in 7 out of the 10 samples,
the count obtained from the room temperature dilution bottle was lower
than the count from the ice-box temperature dilution bottle.
The differences, however, were small in consideration of the errqr
of the method.
Therefore, the milk count was not found to be affected to any appreciable extent by the use of the room temperature dilution bottles
rather than the ice-box temperature dilution bottles.
Ice-box Temperature
Room Temperature
(Official Count)
erimental Count)
5,   1927
7,   1927
11,  1927
15,  1927
18,  1927
19,   1927
21,  1927
25,   1927
26,   1927
28,  1927
The following series gives the range of the specific gravity in simultaneous samples from the right and left kidney at two-hourly intervals.
This recent case of Dr. A. W. Hunter illustrates again the independent
manner in which kidneys may vary their rate of function. Our attention
can not be drawn too often to just such cases. Since the great bulk of
clinical information consists of isolated estimation of bodily functions,
there is a very powerful and constant tendency to create the impression
that such isolated readings represent stationary states rather than points
in a moving panorama as they really are.
Time Volume       Sp. Gr. Volume       Sp. Gr.
10 a.m.         192  cc. 1006 210 cc. 1006
12 noon       100 cc. 1005 46 cc. 1005
2  p.m.          95   cc. 1006 100  cc. 1006
4 p.m.          60 cc. 1007 100 cc. 1004
6 p.m.         90 cc. 1008 62  cc. 1009
8 p.m.         90 cc. 1010 70 cc. 1009
—R. E. C, V.G.H.
Page 3 84 (Continued from Page 3 80)
one died. The matter of dosage is also of great importance. In many
instances the dosage as ordinarily employed may be quite inadequate. In
the Blegsdam Hospital at Copenhagen, they have lately shown a mortality
of under one per cent. Immense doses are used, especially in cases not
received within thirty-six hours of onset. From 40,000 to 200,000
units may be given within twelve hours.
In the treatment of tetanus early recognition is again of the utmost
value, or even in injuries or operations where there is reason to fear the
possibility of its occurrence, the administration of 1500 units as a prophylactic measure. The first signs are those of pain and stiffness at the
site of injury. This may occur long before there is any sign of trismus
and is the ideal time at which to commence treatment. The lecturer
favoured the use of the specific anti-serum intrathecally, getting the
serum to the place where the toxin is becoming fixed. He recognized
that either through the introduction of a foreign protein or because of
the preservative used in the serum a good deal of spinal irritation might
be set up. 5000 units may be given intraspinally, slowly, well diluted
and warm. At the same time a little may be given intravenously and a
large reservoir, of say 20,000 to 30,000 units given intramuscularly for
slow absorption. •
For treatment of scarlet fever anti-sera had been used in Russia for
many years. The heart blood of fatal cases had been used for purposes of
obtaining the cultures from which horses were inoculated. The Dicks
in 1924 were able, by means of their cultures, to reproduce typical scarlet fever.
In botulism, two types of antitoxin were used as two types of toxin
had to be combatted.
Amos of Johns Hopkins Hospital has recently introduced a special
serum for use in erysipelas. This is reported to give fairly satisfactory
results in certain cases. The Connaught Laboratories are now supplying this serum for use in this small group of cases. The dose is from
50 cc. to 100 cc. It is to be remembered that in the vast majority of
cases of erysipelas no such treatment is required, the tendency of the
disease being towards resolution.
In the treatment of meningococcic meningitis, if the specific antiserum is used within the first 24 hours, about 80% of the patients will
recover. It is very necessary that the serum (which is given intrathecally) be used as early as possible after the removal of as much cerebro-spinal fluid as can be obtained. The mortality among untreated cases
is very high, about 75% going on to a fatal termination. Light general
anaesthesia is used for lumbar puncture and the serum, which is warm, is
given slowly. There is no need to wait for a laboratory diagnosis. In
suspected cases, if the cerebro-spinal fluid removed is turbid, give the
serum at once, and, further, it must be remembered that in about one-
fifth of the cases it is difficult, if not impossible, to demonstrate the
presence of the organism.
Page 383 Regarding anti-streptococcic serum, Dr. Fitzgerald said that they
were now trying out in Toronto what they hoped would be an improved
serum made from strains of streptococci isolated from septic uteri.
The serum from convalescent cases of anterior poliomyelitis is probably of value and there is also good basis for the use of the anti-serum
for Type one pneumococcus. Unfortunately, cases of Type one are not
very numerous and there is no serum for Types two and three and the
use of any serum here is unwarranted.
Notes from an address delivered before the Vancouver Medical Association Summer School, June, 1927, by Dr. C. L. Starr.
A number of years ago, on going through the statistics of the hospital, we found we were having very poor results in our cases of acute
infections of bone. A careful study of the problem, however, in a way,
relieves us of the responsibility for the results we were getting. I found
the patient was generally admitted to the hospital three weeks or so after
the disease had started. That meant the infection had had an opportunity
to spread, and we could not do very much to prevent it spreading and
while we could remove certain portions of necrotic bone, we did not prevent the possibility of these things recurring in after years, and we had
the experience of having bone infections lighting up again years after
apparent subsidence. I had an experience in which I opened up a bone
eleven years after suppuration had ceased. I opened into an abscess
cavity and from that cavity we drew staphylococci after eleven years,
so it seemed hopeless to improve the condition unless we could get at the
origin. So I became interested in the acute stage. I do not intend to
touch the great importance of operative procedures in the late stage.
Now for a moment let me recall some of the anatomical features as
they relate to bone growth and development. First, circulation; the
circulation of the shaft of the long bones, where the bulk of these acute
infections takes place. The nutrient vessel enters a little to one side of
the centre of the shaft and divides into a number of branches which
spread in two directions towards the two epiphyses and from that the
entire blood supply is received. These vessels anastomose with the second
source of blood supply, that from the periosteum. This anatomy is important because the bone will survive if either of these two sources of
blood supply is intact. If it were not so in every fracture of the long
bone where you have a complete tear of the nutrient vessels you would
have a death unless it could be supplied from the periosteal vessels. That
is the reason why we have no gross difficulties with the blood supply in
fractures which are complete. Either one of these sources of blood supply is sufficient to keep the bone nourished, but there is a third supply—
from the epihyses.
Page 3 86 The attachment of the periosteum is an important factor. The
periosteum goes down the shaft of the bone and buries itself in the epiphysis, so that you can take a child's bone, in the early stage of development, and you can twist it and you will always separate the shaft from
the epiphysis and the periosteum. The importance of this is that that
attachment of the periosteum to the epiphysis beyond the epiphyseal
line, makes it probable that the neighbouring joint will escape infection.
Care must be taken not to cut across this bar and open the capsule between the periosteum and the synovial membrane and thus make an
entrance for infection into the joint. In days gone by more joints have
been infected by poor judgment on the part of the surgeon than by direct spread of the infection.
One other point—the relation of the epiphyses to the joints. You
will recall that in practically all of the long bones, with one exception,
the attachment of the ligaments of the joint is to the epiphysis. The
one exception is the hip joint, and there the epiphsis of the head of the
femur is inside the capsule so that if you have an infection in the head
of the femur and the infection spreads along the line of least resistance,
then it will be opening directly into the joint. That is the only joint
in which it will do so.
There is one point and that refers to the cortex of the shaft of the
long bones. When we speak of the infection spreading from the cancellous tissue through the cortex to and underneath the periosteum, it rather
startles us, because we think of the cortex as it appears in the middle of
the shaft. These conditions occur, in practically 95 per cent., in cases
of small children. You must also remember that the cortex is of the
normal thickness in the middle of the shaft—one-quarter to three-eighths
of an inch in thickness—and we think of the difficulty that any infection
will have in spreading through that cortex, unless we also remember that
the cortex at the epiphyses is not of that character at all. It thins out,
and by the time it reaches the epiphyseal line it is practically of tissue-
paper thickness. This helps us in accepting the fact of the possibility of
the spread of infection in that way.
The etiological factors in all acute infections of bone are of two
types: a primary focus of infection elsewhere in the body, such as
mouth and tonsils, and much more frequently, some local infection of
the skin, as boils and infected wounds. The organisms most commonly
found is the staphylococcus with some strains of streptococcus. The
infection comes from the skin surface in pretty much all cases and with
us we have found that the infection comes from the feet.
So many children get sore feet either from the so-called stone bruising or from badly fitting boots and the starting point is probably there.
It is easy of demonstration. If you take a rabbit and inject into the
vein of the ear a virulent staphylococcus you can pick it up in the cells
of the medullary area of the cancellous tissue of the bone two hours
afterwards. If you do not put in a very large dose and examine again in
two hours they are gone.    The phagocytosis is so great that it will take
Page 3 87 care of any ordinary infection. If that is true, and we have a bacterium
in all of these cases, either you must have a lowered resistance to disease,
in which you expect to find a focus of infection, or an increased virulence thrown into the blood stream that cannot be taken care of and
you find the organisms are not being phagocyted.
It happens usually on the diaphyseal side of the epiphyseal line. It
makes no difference whether the nutrient vessels point towards the knee
or ankle in determining which end will be the site of location of that
infection, but I think that the question of traumatism is an important
factor. If you get a twist or wrench of the epiphysis, naturally that
particular area will have lessened resistance to the infection than the
parts not traumatized.
These infections are carried in and are found most frequently in the
growing child. You rarely see them after the epiphysis is united, around
the 19th to 20th year. Occasionally you see them, but not often. With
that factor, if you ask whether it starts on the diaphyseal side of the
epiphyseal line, I do not know.   It is simply a fact that this does happen.
We have had more or less difficulty because the commonly accepted
method of the spread of the infection has been a question of debate and
possibly not everyone is of the same opinion even now.
(Dr. Starr then showed a series of slides.)
Continuing Dr. Starr said: From our autopsy specimens, from
microphotographs andf rom our experimental work in growing animals
we can demonstrate that the infection will spread along the epiphyseal
line to the cortex and periosteum; it readily strips the periosteum with
increasing tension as pus is formed and we can demonstrate that with
increasing pressure the infection spreads backwards through the Haversian canals at different levels, giving rise to the spotting character in
•many of these infections.
Now we come to the X-Ray. Roentgen ray findings are always
negative in the early stages, and must not be relied upon in making a
Now taking this as the background of our etiology, the thing that
naturally comes to our minds is what signs and symptoms we shall have
and whether we can make our diagnosis from that standpoint and the
first thing is pain. Pain is always present, moderate at first but increasingly severe with each hour that passes and located in the neighbourhood
of a joint. Now I emphasize the neighbourhood of a joint. Some people
cannot distinguish it from a septic arthritis, but it is in the neighbourhood of the joint and not within the joint and you can move it gently
backwards and forwards without any exacerbation of the pain. The
contour of the joint is not changed. In the early stage there is no sign
of fluid in the joint itself.    So we have
1. Pain in the neighbourhood of the joint
2. Elevation of temperature to 103-5
Page 3 88 3.    A marked Ieucocytosis.
Now, if you have these signs, and, in addition, a localized tenderness, and the tenderness is in the neighbourhood of the location of the
epiphyseal line, the most tender spot will localize the worst area of infection, whether on the inner or outer side of the long bone. If you
make pressure on the bone and grope around say on the inside, where the
infection is most marked, then the child will cry out, thus satisfactorily
locating for you the fact that the infection is nearer the inside than the
With these signs in the growing child, the question of diagnosis
becomes simple and there are only one or two things you can mix it up
with. The most important is septic arthritis, and here you may have the
same symptoms without the same maximum tenderness on the epiphyseal
line, the differentiating feature is that you can get movement in the
osteomyelitic condition and not in the septic arthritis.
The X-Ray is of no value in your diagnosis. You must make your
diagnosis from the history and symptoms.
The question of suppurative acute rheumatic fever may be a difficulty, but here, in the acute rheumatic fever with an arthritic manifestation, you will find that the signs are obviously joint signs and not
neighbourhood joint signs.
It is true you have some pain, some fever and a Ieucocytosis, but
you do not get the excruciating pain you do get in the other condition.
Once you have made your diagnosis it is much safer to cut down
through the periosteum to the bone, over the area of greatest tenderness.
Make the incision towards the centre of the shaft and not towards the
joint so as to be sure not to cut across the epiphyseal attachment. If you
find, with your incision, that you get no pus, you will find an cedema
and then you may run into pus underneath the periosteum. If you find
pus underneath the periosteum a drain there may be all that is necessary,
but I am satisfied now that that is not enough. Take out a little strip of
the cortex so that any infection remaining in the medullary tissue will
find a way of escape and that to the outside. As long as you have this
you will run no fear of infection into the deeper tissues. If you fiind
no pus, you should lift up the periosteum for half to one inch both ways
to see if you have missed the points of greatest tenderness, and then, feeling that you have not done enough, make 2-3 drill holes from the cortex
obliquely downwards to the epiphyseal line, and then if you do not get
free pus I,at least, have never failed to get a culture from the bone itself
in the debris which I have withdrawn from my drill holes. If you get
that I think you are perfectly safe to leave it there, but you would be
using poor judgment to continue your excision until you reached your
medullary canal, which is unquestionably suggested in all the textbooks,
even of today.
One recent System of Surgery says that the surgeon who fails to
continue his cutting through the  cortex until he reaches  the medulla
Page 3 89 has not fulfilled his entire duty. My feeling is that he has overstepped
his duty by a long way and the patient would have been better left with
drill holes only.
Now, with the separation of the periosteum from the cortex, that
portion of the shaft from which the periosteum is stripped is separated
from its blood supply, and it will sequestrate down to the point from
which the periosteum is stripped.
We now have a series of cases (about 25 or 26) which we have
carried through a definite infection, and that is all that was done, and
all recovered health within a month's time, and without sequestra. My
judgment is that once you have an opening made so that it will drain,
you cannot as well determine the line of sequestrum as nature will, and
once it starts to separate you cannot hasten the process; you are building
up new bone and by the time the sequestrum is separated, the involucrum
is quite easily cut through and you can enlarge the opening sufficiently
to take out the sequestrum, and you should have it entire, and I always
do that with the tourniquet. Then swab out the cavity with iodine, and
crush the soft surfaces of the involucrum against one another and put it
in a splint to support it. My feeling is that as time goes on you will
have a gradually increasing number of cases that will get well without
any sequestrum, and that has been my object in presenting a subject of
that sort to any person good enough to listen to it, and, I think, will do
for the osteomyelitis cases what we have succeeded in doing in the Province of Ontario, by missionary tours through the country.
I hope we can look forward to the time when our practitioners
generally will diagnose acute osteomyelitis within twenty-four hours. It
is very easy in the first 24 hours and very difficult afterwards. If we
can accomplish that we will save the children in the future from these
long-drawn-out bone infections.
A large number of medical men had the pleasure of hearing the Hon.
Dr. J. H. King give an address at the Georgia Hotel at a luncheon
meeting arranged by the B.C. and Vancouver Medical Associations. Dr.
H. E. Ridewood, of Victoria, was in the Chair and introduced Dr. King,
who is the Minister of Health for Canada.
Dr. King gave a succinct report of the activities of the Federal
Department of Health. This is a new department, having been inaugurated in 1920, and has many functions of great importance to the national life. The first function to which he referred was that of quarantine. Canada, in uniformity with thirty-four other countries, has a
very complete system of quarantine, and maintains four stations, the one
at Williams Head being well known to British Columbians, and described
by Dr. King as one of the best in North America.
Page 190 Another great department of his work is that connected with immigration, especially as regards selection of those who are fit, mentally
and physically. Until last year examination of immigrants was conducted entirely at the port of disembarkation in Canada, but Dr. King's
Department has been able to persuade the Government that examinations
should be conducted at the ports of embarkation and Dr. King gave
some very interesting figures as to the greater efficiency thus obtained.
For instance, in 1925, Dr. Laidlaw of Alberta reported that of the 1920
insane patients in Alberta, 79% were foreign born, costing an annual
sum of $250,000 to Alberta alone. The same percentage obtains throughout the West, whereas in Ontario, where immigration is small, only 39%
are foreign born.
Examining 20,000 immigrants in Great Britain, the Department
discovered 10% of these to be unfit, whilst previously, of 115,000 landed
in Canada and examined there, only half of one per cent were discovered
to be unfit, owing to examinations being performed hurriedly and inadequately. The Department proposes to send twenty-five Canadian doctors
to Great Britain and Ireland to conduct thorough examinations before
immigrants are allowed to proceed. This is obviously kinder to the immigrants as well as infinitely better for Canada.
Dr. King then touched on the Food and Drugs Act, which, he stated,
is one of the best in any country. Under this Act inspectors are employed throughout Canada. A laboratory is maintained at Ottawa and
dealers guilty of fraud or substitution are prosecuted. Dr. King then
took up the Opium and Narcotic Act which has recently been amended
in concert with other countries under the League of Nations programme.
There are at present 8,000 addicts in Canada and the number of these is
decreasing rapidly under strict administration of the Act. Dr. King
uttered a serious warning to the medical profession which, led astray at
times by a mistaken sentiment of pity, is guilty none the less of breaches
of this law. He stressed the necessity for institutional treatment of
addicts and emphasized the intention of his department to enforce the
law in this regard to the utmost of his ability.
Other functions of the Department are sanitary service on the Great
Lakes of the St. Lawrence with a view especially to prevention of typhoid.    This work is productive of much good.
Inasmuch as matters of health are primarily in the control of the
Provinces, the Federal Government has to exercise great care not to infringe on provincial prerogative. Accordingly, the Dominion Council
of Health has been organized, composed of Provincial Health Officers and
representatives of the Federal Board and this Council meets every six
months at Ottawa with a view to unifying administration in health
matters. Dr. King paid a warm tribute to the Provincial Health Officers
and their work.
Other public bodies of semi-official standing are those connected
with Mental Hygiene, Child Welfare, Red Cross, Tuberculosis, Venereal
Disease and the St. John's Ambulance.    Grants are made by the Govern-
Page 391 ment to each of these bodies and the Federal Department keeps a certain
amount of control to prevent overlapping and waste of effort.
There has been a great awakening in public health matters throughout Canada in recent years. Universities are educating public health
nurses, and the medical profession is awakening to a friendlier and more
co-operative view of public health service. Canada, Dr. King said, was
in the forefront of the nations as regards public health, though she is a
young country, and small in population. He concluded by urging the
medical profession to keep in touch with the development in public
health. This is especially important, as he pointed out, in Vancouver
which is a great and growing port and is faced with problems of great
magnitude which have been thrust upon it rapidly and with little preparation.
Dr. King received a great ovation at the end of his speech and a
vote of thanks was proposed by Dr. R. E. McKechnie, seconded by Dr.
A. B. Schinbein, President of the Vancouver Medical Association. Dr.
McKechnie drew attention to the responsibility that lies on the medical
profession as educated men who have received most of their education at
the public cost, to repay to some extent this obligation by doing their
share of public service and he pointed to Dr. King as a noble example
in this field.
Albuminuria,  Routine  tests  for : i :...  113
Annual  Meeting    t . £ .  256
Antipodes, a Trip to the \ S      55
Arbuckle, Dr. J. W., "Eclampsia" I .  147
B.C. Laboratory Bulletin - 1 113, 149, 180, 215, 381
B.C. Medical Association Notes 23, 54, 86, 121, 142, 195, 219, 241, 281, 320,355, 390
Blood Chemistry in Nephritis . .  178
Book Reviews   119,  144,  192, 243
Boyd, Dr. wm., "Gall Bladder Pathology"  374
Brown, Dr. C. E., "Poor Surgical Risks"  248
Campbell, Dr. J. A. E., "The Mechanism of Growth" ,  284
Champion, Dr. B. H., "Some Observations at the Mayo Clinic"       78
Clinical  Meetings g"  1 105,   141, 179
Coleman, Dr. R. E., "Dose for Glucose Curve" ,       81
"Fatal  Case of  Diabetic  Coma"  151
"Poor   Surgical   Risks"  313
and Donna M. Kerr, "Analysis of 223  Consecutive Glucose
Curve's"  18 0
Diabetic Coma, Fatal Case of  151
Diphtheria   Cultures - .  272
Eclampsia, Aetiology of \  1  111
Eclampsia, Treatment of . :  147
Electricity,  Nature  of  210
Endocarditis  and  Rheumatic  Feyer  348
Eykman   Water   Test  381
Fitzgerald, Dr. F. ., "Serum Therapy"	
Freeze, Dr. D. D., "Poor Surgical Risks"  252
Page 392 Gall  Bladder  Pathology    374
Gellhorn, Dr.  G. E., "Vaginal Discharge" :  _   157
Glioma,  Cystic—a  case  report  79
Glucose Curves, Analysis of 223  Consecutive l .  180
Glucose Curve, the Dose for  81
Golf .  271
Greaves, Dr. G. A., "The Nature of Electricity"  210
Growth,  Mechanism  of .  284
Haemorrhage,   Antepartum    339
Health Department Statistics   (see Statistics)
Hill, Dr. J. W,, "Diphtheria Cultures"  272
Hunter, Dr. A. W., Presidential Address ,  107
Hypertension,  Treatment  of  177
Kerr, Donna M., "Sodium bicarbonate for Intersitial Administration"  21
Kerr,  D.  M.,  and  Coleman,  R.  E.,   "An  Analysis  of   223   Consceutive  Glucose
Curves"     180
Ketosis, Carbohydrates in  191
Kilpatrick, M., "An Unknown Organism Causing Fatal Meningitis in Infants"  150
Kilpatrick, M., "Delayed Typhoid Bacteremia" .  84
Laboratories, Vancouver General Hospital 20,  51,  81
Library Notes 1 85, 109,  143,  192, 209, 242, 372
Lister, Lord  .  243
Lugol's Solution, effect of on Hyperplastic Thyroids  146
Malcolm, M., "Routine Tests for Albuminuria" :  113
Moffatt, Dr. C. D., "Cystic Glioma," a case report j  79
Medical  Education,  Osier  Lecture  220
Mechanism   of   Growth !	
Meeting, Annual   256
Meningitis, Unknown Organism Causing Fatal Meningitis in Infants  150
MacArthur, W. P., Lt.-Col., "Typhus Fever"  303
McEachern, Dr. M. T., "A Trip to the Antipodes"  55
Mackay, Dr. W. F., "Referred Pain" - -  122
McKechnie, Dr. L. N„ Obituary . .  41
McKechnie, Dr. R. E., "Address on Lord Lister" 3   243
McKee, Dr. C. S., "Blood Chemistry in Nephritis"  178
MacLeod, Dr. J. J. R., "The Place of Physiology in Medicine"  275
McNeill, Dr. N., "The Vienna School of Medicine" '  321
Nephritis, Blood  Chemistry in  178
News and Notes 9, 41, 72,  105,  140, 176, 239, 270, 336, 371
McKechnie, Dr. L. N  41
Elliott,  Dr.  J.  E   i  33 5
Rothwe 11, Dr. E.  J -  355
Wilson, Dr. D. H    104
Wilson, Dr. T. H  176
Oille,  Dr.   J    348
Ootmar,   G.   A  3 81
Osier  Lecture,   "Medical  Education"    220
Osteomyelitis,   Acute    r j— 386
Pain, Referred pain in connection with some disorders of the abdominal viscera  122
Pearson, Dr. J. M., "The Treatment of Hypertension"  177
Pipes, Ethel C, "Carbohydrates in Ketosis"  191
Pitts, Dr. H. H., "The Effect of Lugol's Solution on the Hyperplastic Thyroid"— 146
Pitts, Dr. H. H., "Tonsil and Appendix" -  51
Physiology, place of in medicine -  275
Poor Surgical  Risks     248,  252, 313
Page 393 Presidential Address	
Prowd, Dr. C. W., "Analysis of Radium Treatment in 600 Cases"	
Radium Therapy—analysis of 600 cases	
Referred Pain in connection with disorders of the abdominal viscera.
Rheumatic  Fever and Endocarditis , ,	
Royle, Dr. N. D., "Ramisection"	
Schinbein, Dr. A. B., "Poor Surgical Risks"	
Seldon, Dr. G.    E., Osier Lecture, "Medical Education"	
Serum Therapy
Sodium Bicarbonate for Interstitial Administration" i	
Starr, Dr. C. L., "Acute Osteomyelitis" s	
Summer School, Abstract of Proceedings  (1926) .. 9, 43
Statistics, City Health Dept 26, 39, 91, 127, 165, 172, 204, 236, 268, 300, 332,
Thyroid, Hyperplastic, effects of Lugol's solution on !	
Tonsil  and  Appendix _
Turnbull, Dr. W. S., "Aetiology of Eclampsia"	
Tuberculosis, significance of sputum examination in reference to.
Typhoid Bacteremia, Delayed.
Typhus Fever, Old Time Epidemics of_
Vaginal Discharge
Vancouver General Hospital Laboratories  (see Laboratories)
Vienna School of Medicine..
Vrooman,   Dr.   C.   H.,   "Significance   of   Sputum   Examinations   in   Reference   to
filled exactly as written
Phones: Seymour 1050 -1051 Good
The condition of affairs described
on page 803 of the C.M.A. Journal, July, 1927, certainly is astounding — one would scarcely
conceive of such a wide variation
in Liquid Extract and Tincture
of Nux Vomica.
Our safeguard against such a variation is simply to purchase standardized Liquid Extracts and
Tinctures solely from manufacturers whose integrity is unquestioned.
|   Co., Ltd.
Jill prescriptions dispensed
bu, qualified Druggists.
IJou can depend on the Ou?l
for Accuracy and despatch.
U?e deliver free of charge.
5 Stores, centrally located.    We
would appreciate a call while
in our territory. (1
VanfXB^ay Supplies *VDQ[?
There are over 30 Direct Branches now estab'
lished by the Victor X'Ray Corporation
throughout U. S. and Canada. These branches
maintain a complete stock of supplies, such as
X'Ray films, dark room supplies and chemicals,
barium sulphate, cassettes, screens, Coolidge
tubes, protective materials, etc., etc. Also
Physical Therapy supplies.
The next time you are in urgent need of sup'
plies place your order with one of these Victor
offices, conveniently near to you. You will ap*
predate the prompt service, the Victor guar*
anteed quality and fair prices.
Also facilities for repairs by trained service
men. Careful attention given to Coolidge tubes
and Uviarc quart? burners received for repairs.
Main Office and Factory: 2012 Jackson Boulerard, Chicago
Motor Transportation Bldg.
Vancouver, B.C.
Victor X-R-P Safe
A lead-lined steel cabinet for storing
films and loaded cassettes.
for price and detailed information.
Duality  Dependability   Service    Quick-Delivery
«,» Price Jpplies to Ml
*/  or
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.
Page 397 I   STEVENS'
Safety Package
Soft        Pure        Absorbent
The Stevens Safety Package is designed to enable the gauze
to be withdrawn from the carton without removing the
whole roll.
AC     .   . 730 Richard Street,
•    «■ Vancouver, B.C.
SEPTEMBER 19-24, 1927
An unusual opportunity is afforded the Medical
Profession of British Columbia, to attend a distinctly advanced course of Lectures and Clinical
demonstrations by a recognized authority on the
Further information upon request
730 Richards St. VANCOUVER, B.C. Tetanus Antitoxin
<™> P. D. & co. ^
Cj   HROUGH years of biological research we have developed certain refinements in
-*■  the manufacture of Tetanus Antitoxin that enable us to offer to the medical profession a product which, we feel confident, stands alone in point of quality.
Tetanus Antitoxin, P. D. & Co., is supreme in these important particulars: small-
ness of volume, rapidity of absorption, water-white clearness, and fluidity.
And still another point,—on account of the small content of protein and total
solids, the risk of producing serum sickness or other form of protein disturbance
from its use is slight.
Tetanus Antitoxin, P. D. & Co., is supplied in a dose of 1500 units in bulb and
syringe containers for prophylaxis, and in doses of 3000, 5000, 10,000 and 20.000
units in syringe containers for treatment.
Parke, Davis & Company
[United States License No. 1 for the Manufacture of Biological Products^
Page 399 jjflte,
Hollywood Sanitarium
tyor the treatment oj
Alcoholic, Nervous and Psychopathic Cases
Reference •» <\&. Q. dMedical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Westminster 288


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