History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1934 Vancouver Medical Association Jun 30, 1934

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 The BULLETIN
OF THE
111
VANCOUVER MEQJCAfe
ASSOCIATION1^^
Vol. X.
JUNE, 1934
No. 9
In This Issue:
NEWS AND NOTES
SUMMER SCHOOL PROGRAMME
ERYTHEMA NODOSUM
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Vancouver, B. C. THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
"Published ^Jilonthly under the ^Auspices of the Vancouver {Tiledical ^Association in the
Interests of the ^Medical "Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. X. JUNE,  1934 No. 9
OFFICERS   1934-193 5
Dr. A. C Frost Dr. C H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W. L. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L. Graham Chairman
Dr. J. R. Neilson . Secretary
Eye, Ear, Nose and Throat
Dr. R. Grant Lawrence Chairman
Dr. E. E. Day   Secretary
Paediatric Section
Dr. E. D. Carder Chairman
Dr. R. P. Kinsman ; Secretary
Cancer Section
Dr. A. B. Schinbein Chairman
Dr. J. W. Thomson Secretary
STANDING COMMITTEES
Library Summer School
Dr. W. D. Keith Publications Dr. J. W. Thomson
Dr. C. H. Bastin Qr | r McDermot Dr- I E- Brown
Dr. A. W. Bagnall Dr d £ R Cleveland Dr. C. H. Vrooman
Dr. a E^ Kidd Dr Murray Baird Dr. J. W. Arbuckle
Dr. W. K. Burwell Dr. H. A. Spohn
Dr. C. A. Ryan Dr. H. R. Mustard
Credentials „    ... ;
Dinner „ Hospitals
Dinner Dr r a> Simpson
Dr. J. W. Thomson Dr. j. T. Wall ?r" fnCpWALSH
Dr. F. W. Lees Dr. D. M. Meekison ^r> | B„l ^LE
Dr. W. G. Gunn Dr- H- H- Milburn
Dr. S. Paulin
V. O. N. Advisory Board
Dr. I. Day Rep. to B. C. Medical Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees NOW YOU SEE AGAROL
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HE RING around the drop tells the story. A drop of Agarol on
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Agarol is as fine an emulsion of mineral oil and agar-agar with
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of experience acquired in more than three-quarters of a century
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Trial supply sent on request.    *    •    •    Please use letterhead.
AGAROL FOR CONSTIPATION
Agarol is supplied in bofiles containing 6 and 14 ounces.
The average dose is one tablespoonful.
WILLIAM   R.   WARNER   &   CO.,   Ltd.
727  King   Street,   West,   Toronto,   Ont.
_____^^^B
B-Hr'S
■I
|1H|
*«J==S^rts»iM VANCOUVER HEALTH DEPARTMENT
STATISTICS—APRIL, 1934
Total Population (Estimated) ,  243,711
Japanese Population  (Estimated)   7,866
Chinese Population  (Estimated)  8,315
Hindu Population (Estimated)  251
Total Deaths :	
Japanese Deaths	
Chinese  Deaths	
Deaths—Residents only	
Birth Registrations—
Male 137; Female 125	
INFANTILE MORTALITY—
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths (not included in above).
Rate
per 1,000
Number
Population
188
9.4
8
12.4
7
10.2
166
8.3
262
13.1
April, 1934
April, 1933
7
12
26.7
45.4
12
7
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
May 1st
March, 1934 April, 1934 to 15th, 1934
Cases    Deaths Cases    Deaths Cases    Deaths
Smallpox *__	
Scarlet   Fever     371
Diphtheria   	
Diphtheria Carrier	
Chicken Pox ; .	
Measles   	
Rubella 	
Mumps   	
Whooping-cough          13
Typhoid Fever	
Undulant Fever	
Poliomyelitis 	
Tuberculosis 	
Meningitis   (Epidemic )	
Erysipelas	
Encephalitis Lethargica	
Paratyphoid   	
0
0
0
0
0
0
71
0
237
0
103
0
0
0
0
0
0
0
0
0
0
0
0
0
60
0
83
0
37
0
76
0
13
0
0
0
0
0
0
0
0
0
90
0
50
0
26
0
13
0
26
0
21
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
67
14
59
17
22
0
0
0
0
0
0
3
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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Prescription Opticians of America
In accord with the high ethical standards we seek
to maintain, we now have pleasure in announcing
our admission to membership in the above Guild.
HALE OPTICAL CO. LTD.
Dispensing Opticians
631 Birks Building
Page 163 ■   PUBLIC HEALTH
BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid    (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum    (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C. EDITOR'S PAGE
There are times when, as one contemplates this loosely-knit, incoherent
social order that we call democracy, one wonders whether there is not something in the Mussolinian way of doing things. There is such waste and
inefficiency, so much effort leading to so little result—would not it be better,
we think in our more despondent moments, if the whole population could
be mobilized, and everything arranged for them? Of course, we should lose
some of our so-called freedom—but, especially in these days, about the only
freedom most of us really enjoy is freedom from work and the worry that
goes with it. Of course there is a worry that comes from not having any—
and nobody wishes to interfere with our fullest enjoyment of that worry
either.
What brought us to this mental pass was reading the accounts of the
recent graduation from our various hospitals of several scores of new nurses.
The ones already in practice are, most of them, suffering greatly from lack
of work—and yet the mills go on grinding a new grist every year. It seems
rather a tragedy to see these fresh young people, highly trained, keen to
work, full of energy and ideals of service, because this enters largely into
their reasons for taking up their profession—and to reflect that there is
really not enough work for them to assure them all a living wage.
Some years ago Dr. G. M. Weir of the University brought in a very full
and lengthy report on the nursing situation, with recommendations. Perhaps we are mistaken in thinking that very little has been done to implement
these findings of Dr. Weir's. He pointed out in very full detail all the evils
of overproduction as concerned nurses—and many of his recommendations
seemed to us to be very wise and sound, and not only worth trying, but
urgently necessary.
We are apt to feel that there are too many nurses. Even, at times, we
are apt to feel there are too many doctors, too much medical work, too many
operations, and so on. This is really the exact opposite of the truth. There
are hundreds, even thousands, of people in a community like Vancouver,
who need medical care urgently but cannot afford it.
It has been quite clearly shewn by such investigations as that carried on
recently by the Committee on the Costs of Medical Care, working in the
U.S.A., that there is not too much medical care, there is not nearly enough—
and probably, if our antiquated system of medical care could be overhauled
and adjusted to the needs of society as it is today, we should find that we have
not half enough medical men to do the work properly.
And the same is true, no doubt, of the auxiliary professions, dentistry
and nursing. We all see cases every day that urgently need nursing, but
cannot afford it on our present basis of payment. And hundreds of nurses
are there, eager for work.
There must be a solution to a problem like this—and we feel that it can,
and should, be found. Probably it will be along the lines of Health Insurance—and it is vital that those who frame the Act should take due cognizance of the need for trained nursing, and should provide for it in some adequate way. Some system of group nursing will probably be the answer. We
throw out this suggestion now, since Health Insurance is rapidly approaching the stage of practical politics, and both the medical and the nursing professions should be considering this angle of the question. After all, it will
probably be better for us to solve this problem ourselves than to call in the
Page 164 wisest or most expert Mussolini, since it is our own problem, and we know
more about it than anyone else. Perhaps we might give democracy one
more try.
NEWS AND NOTES
The Bulletin would welcome information from medical men in all
parts of the province about their movements from time to time. We should
be glad to publish in this column all such news, as we feel that it would not
only be of interest to the whole B. C. profession, but of value as well. Just
drop a line to the Editor of the Bulletin, c/o Vancouver Medical Association, Medical-Dental Bldg., Vancouver.
It is with keen regret that we record the recent death of Dr. A. D.
Morgan, of Port Alberni. Dr. Morgan had been long in practice in B. C,
and had won the esteem and affection of all who knew him.
Dr. J. Ross Davidson, late Senior Interne in Surgery at the Vancouver
General Hospital, is shortly taking Dr. Bennett's place at Ocean Falls.
Dr. Bennett, we understand, is leaving for an extended postgraduate
course.
Dr. R. N. Dick is going to Lytton to relieve Dr. J. P. Ellis, who is going
for a holiday.
Dr. Isabel Day is leaving for Toronto, for some weeks.
Dr. E. T. Nash, who has been ill, is fortunately quite recovered, and has
returned to duty at Chemainus.
Dr. H. C. Powell is leaving for the Old Country on a trip which, we
understand, is mainly in the nature of a holiday, but will include some
postgraduate work.
During the past month, some hundred or more nurses have graduated
from the three large hospitals of the Lower Mainland: the Vancouver General, St. Paul's and the Royal Columbian, and the columns of the press have
been graced with photographs of the event. To all these young ladies we
extend our congratulations on their success, and wish them Godspeed and
plenty of work.
The Annual International Golf Tournament (medical) took place at
Seattle on May 17, when a large contingent from Vancouver, Victoria and
New Westminster invaded Seattle, under the capable leadership of Drs.
Bilodeau and Keyes. For the past few weeks Dr. Bilodeau has been a very
busy man.
One rejoices always to see keenness and enthusiasm in others, and it is
our privilege to record a rather remarkable example of this. Dr. Lyon
Appleby started for this tournament in Seattle a whole week ahead of time.
Dr. W. A. Drummond has gone to Bella Coola to relieve Dr. H. A.
McLean, who has been ill.
Page 165 Dr. A. W. Hunter is away for two months on work connected with the
American Urological Association.
We publish herewith the full programme of the Summer School, and
believe our readers will be interested in the notes concerning the speakers
at this meeting, appearing in this issue.
We would call our readers' especial attention to the new amendment to
the Medical Act, which is reproduced herewith.
" (3). The Council may by resolution suspend any member "who does not pay the
annual fee within sixty days of the mailing of a registered letter from the Registrar demanding payment, addressed to him at his address as the same appears upon the register, and the
member shall thereupon stand suspended and his name shall be removed from the register
until he pays the annual fee in arrears. Upon payment of the annual fee the member shall
be reinstated and his name shall forthwith be returned to the register by the Registrar."
The Council of the College of Physicians and Surgeons desires to
announce to the profession that the dues for the current year have been
reduced to $12.00.
Dr. John G. Robertson, who has been for some years connected with
the Hollywood Sanitarium, New Westminster, has opened offices at 573 5
Granville St. South, where he will practice as Physician, Surgeon and
Psychiatrist.
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Page 166 -I
Summer School Programme
HOTEL VANCOUVER
June 26th, 27th, 28th and 29th, 1934
TUESDAY, JUNE 26th
9 a.m.—Dr. Max Cutler: "Causes of Cancer and Modern Trends in Cancer Research."
10 a.m.—Dr. Frank W. Lynch: "Retroposition of the Uterus."
11 a.m.—Dr. Walter C. Alvarez: "The Examination of a Patient with Indigestion and what
it can show."
12:30 p.m.—LUNCHEON: Hotel Vancouver.
8 p.m.—Dr. C. A. Aldrich: "Diagnosis of Nephritis in Children."
9 p.m.—Dr. C. E. Dolman: "Staphylococcal Problems." Lecture 1.
10  p.m.—Dr. H. C. Naffziger: "Neuralgias Peculiar to the Head and Face."
WEDNESDAY, JUNE 27th
9 a.m.—Dr. Frank W. Lynch: "Prolapse of the Uterus."
10 a.m.—Dr. Max Cutler: "The Early Detection of Cancer."
11 a.m.—Dr. Walter C. Alvarez: "How to Recognize a Patient who had better not be oper
ated on."
2 p.m.—CLINIC: Dr. Max Cutler at the Vancouver General Hospital: "The Diagnosis and
Treatment of Cancer of the Breast."
8 p.m.—Dr. H. C. Naffziger: "Some Phases of Peripheral Nerve Injuries"  (with Movie
Reel).
9 p.m.—Dr. C. A. Aldrich: "Treatment of Nephritis in Children."
10 p.m.—Dr. C. E. Dolman: "Staphylococcal Problems."  Lecture 2.
THURSDAY, JUNE 28th
9 a.m.—Dr. H. C. Naffziger: "Exophthalmos of Thyroid Disease."
10 a.m.—Dr. C. E. Dolman: "Staphylococcal Problems." Lecture 3.
11 a.m.—Dr. Frank W. Lynch: "Fibroids."
GOLF TOURNAMENT.
8 p.m.—Dr. C. A. Aldrich: "The Art of Feeding Children."
9 p.m.—Dr. Walter C. Alvarez: "Abdominal Pain."
10 p.m.—Dr. Max Cutler: "The Present Day Treatment of Cancer."
FRIDAY, JUNE 29th
9 a.m.—Dr. C. E. Dolman: "Recent Research Work in Bacterial Infections."
10 a.m.—Dr. C. A. Aldrich: "Various Pediatric Conditions and Their Treatment."
11 a.m.—CLINIC, Surgical: Dr. Naffziger at Hotel Vancouver.
2 p.m.—CLINIC, Medical: Dr. Walter C. Alvarez at St. Paul's Hospital.
8 p.m.—Dr. Frank W. Lynch: "Peritonization and Intestinal Obstruction."
9 p.m.—Dr. H. C. Naffziger: "Fractures of Spine with Cord Injury."
10 p.m.—Dr. Walter C. Alvarez: "Dietetics a Physician Should Know."
Page 167
-"■ SUMMER SCHOOL SPEAKERS
Dr. C. E. Dolman, M.B., M.R.C.P., D.P.H. (London), is one of the
brilliant young research workers connected with The Connaught Laboratories, University of Toronto. He came to this country several years ago
from England, and since that time his work has been chiefly connected with
studies of the staphylococcus. While in London he was doing research work
and was at one time associated with Sir Almroth Wright. His original work
in producing a safe staphylococcus toxoid has made him internationally
known in the scientific world, and the results obtained from the staphylococcus toxoid mark another milestone in the fight against bacterial infections.
Dr. C. A. Aldrich has been connected with the Children's Memorial
Hospital, Chicago, for some years. He has taken an active part in the
American Medical Association and was at one time Secretary of the Pediatric Section of that Association. He has been a frequent contributor to
medical literature and his studies on nephritis have added much to the knowl
edge and treatment of that disease.
Dr. Walter C. Alvarez graduated from the Cooper Medical College, now
merged with Leland Stanford University, in 1905. He is at the present
time Associate Professor of Medicine at the University of Minnesota under
the Mayo Foundation and is also a member of the American College of Physicians. He has had a wide experience as a physiologist, particularly in the
realm of gastro-enterology. His reputation as a lecturer and clinician in this
field is well known to the profession at large, through his many articles and
books on the subject.
Dr. Max Cutler, Pathologist, Surgeon, Radiologist, Director of the
Tumour Clinic, Michael Reese Hospital, Chicago, has not yet reached the
dangerous forties. He began his cancer career with Dr. Ewing in the New
York Memorial Hospital, where he spent some four years doing experimental
and research work in tumour pathology. He is an enthusiastic adherent of
the Paris School of Radiology and spends several months of each year in the
French Clinics. He is fortunate enough to have large quantities of radium
at his disposal so that, in addition to carrying on the usual work with radium
elements needles, he has in continuous operation a four and a two gramme
bomb. He is using the so-called saturation method, and is doing with the
Gamma ray of radium what Pf ahler of Philadelphia and Coutard of Paris
are doing with short wave x-ray. In a few years comparative results should
demonstrate the respective merits of these two forms of radiation therapy
and thus add materially to our knowledge of cancer treatment.
Three years ago Dr. Cutler collaborated with Sir Lenthal Cheatle of
London in the production of a monumental work on tumours of the breast.
Dr. Frank W. Lynch, Professor of Gynaecology and Obstetrics of the
University of California and Director of the Women's Clinic of the University of California Hospital, is one of the best known gynaecologists on
the Pacific Coast and well known for his writings on gynaecology and obstetrics.   A graduate of Johns Hopkins of the class of 1899, he has studied
Page 168 extensively both in Eastern clinics and abroad.   He is too well known to
need any further comment.
Dr. Howard C. Naffziger, a graduate of the University of California
Medical School, 1909, now holds the post of Professor of Surgery in his
medical school. He is also a consultant in neurological surgery at the Children's Hospital and is connected with the U. S. Public Health and Marine
Hospitals, Palo Alto. We are told by men who know him that his lectures
are models of meticulous care, that he plays a good game of golf, and is
"easy to meet."
ERYTHEMA NODOSUM, AND ITS RELATION
TO TUBERCULOSIS
Murray McCheyne Baird
Vancouver, B. C.
Since the time of Stephen McKenzie, who in 18 86 taught that erythema
nodosum is a manifestation of rheumatic infection, this view has permeated
all text-books and medical schohols, in spite of the fact that in McKenzie's
own cases only fifteen per cent showed typical rheumatic lesions such as
endocarditis, rheumatic nodes or chorea. Trousseau, in 1869, had maintained that erythema nodosum "is a specific and separate disease, which
manifests itself locally by characters so precise as not to admit of being
mistaken," a view revived by Lendon, of Adelaide, in 1905, and apparently
concurred in by Symes of Bristol in his monograph of 1928. During the last
fifteen years, however, a mass of evidence has accumulated which proves
that a large number of cases of erythema nodosum, particularly in children
and young adults, are intimately associated with tuberculosis, and are probably a manifestation of tuberculous infection. This fact has received very
little prominence in the medical literature of Canada and the United States,
and I believe it to be still insufficiently realised. Connell \ in the Canadian
Medical Association Journal of 1925, notes the constant incidence of tonsillar infection in nine cases of erythema nodosum in nurses, and thinks focal
streptococcal infection accounts for the disease. He dismisses the tuberculous theory as unlikely, but he apparently did not follow the cases very far.
Cruise2, however, in December, 1932, reported 33 cases in nurses, seven of
whom subsequently developed definite tuberculosis and four more suspicious
lesions, making a total of one-third who were probably tuberculous following this illness. Symes in 1928 states in his preface that erythema nodosum
can best be classed with influenza, poliomyelitis and encephalitis lethargica.
Later on in the book he admits that nearly one-fifth of his 102 cases either
had tuberculosis at the time of the attack or developed it afterwards, and
states that "the association of the two diseases has been so striking and
dramatic especially where erythema nodosum preceded tuberculosis, as to
leave no doubt in my own mind that the two were intimately connected."
The object of this paper is to emphasize again the tuberculous associations
and probable etiology of erythema nodosum, and to report clinical observations on some twelve patients whom I have studied during the past three
[We are very grateful to Dr. Baird for the opportunity to publish this paper, which
might well command a wider field than our modest publication can present. We feel, however, that it is in the nature of a progress or interim report—and Dr. Baird's observations
will no doubt be published in even fuller form at a later date.—Ed.]
Page 169 years.  These observations are unfortunately not so complete as one could
wish, and are presented as clinical rather than scientific data.
Erythema nodosum is admitted by all observers to be a local cutaneous
manifestation of a general condition. Briefly, the skin lesions consist of
firm, rounded, tender, slightly elevated nodules of dark red colour which are
usually found on the extensor surface of the legs, but sometimes on the arms
and face. These nodules appear after a period of indefinite malaise lasting
from several weeks to a few days. The eruction is accompanied and sometimes preceded by moderate fever and leucocytosis; occasionally it is preceded by sore throat, or other infection such as scarlet fever or measles.
Relapses and recurrent attacks are not unknown. A very frequent symptom
is pain in the joints, particularly the ankles and knees, with little or no
objective findings. The nodules fade as a bruise fades, and in two or three
weeks the patient is comparatively well, but convalescence is frequently
slow. The condition occurs predominantly in young females, and is said to
have a seasonal incidence in the spring.
Pathologically, the node itself shows in the first few days an acute
inflammation in the medium-sized arteries of the sub-cutis, with proliferation of the intima and thrombosis, and surrounding infiltration with polymorphonuclear leucocytes. At the end of a week the latter cells are replaced
by lymphocytes and endothelial cells. The adjacent fat undergoes some
necrosis, and is absorbed by large endothelial cells, which form giant cells.
The above description is given by Louis Forman, of the Skin Department of
Guy's Hospital4. There have been no constant bacteriological findings from
section or culture of a nodule. Landouzy, in 1913, stated that he had found
the tubercle bacillus in one case. Rosenow, in 1915, claimed to have isolated
a diphtheroid organism which at some stages of growth resembled a streptococcus. Boon and Strauss isolated from three cases an uncatalogued organism, showing coccoid and bacillary forms, which they classify as a coryne-
bacterium, and think is similar to that found by Rosenow. Symes states that
in three cases no organism was found, and concludes that the nodes are
produced by a circulating toxin. Certainly the evidence is conflicting and
unsatisfactory on this point.
What may be called the tuberculous hypothesis of erythema nodosum
is largely due to the writings of Continental authors, particularly the Scandinavians, of whom Ernberg, Wallgren and Pollak may be mentioned. These
authors have shown that erythema nodosum patients are very sensitive to
tuberculin, and that the hypersensitivity tends to appear at the same time
as the erythema. Wallgren believes that the nodes are an allergic manifestation in a person previously sensitized by tuberculous infection. He points
to the positive tuberculin test and the enlarged hilar glands so frequently
found in children as evidence that they are tuberculous. In support of this
argument Wallgren6 quotes 40 cases in female children from four to twelve
years of age. Thirty-seven gave positive tuberculin reactions, three negative. Thirteen showed great enlargement of bronchial glands by x-ray, and
eight more moderate enlargement. Of the thirty-seven with positive tuberculin reactions tubercle bacilli were demonstrated in the sputum of seventeen (by Meunier's method), and the larger the bronchial glands the more
probable that bacilli would be found. In some cases the bacilli were found
over a period of two months, and Wallgren points out that such children
may by coughing and droplet infection inoculate other children.   This is
Page 170 also stressed by Schachter7 who recommends keeping these children out of
school and isolating them.
i i
The fact that erythema nodosum is sometimes apparently contagious,
and that epidemics occur, has always been an argument of those who believe
in the theory that it is a specific infectious fever, caused by an unknown
virus.   Epidemics, however, may be caused by infection from a common
source, as well as by spread from person to person.  One of the best-known
epidemics is that described by Wallgren in a school of 34 girls of about ten
years of age.  During one term 18 of the girls developed fever, and 12 of
these erythema nodosum. All the patients reacted to tuberculin and 13 of
them had definite enlargement of root glands. Six of the erythema nodosum
cases had pathological root shadows. A case of open tuberculosis was found
in the school.   Another epidemic in a convalescent ward is described by
Beggs. Twelve children under 6 years of age, convalescent after pertussis,
all got erythema nodosum one after the other between March 22nd and
April 9th.   All had a positive intracutaneous tuberculin test.   On March
13 th, a week before the epidemic began, the thirteenth child had died of
pertussis, bronchopneumonia and unrecognised miliary tuberculosis.   Such
epidemics do not support the "specific infectious" theory.
The fact that erythema nodosum is frequently found in persons who are
tuberculous contacts is well recognised in Sweden, both by physicians and
by the public. In Sweden erythema nodosum is a notifiable disease. The
Lancet9 in January of this year devotes a short editorial to .he work of
Tornell, who carries on dispensary work serving a population of about
100,000. During eighteen months there were 150 cases of erythema nodosum, of which 107 were "primary" and 43 secondary to some other infection such as sore throat or measles. All but one of the primary cases gave
positive tuberculin reactions and many showed primary tuberculosis of the
lungs. In all but three child and twenty-six adult cases he was able to locate
a source of tuberculous infection, and he found it useful to inquire for a
history of erythema nodosum or pleurisy in fellow-workers. In three factories where several cases of erythema nodosum had occurred he found
people with open cavities.
From the figures quoted, 100 cases per 100,000 population per year, it
would seem that erythema nodosum has a very heavy incidence in Sweden
and that a large proportion of the cases either have or develop tuberculosis.
The same figures do not necessarily apply to other countries, as the Swedish
people have a poor resistance to tuberculosis. It has to be admitted also that
not all cases even in Sweden can be accounted for on a tuberculous basis,
and this is probably still more true of countries where tuberculosis is less
rife and resistance is higher. It is also probably true that the more tuberculosis is looked for the more it will be found. Certainly in England it is only
since 1920 that tuberculous cases have been appearing in the literature to
any extent.
Perhaps enough has been said to convince most people that in some
countries erythema nodosum patients frequently are tuberculous or become
so later, no matter what the mechanism of production of the nodes may be.
It does not weaken this argument at all to admit that not all cases fall into
this category. Undoubted cases have been described in association with tonsillitis, influenza, scarlet fevdgi measles, rheumatic fever, ulcerative colitis
and syphilis. It will be noticed that most of the acute infections noted above
are, or may be, associated with invasion by streptococci. Through the kindness of Dr. W. A. Whitelaw I have recently seen a patient of his, a woman
Page 171 of fifty, who has suffered from recurrent attacks of erythema nodosum for
months. Repeated examination for tuberculosis have been negative, but the
tonsils were badly infected. One of the nurses in this small series developed
erythema nodosum about a week after acute tonsillitis. This was in February and March, 193 3. An intracutaneous tuberculin test had been done in
July, 1931, and in June, 1932, and it was repeated in September, 193 3. All
three tests were negative. The chest was x-rayed in April, 193 3, and again
six months later and was normal. Cases such as these are impossible to fit in
with those who develop tuberculosis, and it is more than probable that they
are produced by a different organism, namely the streptococcus.
This brings us to the work of Collis10, who in 1931 described eight cases
in children which he divided into the tuberculous and the streptoc^cal
groups. He tested intradermally all his cases with tuberculin and with
"streptococcal endotoxin," made by grinding up the dead bodies of haemo-
lytic streptococci. In the first or tuberculous group he places five cases, all
from homes wheie there was an open case of tuberculosis, all positive to
tuberculin and negative to the streptococcus. In three of the five he found
tubercle bacilli in the sputum by Meunier's method, and in all five x-ray
showed pathological root shadows in the chest. In the second group he places
three cases following nasopharyngeal infection, in two of which haemolytic
streptococci were cultured from the throat, and in all three of which the
tuberculin reaction, chest x-ray and sputum were negative, while the skin
reacted to streptococcal endotoxin. These cases he regards as streptococcal
in origin. Collis thinks that those who uphold the rheumatic theory and
those who uphold the tuberculous origin of erythema nodosum are both
right, but both are wrong in trying to make all cases fit into one or the other
category. There is a great deal of evidence that rheumatic patients are hypersensitive to streptococci and Collis thinks the link between erythema nodosum and acute rheumatism is the streptococcus, which might easily produce
one condition in one patient and both together in another. He considers
the nodes to be a reaction of hypersensitive tissue to bacterial antigens, and
states that up to the present the two organisms known to be capable of
producing this response are the tubercle bacillus and the streptococcus.
In support of the tuberculous theory he describes a case admitted to Great
Ormond Street Hospital under Dr. Hugh Thursfield in 1924.
A girl, aged 11, was admitted as a suspected case of tuberculosis and was given
.005 cc. old tuberculin subcutaneously. There was an immediate rise of temperature, and on the eighth day nodes, indistinguishable from those of erythema
nodosum, appeared on the shins. The temperature remained up for thirteen days.
One month later the experiment was repeated and the injection was followed
immediately by similar nodes on the shins, but without temperature  reaction.
As far as etiology is concerned, therefore, we may take it that either the
streptococcus or the tubercle bacillus may produce erythema nodosum under
the right conditions. As Collis remarks, other organisms may also be capable
of producing this form of reaction. To distinguish the tuberculous from the
streptococcal clinically is not easy, as the size and distribution of the rash
really gives no information. I believe that recurrent cases with sore throat
are more likely to be due to a streptococcus, and those with prolonged prodromal malaise are more likely to be tuberculous. Joint pains are certainly
not characteristic of the former cases, as I have seen them prolonged and
severe in cases which afterwards were definitely tuberculous. All cases under
the age of twenty-five should have a Mantoux test, a chest x-ray, repeated
in six months, and in throat cases a swab for haemolytic streptococci.   A
Page 172 combination of all the evidence obtained in this way would probably lead
to a decision in most cases. In hospital, children should have the sputum
tested by Meunier's method, and routine sputum examination should be
done on all cases where possible, as the sputum may be positive before the
x-ray. Where there is a suspicion of a tuberculous origin young patients
should be watched carefully for three years at least, with repeated chest
x-rays. Fortunately the outlook in cases of tuberculosis discovered early in
this way is good.
In order to convince the most sceptical that here in Vancouver some
cases at least of erythema nodosum are tuberculous, I have prepared brief
notes of six out of twelve cases which have come under my notice in the past
three years, with something of their after-history.
CASE 1.—E. S., a nurse, age 21, tuberculin reaction September, 1930—negative. Erythema nodosum October 8, 1931, one week after a paronychia of one
finger. Kept in bed until February 2, 1932, on account of rapid pulse rate. All
tests negative. Chest x-ray negative. Home on rest four months. Examined
June, 1932: pulse 130, chest x-ray showed mass at left root invading lung. Tuberculin positive.  Collapse therapy and sanatorium.
CASE 2.—M. W., a nurse, age 25. Had erythema nodosum in November,
1930, while in training. Tuberculin reaction strongly positive December, 1932.
After graduation was in contact with a tuberculous sister. Returned to hospital
June, 1933, when chest film was normal. In September, 1933, routine chest film
showed two small areas in left lung, probably tuberculosis. These patches persisted. While in bed temperature and pulse were inclined to be too high. Sent to
sanatorium after four months, and is having pneumothorax.
CASE 3.—E. M., a nurse, age 30. Erythema nodosum December 27, 1931.
Kept in bed owing to severe joint pains until February 8, 1932. Graduated and
had a holiday. In October, 1932, after working three weeks, complained of
malaise, colicky pains and swelling of abdomen. Free fluid present in abdomen, with
evening temperature elevation. Sent to sanatorium as a case of tuberculous peritonitis.  Well after twelve months.
CASE 4.—G. R., a nurse, age 22. Erythema nodosum while on holiday, August,
1930. Treated by family doctor. Pleural effusion October, 1930. Was very slow
in clearing up and was kept in bed nine months owing to rapid pulse rate and
unstable temperature on exercise. Tuberculin reaction positive at this time. First
film taken May 1931 shows definite involvement of roots of lungs, especially when
compared with one taken in Marqpl933 when she resumed training.
CASE 5.—E. W., a nurse, age 28. Erythema nodosum May 6, 1929. Kept in
bed until May 27, 1929. On April 1, 1932, slight pain right upper chest and
x-ray showed pleural and parenchymatous lesion. Constant rales were present at
the apex behind. After about fifteen months' treatment resumed nursing. Examination Dec. 1933 showed slight scarring at apex only.
CASE 6.—L. C, a nurse, age 19. Tuberculin reaction October 1931—negative. Erythema nodosum February 1, 1932. Kept in bed until February 18, 1932.
Chest x-ray negative. Second film June 1932 showed infiltration of left lung.
Constant rales present left axilla.   Lesion slowly became fibrotic under treatment.
There were six other patients whom I have seen with erythema nodosum
during the last three years, none of whom have so far developed definite
tuberculosis. One case has been described which was associated with tonsillitis and may have been due to a streptococcus. Another started with an
acute dental abscess, followed by erythema nodosum, followed by the appearance of several small opacities iifisach lung. The tuberculin reaction was
negative. Various opinions were sought, and varied a good deal as to whether
these patches were tuberculous or not. After about two years' observation
I concluded that there was no evidence that they were tuberculous. Another
patient lost considerable weight, and had a resting pulse rate of 90 for four
months, but so far has remained healthy, as have the remaining four patients.
This is a small series, but it suffices to show that of twelve nurses with
Page 173 erythema nodosum, four were tuberculous within four months, and two
more within three years. The number of cases is of course too small to indicate that 5 0 per cent of all cases in Vancouver are tuberculous, and the percentage here is probably smaller than in Scandinavian countries. However,
I should like to call your attention again to the figures of Cruise, who found
3 3 per cent tuberculous in Manitoba.
The practical conclusions at which I should arrive after this consideration of the problem of erythema nodosum are:
1. Erythema nodosum is probably a symptom, rather than a disease.
The theory that it is an exanthem should be abandoned. For the
"rheumatic" etiology should be substituted "streptococcal or tuberculous" etiology.
2. General practitioners, who see these cases, should be alive to the fact
that in Canada probably at least a third are tuberculous.
3. All cases in children and young adults should have at least a Mantoux
test, a chest x-ray and a sputum examination.
4. Children with positive Mantoux, especially with enlarged hilar glands,
are liable to have tubercle bacilli in the sputum, and are a danger to
other children. They should be isolated probably for two months.
5. In tuberculous cases a thorough search of the environment should be
made for persons with open lesions before more damage can be done.
REFERENCES
1 Connell: Can. Med. Assn. Jour., vol. xv, 1925, p. 785.
■'Cruise, J. T.: Idem., vol. xxvii, 1932, p. 603.
" Symes, J. O.: Erythema Nodosum, Bristol, 1928.
4 Forman, L.: Guy's Hospital Gazette, vol. xlvi'i, July 8, 1933, p. 264.
5 Boon and Strauss: Arch. Derm, and Syph., vol. xxvi, 1932, p. 78.
6 Wallgren, A.: Amer. Jour. Dh. Child., vol. xli, 193 1, p. 81.
7 Schachter, M.: Jour de Med. de Lyon, 308, 1932, p. 677.
8 Begg: Brit. Jour. Child. Dis., vol. xxix, 1932, p. 193.
" The Lancet: Editorial; vol. ccxxvi, 1934, p. 3 5 8.
10 Collis, W. R. F.: Quart. Jour. Med. N.S., vol. i, 1932-3, p. 141.
We publish herewith a report by Dr. C. A. Ryan of a case of streptococcus
septicasmia following an infected abortion.
The case presents several points of great interest and Dr. Ryan very ably
discusses and analyses them. The use of scarlet fever antitoxin in these cases has
become a recognized mode of therapy, and appears in many cases to be of very
great value.
With regard to the removal of infected products of conception, we note
that while the patient was admitted on January 1st with retained infected
material, removal was not done till two days after, and to some of us this appears
to be conservative to the point of error. We cannot but feel that removal of
these should be undertaken at the earliest possible opportunity, and that nothing
but good can result. However, this is a highly controversial question and there
is much to be said on both sides.
STREPTOCOCCUS INFECTION
A Case Report
Clarence A. Ryan, M.D., CM.
Vancouver, B. C.
The following case report is offered as a subject for discussion.   Some
incidents may be of interest.
Page 174 Mrs. A., age 44, admitted to the Vancouver General Hospital January 1st, 1934.
Past History: Menses began at 13 years of age, regular every 4 weeks, lasting five days.
Last period October 10th, 1933.
Year of Each Pregnancy: First pregnancy, age 2 5, in 1915, ended in still-birth. Second
pregnancy, age 27, normal delivery, boy died at 8 years of age from pneumonia. Third
child living and well, 13 years old. Fourth pregnancy, aged 32, terminated in miscarriage
at 10th or 12th day. Fifth pregnancy, aged 3 3, normal delivery, child died at 11 months
of age. Sixth pregnancy, normal delivery, child is now 10 years of age, suffering from "heart
disease." Seventh pregnancy complicated by phlebitis of right leg. Delivery normal, child
now 6 Yz years of age.
No other past history of interest.
Present Complaint: Bleeding from the vagina occurred six weeks ago. Flow was not
continuous but occurred from time to time during one or two days. The amount was not
excessive. No clots were passed until two weeks before admission. Some discharge continued up to the time of admission, but there was no odour to the discharge. On the night
before admission to the hospital she complained of cramps in the abdomen. These cramps
were followed by the passage of a considerable quantity of blood and some clots.
On admission her temperature was normal. Examination revealed an enlarged uterus
corresponding to a three months' pregnancy. The cervix was dilated to the size of a fifty-
cent piece. There was apparently a mass still present in the uterus. A diagnosis of "incomplete abortion" was made (Dr. Blair). Red blood cells were 2,850,000, haemoglobin 60%.
White cells were not counted.
Subsequent history is as follows:
On January 2nd, temperature was 99 . January 3rd, 100.2 . On this day, the mass
of tissue lying in the cervix and presenting at the external os was removed, using sponge
forceps. The tissue removed seemed to confirm the diagnosis of "Incomplete Abortion."
Pathological, examination of the tissue did not show the presence of choriouic villi, the
specimen being composed of blood clot only. The temperature continued to rise, reaching
104.4° on January 5th. A blood transfusion, citrated blood, 500 cc, was given. The veins
were cut down upon since it was impossible to puncture. The temperature continued
between 104    and 105  .
On January 6th one ampoule of scarlet fever antitoxin was given. There was some
infection at the site of transfusion.
January 9th, R. B. C. 2,600,000, Hgb. 52%, cells irregular and small. W. B. C. 21,500,
Polymorphs 87%, Lymphs 11%, Monos 2%.
On this date she complained of pain just above her right knee. The knee was painful
to move. On examination, there was a swelling apparently confined to the suprapatellar
bursa. Hot fomentations were applied. Examination of the vagina and cervix did not show
any further evidence of disease.
January 12 th.  Blood culture reported "no growth."
January 16th. A second transfusion of 500 cc. citrated blood was given, using the husband as donor.
January 17th. The suprapatellar bursa was aspirated and 115 cc. creamy yellow,- thick
pus removed. The following day a second aspiration was done, followed by through and
through washing of the sac. 5 cc. tincture metaphen were left in the sac. Hot fomentations
were continued. The site of the second transfusion became infected, the vein again having
been cut down upon.
January 19th. R. B. C. 3,970,000, Hgb. 67%, colour index .86, cells irregular but of
good size. W. B. C. 11,300, Polys 80%, Lymphs 12%. Culture of the fluid aspirated from
the right suprapatellar bursa showed streptococci of the short and long chain types,
reported "Haemolytic streptococci."
January 22nd.   Right suprapatellar bursa again aspirated, 180 cc. pus removed.
January 26th. 5 cc. polyvalent antistreptococcus serum given. Temperature at this
time was 103 , rising to 105 on the 27th. Two abscesses developed on the right forearm,
which were incised, with the removal of approximately one drachm of pus from each. Hot
fomentations were applied.
January 2th. The suprapatellar bursa was again aspirated and 105 cc. of pus removed.
5 cc. polyvalent antistreptococcus serum repeated.
January 29th. Blood culture showed "no growth" (report Feb. 5th). R. B. C.
3,240,000, Hgb. 66%, colour index 1.03, cells slightly irregular in shape. W. B. C. 13,650,
Polys 73%, Lymphs 23%, Monos 3%, Eos 1%, Myeloblasts 200.
February 2nd. Examination of the right knee shows that the suprapatellar bursa is
apparently empty, but there is a new abscess in the upper third of the right thigh, approximately four inches above the former swelling, on the medial surface. Hot fomentations
were applied.
Page 175 February 4th. Temperature commenced to drop. From this time onward the peak of
the temperature curve did not reach 103°.
February 5 th. 5 cc. polyvalent antistreptococcus serum given, and on the seventh,
10 cc. were given.  No reaction occurred.
February 10th. Abscess in right suprapatellar bursa again enlarged. The patient was
seen by Dr. Patterson of the orthopaedic service, and opening of the sac advised. Incisions
were made into the suprapatellar abscess and into the abscess on the thigh. Penrose drains
inserted. Irrigations were ordered every four hours, using Dakin's solution. Hot fomentations were continued.
February 15th. R. B. C. 3,500,000, Hgb. 65%. Examination showed the uterus to
be well involuted and the cul de sac free. A new abscess developed two inches below the
right knee on the medial side of the leg, and on the right forearm over the upper half of
the ulna.   These were opened and drained.   Hot fomentations applied.
February 22nd. Direct transfusion of 500 cc. blood given. The vein had to be cut
down upon, but no infection followed.
The abscesses on the forearm healed within a few days but the leg continued to drain.
Leg placed in Thomas splint. A small amount of traction was applied and hot fomentations
with irrigation continued.
March 1st.   Patient transferred to the Orthopaedic service.
March 7th. The husband of this patient had a pulmonary haemorrhage two weeks
after giving the blood for the second transfusion. For this reason the patient's chest was
x-rayed.  X-ray report was "grade 2 markings."
The temperature at this period varied between 99 and 101 . The local condition in
the right leg continued to improve and the drains were removed. Since the general condition continued somewhat stationary, a fourth transfusion of 500 cc. citrated blood was
given.
March 16th. The temperature still remained between 99 and 100 . Stannoxyl tablets, one t.i.d., were ordered for a week. The following day, the temperature did not exceed
99 and continued within normal limits during the week that Stannoxyl was given. The
day following the discontinuance of the Stannoxyl, the temperature again rose to 100 .
Stannoxyl was again ordered with immediate results as before.
March 31st.   X-ray of right knee showed decalcification, but no bony change.
April 2nd. There is still slight discharge from the incisions in the right leg. Hot
fomentations and irrigations were discontinued. Flexion of the knee is possible only to about
10  .  Physiotherapy was begun, consisting of heat and massage to the knee.
April 9th. A slight amount of swelling occurred beneath the patella. There is some
lateral motion in the patella but little or no up and down motion. Hot fomentations were
again applied with reduction of the swelling within two or three days.
April 14th. The patient was allowed to sit up' and to gradually increase period until
able to stand.   Such is the present condition of the patient.
April 24th.  Cultures of nose, teeth and throat taken.
Report shows: Streptococcus Aureus present in nose.
Teeth—Streptococcus Viridans.
Gram—negative bacilli.
Gram—negative diplococci.
Tonsils—Chain streptococci.
Streptococcus Viridans.
Gram—negative diplococci.
This case has been gone into somewhat thoroughly because it brings up
several points for discussion. We will preface these points with a short
discussion on streptococcic infections.
Streptococci are, first of all, of two types: (a) Those forming short
chains and (b) those forming long chains. The short chain type is considered the more virulent of the two, since division of cells in this type
occurs in more than one direction as compared with the long chain type, in
which division occurs only in one plane. Culturally, both types may be
further subdivided into (i) haemolytic streptococci and (ii) streptococcus
viridans. In suppurative inflammations both types (a) and (b) are
found1 2 5 15.
The haemolytic form occurs in two strains: the human and the bovine.
Of the human strain, four biological types are found4.   One of these, the
Page 176 haemolytic streptococcus of scarlet fever, produces opsonins and agglutinins
which produce specific reactions to haemolytic streptococci from other cases
of scarlet fever, but do not produce any such reaction to haemolytic streptococci from other diseases, such as erysipelas, measles, influenza, or diphtheria .
Bliss6 undertook a similar set of experiments and obtained similar results to
those of Tunuicliff4.
Some forms of haemolytic streptococci produce leukocidin. According
to Nakayama7 leukocidin destroys leukocytes, and the amount of leukocidin
produced bears a definite relationship to the virulence of the infection.
Jordan8 and Rosenow9 state that the primary infection by streptococci
usually occurs about the head: .i.e, the nose, tonsils, middle ear, teeth. When
infections develop elsewhere in the body, such infections are secondary to
the above mentioned primary infection. This primary infection may be
dormant. In appendicitis, for instance, Rosenow has reported several instances where he could demonstrate a primary infection in teeth, tonsils or
sinuses. Jordan also states that streptococci are present in the vagina in pregnant women. Whether this is to be considered as a primary site or not, is not
stated. If the vaginal secretions are alkaline, the number of cocci present is
increased. Therefore, unless strict attention is paid to preparation, any
interference within the vagina of the pregnant woman may result in spreading of the infection into the cervix or uterus. Reference, although it is an
old story, may be made to the writings of Oliver Wendell Holmes11 upon
this subject. As you know, previous to his time, streptococcic infection,
postpartum, was a common occurrence. Puerperal sepsis was the bugbear
of maternity hospitals.
Streptococci, as has been stated, are frequently present in the nose and
throat of even so-called healthy individuals. In fact, swabs taken from the
nose and throat of most of us would be found to contain some form of bacteria. Meleney has stressed this point. In the operating room it is essential that every one coming in close contact with the anaesthetized patient
shall properly protect that patient from chance infection. The resistance
of a patient under an anaesthetic is lowered, hence the necessity on the part
of the surgeon, assistants, nurses and anaesthetist, of wearing a mask over
the nose and mouth, during the time that the patient is under the effect of
the anaesthetic.
When a secondary process does develop from a streptococcal infection,
such secondary infection has a predilection for serous membranes, especially
those of the joints . When osseous tissue and tissues surrounding bone are
invaded, staphylococci, rather than streptococci, are the most frequent
invaders. Rheumatic fever is an example of secondary streptococcic infection localising in tissues about the joints.
The streptococus of rheumatic fever has characteristics similar to those
of the streptococcus of scarlet fever, in that the toxin produced from the
streptococcus of rheumatic fever reproduces the disease in animals injected
with such toxin. Birkhaug12 tried the experiment upon himself and developed a typical clinical picture of acute polyarthritis of the rheumatoid
type. Streptococci isolated from rheumatic fever patients differ from the
streptococci from scarlet fever, in that the rheumatic fever type does not
consist of one single strain. At least four different strains have been isolated.
All four, however, conform to definite rules: they all ferment inulin, all
are insoluble in bile, do not haemolyse blood sugar, nor produce green colouration in blood sugar media.   In certain cases of chronic arthritis or
Page 177 arthritis deformans, the haemolytic streptococci present may so closely
simulate streptococcus pyogenes that differentiation may be difficult. The
streptococci isolated from tonsil infections have always produced arthritic
change when introduced into animals14. Many skin lesions and lesions of
lymph vessels are also the result of streptococcic infection13.
What questions arise out of the study of this case?
(1) Is any other diagnosis compatible with the findings?
(2) What bearing, if any, did interference within the vagina have on
the progress of the case?
(3) Should not more care be exercised in selecting "donors" ?
(4) Upon what rationale was scarlet fever antitoxin given?
(5) Would earlier blood cultures have influenced the treatment?
(6) Would equal or better results have been obtained by persevering
with the closed method of treatment in the bursa infection?
To reply to these questions, the following attempt is made:
(1) Laboratory examination of the material removed from the cervix
did not show the presence of chorionic villi. The physical and clinical evidence would seem to establish the diagnosis. The foetus was most probably
expelled before admission to the hospital.
(2) On admission to the hospital the patient did not have an elevation
of temperature, nor was there any odour noted in the discharge from the
vagina. Threefore it would seem that infection of the uterus had not
occurred up to that time. The day following examination, the patient's
temperature commenced to climb, reaching its height on the sixth day.
As stated in the progress notes, the mass of tissue lying in the cervix and
presenting at the os was removed on the third day. It is to be noted that the
forceps were not passed beyond the external os, the tissue being gripped by
the part presenting at the os. No attempt was made to clean out the uterus.
In other words, thoroughly conservative treatment was carried out. Would
earlier interference have influenced the progress of the case? Had the uterus
been cleaned out at this time, would the progress have been influenced? Bear
in mind that the temperature had already begun to climb. Would complete
cleaning out of the uterus have produced a further spread of the infection
which was already active?
(3) Two weeks after donating blood, the donor suffered a pulmonary
haemorrhage. X-ray findings a day or two later were reported as showing
the presence of a "unilateral pulmonary tuberculosis involving the upper
third of the left chest." So far as I know, no definite evidence excluding
tuberculosis is routinely demanded in "donors," especially where such donors
are relatives or friends of the recipient. Should we not demand an x-ray of
the lungs of all "donors"? We know that pathological evidence is at hand
to prove the frequency of "latent" or unknown pulmonary tuberculosis
lesions, in a great majority of so-called healthy individuals. Furthermore,
are we in any way to blame for activating the husband's pulmonary lesion?
So far as his history can be followed, there is no knowledge of a pre-existing
tuberculosis lesion. From the x-ray evidence, it would seem that his present
lesion is well limited to the upper third of one lung. If the infection is so
limited, the likelihood of a tuberculous bacillaemia may be considered remote.
In such an event, danger to the recipient will also be remote, though still a
debatable point. In the present instance, x-rays taken of the recipient one
month after the transfusion did not show any evidence of active tubercu-
Pr.gc 17 S
mm losis.   I think we may therefore accept this evidence as proof of our good
luck.
(4) Scarlet fever antitoxin produces characteristic laboratory changes
when mixed with serum from scarlet fever patients. Such changes do not
occur, in the laboratory, when scarlet fever antitoxin is mixed with serum
containing streptococci from other sources than scarlet fever. What then
is the reason for using suchh antitoxin in streptococcic infections other than
scarlet fever?
In this connection Dr. Blair has added the following note:1
"Scarlet fever antitoxin has been an accepted remedy in the treatment
of so-called septicaemia for some years. It has been used in most American
and European clinics, and accepted at the Hague Controversy (1930), when
some hundreds of cases were presented. Eight cases with remarkable results
were presented at that Controversy from the Vancouver General Hospital."
Only one ampoule of scarlet fever antitoxin was given, that is on January 6th, at which time the temperature of the patient was 104°. The following day there was a slight rise of less than one degree, not sufficient eleva-
cion to consider such a rise a "reaction." Why was not further scarlet fever
antitoxin therapy persisted in? Again, in the progress notes the statement
is made that the swelling of the right suprapatellar bursa developed approximately forty-eight hours after the administration of the scarlet fever antitoxin. In discussing this case with Dr. Blair he raised the question whether
there could be any connection between the two. A search of the literature
for the past two years does not bring to light any evidence to warrant such
a supposition. Belam10 refers to the close association between treatment and
septic foci, but does not connect the antitoxin with the development of
such foci. Hunt20 feels that where complications develop, such as arthritis
and septic foci, the blame may be laid to the too late administration of antitoxin. According to Box, the suppurative or pyaemic form of complications
develop later than the rheumatoid forms. From this it would seem that had
the administration of antitoxin any bearing upon the question, the complications developing immediately following the use of such antitoxin should
be of the rheumatoid type rather than the suppurative. Box21 says that the
suppurative lesions not only develop later than the rheumatoid, but that the
larger joints such as knee, hip or elbow, rather than the smaller joints such as
fingers, are involved in the suppurative process. Moreover, the suppurative
complications are usually accompanied by less elevation of temperature and
may even occur during the time that the patient is "Dick negative." Excessive dosage of antitoxin does not produce the septic type of disease with local
abscess   .
In connection with the above, a search was made of the case records
from the Infectious Diseases Hospital Division of the Vancouver General
Hospital, for 193 3 to March, 1934. Only one case of abscess formation following antitoxin treatment could be found. This patient was admitted with
a diagnosis of "Scarletina, Septicaemia, Endometritis" following an attempt
at abortion. The final diagosis on discharge was scarlet fever, with gluteal
abscess. In this case, the gluteal abscess was not situated at the site of injection of the scarlet fever antitoxin, but in the opposite buttock about the
site of injection with calcium gluconate. It is therefore obvious that the
administration of the antitoxin had no bearing upon the abscess formation
(Mrs. G.).
On January 19th the laboratory reported that the pus taken from the
Page 179 right suprapatellar bursa contained long and short chain streptococci. Ci
ture was reported "Haemolytic Streptococci." Poly
valent antistreptococcus
serum was given on January 26 th. Should this have been used ear]
disease in place of the scarlet f i
ler in the
ever antitoxins
(6) In the progress notes you will observe that the suprapatellar infection had definitely improved on February 2nd. Up to this time aspiration
and through and through washings had been done. On this same date, new
abscess sites developed, probably due to a further lighting up of the infection. The multiplicity of abscesses would lead one to believe that a blood
stream infection was present even though the blood culture had, up to this
time, been reported negative.
According to J. C. Diamond16, tincture of metaphen injected into nonsuppurative bursitis produces an obliteration of the sac, and in many cases
obviates the necessity of removal of the sac. On January 18th, 5 cc. tincture
metaphen was left in the suprapatellar bursa in this woman. No definite
effect was noted from such therapy. Repeated use of the metaphen might
have produced results, though this present case was one of suppuration and
not a non-suppurative condition.
On February 10th the right suprapatellar bursa was again enlarged. Dr.
Patterson advised incision and drainage, which was done. Hot fomentations
were continued and irrigation of the abscess sac with Dakin's solution done
every four hours. Subsequently an abscess higher up in the thigh had to be
similarly treated. In spite of the formation of these abscesses, the patient's
temperature did not rise to its former height, so that it is permissible to
believe that the virulence of the infection was at this date less than at the
beginning. It is practically impossible to keep a draining sinus free from
secondary infection with staphylococci. For this reason, Stannoxyl was
prescribed when the temperature went above 100° on March 15th. The
results have been noted above. Had closed treatment—that is, aspiration
and through and through irrigation—been persisted in, would the final
results have been improved? The secondary infection of the sinus would,
most likely, have been avoided. If such secondary infection had not occurred, would the temperature have fallen earlier in the course of treatment?
Bernstine reports excellent results from the use of metaphen 1:100 in
puerperal sepsis17. "Its administration is recommended in blood stream
infections." Ten to twenty cc. at from twenty-four to forty-eight-hour
intervals are advised. While it may be recognised that such small quantities
of metaphen injected into the blood stream would result in a very dilute
concentration of the metaphen, and while it may seem that such dilute
concentration would have small chance of influencing the course of the
infection, might not a trial of such therapy have been of interest?
Dr. Blair, under whose service this patient was first admitted, and
myself, will be interested in your discussion.
REFERENCES:
1 Ogston: Brit. Med. Jour., 1881, I, 369.
2Rosenbach: "Mikroorganismen bei d. Wundinfektionskrankheiten," Wiesbaden, 1884.
3 Dochez, A. R., Avery, O. T., and Lancefield, R. C: Jour. Exper. Med., 1919, 30, 179.
4 Tunnicliff, Ruth   Jour. Amer. Med. Assoc, 1920, 74, 13 86.
5Fehleisen   Actiol. d. Erysipeps, Berlin, 1883.
6 Bliss, W. P.: Bull. Johns Hopkins Hospital, 1920, 31, 173.
7 Nakayama, Y.: Jour. Infect. Dis., 1920, 27, 86.
8 Jordan, E. O.: "General Bacteriology," Saunders Company, 1929, 212.
9 Rosenow, E. C.:Jour. Infect. Dis., 1915-16, 240, and 1915, 17, 403.
Page 180 10
11
12
13
14
15
17
18
19
20
21
Meleney: Jour. Amer. Med. Assoc, 1927, 88, 1392.
Holmes, Oliver Wendell: New Eng. Quar. Jour, of Med. and Surg., Apr., 1843.
Birkhaug: Jour. Infect. Dis., 1927, 40, 549.
Kurth: Arb. a. d. k. Ges., 1893, 8, 294.
Davis, D. J.: Jour. Amer. Med. Assoc, 1913, 61, 724.
Holt: Diseases of Children," Appleton, 1925, 871.
Bernstine: Am. Jour. Obs. and Gyn., 18, 220, Aug. 1929.
Blair, E. Murray: Can. Med. Assoc. Jour., xxv, 576, 1931.
Belam, F. A.:M. Officer, 49, 167, April 29, 1933.
Hunt, Luke W.: Jour. Amer. Med. Assoc, 101, 1933, 1444.
Box, C. R.: Lancet, I, 1933, 1330.
Box, C. R.: Ibid, 1328.
AN INTERESTING CASE REPORT
Dr. R. Geddes Large
Prince Rupert, B. C.
The following case is reported because of some interesting features in
diagnosis.
C. V., a male; age 45 years; single; occupation, labourer in cold storage plant.
Past History: V. D. (S.?) in 1912, which was treated for a short time. Ten years ago
had an accident with fracture of the frontal bone.
Present History: In July, 1933, he contracted a cold which persisted. One month later
his voice became hoarse. General health good until the end of September when his back
began to bother him. This became steadily worse and he had pain in the lumbar region
which radiated down the backs of the thighs. Rising from sitting posture and walking both
difficult.  Temperature 100.8.  Pulse 104.  Respiration 20.
When first seen on October 16, superficial examination was negative and for a few days
case was considered to be one of simple lumbago. The throat was examined and showed
general inflammation of mouth and pharynx with multiple small ulcers covered with grey
slough. The tongue was fissured and coated and presented some small ulcers. Larynx was
cedematous and left vocal chord lagged. There was no ulceration of the larynx but subsequently an ulcer appeared on the left vocal chord. Chest and abdomen were negative. The
throat suggested a picture of Vincent's angina and swabs were taken and an initial dose of
neosalvarsan administered.   Culture and direct smears showed streptococcus.
On the 28 th of October bilateral foot drop developed. Examination of the nervous
system at this time showed the following: Cranial nerves normal, pupils reacted to light
and accommodation, superficial and deep reflexes normal down to and including the scrotal.
Knee jerks, ankle jerks and Babinski absent. Muscles below the knee were paralysed. No
sensory disturbances, neither anaesthesia nor hyperesthesia. Muscle sense and co-ordination
normal. Red and white cell counts and urinalysis normal. The blood Kahn test was
reported doubtful. Spinal puncture was done between the third and fourth lumbar but
only a few drops of fluid were obtained, bright yellow in colour and coagulating on standing. X-ray of the spine and pelvis was negative. The diagnosis of multiple neuritis, probably of syphilitic origin, was made, and treatment instituted along these lines.
No improvement occurred but rather the patient became worse, and on November 22
retention of urine developed. Another spinal puncture was done, higher up this time,
between the first and second lumbar; flow was retarded and only 2 cc. of the same yellow
fluid were obtained, which coagulated rapidly. Examination of this fluid showed normal
cell count but quantity was insufficient for other tests. Examination at this time showed
same neurological findings with addition of hyperesthesia over the left calf, acute retention
with over-flow, and paralysis of the anal sphincter. Pain in the legs was intense and almost
continuous. We had suspected spinal cord tumour for some time and on December 2
obtained the patient's permission to operate.
Laryngeal obstruction from the oedema interfered with the anaesthetic and the attempt
was abandoned. December 3 under local anaesthetic a tracheotomy was performed. December 6 under local anaesthetic with intermittent ether anaesthetic a laminectomy was done
involving the first, second and third lumbar vertebrae.   A tumour mass was located lying
[We are very glad to have the opportunity of publishing
which is so well presented by Dr. Large.—Ed."]
Page 181
tnis interesting
case report, at the level of the first and second lumbar vertebrae. It was not encapsulated but appeared
to be arising from the arachnoid, as the nerves of the cauda equina were visible, spread out
laterally on the tumour mass. The dura was left open and a fascial graft sewn over the
opening.
Postoperative course was uneventful and for a few days there was a great deal of relief
from pain, in fact up to the time of death the pain never recurred with as much severity
as previously.
A syphilitic origin of the trouble was still suspected and intensive treatment was given
using bismarsen and pot. iodide. The laryngeal condition improved markedly and the
tracheotomy tube was removed on January 14. The oedema returned and the tube had to
be reinserted. The patient became steadily weaker and death occurred on January 28 without the development of any new symptoms except a little gastric pain on January 14 and
an attack of diarrhoea on the 19th, with mucus and blood.
Postmortem examination showed a large increase in the size of the tumour mass in the
cord. The liver was full of nodules varying in size from a pin head to an orange. The
remainder of the organs showed no pathology except a hypostatic congestion of the lungs.
Pathological report on sections removed showed an extremely cellular anaplastic type of
growth. The cells were epithelial in origin, having a rather alveolar arrangement in spaces,
surrounded by coarse fibrous trabeculae. Section of the larynx and prostate was negative.
The microscopic picture would suggest either thyroid or adrenal as the site for the primary
growth, but unfortunately these two were not removed for section, although negative in
gross examination.
This case is evidently an example of the occurrence of spirochaetal
infection and malignancy in the same individual at the same time. The
condition in the mouth and throat, although somewhat suggestive of Vincent's angina when first viewed, was almost certainly syphilitic, particularly
as it responded so well to arsenicals. Even when a spinal cord tumour
seemed positive the probability of it being a gumma was evident.
The error in making a diagnosis of multiple neuritis is understandable
when one considers the usual symptoms of cord tumour. The patient at this
time had no sphincteric disturbance, no sensory loss and no Babinski sign.
K. Tamaki in reporting a series of thirty-nine tumours of the spinal cord in
a recent issue of the American Journal of Surgery states that, of the subjective symptoms, paresthesia is the most frequent next to pain. Further,
that it was present in all tumours in the lumbar segment and cauda equina.
In this case there was no disturbance of sensation except severe pain. A very
suggestive fact, however, was the spinal fluid which coagulated rapidly, was
bright yellow in colour, and was obtainable only in small quantities.
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Page 182 INJURIES TO
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If this tired, worried, over-worked mother were using Pablum for her babies' cereal feedings, she could have
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