History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1948 Vancouver Medical Association 1948

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 THE
BULLETI
Published By
The Vancouver Medical Association
EDITOR:
dr. j. h. MacDermot
EDITORIAL BOARD
DR. D. E. H. CLEVELAND
DR. H. A. DesBRISAY
Editorial and Business Office
203 Medical-Dental Building
Vancouver, B. C.
DR. J. H. B. GRANT
DR. D. A. STEELE
Publisher and Advertising Manager
W. E. G. MACDONALD
Vol. XXV
DECEMBER, 1948
OFFICERS,   1948-49
Dr. Gordon C. Johnston
President
Dr. Gordon Burke
Hon. Treasurer
Dr. W. J. Dorrance        Dr. G. A. Davidson
Vice-President Past President
Dr. Henry Scott
Hon. Secretary
Additional Members of Executive:
Dr. A. S. McConkey, Dr. Rocke Robertson
Dr. A. M. Agnew
TRUSTEES
Dr. G. H. Clement
Secretary
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical
Dr. E. B. Trowbridge Chairman Dr. J. A. Ganshorn
Eye, Ear, Nose and Throat
Dr. G. H. Francis Chairman Dr. J. F. Minnes Secretary
Paediatric
Dr. G. O. Mathews .Chairman Dr. A. F. Hardyment.—..Secretary
Orthopaedic and Traumatic Surgery
Dr. H. H. Boucher Chairman Dr. Bbtjce Reed Secretary
Neurology and Psychiatry
Dr. A. B. Davidson Chairman Dr. G. H. Gundby..—_ Secretary
Radiology
Db. Andrew Turnbull—Chairman Dr. Marvin R. DiCKEY.___Secretary
STANDING COMMITTEES
Library:
Dr. F. S. Hobbs, Chairman; Dr. R. A. Palmer, Secretary; Dr. R. P. Kinsman;
Db. S. E. C. Tubvey; Dr. J. E. Walker and Dr. E. F. Word.
Summer School:
Dr. A. B. Manson, Chairman: Dr. E. A. Campbell, Dr. J. A. Ganshorn,
Dr. D. S. Munroe, Dr. D A. Steele, Dr. G. C. Large.
Credentials:
Dr. H. A. DesBrisay, Dr. Frank Turnbull, Db. G. A. Davidson.
Representative to B. C. Medical Association: Db. G. A. Davidson.
Representative to V. O. N.: Dr. Isabel Day.
Representative to Greater Vancouver Health League: Dr. J. W. Shier.
Dr. A. C. Frost i'i
r-'l
women
are
always
demanding*
y
f-i
hi
KM
wm
i.n
5-'If,
HI
When growth, menstruation, pregnancy, convalescence or dietary
restrictions increase a woman's demands for iron ...
"Up to the age of menopause, women
require from two to four times more
iron than do men... Pregnant women
also have a higher requirement... iron
requirements are increased ... at
puberty (especially in girls) . .."
Goodman, L., and Gilman, A.: The
Pharmacological Basis of Therapeutics.
New \brk,The Macmillan Company, 1941,
p. 1110,1115.
f Reznitoff, P , and Goebel, \V  F.: J  Clin.
Investigation   16:547, 1937.
FEHCON* iradciyark registered.
Fergon®
BRAND Of ffMOUS
GweOHATt
For Hypochromic Anemias
BETTER TOLERATED: Fergon is only slightly ionized, therefore virtually nonastringent, nonirritating, essentially free of
gastro-intestinal distress.
BETTER ABSORBED: Fergon—stabilized ferrous gluconate—is
soluble and available for absorption throughout the entire pH
range of the gastro-intestinal tract.
BETTER UTILIZED: Comparative clinical studies show ferrous
gluconate to be better utilized than other forms of iron.t
Indicated in the treatment and prevention of anemias due to
iron deficiency; especially valuable in .patients intolerant to
other forms of iron.
Average adult dose is 3 to 6 (5 grain) tablets; for children, 1 to
4 (2/4 grain) tablets or 1 to 4 teaspoonfuls of elixir daily.
Supplied as 0.325 Gm. (5 grain) tablets, bottles of 100 and
500; 5% elixir, bottles of 6 and 16 fl. oz.
New York 13, N. Y.     Windsor, Ont,
1019 Elliott Street West, Windsor, Ontario
423 Ontario Street East, Montreal, P. Q.
m
mm VANCOUVER  MEDICAL   ASSOCIATION
Founded 1898     :   :    Incorporated 1906
PROGRAMME FOR FIFTY-FIRST ANNUAL SESSION
(Spring Session)
January    4.
GENERAL MEETING—
"Experiences in Cleft Palate Repair"—Dr. J. R. Neilson.
"Radiology in Abdominal Pain in Children"—Dr. Wallace Boyd.
January 18.    CLINICAL MEETING—Vancouver General Hospital.
February    1.
GENERAL MEETING—
"The Management of Pregnancy in cases of Hypertension and
Toxemia"—Dr. E. B. Trowbridge.
"Hypertension and Cardiac Complications in Pregnancy"—Dr.
J. Caldwell.
February 15.    CLINICAL MEETING—St. Paul's Hospital.
March    1.    OSLER DINNER AND LECTURE—Hotel Vancouver (Mayfair Room)
Osier Lecturer—Dr. Murray Baird.
March, 15.    CLINICAL MEETING—Shaughnessy Hospital.
April    5.    GENERAL MEETING—
"Prostatism"—Dr. L. G. Wood.
&
April 19.    CLINICAL MEETING—Place of meeting to be announced.
May    3.    ANNUAL MEETING—Auditorium, Medical-Dental Building.
Page 56 AH
Prolonged-Action Penicillin
For Aqueous Injection .. Once Daily
it
SQUIBB Procaine Penicillin G for Aqueous Injection
Offering all the advantages of prolonged-action penicillin without the
disadvantages of the preparations hitherto available. For use in any
condition in which penicillin in oil and wax is indicated.
ONE DAILY
INJECTION
MINIMAL
PAIN
An intramuscular injection of 300,000 units of an aqueous
suspension of Crysticillin provides therapeutic blood levels
for 24 hours in the majority of patients—and for 36 hours
in approximately 50% of patients.
Crysticillin contains no OIL or wax. Consequently, pain
following intramuscular injection is minimal.
EASILY Crysticillin is easily administered in aqueous suspensidti
ADMINISTERED     with a conventional syringe and needle, neither of which
need be dry. Blockage of needle is minimized and cleansing
facilitated.
STABLE
WITHOUT
REFRIGERATION
Crysticillin is stable in the dry state for 12 months. Sterile
aqueous suspension may be kept at room temperature for a
period of one week without significant loss of potency.
Crysticillin is supplied in diaphragm-capped vials containing dry pro- *
caine penicillin G together with a minute quantity of effective and nontoxic  dispersing  and  stabilizing agents—for  suspension with  sterile
aqueous diluent.
1,500.000 unit multiple-dose rials
For Literature write
E. R. SQUIBB & SONS OF CANADA,  LIMITED
2245 Viau Street Montreal
Squibb I j
EADE*   !N   PENICILLIN    RESEARCH   AND   MANUFACTURE
•fr "TRADE   MARK   REGISTERED" VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
CITY
STATISTICS—OCTOBER, 1948
Total Population—Estimated _
Chinese Population—Estimated
Hindu Population—Estimated -
Total deaths
Chinese deaths        15
Deaths, residents only 325
BIRTH REGISTRATIONS:
Male	
 376
Female      385
Rate Per 1000
Population
12.0
22.2
10.8
761
25.4
INFANT MORTALITY: Oct., 1948
Deaths under 1 year of age 11
Death rate per 1000 live births       20.2
Stillbirths (not included above) 8
CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY
Number Rate Per 1,000 Population
October, 1948 November, 1948
Cases    Deaths       Cases     Deaths
Scarlet Fever	
Diphtheria	
Diphtheria Carrier-
Chicken Pox	
Measles	
Rubella—
Mumps.
Whooping Cough	
Typhoid Fever (Carriers).
Undulant Fever	
Poliomyelitis	
Tuberculosis	
Erysipelas.
Meningococcus  (Meningitis).
Infectious Jaundice——___.
Salmonellosis	
Salmonellosis   (Carrier)	
Dysentery	
Dysentery  (Carrier)	
Tetanus	
Syphilis	
Gonorrhoea	
Cancer (Reportable):
Resident :	
Non-Resident	
9
0
8
0
0
0
0
0
0
0
0
0
110
0
306
0
15
0
61
0
4
0
10
0
7
0
17
0
0
0
0
0
0
0
2
0
1
0
0
0
6
0
2
0
42
13
0
0
5
0
1
0
1
0
1
1
0
0
0
0
1
0
1
0
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
30
3
0
0
149
0
0
0
77
0
77
0
15
0
42
0
Page 57
• Three to Four-Day Blood Levels ...
PROCAINE PENICILLIN G IN OIL
With Aluminium Monostearate, 2%
i
The inclusion of aluminium monostearate in crystalline procaine penicillin G
in oil, together with other improvements in the method of preparation, now makes it
possible to prolong the absorption of penicillin and to maintain therapeutic penicillin
blood levels for three or even four days in the great majority of patients.
The recommended dosage of 1 cc. (300,000 units) every 48 hours has been
found to be adequate in most cases, thus overcoming the necessity of injections once or
twice every 24 hours with other forms of prolonged-acting penicillin.
HOW SUPPLIED
1-cc. cartridges, each containing 300,000 International Units of Procaine
Penicillin C in Oil, for use with B-D* disposable plastic syringes or as replacements for B-D* metal cartridge syringes.
10-cc. vials, each containing 3,000,000 International Units.
*T.M. Reg. Becton, Dickinson & Co.
\&%
CONNAUGHT MEDICAL RESEARCH LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S  PRESCRIPTIONS  LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. I
^4e &dito>iX Paae
Many of our readers must have heard the recent CBR broadcast "Points of View on
State Medicine." One speaker was our own Executive Secretary, Dr. F. C. Whitehead,
[and we do not propose to discuss his talk here, except to say that we thought it excellent—dignified and restrained in tone, and to the point.
The other speaker was Mr. Colin Cameron, one of the leaders of the C.C.F. in
B.C. We feel that his speech requires some comment since it contained some glaring
I misstatements, and a good deal of undocumented material equally calculated to mislead.
Mr. Cameron's approach to the subject is by way of abuse of the medical profession, of which he evidently has rather a poor opinion. But surely, in a discussion
such as his, discourtesy and" widespread imputation of unworthy motives are quite unnecessary. Just the fact that a man does not agree with your point of view does not
justify you in accusing him of all the crimes in the calendar. Mr. Cameron makes us
out to be a pack of ghouls, or vultures, waiting for carrion—rejoicing in epidemics,
unwilling to see anything done that will remove our source of income—sickness.
We do not think we need to fear the verdict of intelligent people in this regard.
Just as a good lawyer, and there are many, tries to discourage litigation, even if litigation
means more money to him, so a good doctor tries to prevent sickness. He urges preventive measures on his patients—he inoculates children against disease (if the patients
will let him) he does all he can to discourage disease. But the prevention of disease,
the elevation of health standards, is largely in the hands of the public health authorities,
not the practising doctors'. These authorities do magnificent work, as the records of
the past twenty years or more will show—but their hands are largely tied by the parsimony of governments, which will not furnish the money necessary to make their knowledge effective. If Mr. Cameron wishes to attach blame let him attach it to the right
quarters.
Mr. Cameron is an exception to Bacon's dictum, that "writing maketh an exact
man." He is anything but exact—as we understand the word. Also his reading of
history is defectiye, or perhaps like so many people, he just reads the parts that bear out
his own preconceived ideas.
He says that we do nothing, and have done nothing, to protect the health of the
community. That is a strange accusation. The cure of smallpox and the means of its
prevention were discovered by a doctor, insulin was discovered by a doctor—so were
the sulpha drugs, penicillin, the use of liver in pernicious anaemia, all the vaccines and
serums that we use to prevent and cure infectious diseases. Typhoid vaccine was the
outcome of Dr. Almroth Wright's work, tetanus vaccine, anti-cholera vaccine, the
prevention of malaria, the reduction of yellow fever to nothing, the present great reduction in tuberculosis, modern surgery, modern anaesthetics, and an endless list beside,
are all the work of medical men—many of them men in active medical practice—the
men who are beneath the supercilious Mr. Colin Cameron's contempt.
Even the instance he chooses—infant mortality—is an example of this. As a result
of the work of doctors and public health authorities, who are all doctors, the infant
mortality statistics, say of Vancouver or B.C. generally, are the lowest they have ever
been and are as low as any in the world. Mr. Cameron gives a figure of losses. How
dishonest it is to do this, without giving the total number of births—the percentage
of loss—the record of the past twenty years, let us say—the causes of death and so on.
This is again the type of argument that men like Mr. Cameron employ, the making of
statements without any background, the quoting of facts and remarks without their
context.  Such a methgd of argument is as valueless as it is unworthy.
Page 58
i
'   .'■ SS3
It
He goes on to say that if bridge builders or engineers showed a similar record of
failure they would be out of a job. There is no analogy between the two problems. <
The newborn baby is the product of its heredity and environment, and of other factors 1
which we are only slowly learning to control—and the fault is not with the doctors;
it is rather with community conditions, human inertia and ignorance, and the like.
These cannot be blamed on us. Again let Mr. Cameron and his colleagues seek to place
the blame where it rightly belongs, and attend to it there.
Another remarkable statement, or mis-statement, in Mr. Cameron's remarks, is that j
in which he says that the control of disease has been accomplished, not by the medical
profession, but by sanitary engineers, bacteriologists, bio-chemists and so on, who are
on salaries. Just what he means by sanitary engineers we do not know. Such expeditions as the Canal Zone expedition, the research into malaria at the end of the last
century, the work done by the Rockefeller foundation in China, the work of the Institute of Tropical Diseases in Britain, the researches into cancer, have all been directed i
by medical men, with "sanitary engineers" working under their orders and direction.
Bacteriologists are practically all medical men, and just what bio-chemists have to do
with the prevention of disease only Mr. Cameron knows; they do of course furnish us
with knowledge of the facts of health and disease.
One could go on for a long time—but enough has been said on the subject.
Meantime, it is well for us all to realize just what we have to look forward to if the
apostles of state medicine ever succeed in getting their way. A ruthless standardisation
of medical practice, and its reduction to a state-controlled civil service, where the i
control will be in the hands of men who will try to reduce everything to uniformity,
and conformity with a political dogma, will not lead to better health conditions in the \
community, but to a lowering of health standards and an arrest of progress.
WESTERN DIVISIONS OF THE CANADIAN
ANAESTHETISTS' SOCIETY
PROGRAMME
WEDNESDAY—MAY 4, 1949
7:00 p.m.—Discussion of Premedication and Anaesthetic Technics for May 5th cases.
THURSDAY—MAY 5, 1949
8:00 a.m.—Clinical   Cases   (Special  demonstration  of  Endobronchial  Anaesthesia   by
Dr. W. M. Hall).
2:30 p.m.—Mayo Clinic Anaesthetic Methods—Dr. H. T. Seldon.
3:30 p.m.—Discussion of Premedication and Anaesthetic Technics for May 6th cases.
FRIDAY—MAY 6, 1949
8:00 a.m.—Clinical Cases   (Special demonstration of Transsacral Anaesthesia  by Dr.
Harry T. Seldon, Mayo Clinic).
1:30 p.m.—Therapeutic and Diagnostic Block Clinic.
4:00 p.m.—Business Meeting.
SATURDAY—MAY 7, 1949
Free to visit the following hospitals in the morning:
Royal Columbian, New Westminster, B.C.
f^| Royal Jubilee Hospital, Victoria, B.C.
Shaughnessy Hospital, Vancouver, B.C.
St. Paul's Hospital, Vancouver, B.C.
St. Vincent's Hospital, Vancouver, B.C.
(All doctors will be welcome at the Clinical Programme)
Page 59 VancouverJMedical  Association
President Dr. Gordon C. Johnston
Vice-President : Dr. W. J. Dorrance
Honorary Treasurer Dr. Gordon Burke
Honorary Secretary Dr. Henry Scott
Editor—— '- Dr. J. H. MacDermot
JOHN MAWER PEARSON LECTURE
Introduction by Dr. W. D. Keith
On December 31st, 1936, at a general meeting of the Vancouver Medical Association, it was decided to honour the memory of the late Dr. John Mawer Pearson by the
establishment of a Lectureship to be known as the "John Mawer Pearson Lecture." This
lecture was to be given as often as funds set aside for this purpose would permit. On
December 7th, 1948, at a dinner celebrating the Fiftieth Anniversary of the Vancouver
Medical Association, the inaugural John Mawer Pearson Lecture was given. Prior to
the lecture, the life and work of Dr. Pearson in connection with the founding and many
years of loyal devotion with which he had enriched the development and activities of
our Association, was briefly dealt with by Dr. W. D. Keith as follows:
To understand the character of John Mawer Pearson, it is well for us to know something of the background from which he came. Born on October 22nd, 1869, in With-
ington, Lancashire, England, a small suburban town near Manchester, he was the
youngest in a family of fire boys and two girls. His father and his father's father
before him, were connected with the firm of Pearson and Rutter—importers of dairy
products. His early education was at Manchester Grammar School and at Epworth
College at Rhyl in North Wales.
At the age of sixteen he was sent to Canada on account of poor health. There he
joined his brother near Winnipeg and for the next seven years he worked on his brother's
farm at St. Francis Xavier on the Assiniboine River. During that time the two brothers
started a creamery believed to be the first of its kind in Western Canada. Also during
that time he made two trips back to England to see his people and a young lady to whom
he eventually became engaged.
Something must have been stirring in his nature during these hard working years,
for in 1892 he decided to leave the farm and take a trip to Vancouver. He spent his
first night there sleeping under a log, for by the day he was busy clearing land for the
Canadian Pacific Railway Company. On one occasion he journeyed to Chilliwack with
the idea of starting a creamery there but found that it was not feasible.
He then decided to take up medicine, and in the spring of 1893 he went to Toronto,
studied for six weeks and matriculated in the Trinity University examinations. In the
fall of 1893 he entered Trinity Medical College as a student, and after four years, in
April, 1897, graduated in medicine, second in his class.
The idea of immediately getting started in practice brought him back to Vancouver
to look the field over, and he found that there were only fourteen men in practice in the
city at that time. Realizing something of the great destiny in store for Vancouver, he
immediately bought a practice from a Dr. Thompson who was leaving the city, and at
the age of twenty-eight began to practise.
It was in this year that his fiancee, Miss Julia Jackson, came out from England. Drl
Pearson was to meet her in Banff where they were to be married. However, the young
physician was unable to leave on time, being delayed by a maternity case, and so arranged
to meet her at Yale, where she remained overnight at All-Hallows' School, an institution
established by Anglican sisters for native and white girls. The following day being
Sunday, the whole community, many of whom were Indians, were at the church for the
Page 60
\
■. iK
1*
wedding, which was solemnized after the regular evensong service in St. John's AnglidjS
Church on June 27th, 1897. The church having been decorated with beautiful ferns
and flowers, the whole effect made a lasting impression on the young bride.
It was not many months before Dr. Pearson began to agitate for the formation of a
medical society. In the fall of 1898, he sent out postcards to every physician in the
city, asking them to attend a meeting at 8 p.m. on October 2nd, in the waiting-room of
Dr. Lachlan MacKechnie's office. The waiting-room was shared by Dr. Jackson, a dentist, and wac located over the corner drug-store at the northeast corner of Hastings and
Homer Streets. The meeting was attended by fourteen medical men, and Dr. D. H.
Wilson, uncle of Dr. Wallace Wilson, was asked to take the chair. After some discuM
sion it was decided to form an association immediately, and Dr. D. H. Wilson was voted
into the Presidential chair. Dr. Pearson was appointed the Secretary-Treasurer, whicl
position he held for two years.    In 1901 he became President of the Association.
During the years 1903-4, 1904-5, and 1905-6, Dr. Pearson again held the position
of Secretary-Treasurer. The minutes of these early years were written by him in excellent English and a distinctive hand, as he took much pleasure in doing his duty well. The
meetings were carried on during those early struggling years without a single intermission.
In 1906 Dr. Underhill, the President, and Dr. Pearson as Secretary-Treasurer, affixed
their signatures to the papers of incorporation of the association under the Benevolent
Socities Act. |||||
It was in that year also, that a committee consisting of Dr. Pearson and Dr. Williail
Stephen were appointed to look into the matter of establishing a library, providing that
sufficient funds could be raised and quarters obtained. Dr. Stephen collected the sum
of $865.00 and secured an option on two rooms in the Haddon Building, situated on
the northeast corner of Hastings and Granville Streets. The rent paid was $12.50 per
month.   This was the start of our Library.
In 1908 Dr. Pearson represented the Association at the meeting in Chicago of the
"American Medical Library Association." Our Association allowed $60.00 toward Dr.
Pearson's expenses in attending this meeting. Later in the year Dr. Pearson reportel
fully to the Society regarding the topics discussed at the meetings and also included in
his report impressions gained from visiting the Medical Libraries in Minneapolis and
Winnipeg.
During the year 1910 to 1915, five years in all, Dr. Pearson was chairman of the§
Library Committee and guided its course and development with great wisdom and visioa
In 1921, Dr. Pearson was appointed chairman of the committee to investigate the
possibility of establishing a Summer School, and it was decided on the strength of tha
report to begin the first course of lectures in August of that year. Later, when the
Summer School became part of our structure, Dr. Pearson became its chairman for the
years of 1922 and 1923.
In 1915 at the annual meeting, Dr. Pearson was appointed to the position of Editor.
What he was to edit was difficult to understand, but at the next annual meeting the
same appointment fell to his lot and it is not surprising that when the "Bulletin" of the
Vancouver Medical Association was launched in 1924, Dr. Pearson should have naturally
been expected to take the position of Editor.
In the first issue of this venture, Dr. Pearson reviewed the steps which led up to
the establishment of "The Bulletin." He told how the President, Dr. H. H. Milburn
with characteristic enterprise and energy, was the main force and drive which led to
the establishment of the '"Bulletin," and also told of the arrangements for its publication each month. I will now quote from a number of the editorials which will give an
indication of Dr. Pearson's thoughts on various medical affairs which related to our own
welfare as an Association, and to the medical problems of the day which were of in teres!
to every practitioner in the province. His main theme down through the eight years
of his editorship was the growth and influence of our Association.
Page 61 In one issue the Editor states "this Association is our own, our meetings just what
we care to make them, large and interested audiences are quickly reflected in more thorough and more careful papers."
In another place he writes "if the Association is not up to your ideas of what an
Association should be, you have your remedy—join it, work in it and for it, and give
the benefit of your personality—both will gain immensely, yourself most of all."
In September, 1925, we read: "The medical man should be not only a practitioner
of medicine, he should be an apostle of public health, of sanitation, of good laws and
one of the moral police force of the country, and he can do this most effectually through
the Association."
Other editorials which caught my attention as I read them through recently were
—Dr. Osier and his relationship to our Association.
A tribute to Dr. F. T. Turnbull, who retired after thirty years of valuable service
to the city.   This showed Dr. Pearson's staunch loyalty to an old friend.
In commenting on the desire of so many young men entering medicine tO graduate
into a specialty, the editor writes "no doubt specialists are all right if they possess
knowledge and skill superior to that of the general practitioner. This world would be
the poorer if the family doctor loses his place in the scheme of things."
In the "Bulletin," October, 1928, Dr. Pearson raises the curtain on the fifth year
of its existence by the following—"To serve as a means of communication between
the members, and to link them more closely together, to enhance the status of the
Society, to stimulate interest in its work, to carry to outside points information of its
activities—these were the objects for which this paper was founded, and which those
who have since been responsible for its appearance have endeavored to make effective.
How far they have succeeded it is not easy to say. Perhaps those immediately in charge
know least about its success or failure. Without cost, without request, those on our
mailing list receive their copy month by month, the rest is silence for the most part."
It is well for us at this time to consider Dr. Pearson's interest in matters pertaining
to medicine and education outside the Vancouver Medical Association.
He was on the active staff of the Vancouver General Hospital from 1904 until 1925
and in 1926 was appointed to the consulting staff. During those years, Dr. Pearson
gave many lectures to the resident medical staff and to the nurses in training. He
seemed to possess a natural gift in imparting his knowledge to students.
Before the days of a British Columbia University, Dr. Pearson and Mr. F. C. Wade,
former editor of one of the Winnipeg newspapers and later Gold Commissioner in the
Yukon Territory, toured the province together in an endeavour to create an interest in
the minds of our people towards the establishment of a university in this province. I
might add that Dr. Pearson was a member of the first Senate of the University of
British Columbia, a position which he held for the years from 1916 to 1918. Some
years after the British Columbia University was established, the President of the University—Dr. Wesbrook—who by the way was a medical man, and Dr. Pearson, made a
speaking tour through the province hoping to arouse interest in the establishment of a
medical faculty in connection with the University.
Dr. Pearson was in general practice from 1897 until 1916 and from then until 1932,
when he retired, he was a consultant in medicine. By way of digression I might add
that after his retirement from practice, Dr. Pearson's life was not an idle one, as much
of his spare time was occupied in wood carving, and even at the time of his death he
had partly completed a large figure about one-half normal size, of a young footballer
m action. Those large strong hands were under the control of an artistic mind. Down
through the years he contributed quite a number of scientific papers at the general
meetings of the Association.    A few will be mentioned—
In 1901 "Urinalysis," his first paper, stressed the necessity of carefulness and thoroughness in procedure, the variety of ailments in which the urine varied from the
normal and the significance of these was dealt with in a most interesting way.
Page 62
. '«
*.*
"Life and work of Graves with his original description of the disease called Exophthalmic Goitre—1909."
"Diabetic Foods" and reporting the results of analysis he made on a number of
Diabetic flours as to their Carbohydrate content—1909.
"Periodicity in disease"—a very thoughtful paper.
"Leaves from a consultant's diary"—1932.
The most outstanding contribution Dr. Pearson made to our Association was "Thes
value of style as exemplified in the writings of Sir William Osier." This was the second
Osier oration, given in 1922. The very nature of the subject he chose, the fine diction
used, the wide reading necessary in the handling of such a subject betokened a culture
and a fine literary style and reminded one of what Osier himself said in one of his^
addresses, "There is in the British School of Medicine, or in its best representatives, a
scholarly tincture which is as distinguishable as it is unique." And on this occasion
Dr. Pearson clearly showed that he belonged to that British school.
It is difficult to evaluate the real worth of Dr. J. M. Pearson to this Association.
His contributions to our Society were very great and precious ones—as a founder; as-
the Secretary-Treasurer of the newly formed Association on whose shoulders the res-:
ponsibilities of the meetings largely depended (for a quorum must turn up and a scientific paper must be given); as one of those who helped to found the library and who for
a number of years guided its development with wisdom and vision; as one who played
an important part in the formation of the Summer School and was the chairman of
this committee for the first two years in 1922-23, and finally for the leadership he gave
to the interest of medicine throughout the province through his position as Editor of
the "Bulletin" for a period of eight years.
Dr. Pearson's love for his profession, the simple unostentatious way he lived, the
conduct of a successful practice over many years without the aid of any vehicle to get
about the city, the steadfast persistence in his scientific study without any assistance of
post-graduate work, which by his own steam, so to speak, placed him as one of the
leaders of medicine in this city. This I thought quite remarkable, since it showed great
"steadfastness of purpose and unusual mental gifts and outstanding courage.
He was a very tall man—6 feet 3 inches, of medium build, wore a bow tie and
carried gloves. He looked down upon one with a friendly glint in his eyes. Dr. Pearson
had taken charge of my family during a number of our sicknesses and I held for him
an abiding affection and esteem, yet there was a reserve or barrier beyond which one
could not penetrate. He was one of those whose minds dwelt in a higher plane of
thought than the average. One never heard him enter into the ordinary doctor's chatter.
During all the years I knew him, I never heard him say an ill word of any fellow
practitioner, though there were, I am sure, many occasions when provocation was not
lacking. He seemed to possess a knowledge of conduct of one doctor to another, and of
one doctor to another doctor's patient, which is probably much more rare. He also possessed a dignity, a patience and an equanimity which never seemed to forsake him.
He was a wise and observant student of medicine, who seemed intuitively to know
that there were no shortcuts to be made, but that the skilled and wise must spend years
in active bedside clinical work.
On account of his facility in speaking, he was often called upon to move a vote of
thanks to some distinguished visiting lecturer, and the amenities of the occasion and
some outstanding points in the contribution, were always happily dealt with.
Thirteen years ago tonight, John Mawer Pearson passed to his great reward and in
the following January's issue of the "Bulletin" there appeared from the pen of Dr.
Pearson's worthy successor as Editor of that journal—Dr. J. H. MacDermot, a spontaneous and heartfelt tribute to Dr. Pearson's memory which in depth of feeling and beauty
of thought, expressed not one man's opinion, but the feelings of so many of us over the
loss of this fine scholarly colleague.
Page 63
■' 't Jt; In his last will and testament, besides a competency to his family, Dr. John Mawer
Pearson bequeathed as a benediction or as a blessing, the sum of $100.00 to the Vancouver Medical Association with which his life had been so closely interwoven.
I wish to thank you, Mr. President, and your Executive—Dr. Busteed and the
committee of arrangements, for the distinction, honour and privilege, of a place on the
programme of this important occasion.
(Note: The lecture itself will be published later.   Ed.)
PRIMARY TUBERCULOSIS IN INDIANS
By W. S. BARCLAY
Medical Superintendent, Coqualeetza Indian Hospital,
Director Indian T.B. Control for B.C.
Definition
There is an inclination by certain authorities in America to restrict the definition
of Primary Tuberculosis to lesions which occur only during the brief initial or pre-
allergic phase of infection. Others stress the view that broadly speaking, there should
be no clinical differentiation between primary and re-infection tuberculosis—that they
are simply different stages of an original and often progressive infection. Between these
divergent viewpoints there is a more general concept of primary tuberculosis to which
the majorit yof chest specialists still subscribe. This includes certain diagnostic criteria
and clinical or radiological manifestations which will be outlined quite briefly.
(1) The tubercle bacillus is introduced into non-allergic tissues.
(2) Progression occurs by way of lymphatics to regional lymph nodes.
(3) Haematogenous spread may occur and is characteristic.
(4) There is a definite tendency for lesions to retrogress.
(5) Calcification of regional and local areas in infection is frequent.
(6) Entire course of the infection is often benign. 1^1
Incidence
It might be stated forthwith that primary tuberculous infection is commonest in
the lungs. Of almost 13,000 cases of pulmonary tuberculosis admitted to institutions
in Canada in 1946, 317 or 2.5 per cent were of this type. The figures published suggest
that nearly half of these were Indian. However, the relatively high frequency with
which this condition has been found among the Indians in B.C. has afforded ^ very good
opportunity to study it at first hand and it was felt some observations might prove of
interest to this meeting.  My remarks will apply mainly to the pulmonary form.
During the past seven years it is considered about 60 per cent of the Indians of
British Columbia have had chest x-rays. A diagnosis of active or inactive pulmonary
tuberculosis has been made on 2,000. Six hundred of these, or 30 per cent have been
diagnosed as primary pulmonary tuberculosis. It is not known what the incidence is
among the white population, but I would venture the opinion it is probably not more
than one-fifth that of Indians.
Of these 600 cases, 345 or 57 per cent are Apparently Arrested, Arrested, or
Apparently Cured. An additional 129 have disease considered Quiescent. Well over
one-half of all cases have had or are now receiving institutional treatment. The present
average age for the entire group, both inactive and active, is 12 years. About one out
of six has had tuberculous complications in addition to the primary lesion; pleural
effusion, dry pleurisy and cervical adenitis being most frequent.
Soured
Bovine tuberculosis is recognized as a possible source of human infection. As far ay
B.C. Indians are concerned, however, it is considered to be negligible. Coastal natives
do not have access to fresh milk to any extent, while even in the Interior, cows milk is
Page 64
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much less commonly used than among the whites.   On the other hand, the prevalence
of human  tuberculosis  among  the  Indian population,  coupled  with  the significant
factors of overcrowded living conditions and poor health habits, offer an all to obvioi
explanation for the frequency of this condition.
Diagnosis
In many tuberculosis programmes the tuberculin test is widely used as a screen for
detection of infected individuals.   It has not been possible o use this preliminary test|
very extensively in our Indian work and consequently the diagnosis of primary tuberculosis has been made mostly on chest x-ray films, confirmed later in most cases by|
tuberculin skin testing.
Because of the high incidence of tuberculosis in this group we have been filming
literall yevery person we can reach, including many infants.   This is in contrast with
the plan followed in white surveys where experience has shown that routine filming of
children under fourteen or fifteen gives a very low yield of tuberculous cases.
The typical x-ray finding in a case of active primary pulmonary tuberculosis is aj
parenchymal infiltration which may be located anywhere in the lung fields, with which is
associated visible enlargement of hilar and often mediastinal glands. There are in^
numberable variations of these findings of course, from an extremely small infiltration!
with only slight involvement of regional hilar glands, to extensive bilateral caseo-4
I cavernous or pneumonic processes with grossly enlarged root shadows and bilateral
mediastinal bulging. Pleurisy with or without effusion is noted frequently and- may bl
found in slight as well as in more advanced cases.
In the interpretation of our films, note is always made of calcified parenchymal
nodules and regional glands, but only in those cases showing grosser calcifications haa
it been felt necessary to record an actual diagnosis of healed primary tuberculosis fori
purposes of statistical notification. We acknowledge the fact therefore that our total]
number of reported cases of this condition does not represent 100 per cent of all thejj
Indians who at some time or other have had a primary infection. We have been morel
interested in keeping a record of all who at some future time might conceivably require
medical or hospital care because of reactivation of their tuberculosis.
It is common knowledge that physical findings in primary pulmonary tubercuosis
are usually meagre or absent. When present they cannot be considered truly diagnostic.
As in re-infection disease, detectable signs are too often evidence of fairly well advanced]
lesions.
The diagnosis of primary tuberculous infections other than in the lungs is generl
ally more difficult.   These may occur in the abdomen, in the cervical or other groups
of glands, in the skin, bones and points, or elsewhere, and may be found quite apart
from any detectable pumonary process.  The portal of entry may be tonsils, alimentary!
tract or respiratory tract and spread by the lymphohematogenous route.  The proportion!
of such non-pulmonary cases is relatively small and differential diagnosis more difficult]
History of tuberculosis contact is important even though at times it may be long iid
forthcoming.   Positive tuberculin tests are by no means universal among our Indians |
so this procedure still is a valuable diagnostic aid. X-rays, biopsies and even an occasional|
autopsy are additional necessary procedures.
Symptoms
Probably the earliest symptom in primary tuberculosis is fever.   So often this is
accompanied by anorexia, lassitude; and failure to gain weight that among the morel
discerning white population it would soon be detected by parents, physicians or nurses.
Indian children on the other hand seem subject to so many minor ailments and infectioflj
that mild fever at least, usually must pass unnoticed.
It has been my observation, however, that where symptoms associated with grosser
chest disease are present, Indian parents show concern to a laudable degree and go to|
considerable trouble to seek medical attention for the child.  Such symptoms, of course,
as persistent cough, definite fever, loss of weight, shortness of breath and weakness are
Page 65
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I'M due to progressive lesions often associated with marked enlargement of hilar and mediastinal glands which encroach on the lumen of bronchi or even trachea. Were it not for the
fact that Indians generally have a poor conception of time in relation to illness, it
might be possible to obtain very interesting data with respect to the duration of various
symptoms. One usually finds that the so-called "present complaint" is considered to be
of quite recent onset.
Prognosis
Despite the implication above that Indian children are often found with a more,
or less advanced primary tuberculosis, the prognosis generally must be considered
favourable. We do find many with early lesions whose progress under treatment is most
gratifying. Even with a considerable amount of disease, perhaps complicated by effusions,
pneumonic infiltrations, cavities, and partial atelectasis, amazing recoveries have been
noted. Similar happenings obviously must occur in white children, though in our work
we are seeing them on a much greater scale. The use of the word "benign" therefore,
in describing the course of this type of tuberculosis is derived as much from the relatively
high proportion of ultimate recoveries as from the suggestion that lesions present are
minimal in extent and symptomatology. It is my distinct impression that lesion for
lesion, Indian children have about as much recuperative power as white children. In
other words racial susceptibility is giving or has given way to an appreciable racial
resistance.
Treatment
It is generally acknowledged that primary tuberculosis of the lungs when present
in mild degree may run its course from initial infection to final calcification unknown
to parents or physician. Because of this there has been a tendency to treat diagnosed
cases at home on a regime of extra rest, vitamins and a certain amount of dietary
supervision. Seasonal movements of large numbers of our Indians from their homes to
canneries, berry fields, hop fields, and hay meadows, plus lack of supervision of the
children and at times an indulgent attitude to dietary whims have made us feel that
institutional treatment even of mild cases is necessary.
For the same reasons we feel that there must be no question about the complete
control of the lesions before discharge is even discussed with the parents, as one rarely
can count on a slowly graduated exercise routine being observed after going hoftne.
Removal of a child to hospital, though sometimes accomplished with difficulty, is
important since it may be the only means of breaking contact with an infectious adult
who refuses treatment. On the other hand, it is common knowledge that children
with primary tuberculosis and who are without significant symptoms actually may be
infectious, and a hazard to other children in the home. The hospitalization of the child
too, often paves the way to a complete x-ray check on the entire family circle which
we have found most valuable.
The average length of treatment of these primary cases, which in B.C. in 1946
amounted to 500 days, may seem out of proportion to the average requirements of
pulmonary tuberculosis generally. However we have yet to be shown that our policy is.
wasteful of time and money, and our reward lies in the satisfactory results we have been
getting, even with advanced cases. A fatal outcome usually has occurred only with the
complications of miliary spread, and tuberculous meningitis.
Our institutional routine provides of course, the basic requirements of rest, suitable diet and healthful living conditions along with appropriate attention to complicating lesions when present. Pneumothorax usually is contraindicated in primary tuberculosis. Ultraviolet therapy is used extensively in non-pulmonary cases. The wider acceptance of streptomycin as a valuable adjunct to treatment is now providing us with an
opportunity to try it in primary lesions. Our experience is too recent and too limited
to warrant any observations at this time, but we are favourably impressed.
It is probably appropriate at this time to digress slightly with a reference to B.C.G.
This of course, is not a therapeutic measure, but rather a preventive vaccination of
Page 66
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proven value.   It has the official approval of the Indian Health Services, Department;
of National Health and Welfare.   Use of B.C.G. in tuberculin negative Indians is being
encouraged across the Dominion and this work in B.C. was ,begun in February, 1947.';
To date only about 550 children have been vaccinated, mostly in Residential Schools,
but the programme is being expanded as rapidly as time and staff permit.
Conclusions
(1) Reference has been made to the high incidence of primary tuberculosis in
our native population in B.C.
(2) The application and modification of commonly used case finding methods and
treatment measures has been mentioned.
(3) Stress has been placed on the successful results of treatment of this condition,
in what commonly has been considered a susceptible racial group.
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NEUROCIRCULATORY ASTHENIA
By P. A. C. COUSLAND, M.D.
Victoria
I have gained the impression over the past few years that the incidence of neurocirculatory asthenia in the civilian population, at least on Vancouver Island, is on the
increase. Certain it is that during the lest war many more young women suffering from
this condition were seen than prior to the outbreak of hostilities, the great majority of
whom had husbands or relatives with the Armed Services. No doubt the comparative
shortage of civilian physicians had something to do with the increase—apparent or real—
but as the numbers have not diminished since V-E Day, but have if anything increased,
I incline towards the reality of this increase. From this point of view alone a brief review of the symptomatology, diagnosis and treatment would be well worthwhile. Another point arises, however, which is much more important and that is, that the practising
physician, while in all probability knowing the manifestations of neurocirculatory asthenia in 'its typical or full blown form, is not cognizant of the borderline or aberrant
forms and thus may run into grave difficulties both in diagnosis and treatment.
It has been well known for a number of years that neurocirculatory asthenia per
se is not an organic disease of any part of the cardiovascular system, although it does
occur frequently in association with cardiovascular disease. Neither is it caused by
effort as the old term "effort syndrome" would lead us to believe. With regard to terminology it is generally conceded that neurocirculatory asthenia is at present the name
of choice. "Effort syndrome," D.A.H., and "soldiers' heart" are all bad, as they give a
complete misconception of the condition.
Definition of the condition is still not too easy, Friedman describing it as "characterized in the majority of cases, if not in all, by the appearance of various cardiovascular
and neurological phenomena in patients who may be at complete bed rest or its physiological equivalent," calling these phenomena "episodic neurogenic discharges" due to
cortico-hypothalamic imbalance. He states that it is either acute or chronic, the acute
form being identical with "acute anxiety neurosis" whenever the latter has autonomic
reference in the cardiovascular system, and is cured when the cause is removed. Such
is not the case in chronic neurocirculatory asthenia where the patient hereditarily is'
rendered abnormally sensitive to the influence of external events. White has a definition
which differs in some points from the above—the definition reads—"in the present
state of our knowledge and until the problem is solved, I would suggest the following
"neurocirculatory asthenia is a condition of ill health characterized by a group of symptoms consisting of dyspnoea (often with sighing respiration also), palpitation, exhaustions, praecordial pain (most often an ache), dizziness, nervousness, and sometimes
Page 67
e: tremor, sweating, headache and syncope, aggravated by effort or excitement and attend-
or following anxiety neurosis, infection, or physical or nervous strain, especially in
hypersensitive individuals who in extreme cases may show the condition more or less
constantly with little or no provocation—it is neither fatigue per se, nor infection,
nor thyrotoxicosis, nor nervous strain, nor psychoneurosis; it is a state of ill health
which may attend or follow any of these conditions or indeed others to, or even possibly
stand alone."
In view of the above it is interesting to see how far we have advanced in recent
years. The British Encyclopaedia of Medical Practice contains only two short references
to it in its 12 volumes dated 1936. (1) Under the heading of "Simple Tachycardia"
where it is stated that N.C.A., "effort syndrome," "D.A.H.", are terms employed to
denote a nervous instability of the circulatory system in which the heart rate is either
temporarily or persistently rapid. Treatment consists of the discovery and removal of
cause, and reassurance that the heart is essentially normal in those instances where
there is no evidence of organic disease. (2) Under the heading "Heart and Sport,"
"Effort Syndrome"—'The civil practitioner is less concerned than his colleague in
the services with the difficulties of "effort syndrome" or neurocirculatory asthenia.
During and shortly after the Great War this disorder under the topical description of
'soldiers' heart' exercised the minds of investigators and incurred the expenditure of
millions of pounds. The obligations of the general practitioner will in general be met
if he recognizes that there are individuals who are constitutionally ill-adapted physically
for exertion and that with very few exceptions their disability is irremediable. As a
physiologist he may be interested to speculate upon the cause and situation of the
constitutional imperfection. It may be ill-developed coronary vessels or poor contractile power of the cardiac muscle. The inefficient athlete convicted of a "yellow
streak" may be unfairly condemned; the yellow streak may not be in his spirit but in
the fibres of his heart muscle; an overactive brain may fail to protect the heart from uneconomical activity. A large number of theories have been advanced on physical,
psychical, endocrine or toxaemie lines to explain the sympotms'."
Etiology: Neurocirculatory asthenia is extremely rare in young children, rising to
its greatest incidence between the ages of 20 and 40, and from thence on gradually
declining. Women are more affected than men. Heredity has been briefly mentioned
before. In the great majority of patients there is a family history of nervous instability,
nervous breakdown, or they may even have had neurocirculatory asthenia diagnosed.
Other etiological factors to be mentioned briefly in passing are—emotional conflicts,
family worries, business worries, insomnia, fatigue, both nervous and physical, and
probably infections.
When we come to symptoms we are in a very fertile field. The four commonest
are: exhaustion or tiredness, praecordial pains or aches, dyspnoea and palpitation. Figures given in the past show them to have approximately the same frequency, but in my
limited series of cases, tiredness and praecordial ache occurred most frequently, followed
in order by dyspnoea and palpitation. Tiredness was a complaint of the great majority
of patients, the characteristic statement being that they get up more tired than when
they went to bed. The praecordial pain was of two types, the first a sharp pain,
starting at the apex, shooting posteriorly and lasting for a few seconds only. It has been
stated that examination of the heart revealed either extraordinarily forceful contractions
or E.C.G. studies detected the presence of an arrhythmia at the time the patients complained of praecordial pain of this variety, and also that the patients exhibited cold, wet
hands, accentuated tremor, profuse axillary and palmar perspiration and pupillary
dilatation at those times. The second type is a dull ache, centred in the submammary
region, is worse when tired or emotionally upset, often follows effort (several hours
afterwards) and is not relieved by rest. This type of pain in turn has been blamed on
poor use of the muscles of the lower two-thirds of the thorax during respiration, resulting in "excessive fatigue in the intercostal musculature on both sides of those patients
habitually using only the upper one-third of the chest in respiration.   The contraction
Page 68
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of the heart on the left side against the fatigued musculature probably raises the subclinical fatigue to the clinical threshold of pain perception. This possible mechanism
might also serve as an explanation of why patients having the pain insist on lying on
their right side."
DyspnOea: This is not the dyspnoea of organic heart disease. Patients frequently
remark that they cannot get enough air into their lungs and characteristically, unconsciously show what they mean by frequent and deep sighing respirations. This
occurs at any time, usually when at rest and not infrequently when lying in bed at
night "thinking things over."
The palpitation complained of is of the usual types, ventricular extrasystoles,
auricular paroxysmal tachycardia. Commonest of all, the forceful heart beat of which
the patient is unduly conscious.
Sweating of hands, axillae and feet is common. I find the easiest way to check
on the axillary sweating is to estimate the size of the perspiration stains on the sheet
covering the examining table after the patient has left the table. The hands and feet
are frequently cold and clammy to the touch, while the patient often states that she
has great difficulty in warming them, even in midsummer.
Sleeplessness occurs not infrequently, and on occasion is extreme and is the chief
complaint.
Some complain of dizziness or giddiness, not a true vertigo, but a tendency from
time to time to be unsteady and a little unsure of themselves.
Although, or because, they are afraid and worried about themselves, their loquacity
about themselves is extreme. It is truly remarkable to what extremes of detail they will
go to make sure that the doctor understands.
Headaches, per se, I have rarely met with, but on many occasions there has been a
complaint of soreness or stiffness in the region of the basi-occiput extending inferiorly
down the neck.  In none of these patients has there been a suggestion of hypertension.
Physical Examination: in all probability will reveal a worried anxious expression
of the patient's face. This is quite characteristic and almost universal. There may be
tachycardia, some cardiac irregularity, and possibly some tremor and flushing as well as
the sweating etc., mentioned before. Praecordial tenderness on palpation is frequently
present.
Diagnostic aids are usually of no value except in a negative sense. Apart from
Mood counts and B.S.R. in ruling out infections, two tests may be of some value,
namely B.M.R. for the differential diagnosis of subclinical .thyrotoxicosis and E.C.G.
Both of these however have their pitfalls. I well remember some years ago a nurse
in training came under my care complaining of symptoms suggestive of neurocirculatory asthenia. To make quite sure that she did not have a mild degree of thyrotoxicosis,
she graciously submitted to a B.M.R. the following morning. I can assure you that I
was considerably shaken when the repOrt came back -50. The hospital Pathologist was
consulted, the machine was overhauled and the test repeated in ten days time—result
-55. We gave up any further attempts after that. The lady was not given thyroid
extract, neither was she given Lugol's solution and to my knowledge is alive and well
today, which all seems to boil down to—put not your trust 100 per cent in B.M.
machines.
Electrocardiographic tracings, when taken in the normal supine position, show if
anything very slight changes which must be interpreted with caution. When taken
in the upright position, however, inverted T waves are seen frequently in standard
leads 2 & 3. Originally this was thought to point to a change in cardiac rotation or
a diminution in coronary flow, but this has been disproved by later work, where the
injection of ergotamine tartrate, before assuming the upright position, prevented any
anomalies of the T waves in leads 2 & 3. Here I quote the words of the investigators:
"Supposedly, in the normal subject, the orthostatic augmentation of sympathetic
activity which physiologically develops because of the vascular readjustments which
accompany the vertical stance is not in itself adequate to produce a registrable dromo*
tropic effect upon the events associated with electrical systole, even though a chrono-
Page 69
m tropic effect is evident in the moderate cardiac acceleration that occurs. Orthostatic
T wave distortions in patients with neurocirculatory asthenia are therefore presumed to
represent additive sympatheticomimetic effects, i.e. reflex adrenergic activity superimposed on a state of autonomic imbalance, with sympatheticotonic preponderance."
The pitfalls with the E.C.G.'s were of course quite different but can be potentially more serious. Two patients were seen by a physician on the same day, with very
similar complaints, namely, praecordial pain, palpitation and breathlessness. Having no
electrocardiogram he sent them elsewhere, the tracings were duly taken without any
adequate supervision as to technique and the reports sent no the attending doctor. He
was very concerned when he found that the reports were both bad in that there was
a deeply inverted T wave in lead 4F, and as both the patients were young he referred
them to me for my opinion. Typically they were both neurocirculatory asthenics,
showing no evidence of cardiovascular disease. E.C.G. tracings were taken with CF 2,
4, and 5 instead of 4F—upright T waves were found with nothing abnormal except
sinus tachycardia and an occasional ventricular extrasystole in one patient's tracing.
On subsequent inquiry I found that the original E.C.G. tracings had been taken by
a technician,with no one else in attendance and she had obviously transposed leads. I think
the attending physician should be congratulated on two points—on suspecting a slip
and telling the patients nothing regarding any possibility of heart disease. There is a
moral in this but I will let you figure it out for yourselves.
X-ray of the heart should of course be mentioned among the diagnostic aids. An
enlarged heart shown by proper technique means only one thing and rules out neurocirculatory asthenia except as a concomitant condition.
The diagnosis normally can be made with considerable ease but one must make
sure all aids available that such conditions as mild or subclinical thyrotoxicosis, early
pulmonary tuberculosis and early mitral stenosis are not lurking under cover. The
borderline cases are sometimes extremely difficult and it takes considerable time and
effort before one can be at all certain.
Having made the diagnosis, then it behooves us—like Agag—to tread delicately.
We must not ride rough shod over the patient and tell her it is 'just nerves' and to
forgget about it. Neither must we tell her that she has a slight murmur in her
heart therefore her heart is bad, or to imply by any word or action that her heart is
bad. We must take the patients completely into our confidence, explain everything
in as simple language as possible, particularly stressing the fact that no organic heart
disease is present, and attempt to eliminate or alleviate any predisposing factors. Reassurance this week, reassurance next week, reassurance two weeks hence and ad
infinitum is, I am sure, the greatest factor in the patient's improvement. If we do not
do this and let things slide, or give them to understand that it is "nerves" or a "bad
heart" we are doing them a grave disservice and one from which many of them will
never recover. I am sure that all of us have seen cases treated in this fashion by some
physician in the past and into what hopeless invalidism as a result the patient has relapsed.
I am not at all sure that the psychiatrist and cardiologist should treat these patients. Initial visits until the diagnosis is established and the position explained are
quite in order, but after that a good physician with common sense would fill the bill
better.. The patient would then not have the feeling of being looked after by a specialist, therefore considers that her condition can not be too bad.
And lastly—drugs. They have but a very small place in the treatment of this
condition. Sedation will be necessary for the sleepless and in a milder form for those
who are excessively worried, and nervous. If palpitation in. the form of paroxysmal
auricular fibrillation or frequent extrasystoles is very persistent a course of quinidine
sulphate would be indicated.
Conclusion: I have attempted briefly to outline neurocirculatory asthenia, mainly
as to symptomatology, diagnosis and treatment so that we may get a clearer picture of
the problem that confronts us. As I said before, we have come far in the last decade—
but we have still far to go.
Page 70
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RHEUMATIC FEVER AND RHEUMATOID ARTHRITIS
^ 4   IN CHILDREN        #
By REGINALD WILSON, M.D., F.R.C.P.(C)
The Health Centre for Children, Vancouver General Hospital
While rheumatic fever usually begins in childhood, its effects persist throughout
life. In fact there are an estimated one million sufferers from rheumatic carditis in the I
United States. It causes more deaths than any other disease in children of school ageJ
(x) When to this is added the serious crippling and chronic illness caused by childhood;
arthritis (Still's disease) one is impressed with the magnitude of the problem of theij
rheumatic diseases in children.
The subject is one which demands a fresh approach and a renewed interest.   It is
admitted that as yet, research has failed to provide an answer as to the cause of either
disease.   No miracle cure has been discovered for them.   The latest trend is to classify^
these two diseases with Lupus erythmatosus, Anaphylactoid purpura, Periarthritis nodosa, •
as "The Collagenoses." The search for a common etiologic factor for these relatedi
diseases; may prove to be a fruitful avenue of investigation.    But meanwhile, most
workers stress the importance of accurate diagnosis, rational treatment and the preven-|
tion of recurrences.
Recently emphasis has been placed upon the value of centralizing the diagnostic
facilities for rheumatic fever, arthritis and cardiology of childhood. In a central clinic
a diagnostic service is provided and a register of cases maintained for the community.
In co-operation with the school medical service, preventive aspects are stressed. These
are the essentials of a rheumatic fever control program(x). At present such facilities]
are being developed at the Health Centre for Children in Vancouver.
TABLE I—Main Clinical features of Rheumatic Fever and Rheumatoid Arthritis Compared
and Contrasted.
Age
Incid
ence
Clinical
Manifestations
Rheumatic Fever
5-15  years peak 6-8  years
70%   of first attacks under 16 years.
Fleeting arthritis especially in larger joints.
Carditis in 90 %   of cases
Chorea
Tachycardia common
Sleeping  pulse   accelerated
Nutrition maintained
Fever
High at onset
Skin
Erythema  Marginatum  on  trunk
Nodules
Occasionally  present
X-Ray
Heart enlarged commonly
E.C.G.
Changes almost universal
Salicylates
Effective in stage of invasion
Sedimentation
Rate
Very rapid
Specific
Test
Response to Salicylates helpful
Rheumatoid  Arthritis
Peaks at 2-6 and 12-16 years
5 % of all cases are under 16 years
Progressive arthritis leading to deformity,
especially in small joints
Pericarditis occasionally
Regional Adenopathy
Tachycardia uncommon
Sleeping pulse compatible with temp.
Wasting common
Usually low grade
Erythematous rash chiefly over joints
Rarely present
Heart usually unchanged
Changes uncommon
No specific effect
Moderately  increased
None available
Page 71
§'■!! TABLE II—This table modified from Shapiro (2), indicates the clinical criteria which are helpful in
differentiating so called "growing pains" from mild rheumatic arthralgia. It should be emphasized that postural anomalies or other orthopaedic defects will account for many of these
non-rheumatic pains.
Age
Time of Pain
Location
Other Stigmata
Objective Signs
Lab.  Findings
Growing Pains
Early childhood and often through
adolescence
2-4 hrs., after going to sleep.   Recurrent
during the night and gone in day.
Common  in  muscles  of  legs  and  thighs,
occasionally in knees.  Rare in upper limbs.
Usually none
None
Negative
True Rheumatic Arthralgia
Frequently  between  6   and   8  years.
Often   associated   with   upper   respiratory
infections.
Aggravated by activity  and improved by
rest.  Often causes daytime limp.
In joints of upper and lower limbs
Repeated bouts of pain, pallor, fever, rash,
nose bleeds
Transiently increased heat and swelling of
joints
Anaemia  -
Increased Sedimentation Rate
Slight leucocytosis
Electrocardiographic changes
Sometimes heart murmur
TABLE III—'This table indicates the most striking features which will help to differentiate the diseases
which   are   most   commonly   confused   with   rheumatic   fever.
Rheumatoid Arthritis
Poliomyelitis
Osteomelitis
Serum Sickness
Brucellosis
Leukxmia
Anaphylactoid Purpura
Meningococcaemia
Septic Arthritis
Encephalitis
Cluttons Joints of Prenatal Syphilis
Trauma
T.B.  Arthritis
Carditis and E.C.G. changes
Spinal Fluid & muscle reactions
Extreme Localization
History of innoculation and sed. rate
Agglutination and culture
Marrow puncture
Typical Exanthem
Blood Culture
Joint Fluid
Simulates severe chorea
Interstitial Keratitis  commonly associated
Rash-Leucopenia
History and X-Ray
Tuberculin Test
Page 72
■Mate 5
TABLE IV—This table modified from Taran(3).   It indicates the rate at which the various indices of
activity return to normal in Rheumatic Fever.
r- i
- M
<
WGB
Temp.
(200 cases)
P.R.
Interval        Pul
se
S.R.
W
H.B.
Vital
Cap.
Clinical
Evidence
Clinical Evidence
1.   Appearance of the patient:
Pallor (Not Haemoglobin)
Fatiguability
Emotional Stability
2.   Auscultatory Findings:
Disturbances of Rythm
Changes in the murmur
Rate   of   change   in   pulse   and   rythm   after
stimulation $&££.
Page 73 TABLE V—This table summarizes the essential therapeutic procedures used in the management of
rheumatic fever and rheumatoid arthritis of childhood. In both diseases a strict and prolonged therapeutic regime must be planned. Systematic and enthusiastic use of available
techniques produces a recovery rate twice as high as haphazard application of similar procedures. Meticulous nursing care is stressed as the single most important feature in the
management of Rheumatic Arthritis.of childhood.
Rest
Diet
Transfusions
Salicylates
Rheumatic  Fever
Physical and emotional rest until laboratory and clinical evidence indicates activity subsided  (See table IV)
High calorie
High protein
High vitamin
To combat anaemia
For non-specific stimulation
Useful in adequate dosage in stage of
invasion
Rheumatoid  Arthritis
Rest must be accompanied by judicious
physiotherapy and maintenance of suitable
posture.   Orthopaedic consultation advised.
High calorie
High protein
High vitamin
To combat  anaemia
For non-specific stimulation
Gold No use
Doubtful value in children
X-Ray Not recommended
Doubtful value in children
Prophylaxis Sulphonamides  recommended
Foci of infection should be treated
SUMMARY
The outstanding clinical features of rheumatic fever and rheumatoid arthritis of children (Still's
Disease) are presented in table form. As these are two of the most frequently mis-diagnosed diseases of
childhood, points which help in the differential diagnosis ar emphasized. The essential features of a
community Rheumatic fever control programme are mentioned.
References:
(1) Special Report on Rheumatic Fever and the school child—1948—Pediatrics Vol. 2:3.
(2) Shapiro—Differential diagnosis of growing pains and rheumatic fever.   Journal of Paediatrics
14:315.
(3) Taran 1946—Rheumatic Carditis, Journal of Paediatrics Volume 29:77.
Page 74 M
s, "i
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• i ^ 9cVTy'-*
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i; '8SS'
LIVER FUNCTION—EFFICIENCY TESTS
John Eden, m.b.b.s., Dunel
The use of chemical tests to investigate the functional efficiency of the liver presents
several difficulties.   For example, the liver performs multiple functions.   One or more
of these functions may be severely damaged, whilst others are unimpaired, nad there 9
no single test which will cover all. Again, its functional activity is intimately associated I
with that of other organs, and there is the difficulty of separately assessing the hepatic
factor.   Also, the liver possesses enormous functional reserve and regenerative powers.
These may account in part for our failure to demonstrate functional impairment even
in the presence of marked anatomical changes. This is especially true of slowly progressive
chronic conditions associated with concomitant regeneration of hepatic tissue, such as :
occurs in cirrhosis, malignancy, syphilis, etc.   These are some of the reasons bringing■;!
me to the point I wish "to stress.
Chemical function tests are designed to test the functional activity of the organ,
and any attempt to interpret these in terms of disease, diagnosis or hepatic parenchymalI
damage will lead to erroneous conclusions.
L.F.T.'s will aid in differentiating medical, that is, hepato-cellular or haemolytic
icterus, from surgical or uncomplicated obstructive jaundice.
The simple tests I recommend as satisfactory for the preliminary investigation of
jaundice are:
Quantitative total serum bilirubin.
Serum alkaline phosphatase.
Total and differential proteins.
Thymol turbidity and flocculation.
Quantitative urine urobilinogen.
If the alkaline phosphatase is reported in Bodansky units, all the blood tests can be
performed on 15-20 ml. of clotted blood, but, if it is reported in King-Armstrong units
only 10 ml. of clotted blood are required.
The quantitative urobilinogen is, I think, best estimated on a 2 hour urine collected
over the lunch period, when the flow of bile is stimulated by food, between 12 noon and
2 p.m. All specimens should be examined on the day of collection, as most constitutents
deteriorate on standing (especially chromogens and enzymes).
With regard to the interpretation of these tests:
Serum Bilirubin—normal value for the total is 0-1 mg./lOO ml. of serum. Ratio
D/l may be valuable in haemolytic jaundice. It does not furnish much useful information as a routine. Its chief values are that it detects the presence of latent jaundice and
that it provides a quantitative record of the intensity of the jaundice, if present.
Icterus Index—Technically, this presents difficulties when the serum is haemolysed
or turbid. When interpreting the results one must remember that other pigments will
be estimated, especially carotene. Altogether, this test is a non-specific substitute fos
the more exact quantitative serum bilirubin estimation.
Serum Alkaline Phosphates—Normal values in the adult are:
1.5-5.0 Bodansky units or
5.0-12.0 King-Armstrong units.
Page 75
r& The enzyme shows its greatest rise in cases of obstructive jaundice, as it is believed
to be excreted in the bile. Values greater than 10 Bodansky units and 35 King-Armstrong
units are strongly indicative of extra-hepatic obstruction. These values may be found in
cases of plastic bone diseases, and in a few cases of hepato-cellular jaundice, probably
as a result of intra-hepatic obstruction.
Serum Proteins—In liver diseases, nephritis and malnutrition, the serum albumen
decreases, whilst the serum globulin increases (especially the 8 fraction) in hepatocellular damage and chronic infections.  The usual findings are as follows:
(a) Cirrhosis and subacute hepatitis—the total is normal, the albumen is decreased
and the globulin is raised. The prognosis is said to be poor if the albumen is
less than 2 grms. per cent.
(b) In acute hepatitis the changes are similar but are less striking.
(c) In hepatic carcinoma the changes are minimal or absent.
Associated with these serum protein findings are certain empirical tests. These were
so called because they test no known function of the liver. They are numerous; e.g.,
Colloidal Gold, Cephalin, Cholesterol, Thymol Turbidity and Flocculation, etc. All
depend on alteration in the ratio between gamma globulin and albumen, and alpha and
betaglobulins.  They can be rendered positive by:
1. Raising of the gamma globulin content.
2. Lowering of the albumen or alpha and beta globulin contents.
I prefer the Thymol Turbidity and Flocculation, as they appear to give fewer false
positive results in conditions such as rheumatoid arthritis, chronic infections, cardiac
failure, pernicious anaemia, etc. Also, the reagents can more easily be reproduced and
the results are consequently better standardized.   The normal findings are:
Turbidity 0-4 units.
Flocculation—negative. They are positive in hepato-cellular damage and negative
in uncomplicated, obstructive jaundice. The interpretation of the Flocculation Tests
is not yet adequately assessed.
Quantitative Urine Urobilinogen—Urobilinogen is the colorless precursor of urobilin formed in the intestine from bilirubin by bacterial reduction. It is readily oxidized
by atmospheric air to the colored pigment urobilin. It is, therefore, necessary to examine
specimens in the fresh state. It is re-absorbed and re-excreted in the bile. Therefore,
v die urine urobilinogen is paradoxically negative in complete biliary obstruction. In
intermittent obstructions (stone) the cencentration varies from day to day. The urinary
content increases with hepato-cellular damage and in some haemolytic conditions, and
also after relief of biliary obstruction.  The normal values are as follows:
Trace - 0.8 mgs. % in a single speciment.
0-1 mgs. in a 2 hr. specimen.
I
«
1
Page 76 £«
Book   Review
PSYCHOTHERAPY IN MEDICAL PRACTICE \
By MAURICE LEVINE
Dr. Levine is well qualified to write a book for the general practitioner on the
subjecjt of Psychiatric interest to them and this is a book for the physician who is engaged in general practice. He reviews the common misconceptions related to psychiatry
and places them under 24 headings, which makes the reading very concise.
Chapters in relation to suicide risks of psychiatric patients, the relation of psychiatry
in marriage and the problems of parents and children are given in nomenclature which
is not too technical but which is clear and matter-of-fact.
The final chapter of the book is made up of suggestions for further reading and
covers a long list of text books which would be of interest as references to the general
practitioner.
In all, this book presents to the general practitioner material which will be of
great use to him throughout his career.
E. A. Campbell, M.D.
«.S
:,1
Page 77
/<

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