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The Vancouver Medical Association Bulletin: August, 1927 Vancouver Medical Association Aug 31, 1927

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 95
THE VANCOUVER MEDICAL
§      ASSOCIATION
BULLETIN
Published monthly at
Subscription $1.50
X'<
cAntepartum <lHaernorrhage
^RJyeumatic ^ever and Endocarditis
23. Q. oTfledical cAssociation cAnrxual
(fh'ieeting
AUGUST, 1927
Tublished by
dMc'Beath Spedding Limited, c\Jancovcoer, *25. Q. 1/Vhy an Emulsion
A SIMPLE demonstration shows
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Mix equal parts of Petrolagar and
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In another tube or glass, try to
mix equal parts of plain
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Deshell Laboratories of Canada Ltd.
245 Carlaw Avenue
TORONTO, Canada
Petrolagar
Page 330 THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly  under  the Auspices  of  the  Vancouver  Medical  Association  in  the
Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718  Granville St., Vancouver, B.C.
Editorial Board:
• _^', Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
Vol. 3 | AUGUST 1st, 1927 No.  11
OFFICERS, 1927 - 28
Dr. A. B. Schinbein
President
Dr. W. S. Turnbull Dr. A. W. Hunter
Vice-President Past President
Dr. G. F. Strong Dr. A. C. Frost
Secretary Treasurer
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Representative  to  B.C.  Medical  Association
Dr. C. H. Vrooman Auditor
SECTIONS
Clinical Section
Dr. Gordon Burke Chairman
Dr. L. H. Appleby Secretary
Physiological and Pathological Section
Dr. J. E. Campbell  i Chairman
Dr. F. J. Buller  . Secretary
Eye, Ear, Nose and Throat Section
Dr. E. H. Saunders  . Chairman
Dr. W. E. Ainley  : . Secretary
Genito-Urinary Section
Dr. G. S. Gordon  Chairman
Dr. J. E. Campbell  . Secretary
Physiotherapy Section
Dr. H. R. Ross  ; Chairman
Dr. J. W. Welch • —Secretary
STANDING COMMITTEES
Library Committee Credit Bureau Committee
Dr. C H. Bastin Dr- d- McLellan
Dr. W. C. Walsh dr- l- Macmillan
Dr. W. A. Bagnall Dr- J- w- Arbuckle
Dr. D. F. Busteed Credentials   Committee
r,    a   /       r M Dr- F- W- Lees
Orchestra   Committee ^     ^   t   /-»
Dr. E. J. Gray
Dr. J. A. Smith Dr   ^   p. McKay
Dr. H. A. Barrett c c ,    ,   ^        ... „
T-.     T    ,, Summer   School   Committee
Dr. L. Macmillan
Dr. H. C Powell Dr- G- r Strong
Dr. W. D. Keith
Dinner Committee £>R. h. R. Storrs
Dr. D. D. Freeze Dr.  R.  Crosby
Dr. C. H. C Bell Dr. B. D. Gillies
Dr. T. H. Lennie Dr. L. H. Appleby VANCOUVER MEDICAL ASSOCIATION
Founded 1898. Incorporated 1906.
THE 30th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday of the
month at 8 p.m., from October to April.
CLINICAL MEETINGS will be held on the third Tuesday of the
month at 8 p.m., from October to April.
Place of meeting will appear on Agenda.
General Meetings will conform to the following order:—
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of Evening.
VANCOUVER HEALTH DEPARTMENT
STATISTICS — JUNE, 1927.
Total Population (Estimated)   137,197
Asiatic Population (Estimated)   .  10,576
Rate per 1000 of Population
Total  deaths       141 12.1
Asiatic Deaths  :        14 16.9
Deaths—Residents only      108 9.3
TOTAL BIRTHS      303 24.6
Male       166
Female  137
Stillbirths—not included in above         15
INFANTILE MORTALITY—
Deaths under one year of age        15
Death rate per 1000 births        50.5
CASES OF INFECTIOUS DISEASE REPORTED IN CITY
July 1
May,  1927
Cases Deaths
June,   1927
Cases Deaths
to  15,   1927
Cases Deaths
Smallpox   4
Scarlet Fever         7
Diphetheria         15
Chicken-pox        28
Measles    1     134
7
23
0
17
Mumps, 	
Whooping Cough
Typhoid Fever 	
Tuberculosis  	
Erysipelas   	
Epid. Cerebrospinal Meningitis .
0
0
0
1
0
1
0
0
0
14
1
0
0
7
13
98
44
3
8
1
20
7
0
1
0
0
1
0
0
1
12
0
Diphtheria	
Scarlet  Fever  	
Typhoid Fever ..
Epid. Cerebrospinal Meningitis
Cases from outside city-
1 0
0 0
0 0
-included in above
2
2
1
0
0
0
4
19
1
5
1
0
0
7
1
0
10
2
0
0
0
0
1
0
0
0
0
0
Page 332 Night and Day
Service
Our exclusive prescription
pharmacy is now open all
night for your convenience
and the benefit of your
patients.
ThaoloiyiUs jj Pre?cripkms
Phone Seymour 112
618 Georgia St. West
Page 333 EDITOR'S PAGE
As we promised, with this issue of the Bulletin we commence the
publication of some of the addresses delivered before the recent Summer
School of the Vancouver Medical Association. Owing to our very limited space it will not be possible to print them all even in the two or
three issues we intend chiefly to devote to that purpose. Where all were
good, it is difficult to discriminate. We shall endeavour to select those
which, in our opinion, are particularly valuable clinically.
Many of the papers were elaborated during delivery and this elaboration our readers will miss. Otherwise they are taken from the lecturers' own no tees and so far are authentic.
Probably everyone is agreed that the school itself was one of the
best, if not the best we have ever held. The attendance and interest
which remained unabated until the end, certainly justifies that conclusion.
That the meeting is held at the time of year when similar conventions
occur in the neighbouring section of the United States is unfortunate as
it seems inevitable. If we call upon teachers and professors in our Universities for lectures, vacation time is the only time that we can expect
to get them.
There have been complaints from time to time that the Medical Association has departed from the original plan on which these meetings
shall be conducted. The original intention and, indeed, that on which
the first two or three meetings were carried out, was to use as lecturers
or clinicians, members of the Society itself, with probably one or two
speakers from other places. In this way, diligent study and preparation
on the part of the lecturers was to be promoted, the clinical material
which exists in such profusion in our hospitals was to be utilized and
facilities for the development of lecturers and clinicians was to be provided. To these theoretical proposals there was found by experience to
be one or two objections, that the audience was inadequate and that the
work imposed upon the Committee was excessive. In the face of these
objections the present mode of conducting the school has gradually been
evolved. It is possible that the easier way is not necessarily the better
way, though its immediate utility seems decidedly more evident. Possibly during the coming winter a general meeting of" the Association
might be given an opportunity to debate this matter in the light of the
experience of the last seven years.
On another page we acknowledge the subscriptions which, on nothing further than the strength of the notice which was sent out at the
end of last month, have been paid in to the Sickness and Benevolent
Fund of the Association. These are the first fruits of what the Committee hopes will become a substantial foundation for this new venture.
Recent experience has emphasized the necessity of some arrangement,
the benefits of which can be utilized with due consideration, with ordered
sympathy and as inconspicuously as may be. All contributions which
may be sent in to the office of the Association will be acknowledged in
our columns.
Page 334 PROVINCIAL INCOME TAX
The following ruling has just been received by the B.C. Medical
Association, from the Commissioner of Income Tax:
Administrative ruling No. 8
Car Allowances—Medical Profession
In the absence of actual cost records, deductions in respect of the
operation and maintenence of automobiles may be allowed to medical
practitioners on the following basis:
(a) $600.00 per annum, plus depreciation, where the gross income
returned amounts to less than $12,000.00.
(b) $750.00 per annum, plus depreciation, where the gross income
returned amounts to $12,000.00 or more.
Actual cost will be allowed in any case where satisfactory records
are produced.
OBITUARIES
DR. E. J. ROTHWELL
In the death of Dr. E. J. Rothwell, the city of New
Westminster, and the province of British Columbia, have
lost a citizen of the highest type. Born at Brantford,
Ontario, in 1870, Dr. Rothwell received his medical degree
from the University of Toronto in 1896. After practising for a short time in Eastern Canada, Dr. Rothwell came
west to Trail in 1897, where he remained until 1902, when
he went to New Westminster. Dr. Rothwell was for six
years, until his death, a member of the B.C. Medical Association in which he took the greatest interest and was
ever ready to give valuable advice on medical economic
matters. In 1924 he was elected to the Provincial Legislature and his loss will be particularly felt in the work of
the Royal Commission on Mental Hygiene, of which he
was chairman. His friends had known for some time past
that his health w*s not good, but his death came quite
unexpectedly while at Quesnel where he had gone on a
fishing expedition with his son, Sheldon. In New Westminster Dr. Rothwell was known as a competent and self-
sacrificing physician who lived up to the ideals of his noble
profession and who still found leisure to take a large share
in local affairs. He leaves a widow and son to mourn his
loss.
Page 335 m
DR. J. C. ELLIOT
Dr. J. C. Elliot, of Chilliwack, passed away in the
hospital there on July 4th, following severe injuries received when his car and B.C. Electric Confederation special train from Vancouver to Chilliwack collided on the
crossing in the village of Sardis three miles south of the
city. Dr. Elliot was returning from a professional call.
The car was carried a distance of seventy-five feet along
the track and Dr. Elliot received severe injuries in the head
and chest. He passed away without regaining consciousness.
Dr. Elliot was born in Westminster Township, near
London, Ont., on December 4th, 1873, and took his medical training in Western University. He first practiced at
Lethbridge, Alta., and on coming to British Columbia was
for some time at Ymir and Arrowhead. He came to the
Chilliwack Valley fifteen years ago and for four years
practiced at Rosedale.
Dr. Elliot had a high ideal of his professional calling
and of its relation to his fellow-man. Hard-working, zealous, tireless, and self-sacrificing to a fault, no call for his
aid was ever refused or neglected no matter what his
own physical condition (which was never robust) or the
circumstances which might exist at the time. No night
was too dark, no road too long or difficult, no patient too
poor. His constant selfless service and his everyday life
exemplified that fine character combination of a good man
and a good doctor. Dr. Elliot will for a long time be
greatly missed throughout the Chilliwack district.
Dr. Elliot is survived by his father Mr. James Elliot
of Vancouver, one brother Norman, of Windermere Valley, and his wife and two children, Kathleen and Jack.
NEWS AND NOTES
We deeply regret to record the death of Dr. E. J. Rothwell, M.L.A.,
of New Westminster, and the tragic death of Dr. Elliot, of Chilliwack.
Obituary notices appear in another column.
We are pleased to be able to report that Dr. Fred. C. Bell, Superintendent of the Vancouver General Hospital, who recently underwent
an operation for acute appendicitis, is now convalescent.
We congratulate Dr. Geo. H. Hatfield and Miss Lois Mair on their
recent marriage. Dr. Hatfield is now associated in practice with Dr.
Lyall Hodgins.
Page 336 Dr. Gordon Burke left at the end of June for Chicago for postgraduate study.    The doctor expects to be away about six weeks.
Dr. J. A. Dickson, of the Cleveland Clinic, paid a brief visit to
Vancouver in the middle of July.
The Western Branch of the American Urological Association, consisting of urologists from California, Oregon, Washington and British
Columbia, met in Portland, Oregon, on the 5 th of July, where clinical
papers were given, and on July 6th in Seattle where the general business
of the session was transacted and scientific papers read. On the following day, Thursday, July 7th, the meeting was held in the amphitheatre of
the Vancouver General Hospital, where Dr. George H. Clement acted
as chairman. A discussion of the previous day's papers was followed by
a clinic. Dr. B. H. Champion showed a case of acute pyonephrosis in
which the advisability of operation was thoroughly discussed. Subsequently, Dr. A. W. Hunter demonstrated pyelograms showing lesions in
tabetic conditions of the cord, a case of bilateral congenital cystic kidney and the operative results following a primary papillary carcinoma of
the ureter.
Following the clinic, the party proceeded to Stanley Park for luncheon and the afternoon was spent in recreation. In the evening a dinner
was held at the Georgia Hotel at which forty-four medical men and
eighteen ladies were present. Dr. A. H. Peacock and Dr. Jones were in
charge of the general arrangements and the local committee consisted of
Drs. B. H. Champion, George H. Clement and A. W. Hunter.
SICKNESS AND BENEVOLENT FUND
The Trustees of the Vancouver Medical Association acknowledge,
with thanks, contributions to this fund from the following: Drs. W.
F. Coy, A. B. Schinbein, W. S. Turnbull, H. W. Hill, B. H. Champion,
D. J. Bell, R. E. McKechnie, W. T. Lockhart, J. L. Turnbull, G. E. Seldon, J. S. Shurie, T. A. Swift, J. M. Pearson, A. W. Hunter, L. Macmillan, C. McDiarmid and W. S. Baird.
Dr. W. G. Gunn underwent an operation for acute appendicitis at
the Vancouver General Hospital on July 20th. We are glad to state that
Dr. Gunn is now progressing favourably towards recovery.
SIGNIFICANCE OF SPUTUM EXAMINATION IN
REFERENCE TO TUBERCULOSIS
[Editor's Note:—This is one of a series of articles intended to in
dicate the clinical uses, interpretation and applications of various modern
laboratory tests. Each article will be written by a different author, peculiarly familiar with the uses of the test treated of.]
By C. H. Vrooman, M.D.C.M., Vancouver.
Positive Sputum.—The finding of tubercle bacilli in sputum is one
of the most valuable and positive of our diagnostic procedures, but there
Page 337 are a few pitfalls into which an inexperienced examiner may fall through
faulty technique. The finding of one or even two isolated tubercle bacilli
after examination of two or three slides may occasionally, in the absence
of adequate clinical symptoms, make one wonder if the occurrence is not
accidental. However, the report by a competent examiner of a sputum
positive to tubercle bacilli means tuberculosis of the lungs with probably
the smallest percentage of error of any of our diagnostic procedures.
There is no sputum that is "characteristic" of tuberculosis. Sputum
which is nothing but watery saliva may contain bacilli in as great numbers as frankly muco-purulent or purulent sputum, y
Tubercle bacilli in the sputum indicate that some small or large
caseous areas in the lungs have ulcerated -into the bronchi and are discharging their contents.
The number of tubercle bacilli found in the sputum has no bearing
on either diagnosis or prognosis. Numerous tubercle bacilli may be
found in cases where the disease is neither extensive nor active; and only
a few tubercle bacilli may occur in the sputum of a case of extensive
fulminating pneumonic tuberculosis.
The disappearance of tubercle bacilli from the sputum is certainly
of good prognostic import.    It means the ulcerated area is healing.
The persistence of tubercle bacilli in a case that is clinically quiescent has also a definite prognostic bearing. A case of pulmonary tuberculosis cannot be called "apparently arrested" until tubercle bacilli have
been absent from the sputum for a period of at least three months. Such
a case can at best only be called quiescent and there is definitely much
more likelihood of a relapse if the sputum remains positive after all other
"clinical symptoms have subsided.
Negative Sputum.—A negative sputum might be defined as at least
three, and better six, different specimens obtained from the morning
cough, at intervals of several days; the slides from each specimen proving
negative when examined by a competent technician for at least three
minutes each.
If the sputum is abundant, purulent and possibly foul smelling, and
if the clinical signs point to extensive bronchitis, a negative sputum as
defined above means the case is probably non-tuberculous. But before
such a diagnosis is finally made, one of the concentration methods of
examination should be used and, if negative, followed by guinea-pig inoculation.
If the sputum is negative in the absence of foul pus, even in a
dozen examinations, it helps little with the diagnosis. The diagnosis of
pulmonary tuberculosis, especially the early disease, is not helped in the
slightest by a negative sputum report. The clinician who places the
slightest value on a negative sputum will very rarely diagnose a case of
incipient tuberculosis.
For example, a patient with acute pneumonic tuberculosis had a negative sputum at sixteen examinations;  the seventeenth was found pos-
Page 33 8 itive a few weeks before the patient died. Again, a patient with acute
miliary tuberculosis died after an illness of four months. The sputum
was never found positive though repeatedly examined. Again, a patient
with chronic fibroid pulmonary tuberculosis, moderately advanced, under
observation for ten years, had a negative sputum until she had a relapse
recently, when tubercle bacilli were found for the first time. Finally,
a patient with all the clinical signs of asthma and very little clinical evidence of tuberculosis had a positive sputum in the first examination.
Conclusions.—1. Sputum which is positive to tubercle bacilli indicates pulmonary tuberculosis that has reached the stage of caseation and
ulceration into the bronchi. The disease may be very limited or very extensive; it may be active or quiescent; the prognosis may be favourable;
but these problems will have to be solved by clinical examination and
observation.
2. A negative sputum is of no value in the diagnosis of early tuberculosis. If the clinical symptoms point to advanced pulmonary tuberculosis with breaking down of tissue and discharge of large quantities of
sputum, but the sputum is repeatedly negative, the diagnosis should be
carefully reviewed, as the lung condition is probably non-tuberculous.
3.' A sputum that has been positive and becomes negative under
treatment points to a favourable prognosis. Vice versa, if the patient has
had a negative sputum that after a time becomes positive, the prognosis
is not as favourable.
4. The character of the sputum has little bearing on the diagnosis
or prognosis.
ANTEPARTUM HEMORRHAGE
An Address to the Summer School of the Vancouver Medical Association, June 21st, 1927, by Dr. B. P. Watson, Professor Obstetrics and
Gynaecology, Columbia University; Director of the Sloane Hospial for
Women, New York.
Today I propose to discuss with you cases in which there is haemorrhage prior to delivery excluding cases in the early months which are due
to abortion or miscarriage, threatened or in process of occurring. The
discussion will be limited to cases in which pregnancy has advanced to
or beyond the seventh month.
Before proceeding to the obstetrical considerations let me interject
a word about certain gynaecological conditions which may cause bleeding
during pregnancy. The two commonest are a cervical polyp and a carcinoma of the cervix. I mention such cases at the beginning not because
they are very frequent but because their recognition is so important. I
have seen altogether six cases in which there was a cancer of the cervix
during pregnancy and in all of them the diagnosis was missed for a considerable time because no vaginal examination had been made, the irregular bleeding being ascribed to the pregnancy.    It is obviously im-
■i   ;i!
Page 339 portant to make certain in every case of irregular bleeding, whether the
patient be pregnant or not, that there is no neoplasm present.
Excluding any gynaecological condition, haemorrhage in late pregnancy is the result of a separation of the placenta, the bleeding coming
from the placental site. The placenta may be in its normal situation in
the upper uterine segment in which case we designate the case as one of
accidental haemorrhage, or it may be situated in whole or in part in the
lower uterine segment—placenta praevia. In the latter, haemorrhage is
inevitable some time before the delivery of the child as the cervix cannot
dilate without causing some separation of the placenta from its site in
the lower uterine segment. In the former, the haemorrhage is dependent
upon some other factor than a merely mechanical one—not infrequently
it is apparently due to a toxaemia—hence the term accidental.
The first essential in dealing with a case of antepartum haemorrhage
is to differentiate, if possible, between the two forms, for the treatment is
different for each. In a severe case of either form the differential diagnosis
is generally easy. If the haemorrhage is profuse, if it has come without
any obvious physical cause, if it is unaccompanied by pain, if the uterus is
of its normal consistency and not tender, if the presenting part is high
above the brim of the pelvis, if the condition of the patient corresponds to
the amount of blood lost, and if there is no evidence of toxaemia in the
form of albuminuria or high blood pressure, the case is probably one of
placenta praevia. On the other hand, if the patient gives a history of preceding headache and oedema, if there is albuminuria, if the haemorrhage
was preceded or is accompanied by continuous abdominal pain, if the uterus i shard and tender, making palpation of the foetus difficult, and if she is
shocked out of proportion to the amount of blood lost, the case is probably one of accidental haemorrhage. The mere palpation of the abdomen
in such a case practically establishes the diagnosis. But there are cases
of accidental haemorrhage in which the symptoms and signs are less
marked and less definite, in which there may be only slight haemorrhage
and no general symptoms and in which it is impossible to make a diagnosis without a vaginal examination. In such the bleeding has very often
ceased before we see the patient. It is important, in such cases, to abstain from any vaginal examination until the patient has been properly
prepared so that the examination may be conducted as aseptically as
possible. Every patient who has had an antepartum haemorrhage shou'd,
if possible, be admitted to a hospital and no vaginal examination made
until we are prepared to carry out any treatment which may be determined upon. If hospitalization is not possible, then such preparation
should be made in her home. It is only in this way, as we shall see later,
that certain forms of treatment can be carried out without prejudice to
the patient.
The preparation for examination of a patient with antepartum
haemorrhage should consist in the shaving and cleansing of the vulvar
region as for labour, the provision of sterile drapings, the presence of an
anaesthetist in case he be required and the laying out of any instruments,
bags and packing, which may be needed.
If in making the examination the cervix is found to admit one or
more fingers and nothing but smooth membrane can be felt, the case is
Page 340 one of accidental haemorrhage. If the cervix will not admit a finger
but the presenting part can be easily felt through the fornices, again it
is almost certainly accidental haemorrhage. If, on the other hand, any
part of the placenta can be felt through the os or if with a closed cervix
we get the impression that something intervenes between our fingers in
the fornices and the presenting part, it is a placenta praevia.
The common text-book teaching is that with the occurrence of
slight bleeding and a diagnosis of accidental haemorrhage the pregnancy
should be allowed to continue but with a diagnosis of placenta praevia,
labour, if not begun, should be induced as soon as possible. But, as a
rule, we are not told how that induction is to be done. With a completely
closed or almost completely closed cervix in a case of placenta praevia in
which the haemorrhage has ceased, I think it better to leave the patient
aloneu provided she is in hospital or in such circumstances at home as
will permit of immediate appropriate treatment should she bleed again or
go into labour.
With these preliminary remarks common to both varieties of
haemorrhage, let us now look at each separately from the point of view
of treatment.
Accidental Haemorrhage.—Cases of accidental haemorrhage vary so
much in severity that there are wide variations in the method of treatment. We see many cases of slight bleeding in the last three months of
pregnancy in which the bleeding lasts only a short time and may or may
not be repeated. With the bleeding there may be no pain or tenderness
of the uterus or f.his may be slight. Such patients not infrequently go
to term and are delivered of normal infants, the only indication of anything having gone wrong being a small infarct in the placenta or a small
dark blood clot attached to its maternal surface. Such patients should
be kept in bed for several days after all bleeding has stopped and may
then be allowed up. We, similarly, see cases occasionally where from the
onset of the first stage of labour there is slight bleeding indicating a
partial separation of the placenta. If the bleeding does not become excessive and the labour is progressing normally, no interference is required.
Should the bleeding become more profuse during the first stage, the best
treatment is immediate rupture of the membranes and the application
of an abdominal binder. With the escape of the liquor ammii, the uterine
wall is pressed against the child and the bleeding is controlled. There
is always the possibility in such cases that the child may be born dead.
In all of the cases of the before-mentioned type the haemorrhage results from a separation of the placenta from the placental site through
the decidua and the bleeding is truly retroplacental, the blood finding its
way down between membranes and uterine wall to escape at the cervix.
The cause of the separation of the placenta is vascular change of some
sort in the fcetal or the maternal vessels of the placenta itself or of the
decidua.
There is, however, another and more serious type of accidental
haemorrhage in which the haemorrhage is in the deeper part of the muscular wall of the uterus, infiltrating widely between the muscle bundles
Page 341 extending beyond the immediate area of the placenta and often reaching
into the broad ligaments and cellular tissue surrounding the uterus.
There is extensive thrombosis in the larger vessels of the uterine wall and
even the main uterine and ovarian veins on one or on both sides may be
completely occluded. Such a lesion may or may not originate in the
placental sinuses. There is, so far, no direct evidence either way, but it
seems to me that such an extensive lesion must originate in some of the
larger vessels leading to or from these sinuses.
The cause of this vascular change is probably the presence of some
toxin in the circulation. F. J. Browne in Edinburgh produced all of the
above-mentioned conditions in pregnant rabbits by causing an oxalate
nephritis. Hoffbauer has produced it by the injection of histamine
intravenously. We find in practically every case of accidental haemorrhage of this type in the human subject some evidence of toxaemia, albuminuria, hypertension, preceding headache, sometimes actually eclampsia.
There seems to be no reasonable doubt, therefore, that this type of
haemorrhage is dependent on a toxaemia of some sort which produces
thrombosis of the uterine vessels and an infarction of part of the uterine
wall.
With a lesion of the uterine wall such as described there is bound to
be some separation of the placenta and haemorrhage between it and its
site. The blood may accumulate there, forming a haematoma of greater or
smaller size and none escape through the cervix—true concealed haemorrhage—or, as not infrequently occurs, a small quantity may find its way
between the membranes and uterine wall and appear as a slight vaginal
bleeding—combined concealed and external haemorrhage. In such cases
the symptoms and signs are not dependent on the separation of the placenta but on the lesion in the uterine wall which caused that separation.
Hence the pain, the hardness and tenderness of the uterus and the extreme shock present, and these out of all proportion to the amount of
blood lost externally or retained in the uterus. We are dealing here with
an acute abdominal lesion.
The treatment of such cases calls for major surgery. But first of
all shock should be counteracted by the administration of morphine and
a blood transfusion. There is a rapidly increasing anaemia in all of them
and in transfusion we have one of the best means of remedying this and
putting the patient into condition to stand the operation. We must not
be deceived by the rate of the pulse. Halstead has pointed out in a
paper, at present in the press, that even when extreme shock is present,
the pulse may be well under 100 per minute. Blood pressure is a much
more reliable guide.
With morphine administration and transfusion, the condition of the
patient improves and a few, of lesser degree of severity, may deliver
spontaneously. Dr. Samuel Cameron of Glasgow administers x/z cc.
does of pituitary to stimulate definite labour pains. In such cases he
states that he has had good results from this and feels sure that he has
saved several patients from the necessity of Caesarean section by it. If,
in spite of the administration of morphia and transfusion, the state of
shock  continues  and  the uterus  fails  to  relax,   a  Caesarean  section  is
Page 342 necessary. In extreme cases where the whole uterus and broad ligaments
are infiltrated with blood and black in colour, the wise plan may be to
perform a rapid hysterectomy without opening the uterus at all. In
most it will be perfectly safe to open the uterus and remove the child
and placenta. The child has always succumbed prior to the operation.
The surgeon is then faced with the choice between closing the uterine
wound in the usual way and removing the uterus. If the uterine wall is
only partially infiltrated, is glistening in appearance, and, if after the
application of hot towels and the administration of pituitary, it shows
contractile power, it may safely be left. We are not sacrificing so many
uteri as we used to and it is surprising what a normal convalescence these
patients have. It is, in my opinion, unnecessary to pack such a uterus
for many of the vessels are thrombosed and there is no postpartum bleeding. If, on the other hand, the uterine wall and broad ligaments are
widely infiltrated and the uterus shows no contractile and retractile power,
it is safer to remove it by a rapid supravaginal hysterectomy. Severe
accidental haemorrhage of this type is fortunately not very common, but
a case may crop up at any time. The child will certainly succumb, the
recovery of the mother depends upon prompt surgical measures preceded
and followed by the treatment of shock. Blood transfusion is undoubtedly the best means available for the latter.
Placenta Praevia.—Coming now to placenta praevia we find the same
wide variations in the severity of cases and therefore in the indications
for treatment. There is, to my mind, nothing more essential in the discussion on the treatment of placenta praevia which is going on today,
than a realization that these cases differ widely in their severity and that
what may be good treatment for one may be bad for another. Most of
the articles written within the past few years have dealt with the place
of Caesarean section in placenta praevia and on reading some of them one
gets the impression that there is no other rational treatment for any case.
I am one of those who believe that if Caesarean section were done more
often on the proper indications there would be a decided improvement
in both maternal and fcetal mortality, but I most decidedly do not believe that it is indicated in all cases.
This advocacy of Caesarean section is the natural reaction from the
study of the statistics of maternal and foetal deaths from placenta praevia
treated in other ways. And truly these statistics give us cause for
thought and are not at all flattering to our obstetric skill and judgment.
Along with Dr. Douglas Miller I made an analysis of the 279 cases in the
Edinburgh Royal Maternity Hospital between the years 1914 and 1924.
The maternal mortality was 8.9% and the foetal 64%. Munro Kerr reported a series of 476 cases in the Glasgow Maternity Hospital with a
maternal mortality of 11.5% and a foetal of 71.84%. Miller in New
Orleans in 40 cases reports maternal mortality 20%, fcetal 54%. In the
Boston Lying-in Hospital in a series of 151 cases occurring between 1915
and 1925, Kellog found a maternal mortality of 8.25%. In the five
years 1921-1926, 57 cases treated in the Sloane Hospital, New York,
gave a maternal mortality of 7% and a fcetal of 47.4%. The best results I have seen are those of Moller who, in 132 cases, has a maternal
mortality of 3.7% and a fcetal of 45.6%.
Page 343 The striking thing that came out in the analysis Miller and I made
of the Edinburgh cases, was that there was a group of 35 cases in which
there was no maternal mortality and a fcetal mortality of under 30%.
In 29 of these cases there had been no treatment except that in a few
artificial rupture of the membranes had been done and in six forceps had
been used to complete the delivery. They were all cases of partial placenta praevia with only slight or moderate antepartum and intrapartum
bleeding. At the other end of the scale we had 81 cases where the placenta was central or almost central in position and which were treated
by packing, version, bag, etc., with a maternal mortality of 22% and a
fcetal of 82%. In an intermediate group of 163 partial praevias with the
same methods of treatment, the maternal mortality was 5%.
Heer, then, we have three groups of cases: The first with no maternal mortality, the second with a 5% mortality, and the third with a
22% mortality. Now, while the situation of the placenta, whether central or lateral, has been taken in making this grouping, it must not be
supposed that this is the only or necessarily the most important factor in
determining a line of treatment. The consistency and the state of dilatation of the cervix at the time when we see the patient is of prime importance. A partial placenta praevia with a rigid, closed cervix in a multipara may be more dangerous than a complete placenta praevia with a
soft, partially dilated cervix in a primipara. I do not know of any condition in which clinical experience and judgment count for more than
in the treatment of placenta praevia. All that I can do in a talk such
as I am now giving, is to state the results and conclusions from the experience I have had and to leave it to the individual to judge of these
from his own.
My first contention then is that there are cases of placenta praevia
which call for no treatment at all. They are cases where the patient is
in labour. There is slight bleeding during the first stage, the edge of
the placenta can be felt at the margin of the partially dilated cervix or
slightly overlapping it, labour pains are strong and regular, the general
condition of the patient is good. The dilatation of the cervix not infrequently goes on more quickly than usual and when dilatation is complete
the membranes rupture, the presenting part descends and the bleeding
practically stops. When the child is born the placenta usually comes
away quickly, but if it does not and there is more than the normal
amount of third-stage haemorrhage, it should be expressed as quickly as
possible. If there is an excessive amount of postpartum bleeding, the
lower uterine segment and vagina should be packed with gauze.
In a certain number of cases of this type there may be more haemorrhage during the first stage than we like. In such the membranes may
be ruptured, allowing the presenting part to press against the lower
uterine segment and so control the bleeding. I do not hesitate to give a
small dose of pituitary extract, say four minims, and repeat it, if the
contractions are not strong and the labour is being delayed by reason of
this. If, after full dilatation of the cervix and engagment of the head,
there is delay in the second stage, forceps may be used to complete the
delivery.
Page 344 Let us next try to visualize the case where the patient is in labour
at or after the thirty-sixth week. The cervix is soft and is begining to
dilate, the placenta partially covers the os, and there is faily profuse
bleeding. Here a variety of methods of treatment are open to us. We
may pack the vagina, introduce a bag, do a version and bring down a leg,
or perform a Caesarean section.    Let us take each of these in turn.
Packing the Vagina.—To be effective this must be done under an
anaesthetic, after proper preparation of the vulvar region and the introduction of a large speculum. Some advocate that the packing be done
with pledgets of cotton wool, but we have found sterile gauze, in long,
broad strips, effective. The blood loss will be less, the shorter the time
that elapses till full dilatation of the os occurs. Therefore, in cases where
labour pains have not begun, or in which they are slight and far apart,
we advocate the administration of l/z cc. of pituitary extract, and repeat it at intervals of not less than half an hour if necessary. When the
pituitary acts there is a temporary increase in the bleeding, but we are
satisfied that the increased action and tone of the uterine muscle ultimately means a quicker labour and a smaller loss of blood. If the initial
packing is done properly, the gauze being pushed well into the fornices,
and if this is supplemented by an abdominal binder and a perineal pad
and band, there will be a minimum of haemorrhage in most cases. If
the pack becomes soaked through, it may have to be removed and a fresh
one substituted. The hope is that complete dilatation of the cervix will
take place and the second stage begin with the pack in situ. It is often
necessary, however, to remove the pack because of bleeding through it,
at or shojrtly before the completion of the first stage. Rupture of the
membranes may then be all that is required but in some a version may be
necessary. Our experience is that when an internal version is performed
after packing, there is a great risk of sepsis. Our Edinburgh figures
showed a 9/4 maternal mortality in these cases. For this reason as well
as because of the difficulty of applying the pack properly, especially if
we are treating the patient in her own home, I have come to regard this
form of treatment as one to be undertaken only rarely and when other
methods are not available.
The Hydrostatic Bag.—My own experience in the use of the bag is
not extensive and the bag I have used most is the de Ribes. With the
more compact and more easily applied Voorhees' bag the results reported
from different clinics on this continent are better than I have obtained
with the de Ribes. The orthodox method of introducing it is to rupture
the membranes and place it inside the amniotic sac and then distend it.
In the Sloane Hospital for many years the bag has been placed extra-
ovularly, that is between the membranes and placenta and the lower uterine segment. This method is contrary to all the priniciples which I was
taught and have taught regarding the action of the bag in placenta praevia, but I must confess that the results obtained at the Sloane Hospital
seem to justify the method. The placing of the bag controls the bleeding, helps dilatation of the cervix, and stimulates labour pains. The disadvantages are that the bag is usually expelled before complete dilatation
and another has to be introduced or a version done.    It is a method of
Page 345 treatment only applicable to a patient in hospital on whom the closest
watch can be kept.
Version and bringing down a leg.—In considering version and bringing down one leg of the child, let us realize at the outset that we are
using the child as a plug and, if the version is done early in the first
stage, we are sacrificing it almost as deliberately as if we did a craniotomy.   Granting this, version is the method of treatment which will
give the best results for the mother in the hands of the practitioner who,
unaided and with the minimum of obstetrical outfit has to deal with a
case in her own home.    The child, especially if it be premature, is a
secondary consideration under these circumstances.    In the performance
of the operation and in the subsequent conduct of the labour, there are
several points of importance.    Munro Kerr, has pointed out that an attempt should always be made to do the version by external manipulation.
This is usually easy as the presenting part is well above the brim of the
pelvis, the child is small, and there is plenty of liquor amnii.    When the
breech has been brought over the pelvic brim the membranes are ruptured and a foot laid hold of and brought down.    If the child cannot be
turned by external manipulation, a bipolar version must be done, but the
manipulation through the cervix tends to cause more bleeding and increases the risk of sepsis.   When the leg has been brought into the vagina
nothing more should be done.    Any attempt to deliver the child immediately will result in deep tears of the cervix and profuse bleeding.
The labour should be allowed to proceed naturally.    II bleeding is not
completely stopped, slight continuous traction may be made by attaching a weight of two pounds to the ankle and allowing it to hang over the
end of the bed.    Many a patient has died because of forcible extraction
of the child after version has been performed.    The temptation to do it
is great but must be resisted.
Caesarean Section.—And now we come to the consideration of the
place of Caesarean section in the type of case with which we are dealing—
the woman in labour, the cervix soft and dilating, the praevia partial,
haemorrhage not excessive. In such a case the decision for section will
be made, I think, practically entirely from a consideration of the child.
Unquestionably, more babies will be saved by section than by any other
means of treatment. If the patient is an elderly primipara and it were
likely to be her last chance of childbearing, I think it would be justified,
but in the young primipara or in the multipara with living children, the
indication would rather be towards one of the previously-mentioned
procedures, preference being given to the bag or to the bringing down of
a leg.
Now let us look at another type of case. The pregnancy has advanced to the thirty-sixth week without disturbance of any kind. Suddenly in the middle of the night the patient is awakened by the escape
of fluid from the vagina. She finds it is blood. She loses a large quantity.
She has no pain. She calls the doctor who finds her somewhat blanched
but with a good pulse and blood pressure of over 110 systolic. The foetal
heart is normal. The bleeding is less profuse by the time she is seen but
she passes one or two large clots.    What should be done?    If possible
Page 346 that patient should be got into hospital immediately, a quarter of a grain
of morphia being given hyperdermically before her removal. No vaginal
examination should be made prior to her removal as the symptoms are
practically diagnostic of placenta praevia. Furthermore, such a sudden
profuse haemorrhage without labour pains nearly always means that a
considerable area of the placenta is in the lower uterine segment and
overlaps the os. That is the type of case in which many obstetricians
would at once proceed to a Caesarean without any further examination
and, I think, they are, in most cases, right. Personally, I prefer to make
a vaginal examination after all preparations, such as I have before mentioned, have been made including a thorough application of iodine to the
vulva and vagina. If I find the cervix closed or only admitting a finger
and nothing but placenta can be felt, I would do an immediate section.
It would not matter whether she were a multipara or a primipara. I feel
in such a type of case that the safety of the mother is better ensured by
a section than by any other form of treatment and, of course, the chances
for the child are infinitely better.
We do not always get cases as clear cut as this and it is in those
others that the high maternal mortality occurs—really serious cases of
placenta praevia without being of the dramatic variety in which control
of the bleeding and delivery from below are attempted in one or other of
the ways already mentioned. It is in such that the good judgment of
the obstetrician is so urgently required. I think there can be no doubt
that were we to lean more decidedly towards section in a goodly proportion of them, our results would be better than those shown by the statistics which I quoted to you earlier in my paper. It is necessary, however, that these patients have no careless vaginal examination or instrumentation of any kind prior to the operation. These add enormously to
the risk of sepsis. In hospital practice we are often prevented from doing a section on an otherwise suitable case because of the examinations
which have been made prior to the admission of the patient. I know that
a difficult question may arise if the patient has to be transported a considerable distance and she is still losing much blood. Should the vagina
be packed before the journey is undertaken? In my experience the type
of packing that is usually done in the patient's house is useless for controlling the bleeding and only prejudices her further treatment. Except
in very exceptional cases it is safer to give morphia and leave the vagina
untouched.
If the patient cannot be got to a hospital and a section cannot be
done in her home, then packing the vagina in the way I have already
mentioned is the only treatment if the bleeding continues. These are the
cases in which later a version and bringing down a leg may have to be
done and in my experience this is a bad combination. In fifty such cases
in our Edinburgh series there were nine maternal deaths and four of
these were from sepsis. In a case of placenta praevia, not in labour, with
a closed or almost closed cervix, in which the only way of controlling
the haemorrhage from below was by packing, I should prefer to do a
Caesarean section—did circumstances permit.
I do not think that Caesarean section should be limited to cases of
closed cervix not in labour.   It may be the best treatment even when the
Page   347. patient is in labour and the cervix partially dilated. I wish it were possible to lay down arbitrary guides to help us in our decision, but it is
not and we must exercise our individual judgment in the individual case.
I think, however, that we are justified in making a plea for the more extended use of Caesarean section in the cases of placenta praevia of greater
severity. We are no less justified in making a plea for the more conservative treatment of cases of lesser severity—cases which may require no
treatment at all or a mere rupture of the membranes. To pack, or bag,
or turn such cases, is to subject the patient to an unnecessary risk of
sepsis.
There is one therapeutic measure which, used along with any form
of treatment, is of supreme importance, viz., blood transfusion. If the
patient has lost any considerable quantity of blood she should have a
transfusion of from 300 to 600 cc. prior to and, if necessary, following
any operative interference. For instance, if a Caesarean is to be done, she
should have the transfusion before the anaesthetic has begun and, if necessary, she should have another after she has come out. It is unwise to give
it while she is under the anaesthetic as we cannot tell whether she is going to have a severe reaction from it (Ward). Such reactions occasionally occur even when the typing of donor and recipient has been carefully done. If she is conscious we see it at once and can stop the transfusion. Intravenous saline or gum or glucose may be used but they are
poor substitutes for whole blood. The transfusion should not be given
as a last resort when the patient is in extremis. It should be used as a
means to enable the patient to stand the strain of whatever is being undertaken.
Our hope of reducing the high mortality of placenta praevia lies in
1. Immediate hospitalization of all cases of antepartum bleeding.
2. The examination of the patient only after careful preparation
and when everything that may be necessary in the treatment of
of the case is ready to hand.
3. The more conservative treatment of slight cases.
4. The more radical treatment by Caesarean section of the cases of
greater severity.
5. Blood transfusion of all cases in which there has been much
blood loss.
RHEUMATIC FEVER AND ENDOCARDITIS
An Address to the Summer School of the Vancouver Medical Association June 21st, 1927, by Dr. John Oille, Assistant Professor Clinical Institution, Toronto University.
Rheumatic fever is also called acute rheumatism, inflammatory rheumatism, polyarthritis rheumatica, and acute articular rheumatism. It
might be defined as being a systemic, infectious disease of unknown origin
characterized by localizations (inflammatory nodules) about small vessels in the heart muscle, valves, pericardium, pleura, joints,  aorta and
Page 348 various places in the subcutaneous tissue and about tendon sheaths. The
i-sual definitions of this disease describe it as a variety of arthritis, and
thus give an entirely wrong impression of it. It is very much more a
disease of the heart than of the joints. The cardiac localizations are the
cause of death and not only many times more important that the arthritic manifestations, but also they are much more frequent. The names,
articular rheumatism and polyarthritis rheumatica, should on this account be dropped.
Heart disease ranks first as the cause of death. In England it has
been estimated that three-quarters of the deaths from heart disease are
rheumatic, at least three-quarters of the hospital cardiac patients in
England are rheumatic. Statistics do not correctly represent the situation as so many cases of rheumatic heart disease die of respiratory infection and are registered as such. So it is quite probable that rheumatic
disease of the heart accounts for as many, if not more, deaths than any
other disease in our country.
Though it does occur all over the world, it is much more frequent
in some countries than in others. It is most frequent in temperate and
sub-tropical zones. There is said to be none whatever in the Malay peninsula. It is likely as prevalent in the British Isles as anywhere else in
the world.
It is somewhat more common among the poor, and has the reputation of being related to damp climates. This, however, was not borne
out during the Great War, or in the Crimean War. In these two instances, in spite of the most extreme exposure to wet and cold, rheumatic
fever was almost unknown.
There is a family incidence in forty to fifty per cent, of cases.
This is more likely due to the spread of tonsillitis from one to another
than to an hereditary influence.
There seems to be a racial predisposition to the disease. It is very
frequent amongst Anglo-saxons, Hebrews and Negroes.
It is about equal in the two sexes, though one of its principal manifestations, mitral stenosis, is much more frequent in females.
The disease comes in cycles. It was very prevalent here in 1912-13.
One attack confers no immunity, on the other hand produces a predisposition.
As to its actual cause, nothing definite is proven. Opinion is divided on the point as to whether streptococci cause it or not. The "dip-
lococcus rheumaticus" of Poynton and Payne is probably a variety of
streptococcus, and Rosenow claims to have found streptococci in the
blood and joints. Furthermore, since streptoocci have been demonstrated
to have caused scarlet fever, more probability has been added to the
streptoccic theory because many cases of rheumatic fever follow scarlet
fever. There are many reasons against the streptococcus as a cause of
rheumatism. Streptococcus arthritis is more destructive than the
arthritis of rheumatic fever, and does not respond to salicylates. Furthermore, streptococcus does not cause the characteristic endocardial and
Page 349 myocardial lesions that occur in rheumatic fever. Clinically, streptococcus endocarditis is an entirely different disease from rheumatic endocarditis. Most observers have failed entirely to cultivate streptococcus
from the blood and joints of rheumatic fever. The blood in rheumatic
fever contains no antibodies against streptococci. While there are a few
investigators who think that rheumatic fever and bacterial endocarditis
are different manifestations of the same disease, the great consensus of
opinion holds that they are entirely different, and it is not yet proven
that streptococci cause rheumatic fever.
The pathology of rheumatic fever was summarized in the definition.
It consists in perivascular infiltration about fine vessels in the myocardium, serous membranes, and vasa vasorum of large arteries. These
rheumatic nodules get to be a considerable size in the subcutaneous tissue, fascia, and tendon sheaths in children, up to 1 cm. in diameter.
The vegetations are small, hyaline nodules about the size of the head
of a pin. They are whitish or pale pink in colour and occur on the line
of closure of the valves.    They do not ulcerate or form emboli.
The nodules in the heart muscle are called Aschoff bodies. By most
observers these are considered a specific manifestation of rheumatic fever,
and by weakening the heart muscle, are the cause of death.
The arthritis deserves special mention. It may be of any severity,
comes quickly, and spreads from joint to joint, lasting in each place up
to four to six days. There is no suppuration or deformity and recovery
is always complete. It affects the joints that are the most used, such as
the knees, ankles, wrists and fingers.
The lesions in the nervous system are not well worked out. They,
however, have been demonstrated and are related to chorea.
The fever is extremely variable. Cases may run a fatal course and
die with no elevation of temperature. It may be of any height or any
character, or any duration. It usually runs in bouts lasting about a
month. When it is due to arthritis it is of short duration, but when it
is due to cardiac involvement, it may last months or years. The hyperpyrexia that has been described is extremely rare and is likely due to an
encephalitis, that is, a cerebral localization.
The pulse rate depends on the condition of the myocardium.
Clinical Manifestations.—The mode of onset in both children and
adults may be either sudden and severe, or very insidious. Rheumatic
disease of the heart in 37 to 40 per cent, of cases comes on without any
symptoms whatever, and is only discovered many years later, either by
accident or when the muscle is so damaged that signs of heart weakness
or failure develop. It has been proven by careful histories and autopsy
examinations that mitral stenosis, the characteristic rheumatic lesion,
develops absolutely unsuspected, that is, without anything rheumatic,
no arthritis, chorea, tonsillitis, nor erythema nodosum, in 37 to 45 per
cent, of cases. It may exist without being suspected for fifty or sixty
years. On the other hand, this disease often comes on with all the suddenness and severity of the most acute infection, with pallor, weakness,
malaise, high fever, etc.    It is very rare under two years of age; its fre-
Page 3 50 quency of occurrence then raises rapidly to from seven to nine, and after
this the incidence gradually falls, becoming less frequent the older the
patient becomes. In children the disease is characterized by choreea,
rheumatic nodules, frequent cardiac involvement and absence of distress.
Arthritis is uncommon in childhood. A child may be playing about
quite comfortably with a temperature of 102, a seriously damaged heart,
with oedema of the legs, and a liver down to the umbilicus, and rebel
lustily on being put to bed.
In adults it more often follows exposure and a sore throat. Arthritis
is more common and cardiac localizations become less common as age
advances.    Chorea seldom commences after puberty.
If rheumatic fever did not affect the heart, it would rank in importance with chicken-pox and measles. Thus, the whole point when
this disease is suspected is to ascertain when the heart is. involved. The
heart is affected in the following instances:
1. When there is a persistent rapid rate, even in the absence of
murmurs, after the temperature has come to normal or when there has
been no fever.
2. If the fever persists when there is no arthritis, or recurs after
the arthritis has disappeared.
3. When the murmurs are present, which prove endocardial damage. Diastolic murmurs mean valvular disease. Systolic murmurs may
or may not be significant. A mitral systolic murmur might be considered to be due to a valve disease:
(a) When the heart is enlarged.
(b) When the first sound is absent or altered.
(c) When the murmur is loud, rough and constant and transmitted to the left axilla.
(d) When long continued fever is present and all other causes,
apart from endocarditis have been excluded.
A pulmonary systolic murmur is hardly ever due to endocarditis.
If it can be made to disappear by taking a deep breath or standing and
taking a deep breath, it is due to a normal diliation of the pulmonary
artery. An aortic systolic murmur is usually due to valve damage,
especially in children; in adults it might be due to a dilated aorta. The
tricuspid systolic murmur is usually due to dilation of the tricuspid
orifice. Cardiorespiratory murmurs have to be excluded. These may be
systolic or diastolic and will be found to disappear during inspiration or
during expiration, or^on holding the breath at the end of a deep inspiration, or at the end of a deep expiration. They, of course, have no significance and are produced in the overlying edge of lung. Murmurs indicating severe valve defects often come on months or years after an acute
attack, showing that endocardial inflammation progresses without fever
or symptoms for long periods of time.
4. Pain in the cardiac area probably means that the heart is involved.
Page 3 5 i 5. Important irregularities, such as auricular fibrillation, any of
the varieties of block, or pulsus alternans, prove cardiac damage.
6. Pericarditis is usually serious and prolonged.
7. The heart muscle should be considered damaged if the heart
is enlarged.
8. It is obvious that the heart is seriously damaged if signs of
congestive failure occur.
Diagnosis.—Rheumatic fever has to be distinguished from other
forms of arthritis. This is easily done as a rule by the duration of the
joint involvement, and by the response of the rheumatic arthritis to
salicylates. If there be no cardiac involvemenet, there is no special
necessity to distinguish between rheumatic arthritis and any acute infectious arthritis of short duration. If the arthritis be chronic, it is not
rheumatic.
The most important and sometimes difficult point in differential
diagnosis, is to distinguish rheumatic from subacute bacterial endocarditis. So far as we know there are only four causes of valvular disease,
namely, rheumatic, bacterial, syphilitic, and sclerotic. The existence of
the latter is sometimes questioned. It is difficult to be sure that a scarred
valve in an elderly individual is not infectious in origin. However, it is
certain that atheromatus lesions occur in valves. Syphilitic valvular
disease only occurs secondary to an aortitis in the aortic leaflets, and is
diagnosed by a positive Wassermann, or by a history of infection. Subacute bacterial endocarditis, on the other hand, is sometimes difficult to
differentiate. This disease also comes on insidiously, and in 75 to 80 per
cent, of cases it is engrafted on previously damaged valves. Its manifestations might well be considered in three groups:
1. Those due to a persistent chronic infection. These signs are
weakness, anaemia, emaciation, fever, and possibly chills. The pallor is
out of proportion to the naemia. When pallor occurs in a person with a
rheumatic heart, one should suspect that bacterial endocarditis has been
added to the infection, and commence investigation t oexclude or confirm the suspicion. The blood culture is positive for streptococcus
viridans in only about fifty per cent, of cases, so that the diagnosis has to
be made without this aid.
2. Those due to the heart. These signs are the same as the signs
of rheumatic endocarditis.    There must be proof of endocardial damage.
3. Those due to emboli. Embolic phenomena may occur at any
stage but are usually fairly late in the disease. They may take the form
of petechial haemorrhages, enlarged spleen, hemiplegia, infarct in the
kidney, or in fact anywhere at all. The ephemeral nodes which are
characteristic of the disease, occur most commonly, in the ends of the
fingers. They begin with a slight stinging pain, and a small, barely palpable, red spot with possibly a pale centre develops which lasts only a
day or so. They are thus quite different from the rheumatic nodules
which are hard and may last some weeks. Embolism in the superior
mesenteric artery would stimulate intestinal obstruction.    In the kidney
Page 3 52 it produces pain and haematuria. There are a few other points that tend
to distinguish the two forms of endocarditis. Joint pains, rather than
actual arthritis, occur in bacterial endocarditis. These are probably
embolic manifestations.
Pallor, persistent fever, an endocardial lesion with clubbing of the
fingers, is sufficient to make the diagnosis. Clubbing does occur, but is
very rare, in rheumatic heart disease. Persistent fever, endocarditis, an
enlarged spleen in the absence of passive congestion, is usually bacterial
endocarditis. The course of the two diseases is different. Bacterial endocarditis has greater anaemia, weakness, and emaciation and steadily
progresses.
On account of the difference in prognosis, it is extremely important
to diagnose bacterial endocarditis. This disease in about 99 per cent, of
cases goes steadily on to a fatal ending, the chief causes of death being
weakness and anaemia, embolism, nephritis, and occasionally myocardial
failure.    The muscle in bacterial endocarditis usually escapes.
The prognosis of rheumatic fever is quite different. It is commonly
stated in text-books that the death rate is from 2 to 4 per cent. This
is very misleading. It merely represents the death rate when the cases
are followed for two or three months, that is, the average duration of
one period in the hospital. In a series of 172 cases in Great Ormond
Street Hospital, London, England, in 1919, the mortality in less than one
year was 8.7 per cent., that is, 15 died, 17 were complete invalids, and
70 had organic disease. At the end of two years the mortality in this
series was 13 per cent, and 17 per cent, more were complete invalids.
Carey Coombs, whose prognostic figures are perhaps the best available,
found that of lOOchildren whose hearts were affected in any degree by
rheumatic fever, 31 per cent, made complete recoveries. By the age of
20, 28 per cent, were dead. At 30, 38 per cent, were dead. At 40, 50
per cent, were dead and three-quarters of those still living were unable
to work. Thus, of the original 100, about 35 per cent, either completely recovered, or had sufficiently good hearts to work unimpaired
throughout their lives. This means that in about 65 per cent, of cases,
rheumatic disease of the heart starting in childhood, steadily progresses
until at the age of 40, half are dead, and a further 15 per cent, are complete invalids. The prognosis in mitral stenosis is a little more sferious
than this. In rheumatic cardiac disease commencing in adults, the
prognosis is less serious because the period of greatest activity is from
seven to thirty years of age.
Treatment.—An ordinary case of rheumatic arthritis is kept at rest
in bed until the arthritis and fever have disappeared, and then for three
weeks longer, if the heart be not affected. The arthritis is quickly relieved by any form of salicylate if given in sufficient doses. The ordinary
dose is 20 grains of salicylate or aspirin with twice as much sodium bicarbonate every two hours for six or seven doses per day, so that the
patient gets one grain per pound of body weight per day. Following
the disappearance of the arthritis, the dose is gradually lessened and continued at approximately half the above amount for three or four weeks.
The diet is adequate.    There is no necessity for cutting out meat or pro-
Page 3 53 tein or keeping the patients on fluids. Fixation of the joints by bandages
with local applications of oil of wintergreen may be necessary in severe
arthritis. If toxic symptoms such as tinnitus, nausea, vomiting, disturbances of vision, etc., occur, stop and begin at half or three-quarters
of the dose. Aspirin, of course, has no harmful effect on the heart.
Serums and vaccines are useless.
If the heart be affected, the patient must be kept at absolute rest
in bed until all signs of active infection have disappeared, that is, until
the temperature and pulse rate are normal, and the leucocytosis has subsided, and then for three months longer, on an average. Serious cases
of pericarditis often require a longer period than this.
The method of allowing the patients out of bed is important. They
should be given specific instructions to sit in a chair without other exertion for 10 or 15 minutes the first day, and increase 10 or 15 minutes
per day until they are up as many hours as you consider suited to the
strength of their heart. After they have been sitting up a week or possibly two weeks, let them commence walking a few yards the first day,
and increasing a few yards per day, stopping short of cardiac distress.
At this time one has to find out the reserve of the heart muscle, that is,
how many hours per day the patient can be about and how much work
he can do without harm. In the after treatment the patient is told to lie
down ten or twelve or sixteen hours per day as deemed necessary, to
avoid exertion which produces distress and to avoid future infection
insofar as this is possible. To accomplish this end, foci of infection
are removed, and the patient is warned to keep away from people with
infectious diseases, such as influenza, tonsillitis, common colds, etc., as
any infection might activate the rheumatic disease in the heart. He is
also advised to avoid worry and strain, both mental and physical. He
should be examined at periodical intervals.
A re-activation of his disease should be suspected in later life if from
no special cause there occurs abnormal or peristent fatigue. His temperature should be taken systematically for a week or two at a time at different intervals to see if there is slight fever.
When cases of rheumatic heart disease are discovered during a routine examination, the first question to decide is whether the lesion is
active or healed. Evidences of activity are fatigue or malaise, progressive shortness of breath, possibly cardiac pain, slight fever and a high
per cent, of polymorphonuclear leucocytes in the blood smear. If the
disease be considered active, the patient should be put to bed until signs
of activity have ceased, and then for a further period of from two to
four months, depending upon the severity of the case. Such cases
should have from 60 to 80 grains per day of salicylates or aspirin with
twice as much baking soda, as this has been proven to have a beneficial
effect on rheumatic cardiac disease in 30 to 40 per cent, of cases at least.
If the disease be considered healed, some consideration should be
given to their disability. A person with a healed mitral stenosis or insufficiency, or aortic insufficiency, with a normal exercise tolerance,
should get at least two hours more rest per day than an average person.
Page 354 They should avoid strenuous or violent exertion and infections as far as
possible.
With reference to bacterial endocarditis, there is nothing to be recommended. Every form of treatment imaginable has been tried repeatedly with absolutely no effect. All that one can do is to treat the
patients as well as possible, and keep them comfortable. Someone of the
relatives chiefly interested in the patient should be warned of the outcome.
B.C. MEDICAL ASSOCIATION NEWS
ANNUAL MEETING
The Annual Meeting of the B.C. Medical Association was held on
June 22nd, 1927, during the session of the Vancouver Medical Association Summer School, and we attach hereto summaries of the various reports brought in by the Standing Committees.
At 12:15, a joint luncheon of the Provincial and Vancouver Associations was held in the dining room of the Georgia Hotel. This was
very well attended, some 125 being present. We must congratulate the
management of the hotel on their speed and efficiency in handling this
luncheon. A Summer School lecture was ended at 12 o'clock and within
five minutes the chairs were removed, and the luncheon tables set up
ready for use. The speakers at the Summer School were our guests, and
Dr. H. C. Moffitt of San Francisco, whose speech was all too brief, but
packed with wisdom and sound sense, gave the luncheon address.
During the afternoon meeting of the Association, reports were presented as follows: Dr. T. H. Lennie, the Secretary-treasurer, presented
his report on the work of the Association during the past year. To date,
347 members had paid dues in full for 1926-27, and many more were
expected to pay up. Dr. Lennie appealed for a prompter response to the
bills sent out each year, with a view to saving the time of the Executive-
Secretary.
A grant of $200 was made to the Victoria Medical Society in connection with the C.M.A. meeting held in June, 1926. $125 was advanced in the case of the appeal of Dr. Seldon against the judgment of
Judge Cayley in the trial Seldon vs. Zambowski. This appeal was won
by Dr. Seldon. The case is well known to the profession, and was of
great importance to us, as if allowed to go unchallenged, the judge's decision would make collection of fees by consultants very difficult.
Meetings of Branch Associations were held as follows during the
year:
No.  6 District, Nanaimo, 3.
No. 4 District, Okanagan, 2.
No.  1 District, Victoria Medical Society, monthly.
No. 3 District, Fraser Valley Medical Society, monthly.
East Kootenays Medical Society, 2.
West Kootenays Medical Society, 1.
Page 355 Dr. Lennie, referring to the work of the business office, said "I think
it is being realized that membership in the B.C. Medical Association is
becoming more and more indispensable to the practitioner. Many men
now appreciate the support they can get from the Association in matters
of disputes, contracts, etc. The work in our business office is steadily
increasing. We have a large correspondence and numerous daily visits
and interviews with outside doctors. Over two thousand personal visits
were made during the year. A large number of telephonic enquiries are
received from the public, individuals, insurance companies and other
corporations, for addresses of doctors, standing in the profession, etc.
Frequently, enquiries are received from doctors throughout the province
asking for information as to the standing of certain Medical Credit
Bureaux and timely advice has been given in this connection."
The Auditor's report was presented by Dr. Lennie showing a balance
in the bank of $1,816.05.
Dr. Lyall Hodgins reported for the Educational and Publicity Committee. He described the work of the committee in regard to post-graduate tours, lecturers sent to various points, etc., and detailed the views
of his committee as to publicity from a lay standpoint. The committee's
work in this direction is not yet completed, and is of a nature to which
it is not wise to give publicity until finality has been reached. We will,
therefore, give further details of this later.
It may, however, be said that the executive approved thoroughly of
Dr. Hodgin's report, and it is hoped that results will be forthcoming at
an early date.
Dr. A. J. MacLachlan gave a report for the Industrial Service Committee. This is, in some ways, the most important committee of the
Association and its work touches the individual practitioner most closely.
This committee has been able to give help to many men in connection
with contracts and conditions of practice. Better understandings with
employers have been obtained, assistants procured and so on. The work
of providing locum tenens is becoming a very important department of
the Association's activities. Many of these have been provided during
the year. Localities requiring physicians are constantly applying to the
Association. Disputes or misunderstandings with the Workmen's Compensation Board pass through this committee's hands and the Executive
of the B.C. Medical Association wishes to take this opportunity of again
expressing its confidence in the Medical Referees of the Workmen's Compensation Board.
We are in close touch with the Indian Department, and have taken
up several matters of dispute with the commissioner, Mr. Ditchburn,
who has always shown us the greatest courtesy and helpfulness. He is
making a close survey of the whole province and recommending adjustments to Ottawa. Provincial grants have been obtained for doctors
and, in some cases, larger grants have been obtained.
Many matters are being dealt with constantly by this Association
as evidenced by the following extracts from the report:
"Other matters in hand are the treatment of eye conditions on school
children on Vancouver Island by an irregular practitioner and payment to
Page 3 56 specialists doing Workmen's Compensation Board work for the 'Marine
Hospitals Service.' We have also a committee investigating the proposed
new 'Provincial Turn-over Tax' and its effect on the medical man. A
few months ago we received an urgent letter from a firm of doctors at
an important industrial plant in the interior asking for advice. The employees were asking for the families to be taken in on a contract basis.
Having a complete survey of all contracts in the province in our business office, we were able to send copy of this by return mail to the doctors affected, together with our advice. I 3m told the doctors found it
very useful and it enabled them to deal with the matter to their own
satisfaction. These are just a few of the things of an economic nature
this Association deals with, and that it is proving a boon to medical men
generally is evidenced by the fact that you have before, you at this meeting 29 new men for election to membership in the Association."
Another matter which has been under consideration by the Association for some time is the remuneration of Medical Officers of Health.
Dr. Young, Provincial Health Officer, is working on a scheme which it is
hoped will greatly improve financial conditions so far as the doctors doing this work are concerned. There is much complicated work involved
in dealing with this matter, but I expect the Association will hear something definite in the near future. In this connection it may be stated
the Medical Health Officer at Nanaimo was compelled to resign as a
protest against the inadequate salary he was receiving, and it is pleasing
to note that he is being well supported by the other doctors at that place
who have refrained from taking the job.
Quite recently our attention was drawn to a so-called "manufacturing chemist" in Vancouver who had been treating and prescribing for a
woman with a "goitre." He had charged an outrageous sum ($75) for
two small bottles of medicine. The patient paid $5.00 and was sued
through a Chicago Collection Agency for the balance. Our Executive-
Secretary got busy and, in conjunction with the Dominion Government,
was able to put this man out of business and incidentally saved the
woman from paying out any more money. There is a Mutual Benefit
Association working in this province which is, to put it mildly, very reluctant to pay the doctors who have done their examinations. Pressure
brought to bear by this Association has resulted in a number of doctors
getting their money after waiting about twelve months.
Several complaints have recently been received from doctors regarding unfair treatment in payment of fees and expenses in court cases and
these have been taken up with the Provincial Government. It is believed
that satisfactory adjustments will be made.
It may be noted that in a recent trial, the B.C. Medical Association's schedule of fees was accepted by the judge as a basis for charges,
without question.
The report of the Legislative Committee was made by Dr. Geo.
Hall of Victoria. Coroners' fees are a matter of negotiation with the
Government, With a view to a fairer basis of payment. This includes
fees for coroners' autopsists, travelling expenses, etc. Court fees and
travelling expenses for medical witnesses are also being taken up.
Page 3 57 The Credentials and Constitutional Committee recommended 29
new names for membership.
The Ethics and Discipline Committee also reported. No cases were
brought to its attention during the past year but two matters were
ordered referred to the new committee. One was the question of consultation between medical men and osteopaths, at the request of Saskatchewan, where the issue is a live one. The other is a minor matter
referred at the request of Dr. McCaffrey of Chilliwack. A further report will be made on these.   ,
Officers for the ensuing year were elected. Particulars of all appointments were given in the July issue of the Bulletin.
The retiring President, Dr. J. H. MacDermot, spoke briefly. He
emphasized the value of the Association to every medical man in the
province; they all benefitted by it, whether members or not, and it was
hard to see how any medical man could stand aloof from the Association.
The reports of Standing Committees showed what was being done by the
Association in regard to Workmen's Compensation and other matters.
Dr. MacDermot went on to say that health insurance was now a live
topic and the recent C.M.A. meeting in Toronto had appointed a subcommittee to look after this subject. He thought the Provincial Association should appoint a committee at once and, while not in favour of
the profession initiating legislation, they should be prepared to put their
views forward at the right time. The policy of the profession is "Free
choice of doctors and payment for services rendered" instead of capitation grants or yearly fees. They should try and make labour see their
point of view and work with them.
Another question touched on by Dr. MacDermot was public education in medical matters. The public asked for definite pronouncements
from medical men on certain topics which now they obtained promiscuously from outsiders. This demand for reasonable, wise, public education
must be met.
Closer co-operation with the Vancouver Medical Association was
urged by the speaker. The V.M.A. was a large and influential body and
there must be some way in which co-operation could be secured. These
suggestions he put forward for consideration during the coming year.
Dr. MacDermot introduced the new officers and retired from the
chair, which was taken by Dr. Ridewood, the new president, who made
a few brief remarks, especially touching on the recently inaugurated
Canadian College of Surgeons which had taken definite shape at the recent C.M.A. meeting in Toronto. Dr. Ridewood pointed out that this
new body needed the strong and cordial support of all the provincial associations and colleges of physicians and surgeons throughout Canada.
EXTRA-MURAL POST-GRADUATE TOUR
Another extra-mural post-graduate tour throughout the province
will be carried out jointly by the Canadian Medical and B.C. Medical
Associations,  in September next.     Arrangements have  been  completed
Page 3 5) &"
with Dr. A. Primrose, Associate Professor of Surgery, University of Toronto; Dr. Duncan, Professor of Medicine, University of Toronto, and Dr.
W. B. Burnett of Vancouver to give the lectures and clinics.
The itinerary will be as follows:
;mber    1
Fernie
3
Trail
5
Vernon
7
Vancouver
8
New Westminster
9-10
Victoria
11
Nanaimo
14
Prince Rupert
16
Prince George
Subjects with which doctors will be prepared to deal:
Dr. Primrose-
1. Inflammation and Tumours of the Breast
2. The Acute Abdomen
3. Goitre
4. Any type of abdominal surgery which may be preferred.
Dr. Duncan Graham—
1. Jaundice
2. Acute Rheumatic Fever
3. The Anaemias
4. Constipation
Dr. W. B. Burnett—
1. Pelvic Pain in Women
2. Toxaemias of Pregnancy
3. Some Common Obstetric Emergencies
Page 359 536 13th Avenue West
Fair. 80
cwe Ambulance c
m
PHONE
FAIR.
80
■i
G
e
UP-TO-DATE AMBULANCES AND
INVALID COACHES
ALL ATTENDANTS QUALIFIED IN
FIRST AID
"Sr. John's Ambulance Association"
WE SPECIALIZE IN
AMBULANCE SERVICE ONLY
R. J. Campbell      J. H. Crellin       W. L. Bertrand
Laboratory Supplies
Chemicals
Bacteriological
Apparatus
Microscopes
Complete Equipment
for the Hospital
Laboratory
Cave and Company
Limited
567 Hornby Street
Vancouver, B.C.
Page 360
McBeath
Spedding
Limited
Printers and
Publishers
Vancouver, B. C. Wanfxfiay Supplies "PD-Q"?
There are over 30 Direct Branches now estab'
lished by the Victor X'Ray Corporation
throughout U. S. and Canada. These branches
maintain a complete stock of supplies, such as
X'Ray films, dark room supplies and chemicals,
barium sulphate, cassettes, screens, Coolidge
tubes, protective materials, etc., etc. Also
Physical Therapy supplies.
The next time you are in urgent need of sup'
plies place your order with one of these Victor
offices, conveniently near to you. You will ap'
preciate the prompt service, the Victor guar-
anteed quality and fair prices.
Also facilities for repairs by trained service
men. Careful attention given to Coolidge tubes
and Uviarc quartz burners received for repairs.
VICTOR X-RAY CORPORATION
Main Office and Factory: 2012 Jackson Boulevard, Chicago
Motor Transportation Bldg.
Vancouver, B.C.
^
Victor X-R-P Safe
A lead'lined steel cabinet for storing
films and loaded cassettes.
Write SUPPLY SALES DIVISION
for price and detailed information.
*»
Quality   Dependability   Service    Quick - Delivery
] »» <Priceapplies to Ml »~ .
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
«wSeX«3SK/>
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
Phones Sey. 988 and 672
Phones Sey. 9513 and 1391
Phone Sey. 1370
Brown Bros* & Co. Ltd.
VANCOUVER, B. C.
|| I
Page 361 STEVENS'
Safety Package
STERILE GAUZE
Soft Pure Absorbent
STERILIZED BY 20 lbs. STEAM PRESSURE
The Stevens Safety Package is designed to enable the gauze
to be withdrawn from the carton without removing the
whole roll.
READY FOR USE IN THE OFFICE
HANDY FOR THE BAG
B.C. STEVENS CO. LTD.,
730 Richard Street,
Vancouver, B.C.
Ill III
PRESCRIPTIONS
filled exactly as written
Phones: Seymour 1050 -1051
Day and Night Service
Qeorgia Pharmacy Ltd.
Qeorgia and Qranville Sts.
Vancouver, B. C.
Page 362 The Ou?l Drug
Co., Ltd.
t^.11 prescriptions dispensed
bu qualified Druggists.
l]ou can depend on the Ou?l
for wAccuracy and despatch.
u9e deliuer free of charge.
5 Stores, centrally located.    We
would appreciate a call while
in our territory.
Ambulance
Service
TELEPHONE
Fair. 58 & 59
Mount Pleasant
Undertaking Co.   Ltd.
R. F. Harrison    W. E. Reynolds
Cor. Kingsuiay and Main
B. Q Pharmacal Co. Ltd.
329 Railway Street,
VANCOUVER.
Manufacturers of Hand-made Filled Soluble
Elastic Capsules.
Specimen  Formulae:
No. 60— No. 61—
Blaud Pill, 10 gr. Blaud Pill, 10 gr.
Arsenious Acid,  1/50 gr.       Arsenious Acid 1/50 gr.
Ext. Nux Vomica, \ gr. Ext. Nux Vomica, \ gr.
Phenolpthallin, \ gr. Phenolpthallin, \ gr.
Special Formulae Made on a Few Hours' Notice.
Price Lists and Formulae on
Application.
Page 363
"'   p
1 -»-JEee
aKS-^^fejgr^e
Hollywood Sanitarium
LIMITED
tyor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference 1 "23. Q. dMedical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183 Westminster 288
v<exe
ntSfc*
Page 3 64
_J

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