History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1928 Vancouver Medical Association Mar 31, 1928

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Vol. IV.
MARCH
No. 6
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Vancouver Medical Association
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McBEATH-CAMPBELL LIMITED
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Address      J|   C I ITOI^QHf
Page 170 FnrnMimam:
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.
Volume 4 MARCH, 1928 j No. 6
OFFICERS, 1927 - 28
Dr. W. S. Turnbull Dr. A. B. Schinbein Dr. A. W. Hunter
Vice-President 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
Auditors:    Messers. Price, Waterhouse & Co.
SECTIONS
Clinical Section
Dr. Gordon Burke : Chairman
Dr. L. H. Appleby Secretary
Physiological and Pathological Section
Dr. J. E. Campbell Chairman
Dr. F. J. Buller ! Secretary
Eye, Ear, Nose and Throat Section
Dr. E. H. Saunders . Chairman
Dr. W. E. Ainley Secretary
Physiotherapy Section
Dr. H. R. Ross Chairman
Dr. J. W. Welch ~ Secretary
Paediatric Section
Dr. E. D. Carder Chairman
Dr. G. A. Lamont Secretary
STANDING COMMITTEES
Library Rep. to B. C. Med. Association
Dr. C. H. Bastin Dr. C. H. Vrooman
Dr. W. C. Walsh Credentials
Dr. W. A. Bagnall Dr. p. ^ Lees
Dr. D. F. Busteed Dr- E. j. Gray
Orchestra Dr. W. F. McKay
Dr. J. A. Smith Summer   School
Dr. L. Macmillan Dr. H. R. Storrs
Dr. H. C. Powell Dr. B. D. Gillies
Dr. L. H. Appleby
Dinner Dr. W. T. Ewing
Dr. D. D. Freeze Dr. J. Christie
Dr. C. H. C. Bell Dr. J. T. Wall
Dr. T. H. Lennie Hospitals
Credit Bureau Dr. H. H. Milburn
Dr. L. Macmillan Dr. F. C. Brodie
Dr. J. W. Arbuckle Dr. A. W. Hunter
Dr. N. McNeill Dr. H. H. Planche
Page 171
■85SB VANCOUVER MEDICAL ASSOCIATION
Founded 1898. Incorporated 1906.
PROGRAMME OF THE 30th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on Agenda.
1928
March     6th—General Meeting:
Paper—Osier Lecture, Dr. C. H. Vrooman.
March  20th—Clinical Meeting.
April      3rd—General Meeting:
Paper—Dr. F. Epplen, of Seattle.
"Some newer methods of renal diagnosis."
April     17th—Annual Meeting.
VANCOUVER HEALTH DEPARTMENT
STATISTICS, JANUARY,   1928
Total  Population   (Estimated) 142,150
Asiatic   Population    (Estimated)  10,940
Rate per 1,000 of Population
Total   Deaths            180 14.95
Asiatic  Deaths     14 15.11
Deaths—Residents   only             140 11.63
TOTAL BIRTHS         292
Male        146
Female    146
Stillbirths—not  included  in  above    12
INFANTILE MORTALITY—
Deaths under one year of age  s.  10
Death  Rate  per   1,000   Births  34.25
CASES  OF  INFECTIOUS  DISEASES  REPORTED   IN   CITY
February   1   to  15,.
December, 1927 January, 1928 1928
Cases   Deaths Cases   Deaths Cases   Deaths
Smallpox           13            0 19            0 12           0
Scarlet   Fever             6            0 13            0 10
Diphtheria           25            2 34            0 15             0
Chicken-pox            70            0 140            0 49            0
Measles             10 11            0 7            0
Mumps           33            0 117            0 24            0
Whooping-cough             3            0 18            0 10
Typhoid   Fever               4            1 2            0 0            0
Tuberculosis             9            8 15          18 2         —
Erysipelas             5            0 11             0 2            0
Poliomyelitis             2            0 0            0 0            0
Cerebral-Spinal  Meningitis            0           0 10 0            0
Cases from Outside City—Included in Above
Diphtheria              7 1 7 0 3 0
Scarlet   Fever            4 0 6 0 0 0
Smallpox             4 0 4 0 0 0
Typhoid   Fever            2 1 10 0 0
Page 172 DIATHERMY
A Means of Generating Heat Within the Tissues
THAT is the simplest definition of medical diathermy.
In other words, it is the application of the particular
form of high'frequency current that produces this effect.
It does not come under the category of the hot water
bottle, electric heating pads and other similar devices which
are basically surface applicators.
Consider then a deep seated condition indicating the use
of heat. With an apparatus of correct design you can in a few
minutes produce any desired degree of heat within, from
the point of perception up to the tolerance of the patient.
A modern, correctly designed diathermy machine has
proved its value to thousands of physicians in practically
every branch of medicine. Our Reprint Library Service can
undoubtedly refer you to authoritative literature citing
clinical results with diathermy in conditions common to
your practice, whether general or specializied. Your inquiry
will not obligate you in any way.
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Page 174 EDITOR'S PAGE
A Chinaman lay dying. Chinese Ambassador to the Court of St
James', urbane, popular, steeped in western culture and thoroughly imbued with the spirit of western science, he had sent a request for a close
English friend to visit him. As the friend entered the room a wizened
old Chinese bent over a glowing brazier muttering incantations and now
and again making passes and scattering ashes over the form of the dying
man. "I have sent for you," said the ambassador, "in order that you may
see how a Chinese completely in sympathy with all your intellectual life
and your scientific spirit, still dies—a Chinaman." Atavistic? Doubtless. More definite only in one of a race where tradition greatly exceeds
our own in length and effect. History does not record whether in the
above anecdote the practitioner was ministering to the soul or to the
body of the sufferer. It is no matter. The process in either case has
many features in common. Some such deeply rooted reversion must account for the persistence with which, throughout recorded time, people
have sought help from the irregular professor of the healing art with his
various stock in trade and always the conscious or unconscious appeal to
suggestion. The persistence of the cult reflects the persistence of the demand which in turn represents the persistence of the underlying urge.
Writing in the 16 th century an old author clearly recognizes this
tendency, "This variable and  subtile composition of the  human body
 has rendered the art (of cure) more conjectural and left
the more room for imposture. The weakness and credulity of man is
such that they often prefer a mountebank to a physician. The poets were
clearsighted in discerning this folly when they made Aesculapius and Circe
brother and sister and both children of Apollo (Aeneid VII) for in all
times witches, old women and imposters have in the vulgar opinion stood
competitors with physicians."
No mere wrongheadness peculiar to the age is acting in this direction
today. Methods vary with the period. The principle is ineradicable,
shall we say? Amazingly tenacious anyway. Compared with its hoary
antiquity the discoveries of science and the wonders of modern medicine
are but a thing of yesterday; mere superficial excrescences, outward
adornment for the cloth, not yet the warp and woof of its very being.
Of the three so-called learned professions, those of the Church, Law
and Medicine, only the first and the last offer the amateur a chance of a
career. Apparently the welfare of the soul may be entrusted almost anywhere and that of the body is considered a fit subject for anyone to
claim. Only when it comes to taking care of one's money is it necessary
that one's adviser should be competent. At a time of ill health, when
man becomes really conscious of his body, he generally turns, to do him
justice, at first to the orthodox practioner of medicine. Failing satisfaction or relief, sooner or later these are often sought outside our ranks.
It may be that our apparent very success is our own undoing. The public
seeing our wonderful institutions, hospitals, clinics and the like, noting
the system and precision with which they are managed, the immense
concourse of people coming to them for help, hearing of too or seeing
the result of this successful operation or another remarkable cure, gets
Page 175 an exaggerated idea of our powers. It must seem to him as if all he has
to do is to present himself at one of these intitutions, state his case and
relief will be forthcoming . Little does he realize how many obscure parts
of the path still remain or how slow and toilsome often is the return to
health.
In the reaction to this all embracing optimism the old instincts reassert themselves and we begin to seek for what we cannot find, in the
mysteries and mumeries of that shadowy region lying between magic and
religion.
We have been moved to these reflections by the review in a weekly
newspaper of a book, "Leaves from my Life," by Sir Herbert Barker. Mr.
Barker the "bonesetter" knighted on the recommendation of Mr. Lloyd
George who, whatever his virtues or failings may be, has a very acute ear
for a popular demand. We have the book in the Library and it will be
reviewed at length in a later issue.
Sir Herbert Barker's career and that of the late Dr. Axham (removed
form the roll for giving anaesthetics to Barker's patients) have "been the
subject of a great deal of comment by the press. Staid weeklies and
established dailies have lectured the medical profession at full length,
promising everything from disciplinary measures to total abolition if it
does not mend its ways . Mainly those ways must be amended, as far as
we can judge, in the direction of admitting to recognition, the hitherto
unrecognized doctors of other persuasions. Some, with a saving sense of
humour hasten to add that not all of these should be so admitted, some, an
occasional one, only the best. How and by whom these are to be selected
remains unstated. One of the details left, we suppose, for the profession
to work out.
We imagine that 300 years from now, the then Editorial Board of
this Bulletin, sitting down to comment upon the most recent phase of
this perennial question, will not with interest the peculiar, ancient case
of Sir Herbert Barker. Meanwhile we hope that the medical profession
will have put in a lot of hard (and hardly remunerated) labour, mostly
unrecognized and much of it done by men whose names rarely mean much
to the profession itself, not to mention the public. We hope also that a
good many of our obscurities and blind alleys will be lightened and opened
up. Not all of them to be sure. There will still be room for the assertion
of the ancient instinct to which we have referred.
NEWS AND NOTES
The monthly regular meeting of the Association was held on February 7th, when 59 members attended. Dr. J. R. Neilson and Dr. F. Day
Smith were unanimously elected to membership. The Committee on
Hospitals, through the Chairman, Dr. H. H. Milburn, reported on the
work of the committee in regard to reorganization of the Vancouver
General Hospital Staff, a scheme for a Metropolitan Hospital Area and the
Hospital bed shortage in Vancouver. The report was received and a resolution passed that it be discussed at a special meeting to be called by the
President.    The Executive reported progress with regard to Revision of
Page 176 the Constitution and Bylaws, and Dr. H. R. Storrs, on behalf of the
Summer School Committee, outlined arrangements so far completed for
the 1928 Summer School. The speakers of the evening were Dr. Hugh
Macmillan and Dr. R. E. Coleman who reported on some recent original
work done by them in connection with carbohydrate metabolism in
connection with major operations. As these papers should prove of
considerable interest they will be printed in full in an early issue of the
Bulletin. An excellent discussion followed in which Drs. Freeze, Wallace,
Wilson, Keith, Busteed and Strong took part.
Owing to the fact that the February Clinical meeting was postponed
until the fourth Tuesday we are unable to give a full report, but the
programme, which included demonstration of all the more important
Laboratory tests, as well as four short talks was an exceptionally interesting one. The meeting was held in the Autitorium and the attendance
was excellent.
Dr. R. deL. Harwood has returned from his recent postgraduate
course and has resumed practice in the Vancouver Block where he is
associated with Dr. G. S. Gordon in urological work.
The Summer School of 1928 will be held on June 5th, 6th, 7th and
8 th. This rather early date has been chosen so as not to interfere with
the Canadian Medical Association and the Pacific North West Medical
Association meetings. Speakers already arranged for are Dr. Joseph Colt
Bloodgood, of Baltimore; Dr. John Phillips, of the Crile Clinic; Dr. Andrew Hunter, of Toronto and Drs. F. . Mackay, F. A. C. Scrimger and C.
A. Peters, of Montreal. The last four speakers are coming to us through
the courtesy of the Canadian Medical Association. The meetings will be
held, as last year, in the Ballroom of the Hotel Georgia and we hope this
year's meeting will be as succsseful, if not more so, than the meeting in
1927.
We understand from Dr. F. J. Nicholson that it is his intention to
retire from practice on the first of March.
B. C. MEDICAL ASSOCIATION NEWS
On January 10th the members of the Fraser Valley Medical Society
were entertained by Dr. J. G. McKay at Hollywood Sanitarium where
dinner was served and an excellent address on "The Common Psychoses
met with in General Practice," was given by Dr. McKay. A class is
being formed amongst the members of the Society for the study of Advances in Medicine, to meet weekly and discuss different subjects. Dr. G.
W. Sinclair, of New Westminster, assisted by Dr. Matheson showed an
interesting group of cases on the evening of January 24th, illustrating
Page 177 the different anaemias. A case of hereditary luetic infection in a child
10 years old, simulating hemolytic jaundice with the usual periodic
attacks of haematuria, opened up a field for an interesting dissucion.
Dr. D. E. H. Cleveland of Vancouver appeared before the Victoria
Medical Society on the evening of January 9 th. Two papers were presented by him. The first on the subject of Acne Vulgaris, with especial
attention to the xtiological factors, and the treatment, stress being laid on
the importance of regarding the disease from the view-point of the socio-
logic and economic handicaps which it imposes on the adolescent, and of
treating it seriously and actively, and the good results that can be
obtained by the general practioner. A second and briefer paper pointed out
how important it is that the physician should give careful consideration
to the possibility of external chemical irritation from various sources,
when confronted by acute inflammatory conditions of the skin. The
papers were followed by discussion which showed that they had been
given careful and appreciative attention.
Dr. M. J. Keys, of Victoria and Dr. L. H. Leeson, of Vancouver, who
had just returned from Europe and Vienna told of conditions on the
continent and of the postgraduate programme as carried on at various
centres, but with special reference to Vienna, and the arrangements and
opportunities for study in that city. Drs. Keys and Leeson were both
interested particularly in their specialties of Eye, Ear, Nose and Throat.
The many friends of Dr. J. J. Gillis will be pleased to know that he
has been elected Mayor of Merritt, B.C., for 1928. Dr. Gillis has always
taken a leading part in the development of the Nicola Valley.
We regret to report the sudden death on January 9 th, of Dr. Henry
Procter Cox, late of North Vancouver. Dr. Cox was a popular member
of the Dominion Quarantine and Immigration Service, and prior to removing to Vancouver some months ago was assistant to Dr. C. P. Brown,
of the Williams Head Quarantine Station.
Dr. J. E. Affleck, who was for some years at Penticton, after about
eighteen months postgraduate work in Europe, is now practicing at Nelson, specializing in Ear, Nose and Throat work.
Dr. A. K. Connolly, late of Salmon Arm, is relieving Dr. H. C.
Wrinch, of Hazelton during the latter's absence in Victoria for the
Session of the Provincial Legislature.
Dr. W. J. Knox, of Kelowna, B.C., left Vancouver on'January 9th to
spend a few months in Florida recuperating after his motor accident
last summer.
Page 178 At a recent meeting of the Executive of the B.C. Medical Association
the following members were nominated to the Council of the Canadian
Medical Association:—
Dr. H. E. Ridewood, President; Dr. Theo. H. Lennie, Sec-Treasurer;
Dr. J. W. Arbuckle, 736 Granville St., Vancouver; Dr. G. T. Wilson,
713 Columbia, New Westminster; Dr. F. M. Bryant, Say ward Bldg.,
Victoria; Dr. A. W. Bagnall, 736 Granville St., Vancouver; Dr. W. A.
Clarke, 6th st., New Westminster; Dr. H. M. Robertson, Campbell Bldg.,
Victoria.
A meeting of the Executive Committe of the B.C. Medical Association was held on January 27th, when much important business was
transacted. Dr. H. E. Ridewood, President of the Association, was Chairman and the following out-of-town members attended:—Drs. W. A.
Clarke and S. C. McEwen of New Westminster; Dr. Thomas McPherson
of Victoria; Dr. P. J. McPhee, of Nanaimo; Dr. E. L. Garner, of Duncan
and Dr. B. deF. Boyce, of Kelowna.
The undermentioned were elected to membership in the B. C. Medical Association:—
Drs. M. R. Basted, H. H. Boucher, H. G. Bruce; E. A. Campbell; W.
A. Coburn; E. E. Day; W. L. Graham; W. H. Hatfield; J. M. Jackson; G.
A. Lawson; A. B. Nash; H. M. Ross; J. E. Walker.
The Legislative Committee of the B. C. Medical Association has for
sometime been negotiating with the Provincial Government for higher
fees for coroners, and medical witnesses, medical men doing autopsies and
serological work, mileage, etc. It is satisfactory to learn that the Attorney
General has agreed that the fees generally are too small and has promised
that he will take up with the Executive Council, the question of changing
the Act this session.
At this Executive Meeting the question of cooperation with the
Vancouver Medical Association was fully discussed, and a resolution was
passed that a committee be appointed to arrange a meeting with the
committee of the Vancouver Medical Association, and in the meantime
Dr. T. C. Routley, General Secretary of the C. M. A., be advised of the
whole matter and asked for his opinion. This has been done and we are
now waiting to hear from Dr. Routley.
The Secretary Treasurer read letters from the Canadian Medical
Association re the coming Spring and Autumn Postgraduate tours. An
Autumn tour will be carried out on similar lines to those which were
followed last year. The speakers for the Autumn will be Drs. Bazin
and A. H. Gordon, of Montreal, and Dr. Gordon Bates, of Toronto. Two
local men will also be members of the team.
Representations were made to the Executive regarding the loss
suffered by hospitals owing to the disallowance of hospital stay in accident cases by the Workmen's Compensation Board. This is not a matter
with which the Executive feels justified in interfering, but it was decided
to draw the attention of members to the following two points: (1) that
the patient's stay in hospital must be justified under the Act on
the grounds  of  actual  necessity  and  not  on  account  of  any  home
HS of other conditions, (2.) that reports should be made fully enough to
show clearly the necessity of such stay in the hospital. We would draw
especial attention to these two points and urge our members to exercise
due care in this regard.
The question of more publicity and Education work was brought
up and the desirability of repeating the Health Week of a few years ago. A
lengthy discussion took place in which it was pointed out that many
radio talks had been given during the last two years and had been greatly
appreciated. The duty of bringing some scheme into action for health
publicity and education other than lecturers and radio talks, was left
to the Committee.
THE TOXIC GOITRE
Delivered before the Vancouver Medical Association by
T. H. Lennie, M.D., CM., F.A.C.S., Vancouver, B.C.
When I was asked some time ago to give a title to this evening's
paper, I said "Surgery of the Toxic Thyroid," but on considering the
question subsequently it seemed to me that a general discussion of the
question of hyperthyroidism would be of more general interest, with
some mention of pre-operative, operative and post-operative details.
It was my privilege some years ago to be interested in the administration of anasesthetics, and naturally the bad surgical risk was the
one which received the greatest personal attention. I must say that over
a period of several years, with quite a fair number of extremely risky
surgical conditions, my respect for the toxic goitre was established
and maintained. While none of these cases terminated fatally on the
operating table, a far too high proportion died within the following 36
hours. Let me state definitely that this was not a local condition, but
was pretty generally the experience of those engaged in thyroid surgery at
that time.
As a result of this experience the whole question of hyperthroidism,
particularly from the standpoint of surgical risk and proper handling,
intrigued me; so that when the opportunity arose I visited as many
goitre clinics as possible both in Europe and America.
Ten to fifteen years ago very little was known about the preparation
of toxic thyroid cases for the operating table. Usually the patient was
admitted to the hospital the night previous to operation without any
preliminary medication whatever. I recall very vividly the picture of
the individual upon arriving in the operating room. There was extreme
nervousness, the eyes were frequently popping out of the head, the skin
was flushed, the patient was perspiring profusely and very apprehensive
of what was going to happen. The pulse might be anywhere from 160
up, often so fast that it could not be counted. I have frequently
wondered since just what the metabolic rate would be in some of these
cases.
Page ISO The anaesthetic chosen was invariably nitrous-oxide and oxygen,
more by good luck than from any scientific knowledge regarding the
condition; normal saline was administered interstitially during the operation. Fortified by these the patient survived the actual operation only
to lose the fight within the next 36 hours.
It has sometimes seemed to me that the particular time of which I
speak was one of liberal surgery; the actual operation itself occupied
altogether too large a place in the general scheme of things, to the exclusion of consideration of the patient's condition and the proper time
for operation. I believe that today the trend is towards conservative
methods.
We are greatly indebted to two groups of men on this continent
for placing thyoid surgery in the position which it occupies today. I
beleive there is no other surgical condition in which our ideas have been •
so revolutionized as in the surgery of hyperthyoidism. The mortality
has dropped from a very high percentage to less than 1% in some of the
large goitre clinics.
Crile of Cleveland, who has always preached the gospel of low surgical mortality, endeavored to attain this end by "stealing the thyroid.
His method was to keep the patient in ignorance of what was going to
happen. The patient was given daily a little oxygen, later nitrous oxide
was added, and then one day the whole surgical team would sneak up on
him in his bed and remove the thyroid while he was asleep. If it was a
toxic case a ligation of one of the superior thyroids was done followed in
a few days by a ligation on the other side; then would follow a lobectomy
and finally a second lobectomy. This meant frequently 4 operations.
Crile is still following this method, combined with LugoFssolution, but
I got him to admit that since the use of Lugol's he was doing an increasing number of complete thyroidectomies.
To Plummer and his associates at the Mayo Clinic we are greatly
indebted for an extensive investigation of this question, and for the
introduction of Lugol's solution as a pre-operative   measure.
Plummer classifies thyroid enlargement as follows:
1. Colloid or Simple Goitre.
2. Adenoma without hyperthyroidism.
3. Adenoma with hyperthroidism.
4. Exophthalmic Goitre.
5. Cretinism.
6. Myxoedema.
7. Malignancy.
8. Thyroiditis.
9. Anomalies, such as syphilis, dermoid cysts, etc.
For our purpose the following classification will suffice:
1. Colloid.
2. Adenomatous (simple and toxic).
3. Exophthalmisc.
Of these the adenomatous and exophthalmic goitres are surgical.
Page 181 Before considering the question of hyperthyroidism is may be well
to review very briefly some facts concerning the thyroid gland.
You are all familiar with the rich vascular supply of the thyroid.
The arteries are the superior and inferior thyroid' and the ima. The
superior comes from the external carotid and divides into the anterior
and posterior. The inferior comes from the subclavian and the ima
either from the arch of the aorta or innominate and supplies the isthmus.
The veins are the superior thyroid, the middle (hich is sometimes present.)
the inferior and the ima. Anyone who is doing thyroid surgery, however, will vouch for the great variation in the blood routes to and from
this important gland.
The thyroid receives its nerve supply from the vagus, the sympathetic and the superior laryngeal. The inferior laryngeal does not
supply the thyroid.
The parathyroids are supposed to be in the posterior capsule, two
at the upper pole, and two at the lower, near the inferior thyroid artery
and recurrent laryngeal nerve. It may be of interest to you to know
the McCullough, of Crile's Clinic, a young man who was formerly an
interne in the V. G. H., is investigating the question of parathyroids and
has found many parathyroid bodies in the anterior capsule. He showed
me slides of these parathyroid bodies.
When the vesicles of the thyroid are distended with colloid the
epithelial cells are flattened out. In active glands such as exophthalmic
goitre where the colloid is limited, the epithelium becomes highly columnar. This point is important in connection with the administration of
Lugol's solution pre-operatively. Increased vascularity diminishes the
amount and consistency of the colloid.
Kendall, who has done wonderful work on the chemistry of the
thyroid gland isolated the thyroid hormone which he called "thyroxin."
The administration of thyroxin produces an increased pulse rate, nervous
irritability, tremor, nausea and diarrhoea.
I need only mention to you the intimate association of the thyroid
with the pancreas, adrenals, gonads, liver, pituitary, the thymus, the
nervous system, the osseous system and metabolism. Concerning the
association of thyroid and thymus some authorities go so far as to say
the 70% of cases of Graves' disease have a hyperplastic thymus. Exophthalmic goitre has been produced in dogs by the injection of extract
of thymus from those suffering from Graves' disease.
On the etiology of goitre I would refer you to an article by McCar-
rison appearing in the Lancet of April 30th, 1927. McCarrison had
previously experimentally produced goitre of three types in rats: (1) the
hypertrophic, arising in animals living under unhygienic conditions of
life in iodine-poor localities, or those receiving massive doses of faecal
bacteria in admixture with their food, congenital goitre and cretinism
being thereby produced in their offspring: (2) hyperplastic, arising in
animals with an excess of fats or fatty acids in an otherwise well balanced
diet:   (3)  colloid, where there has been an excessive ingestion of lime in
Page 182 an otherwise well balanced diet. He goes on to say "With the possible
exception of those caused by the administration of faecal bacteria, these
goitres are preventable by increasing the intake of iodine proportionately to the unhygienic conditions of life of the animals, or to the excess
of fats or lime in their food." The fourth type which he describes in
this paper, is one simulating Graves' disease histologically, produced
where white flour enters largely into the diet from which green vegetables and fruit are excluded. This type of goitre will not be prevented
by iodine, but a well balanced vitamin-rich diet will prevent it.
Experimentally these are very interesting facts, but just to what extent they can be applied to the human race remains to be seen. It is,
however, a basis for work on the prevention of goitre.
It has been generally accepted that the human colloid goitre is due
to a deficiency of iodine in the drinking water or soil, but this does not
explain the whole story as illustrated by the excess in females at puberty,
pregnancy and the menopause in an endeavour to supply sufficient thyroxin. If infection is accepted as the causative factor the action of
iodine is explained by its germicidal properties.
We are agreed that goitre is on the increase in America and the
important point in this connection is that it demands treatment in children: (1), because it is in the colloid goitre that the adenoma develops, and
(2), if we allow this condition to go on generation after generation a
condition similar to that which exists in Switzerland today will occur,
namely the remarkable prevalence of cretinism and deaf-mutism.
An adenoma usually develops in a neglected colloid goitre. It is
an attempt on the part of the gland to produce an increased amount of
thyroxin. In these cases the indiscriminate use of iodine is dangerous as
it may turn a non-toxic into a toxic adenoma. About 50% of nontoxic adenomata will become toxic before 45 years of age with damage
to the heart and kidneys. The adenomatous goitre is irregularly enlarged.
The exophthalmic goitre is probably toxic in origin and not due to
an iodine deficiency.    The toxic goitres may be divided into 3 classes:
1. Toxic adenoma or adenomata.
2. Exophthalmic.
3. Iodine hyperthyroidism.
Hyperthyroidism is characterized by symptoms which are due to an
excess of thyroxin.
The differences in the clinical picture of these conditions are quite
marked. The basal metabolic rate is a fair indication of the degree of
toxicity, but varies in the different types of hyperthyroidism. All the
symptoms are not present in every case. There is increased pulse rate in
one—in another tremor—in another diarrhoea—in another exophthalmos
—in another loss of weight. Some show only progressive emaciation.
For the purpose of diagnosis the clinician should require the basal meta-
Continued on Page 190
Page 183 Liver Extract
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Anti-Meningitis Serum
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INSULIN
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CONNAUGHT LABORATORIES
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618 Georgia Street West - Vancouver
Page 185 The
British Columbia Laboratory Bulletin
Published monthly  September  to  April  inclusive  in  co-operation  with  the   Vancouver
Medical Association Bulletin, in the interests of the Hospital  Clinical and
Public Health Laboratories of B. C.
Edited by
Donna E. Kerr, m.a., of The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster;
Royal Inland Hospital, Kamloops;  Tranquille Sanatorium;  Kelowna  General Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.   Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Volume 4
MARCH 1st, 1928
No. 6
CONTENTS
Variations in the Concentration of Iodine in the Lillooet
River Water  Kerr
Vancouver Diabetic Mortality  : Coleman
Alkaptonuria Following Carbolic Acid Applications Welsh
VARIATIONS IN THE CONCENTRATION OF IODINE IN THE
LILLOOET RIVER WATER
Donna Kerr, M. A., V. G. H. Laboratories
Six analyses have been done for iodine on the upper Lillooet River
water at different seasons of the year. These analyses were all done according to McClendon's method (Jour. Biol. Chem. Vol. LX, 1924, 289).
Either 15 or 25 gallons were evaporated down to approximately 1 quart
by a farmer, who had been specially instructed, situated at Pemberton
Meadows close to the river. This was then shipped to Dr. W. D. Keith,
who was undertaking an investigation of the relation of iodine in drinking
water to the incident of goitre. The analyses, with the exception of the
first which was done by Mr. H. Offord at the University of British Columbia, were all done at the Vancouver General Hospital Laboratories.
Method of Iodine Determination in the Concentrated Water
Filter the quart of concentrated water washing the sediment and
filter paper thoroughly with distilled water. Evaporate the filtrate to
dryness on a boiling water bath and reduce the scrapings to a fine powder
in an agate mortar. Place in a combustion boat and insert in a pyrex or
silica combustion tube one end of which is connected with an oxygen
tank and the other end is bent so that it can be inserted into a large test
tube containing 10 c. c. of 10% sodium hydoxide. Pass oxygen slowly
through the combustion tube and heat the tube to dull redness for the
shortest length of time required to burn all the organic matter in the
sample, as determined by inspection. If on removing the combustion
boat the organic matter is not completely burned it can be reinserted and
the heating repeated.    If any of the organic matter is carried over into
Page 186 the sodium hydroxide solution, evaporate it to dryness and if the ash is
not completely burned combine the residue with the ash and repeat the
combustion using another 10 cc. of 10% sodium hydroxide in the receiving tube. McClendon has added a Cottrel precipator to the appartus to
catch the smoke particles which are sometimes not caught by the alkaline
solution and may contain a small fraction of the iodine (Physiological
Reviews Vol. VII., No. 2, 1927). Since the Cottrel precipitator was not
described until several of these analyses had been made it was not introduced so that the results might be comparable). The ash is powdered and
the sodium hydroxide solution together with the rinsings of the tube are
evaporated to dryness and powdered and then both mixed in the mortar.
An accurately measured portion of water is added (15 cc.) and the whole
ground to extract iodides and iodates. Filter and take a measured amount
of the filtrate (7.5 cc.) and neutralize with concentrated hydrochloric
acid and make up the volume to 10 cc Place in a small separatory funnel
(15 cc) and add 1 drop of concentrated hydrochloric acid and 1 cc
of purified carbon tetrachloride and shake. (If any pink color appears
it indicates the presence of iodate.) Add 1 drop of O.lN arsenious acid
to reduce any excess of iodate that might be present and allow it to stand
20 minutes. Add 1 drop of nitrosyl sulphuric acid to oxidize the iodide to
iodine and shake the separatory funnel hard for 2 minutes to extract the
iodine. The carbon tetrachloride is then separated and centifuged to remove any trace of water. The carbon tetrachloride is then placed in a
colorimeter cup and compared with a standard iodine solution in carbon
tetrachloride. (A standard iodine solution can be made up to contain
0.1 mg. of iodine per cc and diluted with carbon tetrachloride if the
unknown contains very much less.) By repeated extractions (usually 3)
with carbon tetrachloride practically all the iodine can be recovered and
measured, adding all together or in some cases the partition coefficient
can be calculated.
Iodine Content (parts of iodine per
Time Amount   Evaporated 100 billion of water)
Jan. 1924
26.5 g;
ulons
102
April, 1925
26.5
,,
103
Aug., 1926
15
a
0*
Feb., 1927
15
9?
89
May, 1927
25
>>
98
Oct., 1927
25
99
21
(*This is
less
than 10
parts per
100
billion
as
we have determined
that the limit
of our technique.)
It is evident from these results that the iodine content of such a
river may vary extensively. The source of supply of the water varies
with the seasons. In winter the supply is from adjacent melting snow
and ice and underground water. In spring the volume of water is
greatly increased. The snow melts receding further and further into
the mountains until in summer the river water practically comes from
glacier streams and springs. In the fall precipitation increases and this
increases ground and seepage water. Thus in summer and early fall
when the ground water supply is low and we would expect less mineral
Page 187
fil salts the iodine is very low. When specimens 3 and 6 were taken the river
was very low and muddy and there was a great deal of silt in the concentrated specimen.
McClendon found as much variation in the water of the Mississippi
River during the year but this he attributed to contamination from
human agencies.
Conclusions
The assay of the iodine content of water supplies, particularly in
the case of rivers, should be made at different seasons.
VANCOUVER DIABETIC MORTALITY
R. E. Coleman, M.B., V. G. H. Laboratories
The first column of the table gives the total number of cases admitted during the year to the Vancouver General Hospital. This is a large
open General Hospital (900 beds) fed by Greater Vancouver, which latter
has a population of about 250,000. The second column gives the total
number of recorded deaths from diabetes mellitus in the city proper and
therefore, of course, includes the data of Table 3, which is the recorded
deaths from diabetes in the Hospital (93).
In the first column is found the general and widely recognized rise in
the number of hospital cases of diabetes mellitus reported by others. This
rise became abrupt during 1922 when the popular reports of insulin
drew particular attention to this disease. In January 1923 insulin
became available and for that entire year the Hospital drew patients
from considerable distances.    After that the figures are fairly constant.
Columns 2 and 3 show a parallel arrangement with an increased
mortality up till 1922 but a fall in 1923 and after. The total deaths in
the Hospital, however, do not rise in any comparable manner to the
total cases admitted, i.e., the mortality per cent, in 1923 when insulin
was introduced was the lowest of all years.
There are two features which make this material of special interest.
In the first place it covers the period during which insulin was introduced. In the second, place it reflects the effect of its introduction on
a special group of physicians. It is the unique character of this second
feature that renders the table at least suggestive. The Vancouver General Hospital with its Dietetic Department and Laboratory make it possible for the general practioner to treat his own case along scientific
lines. Many cases are turned over to internists but in the last three years
there has been a marked tendency for the general practitioner to treat his
own case. It might have been expected from Rabinovitch's study that
such a condition would lead to an increased mortality. Inspection of
our Table shows this is not the case. In 1919, of 29 cases, 60 per cent,
died. In 1926, of 84 cases, only 20 per cent. died. The same trend
holds throughout.
Though the figures are small they do not support the idea that
insulin has increased the mortality in general practice, but rather indicate
a decided improvement when scientific facilities are available to the
general practitioner.
Page 188 TABLE
1.
2.
3.
Total Cases
Total Deaths
Total Deaths
Year
V. G. Hospital
Vancouver
City
V.
G
Hospital
1917
—
13
—
1918
—
10
—
1919
29
17
3
1920
58
19
10
1921
83
19
14
1922
107
29
25
Insulin Introdu
ced
1923
133
24
10
1924
75
14
4
1925
86
18
12
1926
84
19
11
1927
83
—
6
ALKAPTONURIA FOLLOWING CARBOLIC ACID
APPLICATIONS
Rae Welsh, B.Sc, V.G.H. Laboratories
The diagnosis of alkaptonuria was suggested when a urine during
routine examination was found to give an unusual reaction with Benedict's qualitative sugar reagent. Inspection of this specimen then revealed a dark brown surface layer which in time extended till at the
end of twenty-four hours the entire urine was a dark brown. The
result of the routine examination was: Reaction, acid; albumin, -j-1 =
trace of alb.; sugar, 0; white blood cells -f-1; epithelial cells -|-2; bacteria -j-2.
On searching the literature it was discovered that this laboratory
sequence of events is typical of alkaptonuria.
Alkaptonuria may be familial or may be caused by the extensive
use of carbolic acid, or may be of unknown etiology. When familial,
it is due to a condition of the protein metabolism of the body wherein
the aromatic amino acids, tyrosin and phenylalanin are involved, producing homogentisic acid in the urine. It is found more commonly in
males than in females, and is constantly found associated with ochronosis, a rare disease in which a blackening of the cartilages and pigmentation of the skin occurs. Acquired, transient alkaptonuria was more
common in the early days of Lister's extensive use of carbolic acid
applications.
A close check was kept on the urine, and at the end of two weeks
all evidence of alkapton bodies had disappeared. The patient, in this
case a female child of about two years, had entered the hospital suffering
from impetigo. The treatment consisted of applications every two hours
of calamine lotion containing carbolic acid. This was commenced December 10, 1927, and discontinued December 17, 1927, while the alkaptonuria was first detected December 12, 1927, and had entirely disappeared by December 27, 1927.
Reference—Arch. Int. Med., Vol. 28, 1921, 632.
im Continued from I?age 183
bolic rate in only a very small percentage of cases; but it is very desirable that this test be done during the progress of the disease, as it is a
good indication of the efficacy of the treatment.
We must also recognize a type of hyperthyroidism which' develops
following some severe psychic disturbance. We have here what Julius
Bauer of Vienna calls a "neurosis of the thyroid." There is a hyperthyroidism but the underlying cause is in the central nervous system. These
patients should be treated by rational psychotherapy.
Let us consider for a few moments the toxic adenoma, exophthalmic
goitre, and iodine hyperthyroidism.
In adenoma with hyperthyroidism the onset is more gradual and less
severe than in exophthalmic goitre. There is usually the history that a
goitre has been present for years. The symptoms are nervousness, palpitation, tremor, moist warm skin, loss of weight, which becomes rapid
when the hyperthyroidism has become established.
Pressure symptoms depending on the size and position of the adenoma. Heart and kidney derangement as a result of continued toxicity—
heart usually enlarged—auricular fibrillation and myocardial degeneration are fairly common. I shall have more to say later on about the cardio-
vasclar changes in hyperthyroidism. The basal metabolic rate is not so
high as in exophthalmic goitre, rarely being above plus 60.
Exophthalmic goitre usually occurs between the ages of 18 and 35
but is by no means limited to these ages. The onset is acute. It progresses in waves with periods of exacerbation and remission of symptoms.
The symptoms are tachycardia, nervousness, irritability, emotionalism,
exophthalmos, restless movement, fine tremor, heat tolerance, moist skin
and excessive perspiration, palpitation, dyspnoea, insomnia, loss of
strength, particularly in the quadriceps, loss of weight sometimes associated with an increase in appetite. Exophthalmos does not appear at
the onset. There may be no evident enlargement of the thyroid. Gastrointestinal disturbances do not occur until the disease is well established.
Cardiac bruits are frequently present and there is a high pulse pressure.
The basal metabolic rate is usually higher than in toxic adenoma. The
heart may be enlarged.
Graves' disease in young girls, with a large soft gland, offers more
difficulty surgically than the others, as the pulse rate may not drop for
several months following operation and the remaining fragments of thyroid tissue may develop into large lumps and require further surgical
measures.
IODINE HYPERTHYROIDISM
Jackson of Madison, in a recent and very excellent book on the
thyroid, gives a classification of iodine hyperthyroidism, placing it between the toxic adenoma and the exophthalmic goitre.
Page 190 It seems to me that quite a fair percentage of the toxic goitres that
are presenting themselves today are due to the indiscriminate use of
iodine, either in the form of iodized salt or some other preparation. I
endeavoured to substantiate this opinion both in Europe and America
and the information was rather interesting.lt was pretty generally admitted that it was dangerous to administer iodine in the case of the adenoma, but the experience of Switzerland is rather enlightening. As you
all know goitre is very prevalent in that country. The great majority of
goitres are Of the colloid type, with no symptons of hyperthroidism; in
fact cretinsm and other manifestations of hypothyroidism are very common. I learned that since iodine has become fairly generally used the incidence of hyperthyroidism has increased. This would bear ont the contention of some of the Vienna teachers that iodine can change a colloid into a
hyperplastic thyroid, which seems rather strange, since we know from
pathological experience that the toxic goitre becomes colloid after the
administration of Lugol's solution pre-operatively.
I shall cite one case as an example of iodine hyperthyroidism, which
came to my notice recently. A young woman, aged 25, who had recently come from the East, gave a history of having a thyroidectomy
done about one year ago. I presumed from examination that she had
had a complete right lobectomy and removal of the isthmus with a
partial resection of the left lobe. The operation appeared entirely satisfactory for a time. She had been advised by her physician to take a
preparation of iodine. When I saw her she had definite symptoms of
toxic goitre with considerable enlargement of the left lobe. I immediately stopped the iodine and in two weeks the gland had decreased in size
to a marked extent, her symptoms had gone and her basal metabolic rate
was normal.
Patients with toxic goitre produced by iodine are frequently frightfully ill, sometimes becoming maniacal, the illness ending fatally. The
picture of iodine hyperthyroidism closely resembles that of exophthalmic
goitre. Digitalis does not benefit the tachycardia in these cases; they
are poor surgical risks.    In the early cases the prognosis is good.
Some remarks about iodine in the treatment of goitre might be in
place here. A deficiency of iodine is the important etiological factor
in colloid goitre; untreated colloid goitres are predisposed to the development of adenomata. 50% of the simple adenomata become toxic before
45 years of age. Children stand iodine well. The time for treatment of
the colloid goitre is, then, in the years of childhood. In adult life iodine
is not effective in the treatment of this condition. The gland may be
reduced temporarily but the colloid again accumulates.
In adult life iodine should only be administered pre-operatively with
the distinct understanding that surgery is to be undertaken. In other
words as Bauer says, "Iodine should only be given with the knife in the
hand." It is best given in the form of Lugol's solution either in milk or
grape juice 10-15 ms three times a day for a period of six days to two
weeks. The effect in exophthalmic goitre is nothing short of marvellous.
Pathological examination of the glands removed at operation show colloid
Page 191 goitres in most instances, the picture of exophthalmic goitre having
almost completely disappeared. This explains to a large extent the
lowered mortality. With the proper use of Lugol's solution we are no
longer operating upon toxic goitres though a few days previously the
clinical picture was one of typical exophthalmic goitre. The pulse slows
and the metabolic rate is decreased with the use of Lugol's solution, in
fact Lugol's has practically eliminated the necessity for ligation.
It is generally conceded that iodine treatment for adenomatous goitres
is particularly dangerous and for this reason up until very recently
Lugol's solution was not used pre-operatively in these cases. In fact
this is still the custom in many, places. In such clinics as Crile's and
the Mayos', however, all cases of hyperthyroidism are given Lugol's
solution for operation, and the effect seems to be pretty universally beneficial. The desirable method would be to administer Lugol's solution
only as a preparation for operation and in the hospital, where its effect
can be very closely watched, and its use discontinued at the first indication of any harmful effect.
Regarding the cardio-vascular features of hyperthyroidism a very
interesting article appeared in "The Annals of Clinical Medicine," January, 1927, by Smith and Col din of the Henry Ford Hospital. I shall
give you a summary of some of their findings:
FEATURES IN CASES HAVING NO HEART IRREGULARITY
1. The most common, tachycardia.
2. Increased pulse pressure in both adenomatous hyperplastic varieties, pulse pressure equal to 50% or more of the systolic pressure.
3. Peripheral throbbing, especially noticeable in the carotids and
in the abdominal aorta.
4. Cardiac impulse often diffuse covering two or more interspaces.
5. Systolic murmur frequently present, which disappears when the
disease is arrested.
6. Pistol shot sound over the femoral artery.
AURICULAR FIBRILLATION IN HYPERTHYROIDISM
This occurs in the great majority of cases with adenomata, which
may be quite small. Properly treated, cardiac deaths in exophthalmic
goitre and in adenomatous goitre with hyperthyroidism is a very rare
occurrence. They go on to say, "A comparison of results obtained in
the patients with hyperthyroidism and auricular fibrillation who are
operated upon, with those who are treated medically, may be of interest.
There were eight patients presenting this combination in the latter
group. Four of these are dead, having been admitted in extremis or
having succumbed to other causes. The remaining four who refused
operation still present auricular fibrillation and in spite of measures of
cardiac protection, and digitalis medication, are all in a state of considerable cardiac failure.    It seems evident then that without operation these
Page 192 patients have very little to hope for; at best a few years of well marked
chronic invalidism.
From a cardiac standpoint, the results in 22 patients of this type
who elected to have an operation are in startling contrast to the foregoing
There was one death from thyroid crisis. Among the others every patient
operated upon had been able to return to his or her usual work."
The basal metabolic rate is an index of the rate of oxidation going
on in the cells of the body. No food should be taken for 12 hours and
there should be complete rest for a half hour, previous to the test. Minus
10 to plus 10 is considered normal. Over plus 15 indicates a proportionate degree of clinical significance.
In every toxic exophthalmic goitre with rapid loss of weight the
rate may reach plus 100 or over. It is of great importance to operate
on a falling and not on a rising rate. It is more dangerous to operate
on the verge of a crisis with a moderately high rate, than on a patient
with a high rate who has passed the crisis and is improving clinically.
The metabolic rate is not necessarily an index to the ability of the patient
to withstand an operation; of greater signifigance is a rapid and recent loss
of weight together with a high pulse pressure. The metabolic rate is of no
great value when the diagnosis is obscure and might be confused with
Cardiac condition or the nervous manifestation of the menopause. The
constitutional neurotic, if I may use the term, who happens to have an
enlargement of the thyroid, may be spared unnecessary surgery by showing a normal or nearly normal rate. In toxic adenomata it is usually considerably lower thanin exophthalmic goitre. It is in the toxic adenomata
that one sees the serious permanent damage to the cardio-renal systems.
In an established case of hyperthyroidism where there are foci of infection present it is probaly wiser to remove the foci after thyroidectomy
than before, as such preliminary operations as tonsillectomy, sinus drainage and teeth extraction may precipitate a marked hyperthyroidism.
TREATMENT.
The treatment of hyperthyroidism may be divided into:
1.    Medical; 2.    X-Ray; 3.    Surgical.
Time will not permit me, nor is it my intention in this paper to
discuss the medical treatment of this condition.
A very few words will suffice for X-Ray. I believe that this,form
of treatment, for different reasons, is being used less and less as time
goes on. The great advantage of X-Ray was in the preparation of the
toxic type for operation, but its place has been taken by the use of
Lugol's solution.
Some of the disadvantages are: the dosage of X-Ray is difficult to
control and is not as reliable as operation; the more active the goitre the
more difficult to determine the required dosage; individuals react differently and require different amounts; X-Ray affects all the cell of the thyroid and myxoedema may develop; one always has in mind the possibility
of X-Ray burns; if operation must be undertaken eventually, X-Ray
makes the procedure much more difficult.
Page 193
Si X-Ray is applied in some cases where operation is refused. Also in
malignant condition of the thyroid and in the senile. Some writers admin-
ster X-Ray in the milder forms of hyperthyroidism following upon physical disturbance.
SURGICAL TREATMENT
It is pretty generally accepted today, I believe, that all cases of
severe hyperthyroidism should be operated upon and I believe that the
operation should be performed as early in the disease as is compatible
with safety. This is true both of hyperplastic and adenomatous thyroids with hyperthyroidism. Non-toxic adenomata require surgery (but
not emergency surgery) because of their tendency to become toxic
before the age of 45.
PRE-OPERATIVE PREPARATION.
Having accepted this dictum it becomes the duty of those interested
in the case to see that the patient goes to the operating room at the
proper time, and that there is accurate record of pulse rate, blood pressure readings, basal metabolic rate, a knowledge of the cardio-renal
systems, etc., always keeping in mind the importance of operating on
the downward metabolic curve.
Pre-operative X-Ray examination to determine the possibility of
substernal or intra thoracic goitres, and laryngeal examinations to ascertain the condition of the vocal cords are very valuable.
A variable length of time of absolute rest in bed is essential. When
it is decided that the operation is to be performed, the following preparation is of considerable value:
2.
3.
5.
6.
Lugol's solution nl-10-15 T.i.d. in 1 ounce of cream or grape
juice for from 6 to 14 days.
A high caloric diet low in protein but high in carbohydrates.
3,000 cc of fluids daily to include orange juice containing 10%
glucose between meals.
Luminal gr. \l/2 night and morning for first two days, then at
night only.
Bromides in addition if necessary.
Ice cap to the heart.
About digitalis there is considerable dispute, but I would say that
for auricular fibrillation or signs of decompensation, digitalis should be
adminstered, m-30 for six doses. If there are signs of heart failure fluids
should be reduced. With the above preparation it is usual to find a marked
a marked decrease in the toxicity as evidenced clinically and by the basal
decrease in the toxity as evidenced clinically and by the basal metabolic
rate. Morphine gr. 1/6 with atropine gr. 1/150 is administered hypo-
dermically a half hour before operation.
In extremely toxic cases which do not respond sufficiently to preoperative preparation and in toxic adenomata when it is deemed unwise
Page 194 to give iodine, ligation, or the method followed by Crile of multiple
operations, has a definite place, but it is found that these methods are
becoming less often necessary.
The universal operation today is bilateral resection excepting in the
single toxic adenoma which can be enucleated. Deep anaesthesia is contra-indicated, this applies particularly to ether. As pointed out by Crile
inhalation anaesthetics cause sub-oxidation and are therefore dangerous.
This would indicate that local anaesthesia is the one of choice. Nerve
blocking is not without danger. I saw one instance of this in Switzerland where the anaesthetic was injected into the carotid artery with very
nearly fatal results.    The infiltration method is quite satisfactory, but
<%
'O
the amount of fluid should be ample. About 200 cc of l/z to % of m
of novocaine (without adrenalin) is used. The subcutaneous tissue is
injected about the whole of the anterior aspect of the neck with the
needle kept constantly in motion. When the incision is made and flaps
dissected the muscles are then injected and incised from above downwards. If this incision is long enough, by retraction, ample exposure is
usually obtained. The gland itself is then injected, particularly in the
upper and the lower poles and the resection begun. About the only time
that pain is complained of is when the superior pole is clamped, but this
is slight if the anaesthetic is properly administered.
With local anaesthesia there is less danger of injury to the recurrent
laryngeal nerve and haemorrhage is better controlled. There is the advantage of having the patient talk or cough to see if there is any nerve
injury, or bleeding points neglected.
A method which seems to me very reasonable and rational is that
adopted at the Mayo Clinic. It is a combination of local and gas anaesthesia, local is used up to the point of resection of the gland when gas is
administered and discontinued immediately the gland is removed. Tying
of the bleeding points and closing of the wound is done under local. This
lessens the length of general anaesthetic and has the advantage of local in
the opening and closing processes.
A soft rubber drain is left in for 24 hours. The tract is then kept
open until the discharge has stopped.
There is no surgical operation which requires tact and co-operation
among all those concerned so much as the operation upon the thyroid.
The attitude of the operator, assistant, anaesthetist and nurses, in fact all
those connected in any way with this procedure, should be such as to
inspire confidence in the patient.    Quiet is absolutely essential.
POST-OPERATIVE CARE
Morphia gr. 1/6 should be given immediately following operation,
also subcutaneous saline 2,000 cc If this contains novocaine 1/32 of 1%
it will lessen the pain considerably. Lugol's solution m 30-40 per rectum as
soon as possible then m 10-15 three times a day by mouth for three days.
Rectal salines oz. 6 containing 10% glucose every four hours. Mor-
phin should be administered liberally as often as every two hours if neces-
Page 195
mm
1 sary to insure absolute quiet: 2,500-3,000 cc. of fluids should be taken
by mouth on the second day.
The skin sutures should be removed early on third or fourth day.
This has a very decided effect on the appearance of the scar.
SOME POST-OPERATIVE COMPLICATIONS
Post-operative bleeding is not likely to be excessive if the operative
technique described above is followed and all bleeding points secured.
Pressure and ice caps will help to control oozing. Haemoplastin may be
given to advantage. If haemorrhage is execessive it may be necessary to
open the flaps and secure bleeding points.
Acute post-operative hyperthyroidism is practically unknown since
the use of iodine as a preparation for operation and for the following
72 hours. This was a fairly common complication formerly. If during
the operation it is found that the pulse is rising alarmingly it is wise to
stop the procedure, pack, and complete the task later on.
Post-operative tetany is a very annoying complication. It may be
controlled by calcium lactate, by mouth or subcutaneously, or if these
fail parathyroid extract subcutaneously.
Hypothyroidism may follow a very radical operation. In fact some
surgeons, notably Crile, aim at a mild hypothyroidism. This is controlled by small doses of thyroid extract which does not usually need to
be continued long.
For my failure to achieve literary excellence in this paper I crave
your indulgence. The prodigious and almost presumptuous task which I
set for myself in attempting to cover such a wide subject in a single
paper has excluded rhetoric and become mostly a statement of cold facts
or opinions.
In conclusion I would like to emphasize the following points:
1.    The necessity for treatment of goitre in children.
The harmful effects of the indiscriminate use of iodine.
The limitation of iodine in adults to the pre-operative period.
The tendency of the simple adenoma to become toxic.
The histological change in the toxic goitre by administration of
Lugol's solution pre-operatively.
The necessity  for surgery as  early in  the  disease  as possible,
before there is permanent cardio-renal damage.
The importance of operating on a falling metabolic rate.
The value of the metabolic rate for diagnosis and in the progress of the case.
The necessity of a most careful pre-operative preparation and
accurate knowledge of the conditions existing.
The importance of  co-operation  amongst  all  those connected
with the management of the case.
The  necessity  of   removing   an   adequate   amount   of   thyroid
tissue.
2.
37
4.
5.
6.
7.
9.
10.
11.
Page 196 <r^/s
•-*ns&M&&rto!
ADRENALIN
INHALANT
For Rapid Relief in Cases of
Nose  and   Throat  Infection
TT then the nose is blocked and the accessory sinuses
yy are closed by pathogenic organisms and the resulting inflammatory exudate, Adrenalin Inhalant usually
affords the patient immediate relief and aids the healing
process by maintaining drainage through its tonic,
astringent effect on the tissues and blood vessels.
Adrenalin Inhalant is also of value in the control of
hemorrhage from accessible mucous membranes. It may
be applied directly to the bleeding surface on cotton or
in the form of a spray.
In rhinitis, pharyngitis, tonsillitis, laryngitis, angina,
hay fever, etc., Adrenalin Inhalant is very useful. It
likewise promptly controls certain forms of bronchial
irritation attended with coughing.
Adrenalin Inhalant is supplied in
l-o%. bottles only.
a?cs
<p«f=
Parke, Davis & Company
adrenalin inhalant has been accepted for inclusion in n. n. r. by
the council on pharmacy and chemistry of the
american medical association
»<3^s||££rS><>=
r»rt^
Page 19) Emergency Service
Given all Medical Men
Knowing how essential the automobile is to the Doctor, we
go out of our way to give the Doctor's damaged car
preference.
BODY FENDER WHEEL REPAIRS
Quick touching-up with Duco Finish
Complete Painting—Duco or Varnish
Tupper and Steele Ltd,
1669 3rd Avenue West
BAYVIEW 138-139
McBeath-
Campbell
Limited
Printers and
Publishers
Vancouver, B. C.
The Owl Drug
Co., Ltd.
Jill prescriptions dispensed
bu qualified Druggists.
IJou can depend on the Ou?l
for utecuracu, and despatch.
IDe deliver free of charge.
5 Stores, centrally located.    We
would appreciate a call while
in our territory.
Page 198  ***** I'V^I'
30<>'
Hollywood Sanitarium
LIMITED
'tfor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference | <%5. Q. <&ttedica\ Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
*©<e
SKSk*
Page 200

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