History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1931 Vancouver Medical Association Jan 31, 1931

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 The Bulleti
^^^B     OF THE   HHHH
Vancouver Medical Association
<A 1)ery 'Diappy VHew year
Contents
Acute Mastoiditis
Laboratory Bulletin
ANNUAL MEETING
CANADIAN MEDICAL ASSOCIATION
JUNE 22—26, 1931
VANCOUVER, B. C.
Vol.   VII.
JANUARY,   1931
Meetings
General—Jan.  6th
Clinical—Jan. 20th Why Milk of Magnesia
mm;  with Petrolagar   Wm
XT is widely and successfully used in
the management of gastric conditions
due to hyperacidity accompanied by
constipation.
Petrolagar - with Milk of Magnesia
(green label) has a prolonged neutralization effect, a low exciting power, if
not an inhibitory action on the
production of HCL.
A combination most acceptable to
internists. Some have reported a
marked reduction in the dosage of
alkalies, otherwise required to bring
about neutralization.
Petrolagar'with Milk of Magnesia
has a soothing and alleviating effect on
granulation tissue or ulcer surface.
Also for general purposes as a laxative, Petrolagar-with Milk of Magnesia
(green label) is preferred by many
practitioners because of its increased
activity over Petrolagar-Plain. This is
due to the presence of milk of magnesia, 8 per cent.
*	
For the convenience o/ the physician in the
treatment of various conditions accompanying
constipationt Petrolagar is issued in four types.
Petrolagar-with Milk of Magnesia is identified
by the number   '3" and bears a green label.
Petrolagar Laboratories of Canada, Ltd.
907 Elliott Street, Windsor, Ontario THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly By McBeath-Campbell Ltd., 326 West Pender St. under the Auspices
of the Vancouver Medical Association in the Interests of  the Medical  Profession.
Offices:
203   V1.-dic.il jrd Dental  Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J.  II. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at  the abov; address.
Vol" VII. " JANUARY. 1931 No. 4
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
Trustees
Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson
Auditors:   Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr.   S.   Sievenpiper Chairman
Dr. J. E.  Harrison i , Secretary
Eye, Ear, Nose and Throat
Dr. N. E. MacDougall    Chairman
Dr. J. A. Smith — : Secretary
Pediatric Section
Dr. H.  A.  Spohn      Chairman
Dr.  R. P.  Kinsman    Secretary
STANDING COMMITTEES
Library Orchestra Summer School
_>t^^t. T-.Tr.i-. Dr. B- P-  Kinsman
Dr. D. F. Busteed Dr. J. R. Davies „ ™.   T    „
t^t^-,,,, T^TTjru^T-. Dr- w. L.  Graham
Dr. D. M. Meekison Dr. J. H. MacDermot Dr C   E   Bro   n
Dr. W. H. Hatfield Dr. F. N. Robertson r»„' t ' t 'u...™
„.^ttt> t-.tac Dr- t- L. Buttars
Dr. C. H. Bastp* Dr. J. A. Smith Dr   q h   Vrooman
Dr. C. H  Vrooman Dr  j  w  Arbuckle
Dr. C. E. Brown                                      Publications
Hospitals
Dr. J. M. Pearson Dr. J. W. Arbuckle
Dinner Dr. j. H. MacDermot Dr. j. A. Gillespie
Dr. L. H. Webster Dr- d- e- h- Cleveland Dr. W. C. Walsh
Dr. J. E. Harrison Dr. F, W. Lees
Dr. E. E. Day                                          Credentials VQN Aivhory Board
ntJl    n^i^j    a Dr. W. S. Turnbull Dr. Isabel Day
Rep. to B. C. Med. Assn.   -^     .   T •» i    T n     u  o   r „
* Dr. A. J. MacLachlan Dr. H. H. Caple
Dr. H. H. Milburn Dr. P. W. Barker Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS,
Total   Population—Estimated   	
Asiatic   Population—Estimated   	
NOVEMBER,  1930
Total   Deaths         171
Asiatic   Deaths  14
Deaths—Residents   only     155
Birth   Registrations     .  365
Female   184
Male       181
INFANTILE MORTALITY—
Deaths under one year of age    11
Death Rate—per   1,000  Births   —- 30.1
Stillbirths   (not  included  in  above)     3
CASES OF CONTAGIOUS DISEASES REPORTED IN
         240,421
  9,3 3 5
,000 of Population
8.7
18.2
7.8
18.5
October, 1930
Cases    Deaths
November, 1930
Cases     Deaths
Smallpox     _   0
Scarlet  Fever      45
Diphtheria      10
Chicken-pox       46
Measles    '-  2
Mumps     4
Wliooping-cough     13
Typhoid Fever   5
Paratyphoid     0
Tuberculosis     19
Poliomyelitis      8
Meningitis    (Epideic)      0
Erysipelas     — 4
Encephalitis   Lethargica     0
CITY
December 1
to 15, 1930
Cases    Deaths
in cystitis and pyelitis
TRADE
PYRIDIUM
Phenyl-azo-alpha-alpha-diamino-pyridine hydrochloride
(Manufactured by The Pyridium Corp.)
MARK
For oral administration in the specific treatment
of genitourinary and gynecological affections*
Sole distributors in Canada
MERCK & CO. Limited
412 St. Sulpice St.
Montreal
Page 75 tHE   PROFESSION   RENDERS  ITS   VERDICT   ON   THE   VICTOR SHOCK-PROOF
Only the Victor Shock-
Proof permits this
Illustration shows the Victor Shock-
Proof X-Ray Unit, Model B, applied
in a manner never before possible
with any other type of x-ray apparatus. Assume this to be an emergency
case, where a radiograph of the head
is desired, and the condition of the
patient preventing transfer to the
x-ray table.With this Victor Shock-
Proof Unit, it is only necessary to raise
the table top, wheel the patient's cart
into position, focus the tube (within
the shock-proof head), and proceed
with the making of the radiograph.
A fluoroscopic examination may be
done with the same facility.
Bear in mind, that in such procedure there is no danger of the high
voltage system coming in contact
with you or your patient, as the
Victor Shock-Proof Units are, as the
name implies, 100<* electrically safe.
'The Shock-Proof has given me a new
conception of the use of x-ray technic"
I HAVE been the proud possessor
of the Victor Type A Shock-Proof
X-Ray Apparatus for almost one year
and can give unqualified endorsement
of its capability and ease of handling,"
writes a Missouri physician.
"As a general practice in which it
has been used, it has been revolutionary in the excellent quality of pictures,
unusual adaptability to any position or
angle, and in the feature of electrical
safety. It is especially satisfactory in
fluoroscopy above or under the table,
or for the unlimited positions at any
conceivable angle or across table. The
apparatus is easily and readily changed
to meet the desired setting, even by
a very small technician as I happen to
have.
"The shock-proof apparatus has
given me a new conception of the
use of x-ray technic. To say that I am
highly pleased with my outfit is scant
praise ... I can gladly recommend
this apparatus to any prospective user
of x-ray equipment."
Let us send you an illustrated brochure and tell you where in your
vicinity you may see the Victor Shock-
Proof X-Ray Unit in use.
GENERAL H ELECTBIC
2012 Jackson Boulevard
FORMERLY   VICTOR
Chicago,IIl.,U.S.A.
X.RAY-CORPORATION
oin us in the Qeneral Electric program, broadcast every Saturday evening over a nationwide N. B. C. network
Vancouver Branch: Motor Transportation Bldg., 570 Dunsmuir Street
L. An Appreciation
NOW, as we stand on the threshold
of our 24th year of service to the
citizens of Vancouver, we wish to
take this opportunity to express to the
medical men of this city our sincere
appreciation of their confidence in our
institution. Such confidence, extended to
u3 throughout these many years, has been
a constant source of inspiration to every
member of our staff.
Leslie Q. Henderson
Georgia Pharmacy ltd.
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H Say It ''With tylolvers
and
For SERVICE, QUALITY and SELECTION
Phone us at Seymour 1484
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H BROWN BROS. & Co. Ltd. I
Vancouver's Master Florists
Private Exchange, Sey. 1484 connects all Departments.
lti 1111111111M1111111111111111111111 i 111111111111*: EDITOR'S PAGE
"SO ENDS ANOTHER DAY"
It is the habit of humanity to regard the end of the calendar year
as a milestone, and perhaps a healthy and profitable habit. To many, it
means the time at which they make good resolutions for the coming
year. It is just a question whether this is of any value, unless one first
takes stock of the past year. Medical men particularly should appreciate
this attitude—for we are taught, and wisely, that the only basis of true
progress is by way of the post-mortem room, and that a true knowledge
■of pathology is the prime essential for a sound conception of therapeutics.
So perhaps a review of the past year will be the best preparation for
our new year resolutions. We commend this idea for the consideration
of our readers.
This is the organ of the Vancouver Medical Association, and its
prime duty is towards that body—to help in its development and growth
of usefulness to its members. Only insofar as the Bulletin does this, is
its continued existence justified and guaranteed. It is not merely a
publication pro gloria, nor one in which we may see recorded our vital
statistics, our post-graduate trips, or even our literary outpourings. Our
conception of the Bulletin is that it should be, if possible, a leader to the
profession, where constructive and educational ideas can be expressed
and developed. The Vancouver Medical Association represents the organized profession in Vancouver, and one of the objects of the Bulletin
should be to intensify and strengthen the ideals of unity and organization amongst the profession—not forgetting that this involves us to some
extent in the unity and organization of the medical profession in a wider
sense. But it is true, too, that as long as we keep this broader responsibility in mind, we can serve our purpose best by perfecting and solidifying our own organization.
And let us make no mistake, we need this organization, and we
need unity, the hardest thing to achieve in the medical profession, it is
sad to think. For, with the new year, we have many problem facing us
as a profession. The vexed question of hospital relations, while, as we
confidently believe, it is nearing an honourable and equitable solution, is
not yet a closed question. And here we would take the opportunity to
say that we welcome Dr. A. K. Haywood as the new superintendent of
the Vancouver General Hospital and feel sure that the confidence that
we have expressed, as an Association, in his sincerity and honesty of
purpose, will be amply justified. The past year has been a sad one for
many of us, in this regard, with its unhappy misunderstandings and
bitternesses—but we are hopeful that these will be cleared away, and the
old friendliness and harmony restored. And in this connection, we feel
it fitting to pay particular tribute to the wise and sane leadership of one
man, Dr. J. A. Gillespie, who has truly won his place in our medical
community, as a temperate and loyal leader.
Then, too, there is the whole question of "charity" practice, opened
up by the attitude assumed by some, at least, of the City Council. This
will need our careful consideration.
Page 76 Again, there is the perennial question of those wolves, who seek by
stealth to "creep in and sneak into the fold." Much as we dislike our
position in this regard, it is our duty to do what in us lies to safeguard
and protect the public, if necessary against themselves.
And lastly, there is the imminent possibility, almost a certainty, of
Health Insurance—which may, overnight, create new situations and
arrangements with which we must deal.
Yes, we must unite, and remain united, and widen and maintain
our organization. There are dangers ahead, shoals perhaps, and reefs,
but we have it in our power to escape these, and come safe into harbour,
if we keep our courage, and our heads.   And so we wish all of our readers
A HAPPY AND PROSPEROUS NEW YEAR.
The Degree of P. G. F. was this year conferred upon Dr. J. A.
Gillespie at the Annual Dinner, and while it apparently came as a complete surprise to the recipient, the ovation which followed its bestowal
bore ample testimony to the high degree of esteem in which Dr. Gillespie
is held by his fellows and endorsed the choice of the Executive for this
year.
CORRESPONDENCE
Canadian Association of Massage and Remedial Gymnastics
(Vancouver Branch)
To the Editor,
Vancouver Medical Association Bulletin,
Vancouver, B. C.
Dear Sir,
The above Association which is a chartered Society incorporated
within the Dominion of Canada, would like to draw the atention of
the Vancouver Medical Association to a few of the principal by-laws of
its Constitution.
1. Not to undertake any case of massage or remedial  gymnastics
except under medical direction.
2. Not to advertise in  any way whatever,  except in  recognized
medical papers.
3. Only Graduates of recognized schools are eligible for membership.
We would like to take this opportunity of pointing out that a
two-year course in physio-therapy has been incorporated at Toronto
University.
It is our aim to keep up the standard of our work on a purely ethical
basis. There are a great many people doing our work in this Province
who are unqualified and unethical in every way.    On the other hand,
Page 77 there may be many qualified workers whom we do not know, and would
like to know. Perhaps the Doctors will be good enough to refer them to
our Secretary, so that we can communicate with them.
In the last three years, our membership has grown from four to
twenty-six.
Yours faithfully,
Ada E. Markham, President
Beatrice Gallop, Secretary
To the Medical Profession.
Doctors become so engrossed in securing the future of the health
of their patients that they, more than any other group of professional
men, fail to secure the future of their personal affairs.
The mere making of a will appointing an individual as executor of
your estate without first investigating the many distinct advantages of
Trust Company Executorship and Trusteeship dos not give the beneficiaries of your estate the proper protection and security for their future.
A strictly confidential service is made available to aid you in working out the details of distribution of your estate at no cost to you and
without solicitation of insurance or any other business.
The estate experts of The Yorkshire & Canadian Trust, Limited, are
at your service for consultation at your office by appointment to explain
the details and many advantages to be derived from trust company administration.
The Yorkshire & Canadian Trust, Limited has been in existence in
Vancouver for over forty years. It has a strong directorate in England
and the two directors resident in Vancouver are George Kidd, Director
B. C. Power Corporation, Limited, and H. W. Dyson, President of the
Trust.
Should you wish to take advantage of this service, please make an
appointment with Mr. W. L. Waldie, Trust Officer, or his assistant,
Mr. E. B. F. Collier, at Seymour 6188.
The Yorkshire & Canadian Trust, Limited,
By H. W. Dyson, President..
NEWS AND NOTES
We offer our heartiest congratulations to our colleague, Dr. William
Elliott Harrison, on his recent marriage to Miss Dorothy Banks of
Chilliwack. The bride was a graduate of the 1927 class of the Vancouver General Hospital Training School. Dr. and Mrs. Harrison spent
their honeymoon on a motor trip to California.
With the customary goodfellowship and conviviality the Annual
Dinner of the Association has once more passed into the limbo of pleasant memories. The crowd—the largest yet to attend one of these func-
Page  78 tions—was handled by the president with his usual grace and urbanity.
Our honoured guest, Dr. A- K. Haywood, gave his imagination full
rein in his reply to Dr. Wilson's somewhat frank dossier of his past,
although he was obviously rather upset by the attire of the Presidentelect of the C. M. A. In an endeavour to keep in step with the present
electrical age, the type of entertainment prevailing in the past was to
some extent departed from. Dr. McJoy's broadcast of bedtime stories
was of infinite value to the Intellectuals, while Amos 'n' Andy, by special
permission of the Pepsodent Company, and Al. Capone, were hot on
our trail. A ride over the bumps of some of our well-known highways
of knowledge showed that the eminent phrenologist has not entirely
wasted his time in attendance at occipital presentations. The address on
"The Medical Profession," delivered in the open, was highly appreciated
as the masterpiece of the profound philosopher who gave it, fresh as he
was from his lion-taming proclivities. "As Others See Us," in black
and white, was well received. The orchestra, under Okey, once more
held us in thrall, whilst the harmony of the quartet was the feature of
the evening. As a credit balance is hinted at, the party may be called
an eminently successful one.
On the occasion of the Annual Dinner, the wives of the medical
men, to the number of eighty, were present at a very enjoyable function
at the Shaughnessy Golf Club, arranged by Mrs. J. J. Mason, assisted by
an energetic committee. Dinner was served at 7 p.m. After dinner the
ladies discussed plans and arranged for a ladies' golf tournament to be
held  one day  during  the   coming  summer.     Later,   bridge  was  played
until midnight.
The evening was felt  to be such a success that  it is
hoped it will become an annual affair.
The North Pacific Surgical Association held its 1930 meeting on
the first Friday and Saturday in December at Tacoma. The attendance
from Vancouver included: Drs. Burnett, Hunter, Lennie, MacLennan,
Monro, Patterson and Storrs. The papers read by Dr. Hunter on
"Diagnosis and Treatment of Papillary Tumours of the Urinary Tract"
and by Dr. Lennie on "Some Observations on the Surgical Goitre" were
among the outstanding papers of the Convention. Dr. Peter MacLennan
was elected President for the ensuing year. The next meeting in 1931
will be held in Vancouver.
Dr. C. W. Prowd spent the earlier part of the month at Los Angeles
where he attended the meeting of the Radiological Society of North
America which was held from December 1st to 5 th. There was an excellent display of new apparatus while the scientific programme was well
up to the usual standard.
Under date of December 8th, 1930, Dr. A. D. Lapp, of Tranquille,
informs us that the Sanatorium will shortly be issuing invitations to all
members of the medical profession in British Columbia, who are in good
standing in the Provincial or Vancouver Medical Associations, to apply
for a short intensive  course  in  tuberculosis  work.     Attention will  be
Page 79 directed particularly to special treatments which have to be carried out
at the Sanatorium at the present time and which might be carried out
at home if men in various centres were familiar with them. The course
will occupy one week and will be limited to ten men. The Sanatoriu
will pay the travelling expenses of those attending. Dr. Lapp hopes to
be able to make this school an annual event. The order of receiving
applications will influence the selection of the classes to some extent, but
an atempt will be made to have it as representative of the various parts
of the province as possible.
Dr. W. Keith Burwell, of Renfrew, Ontario, has recently arrived in
Vancouver and will open an office in the Birks Building about
January 1st, confining himself to the practice of obstetrics and gynaecology. Dr. Burwell graduated from McGill in 1926 and since then has
spent three years in post-graduate work in Paris, Vienna and New York.
He worked for a year with Dr. Thierry de Martel, the celebrated French
surgeon and then went to Vienna for further study in the anatomy and
pathology of his specialty. In New York Dr. Burwell worked for two
years under Dr. George Gray Ward.
Dr. G. F. Strong paid a visit to San Francisco during December to
attend the meeting of the Pacific Interurban Clinical Club on December
12th and 13 th. The Club was inspired by the late Sir William Osier,
who founded the first Interurban Clinical Club which drew its members
from the cities of Philadelphia, Baltimore and Montreal.
Dr. Irlma Kennedy will address the B. C. Academy of Science on
"Personality Study" on January 21st, 1931, at 8 p.m. in the Science
Building, U.B.C.
MEETINGS
A Special General Meeting of the Vancouver Medical Association
was held in the Auditorium on November 25 th to receive a report of the
special committee appointed to interview Dr. Haywood re the Hospita
Survey Commission report and to discuss the hospital situation generally.
Over a hundred members attended. Dr. Haywood was present, with the
full approval of the Board of Directors, and addressed the meeting. He
appealed for the support and co-operation of the Association in his
endeavours to arrive at a solution which would satisfy all parties and
promised on his part to interpret the regulations as broadly as possible
in the best interests of the hospital and of the profession. He strongly
advised the profession against taking any adverse action at the present
time. Dr. fiaywood's remarks were received very cordially by the members present and after he had retired the meeting discussed the matter
generally.    The following resolutions were unanimously carried:
1. "That this Association re-affirms its opinions and suggestions as
expressed in the report adopted without dissenting vote by the
Association on October 6th and that we again request the
Board   of   Directors   of   the   Vancouver   General   Hospital   to
Pag modify the regulations now in existence to conform with the
plan suggested in that report."
"That the Board of Directors of the Vancouver General Hospital be notified that the members of the Vancouver Medical
Association in signing applications for attending Staff positions,
re-affirm their objections to the regulations promulgated in
January, 1930, re Staff cases."
"That our members be requested to send their applications
through the Vancouver Medical Association Secretary."
The December General Meeting was held on the 2nd. Drs. E. H.
Saunders and N. E. MacDougall were the speakers of the evening. Dr.
Saunders spoke on "Acute Mastoiditis" and Dr. MacDougall's subject
was "The Common Cold." Both papers were excellent and much appreciated by the audience.
Dr. Walter W. Kennedy was elected to active membership in the
Association and Dr. J. G. Robertson, of the Hollywood Sanitarium, New
Westminster, was elected an Associate.
Dr. J. J. Mason gave notice of his intention to move, at the next
meeting, for the appointment of a Cancer Committee, to make an intensive study of the disease as it affects Vancouver.
On the following evening, Wednesday, December 4th, the members
had the pleasure of meeting Dr. William Boyd, Professor of Pathology
at the University of Manitoba, and Dr. Emil Ries, the eminent surgeon
of Chicago. , Dr. Boyd gave an interesting outline of the history of the
conquest of Yellow Fever, paying a tribute to William Gorgas and the
men associated with him in this work. Dr. Ries spoke on pseudomyxoma
and illustrated his remarks by some very beautiful lantern slides. This
proved one of the pleasantest evenings of the present session.
Through the courtesy of the Staff, the monthly Clinical meeting was
held at St. Paul's Hospital on November 18th.
Dr. C. E. Brown presented two cases.
Case 1. Retinitis Pigmentosa—Operation. Miss A. M., age
23. History dates back to 17 when she began to complain of gradually
diminishing vision and blurring of objects. This has gradually progressed
to date. Recently has shown loss of weight with lack of energy, poor
appetite and tiredness.
General examination revealed very little of note. Wassermann
negative, blood pressure normal, Hgb. 85' < . Sinuses showed no definite
signs of infection. Slight cloud of albumen in the urine. Gastrointestinal study showed hypochlorhydria in the fractional gastric analysis,
high HCl. content being 6. Barium meal showed some fixation and
stasis in proximal caecum with non-filling appendix.
Page SI Eye examination disclosed a typical picture of retinitis pigmentosa,
arteries being almost threadlike.
Case  presented  preliminary   to   cervical   sympathectomy,   which  is
suggested by the work of Royle of Australia, who has already reported
two or three cases of retinitis pigmentosa which have been treated by
the section of the cervical sympathetic trunk above the second cervical
ganglion.
It is hoped that it will be possible to present the case later with a
demonstration of the value of the operation. The operation was suggested by Dr. Glen Campbell and is to be performed by Dr. R. E.
McKechnie.
Case 2. Recurrent Ulceration of the Throat. Mrs. H. A. B.,
age 32. Chief complaint, recurrent acute extensive ulceration of throat
at about the time of the menstrual cycle, dating back three or four years.
There is a history of dental infections, frequent sore throats, with
quinsy on one occasion and a pharyngeal abscess on another, the occurrence of boils in neck, and chronic inflammation in glands of neck, especially on the right side, with occasional flare-ups, which eventually resulted in a breakdown of the glands and drainage.
A year ago the retroperitoneal glands also showed marked swelling
and were eventually removed by extensive operation and found to be
necrotic. Guinea pig inoculation revealed tuberculosis. Subsequent to
this abnormal operation, which also included an appendectomy and removal of an ovarian cyst, patient's weight increased from 91 pounds to
present weight of 128 pounds, with great improvement in her general
condition, but no relief of the ulcerative condition in the throat.
At the time the cervical glands were giving her most trouble she
became anemic, very weak and emaciated, requiring upwards of twelve
small blood transfusions to carry her over this difficult period. Wassermann and Kahn tests repeatedly negative. Smears from throat reveal
nothing of significance. A fractional gastric analysis recently showed
marked hypochlorhydria and a previous test showed a complete achlorhydria.
X-rays of spine and colon enema revealed nothing of consequence.
Cystoscopic examination and catheterization of both ureters negative.
We have then a patient giving a history of recurrent infections over
a period of seven or eight years, involving skin, teeth, and tonsils. In
spite of thorough removal of the tonsils, there has been a history for the
past four years of acute recurrent extensive ulcerations of the throat.
This has been associated with what appears to be a tubercular lymphatic
glandular involvement in the cervical and retroperitoneal glands. Apparent cure of this tubercular glandular condition, however, has seemingly had no effect on the recurrent ulcerations of the throat.
Physical examination on November 15th, 1930, reveals a fairly
healthy woman, weight \2Sy2 pounds, Hgb. 88%, normal blood pressure
and a slight trace of albumen in the urine, but suffering with an exten-
Page 82 sive ulceration in the left side of the throat, involving the soft palate, the
pillars of the fauces and extending up the pharyngeal wall to the
Eustachian tube.
It is very difficult to ascribe this recurrent ulceration in the throat
to tubercular infection because repeatedly it has shown a very rapid
tendency to recovery, and in spite of its apparent deep nature, heals within a week to ten days, leaving no scar in the throat. Lues has been
ruled out fairly definitely, and on one occasion a small dose of novar-
senobenzol was given with a very severe reaction and it was not thought
wise to repeat it. No local infection has been discovered to account for
the ulceration, its association, however, with the tubercular lymphatic
glands might suggest some allergic reaction. The association with the
menstrual cycle suggests a disturbance in the endocrine system and a
metabolic basis seems to be the most reasonable explanation at present.
Dr. F. P. Patterson showed a case of neglected hand infection. This
was a male, age 2 5 years, a miner, who got a scratch on the little finger
on September 22, 1930. By September 24, 1930 the finger was painful
and swollen with the swelling gradually extending towards the wrist.
By September 27, his temperature was 103°, the pain and swelling was
still more marked and it was not until the 29th of September, when there
was marked bulging, that incisions were made in the lateral side of the
little finger and both sides of the wrist. By this time, however, pus had
reached the forearm and infection had become well established. Six
weeks after onset this case was sent to the hospital. Hand was held in a
rigid flexed position and patient could not move fingers. Discharging
sinuses were present on radial and ulnar side of wrist. Hand opened
along anterior lateral border of little finger and on palm just lateral to
base of little finger. Incisions also made along radial and ulner side of
lower forearm, and extended bluntly between deep surfaces of tendon
sheaths and bones. Previous incisions had been too superficial and had
not opened tendon sheaths adequately.
Dr.. Patterson reviewed signs of tendon sheath infection. First
tenderness along course of sheath in finger, with flexion of the finger,
especially at the base, and pain on extension. If the ulnar bursa be
involved, tenderness follows up along its course. Very little or no swelling occurs in palm, but the back of the hand does swell because the
lymphatics drain from the bursae to the dorsum. Thenar bursa is often
tender because of proximity to the ulnar bursa, and thumb is frequently
involved in from 48 to 72 hours.
Treatment: Rest and heat at first, but when finger becomes
flexed slightly and local signs appear along course of tendon sheath,
incision must be made immediately, and if the infecting organism is the
streptococcus, incision must be made within 24 hours if a good result is
to be expected. Incisions should be made laterally to avoid nerve involvement, and drainage by strips of rubber dam or Pemrose drain, rather than
gauze, should be used. If ulnar bursa be involved an incision may be
made longitudinally in the palm, extending proximally from a point between the heads of the fourth and fifth metacarpals. At thewrist incision must be carried deep just above the interosseous membrane. If
these cases are drained within one or two days, a good result is usually
Page 83 obtained, although most of them will have some disability. Hot baths
and moist heat are not to be recommended after 24 hours to 48 hours,
but if the pain increases and there is danger of systemic infection, they
are useful to help wall off the infection, otherwise one should use dry
heat with early active and passive motion.
Dr. T. H. Lennie then presented a case of general peritonitis from
perforation of the bowel, which was interesting because it gave a demonstration of human endurance and of what may be accomplished by
conservative treatment.
The patient was a Finlander, 35 years old, robust, admitted to hospital on September 9, 1930. Two weeks previously had been taken off
his boat up the coast and operated upon for right femoral hernia, which,
had strangulated two hours before operation. On admission to hospital,
on September 9, 1930, patient was very toxic, abdomen distended and
acutely' tender on both sides and fever was high. Had had a bowel movement 24 hours previously. Taken at once to operating room; incision in
mid line. On opening abdomen bowels were found matted together and
covered with lymph. No free pus present. About the old hernia wound
adhesions were more strongly organized, and upon separating these a
small perforation was disclosed in the bowel, from which pus poured.
This was evacuated by aspiration and as his condition was poor nothing
was done except drainage by three soft rubber drains. A jejunostomy
was done by the Witzel method, a No. 24 catheter being inserted in
the bowel. By the following morning one-third of a large bottle was
filled with pus and one-half bottle was filled with fluid. The jejunostomy
tube was removed in four days, and wound closed quickly. The patient
began to discharge faeces through the old and new incisions in the
lower abdomen, requiring continuous changing of dressings. He next
developed a phlebitis in the left leg, followed by infarct in the left lung
followed by an abscess in the left upper lobe. In a few weeks his abdominal wounds closed entirely and he was well except for the lung
abscess which has been treated conservatively.    Patient is doing well.
Dr. Vrooman stated that there are multiple abscesses in the left
upper lobe and the patient is coughing up a foul sputum. The conservative treatment used consists chiefly of postural drainage and forced feeding. The question arises: "should the lung be collapsed? Dr. Vrooman
thinks not because the patient apparently forms pus easily and it might
set up an empyema.
Dr. Prowd reviewed the X-rays of this case and drew attention to
the increase in the heart shadow caused by debilitated condition.
Dr. E. J. Gray next presented a case of peptic ulcer which was
interesting because of its large size. The case was of a male, 26 years of
age, whose father had died of cancer of the stomach. For the past two
years this patient had suffered from stomach symptoms, chiefly pain.
Since March, 1930, weight had dropped from 162 to 138 pounds, and he
was in a very weakened condition with no appetite and constant pain in
the epigastrium which bore no relation to food. Urine negative; R.B.C.
4,750,000; Hgb. 87%. Gastric analysis showed an increase in the fasting residue and a negative HCl.   X-rays showed the whole cardiac part of
Page  84 the stomach involved in a large ulcer with a considerable inflammatory
area about it. This patient was put on a' Sippy diet and in four months
had gained 12 pounds and other symptoms had subsided. Blood picture
improved; emptying time of stomach was two hours and there was a
normal fasting gastric residue with no HCl. present.
Dr. Spohn presented two cases of enlarged thymus. The first was
a baby of a normal delivery at full term, who at four months showed
good development. Its nurse, however, stated that although its colour
was good, at times she could hear a gurgling noise in the throat usually
at feeding time. No cyanosis, no history of collapse, no respiratory distress, in fact it appeared to be a well child but X-ray showed an enlarged
thymus gland. This case was treated by X-ray and in two weeks had
improved.
The second case was of an eight months child weighing 5 pounds
6 ounces at birth, whose robust mother had suffered from a slight kidney
trouble during pregnancy. Dr. Spohn saw the child four days after
birth. It was puny and the colour was good, but it had recurring attacks
of cyanosis. It was thought, at first, that these might be due to an
enlarged thymus or mucus or a weak heart, but X-ray showed no thymic
enlargement. Baby went home after three weeks in hospital, having gained
well, but at intervals showed slight roughness of respiration or wheezi-
ness with very slight cyanosis. After the first month these attacks were
even less marked but the nurse still noted a definite spell. When three
months of age another X-ray showed a thymus almost three times larger
than before. After three full treatments the case cleared up entirely.
Dr. Spohn feels that some children suffer, from a toxic thymus as some
adults suffer from toxic thyroid and often bad symptoms occur with
small thymuses and few symptoms with large ones.
Dr. Hunter asked how thymic deaths are explained. He had noted,
at autopsy, cases of enlarged thymus glands, petechial haemorrhage in
the thymus, pericardium, along the coronary vessels and on the pleural
surface. He asked if these deaths have anything to do with the innominate vein or the inter-clavicular ligament and whether pressure does or
does not play a part. Dr. Hunter also asked if all thymuses, with symptoms, show enlargement on X-ray.
Dr. Spohn replied that the cause of death is unknown. Symptoms
have occurred in cases where there is no large shadow while on the other
hand an enlarged thymus is not always indicative of the type of symptoms. In several cases no thymic enlargement has been visible but everything else being excluded these were treatd with X-ray and improved
clinically. The size of the shadow can, therefore, only be taken as an
indication. There is a close anatomical communication between the
thyroid and thymus. Williamson has shown that the secretion, and
possibly that conditions of the thymus, are similar to those of the thyroid.
Some children, who have died thymic deaths, have shown small thymuses,
but hyperplasia of other lymphatic glands. We must not be too dogmatic but we do know that treatment of the thymus gland by X-ray
saves life. Dr. Spohn also said that he never saw a case treated by X-ray
which showed damage subsequently to the thymus or thyroid gland.
Page 85 There was some discussion on the treatment by Kirkham of St. John,
who claimed to have reduced the amount of X-ray treatment necessary
by giving calcium chloride during the treatment. Dr. Spohn felt, however, that in the past these cases have been given more treatment than
was necessary and he said that while he has known of cases to die after
one treatment, he has never known one to die after two treatments.
They used to be given six or seven treatments, now they are usually
given three, and even this might be diminished. Dr. Prowd stated that
only a small X-ray dose is required as the thymus is very sensitive to the
ray and other tissues are not affected.
Dr. C. A. Eggert said that the same ideas that we have are entertained by the clinics of Europe. What causes the attacks is not explained. He knew of one child who had four treatments and died apparently
a thymic death; at autopsy the gland weighed 15 grammes.
Dr. Hunter felt that if these cases do not show haemorrhages at
autopsy, as above stated, they are not thymic deaths. He also felt that
X-ray diagnosis does not help much, but that clinical symptoms are
important.
Dr. Spohn cited a case of a child, four months old, where the father
had been called home two or three times a week to find the child white,
panting for breath, in collapse and apparently dying. It was treated
with X-ray and in eight weeks was entirely well.
Dr. A. Y. McNair presented an interesting case of ruptured aneurism
of the abdominal aorta.
SOME OBSERVATIONS AND ADVICE IN
ACUTE MASTOIDITIS
By Dr. E. H. Saunders
History is essential to the philosophy of any branch of medicine,
and is today justly receiving increasing attention. It is to the Egyptian
civilization that we must turn, which dates so far back beyond that of
Greece and Rome, as to make it, by comparison, a matter of yesterday.
The schools of Alexandria, fathered by Ptolemy Sotor, King of Egypt
(B.C. 285) were the first to systematically study and teach anatomy,
but all the knowledge gathered by them was destroyed in the sacking
and burning of the Alexandrian libraries by the Crusaders in 640 A.D.
With this destruction went the anatomical and surgical treasures of
mediaeval Egypt and the spirit of man was content to mark time for
over 1,000 years.
Some of the practical knowledge of the Alexandrian school, however, remained.    Ligation of the arteries for the arrest of haemorrhage
with silk and catgut, is well noted by Celsus in 50 B.C.    He refers to
this surgical procedure, not as a new discovery, but as a matter of cur-
Paper read before Vancouver Medical Association, December, 1930.
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Medical-Dental Building Vancouver rent practice, and Galen (150 B.C.)  tells where silk and catgut can be
obtained and explains how they are to be used.
Now the writings of the ancients show a knowledge of the broad
clinical facts in diseases of the ear. Hippocrates (460-350 B.C.) devotes
a great deal of attention to the ear, and his observations are not inferior
to the wisest of today. On one occasion he calls atention to the peculiar
facial expression of the adenoid patient when he says, "of those who have
pointed heads some have the neck strong and robust, both as to the
bones and the rest of the body, but suffer from headaches and running
ears, and these have slightly arched palates and irregular teeth."
Listen again to his clinical description of a young girl, twenty years
of age, who, while playing with another young girl, received a blow with
the flat of the hand over the side of the head. Immediately she became
unable to see and respiration was suspended. As soon as she got home
she was seized with fever and pain in the head; red tinged pus escaped
from her right ear and she was much relieved and seemed to be improving. Later on fever became more intense, she became drowsy and did
not speak, the right side of the face was contracted, there was dyspnoea
with spasms and twitching, the tongue became embarrassed and her
eyes fixed.    The ninth day she died.
Celsus (50 B.C.) also devoted a chapter to ear diseases and clearly
appreciated the gravity of ear inflammations. After his time, and up
to the 14th century A.D., there is very litle information recorded. The
use of the ear speculum with the aid of sunlight appeared about 1575
A.D. It does not appear that reflected light by a mirror was employed.
This principle was not applied to the head mirror until after Helmholtz
discovered the ophthalmoscope, only then was reflected lamp-light used
to illuminate the membrana tympani.
The revival in the 16th century of systematic anatomical study is
marked in the aural department with the names of Vesalius, Eustachius,
Fallopius,—all of whom paid a great deal of attention to the ear, while a
short time later, Valsalva, Morgagni and Scarpa stamped their names on
its anatomical history. Valsalva was certainly acquainted with the
antrum and mastoid cells when he says—"The mastoid sinus forms a sort
of cave communicating with the smaller sinuses of the mastoid bone,
and serves as an annex completing the tympanic cavity, with the upper
part of which it communicates by a fairly large opening, as is evident
on careful inspection. I therefore do not regard the mastoid sinus as
distinct from the tympanum but as united and amplifying it."
The first book on Otology was printed in 1683 by De Verney. In
1724 Guyot proposed to the French Academy of Science to inflate the
tympanum by means of an instrument introduced through the mouth,
and in 1741 Cleland used the nasal route to pass the Eustachian catheter.
J. L. Petit in 1760 successfully opened the mastoid for relief of
suppuration due to caries, but the operation soon fell into disrepute, for
he died after the operation had been performed upon himself. However,
he was the first man to advocate early opening of the mastoid process for
evacuation of pus.    He wrote, "These abscesses may persist a long time
Page 87
usmu before they cause death, but from the very beginning of their formation
they ought to be opened." A short time after, in 1776, Jasser operated
on a mastoid to evacuate pus and cure deafness. He bored a hole in the
bone, fitted into this a nozzle of a syringe and forced lotion in to drive
out the pus. He had some success, but after Berger, the Danish court
physician on whom this operation had bene performed on account of
tinnitus and deafness, died, the operation again went into the discard.
In 183 8 De Zeimeris wrote in its defense. He reviewed the liter
ture, including Petit's and Berger's deaths, pointing out that adverse
criticisms were unfair and that the operation had many merits and should
be encouraged. It took many years, however, before its value was stabilized and appreciated, and in 1860-1870 it became recognized as the
proper surgical procedure. It thus took centuries to evolve and establish
the idea of opening the mastoid process for the evacuation of pus.
This long period of "groping for the operation," as wc might call it,
was brought to an end by the able work of Wilde (Dublin), Toynbee
and Hinton (London), Von Troltsch and Schwartze (Germany), and
thus mastoidectomy is now very much on the surgical map.
Mastoiditis has come now to be rather a broad term with no strict
anatomical limitations, including not only inflammations of the pneumatic cells of the mastoid process proper, but all extensions into the
neighbouring cells of the zygoma, occipital, squamo-temporal and the
petrus portions.
Tonight I would like to deal with the conditions under three heads:
(1) Prevention.
(2) Symptoms.
(3) Treatment.
Now the prevention of mastoiditis, as in all branches of preventative
medicine, does not get its proper amount of attention, praise and reward.
It is unfortunate that neither the patient nor the doctor can accurately
measure, view or compare, the grief and suffering they surely escape by
sharp and efficient preventative measures. The major part of successful
prevention starts before inflammatory processes of the ear begin. It is
an absolute and incontrovertible fact that a healthy pharynx, nares, and
naso-pharynx is the first and greatest essential factor in the prevention
of ear troubles. Inflammatory conditions, either acute or chronic in
these structures, are always potentially ear involvements.
And why not? What more could you expect, when you remember
that the Eustachian tube, middle ear, mastoid antrum and cells have one
common embryological origin with the pharynx and naso pharynx. That
means all your mucus membrane, lymphoid tissues, blood vessels, lymphatics, connective and supporting tissues are intimately interwoven,
springing from the same foundation in life. This common source is the
first branchial cleft which pushes a wing-like diverticulum in between
the membrane obturator and the labyrinthine capsule or what becomes
later the membrana tympani and the bony labyrinth of the internal ear.
At first it is simply a slit-like connection, but as the embryological development continues, the connection with the first branchial cleft be-
Page 88 comes the Eustachian tube and the wing-like diverticulum becomes the
middle ear, antrum, and cells of the mastoid.
At birth these are filled with a myxomatous tissue which is covered
with cuboid epithelium. This gelatinous material soon absorbs, and in so
doing leaves the chorda tympani and the rudimentary ossicles attached
in their permanent location, and develops later into their permanent
ligaments. As this embryonic mucoid tissue is absorbed the cuboidal-
type cells change to endothelial cells, one or two layers in depth, covering the submucus tissue and lining the air cells, first of the tympanum
and its recesses, then the antrum and its communicatory cells.
Now, knowing this embryological fact, we must cease wondering
why the middle ear is so easily involved in nasal and pharyngeal disturbances. Developed from the same embryologic tissue, in close, wide open,
and direct communication, lined by the same mucus membrane, supplied
by the same blood vessels, lymphatics and nerves, it is a wonder to me
that the middle ear escapes as often as it does.
Acute inflammatory disturbances of the throat manifest themselves
early in the ear. So long as these parts remain healthy the micro-organisms are powerless, but when the resisting powers of the middle ear structure are lowered, these ever present organisms give rise to inflammatory
phenomena, that vary in intensity according to the virulence of the infection, resistance of the patient, or previous phlegmasia of the middle
ear.
Measles, scarlet fever, diphtheria, typhoid fever, and smallpox are
prolific sources of middle ear troubles and in fact any infective condition
of the mucus membranes elsewhere in the body can be demonstrated in
the middle ear. To any who doubt the very constant involvement of
the middle ear in any and all inflammatory conditions of the nasopharynx and nares, it will be an eye opener to make a routine examination of the middle ear at this time.
Often acute inflammations of the middle ear are caused by mechanical means, such as accidental entrance of liquid through the Eustachian
tube. During the summer months it is a common occurrence and has
been traced to and has developed at our beaches. The act of blowing the
nose while swimming should be absolutely stopped. Salt water loaded
with sewer contamination is forciby driven up the Eustachian tubes into
the middle ear by expulsive force while you intermittently open and close
your nostrils. Infect virgin soil with inflammatory organisms and you
are lucky to escape without a mastoiditis. There is nothing to stop the
wide spread of the inflammation. Attacked by this infection, without
one moment's preparation and before the protective lymph bodies can be
brought into the fray, the whole mastoid process is involved before it
can be stopped. I advise all swimmers, if water enter the nose, never to
blow, but forcibly inspire, catching the infecting liquid in the mouth
and expectorating.
Another common source of ear infections is the positive pressure of
the nasal douche. This forces the liquid into the one postril with enough
pressure to drive it out of the other.    But before doing so it runs into
Page 89 all nooks and corners, dropping into the orfices of the Eustachian tubes,
waiting a little extra force to enter the middle ear. Negative pressure
douches or inhaling at the time of douching is a better procedure and is
fairly safe, but I make it a rule never to blow the nose while douching
and for some time after; in fact I think your nose was put on your face
for other reasons than to blow. In the erect position the floor of the
nares is tipped backwards so all secretio nnaturally flows that way. In
blowing the nose the force of the air goes up to the vault, around the
upper turbinate and then down, guided by the roof of the nose. I have
often endeavoured to have patients clear pus from the floor of the nose
by blowing, not accomplishing my object; they could easily dislodge it
by inspiring.
Strict attention must be given all defects, abnormal, and inflammatory conditions of the nose and throat. The incidence of mastoid
troubles is greatest in the first fifteen years of life—the years of small
and imperfectly aerated nasal and naso-pharyngeal cavities, most of them
obstructed by lymphoid growths, always enormously enlarged by any
and all the inflammatory processes that youth is heir to.
It is pretty well accepted now as a pathological fact, that the normal development of the mastoid process and the Organ of hearing is
interfered with at any stage by the presence and effects of local inflammations and obstructions in the nares and naso-pharynx. The development of the pneumatic cells of the mastoid takes place during the second,
third and fourth years ,and if, up to the fifth year, ventilation of the
middle ear cleft is obstructed, we get an incomplete development of the
middle ear and mastoid process, with chronic abnormal thickening and
phlegmasia of the mucous membrane, favouring and inviting inflammatory processes both chronic and acute. It is therefore important for
normal development and pneumatization of the middle ear and mastoid
process that no obstruction to a free and patent Eustachin tube exist
at any time in these years. Now this means removal of tonsils and
adenoids before five years of age. I think I am honest when I say I
believe it would be better if no tonsil or adenoid were left in a child's
throat. I believe it would be better and safer if they all came out, irrespective of whether at the particular time of examination you can find
disease or not.
On account of the overwhelming evidence, no one can dispute the
fact that tonsils and adenoids should be removed in acute otitis media
conditions. It is the mild low-grade catarrhal otitis that escapes recognition, and this is where we slip. There is much mild catarrhal inflammation of the middle ear in early childhood that escapes attention, and
mal-development of the middle ear is slowly being produced by obstructed and imperfect aural aeration. Later in life impaired hearing develops,
when no amount of treatment or any operation will arrest the onset of
deafness. Possibly no amount of argument or persuasion would have
brought the parent of this now adult patient to have had its tonsils and
adenoids out on such trivial and trumped up symptoms. You would
probably be accused of only seeing the financial gain for yourself. But I
advise you to visualize all the adult deafness you know and increase your
desire to remove more tonsils and adenoids in childhood. It is the unsuspected tonsil and adenoid that causes grief.    Please do not understand
Page 90 me to say that I believe tonsillectomy and adenoidectomy to be a cure
for all ills, but I have seen so much benefit and improvement in young
and old alike after the removal of tonsils and adenoids, thought at the
time to be fairly healthy, that I have come to consider them a menace
at all times and liable at any time to change a normal into an abnormal
metabolism.
I once heard a very ingenious explanation of the presence of the
tonsil by Perry of Seattle. He said he believed the tonsil to be a systemic
gland, so situated in the throat that sooner or later it had its covering
of palato-glossus and palato-pharyngeus destroyed. Its capsule once
opened, it was immediately exposed, falling a prey to all throat infections. With me this about fills the bill as far as the value of the tonsil
is concerned. Now I hope I can get my first point over and it is this:
that the greatest source of prevention of ear troubles is a healthy nares,
naso-pharynx and pharynx in childhood.
If your throat has been neglected, and an acute attack of inflammation hits your lymphoid structures, you must at once consider your
ear a party to this same inflammation and if pain is present in the ear
act quickly. Let us go back to Hippocrates again and listen when he
says, "acute pain in the ear with continued strong fever is to be dreaded.
Since then this is a hazardous spot one ought to pay particular attention
to all these symptoms from the beginning." Never mind your ear canal,
I have seen more harm than good done to it, and I think Hippocrates did
too, for he says, "It is a good remedy sometimes to apply nothing at all
to the ear."
Some of you rush to 5% carbolic and glycerine, enough carbolic
when constantly applied and held in a closed canal to destroy any epithelium, filling the canal with a big, moist plug of epithelial debris,
burning deeply, producing swelling and tumescence. The membrana
tympani, drowned in liquid, air excluded from it, inflamed and with
pressure from within, can do nothing but rupture.
If you stop to think, you know you cannot stop the lancinating pain
with any ear drops. Your pathology of this condition tells you the pain
is due to swellings and tension in the Haversian system of the bone and
its overlying musoperiosteum of the whole mastoid process. When you
remember pain is due to local rise of blood pressure in unyielding bone,
your first endeavour would be to reduce that pressure. The quickest and
best way is diuresis and diaphoresis. Sweating especially, must be sharp
and prolonged, only letting up when your pain ceases, and another rule
to be strictly enforced is to keep the patient in bed 48 hours after the
last ear-pain ceases. A very common mistake, and one that gets you and
the patient into trouble lots of times, is letting them up the next day
and possibly to school, for the second night the pain usually returns with
renewed violence.
You now have a changed condition in the ear, serum is now present
and you pass into the second stage, which is more difficult to treat without lancing the drum. As I go along I am getting less inclined to lance
ear dsums. I know I am approaching dangerous ground and I would
rather be called a heretic than have my confreres shake their heads and
say: "Too bad, old Saunders is slipping." However, when you remember
that the normal tympanic cavity, like the bladder, is sterile, and you
Page 91 study with Preysing, who found in a series of one hundred and fifty-four
temporal bones in children under two years of age that thirty-three were
sterile, ninety-six showed a straight culture of pneumococci, and twenty-
six only mixed infection, you well might have ground to hesitate before
lancing. Pneumococcus, as you know, has a self-limited life cycle of
from three to nine days. Relieve your pain by appropriate treatment
and leave the pneumococcus in a pure culture. You will often be surprised when you see how an acute bulging ear drum will subside.
I have seen so many unattended ear drums rupture and a sero-
sanguineous fluid escape for a day or so, then heal themselves without untoward symptom, that I began to wonder. Again I have seen many
lanced and the same sero-sanguineous fluid escape with the same history
of healing. It is the other class, that shows the same sero-sanguineous
fluid for two days after lancing, then changing to frank pus, that raises
the thought of secondary infection in an ear that might have subsided
under expectant treatment. If pus is present in the middle ear please
understand me to say "lance," but if we are not reasonably sure of this
condition I think it is a mistake to do so. We all know that you
strenuously fight any thought of opening synovial or serous cavities
containing fluid that is not surely infected with pus organisms.
I cannot be too forceful in advising you that after lancing an ear
drum the real work begins. To lance an ear drum and leave the ear
canal filled constantly with pus is criminal. Here cleanliness precedes
godliness, and "religiously clean" is the demand. It is a personal question,
and worst of all a dual personality—parent and doctor. If either or both
fall down in cleanliness, God help the ear, for it is only He that will
pull you out.
Now we will not get mixed up in the hot discussions on the histo-
pathology of mastoiditis, for tonight we care very little whether the
onset and initial stage of mastoiditis has its origin in the Haversian
system of the bone or begins first in the muco-periosteum, nor do we
wish to enter into an argument and attempt to settle whether mastoiditis
is a genuine empyaema of the mastoid with resultant caries, or a caries of
the mastoid cells first and resultant empyaema.
Even the term mastoiditis is said by one school to be wrong, but
most big clinics and men call it by this term and it pretty well fills the
bill.
Much work has been directed toward the pathogenicity of the
various micro-organisms that produce mastoiditis, but it has been disappointing. No one set of "bugs" can claim the field exclusively.
Streptococcus haemolyticus has proven itself the most dangerous as
regards intra-cranial complications and is always found in scarlet fever
and to a less extent in influenzal mastoiditis. The type of microorganism has little influence on the increased liability of the bone to be
affected, nor are any clinical symptoms in direct relationship to the kind
of organism present. Among the offending micro-organisms, staphylococci, pyogenus and aureus, streptococcus-haemolyticus and mucosus
and pneumo-coccus may be found in single or mixed infection. Very
often one can designate the cocci present by the character and consistency of the discharge. All pus from acute mastoiditis is odorless, from
chronic very  foul.     A  thick  stagnant  pus  and  quiet   course  denotes
Page 92 staphylococcus mucosus, a pulsating, violent, profuse discharge marks it
as a staphylococcus pyogenus, and a bloody, thin discharge is due to
streptococcus haemolyticus.
The diagnosis of mastoiditis is made from a set of complex symptoms, and is only arrived at through the composite picture of all symptoms, often a very small one deciding the picture. Not that the
symptoms of mastoiditis are by any means vague, each symptom has its
own sharp identity but nevertheless it is a composite picture that decides
us. Some cases run a sharp, painful, fulminating course, while a more
serious case may be quietly eroding the inner table of the process, producing lateral sinus thrombosis, pyaemia or septic pneumonia. Continued
pain after the ear is running freely should be considered serious, but the
ear may never run one drop and much pain be present. Tnederness over
the mastoid is very often present in a simple acute otitis. The periosteum
of the mastoid cells is continuous with that of the middle ear, and is
subject to the same attacks of inflammation. If your external table of
the mastoid process is thin, any pressure on it is easily conveyed to the
painful and swollen cells below. Relieve the pressure in the middle ear
and your external tenderness will disappear. Another case may have such
an ebonized overlying external plate, that no amount of pressure can
react on the cells, and you get no tenderness.
Profuse escape of pus is suspicious, you must remember that the
middle ear itself is small and its pus-producing capability is limited. If
the discharge continues after good treatment for over four weeks, the
mastoid should be opened up. This is imperative if you wish to save
the child's hearing. No mastoid operation in acute mastoiditis hurts the
hearing. This is done by the discharge before operation, for the operator
does not touch the middle ear, membrane or ossicles.
So if you only get one thing from these rambling notes please get
this: Do not let a child's ear run more than six weeks, or deafness will
surely follow it all the days of its life.
It seems funny, but fever is a very unreliable symptom, often adults
have no fever whilst in children the temperature may only remain up
as long as they are in the acute inflammatory stage. There is one symptom that will immediately cause a mastoid to be opened up, and that is
a chill. Remove the other causes, of course, and you will find a
peri-sinus abscess or sinus thrombosis. Be sure to treat a chill in a person
with a running ear as a death notice. A perfectly normal membrana
tympani does not exclude a mastoiditis which may terminate fatally, as
they have done.
Now treatment of mastoiditis is operative whether acute or chronic.
In the acute, fulminating type you are forced to operate at once to relieve symptoms otherwise untreatable. If the ear persists in running
after continued and satisfactory treatment you must operate. No ear
should run more than four weeks, any and all ears that give a history of
chronic discharge or repeated attacks of discharge for a few days only
should be opened up. Not a drop of pus should be left in them at any
time. It is very much of a danger and many have paid with their life
for procrastination. I leave the particular method of opening, clearing,
and closing the mastoid process to the surgeon. You have listened to me
already too long.    If I were to proclaim one method better than the
Page 9} other I would pull the heavens  down upon us,  lightning and  thunder
would fly, and like Omar Khayyam you would say:
Myself when young did
Eagerly frequent
Doctor and Saint, and heard
Great argument; but
Evermore
Came out by the same door
As in I went.
ABSTRACTS
The British Journal of Surgery for October, 1930, brings its usual
wealth of excellent material which will amply repay the reading. D.
Stewart Middleton publishes an exhaustive and copiously illustrated article
on "The Pathology of Congenital Torticollis," of interest to all orthopaedists and those so inclined. "The Anatomical Result of Peri-arterial
Sympathectomy" a careful study by Blair, Duff and Bingham, should
be studied by all surgeons as this is a procedure that is coming into more
common use as time goes on. "Osteoplastic Craniotomy" both historical
and modern, is splendidly reviewed by Lambert Rogers. This includes a
description of an interesting new technique.
While we cannot always subscribe to the views on fractures propounded by Ernest Hey-Groves, nevertheless, the piece de resistance of
this number is probably his contribution to "The Treatment of Infected
Open Fractures." This brings up questions that have disturbed the
reviewer for some time. He states three broad principles that should be
observed in caring for cases of this kind.
I. Every infected fracture should be treated with the same care as
would be given to a case of penetrating wound of the head or the
abdomen. The full surgical team should concentrate on the problem,
the pathological and radiographic services should give the necessary cooperation.
II. This extensive examination and treatment should take place
at once, with no more delay than is permitted in the case of a ruptured
gastric ulcer.
III. The ultimate treatment of the fracture should be carried out
in such a way as to assist and not endanger the primary object of curing
the infected wound. Unless or until the infection has been cured drainage
must be provided, and the infected tissues must not be left loaded with
foreign bodies. The limbs must be put up in such a way as to give
every assistance to free circulation of blood and lymph. Dr. Winnet
Orr appends an interesting case history to the article.
The B. M. J. for October 11th, and the Lance of the same date
each carry a classical address by Lord Moynihan, the president of the
Royal College of Surgeons. In the former, he deals with "Surgery in
the Immediate Future"; in the latter with "The Science of Medicine."
The style, diction and substance of these articles by Lord Moynihan are
synonymous with perfection. We will not attempt to give the gist
of these two gems but would suggest that for an entertaining hour to
be spent along a little less frequented path in our reading, these cannot
be excelled.—D. M. M.
Page 94 British Columbia Laboratory Bulletin
Published irregularly 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
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 fifteenth day of the month of publication.
Vol. V.
JANUARY, 1930
No. 1
CONTENTS
Erratum    Hill
B. C. Tularaemia Ootmar
Hereditary Susceptibility in Tuberculosis {Abstract)
ERRATUM RELATING TO
"CHANGES IN LABORATORY SERVICE"
By H. W. Hill, M.D., Director
V. G. H. Laboratories.
(Vancouver Medical Association Bulletin, December, 1930)
In the table, page 74, demonstrating increase in the V. G. H. Lab.
work in 1930 over that in 1929, the dates (1930-1929) are inverted,
indicating apparently a decrease. These dates should be reversed to show
the facts which were—increases in 1930 in the gross total and increases
also in all the individual items except that of urines.
B. C. TULARAEMIA CASE REPORT
By G. A. Ootmar, M.D.
Provincial Board of Health Laboratory, Kelowna, B. C.
In the late spring of 1930 I received word that several rabbits had
died in some remote parts of the district and, suspecting tularaemia, I
asked for specimens of the dead animals. Meeting Mr. Eric Hearle from
the Entomological Laboratory in Kamloops he told me that he was very
interested in the disease and I had the pleasure of seeing him with Dr.
Parker of the Laboratory of Hamilton  (Montana)  in Kelowna.
In September I got a letter from Mr. Hearle that on a recent trip
to the Kootenay district, he located a case which appeared to be tularaemia, and that he would arrange to send a sample of blood to our
Laboratory.    This arrived October 24, 1930.
Page 95 We had made an emulsion of our tularaemia culture (grown on
glucose cystine agar slant) with normal saline to which o.2% formalin
was added, the suspension having such a turbidity that in a test tube
10 mm. in diameter a clear type can just be read through it.
The further test is done as for the macroscopical Widal and the
tubes are incubated in the incubator (for want of a waterbath) for two
and one-half hours, after which the tubes are placed over night in a cold
room.    We secured agglutination up to 1/80.
On account of the cross agglutination between B. tularensis,
abortus and melitensis we tested the blood for these, but found it negative. As this was the first time we have found a positive tularaemia we
wished to have it confirmed by Dr. Parker, who is a specialist on
tularaemia and Rocky Mountain fever. His answer was that the serum
forwarded gave a good positive test for tularaemia; he found complete
agglutination for tularensis in all dilutions up to and including 1/80
and partial agglutination in dilutions of 1/160 and 1/320.
He also found the serum negative for Brucella abortus.
The particulars of the case are:
On the evening of August 10th, 1929, the patient was bitten
by a deer fly. On the following morning there was marked redness
and swelling at the site of bite. Three days later he developed a
high temperature and some ulceration on the side of the nose. The
condition was diagnosed as erysipelas. He was moderately ill for
three weeks at the end of which time the local condition practically
subsided. Then he developed severe pain in the left kidney region,
ran a high temperature and was critically ill in Calgary. On October 7th he had a peri-nephritic abscess opened and drained, about
\l/2 pints being obtained. After three month in hospital he made
an uninterrupted recovery.
As far as we know this is the first case of tularaemia definitely recognized by agglutination tests in B. C. In all known cases it is mentioned that at the site of the bite of ticks or deer flies, ulceration
occurs; which ulcer appears as if made with a punch (clear, cut margin).
In this case the infection was caused by the bite of a deer fly. The
most common sources of infection are the handling, skinning or dressing
of rabbits (jack, cottontail, snowshoe) and the bites of woodticks and
deer flies. Other less frequent sources are the skinning or other manipulation of wild animals other than rabbits, especially other rodents. The
bites of such animals convey the infection; in the case of ticks, the tick
excreta (usually rubbed in eye). Cases are quite common among persons
handling sheep. There are probably other sources that have not yet been
determined.
HEREDITARY SUSCEPTIBILITY IN TUBERCULOSIS
{Being the "Conclusions" of the Report on "Tuberculosis amongst
the Indians of the Great Canadian Flams"; R. G. Ferguson. "Transactions of the Fourteenth Annual Conference of the National Association
for the Prevention of Tuberculosis")
The following conclusions are here reproduced because of the general confirmation they give to the hypothesis of Hill   (H. W.)   on the
Page 96 Epidemiology of Tuberculosis. (See Vancouver Medical Association
Bulletin of August, 1930, Vol. 10, No. 7.) The italics are the Editor's,
not the Author's.
1. The Indians of the Plains are universally tuberculized. The
epidemic is now on the wane. The mortality is still twenty times that
of the surrounding white population.
2. There has been no loss of infectiveness, as seen from the fact
that over 90% of the school children react positive to tuberculin.
3. There has been no apparent loss of virulence, as shown by the
fact that three out of four deaths among a group of 15 cases of recent
infections occurred within five months from the time they had been
examined and found to have had no active disease.
Until recently the Plains Indians have consumed little milk or milk
products. Their cattle are more or less tuberculized. 7% reactors were
found at File. Hills, one of the reserves under investigation.
4. The type of germ, so far as indicated by typing of 15 specimens of glandular material, is human.
5. The type of disease among the survivors still falls into two
distinct classes with widely varying resistance:
First, running rapidly fatal course.
. Second,, .reacting well with localized pulmonary or glandular lesions,
and in no way differing from white children. Among these Indians
this appears to be an individual trait, rather than family or generation
trait.
6. Among the bands studied, survival was assured to family trees
which were more prolific and more resistant to white man's diseases in
general rather than to those naturally resistant to tuberculosis.
In the process of civilization just oyer every second family tree
has died out within three generations. Among the families eliminated,
31% died of tuberculosis compared with 19 %, among families which
have survived.
Family resistance to tuberculosis was found to vary in degree, but
practically all families suffered from the disease. The exceptions (those
apparently naturally resistant), as also those susceptible to the extent of
extermination by this disease alone, were unimportant.
7. Resistance to tuberculosis appears to far outshadow any effect
of predisposing factors, such as food, housing, and sanitation, in survival and m recession of the epidemic.
8. Among the predisposing factors the effect of acute epidemic
diseases, such as pertussis, measles and influenza appear to be of first importance.
Food would appear to be a modifying factor; housing less important.
Page 97 Sanitation and personal cleanliness have not yet attained a position
where they modify infectivity as shown by the tuberculin test.
That the combination of good food, housing and sanitation does
have a noticeable effect upon morbidity has been observed in the health
of children in schools of varying hygienic status. Its effect on mortality
from tuberculosis is evident. When comparing the File Hills Demonstration Colony with the adjacent Reserve, it was found that 14% of
the third generation of the Colony have died from tuberculosis as compared with 21 % of the same generation on the Reserve.
9. The effect of rest and general hygienic treatment on recovery
and mortality of the resistant type has been demonstrated by results
under sanatorium treatment. The resistant type of Indian children respond approximately as well as do the white children.
10. Infusion of white blood by crossing has been shown to have
conferred increased resistance. It has not decreased morbidity, but it
has reduced mortality.
11. The resistance produced through one generation of sensitization by uncontrolled infection appears to be limited. The increase in
resistance, as indicated by present and probable mortality among the
third or more sensitized generation compared with the second generation
of childhood infection on virgin soil, forces this contention.
12. The processes by which the resistance of the Plains Indians to
tuberculosis has been increased are manifold.
(a) By the elimination of the weak and non-resistant. Among the
families surviving the epidemic, 18.7% of their members have died of
tuberculosis compared with 31.7% among those families which have
succumbed.
(b) By infusion of the more resistant white blood by crossing. A
mortality of 19.92% occurred among full bloods of the third generation
compared with 12.5% among the crosses.
(c) By sensitization of soil evident in the third generation. A
mortailty of 28% in second generation compared with 22% in the third.
(d) By improved living conditions in the widest sense. A mortality of 14% occurred among children on the Demonstration Colony
compared with 21 % on an average reservation.
It must be pointed out that the above factors are interdependent
and overlapping. In no case is the amount of improvement due entirely
to one factor.
13. From a comparative study of the mortality from tuberculosis
of the sexes by age-groups during the two decades 1906 to 1926, it
was found that child-bearing had no appreciable effect on the resistance
on the females to this disease.
14. After three generations of tuberculization the surviving Indians are biologically strong. The birth-rate has been maintained, and
the infants at birth are well nourished and strong.
Page 98 PROGRAMME OF THE 3 3rd ANNUAL SESSION
VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
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 the Agenda.
January       6th—General Meeting:
Speaker—Mr. Justice Morrison; Certain Contacts of
Medicine and the Law."
January     20th—Clinical Meeting.
February      3rd—General Meeting:
Speakers—Dr. F. N. Robertson; "Some Unusual Uses
of Common Drugs."
Dr. Wallace Wilson; "Stenosis of the Mitral Valve."
February    17th—Clinical Meeting.
March 3rd—General Meeting:
THE OSLER LECTURE—
Dr.  R.  E.  McKechnie;   "Reminiscences  of  Forty
Years' Practice."
March        17th—Clinical Meeting.
April 7th—General Meeting:
Speaker—Dr.   C.   F.   Covernton;   "Problems   of   the
Primipara."
April 21st—Clinical Meeting.
April 28 th—Annual Meeting.
In cardiac and respiratory crises ....
when danger is great and the need urgent
CORAMINE "CIBA"
(pyridine—B—carbonic acid diethylamide)
stimulates   the   medullary   centers   and   the   heart  muscle;
causing an increase in respiration, blood-pressure, and the
strength of cardiac contractions.
AMPOULES of 1.1 cc.
boxes of 5, 20 and 100
LIQUID
bottles of IS cc. and
100 cc
DOSAGE:
Subcutaneously, intramuscularly or intravenously 1
to 2_ ampoules
Internally 1 to 2 cc with a.
little water.
Literature and samples sent on request.
CIBA COMPANY LIMITED Montreal So PURE, It Needs No FLAVORING
Vitamin A is known to possess certain anti-infective
properties, particularly in relation to the eyes, lungs
and upper respiratory tract, including the sinuses.
Vitamin   D  is  known  to  prevent  and  cure  rickets.
MEAD'S 10D COD LIVER OIL WITH VIOSTEROL
Many physicians prefer to prescribe vitamins A and
D in the form of Mead's Standardized Cod Liver
Oil. In cases where extra Vitamin D is required or in
cases where the patient cannot tolerate normal doses
for VITAMIN A DEFICIENCIES and
of Mead's Standardized Cod Liver Oil and is thus
unable to obtain the necessary amount of vitamin D,
Mead's 10 D Cod Liver Oil with Viosterol is indicated
because it may be given in half the normal dosage,
still assuring adequate amounts of vitamins A and D.
for the PREVENTION arid CURE of RICKETS
Samples and Literature on Request. Mead Johnson & Co., of Canada, Ltd., Belleville, Ont.
I Pioneers in Vitamin Research and Specialists in Infant Diet Materials	  536 13th Avenue West
Fairmont 80
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell J. H. Crellin W. L. Bertrand
STEVENS'
SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity
for the bag or the office.
Supplied in one yard, five yards and
twenty-five yard packages.
ESTABLISHED   NEARLY  A
^CENTURY*:
B. C. STEVENS CO.
Phone
Seymour 698
730 Richards Street
Vancouver, B. C. 

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