History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1937 Vancouver Medical Association Oct 31, 1937

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 The BULLETM
(*_.
/
OF THE
^_
VANCOUVER MEDICAL
ASSOCIATION
Vol. XIV.
OCTOBER,  1937
No. 1
In This Issue:
NEWS AND NOTES
ANNUAL MEETING OF No. 4 DISTRICT
MEDICAL ASSOCIATION
SUMMER SCHOOL PAPERS BULKETTS
(With Cascara and Bile Salts)
. JlFOR . .
Chronic  Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED WITH CASCARA AND
BILE SALTS PRODUCE BULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Stores) THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices:
203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Db. J. H. MacDermot
De. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XIV.
OCTOBER, 1937
No. 1
OFFICERS  1937-1938
Dr. G. H. Clement Dr. Lavell H. Leeson Dr. W. T. Ewing
President Vice-President Past President
Dr. W. T. Lockhart Dr. A. M. Agnew
Hon. Treasurer Hon. Secretary
Additional Members of Executive—Dr. J. R. Neilson, Dr. J. P. Bilodeau.
Dr. F. Brodie
TRUSTEES:
Dr. J. A. Gillespie
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommeb
Dr. F. P. Patterson
|r    SECTIONS
Clinical Section
Dr. R. Palmer Chairman    Dr. W. W. Simpson Secretary
Eye, Bar, Nose and Throat
Dr. L. H. Leeson  Chairman    Dr. S. G. Elliott Secretary
Pcediatric Section
Dr. G. A. Lamont , Chairman    Dr. J. R. Davies Secretary
Cancer Section
Db. B. J. Harrison Chairman    Dr. Roy Huggard Secretary
I STANDING COMMITTEES
Library
Dr. A. W. Bagnall
Dr. S. Paulin
Dr. W. F. Emmons
Db. R. Huggard
Dr. H. A. Rawlings
Dr. R. Palmer
Dinner
Dr. G. F. Strong
Dr. R. Huggard
Dr. D. D. Freeze
Publications
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland
Db. Mubbay Baibd
Summer School
Db. A. C. Fbost
Db. R. Mustabd
Dr. J. R. Naden
Db. H. A. DesBbisay
Dr. A. B. Schinbein
Dr. A. Y. McNair
Credentials
Dr. A. B. Schinbein
Db. D. M. Meekison
Db. F. J. Bulleb
Metropolitan Health Board
Advisory Committee
Db. W. T. Ewing
Db. H. A. Spohn
Db. F. J. Bulleb
Representative to B. C. Medical Association—Db. Neil McDougall.
Sickness and Benevolent Fund—The Pbesident—The Tbustees
V. 0. N. Advisory Board
Db. I. Day
Db. G. A. Lamont
Db. Keith Burwell Serunas, Vaccines, Hormones
AND
Related Biological Products
Anti-Anthrax Serum
Anti-Meningococcus Serum
Anti-Pneumococcus Serums
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoids
Old Tuberculin
Perf ringens Antitoxin
Pertussis Vaccine
Pneumococcus Typing-Sera
Rabies Vavvine
Scarlet Fever Antitoxin
Scarlet Fever Toxin
Staphylococcus Antitoxin
Staphylococcus Toxoid
Tetanus Antitoxin
Tetanus Toxoid
Typhoid Vaccines
Vaccine Virus (Smallpox Vaccine)
Adrenal Cortical Extract
Epinephrine Hydrochloride Solution (1:1000)
Epinephrine Hydrochloride Inhalant (1:100)
Heparin
Insulin
Protamine Zinc Insulin
Liver Extract (Oral)
Liver Extract (Intramuscular)
Pituitary Extract (posterior lobe)
"Prices and information relating to these preparations will be
supplied gladly upon request.
CONNAUGHT LABORATORIES
UNIVERSITY   OF   TORONTO
Toronto 5
Canada
I Depot for British Columbia
Macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—AUGUST, 1937
Total population—estimated  253,363
Japanese population—estimated  8,522
Chinese population—estimated   7,765
Hindu population—estimated  352
Rate per 1,000
Number        Population
Total deaths . |    157 7.3
Japanese deaths        4 5.5
Chinese deaths        4 6.1
Deaths—residents only    136 6.3
BIRTH REGISTRATIONS—
Male, 181; Female, 147    328 15.2
INFANTILE MORTALITY— Aug., 1937      Aug., 1936
Deaths under one year of age        9 4
Death rate—per 1,000 births      27.4 13.4
Stillbirths (not included in above)        7 6
CASES OF COMMUNICABLE DISEASES
July, 1937
Cases Deaths
Smallpox   0 0
Scarlet Fever  13 0
Diphtheria  0 0
Chicken Pox  12 0
Measles     3 0
Rubella   0 0
Mumps    11 0
Whooping Cough  2 0
Typhoid Fever  2 0
Undulant Fever  0 0
Poliomyelitis   0 0
Tuberculosis   37 8
Meningitis  (Epidemic)  0 0.
Erysipelas   3 0
Paratyphoid Fever  0 0
REPORTED IN THE CITY
Sept.
1st
Aug.
,1937
to 15th.
1937
Cases
Deaths
Cases Deaths
0
0
0
0
11
0
5
0
1
0
2
0
5
0
5
0
1
0
2
0
0
0
0
0
5
0
4
0
0
0
2
0
2
0
0
0
0
0
0
0
0
0
0
0
28
11
13
0
0
0
0
0
0
0
0
1
0
0
0
WYETH'S  HEMATINIC  PLASTULES
EFFECTIVE IN SMALL DOSAGE
The daily dose of three Hematinic Plastules Plain yields gratifying
results in the average case of hypochromic anemia. Each Hematinic
Plastule Plain contains 5 grains of ferrous iron in a "well tolerated,
easily assimilated form. . . . Two types of Hematinic Plastules, Plain
and with Liver Extract, are now available in bottles of fifty on your
prescription. Your patients will find the cost of this medication well
within their means.
Samples on Request.
JOHN WYETH & BROTHER, Inc.
WALXERVILLE, ONTARIO
Paget OF HYPERTENSIVE
HEADACHES
RELIEVED
FOR rapid, efficient and safe relief of high
blood pressure and its associated symptoms, you can rely on Hypotensyl.
This is a synergistic combination of dependable hypotensive agents—Viscum album ( Au-
ropean mistletoe) and hepatic and insulin-free
pancreatic extracts. It hastens recovery and
wins your patient's confidence.
Viscum album has proven remarkably effective for relief of hypertension (O'Hare and
tfoyt 1928, Barrow 1930 and Danzer 1934).
Frequently Hypotensyl effects a reduction of
20 to 30 mm. Hg. in 12 hours. Headaches and
dizziness vanish and reduction is sustained.
Excellent results are obtained in cases of essential hypertension or benign hyperpiesia*
Hypotensyl is also efficacious in treatment of
high blood pressure accompanying pregnancy
or due to fibrotic kidney. The benefit obtained
from careful control of diet, as well as mental
and physical rest, is accentuated by Hypotensyl.
The usual dose is 3 to 6 tablets daily, one-
half hour before meals. Best results are
obtained when treatment is given in courses
lasting two to three weeks, with a week's
interval between. Supplied in bottles of 50
and 500 tablets.
HYPOTENSYL
The Anglo-French  Drug  Company
354 St. Catherine Street East Montreal, Quebec
._ EDITOR'S PAGE
One of the speakers at the recent B. C. Medical meeting made a remark
which has set us thinking. It was about the supposed attitude of the specialist
to the general practitioner of medicine. The speaker had been urging the
latter to acquire dexterity in a certain manceuvre (diagnostic puncture of
the antrum of Highmore, to be exact), in order to diagnose sinus involvement, and warned us that the specialists might object to this profanation of
their sanctuary by the uncircumcised heathen of general practice. Even if
they did object, he thought the general practitioner should persist.
The specialist has been the subject of a good deal of sniping of this nature.
Sometimes, as when our good friend Dr. Dyer of North Vancouver unlimbers
his batteries and goes into action, he encounters a full-sized barrage; mostly,
however, the attacks are on a smaller scale, semi-jocose at times, but always
somewhat derogatory—and we question very much whether they are justified
by the conduct of the great bulk of specialists. The shouiders of the specialist
are broad, and he does not need us to help him carry his burdens for him,
but it is so easy to adopt an attitude of cheap criticism and to create an
atmosphere of mind which is unhealthy, and apt to lead to misunderstandings.
Speaking from an experience of over thirty years in general practice (and
that ought to make one a specialist in general practice), we wish to say
quite categorically that we have never encountered in any competent
specialist the attitude of mind attributed to them by our speaker: the attitude that regards a general practitioner as merely a feeder to a specialist,
who should keep his place. It is quite the other way ; the competent specialist
rejoices to see evidence of competence and ability in the man who consults
him, and does everything in his power, by friendly advice and information
gladly and freely given, to add to the armamentarium of his colleague; that
has been our own experience, and we feel sure every other man in general
practice will endorse this.
It is time that someone spoke frankly in this matter, we think, and so
we gladly take the task on ourselves. The specialist, rightly derived and
trained, is, we all know, our best and most indispensable friend. He has, we
suppose, his faults—but his virtues outweigh them. It is true he charges
more than we do—but there is much room for argument in this. But he is a
medical man, as much as any of us,and he is not of a different breed of
medical man as some seem to think. He is loyal to his cloth, and, in Vancouver
at least, has more than once proved to be a tower of strength to the profession as a whole. We cannot do without him. In the words of a great man:
"The eye cannot say to the hand, 'I have no need of you'; nor again the head
to the feet, 'I have no need of you.' . . . there should be no schism in the
body . . . and if one member suffer, all the members suffer with it. . . ."
And besides, we may want to specialise some day ourselves.
♦ •   ♦      h-      .
It is always a pleasure to record the acknowledgment of good work and
good citizenship. The Latins, in speaking of a good citizen, said not that he
had "served" his country well, but that he had "deserved well" of his
country. So much good work is accepted as a matter of course, with little
or no acknowledgment, and this is to be deplored.
Dr. R. E. McKechnie, that well-known and well-beloved dean of the
profession in Vancouver, was presented at the Annual Dinner of the B. C.
Medical Association with the Life Membership of the Canadian Medical
Association. He is also, we understand, the recipient of the Coronation
Medal at the hands of His Majesty the King.
Dr. W. D. Brydone-Jack, another of our greatly-honoured senior members, recently had the Good Citizen's Medal of the Native Sons of British
Columbia conferred on him, a greatly-coveted mark of distinction. Every
man who knows Dr. Brydone-Jack will agree that no better choice could
possibly have been made. His long record of unselfish service to the city and
Page 2 its people, and to his own profession, is one that we must all admire and
applaud, and we hope that he may soon be restored to a degree of health and
comfort which will enable him to return to a normal and. happy life.
The whole profession in this Province extends its congratulations to
Drs. R. E. McKechnie, Geo. E. Seldon, H. H. Milburn and G. F. Strong, on
their receipt of Coronation Medals in recognition of their services to
Canadian medicine.
VANCOUVER  MEDICAL  ASSOCIATION
GENERAL MEETING OCTOBER 5 th M
The first General Meeting of the Association in the 1937-38 Session will
be held in the Auditorium of the Medical-Dental Building on Tuesday, October
5th. The paper of the evening will be given by Dr. Howard Spohn on "Conditioned Reflexes and Their Relation to Medical Practice."
In 1901 Pavlov conducted his conditioned reflex experiments and later
requested Krasnagorski, his pupil and co-worker, to carry on in children the
experiments that Pavlov had done with dogs. The difficulties of studying and
accurately recording the mental activities of the central nervous system were
difficult and almost insurmountable, but Krasnagorski has worked patiently
and almost untiringly with these experiments since 1907. The aim of these
two men has been to carry out the most complete analyses of the central
nervous processes of the brain and so reveal the fundamental physiologic
mechanisms of the cerebrum and its adjacent parts.
The object of Dr. Spohn's paper is to discuss very briefly a few of the
methods of Krasnagorski and show how he has applied the physiologic facts
that have been revealed, to the practice of medicine.
NEWS AND NOTES
Dr. and Mrs. W. L. Harrison left in July for England, and are expected
to return about the end of October.
* *      *      *
We offer congratulations to Dr. Karl Haig of Vancouver, who was married
in Oklahoma City on August 21st to Dr. Lillian White. Dr. and Mrs. Haig
returned to Vancouver early in September.
* *      *      *
Dr. J. R. Davidson has moved from Ocean Falls to Vancouver, and has
opened offices in the Medical-Dental Building.
Dr. J. E. Harrison expects to leave very shortly for Europe. He will go
to Vienna for postgraduate work, and then to England. He will be away
about six months.
We congratulate Dr. Russell D. A. Bisson on his marriage recently to
Miss Betty Williamson of Vancouver. Dr. and Mrs. Bisson will make their
home in Vancouver.
Dr. Lee A. Patten was met in Chilliwack recently as he was making
preparations for a hunting expedition, with Mrs. Patten, into the interior
of British Columbia.
PageS Dr. D. W. Moffatt has returned from doing postgraduate work in Vienna
and Edinburgh, and will take up practice in the offices of Drs. W. A. Moffatt,
C. D. Moffatt and H. A. Robertson.
* .      *      *
Dr. B. B. Muscovitch, staff surgeon at the Vancouver General Hospital
for two years, has opened offices in the Birks Building, Vancouver, B.C.
* .      *      *
Dr. D. T. R. McColl has moved to Queen Charlotte City and taken over
the work of the Skidegate Inlet Hospital.
* *     *     *
Dr. W. R. S. Groves is at Port Alice relieving Dr. G. A. Lawson, who is
on vacation.
* *      *     *
Dr. D. C. McKenzie left on the Empress of Japan as ship's surgeon.
* *      *      *
It is gratifying to note that over 80 members from throughout the Province
attended the Annual Meeting of the British Columbia Medical Association.
* *      |      I
Dr. J. M. Hershey, Director of the Health Unit at Pouce Coupe, attended
the meetings of the British Columbia Medical Association.
* .      *      *
Dr. G. F. Young is at Tofino relieving Dr. J. G. Robertson during the
absence of the latter.
* *      *     *
Dr. J. A. Kirkpatrick is relieving Dr. Douglas Galbraith at Bella Coola.
* *      *      *
Dr. H. O. Smith is now at Port Simpson.
* *      *      *
Dr. A. E. Perry has relinquished his practice at Port Simpson and will
visit in the East before again taking up active work.
* *      *      *
Dr. R. E. Mitchell is now well installed as Radiologist in the Royal
Columbian Hospital in New Westminster.
* *     *      *
Dr. A. L. Cornish has moved to Courtenay and is associated with Dr.
Peter L. Straith and Dr. H. A. L. Mooney in that practice.
* *      .      *
Dr. A. O. Rose has taken up practice in Vernon.
* *      *      .
Dr. W. S. Huckvale has joined the Kimberley group and is assisting Drs.
D. Wayne Davis and John F. Haszard.
PLEASE NOTE
Vancouver Medical Association Bulletin
Index to Vol. XIII.
It is regretted that due to an oversight the index to Volume XIII
of the Bulletin was not printed in the September (final) number
of that volume. It is printed at the back of this (October) number
in such a way that those desiring to have their Bulletins bound up
may remove the index without damaging the rest of the book.
Page 4 THE B. C. MEDICAL ASSOCIATION
ANNUAL MEETING
Our readers may wonder why this, the most successful meeting ever held
by the B. C. Medical Association, has not been recorded in this issue. The
primary reason is, of course, lack of adequate space at this time. But our
more cogent reason is that we feel that it would be missing an opportunity,
merely to give a brief account of the meeting and spread the papers over
several months' issues of the Bulletin, thereby denying the meeting the
identity that it possesses.
We are hoping, therefore, with the aid of the B. C. Medical Association,
to collect all the material—and it is valuable material—and issue it in the
form of a supplement to the Bulletin. The advantages of this are obvious:
the papers will be all together in a compact form that a man can read at his
leisure; the members who were unfortunately unable to come will get a good
share of the feast from which they were barred through circumstances; and
so the educational work of the B. C. Medical Association will be more efficiently performed.
THE DOCTOR AND THE DRUGGIST
The Bulletin has recently been in correspondence with Mr. R. G. Stewart,
Registrar of the B. C. Pharmaceutical Association, who has made what we
think is a very good suggestion. The doctor and the pharmacist, Once combined in the one person, have gradually become dichotomized into two different branches of the medical profession. They are tending in some ways
to diverge from each other more widely than is good for either of them, and
certain misunderstandings and even occasions of friction sometimes result.
Mr. Stewart's suggestion is that the Bulletin should during the winter
session run short and concise notices contributed by the Pharmaceutical
Association, setting forth the chief difficulties that the pharmacist meets in
his daily work; that is, the difficulties caused by his relation with the doctor.
We, as doctors, regard the druggist as a most indispensable confrere, who
gives almost invariably the most accurate and careful service, who acts as a
very valuable corrective to our human tendency to error, and implements, day
and night, our efforts to relieve and cure our patients. Occasionally, perhaps,
we make the going rather difficult for^tiim, through thoughtlessness mainly,
or ignorance perhaps of his particular problems. The Bulletin is very glad
to devote a part of its space to the efforts of the B. C. Pharmaceutical Association to make our relations happier and productive of greater satisfaction
to both sides.
Mr. Stewart's first suggestion runs as follows:
PLEASE DO NOT ORDER NARCOTICS BY TELEPHONE!
Any pharmacist "who allows narcotics to leave his stock before receiving
a "written order covering same, is liable to a fine of not less than $200.00,
or to imprisonment, or both.
BE FAIR TO YOUR PHARMACIST!
We need not comment extensively on this, except to endorse this suggestion. There is undoubtedly here a difficult situation for both doctor and
druggist, but we must recognize the inescapable fact that when we ask a
druggist to send narcotics, where we do not leave a written prescription,
either at his store, or with our patient for the druggist to send for before he
makes up the prescription, we are asking him, first, to break the law; second,
to risk a very heavy punishment. We have no right to do this, and still less
'have we the right to feel aggrieved when the druggist refuses our request.
Page 5 VANCOUVER MEDICAL ASSOCIATION
FALL GOLF TOURNAMENT
The Fall Golf Tournament of the Vancouver Medical Association was
held this year at Quilchena Golf Club. Sixty-eight teed off and sixty-six
remained for the dinner which followed, at which Dr. W. N. Kemp was chairman. The guest of honour on this occasion was Dr. Joe Bilodeau, and following the dinner Dr. Kemp presented Dr. Bilodeau with a fine Lawson-Little
brassie, as a memento of the five years during which Dr. Bilodeau was
responsible for the arrangement of the golf affairs of the Vancouver Medical
Association.
The results of the various events at the Fall Tournament were as follows:
Ramshorn Trophy for low net, won by Dr. G. A. Davidson.
McDonald Trophy for best match score, won by Dr.G. A. Davidson.
Worthington Cup, won by Dr. F. Saunders.
Best low gross, won by Dr. E. E. Day.
Prize donated by Imperial Optical Co. for best net score in class with
handicap of 17 and under, won by Dr. E. E. Day.
Prize donated by Dr. A. B. Schinbein for best net score in class with handicap of 23-18 inclusive, won by Drs. Burray Baird and Dr. F. Sinclair of
Cloverdale.
Prize donated by Dr. G. E. Seldon for best net score in class with handicap
of 24 and over, won by Dr. F. Saunders.
Prize for ex-captains, won by Dr. B. D. Gillies.
Best hidden hole, won by Dr. G. H. Clement; second, Dr. G. E. Seldon.
Longest drive, won by Dr. G. E. Harrison.
Putting competition, won by Dr. L. Macmillan.
BRITISH COLUMBIA MEDICAL ASSOCIATION
I GOLF TOURNAMENT
It was a beautiful day at the Capilano Golf and Country Club when 128
medical golfers from all parts of the Province met for this annual Tournament. Under the able and genial captaincy of Dr. Joe Bilodeau, the various
events were run off smoothly and efficiently. The results were as follows:
Mead Johnson & Company Silver Cup for best low net—1st, Dr. Fraser
Murray; 2nd, Drs. J. A. McLean and K. Craig (tied). This is the first time
this cup has been competed for. The winner's name is engraved on the cup
and a silver replica is presented to him, while the very handsome large trophy
is to remain in the offices of the College of Physicians and Surgeons permanently.
T. Ewing, Vancouver.
E. Sheldon, Vancouver.
Brydone-Jack, Vancouver.
Agnew, Vancouver, and Dr. Herman Robertson, Victoria (tied).
1st nine low gross—Won by Dr. E. E. Day, Vancouver.
2nd nine low gross—Won by Dr. T. H. Lennie, Vancouver.
Nearest to flag at 11th hole—Won by Dr. E. H. McEwen, New Westminster.
Nearest to flag at 4th hole—Won by Dr. Jack Wright, Vancouver.
Fraser Valley Medical Association
1st low gross—Won by Dr. G. S. Purvis, New Westminster.
2nd low gross—Won by Dr. G. T. Wilson, New Westminster.
Victoria Medical Association
1st low gross—Won by Dr. Geo. Hall, Victoria.
2nd low gross—Won by Dr. H. N. Watson, Duncan, and Dr. J. M. Keyes,
Victoria (tied).
1st low gross—
-Won by Dr. W.
2nd low gross-
-Won by Dr. G.
Longest drive-
—Won by Dr. F
Hidden holes-
-Won by Dr. A.
Page 6 Interior Medical Association
1st low gross—Won by Dr. Llewelyn Jones, Revelstoke.
2nd low gross—Won by Dr. S. A. Wallace, Kamloops.
High gross won by Dr. Stanley Paulin, who played his first game of golf
at this tournament. Dr. Bilodeau slyly suggests that Dr. Paulin carried an
adding machine!
Dr. Joe reports that 128 teed off, and 128 teed up when they came back!
LIBRARY CORNER
RECENT ADDITIONS TO THE LIBRARY
Medical Clinics of North America, July, 1937.
This is the Philadelphia Clinic number, and contains a symposium on
Cardiovascular Disease.
Surgical Clinics of North America, June, 1937.
This is the Lahey Clinic number and contains a symposium on Gastrointestinal Surgery.
International Clinics, June, 1937.
Crile, George—Diseases Peculiar to Civilized Man. 1934.
Allen, Clifford—Modern Discoveries in Medical Psychology. 1937.
New and Nonofficial Remedies, 1937.
The substantial row formed on the library shelf by the successvie volumes
of Neio and Nonofficial Remedies represents a valuable service to the
medical profession for more than thirty years. These volumes are a guide
in authorizing purchases of nonofficial drugs. A great many brands of
official preparations are listed in New and Nonofficial Remedies, which
have been considered by the Council of the A.M.A. at the request of
manufacturers who desire this extra prestige for their products.
Many new drugs have been added to the 1937 edition and some changes
in the classification of drugs made. There is a chapter on ('arbohydrate
Foods, and another on "Organs of Animals," which includes not only
endocrine preparations, but liver and stomach preparations and insulin.
The Thyroid and Its Diseases—J. H. Means. 1937.
An excellent text on Thyroid disfunction. Dr. Means' book deals with
diseases of the thyroid on the basis of departure from normal anatomy,
physiology and biochemistry. One is constantly reminded of the relationship of various disorders to the normal functioning gland. Even in management of patients the mechanisms of causation of various malfunctions
of the thyroid are explained. The work includes introductory chapters on
normal structures and function, methods of examination and history
taking, classification, excellent individual descriptions of the various
thyroid functional abnormalities and their treatment, as well as pre- and
post-operative care. The inflammatory, neoplastic and anatomical anomalies of the gland are also adequately treated, and finally considertion
is given to certain non-thyroid diseases where thyroid administration is
indicated on the hand, or thyroidectomy has proven of benefit on the other.
All the various clinical entities discussed are well illustrated with personal case histories and clinical material of which the author has had
wide experience. Controversial points are handled with a presentation of
the evidence of both sides and the reader is free to make his own conclusions. This excellent book reviews the most recent literature and presents the subject in its latest development. It well merits reading by both
physician and surgeon.
—w. w. s.
Paget IMPORTANT!
Suggestions from the Laboratory of the Vancouver General Hospital
This insertion in the Bulletin is prompted by the desire to institute a
more satisfactory service for physicians in the outlying districts who send
specimens into the laboratory for examination.
The proper fixation of tissue in transit will expedite the examination and
subsequent report and also make for better sections, as frequently tissues
are received in alcohol and even in carbolic, which makes proper evaluation
of the ultimate sections difficult.
It is suggested that the biopsy specimen, tumour, etc., be placed in
adequate amount of fluid (somewhat more than enough to completely cover
it), consisting of one part of pure formalin and nine parts of either water
or 95% alcohol. Further, a short history with age of patient, location and
appearance of growth, is helpful. To obviate physicians being inconvenienced
by receiving accounts from the Hospital for these examinations, it is requested
that the full name and address of patient be given, so that they may be
billed direct, or, if the patient is indigent, so indicate on the requisition or
letter accompanying the specimen.
The name of the patient is very important for purposes of recording and
indexing, for very frequently this is omitted, and on several occasions we
have had requests to look up reports of patients, who apparently have moved
to other localities and have consulted a new physician, who is told by the
patient that their former physician removed a tumour for biopsy some time
previously, and this new physician may feel that there is some relation
between the patient's present condition and that for which the biopsy was
previously taken, and he wishes to ascertain what the former condition was.
After a great deal of trouble, the record may or may not be found, owing
to the fact that in the first instance the patient's name was not given. I have
in my desk at the present moment a report of carcinoma of the breast examined nearly 2% months ago, with which we received only the patient's name
and no doctor's name, and the postmark on the wrapping was so blurred as
to be illegible.
When urines are sent in for the Friedman's modification of the Ascheim-
Zondek pregnancy test, it is requested that the patient be asked to withhold
fluids the night before for the purpose of concentration of the morning
specimen, which probably increases the potency of the hormone, if present.
Three ounces of the first morning specimen are saved and three drops of
pure carbolic or tricresol are to be added to this, as a preservative. The name,
address, age and date of last period are also requested in this test, and it
would appear that it is relatively useless doing the test less than two weeks
after the last missed period. u „ ~ ,, -r.
v H. H. Pitts, M.D.
Director of Laboratories, Vancouver General Hospital.
Page 8 SYMPOSIUM ON ARTHRITIS
(Presented at Vancouver Medical Association Summer School, June, 1937.)
CHRONIC ARTHRITIS AND ITS MANAGEMENT
Dr. Leonard Rowntree
Chronic disease spells failure. The world is full of chronic arthritis.
Failure means the lack of some crucial knowledge of the disease. Usually
that lack is in relation to its cause. I want to tell you a story. About ten or
twelve years ago there came to the Mayo Clinic a young lady, beautiful and
charming, beautiful beyond belief. She had shiny golden hair, sparkling eyes,
dimpled cheeks, glittering teeth. Her personality was just lovely. She was
sick. It was a ceremony to go in and see her. You couldn't see her until she
was fixed up and when she was fixed up she was beautiful. Naturally the
old doctors took a great interest in her. Even some of the younger ones did.
Well, the combined efforts of the clinic were centred on this young lady and
she got better not at all but continued to get worse. It so happened Dr. M.
was a friend of her family. Despite this she continued to grow worse. Things
got so bad that she decided to leave us and she went to California for the
climate, and that is the last we ever saw of that beautiful young lady; but
one and a half years later there returned in her place a middle-aged hag,
just the shadow of what this girl had been. Her hair was hanging in strings,
her face was dirty, her teeth were ugly, her clothes were dirty. She had not
the slightest interest in the doctors and very few doctors had any interest
in her, just in her disease. She scarcely knew her doctors. She got worse,
her mental symptoms rose and she was sent to an insane hospital, where
she died.
This story tells better what chronic arthritis is. It is a disease which
destroys personality, may lead to death and may lead to destruction. At the
end I went to see Dr. Henderson and I said it was a pretty poor reflection on
medicine, and he said, yes it was. So we decided to get a group together who
would interest themselves in chronic arthritis. And we had orthopaedic surgeons, neurologists, all branches of medicine, including internal medicine,
and we studied arthritis and learned many things about it, but we still have
to learn some very crucial things about which we know absolutely nothing
at the present time because chronic arthritis continues to exist.
Now, I have done something today that I don't very often do. I had a
chance to have a talk with Dr. Magnuson today and I learned a great many
things about his mind. He thinks like a medical man, not a surgical man. So
I changed a few of my slides.
Before we show the slides I want to tell you I have a very personal
interest in this subject, as I myself was the victim of arthritis and I speak
to you as a patient as well as a doctor. (Slides shown here.)
In arthritis we have to speak of the joint. Here we have the various
structures, the ligaments, the fascia, bone, different types of bone, cartilage;
all have to enter into consideration as well as many other things not depicted
here. Here we see a joint open. This is a very unusual structure. As a rule
it functions through all the years without giving the slightest difficulty,
and when we look at it we wonder how it is possible for that joint to
function. Where is its blood supply? Where is the nerve supply? Is that
important? It must be exceedingly important, because this functions as an
organ. When we started our little group, I sent to the librarian and told her
that I would like to have a good article on the physiology of the joint. That
was ten years ago, and I haven't seen it yet. Neither have I ever seen one,
which means that we know very little about its physiology. We must study
the actions of the body as a whole, then we have muscle action, as of the toes,
we have relaxation, weight-bearing, in relation to joints. When we come
Page 9 to secretion we are again met with ignorance. We know that secretion is
related to synovial membrane. There is actual secretion because we find
fluids which cannot come through dialysis. There is absorption in these
joints. We have metabolism in the joint. We have growth and repair. I once
had a group of six students give a symposium on the joints. Not one said
that joints have nerves. One of our boys undertook to study absorption from
the interior of the joint cavity in rabbits and he placed india ink in the
joints, and we found macrophages functioning. This function had never been
known before and added new knowledge. Yet bacteriologists seek for the
germ responsible for this disease.
Now, about the chemistry of joints. We know that we have a transudate
or an exudate. We have water, we have organic material, we have carbohydrates, we have lipoids, we have mucin or synovin, we have inorganic salts,
and we have the gases carbon dioxide and oxygen. What does happen in a
joint when it is at rest compared with a joint in exercise? What does fatigue
bring to a joint? What does digestion do to the metabolism of a joint? What
changes come from age? In disease we have many different changes. The
physical characteristics of lubrication of a joint are unknown. Neither do
we know anything about the metabolism in a joint.
Now we come to the different causes of arthritis, many of which we don't
understand. It is thought that allergy plays an important role in this disease.
Next we come to the blood pictures in arthritis. All workers are willing to
admit that there are indications in the blood picture of these cases. If we study
the material taken from the body of the joint and submit this to pathological
investigation, the result is encouraging. We now introduce a new subject in
medicine—paleopathology. In Tut's tomb we find many bodies which throw
light on disease and illness. Here in this picture we have four vertebrae which
show exactly the same pathology as cases in our present day.
Wherever we have chronic disease we have always had various methods
of classification. On the two main types we all agree—the proliferative and
the degenerative. There is great differentiation and this is definitely important. To me the whole thing was a haze until I got a distinct classification.
We have the infectious type ; the senescent type; the metabolic type (gout) ;
the traumatic type (dynamic and static), and the neurogenic type.
(Slides were then shown of these different types of arthritis.)
The form of arthritis most frequently overlooked is gout. The clinical picture is usually quite different from any other type. It is usually found in men
over thirty-five. If the pus which comes from the joints is examined, it will
be found to contain uric acid. Here is a criteria for the diagnosis of gout:
Early: 1. Acute recurring arthritis with complete remissions.
2. Location of first attack—foot.
3. Blood uric acid over 5 mg. per 100 cc.
4. Response to medication.
Late:   1. Asymmetrical joint changes.
2. Tophaceous deposits.
3. X-ray.
4. Secondary nephritis.
The next series has to do with the clinical management and treatment of
chronic arthritis. (Slides were then shown.)
1. Removal of foci.
2. Baking and massage. (Diathermy and contrast baths.)
3. Diet.
4. Vaccines.
5. Foreign proteins.
6. Drugs  (and be very careful with drugs)—Salicylates;  Fowler's
solution; iodine; iron tonics.
Page 10 7. Orthopaedic care. (Prevention and cure of deformities.)
8. Education.
9. Climate (first winter in South, if possible).
Now, this is what we would do in the management of foci. All bad teeth
should be removed; also all tonsils if you cannot affect a cure otherwise.
Then sinus symptoms; the ears—rarely. The gall bladder sometimes. Appendix not very frequently the cause. The intestine is very commonly the cause.
The prostate, in the male, should always be examined; the pelvis, in the
female, should be given attention.
Now, as to physiotherapy in arthritis:—
1. Heat—diathermy and baking.
2. Massage.
3. Exercise.
4. Forced movement.
5. Contrast baths for extremities.
Orthopaedic surgeons have made new joints that are exceedingly remarkable in suitable cases and under suitable conditions—arthroplasty and
arthrodesis.
(A tabulation was then shown, giving the different types of arthritis with
a list of their respective treatments.)
This next slide introduces a new subject. Why is it that changes in weather
affect arthritis cases? We made a very complete study of this question. We
had many patients who said that the weather had nothing to do with their
condition, but statistics showed that it really had. We don't really understand this, but it is so, and some day we may find out more about this subject.
In some cases relief is. obtained from sympathectomy. However, this is
only used in selected cases, not in general chronic arthritis. It is used in
young patients where the patient is bed-ridden, with cold clammy hands or
feet, etc.
I now want to speak of my own personal experience. My onset was very
sudden. I was crippled with general arthritis overnight. The symptoms were
pain and this pain was very variable. I had extreme tenderness of the joints
involved. Cold was almost as bad as pressure in bringing out pain. The weakness was something terrible. Sweating was profound. There was swelling of
the joints, inability to use the joints. There was a secondary anaemia which
was very marked. My response was greatest to warmth. I went down to
Southern Arizona and my pain just melted away. I had removal of foci—
a dead tooth was removed. Vaccine seemed to help a little. Sunshine, warmth,
mud baths, all worked wonders with me. Tropical climate was obtained by
control of room temperature. Dietetic treatment was given; also control of
constipation.
Now, we need more light on the cause. Why do we have bilateral symmetrical enlargement of the joints with chronic arthritis? Why do we have
the pain, the weakness, the sweating, the sensitivity to cold, constitutional
and personality changes ? Why do we have such wonderful effects from heat,
sunshine and clothing?
SURGICAL TREATMENT OF ARTHRITIS
Dr. Paul B. Magnuson
It has never been my privilege before to listen to such a sensible article
on arthritis as Dr. Rowntree has given, and I feel very much embarrassed
as a surgeon on this subject. But over the last thirty years I have formed
a lot of opinions from clinical observations of arthritis. Dr. Rowntree mentioned the two groups of arthritis and the names that the various men had
given to those two groups. We have to have names for things to differentiate.
When so many men give so many different names to one or two conditions, it
is a good sign that these conditions are not entirely plain, and that is cer-
Page 11 tainly true with arthritis. I have opened a good many joints which have been
considered arthritic and I have never seen a true case of either type. I have
never seen pathology in arthritic joints that was not more or less mixed. Dr.
Rowntree emphasized another thing that I have never heard emphasized
before in any talk on arthritis. That is, that arthritis is a systemic disease
with local joint manifestations. These two forms have their general characteristics. The atrophic or rheumatoid form usually starts in the small joints
of the hands or feet but can start in any joint. It is, quite evidently, from
the work which has been done upon it, an infectious thing.
Dr. Rowntree showed the foci from which these various bacteria have been
recovered. There were two that I think are important that he didn't have on
his slides; one of them is the nasopharynx. There is a young man in Chicago,
Thomas O'Connor, in a large dispensary and a large prviate practice, who has
taken culture on every nose he has examined, and this man has found so many
of these hidden infections, and eliminated so many cases of mine, that I have
begun to believe that the nasopharynx is the harbour of bacteria which is the
cause of arthritis in a large percentage of cases where the foci cannot be
found in other places. The nose and throat men have passed this up for a good
many years. This man has developed aspecific treatment in some classes of
infection which seems to hit the spot. One of these is a filtrate in a certain
type of streptococcus. And the pneumococcus has been at the base of a few of
the cases, and the nasopharynx must be alsolooked at. I believe it should be
cultured and cultured repeatedly. It is a thing which should be insisted upon.
There is another place that we find infection which is frequently overlooked—a chronic urinary infection with colon bacillus where there is no pus
in the urine, simply bacteria. It is apparently possible to have a chronic infection in the urinary tract without symptoms. So those two things are placed
where we should at least look for foci of infection. When we have a systemic
infection of some other type, what do we do? Because a patient can get
around with arthritis is no reason why he should be allowed to get around.
In other types of infection we insist on patients being at rest. We insist that
they build up their resistance. In T.B. what do we do? We put them to bed;
we feed them, we don't starve them; and I feel sometimes that my friend
Pemberton, in Philadelphia, has done a good deal of harm in some ways by
advocating a cutting down of the diet and especially he cuts down on the
carbohydrate diet, I believe. These patients are sick people. They should have
a balanced diet, one that is up to their own requirements. Each patient is
a different one from the one before and has his own requirements. Each
patient must have individual treatment which is suitable to him alone. And
that's where the doctor comes in. He analyzes that particular case. I pass
these cases on to the men who know more about them than I do. I turn them
over to the nose and throat men, to the internes, etc., but that doesn't prevent
me from asking certain questions.
Dr. Rowntree laid more emphasis on this group of patients (the infectious group) than the others. ^Fortunately this group is in the minority. The
hypertrophic, osteoarthritic patient is in the majority. This patient that I
am talking about is not a young beautiful woman. This patient is one past
35 or 40. The infectious type comes in the younger individual for the most
part, but the hypertrophic type come in the patient past 35, usually past 40.
They are usually continually in pain although able to get up and be around
and do their work. What is it that happens after 35 or 40 that precipitates
this sort of thing? You will notice that the butcher that goes into the cooler
and takes a big piece of meat out with his right arm gets arthritis in the
right shoulder. The boxer gets it in the elbow from constant pounding. The
miner or labourer gets it in the spine.
Now Dr. Rowntree spoke about gout and I am going to ask him a lot of
questions. What is gout? Is it just uric acid in the blood? I had backache
when I was twenty-six and I started working on backs. I told Dr. Rowntree
this evening at dinner about a man who came in complaining of backache a
Page 12 long time ago. What possible effect has metabolism on gouty arthritis? The
patient wakes up with a backache, gets up and walks around for fifteen
minutes, goes back to bed improved, but gets up in two hours with this backache again. This man is an engineer on construction work. He went to the
hospital and I questioned him for hours about everything and I didn't get to
first base. I told him this on the Friday and then did a gastric analysis and
we found a complete achlorhydria. I gave him some hydrochloric acid and
he had no more backache after taking it. He then got out of the medicine and
wanted some more. I sent him some citric acid then and within the next three
or four days he called me up and said he had the backache again. He called
me within the week and said he had a terrific backache, so I sent him some
hydrochloric acid, and as long as he took this he didn't have backache.
I had a professor and he had swollen knees; intermittent swollen knees.
They were not so dreadfully painful but they certainly did swell up. They
would clear up spontaneously and then get bad again. It seemed to be caused
by some allergy, so I asked him to keep a list of all the things he ate and
see if they had anything to do with his condition. We eliminated several
things at different times. At the end of about six months we were going over
this list and I said that spinach seemed to be the only thing that he ate which
gave him the swollen knees. So we cut out the spinach and he had no more
swollen knees. As an experiment, we gave him some spinach some time after
and he had swollen knees after eating it for a few days. So this wasn't anything but an allergic reaction.
How many other toxins may be formed in any individual or group of
individuals from some idiosyncrasy which crops as a result of intolerance,
insufficient elimination, an upset of some sort, that we don't know how to
analyze? Well, if these metabolic things can occur, what is one man's meat
is another man's poison. There are many toxins formed which are improperly
eliminated.
I have seen an active case of gout in a boy of 18 who is playing polo three
times a week and sweating like a horse. I have seen gout in a boy of 21 who
was playing football in a professional team—all young active people. So gout
is a metabolic sort of thing, and no one can say what is the normal chemistry
in a patient. These things, I believe, have a direct effect on arthritis. The
x-ray in these cases should not be resorted to for it doesn't show this condition until the destruction has been done. It is of no value except to corroborate the diagnosis. The diagnosis should be made clinically.
The joints most frequently affected in the osteoarthritic group are the
joints most frequently traumatized. In the rheumatoid type, many cures have
been established, but it takes persistence, proper management, proper diagnosis ; but when disability and deformities occur, frequently the joints which
are most affected will clear up first. In a great many of these cases we find
the hips and the knees disabled. The joints have been allowed to contract,
and I believe that with these cases rest is essential. A patient had been in an
auto accident and had received an injury to the neck. Someone applied extension, but applied fifteen pounds extension to his head night and day for five
weeks. And if this patient didn't have an injury to his neck before the accident, well, he certainly had it after that extension was applied. These joints
cannot stand that weight. These people have spasms of pain and the gradual
easy extension of a Buck's will give tremendous relief to many of these
patients, if properly applied; and besides that, it keeps the joints in position;
but they should be allowed to have some motion. Those joints, if fixed, are
thrown out of plumb. Now our joints, after working perfectly all our lives,
if put at an angle with an extension, cannot hope to heal properly. In the
hypertrophic cases, in the joints which are most frequently traumatized, the
symptoms will continue.
Now, my thesis is this: In the hypertrophic cases, a chronic toxaemia, a
chronic low-grade infection, has a more definite bearing on joints than any
other thing.
Page IS CANCER OF THE COLON
Dr. Harold Brunn
(Given at the Vancouver Medical Association Summer School, June, 1937).
When I take up cancer of the colon, which is a large subject, I feel rather
terrified. The literature, of course, is full of articles on this subject, and
every day someone talks about and uses a different operation. But you have
to be careful with this operation. It should not be done by the infrequent
operator. It is a difficult thing.
There are a lot of new points in this disease which I shall touch upon.
First, the question of metastases. We all know that the colon, fortunately, is
a very good place to have cancer. We only wish we could get them early, for
the results then would be much better. As I said before, the different types
of operation are very numerous. One type is the colostomy, which is a
favourite one amongst doctors. Then again, there comes a period when
doctors like to fight shy of colostomy so as to prevent a recurrence of the
condition. So at the present time I believe that there is coming an era when
we are going to have many more types of operation for the prevention of a
permanent colostomy. There are many glands growing here, as you know,
and their enlargement does not prove that they are malignant. In many cases
of cancer the malignancy only occurs in the mesentery and the glands are
not affected at all. My belief is that if the glands are very much affected, a
too extensive operation should not be done.
Surgeons deal a great deal with tubes—the bronchial tube and all the
other tubes. The opening of tubes is a most interesting subject—the difference between a sphincter and a valve, how they work, etc. I always draw an
analogy between cancer of the lung and cancer of the colon. Cancer of the
colon starts in a small way and does not give symptoms for a long time, just
as in cancer of the lung. You don't get symptoms until you get obstruction—
in cancer of the lung you get obstruction of the bronchus or from metastases.
So in the colon. A patient goes along for a long time without symptoms.
Examination of this condition by a barium enema often leads to it being
missed, especially in its early stages. Inflammation and carcinoma always
go together, and this inflammation causes irritation. Of course, different
people have different symptoms. Whenever I suspect anything in the colon
I never depend upon the x-ray man alone. In fact, I always like to be present
when the x-ray is taken, because I know the history of the case. In one case
I know, where cancer was suspected, a barium enema was done and they
said there was nothing there, but six months later the patient had symptoms
of obstruction. Most of my cancers come to me obstructed and in most of them
the cancer has been there for 15 months or even longer.
Cancer of the colon does not metastasize nearly as widely as does cancer
of the lung. In studying cancer of the colon you think first of polyp, for often
cancer will be found to grow on a polypoid basis, and when we operate we
find many more polypi which are likely to become cancerous, and often at
operation we leave some polypi still in the area which/ should have been taken
out. These polypi are different. In the anal canal they are fibrous and smooth
and not very often malignant. Then, further up in the rectum, we have the
adenomatous polyp. These polyps that are in the bowel are of two kinds under
the microscope. One is very smooth. It looks just like a bowel mucosa and
its contents are the same. The other one has more possibilities within it. The
connective tissue grows more, there is more proliferation, and they have
more the possibility of malignancy.
Now we come to the question—what is malignancy? Since diathermy and
radium havej been here I have never taken out a bowel for polyp in the rectum,
for I don't believe that these are so very malignant and I don't depend too
much on the pathologist. Besides the single polyp we have multiple adenomatous polyposis, and this is related very much to cancer and it is inherited.
Page 14 All these cases die eventually from cancer somewhere and usually around
35 to 40 years of age, and this condition goes right through the families. You
don't inherit the cancer; you inherit the polyposis. However, there are many
other things which cause polyposis. We have ulcerative colitis, which
develops multiple polyposis which is not of the inherited type.
(Slides were then shown.)
This patient had a barium enema and was diagnosed as a polyposis. He
was given x-ray therapy and got better. He passed material in handfuls.
However, two years later he came back and was found to have had a lymphosarcoma all the time.
A perforation of the caecum often occurs when you have a carcinoma on
the left side. This, of course, is traumatic. The left side of the large bowel
and the right side of the same bowel are two different organs. The right side
of the bowel is automatically, embryologically and functionally separate from
the left side. It has a great deal to do with the digestive process, while on
the left side it is more or less of a cistern. The carcinomas, therefore, take
different symptoms on the left side to those on the right. And you will find
that when the disease is on the left side, the symptoms will be found on the
right side, due to distension and obstruction. Many of these people have their
first symptoms on the right side, and it looks like appendicitis. What happens?
There is a mechanical law here—the law of tubes. The caecum is the largest
part of the organ, and when you get a large quantity of gas and air this
organ bursts and causes symptoms there. When the large bowel is obstructed
the large vessels are pressed upon and they lose their carrying power. And
we always found these breaks in the bowel about 2 to 2^ inches from the
colon.
(Case history was then given.)
You do not get symptoms of small bowel obstruction in large bowel
obstruction, according to recent literature, but I disagree. In this case a
diagnosis of subacute appendicitis was made from the symptoms. Operation
was done and much gas was found in the abdomen and two perforations were
found on the caecum on the mesial side.
(Another case history was given.) A diagnosis was made of colonic
obstruction with perforation of the caecum. However, the rest of the hospital
staff disagreed and gave a diagnosis of appendicitis. At operation the appendix was found normal but there was found a multiple polyposis of the bowel.
In the mass of literature that is written about cancer of the colon, the
various types of operation are discussed at great length. I do the Miles operation in some cases, the Mikulicz in some, and the Lahey in others. The mortality rate after anastomosis is great and I get away from it as much as
possible.
(Slides were then shown of the technique of an operation done by one
Australian surgeon.) This operation resembles our Mikulicz, but should not
be done when the bowel comes out under great tension. It should come out
at least two inches with easy tension. The mucosa of the bowel always rolls
outward and is always in the way when you want to close.
(Another group of operations was then shown, those on the transverse
colon.)
Now, about inoperable carcinoma. This is important. We have had now
quite a number of cases operated on and they have been so-called inoperable
cases. Colostomy was done only, but we have taken these cases—so-called
inoperable—and they looked pretty good. The inflammation has gone down
and we have given them very weak doses of x-ray therapy, and within twenty
days we have gone in and we have taken those cancers out and they were
not inoperable at all and they had very good results, and we think this is a
very good way.
In carcinoma of the rectum with sinuses, suffering pain, anaemic, hopeless, A. A. Strauss has burned out their carcinoma, and we have prolonged
the lives of some of these cases by two and three years.
Page 15 No. 4 DISTRICT MEDICAL ASSOCIATION
1937 ANNUAL MEETING—REVELSTOKE
October 3rd and 4th, 1937
Revelstoke will be the host city for the Annual Convention of the medical
men from that large district which extends from the Boundary in the South
to the far North. For those who are able to attend, the Executive Committee,
with Dr. A. L. Jones as President and Dr. J.H. Hamilton as Honorary Secretary-Treasurer, has prepared a very attractive programme which should
have a wide appeal. Monday, October 4th, has been set for this main part of
the programme. Everyone will motor along the new Big Bend road to Gold-
stream at the 60-mile post. There they will have luncheon provided by the
highway staff of the Federal Department of Mines and Resources. The party
will return to Revelstoke after lunch and then the members will sit in on
the clinical programme.
Dr. P. A. McLennan and Dr. Lee Smith of Vancouver will present papers
and will request that the members form a Round Table Conference. They
are invited to send or bring questions or topics for discussion.
Dr. McLennan will deal with "Fractures Involving the Upper Extremities" and will show films.
Dr. Lee Smith has chosen as his subject, "The Urological Problems of the
General Practitioner."
The success of the meeting will rest on the members, in that the two
speakers will require their help to develop the discussion. Following the
Clinical Session, pre-prandial potations will prepare the party for the Annual
Dinner to be held at the King Edward, where Harry McSorley will provide
his famous "groaning board." The ladies attend the Annual Dinner and it is
a merry affair. All members are accompanied by wives, who have a further
soiree while the men hold the Annual Meeting, the agenda for which consists
of reports, new business, payment of dues, selection of location of next Annual
Meeting and election of officers.
The Annual Meetings in the Interior are whole-hearted affairs abounding
in good fellowship and a camaraderie difficult to duplicate. Revelstoke lends
itself admirably to a successful meeting.
On Sunday,. October 3rd, golf will be arranged and it is hoped that
all will come for this feature. Harry McSorley will house everyone at the
King Edward.
Dr. M. W. Thomas, the Executive Secretary of the College of Physicians
and Surgeons, will attend this meeting, arriving via the Arrow Lakes following the Annual Meeting of the West Kootenay Medical Association at
Nelson on September 30th. Members of the No. 4 District are urged to attend
their Annual Meeting in Revelstoke on October 3rd and 4th.
Page 16 HODGKINS' DISEASE
Report of a case with widespread itchiness of the skin
as an early symptom.
Dr. W. D. Keith, Vancouver.
E. A. S., aged 54 years. Height, 5 ft. 9 ins. Weight, 165 lbs. A well-built,
thick-set man who up to the last few years had led a very active life.
Eleven years before his death, that is in 1924, the patient first noticed
blotchy, slightly raised red areas on the skin of the trunk of the body, front
and back. These areas appeared suddenly, were very itchy, and would disappear in a few days, after the application of a soothing lotion. Some
weeks or even a few months would pass by, then the rash with its itchiness
would return. The intervals between attacks gradually became shorter and
the rash and itchiness extended to the legs and lower parts of the thighs.
In January, 1933, the patient noticed that he became tired about 10 o'clock
each morning and that by mid-afternoon would be completely fagged out.
Although retired from business he was forced to give up what little work
there was to be done. This continued till August, 1933, when he had an
influenza-like attack, followed in two or three days by tonsillitis and in a
few days more by what seemed to be an acute hay-fever: red eyes, lachryma-
tion and considerable nasal discharge.
During September, October, November, 1933, patient was troubled with
flatulence and fullness after meals, nausea and occasional vomiting and
increasing constipation. A diagnosis of gall bladder disease was made at this
time by his physician, Dr. R. H. McCutcheon, and as this was concurred in
by another physician, Dr. McCutcheon removed the gall bladder on January
5th, 1935.1 saw the patient in consultation a week after this operation when
he was suffering from an acute sore throat and enlargement of the lymph
glands at the angles of the jaws on both sides. Examination of the tonsils
at this time showed them to be quite swollen and to contain large cheesy
masses. Tonsillectomy, to be undertaken at a later date, was advised, hoping
in this way to remove another possible infective focus which might play a
part in causing the skin condition.
Dr. McCutcheon removed the tonsils on January 31st, 1935, but found in
the succeeding months that the skin trouble was as persistently irritating
as ever.
On April 11th, 1935, after a sleepless night from skin irritation, the
patient went to the bathroom about noon to shave, when he fell in a collapsed
state on the floor. Dr. McCutcheon saw him in a few minutes and found him
pulseless, blueish in the face and perfectly limp. I saw him 25 minutes later
and could not feel the pulse at the wrist nor hear the heart beat. Adrenalin
was administered and in a few moments an occasional pulse could be felt at
the wrist. He was immediately sent to the St. Paul's Hospital and the special
nurse noted on the chart that she was unable to get the pulse at the wrist
for the first eight hours. The patient ran a little temperature for the following
few days, the skin was very irritable and there was a return of the signs of
hay-fever. Dr. McCutcheon had a consultation with Dr. N. McDougall, nose
and throat specialist, and the skull was x-rayed but no focus of infection in
this region was found. Also a blood count at this time was within normal
limits. Allergic tests for some foods and a number of other materials to
which he had been exposed failed to give any positive results.
Patient left St. Paul's Hospital on April 18th, 1935, and on April 24th,
1935, was admitted to the Vancouver General Hospital with a temperature of
101, which dropped to normal the following day and remained there till he
left the hospital on May 24th, 1935. During his stay in the hospital at this
time there was an urticarial rash, very itchy, fairly well distributed on the
Page 11 trunk and limbs; there was also congestion of the nares, watering of the
eyes and dyspncea. This was the third attack of hay-fever-like symptoms that
the patient had had and was only acute for a few hours.
During this stay in the hospital Dr. W. H. Hatfield tested the patient for
allergic reactions, using a great variety of food and other proteins. The
results, however, were negative.
Dr. D. E. H. Cleveland, dermatologist, saw the patient on April 25th,
1935, and considered that the heavy metals—arsenic, lead, mercury and
-bismuth—should be tested for as a possible cause of the patient's trouble,
particularly as the patient did some work with insecticides for his plants and
chickens. Arsenic was tested for and proved to be negative, but measures for
testing for the other metals were not available.
Dr. Cleveland noticed at this time that there was a palpable enlargement
of the inguinal glands and in his notes made on May 4, 1935, questions the
possibility of leukaemia, Hodgkins' disease or mycosis fungoides being the
basic disease.
On October 28,1935, patient was again admitted to the Vancouver General
Hospital with a temperature of 102 and pulse of 120, spleen palpably enlarged, eyes reddened and watery, glands in axillae and inguinal region
slightly enlarged and those in the anterior triangle of neck pigeon-egg size.
Dr. Wallace Wilson, who was in consultation at this time, had an inguinal
gland removed, and on November 8, 1935, Dr. Pitts, the pathologist, reported
Hodgkins' disease. The patient's temperature reached 104 on November 1st
and gradually returned to normal by November 21st. The temperature remained normal for six days then rose again, continued high with hyperexia
for two days, with death on December 3, 1935.
Oct. 28, 1935—84% lymphocytes and haemo 60% and g-eneral lymphoadenopathy.
Oct. 29, 1935—Urine, acid; S.G., 1010; alb., plus 1; W.B.C., 1.
Oct. 31, 1935—Urine, acid; S.G., 1014; alb., plus 3; R.B.C., 3.
Nov. 15, 1935—Blood count: R.B.C, 4,000,000; haem., 85%; W.B.C., 7,800.
Nov.   2,1935—Blood count: W.B.C., 3,500; diff. count, P-20; lymph., 26; mon.,
40; E., 14.
Nov. 18, 1935—Blood count: W.B.C.,  6,600;  diff.  count, P-14;  lymph,  25;  mon.
16; E., 42.
This case is reported in order to draw attention to the importance of
widespread itchiness of the skin of the body as an early symptom of Hodgkins'
disease. The itchiness of the skin in this particular case was accompanied by
urticarial-like patches very slightly raised, appearing quite suddenly and
disappearing gradually in a week or ten days as the itchiness lessened. The
itchy reddened areas first appeared on the trunk of the body, then extended
to the legs and lower portions of the thighs. Scratch marks on the skin after
the rash began to fade gave an appearance suggestive of scabies or pediculosis.
The skin lesion in this patient first appeared eleven years before his
death, was not present all the time, but came and went in periodic fashion,
though in the last year and a half the itchiness.never completely left him.
Auld, in the Canadian Medical Association Journal for April, 1935, reporting two cases of ex dermatitis, states that any of the forms of lymphoblastoma, such as mycosis fungoides, leukaemia, Hodgkins' disease and even
T.B., may cause ex dermatitis. He also states that for months or even a year
or two there may be itching of the skin alone or the itchiness may be accompanied by a skin eruption, e.g., urticaria, eczematiform, erythema, multiforme
or a diffuse erythroderma. Exceptionally the only form that the eruption
takes is ex dermatitis.
In considering secondary exfoliating dermatitis, Auld stresses the fact
that it may develop from any of the forms of the lymphoblastoma, and
further states that any of the lymphoblastomata may make their debut in the
skin. For months or even a year or two there may be itching alone with or
without any form of eruption—urticaria—eczematiform, erythema multiforme, or a diffuse erythroderma; exceptionally the early eruption takes the
Page 18 form of exfoliating dermatitis. Therefore, if confronted with a case of persistent widely spread itchiness of the skin with or without dermatitis of some
kind, or even an exfoliating dermatitis of unknown origin, be careful to
include the lymphoblastoma as a diagnostic possibility.
Blood examinations, chemical tests for certain metals, x-ray examinations
of the chest and abdomen and a biopsy of any even slightly enlarged glands
or biopsy of infiltrated areas of the skin may be of definite help in clarifying
our diagnosis.
Concerning the therapeutic measures of value in combatting the itchiness:
at present the most reliable is x-ray treatment given by an expert.
SUMMARY
A case of widespread itchiness of the skin of long duration which was
eventually shown to be due to Hodgkins' disease is reported.
The mucous membrane of the nares was also subject to infiltration and
congestion, at times producing hay-fever-like attacks.
A severe syncope attack lasting some hours occurred on one occasion, and
was also probably due to invasion of the heart muscle with Hodgkins' disease
cells.
HYPERTENSION AND ITS MANAGEMENT
Dr. Leonard Rowntree
(Presented at Vancouver Medical Association Summer School, June, 1937)
Ladies and gentlemen, I have been asked to talk tonight on the subject
of Hypertension. This is a subject that I have studied much for many years
and know too little about. It would be downright folly to come to an organization of this type and present a textbook picture of the subject of hypertension,
because hypertension is one of the things that we meet most frequently in
this world and with it you are all very familiar, particularly with its clinical
associations and manifestations. So I thought it would be of help to you if
I gave you my thoughts on this subject and my viewpoints which might
prove helpful to you.
You all know that it is possible to isolate fresh living tissue, and by
bringing to that tissue daily a supply of food in liquid form and by removing
daily the wastes that have accumulated, we are able to keep this tissue alive
indefinitely. Every cell in our body behaves accordingly, and all that it asks
is that it be furnished a constant environment and that there be brought to it
daily what it needs and there be removed from it daily the waste products.
Now, the blood of course represents the food. The function of the bringing
and of the removing is exercise in this experiment by man himself, but the
vascular system, the heart and the vessels, play that role ordinarily. Now,
every cell is demanding certain things all the time—less of those things when
that cell is at rest and more when the cell is active—and the reaction of the
supply to the demand on the part of the cell is the function of the circulatory
system, and this system is controlled largely through the nervous system.
Now, I am going to cover this subject again by reference to a series of slides.
The purpose of the circulation is to supply blood for the essential needs
of the cells for existence and to supply blood for various needs of particular
cells for work. And these cells outside the body can live, as has been proven.
Cells are active or at rest. Why do we have blood pressure? (Answer shown
on slide.) The physiologic factors in blood pressure were then explained
—the heart, brain, endocrine glands, the biophysical factors and the arterioles.
A slide was then shown of two hearts—one of Addison's disease (wt. 160
gms.) and one of essential hypertension  (wt. 922 gms.). We know much
Page 19 more now about atrophy and hypertrophy than in previous years. We wonder
now if hormone influence plays any part in these conditions. Now we come to
the nervous system. We have a series of nervous structures which play a
role and we know that the sympathetic chain has something to do with this
question of hypertension. Then in this nervous system we have reflexes. The
one we know most about to date is the one which has to do with the carotid
sinus. This sinus is concerned with the circulation of the brain itself and
must be concerned, indirectly at least, with these changes in the blood vessels.
Now to come to the endocrine glands. We have been told that adrenalin is
not concerned in hypertension. That may be perfectly true. Nevertheless,
pathology of a certain type in these glands does bring about hypertension.
The next slide has to do with the volume, viscosity and chemistry of the
blood. In polycythemia we have frequently a blood volume of from 50% to
100%, yet hypertension is rare in this condition. The viscosity of the blood
is also increased to a marked degree.
Now I want to speak of the capillaries. We have to consider the artery
and its nerve supply. This slide shows the distribution of nerves and arteries
to the veins. We have in capillaries certain peculiar cells, particularly in the
amphibia. These are called rouget cells. Here are pictures of actual capillaries. These capillaries have non-myelinated fibres. This is another capillary,
showing it in its normal condition. Now this is an exceedingly interesting
piece of work by Crowe. Recently I have seen two things which interest me
as other possible factors. One is a peculiar vascular shunt that often is seen
just in the artery leading to the glomerulus in the kidney. This slide shows
the type of reaction that one may get. In addition to the capillaries, we
have to consider the composition of the blood itself. Now, blood ordinarily
is limited within rather narrow limits, but we can affect dilution or concentration, and this slide has to do with some dilution experiments with water
and intoxication. This is a group of three different workers in three different
parts of the world, showing that they have found points which are exactly
the same.
How does change from the normal blood pressure affect duration of life ?
If we lower blood pressure from 5 to 15 mms. we have normal risk or prolongation, but if we increase the blood pressure we get an increase in the
mortality. Both systolic and diastolic blood pressure increases with age.
(Next was shown the pathogenesis of hypertension.) Heredity, mechanical,
chemical, neuroglandular—all these play a role in hypertension. Dr. George
Brown has done some interesting work at the Mayo Clinic. He argues there
is something other than heredity playing a role in hypertension from earliest
childhood. Overweight plays an important role. The kidney is important from
some points of view. The sympathetics in the kidneys have to come into consideration. Now hypertension from a clinical point of view is idiopathic
rather than essential. It may be mild or severe. The secondary form often
has nephritis associated with it, also polycystic kidneys, myocardial insufficiency, arteriosclerosis, lead poisoning, eclampsia, obesity, focal infection,
hyperthyroidism, suprarenal toumours and polycythemia.
This picture is an attempt to show the vessels in the nullifold. Here is
another clinical test. This next, I think, is the finest slide I have ever seen
on hypertension. It tells a whole lot about hypertension in a small space. The
retina plays a large part in this condition.
Now we have, in addition, vascular crises—the cerebral type, the thoracic
type, the peripheral type, the retinal type, the abdominal type and then the
general type. Now, malignant hypertension occurs, as a rule, in patients of
35 to 50 years. Duration, one month to six years. Now, there is a very simple
thing that you can use clinically. No patient should be put on any form of
treatment and conclusions drawn as to the effect of that treatment until the
patient has been stabilized, and that cannot be done in a hurry.
Page 20 Now, as to the general management:
1.   Regulation of life, infinitely more than drugging, without introduc
tion of fear.
2. Readjustment of life—physical, mental;  readjustment of work,
rest, care of diet and bowels, care of focal infection.
3. Bleeding.
4. Physiotherapy of various forms.
5. Drug therapy.
We have the nitrites and I think they are helpful clinically and I think
these should be used when headache is intractable and where you think there
is a vascular accident pending. Digitalis is valuable in cases of myocardial
involvement. Bromides and sedatives are also helpful in some cases. However,
it is not a disease which is helped very much by drugs. Some endocrine
extracts are of value. Here we see the effect of luminal with a drop in blood
pressure.
Now, it occurred to me eight or ten years ago that we might put a safety
valve into the circulation somewhere, so that in times of a crisis blood vessels
would give. So we did this on some cases, with the sympathetics. Then I
tried, some years ago, x-ray treatment to the adrenals with some effect. Then
we tried x-ray treatment to the pituitary. However, Hutton treated both
these glands at the same time with radiation and in most cases had symptomatic relief. Now, we think of hypertension only as to the body as a whole,
but here we have portal hypertension. Then occasionally we have hypertension due to obstruction from anatomical dilatation. Here is the anatomical
picture.
Now, in conclusion, may I say that this is a subject that has been studied
throughout many decades by many of the best men in medicine and surgery.
I think that we have learned a great deal that is important, a great deal
that contributes to the management and the understanding of hypertension.
Hypertension, however, is not one single disease. It probably represents
various disease expressions from various sources. My opinion is that we must
continue to instigate the search, particularly the search for the cause of
hypertension.
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