History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1934 Vancouver Medical Association Oct 31, 1934

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 STO is A€ £ ^$fcg.-JI:
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U.B.C. LIBRARY
t*y«im.n. i.<!1W      The BULLETIN
OF THE
VANCOUVER MEDICAL
ASSOCIATION
Vol. XI
OCTOBER, 1934
No. 1
w
In This Issue:
ANNUAL MEETING OF B. C. MEDICAL ASSOCIATION
PROGRAMME OF  37th ANNUAL SESSION
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Vancouver, B. C. 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:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XI OCTOBER, 1934 No. 1
OFFICERS  1934-1935
Dr. A. C. Frost Dr. C. H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W. L. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L. Graham   Chairman
Dr. J. R. Neilson     Secretary
Eye, Ear, Nose and Throat
Dr. R. Grant Lawrence Chairman
Dr. E. E. Day—       .Secretary
Paediatric Section
Dr. E. D. Carder  ..Chairman
Dr. R. P. Kinsman     Secretary
Cancer Section
Dr. A. B. Schinbein      Chairman
Dr. J. W. Thomson    Secretary
STANDING COMMITTEES
Library Summer School
Dr. W. D. Keith Publications Dr. J. W. Thomson
Dr. C. H. Bastin Dr t r MacDermot Dr. C. E. Brown
Dr. A. W Bagnall Dr       e       Cleveland Dr. J. E. Walker
Dr. a E^ Kidd Dr Murray Baird Dr. J . W. Arbuckle
Dr. W. K. Burwell Dr. H. A. Spohn
Dr. C. A. Ryan Dr. H. R. Mustard
Credentials „    ... t
Dinner „    p    .   Q Hospitals
Dr. R. A. Simpson -.    -r tr T r«Mn!
Dr. J. W. Thomson Dr  t T Wall Dr- T" H- Lennie
• Dr  F W T FFS t\    l\ w »? Dr- C R Covernto>
•ur. r. w. lees Dr. D. M. Meekison ~.    tt tj l/r„„TT„^T
Dr. W. G. Gunn Dr- H- H- Milburn
Dr. S. Paulin
V. O. N. Advisory Board
Dr. I. Day Rep. to B. C. Medical Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees
:-w Reprinted from the Illinois Health Messenger of Illinois
State Department of Health, February, 1934.
Non-Pulmonary Tuberculosis
I in Chicago
"Where the mortality records concerning non-pulmonary
tuberculosis in Chicago and down-State are examined it is
found that in Chicago the rate went down from 23 to 14
between 1912 and 1920.
"During the same period the death rate from non-pulmonary tuberculosis went up from 11 to 18 per 100,000
people in down-State.
"These figures indicate that during the eight years mortality from non-pulmonary tuberculosis declined almost
one-half in Chicago, while down-State it almost doubled in
proportion to the population.
"Milk pasteurization was started in Chicago in 1912 but
the practice did not become extensive down-State until the
early twenties. Furthermore, the tuberculin-testing herds
and the elimination of tuberculous cattle did not become a
significantly extensive movement in Illinois until well into
the twenties.
"Thus it appears that the prime factor in the reduction of
non-pulmonary tuberculosis in Chicago during the eight
years ended with 1920 was the pasteurization of milk."
The human tuberculosis produced by the germs
from cattle frequently takes the form of diseases of
the joints. Tuberculosis of the hips or elbow joint was
fairly common in the period preceding the general use
of pasteurized milk.
This disease is still common in England and the
English surgeons frequently express their astonishment
at its almost total absence in the American cities where
pasteurized milk is used almost universally.
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
service phones:
Fairmont 1000     North 122     New Westminster 144 5 VANCOUVER HEALTH DEPARTMENT
STATISTICS—AUGUST,  1934
Total Population (Estimated)  _.«jLji  _  243,711
Japanese Population   (Estimated) _     ._  7,866
Chinese Population  (Estimated)    8,31J
Hindu Population (Estimated)  251
m
Total Deaths  	
Japanese Deaths	
Chinese  Deaths 	
Deaths—Residents   Only	
Birth Registrations—
Male, 190; Female 129.
Rate
per 1,000
Number
Population
180
8.7
7
10.5
9
12.7
157
7.6
319
15.4
INFANTILE MORTALITY—
Deaths under one year of age	
Death rate—per  1,000 births ~
Stillbirths (not included in above).
August, 1934 August, 1933
6 5
18.8 16.8
10 10
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
Smallpox 	
Scarlet   Fever  _
Diphtheria  	
Chicken Pox	
Measles     	
Rubella  	
Mumps   - 	
Whooping-cough   	
Typhoid Fever	
Undulant Fever	
Poliomyelitis	
Tuberculosis  	
Meningitis   (Epidemic) _
Erysipelas   	
Encephalitis Lethargica..
Paratyphoid   	
Sept
. 1st
July,
1934
August
, 1934
to 15tl
i, 1934
Cases
Deaths
Cases
Deaths
Cases
Deaths
0
0
0
0
0
0
52
1
34
1
14
0
2
1
2
0
0
0
5
0
6
0
2
0
1
0
2
0
0
0
0
0
0
0
0
0
2
0
3
0
3
0
3
0
13
0
3
0
0
0
2
0
0
0
0
0
0
0
0
0
1
0
3
0
0
0
52
13
34
11
18
0
0
0
0
0
0
1
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
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Founded 1898     ::    Incorporated  1906
Programme of the 37 th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
1934.
October 2nd—GENERAL MEETING.
Dr. G. F. Amyot: "Infection, Its Spread and Control."
Discussion: Dr. E. D. Carder
Dr. H. A. Spohn.
October 16th—CLINICAL MEETING.
November 6th—GENERAL MEETING.
Dr. C. E. Brown: "Some Secretory Disturbances of the Stomach."
Discussion:  Dr. H. A. DesBrisay
Dr. A. Y. McNair.
November 20th—CLINICAL MEETING.
December 4th—GENERAL MEETING.
Dr. A. B. Schinbein: "Tumours of the Breast."
Discussion :..Dr. J. J. Mason
Dr. B. J. Harrison
Dr. H. H. Pitts.
December 18th—CLINICAL MEETING
1935.
January 8th—GENERAL MEETING.
Dr. W. E. Ainley: "The Relation of the Retina to Cardio-Vascular
and Renal Disease."
Discussion:  Dr. W. D. Keith
Dr. Wallace Wilson.
January 22nd—CLINICAL MEETING.
February 5th—GENERAL MEETING.
Dr. Murray Blair: "Physiological Observations in Obstetrics."
Discussion: Dr. W. S. Baird
Dr. F. S. Hobbs.
February 19th—CLINICAL MEETING.
March 5 th—GENERAL MEETING.
The Osler Lecture—Dr. Wallace Wilson.
March 19th—CLINICAL MEETING.
April 2nd—GENERAL MEETING.
Dr. F. W. Emmons: "The Surgery of the Presacral Nerve."
Discussion:  Dr. J. J. Mason
Dr. F. Turnbull.
April 16th—CLINICAL MEETING.
April 23rd—ANNUAL MEETING.
Page 2
•'•MI
m EDITOR'S PAGE
Perhaps the most important question in all our minds at the moment is
the forthcoming legislation promised by the B. C. Government on the
matter of health insurance. "We have been told in so many words by the
Provincial Secretary, the Hon. Dr. G. M. Weir, that in some form or another,
legislation providing for a measure of health insurance will be placed on the
statute books at an early date. Our minds have been, no doubt, very much
confused by the difficulty of separating clearly the various elements that
enter into this question. Thinking it over, we believe that there are two main
aspects, one of which is to some degree not our business at all but that of
the Government, while the other is distinctly our business, and it is necessary
to get these two points clearly separated in our minds.
We may take it as clearly established that a need exists for some change
in our present method of treatment of the sick, chiefly as regards the method
of payment. The Provincial Secretary has dwelt at some length on the
necessity for actuarial soundness in any scheme that may be adopted. We
believe that he is right, but this is the part of the scheme of which we know
and can know very little. If the ordinary medical man's affairs were presented to an actuary for examination we believe it would be at risk of a
great shock to the actuary, and we must perforce leave this question to those
who are competent to judge of it, but we submit with all due deference that
this is only one-half of the picture. The actuarial soundness, while desirable
and no doubt attainable, must also be accompanied by medical soundness.
The scheme must be medically sound as well as actuarially sound, or sooner
or later it is doomed to failure, and we would submit this aspect of the
matter for Dr. Weir's careful consideration. No doubt, many schemes of
medical care could be evolved which would be financially and economically
quite feasible, while medically they would be very imperfect and unsatisfactory and would not adequately supply the need. We believe that Dr.
Weir realises this as much as we do.
We submit, too, that only the medical profession can pass on the medical soundness of any scheme, and we feel that it is to this point that we
should give our earnest attention, rather than worry ourselves about the
actuarial basis of which so much has been made. It is a truism, but nevertheless an inescapable fact, that the success of any scheme will ultimately
depend upon the work of the medical man. We are sure that Dr. Weir
appreciates this fact, but it is worth referring to. There are certain points
that we feel are essential before medical soundness can be insured to any
scheme. Dr. Weir referred in his address to the British Health Insurance
Act, but no medical man will agree that this is a medically sound scheme.
The report of the British Medical Association made in 1930 shews that in
the eyes of the medical profession of Great Britain this scheme is regarded
as utterly inadequate to the needs of the nation. In spite of the
statements of some who have defended it, it is an utterly cheap and
inadequate method of treating the sick, and the main concrete advantage that has been derived from it has been an increase in preventive medicine. Any scheme adopted in British Columbia, it is to be hoped, will adhere
as closely as possible to the present set-up of medical practice, will include
families and will provide complete care for the sick.
Again, we feel that it is essential for the success of any health insurance
act that it should have the willing co-operation and support of the great
bulk of the medical profession. Some few will resent any change, but we
Page 3 firmly believe that the great majority of the medical profession in British
Columbia recognizes that some measure of improvement is urgently necessary, and stands ready to support the government in any fair and equitable
scheme.
We do not ask for special treatment, but we believe that a generous consideration of a profession which will have to carry the great burden of the
work will do much to insure the success of the scheme. We in our turn
must do two things. We must consider the ultimate needs of the people
amongst whom we work and who depend on us for medical care, and we
must amongst ourselves strengthen the bond of union so that we may
present a united front and our voice may carry the weight it should. With
this in view we urge our readers to consider the advice of the leaders of the
Canadian Medical Association that the various provincial associations should
become an integral part of the national body and that in all our problems
we should speak as a united Canadian profession rather than as common
provincial units. Only thus can we bring to bear all the force at our
command. 	
NEWS AND NOTES
Dr. W. E. Austin, who has been at Bella Bella for the past year, has gone
to Edinburgh for a post-graduate course. On his way through Victoria he
married Miss Clara M. Castle of Dauphin, Man., and together they sailed for
the Old Country via the Panama.
Dr. James Cull has left West Vancouver for the present and intends to
.spend the next year in Toronto. He hopes to return with his D.P.H. degree.
Dr. S. A. Wallace of Kamloops has just returned from a three months'
trip to European clinics.
As Shakespeare is reputed to have said, "There's always something doing
in the lives of famous men." Since we reported in last month's Bulletin
that Dr. E. T. W. Nash had gone to the Orient as surgeon on the Empress of
Russia, the Exhibition Association presented him with a free round trip to
.see the World Series. We opine that he will accept the cheque for $500
which is offered as its equivalent.
We are glad to see Dr. D. D. Freeze back on his professional throne after
a prolonged holiday which followed a serious illness in the spring.
Dr. and Mrs. D. M. Meekison have left for the east on a tour of centres
of clinical and other attractions.
Dr. Peter L. Straith, who has been practising in Regina for some years
past, is coming to B. C. and will practise at Courtenay, Vancouver Island,
in the place of Dr. H. P. Millard.
Dr. W. A. Doidge, of Toronto, has succeeded Dr. W. E. Austin at Bella
Bella for one year.
Another new registrant in the Province is Dr. Robert Andrew Hunter,
formerly of Winnipeg, who is now practising from the Belmont Building
in Victoria. "
S3
DR. D. M. McKAY
OBIIT AUG. 28, 1934.    AETAT 64.
Dr. McKay's death on. August 28th, 1934, from heart disease,
came as a shock to the whole of the Vancouver medical profession.
To those of us who have been in practice for twenty years or more,
it meant the removal of a landmark, one might say even of an
institution.
"Danny," as he was always called, was a unique character.
He was always dramatic, hut had no trace in him of the theatrical.
He never posed, and was never unreal; one always knew where he
was. He had lived a varied life, hut a life full to the brim at all
times. He always gave one the impression of happiness and cheer,
and as long as the writer can remember Danny, he can never
remember a time when he seemed sorry for himself, or worried
about anything.
Nothing shewed his calibre better than the attitude with which
he faced two very serious illnesses that he had. Many years ago he
had an attack of uraemic coma, from which he recovered with
difficulty. But nobody was so unconcerned about it as Danny himself—nor when he had a gastroenterostomy done later, did he allow
the operation to interfere in the least with his enjoyment of life.
The surgeon who operated on him will not lightly forget how Danny
rang him up some two days after he had gone home from the hospital, and asked if it would do any harm if he had some pork and
beans. "My God! yes," said his physician; "don't eat anything like
that, it'll kill you." To which Danny replied, 'That's too bad, for
I've just had some."
And his life-story would be full of droll tales like this. Nothing
delighted him more than to play some mild joke on one of his
fellows, at golf, or elsewhere; but his humour was always kindly
and had no sting to it. He was a brave companion, and a welcome
partner in any game or sport, and he indulged in them all at one
time or another.
To know Danny was to be fond of him, and we are all glad
that death came to him as it did—quietly and almost at full tide.
He did not have to linger on his passing, but "went out into the
night, quickly," and without fuss or trouble, which, with all his
soul, he would have loathed.
DR. E. W. CONNOLLY
OBIIT AUG. 30, 1934.     AETAT 60.
We regret to record the death of Dr. E. "W. Connolly of heart
disease on August 30th; 1934.
Dr. Connolly had been a practitioner in Vancouver for many
years. He was here twice, with an interval in between of some
years, when he was practising in Cranbrook.
Dr. Connolly was a very quiet, unassuming man, whom few of
our members can even have known by sight. This was partly due
to his ill-health. For years he had suffered from anginal attacks,
and it was necessary for him to live quietly and exert himself as
little as possible.
But some of us had the privilege of knowing him better—and
his geniality and friendliness were conspicuous elements of his
character. At one time a very busy man, of late years he had, as
stated above, been forced to restrict his activities, but those to
whom he ministered, as well as those who knew him at all well,
will feel deep regret at his passing.
f age > THE ANNUAL MEETING OF THE
B. C. MEDICAL ASSOCIATION
The annual meeting of the British Columbia Medical Association, held
at Kamloops on Sept. 17th and 18 th, turned out to be an outstanding
success. Much credit is due, and we gladly render it, to the courage and
devotion to an ideal, shewn by Dr. W. S. Turnbull, president of the
B.C.M.A., and his executive, when they selected Kamloops as the scene of
this meeting. There had been some dark prophecies of failure, and these
have been proved to be wrong.
We cannot but feel glad that the executive has been so thoroughly
vindicated. It is a confession of weakness, as well as being very unfair and
selfish, to insist on all these meetings being held in the bigger cities. We in
Vancouver are apt to sit back and wait for men from other centres to come
to us. We do occasionally allow that Victoria is a reasonable alternative
(not too often), and some of us journey over there—but Kamloops, or
Nelson, or Prince Rupert! why, we couldn't go that far. We are spoiled by
the riches that are ours. When one comes to a meeting like the one at
Kamloops, and sees men here from all over the province—men who have
travelled hundreds of miles by auto, one regrets that there were not fifty
or sixty men from Vancouver at least, to acknowledge by the effort they
had made to come here, the effort that these men of the interior have made
to entertain and receive us.
Still, there was a fair contingent from the coast, and perhaps the depression is not yet over. The hotel accommodation of Kamloops was badly
strained before the meeting began—and at the time of writing there cannot
be room for many more.
From the beginning (this is a despatch from the front) there has been
a most delightful atmosphere of friendliness and hospitality about this
meeting. The meeting arrangements have worked perfectly, and our cordial
thanks are due to Dr. Ethlyn Trapp, secretary of the B.C.M.A., for the easy
efficiency with which she has met every problem. Dr. A. D. Lapp of Tranquille, our host on Monday, has been a tower of strength, and has helped
tremendously to make our stay here very pleasant.
There are one or two other features of this meeting that deserve recognition. We were honoured by the presence of Dr. J. S. McEachern, of Calgary, the president of the Canadian Medical Association, who addressed the
luncheon meeting at the Tranquille Sanatorium on Monday.
Dr. McEachern made a bold and earnest appeal to the profession for a
real national unity. In these days of stress, it is more than ever important
that the medical profession of Canada should speak with one voice, through
its national b°dy; and that there should be a genuine organic union of the
various local and provincial associations in a strong federal body.
He suggested that instead of a British Columbia Medical Association,
there should be a British Columbia branch of the Canadian Medical Association.
Every medical man should be a member of the Canadian Medical Association first, and of a provincial organisation second.
To those of us who believe in centralisation in all matters which are
federal in scope, such as health, education, defense, as well as law, this is
merely a new challenge to a deepening of our faith, and to more fruitful
expression of that faith, and Dr. McEachern's remarks were excellently
pointed and underlined by the remarks of Dr. Routley, General Secretary
Page 6
i k
•iii
of the C.M.A., who, by brief references to the annual report of the Council
of that body, shewed us a dozen accomplishments which have been made
in the last year through the Canadian body, which could never have been
made through any provincial body.
The Programme
The two-day programme of addresses was a really excellent one, as one
would expect from the list of speakers.
Dr. Heber C. Jamieson, Associate Professor of Medicine in the University of Alberta, was the first speaker. His paper on Recent Work in Diabetics
is published in this number. But his second paper, given on Tuesday morning, on Bright's Disease, was of the two far the most important, as it dealt
with a new conception and classification of renal conditions, which clarifies
and simplifies the whole problem greatly.
Dr. T. C. Conn, of the same university, also gave two papers, one on
Backache in Gynaecological and Obstetrical Conditions, which we regarded
as one of the sanest and most practical papers on the subject we have ever
heard. This is abstracted in this issue. His other paper, on The Relief of
Pain in Obstetrics, will appear later, as he has promised us a copy.
Dr. J. C. Masson, of the Mayo Clinic, gave also two excellent papers,
one on "Malignancy of the Large Bowel," and one on "The Use of the
Living Suture in Large Abdominal Hernia;." The second is appearing elsewhere, but we have hopes of securing a copy of the first.
Dr. F. M. Pottenger, of Monrovia, California, was a notable contributor
to the programme. His first talk about Early Diagnosis of Tuberculosis and
the role of the general practitioner in this, was given at the luncheon at
Tranquille Sanatorium, and will be abstracted in this Journal; while he
gave another talk on the Treatment of Early Tuberculosis that was excellent. Dr. Pottenger is well known as an author of several monographs on
tuberculosis.
We were fortunate to have Dr. Wm. P. Murphy, of Boston, whose
association with Minot is so well known. He gave an address on the use of
intramuscular injections of liver extract in conditions other than pernicious
anasmia.
Another contribution of outstanding interest was that of Dr. Wall on
Trachoma: Its Diagnosis and Treatment. This was illustrated by numerous
living examples, and was followed with most intense interest.
Lastly, Dr. R. E. McKechnie gave a thoughtful talk on Specialties, and
particularly diagnostic specialties.   We reproduce this in this issue.
The convention headquarters was the Plaza Hotel, but the meetings
were held in the auditorium of the Elks Hall.
The opening address was given by His Worship Mayor Moffatt of
Kamloops, who in a brief and witty speech welcomed the Association to
Kamloops and assured them of the pleasure with which Kamloops saw this
meeting being held.
The registration was over ninety, and members brought their wives
and daughters, so that the hotel accommodation of the city was taxed to
the limit.
The first day was taken up by addresses in the morning, following which
the members of the association were entertained at a luncheon at the Tranquille Sanatorium by Dr. A. D. Lapp and his staff.
The afternoon was devoted to various entertainments, and in the eve-
Page 7 ning a big dinner was held at the Plaza Hotel, at which the Hon. Dr. G. M.
Weir was the guest of honour and the speaker of the evening.
A definite note of cheer was sounded by the President when he announced that Jimmy McLarnin had won his fight and that Endeavour had
beaten Rainbow. This all made for happiness, and lest we should forget, our
President announced it again in somewhat greater detail later on.
The feature of the dinner was the speech by Dr. Weir on the question
of Health Insurance. Dr. Weir began by frankly declaring that he was not
going to make any commitments on behalf of the Government and himself.
Indeed, he could not, as matters had not reached the stage where any definite
announcement could be made. He reminded us of the fact that tradition
and habit must not stand in the way of social progress, and that whenever
a need for change could be proved to exist it is the duty of the state to
recognize and meet that need. The state can and will undertake activities
which the single unit cannot solve. That there is a need for change in the
matter of medical care of the citizen would seem to be evident to all, and
the manner of its solution must be worked out on a sound basis. He dwelt
on the necessity for insuring that the basis of any scheme evolved must be
actuarily sound. To this end the Government has engaged the services of
actuaries. He referred to the advantages that have been claimed from the
British National Health Insurance Act by such men as Lord Oxford and
Asquith, Sir George Newman, and others.
The address of the speaker was couched in clear and forceful language,
rising at times to high levels of oratory, and was listened to with close
attention by all present.
The second day of the convention followed the lines of the first, except
that in the afternoon many journeyed out to the golf course, whilst others
went out to Paul Lake and other points. Several went shooting and
appeared in the evening with the trophies of their sport.
m
CONVENTION NOTES
Amongst those present at the Convention from Vancouver were Drs.
G. F. Strong, Wallace Wilson, H. W. Riggs, C. H. Vrooman, H. H. Caple
and Mrs. Caple, Ethlyn Trapp, H. H. Milburn, Colin Graham, L. H. Leeson
and Mrs. Leeson, W. B. Burnett with Mrs. and Miss Burnett, G. E. Seldon,
R. E. McKechnie, W. S. Turnbull, D. E. H. Cleveland, A. S. Lamb, F. A.
Turnbull, H. Carson Graham of North Vancouver, A. J. MacLachlan and
J. H. MacDermot. New Westminster contributed Drs. G. Sinclair, H. B.
McEwen, S. C. McEwen and G. S. Purvis, while Dr. F. R. G Langston of
Coquitlam was also present. Victoria was represented by Dr. Thomas
McPherson, a small representation, some might feel, but extremely able and
as he took about half a car to himself it had the effect of spreading him out
a bit. Still his room was a very delightful spot for some of us. "Tommy"
is always a host in himself and a very congenial host.
• From Prince George they came, and Cranbrook and Trail and Salmon
Arm and Agassiz and Kelowna and everywhere around, and there was a
congested area in the lobby of each hotel, so much so that Dr .George Seldon
has declared that from now on he brings his own bed and Restmore mattress
with him to conventions.
Dr. W. S. Turnbull, our most indefatigable President, met every train
Page 8 himself and saw to the comfort of each of the men, whom he regarded as
his own personal responsibility. We have already referred in terms of
praise to Dr. Turnbull, but it is difficult to estimate how much such keenness and devotion to detail, tiresome and exacting though it may be, contributed to the success of the meeting. Many men motored up from Vancouver, Dr. Caple and Dr. Leeson amongst them. Dr. Hanington of Lady-
smith and his daughter also came by car, and all reported good roads and a
delightful trip.
In this number will be found abstracts from most of the addresses given
at the convention. Dr. Masson of the Mayo Clinic has promised us his paper
on Malignancy of the Large Bowel, and this will be published at a later date..
ANNUAL DUES
Members of the Vancouver Medical Association whose dues for 1934-3 5
are still unpaid are asked to send in their cheques as soon as possible. These
dues were payable on April 1st last and to date only a small minority of our
members have "come across." In accordance with the resolution carried
last year no drafts are being issued in November as was done for many years,
—hence this gentle reminder.
fc'
"CONCERNING SPECIALISTS"
Dy. Dr. R. E. McKechnie
Vancouver, B. C.
In the early days, when I first came to British Columbia, we had no
specialists, that is, doctors devoting their practice entirely to one branch of
the art. Even the functions of an eye specialist were carried on in Vancouver by a general practitioner, who was also a good surgeon. The fact
was that the town was too small to support a specialist, and the hinterland
was too sparsely settled to provide a reserve of patients to support one.
Finally Dr. Glen Campbell made the venture and succeeded.
In those days I was a general practitioner with a special training as a
surgeon, but I was ten years in practice in Vancouver before I had the
courage to cut out medicine and appeal to the profession as a surgeon. And
it was as a general surgeon I appealed. I saw recently at the O.R. at the
Vancouver General Hospital an oak wedge, covered with felt and leather,
with my name on the bottom, which I had made for correcting deformed
feet, for I included orthopedics in my list of accomplishments. I was the
first man to establish himself as a specialist in surgery in Vancouver, and
covered all the field; while earlier than that I had tried, as a mining doctor,
to cover the field of eye, ear, nose and throat work. Not that I wanted to
do so but the work was there to be done and no one else to do it.
In my work as a general surgeon, if I had tried to limit my field to one of
its specialties, I should not have succeeded, as the population of the province
was too small to support one in orthopaedics, or genito-urinary work, and
so on. And it was only as the population increased that enough work was
provided to support those practicing a specialty.
I can remember in my student days at McGill, we had Buller on the eye
and ear, Gardiner as a gynaecologist, and later Major on the nose and throat.
The general surgeon poked fun at the gynaecologist, as the surgeon had been
covering all that field previously, and jealousy may have also been evoked
Page 9 for having some cases diverted to the new specialty. Bell at that time was
evolving genito-urinary surgery, but he was by no means letting go his
general surgery.
But the demand grew there, as it later grew out here—grew with an
increased number of patients in the various lines, and when there was enough
ore in the stopes to warrant a mill, why, the mill appeared, even if only a
pilot mill.
As to the value of specialists in the various branches of medicine and
surgery there is no room for argument. They must be better in their chosen
branch, for they are specially trained in it both by practice and study, and
so the day of the specialist has arrived, and will remain, both because of his
value to the other members of the profession and also to the public. But
while it will remain, the day of the general practitioner will also remain,
for 80 to 90 per cent of the medical work can still be done by him as in the
past. The smaller towns and country places cannot support specialists, the
people cannot afford to bring them in, and so the general practitioner must,
as in former times, do yeoman service and cover the field as best he can.
Past records are that he has done well. The only danger to him is that
he will get to rely too much on the specialist and so weaken his self-confidence and develop an "inferiority complex."
So far there has been nothing of a controversial nature in my remarks,
but what I am now going to present may lead to comment, as it will strike
vested interests. I refer to the specialization which has sprung up in laboratory work so that the results there are being more and more utilized by the
profession, and the microscope in the doctor's office used less and less. There
is no doubt that the results attained in the laboratory are of much greater
value in investigating disease than the results obtained by the busy practitioner. It is the old story—a specialist devoting his whole time to laboratory work and laboratory methods must attain greater skill in his branch
of the profession and have a better grounded education in those methods,
while at the same time developing a better judgment in interpreting what
he sees, than can the man who only occasionally uses the microscope or the
test tubes. So the pathologist has come to stay with us, for not only does
the profession need him but the public as well.
This has become so self-evident that our Provincial Public Health
Department, under Dr. Young's skilful guidance, has subsidized laboratories
in Victoria, Vancouver, Kamloops, Kelowna, Trail, and possibly other places.
The northern portions of the province seen^ to have been neglected. But it
is of distinct advantage to the people of the province that the doctors attending them have proper laboratory facilities, to help them in arriving at a
diagnosis. To be able to do this work himself the doctor would have to have
a costly laboratory equipment, too costly for the ordinary doctor, and hence
another specialist arises. With his costly equipment, with his specialization
confining him to a limited field, comes the necessity of his charging a fee
sufficiently large to recompense him for his time and equipment. Hence we
have high fees for this class of work—too high for the ordinary patient to
take advantage of, so high that the doctor is loath to ask his patient to
take advantage of the laboratory aid. Hence many a patient has to rely on
the general practitioner and Providence, although definite help is near at
hand.
Dr. Hill, in the July number of the Public Health report, which is
issued monthly to all members of the profession, entered into a detailed
examination of costs.   He charged up for everything almost—the almost
Page 10
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p1 ft
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refers to "air," which was the only thing omitted. Just to run through the
items is instructive, for the ordinary man would miss many of them in his
estimate. Thus we have rent, taxes, insurance, repairs, depreciation, laboratory equipment and furniture, office equipment and furniture, supplies,
janitor service, heat, electricity, gas, water, refrigeration, laundry, books,
journals, attendance on conventions, vacation, relief, publicity, salaries and
wages, etc. Now, none of these things can be omitted in a correct estimation of the cost of a given laboratory examination. He then takes a specific
example, diphtheria smears. This of course includes culture media, test
tubes, incubator service, technical services and the proportion of the general
expense of the laboratory and arrives at the conclusion that the actual cost
to the laboratory was 75 cents. This estimate is based on a year's work in
that particular work, say 6,000 specimens in a year. In this estimation Dr.
Hill figured that 10% should be charged for these diphtheria examinations
against general expense, but also says that if 20% were charged the cost
would be only 8 2 l/z cents.
The Provincial Government has found it in the public interest to provide free examination for various diseases, tuberculosis, diphtheria, typhoid,
venereal diseases, etc. But why limit it to these diseases? It is just as important to the public (which in the end pays through its taxes for these services) that doctors should be furnished with every facility to diagnose the
ailments of their patients, not in the interests of the doctors but in the
interests of the patients, our citizens. In many cases the fees charged now
are prohibitive and limit these examinations to the few. But many need
them. A differential blood count together with estimation of haemoglobin
and the morphology of the cells will cost $7.00, but a technician informed
me that it took only half to three-quarters of an hour of her time to do it;
half an hour if not disturbed. This is routine examination which is not
utilized as often as needed. The same can be said of a basal metabolism
test. Five to seven dollars seems out of reason as a fee for this. Yet for
private internists, who are doing such work, the fees are not too high,
taking into account the capital cost of properly equipping a private laboratory, the relatively few cases handled, and the high grade of the physician
doing the work.
But my contention is—why should the public suffer in health work if it
can be done much cheaper (and hence more utilized) in provincial laboratories or laboratories subsidized by the Province?
As stated before, the Province is doing an enormous work in the interests of health. It has established free clinics for the treatment of venereal
diseases and during 1932 over 47,000 treatments for gonorrhoea and over
16,000 for syphilis were given.
Why could not the Province extend its work, establish, in addition to
the present subsidized laboratories, others in various parts of the province,
with their work embracing the full laboratory field, so that the public
would reap a richer benefit. I do not ask for this work to be done free. Let
reasonable fees be charged, except in the case of those unable to pay, and
have it so that a doctor's certificate covering this fact would be all that was
needed. The provincial authorities are seriously thinking of state medicine.
We know that will cost the Province, for its share, a large sum of money
(indirectly the people pay it). The scheme of provincial laboratories would
cost much less, might even be self-supporting, after the initial expense of
equipment, and would do untold good to the people for the aid it would
give the medical profession in arriving at early diagnoses.
Page 11 BRIGHT'S  DISEASE
By Dr. Heber Jamieson
University of Alberta
[The following is a summary of Dr. Jarr.iesons address, which contained a
description of Bright's disease that is the clearest and most concire we have heard.
It is based on the work of Volhard, a German worker, whose monographs on the
subject have not yet been translated into English. This conception of Bright's
disease will appeal to our readers on account of its simplicity and logical thought.]
From the time of Bright, there has been much confusion in the classification and separation of various types of kidney conditions. Throughout
this time, there have been endless classifications, and this has added greatly
to the confusion. The basic difficulty would appear to have been caused by
the feeling that we must find, in kidney lesions:
1. Albumin in the urine, at some stage or another;
2. Oedema or dropsy;
3. At autopsy, marked changes in the kidney.
Thus we have heard of parenchymatous and interstitial nephritis, diffuse
nephritis, etc., and where gross lesions have been present, there has been no
difficulty in establishing the presence of nephritis.
But the fact is that neither albumin nor oedema is necessarily present in
Bright's disease.
Again, hypertension (high B.P.) has been a cause of stumbling, since in
this neither albumin, or haematuria or oedema need be present, and not till
the final stages of hypertension are there any objective evidences of renal
insufficiency.
Dr. Jamieson described a new classification, based on the work of
Volhard. To understand this, we must first briefly review the anatomy of
the kidney, and its physiology.
Anatomy. The kidney is composed of units.
Each unit contains:
Glomeruli (of which each kidney has two million) ;
Tubules (straight and convoluted);
Arterio-vascular elements.
If the capillaries of the glomeruli were spread out flat, we should have
an area of 5 ft. square, roughly equal to the body surface.
Physiology. Four to six ounces of fluid pass through the glomeruli every
minute, about 9 quarts per hour. Over 90% is reabsorbed in the convoluted
tubules; less than 10% passes through.
Thus we have, in urinary excretion, filtration phis absorption. It is
important to bear this clearly in mind.
Volhard says there are three signs of Bright's disease, and three only:
1. Haematuria;
2. Oedema;
3. Hypertension.
We have thus various forms of kidney disease.
1. Circumscribed form.
This has one sign—hematuria—no other signs. It is due, in over 90%
of cases, to the streptococcus, and occurs at the height of an acute infection,
nearly always upper respiratory tract infection. Thus it may occur in acute
tonsillitis, acute toitis media, etc.
Often the haematuria is slight; it is usually transitory, and very frequently is not recognised at all.
Only the glomeruli are affected in this type.  It is due to thrombosis in
Page 12
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the glomerular vessels, especially the capillaries. There is no retention of
metabolites: hence no oedema.  The streptococcus may often be recognised.
The most important point in diagnosis is the finding of blood casts:
proving that the bleeding is from the glomeruli, not from the pelvis of the
kidney, bladder, etc.
The second form is sometimes called nephrosis, and the outstanding sign
is oedema.
This is believed usually to be not inflammatory in origin, but degenerative. It is found in syphilis, pregnancy, etc.
Volhard's conception is that it is nearly always infective in type to begin
with, and later degenerative.
He calls it "nephritis with a nephrotic tendency." The tubules are
involved in this form, and the cedema is due to the retention of metabolites
and water
The third form is the hypertensive form.  Here hypertension is the only
sign.
The pathology of this is that the arterioles of the kidney unit are
involved—and it is really an arteriolars clerosis.
Every person with hypertension is potentially a case of Bright's disease.
The only difference is one of renal insufficiency. As soon as this develops,
we have Bright's disease. If the patient lives long enough, it always develops.
The younger the age at which hypertension appears, the sooner we shall have
renal insufficiency developing.
The old classification was into benign, or essential hypertension, where
there was no oedema or haematuria, and malignant hypertension, where renal
insufficiency appeared.
This is not a good distinction, because it is only a matter of time. But
in the early stage of hypertension, while there is arteriolar-sclerosis, there
is no retention of metabolites, and no haematuria.
The commonest form of Bright's disease is a fourth form, which overlaps all these separate simple forms. It has been variously called mixed
nephritis, combined or diffuse nephritis. It means that all the elements of
the unit are involved, and so we get haematuria, oedema and hypertension
existing in various degrees.
Tihs type may be acute, subacute or chronic.
It is acute when healed in two months or less, siibacute when healed in
less than six months, after which time it becomes chronic.
Acute. This form is due to the streptococcus in nearly all instances,
but, unlike the simple haematuric form, comes on within two to four weeks
after infection has subsided. It follows scarlet fever, otitis media, etc. The
three elements of the kidney are involved, hence we get haematuria, cedema
and hypertension.
Upper respiratory infections are the most common cause—this is the
type that follows scarlet fever.
Oedema and hypertension in this may be very transitory, lasting only
24 hours, and must be watched for. If the patient recovers, they remain
absent—or cedema may reappear, and become marked. The patient becomes
nephrotic.
These patients may develop hypertension, or they may become nephrotic,
and later hypertensive. These changes, of course, are brought about by the
failure of one or more of the elements in the kidney unit.
We can see how this plan fits any classification hitherto made of kidney
disease. Acute haemorrhagic nephritis, chloraemic nephritis, nephritis with
Page 13 or without cedema, all descriptions may be brought within this conception
of kidney disease.
Dr. Jamieson had a word to say about nephrosis.
The nephrosis that is non-infective will nearly always end in complete
recovery.  Where it follows nephritis (acute) it may go on to hypertension
and so end in true Bright's disease eventually.
Prognosis:
1. Hatmaturic type. Usually recovers, though haematuria may continue
as long as a year.
2. Oedema may also go on for a long time with recovery. The prognosis,
as indicated, depends to some extent on the cause. If post-nephritic, it is not
so good, as it tends to lead to hypertension.
3. Hypertensive type. The most serious. Volhard divides this into "red"
and "white" forms. "Red" forms have no renal insufficiency; life is longer.
"White" or pale types have renal insufficiency, and do not recover.
Prognosis is bad in the young with hypertension, as they will all develop
renal insufficiency sooner or later.
Treatment:
1. Hxmaturic type.   These are nearly all missed—treatment is that of
the associated disease.
2. Nephrosis (simple). Here there is marked oedema and albuminuria.
We give large amounts of protein, and thyroid extract.
3. Hypertensive type. Allen suggests lowered salt intake. We must
not reduce protein intake, as this brings about marked loss of weight.
4. Combined form.  While acute, reduce chlorides and protein intake.
There are two methods of estimating the damage done to the kidney—
easily done and accurate. The first is the dilution test, which involves giving
the patient a large quantity of fluid on an empty stomach, and estimating the
sp. gr. of specimens taken at close intervals thereafter. This shews the
capacity of the glomeruli to secrete large quantities of water.
The concentration test is just the opposite, and consists in the removal
of fluids. This depends on the ability of the tubules to reabsorb fluid. If a
high sp. gr. is obtained, well and good; if low, the tubules are failing.
These tests cannot be carried uot where there is cedema, diarrhoea or
vomiting, or where there is much sweating.
BACKACHE  IN  GYNECOLOGY AND
OBSTETRIC^
By Dr. T. C. Conn
University of Alberta, Edmonton, Alta.
Backache is very common amongst women, one of the commonest complaints, in fact. It moy be referred to the lumbo-sacral or sacral region, the
sacro-iliac region, or down the back of the thigh.
For many years gynaecologists and surgeons have been laying too much
stress, in Dr. Conn's opinion, on the supposed fact that backache is chiefly
seen in women.
Orthopaedists show that many orthopaedic conditions are responsible, and
there is a whole series of conditions due to bad posture, bad carriage and
general lack of proper hygiene, which cause backache, both in men and
women.
Dr. Conn feels that too many operations have been performed in the
past for the relief of backache, and his opinion is that by careful elimination
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of the causes of backache we may reduce the indications for operation to a
very small number. Too often suspensions and plastic operations are done
without subsequent relief of the backache complained of.
First, frequency of backache in pelvic conditions. Some report 85%
of backache due to pelvic conditions (Ward & Buller); Lynch claims 70%,
but many gynaecologists, including Dr. Conn, think that this is too high
an estimate.
History. A careful history is of very great importance. We should find
out the time of onset of the backache, before or after marriage, or before
or after pregnancy. Has there been any injury or strain in the past, and
here we must remember that an injury does not always lead to backache
immediately. Sometimes, even a slight injury may have been sustained
which eventually causes backache. What is the relation to the menstrual
period?  Is it worse at that time or not?
Examination. The patient should be examined lying down, sitting up
and standing. The back and the posture should be carefully examined.
Points of tenderness and muscular spasms should be looked for. Any signs
of sacro-iliac involvement. An x-ray is a very important help and this
should be taken both antero-posteriorly and laterally. We must remember
that developmental conditions may render a patient more liable to strain or
fatigue.
As regards gynaecologcal causes of backache, There are four main
groups.
First, pelvic displacement, and here there is a great difference of opinion
amongst authorities. Second, pelvic inflammation. Third, pelvic neoplasms. Fourth, relaxed pelvic floor.
First, displacements. A definite number of women are born with congenital retroversions and displacements, and the speaker did not think that
these had much to do with backache in nulliparous women. He feels that
operation here is unnecessary and useless. In parous women it is thought
that displacements may cause symptoms due to congestion, prolapse of
ovaries, etc. This may be so, but we should not operate until these symptoms
appear. The mere presence of a displacement does not in itself constitute a
reason for operation and we must remember that frequently there is a general enteroptosis associated with displacement and operation will not relieve
this.  Proper supports will be more useful.
Where the uterus is at the proper level it is unwise to interfere. Where
there is prolapse of the uterus, we do get backache as a result, due to the
stretching of the ligaments, and here operation may relieve the condition.
Sometimes we find complete prolapse without backache.
Second, pelvic inflammations. These are certainly the cause of backache,
which any inflammatory or congestive condition will bring about. Here
we must treat the cause and get rid of the inflammation. G.C, inflammation
following abortion, pelvic cellulitis are common causes of backache.
Cervical inflammation and infection are not sufficiently thought of as
a cause of backache, but are a very common cause, and treatment of this
by the electric or other cautery will often cause backache to disappear.
Third, pelvic neoplasms. These will cause backache and must, of course,
be treated.
Fourth, relaxed pelvic floor. This has a tendency to cause backache,
especially with poor posture, relaxed abdominal wall and retroverted uterus.
There are several very important causes of backache which we should
consider.
Page IS Posture. Poor posture is a very frequent cause of backache and proper
muscular exercises and attention to carriage will do much to relieve the
patient.
Fatigue. This is most likely to show at the end of the day and rest must
be prescribed.
Injuries to spine from falls, etc. Often patience is necessary to get a
history of injury, and even slight injuries may at a later date cause trouble.
Spinal anomalies, such as spina bifida occulta, and spondylolisthesis.
Women with these are more subject to strain and so deliver backache.
Lumbosacral and sacro-iliac strain. It is somewhat hard to distinguish
between these two and the x-ray is of great help.
Arthritis. Women over forty years of age are very liable to have some
degree of arthritis and the x-ray will show this. Osteo-arthritis does not
necessarily cause backache but it frequently does, and there is a possibility
of foci of infection which need removal.
Backache in obstetrical conditions. This may appear after the third
month of pregnancy, due to a loosening of the sacro-iliac synchondrosis.
There is also postural backache due to the enlargement of the uterus and
the weight. Backache may also appear after labour. Dr. Conn has been in
the habit of late years of inserting a pessary before the patient leaves the
hospital, which he thinks reduces subinvolution and so backache. The
importance of securing a good pelvic floor following labour is very great,
and Dr. Conn feels that sometimes we wait too long for the head to be
delivered and feel that the fact that no tear occurs is sufficient. It is important to avoid a relaxed outlet and sometimes an early episiotomy will secure
this.
When the patient comes back for her six week examination we should
check the condition of the abdominal wall. Since a firm abdominal wall has
much to do with the comfort and health of the patient, suitable exercises
should be prescribed. We should impress upon the patient the importance
of a good firm wall and also the importance of carriage. As this time we
should again examine the sacro-iliac joint, giving support if necessary in
the shape of a firm corset.
The cervix should be examined and erosions treated by the cautery.
Usually two applications five to six weeks apart are all that are necessary.
This eliminates low grade cellulitis as a cause of backache. Examine the
patient again at the end of six months for a re-check. Sometimes everything is apparently normal at six weeks examination, abnormalities appear-
later, i
Dr. Conn feels that by careful attention to these details we shall find
that our patients will escape many causes of backache.
We shall, too, eliminate the operations so frequently done in the past
in a blind hope that a backache will be cured, but which were performed
without a thorough examination of the patient and so proved useless.
U\
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NEWER PROBLEMS  IN THE DIABETIC
By Dr. Heber C. Jamieson
Edmonton
Few discoveries in medicine are as rich in fulfillment as in early promise.
Often years of clinical experience with a new therapeutic aid are necessary
for a proper assay of its value. Frequently, too, marked changes take place
in the course, severity and outcome of a disease, under the influence of a
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remedy. This has been the case with insulin in diabetes mellitus, and, our
knowledge having become more seasoned after ten years, it seems an opportune time for a review.
Looking at the situation in a broad way, one can say that diabetes is
on the increase, due partly to greater longevity of the population as a whole.
Also, the diabetic lives longer than he did and enjoys a more normal and
useful life. But during the last decade better treatment has introduced new
problems.  It is of these that I wish to speak.
Before discussing the notable changes which have occurred in diabetes,
it is important to mention the newer theories in regard to this disease.
Until recently it was believed that the sole cause of diabetes was disease
or damage to the pancreas. In 1926, Houssay removed the pancreas from
dogs, and typical diabetes resulted. Then he removed the pituitary and the
pancreas at the same time. No diabetes resulted. Grafting the pituitary
under the skin of such a dog immediately brought on a rapid and fatal
diabetes. Collip has repeated this work and advanced our knowledge of
pituitary function.
Briefly, it can be stated that there is an anterior pituitary hormone which
counteracts insulin. Collip has shewn that this is identical with the growth-
producing hormone of the anterior pituitary. There are in the pituitary
gland hormones and anti-hormones. It is possible that there are two forms
of diabetes, depending on the cause—one pancreatic and one extra-pancreatic. It may well be also that cases of so-called renal diabetes are due to
pituitary dysfunction.
A recent survey of diabetic deaths in Alberta over a twelve-year period
revealed a remarkable change in death-causing complications. This condition is but a parallel to that found elsewhere.
I have made a chart to show the findings in the years 1921-22, before
insulin; and in the years 1931-32, when insulin and adequate diets were in
use. It will be seen that coma has decreased from 63 to 21 per cent, whereas
heart and arterial disease has risen from 9 to 53 per cent. Deaths from
gangrene and infection have remained more constant. It is with the use and
action of insulin in relation to those more common death-dealing complications that I wish to speak today.
Pregnancy in the diabetic is more common than formerly. Then disturbances of menstruation and even atrophy of the uterus occurred and
produced sterility in this disease. One often finds a gain in carbohydrate
tolerance as pregnancy advances, and frequently an increased tolerance after
delivery. A point of practical importance has been settled in this connection.  No permanent ill effects result from pregnancy in the diabetic.
One must here mention the glycosuria that develops during pregnancy.
Sometimes this disappears before delivery or shortly after, and it would
appear to be due to pituitary dysfunction. One has difficulty, however, at
times in deciding during the course of such a condition whether it is a
temporary or permanent metabolic disturbance.
Before the days of insulin, hydramnios was said to complicate pregnancy
in 27 per cent of cases in the diabetic female and to cause premature labor.
Under careful treatment, hydramnios does not occur now. Congenital
abnormalities were common, but are now less frequent.
The foetuses of diabetics have a tendency to be overweight with increased
skeletal development and increased length, another indication of pituitary
disturbance. Foetal hypoglycaemia may occur, and it is advisable to give
glucose to the expectant mother just before delivery and to administer a
Page 17 glucose solution to the new-born babe at frequent intervals. What of congenital diabetes? This is very rare, but there is a hereditary tendency to the
disease, which, with increase of children from diabetic mothers, will become
more common.
Coma. The management of coma is so well known that one can only
exhort the physician to be bold in the use of insulin. The management of
coma calls for urgency. This complication is as serious and death-dealing as
an acute abdominal condition. Use insulin as the surgeon uses the knife—
early and with boldness. Small doses are not only useless, but dangerous.
Give it till the effect is obtained; an overdose can easily be corrected.
Infection. It will be noticed that deaths from infection have not
decreased since the advent of insulin. Why? Lack of proper knowledge of
the underlying condition has been responsible. We know now that a diabetic
acquires an infection of any kind more readily if he has a blood sugar above
normal. Clinically, this latter is demonstrated by large amounts of glucose
in the urine. We know also, and this is most important, that as soon as the
blood sugar is brought within normal limits, resistance of the body to
infection becomes normal. The amount of insulin required to bring about
this normal condition cannot be predicted in any given case. One has given
as high as 270 units of insulin daily for weeks in a badly infected arm. Here,
again, one must be bold. Give insulin till the urine becomes sugar-free or
almost so, and keep it there. To accomplish this it may be necessary to
examine the urine five or six times a day to prevent overdosage, but remember that only by adequate dosage will one give the diabetic patient the same
chance as a non-diabetic.
Arteriosclerotic disease, including gangrene and coronary sclerosis. In
order to get a better conception of these important and increasing complications, it is necessary to explain briefly the modern theory of arteriosclerosis.
The importance of arteriosclerosis as a complication of diabetes is increasing. As we have seen, more and more patients are living longer, and,
in consequence, arterial change and the signs and symptoms of it bulk larger
in the complaints of the diabetic. What causes it and how does it develop?
It is believed that increased lipoids in the blood are responsible for it. A few
words about the pathological progress of arteriosclerosis will explain some
of the problems of treatment.
The intima and the inner two-thirds of the media of the larger blood
vessels obtain their nourishment directly from the blood stream. A continuous flow of plasma percolates through the intima as far as the elastic layer.
The facility with which this plasma permeates the intima depends on the
pressure in the vessel. The greater this pressure the more saturated does the
intima become. Only in some arteries, such as the aorta, carotids and coro-
naris, does part of the media share in this nutritional bathing. In these
arteries the elastic layers of the intima are rather loosely knit next to the
media.
It is on these facts that the modern conception of arteriosclerosis is
formed. Lipoids or cholesterol esters, whether from the food or from metabolic changes within the body is not clear, are present in the plasma which
soaks the intima and they are deposited close against the elastic laminae and
in many cases between their fibres, where there appears to be a cementing
substance which is replaced by cholesterol esters.
While this disposition of lipoids is taking place, certain protein substances from the blood also enter the intima and cause a hyaline swelling.
At the same time there is a true hypertrophy and new formation of collagen
Page 1 S
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and elastic fibres. When this process attains an advanced state, necrosis may
occur. The lipoids in the deposits change and cholesterol is let loose, and
at the same time there begins the deposition of calcium salts, giving the
condition known as arteriosclerosis.
Now, besides the lipoids and the protein bodies which we have just
considered, several other constituents of the blood plasma play a part in the
changes which take place in the vessel wall structure. The chief of these is
mucin. This substance, which is normally present in the blood, as soon as
intimal changes occur, passes through the elastic layer and forms a deposit
in the media. Now we have the complete picture of the arteriosclerotic
process as it affects the intima.
One must consider, however, the calcification of the media, if only
briefly, since it is present so frequently in the diabetic. This is not preceded
by any deposition of lipoids, but takes place in the muscular layer. There
occurs a calcifying process of the muscle fibres and collagen fibres about
them, and this is followed by necrosis. The peculiarity of this process is its
predilection for certain vessels, particularly the tibials. The aorta and the
heart and cerebral arteries escape. It is believed that the special neuromuscular layer of the leg vessels predisposes them to calcification. Lipoid
infiltration of intima and calcification of media may of course co-exist.
This explanation of the formation of arteriosclerosis is of particular
importance in relation to the diabetic because there is an increase of
cholesterol in the blood in this disease. Joslin believes that arteriosclerosis
develops from ten to twelve years earlier in the diabetic than in the non-
diabetic. It has been also demonstrated that with increased blood sugar
there is increased permeability of the tissues, a condition favoring the laying
down of lipoids in the blood vessel walls. The insulin treatment shows a
lowering of death rates from coma, but an increased rate from arteriosclerosis.
Warren found among 300 fatal cases autopsied that 5 5 had gangrene
and in 27 it was the primary fatal lesion. Joslin reports that in the last four
years gangrene caused 1 in 11 diabetic deaths. The Alberta experience was
1 in 2 in the first period and 1 in 14 in the last period. One must remember
here, however, the smaller percentage of middle-aged and old people in a
new country before making too much of this favourable showing. Warren
calls attention to the association of coronary sclerosis with gangrene. Of
the 5 5 cases of gangrene just mentioned, 25.5 per cent showed infarcts of
the heart at outopsy. Nathanson, in reviewing 100 diabetics over 50 years
of age as against 8 per cent in general outopsy material.
Gangrene, which may be precipitated by frostbite, tight-fitting shoes,
trauma or paring of corns, presents several difficulties in treatment. Gangrene is usually of the lower extremities, and occurs in limbs with arteriosclerotic changes. In many cases the x-ray shows calcareous deposits in the
vessels of the foot and leg. The treatment here is insulin first, last and all
the time until healing takes place. If an operation is necessary, prepare the
tissues for healing by insulin and a maintenance diet.
And now a word of warning about the insulin dosage. Your patient
with gangrene has probably got a sclerotic coronary artery and hypogly-
caemic reactions may cause thrombosis and death. I have seen two such cases,
and a number with precordial pain and distress during an insulin reaction.
Great care is necessary in the management of gangrene, since normal
Hood sugar is required for healing and the danger of insulin overdosage a
menace.
Page 19 One other point in the case of these patients is sometimes learned bv
experience. Hot water bottles may cause areas of gangrene with your
patient under treatment. A limb with arteriosclerotic vessels has diminished
sensation.
If the limb cannot be saved and an amputation is necessary, do not temporize. If the foot is greatly involved, there is only one site of election—
the middle third of the thigh.
And what about the anaesthetic? If available, gas and oxvsren are safe.
Repeatedly, I have taken the blood sugar before and after operations on the
diabetic where this anaesthetic was used, and seen practically no change.
Where this is not on hand, one takes greater risks unless spinal anaesthesia
is available.
There is one complication, mainly seen in the female, that sometimes
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Page 20 « .1
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calls urgently for relief—pruritus vulvae. Recently a yeast has been indicted
as the offending organism responsible for it. In many instances the affection
disappears when the urine becomes sugar-free. If it does not, painting with
a 1 per cent aqueous solution of gentian violet twice weekly, and a vaginal
douche of 5 per cent soda bicarbonate, gives improvement.
Having stressed the free use of insulin in the treatment of diabetes, one
must not forget that it may produce profound and alarming reactions at
times.
The most common symptoms of hypoglycaemia are weakness and mental
exhaustion, nervousness, twitching, sweating and a sensation of hunger.
These are familiar to anyone who treats even a few patients with insulin.
When convulsions are encountered, there may be more difficulty in
recognizing the condition. One sees seizures which are typically epileptic.
Hemiplegia may be observed and be so marked that a positive Babinski
response may be obtained.
All these signs are completely relieved by the giving of sugar or of sugar
and adrenalin.
Few patients die of hypoglycaemia, but many have the unhappy experience of insulin shock. This may be brought on by exertion, extreme heat
or menstruation—to mention a few causes.
Hypoglycaemia occurs most commonly in the evening about nine or ten
o'clock.  The afternoon sees fewer reactions and the morning least of all.
In this survey I have attempted to show the changes which have taken
place in the diabetic picture after ten years, and call attention to the new
problems that have arisen and the way in which they may be met. Will
another ten years see the older diabetics relieved of arteriosclerotic complications? Should that happen, another of the thousand doors to death will
be closed.
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By reason of its marked hygroscopic properties,
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DEXTRI-MALTOSE, over 23 years,
CARBOHYDRATE OF CHOICE
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1911
"The limits of assimilation of the different sugars vary
and are as follows:
"Grape sugar: In babies, about 5 grams per kilogram
(Langstein and Meyer).
"Grape sugar: In one-month baby, 8.6 grams per kilogram (Greenfield).
"Galactose: No accurate data.
"Levulose: (Lower for babies than adults.) One gram
per kilogram (Keller).
"Maltose: Over 7.7 grams per kilogram (Reuss).
"Lactose: 3.1-3.6 grams per kilogram (Grosz).
"Cane sugar: Probably about the same as lactose
(Reuss)."—J. L. Morse, and F. B. Talbot: Physiology and
pathology of the digestion of the carbohydrates in infancy,
Boston M. &■ 5. J., 164:852-856, June 15, 1911.
1912
'' Maltose has for many years been considered one of the
most valuable of infant foods in modifying milk formulas; but the German school in the last few years has
called special attention to the value of this sugar as a
substitute for milk and cane sugars in conditions of
intestinal fermentation. It is more easily assimilated
and more rapidly absorbed than lactose or saccharose
and it may be taken therefore by the infant in larger
quantities without producing sugar fermentation."
"Maltose is especially indicated in the feeding of very
young and delicate infants, and in all cases where either
milk or cane sugar has produced intestinal fermentation
and sugar intoxication. In the feeding of maltose it has
been found advisable to combine it with about equal
parts of dextrin. In Germany, and later in this country,
'Soxhlet's Nahrzucker' (which contains maltose 52.44
per cent., dextrin 41.26 per cent., and sodium chlorid
2 per cent.) has been largely used. Mead's Dextri-Maltose
(malt sugar), which contains about equal parts of dextrin and maltose, is a similar preparation which may be
used instead of milk sugar or cane sugar for modifying
milk mixtures."—B. K. Rachford: Diseases of Children,
D. Appleton &° Co., New York, 1912, p. 125.
1913
"It is well to start with one ounce (albumin milk, or
albumin-buttermilk) to every pound of body-weight in
the twenty-four hours, increasing gradually until two
or three ounces to the pound of body-weight are being
given. Then add sugar, preferably a malt sugar, about
one-fourth of an ounce at a time to the twenty-four-hour
quantity, until an ounce or an ounce and a half is being
given."—J. Foote: Principles of treatment in malnutrition and atrophy of infants. Interstate M. J., 20:1913,
No. 6.
1914
"Milk sugar and cane sugar may be used in infant
feeding, but my preference is for malt sugar. Mead and
Johnson put up a convenient preparation which they call
Dextri-Maltose and which consists of maltose 51 per cent.,
dextrin 47 per cent., sodium chloride 2 per cent., and
which has a food value of about 110 calories per ounce."
—J. A. Gannon: Whole milk dilutions in feeding normal
infants, Washington Med. Annals, 13:38-43, Jan., 1914.
1914
"Dextrin-maltose causes the greatest gain in weight,
cane sugar less, and lactose produces the least gain."—M.
S. Reuben: Observations on milk station infants. Arch.
Pediat., 31:176-198, March, 1914.
1914
"A composite opinion of the sugars is in favor of
dextri-maltose, milk sugar and cane sugar in the order
named."—R. A. Strong, Essentials of modern artificial
feeding of infants, Lancet-Clinic, March 14, 1914.
1914
"Experiments show that sugars vary in their rate of
absorption, some being assimilated rapidly, while others
distribute their nutriment over a longer period. For
example, maltose is most promptly assimilated, cane
sugar next and mUk sugar slowest."
"The condition in which dextri-maltose is particularly
indicated is in acute attacks of vomiting, diarrhea and
fever. It seems that recovery is more rapid and recurrence less likely to take place if dextri-maltose is substituted for milk sugar or cane sugar when these have
been used, and the subsequent gain in weight is more
rapid.
"In brief, I think it safe to say that pediatriciansare
relying less implicitly on milk sugar, but are inclined to
split the sugar element, giving cane sugar a place of
value, and dextri-maltose a decidedly prominent place,
particularly in acute and difficult cases.' —W. D.HoskinsM
Present tendencies in infant feeding, Indianapolis M. J.,
July, 1914.
1915
"In the severe cases (of diarrhea) he (Benson) uses
Finkelstein's casein milk with malt sugar. He also believes [
that dextri-maltose is to be preferred to milk sugar or
any other sugar, as the infants gain more rapidly and
digest more easily this form of sugar."—R. A. Benson:
Observations on 1,500 artificially-fed infants, Med. Century, Feb., 1915, p. 33; abst. Arch. Pediat., 32:556-557,
July, 1915.
1915
"Until very recently we have taken it for granted that
milk sugar was the best, but now many consider that
malt sugar is even better. However, the malt sugar is
not used in its pure state, but in the form of extracts, as
dextri-maltose."—E. B. Lowry: Your Baby, Forbes 6V Co.,
Chicago, 1915, p. 162.
1915
"Cane-sugar (saccharose), like most of the other
disaccharids, is not absorbed as such, but must first be
split by the invertase of the intestinal secretion into the
two glucoses, dextrose and levulose, which are readily
absorbable. Maltose (malt-sugar) occupies an exceptional position among the disaccharids, in being partly,
absorbable as such. This is probably due to the fact that
it can be split not only by the maltase of the digestive
juices, but also by the same ferment being present and
active in the circulating blood (Chittenden and Mendel)."
"Anticipating a little, we may mention that all cases,
in which lactose may advantageously be replaced by
other carbohydrates, are pathological, and without exception the result of unsuccessful attempts at artificial
feeding; they will therefore be discussed under that head.
"Dextrin, intermediate between sugar and starch, is
physiologically nearer to the former; we shall have
occasion to see that, under certain conditions, it may
supplement sugar very advantageously. Given together
with maltose, it materially delays the fermentation of
the latter; Stolte observes that the more complex the
carbohydrate the longer fermentation is postponed."
"All malted foods contain dextrin, and there is reason to
believe that theirvalue largely depends on their being somewhat complicated; such, at least, is the opinion of Usuki and
Stolte, who believe that a mixture of carbohydrates is
more slowly absorbed than a pure sugar, and therefore
tends to check fermentation in the intestine. South-
worth explains the matter more definitely, by attributing the antifermentative action entirely to the dextrin,
which is not fermentable as such, but only after it has
been split into maltose, a process that takes place only
gradually, and in the later stages of digestion."
"I make it a rule to give the ordinary formula with
dextrin-maltose whenever the usual milk or cane-sugar
mixtures seem to cause excessive fermentation and colic,
or are attended with the evacuation of soap stools. I
decidedly prefer this, as a preliminary measure, to going
over at once to some very low fat combination, which
can only be a temporary makeshift at best. I also find
dextrin-maltose an excellent addition to albumin-milk
when the first object of that food has been achieved and
a gain in weight is desired; in this way I have succeeded
in feeding albumin-milk far beyond the period usually
advised, with highly gratifying results."—F. L. Wachen-
heim: Infant-Feeding; Its Principles and Practice, Lea c?"
Febiger, Phila., 1915, pp. SI, S3, 146, 168.
Continued down to 1934
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