History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1927 Vancouver Medical Association Jan 31, 1927

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 THE VANCOUVER MEDICAL
mm     ASSOCIATION
BULLETIN
Published monthly at Vancouver, B. C
Subscription $1.50 per year
*5B. Q. Laboratory ^rnktis
Presidential cfAddress
erRgferred 'Vain
JANUARY, 1927
Tublished by
o!Mc'3$eath Spedding Limited, UancouDer, GB. Q.
>K  THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718 Granville St., Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
Vol. 3. JANUARY 1st, 1927 No. 4
OFFICERS, 1926-27
Dr. A. W. Hunter
President
DR. A.  B.  SCHINBEIN Past President
Vice-President ;DR.   J.   A.   GILLESPIE
Secretary Treasurer
Dr. F. w. Brydone-Jack Dr. W. S. Turnbull
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Representative to B. O Medical Association Auditor
Dr. A. C. Frost Dr. F. W. Lees
SECTIONS
Clinical Section
Dr. F. N. Robertson   -       -        -        -        -                - Chairman
Dr. Gordon Burke     ------------ Secretary
Physiological and Pathological Section
DR.   C.   H.   BASTIN         -    '     -         -                     -         -         - Chairman
DR.   C.  E.   BROWN   -                                                        ... Secretary
Eye, Ear, Nose and Throat Section
Dr. E. H. Saunders   ------------ Chairman
Dr. W. E. Ainley   ------------- Secretary
Genito-Urinary Section
DR. G.  S. GORDON  Chairman
DR.  J.  A.  E.  CAMPBELL  Secretary
Physiotherapy Section
Dr. G. A. Greaves    --------- Chairman
Dr. H. A. Barrett     -      -      -      -      -      -      -      - •   - Secretary
COMMITTEES
Library Committee Credit   Bureau   Committee
DR. W. F. MACKAY EJ- nACrLp?^ACMILLAN
DR. W. D. KEITH ^R. D.  a  PERRY
Dr. c. H. Bastin Dr- d- ^c^EI;LANr,
DR.  W.  C  WALSH DR   E   HCt;UNDERCS°mm'ffee
Orchestra   Committee DR. B. H. CHAMPION
Dr. f. n. Robertson Dr. t. R. B. Nelles
Dr. J. A. SMITH Summer School Committee
Dr. l. Macmillan Dr. G. F. Strong
Dr. W. L. Pedlow Dr. W. D. Keith
Dinner Committee DR- H. R. STORRS
Dr. C. F. Covernton £r- *i?R°SBY
Dr. A. C. Frost Dr- b- d- Gillies
Dr. g. B. Murphy Dr. L. H. Appleby VANCOUVER MEDICAL ASSOCIATION
Founded 1898. .     Incorporated 1906.
PROGRAMME OF THE 29th 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 Evening.
1926.
Oct.     5 th—General Meeting:
Presidential Address, Dr. A. W. Hunter.
Oct.   19th—Clinical Meeting:
Nov.    2nd—General Meeting:
Papers—1.    Dr.  C. "W. Prowd,  "An Analysis of Radium
Therapy, reporting 600 cases.
2.    Dr. J. A. Sutherland, "Pain and disability from
lesions about the Anus.
"Nov.  16th—Clinical Meeting.
Dec.     7th—General Meeting:
Papers—1.    Dr. W. F. MacKay, "Diagnosis and Signifcance
of referred Pain in Disorders of Chest and Abdomen."
2.    Drs.   W.   S.   Turnbull   and   J.   W.   Arbuckle,
Eclampsia.
Dec.    21st—Clinical Meeting.
1927.
Jan.      4th—General Meeting:
Papers—1.    Dr. G. A. Greaves, "Physiotherapy in Orthopaedic Conditions."
2. Dr. H. A. Barrett, "Treatment of Infections by
Physical Agents."
3. Dr. H. R. Ross, "Physiotherapy in Gynaecological Conditions."
Jan.    18th—Clinical Meeting.
Feb.       1st—General Meeting:
Papers—1.    Dr. J. M. Pearson, "Treatment of Hypertension."
2.    Dr. C. S. McKee, "The Interpretation of Findings in Blood Chemistry."
Feb.    15 th—Clinical Meeting.
March   1st—General Meeting:
Paper —       Dr. George Seldon, The OSLER Lecture.
Mar.   15th—Clinical Meeting.
April    5th—General Meeting:
Paper—       Symposium, "The Treatment of the Poor Risk
Patient," Drs. C. E. Brown, A. B. Schinbein,
D. D. Freeze and R. E. Coleman.
April 19 th—Annual Meeting.
Page 100 Section of X-Ray Department, Anson General Hospital,
Iroquois Falls, Ontario, Canada.   Installation made by
Toronto Branch of Victor X-Ray Corporation.
Victor Nation-Wide Service
THE Victor X'Ray Corporation has assumed a
responsibility to the medical profession which
does not end with developing and manufacturing
X-Ray apparatus of the most approved type. It is
a tenet of the Victor code that the operator of a
Victor machine has the right to receive technical
aid when he needs it.
So, a nation-wide Victor Service Department
was organized years ago and direct branches estab'
lished in the principal cities of the United States
and Canada, where Victor trained men are always
available. No matter where a Victor machine may
be installed Victor Service stands ready, on request,
to inspeGt it or to render such technical assistance
as may be required.
Victor alone maintains so comprehensive a Service Organization.
VICTOR X-RAY CORPORATION
2012 Jackson Boulevard Chicago, Illinois
33 Direct Branches Throughout U. S. and Canada
Jr
X'RAY
v&      Diagnostic and Deep Therap
S££:      Apparatus.   Also manufacturers
"" L            of the Coolidge Tube
^  t
Victor X-Ray Corporation of Canada Ltd., Motor Transportation Bldg. Vancouver, B.C
Victor is as old as the X-
Ray. Adequate service can
be rendered only by an organization of proved stability and performance.
Whether your X-Ray needs
are small or large, for limited office work or for
the specialized laboratory,
Victor Service can help you
in the selection of equipment best suited for the
desired range of service.
PHYSIOTHERAPY
High Frequency, Ultra-Violet,
Sinusoidal,  Galvanic  and
Phototherapy Apparatus Dependability
Already Physicians realize that
they can depend on us to dispense
their prescriptions with ingredients of the highest quality, and
deliver them speedily.
Many people have expressed
their approval at this exclusive
prescription service — your patients will too.
PHONE SEYMOUR 112
HlacJ<malcl<
SEY
s mi hrescro
i-lMiTEO
618 Georgia St. West
'Quickest Possible Service'
Page 102 EDITOR'S PAGE
"With this month's issue we introduce to our readers an important
addition to the Bulletin. Each month, from September to April, we shall
print by arrangement an insert, the material for which is supplied by the
joint activities of the various laboratories of British Columbia.
This, in part, has grown out of the series of contributions to our
pages-furnished by the laboratory of the General Hospital, assisted by a
desire for closer co-operation between the various laboratories of the province and made immediately possible by the interest of the Secretary of
the Provincial Board of Health.
We believe that this publication will form a valuable means of interchange of thought and action among the various laboratories, will
lead to a corresponding stimulation in their work and will enable some, at
all events, of the procedures which they conduct to be more readily correlated.
We think, too, that our more general readers will be interested in
these articles and will the more readily recognize the earnest and valuable
contribution which the modern laboratory brings to the practice of
modern medicine.
The laboratories will themselves also benefit by a wider publicity for their efforts in this direction. Some of us have perhaps too
little knowledge or too little apprehension of the nature of the work
which day by day is turned out in these useful adjuncts to the hospital.
The laboratory movement will grow—must grow—so that in some
degree its services will be available to almost any practitioner in the province. We say "must grow" advisedly, because our medical schools- are
now turning out men who are intimately acquainted with the fundamental part which a well equipped laboratory plays in the diagnosis and
treatment of many, if not most, serious and important ailments. These
men, in practice, are not going to be content to forego these important
aids in their work and therefore we feel confident that the laboratory
work is destined to a great expansion in the near future.
We hope this new venture will meet with success. Taking a leaf
from the books of the broadcasting stations we too may "hope that all
_who have enjoyed these offerings" will write and say so. We don't hear
often enough from our unseen audience anyway. Month after month
we consign our material to H.M. mail in the pious hope that it will meet
with your approval, and there the matter ends. Have our readers any
remarks to make, any criticism on the paper or the papers we publish,
any questions to ask? We shall be delighted to open up a correspondence
column. Finally we must thank Dr. Hill and Dr. Coleman of the General Hospital Laboratory for the interest they have shown in making this
work possible, and we hope, successful.
We record, with regret, and sincere sympathy for the surviving relatives, the death of one of the pioneers of medical practice in this city
Page 103 in the person of Dr. D. H. Wilson. It is now a sadly diminshed band,
who did great work under difficulties which it is hard for us to realize.
So many have gone, Dr. Geo. D. Johnston, Dr. Poole, Dr. Tunstall, Dr.
McGuigan (now that Dr. Worthington has disappointed us, our only
medical mayor), Dr. Carroll, to mention only a few. We knew the late
Dr. Wilson for many years. In our salad days it was one of the sights
of the town—a very much smaller town, of course, than the metropolis
of today—to see the doctor driving his horse and buggy down Hastings
Street at the then fire-engine rate of speed. It used to be said that a
doctor could wear out two horses but that three horses would wear out
a doctor. We do not know many horses Dr. Wilson used, but we do
know that he certainly wore himself out by assiduous attention to his
many patients, for he had a very large practice. We remember, now
more years ago than we care to recall, being turned out one snowy winter
night by Dr. Wilson to attend a confinement somewhere in the then
suburban wilds lying on the other side of False Creek. It must have
been towards the end of the doctor's active medical carrer, for he had a
high temperature at the time and even his determination was not equal to
the task. We spent an active night with the aid of an oil lamp, a practical nurse and an agitated husband. But our strength held out and the
forceps did not slip, so in the early and chilly hours before daybreak of
a December morn we plodded a long but satisfied way home, to breakfast
and bed.
Dr. Wilson was one of the organizers of this now flourishing medical society. The organization meeting was held on the neutral and central ground of the waiting room of a dentist. There might have been
eight or ten of us present and Dr. Wilson was obviously the man for
president, and the first president of this association he became. The annual fee. was One Dollar—so great was the purchasing power of
money in those days. We were a member of the Committee on Constitution and Bylaws which met in the president's office on the corner of
Robson and Thurlow. The committee saved time by "lifting" the constitution "en masse" from some previously defunct society in another
place undeterred by its fate. Doubtless we none of us thought the newest
venture was destined to any great length of life or prosperity. The soil
and climate of the West were not excessively favourable for medical
societies in those days.
Dr. Wilson did his share in fostering the infant society and was always interested in its subsequent prosperous career. He was a most excellent practitioner, a valuable asset to the profession, a citizen of influence and to his patients a wise counsellor and valued friend, the end of
whose medical career left a blank in many homes.
To all our readers the Editorial Board and Staff of this little publication send their best wishes for a Happy and Prosperous New Year.
Page 104 NEWS AND NOTES
We deeply regret to note the death of Dr. D. H. Wilson who was
the first President of the Vancouver Medical Association, and the very
sudden death of Dr. H. C. Steeves the Superintendent of the Mental
Hospitals at New Westminster and Essondale.
At the Annual Meeting of the North Pacific Surgical Association
which this year was held in Vancouver, the following Vancouver men
were elected to membership: Dr. A. W. Hunter, Dr. W. B. Burnett, Dr.
W. S. Turnbull and Dr. A. J. MacLachlan. Dr. Herman Robertson was
elected President and Victoria chosen for the place of meeting in 1927.
The meeting was a very successful one, fifty members being present out
of a possible sixty. The only Vancouver member to give a paper was
Dr. R. E. McKechnie who spoke on the "Treatment of Certain Forms of
Spinal Injury."
The December General Meeting of the Association was held on the
7th, when J 3 members attended.
The Secretary announced that a letter had been received from the
Vancouver General Hospital stating that Dr. Fred N. Robertson had
been appointed to the Staff on the Medical side and Dr. William Morris
to the Tuberculous Division.
Dr. Kenneth L. Craig was unanimously elected to membership in the
Association.
Dr. J. G. McKay announced the sudden death of Dr. Steeves,
Superintendent of the Mental Hospitals at Essondale and New Westminster. A standing vote of sympathy with the relatives was carried
and the Secretary was instruced to send a letter of condolence to Mrs.
Steeves.
Dr. W. F. Mackay gave a very interesting paper on the subject of
referred pain in connection with disorders of the abdominal viscera. Dr.
Mackay's paper is published in full in this issue.
Drs. W. S. Turnbull and J. W. Arbuckle gave papers on eclampsia.
Dr. Turnbull's paper is published in this number. Dr. Arbuckle's contribution will appear in our February issue. The papers were discussed
by Drs. J. J. Mason, V. E. D. Casselman and G. E. Duncan.
A letter was read from Dr. Lane, of the Seattle Academy of Medicine,
inviting members to attend a lecture by Miss Maud Slye on the 13 th.
The Clinical Meeting of the Association was held on Tuesday, December 21st. 35 members were present. Dr. Frederic Brodie presented
a case of disseminated sclerosis with an interesting resume of the condition in general. Attention was called to the inability, in most cases, to
determine a definite aetiology, some cases presenting a history of infection
or lead poisoning, and many of them one of protracted mental worry and strain. Heredity seems to be negative. Pathology finds plaques of fibrosis, from microscopical size to one to two cm. scattered generally
throughout the nervous system, but particularly on the basal ganglia.
Grey matter is less involved than the white. Histological pathology shows
degeneration of the myelin with proliferation of the neuroglia. The
symptoms are of a very protean character, the typical picture of intention tremor, scanning speech and nystagmus is frequently introduced by
a simple weakness of one extremity, later involving the others, with
numbness, etc. In diffierential diagnosis the luetic conditions, cerebrospinal types, G.P.I., brain tumour, sub-acute combined degeneration and
hysteria should be considered. The prognosis is bad; the average duration
is ten years with recurring remissions in severity and symptoms. Treatment is primarily rest, preferably in an equable temperate climate, which
can be accomplished with difficulty among the middle and lower classes
in whom the disease is most common.
Tonics are indicated, arsenic may help, but strychnine is contraindi-
cated on account of tremor.
The case presented showed first weakness of left hand, then left leg
with numbness, incoordination and failing vision. The scanning speech
has become slurring. The pupils, at first unequal are now equal. Reaction to light and accommodation normal. A slight nystagmus is present at times. There is atrophy of the optic nerve which is present in
50% of the cases. Slight paresis of the face and tongue have disappeared.
Slight intention tremor present with a marked Rhomberg whether eyes
are open or closed. Reflexes much exaggerated. Babinski on the left,
slight clonus.    The picture is essentially one of lost muscle control.
Dr. J. W. Ford presented a case of spontaneous pneumothorax complicating what appeared to be a typical pneumonia, which ran its usual
course. Sputum was later found positive for T.B. Under routine treatment the sputum has become negative and the symptoms have disappeared. The pneumothorax has been replaced by a hydrothorax, the
heart continuing away to the right side, the left chest cavity being full
of fluid as shown by the X-Ray.
A series of cases of back injury was presented by Drs. Gillespie,
Gunn and Walsh, which included fractures of the transverse processes
and fracture of the vertebra. Attention was drawn to the failure of
the X-Ray to show adequately fractures of the vertebra. The value in
diagnosis of heavy percussion upon the heel or top of the head was emphasized in determining vertebral fractures. The most interesting case
was presented by Dr. Gillespie, the patient six months ago having fracture of the lumbar vertebra with complete picture of pressure symptoms. The patient is now able to walk fairly with very marked improvement in the other symptoms.
Dr. Nay, of the Workmen's Compensation Board closed the discussion with interesting notes from the Compensation Board standpoint.
Page 106 PRESIDENTIAL ADDRESS
Dr. A. W. Hunter, October, 1926
Members of the Vancouver Medical Association:—
This year has been an eventful one to me. It is the culmination of
your many honours to me. It has seen my appointment to the highest
honor in your association—your president. I wish to thank you from the
bottom of my heart and I trust that my future work in your association
will continue to hold your confidence.
The presidency of your association carries with it the arduous task
of an address.
To some this is a pleasure, but to me it is a task strewn with pitfalls, due to my lack of skill as a speaker and the great problem of what
to talk about. As there are no restrictions, I have chosen this evening
to discuss the observations that I have made as a clinician and the suggestions I have to make as to how we may mutually benefit ourselves.
I am not going to speak on pathological lesions but endeavour to draw
general conclusions from observations made in a department which may
be the back door of medicine, but is also the backbone of medicine.
Before going on with my paper, I wish here to pause for a moment
and express our regrets over the illness and deaths which have occurred
since our last meeting.
We regret very much the prolonged illness of Dr. John McDermot
and trust he will soon be back to his work. He is one of our valued
members. His wit on dinner committees, his energy in medical politics,
his devotion to his practice, are most commendable.
We regret the passing of our good friend Dr. Good. He was an
outstanding figure in his chosen branch of medicine. He was prominent
in the formation of the medical college at Winnipeg and on coming to
Vancouver he showed much interest in our society. His genial smile
and his optimism will long remain in our memory.
The passing of Dr. L. N. McKechnie was the ending of a very useful career. A man who had gained a large practice, he wisely invested
his earnings. He gave of his time and money for the advancement of
the church of his choice. He was an excellent golfer. His quiet but
pleasant manner was contagious and made many friends for him.
In the death of Dr. Alison Cumming, we lost a member whose illustrious career has been intimately associated with our society. He was
one of our past presidents. In his undergraduate days, he was always
to the front both in studies and athletics. As an interne in the Royal
Victoria Hospital, Montreal, he was most active and was always willing
to share his knowledge with the students. In practice, he soon became
a busy general man. His medical ambition kept him associated for some
time with the General Hospital as Pathologist. There, I feel he observed
the necessity and opportunity for men of better diagnostic skill and he
seized the opportunity.   We find him a student in chemistry in our Uni-
Page 107 versity at the onset of his final illness. Clinically, he was one of our
leading internists. He enjoyed competition in sport or science. We find
him donating a prize to the graduating class of nurses of the Vancouver
General Hospital. It was a gold medal, to the member of the senior class
obtaining the highest marks in medical nursing. Would it not be an
appreciation of his work among us if we perpetuated this medal as "The
Alison Cumming Memorial Medal," donated by the Vancouver Medical
Association?
There is today in Canada a tendency for many young doctors to
rush into the more remunerative branches of medical practice, particularly that of surgery. As a preparation they may, after acting as internes on the surgical side of a hospital, enter into practice as surgeons.
If they are studious they may gradually enlarge their knowledge of clinical pathology and make themselves better diagnosticians and eventually
better surgeons. Until that time the paths of some, at least, are apt to
be associated with an abnormally high mortality rate which may, in un-
autopsied cases, appear as the result of unavoidable complications.
How can we remedy this? The English practitioners for generations, have been using a system that appeals to me. It gives the younger
man an opportunity to see much material at a time when he is full of
energy and theory. It assures him a good living and an opportunity of
greater possibilities in later life. It creates an asset that enables the older
practitioner to sell on his retiring and this in turn passes on to all concerned. The system I refer to is the practice of an older practitioner
taking a younger assistant into this business and who eventually becomes
the chief. The system is in vogue in a modified form in our medical colleges. There the professors have their assistants, who by co-operation,
make it better for all concerned and it gives an assurance of greater
things to come.
How can we help ourselves? In the present generation, in one of
America's busiest cities, a man named Harris felt lonely. He felt he was
not getting as much out of life as he should. He thought of an objective
and he formed a group of friends into a club with the motto of "Service
not Self."
Today, this principle has effected much good. Today, we have large
service clubs. The members who are most active in these organizations
are also the men most respected by their fellow members, and the community at large. I would like to see the day when we, as medical men,
in this city, would take a more active part in the medical problems of our
community.    I feel again that he who serves best gains most.
Today, we are confronted with two outstanding questions:
(1) The need of a medical college.
(2) The necessity for increased hospital facilities.
Page lOi Who are better qualified to pass on the advisability of having a medical faculty in our University, than the practitioners of B.C. The members of our society should act and pass their views on to our provincial
organization, the B.C. Medical Association.
It is said that $100,000 is spent annually in eastern centres by students from this province. The Board of Governors of the University is
giving this subject much thought. What have we done? Gentlemen, we
must be broad minded. We must look forward, we must help guide the
destinies of this medical problem. If we wish to get the support from the
public in increasing our hospital facilities, we should in return help them
in working for a cheaper, adequate medical education for their, your and
my children. Apathy on our part, lack of a united front, will lead to
factional propaganda. This will lead to the formation of a faculty by
them and a loss of our prestige with the public.
There is an abnormal shortage of beds in our hospitals. There is inadequate accommodation in our operating rooms, or at least, in the time
allotted for operations. The time is opportune for the medical fraternity
to get out and electioneer for increased hospital facilities. True, the staff
of the Vancouver General Hospital elected a committee to impress upon
the directors the necessity for increased accommodation. What has been
done by our society as a body. You find that the city council may be
a line of obstruction. If the city council requires support to raise money
for hospital extension, who should be behind it? The whole medical
fraternity. I belive this fall, there will be a by-law submitted to the
electorate. Should we not know now what it is expected to be? Should
we not see to it that it is not allowed to drift and in all probability be
defeated? We must back up the hospital superintendent, the board of
directors, and all parties who are endeavoring to increase these facilities.
We have good politicians, we have excellent speakers, let us see to it
that we use them in this urgent cause. You may feel that the best interest of the future would be served by the formation of, say a university
hospital, somewhere else. I think we should decide now whether we will
support the future building programme of the Vancouver General Hospital in every way that we can or else suggest some alternative plan to
better relieve the present inadequate accommodation.
There is a branch of medicine that I am personally interested in, you
may be. We can help each other. I like B.C., especially Vancouver. I
want to live here, I want to lengthen my stay with you. Will you help
me?
It is said that Methuselah, the oldest man, was drowned in the flood.
It is significant to note, that for centuries before and after King "Tut,"
down to the discovery of America, the average length of life was 18
years. At the time of the French Revolution, it had increased to 33
years. At the time of the American Civil War, it had increased to approximately 45 years. At present, it is about 57 years. The longed for
70, may be reached within the next 50 years, maintaining the present
rate of medical progress. Dr. Knight said, "Consider that 7 to 10 per
cent, of all applicants for life insurance are rejected or postponed."
Page 109 It is the experience of insurance companies, that a goodly proportion
of their applicants are absolutely unaware of what is the matter with
them, and learn for the first time of the existence of the impairment
when notice of rejection reaches them. That man's attitude is often
one of angry disappointment but his second reaction is one of inquiry
into his state of health and of determination to do all within his power
to make himself physically fit.
Now for the monetary side, which, of course, will appeal to those
now asleep.
Medical examinations are an expensive part of the cost of life insurance administration. We can easily make them worth all that they cost
and a great deal more, through the simple expedient of periodical follow-
up examination of the persons insured. Fortunately, this matter is no
longer in the experimental stage. We are able to show that those who
were examined in 1914 and 1915, for the period of 5 years following the
examinations, showed a mortality 28% more favourable than that for
the entire ordinary department in the same years. We further calculated
that the savings in mortality gave a return of $2 for every $1 expended
for insurance examination.
Again, let us draw on the experience of the Metropolitan Life Insurance Co., as a striking example of the economic soundness of a preventive and educational programme. This business organization, in the
last 15 years, expended $18,700,000 for a public health campaign for its
industrial policy holders. In the interval the mortality rate declined
more than 30% and the saving amounted to $35,000,000, nearly twice
the total expended.
What should be our deductions? That periodical health examinations pay, lessen degenerative diseases by their earlier diagnosis, prolong
life by earlier treatment, increase the happiness of our homes and give a
handsome return for the money expended.
I would like to see the members of this association start a complete
systematic examination of ourselves, record the facts, that the findings
be kept private; that the doctor patient be then given the privilege of
taking treatment from the doctor of his choice. Once we became organized, we would appreciate its value. We could then advocate it to the
public. It would bring better health to the community, happier homes
and a financial return to the patient and to the medical fraternity.
Now following on the above plan comes the question of group insurance. True, many of our members may be now carrying adequate
insurance for the benefit of their dependents, but the doctor of today
may be in affluence and tomorrow may be unfortunate enough through
circumstances beyond his control, to require financial help. Would it
not be better to have group insurance, so that when one is sick, he will
receive through the association, a sum adequate to tide him over an
emergency. It would be a fund from a common chest and would not
savour of charity. If this suggestion appeals to you, there are many ways
in which it might be worked. The details can be worked out by members of our association.
Page 110 How can we put dollars in our pockets? This appeals to all. We
all drive cars; the cautious as well as the careless drivers carry insurance
on their cars. It is possible to obtain, through group insurance of our
cars, a discount on our present premium that will amount to from 10 to
20 dollars per annum.
Your president has already received an offer on your behalf from
one company. This company is willing to give a discount of 20% if
we get twenty or more members to subscribe to such a policy.
It seems to me that we should go into this type of policy and save
ourselves at least half the price if not all of our annual dues. Even by
this means, we could collect an amount sufficient to have a sickness fund.
In conclusion, let us get together. Let us take more active interest
in our society, let us show the public that we are alive to its interests.
Let them hear the results of our recent medical achievements and again
we will find that he who serves best, gains most.
I thank you.
ECLAMPSIA
Read before the meeting of the Vancouver Medical Association
By Dr. W. S. Turnbull
The subject of eclampsia with which we propose to deal tonight, is
one which has given rise in the past to much investigation, to many
theories and to widely divergent views in the matter of treatment.
The definite etiology of this trouble is still, one might say, up in the
air, and in the limited time at our disposal we will touch only lightly
upon that phase. The former tendency to consider eclampsia as a nephritic manifestation, is no longer acceptable to the great majority, who
regard it as the result of some other agency. What this other agency or
factor is, has given us many opinions of different kinds. Delore maintained that it was due to a bacterial invasion; Stroganov, that it was an
acute infectious fever introduced through the lungs. The German investigators maintained that it was a dietetic condition, that the decreased
use of proteins and fats was responsible for the decrease in the incidence
of eclampsia, but in Russia during the war and the revolution which followed it, eclampsia increased in spite of a long period of starvation. The
liver has been blamed, every member of the endocrine family, the blood,
the foetus itself, in an effort to arrive at some solution of the problem.
Cary in 1925 formulated some rather unique hypotheses. He maintains there is a toxic substance or substances liberated which is probably
a split product of the protein molecule. There are three or more parts
of entrance into the maternal circulation; from autolysis of degenerating
placenta, from absorption through the large intestine of split products of
bacterial origin, and lastly from primary foci of infection. The maternal
circulation becomes overwhelmed by these products and its ability to
neutr.lize them is diminshed, resulting in the syndrome eclampsia.    This
Page 111 theory would appear to be somewhat offset by the fact that the mother
and not the child is affected by an organ which nourishes the latter. Then,
too, as against the theory that a toxin is the cause, stands the fact that
so many eclamptics recover with remarkable rapidity.
The etiological theories which have had the strongest support up to
the present time are (1) infection; (2) glandular dysfunction; (3) incompatibility between foetal and maternal blood; (4) foetal toxins; and
(5)  diet and faulty elimination.
The effects of foetal toxins and anaphylaxis as the cause are supported by a good many. Levi-Solal and Tzanck have found in the serum of
eclamptics two toxins, one convulsive and the other lethal. They believe the susceptibility to toxins is due to variation in sympathetic tone,
and of the drugs used to act on the nervous system. Pilocarpine was
employed in a case that had nine convulsions, with complete cessation of
the fits and recovery.
The definition of Williams in which he says, "Eclampsia is an acute
toxaemia occurring in pregnant, parturient or puerperal women, and is
accompanied by clonic and tonic convulsions, during which there is a
loss of consciousness, followed by more or less complete coma, and frequently results in death," tells practically all that is definitely known up
to the present time of the etiology of this disease.
We are all too well familiar with the clinical picture presented in the
convulsive seizures to take the time allotted in their description. A
reference, however, to some of the manifestations of this stage, with their
significance may be permitted.
Usually between the convulsions the patient is quiet, but occasionally there is great restlessness with wild and exhausting delirium. In
these cases there is usually some liver involvement. Jaundice is rare, but
when present is a very grave symptom. With regard to the oedema, the
acute cases may show very little, and as a rule those with marked oedema,
have had a pre-existing chronic nephritis.
Labour usually commences if the seizures are severe, and is generally
rapid. Post partum, the condition is more favourable, but it is to be remembered that convulsions may recommence as late as a week after delivery. As a rule the foetus dies, but early rapid delivery may produce
a living child and cases are on record where convulsions have occurred
during the course of a pregnancy, without precipitating delivery, or
interfering with the welfare of the child.
Increase in the number and frequency of the seizures, with increasing temperature and pulse usually indicate a fatal termination, the final
picture being one of pulmonary oedema, possibly deepening coma, or at
the height of a violent convulsion, cerebral hemorrhage or cardiac paralysis.    Usually three days sees the case on the way to recovery, or hasten
ing to a fatal termination
Continued on Page 117
Page 112
»^™" The
British Columbia Laboratory Bulletin
Published   monthly  September  to  April  inclusive  in   co-operation  with   the  Vancouver
Medical Association bulletin, in the interests of the Hospital Clinical and
Public Health Laboratories of B. C.
Edited by
Donna E. Kerr, m.a., of The Vancouver General Hospital Laboratories
financed by
The British Columbia Provincial Board of Health
All communications should be addressed to the Editor as above.   Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Volume 1
JANUARY, 1927
No.l
CONTENTS
ROUTINE TESTS FOR ALBUMINURIA—Malcolm
IMPORTANCE OF REPEATING BASAL METABOLISM
DETERMINATIONS—Wilson
Editor's Note.
Since August 5, 1926, the Vancouver General Hospital Laboratories
have been issuing a weekly bulletin, originally intended solely for our own
staff. The material for this bulletin was taken chiefly from the daily
routine tests and thus anything of special interest or of an unusual character was recorded in a manner easily available for future reference. It
was not long, however, before other laboratories in B.C., and even in
Eastern Canada, became interested and requested to be put on the mailing
list, so that we increased the number of carbon copies to twelve, some
of which at times were almost unreadable. This seemed inadequate and
Dr. H. W. Hill, Director of the V.G.H. Laboratories was appealed to,
with the result that the Provincial Board of Health through Dr. H. E.
Young offered to finance a B.C. Hospital Laboratory Bulletin, in the interest of the hospital laboratories of B.C., to be published in the Vancouver Medical Association Bulletin. This, it is hoped, will link together the
common interests of the laboratories large and small throughout B.C.
The Vancouver General Hospital Laboratories Bulletin, though only
in existence for a short time, has been successful far exceeding our expectations. This has been due to the unfailing interest and support of the
individual members of the staff. We hope that all the hospital laboratories, even to the smallest, will realize the value of co-operating in making this common link of mutual benefit. If they do, the Bulletin is assured of success.
ROUTINE TESTS FOR ALBUMINURIA
By Mabel Malcolm, V.G.H. Laboratories.
For the past six months we have been reinvestigating our method for
making qualitative albumin tests on routine urine specimens received in
Page  11?
\ the laboratory daily.   As we receive from 150 to 250 specimens per diem,
the test must be rapid as well as accurate.
The heat and acetic acid method is now being used in this laboratory,
but it was thought, after looking into several other methods, that another
might prove more satisfactory. The nitric acid ring test and others were
again discarded and it was decided to try out the sulphosalicylic acid-
sodium sulphate reagent as recommended by W. J: Exton, Director Prudential Laboratory, Newark, N.J., in the J.A.M.A., Vol. 80, No. 8, February 24, 1923. This technic was reported in our Laboratory Bulletin,
Vol. 1, No. 9, September 30, 1926, and is as follows:
Reagent:—200 grams of sodium sulphate is added to about 700 cc. distilled water and heated until dissolved. It is then cooled to
about 3 5 degrees C, when 50 grams of sulphosalicylic acid is
added and dissolved without further heating. The solution is
then made up to one litre with distilled water.
Test:—Mix equal parts of urine and reagent, warm in water bath; boiling
does not spoil reaction but is unnecessary.
Readings:—Albumin free urines treated in this way give a perfectly
clear, transparent mixture; albuminous urines, a clouding with
the degree of turbidity directly proportionate to the concentration of albumin.
Over 400 comparative tests were made between the heat and acetic
acid method and the above. In all comparisons these tests show practical
agreement, except for the fact that Dr. Exton's method does not change
from a milky precipitate to a flocculence as soon as the acetic acid method,
thus losing for us one of our important end points, as will be shown later.
If this method were adopted in the laboratory it would be necessary
to set up an entirely new set of tubes for the qualitative sugar tests,
whereas at present when the acetic acid albumin test is finished the tubes
are inverted, there remaining approximately two drops of urine in the
tube when they are returned to position, and Benedict's solution is then
added to these tubes, any specimen showing a reaction being checked by
a duplicate test. When the sulphosalicylic acid method is used, however,
the amount and nature of the reagent used precludes using the same tubes
for the sugar test.
We are also contemplating the trial of a new method for a quantitative albumin determination, of which the first stage is the heat and acetic
acid method. Should this new test prove more satisfactory than the
Esbach method, it would be better to have but one method in use for
both qualitative and quantitative tests.
While the above studies and experiments were being made, Mr.
Wood-Taylor has been checking up our results with the method already
in use in our laboratory. He has made 177 quantitative albumin tests
(Esbach's method) on routine urines containing albumin in amounts reported by us as plus 1, plus 2, plus 3 and plus 4.
Page 114 Up to date we have made the readings as reported in the Laboratory
Bulletin, Vol. 1, No. 3, August 19, 1926, as follows:
-1-1  a trace of albumin.
-|-2 a flocculent precipitate.
-|-3  a large mass of solid albumin.
-j-4 an almost solid mass of albumin.
It is the change between -|-1 and -|-2 that is lost
Exton's method, his method merely showing a greater turbidity; the floc-
culation not appearing in amounts of albumin much below that which
we report as -j- 3.
Owing to conclusions made possible by Mr. Wood-Taylor's work we
are now able to indicate our readings as roughly quantitative thus:
-1-1 up to 0.25  grams albumin per litre of urine  (no satisfactory
reading is obtained with less than 0.2 grams.)
-|-2  0.2 5-1.0 grams albumin per litre of urine.
-|-3   1.0-5.0 grams albumin per litre of urine.
-1-4  5.0 grams and over albumin per litre of urine.
It should be appreciated that there is some little difficulty in deciding on a border line case macroscopically; for instance, a specimen showing albumin amounting to approximately 1 gram per litre, may be reported as -|-2 or -|-3; being what we call in the laboratory a high two
or a low three.
The following tables show the results:
1.—35 specimens of urine reported as - -1 albumin.
Quantitative albumin tests   (Esbach)   showed:
24 specimens less than 0.2 grams albumin per litre of urine.
9 specimens 0.2 grams albumin per litre of urine.
2 specimens 0.25 grams albumin per litre of urine.
2.—100 specimens of urine were reported as -1-2 albumin.
Quantitative albumin tests (Esbach) showed:
7 specimens 0.2    grams of albumin per litre of urine.
3 8 specimens 0.2 5 grams of albumin per litre of urine.
25 specimens 0.5 grams of albumin per litre of urine.
18 specimens 0.75 grams of albumin per litre of urine.
11 specimens 1.0    grams of albumin per litre of urine.
1 specimen  2.0    grams of albumin per litre of urine.
3.—30 specimens of urine were reported as -1-3 albumin.
Quantitative albumin tests (Esbach) showed:
8 specimens 1.0    grams of albumin per litre of urnie.
1 specimen 1.25 grams of albumin per litre of urine.
6 specimens 1.5    grams of albumin per litre of urine.
4 specimens 1.75 grams of albumin per litre of urine.
3 specimens 2.0    grams of albumin per litre of urine.
2 specimens 2.5    grams of albumin per litre of urine.
3 specimens 3 grams of albumin per litre of urine.
1 specimen   3.5    grams of albumin per litre of urine.
1 specimen  4
1 specimen   5
grams of albumin per litre of urine
grams of albumin per litre of urine 4.—12 specimens of urine reported as -|-4 albumin.
Quantitative albumin tests (Esbach) showed results between 5 grams
and 15 grams of albumin per litre of urine.
The above tables show the degree of accuracy which may be reached
by an experienced worker, with this qualitative albumin test. As the
sulphosalicylic acid method has not proven to be any more accurate than
the heat and acetic acid, we have decided to abandon the idea of adopting
it in this laboratory.
SUMMARY:—
1. The sulphosalicylic acid method was found to be as good
but no better than the heat and acetic acid.
2. Objection is made to adopting the new method in this laboratory owing to the resulting loss of time setting up tubes
for routine sugar tests.
3. In a new quantitative albumin test about to be tried out
heat and acetic acid method is used.
4. With experience, readings of the heat and acetic acid test
are made with a small degree of error.
5. We have decided to continue using the heat and acetic acid
method, as in the past.
THE IMPORTANCE OF REPEATING BASAL METALBOLISM
DETERMINATIONS
Grace Wilson, M.A., V.G.H. Laboratories.
In severe cases of hyperthyroidism, the clinician may sometimes
question the advisability of having the basal metabolism test repeated. In
such cases every unnecessary physical effort, however small, is to be
avoided. The clinician, therefore, naturally asks himself whether the
added accuracy resulting from a repetition of the test is worth the effort
on the part of the patient.
To help answer this question we have reviewed 15 basal metabolism
readings over plus 60%. In 80/r of these cases the second reading was
lower than the first reading. In 20% of the cases the second reading was
20% or more below the first reading. In one case which gave a first
reading of plus 91%, a second gave a reading of plus 5 5%.
From the above figures it is quite clear that a single determination
may be expected to be misleading in about 20r/( of the cases. For instance, if treatment had been instituted in the above series, following a
it t
single determination, then at a later determination, one in five of the
cases would have apparently improved to a considerable extent, when
actually no change had occurred. Therefore, since a laboratory examination is only of value in so far as it gives accurate information, a basal
metabolism estimation should be repeated until it is known to be at least
reasonably accurate.
Page 116 Continued from Page 112
As regards the effect of the kidney disease on the pregnancy, the
child is likely to die, resulting in abortion or premature delivery. Strangely enough these cases are not perdisposed to eclampsia, presumably because
the organism has become inured to the toxin. There is, however, the
likelihood of an attack of acute tubal nephritis supervening on the chronic disorder and usually a fatal termination.
Detection of albumin in the urine of pregnant women may be due to
several causes:
(1) Albuminuria associated with pregnancy.
(2) Albuminuria due to pregnancy.
In the first, the albumin, may be due to cardiac disease, or renal
disease, e.g., chronic nephritis, calculus, tubercle, pyelonephritis or cystitis,
or possibly to the presence of a vaginal discharge. In a case where a vaginal discharge exists, a catheter specimen should always be taken.
An attack of eclampsia may appear suddenly without warning, but
these cases are exceptions as there are usually sufficient prodromata to
warn one of the impending danger if the case has been under careful
supervision. Headache, dizziness, nausea, vomiting, nervous excitation,
possibly slight mental disturbance, or probably muscular cramps or
twitching. All or any combination of these symptoms in a pregnant
woman are sufficient to warrant a close observation and a close check of
the urine and possibly of the blood chemistry. Stress has been laid upon
pain in the epigastrium as an important indication, and Berkeley and Bon-
ney report a case where it was the only symptom in a case which rapidly
terminated fatally. On examination of these cases, one not infrequently
finds definite tenderness in this region. Examination at this time also
usually reveals some oedema of the feet, possibly of the eyelids or hands,
a pasty skin, arterial hypertension, exaggerated reflexes and diminished
urine. This urine on examination may be negative, but more usually
shows high specific gravity, albumin with granular and hyaline casts, and
a low urea content.
The majority of eclamptic patients are young, 50% not being over
twenty-five years of age. They are often of small stature and of considerable weight. There is frequently a history of late onset of menstruation
and atypical menses. The toxaemias are more common in women of the
dyspituitary type, and usually the hypofunctional. The depth of respiration in pre-eclamptic patients greatly exceeds that of normal individuals,
and may be noted hours or days before the onset of convulsions. It is
always an early symptom of eclampsia, while its persistence after the
convulsions are over, is a sign of persisting intoxication, and dyspnoea
an unfavourable prognostic sign.
It has been demonstrated that in normal pregnancy there is a slight
decrease in the non protein nitrogen of the blood, and in the blood urea
nitrogen.    The carbon dioxide combining power is decidedly lower in
Page 117 the gravid than in the non gravid state.    Certain well defined variations
from normal occur in eclampsia:
(a) Elevation of the uric acid of the blood.
(b) Decrease in the carbon dioxide combining power.
(c) Elevated blood sugar.
(d) An increase in the ratio of phosphorus to calcium due to a
high inorganic phosphorus value.
According to Blass the period of immediate convalescence from the
late toxaemias of pregnancy is usually associated with higher non protein
nitrogen values, than in the period of most acute clinical signs. The blood
nitrogen rise is synchronous with a fall in the plasma protein percentage,
indicating a plasma dilution.
The determination of the ammonia coefficient is important from the
stand point of prognosis, indicating as it does the severity of the toxaemia.
Let us spend just a few minutes on a consideration of the blood
pressure in this and allied conditions, as considerable attention has been
given to this phase during the past few years. The readings, and especially regularly charted readings, afford valuable information with regard
to diagnosis and prognosis.
(a) Uncomplicated toxaemia exhibits a blood pressure of 130 to
150 which rises in the pre-eclamptic and eclamptic stages to
even 200.
(b) Nephritic toxaemia is characterized by a blood pressure of 150
to 200 with corresponding elevations as in the former, but the
elevations are smaller.
(c) Uraemia is accompanied by a blood pressure of over 200.
Certain events, however, will minimize the value of these findings.
1. The patient may be in convulsions when first seen.
2. There may be a concealed haemorrhage, which is very likely to
occur in these conditions.
3. When heart failure is a complication, the blood pressure will be
low.
After delivery the blood pressure is as a rule somewhat lower. Consequently a rise in the pressure after delivery will usually herald convulsions, or if the usual fall does not take place a continuance of the convulsions .may be expected.
As to its value in prognosis, if the fall to normal does not take place
after a few days in the purely toxaemic case, the continued slight elevation may be regarded as indicative of some damage to the kidneys, and in
such a case the albumin is very slow in disappearing from the urine. During pregnancy a steady rise of blood pressure, in spite of preventive treatment, is in general an indication for terminating pregnancy, arid a sudden rise of blood pressure, a danger signal of impending trouble upon
which we must act promptly.
Pane 118 LIBRARY NOTES
The Library is situated in 529-531 Birks Building, Granville Street,
Vancouver, B.C.
Librarian: Miss Firmin
Hours: 10 to 1,2 to 6
The library committee, as a matter of policy for the future, has decided to continue developing along the lines of a reference library, but in
the meantime, till more commodious quarters are obtained, many of the
older works and older editions of modern works are being boxed and
stored. It is our desire at present to make the library a working library
for each member of the profession.
Are you satisfied with its management? We would like criticism
and suggestions from every member of the Association.
How can the library be made an adjunct to the office of each member
is the problem before the committee.
BOOK REVIEWS
Modern Clinical Syphilology, By John H. Stokes, M.D., with co-operation of Paul A. O'Leary, M.D., Wm. H. Goeckermann, M.D., Lor en
W. Shaffer, M.D., and Cleveland J. White, M.D., W. B. Saunders Co.,
1926, $12.00.
The author disclaims, in his preface, for this work any encyclopaedic pretensions; but that is only modesty. Anyone who has the
courage to attempt to bring order out of the bewildering and utterly
wearisome mass of recent literature on syphilis deserves the greatest consideration. Has he succeeded? One criticizes with all due deference, for
it is extremely probable that this will be the standard work on syphilis, at
least on this continent, for some years. Frankly he has not simplified our
conceptions of the disease and its mechanism in the least degree, in fact
he has made them much more complicated; perhaps that is inevitable.
However, one rather gets the impression that modern convention, particularly in America, demands that an authority in any department of medicine must display an amazing amount of work done, or show in some
way that he is constantly and seriously active. A picture in this book
seems to illustrate that idea. It shows the operation of lumbar puncture
and the ritual is most impressive. Three people assist fully gowned,
gloved and masked; there is no doubt about the solemnity of the occasion.
The book is unquestionably encyclopaedic and at the same time practical, but irritating to read as there is so much fine print, so many diagnostic tables and case reports. The invariable padding in works on syphilis,
such as illustrations of skin lesions, naturally is to be found and an occasional funny word like "critizable," possibly a misprint. Still, it
seems to contain all our information on syphilis and it is weighed and
discussed in an eminently sane manner; yet one would have liked to find
a new idea of some value.—J.E.C.
Page  119 Studies in Intracranial Physiology and Surgery, Harvey Cushing, M.D., Oxford University Press, 1926, 10s/6d.
This is a publication in book form of the Cameron Prize Lectures
delivered at the University of Edinburgh, October, 1925. The first of
the three lectures is devoted to the study of the third circulation and its
channels. Some historical reference is made to the study of the cerebrospinal fluid, but its production and circulation are minutely discussed as
are also the experimental procedures by which such detail has been accumulated. The second lecture on the pituitary gland reviews the knowledge of the hypophysis up to the present time. The functions of the pars
anterioris et posterioris are elaborated and the lecture concludes with some
surgical considerations. The last lecture is entitled "Intracranial Tumors
and the Surgeon." After a brief resume of the history of brain neoplasm
study, symptoms, diagnosis and pathology are discussed. Finally an exhaustive classification and some surgical considerations are given.
The book which is beautifully printed on some hundred and forty
pages of excellent paper, and written in the author's own inimitable style,
is very readable, interesting and instructive but possibly its chief value
lies in the exhaustive bibliography which it contains.—F.B.
Chronic Rheumatic Diseases, Their Diagnosis and Treatment, By
F. G. Thomson, M.D. and R. G. Gordon, M.D., London and Oxford
University Press, 1926, 8/6 net.
In this little work which is one of the Oxford Medical Publications,
the authors have displayed considerable ability in successfully presenting
in a condensed form, the essential present-day knowledge of sciatica, lumbago, fibrositis and arthritis, all of which are grouped under the title
"Chronic Rheumatic Diseases."
The interrelationship of these ailments is now well established and it
is very necessary that the general practitioner, who usually is first consulted by the patient, should have a clear-cut conception of the symptoms and nature of these disabling conditions.
To anyone desirous of obtaining a correct perspective of "Rheumatism," this work is recommended for its concise, well-balanced presentation of same.—A.S.M.
ABSTRACT
Dermatitis of the Diaper Region in Infants  (Jacquet Dermatitis),/. V. Cooke, D.D., Arch, of Derm, and Syph., 14s539, Nov., 1926
In this paper the associate professor of pediatrics in Washington University brings to the attention of dermatologists a condition the nature
and etiology of which he states is widely known to pediatricians, who
now use the treatment he recommends almost routinely. As this may not
be the case amongst the numerous practitioners who are neither pediatricians nor dermatologists who are attendant upon children for this condition, this paper should be of considerable value.
Page 120 The author has found that the dermatitis is due to irritation from
ammonia liberated from urea by the action of B. ammoniagenes, which
occurs in faeces, particularly of those children fed upon a relatively high
protein diet.
In dealing with the disease the diaper rather than its wearer is treated. The object of the treatment is to inhibit bacterial growth upon the
diaper and thus prevent the liberation of ammonia. It consists simply
in rinsing the previously washed diapers in 1:4000 biclorid solution, after
which they are wrung and dried in the usual way.
The paper is well illustrated by photographs of typical cases.
—D.E.H.C.
B.C. MEDICAL ASSOCIATION NOTES
Dr. John Wallace Coffin, whose death after a long illness from
chronic nephritis, occurred at his home in Rossland on November 21st,
was born at Mount Stewart, P.E.I., in 1873. After a preliminary education at Prince of Wales College, Charlottetown, he taught school for
several years before proceeding to McGill, where he graduated in 1904.
After a year in surgery with the late Professor A. E. Garrow in the
Royal Victoria Hospital, he went to Cranbrook where he was assistant
to Drs. J. H. King (now Federal minister) and F. W. Green. For the
fifteen years previous to his death he practised in Rossland, where he enjoyed a very large clientele, drawing patients from all over the province.
He was especially fond of surgery at which he was particularly successful, his advice being sought by his colleagues in any difficult case; his
reputation as a surgeon was second to none in the interior of British
Columbia. Any spare moment he had was spent in reading, and his
post-graduate study was done at various centres in the United States and
in London.
As a man, his friendship was valued by everyone with whom he
came in contact, and although he was perhaps really intimate with only
a very few, by these he was beloved. Funeral services were conducted
under Masonic auspices and burial was at Vancouver. He is survived
by his mother, wife and two adopted children, who together with the
whole district mourn the loss of one whose greatest pleasure was in helping others.
Recent medical visitors to Vancouver include Dr. W. J. Knox of
Kelowna; Dr. M. G. Archibald, of Kamloops; Dr. Douglas Corsan, of
Fernie; Dr. Geo. More, of Nanaimo; Dr. O'Hagan, of Jasper and Dr. D.
W. McKay, of Nelson.
Dr. A. S. Underhill, who has been relieving at Waldo, B.C., for the
last two months, is now working in the Pathological Department of the
Vancouver General Hospital.
Dr. J. W. Laing, of Vancouver, has been appointed assistant to Dr.
A. M. Menzies at Britannia Beach, taking duty there as from December
1st.
Page 121 Dr. R. J. Wride, who has been in the Pathological Department of
the Vancouver General Hospital for some months has been appointed
medical officer at Atlin, succeeding Dr. M. Fox. Dr. Wride left for
Atlin on December 27th.
Dr. R. Felton, of Alert Bay, is taking a well earned two-weeks'
Christmas holiday and will be relieved by Dr. H. J. Wride.
Dr. Geo. E. Seldon, of Vancouver, was the speaker at the December
meeting of the Fraser Valley Medical Society, which, by the way, has
changed the date of its monthly meeting to the third Tuesday of each
month. The staff meeting of the Royal Columbian Hospital will be held
on the first Tuesday of each month.
The sympathy of the profession is extended to Dr. Geo. T. Wilson,
of New Westminster, in the loss of his father who recently died suddenly
in California. The late Mr. Wilson was well known in British Columbia
where he resided for many years.
A meeting of the local members of the executive committee of the
B.C. Medical Association was held on November 26th, when a number
of important matters were dealt with. The applications of seventeen
new members of the B.C. Medical Association were handed to the Chairman of the Credentials Committee for consideration.
The new proposed Provincial "Turn-over" tax on gross incomes
is being investigated by a special committee, as to the effect on the medical profession.
The year 1926 was a busy one for the British Columbia Medical
Association. The value of the business office is being more and more
recognized and rarely a day passes but that the Executive Secretary is
not visited by several medical men in quest of information or advice.
Quite a number of vacancies have been filled during the year whilst
about forty "locum tenens" have been supplied. Enquiries have been
made by industrial firms in regard to their medical services, and in certain cases adjustments, to the benefit of the medical officer have been obtained. There is much work to be accomplished during the coming year
and all we ask is the hearty co-operation of every member, plus a prompt
remittance of the annual membership fee. This will save the time of
the Executive Secretary and tend to a greater efficiency in the general
work of the Association.
REFERRED PAIN IN CONECTION WITH SOME
DISORDERS OF THE ABDOMINAL VISCERA
Read before the meeting of the Vancouver Medical Association
By Dr.W. F. Mackay
The diagnosis of disease depends on the recognition and interpretation of certain abnormal phenomena. Of these, pain, from the patient's
point of view at least, is perhaps the most important. It it is the most
impressive and urgent warning that he receives from nature that something is amiss, and the one which usually inclines or compels him to seek
some means of relief.
Pagge 122 It is not surprising, then, that of late years considerable study has
been devoted to the mechanism of the production of the various pains that
afflict humankind. But the study is beset with special difficulties, as it is
one which does not readily adapt itself to the ordinary methods of research. The laboratory experimentalist can do little to elucidate its
mysteries, for subjective phenomena are difficult to study in animals, and
the varieties of pain which can be produced and studied in healthy human
beings are necessarily limited. Hence the advancement of our knowledge of this subject must depend chiefly on those who have the most
frequent opportunities of observing the experiments in pain with which
nature herself provides us, that is, those engaged in the active practice of
cine and surgery. It is unnecessary to remind you that these have many
other problems to interest or worry them, hence progress in this special
study has been slow. But progress has been made, and I wish first to
review briefly some of the chief points in its advancement.
It was early recognized that pains might be divided into two classes:
(1) those occurring in the immediate neighborhood of the causal lesion,
and (2) those felt in an area more or less remote from it. The latter
were spoken of as "sympathetic pains." The vagueness of the idea conveyed to the minds of our ancestors by this term will be better appreciated when we recall that the efficacy of the weapon treatment of wounds,
which was in vogue in Europe as late as the 16 th century, and which
consisted in applying curative ointments to the weapon which caused the
wound, was supposed to depend on some occult "sympathy" between the
wounded part and the weapon. It was observed that while these sympathetic pains were sometimes found in diseases of the external structures
of the body, for example, pains in the knee accompanying hip-joint
disease, their most frequent occurrence was in connection with internal
disorders. That their true nature was to some extent appreciated as
early as the middle of the last century is apparent from the following
quotation from Jno. Hilton's classic work „Rest and Pain" first published
in 1860: He says "In connection with these sympathetic pains, I should
like to displace, to throw aside, the term 'sympathetic' and would ask
you to consider such pains in their obvious, intelligible and more natural
relation. I would ask you to regard them as resulting from some direct
nervous communication between the parts where the pains are expressed,
and the real and remotely situated cause of the pain."
John Ross of Manchester further advanced this idea, and was the
first to elaborate the now generally accepted theory of the origin of referred pain. In an article published in "Brain" in 1888 he says: "Disease
of an internal organ, say the stomach, is accompanied by pain over the
seat of the organ, a pain that may be regarded as of splanchnic origin
and named accordingly splanchnic pain. In addition to this, the patient
complains of pain between the shoulders and in front of the chest. These
associated pains are situated in the region of the distribution of the fourth
and fifth dorsal nerves. The splanchnic nerves supplying the stomach
are supplied from the fourth, fifth and sixth dorsal nerves, and when
the splanchnic terminations of these nerves are irritated, the irritation is
conducted to the posterior roots of the nerves, and on reaching the grey
matter of the posterior horns it diffuses to the roots of the corresponding
Page 123 somatic (or cerebro-spinal) nerves, and thus causes an associated pain in
the territory of distribution of these nerves, wihch may appropriately be
called the somatic pain."
You will note that Ross recognizes two varieties of pain occurring
in visceral disease, the direct or splanchnic pain in the organ itself, and
the referred or somatic pain felt in the external parts of the body.
Lennander of Sweden, after a long series of experiments on animals
and human beings, in which he found that after the abdominal cavity
was opened the viscera could be cut, stitched, pinched, burnt and otherwise maltreated without producing any evidence of pain, (in an address
before the American Medical Association in 1907) expressed his conviction tha tthere is splanchnic pain, but that all organs supplied only by
the sympathetic nervous system are totally devoid of the sense of pain,
and that the pain which seems to be in a diseased abdominal viscus is
really in the tissues over-laying it, chiefly in the skin, the muscles or the
layer of loose connective tissue lying immediately outside of the peritoneum. The controversy thus aroused is still unsettled, but a discussion
of its merits is outside of our province tonight. Perhaps the majority at
the present time inclines to the ideas originally promulagted by Ross.
Sir Jas. Mackenzie, however, agreed with Lennander, and in his book on
"Symptoms and Their Interpretation," which was first published in 1907,
ably advocates the view that the viscera are absolutely insensitive under
any conditions.
Henry Head, whose contributions on this subject are of the highest
value, has formulated this law: when a painful stimulus is applied to a
part of low sensibility, the pain produced is felt in the part of higher
sensibility rather than in the part of lower sensibility to which the stimulus was actually applied.
Head has also mapped out on the surface of the body the skin areas
supplied by the sensory nerves arising from each segment of the cord, so
that pain expressed in any of these areas can be related to the segment
from which the disturbance originated.
I would like now to call your attention to some observations of a
more strictly clinical character that have been made regarding the association of pains referred to special areas with diseases of different viscera. All of the abdominal viscera being supplied by the vagus and
splanchnic sympathetic nerves, referred pains arising from them must be
felt in supeficial areas supplied by cerebro-spinal nerves having central
connection with either of these. With regard to the vagus, there is general agreement that this connection must be with the sensory part of the
fifth cranial or trigeminal nerve, and Ross inferred that the headache so
common in digestive disorders was due to this connection. Head has
shown that affections of different organs produce pain in different head
areas, diseases of the stomach or liver producing a headache chiefly in the
frontal, temporal and parietal areas, those of the intestines in the vertical,
parietal and occipital areas, etc. Rasdolsky, in a paper entitled "Sensory
Phenomena from the Vagus in the Course of Affections of Internal Organs," based on the study of 83 cases, notes that the headache accompanying these conditions usually begins in, or is restricted to, the same side as
the lesion.    But the most common phenomenon he observed was hyperal-
Page 124 gesia of the posterior wall of the external ear.   A pin-prick or pressure
this region induced violent pain in practically every case—always on the
side nearest the lesion.
A child of six had had some slight abdominal symptoms for some
hours, but complained chiefly of severe spasmodic pain in the right side
of the neck, just below the right ear. He had not vomited. His temperature was 100, and there was a little indefinite tenderness in the right
iliac fossa, and it was noticed that there was a slight increase in tension
in the right rectus occurring synchronously with the spasms of pain in
the neck. A consultation was held, and in view of the very indefinite
local symptoms and the absence of vomiting, it was practically decided
to treat the case expectantly. Just then Dr. H. B. Gourlay happened to
enter the ward and was asked to examine the child. He advised immediate operation, and an acutely inflamed appendix was removed. There
was no recurrence of the pain in the neck. It would not have been
surprising if the ear tenderness described by Rasdolsky had been found in
this case at least.
An article by Goldbloom of Montreal in the October C.M.A.J.
would seem to suggest that whatever nervous association is operative in
such cases can, in children at least, work both ways, as he cites several instances in which children suffering from throat affections presented
abdominal symptoms.
According to Head, the splanchnic sympathetic nerves supplying the
abdominal organs are connected with all spinal segments from the fifth
thoracic downwards. The higher organs are connected with the higher
segments, the lower with the lower. The stomach is supplied by filaments having an association with the sixth and seventh thoracic segments,
and the spinal nerves from these segments supply the skin in the epigastric area. Hence referred pain resulting from disease of the stomach
is felt in this area. If the pain is severe, the stimulus may spread to the
fourth and fifth segments and then the associated pain radiates to the
front of the chest. Mackenzie says that when a lesion, for example, an
ulcer, is situated near the cardiac end, the site of pain and hyperalgesia
is in the upper part of the epigastrium; and when in the middle, the pain
and tenderness are in the mid-epigastrium, and when at the pyloric end,
in the lowest part of the epigastrium, always in the middle of the body.
He emphasizes the point that this occurs independently of the relation
of the stomach to the external structures as when this relation was altered by deep inspiration or by changing the position of the patient, the
site of the pain and tenderness remained unchanged. He verified this in
many cases by the findings at operation or post-mortem examination.
In connection with diseases of the liver and gall-bladder, Butler
calls attention to the diagnostic importance of a particularly tender point
at the ninth costal cartilage as an evidence of an inflamed, impacted, or
cancerous gall-bladder, or a gall-stone lodged in the common duct. In
a paper appearing in the J.A.M.A. in 1924, Livingston of New York refers-especially to an area of skin tenderness, having the tip of the ninth
costal cartilage as its centre, and a radius of two inches. He found pronounced cutaneous hyperaesthesia in this area in over nine out of ten
cases of acute gall-bladder disease.
Page 125 The phrenic nerve, which is distributed to the diaphragm, the liver
and the gall-ducts, passes out of the spinal cord with the fourth cervical
nerve, receiving small branches from the fifth cervical. The skin over
the top of the shoulder and down the outside of the arm is supplied by
the sensory branches of the fourth and fifth cervical nerves. Hence
shoulder pain is a not infrequent complaint in gall-bladder disease, and
the pain may extend down the outer side of the upper arm. This arm
and shoulder pain may be so severe, and pain in the regions more ordinarily affected so slight, that the true causal condition may be undetected,
and the case looked upon as one of neuritis.
The importance of tenderness on deep pressure in the right iliac
fossa as a sign of appendicitis has long been recognized, but superficial
tenderness is comparatively seldom looked for, though Jas. Sherren, in
1903, drew attention to its presence. In a third of the cases of acute
appendicitis he examined, he found cutaneous hyperaesthesia in an area
corresponding to the distribution of the eleventh dorsal nerve as mapped
out by Head. He was careful to avoid stimulating the tissues below the
skin, and hence carried out his tests by gentle stroking with a pin or a
very light pinch. Some of the conclusions he drew from these tests were
that this tenderness was probably always present in first attacks of appendicitis, that its absence indicated that the appendix was either gangrenous or had ruptured and that the position of the appendix had no
bearing whatever on the location and occurrence of the hyperalgesia.
His tests were repeated and his results practically confirmed by
others during the semi-decade following the appearance of his paper,
but the matter seems to have been allowed to drop then until a couple of
years ago, when Livingston carried out similar investigations,     fie
nas
modified Sherren's technique, however, employing a twisting pinch severe enough to cause discomfort on normal skin, the positive result being
evinced by a very noticeable increase in pain in the hyperaesthetic area.
The ninth, of course, stimulates the subcutaneous tissues as well as the
skin. By using this method he claims that a very definite hyperalgesia in
a specific area can be demonstrated in practically every case of acute
appendicitis unless the appendix has ruptured or is gangrenous. This
area he defines as a triangle enclosed by lines connecting the umbilicus,
the summit of the crest of the right ilium, and the right pubic spine.
In one series of seventy-five cases diagnosed as acute appendicitis and
subsequently operated on, he found hyperalgesia in fifty-four, and all of
these had acute appendicitis. Eleven of those presenting negative signs
had gangrenous or perforated appendices; th eremaining ten suffered from
other diseases. These results seem to justify his rather striking conclu-
ions, which are:
1. All cases of acute appendicitis in which the organ has not become gangrenous or necrotic present these localized skin signs.
2. The presence of skin signs within the triangle described confirms
the diagnosis of appendicitis.
3. If skin signs are negative, or are present elsewhere, in the absence of signs of gangrene or rupture of the appendix, the case is not one
of acute appendicitis.
Page 126 These findings are rendered more impressive by the fact that the
observations were not made in all the cases by Livingston himself, but
by twenty different attending surgeons or internes.
As an indication of the value of the sign he compares the frequency
of its occurrence with that of the usual classical signs as follows: In a
series of fifty-four cases, muscular rigidity was present in thirty-four,
tenderness on pressure in forty-one, pain in forty-four, elevation of temperature in forty-five, and nausea or vomiting, leucocytosis, and this
superficial hyperalgesia which he calls the skin sign, each in forty-seven
cases. It would seem that any sign for which so much is claimed is at
least worth investigating, and it is strange that one can find no report
so far of any attempt to verify or disprove Livingston's statements.
I have given a comparatively full summary of his views because the
work on which it is based, carried on as it was without any special apparatus, and involving only relatively simple observations that could be
made by any medical student, shows in a very striking way what interesting possibilities there are in this line of investigation.
I have made no attempt to give a full description of all the referred
pains connected with any organ or disease. I have tried rather to review
the mechanism of the production of these pains and give a few typical
illustrations, in the hope that general interest may possibly be stimulated
in a matter which does not seem to be receiving'the attention it deserves.
There is a striking contrast between the enthusiastic statements of those
writing on this subject, and the scant attention paid to them in works
on general medicine, or by the rank and file of the profession. Many
intricate problems connected with the subject are still unsolved, and will
require years of patient work. Much of this doubtless can be done only
by men with special training, but the least scientific of us can do something to help by keeping in touch with what is being done by these men,
and, when possible, clinically testing their results. Rasdolsky says, "The
reflexes from the automatic nervous system form a periscope through
which we can view the condition of the internal organs." This may be
a picturesque overstatement, but I think that enough has been accomplished already to show that with fuller investigation and a better understanding of the subject, new diagnostic signs, some possibly of very
great value, may be confidently expected.
CITY HEALTH DEPARTMENT
Vancouver, B.C.
•STATISTICS—NOVEMBER, 1926
Total Population  (estimated)    128 366
Asiatic Population  (estimated)      10,100
Rate per 1000
of Population
Total Deaths      142 13.5
Asiatic Deaths   14                           ig.8
Deaths (Residents only)   102                             9.7
Total Births   327                           31.0
Male,      149
Female,  178
Stillbirths—not included in above   9
Page 127 Oct.,  1926 Nov.,  1926
Cases Deaths Cases Deaths
Smallpox           0 0 0           0
Scarlet Fever        26 1 37           0
Diphtheria           13 1 40           3
Chicken-pox         70 0 77            0
Measles         116 0 152            0
Mumps            2 0 19           0
Whooping Cough ....        3 0 10
Erysipelas             8 4 8           0
Tuberculosis           7 14 8         12
Typhoid Fever          2 0 3           0
Cases from outside city included in above.
Diphtheria           10 0 7           1
Scarlet Fever         3 0 8           0
Typhoid Fever           3 0 3           0
Dec.
1st, to
15th,
1926
Cases
Deaths
0
0
11
0
4
0
11
0
29
0
2
0
0
0
0
0
2
—
0
0
1
0
3
0
0
0
J{\\ prescriptions dispensed
bvj qualified Druggists.
\\o\x can depend on the Ou?I
for Accuracy and despatch.
IPe deliuer free of charge.
5 Stores, cenirally located.    We
would appreciate a call whde
in our lerritory.
Page 128
Ambulance
Service
TELEPHONE
Fair. 58 & 59
Mount Pleasant
Undertaking Co.  Ltd.
R. F. Harrison    W. E. Reynolds
Cor. Kingsway and Main
SfHg B. Q Pharmacal Co. Ltd.
329 Railway Street,
VANCOUVER.
Manufacturers of Hand-wade Filled Soluble
Elastic Capsules.
Specimen Formulae:
No. 60—
Blaud Pill, 10 gr.
Arsenious Acid,  1/50 gr.
Ext. Nux Vomica, \ gr.
Phenolpthallin, J gr.
No. 61 —
Blaud Pill, 10 gr.
Arsenious Acid 1/50 gr
Ext. Nux Vomica, \ gr.
Phenolpthallin, \ gr.
Special Formulae Made on a Few Hours' Notice.
Price Lists and Formulae on
Application.
PRESCRIPTIONS
filled exactly as written
Phones: Seymour 1050 -1051
Day and Night Service
Qeorgia Pharmacy Ltd.
Qeorgia and Qranville Sts. Vancouver, B. C
Page 129 I
Apparatus for Laboratory
Practise
as used and recommended in his B.C. post-graduate lectures
by Dr. Daniel Nicholson, University of Manitoba.
GASTRIC ANALYSIS—
Ewalds Stomach Tube and Bulb.
Hollanders H.CX. Scale.
Dimethyl Indicator 1 oz.
BLEEDING TEST—
Spring Lancet.
HAEMOGLOBIN ESTIMATION—
"Non-fade" Haemoglobinometer.
SUGAR IN URINE, Quantitative-
Benedicts Solution 16 oz.
Luer Syringes, l1/^ and 5 cc.
Test Tubes, 54x6 inches.
RENAL FUNCTION, Estimation—
Salivar3r Urea Apparatus.
The above can be obtained at
B.C. SteVeilS CO.       730 Richards St. Vancouver.
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
Phones Sey. 98 8 and 672
Phones Sey. 9513 and 1391
Phone Sey. 1370
Brown Bros. & Co. Ltd.
VANCOUVER, B. C.
Page 130
_u —H3@e
DIPHTHERIA
ANTITOXIN
P.D.
CONCENTRATED AND REFINED (GLOBULIN)
IN SYRINGE CONTAINERS OF
RECENT DESIGN
NOTWITHSTANDING the fact that Diphtheria Antitoxin
is specific, the mortality from diphtheria is still too high,
and it rises with each day's delay in the administration of the
antitoxin. If the dose is inadequate, cardiac failure may cause
death, or paralysis may intervene, with its attendant incapacity.
For best results, the antitoxin must be highly concentrated,
of low protein content, and of maximum potency.
Diphtheria Antitoxin, P. D. & Co., meets these requirements.
Its superior quality is the result of years of research endeavor
and scrutinizing care in manufacture. The syringe container is
especially designed for convenience and ease of manipulation
under the most trying conditions, such as those attending the
injection of antitoxin in children.
Diphtheria Antitoxin, P. D. & Co., is supplied in syringe containers of 1000
antitoxic units for prophylaxis, and 3000, 5000,10,000 and 20,000 units for curative
effect.
Our 22-page booklet,  "Diphtheria—Prophylaxis and
Treatment," is available to physicians upon request.
PARKE, DAVIS fe? COMPANY
{United States License No. z tor the Manufacture of Biological Products}
DIPHTHERIA ANTITOXIN, P. D. W CO., IS INCLUDED IN N. N. R. BY THE COUNCIL ON PHARMACY
AND CHEMISTRY OF THE AMERICAN MEDICAL ASSOCIATION
v®t; a<s"^s|^rae
»s^f-*~
Hollywood Sanitarium
LIMITED    ;
"tfor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference | ^B. Q. oZKCedical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183 Westminster 288
=*©(?
H©»9
Page 132

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