History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: May, 1934 Vancouver Medical Association May 31, 1934

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 The BULLETIN
►r«fl
OF THE
VANCOUVER MEDICAL
ASSOCIATION       ?
Vol. X.
MAY,  1934
No. 8
In This Issue:
THE ANNUAL MEETING
DRUG ERUPTIONS
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finest quality Acetylsalicylic Acid so compressed as to insure immediate disintegration
in the stomach.
IVz DOZ. IN GLASS VIALS, BAKELITE
CAP.
VANASPRA  5-GRAIN PLAIN.
VANASPRA COMPOUND No. 202.
VANASPRA COMPOUND No. 303 with
CODEINE.
We commend VANASPRA to the profession
as of the highest standard at less than half
the price of other makes.
Western Wholesale Drug
Limited
45 6 Broadway West
Vancouver, B. C. THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
"Published ^Monthly under the ^Auspices of the Vancouver Medical ^Association in the
Interests of the tMedical "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. X. MAY, 1934 No. 8
OFFICERS  1934-193 5
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. McIntosm, 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.CHBastin Dr.J.H.McDermot °r. C. E. Brown
Dr. A. W. Bagnall Dr. D. E. H. Cleveland Dr. CH. Vrooman
Dr. G. E. Kidd Dr Murray Baird Dr. £W. Arbuckle
Dr. W. K. Burwell Dr. H. A. Spohn
Dr. C. A. Ryan Dr. H. R. Mustard
n. Credentials Hospitals
umner Dr r a Simpson
Dr. J. W. Thomson Dr. j. T. Wall {£• Jfp™
a" IT* rE$ DR- °- M- MEEKISON S: H H m'burn
Dr. W. G. Gunn ._    „ _
Dr. S. Paulin
V. O. N. Advisory Board
Dr. I. Day R*P- io &• C Medical Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees T,
■■ i«i ■■■ '■> ■■■
NOW YOU SEE AGAROL
. . . NOW YOU SEE
SOMETHING   ELSE
HE RING around the drop tells the story. A drop of Agarol on
blotting paper holds together firmly. Try this with a poor emulsion,
and you will see that the mineral oil will be soon taken up by the
blotting paper, forming a greasy ring around the drop.
Agarol is as fine an emulsion of mineral oil and agar-agar with
phenolphthalein as the modern art of pharmacy, aided by the skill
of experience acquired in more than three-quarters of a century
can produce. It never leaves an oily taste.
Finest, purest ingredients make Agarol palatable without artificial
flavoring. It contains no sugar, no alcohol, no alkali.
For dependable efficacy Agarol has attained a reputation all its own,
generously granted by those who have observed its good effects in
the resultful treatment of constipation.
Trial supply sent on request.    *    *    *    Please use letterhead.
AGAROL FOR CONSTIPATION
Agarol is supplied in bottles containing 6 and 14 ounces.
The average dose is one tablespoonful.
WILLIAM   R.   WARNER   &   CO.,   Ltd.
727  King   Street,   West,  Toronto,   Ont. VANCOUVER HEALTH DEPARTMENT
STATISTICS—FEBRUARY, 1934
Total Population (Estimated)     243,711
Japanese Population   (Estimated) — _.     7,966
Chinese Population (Estimated)         8,31)
Hindu Population (Estimated) IPslP "i.5\
Rate per 1,000
Number Population
Total Deaths   212 12.1
Japanese Deaths _  ,  11 16.5
Chinese Deaths  -       11 \i.i
Deaths—Residents only  197 9.5
Birth Registrations—
Male, 149; Female, 140  289 14.0
INFANTILE MORTALITY—
March, 1934    March, 1933
Deaths under one year of age  8
Death rate:—per 1000 births .  24.2 30.4
Stillbirths (not included in above)  11
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
April 1st
February, 1934 March, 1934 to 15th, 1934
Cases    Deaths Cases Deaths Cases    Deaths
Smallpox          0             0 0 0                  0 0
Scarlet   Fever ]     268              0 371 0 97 0
Diphtheria          10 0 0                 0 0
Diphtheria Carrier '.         0             0 0 0                 0 0
Chicken Pox       49             0 60 0 29 0
Measles    —EP    2             0 76 0                  6 0
Rubella          0             0 0 0                  0 0
Mumps       93              0 90 0 28 0
Whooping-cough         16             0 13 0                 5 0
Typhoid Fever         0             0 0 0                 0 0
Undulant Fever         0             0 0 0                 0 0
Poliomyelitis          0             0 0 0                  0 0
Tuberculosis        69           11 67 14 3 3
Meningitis   (Epidemic)         0             0 0 0                 0 0
Erysipelas .«j|                3              0 3 0                  0 0
Encephalitis Lethargica         0             0 0 0                 0 0
Paratyphoid    s|         0             0 0 0                 0 0
S. BOWELL & SON
DISTINCTIVE  FUNERAL
SERVICE
Phone 99i
66 SIXTH STREET
NEW WESTMINSTER, B. C.
Page 143 ■   PUBLIC HEALTH j||
BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid   (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum   (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price*1fJst Upon Request
Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C.
.. EDITOR'S PAGE
The last session of the Legislature will go down in history, no doubt, as
a somewhat notable one in Canadian history—indeed in British history.
One of the glories, of course, of the political system under which British
countries live, is its flexibility and adaptability to the demands of circumstance; nevertheless, many of us must have gasped at the advantage that
was taken of this feature, by our present government. The Special Powers
Act, if it can be made to stick, brings us, one would think, perilously close
to a dictatorship—though we believe that it will not be a one-man affair,
but government by a small council. One is always sorry to see any tampering, no matter how slight and how well-meant, with the principle on
which our parliamentary system is based, namely, control at all times of the
executive by the elected representatives of the country; but there is an
emergency, and we have elected a government to do certain things, on their
promise to do these things. We must, in common fairness, give them every
opportunity to make good their promise, and stand behind them while they
try to do so.
But this was not the thing about the last session that most immediately
concerns us. We have seen the day come at last, in spite of all our efforts to
the contrary, when a government, whose duty it is to safeguard health and
the lives of its citizens, has yielded to popular clamour, and allowed rights
of practice to a body of men who, while we might admit that they are sincere and honest in the claims they make, inasmuch as they believe in the
efficacy of their treatment, are yet quite untrained—many of them with no
scientific or cultural background.
Over the years this province, like others, has built up an elaborate system
of health laws and health measures. Medical Acts have been framed, designed
to protect, not those who claim to practise medicine, but the public, against
ill-trained men or charlatans. The standards of medical licensure, of medical
training, have grown higher year by year, and the tests more rigid. Health
laws dealing with sanitation and epidemiology, school medical work, maternal protective measures—all these have been built up along the most
advanced lines. Yet we find the premier of this province defending and
endorsing an act which admits men who for many years denied the existence
or importance of bacteriology or epidemiology, whose knowledge of the
human body, its laws and diseases, is minimal, and whose preliminary standards of education and scientific training are sketchy, to practise medicine, in
the sense of the healing art. We understand that certain restrictions have been
attached to the Act—and it may be that not much harm, and some real
good, may be done by these men—but we submit with all due deference that
this is a distinct dereliction of duty on the part of those to whom we must
entrust the health and safety of our growing children and our families.
Nominally, we understand, this is not a government measure, yet the list of
names of those voting for it reads almost like a list of the cabinet, and we
cannot see how they can escape the responsibility for its passage.
We are glad, however, that the Medical Council saw fit to stay out of it.
We believe they did the right thing. We have, and we are proud of it, resisted
this letting-down of our educational and health standards for many years
—but after all, the protection of the public, which, in spite of our detractors, was our only object, is the duty and responsibility of the Legislature,
and not ours—and we believe it was a wise thing to leave it so.
A third matter of great import is the nearness on our horizon of a Health
Page 144 Insurance measure. Time will not permit us to deal with this now, but the
latest developments referred to above make it all the more necessary that
we should be on the alert in this regard.
NEWS AND NOTES
We are glad to note that Dr. H. C. Wrinch, of Hazelton, has been
chosen to serve on Dr. Carrothers' "Brain Trust." We feel that Dr. Wrinch
can contribute a very sane and proven wisdom as his share.
Signs of spring are becoming increasingly evident. Instead of hanging
around in the dank and depressing atmosphere of a curling rink, men are
beginning to appear out in God's out-of-doors, where we noticed the other
day our worthy past president sinking his fourth putt, very successfully too.
And we rejoice that Dr. Bilodeau seems to have recovered considerably
from the affliction of his knee which kept him from his avocation of trying
to break 80.
Another sign is the notice on the Bulletin Board regarding the game with
Seattle, which will be played off on or about May 17. There are not many
names yet—but no doubt a good many of us will be rattling the missionary
bank to see if there is the price of a ticket to Seattle about that date. We
cannot let Seattle get away with it.
The ranks of the eye, ear, nose and throat men are being sorely thinned
these days, by the departure of such eminent members of the cult as Dr. F.
W. Brydone-Jack, who has gone away for a holiday in Europe.
Dr. Leeson, too, is away for a while, and Dr. J. A. Smith has left us
temporarily. We have always felt that we made a mistake in sticking to
general practice: where virtue is about the only reward for itself.
We are glad to be able to report that Dr. T. Butters is very much better,
after a long stay in the hospital. We hope soon to see him back at work.
Our readers are reminded that the Summer School is one month nearer,
and plans should be laid for attending what promises to be one of the best
meetings we have ever had. The B. C. Medical Association, too, has a really
outstanding programme in hand for the Annual meeting at Kamloops in
September, and details of this will appear later.
THE ANNUAL MEETING
The Annual Meeting of the Vancouver Medical Association was held in
the Auditorium of the Medical-Dental Building on Tuesday, April 24th,
1934. The meeting was small even if enthusiastic and one cannot but regret
that annual meetings are not better attended. Various reasons are given for
this lack of enthusiasm, amongst which is the absence of a contest in elections, "but this does not seem enough to explain the fact that the majority
Page 145 of members stay away from what is one of the most important meetings
of our year. Perhaps some bait will have to be held out to attract our
membership.
Several reports were presented. The report of the Hon. Treasurer was
particularly gratifying even if the bulk of the surplus which he reported
had been earned by the efforts of the Bulletin. We are very gratified to
Dr. Lockhart for the kind things he said about our journal. It was indeed
"praise from Sir Hubert." The finances of the Association appeared to be in
excellent condition, which does not really surprise us in view of the hard
work and real genius for his job displayed by the Hon. Treasurer.
The Trustees' report, with that of the Sickness and Benevolent Fund,
was presented by Dr. Brodie and again we cannot but admire the great care
and interest shown by these gentlemen in the affairs of the Association,
which are indeed safe in their hands.
The report of the Library Committee, by Dr. Kidd, called special attention to the bad habits of members in not returning journals and books borrowed, and we would add our endorsement to his remarks on this matter.
Dr. Mustard reported for the Summer School Committee and his report
showed a great deal of work. Fuller details will appear in a later issue, but
our members should seriously consider attending this school, as there is no
doubt that the programme arranged is one of the best ever offered.
Dr. Strong, reporting for the B. C. Medical Association, spoke of the
alterations in the status of the Association and consequently in its work. He
pointed out that the Association had two main objects, (1) postgraduate
work especially for men in the outlying areas, and (2) establishing contact
between these men and their fellows in other parts of the province, a work
which was formerly done by the Executive Secretary. Dr. Strong announced
that plans had been drawn up to include a visit to each electoral district of the
province by a team of speakers once every year, this team to be accompanied
by a representative of the Council or a member of the Executive of the
B. C. Medical Association. The budget for this purpose has been provided
by the Council. In areas such as Vancouver where postgraduate tours are
omitted, a grant has been made to the Summer School as an acknowledgment
in lieu of a tour. Dr. Strong referred to the forthcoming annual meeting
to be held at Kamloops on September 17th and 18th. The time has been
picked carefully so as not to conflict with the Summer School in any way.
An excellent programme has been arranged. Again we will have more definite
details of this later on, but it is obvious that this is going to be an outstanding
meeting.
Other reports given were the Eye, Ear, Nose and Throat Section, the
Clinical Section, the Cancer Section and the V. O. N. Advisory Board, as
well as reports of the Standing Committees on Library, Publications and
Hospitals.
With regard to the Cancer Section. Dr. Schinbein referred to the possible establishment at an early date in Vancouver of a Tumour Clinic. In
the move for this the Hospitals are co-operating fully, but nothing will be
done without the endorsement of the Vancouver Medical-Association.
A motion of Dr. Gillespie's with regard to the Sickness and Benevolent
Fund was presented, whereby the trustees would be allowed at their discretion to give relief to members of the profession who had been at some time
members of the Association, but for one reason or another had dropped their
membership. This gave rise to the keenest discussion of the evening. It was
felt by many that this departure contained a germ of danger, in that the
Page 146
WWS fund was designed for members only and that it established a dangerous
precedent. Others felt that the trustees should be given some latitude for
special cases. Many members participated in the discussion but in the end
our confidence in the discretion of our trustees won the day and it was
decided to pass the motion and comply with the trustees' request.
A letter from the Florence Nightingale Memorial Fund also aroused
some discussion, which was ended by the decision that the Association should
contribute a small donation to this fund as a gesture of friendliness and
regard for our sister profession, and should endorse the purpose of the Fund.
The election of officers then took place, the entire slate being elected
without any additional nominations. A perusal of the slate is probably the
best explanation why no contest occurred. At the same time one feels an
unregenerate homesickness for the good old days when the battle raged
furiously till the early hours of the morning and eighty-five to ninety-five
per cent, of the membership took part in the annual meeting.
A lot of formal business was done and the retiring president, Dr. Pedlow,
then addressed the meeting briefly. We publish his remarks herewith.
Dr. Frost, the incoming president, made a short speech thanking the
Association for electing him, and promising us his best efforts in the forthcoming year. To those of us who know Dr. Frost, especially to those of us
who have played golf with him, this was a work of supererogation, since
there is no question that he will be doing his best every minute of the time.
To Dr. Frost and the retiring president we would say "Ave atque vale."
REMARKS OF RETIRING PRESIDENT
(Dr. W. L. Pedlow)
At the close of his term of office, it is the privilege of your President to
reflect upon the year which has passed. It is also his privilege to present for
your consideration various suggestions on matters which the intimacy of
the office has afforded him a special opportunity to observe.
In many respects the past year has been a most eventful one. This is
particularly true from a scientific and an economic point of view.
While by no means an Association effort, it was our good fortune to
entertain the Pacific Northwest Medical in Vancouver last July. On
that occasion we had presented to us an all-British programme, which
was probably one of the most delightful, entertaining, and instructive programmes we have ever enjoyed. Our thanks are due to Dr. B. D. Gillies and
the members of his local executive for their efforts on behalf of the profession. It was also our good fortune to entertain Dr. Archibald and Dr. Pen-
field of Montreal, Dr. Furuhata of Japan, and Dr. Ride of Hongkong, during
the past season. The meetings addressed by these speakers were well attended,
and their papers greatly appreciated.
Undoubtedly one of the most outstanding events of the year, and one
of far-reaching importance, has been the successful negotiation of an agreement with the ciyic and provincial authorities for the medical care of relief
recipients. We probably do not as yet fully really realize the milestone this
event marks out for us as a profession in years to come. While your Committee, responsible for these negotiations, frankly admits that the remuneration is totally inadequate, we must agree that the principle of payment for
medical care has at last been accepted.
It would seem inconceivable that, having established this principle and
Page 147 having also established a definite contact between the relief or indigent
patient and his doctor, we should ever again revert to the old custom whereby
the doctor carried the entire burden.
Just at this point I would like to make a suggestion. As you know, the
present plan endorsed by the City and this Association is for a period of one
year only. In other cities and provinces various plans are in operation or in
the course of evolution. Some of these plans, from a casual inspection, would
appear to be much more desirable than the one under which we are now
operating. Obviously a great deal of preliminary work must be done in
making a thorough study of these various plans before we can renew our
negotiations with the City Council. A committee should be appointed at an
early date to undertake this study, or your present Administrative Committee would appear to be in a favorable position to undertake such a task,
if its members would permit the addition of this added burden to their
present duties.
Association Membership:
To most of us, our Association membership is a cherished possession.
During the past year I sought to interest a number who, for one reason or
another, have either not joined this Association or who have dropped their
membership. Many and various reasons were advanced, the chief one being
that of financial embarrassment.
Reviewing the Relief Administration Fund for January, February and
March, we found that eighty-two non-members benefited by this fund to
an amount in excess of $3,000.00. This amounts to over one-third of the
total allowance for these three months. Omitting a few who benefited the
least, we found that the major portion of this amount was divided amongst
sixty of these non-members. Similarly, under the Maternity Relief, we
found that over one-third of the total disbursements is being shared by a
limited few, who are not members.
Surely any Association which has been chiefly instrumental in obtaining
such financial assistance is deserving of support.
Probably we, as an Association, are in a measure at fault that many of
these eighty-two are not members of our Association. A definite and continued effort has never been made to maintain our membership up to one
hundred per cent. I am, therefore, particularly anxious that you should
consider the suggestion of a Membership Committee. This committee should
be one of our most important Standing Committees.
Sickness and Benevolent Fund
I am pleased that you have seen fit to adopt the amendment revising the
by-laws dealing with this fund. My views regarding the fund have changed
greatly during the past year. Personally, I would like to see it gradually
built up to such a sum that it could be considered more in the nature of an
Endowment Fund, that, when occasion demanded, we might be in a
position to make a grant worthy of an Association such as this—something
that would give worthwhile help to an ailing member or to his bereaved
family in case of death. Various suggestions have been received which would
be of the utmost assistance in reaching such a goal. It seems to be, however,
the feeling of a number of our members that the present is not an opportune
time to consider such a move. I leave this suggestion with you for your
thoughtful consideration.
In closing, I wish particularly to express to the personnel of the various
Page 148 Standing Committees my appreciation of the capable and conscientious
manner in which they have discharged their many duties. I also wish, on
behalf of the Programme Committee, to thank those members who, during
the past year, have favored us with the "Papers of the Evening" and to
assure them that their efforts have justly merited the commendation of their
audiences on each and every occasion.
Last, but not least, I wish to express my appreciation of the loyal cooperation and support afforded me by the members of the Executive. To
make special mention of any one in particular would be difficult, unless it
be that we on the Executive appreciate, possibly more than the membership
at large, the amount of time and service so cheerfully given by our worthy
treasurer, Dr. Lockhart. For whatever measure of success may have attended
me throughout the year, I wish to give the credit to these, my loyal supporters.
It is now my pleasure to call upon your new President, and, like the
contestant in the relay race in ancient Grecian days: My course is run. To
other hands I throw the torch! Keep it burning! Hold it high!
DRUG ERUPTIONS
D. E. H. Cleveland, M.D., CM.
Vancouver, B. C
In its common acceptance the term Drug Eruption is confined to eruptions resulting from the introduction of drugs into the body which undergo
absorption and elimination. This class of skin eruptions, spoken of gener-
ically as Dermatitis Medicamentosa, is distinguished from Dermatitis
Venenata, which refers to eruptions resulting from external contact with
irritating substances.
It may be said at the outset, however, that this distinction is not as
clear cut as we might think, and in a recent paper Wise and Sulzberger of
New York have arbitrarily included under the heading Drug Eruptions all
cutaneous manifestations due to substances used as medicaments, disregarding the manner of contact, whether internal or external. There is undoubtedly much logic in this view and further support for it will appear later.
If we look up the subject in a text-book of dermatology the situation
appears very confusing. It will be seen that nearly every type of primary
skin lesion, resulting in nearly every variety of eruption, may be produced
by nearly every one of the remedies with which we are acquainted. The only
exceptions to the last are the salines. It is very evident that a classification
based upon the type of eruption produced is not practicable. This being the
case it is not intended in this paper to do more than discuss the subject in
general terms, and to refer in detail to only a few matters of special interest
in this connection.
The majority of drug eruptions seen today are due to a comparatively
small number of drugs. These include the following:
(a) Halogens
(b) Arsenicals
(c) Phenolphthalein
(d) Hypnotics, analgesics and sedatives
(e) Heavy metals
(f) Alkaloids
Given before a meeting of the Vancouver Medical Association, April, 1934.
Page 149 It will be observed that the newer synthetic remedies form a considerable
proportion of these. With the introduction in the last four decades of enormous numbers of synthetic drugs there has appeared a corresponding
increase in the number of cases of so-called idiosyncrasy or susceptibility to
such medicaments. Probably no such drug ever introduced has not in isolated cases given rise to symptoms of intolerance with cutaneous eruptions.
These vary from mild erythemas to fatal dermatoses.
The recognition of a drug eruption is often a matter of considerable
difficulty. Even where we know that the patient is taking medicine it is not
always easy to be sure that it is the cause of the eruption; it may resemble
very closely some well-known skin disease, and it may not appear until the
remedy has been taken for some time, nor disappear-with the withdrawal of
the latter. In certain instances it may disappear while the drug is still being
taken, or if the drug is withdrawn and then commenced again as a test, the
rash may not reappear. When it is a case of self-medication the situation is
still more difficult. In such cases all our powers of searching cross-examination may be required to drag out the truth. When we are finally successful
the patient admits quite candidly that of course he was taking this laxative,
or that cough-remedy or the other headache tablet, but he "didn't think
that was medicine."
The resemblance to infectious exanthemata in sudden onset, bright
colour and striking appearance is often notable, but there is usually no
accompanying and characteristic systemic disturbance. Fever does occur in
certain instances, however, and the fact that it is lower than that to be
expected in the infectious exanthem and may subside with disappearance of
the rash upon withdrawal of the drug is not a safe basis for the distinction.
In these suspicious cases a leucocyte count should be made.
When it is suspected that a certain drug is being taken, and no other
evidence to this effect is obtainable, its demonstration in the body-fluids,
urine for instance, proves only the ingestion of the drug; it does not prove
that it is responsible for a skin eruption which may be present.
The current view of the nature of drug eruptions is expressed in the
recent paper by Wise and Sulzberger already referred to. It is that they are
nearly always idiosyncrasies or reactions of sensitization, generally not to be
identified with and entirely different from the pharmacologic effects of
the causative drugs or the results of poisoning from overdosage. Sensitization may take place from either an internal source, as in the case of a drug
ingested in minimal quantities over a long time, or from without by frequently repeated external contact with a drug. The reaction also may be
caused by internal or external sources. For instance as an example of a sensitization from without and a reaction from within may be quoted the case
of a patient who had become sensitized to quinine by the use of a hair-tonic
and who later reacted by a general eruption following the ingestion of
quinine.
Halogens
The use of iodides and bromides is very widespread, and eruptions from
these drugs are fairly common. The lesions are usually papules or pustules,
occasionally vesicular, less frequently fungating or framboesiform plaques
and nodules are formed. In children the eruption due to bromides appears
more commonly than in adults as pustular lesions on the extremities. The
drugs may be demonstrated in the blood, urine, sweat, milk and saliva. They
are not found in the pus of lesions unless there is an admixture of blood-
serum, but are found in the fluid of artificially produced blisters, or blisters
Page 150
BOB which may be present due to co-existing disease such as pemphigus. The
tendency to pustulation has no relation to the amount of drug taken. The
pustules are not always sterile, as has sometimes been asserted, but often
contain staphylococci.
There are some very interesting differences in the chemical behaviour
of Iodides and Bromides. Iodides are readily excreted by the kidneys and
their ingestion has no effect on the chloride excretion; but a marked increase
in the chloride excretion folows the taking of bromides, and this continues
for some time after the drug has been continued.
Both ioderma and bromoderma are typical idiosyncrasies in the skin and
mucous membranes brought about by sensitization. In a fatal case reported
by Eller and Fox in 1931 the patient had been taking iodized salt daily for
years, and the eruption developed after the patient had been taking a daily
dose of only 15 grains of potassium iodide for four months. In Bloch's fatal
case of bromoderma the first skin eruption did not appear until six months
after the bromide had been stopped, and was detected in the urine up to
the time of death, which was more than twelve months after bromide had
last been taken. This retention of the drug is not observed in the case of
iodide, as pointed out above, nevertheless much iodide is held in certain
organs. In the case of Eller and Fox mentioned above post mortem examination showed that iodide was present in the kidneys in the proportion of
0.018 mg. per 100 gm. of tissue, 0.022 mg. in the liver and 0.2 in the skin
(five times as much in the skin as in kidney and liver combined). No
albumen was present in the urine until slight traces appeared just before
death. In Bloch's case of bromoderma there was a different pathological
picture. The greatest amount of bromide was found in the thyroid, next in
the skin and mucous membranes, and none at all in the kidneys.
Halogen eruptions furnish one of the few instances in drug eruptions
where a specific treatment is available. This consists simply in displacing the
bromide or iodide by chloride in the form of sodium chloride. It is a mass
action, just a reversal of the phenomenon already noted that ingestion of
bromide increases chloride elimination. It is not due merely to increased
diuresis, for no bromide appears in the urine when diuresis is promoted by
potassium citrate and fluids. Bromide unlike iodide passes the renal epithelium
only with difficulty and the production of albuminuria, hence nephritis is
a contraindication to this method of treatment. In an ordinary case of
halogen eruption the sodium chloride may be taken by mouth in salol-coated
tablets 60 grains daily. Where more rapid effect is necessary it is usual to
give deci-normal saline intravenously in quantities from 100 to 400 cc.
every three to five days.
It is well to remember that a great number and variety of preparations
used in self-medication, such as tonics, cough-mixtures, anti-rheumatic
remedies, asthma remedies, "pick-me-ups," headache cures, etc., contain
iodides and bromides. Bromo-seltzer, for instance, is not an uncommon
source of bromism, and the patient never regards it as a medicine; while
iodized salt, which contains 1 mg. of iodide to each gram, is used so indiscriminately and commonly that most people cannot tell you off-hand
whether they are using it daily or not. It is believed that a good many cases
of apparently stubborn acne vulgaris are due to the patient's steady use of
iodized salt, or in particularly susceptible individuals even to other articles
of diet rich in iodide, such as fish. Another possible source of bromide is the
potassium bromate contained in the "improvers" used in the baking of
practically all white bread sold today.
Page 151 One other source of halogen dermatitis is to be mentioned, and that is
iodine used as a diagnostic agent. At least one fatal case of iodism from
lipiodol has been reported, and there is no reason to expect that with the
increasing use of this and similar substances in radiodiagnosis other cases
may not occur.
Arsenicals
The use of arsenic as a medicament has long been established, but until
the advent of synthetic compounds employed in treating syphilis and other
protozoan diseases, twenty-five years ago, arsenic was used in relatively
simple compounds and in its pentavalent form.
The difference in the behaviour of the skin when it shows unfavourable
reactions towards the new trivalent arsenicals, usually called the arsphena-
mine group, and the pentavalent arsenicals, which include the older preparations as well as tryparsamide and atoxyl, is quite marked. With the pentavalent group anomalies of pigmentation, keratotic reactions and herpes
simplex and herpes zoster have long been recognized as characteristic. With
the trivalent group urticaria; erythematous, morbilliform or scarlatiniform
rashes; exudative types resembling erythema multiforme or papulo-vesicular
or vesicular dermatitis with or without cedema of the face and extremities;
generally dry scaly eruptions shading into the exfoliative type and purpura
are the common types. Certain lesions may occur with either form of the
drug, such as herpes simplex and herpes zoster, lichenoid eruptions and fixed
pigmentary changes.
Another class of arsenical eruptions, while not properly belonging under
the heading of drug eruptions, is that to which so much attention has been
drawn in recent years by Throne and Myers and their associates in New
York. They have found that a very large number of generalized eczematous
eruptions of a very intractable character, associated with pigmentation and
frequently loss of hair and nails, generally regarded and treated as eczemas
of dietary or similar origin, are in reality cases of arsenical dermatitis. The
chemical has been absorbed, usually through the alimentary route, in
minimal quantities, over a long period of time, not as a medicament, but
from various totally unsuspected sources in the dietary or other environment.
Osborne believes that he has demonstrated well-defined histological distinctions between the action of the trivalent arsenicals (the so-called
arsphenamine group) and the pentavalent arsenicals. The former apparently
are distributed about the cutaneous vessels, producing vascular injury and
a resulting dermatitis, while the latter have an affinity for ectodermal structures and thus give rise to pigmentation, keratoses, etc., also injuries to the
nervous system. In this connection will be recalled the superior effect in
neurosyphilis of tryparsamide which is a pentavalent arsenical.
Owing to the very widespread use of the trivalent synthetic preparations in large quantities, we are very much concerned with the question
of the eruptions which may result from them, especially as prolonged illnesses and even fatalities are none too rare. It is important that we should
be able to recognize readily the development of a rash and to have some idea
as to its manner of causation, its nature, whether likely to be serious or not,
and what can be done to arrest its progress, or, if already developed, to
control the situation.
Osborne considers that there is experimental and clinical evidence that
an allergic susceptibility to the arsphenamines may be induced in man by
their intradermal deposit resulting after a variable lapse of time in an explo-
Page  152 sion of dermatitis following an intravenous injection. According to this
view a number of cases apparently are due to faulty injection' technique, but
it is only fair to add that Moore of Johns Hopkins disagrees with this.
It is also commonly considered that various inflammation-producing
agencies, general allergic body conditions, and acquired polyvalent sensitivity due to focal or intercurrent infections, are important contributing
factors, either in precipitating or modifying the course or outcome of
arsphenamine reactions. Stokes warns against neglecting focal infections in
the patient about to receive a course of arsphenamine, failing to note mild
intercurrent infections especially when slightly febrile, or to appreciate the
significance of the seborrhceic skin, or skins showing evidence of neurovascular instability. Oversights in this respect often lead to disaster.
If a rash occurs in the course of arsphenamine treatment which cannot
readily be identified and stated to be not due to the drug, there is one of
two courses which may be followed with safety. Which is taken will be
dictated by the character of the lesions composing the rash.
(1) If the rash contains vesicles or blisters, or if there is any evidence
of scaling or exfoliation, or of a purpuric character, or if there is severe
itching, arsphenamines should be discontinued permanently.
(2) If these elements are lacking, treatment should not be resumed
until the rash has completely disappeared, and then only resumed with the
greatest precautions. These consist primarily in testing out the patient's
sensitivity to arsphenamines. In spite of one or two reports favouring the
procedure, the most reliable opinion is opposed to placing any reliance upon
the patch-test for determining this. Two or three months after complete
subsidence of the rash we may resume treatment with a different product
from that formerly used. The first dose of neosalvarsan for instance should
be 0.02 J, and this should be increased very gradually by small weekly increments. If the first or early doses are followed by (a) generalized itching,
(b) a mild dermatitis resembling but less intense than The first one, (c)
malaise or "all in" feeling disproportionate to the dose and persisting for
several days, or (d) fever following each injection and lasting 24 hours or
more, arsphenamines should be discontinued permanently. In the case of
the malaise or fever a white and differential count should be done. A leukopenia with a decrease in neutrophils, eosinophilia or increase in monocytes
indicates that trouble is imminent and a state of emergency exists.
Urticaria is usually transient and of little significance. The occurrence
of blisters in such an eruption as herpes simplex or zoster should of course
lead to no confusion, as these are not of grave significance.
The macular, erythematSus, morbilliform or scarlatiniform, erythemato-
squamous, papulovesicular, exfoliative and lichenoid rashes generally have
four common characteristics: there is general and often very severe itching
and scaliness of the skin, associated constitutional symptoms and evidence
of visceral damage, and the certainty of aggravation or recurrence on taking
further injections of arsphenamines. There is generally a lowered resistance
to infection accompanying these rashes, particularly in their common
sequel, exfoliative dermatitis, and this is considered to be due to bone-
marrow damage.
An important point is to make a routine habit of asking the patient
before each injection if any itching or eruption followed the last injection.
For the past ten years the use of sodium thiosulphate has been almost
universal in the treatment of exfoliative dermatitis due to arsphenamines.
Three hypotheses have been advanced to account for its supposed beneficial
Page 153 results: (1) it forms nontoxic insoluble sulphides; (2) it forms more highly
soluble compounds which are rapidly eliminated by the kidneys; (3 ) it has
a sedative effect on the sympathetic system relieving vaso-motor irritation.
None of these are supported by experimental evidence, in fact, evidence
has apparently been adduced in direct opposition to the first two. Moore
emphasizes this and goes on further to state that his clinical experience is
such as to lead him to the conclusion, after seven years' use, that it is of no
value whatever, and in the last year he has abandoned it as worthless. In
spite of Voegtlin's reports that the toxicity of arsphenamine when administered to laboratory animals in a solution of sodium thiosulphate is considerably decreased, Moore considers that there is no evidence as yet indicating
the value of this procedure in treating patients intolerant to arsphenamines.
To many of us, perhaps, all this sounds like rank heresy, but in looking
over the literature since the appearance of Dennie and MacBride's first
reports on the use of sodium thiosulphate in poisoning with arsenic and
heavy metals in 1922, the speaker has received the impression that Moore's
views may meet with general acceptance before long. At the outset it was
stated with assurance that the mechanism was simple: insoluble sulphides
were formed and after that the arsenic could be forgotten. A little later
questions began to be asked about the ultimate fate of this immobilized
arsenic. Then someone explained that certain body proteins entered into the
reaction and very highly soluble compounds of arsenic were formed which
passed the kidney-filter rapidly and without doing any damage en route.
At first it was stated that sodium thiosulphate was effectual at long intervals after the drug had been taken. Much more recently we find Throne and
Myers in reports of their very important studies in arsenic poisoning stating
that sodium thiosulphate is of no value except in the very early days of the
poisoning. After that it is not only useless but harmful!
On account of the probable value of calcium in patients with hepatic
damage, and its supposed effect in decreasing capillary permeability in
allergic conditions, but in spite of the absence of confirmatory experimental
evidence of its favourable effect in arsphenamine dermatitis, Moore has been
using daily injections of 1.0 gm. of calcium gluconate in patients with post-
arsphenamine dermatitis and has the impression that it is of some value.
Phenolphthalein
On account of its cheapness, efficacy and freedom from griping effect
phenolphthalein is one of the most popular laxatives, and is a constituent
of nearly every one of the host of proprietary laxative preparations sold
today. It is also the active principle in various reducing remedies or obesity
cures not sold as laxatives. Many mouth-washes and dentifrices owe their
pink colour to it, and it is even used to produce pink colour in confectionery.
There is at least one mouth-wash sold, in connection with which the user
is informed that if he takes the colourless fluid in his mouth and it becomes
pink this is evidence that he has mouth-infection. Then if he continues to
rinse his mouth with it, it again becomes colourless, showing its efficacy in
ending the septic condition. This appearance depends upon the fact that the
reaction of the normal mouth is slightly acid to phenolphthalein but is soon
reversed by rinsing with the alkaline wash.
It is obvious, when one considers the enormous amount of phenolphthalein which is absorbed by the public daily, that phenolphthalein dermatitis
.    Page 154 is relatively rare. Nevertheless it occurs in everyone's experience, and we
should always keep it in mind.
The characteristic phenolphthalein eruption consists of widely scattered,
often numerous, irregular grouped macules or plaques, varying in size from
a pin-head to several inches across, the colour ranging from pink through
red and purple to a deep purplish-brown. The deeper coloured lesions may
persist for a very long time. Slight scaling is common. On the skin of the
genitalia and the mucous membranes, vesicles, erosion and superficial ulcerations may appear. Genital lesions have sometimes been mistaken for chancres.
A very similar eruption is sometimes produced by antipyrin, and as in the
case of the latter drug, there appears to be a variable and fluctuating idiosyncrasy. The lesions may regress while the drug continues to be taken. Again,
if the drug is stopped and the eruption clears up, it may not recur upon
resuming the drug. Burning and itching sensations at the site of the lesions
are common. In the experience of the speaker pruritus ani is a constant
accompaniment, and also occurs frequently where the drug does not produce' any skin eruption. Brunettes are more susceptible than blondes, and
normally hyperpigmented areas are sites of predilection.
The late Dr. Campbell of the Montreal General Hospital was the first to
report a peculiar bluish-purplish sharply demarcated discolouration of the
nail-bed occurring in a series of cases. These were phenolphthalein eruptions
which showed through the nail-plate like a subungual bruise.
Recent researches by Novy show that the eruption is due to the phenolphthalein itself, and not to impurities of split products. Tests of the split
products separately were negatve, and in a sensitive individual chemically
pure phenolphthalein was found to produce just as severe an outbreak as
the commercial product. Patch-tests were negative.
Incredibly small quantities of this drug, insufficient to permit chemical
detection in tissue or fluids, have been capable of producing the eruption.
For instance, when one considers its poor solubility and its high dilution in
body-fluids before it reaches the skin, and the speed with which the reaction
may appear—often within ten minutes after taking it into the mouth—the
infinitesimal quantity which reaches the skin and causes the eruption makes
us marvel. Consider further that all this can take place and has done so when
two grains (0.13 gm.) have been taken by a man weighing over 200 pounds
(90,000 gm.). This is very strong evidence in favour of the view that we
are dealing with an immune biologic reaction. The speed with which a
reaction may appear suggests that some of the drug penetrates through parts
of the digestive tract above the pylorus.
Hypnotics, Analgesics and Sedatives
The non-alkaloidal drugs of this class which most concern us at present
are the barbituric acid derivatives. These produce the eruptions most often
confused with the contagkms exanthems, being predominantly erythematous, and of morbilliform and scarlatiniform types. The simulation may
even go so far as to cause elevation of temperature in about 50% of all
cases, conjunctivitis and desquamation. An eosinophilia is usual in these
cases. Urticarial reactions are also frequently observed. There is no constant
relationship between the size of the dose and the reaction.
Atophan or cinchophen has been rather frequently observed giving rise
to angioneurotic redema and erysipelatous eruptions with chills and pruritus.
Morbilliform and scarlatiniform eruptions are also reported occasionally.
Page 155 The eruption from acetylsalicylic acid is fairly constant. It is usually
of the angioneurotic type, especially involving the face, and the nasal, buccal
and pharyngeal mucosa, with intense general malaise. Banal urticarias are
sometimes caused by this drug. The speaker has been on a few occasions
completely baffled in cases of conjunctivitis accompanied by oedema of the
eyelids in women who over and over denied emphatically that they were
taking any drugs whatever, only to discover eventually that a box of
"aspirins" was a regular inhabitant of the handbag and resorted to on any
and every pretext. Phenacetin and antipyrin also produce discrete lesions,
usually urticarial in type, those of antipyrin being deeper in color and more
persistent, and practically identical with the phenolphthalein eruption.
Heavy Metals
The eruptions produced by ingested and injected mercury and injected
bismuth and gold are not common and are chiefly of an erythematous character. Almquist states that in a susceptible person the mercury circulating in
the blood-stream produces a paralysis of the sympathetics and a resulting
vascular dilatation and oedema. The similar reactions from bismuth and gold
are probably produced by a similar mechanism. The local conditions are
favourable for bacterial growth, and leucocytosis, especially with eosino-
philia, is often found. The mercury and bismuth eruptions are usually unas-
sociated with the signs of mercurial or bismuth poisoning; stomatitis, gingival deposits, colitis and nephritis. After an exfoliative dermatitis from
arsphenamines a single intramuscular injection of mercury months after
apparently complete recovery will produce a return of dermatitis, and the
exfoliative dermatitis may recur if the injections are persisted with. On the
other hand, while rare cases of exfoliative dermatitis from bismuth have been
reported, post-arsphenamine exfoliative dermatitis seldom if ever recurs
upon the later employment of bismuth injections. Gold dermatitis is usually
mild, and gold can often be resumed, with safety, although caution is demanded, after it has cleared up.
The pigmentation of argyria is familiar to all. Stillians of Chicago has
succeeded in devising an ingenious method for dealing with this. He injects
intradermally a solution of 1% potassium ferricyanide and 6% sodium
thiosulphate which converts the silver oxide into a soluble salt which is carried away in the lymph-stream. The method necessitates a general anaesthetic, as the whole area has to be covered with punctures and tiny injections, and a local anaesthetic would interfere with lymph-drainage.
Alkaloids
Digitalis and its derivatives are responsible for generalized erythema.
The eruptions from morphin and other opium derivatives, and atropin or
belladonna, are more commonly discrete lesions and urticarial in character.
Attention has been drawn recently to codein rash, which, while apparently
rare, should be kept in mind, considering the amount of codein used today.
It produces a scarlatiniform rash with intense pruritus. It is to be remembered that belladonna is not only a constituent of various popular laxatives,
but also is absorbed from various internal and local remedies for hemorrhoids.
An increasing number of cases of urticarial eruptions from quinin appear
to be reported not only from its use in various proprietary remedies for colds,
but also from its use in obstetrics, and its widespread use in contraceptive
suppositories and douches.
In concluding, the speaker wishes to say that he is conscious not only of
Page 156
gS&BB numerous omissions in this partial enumeration of causes of drug dermatitis,
but that he may have been unfortunate in the selection he has made. In
extenuation he may state that he has been guided in his choice of what to
mention and what to omit chiefly by his own limited experience, hoping
that it might represent to his hearers some of their difficulties as well.
Whatever value this talk may have will depend upon how accurately these
have been visualized.
A REPORT ON A SERIES OF CASES OF ERYSIPELAS
TREATED AT V. G. H. SINCE JANUARY, 1931,
IN WHICH QUARTZ LIGHT WAS USED
IN THE TREATMENT
George A. Greaves, M.D.
Director of Physiotherapy, Vancouver General Hospital.
In January, 1931, we began using quartz light in the treatment of this
condition, the first case being one of Dr. Carder's. Since then it has been
used in 126 cases, being the only treatment applied in 65. In the remaining
61, additional treatment was used, such as erysipelas antitoxin, mag. sulph.
compresses, ichthyol, etc.
Among the 65 cases where only quartz light was used were cases of
almost all degrees of severity. Three of this series died. Two were infants,
one 10 days old, the other 5 weeks, and there was one male aged 80 who had
as complications, ulcers on his feet, osteomyelitis and infected cervical
glands. He was discharged, apparently well of his erysipelas, to Glen Hospital, where he died three days later.
In the series where quartz light was used along with other treatment,
there were also three deaths, though only two should be included in the list
as one was practically moribund when the treatment was administered. This
was a female, age 57, with facial eryjsipelas and a "septic" throat. She was
admitted on March 1, 1933, was given erysipelas antitoxin, intravenous
glucose, mag. sulph. compresses. Next day quartz light was ordered and
given. The patient died the same day. Another of the fatal cases was a male
of 3 8 years with facial erysipelas who had as complications a septic throat,
cervical adenitis and septicaemia. He was admitted on Jan. 16, 1932, and
died on Jan. 18, 1932, after having had diphtheria antitoxin, mag. sulph.
compresses, intravenous glucose and quartz light. The other fatal case, a
male of 76 years, admitted with facial erysipelas, had some malignant condition in the abdomen, and heart disease. He was admitted May 17, 1932,
and died May 20, 1932, after having received antistreptococcus serum and
mag. sulph. applications and two doses of quartz light.
In the series where no quartz light was used there were four deaths, one
of facial erysipelas in a female, aged 65, who developed septic throat and
died. Another female, age 60, had chronic otitis media, developed pneumonia
and empyaema and died. The third was a male, age 65, who was admitted
on Oct. 5, 1932, with facial erysipelas, was given antistreptococcus serum
and died Oct. 14.1 have no note of the cause. The fourth case involved the
leg, in a male aged 62. He developed cellulitis, phlebitis and septicaemia, and
was given antistreptococcus serum, but died.
In the whole series there were 10 fatalities. Altogether since January,
1930,—as far back as I have checked the records—there have been 187
cases of erysipelas treated at this hospital. Of this number, as I have men-
Page 157 tioned above, 65 received quartz light only, 61 received quartz light and
some other treatment, and 61 received no quartz light. We have, then, three
groups with roughly 60 in each.
In going over the hospital records of these cases I have obtained the following figures which may prove of interest.
In the group receiving only quartz light the average number of treatments was 2.4 and the average days' stay in hospital was 5.5. In those
receiving quartz light combined with other treatment the average number
of quartz light treatments was 2.64, and average days' stay in hospital 9.5.
In the last group, i.e., those not receiving quartz light, the average days'
stay in hospital was 11.25 days. Because of the variety of treatments used
and the different types of cases treated there is no particular value in the
figures just given. I give them so as to compare the results of quartz light
treatment against the field, so to speak. But to obtain figures from which we
might draw fair conclusions, I have picked out of each of the three groups
those cases which were as similar as possible. The cases chosen for the following figures were those which would be described as idiopathic cases with no
complications.
In the first group (cases treated with quartz light only) there were 47
of the idiopathic type. Their average stay in hospital was 5.7 days. In the
second group there were 32 cases with average stay of 8.8 days. In the third
group there were 45 cases with an average stay of 9 days. From these figures,
obtained from as similar groups as possible, it would appear that those
receiving only quartz light did the best.
In considering the use of quartz light in these cases there are some points
of more or less importance which should be taken into account, in addition
to any therapeutic value it may have. Included among these would be the
cost, to the hospital in the case of staff cases, and to the patient in private
cases. It costs the hospital about 50 cents to give a quartz light treatment.
The average cost, therefore, for staff cases would be about $1.25 per case.
Pay patients are charged double this price. Second, the convenience of its
administration. It can be given in a few minutes in any warder room of the
hospital. Third, there is little or no discomfort caused to the patient either
during or after the treatment. Fourth, it saves nurses' time, if no local appli-
caions are used, such as mag. sulph., etc.
I am aware that erysipelas runs a self-limited course in most cases, but
from what one learns on reading the histories of these cases, none are allowed
to get along on their own, all have been given some sort of treatment, the
object apparently being to reduce this self-limited time and improve the
comfort of the patient and prevent complications. I have no figures of cases
allowed to run their own course with which to make a comparison, but
taking the figures I have mentioned those treated by quartz light show up
as well or better than the rest.
[We are very glad to have this note from Dr. Greaves.
The value of this note lies in two things: first, it gives the conclusions
of a man who, as we all know, errs on the side of conservatism and caution
in drawing conclusions. Dr. Greaves, as we have known for years, is
extremely guarded in attributing virtue or curative powers to physical treatment—and this makes it all the more dependable when he does pronounce
favourably on any physical therapy.
Secondly, it gives the results of work done in the Vancouver General
Hospital, and we are very anxious always to publish such results. The cases
Page  158 have been carefully surveyed: their records are all available, and can be
checked by ourselves, when we are looking for help.
Lastly, we asked Dr. Greaves "What about the method of treatment?"
After all, while these scientific blokes are probably right, academically,
when they consider this thing from a coldly scientific standpoint, we lesser
mortals are really quite concerned about methods and technique, etc.
Dr. Greaves points out in his remarks on treatment that: (a) Either
air- or water-cooled quartz may be used; (b) no stated time of exposure can
be given. This depends on a great variety of factors: nationality, pigmentation of skin, hair, etc., length of attack, severity of attack—as well as the
age and make of lamp—besides other factors. But it may be broadly stated
that a dose just short of blistering, full 2nd degree dose (blistering is 3rd
degree) should be given. We should wait 24-48 hours, or more if necessary,
till reaction subsides, before giving another. The average exposure would be
about 2 J/2 mins., but very fair people would need less, very dark ones more.
—Ed.]
ANNUAL REPORT OF THE
LIBRARY COMMITTEE
The committee held ten meetings during the year with a good average
attendance.
The total amount of money expended during the year was $1235.70.
This was apportioned as follows:
Journals and other periodicals $834.69
Books   271.36
Binding  319.65
Membership in Library Association   10.00
It will be noted that the expenditure for binding absorbs a large part of
the total—about 26%. Ways and means of reducing this have been considered by your committee, but found impractical if the standard of binding
and the continuity of the periodicals on the shelves is to be maintained.
An attempt was made to keep the literature dealing with each of the
various subjects up to date, by purchasing well recognized and authoritative
books, without undue duplication. It was the custom of your committee to
refer any book, the purchase of which was proposed, to some member of
the Association who was an authority on the subject dealt with, for his
approval. Requests for special books by members were always carefully
considered. Books dealing with highly specialized subjects were, as a rule,
not purchased, the policy of the Committee being that expenditures should
be made with a view to obtaining the greatest benefit for the greatest number; such highly specialized information being available through the Journals on our shelves.
The Librarian reports that through the good offices of the Medical
Library Association it has been possible to complete many of our files by
obtaining missing back numbers of Journals of which other libraries held
duplicates. Some of the libraries in the larger centres across the line have been
particularly accommodating in this respect.
Frequent complaints are received by the Librarian regarding conversation being carried on in the reading room, and your committee asks that the
members observe the rule of silence while in this room. A door has been
placed at the entrance, at the expense of the owners of the building, with a
view to further excluding noises.
Page  159 There is a certain unavoidable wastage of library property due to unregistered books and periodicals not being returned; or to pages being torn
from bound volumes. This will probably continue so long as members carry
keys and have access to the rooms in the absence of the Librarian. The committee does not recommend the withdrawal of these privileges, holding that
the use of the library to the fullest extent should be encouraged, but asks
the members to note that they are privileges enjoyed by few other libraries;
and urges co-operation in preserving the efficiency of the library by returning books to the shelves in accordance with the rules.
Dr. G. E. Kidd, Secretary Library Committee.
THE NORMAL LEUCOCYTE COUNT
Leading Article, British Medical Journal, March 31, 1934.
There are clinicians who place too blind a reliance on laboratory reports,
treating them sometimes as if they afforded the one haven in a stormy sea of
diagnostic doubt. This confidence may be unmerited, either because "facts"
in a report are not facts, a circumstance for which there may be more than
one explanation, or because the facts are wrongly interpreted. The performance of a blood count is usually looked upon as a simple if tedious proceeding, and it is certainly not beset by such possibilities of error as are
examinations in which the specimen itself may only be secured with a varying admixture of other material; but its finer accuracy depends very much
on the experience of the operator, and on the side of interpretation we have
A. F. Bernard Shaw's exposure1 of the "haemoclasic crisis" fantasy to warn
us that an accepted significance may be ill founded.
A still more severe blow at any attempts to base conclusions on minor
variations in the leucocyte count has been delivered by Simpson,2 who set out
to determine the normal limits of the count in order to assess at their proper
value the variations observed in the blood of x-ray and radium workers.
He confirms the previous observations of Shaw, Sabin and her co-workers,
and Doan and Zerfas, that in the normal subject the numbers of leucocytes
in the peripheral blood are subject to wide and rapid fluctuations: the
extremes in a single individual were counts of 2,800 and 11,200 per c.mm.,
while even higher figures were sometimes obtained in other subjects apparently in perfect health. Whereas other workers have sought to identify
rhythmic "tides" on which these variations depend, Simpson, beyond confirming a moderate average increase in the count as the day proceeds, could
observe no sort of constancy in these fluctuations. A series of counts performed regularly on a single individual at the same time of day exhibited
the usual variations, and successive counts at increasingly short intervals,
even of five minutes, two minutes, and finally of one minute, betrayed
nothing in the nature of a steady rise or fall, but only a capricious irregularity which it is perhaps not altogether inappropriate to compare to the
density of clouds of smoke rising from a fire. It is natural at this point to
inquire whether the methods used were accurate: this appears to have been
sufficiently tested and demonstrated. And what would be the results of
simultaneous counts? These, although too few in number, were performed
on blood from adjoining fingers, and gave concordant results. It is a little
difficult to picture the conditions in the circulation as a whole which underlie
these rapid fluctuations: it would be interesting to repeat these studies using
venous blood, in order to demonstrate with certainty that the changes
Page 160
«« observed affect the circulation as a whole, and are not dependent on local
conditions.
Whatever the explanation of these results may be, the fact remains that
leucocyte counts performed in the usual way vary over a very wide range,
and results which in a patient would confidently be taken as evidence of a
leucopenia or a moderate leucocytosis are obtainable in a healthy subject:
whether the count is high, "normal," or low, is a matter of the purest
chance. Although the variations affect chiefly the polynuclear cells, lymphocytes are also subject to fluctuation, and in four out of thirty-one healthy
subjects Simpson obtained lymphocyte counts below 1,500 per c.mm., the
figure given by Mottram as the low limit of the normal, the transgression
of which in an x-ray or radium worker indicates damage to the bone marrow. What is now to be done about blood examinations in those exposed to
irradiation is by no means clear. The alternatives appear to be to continue the
present practice of single counts at intervals of three or six months, ignoring minor changes and watching closely only for the onset of anaemia; or to
perform a dozen counts in a single day in order to obtain a representative
average. This laborious proceeding would only be worth while if we could
interpret its results with certainty, but the whole literature of blood
changes in those exposed to irradiation is so confused and contradictory,
owing doubtless in part to the fallacies which we have here been considering,
that no such interpretation yet appears possible. Meanwhile clinical medicine
as a whole has received a warning against too close an interpretation of the
findings in a blood count. A false assumption based on unreliable data is
much worse than having no data at all: this may perhaps mean that some
blood counts were better not performed at all, and a good deal of soul-
destroying labour would be saved if they were not. Some would go so far as
to say that an accurate haemoglobin estimation will ordinarily yield all the
information that is needed in states other than actual blood diseases. This,
of course, implies that the function of the clinical pathologist is to confirm and define conditions of which there is clinical evidence, and not to
conduct innumerable fruitless investigations for the sake of an occasional
unlikely or unexpected discovery.
1 British Medical Journal, 1925, i, 914. 2 Brit. Journ. Radiol., 1933, vi, 705.
ABSTRACTS
PARATHYROID TUMOURS ASSOCIATED WITH HYPERPARATHYROIDISM—11 cases treated by operation: By Edward D. Churchill and Oliver Cope, Boston. Surgery, Gynaecology and Obstetrics,
Vol. 58, February, 1934.
The development of the surgery of the parathyroids parallels the surgery
in the case of tumours of the Islands of Langerhans and adenoma of the
pituitary. "The diameter of these adenomata of the endocrine glands may
be measured in millimeters, yet the associated constitutional disturbance
frequently alters the entire aspect of the body or leads to its total destruction." In hyperparathyroidism the body loses its ability to retain calcium
and phosphorus in the bones. High calcium in the blood is manifested by
plus serum calcium and plus calcium excretion in the urine. A plus urinary
phosphorus excretion in spite of decreased semru phosphorus. "An excessive
excretion of both calcium and phosphorus determined by metabolic studies
with the patient on a test diet constitutes the basic dusturbance." Clinical
manifestations: a generalized decalcification of the skeleton or "osteitis
fibrosa cystica generalisata." This is late and may be only one of the mani-
Page 161 f estations. As a result of excessive urinary excretion calcification may occur
in the cortex or pelvis of the kidney with progressive kidney impairment.
Other signs are polydipsia, polyuria, weakness, loss of weight, indefinite
muscle and joint pains, anaemia and leucopcenia. In all cases reported (11)
there has been found a grossly recognizable adenoma of one of the parathyroid bodies. Removal of the tumour as in all cases reversed the metabolic
change. Arthritis has not been observed in any of the 11 cases of proved
hyperparathyroidism studied at the Massachusetts General Hospital. There
is no relationship to Paget's disease. Only 2 of the 11 cases gave external
evidence of a tumour in the neck. Anatomical positions of the 11 parathyroid tumours—in contact with the thyroid: left upper pole 2, left lower
pole 2, right upper pole none, right lower pole 2; retrotracheal 1, retro-
oesophageal 2, anterior mediastinum 2. Operation described: Meticulous
hxmostasis—lateral approach and palpation of the mediastinum. Results:
serum calcium falls with dramatic rapidity. Tetany may appear even with
plus calcium. Tetany controlled by calcium gluconate, irradiated ergosterol
and parathormone. Improvement may be expected in a few days. Many
months may elapse before x-ray shows evidence of increased calcium in the
bones. The only fatality in the 11 cases occurred following the removal of a
ureteral stone several weeks after the resection of the parathyroid tumour.
—Theo H. Lennie.
ANGINA PECTORIS: PROGNOSIS. Eppinger and Levine, Boston. Arch.
Ind. Med., Vol. 5 3, p. 120.
A clinical study of 141 cases seen in private practice. Cases seen first
in an attack of coronary thrombosis were excluded. Ill men and 30 women,
ratio 4 to 1. Age of onset, men 56, women 58.1. Average duration 4.6 and
4.5 years. Extremes were from a few weeks to 23 years. Average ages at death
60.7 for men, 62.7 for women.
B. P. Average reading for men 149/89, women 190/102. 46 men
had a reading under 140, no women. This is a diagnostic point. In those with
normal B. P. the disease began 4 years earlier and lasted a little longer and
age at death was about 3 years less. No significant differences in B. P. were
found in those living less than a year as compared with those living over 5
years.
Cases where attacks occurred while patients were at rest were compared with those who had angina of effort only. Duration of life after onset,
age at death, and B. P. were not different. Heredity plays a great part.
Patients whose parents died at an average age under 60 years died 5.6 years
earlier than those whose parents lived to an average age of over 70.
Tonsillectomy made no difference. Hypertension made cardiac decompensation more likely to occur, and during this phase the angina frequently
did not disappear, as it is supposed to do. Women showed more frequent
decompensation than men. Obesity had no effect on prognosis, but of 82
patients whose weights were known only 10 were normal or subnormal.
Of 104 for whom E. K. G. was done, 2 0 had normal curves. These died
at an earlier age than whole group or those with abnormal tracings, but their
angina averaged a year longer. Those with inverted T wave in lead I or in
I and II, life was 1 year less after onset, but increased P. R. or Q. R. S. complex was not of bad significance.
About 50% of these patients "dropped dead" or died suddenly. About
30% died of coronary thrombosis. Less than 10% died of congestive failure.
The rest died of miscellaneous causes. —Murray Baird.
Page 162 PTOSIS, KIDNEY and ABDOMINAL BELTS
made to order for each case and guaranteed.
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ROY WRIGLEY LIMITED
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KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. F. HARRISON W. R. REYNOLDS Salpingitis flGj^M
f| Pelvic Cellulitis ■
WHm Pelvic Abscess
A MOST DESIRABLE method of applying sustained and uniform moist heat to the vagina is
through the medium of Antiphlogistine tampons.
Their marked thermogenic action increases the
pelvic circulation, which hastens the resolution of
the congestion and the relief of the painful symptoms.
Being plastic, Antiphlogistine can easily be moulded
to all contours; it will penetrate the culs-de-sac, thus
giving ample support to the uterus and facilitating
drainage.
Its high  glycerine  content   (45%)   and  its other
components, makes Antiphlogistine an ideal dressing for the relief of pain, inflammation and congestion associated with gynaecological conditions.
Sample and literature on request.
The Denver Chemical Mfg. Co.
153 Lagauchetiere Street W.
MONTREAL
ANTIPHLOGISTINE
ANTIPHLOGISTINE IS MADE IN CANADA
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OINTMENT, FROM PERCAINAL TO
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Also Two Improvements in the Presentation of
NUPERCAINAL "CIBA"
(1) Nupercainal "CIBA" will no longer be issued in lithographed
containers; it will now be available in tubes with an easily-
detachable paper label.
(2) Each package of Nupercainal "CIBA" will now contain a rectal
applicator.
I CIBA COMPANY LIMITED 9
MONTREAL
Messrs. Macdonald's Prescriptions Ltd.
and Georgia Pharmacy Ltd., of Vancouver, B. C.
and Messrs. McGill & Orme Ltd., Victoria, B. C,
keep a full range of "CIBA" specialties.
For the Failing Heart
H Theocalcin ■
(theobromine-calcium salicylate)
Council Accepted
Give Theocalcin to increase the efficiency of the heart
action, diminish dyspnea and to reduce edema.
Dose: 1 to 3 tablets, three times a day, with or
after meals.
In 7 l/z -grain Tablets and as a Powder.
Literature and samples upon request
MERCK & CO. LTD.
412 St. Sulpice St. Montreal
BILHUBER-KNOLL CORP., Mfrs., JERSEY CITY, N. J. Nutritive Value of
I Pasteurized Milk I
Drs. J. D. Stirling and J. H. Blackwood of the
Hannah Dairy Research Institute, located near
Ayr, Scotland, and under joint supervision of University of Glasgow, the West of Scotland Agricultural College and the Secretary of State for
Scotland, have issued a bulletin on the properties
of milk in relation to pasteurization.
The subject is covered most exhaustively.
Amongst other things discussed Doctors Stirling
and Blackwood had this to say on the "Effect of
Pasteurization on Digestion":
"There is one further point which should be mentioned with
regard to the coagulation of milk in the stomach of the
infant, and to the behavior of the coagulum with digestive
enzymes.
"It has been fairly clearly demonstrated that the clot which
results from the coagulation of heated milk consists of much
finer particles and is of a much more open texture than the
clot from raw milk.
"It might be expected, therefore, that the proteolytic enzymes of the digestive tract could obtain more ready ingress
to the clot from the heated milk."
Put into everyday phraseology, heating tends to
develop a soft, open curd which is more readily
mixed with the digestive juices of the stomach.
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445 GRANVILLE STREET VANCOUVER, B. C.
Ntttut & dtyumfiim
2559 Cambie Street
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| General Stimulation I
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for
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Post Influenzal Asthenia
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A large percentage of the cases treated by the
general practitioner are of an asthenic type and
call for the use of some supportive and stimulant
treatment.
In all materia medica there is no drug that is
so admirably adapted to such a class of cases as
Kola—the seed, or nut, of the Sterculia Acuminata.
The stimulation of Kola is peculiar in that it is
tonic in effect and that, unlike that of ordinary
stimulants, it is never followed by after-depression. Its co-operating tonic action maintains its
beneficial stimulation.
In KOLA ASTIER GRANULATED, the physician has available to him in convenient form a
skilfully prepared standardized extract, containing all the active principles of the Kola Nut:
Caffeine, Theobromine, Kola-Red and Tannin.
Kola Astier is not habit forming.
Write for Sample and Literature
ROUGIER FRERES
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3 5 0 Le Moyne Street
Montreal, Que. I rllll
OUR 24-HOUR SERVICE
Urgent calls for medicines and sickroom supplies reach us at all hours.
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SODIUM BUTOBARBITAL
This product is now being used with highly satisfactory results as
a pre-operative basal anaesthetic and in obstetrical work.   It possesses marked hypnotic properties combined with low toxicity,
which render it potent, reliable and safe.
In capsules of 0.15 Gm. for oral administration
As a Basal Narcotic: 3 to 6 capsules one hour before operation.
For obstetric work: 1 to 3 capsules.
SUPPLIED IN BOTTLES OF 20 CAPSULES
Ask for detailed literature
LABORATORY POULENC FRERES
OF CANADA LIMITED
Distributors: ROUGIER FRERES, Montreal THE PRESCRIPTION CHEMISTS
OUR ENTIRE ATTENTION
Is devoted to the rendering of a dependable and strictly
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I AAcGi  6 Otfmo H
FORT STREET (opp. Times)      Phone Garden 1196     VICTORIA, B. C
WE HAVE BEEN PRACTICING IN
VICTORIA FOR THE PAST 67 YEARS
B.C. FUNERAL CO.
HAYWARD'S IiTD.
Established 1867
Phones: E. 3614 and G. 7679
734 BROUGHTON STREET VICTORIA, B. C.
STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office. Supplied
in one yard, five yards and twenty-five yard packages.
ESTABLISHED   NEARLY A
~~ ^CENTURY^
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C
■XPBW I DIARRHEA
"the commonest ailment of
infants in the summer months
(HOLT AMD McINTOSH: BOLT'S DISEASES OF INFANCY AND CHILDHOOD, 1933)
One of the outstanding features of DEXTRI-MALTOSE is
that it is almost unanimously preferred as the carbohydrate j
in the management of infantile diarrhea.
the sugars? dextrjn and mal!"tion Jcnownr
^port.ons °* f *£dthe P«^XiS<W: F
>oseness. ^hydrates; ■ • • ,   JLn^iaL.
in in!anc
earance,
fiASfe^-rbo.h^-
>n th
'np-vtri-mnltose is a very excellent carbohydrate. It is made up
of maltose, a disaccharide which
in turn is broken up into two
molecules of glucose—a sugar that
is not as readily fermentable as
levulose and galactose—and dextrin, a partially hydrolyzedstarch.
Because of the dextrin, there is
less fermentation and we can therefore give larger amounts of this
carbohydrate without fear of any
tendency of fermentative diarrhea."—A. Capper: Facts and fads
fit fit'""' frnrffr-    ""   "     "    ' ~
In cases of diarrhea, "For the
first day or so no sugar shouia
be added to the milk. I? the bowel
movements improvecarbony^
drates may be added. This shou d
be the one that is most easil)
assimilated, so.d^'ri-r"^0*!. 'c
the carbohydrate ot cnoice.
W H. McCaslan: Summer diarm
xkeas in infants _and_ W^ckM
h
should b«
ing the teachii_Tofeth__ay-b? adde
33:
^T5T3B*^ff««».or
<* discussion „frout tr°uble. "-.«
infantile JSLZO0"""/^
and th.
e form
»ce, usuafl
the diets
JHmmmmm
diarrhe
comma
B. Jo*
SERIOUSNESS
OF DIARRHEA
There is a widespread opinion that,
thanks to improved sanitation, infantile diarrhea is no longer of serious aspect. But Holt and Mcintosh declare that diarrhea "is still
a problem of the foremost importance, producing a number of
deaths each year...." Because dehydration is so often an insidious
development even in mild cases,
prompt and effective treatment is
vital. Little states (Canad. Med.
A. J. 13:803, 1923), "There are
cases on record where death has
taken place within 24 hours of the
time of onset of the first symptoms."
=.   easily  ab-,
-Maltose  « «<>£ milk sugar,
rbed than cane ^hydratej
' by Cha££vtnt a deficient sup-
■xe may vrc,,
jv of sugar.       „uses diarrhoea
WY-When "W^J'SSfonn of §
t#alt22g.,s there
ummer diar
setms not to hZhB GladstorU
tor   sugar. Tf ' a1td   NulrUior
 I " 'HI' "I ilinii  ,
IxativV „5d have a definitd
laxative tendency, which ma.
when carried to excess <£^
severe intestinal irritatbn.      "
drates'e«m0rt-C8mPlex carbohy
orates, of which  dextrin is th
do not have this laxative effect ' 1
diated"Tg   the ' *«atment   o
K^ine use ^Mead-sfe
"The condition in whirh rlpxtri-maltose is partic
in acute attacks of vomiting, diarrhea and fever,
covery is more rapid and recurrence less likely to take place it
tri-maltose is substituted for milk sugar or cane sugar when tl
have been used, and the subsequent gain in weight is more rapid
"In brief. I think it safe to say that pediatricians are relying les
implicitly on milk sugar, but are inclined to split the sugar element
giving cane sugar a place of value, and dextri-rnaltoy. a decidedl
prominent place, particularly in acute and difficult cases.■ —W. L
Hoskins: Present tendencies in infant feeding, Indianapolis at. j
July. 1914
evaporated milk formuW'i^ wm ?hai,S? * ' — -™P °f °'
one and one-half to tw*------ ™   s-up-ply abou*
centage of sugar be required it is better to replace
it by dextri-maltose, such as Mead's Nos. 1 and 2,
where tiie maltose is only slightly in excess of the
dextrins, thus diminishing the possibility of excessive fermentation."—W. J. Pearson: Common
practices in infant feeding, Post-Craduale Med. J.
6:38, 1930; abst. Brit. J. Child. Dis. 28:168-168,
April-June, 1931.
ism.
sms
every pound of bodv weicJh}"?68 °f *h°kmMi to
shouidW »^«ti?„'5a£2!5Sa
") and high i',;'pro--(t-e^od whic;
amounting to
Strong: ¥
childhood.
^a^gggg
natemi,kaccomS^^
't was necessary to uLt
then stopped it anS of/!. *!" ««ein
■   °-x°o-%36, April, i
id rlovt.:" ca.CIUm for from .<_.« a
m casei
e. fou
days; wfl
rmula."—A   G
m coseinate milk h
Just as DEXTRI-MALTOSE is a carbohydrate modifier of choice, so is CASEC (calcium
caseinate) an accepted protein modifier. Casec is of special value during the summer
months (1) for colic and loose green stools in bseast-fed infants; (2) in fermentative
diarrhea in bottle-fed infants; (3)  as a prophylactic against  diarrhea in infections.
When requesting samples of Dextri-Maltose, please enclose professional card to cooperate in preventing
their reaching unauthorized persons.    Mead Johnson &• Co. of Canada, Ltd.. Belleville, Ont. ss&s
^t^'BjiSikVv^^''^i^^^^^™
53 6 13th Avenue West
Fairmont 80
Exclusive
Ambulance
FAIRMONT 80
Service |
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St.
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WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell
J. H. Crellin
W. L. Bertrand
Center $c ifatma Hffr
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.      Powell River, B. C.
Published monthly at Vancouver, b. C, by ROY WRIGLEY LTD., 300 West- Pender Street f^M^^^^^^^^^^^^^M^W^i
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 28*8
!^S^^g?S^^S^SS^^^^SK>SSSS^

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