History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1931 Vancouver Medical Association Jun 30, 1931

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VANCOU VBPw, CANADA
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57
PRESCRIPTIONS
We Deliver Anywhere
CHAS. H. ANDERS, Chemist
GORDON  M.  CLAY, Associate Chemist TH£   VANCOUVER   MEDICAL   ASSOCIATION
B U L L EJT I N
Published Monthly under the Auspices of the Vancouver Medical Association in  the
Interests of the Medical Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H.'MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abov; address.
Vol. VII. JUNE, 1931~ " No. 9
OFFICERS 1929-30
Dr. C. W. Prowd Dr. E. Murray Blair Dr. G. F. Strong
President Vice-President Past  President
Dr. L. H. Appleby Dr. "W. T. Lockhart
Hon.  Secretary Hon.  Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. "W. L. Pedlow
Trustees
Dr. "W. D. Brydone-Jack Dr. J. A. Gillespie Dr.. J. M. Pearson
Auditors:   Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. J. E. Harrison  Chairman
Dr. A. M. Agnew Secretary
Eye, Ear, Nose and Throat
Dr. N. E. MacDougall  Chairman
Dr. J. A. Smith    Secretary
Pediatric Section
Dr. C. A. Eggert .. Chairman
Dr. S. S. Murray Secretary
STANDING COMMITTEES
Library Orchestra Summer School
^     „   ,,  ,, i-.TT.-i-. Dr.  R. P. Kinsman
Dr. D. M^ Meekison Dr. J. R  Davies Dr_ w> | Graham
Dr. WH  Hatfield Dr. F. N. Robertson Dr   | £   Brqwn
Dr. C. H. Bastin Dr. J. A. Smith Dr   T  L   Butters
Dr. C. H. Vrooman Dr. J. E. Harrison Dr; | ^   Vrooman
Dr. C. E. Brown Dr  j  W- Arbuckle
Dr. H. A. Spohn                                    Publications
Hospitals
Dr. J. M. Pearson Dr. V. C. Walsh
Dinner Dr. J. H. MacDermot Dr. F. W. Lees
Dr. J. E. Harrison °r. d- e- h- Cleveland Dr. A. W. Bagnall
Dr. H. H. Pitt Dr. F. J. Buller
Dr. N. McNeill                                      Credentials V.O.N. Advisory Board
r, ^   .    r,   ^   it j    a Dr. A. J. MacLachlan Dr. Isabel Day
Rep. to B. C. Med. Assn.   „.      »   v  w Xt r>=   u   m   r-.^T,
K Dr. A. Y. McNair Dr. H. JH.. Caple
Dr. H. H. Milburn Dr. T. L. Butters Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS, APRIL,
Total  Population   (Estimated)   	
Asiatic Population   (Estimated)   	
1931
 ,         242,629
 I - '        14,227
Rate per 1,000 Population
Total Deaths    j
Asiatic   Deaths   	
Deaths—Residents only 	
Birth   Registrations    	
Male      169
Female  186
INFANTILE MORTALITY—
Deaths under one year of age  ;~
Death   Rate—Per   1000   births   I	
Stillbirths  (not included in above)    ,	
CASES OF CONTAGIOUS DISEASES REPORTED
March,
Cases
0
17
8
172
12
160
355
11
31.0
11
IN CITY
May
8.6
10.3
8.0
17.8
1st
Smallpox 	
Scarlet Fever 	
Diphtheria :	
Chicken-pox        107
Measles         3
Mumps        157
Whooping-cough   	
Typhoid Fever 	
Paratyphoid   	
Tuberculosis  	
Poliomyelitis   	
Meningitis   (Epidemic)   	
Erysipelas   	
Encephalitis Lethargica 	
6
3
0
65
■.;0*
0
0
1931
Deaths
0
1
0
0
0
0
2
0
0
19
0
0
0
0
April
Cases
0
13
14
54
1
108
6
0
0
75
0
0
11
0
1931
Deaths
0
0
0
0
0
0
0
0
0
18
0
0
1
0
to 15th, 1931
Cases    Deaths
0
6
2
39
1
83
7
0
0
39
0
0
6
0
in cystitis and pyelitis
TRADE
MARK
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For oral administration in the specific treatment
of genitO'Urinary and gynecological affections*
Sole distributors in Canada
MERCK & CO. Limited      Montreal
412 St. Sulpice St.
Page 195 IT'S NEW!
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L't T I 1 I t I i ! 1 I t I t 1 t i 1 t 1 I 1 t 1 1 t i i t t i t T T i t i t t i t t i t I i i t' EDITOR'S PAGE
This month Vancouver is to have the privilege, once more, of
welcoming the Canadian Medical Association, as it holds its annual meeting. It is ten years since this meeting was held in Vancouver and we are
very glad of this opportunity to be the hosts to our colleagues from
other parts of Canada. "We hope they will come in large numbers and
feel that we can promise them a delightful and profitable time. The
latter is assured by the programme already published—the former is,
we have every reason to believe, equally certain.
This annual meeting of the Canadian Medical Association has many
functions. It is, of course, partly a scientific meeting, partly a social
event. But it is more than these. It is an occasion on which reports are
rendered of the work done for the year by our national medical association. If anyone has any doubt as to the amount or quality of this
work he should attend a Council meeting or read the published reports.
The Canadian Medical Association has much to be proud of. Since its
reorganization some years ago when Dr. T. C. Routley was appointed
General Secretary, it has climbed from being a weak, insolvent, and
practically useless body, to a position where it is a strong, living, active
force for good in our medical lives. Its Journal is one of the best published anywhere and is a necessity to every Canadian physician. Its
educational work is extensive and of very great value, and here we must
pay our tribute to the Sun Life Assurance Company of Canada, whose
generosity has made possible the post-graduate tours which mean so much
to us. The C. M. A. has inaugurated periodical medical examinations,
it has a programme of public education, it has a strong Hospital Service
Department and in innumerable other ways it is taking the lead and
contributing to the national weal.
One sometimes hears medical men questioning the value of belonging to all these associations. Of course, to belong to them, one has to
pay fees, always an unpleasant duty and one especially grievous to bear
at this particular time. What do we, as individuals, get out of it? Is
it worth while? The answer to this, we feel, is that we get out of it
precisely what we put in in, and the result depends also, to some extent,
on the manner in which we make our contribution. It can hardly be
denied that the medical ^profession needs organization and unification.
It needs a strong united organization which will protect its interests
and present its views in clear and forcible ways. But to attain this organization and to ensure that it shall be strong and efficient, it must build
on broad and strong bases. The national organization can never be fully
representative and adequately strong, unless it has developed from strong
provincial and local associations, which will truly and adequately represent the individual members, the practising physicians of the country.
The chain must be a continuous one, each link soundly forged and dependable, or it is of no value at all.
We must have, first, active and representative local associations,
such, for example, as the Vancouver Medical Association. But such
associations must realize that the strength and unity which they develop
are only of value when contributed to the making of a strong provincial
association, and when this is combined with the strength of other provincial bodies, to form a living and powerful national organization.    Work-
Page 196 ing separately we can do nothing, working together we can do everything
that we have any right or need to do. Our first duty, it is true, is to
our local organization, but unless we do the rest of our duty, to our
provincial and national organizations, we shall get nowhere—since governmental bodies and others with whom we must deal cannot take
account of purely local bodies, no matter how strong or numerous they
are. Local organization is essential to ensure that local conditions are
adequately represented since the larger body, especially in a country so
large and diffuse as Canada, cannot properly represent all interests unless
it can depend upon accurate and full information from the provincial
and local societies. But local organization is only the first link in the
chain.
One sees with gratification that this feeling is gradually taking
hold of the medical profession. It is well, for never in our history did
we need unity so much. It is the old story, we must hang together, if
we do not want to hang separately. The cost is nothing, it is merely
insurance and without this insurance we shall lose infinitely more than
the trifling sums we must contribute for our own self-protection.
NEWS and NOTES
The Vancouver Medical Association Cancer Committee is maintaining a steady activity. There is, however, a lack of interest which is
apparent among the large proportion of doctors in Vancouver who are
not as yet active members of the Committee. The open meetings which
have been held, while they have presented excellent programmes, we regret to say have not had the attendance they merited. Perhaps the
Cancer Committee is not making enough noise, but it is to be pointed out
that noise is not a characteristic of smoothly running, highly efficient
machinery. Every member of the Vancouver Medical Association should
join one of the Regional Study Groups.
The Autumn Post-graduate Lecture Tour, which will take place in
August and September, will bring to the Coast two prominent members
of the Montreal medical profession. These are Dr. C. C. Birchard, Chief
Medical Officer of the Sun Life Assurance Co., and Dr. F. H. MacKay,
Associate in Neurology at the Royal Victoria Hospital and member of
the teaching staff at McGill.
The St. Paul's Hospital Training School held its annual graduating
exercises at Lester Court on May 5th. The 1931 class of 24 graduates
provided an array of beauty and talent (we had to drag that last in for
balance, as of course cela va sans dire), and was fittingly addressed by
Dr. Theodore Lennie^. Other speakers were Rev. Father M. N. Sweeney
and Alderman G. C. Miller, representing the Mayor and City Council.
The St. Paul's Glee Club furnished the entire musical programme and
Miss Campbell made the valedictory address.
The Vancouver General Hospital had a graduating class of 83
members at the Annual exercises which were held at the Arena Auditorium on May 29th.   The Board of Directors of the Hospital entertain-
Page 197 ed the graduates at a dance on May 22nd, and a special religious service
took place on May 24th.
On the occasion of the opening of the new Nurses' Home at St.
Paul's Hospital on May 12th, Dr. R. E. McKechnie delivered himself of
an emphatic pronouncement in which the intelligence of the general
voting public, which turned down a new Nurses' Home at the Vancouver General Hospital, was contrasted with that of the Sisters who direct
the affairs of St. Paul's Hospital, to the advantage of the latter. This
received merited attention in the daily press.
That the prestige of the Vancouver General Hospital has advanced
very materially in recent months is becoming generally realized. New
evidences of this is furnished by the fact that recently 142 enquiries were
received referring to interne appointments and 105 definite applications
were made. On July 1st the resident staff will be augmented to a total
of 3 5 internes including six seniors.
The golf addicts of the Vancouver Medical profession, and this
term applies to a large part of the said profession, are feeling in thorough
accord with Browning in his views of the spring, which conclude with
the reflection, "God's in His Heaven, all's right with the world." After
many years of wandering in the wilderness, the Perry Cup has returned
to what we naturally feel is its rightful place, Vancouver. All of which
means that our Annual Golf Tournament with Seattle took place in May,
and, as always, was a thoroughly successful and enjoyable event, made
more enjoyable by the fact that Vancouver nosed Seattle out—by a very
narrow margin, it is true, but still sufficiently.
Vancouver (with some additions from Victoria and New Westminster) , journeyed first to Seattle, and the highway between the two
cities was alive with 19,000 licenses for two or three days. The match
at Seattle was lost by us, by the margin of two points, 80% to 82%.
Next week we had the pleasure of entertaining the Seattle men, and we
have reason to believe they enjoyed themselves. This time the score was
in our favour, 83% to 77l/2, and by the noble margin of 6 points, we
established our right to the cup. There are those cynical souls who
say that the air of Vancouver was rather detrimental to our unseasoned
visitors—and that many of them found it difficult on occasions to decide
which of the two balls they should putt, and into which hole. We feel
that this is a calumny, and repudiate it as such—preferring to believe
that it was superior skill that triumphed. The event closed with a
dinner, at which song and story enlivened the proceedings. No casualties occurred, coming or going, and everyone had a good time.
Dr. Langston, who has been until recently interne on the Vancouver
General Hospital Obstetrical Service, has entered private practice, taking
over from Dr. Sager in Coquitlam.
Local members of the Canadian Medical Association are urged to
apply to the Transportation Committee (Chairman, Dr. Meekison), for
"Courtesy" stickers to attach to the windshields of their cars during the
week of the Convention.
Page 19 Z lamuiimiii
Dr. Jeffery, of Seattle, gave an interesting and very instructive address before the Staff of the Vancouver General Hospital and the medical
men of the City in the Auditorium of the Hospital on May 15th. Dr.
Jeffery, who was accompanied by his bacteriologist, Mr. Gibb, described
fully his treatment of arthritis by specific vaccines. Mr. Gibb gave particulars of the progress that had been made in isolating the different
bacteria in cases of arthritis, and described culture methods. From what
our visitors told us we judge that the progress that is being made in isolating the different types of bacteria in these cases is very marked.
MEETINGS
The Annual Meeting of the Vancouver Medical Association was
held on Tuesday, April 28th, in the Auditorium of the Medical Dental
Building. Fifty-one members were present. After the Minutes had
been read and confirmed the various Officers, Standing Committees and
Sections reported on the activities of the Association for the past
year. For the first time in the history of the Association it was possible
to report a hundred per cent, paid up membership. In other respects also
the Treasurer was able to report satisfactorily on the financial position
of the Society.
The Executive recommended the election to Life Membership of
Dr. W. F. Coy, who for many years has been one of the Trustees. The
meeting was unanimous in endorsing this recommendation of the Executive.
The following were the new Officers and members of Standing Committees elected for the Session 1931-1932:
President: Dr. C. W. Prowd; Vice-President: Dr. E. Murray Blair;
Hon. Secretary: Dr. L. H. Appleby; Dr. W. T. Lockhart was re-elected
to the onerous post of Hon. Treasurer; Dr. W. D. Brydone-Jack and
Dr. J. A. Gillespie were elected trustees to serve with Dr. J. M. Pearson;
Dr. H. H. Milburn was re-elected representative of the Association on
the Executive of the B. C. Medical Association. The Library Committee
remains the same, with the exception that Dr. H. A. Spohn replaces
Dr. Busteed, who has served for two terms. Dr. Bagnall and R. A. Simpson were elected to the Standing Committee on Hospitals. Dr. J. E.
Harrison, H. H. Pitts and Neil McNeill were entrusted with the task
of arranging the 1931 Annual Dinner in November. The Publication
Board of the Bulletin remains the same, with Dr. J. M. Pearson as Editor.
The Auditors, Messrs Shaw, Salter and Plommer were re-appointed for
the coming year.
Dr. G. F. Strong, the retiring President, in his closing address said:
"Since I was not present at last year's annual meeting when I was
elected to this office, I want to take this occasion to express my appreciation of the high honour you have conferred. upon me. Coming here as
I did, an outsider, I have been received with open arms and I am not
unappreciative of the true spirit of that reception. My sincerity can
best be expressed not in words but in the service that I have endeavoured
and will continue to endeavour to render to this Association and to the
profession in Vancouver. What I have to say, will, of necessity, appear
fragmentary because I want to touch on a number of points concerning
our Association which to my mind merit brief emphasis.
Page199 Amalgamation
Under constant consideration during the year has been the question
of amalgamation with the British Columbia Medical Association, and it
is my earnest hope that before the conclusion of another year we shall
see this an accomplished fact. It is desirable before bringing about any
such change that the whole situation be carefully canvassed and this
Association will be better satisfied I feel sure to have the amalgamation
brought about after the careful consideration it has received. The union
of the two associations as far as executive offices is concerned has been
effected most happily and that in itself augurs well for the success of
the more complete amalgamation.
Entertainment
Outstanding in the extra events of the past year was the entertainment here of a group of distinguished visitors from the Old Country
following the Winnipeg meeting of the British Medical Association.
We endeavoured in the short time these visitors were here to provide
them with an opportunity to see something of Vancouver and its environs. The pleasure of this visit was enhanced by the excellent dinner
tendered to our guests by his Worship, Mayor Malkin, and the City
Council. Our part of the expenses of the entertainment were defrayed
from a fund raised by a voluntary levy of our members. The generous
response to this call left a surplus which has been placed in a special
fund ear-marked for the entertainment of distinguished visitors and this
money has been used to defray in part the entertainment of such guests
as Dr. J. B. Collip of Montreal, Dr. Harold Dew of Sydney, Australia,
Dr. Dwyer of Seattle, Dr. Boyd of Winnipeg and Dr. Ries of Chicago.
Hospital Regulations
A special committee appointed in December, 1929, to deal with the
subject of the new regulations regarding the admission of non-pay
patients to the General Hospital has, after a very great deal of work,
made its final report and been discharged. While this matter has not
been concluded to the entire satisfaction of all our members the committee should receive great credit for the considerable work it devoted to this subject. The untiring efforts and constant tact of the
chairman, Dr. J. A. Gillespie, is almost entirely responsible for what the
committee has accomplished. While the regulations have not been
rescinded they are not now being enforced in the spirit in which they
were first brought forward and the change in attitude in the handling
of cases on compassionate grounds has been considerable. Dr. Haywood,
the new General Superintendent, has shown a real desire to restore
harmony between the Association and the Hospital and we may rest
assured that his good efforts in this direction will ultimately be crowned
with success.
Cancer Committee
Of the accomplishments of the year, none gives greater promise
than the recently organized Cancer Committee. Conceived and ably
chairmaned by Dr. Mason, the committee is away to an excellent start on
the study of the various phases of the cancer problem. The work is
being taken up along various lines in a manner which should prove of
interest and of value to every member of the Association. The committee is working in conjunction with Dr. J. W.  Mcintosh,  the City
Page 200 Health Officer, in an effort to secure the reporting of cancer cases so
that more complete details may be available for study.
Canadian Medical Association
In two months' time we will be hosts to the Canadian Medical
Association and it is needless to emphasize that the success of that
Convention depends upon the enthusiastic support of every member of
the local Association. It is only once in ten years that we are permitted to entertain the Dominion Organization and we must see to it
that the visitors leave with the proper appreciation of true Western
hospitality. This will mean some individual sacrifice of time and money
but the Canadian Medical Association is worthy of all our best efforts.
Because of this meeting there will be no summer school this year, but I
am sure that you will find our summer school committee engaged very
shortly on the plans for the 1932 session.
Officers and Executd/e
These few remarks can not be concluded without reference to the
loyal assistance given me by the officers, executive and other committees.
The fact already reported by the Treasurer that the Executive Committee
was not compelled to strike any names from the role for non-payment of
dues must not be passed without further comment. This is the first
year that such a record has been achieved and it is the more remarkable
in view of the prevailing financial depression with the resulting poor
collections. Credit for this splendid record belongs to our Treasurer, and
this Association is to be congratulated on retaining the services of this
indomitable officer.
I could with equal force commend the activities of each and every
one of the other officers. The Executive Committee has given me constant help, not in the sense of unfailing concurrence, quite the contrary,
because we frequently have been faced with a wide variance of view
points in this committee. Fortunately the Executive has been truly representative of the various parts of the Association, and is not dominated
by any one group or clique, and the result has been a fusion of the varying
view points into a policy which we hope has been representative of the
Association as a whole.
It is customary for the retiring president to make some recommendations and generalizations regarding the Association. I would crave
your indulgence, therefore, if in this brief valedictory I make a few
suggestions regarding our relations with the public. As a profession we
are apt to be too reticent in giving information to the public regarding
health problems, but with the increasing general interest in these matters
we must be ready to assume our share of the burden and keep the public
intelligently informed. That means of course, that we must keep ourselves informed of the health side of these various problems as they arise.
How many of us, for instance, have a clear conception of the health
side of the milk problem so recently under discussion in the legislature
and given such wide publicity through the press? As an Association I
am sure that we stand for the principle that only safe milk should be
sold, yet are we aware of the best means to this end? Here the public
may very rightly look to us for guidance. Probably the best recommendation is that all milk be pasteurized, for while we know that under
ideal conditions certified milk is usually safe, there can be no question
3= that for the public at large and for the protection of the milk-consuming
infant population, pasteurization offers the safest milk.
Other problems of a public health nature are constantly before us
and I would urge that these matters be brought up for discussion in this
Association that our views may be crystallized in order that we may be
of greater service to the community.
Another matter, which will shortly be before us, is in connection
with the Out-patient Department at the General Hospital. The enormous increase in that department has led the Hospital to consider a
means of securing some return for the service given, and there is, in contemplation, the making of a small charge, for the registration card, for
each visit, for the medicine, etc. This matter will be laid before your
new Hospital Committee and will, I feel sure, come before a general
meeting. Here again the question is a many-sided one and merits your
careful consideration. It depends entirely on the adequacy of the social
service investigation made on the patients attending the Out-patients
Department. Patients able to pay should and will be referred to their
own doctor. Patients entirely unable to pay will be cared for without
charge of any kind, but for those able to pay some small sum, yet not
able to pay a private doctor, the plan has the merit of saving them from
the stigma of indigency.
All the other local health agencies should have our sympathetic
support and co-operation because there is no way in which the medical
profession can regard itself as a thing apart from the whole community.
The Victorian Order of Nurses, the recently organized Greater Vancouver Health League, the City Health Department and the Medical Department of the School Board, all represent phases of public health activity
directly associated with our contact with the public. Obviously, it is
essential that we have a sympathetic understanding of the activities
and the problems that confront these organizations.
Lastly, let me urge that the Vancouver Medical Association raise
itself above the petty politics of professional activity and strive to serve
its members best by making a constant effort to benefit them through
post-graduate activities, through scientific and clinical meetings,
through increasing the resources of our already excellent library. These
are the things that will bring us'to the position in which no doctor in
Vancouver can hope to practice a brand of medicine that he can be
proud of without being a member of the Vancouver Medical Association,
ation.
In closing I want to call upon the new President, Dr. C. W. Prowd,
to take the chair. You have chosen wisely a man who has the best
interests of the profession at heart and who has always stood for the
ideal of unity in our medical organization.
THE THEORIES OF THE CAUSES OF CANCER
Lyon H. Appleby, M.D., F.R.C.S.  (Eng.)
We are frequently faced with the necessity of finding an answer
to the question: what caused this cancer? and have so often had to admit
that we do not know the real cause of cancer, that to some extent we
Delivered befor a meeting of the Cancer Committee of the Vancouver Medical Association,
April,  1931.
Page 202 have ourselves come to believe that we really do not know anything
about the causes of cancer. In pursuing a study such as this committee
has commenced, one of the most striking things, to me at least, is the
amount that actually is known. My particular field, the theories of
causes of cancer, is so vast, that I can merely outline briefly some of the
more widely known and more generally accepted theories, and simply let
the other limitless thousands go.
Amongst the laity, probably the most widely held theory is that of
heredity. I find a great confusion in people's minds over what is meant
by the terms congenital and hereditary. A congenital condition is one
present or developed at or before birth. Hereditary disease is something
we have transmitted to us through our ancestry. It is well to point out
that although familial traits, such as blue eyes, red hair and avoirdupois,
may be transmitted from father to son, there is no possibility of the
transmission of acquired physical defects. The Manx cat is born without a tail because that is a special characteristic, but spaniel pups are
still born with tails, though a hundred previous generations may have
had their tails amputated; and in spite of centuries of circumcision, the
infant Hebrew still boasts a foreskin.
In a careful examination of many published statistics covering many
thousands of cases, I find a family history of cancer was found in 17%
of the lowest series and 33% of the highest series; so that to strike a
rough average, 25% of cancer cases will give a history of carcinoma in a
parent or member of the immediate family. Now, undoubtedly, many
of these recorded instances of "father or mother died of cancer," may
have been some non-cancerous condition; and equally certain, many
deaths listed as pneumonia, intestinal obstruction, etc., may have been
cancer. The point I am trying to make, is that not one case in fifty
can furnish.proof satisfactory to modern standards that a parent 25 years
before had died of cancer. Consequently, such statistics are only approximately accurate.
We hear a great deal at times about cancer families. One man
reports a mother and her five daughters with cancer of the breast.
Another man reports 17 out of 37 members of a family died from cancer.
Now, Boshford, in England, shows that one man in every eleven and
one woman in every eight, will die of cancer. This makes 2 in 19
people or one in every 9% per population. If the average family is
four or five, this means that one in every second family will die of
cancer. . If then, the modern incidence of cancer is so high that 50%
of the families have or will have it, a family history of cancer becomes
practically valueless. There are other reasons than heredity why cancer
may develop more frequently in certain families than in others. It is a
well known fact that certain strains of families age much earlier in life
than others. In family A, everybody may be grey haired at forty and
show other unmistakable signs of premature senility. Precocious senility
advances the cancer age from, say forty to thirty, and this family will
naturally show a higher incidence of malignancy. The rising tide of
malignancy closely follows the ebbing tide of sexual virility. The hereditary nature of cancer is frequently weakened by a more detailed investigation. Families are prone to be exposed to common known excitants of
cancer. I have seen a father one year and a son the next with carcinoma
of the scrotum.    On superficial examination at once the significance of
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IN    THE    CANADIAN    ROCKIES heredity is apparent, yet both of these men were "mule spinners" in a
cotton factory, where carcinoma of the scrotum is so common 'that it is
recognized by the Government as an accident of industry and compensation is paid for it. The exposure of members of the same family to
common excitants will remove many cases from the category of heredity.
The common exposure to similar foods, habits, clothing, climate, etc.,
may explain the familial occurrence of many cancers. Just what the
influence of heredity is in these cancer families, it is impossible to say.
They are too frequent to be explained by environment or coincidence,
and show that a hereditary predisposition to cancer certainly does occur.
The cancer medium is there; if the germs of cancer are sown they will
develop. One of the most interesting pieces of research into the effect
of heredity on cancer is the work of Maud Slye, already well known.
Very briefly; she was able by cross breeding to produce a race of mice
100% of which would develop cancer, and by counter-breeding to develop a race of mice 100% of which would not develop cancer. She,
however, is extremely careful to point out that, even in the hereditary
families, only those subjected to chronic tissue irritation developed
cancer. In other words, the suitable soil was the hereditary feature, not
the cancer; and proper breeding can eliminate from the soil something
essential to the development of cancer. Maud Slye has proved the
influence of heredity in cancer. The great reluctance of the world to
accept- her work in toto is undoubtedly because if we accept cancer
per se as hereditary, then the position becomes at once a hopeless and
irremediable one, and the burden of cancer is already great enough without adding a further hopelessness to it. Furthermore, it is well to remember that her valuable work is undoubtedly true for mice—but men are
not mice.
In considering the special causes of cancer it would seem that a
combination of known causative factors, rather than any specific feature is essential to the development of most malignant growths. We
know that amongst the cancers we meet are many which may be definitely listed as occupational cancers. To be brief: such tumours as
scrotal cancers in "mule spinners," X-ray cancers, the lung cancers of
metal workers, have a definitely known aetiology. So also with the
causes of the many so called "habit cancers." The old clay pipe cancer,
the skin cancers of arsenical workers, Kangri cancers of the Kashmir
district of India; have a definitely known aetiology. So too, the tongue
and cheek cancers of irritation by jagged teeth are well known. I have
seen two cases of carcinoma of the mouth develop at the site where a
wad of Copenhagen snuff had been carried for years by habitual users.
Many of you have seen the mouths of these "snoos" eaters; the pale,
bloodless, insensitive, thickened mucosa, the result of years of insult by
an astringent mixture, a definite "habit cancer." Physical trauma is,
beyond question, in many instances, a cause of cancer. But here again
one must realize the complexity of aetiology—probably Maud Slye's
theory of the fertile soil prepared by some hereditary taint, will explain
why direct trauma will develop a sarcoma in one man and not in a
hundred others. We have all seen sarcoma develop at the site of injury
—it is too frequent to be accidental or a coincidence, yet it is almost
necessary to assume the pre-existence of some predisposing factor—which
may be hereditary.    Again,  the direct and long  continued trauma of
Page 204 chronic inflammatory conditions has an undoubted bearing upon the
subsequent development of malignancy, as we see frequently in gastric,
nephritic and prostatic malignancy.
Coming now to the theories of the organismal cause of cancer, I
might say that to merely enumerate the thousands of germs which are
supposed to cause cancer, would take many days, if I knew them; and I
do not. Ever since Pasteur, the world has been hunting for the germ
of cancer. I might say that I believe the germ theory of cancer is the
weakest of all the wealth of suppositions hitherto advanced. There is
no germ definitely known to cause cancer. No completely cell-free
extract producing cancer in 100% of injected animals has ever been or is
ever likely to be produced. There appears to be in the minds of the
cancer investigating world, a fairly uniform agreement that malignancy
is not an invasion from without, but a breakdown from within. The
most widely heralded cancer germs of recent date have been those of Gye
and Barnard in England, and of Glover in Canada. I pass them both
with a mere mention, as both have been long since discredited.
I come now to the embryonal or cellular theory of the development
of cancer. To this great theory, which, with its modifications, is the
most widely accepted and most scientifically worked out, the name of
Cohnheim is associated and though we do not accept it in quite the
form in which it was originally presented, it still is the one great known
fundamental fact of cancer. The theory of cell inclusions is very intriguing. In embryonic life the epithelial tissue seems at all times to
be the dominant tissue until restrained by growth development. The
theory of cell inclusions, or rather the fact of cell inclusions occurs
during the healing of evolutionary wounds, whereby bits or islets of
epithelial tissue become pinched off and included in the midst of tissues
to which epithelial tissue is foreign, or during the healing of these a
heaping up occurs or a superfluous number of cells develop though not
necessarily included. These superfluous cells are most readily seen at
muco-cutaneous junctions microscopically, or grossly, at the site of fusion
of the median septum of the body. It is well to remember that anatomically one can trace this median septum very easily. It is perhaps
best seen in the linea alba, the septum of the scrotum, the falx cerebri
and cerebelli, the dipping of the fascia to the spinous process, the frenum
of the tongue and penis, etc. The heaping up of such cells at the junction of the two halves of the scrotum is abundantly evident.
It is a basic fact of tissue pathology that embryonic tissue retains a
tremendous potentiality of growth and from an embryological sense the
earlier the inclusion, the greater the growth possibilities. To refresh
your memories, let me repeat the embryological fact that the embryo at
the sixteen cell stage may have a cell detached and have that cell develop
into a complete embryo, and if it were possible to divide the sixteen cells
from each other, we could get sixteen complete embryos, showing the
tremendous capacity for growth of early embryonal tissue. Cohnheim's
theory presupposes the development of malignancies in these islets of
misplaced or superfluous embryonal tissue which have retained their embryonal character and capacity for growth.
At   once,   into   this   group,   fal
the   teratomata,   the   heterologous
tumours, and such things as malignancies developing in  thyroid foetal
adenomata.    The malignancies of rudimentary organs show the peculiar
Page 205 susceptibility of these embryomal tissues to malignant change. We have
all seen malignancies of undescended testes, the parovarian bodies, Wolf-
ian tumours of the kidneys, congenital sacro-coccygeal tumours, etc.
Similarly, local failures of development, such as dentigerous cysts, ada-
mantinomatas, odontomata, gliomata of spina bifida, etc., are relatively
not uncommon. The embryonal tissue of pigmented moles, retention of
the lanugo or like hairy areas are all peculiarly susceptible to malignant
change. The persistent remnant of embryonal structures such as branchial
cysts, thyreoglossal duct cysts, urachal tumours or cysts, the ostia of
the points of fusion of evolutionary wounds, are all evidence of a predilection for malignant change.
Let me point out that cell rests are by no means an uncommon
thing. There are myriads in every human body; one has only to think
of the islets of supra-renal tissue all through the retroperitoneal fossa—
the multitude of small accessory splenic bodies, the many islets of
detached thyroid tissue and parathyroid tissue found right down into the
pelvis, to appreciate the great frequency of these cell rests. Why should
a malignancy develop in one cell inclusion and pass up the myriads of
others? Why, when these cell rests start to grow, do they not produce
normal tissue or organs, instead of dermoid, teratoid or malignant
tumours?
It becomes at once obvious that Cohnheim's theory is not a theory
of the cause of cancer. It does explain, and explains beyond refutation,
the occurrence and structure of many cancers, but why these islets
should suddenly start to grow, it does not even attempt to explain. It
is a theory of the occurrence of cancer rather than a cause. It remains,
however, the one basic fact which tissue pathologists know about cancer.
In an attempt to develop the missing link, so to speak, and to explain
why these misplaced or superfluous cells suddenly became activated, the
theory of tissue tension was developed, which is the modern cellular
theory of cancer. This theory simply assumes that cells are capable of
growing indefinitely unless restrained. The tremendous growth and
hypertrophy of cells of the gravid uterus, the regenerative powers of
injured tissues, etc., show that cells are capable of growing practically
without limit. Cancer cells have no unusual powers of proliferation, but
once freed from the tissue tension, or growth restraint, they merely
exhibit the powers of growth with which they were intrinsically endowed
from the ovum. According to Ewing the restraints making for "tissue
tension" are five in number.
1. Mechanical pressure of cells on each other.
2. Distribution of nourishment.
3. Growth stimulation influences (placental hormones, etc.)
4. Influence of specialized functions.
5. Organization.
I have not time to elaborate upon the theory of tissue tension. It
is much too vast to be approached lightly. The last theory I wish to
mention is that of Loeb—theory of chronic irritation. Very briefly
Loeb's theory of what happens in chronic irritation is that certain cells
die and develop an acid reaction, as lysis progresses, protein combinations
become broken up and salts are liberated, and the reaction becomes alkaline. This develops a group of cells rich in mineral salts which draws an
increased fluid and consequent increased nutriment for the dilution of the
Page 206 excess of salts—a process of simple osmosis. High mineralization and
over-nourishment embryologically excites division and growth commences. This cumulative effect on successive generations of cells gradually breaks through the tissue tension and growth restraints and allows
abnormal growth to commence. This theory of tissue tension attempts
to provide Cohnheim's theory with a cause of growth as well as a cause
of occurrence and structure of cancers. The importance of chronic
irritation in the aetiology of cancer, is impossible of over-estimation.
To briefly recapitulate; it is wise to believe that no single specific
aetiological factor is known, and rather to regard cancer as being caused
by a complexity of aetiological factors; a great many of which are
known, and many combinations of which may serve to explain individual cases. It is impossible to discredit the part which a favourable
soil engendered by an hereditary predisposition plays in cancer. It is
impossible to deny the part played by the many special causes of cancer,
trauma, occupation environment, food, chronic inflammation, chronic
irritation, vestigial remnants, atavistic anomalies, etc. The embryonal
theory of cancer and the theory of tissue tension are sound, accepted and
proven.
Gentlemen, the aetiological factors predisposing to the development
of cancer are known, the specific factor incident to the development of
the individual case is not, or may not be known. Nevertheless, as I have
said in my opening remarks—we are too prone to say, and in saying, to
ourselves believe, that the cause of cancer is unknown. In pursuing a
study of cancer, it becomes perfectly astounding how much is really
known about the causes of cancer in general. However, if one is asked
the question, why John Smith, previously healthy, suddenly develops a
cancer in his left kidney, the answer still is: God only knows.
BLOOD CULTURES
By H. W. Hill, M.D., D.P.H.
Director, Vancouver General Hospital Laboratories
Vancouver, B. C.
A recent editorial of the "Journal of the American Medical Association" (96: 14; April 4th, 1931, p. 1147) rather pessimistically sums
up the present status of blood cultural work, especially in relation to
rheumatic fever and some of the forms of arthritis.
While it is perhaps well thus to restrain the over-enthusiasm generated by some of the reported findings in these diseases as to immediate
practical diagnostic and therapeutic applications, there can be no doubt
that some advances have been made by the researches carried on, and the
next few years should show some definite returns to patient and to
physician.
Unfortunately, wide spread corroboration of the most promising
of the varied results is lacking. Contaminations on the one hand, to
account for positive findings, and poor technique on the other hand, to
account for negative findings, have been alleged freely by various workers
to explain contradictory or incompatible results.
Until further work elucidates the true situation, an attitude of
watchful waiting, combined with careful investigation in favourable
cases, would seem to promise the best ultimate results. An estimate of the situation up to date is attempted here.
In health, bacteria, non-pathogens certainly, pathogens probably,
enter the blood stream not infrequently. Whether pathogenic or not,
they probably gain access to the blood stream from the intestinal tract;
perhaps, in tuberculosis at least, by migration into the lacteals and thence
to the bloodstream. Meningococci have been supposed to enter ordinarily by migration into lymphatics of the nose, and so into the bloodstream. The tonsils are held to be a similar point of entrance. Abrasions
of the skin may give access to both lymphatics and blood stream.
Doubtless the paths of entry of pathogens and non-pathogens need
not differ, mutatis mutandis. It is hard to believe that one tiny particle
of protoplasm differs in this respect from another, whether pathogenic
or not. At the instant of entry it would seem that there can be little,
if any, specific influence of toxins, etc., on the local tissues sufficient to
compel a particular method or portal of entry, for each particular species.
It is true that those organisms which first produce a local lesion
at the point of entry, and are then taken on .from that point into the
blood stream or lymphatics, may have other than this simple direct
means of entry. But the necessity for a local pathological lesion as a
portal of entry is not now insisted on as much as it once was. Ravenel
showed that even tubercle bacilli were absorbed through the presumably
uninjured intestinal wall very promptly. Scott believes he has conclusive
proof to the same effect. The early bacteremia of typhoid doubtless
precedes the ulceration of Peyer's patches.
Granted, then, that bacteria do reach the blood stream both in
health and in disease, their sojourn there may be very short, or fairly
continuous, or intermediate in length. Evidently also they may be
intermittently present, or at least fluctuate widely in relative numbers
and distribution at different times. They may actually grow and flourish
in the blood stream as their main habitat, or they may appear in it
merely as transients, set free from local lesions and en route from one
part of the body to another.
A single blood culture is, therefore, an attempt to find from the examination of 10 cc. of the blood at one moment what is happening or
may happen in the total 5000 cc. during the course of the disease. Only
if very frequently repeated can blood cultures pretend to picture the
actual situation with all its variations. Multiple blood cultures are
obviously called for, if the actual situation is to be fully determined
in all cases.
For clinical purposes, interest centres on the opportunities afforded
by blood cultures for diagnosis; and on the opportunities for therapeutics, e.g., vaccine treatment of those patients whose bacteria may
appear in the blood stream in sufficient numbers, or sufficiently often,
to make practical the isolation and recognition of those bacteria.
Granted about 5 litres of blood in the human body, 500 bacteria free
in the blood stream at a given instant, and equally distributed throughout the blood, would carry one bacterium to each 10 cc. of blood, the
usual amount taken. It is wholly unlikely that any bacteriological
methods could be counted on to detect such small numbers. As for
direct microscopic examination, one hundred thousand tubercle bacilli,
it is said, must be present in 1 cc. of sputum to make recognition in
smears possible.    It would not be extravagant to suppose that similar
Page 208 proportions would be necessary in the blood stream, so that about
500,000,000 bacteria should be free in the blood stream in order to permit direct microscopic recognition of their presence in smears of blood.
Needless to say, such recognition is rare, but not unheard of. In
advanced septicemic anthrax it may readily occur. In one case of pneu-
mococcic septicemia here a smear of blood showed pneumococci (Pottinger.
Ordinarily, however, cultures are required. We do not know how
many bacteria must be free in the blood stream before cultures are likely
to detect them; but doubtless far less than would be necessary for direct
microscopic detection.
Many factors enter into such detection besides the number of organisms present. The mere bulk of the medium used is one of these; for it
is well known that the introduction of a very small number of bacteria
into a relatively very large amount of medium may result in delay
("lag") in development, or even no growth at all; while the same number of the same bacteria introduced into a relatively small amount of
medium may yield growth, and yield it promptly. On the other hand,
the bacteriostatic of fresh blood is accepted as a reason for considerable
dilution of the blood (usually 10 cc. blood in 50 or 100 cc. of broth),
lest growth be suppressed by the concentration of the blood.
Besides quantitative relationships of this character, qualitative factors such as pH of medium, composition of medium, temperature of
incubation, oxygen and C02 tension, etc., come into play with differing
effects on different organisms.
Of late, several radically different special methods have been advocated, especially in relation to the rheumatoid and arthritic streptococci.    There seems to be as yet little agreement as to standards.
One author claims excellent results from the use of a concentrated
blood medium, the blood derived from the patient himself; explaining
his high percentage of results on a selective action exercised by the blood
in discouraging the growth of the unimportant organisms concerned,
and thus encouraging the "guilty party." Although improbable theoretically, if actual results on a large scale in the hands of different workers
support these claims, they must of course be admitted; but so far no
very general acceptance of so revolutionary a method seems to have developed.
Another set of workers, using ordinary media, secures growths from
rheumatoid conditions by repeated tests of the blood culture prolonged
for weeks, averaging about fifteen days to the first positive. Positive
results were obtained in about 62% of 154 cases. The findings in any
one patient's blood were inconstant, positive one day, then negative, or
vice versa.   A few of the controls showed the same organism.
Another worker uses 10% peptone in his media to do away with
"alexin" (complement) in the blood and then sodium carbonate. He
reported 10% of cases yielding positives.
Another worker finds "streptococci," in late October, becoming
diphtheroidal as the season advances, but again streptococcoidal in February, with no organisms at all in the summer months.
What all this means is problematical at present, but one may be
pardoned for considering that these matters have not yet been brought
down to a sound basis for routine diagnosis, and that explorations into ■■-'--■<§* iSs,
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Meantime, methods more or less standardized by experience and
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Whatever we may be justified in hoping from research in the next
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objectives, on a par with blood counts or diphtheria cultures, or sputum
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ANAEMIA
By Dr. W. H. Hatfield
Anaemia has always been a subject of a great deal of interest, but
the comparatively recent discovery of liver therapy by Minot and
Murphy, based on the work of Whipple, has given new encouragement
to both the research worker and the clinician, so that the recent literature on the subject is most voluminous. This paper is but an attempt
to review some of the newer work on this condition, which has brought
to light many new and interesting facts and has led to the propounding
of many new theories.
What an important part the blood plays in the life of the organism
and how labile are its components! Anaemia, either as an entity or as a
part of another disease, is probably the most common of all human ailments. The economic loss from this one condition is enormous. An
individual suffering from a mild degree of anaemia is under par, unable
to do his quota of work owing to loss of resistance, more open to infections. Anaemia reduces the oxygen-carrying power of the blood
and throws an extra burden on the circulatory system. It is a great
handicap in anaesthesia and surgery. With a decrease in platelets, secondary haemorrhage is more likely to occur. Wounds heal less rapidly,
acidosis and infections are more prone to develop, and there is increased
liability to surgical shock. The more one thinks of it the wider the
ramifications of this condition become.
Many attempts have been made to classify anaemias, but the most
rational and probably the most widely accepted classification is that
which has for its basis the primary causes of anaemia.
1. Loss of blood
2. Increased blood destruction
3. Decreased formation of blood.
It is a comparatively simple matter to place any case of anaemia
into one of these three groups. Blood loss is usually obvious, but in
some cases may be not immediately apparent; however, a careful search
will easily eliminate any source of bleeding. There are two simple tests
which are of great aid in placing a given case in one of the two other
groups.    These are the reticulocyte count and the icterus index.
Delivered before the Vancouver Osier  Society,   February,   1931.
Page 210 The reticulocyte cell count is a reliable measure of blood production.
It is always high in early childhood and following haemorrhage. Any
count above 1.5% may be considered above the normal.
The icterus index likewise is a reliable measure of blood destruction. The quantity of pigment measured may include pigment from
broken down haemoglobin bilirubin further altered by the liver cells
and excreted into but re-absorbed from biliary channels and food pigments such as carotin and xanthophyll.
It is necessary, in order to get a reliable indication of cell destruction,
to be sure that the biliary tract is normal and to take the blood specimen on a fasting stomach.    The range of normal is taken as 2.5-6.
Cases of blood destruction resolve into a search for the causative
agent such as infection, occupational causes, etc.
It is the last mentioned cause, namely, deficient formation of blood,
which has led to the extensive experimentation which is going on. This
paper will deal mainly with the problem of blood regeneration.
The classification of anaemia, as given, is broad, and in order to keep
in one's mind the many causes of anaemia, a more detailed classification
is given.
1. Haemorrhage. Loss of blood may result from a variety of
causes, such as injury to soft tissues, fracture, rupture of an organ or
blood vessel, intestinal ulceration, irritation due to parasites, peptic ulcer,
tuberculosis, cardiac disease, excessive menstrual flow, etc.
2. Infection. This is one of the most common causes of secondary anaemia. Anaemia in syphilis and tuberculosis is a common finding.
Any small focus of infection may be a source of anaemia. Parasites such
as amoeba, hookworm or tapeworm, might be mentioned under this heading.
3. Malnutrition. Lack of essential dietary factors leads to
anaemia as evidenced in rickets, scurvy, xerophthalmia, osteomalacia,
pellagra, etc.
4. Chemical Toxins. This is most commonly found as a cause
of anaemia in occupational diseases, such as found in painters, garage
workers, etc.
5. Metabolic Diseases. Diseases of the liver, spleen, pancreas
and endocrines usually have an associated anaemia.
6. Neoplasms. Anaemia is a constant finding in malignant disease, especially in the terminal stages.
7. Pregnancy. Anaemia complicating pregnancy may be the
result of dietary deficiencies, metabolic disturbances, infection, postpartum haemorrhage or the condition known as the anaemia of pregnancy, the aetidogy etiology of which is still unknown. It is upon this
latter condition that Sir William Osier wrote his last paper.
To most people the term haemoglobin applies solely to the red coloring matter of the blood, but there is also muscle haemoglobin which
is of extreme importance. Whipple has shown that these are distinct
substances, but almost indistinguishable by modern chemical methods.
The difference in color of skeletal muscles, e.g. veal and beef, is due to
the muscle haemoglobin, not the blood. The content of haemoglobin
within the muscle depends largely on work demand and exercise. Young
animals contain less than the adult. In very high altitudes where extra
exertion is necessary to obtain the same end, muscle haemoglobin in-
Page 211 creases. The heart muscle haemoglobin is probably the most constant of
the body, owing to the uniform work, but in such cases as severe training, it increases. Short periods of anaemia, i.e. 1—3 weeks, will cause
no change in muscle haemoglobin, but long continued anaemia of 10—12
weeks will cause a decrease. Whereas blood haemoglobin is labile, subject
to sudden fluctuations and capable of rapid repair or renewal, and perhaps rapidly used up and discarded, muscle haemoglobin is not labile and
is tenaciously held by the muscle. It has been found that blood haemoglobin can be controlled at will by dietary measures, but muscle haemoglobin is changed very slowly and in pups Whipple found no change after
fifteen weeks.
Body pigment metabolism is much better understood today, but our
knowledge is still far from complete.
Urochrome is derived from both body and food proteins, but has
no direct relation to blood or bile pigments. The pigment complex indicates the transition stage from food split products (amino-acids, etc.) to
finished haemoglobin. It can be considered to consist of a progressive
synthetic grouping of animo-acids, iron and other materials which combine together to form the finished product haemoglobin. This process
is thiught to take place in the liver cell.
The connection between haemoglobin and the pigment complex
indicates the belief that when haemoglobin is injected into the blood
stream, it is broken down into its component parts and then rebuilt
into new haemoglobin. Both blood and muscle haemoglobin contribute
to the formation of bile pigments. The present evidence, while not complete, is against the direct exchange between muscle and blood haemoglobin.
The stereobilin and urobilin are formed in the intestine.
It was formerly believed, as stated by Rous and Drury in 1925, that
the colouring matter responsible for jaundice was derived from blood pigment alone, but Whipple has afforded ample proof that muscle haemoglobin is also a factor. At the present time there is no evidence in
favor of the absorption of bile pigments from the intestine with utilization to form new haemoglobin.
It has been found that when haemoglobin is injected intravenously
or intraperitoneally there is the same curve of regeneration as that following favourable diet factors. There is a lag in the output which is
usually about one week. This is believed to be due to the breakdown
of the introduced haemoglobin with its regrouping and synthesis into
new haemoglobin. The cells and tissues participating in this reaction are
most varied, e.g., the liver and great variety of endothelial and phagocytic cells as well as mesothelium of pleura and peritoneum.
There are many factors which influence the regeneration of erythrocytes and haemoglobin. A state of anaemia is perhaps the greatest
stimulus to the hematopoietic organs. Robscheit-Robbins aptly points
out that many experimenters have shown a tendency to draw conclusions
from one type of anaemia and apply them to another, or to compare
results obtained in one species of animal with those belonging to another
group.
Page 212 The reactions following haemolytic and haemorrhagic anaemias are
distinctly different. In haemolytic anaemia there is no actual loss of
blood, but instead a large store of liberated haemoglobin is made available.
This haemoglobin as pointed out is broken down before being re-utilized
in the formation of new cells, thus the delay before regeneration sets in.
In spite of this delay the final recovery is complete at an earlier date than
in haemorrhagic anaemia.
Attempts have been made to render the bone marrow aplastic by
long sustained blood loss. Whipple and Robscheit-Robbins have shown
that there is a tremendous reserve of materials for haemoglobin and red
cell construction which may take many months to exhaust.
McMaster and Haessler attempted to deplete the bone marrow of
stores for red cell stroma and induce it to produce fragile red blood cells.
They repeatedly bled rabbits and introduced haemoglobin into the circulation, hoping to increase blood regeneration and thus exhaust the store
of stroma substances. A typical currant jelly marrow with hyperplasia
developed. They found that there was not sufficient depletion of stroma
to affect the resistance of red cells to hypotonic salt solution. They thus
conclude that the body can provide stroma formation in excess of any
emergency. It has been found that with haemorrhage and haemolytic
anaemias the red cell resistance increases. This is thought to be due to
incomplete oxidation. It is now definitely established that young red
cells show increased oxygen consumption and it has been suggested that
oxygen consumption be used as a test of cell regeneration.
Numerous experiments have been conducted to show the effect of
light upon the blood. Horses which have been confined in coal mines
for years show no anaemia. The members of the Nansen polar expedition,
subject to long polar nights, failed to show any change in their blood.
The effect of altitude on the blood has long been known. There is
a definite increase in both red cells and haemoglobin, the immediate increase being due to a change in plasma volume. Following this, there is
a gradual increase of both red cells and haemoglobin.
By far the greatest portion of the literature dealing with anaemia
deals with iron and other inorganic materials and with diet. These will
be taken up individually.
Iron, Etc The presence of iron in the blood was first demonstrated in 1747. The essential chemical nature of life is a process of
combustion, involving the continuous building up and breaking down of
tissue. For this chemical process there is needed a constant supply of
oxygen and simultaneous removal of carbon dioxide. Blood plasma can
only hold a small quantity of these gases. This function of gaseous exchange is mainly performed by haemoglobin, of which iron is an important constituent. The total iron content of the adult is approximately
three grams or one-tenth ounce. Therefore, the adult body is about
0.004% iron. About half of this quantity is in the blood, the other half
being distributed in the tissues. An infant at birth has a store of iron
in the liver sufficient to last about nine months. Milk has very little iron
content and therefore too long a milk regime is bad. The body need is
about 15 mgms. of iron per day. Iron in the body depends on the food
ingested and food iron depends on the soil the food is grown in, and also
Page 213 on the climate. Therefore some foods will be found to vary. It is believed
that iron takes part in many of the vital activities of the body oxidation
and reduction. The nuclei of all cells contain a minute quantity of iron.
Iron is absolutely necessary as a material for building the chemical structure of the haemoglobin molecule. Its influence as a stimulant or
catalyst is not completely understood. Iron as a medicine is one of ever-
changing fashion. It has been administered in a multitude of forms.
Controversy has ranged between ferri-and ferro-salts, inorganic or organic
and soluble and insoluble preparations. Dosage has varied as much as the
type. The effect of iron in anaemia depends upon the type of anaemia.
In reading the literature on the subject, one is at first rather perplexed
by the lack of uniformity of the anaemias studied and the variable conclusions reached. In anaemias of short duration iron is of no value, but
in long continued anaemias due to loss of blood, it has a distinct value, as
here the iron reserve of the body is depleted or exhausted. As has been
mentioned, the blood is a most labile substance, freely altered by dietary
measures. In many of the experiments on iron this fact has been lost
sight of, rendering the experiments valueless.
Robscheit-Robbins summarizes our present idea of iron absorption
storage and excretion as follows: "Varying portions of iron are absorbed.
The site of absorption is the entire intestinal tract, although the duodenum and a portion of the upper small intestine probably play the
major role. The absorbed material either dissolved, or in the form of
fine colloidal particles is carried by the blood and to a less extent by the
lymph channels. This last point is still an open question. Elimination
is almost entirely by way of the intestine, especially the colon; very
slight amounts are found in the urine and bile."
It is generally conceded that the liver is the main storehouse for
iron, both food iron and inorganic forms. Jacobi found that 50% of
the iron injected intravenously was found in the liver; 10% was regained
from the urine, bile and intestine, and the remainder was in the spleen,
kidney and intestinal wall. Krumbhaar believes that the spleen may be
needed in iron excretion, so acting upon iron that it becomes available
to the bone marrow for the building up of the haemoglobin molecule.
Barlow, Whipple and Robscheit-Robbins, Hart, Steenbock, Waddel
and Elvehjem Alberhalden, and many others have studied the influence of
iron and other metals in blood regeneration in anaemia. Barlow studied
the effect of the administration of inorganic iron on rice disease in
pigeons. Addition of ferrous carbonate as Blaud's pills over a six weeks'
period in quantities ranging from therapeutic to toxic doses to iron-free
rice diets did not benefit the anaemia. With the exception of vitamin
B, all known deficiencies in the diet had no effect. The ineffectiveness
of iron in this case is explained by the absence of a body iron deficit in
spite of diminished iron intake. It seems that inorganic iron is utilizable
for blood regeneration in experimentally induced anaemias only under
conditions where a dietary or actual body iron deficit exists.
There is no argument about iron and its positive effect in severe
anaemias due to haemorrhage in dogs, but in nutritional anaemias there
are grounds for a difference of opinion. Whipple and Robscheit-Robbins
have experimented extensively with dogs subjected to repeated bleedings,
Page 214 until a definite chronic anaemia is established. In this type of anaemia
they found that iron when administered orally in doses of 40-50 mgm.
daily will cause an average output of haemoglobin of 50-60 grams,
resulting from a two week feeding period. The addition of liver in this
case will markedly increase the haemogrobin output, even up to 140
grams of haemoglobin over a two week period. It was found that the
optimum intake of iron exceeds by threefold the loss of iron by bleeding
and wastage of red cells. This'iron in excess of haemoglobin iron requirements obviously exerts some influence upon internal body metabolism, so
that more haemoglobin is produced. This may be called a salt effect,
and is probably similar to the effect noted with feeding salt mixtures,
copper and other metals, and ash from tissues.
A rather interesting and not uncommon type of anaemia, namely
simple achlorhydric anaemia, is taken up in some detail by Witte. It is
of the microcytic type, with a low colour index and a negative Van den
Bergh, no megaloblasts are seen. The bone marrow shows an increased
erythroblastic activity. The reticulocytes are within normal limits and
the fragility of the red cells is normal. The only findings are anaemia
with achlorhydria. In 100 patients with achlorhydria uncomplicated by
neoplasm or such serious disease, he states that 10% would have pernicious anaemia and 20% secondary anaemia. Gordon Taylor states
that 80% of 52 gastrectomies developed achlorhydria and 44% secondary
anaemia. This condition of achlorhydric anaemia is benefited by iron
only and large doses are essential. Successful treatment takes about three
months. The improvement in the first month is small. Liver and hydrochloric acid are of no value.
Whipple and Robscheit-Robbins have experimented with many
metals beside iron. They found that manganese by mouth caused irregular responses, sometimes favourable to blood regeneration, sometimes not.
Copper is most potent next to iron. Zinc is negative. Aluminium,
antimony and calcium phosphate had little if any influence on haemoglobin regeneration. Sodium iodide was inert and may even at times
inhibit the salt effect of iron and copper. Arsenic is one of the drugs
which has lost favour in the treatment of anaemia. Arsenic acts as a
depressor of bone marrow with decreased production of young red cells,
but with the elimination of the drug the bone marrow responds with
an increase in the rate of maturation of erythroblastic tissue and an
increased production of young red cells.
Waddell, Steenbock, Elvehjem and Hart have shown that nutritional
anaemias in rats could be cured by the addition of various ashes and
extracts to inorganic iron. Rats rendered anaemic by prolonged milk
diet showed no improvement when given pure iron. Iron, plus extracts
of cabbage or cornmeal, resulted in recovery. Copper was found to be the
active principle and they proposed that copper acted as a catalyzer for
some reaction concerned in haemoglobin building. Copper is found in
small quantities in the normal blood. Manganese added to iron and milk
diet produced almost as much effect as copper.
Dietary Factors in Anaemia
Although inorganic materials are important in blood regeneration,
they cannot begin to compare in potency with those factors contained
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The Empress Hotel
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A   CANADIAN    PACIFIC   HOTEL in dietary materials. It has been shown that the amount of blood regeneration in the animal can be modified at will by dietary control.
There is a maximum response to liver and kidney with a minimum to
food grains. Between these two extremes are seen all types of reactions.
The different foods have been extensively studied, especially by Whipple
and Robscheit-Robbins and by Peabody and Muller. Liver stands at the
head of the list and has been studied from a variety of angles, both as an
extract and as whole liver. Minot and Murphy first drew attention to
the dramatic effect of liver in pernicious anaemia. It was then tried in all
types of anaemia and the first reports of the effect in other anaemias was
not encouraging. Whole liver in large quantities was used at first and
then extracts began to be prepared. The earlier extracts were alcoholic
fractions or slightly acid water extracts. Whipple and Robscheit-Robbins have established the fact that a watery extract of liver contains
about 20%—25% and alcoholic extract 25%—30% of the active
materials when used in secondary anaemia. Liver extract No. 343 Lilly,
which is free of iron, gives only 10%—15% of the response elicited
when whole liver is given in secondary anaemia. In pernicious anaemia
these fractions appear about as potent as whole liver. Supplementing the
extracts with a small amount of liver in secondary anaemia gives values
in excess of the sum of the two separate reactions. Raw or cooked liver
give similar reactions. Liver intake either as beef, pig or chicken liver of
from 200 to 400 grams daily results in an output of 70—110 grams
of haemoglobin per two week period in chronic secondary anaemia, produced by haemorrhage. It is obvious from experiments that liver parenchyma contains a large amount of potential red cell and haemoglobin-
building material. Amongst the meats, kidney is next to liver in
potency. It is interesting that the livers obtained from a variety of
deep salt-water fish are relatively inert.
Both striated and smooth muscle are favourable food factors for
the manufacture of red cells and haemoglobin, smooth muscle such as
chicken gizzard and cows stomach being more potent than striated.
Skeletal muscle gives between 10 and 40 grams of haemoglobin production per week period. Smooth muscle gives from 60—100 grams when
fed in amounts of 200—300 grams daily for two weeks. Brain and
pancreas are moderately potent, pancreas being slightly more so, giving
20—35 grams of haemoglobin. Fresh cooked spleen demonstrated wide
fluctuations, the output of haemoglobin for the two week period varying from 20—50 grams. A considerable portion of the response to
spleen feeding may be due to the blood content of the organ. Bone
marrow has about the potency of spleen. Liver therapy in pernicious
anaemia is spectacular, results being obvious within two weeks, whereas
the reaction in secondary anaemia is slow and may even be delayed. In
pernicious anaemia there is a great surplus of haemoglobin pigment and
related pigments. The red cells are saturated and the muscle haemoglobin
is high. The blood serum and the body fluids contain an excess of pigments related to the blood haemoglobin. On the basis of the pathological
findings in blood, bone marrow, etc., Whipple proposed an explanation
for these findings in pernicious anaemia, not on a basis of red cell destruction, but on a basis of faulty construction or lack of red cell stroma
constituents. It is assumed that liver feeding supplies the missing element necessary for maturation of the red cell stroma; that large reserves of pigment building materials as well as pigment are stored in body and
the red cells are then produced in extraordinary numbers. In secondary
anaemia there is a deficit of haemoglobin pigments and related pigments.
The red cells are lacking in normal content of haemoglobin and consequently there is a relative excess of stroma. The body pigments are subnormal in concentration and there are no excess pigment derivatives unless active red cell destruction is in progress. Evidently the normal
haematopoietic tissues under the stimulus of a low blood haemoglobin level
can produce stroma more actively than new haemoglobin. The reserves
are exhausted and can only be restored by food intake, organic and inorganic. Liver and kidney in the diet furnish the maximum supply of
substances favourable to new red cell and haemoglobin fabrication. A
new liver fraction has recently been described by Whipple and Robscheit-
Robbins, representing 3% of the weight of whole liver and containing
65%—75% the potency of whole liver for new haemoglobin production
in experimental anaemia due to haemorrhage.
The fact that the only three conditions in which there is evidence
of megaloblastic hypertrophy of bone marrow are the three which respond in a characteristic way to liver suggests that the underlying disturbance is the same, a domination of the megaloblast. These three
conditions are pernicious anaemia, sprue and the anaemia of pregnancy.
Muller has considered the underlying pathology of pernicious anaemia as
an over-stimulation of the reticuloendothelial system, characterized by
an excessive production of megaloblasts, increased blood destruction, and
bilirubin formation. Liver acts, she believes, by inhibiting production of
megaloblasts. Minot believes that in pernicious anaemia liver provides a
substance necessary for maturation of the megaloblasts. The megaloblasts, owing to lack of substance, are unable to develop and therefore
unable to utilize the pigment present from the normal breakdown of red
cells. The color in pernicious anaemia is due then to a deficient utilization of pigment rather than excessive destruction, the anaemia due to
deficient production rather than massive destruction.
W. B. Castle recently has shown that the stomach contents of a
normal man recovered during digestion of a meal of beef muscle and subsequently incubated with additional hydrochloric acid contain a substance capable of causing remissions in certain cases of pernicious anaemia,
comparable to those produced by moderate amounts of liver. From this
is implied that either there is a direct action of some constituent of the
secretions produced by the normal man or some action of these secretions
on the meat. Beef muscle alone or gastric secretion alone were shown
to have no effect. He puts forth the hypothesis that the development
of pernicious anaemia is dependent upon an inadequate gastric digestion
of protein, thus permitting the development of a virtual deficiency in the
presence of a diet adequate for the normal man. The active constituent
or intrinsic factor of the normal human fasting gastric contents is in all
probability secreted by the mucosa of the stomach and is not detectably
present in normal saliva, or duodenal contents free from gastric juice,
or in the secretions of the gastro-intestinal tract of the pernicious anaemia
patient. This substance, he states, is probably organic, an enzyme capable
of interaction with protein, or an extrinsic factor, or closely related substances in neutral solution, resulting in the production of material which
Page 217 when given to pernicious anaemia patients has a marked haematopoietic
effect. The lack of this intrinsic factor, he believes, is probably the essential defect leading to the development of the disease, and the existing
tests for hydrochloric acid and pepsin of the gastric juice are not necessarily of value in determining the presence or absence of this intrinsic
factor, so essential to the reactions between normal human gastric juice
and beef muscle.
Sturgis and Isaac, following this work of Castle, fed whole dessicated
hog stomach and found it gave a marked haemotopoietic effect in pernicious anaemia. Dried stomach extract is now available for use. Jones,
Phillips, Larsell and Nokes have thrown some light on liver fraction giving haematopoietic response. They prepared nucleoprotein and sodium
salts of nucleic acid from various tissues. The product from chicken blood
corpsucles displayed the greatest potency while next most marked came
from beef spleen and salmon liver. They believe that the haematopoietic
stimulant is an integral part of the cell mucleus. It still remains to be
seen whether these nucleoproteins and the salts of nucleic acid hold minute quantities of inorganic compounds that are believed to take part in
regeneration.
Liver contains other dietary factors than those mentioned. It is
rich in iron, in vitamines, both fat soluble and water soluble, and in
proteins.
Extensive research has been carried on to determine the active principle in liver. It was found to be devoid of sulphur and iron. Dakin,
West, and Howe have recently isolated a substance clinically potent in
pernicious anaemia and have shown that it is a compound of betahydroxy-
glutamic acid and hydroxyproline. Both of these substances possess the
characteristics of protein derivatives, but the mode of their linkage still
remains to be determined.
Most of the experimental work on diet in anaemia has centred on
liver and meat products, but lately more literature is appearing on the
other foods. Whipple and Robscheit-Robbins have given us much valuable information on vegetables, fruits, etc.
There are varying opinions as to the importance of vegetables and
fruits in diet. Whipple has shown that spinach and other chlorophyll-
containing vegetables have had reputations better than they deserve,
based on the assumption that animals can utilize chlorophyll to construct
new haemoglobin. There is strong evidence to show that this pigment
cannot be utilized. The chlorophyll content seems to have no relation to
the action of vegetables in aiding regeneration in anaemia. Whipple has
reported that vegetables are fairly uniform in their actions, and possess
only a moderate amount of substance favourable to new haemoglobin
production. Various methods seem to have yielded different results.
Mitchell and Schmedt have reported that spinach added to a milk diet
gives good results and the Wisconsin workers have found value in cabbage
and lettuce or their ash, when added to the diet in milk anaemia.
Fruits on the other hand possess a varying degree of potency. Such
fruits as raspberries are inert, but peaches and apricots are second only
Page 218 to liver, kidney and smooth muscle in their ability to aid blood regeneration. 200 grams of cooked apricots or peaches may cause an average
output of 40—50 grams of haemoglobin per two-week period in the
anaemic dog on basal bread ration. Prunes are nearly as efficient. Raisins
and fresh grapes are somewhat less efficient. Apples show considerable
variation, but are, on the average, in the same class with grapes. The
effect of these fruits is probably due to a combination salt effect, as the
effect of feeding apricot ash is about equal to feeding the fresh fruit.
This salt mixture is known to contain at least iron and copper. Fresh
orange juice was found to have little influence on haemoglobin production.
Whipple and Robscheit-Robbins found eggs and milk to have no
significant influence on blood regeneration. In fact they state that milk
can be placed at the foot of the class of diet factors which bring about
rapid blood regeneration in severe anaemia. Mitchell and Schmedt, on
the other hand, report that eggs have a definite effect on blood regeneration.
It must be remembered that diet in the treatment of anaemia must
include all the essentials of adequate nutrition. Food factors may be
present in small quantities sufficient to prevent development of typical
symptoms of nutritional disease, yet insufficient to maintain proper
health.   More than one deficiency may be present in a given diet.
From the foregoing the relative haemoglobin producing value of
foods can be classified as follows:
1. Most favourable—liver, kidney, chicken gizzard.
2. Apricots, peaches, prunes.
3. Leafy vegetables, skeletal muscle of beef, pork, veal, pancreas
and spleen.
4. Least  favourable—grains,  breadstuffs,   the  common vegetables,
some fruits and all fish.
General Treatment of Anaemia
Diagnosis of the type is, of course, of prime importance. Occupational causes such as occur in lead workers, garage workers, etc., must
be watched for. A search must be made for a condition giving rise to
continual loss of blood, and for any source of infection, either general
infection or a local focus. Metabolic diseases that give rise to anaemia
must be looked for and treated, such as disease of the heart, liver, spleen,
kidney or endocrine system. A blood count is essential, and in some
cases special tests, such as reticulocyte count or icterus index, may be
essential.
If it is found that the red cells and haemoglobin are low, a transfusion may be necessary. Surgery may be necessary to produce results,
such as in Banti's Disease.
No matter what the diagnosis, dietary measures are essential in the
treatment of anaemia and are in many cases the only method of treatment. In pernicious anaemia the diet as outlined by Minot and Murphy
should be carefully followed.
Page 219 If the anaemia is mild, and secondary to a disease,  the following
dietary principles should be adhered to:
1. Calories. A sufficient number of calories to suit the patients'
needs is essential.
2. Fluids.    The fluid intake should be at least six glasses a day.
3. Proteins. Two-thirds of 1 gram per kilo body weight of good
protein should be taken daily. Children should have 2-3 grams
per kilo per day.
Foods rich in superior protein are whole wheat, eggs, milk,
cheese, meat and fish. Proteins of refined cereals and vegetables
and fruits are inferior.
Fat. Superior fats, i.e., those associated with the fat soluble
vitamines A, D and E should be used. Cod liver oil, liver, eggs,
milk and cream contain fats rich in vitamine A, C, D. Olive
oil and corn oil possess vitamine E.
Calcium. The daily intake of calcium should be 750 mg. for
an adult and 1,000 mg. for a child or a pregnant woman.
Cereals, vegetables, fruits, nuts and dairy products contain
most calcium, but vary tremendously, Swiss cheese topping
the list with 1.050 mg. per 100 grams edible portion; almonds
239 mg.; dry figs 162; cabbage greens 160; olives 122; wheat
bran 120; egg yolk 137; oatmeal 69; oatmeal 69; spinach 67;
turnips 64; dates 65.
Phosphorus. The daily intake of phosphorus should be 1,320
mg. for an adult or 1,500 for a child or pregnant woman.
Cereals, vegetables, fruits, nuts, dairy products and meat corrtain
phosphorus. Millet contains 2,370 mg. per 100 grams edible
portion; almonds 465; whole wheat 423; barley 400; peanuts
399; egg yolk 524; kidney beans 475; lentils 43 8; pecans 335;
beef liver 220; lean beef 218; raisins 132; apricots 117, etc.
Iron. The daily intake of iron should be 20-25 mg. per day.
Foods rich in iron are many, such as: liver 29.4 mg. of iron per
100 grams edible portion; hog spleen 25; beef kidney 18.8;
parsley 19.2; lima beans 11.7; kidney beans 6.9; spinach 6.6;
beets 2.4; bran 7.8; wheat 3.5-5; apricots 7.3; raisins 7;
Peaches 6.1; prunes 5.2; pistachio nuts 7.0; walnuts 6.0; egg
yolk 7.6; molasses 8; cocoa 3.1; oysters 3.1; etc.
Anaemia-Preventing Factor of Whipple and Robscheit-
Robbins must be present in large quantities. Liver contains
most of this, and then kidney, chicken gizzard, peaches and
apricots.
Iodine. 0.1 mg. is the daily amount required. Sardines, salmon and other sea food contain iodine, and should be eaten at
least once a week. Cod-liver oil is also rich in iodine, containing about 1 mg. in 7 gms. of refined oil.
Base-Forming Foods should preponderate over acid-forming
foods. The greatest acid-forming foods are wheat, oats, egg
yolk, whitefish, oysters, meat and chicken.    The greatest base- d.
e.
forming foods are lima beans,  spinach,  carrots, parsnips, figs,
dates and raisins.
11.    Vitamines.    Vitamine-rich foods are:
a. Anti-Ophthalmic. Butter, carrots, cheese, cream, cod
liver oil, egg yolk, peaches, spinach, tomatoes, pineapple,
etc.
b. Anti-Beri-beri. Whole wheat, whole barley, whole rice,
egg yolk, onions, cabbage, parsnips, turnips, asparagus,
lemons, oranges, yeast, etc.
c. Anti-Scorbutic.      Berries,    cabbage,    celery,    lettuce,
tomatoes, oranges, lemons, peaches, etc.
Anti-Rachitic    Cod liver oil, egg yolk, milk, etc.
Anti-Sterility.    Wheat, corn, oats, olive oil, corn oil,
peanut oil, liver.
/. Anti-Pellagra. Milk, eggs, fresh meat, carrots, spinach, tomatoes, yeast.
Results of Treatment with the Principles Outlined
It is important to remember that a diet in the treatment of anaemia
must include all the essentials of adequate nutrition as outlined. A
diet which falls even slightly short, either qualitatively or quantitatively,
will not bring about the expected results. In pernicious anaemia liver
may be given and in diabetes we may regulate the fat, protein and carbohydrates, but the kind of fat or protein is unimportant and there need
be no thought given to the mineral or vitamine content. At times
there may be superimposed upon the original pathological condition a
deficiency not present at the beginning. Any diet must aim to correct
all errors in the patient's diet.
In pernicious anaemia the first result seen from the Minot and
Murphy diet is an increase in appetite, which occurs within 3-5 days.
Sore tongue, digestive disturbance, pallor, oedema and weakness are relieved in 4-6 weeks. The colour index comes to normal and the red
cells gradually become uniform in size and shape. The earliest and most
significant change in the blood is the appearance of reticulocytes in large
numbers. From 1-3% they increase to 5-6% within a few days. In
some cases it has reached as high as 30%. The increase is noticed
usually by the third day, and never later than one week, and the peak
is reached between the sixth and ninth days. The decrease is more gradual than the increase, usually reaching normal in about ten days. When
the red cells begin to approach normal, the reticulocytes almost disappear. When the red cell count is three millions or more, the increase in
reticulocytes may be so small as to be undetectable. Along with the
increase in red cells, the white cells and platelets increase.
At the end of the first week the icterus index begins to fall, and
reaches normal in 3-4 weeks. The bone-marrow is seen to gradually
return to normal. The two pathological conditions that persist are
achlorhydria and advanced change in the nervous system. Only three
cases are reported in the literature where free hydrochloric acid appeared
in the stomach after therapeutic measures had been instituted. The milder
symptoms resulting from degeneration in the spinal cord such as paresthesia,  numbness  and  tingling,  etc.  are improved.     Serious  changes in
Page 221 the cord are practically always unaltered. However, cases have been
reported where even marked changes have been benefited by liver therapy.
Conner found marked improvement in the neurological symptoms and
signs in a patient with subacute combined sclerosis and peripheral neuritis,
associated with pernicious anaemia. It must be remembered that to treat
pernicious anaemia successfully the patient must continue to take liver
or liver extract even after clinical improvement takes place, in order to
prevent a relapse. If the patient is averse to liver, kidney, chicken
gizzard, apricots, peaches and prunes can be used and be supplemented
occasionally by liver; thus the Minot-Murphy diet is not a liver diet,
but one rich in the anaemia-preventing factor and also an adequate diet
in all respects. It is also important to remember that adequate quantities of these foods must be administered. The amount may vary with
the patient, but must be sufficient to call forth the maximum response
in the blood regeneration. The only criteria of adequacy of treatment
are the blood-count and reticulocyte-count. The administration of dilute
hydrochloric acid is not essential. Results appear to be equally good without it. Lemon juice is probably preferable to dilute hydrochloric acid, as
it not only furnishes the necessary gastric acidity, but is more palatable
and furnishes a rich supply of water soluble vitamine. A point to bear in
mind when substituting liver extract for whole liver is that we are giving
a substance free from iron, instead of one rich in iron, so that it is necessary to add foods rich in iron. If after instituting the correct dietary
procedures, the expected results not obtained, a focus of infection should
be searched for, as, in the presence of infection, the bone marrow may
respond poorly. However, with reference to infection, it has been reported that anaemia secondary to chronic pyogenic foci will improve when
the dietary principles as outlined are applied.
Sprue appears to be definitely relieved by the dietary principles outlined. In aplastic anaemia no effect is seen. Anaemia due to haemorrhage either acute or chronic is markedly benefited.
The literature is somewhat conflicting regarding the results of diet
therapy in secondary anaemia. Many report favourable results, while
others are somewhat pessimistic. It depends to a certain extent on what
the condition is to which the anaemia is secondary and how the results are
interpreted. The reticulocyte count is not an indication of results, as in
anaemia with a count of over three million red cells, there may be no
increase in reticulocytes seen. Since many cases of secondary anaemia
respond to diet therapy, it is logical to apply the known dietary principles to any anaemia in the hope that it falls into a type that is benefited.
Anaemias resulting from cardiac disease, syphilis, chronic functional
anorexia, chemical poisons, pregnancy, chronic pyogenic infection, and
many other conditions are reported in the literature as being markedly
benefited by diet therapy.
[Dr. Hatfield's paper is accompanied by a most complete bibliography, which we regret is withheld, owing to the limited space at our
disposal. The names most prominent in this reference list are those of
Whipple and Robscheit-Robbins, Minot and Murphy, Muller and Castle.
Editor's note.!
Page 222 HOTEL GEORGIA
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MRS. KATE PEGRAM
CA.M.R.G.
Medical   and   Surgical   Massage
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1645  11th AVENUE WEST
Vancouver,   B.   C.
Office Sey. 2855
Res. Doug. 4682Y
MISS BEATRICE GALLOP
C. A. m. r. g.
Graduate
McGill   University   School   of   Massage
and Remedial Exercises
419 VANCOUVER BLOCK
Vancouver,  B.   C.
Telephone Sey. 3334
MRS.  E.  M.  PARR
Chartered Society of Massage and Medical  Gymnastics,  England
Canadian   Association   of   Massage   and
Remedial Gymnastics
430-431   BIRKS   BUILDING
Vancouver,  B.   C.
Office Doug.  908 Res. Doug. 908
MISS A. E. MARKHAM
Chartered Masseuse, England
Canadian   Association   of   Massage   and
Remedial   Gymnastics
924   BIRKS   BUILDING
Vancouver,   B.   C.
i i
j Electro Medical Apparatus Repair j
! Specialists I
f Ultra Violet Twin Carbon Arc Lamps. $75.00 j
i Infra Red Lamps  $37.50 >
j CARROLL ELECTRIC }
ELECTRO MEDICAL ELECTRICIANS
525 Dunsmuir St. Vancouver, B. C. Correcting an Error
In the Journal of the A. M. A., March 28th,
1931, page 30, we inadvertently stated the
iron content of Mead's Cereal to be 68 milligrams per hundred grams. (This figure was
confused with .0068 gms. iron per ounce.)
The correct content is 24 mgs. iron per 100
gms     But even so, Mead's Cereal contains B
26% more food iron than kidney
73% more food iron than spleen
100% more food iron than romain
172% more food iron than liver
179% more food iron than egg yolk
These five foods are
compared because
they are considered
highest in food iron.
(Mead's Cereal contains
100 times as much iron as
whole milk)
A well-known paediatrician has drawn attention to the fact that in practice, Mead's Cereal is more palatable and more readily taken
by children than other iron-containing foods,
some of which are quite unappetizing and even
repellent, especially after long-continued use*
Mead Johnson & Co. of Canada, Ltd., Belleville, Ont. d^^&als
Mead's Cereal also is rich in copper, calcium, phosphorus and in other essential minerals. B* C* Pharmacal Co* Ltd*
Established  1913
Manufacturers of
HAND-FILLED SOLUBLE ELASTIC CAPSULES
May be obtained through any Pharmacy.
Complete formulary on application.    Capsules containing
special formulae can be obtained within 48 hours.
329 Railway Street      -      Vancouver, B. C.
Phone Seymour 597
w/jone
Therapeutic Corsetry
VISIT BOOTH 11
Oval Room, Hotel Vancouver
during the Canadian Medical Association
meetings,  June  22   to  26.
Demonstrations of our surgical supporting
garments will gladly be given.
Nu-Bone — Nu-Trend — Nu-Zip
Office—455 Granville St., Vancouver, B.C. Sey. 7258 Surgical Supplies Sterilizers
Surgical Dressings
Fisher & Burpe Ltd*
X-Ray and
Physiotherapy Apparatus
Phone Trinity 6253
536 SMYTHE STREET VANCOUVER, B. C.
eo
J        Jl. hm IWa Too*
 'WHEAT _
53    BRAN   BB
""*■   J1AX    -*~
4k t~ .( Ca.ttpmSo.
mutn nm nirui UKIO
You can recommend Dina-Mite for your patients.
Made from the full ripened grains, all thoroughly cleaned and washed, finely ground, rich in the vitamins and
mineral salts. Easily assimilated into acid. The flax content a tonic to the intestinal tract.
Your name and address forwarded to
The Dina-Mite Food Co* Limited
49 Broadway East, Vancouver, B. C.
will bring you a free package. «     «
ANNOUNCING  » I
= A NEW ==
CAPITOLA PHARMACY
S.W. Cor. Granville and 41st Ave.
Free Motor Cycle Delivery Anywhere
From 8 a.m. until 11 p.m. Daily
Capitola Pharmacy Ltd.
FRED G. BROWN   ;^fj
Kerr. 1221';-—    Phones    —    Bay. 3700
(Sinter & ||arara, JUlb*
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C. Rest Haven Sanitarium and Hospital
MARINE  DRIVE,  SIDNEY,  B.  C,   (Near  Victoria)
Particularly convenient and  desirable for   Rest—Recuperation  and   Convalescence.
Rates  are   reasonable,   with   meals  and  treatments  included.
Direct patients to Rest Haven from Victoria by the Vancouver Island Coach Lines, Ltd.,
at  the  Broughton   Street   Station.    Private car  will  meet  boats  if  desired.
FOR  RESERVATIONS  AND   FURTHER  INFORMATION  WRITE  OR
TELEPHONE MEDICAL  SUPERINTENDENT OR MANAGER,  SIDNEY 95—61L.
Sistomensin "Ciba" Agomensin "Ciba"
The Specific Female Sex
Hormone
Standardized by the Allen-
Doisy test on spayed rats,
and also by the Hermann test
on the infantile rabbit uterus.
INDICATIONS: Functional
dysmenorrhea, menorrhagia,
haemorrhages of puberty and
menopause, hypoplasia of the
uterus, disturbances
subsequent to menopause or
oophorectomy.
The Hydrosoluble Ovarian
Substance
causes hyperaemia of the
female genital organs. Stimulates the function of the
genital glands and menstruation.
INDICATIONS: Functional
amenorrhea, oligomenorrhea,
sterility, vomiting during
pregnancy, etc.
Tablets:
bottles of 40
and 100
Ampoules:
boxes of 5
and 20
Tablets:
bottles of 20
and 100
Ampoules:
boxes of 5
and 20
CIBA COMPANY LIMITED
146 ST. PETER STREET, MONTREAL  ♦
ye^m&r&i
aa*-*-
Hollywood Sanitarium
LIMITED
tyor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
''Reference ~ <\B>. Q. dMedical (^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
"*<3>*

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