History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1942 Vancouver Medical Association Oct 31, 1942

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 *_2-
U.B.C LIBRARY      m
•JT^jTMSx-.*:
Tlhe B U L L SEMI
of the
VANC0UV|R|
MEDICAL ASlOCIATION
■Vol. XIX
OCTOBER, 1942
No. 1
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
StMPaurs Hospital
In This Issue!!
|||JDEX TO VOLUME XVIII
NEWS AND NOTES ft-	
DEPARTMENlif&F DIETETICS	
REVIEW, CASES OF ARGENTAFFI_4^_ATA1^^
PLASMA PROTEINS jjj—jj|	
GECOSTOMY INDICATIONS AND TECHNIQuf|j
Page
4
14
17
20
22 Standardized
LIVER EXTRACT
HEPAROL eTs
HEPAROL E.P.S. is standardized according to the
methods of the Antianemia
Advisory Board of the
V.S.P. to contain 4 U.S.P.
injectable units in'Jjeach
ampoule.
A Standardized Liver Extract for Intramuscular
Injection, containing 4 U.S.P. units ineach2cc.
ampoule (2 units in each cc).
.f: ll R EG E:i E R AT if E  § RE ATM EN T jj||
This Standardized Liver Extract enables the physician to treat the nutritional types of macrocytic anemia, Addisonian pernicious anemia and the
anemia of pregnancy with knowledge of the result to be expected. As the
patient receives a specific amount of the antianemia fraction of liver in
each Heparol ampoule, it becomes unnecessary for him to consume large
amounts of liver in his diet and the advantages of administering active
material in sufficient amounts by a single route at regular intervals, are
obvious. II     |R2 MAINTENANCE - *mBm     ^H
After regeneration has been accomplished, the normal blood picture may
be maintained by less frequent injections of Heparol, which render the
ingestion of large quantities of liver, for maintenance, unnecessary.
hypochromicIanemia
Many patients suffering from hypochromic
anemia respond to a combined treatment
with liver and iron. In these cases, in
addition to the intramuscular injection of
Heparol E.B.S., it is advisable to prescribe
Ferrochlor with Vitamin B£l Ferrochlor
with Vitamin B_ exhibits iron in the
form in which it is most readily assimi
lated by the system without gastric
disturbance.
HEPAROL AMPOULES E.B.S. are supplied in convenient boxes of 6's and 12's
FERROCHLOR with Vitamin B_ is sup*
plied in two convenient forms: Liquid and
Tablet (S.C.T. #338A).
Identify these products on your prescriptions by inserting the letters E.B.S.
following the product name.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA THE    VANCOUVER    MEDICAL    A S S O C t!__T-I__*L.
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDermot
De. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XLX.
OCTOBER, 1942
No. 1
OFFICERS, 1942-1943
Dr. J. R. Neilson
President
Dr. H. H. Pitts
Vice-President
Dr. C. McDiarmid
Past President
Dr. A. E. Trites
Hon. Secretary
Additional Members of Executive: Dr. Wilfrid Graham, Dr. J. A. McLean
Dr. Gordon Burke
Hon. Treasurer
TRUSTEES
Dr. P. Brodie Dr. J. A. Gillespie Dr. W. T. Lockhart
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Dr. D. A. Steele Chairman Dr. J. W. Millar Secretary
Eye, Ear, Nose and Throat
Dr. A. R. Anthony Chairman Dr. C. E. Davies Secretary
Pediatric Section
Dr. G. O. Matthews Chairman Dr. J. H. B. Grant Secretary
STANDING COMMITTEES
Library:
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. A. Bagnall, Dr. A. B. Manson, Dr. B. J. Harrison
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. J. E. Harrison, Dr. G. A. Davidson, Dr. R. A. Gilchrist
Dr. Howard Spohn, Dr. W. L. Graham, Dr. J. C. Thomas
Credentials:
Dr. A. W. Hunter, Dr. W. L. Pedlow, Dr. A. T. Henry
V. 0. N. Advisory Board:
Dr. L. W. McNutt, Dr. G. E. Seldon, Dr. Isabel Day.
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont.
Greater Vancouver Health League Representatives:
Dr. R. A. Wilson, Dr. Wallace Cobubn.
Representative to B. C. Medical Association: Db. C. McDiabmid.
Sickness and Benevolent Fund: The Pbesident—The Tbustees. *s
0> JP
"\
»«co——-_«_ by
Co**, of Feodi _
Nutrition, Notional
B««or;h CognoL
VITAMIN       VITAMIN
(THIAMINE
HYDRO*
CHLOHDf)
VITAMIN NICOTINIC    VITAMIN
B2 ACID C
IRIBO- (ASCOBBK
FLAVIN) ACID)
CALCIUM        IRON
=¥=
SHADED AREAS SHOW
PROPORTIONS  SUPPLIED
BY  PARGRAN
•     •
2 PARGRAN-V
PERLES
A PARGRAN-M
CAPSULES
HH
Now, more than ever before, it is necessary to make
certain that our people are receiving adequate
amounts of accessory food elements. Now, with
physicians busier than ever, there is need for
products which will simplify the application of the
basic principles of good nutrition.
The House of Squibb has made a real contribution
to practical nutrition by providing Pargran-V and
Pargran-M. Study the charts above and you will
see that Pargran—
. . . provides a rationally balanced and adequate
vit_ur_n-rnineral supplement for use when food
sources fail;
affords flexibility of dosage—supplying vitamins
-in 34, /_, M or the full daily
or minerals or both-
allowance;
. . . fulfills the recommendations of the Committee
on Foods and Nutrition of the National Research
Council U.S.A.
. . . provides the advantages of convenience and
economy.
PARGRAN- V
SQUIBB
8Iutti»St*mi» F*_l
KOUJOSCAUAfi
Ke^ \n * c_* {
PARGRAN-I
squibs
0#«fum-lron Capsut« \ \
-__g?» *a<tt*lt**vcpa***k??^LJ ■
Write now for complete
information about Pargran-V
and Pargran-M. Address
36 Caledonia Rd. Toronto, Ont.
E-fcSopb- &Sqns of Canada, Ltd.l
MANUFACTURING   CHEMISTS   T0   THE   MEDICAL   PROFESSION   SINCE   1858 VANCOUVER     HEALTH     DEPARTMENT
STATISTICS—AUGUST, 1942
Total Population—estimated 272,352
Japanese Population—estimated 8,769
Chinese Population—estimated 8,558
Hindu Population—estimated 360
Rate per 1,000
Number
Total deaths 1    239
Japanese deaths I t        3
Chinese deaths .      13
Deaths—residents only     198
BIRTH REGISTRATIONS :
Male, 301: Female, 288	
Population
10.4
3.9
17.5
8.6
INFANTILE MORTALITY:
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths (not included in above).
Aug., 1942
.__ 11
_ 18.7
_     15
Aug., 1941
16
36.1
8
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
July,
Cases
Scarlet Fever 18
Diphtheria 0
Diphtheria Carrier 0
Chicken Pox j 126
Measles      7
Rubella 0
Mumps  251
Whooping Cough    10
Typhoid Fever      0
Undulant Fever        0
Poliomyelitis \      0
Tuberculosis    35
Erysipelas      0
Meningococcus Meningitis      0
V  D   CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
West North      Vane.  Hospitals &
Burnaby   Vancr.  Richmond   Vancr.     Clinic  Private Drs.  Totals
Syphilis	
Gonorrhoea	
Not yet available
A DYNAMIC MENTAL AND PHYSICAL TONIC
INDICATED IN THESE DAYS OF STRESS
BIOGLAN "A
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
1942
Augus
it, 1942
Sept. 1-1
5,1942
Deaths
Cases
Deaths
Cases
Deaths
0
10
0
20
0
0
0
0
0
0
0
1
0
0
0
0
78
0
11
0
0
4
0
1
0
0
0
0
0
0
0
112
0
20
0
0
14
0
5
0
0
0
0
1
0
0
0
0
0
0
0
5
0
9
0
10
43
19
18
0
5
O
0
0
0
3
1
2
0
ii A  »» B. D. H. I
COMMON COLD VACCINE TABLETS
(For Oral Use)
A vaccine effective against the virus of the common cold is not as yet
available, but the use of an anti-catarrhal vaccine against the secondary
bacterial invaders is of value in that the incidence and virulence of the
infection are reduced.
The results of clinical use have shown that in cases responding to vaccine therapy an effective degree of immunity can be produced by oral
administration, thus eliminating the necessity of repeated injections.
One B.D.H. Common Cold Vaccine Tablet daily for a week, followed
by a further week's treatment after an interval of two weeks, usually
produces an optional level of immunity. Immunity, when established,
is maintained by giving at least one tablet weekly throughout the subsequent winter months. During periods of epidemic, it may be advisable to revert to daily administration.
Stocks of B.D.H. Common Cold Vaccine Tablets are held by leading druggists
throughout the Dominion, and full-particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Toronto Canada
CCV/Can/4210 VANCOUVER MEDICAL ASSOCIATION
FOUNDED 1898    ::    INCORPORATED 1906
Programme of the Forty-fifth Annual Session
(Winter Session)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings are to be amalgamated with the clinical staff meetings of the
various hospitals for the coming year.   Place of meeting will appear on the agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
1942
October 20—COMBINED CLINICAL MEETING and CLINICAL STAFF MEETING at ST. PAUL'S HOSPITAL.
November    3—GENERAL MEETING.
November 17—COMBINED CLINICAL MEETING and CLINICAL STAFF MEETING AT VANCOUVER GENERAL HOSPITAL.
December    1—GENERAL MEETING.
Dr. H. A. Desbrisay: To be announced.
December 15—COMBINED CLINICAL MEETING and CLINICAL STAFF MEETING at SHAUGHNESSY HOSPITAL.
"after a debilitating illness...
Guinness often supplies just the necessary fillip to nudge the patient out of
the rut of low health."
M. B.
Literally by the thousands, doctors in Britain have reported in this way.    As
you know, the tonic properties of Guinness Stout are famous.
In addition, Guinness has proved invaluable in
treating insomnia. It obviates the depressing after
effects which most hypnotics produce. Guinness is
a stimulating, appetizing food for middle-aged
and  elderly people.
All of its natural   goodness  is  retained.  Nutritional elements  are not filtered out  for  the  sake
AN ANALYSIS OF GUINNESS STOUT 100 cc.
Total solids 5.87 gas.
Ethyl alcohol   (7.9%  by volume) 6.25 gm.
Total carbohydrates -     3.86 gm.
Reducing  sugars  as  glucose | 0.66 gm.
Protein i Nome
Total nitrogen -. 0.10 gm.
Ash  .    ...' 0.28 gm.
Phosphorus 38.50 mg.
Calcium I :     7.00 mg.
Iron I     0.072 mg.
Copper     0.049 mg.
Fuel value SI cat.
Vitamin  Bx  6 Int. Units
Vitamin G J3  Sherman Bourquin Units
S317
of sparkle. And because it is not pasteurized,
Guinness in bottle continues to mature, contains
active yeast—a source of Vitamins B and G. Only
four ingredients are used: barley malt, hops,
Guinness yeast and water. Brewed in Dublin
since 1759. Foreign Extra Guinness is obtainable
through   all   legal -outlets.   Write   for   file   card
giving complete an- IN THE TREATMENT OF
PERNICIOUS ANAEMIA.
THE BEST Therapeutic measure at present available is the intramuscular injection of a potent, concentrated, -and purified liver
extract. The concentrated extract prepared by the Con naught
Laboratories has the following advantages:—
0 ASSURED POTENCY—Each lot is tested clinically
for therapeutic activity.
0 SMALL DOSAGE—In most cases initial treatment
with one cc. per week is sufficient—for maintenance, one cc. at less frequent intervals is
generally adequate.
0 PURITY—The extract is a clear, light brown solution, containing less than  100 mg. sojids per
cc.
PURIFIED LIVER EXTRACT (Highly Concentrated) IS SUPPLIED BY THESE
LABORATORIES IN FOUR-CC. RUBBER-STOPPERED VIALS.
CONNAUGHT LABORATORIES
UNIVERSITY OF TORONTO
Toronto 5
Canad THE   EDITOR'S   PAGE
The Vancouver Medical Association has called a meeting at an early date to consider what attitude it should assume in the present controversy about the chlorination
of water in Vancouver and other centres. By the time this appears in print, -the meeting will be over, and we feel sure that the collective wisdom and common sense of our
profession will express itself in a form that will be constructive and helpful. But the
whole affair leads to certain reflections and thoughts which seem to demand expression.
Why is it that almost without exception, whenever a suggestion comes regarding
public health measures, from those who, qualified by training and research, might be
supposed to know what they are talking about, there immediately arises and becomes
vocal a large body of antagonistic public opinion? We see this in the matter of vaccination, of pasteurization of milk, and so on. All those who know least about the scientific merits of the case, rush eagerly into print, and speech on public platforms. A
newspaper can always be found to champion the cause of the objectors, and the fight
is on. Public feeling is aroused, by the appeal to sentiment and that natural objection,
which we all share, to change of any kind—and the honest, scientifically based efforts of
those who really know, and who alone are really qualified to express a correct opinion,
are put to nought, or hampered for a long time.
We, as medical men, should be particularly on our guard against allowing ourselves
to fall into this error. For firstly we are more or less scientifically trained ourselves—
and these men who are offering us their expert opinion are themselves medical men, with
our own point of view and our own keen anxiety to improve public health. Our duty
is to support these men, and endorse their efforts: not to allow ourselves to go with the
crowd, who having no exact knowledge, and merely strong emotions, are at the mercy
of the glib, and totally untrustworthy, demagogues and charlatans who inevitably appear
to lead the opposition. We do not mean by this that everyone who disagrees with our
point of view falls into this class. But we of the rank and file of medicine, while we
have a knowledge of general principles of public health, have little more. We have not
the facts at our disposal to study and estimate. We have not the exact knowledge of
bacteriology and epidemiology that are necessary before we can form and express an
opinion of any real value. Then it would seem logical that we should trust those who
have these facts and this knowledge. We know that their honesty and sincerity are
above reproach: and we must trust to their experience and judgment rather than to
our own, and shew the public that we have confidence in the men whom we and they
have appointed to look after our health.
We publish in this number "Regulations governing prescriptions for codeine," and
would draw especial attention to paragraph 2 of the article.
We must back up our friends the druggists in this matter. For them the temptation
is, not the few cents they make out of a prescription, but their desire to help us out:
they know that for a doctor, called far from his office, or on an emergency, it may be
impossible, without the greatest inconvenience, to give a written prescription into the
hands of the druggist. They are, as always, most anxious to help us: but when they do
so in violation of the rigorous mandate of the Narcotics Act, they lay themselves open
to penalties whose severity is such that we have no right whatever to ask them to
expose themselves to such risk.
We feel that the druggists are perfectly right in refusing absolutely to fill any prescription containing any narcotic, unless the law has been complied with in every detail.
Page 3 We take this opportunity of congratulating the Summer School Committee on the
success of the Summer School last month. The membership was very good indeed—and
better still, the programme was excellent. Their work was accomplished in spite of the
severest difficulties that have ever faced a Summer School Committee, and they deserve
our thanks. To all the speakers, we are very grateful—and we should not forget that
the smooth and noiseless working of the machinery of the meeting was made possible by
the office staff of the Association, Mrs. Craig, our Librarian, and Miss Smith, her assistant, to whom also we express our sincere gratitude.
NEWS    AND    NOTES
Dr. and Mrs. J. G. MacArthur of Prince George are receiving congratulations on
the birth on September 4th of a son, Ronald Douglas.
Congratulations are extended to Dr. and Mrs. L. S. Chipperfield of Port Coquitlam
on the birth on September 12 th of a son.
Congratulations to Dr. and Mrs. R. J. Macdonald of Prince Rupert (formerly Pouce
Coupe) on the birth on September 15th of a son.
The profession extends sympathy to Dr. N. W. Strong of Vernon in the loss of
his wife.
According to latest reports, Capt. R. R. Laird, R.C.A.M.C, listed as missing at
Dieppe, is now a prisoner of war in Germany. Dr. Laird, a graduate of Queen's University, will be remembered by many as an interne at the Vancouver General Hospital
and later serving as ship surgeon on the Empress of Russia. Captain Laird went overseas in December, 1940.
We regret to announce the passing of the wife of Dr. R. G. Stevenson of Vancouver.
The sympathy of the profession is extended to Dr. Ross Stone of Vanderhoof in the
passing of his brother, Clifford E. Stone of loco.
Congratulations to Dr. S. A. Creighton upon the occasion of his marriage in Toronto
to Miss Ethel Moffatt, daughter of Dr. W. A. Moffatt.
Dr. and Mrs. M. E. Krause of Trail spent a week in Vancouver recently.
Dr. and Mrs. J. S. Daly of Trail have returned from a two weeks' trip to Belleville, Ont.
Dr. Heber Jamieson of Edmonton, Alta., visited his brother-in-law, Dr. E. J. Lyon
and Mrs. Lyon of Prince George.
Members travelled from far corners of the Province to attend the Sessions of the
Summer School in Vancouver. From Michel—Dr. C. E. Cook; CrestonDr. J. V. Murray; Trail—Dr. M. E. Krause; Nelson—Drs. R. B. Brummitt and C. M. Robertson;
Field—Dr. G. A. Cheeseman; Burns Lake—Dr. T. C. Holmes; Prince Rupert—Dr. L.
W. Kergin; Oliver—Dr. M. C. Bridgman; Penticton—Dr. G. C. Paine; Kelowna—Dr.
W. F. Anderson; Armstrong—Dr. R. Haugen; Kamloops—Drs. J. L. Coltart and C. J.
M. Willoughby; Merritt—Dr. A. Gillis.
Page 4 Congratulations are extended to Dr. and Mrs. G. B. B. Buff am of Victoria on the
birth of a son.
Drs. P. A. C. Cousland and A. B. Nash of Victoria have returned to their offices
after a week's holiday.
Dr. C. W. Duck of Victoria was on a hunting trip up the Island.
Dr. L. Giovando of Nanaimo returned from a hunting trip at Campbell River with
two deer and a good bag of grouse.
. Drs. E. D. Emery and S. L. Williams of Nanaimo attended the sessions of the Summer School.
Dr. C. C. Browne of Nanaimo took his sloop Ann to the evacuation manoeuvre at
Montague Harbour.
Capt. W. H. White was on leave in Penticton recently before going East.
At the Annual Meeting of the North Shore Medical Society held on September 8 th,
the following were elected to office: President—Dr. C. M. R. Onhauser, West Vancouver; Vice-PrPesident—Dr. G. A. McLaughlin, North Vancouver; Honorary Secretary-Treasurer—Dr. Christina Fraser, North Vancouve.
*? *& »s* **.
Dr. Harold Ostry, recently of Kamloops, has joined the R.C.A.M.C.
Dr. C. E. McRae of Williams Lake is now at Kamloops with Dr. R. W. Irving and
associates.
*       *       *       *
Dr. and Mrs. G. F. Young, formerly of Salmo and now of Belcher Hospital, Calgary, recently visited Nelson.
•j. *». »t *t
Dr. R. B. White of Penticton called at the office when in Vancouver recently.
The following members from Vancouver Island attended the Summer School: Drs.
D. M. Baillie, E. W. Boak, A. C. Sinclair, Dorothy Saxton, Victoria; Dr. E. N. East,
Qualicum; Dr. E. R. Hicks, Cumberland; Dr. P. L. Straith, Courtenay; Drs. E. D.
Emery and S. L. Williams, Nanaimo; Drs. S. W. Baker and D. P. Hanington, Lady-
smith; Drs. George More and H. N. Watson, Duncan; Drs. R. W. Garner and G. B.
Helem, PoPrt Alberni; Dr. W. E. Bavis, Port Renfrew.
The Fraser Valley was represented at the Summer School by: Drs. D. A. Clarke, E.
K. Hough, J. T. Lawson, E. H. McEwen, S. C. MacEwen, R. A. McLeod, H. H. MacKenzie, W. A. Robertson, New Westminster; Dr. R. C. Novak, Essondale; Dr. L. S.
Chipperfield, Port Coquitlam; Dr. G. Morse, Haney; Dr. P. McCaffrey, Agassiz.
Dr. F. Inglis, Gibson's Landing; Dr. Gordon James, Britannia Beach; Dr. Dallas
Perry, Ganges; Dr. A. C. Nash, West Vancouver; Dr. C. M. R. Onhauser, North Vancouver, attended the sessions of the Summer School in Vancouver.
Page J LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY:
A Bibliography of the Writings of Harvey Cushing.   (Nicholson Collection.)
Surgical Clinics of North America, Symposium on Industrial Surgery, August, 1942 (2
copies).
Occupational Diseases, 1942, by Rutherford T. Johnstone.
War Medicine—A Symposium, edited by Winfield  Scott Pugh.   Gift of Publisher—
Philosophical Library.
Treatment by Diet, 1939, by Clifford T. Barborka. Gift of Dr. A. B. Manson.
Advances in Internal Medicine, vol. 1, 1942.  Edited by J. Murray Steele.   Gift of Publisher—Interscience Publishers, Inc.
STATE JOURNALS
The sample index from a state journal for this month is from Northwest Medicine,
September, 1942.  The titles are listed below:
Hypertension. Follow-Up of 481 Patients—Robert L. King, M.D., Thomas Carlile,
M.D., John M. Blackford, M.D., Seattle, Wash.
Dizziness from Hypertension. Controlled by Histamine Phosphate—Wallace Marshall, M.D., Appleton, Wis.
Urticaria—J. E. Stroh, M.D., Seattle, Wash.
Recent Advances in Surgery. Their Clinical Applications—John A. Gius, M.D.,
Portland, Ore.
Diagnosis of Paresis with Negative Spinal Fluid—William B. Dublin, M.D., and
Robert W. Brown, M.D., Fort Steilacoom, Wash.
Traumatic Rupture of the Kidney—H. D. Norris, M.D., Seattle.
Subacute Cor Pulmonale—John J. Krygier, M.D., and I. C. Brill, Portland, Ore.
BOOK REVIEWS
BLOOD GROUPING TECHNIC, Fritz Schiff, M.D., and William C. Boyd, Ph.D.,
pp. 248, illus. Interscience Publishers, Inc., New York, N.Y., 1942.
This book is probably the last word on this subject. Medical men will find much in
its pages and will be well repaid by giving some time to reading it, if only to get a
knowledge of the progress that has been made and is in prospect. The biologists, anthropologists and medicolegal experts will find it indispensable.
This book should be in all hospital and medical libraries so that those interested may
find it for reference.
W. B. McK.
WAR GASES, Morris B. Jacobs, Ph.D.    180 pp.   Interscience Publishers, Inc., New
York, N.Y. 1942.
In his preface the author states that the aim of his book is to present a system for
the detection, the sampling, and the identification of the chemical warfare agents and
the decontamination of areas and materials polluted by them, so that the information
will be useful to the gas identification officer, the war gas chemist, the decontamination
officer, and the health officer.
War gases are defined and classified according to physiological effect and chemical
composition. Under this classification the various gases are described. Their effects on
materials, water and food are also considered. The techniques of sampling, identification,
detection and decontamination, are described in detail.
Throughout the monograph the author places special emphasis on those war gases
which have been found to be practical agents of warfare. "About 3000 substances were
investigated to determine their value as poison gases and of these only 38 were actually
Page 6 used in warfare. It can be added that of these 38, only 10 or 12 were used to any extent
and that of these 10 or 12, only 6 were really efficient or of great importance as warfare agents.
While the physiological effects of these gases are clearly described, the reader is
referred to other sources for the first aid treatment and care of gas casualties. Much of
the material presented should prove valuable to the air raid wardens and other laymen
in the A.R.P. services for a fuller knowledge of war gases.
There are numerous references given with every chapter. This makes the book a
valuable one for reference as well as a source of facts on war gases. The reader will
readily agree that the author has achieved the aim set for himself and has given us much
useful information in a very accessible form.
J. C. T.
* * * K-
WAR MEDICINE: Edited by Winfield Scott Pugh, M.D., Commander (M.C.), U.S.N.
Retired,  pp. 565, illus.  Philosophical Library, New York, N.Y., 1942.
This is a symposium about the many problems of medicine that are related to war.
Fifty-seven separate subjects classified under the headings of surgery, aviation and
naval and general medicine, are discussed by American and British authors, most of
whom are outstanding authorities in their special field. The range of material is so great
that no medical man who is associated with the war effort in any capacity can fail to
find many chapters of interest. Articles on War Burns by Cecil Wakeley and Abdomino-
Thoracic Injuries by Gordon Gordon-Taylor illustrate the best conservative English
opinion, based on the experiences of World War I, tempered by the experiences of the
past three years. From Americans of equivalent category there are discussions of War
Wounds of the Brain by Gilbert Horrax and War Wounds and Compound Fractures by
Winnett Orr. The latest word from the practical physiologists is related in Physiology
and High Altitude Flying by John Fulton, who also contributes a chapter on Blast and
Concussion in the Present War. Subjects as unrelated as Wounds of the Heart, and
Chigger and Jigger Bites, are all found under the same cover. With such a miscellany of
material it is not hard to find a few pot-boilers written by eminent men who could do
better, and to frequently find lack of relation between the importance of the subject and
length of the article. The book is recommended to all medical men in the Armed Forces,
and to those at home who know the necessity, in these days, of being prepared for any
eventuality.
F. T.
COSSACK CAVALRY ON THE DON
Getting Big Supplies for Wounded Horses front London
Russia's war horses are getting a steady flow of veterinary supplies and equipment
from Britain's Royal Society for the Prevention of Cruelty to Animals. The Society has
already raised £15,000 towards the £40,000 needed to meet the requests made by the
Soviet Government through the British Ambassador.
To date the Soviet Army Veterinary Corps has received 1500 kilogrammes of drugs
and dressings. About 1000 veterinary surgeons' wallets complete with instruments and
drugs have been dispatched and 1000 more are on the way. Field chests costing £18
apiece have gone out and the latest .batch of supplies included microtomes, syringes, and
17 field microscopes. The drugs sent are for dressing burns, removing tape worms,
healing up wounds, and combating fever.
The Russian Army has an excellent system of dealing with its sick and wounded
horses, but its large supplies are being drained and the Soviet Government have asked
for 5 outfits for veterinary hospitals, which will include special veterinary tents and
lighting apparatus, each costing £1000.
The Royal Society is getting the money for them.
Page 7 V
ancouver
Medical Association
THE SUMMER SCHOOL
The twentieth annual Summer School of the Vancouver Medical Association was
held in the Hotel Vancouver on Sept. 15, 16, 17, 18.
The total registration for this year was 239. Of this number 22 were Army Medical
Corps Officers, 7 were Naval Medical Officers, 3 were Air Force Medical Officers and 2
were U.S. Naval Medical Officers. As well as the above men the privilege of attending
the school was extended to 22 hospital internes.
It is particularly gratifying to the committee to report that 51 men from B. C, outside the Greater Vancouver area, and 10 men from the U.S.A. found time to attend
the sessions in spite of heavy demands on their time.
The luncheon was particularly well attended on Tuesday noon. Dr. Archer, President of the C.M.A., was guest speaker. His address placed before us clearly and forcefully the present status of two vital matters. He dealt with the organization and
functions of the Procurement and Assignment Board, touching on some of the problems
confronting them. He discussed in some detail the present position of organized medicine in relation to health insurance. For those who could not hear this address we would
pass on his plea that Canadian doctors make the C.M.A. the spokesman for every medical
man in Canada by joining now.
The problem of obtaining speakers for this year's school was a large one. Repeatedly
the committee had to revise its programme because of cancellations due to the prior
demands for war service. However, it was with great satisfaction that the final programme was presented and so well received.   The attendance at all the lectures was good.
Dr. Alvarez of the Mayo Clinic was here for his second time and the reception his
lectures received showed the wholehearted approval of the Committee's choice. The
Committee and the School are indebted to the Canadian Medical Association for so generously providing us with Drs. Gillespie and Scott of Edmonton, both of whom proved
themselves to be experienced clinicians with fine teaching ability. Dr. Bannick, of
Seattle, at short notice gave two fine lectures of interest to all. As usual, Dr. Donald
Williams presented a very informative and orderly lecture, which proves that Vancouver
has men of teaching ability.
The golf and dinner were combined this year with the Vancouver doctors' final tournament of the year. A beautiful autumn day on the scenic Capilano Golf Course
attracted 61 men to the first tee. Careful check-up shows that all reached the 11th tee
safely. The informal dinner and presentation of trophies and prizes appeared to meet
with approval from many, for the attendance was large. The change made this year
might well be taken as a precedent in future.
The Round Table Conference was carried on this year and received approval in the
form of large attendance and many questions. This would appear to be an established
part of our future programmes.
After a stormy course it is gratifying to know that this 20th Annual Summer School
has been succecssful and it will be an incentive to the Cornmittee in future war years,
when difficulties must increase, to continue this useful work.
Page 8 REGISTRATION
Vancouver Medical Association Summer School
Sept. 15th- 18th, 1942
A. M. Agnew Vancouver
T. H. Agnew .  Vancouver
W. F. Anderson Kelowna
T.  F.  H.  Armitage Vancouver
J. W. Arbuckle Vancouver
D. M. Baillie Victoria
A. W.  Bagnall Vancouver
Surg.-Lt. H. G. Baker.
S. W. Baker Ladysmith
Lt.-Com. H. A. Barner Bremerton, Wash.
C. E.  Battle Vancouver
W.  E. Bavis ft Port Renfrew
Surg.-Lt. D. M. Bean.
Major Alan Beech.
S. A.  Bell . Vancouver
Capt. C. H. Beevor-Potts.
E. M. Blair Vancouver
E. W. Boak  Victoria
Major R. P. Borden.
M. C.  Bridgman Oliver
C E. Brown Vancouver
Harold   Brown , Vancouver
R. B. Brummitt Nelson
R. K. Brynildsen .Vancouver
F. J. Buller Vancouver
Gordon Burke Vancouver
E.  A. Capmbell Vancouver
H. H. Caple Vancouver
R. S. P. Carruthers Vancouver
H. L. Chambers—V. G. H.
G. A. Cheeseman Field
L. S. Chipperfield Pt. Coquitlam
D. A. Clarke New "Westminster
Major W. A. Clarke.
J. W. Cluff—V. G. H.
W. A. Coburn Vancouver
J.  L.  Coltart Kamloops
C. E. Cook , Michel
E. H. Cooke Vancouver
C.   F.   Covernton Vancouver
Surg.-Lt.-Com. M. A. Currie.
Capt. E. J. Curtis.
Capt. T. Dalrymple.
G.  A.  Davidson Vancouver
J. R. Davies . Vancouver
Isabel Day Vancouver
H.   A.   DesBrisay i Vancouver
O. E. DeMuth Vancouver
Major M. R. Dickey Nanaimo
W. J. Dorrance Vancouver
Victor Drach Vancouver
J. M. Dugas—St. Paul's,
G. E. Duncan Vancouver
G. P. Dunne Vancouver
H. A. Dyer North Vancouver
"Watson Dykes Vancouver
E. N. East Qualicum
C M. Eaton Vancouver
R.  Elder : Vancouver
B.  S. Elliott Vancouver
E. D. Emery Nanaimo
W. F. Emmons Vancouver
W. T. Ewing __ Vancouver
J. Fenwick—V. G. H.
Lt.-Com. E. F. Ferciot—U. S. Navy.
E. P. Fewster Vancouver
R. H. Fraser : Vancouver
W. R. Fraser—V. G. H.
A. C. Frost Vancouver
J.  D.  Galbraith ,— Sardis
F. O. R. Garner Vancouver
R. W. Garner Port Alberni
J.   A.   Gillespie j ■ Vancouver
G. E. Gillies Vancouver
Austin  Gillis Merritt
M.   Gorkin .Vancouver
W. R. Govan—V. G. H.
W. L. Graham Vancouver
H. C. Graham North Vancouver
Surg.-Lt.-Com. Gordon Grant.
J. H. B. Grant: Vancouver
W. H. Gray Colville, "Wash.
I. B. Greene Everson, Wash.
L.   O.   Griffin \ Vancouver
J.  C.  Grimson ^Vancouver
W. R. S. Groves Vancouver
Capt. K. J. Haig Nanaimo
M. Halperin __, Vanouyer
D. P.  Hanington ! Ladysmith
J. C. Haramia.
J.   E.  Harrison Vancouver
W. E. Harrison Vancouver
W. H. Hatfield  Vancouver
R. Haugen Armstrong
F. Hebb Vancouver
G. B.   Helem i Port  Alberni
A. T. Henry Vancouver
E. R. Hicks Cumberland
G.  L.  Hodgins , Vancouver
T. C. Holmes— Burns Lake
E. K. Hough New Westminster
G.  H.   Hutton Vancouver
F. Inglis _Jj Gibson's Landing
J. R. Ireland.
Paul Jackson—St. Paul's Hospital.
E. S. James Vancouver
Gordon James Britannia
Capt. A. M. Johnson.
E.  A.  Johnson Vancouver
W. D. Keith  Vancouver
J. C Kennedy—St. Paul's.
L. W. Kergin Prince Rupert
W. T. Kergin-, Vancouver
G. E. Kidd Vancouver
G. F. Kincade Vancouver
R. P. Kinsman Vancouver
M. E. Krause Trail
Flight-Lt. A. W. Large.
P. L.  Lavers Vancouver
J. T. Lawson New Westminster
G. H. Lee Vancouver
I. E. Lloyd _Mt. Vernon, Wash.
W. T. Lockhart Vancouver
Capt. J. Margulius.
Surg.-Lt.-Com. A. Marshall.
I.   Martianoff Steveston
G. O. Matthews Vancouver
H.   H.   Milburn , Vancouver
Major R. L. Miller.
G. A. Minorgan Vancouver
Page 9 Capt. D. W. Moffatt.
G. More Duncan
Wm. Morris : —.Vancouver
M. Morrison Vancouver
G.  Morse : Haney
Capt. B. B. Moscovich.
D. F. Murray Vancouver
J. V. Murray Creston
J. A. McLean ; Vancouver
J. A. McNab , Vancouver
Capt. R. P. McCaffrey.
P.   McCaffrey Agassiz
R. C. McDaniel Portland, Ore.
C. A.  McDiarmid _.         Vancouver
E. H. McEwen i New Westminster
S.  C.  MacEwen New Westminster
J. A. McFadden—V. G. H.
Lieut. D. Mclntyre.
R. E. McKechnie Vancouver
H.  H. MacKenzie New Westminster
A.   J.  MacLachlan Vancouver
D. McLellan Vancouver
E. C. McLeod Vancouver
R. A. McLeod New Westminster
L.  Macmillan = Vancouver
A.  Y.  McNair Vancouver
J.  McNichol ; Vancouver
J.  H.  MacDermot Vancouver
J. R. Naden Vancouver
A. C. Nash ! West Vancouver
J. R. Neilson Vancouver
W. P. Neufeld Vancouver
R.  C.  Novak Essondale
M. J. O'Brien—St. Paul's.
A. O'Neill—V. G. H.
C. M. R. Onhauser North Vancouver
H. M. Page Portland, Ore.
G.  C  Paine  Penticton
K. D. Panton Vancouver
Surg.-Lt.-Com. W. M. Paton.
N. J. Paul Squamish
Stanley  Paulin Vancouver
P. E. Pemberton—V. G. H.
Dallas Perry Ganges
S.   C.   Peterson Vancouver
H. Planche Vancouver
K. Pump—St. Paul's.
P. Ragona —j Vancouver
W.   H.   Riggs Vancouver
C. M. Robertson Nelson
W. A. Robertson New Westminster
A. Q Ross New Westminster
Flight-Lt. H. M. Ross.
Capt. M. F. Savisky ,     Vernon
G\  Schildrer Vancouver
G. Schilder ! Vancouver
W. A. Shea _ Portland, Ore.
G. E. Seldon : Vancouver
K.   Shimotakahara Vancouver
W. W. Simpson Vancouver
A. C. Sinclair Victoria
J. M. Sinclair—V. G. H.
D. A. Smith—St. Paul's.
A. H. Spohn  Vancouver
H. D. Sparks—St. Paul's.
Dorothy Saxton ■. Victoria
R. A. Stanley Vancouver
Surg.-Lt. J. G. Stapleton.
P. L. Straith Courtenay
J.  A.   Sutherland Vancouver
D.   J.   Sweeney : Vancouver
R. M. Tait Vancouver
D.  Telford ; Vancouver
J.  L.  Telford Vancouver
K. M.  Telford Vancouver
J. W. Thomson Vancouver
G. I. Theal—V. G. H.
J. Q Thomas Vancouver
Capt. W. M. Toone.
Ethlyn Trapp Vancouver
A. E.  Trites Vancouver
A. S. Tsai.
F. A.   Turnbull Vancouver
H. L.  Turnbull Vancouver
R. G. Turner—V. G. H.
S. E. C. Turvey Vancouver
J.  J.  Verhalen Tacoma, Wash.
C.  H. Vrooman _. Vancouver
Major J. E. Walker.
Major S. A. Wallace.
A. W. Wallace—V. G. H.
J.  T.  Wall Vancouver
.W C. Walsh Vancouver
H. N. Watson ! Duncan
H. G. Weaver—V. G. H.
Ft.-LtL. R.  G. Weaver Australia
L. H.  Webster Vancouver
J.   W.   Welch j Vancouver
P. Whelan Seattle, Wash.
Capt. W. H. White.
K. Whittaker Vancouver
S. L. Williams— Nanaimo
C. J. M. Willoughby Kamloops
R. A. Wilson Vancouver
W. A. Wilson \ | Vancouver
Surg.-Lt. T. V. Wilson.
Lt.-Col. Wallace Wilson.
G. W. Wolfe—V. G. H.
Capt. G. H. Worsley.
FOR SALE
As new, portable Short "Wave Bi-polar 300 Watt Electro-Therm
unit. Complete with rubber cable, felt pads, sinus pad, foot switch and
instrument case containing a dozen instruments for such things as
removal or cure of warts, moles, superfluous hair, furuncles, carbuncles,
etc.   Used only three months.   Owner overseas.   Telephone ALma 1419.
Page 10 College of Physicians and Surgeons
President . Dr. W. A. Clarke, New Westminster
Vice-President . Dr. F. M. Bryant, Victoria
Treasurer . Dr. H. H. Milburn, Vancouver
Members of Council—Dr. F. M. Auld, Nelson (District No. 5); Dr. F. M. Bryant, Victoria
(District No. 1); Dr. W. A. Clarke, New Westminster (District No. 2); Dr. Thomas
McPherson, Victoria (District No. 1); Dr. H. H Milburn, Vancouver (District No. 3);
Dr. Osborne Morris, Vernon (District No. 4); Dr. Wallace Wilson. Vancouver (District
No. 3).
Registrar I Dr. A. J. McLachlan, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
RUBBER SHORTAGE
THE WARTIME PRICES AND TRADE BOARD
Dr. M. W. Thomas,
Executive Secretary,
British Columbia Medical Association,
203 Medical-Dental Building,
Vancouver, B. C.
318 Marine Building,
Vancouver, B. C,
Sept. 25th, 1942.
Dear Dr. Thomas:
Thanks very much for your letter of September 24th. The writer was sure we could
count on the support of yourself and the members of your profession.
We do not wish you to misunderstand our previous communication. It is not the
intention of this Department to refuse Doctors necessary equipment in their very essential profession, but, frankly, the situation on new tires is becoming so acute that what
we are afraid may happen is that undue allocation of new tires now or the extravagant
use of them in any way might interfere later on with equipment vitally needed.
• I think I told you in my previous letter that passenger tires are no longer being
manufactured in Canada and the United States. We are, therefore, working against an
inventory which naturally grows less with each permit that is issued, and our letter was
merely a desire on our part to acquaint your profession with the situation so that, firstly,
they would take every care of the rubber now on their cars, and, secondly, where possible—and we both know there are any number of doctors whose general practice is very
limited—use retreaded tires or used tires.
You may, of course, use my letters in any way you see fit, because the purpose 1
really wanted to serve was to get this message to your profession more as a matter of
warning as to the future than as it affects just the immediate present.
The writer has not a doubt in his mind that we will receive your very full co-operation, and while it is to be regretted that we have had to issue this warning, it would be
far worse if we allowed a crisis to arise in connection with the supplying of new tires at
a time when it would be most important for us to have the equipment available.
Yours faithfully,
B. M. BREMNER,
Regional Tire Rationing Officer.
Page   11 NATIONAL WAR FINANCE COMMITTEE
M. W. Thomas, Esq., 1227  Vancouver Block,
Vancouver, B. C.
September 25, 1942.
College of Physicians & Surgeons,
Medical-Dental Building,
Vancouver, B. C.
Dear Sir:
This is a critical time in the history of the world and demands that we be realistic
in our actions.
In the important task of financing Canada's war effort which the National War
Finance Committee has undertaken, it is imperative that active assistance be obtained
from every possible source. The Minister of Finance will shortly be asking all Canadians to invest as much money as they have available in Victory Bonds and the minimum
sum that is required at this time is $750,000,000.
The organization with which you are associated may have funds lying idle in a bank
account, and if so, the best possible use to which this money could be put would be to
buy Victory Bonds with it. Any sum from $50.00 up will help to provide the sinews
of war. We need not elaborate on the important responsibility which now rests on the
nation. You are well aware of it and fully conscious of the plain duty of every citizen
to lend all available money to the government. Needless to say, Victory Bonds provide
a nest egg for the future and should an emergency arise in the meantime, the Bonds are
readily saleable.
Will you please take advantage of the first opportunity to bring the matter before
your association or if a meeting does not take place before the middle of October, might
We ask you to call a special meeting for the purpose.
We would appreciate an acknowledgment on the attached card, and thank you in
anticipation of your co-operation.
Yours very truly,       D. C. RITCHIE,
National War Finance Cornmittee.
Special Notice ...
R. C. A. M. C.
SKILLED AND UNSKILLED MEN OF THE LOWER CATEGORIES
ARE NEEDED IN THE ROYAL CANADIAN ARMY MEDICAL CORPS
Men are needed to serve as nursing orderlies, laboratory assistants, operating room
assistants, etc. Others are needed as clerks, cooks, store men, and for general hospital work.
Experience in medical work is not necessary. For those who have been unable to
enlist in the Army because of their physical condition, an excellent opportunity
affords itself in the R.C.A.M.C.
MEN IN CATEGORIES HIGHER THAN Bl NEED NOT APPLY
The co-operation of all Medical Men in British Columbia is requested
towards the success of the R.C.A.M.C.
RECRUITING OFFICES
VANCOUVER
(Old Hotel Vancouver)
PRINCE RUPERT   -   VERNON   -   KAMLOOPS
VICTORIA
(Bay Street Armouries)
TRAIL   -   NEW WESTMINSTER
Page 12 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. A. H Spohn, Vancouver
First Vice-President S Dr. P A. C Cousland, Victor-
Second Vice-President Dr. H. McGregor, Penticton
Honorary Secretary-Treasurer Dr. G. O. Matthews, Vancouver
Immediate Past President : Dr. C. H. Hankinson, Prince Rupert
Executive Secretary Dr. M. W. Thomas, Vancouver
ROYAL CANADIAN AIR FORCE
REGULATIONS REGARDING SICK PERSONNEL
Extracts from letter from Wing Commander S. G. Chalk, Principal Medical Officer,
Western Air Command.
Personnel Reporting Sick
1. R.C.A.F. Regulations require that any personnel, if taken sick, should report to a
Service Physician, or if on leave, and one is not available conveniently, to a civilian practitioner. In the latter connection, Air Force Routine Order No. 369 dated 4-4-41, contains the following paragraphs:—
"1. An officer or airman of the R.C.A.F., R.A.F., R.A.A.F., or R.N.Z.A.F., who
requires medical attention when on leave in Canada, is to report to the nearest
R.C.A.F. Medical Officer.
2. In cases of urgency, when the services of an R.C.A.F. Medical Officer are not
readily available, an officer or airman on leave may report to:—
(a) An R.C.A.M.C. Medical Officer,
(b) A Medical Officer of the D.P. & N.H., or
(c) A civilian practitioner
in that order.
3. When personnel report as in para. 1 above, the R.C.A.F. Medical Officer, in every
case, is to notify immediately the Commanding Officer of the individual's unit
and forward one copy of M.F.B. 292, Morning Sick Report, covering the case, to
the Commanding Officer, and one copy to the Air Officer Cornmanding the Command in which the individual's home unit is located.
4. When it is necessary to call in a Medical Officer as specified in para. 2 above,
arrangements are to be made to notify the R.C.A.F. Medical Officer as soon as
possible, if one is located in the vicinity, in order that he may assume charge of
the case. In any event, immediate action is to be taken where the illness is of a
serious nature or likely to delay the individual reporting to his unit, on the termination of his leave."
(Note:—Wing Commander Chalk wishes to draw the attention of the profession to
these regulations and points out that only under exceptional circumstances outlined
above may a member of the Forces (either officers or other ranks) secure medical care
or treatment from a civilian doctor. In these cases it may prove a serious matter for
the offender. It is requested that all doctors take cognizance of this procedure and
co-operate in attempting to conform to the regulations and thus protect the officer or
man involved.)
2. The provisions of the Routine Order referred to above show that the Service Member
is open to punishment in such cases, and it is considered both of these should have
reported to Service Medical Officers and not to Civilians.
3. In order to prevent further cases of this nature and to ensure that Civilian Physicians are aware of R.C.A.F. Regulations, it would be greatly appreciated if you would
publish a notice to this effect in your monthly Association Publication.
Thanking you for your co-operation in the past.
Page   13 Department of Dietetics
Eileen M. Dunn, B.A., B.Sc.
DIET IN DISEASE OF THE GALL-BLADDER
The following three diets are used for diseases of the gall-bladder:
I.    For gallstones or cholecystitis in the overweight patient.
II.    For gallstones or cholecystitis in the patient of normal weight.
III.    For biliary dyskinesia.
The first diet is low in fat, moderately low in cholesterol and low in calories; the
second is low in fat, moderately low in cholesterol, but unrestricted in calories; the
third is a bland diet.
Diet I.
Avoid:
Alcoholic beverages, carbonated beverages, strong tea, coffee.
Figs, dates, raisins, raw apples, plums,
melons, loganberries, raspberries, black-
berires, and all other raw fruits except
bananas and oranges.
Cereals and breads containing bran.
Butter, margarine, cream, ice cream, eggs,
cheese (except cottage cheese).
Oils of all kinds, mayonnaise and salad
dressings.
Lard, suet, beef fat, mutton fat, gravies,
bacon, pork, tongue, corned beef, ham,
duck, goose, salmon, liver, kidney,
sweetbreads, brains, herring, sausages,
bologna, sardines.
Fried foods of all kinds.
Pickles, relishes, ketchup, horseradish,
dressings, spices, mustard, vinegar, pepper and canned soups.
Salads, corn, kidney beans, cauliflower,
leeks, cucumber, lentils, olives, cabbage, onions, turnip, brussel sprouts.
Sugar, sweetened fruits and desserts, candies, pies, cakes, pastries, cookies, muffins, chocolate, nuts, and peanut butter.
Foods Allowed:
Unsweetened fruits or fruit juices—3 to
4 servings daily. Use unsweetened
stewed peaches, pears, cherries, apricots,
applesauce, prunes; or apple, pineapple,
grapefruit or orange juice; or jello.
Milk—3 glasses daily.
Bread—1 l/z thin slices white toast daily.
(1/3 cup of cereal may be substituted
Page 14
for J/_ slice of bread if desired. Use
Cream of Wheat, Rolled Oats, Puffed
Rice, or Puffed Wheat.)
Lean Meats or Fish—2 average, servings
daily (each serving about size of palm
of the hand.
Use boiled, roasted, or broiled beef,
round steak or leg of lamb; or steamed
or baked halibut, haddock, cod or oysters.
Cottage cheese (% cup) may be substituted for 1 serving of meat or fish
if desired.
Vegetables—4 servings daily.
Use beets, beet greens, cooked celery,
squash, stewed tomatoes, marrow, carrots, spinach, string beans, or asparagus.
Tomato juice, or fat free beef or chicken
broth, if desired.
Weak tea or Postum, if desired.
Sample Menu
Breakfast:
Unsweetened fruit or fruit juice.
Cereal—1/3  cup, with milk—1 glass.
Dry white toast—1/2 thin slice.
Clear weak tea.
Lunch:
Lean meat or fish—1 serving.
Vegetables—2 kinds.
Unsweetened fruit.
Milk—1 glass.
Supper:
Clear fat free broth.
Lean meat or fish—1 serving.
Vegetables—2 kinds.
Dry white toast—]/2 thin slice.
Unsweetened fruit or jello.
Milk—1 glass. Diet II.
Avoid:
Alcoholic beverages, carbonated beverages, strong tea, coffee.
Figs, dates, raisins, raw apples, plums,
melons, loganberries, rasriberries, blackberries, and all other raw fruits except
ripe bananas and oranges.
Coarse cereals and breads containing bran.
Cream, cheese (except cottage cheese),
ice cream.
Oils of all kinds, mayonnaise, and salad
dressings.
Lard, suet, beef fat, mutton fat, gravies,
bacon, pork, tongue, corned beef, ham,
duck, goose, salmon, herring, sausages,
bologna, sardines.
Fried foods of all kinds.
Pickles, relishes, horseradish, dressings,
spices, mustard, ketchup, vinegar, pepper, olives, canned meat, fish, or canned
soups.
Salads, corn, cauliflower, cabbage, onions,
turnip, brussel sprouts, leeks, cucumbers.
Pastries, cakes, rich cookies, pies, candies,
chocolate, waffles, griddle cakes, fresh
muffins, rich pastries, rich desserts.
Nuts, peanut butter, and large amounts
of sugar.
Foods Allowed:
Fruits and fruit juices—Appl e sauce,
baked apple, apricots, ripe bananas,
peaches, pears, cherries, prunes, oranges,
apple juice, orange juice, grapefruit
juice, pineapple juice, grape juice,
prune juice.
Cereals—Cream of Wheat, Rolled Oats,
Oatmeal, Puffed Wheat, Puffed Rice,
Cornflakes, Rice Krispies. Plain boiled
noodles, macaroni or spaghetti.
Breads-—White or graham day-old bread
or toast, rusks, white rolls, crackers,
graham wafers, plain sugar cookies,
arrowroot biscuits.
Meats and Fish—Boiled, roasted or broiled
lean beef, lamb, liver (beef or pork),
sweetbreads or chicken, and steamed or
.baked halibut, haddock, cod, oysters.
Eggs—2 or 3 a week, if tolerated.
Vegetables—Well cooked peas, string
beans, beets, beet greens, carrots, parsnips, squash, marrow, pumpkin, spinach, tomatoes, stewed celery, or tomato
juice. Boiled, creamed, mashed or
baked white or sweet potatoes.
Desserts—Rice pudding, sago, tapioca,
junket, jello, semolina, fruit whips,
cornstarch pudding.
Milk—at least 2 glasses daily.
Weak tea or Postum, if desired.
Butter—1 level teaspoon at each meal.
Cottage cheese—may be substituted for 1
serving of meat if desired.
Soup—Fat free beef or chicken broths or
cream of vegetable soup.
Sweets—Small  amounts  of honey, jelly,
or molasses, if desired.
NOTE: Take nourishments of milk or
fruit juice with plain cookies, arrowroots, graham wafers, crackers, or toast
in between meals and at bedtime.
Sample Menu
Breakfast:
Stewed fruit or fruit juice.
Cereal with milk.
White toast with jelly—2 teaspoons.
Weak tea with milk.
10 a.m.—Applejuice with graham wafer.
Lunch:
Lean broiled beef or lamb—1 medium
serving.
Cooked vegetables—from list allowed.
Potatoes.
Bread, with butter—1 teaspoon.
Milk pudding.
Milk.
3 p.m.—Milk with arrowroots.
Supper:
Fat free broth.
Steamed or baked whitefish or cottage
cheese.
Cooked vegetables from list allowed.
White toast with butter—1 teaspoon.
Cooked fruit.
Milk.
At bedtime:
Milk.
White toast, with jelly—1 teaspoon.
Page  15 Diet III.
Avoid:
Strong tea and coffee, alcoholic beverages,
carbonated beverages.
Brown breads, whole grain cereals and
foods containing bran.
Muffins, waffles, griddle cakes, hot biscuits, fresh breads and rolls.
Fried foods.
Highly seasoned foods, spices, meat soups,
and sauces.
Mustard,  vinegar,   ketchup,   horseradish,
relishes, pickles, salad dressings, olives,
canned soups.
Smoked or salted or canned meats or fish,
corned  beef,  sausages,   bologna,   crab,
lobster, shrimp, veal.
Salads, raw fruits and raw vegetables, and
gas-forming vegetables such as cabbage, cauliflower, onion, turnip, kale,
corn, brussel sprouts, cucumber.
Seedy foods such as figs, loganberries,
raspberries, blackberries, and tomatoes.
Concentrated sweets such as iced cakes,
rich cookies, candies, chocolate, jam,
marmalade, pastries, and rich puddings.
Strong cheeses, nuts, raisins.
Foods Allowed:
Milk, cream, eggnogs, malted milks, milk
shakes, oval tine, vitone, milky cocoa.
Fine cereals, such as Cream of Wheat,
well cooked strained rolled oats or oatmeal, Cornflakes, Puffed Rice, Puffed
Wheat, Rice Krispies.
White toast, crackers, plain cookies such
as arrowroot biscuits and graham wafers, hard bread rolls.
Steamed or baked halibut, haddock, fine
cod, oysters or sweetbreads.
Steamed, baked or broiled lamb, scraped
beef, or chicken.
Well cooked pureed (see note) green peas,
string beans, carrots, young beets, beet
greens, tender spinach, squash, marrow,
parsnips, pumpkin, chard.
Mashed, creamed, baked, or boiled sweet
or white potatoes.
Cream soups, made with vegetables from
the list allowed.
Well cooked pureed (see note) prunes,
peaches, pears, apple sauce, baked
apple (without skin or seeds), white
cherries, ripe bananas, apple juice, diluted orange juice, prune juice, tomato
juice*.
Custards, rice pudding, cornstarch pudding, sago, tapioca, jello, junket, Spanish cream, bread pudding, plain sponge
cake, plain ice cream.
Butter, cottage cheese, and eggs in any
form except fried or hard cooked.
Boiled or baked macaroni, spaghetti,
noodles or rice.
Sugar and salt in moderation.
NOTE: To puree vegetables or fruits,
cook until tender, drain, then press
through a sieve until only tough fibres
or skins remain. Use only the smooth
portion that has passed through the
sieve.
* Fruit juices should be taken only after
meals.
Sample Menu
Breakfast:
Pureed cooked fruit or fruit juice.
Cereal with milk or cream.
White toast with butter.
Soft cooked egg.
Milky cocoa.
Lunch:
Well cooked tender lamb, scraped beef
or whitefish.
Pureed vegetable from list allowed.
Well cooked potatoes.
White toast with butter.
Milk pudding.
Milk.
Supper:
Cream of vegetable soup.
Soft  cooked eggs OR cottage cheese
OR creamed whitefish on toast.
Pureed vegetables from list allowed.
Bread and butter.
Well cooked pureed fruit.
Plain cookies or crackers with butter.
Milk.
Page 16 A REVIEW OF CASES OF ARGENTAFFINOMATA
AT THE VANCOUVER GENERAL HOSPITAL
By L. B. Harville, M.D.
Previously Senior Resident in Surgery, Vancouver General Hospital.
Only six cases of argentaffin tumours have been found in the Vancouver General
Hospital since 1935, so these tumours are rare. Clinically they are never diagnosed
although they are frequently considered in the differential diagnosis with other tumours
of the appendix, caecum and lower ileum.
The symptomatology varies with the site. The symptoms appear earlier when the
appendix is involved, and are suggestive of appendicitis. In the intestine, diarrhoea without melena is common. Metastasis may, but rarely does, occur, usually to the regional
lymph nodes, and produces more generalized abdominal symptoms. The symptoms and
physical signs encountered in this series of cases will be given in the six case reports. The
disease is usually seen in adults. In this small series, the youngest was seventeen years
of age and the oldest sixty-three. Three were under thirty-five and three were over
sixty years of age. In larger series, the average age incidence is about fifty-five years.
Males are affected slightly more frequently than females. The appendix is twice as often
the site of these tumours as the small bowel. They are found in the colon, stomach, and
have even been reported in the rectum and suprarenal gland. They may be multiple.
In the intestine, the most common site is the terminal ileum. The appendiceal argen-
taffinomata do metastasize to the regional lymph nodes but apparently go to no other
sites, and if the primary tumour is removed a clinical cure results. In the small intestine, about 20% metastasize to the lymph glands and liver and are thus regarded as
being more malignant than those of the appendix. In the appendix, the picture is that
of appendicitis, and at operation an acute inflammatory or obstructive process may be
present. In the small intestine, obstruction may be produced by the growth assuming
an annular structure. In the suprarenal gland, a varied symptomatology is encountered,
and in one patient reported in another series Addison's syndrome, with vasomotor
instability and fainting, was noted.
Kuebscham, in 1901, thought these tumours arose from the chromaffin system.
Oberndorfer had differentiated them previously from carcinomata, and had named them
"carcinoid." Although they have been reported in many sites along the gastro-intestinal
tract from the stomach to the rectum, the usual organs involved are the appendix, small
intestine and caecum, in the order named.
The condition has been called primary carcinoma of the appendix although it is not
a carcinoma. It is called carcinoid because it resembles a carcinoma microscopically,
but it is a benign lesion according to Boyd. Dean Lewis refers to them as paraganglioma.
It appears from the work of Pierre Mason that these tumours are chromaffinomata, or
tumours of the endocrine system, arising from the Kultchitsky cells of the intestinal
mucosa which are found between the columnar cells of the crypts of Lieberkuhn and
belong to the chromaffin system. Both the Kultchitsky cells and the tumour cells are
stained intensely by silver impregnation methods and therefore the term "Argentaffino-
mata" has been applied to this tumour most commonly.
The gross appearance of the tumour in the appendix is usually characteristic. A
firm nodule is felt and on cross-section appears as a yellow ring encircling the appendix
and situated in the thickened submucous coat. This nodule is situated most often at the
tip of the appendix but the next most frequent site is at the base. Microscopically this
tumour is found to consist of masses of spheroidal or polyhedral cells with granular or
finely vacuolated cytoplasm. The cells are rich in lipoid similar to that found in the
suprarenal cortex, and it is to this that the grossly yellow colour is due. The tumour
cells are usually confined to the mucous and submucous coats but may reach the serous
coat.
Page  17 CASE I: Male, aged thirty-two.
Complaints on admission:
1. Stabbing midline abdominal pain for six months.
2. Aching midline abdominal pain for two months.
3. Loss of appetite and thirty pounds in weight during the last five months.
4. Lump in right lower quadrant, the size of a hen's egg.
History: Pain at first occurred after eating but later became more or less constant
and of a dull aching character. Appendectomy sixteen months previously for pain in
right lower quadrant had given slight relief.
Exarnination: There was a smooth rounded mass in the right lower quadrant, slightly
above and lateral to an old appendectomy scar. There was no tenderness. Radiographic
examination revealed an intrinsic mass in the caecum which encroached upon the lumen
of the caecum but did not obstruct it. On two occasions, examination of the stools
releaved -j-4 blood. Skin tests for tuberculosis were positive while test of the sputum
was negative.
Course in Hospital: After a week in hospital, he was presented at Medical Ward
Rounds and the differential diagnoses were tuberculosis of the caecum and carcinoma of
the caecum. On the fifteenth hospital day, the abdomen was incised and a mass found
in the caecum with adhesions to the anterior abdominal wall. The appearance was that
of carcinoma. Resection and ileo-colostomy were carried out. Death occurred on the
twenty-third post-operative day. Autopsy showed that death was due to generalized
peritonitis, paralytic ileus, subphrenic abscess and pneumonia of the right lower lung.
CASE II: Male, aged sixty-two.
Complaints on admission:
1. Gnawing pains in the epigastrium.
2. Belching and flatulence.
3. Indigestion.
4. Dizzy spells.
5. Two fainting spells in the past year.
History: The pain was of a generalized nature but was worse in the midline of the
epigstrium. It occurred about one hour after meals and was relieved by belching,
drinking water, and sometimes by lying down. At times pain during his sleep at night
woke him up. He consulted the Outpatient Department on May 9, 1941, and was
admitted May 17, 1941.
Examination: There was a mass in the right lower quadrant extending up to the
level of the umbilicus and not very tender. The right testicle was absent from scrotum
and canal. Radiographic examination confirmed a mass "lying between the angle of the
caecum, ascending colon and hepatic flexure." Tt appeared to involve the caecum secondarily and "did not suggest an intrinsic organic lesion of the colon itself."
Course in Hospital: Exploratory laparotomy on May 29, 1941, revealed a mass, the
size of an orange, involving the caecum, distal end of the ileum and ascending colon,
with these structures bound together by dense adhesions. As the diagnosis was inoperable carcinoma, an ileo-transverse colostomy was made and biopsy taken. The pathological report was "Argentaffine tumour of lymph gland." The patient's recovery was
uneventful.
CASE III: Male, aged sixty-three.
Complaints on admission:
1. Recurrent gaseous distension of the lower abdomen for ten days.
2. Loss appetite and loose stools for ten days.
3. Loss of weight, over twenty pounds, during the past year.
History: Previous health had been good. No blood had been noted in the stools.
In spite of the loss of weight, strength and energy were not impaired.
Examination: There was a moderately tender mass in the right lower quadrant. The
small lower bowel was distended.
Page 18 Course in Hospital: Laparotomy twenty-four hours after admission for "abdominal
mass" revealed an "extensive carcinomatous process in the caecum with many metastases
in the mesenteric glands." The caecum was resected with part of the ileum and transverse colon, a side-to-side ileo-transverse colostomy being made. The pathological report
was "Argentaffine tumour of the appendix involving the caecal wall with metastasis to
the regional lymph glands and producing obstruction of the ileo-caecal valve." The
patient developed bronchopneumonia and died on the thirteenth post-operative day.
The final diagnoses made at autopsy were:
1. Pulmonary embolism.
2. Bronchopneumonia.
3. Thrombophlebitic veins at the operative site.
4. Argentaffine tumour of the appendix.
CASE IV: Female, aged seventeen.
Complaints on admission: Pain in the lower abdomen with nausea and vomiting for
one day.
History: The onset was sudden with severe pain in the lower abdomen at two o'clock
in the morning. The patient had vomited several times, and nothing relieved the pain.
Although well developed for her age, she had had no menstrual periods. She had had
pelvic pains each month, lasting two days.
Examination: The temperature was 101.8, and the pulse 140. The patient was
acutely ill with great abdominal pain. There was abdominal rigidity with tenderness in
both lower quadrants and rebound tenderness over the bladder region.
Course in Hospital: Acute appendicitis was suspected. The post-operative diagnosis
was "Acute appendicitis with abscess and pelvic peritonitis." The pathological report
was "Argentaffine tumour of the appendix producing an infected mucocele." The postoperative course was uneventful.
' CASE V. Male, aged twenty-two.
Complaints on admission:
1. Abdominal pain for eight hours.
2. Nausea for six hours.
History: The patient was awakened in the early morning with an uncomfortable
feeling in the abdomen. In a few hours severe pain developed which doubled him up.
He was nauseated but did not vomit.
Examination: The temperature was 98.3, the pulse 80 and respirations 22. There
was no abdominal mass. The right lower quadrant was very tender. Laboratory investigations were negative.    The .diagnosis was acute appendicitis.
ourse in Hospital: Operation for acute appendicitis was performed immediately but
the organ did not appear inflamed. The pathological report was "Argentaffine tumour
of the proximal end of an otherwise normal appendix." The post-operative course was
uneventful.
CASE VI: Female, aged twenty-three.
Complaints on admission: Recurrent attacks of pain in the right lower quadrant for
three months.
History: During the last three months, attacks of pain in the right lower quadrant,
lasting as long as three days, have occurred, but there has been no vomiting and only
slight nausea.   The menstrual history was negative.
Examination: There was a tender area just above McBurney's point.
Course in Hospital: On the evening of admission, laparotomy for removal of the
appendix was carried out. There was a slight amount of free serosanguinous fluid in the
abdominal cavity but the pathological report mentioned no inflammation in the appendix.
Macroscopically there was a yellow appearance to the proximal portion of the appendiceal wall, and microscopic exarnination showed a typical Argentaffine tumour. The
post-operative course was uneventful.
Page   19 Summary
1. Argentaffine tumours arise in the chromaffin system of the gastro-intestinal tract
and a few other structures, having been found in the suprarenal gland.
2. The appendix is the most frequent site, being found twice as often as in the
small intestine, where the lower ileum is most frequently involved. In the cases at the
Vancouver General Hospital, the caecum was involved in fifty per cent of the cases
although the appendix was probably the primary site in one of these.
3. The symptomatology varies with the site. It may simulate appendicitis or even
cause it through obstruction of the appendiceal lumen. Intestinal obstruction may be
caused by these tumours when they assume an annular shape. In the appendix, they may
cause diverticula.
4. Metastasis is slow. They are not regarded as being malignant by most pathologists, and while those arising from the intestine may reach the liver, those from the
appendix only involve the regional lymph glands after a relatively long time.
5. In this series presented no conclusions are to be drawn and the cases are presented only to refresh the memory of an interesting pathological process.
PLASMA PROTEINS IN MODERN MEDICINE
a
From The Department of Medicine, The Vancouver General Hospital.
By Captain A. M. Johnson, M.D.
Previously Resident in Medicine, The Vancouver General Hospital.
The purpose of this paper is not to give a complete account of the plasma proteins
but rather to elucidate a few points about them which will be of interest to the practising physician. The determination of plasma proteins has become a much simpler process by the use of the Kagan technique, which is really a measurement of the rate of
fall of a drop of serum through a mixture of methyl salicylate and mineral oil. This is
practically a bedside method and just as accurate as the old complicated method. The
commonly accepted normal variation for the total plasma protein value in man is 6-8
grams per 100 c.c. If the value is less than 6 rnilligrarns per 100 c.c. it is hypopro-
teinaemia, and over 8 is hyperproteinaemia. The albumin fraction varies between 4 and
5.5 grams and the globulin 1.5 to 2.5 grams. It has been customary in the past to lay
great stress on the albumin-globulin ratio but this has been shown to be of little clinical
value. Thus, an albumin-globulin ratio of 0.5 is obtained when the albumin is 1.5
grams and the globulin is 3 grams. The same ratio is present when the albumin is 3 and
the globulin is 6. It is obvious the decrease in the albumin is the striking feature in the
first case and the increase in globulin in the second, despite identical ratios. The physiological and clinical implications are totally different.
Hyperglobulinaemia is rather a rarity and its value at present is purely diagnostic.
The globulin fraction is increased in the following disease states:
1. Infections, such as Boeck's sarcoid, disseminated lupus erythematosis, rheumatoid
arthritis, leprosy, and subacute bacterial endocarditis.
2. Neoplasms, such as multiple myeloma, lymphoblastoma, and leukaemia.
3. Metabolic disorders, such as cirrhosis of the liver, and cardiac failure.
The factors causing hypoalburrunaemia fall into three large groups:
1. Inadequate protein intake, such as economic causes (hunger oedema), poor appetite, mechanical interference with food intake, and poor intestinal absorption.
2. Excessive protein loss, such as recurrent haemorrhage, massive chronic suppuration, severe burns, uncontrolled diabetes, nephrosis, various entero-enterostomies
and repeated abdominal taps in ascites.
3. Failure of albumin synthesis, such as chronic parenchymatous liver disease,
nephrosis, cardiac oedema with passive congestion, and prolonged cardiac starvation.
Page 20 The problem of regeneration of the plasma proteins is far from being answered. It
is agreed that the larger amount of protein synthesis is carried out in the liver and that
if no liver damage exists rapid regeneration can take place, provided the protein intake
is adequate. If the liver has been damaged or the hypoproteinaemia is a long standing
condition liberal administration of protein by any route will cause a rise in body proteins
but very little if any increase in serum proteins. This is evident in cirrhosis of the liver,
the nephrotic state or chronic cardiac conditions.
The clinical importance of hypoalburninaemia is dependent on its normal functions.
The serum albumin normally (1) maintains the effective osmotic pressure of the blood
plasma, (2) maintains normal plasma volumes, (3) serves as a source of energy in starvation, (4) acts as a chemical buffer. The most important physiological function, and
the one of most importance to the clinician, is the maintenance of osmotic pressure. The
body fluids are kept in balance by the capillary pressure forcing the fluid out into the
tissue spaces and the colloid osmotic pressure of the plasma proteins drawing it in. Thus
if there is any excessive capillary pressure, or any decrease in colloid osmotic pressure,
oedema occurs. In this discussion, only the decreased colloid osmotic pressure is being
considered, and the importance of this in clinical medicine is being realized more all the
time. The albumin molecule exerts five times more osmotic pressure than the globulin
molecule by virtue of its smaller molecular weight and higher concentration in the
serum. Consequently hypoalburninaernia leads to oedema and 2.5 grams of albumin per
100 c.c. is considered to be the "critical level" beyond which oedema occurs. However,
other factors such as intake of sodium salts, local renal factors of blood flow, glomerular
filtration pressure, tissue pressure and probably many other unknown factors may be of
considerable importance.
The clinical effects fall into several main categories which are listed below:
1. Peripheral oedema: This is the earnest and most frequently recognized symptom
of plasma protein deficiency. When this condition appears in the loose areolar tissue of
the subcutaneous spaces, and no pressure factors are evident, it demonstrates that a
nutritional deficiency exists which should be immediately treated. Since the body can
regenerate protein so rapidly, a search must be made for a reason for inadequate protein
absorption or excessive loss and if none can be found the regenerating mechanism must
be impaired, as in nephrosis, cirrhosis of the liver, long standing cases of cardiac decompensation, chronic suppuration, recurrent haemorrhage or severe burns. Feeding protein
is an adequate therapeutic test.
2. Visceral oedema, primarily pulmonary oedema. Pulmonary complications in postoperative patients are usually diagnosed as pneumonia or atelectasis when actually they
are pulmonary oedema. " Right heart failure is the commonest cause of pulmonary oedema
but if the heart is normal, a patient cannot be "waterlogged" or pulmonary oedema produced by the adrninistration of excessive fluids, providing the serum proteins are normal
and that excess sodium chloride has not been administered. Actually the body can be in
negative water balance and pulmonary oedema produced if hypoproteinaemia is present.
3. Disturbances in gastro-intestinal motility. Frequently persistent vomiting occurs
after gastro-enterostomy, gastrectomy, or other operations on the bowel. It has been
observed that the stoma and walls of the bowel are swollen and oedematous. If proteins
in large quantities are given the oedema quickly subsides. Inasmuch as these cases have
probably had improper absorption pre-operatively and no proteins during the operative
period, hypoproteinaemia has -developed. In most centres, excess pre-operative protein
feedings are given and feeding proteins by intubation or intravenous routes immediately
following operation. This also will lessen the chance of the patient developing pulmonary oedema.
4. Disturbances in wound healing. It has been frequqently noted that patients with
poor healing have hypoproteinaemia. It is probably due to the specific absence of proteins (fibroblasts) plus the resulting tissue oedema.
Page  21 5. Effects of severe protein loss. In conditions such as severe burns, acute or chronic
haemorrhage, and surgical shock, the reason for the hypoproteinaemia is evident and
restoration of proteins usually alleviates the condition.
Treatment
The treatment of hypoproteinaemia should be prophylactic. In all cases where hypoproteinaemia is evident clinically, or any cases undergoing serious operating procedures,
the nutritional status and serum proteins should be determined. The restoration of
protein level is not always a simple task. It depends largely on whether there is any
damage to the regenerating mechanism or whether the abnormal loss of protein can be
stopped. As a rule, the second factor can be controlled because sufficient protein can be
given to counteract this loss. In cases where the first factor is involved the problem is
not so simple and many times these cases resist all attempts to raise the protein to its
normal level. There is some evidence that the liver or cells of the reticulo-endothelial
system are the site of formation of serum proteins. These cells are frequently injured
and their function impaired as by anaesthesia, sepsis and anoxaemia.
The best method for the administration of protein is by mouth. The split protein
is absorbed from the small bowel and the regeneration carries on from there. If, in surgical cases, difficulty is encountered in oral administration, an indwelling stomach tube
can be used both before and after the operation.
Intravenous plasma is used where the other methods fail. It can be given in unlimited
quantities without fear of reaction and can be immediately utilized without calling the
regenerating mechanism into use.    Its only drawback is the expense.
Whole blood is used in cases where an anaemia also exists but it is important to
remember not to overload the circulation with red cells just to supply protein when it
can be so easily and more efficiently supplied by plasma.
Much research is being done at the present on feeding essential amino acids to supply
proteins and results are encouraging except in cases where the regenerating mechanism is
at fault. These have now been perfected so that they can be given in unlimited amounts
either by mouth or intravenously.
CECOSTOMY—INDICATIONS AND TECHNIQUE
Roscoe R. Graham, M.B.
University of Toronto.
The basis of this discussion is an analysis of the histories of ninety-six patients upon
whom the author has performed cecostomy for either acute or chronic obstruction of the
colon during the last twenty years. The chronicle of the procedures carried out really
is the history of the evolution of surgical operations upon the colon during this period.
The principle of decompression of obstructed lumina in various parts of the body
has long been known. The earliest application was in decompression of the urinary
bladder distended as a result of obstruction of the urethra. It is in the application of this
principle in the treatment of acute obstruction of the colon that a "blind" cecostomy
becomes an invaluable procedure. By "blind" cecostomy is meant a cecostomy which is
performed without coincident exploratory laparotomy. The administration of a barium
enema prior to the operation will in most instances localize the obstruction.
That the principle of decompression finds complete expression in blind cecostomy is
substantiated by the fact that in this series there were thirty-three instances of acute
obstruction of the colon which were submitted to a blind cecostomy, with but two
deaths from obstruction, a mortality of 6 per cent, which is unusually low in any group
of cases suffering acute intestinal obstruction. Following are the details of patients who
failed to recover from the obstruction: (1) a male, aged 74, obstructed for eight days,
who died of peritonitis; (2) a female, aged 56, whose cecum was so distended that gangrenous patches were present, one of which perforated during the operation. A third
patient died some weeks following the cecostomy, from inanition due to very extensive
local disease with multiple metastases.
Page 22 It thus becomes obvious that as a simple safety measure a "blind" cecostomy offers
an admirable solution of the emergency resulting from an acute obstruction of the large
bowel.    It is felt that if this procedure fails to save the patient from the disasters of'
obstruction, no other operative procedure would have succeeded. The details of the three
operative deaths cited above would support this contention.
The lesions for which cecostomy has been carried out in this group of patients are
shown in Table I, and provide an interesting comment on our therapy during this period.
TABLE 1
Carcinoma of the colon  74
Diverticulitis of the sigmoid  8
Sigmoid obstruction due to band  2
Volvulus  of the   cecum  1
Perforated   appendix  2
Bullet   wound   colon  1
Colitis,   idiopathic  2
Colitis,   tuberculous  1
Benign  tumour  with   intussusception.  2
Gastrojejunocolic fistula  3
Total number of patients having ecostomy 96
It becomes obvious from this table that cecostomy is most useful in the malignant
lesions of the colon. Its value here lies in the relief of obstruction, either acute or chronic.
TABLE II
Distribution of Carcinomata
Ascending   colon : -— 1
Transverse  colon I  8
Descending   colon -■  9
Sigmoid  colon 1  49
Rectum    .  7
A most valuable observation was made in one case, where the obstruction of the
transverse colon was due to an intussusception of a benign submucous lipoma. The
cecostomy adequately relieved the abdominal distention and an abundant fecal discharge
came from the cecal stoma. Despite this the patient suffered a persistence of the cramps
like abdominal pain. The significance of the relief of the obstruction without coincident
relief of the cramp abdominal pain was not appreciated until a laparotomy was performed. We experienced the same phenomenon in a second case, and, correctly interpreting it, were able to proceed with the second stage of the operation as soon as the abdominal distention and the biochemical upset accompanying the obstruction was relieved.
This is important with such a diagnosis, as undue delay makes the second stage of the
operation more hazardous because of the edema and potential infection which persists
about the intussusception.
While only three deaths occurred when a "blind" cecostomy was performed, five died
when the cecostomy was coincident with a laparotomy. These five patients died of peritonitis. This is ample evidence of the rationality of the aphorism, "In all abdominal
emergency operations, carry out only the most simple and atraumatic procedure directed
solely to saving life, dealing only with the cause of the emergency."
A second aphorism is worthy of remembrance in acute abdominal disease: "Assess
the clinical picture carefully in order to ascertain the role which the various factors
contribute in creating the emergency." One would defer operation for carcinoma of the
breast in a patient who when first seen was also suffering from acute appendicitis. This
latter disease created the emergency, and must be dealt with adequately as a primary
manoeuvre. With similar logic, one must defer operation on a carcinoma of the colon
until the obstruction is adequately relieved. A blind cecostomy is the most simple, safe
and satisfactory primary procedure which will adequately solve the problem.
In addition to the pitfall where the chronic obstruction was due to the intussusception of a submucous lipoma, we have encountered a second lesion of the large bowel in
which a blind cecostomy alone would be inadequate to control the emergency. We refer
to a volvulus of the sigmoid colon.   Our practice of using X-ray examination with a
Page 23 barium enema as a diagnostic aid will, if correctly interpreted, lead to an accurate diagnosis of this lesion. In the X-ray examination the great mass of the barium in the colon
lies in the right upper quadrant. This observation, made in our department of radiology,
has been reported by Hall1. With this diagnosis, the need for a laparotomy is obvious,
but a coincident cecostomy is of real value in completing the decompression of the colon
after a volvulus is adequately dealt with. The coincident laparotomy and cecostomy do
not carry the potential danger of peritonitis, as is the case where the obstruction is due
to an ulcerative carcinoma with associated edema.
Occasions arise, however, when one is confronted with the necessity of making the
diagnosis of intestinal obstruction in a very ill patient suffering from ill-defined, bizarre
abdominal symptoms, under circumstances where all the physical aids to diagnosis such as
the X-ray and other laboratory facilities are not available. The diagnosis of intestinal
obstruction can usually be made. The site and cause are often difficult to determine. If
the obstruction be inflammatory, the appendix is the most common offending organ. If
the site of the obstruction be in the small bowel, and the common hernial sites are eliminated, an exploratory laparotomy is essential. If the site be in the colon, and the volvulus
of the sigmoid can be eliminated, an exploratory laparotomy is highly undesirable. This is
made evident by this study, as in this group of seventy-four cases of carcinoma of the
colon accompanied by obstruction there were twenty-two deaths, but only eight of these
could be attributed to the phenomena accompanying obstruction and only three of these
died following a blind cecostomy. Five died when the cecostomy was accompanied by
an exploratory laparotomy, and in each instance death was due to peritonitis. The source
of the peritonitis we believe to be infection in and about the edematous, obstructed bowel
wall. The trauma incidental to the exploration, even though gently carried out, is sufficient to break the barrier and release the infection. It is very similar to the waterproof
qualities of a tent in a rainstorm. If a finger touches the nside of the tent, a break
develops. We have been impressed with the fact that patients suffering from obstruction
of the colon tolerate even the most simple operative procedures very badly. The incidence of streptococci in and about the edematous, obstructed bowel has been admirably
shown by Garlock and Seley2, where cultures taken from the various sites about the
lesion yielded a high incidence of haemolytic streptococci. Their suggestion to bring such
patients under control by sulfapyridine before operation would appear to be very sound.
Our method of procedure is to operate with a spinal anaesthetic and explore the abdomen through a McBurney split muscle incision. The cecum and terminal ileum are
located. If the terminal ileum is not dilated, then the obstruction is in the small bowel,
and a paramedian incision is made. No harm has been done, and but a few minutes have
been consumed by making the McBurney incision. If, on the other hand, the cecum
and terminal ileum are distended, the site of the obstruction is distal to the cecum and
the obstruction will be relieved by a blind cecostomy without any of the increased hazards
which would have accompanied a coincident laparotomy. It as been our custom to bring
out a piece of cecum, which bulges into a circular mass approximately 1 inch in diameter.
This segment of cecum is fastened to the skin with four interrupted catgut sutures.
Failure to sew the cecum to the skin is often followed by a retraction of the cecum to a
below-skin level. This renders the procedure less efficient, and is almost invariably accompanied by infection of the abdominal wall. The abdominal wound is closed about the
protruding piece of cecum with a few interrupted catgut sutures.
No attempt at an elaborate closure of the abdominal wall is made at this time, as we
recognize a second operation will be necessary to close the cecostomy, and at this time
the abdominal wall may be adequately repaired. After an experience which involves
many types of cecostomy operations designed to obviate the necessity for subsequent
closure, we believe that the efficiency of the procedure here described, where a mucocutaneous fistula is established, provides so much more efficient decompression as to justify
the additional operation necessary for its closure. We are insistent that no sutures be
placed in the bowel except those uniting it to the skin. To suture the bowel to the subcutaneous structures is to invite infection of the abdominal wound.
Page 24 The cecum is not opened for twelve to twenty-four hours following the operation.
During this time the biochemical upset is corrected by the administration of glucose, salt,
water and blood as indicated. It is amazing how much such patients improve during this
period, even though the obstruction is not relieved.
The cecum is opened with the actual cautery. The incision is placed at right angles
to the long axis of the bowel. One rarely has to tie any blood vessel in the bowel wall,
although provision should be made to do this at the time the cecum is opened. We then
immediately begin the instillation of oil into the cecum by means of a small rubber
catheter. Because it is cheap, efficient and readily available, we use raw linseed paint oil,
injecting 3 to 4 ounces two to four times in the twenty-four hours, the amount and
interval depending upon the degree of return of the oil through the cecostomy, which in
turn is in direct ratio to the completeness of the obstruction. As the edema about the
carcinoma subsides, the oil appears at the rectum, and then saline irrigations are carried
out through the cecostomy and through the rectum. This manoeuvre, together with a
low residue diet, is efficient in a large percentage of cases in keeping the colon empty and
permitting the subsidence of the edema in the bowel wall and about the tumour.
Because we plan later to repair the abdominal wall, these patients are allowed to be
up and about the ward in forty-eight to seventy-two hours after the operation. This,
we believe, is a real asset, as the general muscle tone and exercise tolerance is maintained
during the preparation, and the patient is thus much better able to withstand the next
operative procedure.
How long should the interval be between the cecostomy and the resection of the
obstruction lesion itself? This question is answered by an analysis of the deaths which
have occurred after this second stage. There were thirteen deaths in the group where,
although the cecostomy was effective in relieving the acute obstructions, the patient succumbed following resection of the growth. In all but two instances, death resulted from
infection.
In reading the histories of these cases, one is impressed by the repetition of the statement in the operative note: "Bowel wall still shows edema," or "Bowel contains fecal
content." These statements are susceptible of two interpretations: first, the interval
between the cecostomy and the second stage was too short to permit adequate preparation; or the obstruction was so nearly complete that some additional procedure was necessary to enable the bowel to remain empty and free from edema. In no instance should the
resection be undertaken less than two weeks after the cecostomy.- If the cecum at the
time the cecostomy is performed shows evidence of gross edema, an interval of at least
three, and preferably four weeks should elapse between the two stages.
Even with the most painstaking and apparently adequate preparation, when the abdomen is opened for the second stage, one is occasionally chagrined to find residual edema
in the bowel wall and about the growth. Under such circumstances one should never
attempt any form of anastomosis in continuity. Rankin's3 obstructive resection of the
Mikulicz type may be used. If, however, the lesion be in the left colon, we believe there
should be an additional operative stage, and, despite a limited experience, we are most
favorably impressed with Devine's4 defunctioning transverse colostomy. This permite
of the most adequate preparation of the distal colon.
If during an operative procedure the colon be involved or wounded, and one wishes
to provide a safety valve as a temporary procedure, the use of a Pezzer catheter witzelled
into the cecum, is an admirable procedure. This may be carried out through the laparotomy wound. This manoeuvre permits the escape of gas and fluid content of the
cecum, preventing distention, and is worthy of greater recognition than is generally
accorded it. Witzelling the catheter where it lies between the cecum and parietal peritoneum, enables the catheter to be cut off at the skin level when the need for the cecostomy is past. The distal fragment will be passed per rectum and the fistula will heal
readily. We have used this type of cecostomy in cases of gastrojejunocolic fistula, but
the rod colostomy of the ascending colon, as suggested by Damon Pfeiffer5 of Philadelphia, is a more efficient and most valuable procedure.
Page 25 In retrospect, and with the perspective of twenty years in the material presented by
these case histories, one is more and more impressed with a few simple fundamental and
obvious truths in regard to obstruction of the colon, particularly when the obstructive
lesion be carcinoma: firstly, our operative therapy in cases of acute obstruction must aim
only at decompression of the colon, this to be achieved with the minimum of intraperitoneal manipulation; second, the colon must be kept relatively empty by non-residue
diets and irrigations. This must be kept up for from two to four weeks, in order to
permit the disappearance of the edema in the bowel wall and about the tumour; third,
the biochemical balance of fluids and salts must be restored and maintained. The value
of the proper proportion of glucose in saline and glucose in distilled water has been
adequately presented by Coller and Maddock6.
These three fundamental truths seem so obvious that stating them, much less repeating them, would seem superfluous, and yet how often have patients been sacrificed because of failure to grasp their importance completely and adequately. In the presence of
acute obstruction of the colon, a blind cecostomy fulfills adequately and simply the
requirements of the operative procedure, and it is in dealing with this problem that we
have, in blind cecostomy, a safe, simple and satisfactory method of combatting the
emergency. If, when the second stage of the operative procedure is undertaken, the
edema in the bowel wall or about the growth is not entirely relieved, or if the bowel is
not adequately empty of feces, this is not necessarily a condemnation of the value of
cecostomy, but evidence that following the relief of the acute emergency, further and
more efficient means should be employed to secure an empty bowel free from edema. The
Devine colostomy does just this, and probably as experience increases, will become the
second operative procedure when the lesion responsible for the acute obstruction is a
carcinoma in the left large bowel. This should be seriously considered in all cases where
saline does not run through the colon freely during the irrigations. This additional step
would entail two further operative procedures—first, excision of the growth, with anastomosis, and second, coincident closure of the cecostomy and colostomy.
The principle of multiple stage procedures is sound. We have been slow to appreciate
and apply this principle, which has contributed so much to the safety and efficiency of
surgical operations upon the colon. That multiple stage procedures are time-consuming
is no valid argument against their use. The procedures are much shorter than eternity,
which may be the alternative time to which we condemn the patient.
How long should be the interval between resection of the obstructing lesion and the
closure of the cecostomy? In only five of the ninety-six cases was the discharge from
the cecostomy so insignificant that the patient elected to carry on without further operation. The shortest interval in this series was six weeks. It has been considered wise to
defer closure for three months, in order to permit a complete subsidence of all the inflammatory reaction about the anastomosis. If, however, there is continuous gross -soiling,
which is most infrequent, with great discomfort to the patient, the cecostomy may be
closed any time after six weeks, providing X-ray examination with a barium enema shows
a good lumen at the site of the anastomosis, thus ensuring a disappearance of any obstruction from postoperative edema.
The details of the dissection which we carry out in closing the cecostomy are adequately presented in Figure 2. In most instances this can be carried out extraperitoneally.
One need have no concern, however, if the peritoneal cavity be opened. Using the technique which we have developed, there has been no case of peritonitis following closure.
The incidence of infection in the abdominal wall has been negligible. The use of BIPP
rubbed into the layers of the abdominal wall after excision of the scar tissue we believe
to be of real value in preventing wound infection. If, when the bowel has been closed,
as indicated in Figure 3, the peritoneal cavity has been opened, a continuous catgut suture
closes the anterior peritoneal peritoneum. The internal oblique and transversalis muscles,
as well as the aponeurosis of the external oblique, are united with a few interrupted catgut sutures, the skin being loosely closed with a few widely separated interrupted silk
sutures. The patient is allowed out of bed in ten days.
Page 26 Conclusions.
1. In acute obstruction of the colon, a blind cecostomy offers a safe, simple and
satisfactory means of combatting the emergency.
2. The technique of sewing the cecum to the skin ensures efficient drainage of the
cecum with a minimum of wound infection.
3. The patient is able to be out of bed within forty-eight to seventy-two hours of
the operation, and muscle tone and exercise tolerance are maintained during the preparation for the subsequent operative procedure.
4. A minimum interval of two weeks should elapse between the cecostomy and
resection of the tumour, longer intervals being required in direct ratio to the degree of
edema at the cecum.
5. If at the second operative stage, edema of the bowel wall be still present, this is
not a condemnation of cecostomy, but an indication to defer resection and carry out a
procedure to more efficiently defunction the colon.
6. Closure of the cecostomy should be deferred for a minimum of six weeks, and
preferably for three months following the resection:
REFERENCES
1. Hall, M. R.: Am. J. Roentgenol., 39:925  (June)  1938.
2. Garlock and Seley: Surgery, 5:794, 193 8.
3. Rankin, F. W\, Bargen, j. A., and Bute, L. A.: The Colon, Rectum and Anus.    Philadelphia, 1932.
W\ B. Saunders Co.
4. Devine: Surgery, 3:165, 193 8.
5. Pfeiffer, D.: To be published.
6. Coller, F. A., and Maddock, W.   In Bartlett, R. M., Bingham, B. L. C, and Tederson, S.: Surgery,
4:441, 614, 1938.
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