History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1927 Vancouver Medical Association Mar 2, 1927

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 THE VANCOUVER MEDICAL
ASSOCIATION     1 ^-v
BULLETIN
Published monthly at Vancouver, B. C.
Subscription $1.50 per
rUaginal
Eclampsia
thyroid c{Kistology
FEBRUARY, 1927
^Published by
ePttc'ZBeath Spedding Limited, TJancouDer, "3. Q. Apparatus for Laboratory
Practise
as used and recommended in his B.C. post-graduate lectures
by Dr. Daniel Nicholson, University of Manitoba.
GASTRIC ANALYSIS—
Ewalds Stomach Tube and Bulb.
Hollanders H.C.L. Scale.
Dimethyl Indicator 1 oz.
BLEEDING TEST—
Spring Lancet.
HAEMOGLOBIN ESTIMATION—
"Non-fade" Haemoglobinometer.
SUGAR IN URINE, Quantitative-
Benedicts Solution 16 oz.
Luer Syringes, ly£ and 5 cc.
Test Tubes, 54x6 inches.
RENAL FUNCTION, Estimation-
Salivary Urea Apparatus.
The above can be obtained at
B.C. SteVeilS CO.       730 Richards St. Vancouver.
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
WRSWSJJW
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. "W.
Phones Sey. 98 8 and 672
Phones Sey. 9 513 and 13 91
Phone Sey. 1370
Brown Bros. & Co. Ltd.
VANCOUVER, B. C.
Page 134 THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718 Granville St., Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
Vol. 3. FEBRUARY 1st, 1927 No. 5
OFFICERS, 1926-27
Dr. A. w. Hunter
President
DR. A.  B.  SCHINBEIN Past President
Vice-President DR.   J.   A.   GILLESPIE
Secretary Treasurer
Dr. F. W. Brydone-Jack Dr. W. S. Turnbull
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Representative to B. C Medical Association Auditor
Dr. A. C Frost Dr. F. W. Lees
SECTIONS
Clinical Section
Dr. F. N. Robertson -       -       Chairman
Dr. Gordon Burke     ------------    Secretary
Physiological and Pathological Section
DR.   C   H.   BASTIN - ... Chairman
DR.  C  E.   BROWN   - ... Secretary
Eye, Ear, Nose and Throat Section
Dr. E. H. Saunders   ------------    Chairman
Dr. W. E. Ainley   -------------    Secretary
Genito-Urinary Section
DR.  G.  S.  GORDON - - - - - - - Chairman
DR.  J.  A.   E.  CAMPBELL Secretary
Physiotherapy  Section
Dr. G. A. Greaves    ---------    Chairman
Dr. H. A. Barrett     ---------     Secretary
COMMITTEES
Library Committee Credit  Bureau   Committee
DR. W. F. MACKAY {*■ r5ACGHL^R^ACMILLAN
DR.  I   C.  WALSH DR   E   £reSd^^rmittee
Orchestra   Committee dr_ g, h. CHAMPION
Dr. F. n. Robertson Dr. T. R. B. Nelles
Dr. J. A. SMITH Summer School Committee
Dr. L. Macmillan Dr. G. F. Strong
Dr. W. l. Pedlow Dr. W. D. Keith
Dinner Committee DR. H. R. STORRS
DR. C F. Covernton Dr- r- Crosby
Dr. A. C. Frost Dr. B. D. Gillies
Dr. G. B. Murphy Dr. L. H. Appleby VANCOUVER MEDICAL ASSOCIATION
Founded 1898. Incorporated 1906.
PROGRAMME OF THE 29th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday of the
month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the
month at 8 p.m.
Place of meeting will appear on Agenda.
General Meetings will conform to the following order:—
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of Evening.
1926.
Oct.     5th—General Meeting:
Presidential Address, Dr. A. W. Hunter.
Oct.   19th—Clinical Meeting:
Nov.    2nd—General Meeting:
Papers—1.    Dr. C. W. Prowd,  "An Analysis of Radium
Therapy, reporting 600 cases.
2.    Dr. J. A. Sutherland, "Pain and disability from
lesions about the Anus.
Nov.   16th—Clinical Meeting.
Dec.     7th—General Meeting:
Papers—1.    Dr. W. F. MacKay, "Diagnosis and Signifcance
of referred Pain in Disorders of Chest and Abdomen."
2.    Drs.   W.   S.   Turnbull   and   J.   W.   Arbuckle,
Eclampsia.
Dec.    21st—Clinical Meeting.
1927.
Jan.      4th—General Meeting:
Papers—1.    Dr. G. A. Greaves, "Physiotherapy in Orthopaedic Conditions."
2. Dr. H. A. Barrett, "Treatment of Infections by
Physical Agents."
3. Dr. H. R. Ross, "Physiotherapy in Gynaecological Conditions."
Jan.    18 th—Clinical Meeting.
Feb.       1st—General Meeting:
Papers—1.    Dr. J. M. Pearson, "Treatment of Hypertension."
2.    Dr. C. S. McKee, "The Interpretation of Findings in Blood Chemistry."
Feb.    15 th—Clinical Meeting.
March   1st—General Meeting:
Paper—       Dr. George Seldon, The OSLER Lecture.
Mar.   15th—Clinical Meeting.
April    5th—General Meeting:
Paper —       Symposium, "The Treatment of the Poor Risk
Patient," Drs. C. E. Brown, A. B. Schinbein,
D. D. Freeze and R. E. Coleman.
April 19 th—Annual Meeting.
Page 13 6 Section of X-Ray Department, Anson General Hospital,
Iroquois Falls, Ontario, Canada.   Installation made by
Toronto Branch of Victor X-Ray Corporation.
Victor Nation-Wide Service
THE Victor X'Ray Corporation has assumed a
responsibility to the medical profession which
does not end with developing and manufacturing
X-Ray apparatus of the most approved type. It is
a tenet of the Victor code that the operator of a
Victor machine has the right to receive technical
aid when he needs it.
So, a nation-wide Victor Service Department
was organized years ago and direct branches estab'
lished in the principal cities of the United States
and Canada, where Victor trained men are always
available. No matter where a Victor machine may
be installed Victor Service stands ready, on request,
to inspect it or to render such technical assistance
as may be required.
Victor alone maintains so comprehensive a Ser-
vice Organization.
VICTOR X-RAY CORPORATION
2012 Jackson Boulevard Chicago, Illinois
33 Direct Branches Throughout U. S. and Canada
X'RAY
Diagnostic and Deep Therapy
Apparatus.   Also manufacturers
of the Coolidge Tube
^ f
Ictor X-Ray Corporation of Canada Ltd., Motor Transportation Bldg. Vancouver, B.C
Victor is as old as the X-
Ray. Adequate service can
be rendered only by an organization of proved stability and performance.
Whether your X-Ray needs
are small or large, for limited office work or for
the specialized laboratory,
Victor Service can help you
in the selection of equipment best suited for the
desired range of service.
PHYSIOTHERAPY
High Frequency, Uitrd'Vio/et,
Sinusoidal,   Galvanic  and
Phototherapy Apparatus  EDITOR'S PAGE
Under the heading of "Smallpox and Commerce" the British Medical
Journal for November 13th, 1926, prints a commentary upon the Annual
Report of the Provincial Health Office for the year ending June, 30th,
1926.
The article has particular reference to the epidemic occurring in
Vancouver in the year 1925, and our readers will still have lively recollections of the ban which was placed by the United States authorities
against the irnrnigration of non-vaccinated persons. The gist of the article is the effect which a ruling of this kind has upon the business interests
of the Province and the manner in which the necessity for vaccination
is, in this way, forced upon the attention of the people. The article
points out that the Canadian Pacific Railway Company agreed to instruct
its heads of departments that applications for any employment which
brings the applicants into contact with the travelling public must produce evidence of successful vaccination, and following this ruling the
western lines of the Canadian National Railway were persuaded to take
corresponding action. Quoting from the report the commentary concludes with Dr. Young's message where he says "We think this has been
one of the greatest advances that we have made along the lines of preventing disease. The fact that these two large companies, the largest
employers of labour in Canada, have made this ruling, will be an argument hard to answer when other employers are approached.
We must congratulate Dr. Young and the Provincial Health Office
on their successful conduct of this campaign and on the prominence
which has been given to their efforts in one of the leading medical journals of the world.
We are requested by the Executive of the Association to call the attention of members once more to the question of doctors driving their
automobiles at excessive speed. The Association is in receipt of a
letter from the Chief of Police enclosing a report of the Traffic Inspector
on this point. It appears that on several occasions medical men have been
stopped and on enquiry no reasonable excuse for exceeding the speed limit
has been produced. While everyone, the traffic department included,
realizes that on occasion haste may be a rrfatter of vital necessity, still
these occasions are comparatively few and far between and we would
urge upon the members in the interests of these special occasions that
they more regularly conform to the traffic bylaws of the city.
Once again we approach the welcome task of notifying our readers
that the Summer School of the Vancouver Medical Association is becoming a live issue.    This important part of the Society's work is, we need
Page 139
i not say, deserving of the greatest interest and whole-hearted support of
every member of the Association. While to the committee in charge for
the time being is delegated the arrangements of the details of each meeting, the responsibility for the success of that meeting lies directly upon
the shoulders of each and every one of us. No persuasion should be needed
to secure attendance. This co-operative means of bringing to our door
at a cost which is ridiculously small, some of the very best exponents of
the science and art of medicine should appeal without further comment.
The committee in charge this year has started the work both early and
vigorously and a very great deal has already been accomplished. The
speakers who so far have been secured are: Dr. B. P. Watson, formerly
of Toronto and Edinburgh, now Professor of Gynaecology at the Sloane
Hospital, New York; Dr. Clarence Starr, Dr. John Oille and Dr. J. G.
Fitzgerald, of Toronto; and Dr. Herbert C. Moffitt of San Francisco. We
hope in our next issue to be able to print more particulars with regard to
the actual programme which will be presented. Meantime we would ask
our readers to make mental and actual note of the date of this meeting—
JUNE 21st to 24th INCLUSIVE AND TO RESERVE THESE DATES.
Dr. N. D. Royle, of Sydney, Australia, will, we understand, arrive
in this city early in March on his way to San Francisco. Dr. Royle's
name will be recalled at once on account of his connection with the late
Dr. John I. Hunter in the work on spastic paraplegia and the sympathetic
innervation of muscle fibre. Dr. Royle is the man who endeavoured to
put to practical use the important researches along these lines made by
the late Dr. Hunter. We understand Dr. Royle is bringing with him
films of his cases and the instruments used during his operations and that
arrangements have been made by the Executive of this Association for
Dr. Royle to lecture before the Society on his arrival. A great deal of
controversy has arisen as to the actual value of this operation in those
cases for which it seems suitable and it will be a matter of the greatest
importance and highest interest to have from the lips of the originator of
this operation a first-hand account of the operative proceedings and of
the nature of the results which have been obtained. The exact date has
not yet been fixed but our readers will receive due notification when arrangements have been completed.
NEWS AND NOTES
The monthly general meeting of the Association was held on January
4th. The attendance at this meeting was very small, owing probably to
the influenza and the recent holidays. Owing to illness Dr. H. R. Ross
was unable to give his paper on physiotherapy in gynaecologic conditions. Dr. G. A. Greaves discussed physiotherapy in orthopaedics and
Dr. H. A. Barrett read a paper on the use of this form of therapy in the
treatment of infections.
Page 140 Drs. R. C. Weldon, C. D. Moffatt, S. Sievenpiper, L. H. Webster and
W. R. Brewster were elected to membership in the Association and
Drs. J. A. Street (Port Alice), J. E. Harrison and W. L. Boulter were
nominated for membership at a later date.
We congratulate Dr. and Mrs. L. H. Appleby on the birth of a son
on December 30th. The doctor is beginning to get over his disappointment at a second son instead of the wished-for daughter.
'Dr. Oliver and Mrs. Large left by the Niagara in the middle of the
month for a tour in Hawaii and other Pacific islands and expect to be
back about the middle of March.
We are pleased to learn that Dr. A. Y. McNair is convalescing from
his recent severe attack of pneumonia.
A joint luncheon meeting of the British Columbia Medical and Vancouver Medical Association was held on January 25th when an address
on "Legal Medical Problems" was given by R. L. Calder, K.C., of Montreal.   This address will appear in a later issue.
Dr. W. E. Ainley, Dr. F. W. Brydone-Jack and Dr. A. H. Spohn are
sailing from New York by the Mauretania on February 14th en route for
Vienna for post-graduate work and expect to be back in Vancouver
about the end of May.
CLINICAL MEETING
The clinical meeting of the Association was held on Tuesday, January 18th, and was very well attended. The first case, shown by Dr. G.
C. Draeseke, was a patient with multiple sinusitis. Dr. Draeseke demonstrated the diagnosis of such conditions by transillumination in a very
striking way. Attention was called to the untoward consequences of
anatomical defects in reducing the surface of the mucous membrane, leading to bronchial infections as a result of the inspiration of warm, dry air.
A case of chronic colitis was shown by Dr. J. A. Sutherland and contrasted with dysentery of the bacillary and amoebic types.
Dr. Bagnall showed a case of chronic nephritis of several years standing in which the blood creatinine went to 7.7 and other laboratory findings correspondingly high. This woman bore two children in spite of her
kidney condition. The striking symptoms were weakness, anaemia and
spots before the eyes. Discussion emphasized the diagnostic value of pallor, oedema and weakness, also of the N.P.N, and phenolsulphonephtha-
lein tests and two hourly urine test. Rest is the most important single
factor in treatment. B.P. over 150, cardiac enlargement and eye findings
offer a bad prognosis.
A contrasting case in a young man, rejected three times for insurance on account of suspected nephritis, was presented by Dr. Bagnall,
which showed only a low Sp.G. and B.P. of 140. The two hourly test,
phenolsulphonephthalein test and fatigue helped to make the diagnosis
in spite of normal blood chemistry.    The only etiological factor seemed
Page 141 to be infected tonsils.   Attention was called in the discussion to the necessity for hydrometers more accurate than those in general use.
Dr. Covernton presented a case of congenital lues in a girl of 16,
interesting on account of the absence of a positive Wasserman over a
period of three years and uncertain family history, eye disturbance being
the principal symptom. Wasserman was finally returned four plus. The.
case now shows severe pains particularly in the left side. This case went
the round of the various specialties without a diagnosis until a positive
Wasserman was finally secured.
Dr. Brewster submitted a case history for Dr. Thomson, showing the
striking result of the use of antistreptococcic serum (erysipelas) in the
treatment of a case of erysipelas, and attention was called to the success
of other physicians recently in the treatment of similar conditions.
Dr. Brodie showed a case- of fractured cervical vertebra which over
a period of months has shown a very remarkable recovery in muscular
function, sphincter control and general strength.
A case of exophthalmic goitre by Dr. Pearson and another of ascites
by Dr. G. F. Strong could not be presented on account of the lateness of
the hour. The value of the meeting was much enhanced by a very free
discussion.
B.C. MEDICAL ASSOCIATION NOTES
We are pleased to report that Dr. A. W. Montague of Victoria has
recovered from an operation for appendicitis.
The Victoria Medical Society was delighted by Dr. E. L. Garner of
Duncan when he presented a paper on "Fractures and Their Treatment."
The lecture was illustrated with lantern slides and Dr. Garner was able
to show a number of patients with results of special treatment and demonstrated a large collection of splints and appliances which he used
in this work. Those present will long remember the instruction given
and their gratitude to Dr. Garner was evidenced in an enthusiastic vote
of thanks and long continued applause.
The November clinic meeting at the Jubilee Hospital was well attended and a most interesting collection of cases and other clinical material comprised an instructive evening.
Dr. W. Allan Fraser of Victoria, son of the late Dr. R. L. Fraser,
was married on December 18 th, in San Francisco to Miss Laura Margaret
Eng of Victoria. After honeymooning at Del Monte Dr. and Mrs.
Fraser have returned to Victoria and taken up residence at 800 St. Charles
Street.
Dr. Stuart G. Kenning of Victoria has recently returned from Eastern centres where he spent some time in post-graduate work.
Dr. A. S. Underhill left on January 17th to relieve Dr. Carson at
Premier gold mines for three or four months.
Page 142 Dr. H. C. Wrinch, M.L.A., was detained in the Vancouver General
Hospital for a few days with an infected leg whilst on his way to attend
Parliament in Victoria.
Dr. P. J. Emerson of Nakusp, whilst on his way to see a country
patient sustained an accident which has necessitated a rest for a few
weeks.
We regret to record the death of Dr. R. T. Wilson Herald of Nelson, B.C., who passed away after a brief illness from pneumonia. An
obituary appears in the current number of the Canadian Medical Association Journal.
Our congratulations to Dr. and Mrs. S. G. Baldwin of Vernon,
B.C., on the birth of a son on January 13 th.
Recent medical visitors to Vancouver include Dr. J. S. Burris of
Kamloops, Dr. D. Corsan of Fernie, Dr. H. C. Wrinch, Hazelton and
Lt.-Col. Lome Drum of Victoria.
Dr. H. E. Young, Provincial Health Officer for British Columbia,
gave an interesting address on January 3rd, before the Health Bureau,
Vancouver Board of Trade. Dr. Young took for his theme "The Potential Value of a Man."
LIBRARY NOTES
The Library is situated in 529-531 Birks Building, Granville Street,
Vancouver, B.C.
Librarian: Miss Firmin
Hours: 10 to 1, 2 to 6
The Injection Treatment of Varicose Veins
The success attending the use of injection treatments in selected
cases of haemorrhoids has resulted in attempts to cure varicose veins in
the extremities by the same means. Standard works on surgery state that
apart from operation the only measure holding out any hope of relief lies
in some form of mechanical support.
Credit for the injection treatment probably goes to Genevrier. He
uses the following solution:
Quinine Hydrochlor, 4 grams.
Urethan, 2 grams.
Distilled water, 30 cc's.
A pneumatic tourniquet is applied to distend the veins, or, if below
the knee, merely allowing leg to hang over a chair or couch is sufficient.
% cc of above solution is injected into the vein through a small hyper-
dermic, perivenous introduction is not necessary. The puncture is sealed
with colloidan and the vein repunctured 2 inches higher—about 8 punctures is the limit at one sitting.
Page 143 Rather startling results are claimed for this treatment. Pain is said
to vary from none to slight cramp but never sufficient to prevent walking. Several able to play tennis next day. The lancinating pains and
bursting sensations rapidly disappear, eczema and ulcers heal completely.
Recurrences have not been observed.
At first this procedure might seem to be foolhardy, but clotting is
instantaneous and extremely firmly attached to the wall, so much so that
such veins subsequently excised and opened were found to be impermeable
and the clot so densely adhered as to be almost irremovable.
The writer has collected from the literature or from personal correspondence with men using this treatment 214 cases involving 3200 injections. Many were in fat women. All cases are reported completely
successful. Embolism has never been observed and only 11 localized abscesses are reported. Many women have subsequently borne children and
without any sign of recurrence. Neither work nor pleasure is interfered
with. Neither preparation nor anaesthetic is required. No harmful effects follow.
Tkink it over. —L.H.A.
BOOK REVIEWS
Carbohydrate Metabolism and Insulin, By J. J. R. MacLeod, Longman's Green and Co., London, $6.00.
This is the latest addition to the series of Monographs on Physiology.
Each of these monographs is designed to render available the current
opinion with regard to a limited aspect of physiology, and they are all
written by men who are actively engaged in the sphere covered by the
monographs. As might be expected Professor Macleod's style has produced a book that is very readable and clear. The physician has in this
book a ready means of access to the present status of carbohydrate metabolism which is probably the most rapidly advancing field of medical
physiology today. On every hand the clinician meets accounts of clinical
observations concerning the carbohydrate metabolism in various diseases
which appear to be quite contradictory. He knows that a great many
new and quite solid facts have been contributed during the last few years
but is at a loss as to how to get his feet on solid ground. In this small
book he is enabled to find the solid ground for almost any problem he is
likely to meet.
The reader cannot help being impressed with the volume of work
which has been done in the author's laboratory. There is scarcely a feature of the numerous phases treated of but is supported by first-hand experimental data.
There is, however, one criticism which can be applied to all of the
books of this series when reviewed from the standpoint of a clinician
and that is that they are not sufficiently "popular." In the opinion of
the reviewer all scientific literature should aim at a style which will reach
the widest audience. Obviously this book is written only with the teacher
of physiology in mind. Unquestionably a large number of clinicians are
going to look to this book for reference but they are going to meet with
certain difficulties which could readily be avoided without in any way
Page 144 detracting from the value of the book to the teaching physiologist. For
example many of the figures in the text could bear legends which would
save considerable searching of the text. Also some authors are quoted
without any appearance of the reference in the list of cited literature
given at the end of each chapter. The fact that such an author may be
familiar to the teaching physiologist makes it the more important in
teaching clinicians that the reference be given. One thing will be particularly misleading to the clinician and that is such errors as calling a
figure mgs. of glucose when it is obviously per cent (p. 91); also the
author speaks of a dog's blood pressure when he is really speaking of blood
sugar (p. 278); again in quoting from Hamburger the author states that
by varying the sugar concentration in the perfusion fluid the amount of
sugar in the urine varied when he should have said that by varying the
bicarbonate concentration in the perfusion fluid the amount of sugar in
the urine varied (p. 190).
The high regard with which the clinicians receive any contribution
from the distinguished authors of these monographs and the avidity with
which they are read by a wide circle of professional men anxious to keep
abreast of the times, make it very desirable that such books of reference
should be written with these facts in mind—and therefore with scrupulous attention to making clear the findings, not alone to the physiological
specialist, but to the earnest clinical student as well. Indeed it would not
be at all out of the way if the authors made a point of submitting their
finished mss. to a clinician just before sending them to the printer. An
index would be a valuable addition.
In spite of these objections, however, Professor Macleod's naturally
clear style is such that the clinician with the above hints will find the
monograph easy reading.
—K.E.C.
Clinical Pediatrics, By John Lovett Morse, M.D., 1926, W. B. Saunders
& Co., Philadelphia and London. Cloth, $9.00, net.
This book, coming from a man with the wide experience of Professor
Morse is a decided addition to practical pediatrics. Professor Morse who
is now the dean of American pediatricians gives in this book conclusions
found after many years of careful observation in an outstanding university hospital. This book aims to provide a safe guide to medical men interested in this branch of medicine and accomplishes this purpose in a
concise manner. In method and arrangement it is not unlike that old
standard—"Holt & Howland."
The chapters on feeding and preparation of foods are elaborate and
interesting. Professor Morse still favours the percentage method of feeding infants and presents many arguments in favour of this rather intricate procedure. He has little use for the more "theoretical" side of medicine. The almost brusque manner in which he opens the section of "Diseases of the Glands of Internal Secretion" is characteristic of a man who
demands a reason before employing a therapeutic agent. To quote
briefly he states: "In the present state of our knowledge, or lack of
knowledge, it is absolutely irrational to give a mixture of glandular ex-
Page 145 tracts, pluriglandular therapy, because no one knows just what each gland
does or what each does to the other. I should expect to know as much
as to what would happen if I threw a monkey-wrench among the wheels
of the universe as I would if I gave a child a combination of glandular
extracts. Physicians must be careful that they do not use glandular
therapy, as Mr. Dooley said of Christian Science, as 'another way of getting money.' "
This volume is attractively printed, contains many useful illustrations and charts and will prove a valuable addition to any medical library.
—A.H.S.
THE EFFECT OF LUGOL'S SOLUTION ON THE
HYPERPLASTIC THYROID
By Dr. H. H. Pitts, Pathologist to the Vancouver General Hospital.
(This paper is based on the results of two years' histological examinations
of goitres at the Cleveland Clinic, Cleveland, Ohio.)
The effect of Lugol's on the hyperplastic thyroid, both from a clinical and histological standpoint, has been a much mooted question since
Plummers' work was first published (Illinois, N-J Dec. 1, 1924) and
there has arisen a great deal of controversy regarding it.
Unquestionably, the prolonged use of iodine, even in small doses
(e.g., iodized salt), has a stimulating effect on the gland, producing definite hyperthyroidism (Hartzock, J.A.M.A., May, 1926), but the preoperative exhibition of Lugol's over a period of from 10-14 days is without doubt beneficial in practically all cases, reducing the heart rate, the
basal metabolic rate, the tremor and in fact increasing the general well-
being of the patient and decreasing the operative risk.
In the Cleveland clinic, prior to May 1st, 1925, Lugol's was not
used routinely, being administered only to the more toxic cases and only
very occasionally to those with adenomata, as these latter were at that
time thought to be a type which were rendered more toxic by the use of
iodine. However, iodine was frequently given to these patients when a
clinical diagnosis of adenomata could not be made, but was shown postoperatively. It was found that these cases did not react any differently
from those showing frank diffuse hyperplasia as indicated by pulse and
metabolic rate. Therefore from May 1st, 1925 onwards, it has been the
routine to give Lugol's m XV t.i.d.p.c to all cases of hyperthyroidism, be
they adenomatous or diffuse hyperplasias. A careful histological study
and record of all cases of hyperthyroidism from May 1st, 1924, to May
1st, 1926, was made and the following tables set forth these data. They
are interesting some particularly from the histological stand-point and
the effect of the Lugol's in transmuting what clinically was a well-defined
hyperthyroidism into a histologically, at any rate, mild hyperplastic or
even colloid type of gland.
Page 146 May 1/24 May 1/25
May  1/25 May 1/26
Hyperplasia and hypertrophy     187 51
Moderate hyperplasia and hypertrophy      184 179
Slight hypertrophy      131 265
Colloid and cystic colloid goitre      399 637
Colloid adenoma      101 243
Foetal adenoma       85 216
Intermediate type of foetal adenoma .      30 78
Total   1117 1669
Of the adenomata in the first year period (May, 1924-25), 48
showed some degree of hyperplasia as follows:
Colloid adenoma with slight hyperplasia  10
Colloid adenoma with slight hyperplasia   10
Foetal adenoma with moderate hyperplasia  7
Foetal adenoma with slight hyperplasia  2
48
In the second year period, only 2 colloid adenomata with slight hyperplasia were found.
From the above tables, it will be seen that the adenomata were
greatly increased in the second year period; since the greater majority of
these cases, especially in the second year period, have been using iodized
salt we have thought that possibly iodine may have some action on stimulation of minute adenomata which lie dormant in the gland, and cause
them to grow quite rapidly. This, of course, is only theory and not
substantiated by any experimental proof.
These tables show a marked decrease in the number of the more
marked hyperplasias in the second year period as compared to the first
year period even though the grand total in the second year period is over
500 greater than the first. They are transmuted apparently to a less hyperplastic type and the numbers gradually rise directly with the decrease
in hyperplasia; especially is this true in the slight hyperplasias and colloid
types.
CONCLUSION
It would seem that Lugol's has a well-established place in the preoperative preparation of patients with hyperthyroidism and that it seems
well proven in the series given above that it has a definite action in reducing the hyperplastic gland to a less active state.
TREATMENT OF ECLAMPSIA
Delivered before the Vancouver Medical Association by
Dr. J. W. Arbuckle.
One hundred years ago, when eclampsia was looked upon as a disease
of the nervous system, and the treatment was to bleed and to purge, the
Page 14/ mortality was around 20%. Later, about the middle of last century,
when it came to be regarded as an infection of the kidneys and hot packs,
sweating and more active treatment came into use, the mortality rose to
25% and 30%. Then with the more general use of anaesthetics and the
advances in surgery, and the theory that eclampsia was a toxaemia in
some way due to the presence of the foetus rapidly emptying the uterus
either by accouchement force or Caesarean section became the accepted
treatment, and the mortality climbed to 40% and 45% and in some
clinics to 50% and 60%. Today we are not quite sure that eclampsia is
entirely a toxaemia, and we have gone back to expectant treatment and
our mortality rate is again down to 20%.
Credit for the return to conservative treatment is generally given to
the Russian pathologist Stroganoff. Stroganoff as far back as 1897 began
what he called his prophylactic treatment of eclampsia, and in his first
57 cases did not have a single death. In 1900 in Paris he reported 92
cases with a mortality of 5%. In 1902 in Rome 126 cases with mortality
of 6%. And by 1908, by visiting large centres such as Leipsic, Berlin
and Vienna, he was able to demonstrate his treatment in 3 60 cases with a
mortality of 6.6c/<. In 1918 he had collected from different clinics 1800
cases and two years ago when he came to England to demonstrate his
methods of treatment he showed a series of 3302 cases with a mortality of
9.8' ( . In Europe and on this side the treatment of eclampsia by morphine is spoken of as the "Stroganoff Treatment;" in England it is called
the "Rotunda Treatment." Some years before Stroganoff was heard of,
Tweedy, then Master of the Rotunda in Dublin, had published a new
treatment for eclampsia practically the same as that advocated by Stroganoff, and his treatment was the routine treatment in the Rotunda up
to a few years ago.
Unsatisfactory as has been, and still is, the active treatment of
eclampsia, when we turn to the side of prevention it is another story.
Certainly we are seeing less cases of eclampsia today than we did 25 years
ago; less than we saw ten years ago. Why is this? Two factors are responsible. First, women are looking after themselves better; they know
more about diet, more of the dangers of constipation and they are getting
more exercise in the open air. These things alone have cut down the
number of cases of eclampsia very considerably. No better illustration
of this can be found than what took place in Austria and Germany during the war. In those countries during the war non-combatants and
especially women had to live on rough vegetables (cabbage, turnips, coarse
rye bread), and they had to work chiefly in the fields. They were doing
what our patients would do today when we tell them to go on a low
protein diet and get lots of exercise in the open air. Under these conditions in Austria and Germany the incidence of eclampsia fell away down,
only to rise again with the return of pre-war modes of living and diet.
The other factor in reducing the number of cases of eclampsia is
ante-natal care. A striking example of what ante-natal care can do is
shown by what has taken place in certain parts of France. In France,
especially in the rural districts, confinement work is in the hands of mid-
wives.    These midwives are licensed by a Central Health Board;  they
Continued on Page 153
Page 148
asm The
British Columbia Laboratory Bulletin
Published  monthly  September   to   April  inclusive  in   co-operation   with   the   Vancouver
Medical Association Bulletin^ in the interests of the Hospital Clinical and
Public Health Laboratories of B. C.
Edited by
Donna E. Kerr, m.a., of The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St.  Paul's Hospital, Vancouver;  Royal Columbia Hospital, New Westminster;
Royal Inland Hospital,  Kamloops;  Tranquille Sanatorium;  Kelowna  General  Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.   Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Volume 1
FEBRUARY, 1927
No. 2
CONTENTS
Effect of Treatment on the Basal Metabolic Kate Wilson
Unknown Organism Causing Fatal Meningitis in Infants Kilpatrick
Fatal Case of Diabetic Coma k Coleman
Routine Spinal Fluid Examinations  Welsh
Editor's Note.
Judging from the opinions expressed in letters received from the various hospital laboratories there is a strong feeling that our new venture is
timely. Incidentally these views are most encouraging to the editor as
indicating both ample support and material. We have commenced this
month to give a list of the collaborators, but next month we hope to include the names of some in the body of the Bulletin. If there are any
other hospital laboratories in B.C. the editor will be glad to hear from
them.
THE EFFECT OF TREATMENT ON THE BASAL METABOLIC
RATE
Grace Wilson, M.A., V.G.H. Laboratories.
In the following series of 23 cases of hyperthyroidism, basal metabolism tests were performed at intervals during the treatment by various
physicians attending this hospital. At least two tests were done on each
patient, the interval depending on the clinical condition, and ranging
from one week to eight months.
The following table summarizes the results:
At the second test (1 week to 6 months after the first) —
The basal metabolic rate fell in 17 (74%)    •
The basal metabolic rate rose in 6 (26%)
At the third test (1 week to 14 weeks after the second) —
The basal metabolic rate fell in 15  (83%)
The basal metabolic rate rose in 3  (17%)
At the fourth test (4 weeks to 14 weeks after the third) —
Page 149 The basal metabolic rate fell in 2 (25%)
The basal metabolic rate rose in 6 (75%)
In final determination (from 1 week to 8 months after the first)-
8 (35%) were above -J- 40%.
15 (65%) were below -+- 40%.
AN UNKNOWN ORGANISM CAUSING FATAL MENINGITIS
IN INFANTS
Myrtle Kilpatrick, M.A., V.G.H. Laboratories.
In November, 1924, a Gram negative bacillus was found in the spinal
fluid of an infant.    Since that time a similar organism has been found to
be the causative agent of typically acute fatal meningitis in three other
infants.
CASE A.—A patient of Dr. C. F. Covernton, Vancouver, referred
to him from Powell River, B.C.:
November, 24, 1924, the first specimen of spinal fluid was received
at the laboratory. The fluid was cloudy with a cell count of 7,600 cells
per cmm., polymorphonuclear leucocytes predominating. The following
day another specimen of spinal fluid was received with a cell count of
6,500 cells per cmm., polymorphonuclear leucocytes predominating. November 26 th, November 27th and December 1st specimens were received
which contained thick pus and cell counts could not be done. The patient
was admitted November 24th and died December 3rd.
CASE B.—A patient of Dr. W. C. Walsh of Vancouver.
November 22, 1925, the first specimen of spinal fluid had a cell
count of 80 cells per cmm., polymorphonuclear leucocytes predominating.
A second specimen was received November 24th; this specimen was
cloudy and had a cell count of 2,500 per cmm., polymorphonuclear leucocytes predominating. Subsequent specimens were thick with pus and
could not be counted. The first specimen of spinal fluid was brought in
November 22 nd and the patient died November 25 th.
CASE C.—A patient of Dr. E. D. Carder of Vancouver.
December 3, 1925, the first specimen of spinal fluid was cloudy with
a cell count of 1,700 cells per cmm., polymorphonuclear leucocytes predominating. A second specimen received December 4th was thick with
pus and a cell count could not be done. The patient was admitted December 2nd and died December 4th.
CASE D.—A patient of Dr. F. C. Dunlop of Vancouver.
November 26, 1926, the first specimen of spinal fluid was received
at the laboratory. It was blood tinged and cloudy with a cell count of
approximately 2,500 cells per cmm., polymorphonuclear leucocytes predominating. A second specimen received November 27th was very cloudy
with a cell count of approximately 50,000 cells per cmm., polymorphonuclear leucocytes predominating. The following day the specimen received
was so thick with pus a cell count could not be done. The patient was
admitted November 26th and died December 3rd.
Page 150 BACTERIOLOGICAL FINDINGS.—Direct smears were made from
all specimens of spinal fluid as received from each of the four cases:
Gram negative intracellular and extracellular bacilli varying from
a coccoid form to a fairly long rod in every instance were present. On
culture media these organisms varied in size and shape to such a degree
that it was difficult to associate them with the organisms found in the direct smears. At times they assumed conidia-like forms as large as a yeast
cell, sometimes they lengthened into long filamentous rods. A good
growth was obtained on ordinary media. The growth was fine like a very
fine streptococcus growth. Every precaution was taken to keep these organisms growing indefinitely on artificial media but without success; even
by using blood agar, from which the most luxurious growth was obtained, these cultures did not survive for longer than six weeks. The organisms were facultative aerobes and grew best at 37.5° C; they gave a
positive Indol reaction; there was no motility present; there was no capsule formation; and none of the ordinary sugars were fermented. When
inoculated intraperitoneally into white mice, intravenously into rabbits
and into the brains of guinea pigs, they proved to be non-pathogenic for
the test animals. It is a point of interest to note that all of these cases have
occurred either at the end of November or the beginning of December.
The infection is sporadic, one case occurring in 1924, 2 cases in 1925, and
1 case in 1926.
In so far as we have been able to ascertain, this organism has not
been described in the literature.
FATAL CASE OF DIABETIC COMA
R. E. Coleman, M.B., V.G.H. Laboratories.
Since we learn more from our failures than from our successes the
attending physician has given us permission to publish the following record of a failure.
An elderly female diabetic who had neglected her diet, but continued
her 15 units of insulin twice a day, developed diabetic coma one evening.
Her regular physician was not available so a stranger was called in. The
new physician gave her 15 units of insulin that evening and admitted her
t othis hospital the next morning. The following is a record of her treatment during the following 19 hours:
9:30 a.m. insulin, 15 units.
10:00 a.m. admitted to hospital.
10:15 a.m. blood sugar, 770 mg.
(normal 80-110 mg.)
10:30 a.m. insulin, 10 units.
11:00 a.m. insulin, 30 units.
12:00 noon insulin, 20 units.
12:30 p.m. blood sugar, 762 mg.
1:00 p.m. insulin, 20 units.
2:00 p.m. insulin, 20 units.
3:00p.m. insulin, 20 units.
blood sugar, 710 mg.
4:00 p.m. insulin, 20 units.
5:00 p.m. insulin, 20 units.
blood sugar, 680 mg.
6:00 p.m. insulin, 20 units.
7:00 p.m. insulin, 20 units.
8:00 p.m. insulin, 20 units.
9:00 p.m. insulin, 20 units.
10:00 p.m. insulin, 20 units.
blood sugar, 350 mg.
11:00 p.m. insulin, 20 units.
intravenous glucose,
500 cc, 10%.
4:45 a.m. patient died suddenly.
Page 151 Clinically the treatment had no apparent effect from beginning to
end. We have no explanation to offer for this failure or that of a similar
case, a young girl several years ago. Both cases were kept warm and received good general care. Our record shows that those cases in which the
blood sugar remains high in spite of what, in other cases, would appear to
be huge doses of insulin, do not recover.
ROUTINE SPINAL FLUID EXAMINATIONS
Rae Welsh, B.Sc, Ph.C, V.G.H. Laboratories.
There were 247 spinal fluids examined from January to November,
1926, inclusive.   The following is a classification according to the reduction of Fehling's test:
No Slight Definite
reduction of     reduction of     reduction of
Fehling's Fehling's Fehling's
Solution Solution Solution
Cell count under 10  2(   1%) 11 (   8%) 122(91%)
Cell count between 10 and 100  6(  3%) 14(  7%) 175(90%)
Cell count over 100 21(40%) 11(21%) 20(39%)
Showing positive  culture 12(67%) 0 6(33%)
The highest cell count showing a reduction of Fehling's solution was
4,200.
The highest cell count showing no reduction of Fehling's solution
was 50,000.
The lowest count showing a positive culture was 5 cells (pneumococcus) .
The highest count showing a negative culture was 3,400 cells.
The mean of the counts showing a positive culture was 3,514 cells.
There were 40 specimens cultured with the following results:
Organism Negative Fehling's Positive Fehling's
Meningococcus      2 0
Pneumococcus     7 3
Streptococcus         1 1
Staphyloccuspy      1 1
Gram negative bacilli     1 1
The remainder of the specimens showed no growth.
The above data indicate that the loss of reducing substance from the
spinal fluid obtained in pathological conditions is related to the organism
rather than the cell count; first, because of 27 spinal fluids showing a reduction of Fehling's solution, 21 had a cell count over 100, while only
12 indicated a positive culture; second, because of those showing no reduction of Fehling's solution, 11 had both a high cell count and yielded
an organism on culture.
Thus there were double the number of spinal fluids with a negative
Fehling's showing a positive culture as compared with the number of
spinal fluids showing positive Fehling's.
Page 151 Continued from Page 148
have to see their patients frequently; do urinalysis; take blood pressure
and watch carefully for any sign or symptom of impending trouble. If
one of these patients should develop eclampsia, infection or any other
complication, the midwife, under whose care she is, is called before the
Central Board and if it can be shown that she was in any way negligent
either in her attendance during labour or in her ante-natal care, her license is cancelled at once. Under such supervision, and I had the word
of Professor Eden of London for this, eclampsia in the rural districts of
France has practically disappeared.
So successful has prophylactic treatment been, that there are those
who say that eclampsia is entirely a preventable disease, and for a patient
to develop convulsions is a reflection on the doctor under whose care she
has been. This we all know is not entirely true. Most of us can recall
cases that have come without the slightest warning. No, with our present knowledge there are always a certain number of cases of eclampsia
that we have to have with us and these we shall have to treat.
For treatment it is convenient to divide eclampsia into three groups:
1. The so-called albuminuria of pregnancy.
2. The pre-eclamptic toxaemia.
3. The woman in convulsions.
In the first groups we get a patient who comes complaining of
slight headache, indigestion and often irritable and depressed. On
examination we find more than a trace of albumin and a blood pressure around 130 to 140. On questioning her she will tell you that she
has been eating large heavy meals, or that she is constipated, or that she
has not been getting any exercise, generally all three. Correct these and
she will be alright. They all get well. We are not absolutely sure that
these cases have anything to do with eclampsia. I have never seen one of
these women, even those that I knew were not following the treatment
prescribed, drift into the pre-eclamptic group. All the cases of eclampsia that I have seen have been pretty sick women from the very first.
It is in the second group, the pre-eclamptic, that we often have our
most difficult problem. A patient I saw in consultation some months
ago, will serve to show what we are up against in these cases, and also
illustrate a method of treatment in comirion use.
This was a woman in her third pregnancy. She had lost her first
baby, her second was alive and well and she was now again a little over
six and a half months pregnant. She had just come into the hospital
when I first saw her, she was nauseated, had been vomiting, a lot of abdominal discomfort and headache and she was worried and depressed. There
was considerable oedema, a fair amount of albumin and a blood pressure
of 180. Certainly a woman in a bad way and if left untreated, she would
most likely go into convulsions. What could we do for her? It is the
pregnancy that favours the development of the eclampsia. If we cannot prevent or cure the eclampsia we can terminate the pregnancy; but
to do this at this stage means sure death for the child, and this woman
was very anxious that everything should be done to make things safe for
her baby. She was put to bed and given no food for the first 24 hours. Her
Page 153 stomach was washed out and an ounce of mag. sulphate left in. A high
enema was given and colon irrigated with some gallons of saline. On the
second day she was put on a low protein salt-free diet and was encouraged
to drink all the water she could. She responded well to treatment and
when I saw her again in six or seven days, there was no oedema, no nausea,
no abdominal distress, blood pressure between 140 and 150, and she was
bright and cheerful and wished to go home and wait until her time was
up. The only thing was that her blood pressure was a little high, so it
was decided to keep her in the hospital for a few days more. The next
morning without any apparent cause her blood pressure was up to 160
and in the evening 170, and she had headache and an anxious, worried
look. It was decided to induce labour which was done by passing bougies.
Labour came on early in the morning, she was taken to the case room
and was well into the second stage when she took a slight convulsion and
became unconscious. The child was easily delivered with low forceps,
but she never regained consciousness. She probably had a large cerebral
haemorrhage. I saw a similar case two years ago, and that was what was
found at post mortem.
Now is there any way by which we can tell when these patients are
going bad? Any sign or symptom that will give us warning of approaching trouble? Comyns Berkeley of the Middlessex in London lays great
stress on the urea output. He says with the blood urea over 40 mg. per
cent, and the urea concentration test below 1.5 the patient is in danger
and labour should be induced. Williams of Charing Cross, commenting
on this, says that the chemical examination of the blood for urea, uric
acid and non protein, nitrogen is no guide as to the seriousness of the
symptoms in eclampsia. In a recent bulletin from Johns Hopkins it is
stated that the chemistry of the blood gives no useful information in our
treatment of eclampsia. At the Rotunda in Dublin, Gibbon FitzGibbon
the present Master goes largely on the amount of urine excreted. With
the patient passing 40 ounces or more there is no danger. Many still depend on the ophthalmoscope. The patient I was speaking of was examined 12 hours before she took the convulsions and the retinae were
normal. In the Kermauner Klinik in Vienna, in the Chicago Lying-in
and in most clinics on this side they depend entirely on the blood pressure.
They say with a patient in bed and under treatment, if the blood pressure remains high or if it drops and again begins to rise, look out, there
is trouble impending.
No doubt many of these cases can be carried through to full term
and a normal confinement, but I have never had much luck with them.
Carry them along for two, three or four weeks, and then premature
labour comes on, very often a dead baby, at best an immature child difficult to raise, and all the trouble for nothing.
Then we come to the third group, the wOman in convulsions. It is
here that there is the greatest difference of opinion as to what is the
best treatment. There are still exponents of radical treatment, but
they are getting fewer every year. Stroganoff for a long time gave
us our most conservative treatment. His treatment is directed almost
entirely to warding off or preventing the convulsion. He claims that the
eclamptic patient in most cases dies from the direct action of the fits
Page 154 upon the heart, respiratory centre, etc., and the convulsions must be repressed.
Stroganoff Treatment—
Darkened room and as little noise as possible.   Only absolutely necessary examinations and those under chloroform anaesthesia.
At once, morphine gr. %
In one hour, chloral hydrate gr. 3 0
In three hours, morphine gr. 1/5
In seven hours, chloral hydrate gr. 30
In thirteen hours, chloral hydrate gr. 30
In twenty-four hours, chloral hydrate gr. 30
All hypodermic injections given under influence of chloroform. If
chloral hydrate has to be given by rectum, use chloroform.
Rotunda Treatment—
They claim that they do not know what eclampsia is, or what has
caused it, but they do know that the kidneys as eliminating organs
have fallen down and treatment is largely eliminating through bowels.
Aims at thorough elimination of the toxins by copious ingestion of
water and free purgation.   Give salines subcutaneously and by bowel.
Morphine only if patient is restless.
Williams-Stander Treatment (Johns Hopkins) —
They claim that a moderate rise in blood pressure should facilitate
osmosis and elimination and resents, therefore, a protective mechanism.    No purging, no sweating, is done.
No chloroform.
On admission morphine gr. %
To have water freely when conscious; if not, 500 cc. of 5% glucose
intravenously.
In one hour chloral hydrate.
3 hours after admission morphine gr. %
7 hours after admission chloral hydrate.
13 hours after admission chloral hydrate.
21 hours after admission chloral hydrate.
Darkened room.
Examined under nitrous oxide.
In my own practice I have had eighteen cases of eclampsia and I do
not think any two did I treat in the same way. I think that is true of
all cases, no two are alike. The treatment has to be fitted to the individual patient, the surroundings and the time of onset. A general outline
of treatment would be something like this: The patient is at once given
a hypodermic of morphine, gr. % is enough. Then as soon as she is
under the influence of the morphine she is moved to the hospital or if she
is already in hospital, the further treatment can be started. Wash out
stomach with a solution of soda bicarb, and then leave 2 ounces of mag.
sulphate in stomach. A high enema and a pint of 10% solution of glucose left in bowel. Then the patient is turned on her side, practically in
Sims position. This is to prevent saliva and secretions from mouth beinv
drawn into lungs and aspiration pneumonia. Put gag between patient's
teeth and have her carefully watched in a quiet warm room.
Page 155 Now what will be the progress of patients treated in this way at the
end of, say six hours? Quite a fair number of them will be definitely
better. They will be conscious or show signs of regaining consciousness
and will have no more fits. Another fairly large number will be neither
better nor worse and treatment, eliminating treatment and perhaps some
morphine will have to be continued. A number of cases perhaps larger
than either of the other groups will be definitely worse, convulsions will
have continued, may be in deep coma and pulse and respirations show
signs of distress.   These are the cases that will test one's faith in any one
fir*
method of treatment, but nothing is surer than this, if we have any faith
in statistics at all, no other treatment will give better results and nothing
is to be gained by multiplying treatments. A short time ago Karl Wilson collected all the cases of eclampsia in the Johns Hopkins for the last
30 years. He divided them into two groups. In one group those that
had been delivered by some operative procedure, either forceps or Caesarean section and in the other group those that had been treated with the
minimum of obstetrical interference and the mortality in the latter was
less than half that of the group that had been treated actively. These
findings were open to the objection that the mild cases had the conservative treatment and the bad cases the radical treatment and the comparison
unfair. So, another grouping was made and they were first divided into
three groups: mild cases, fairly severe cases and very severe cases, and
the result was about the same. The mild, and moderately severe and the
very severe that received the minimum of obstetrical interference showed
by far the lower mortality rate. Two years ago in Great Britain 2000
cases were collected from different centres, covering a period of ten years,
and they were grouped in a similar manner to the Johns Hopkins' report.
These statistics were analyzed, not with idea of trying to prove
or disprove any one line of treatment, but simply to try to find out what
method of treatment had in the past given the best results. These are
the results:
Mild Cases Severe Cases
Natural delivery        4.5% 36%
Assisted delivery        5.6% 31%
Induction        6.6% 26%
Caesarean Section     11.3% 46%
Accouchement force      18    % 63%
Clearly showing that our patient has by far the better chance if we
withhold our hand and do nothing; a mighty difficult thing to do with
friends and relatives clamouring for something to be done at once. Fortunately a great majority of these cases go into labour spontaneously and
deliver themselves. The pains of the first stage can do no harm, but the
hard bearing down pains of the second stage must increase tension, and
death often comes at this stage with a cerebral haemorrhage, and for this
reason I think the second stage should be shortened as much as possible
by forceps delivery.
What about the patient that comes out of her convulsions and regains consciousness without going into labour? Stroganoff is very strong
on leaving these patients alone.    He considers eclampsia an acute in-
Page 156 fection, a self-limiting disease. It is true that many of these patients will
go on to full term and normal labour without further mishap. But you
have a patient whose excretory organs are damaged, whose blood pressure
is still up and who may go into convulsions again, and you will not be
safe or happy until she is delivered. If she is a multipara I would rupture
the membranes and let labour come on. If she were a primipara, I would
do a Caesarean.
THE CAUSES AND TREATMENT OF VAGINAL
DISCHARGE
By George Gellhorn, M.D., F.A.C.S., St. Louis, Mo.
Address delivered before the Summer School,
Vancouver Medical Association, September, 1926.
When a woman consults you because of vaginal discharge, she thinks
that her discharge is a disease; whereas you know that it is merely a symptom—a symptom not only of one, but of a number of different pathologic conditions. In the following table I have compiled the more common causes of leucorrhoea, and while this list is not complete, it is obvious
that no single method of treatment can yield satisfactory results in so
large a number of different diseases. The various causes have been grouped
according to the epochs in woman's life.
A.
B.
CAUSES OF LEUCORRHOEA
UNTIL PUBERTY—
1.    Vulvo-vaginitis of children.
Adol
C.
escence.
DURING SEXUAL MATURITY—
1. Vaginitis.
2. Acute Endocervicitis.
3. Chronic Endocervicitis.
4. Parasites.
5. Foreign Bodies.
6. Uterine Tumors and Displacements.
7. Subinvolution.
AFTER MENOPAUSE—
1. Senile Vaginitis.
2. Cancer.
UNTIL PUBERTY
In childhood vaginal discharge is most often due to vulvo-vaginitis
which may occur from the first weeks of life up to ten or twelve years.
The effective organism is usually—but not always—the gonococcus, and
the mode of transmission is not as often rape, (as we formerly believed),
Page 157 as it is contaminated sponges, wash rags, towels, diapers, and the like. In
large families living under unhygenic conditions, a number of children
may thus become infected, and in orphan asylums, a careless attendant
may cause a veritable epidemic. The outer genitals, bathed in the copious, purulent discharge, are reddened, swollen and painful. The customary treatment is instillation into the vagina of a watery solution of a
silver salt; but as the fluid remains in contact with the inflamed mucosa
only a few minutes, the results are altogether unsatisfactory.
Some years ago, I recommended  (Journ. Amer. Med. Ass'n., 1920,
75,1647) a treatment with an ointment of the following formula:
Silver nitrate 1.0
Anhydrous lanolin
White vaseline aa 50.0
This ointment is injected into the vagina by means of an ordinary glass
syringe with a slender nozzle to which a piece of soft rubber catheter or
tubing, about 3 inches long, is attached. The tubing is changed for each
patient. If well lubricated, it can be introduced without pain into the
vagina of even a very .small child, and it is slowly pushed inward the entire length of the vagina. The latter is then slowly filled to capacity
with the silver salve. The excess of salve which oozes back through the
hymeneal opening is not wiped off, as it is meant to cover and protect the
irritated vulva and its surroundings.
The treatment is given once a day without any additional douches.
Every seventh or eighth day, after a day of rest, a smear is examined, and
the injections are continued if gonococci are present. The pus disappears
very soon, but even in a clear, watery secretion gonococci may be found.
If they are absent, smears should be examined at weekly intervals without
any further treatment. Occasionally, provocative silver nitrate injections (5 per cent.) should be made, and smears examined the next
day. After at least three negative smears, the child may be discharged
until a final examination one month later. Only then may the patient
be considered cured. The length of time required for treatment varies
between four and eight weeks.
In young girls within the adolescent period there occurs not infrequently a white discharge resembling library paste. An anxious mother
may bring her daughter to ask for a remedy. Microscopic examination
fails to show bacteria. Vaginal douches only make matters worse. In
fact, no local treatment should be used in such cases, as it merely attracts
the attention of the patient to her genital sphere. What these girls need
is a strengthening of the entire organism by means of fresh air and sunshine, by lightening the work in school or shop or factory, by regulating
the bowels, and by the admistration of iron and arsenic. In some such
cases an endocrine factor is undoubtedly at work, usually an excessive
ovarian function which manifests itself in the form of menorrhagias.
Pituitrin and calcium are then indicated.
DURING SEXUAL MATURITY
During sexual maturity, the causes of leucorrhoea are much more
numerous; and this is readily understood if we reflect that durine this
Page 158 time a woman is frequently exposed to traumatisms and infections of all
kinds.
The vagina of the newborn girl is sterile, but within a day or two,
bacteria find an entrance and multiply until, eventually, all sorts of germs
will be found, even pathogenic organisms. These bacteria, however, live
in the vagina as harmless parasites until such time as a traumatism occurs; they can acquire a new virulence and may produce an inflammation, a true vaginitis. Whether endogenous or introduced from without,
they find in the warmth and moisture of the vagina a most favourable
soil in which they grow in very large numbers; colon bacilli and staphylococci are rarely absent. The vaginal mucosa is diffusely reddened, and
the copious discharge is thick and yellow, of the appearance of pea soup,
and with an unpleasant odor.
Vaginal douches are entirely useless in this condition, no matter how
many are taken every day. The sovereign therapy is the powder treatment devised by Nassauer, of Munich, in 1909 (Muenchener Mediz.
Wochenschr. 1909, No. 15). This author proposed the use of kaolin, a
very fine, hygroscopic porcelain clay. Equally hygroscopic is another
form of clay, known as Fuller's Earth. I have found the combination of
equal parts of either of these clays and bicarbonate of soda particularly
satisfactory. The powder is applied by means of a special instrument
designed by Nassauer and termed "siccator." A pear-shaped bulb of glass
is thinned out conically at one end. Introduced into the vagina, the bulb
completely closes the vaginal entrance no matter how wide it is. A canal
in the long axis of the bulb communicates with a small glass reservoir
which is connected at its other end with a rubber tube and bulb. The
reservoir is filled with the powder and securely closed with the stopper
The glass bulb is now introduced into the vagina and held firmly against
the introitus, and at the same time the rubber bulb is compressed with
the other hand three or four times in succession. The air pressure completely unfolds the vagina and simultaneously distributes the powder over
the entire mucosa. When this distention has reached its maximum degree, the air escapes along the four grooves upon the outer surface of the
glass bulb. The manipulation may now be repeated until all the powder
has been deposited in the vagina. At the end of each treatment the vulva
is dusted with same powder.
If this very practical appliance is not available, the patient's pelvis
may be raised and a larger amount of the powder poured into the vagina
through an ordinary bi-valve speculum, very much as a dentist fills a
tooth. To retain the powder, a tampon or two are inserted to be pulled
out by their string by the patient herself on the next day. The treatment is repeated every other day.
The effect is almost instantaneous. The annoying sensation of moisture is relieved immediately. The discharge, after a very few treatments
appears less purulent and becomes scantier and soon disappears—and this
without a single douche! The explanation is simple enough. The hygroscopic powder deprives the bacteria of the moisture necessary to their ex-
Page 159 istence and thereby mummifies them, and thus gives the vaginal mucosa
a chance to recover its own power of resistance.
So-called "vaginal" discharge is produced in the vagina itself only in
a minority of cases. In most instances it issues from the cervical canal
and is the manifestation of an endocervicitis. In its most acute form,
this disease is usually caused by gonorrheal infections. The inflamed
mucosa of the cervical canal pours out a large amount of thin, greenish
pus which is intensely irritating to the vagina and vulva, and may—and
usually does—infect the bartholinian glands. Gonococci are found in
pure culture in the smear. It is a generally accepted axiom not to give
any local treatment to the cervix at this stage. The therapy should be
general and consist of rest in bed, a bland diet, and attention to the bowels. I have, however, found Nassauer's powder treatment of inestimable
value in this acute stage for, without disturbing the patient, it reduces
temporarily the amount of discharge and thereby lessens the marked subjective discomfort and prevents the secondary infection of the bartholinian glands. It thus tides the patient over until the chronic stage has
been reached, when more active treatment is indicated.
My personal experience with acute endocervicitis is comparatively
small. Most of my patients with endocervicitis present themselves in the
chronic stage. It is then not always easy to determine the gonorrheal
origin with accuracy. The cervical smears at this timje contain a large
number of various bacteria among which gonococci cannot be identified.
The vagina is filled with muco-purulent discharge, and a thick plug of
opaque mucus protrudes from the edematous or fibrotic cervix. It is only
from the history of the case, the sterility, and the findings of tubal involvement, that a tentative diagnosis of chronic gonorrheal endocervicitis
can be made.
Nor is the gonococcus the only microbe that is responsible for chronic endocervicitis. Even more often is infection after childbirth the cause.
Any tear at that time may lead to an eversion of the cervical lips. Thereby the cervical mucosa which ordinarily is sterile and protected from
contact, becomes exposed to the bacteria living in the vagina and so to
infection. The racemose glands in the cervix produce mucus which is
discharged through fine ducts, but in any inflammation and swelling of
the mucosa these ducts are easily compressed. The body of the gland,
however, continues producing mucus which leads to retention and cystic
enlargement of the gland until the latter projects as the well-known
nabothian follicle upon the surface of the cervix.
Chronic endocervicitis of whatever origin, rather commonly leads to
a more or less extensive erosion which is covered with purulent discharge
and very often bleeds on being touched.
The customary treatment is extremely unsatisfactory. Vaginal
douches, no matter how frequently employed, are obviously illogical, and
it is superfluous to point out that no douche can possibly reach the seat
of the inflammation within the cervical canal. Our medical fathers and
grandfathers were very fond of intracervical treatment. Playfair devised
a special probe for that purpose, and a good many other appliances have
Page 160 been designed since. The remedies used were tincture of iodine or nitrate
of silver and they were applied day after day and month after month
until even the most patient patient lost hope. I suspect that it was this
useless intracervical cauterization, more than any other conservative
method, which brought minor gynecology into disrepute and earned for
it the epithet "tinkering."
It may be that diathermy will in time rehabilitate intracervical
treatment and put it on a more sound basis. For the present, however,
we possess an entirely satisfactory therapy in electrocauterization. This
is a method with which every practitioner should familiarize himself.
Hunner, of Baltimore, introduced it in America, and Dickinson, of New
York, perfected it. The instrumentarium consists of the cautery handle
and tips used in nose and throat work. For further details, the reader is
referred to Dickinson's article (Amer. Journ. of Obst. & Gyn., 1921, 2,
600) and to an excellent presentation of the subject by Matthews which
has appeared quite recently (Journ. Am. Med. Assn., Nov. 27, 1926).
The electric cautery changes the nature of the discharge almost immediately. The thick, tenacious pus turns into a much thinner secretion.
Since the patients still have the unpleasant sensation of being moist it is
wise to follow the treatment up for a week or two by the powder treatment described previously. The electric cautery treatment is given only
at monthly intervals, and hardly ever are more than two treatments required.
However, there is no one method which is applicable to all cases.
There may be cases so badly infected or so difficult to treat that they will
require operation. In former years we used to perform trachelorrhaphy;
but since Leonard, from Kelly's clinic in Baltimore, has demonstrated the
unsatisfactory results of this operation, we nowadays resort to amputation
of the cervix and prefer, for this, methods of the type of the Sturmdorf
operation.
Vaginal discharge is sometimes caused by parasites. Of these, the
trichomonas vaginalis, a member of the flagellate family, is of particular
practical importance. The discharge is very copious, thin, yellow, and
foamy. It has no odor, but is highly irritating. The diagnosis is easy.
Place a drop of pus on a slide and add a drop of normal saline solution,
put a cover slip over it and look at it through an oil immersion lens when
you will readily recognize the parasites by their rapid motion. For treatment, the vagina is exposed by a speculum, and the vaginal walls are energetically wiped out with a sponge saturated with a 2 per cent, silver nitrate solution. After each treatment, the vagina is filled with the kaolin
and soda bicarbonate powder.
Any foreign body within the vagina produces discharge. This fact
must be borne in mind when we ourselves introduce foreign bodies in the
shape of pessaries. It then becomes necessary to instruct the patients to
use alkaline douches as a matter of prophylaxis, and this is about the only
time that vaginal douches are indicated in the treatvient of vaginal discharge. If this precaution has been neglected, and pressure marks and
ulcerations have resulted, the pessary must be removed and the irritated
Page 161 vaginal mucosa treated by means of a 1 per cent, silver nitrate ointment
on a tampon.
The discharge caused by fibroids of the interstitial or submucous
variety calls for enucleation or hysterectomy, according to the seat of the
tumors, if the woman is below 40, or for radium treatment if the patient
is above that age.
In retrodisplacements of the uterus which quite commonly give rise
to discharge, we have to resort to operation, if pessary treatment is not
advisable. The operation consists of shortening of the round ligaments
and should be com'bined with curettage. This is the only occasion when
curettage will be of any value in the treatment of discharge.
A prolific source of discharge is subinvolution. The uterus is large
and boggy or, if the subinvolution is of long standing, hard and fibrous.
The menses are both abundant and protracted, and in the intermenstrual
period there is a copious, thin, watery discharge from the glands of the
uterine mucosa. Once firmly established, this condition has justly been
considered incurable by ordinary means and forms a legitimate indication
for many a radical operation. For some years past, however, I have had
such signal success with conservative treatment that I would urge at
least an attempt at depleting the enlarged organ. For this purpose, I have
suggested (Non-Operative Treatment in Gynecology, Appleton & Co.,
New York, 1923, p. 161) protracted vaginal douches which can be arranged in any household where there is running hot water.
The patient lies in the bath tub on several thicknesses of blankets
which are covered with an oilcloth. The buttocks project an inch beyond the edge of the blankets. The head and back are supported by pillows. The feet rest on bricks, flat irons, pieces of wood, or the like. A
piece of soft rubber tubing' has previously been fitted over the faucet and
fastened to it with a string. The smallest caliber of tubing is used. Now
the hot and cold water supply is regulated to a suitable temperature, the
force of the water stream being kept down to a -minimum. The patient
introduces the free end of the nozzle; the tubing, hanging over one knee
and fastened to the inside of the thigh by a strip or two of adhesive
plaster, needs no further handling. The water runs into the vagina in a
steady stream and out into the bath tub without wetting the patient who
is in so comfortable a position that the procedure can easily be continued
for one or even two hours. One treatment every other day, preferably
before retiring, is sufficient. The heating of the vagina produces an active
hyperemia which, theoretically, should be followed by relaxation and venous stasis. In practice this does not happen, and absorption is actually
encouraged by the prolonged application of heat. The wrinkled hands of
a washerwoman at the end of a day's work is a good analogy.
On the intervening days, glycerine tampons, properly applied, will
keep up the process of depletion. I know of at least four patients who
have been cured and have had children following this combined treatment—women who, otherwise might never have had another child because of the condition of their subinvoluted uteri.
Page 162 Diathermy, with one electrode in the vagina, the other encircling
the waist of the patient is another way of heating the uterus and its surroundings and thereby producing an active hyperemia which will wash
out the products of congestion.
If depletion cannot be brought about and menorrhagia and discharge
persist, surgery is indicated. By a curettage, however, success cannot be
accomplished. We must resort to hysterectomy, leaving the ovaries behind; or, if such an operation is inadvisable for other reasons, we may apply radium whereby a premature menopause with cessation of the discharge is achieved.
AFTER THE MENOPAUSE
Ordinarily, the menopause means the end of all functional activity
of the cervical or uterine glands; hence, there is no more secretion or discharge. Occasionally, however, climacteric women will seek medical aid
for an intense irritation of the vulva produced by a scanty and colourless
discharge which, at times, may be tinged with blood. On examination,
the mucosa of the vulva and vagina exhibits highly reddened areas varying in size from small dots to patches 1 cm. in diameter. This condition
has been misnamed senile vaginitis. It does not represent an inflammation, as the term would imply, but merely the physiologic thinning out
of the squamous epithelium covering the papillae with their loops of
small bloodvessels. The rate of desquamation exceeds the regenerative
power of the epithelium. The mucosa thus thinned out, becomes transparent which explains the reddened appearance, and where bloodvessels
are actually exposed, a transudation of acrid blood serum, now and then
with traces of blood, produces most distressing burning.
The treatment of this condition is very simple. A tubular speculum
is introduced into the vagina and filled with pue pyroligneous acid. By
moving the speculum up and down for a few minutes, the entire surface
of the vagina is bathed with this astringent which may be considered almost a specific remedy. The irritated surface of the vulva and its surroundings is touched with a silver nitrate solution. Subjective improvement is instantaneous, and a temporary cure is effected after two or three
treatments given at intervals of two days. It is advisable to warn the
patient that the treatment may have to be repeated every few months, as
the condition is a physiologic phenomenon and apt to return.
Another source of discharge in women past the menopause is cancer.
I am speaking more in particular of inoperable cancer of the cervix with
its excessive, stinking, and bloody discharge which no vaginal douche,
however often repeated, can ameliorate. The sovereign palliative remedy
is radium which, if applied by an expert, will promptly bring about an
improvement that may last for many months. There are, however, two
weighty drawbacks to radium. It is not available everywhere and, in the
most desolate cases which require relief most urgently, its use is fraught
with great danger. The practitioner, therefore, must have other means at
his disposal to relieve his patients. The kaolin treatment of Nassauer
may improve matters a little, but on the whole is inadequate against the
Page 163 massiveness and stench of the discharge and powerless to prevent haemorrhages. • The same is true, to a large extent, of the method of Berczeller,
of Russia, who recommended filling the vagina ad maximum with finely
powdered granulated sugar, the latter to be retained by means of a tampon or an iodoform gauze pack.
Far better than either of these two procedures, and preferable even
to radium in the most advanced cases, is the acetone treatment which I
designed twenty years ago. (Journ. Am. Med. Assn., 1907, 48, 1400;
Am. Journ. of Obst., 1909, 59, No. 5). This method has stood the test
of time and has been included in many textbooks in this country, England, and Germany. As it is extremely simple and highly efficacious, I
quote the technique from my latest article on the subject (Journ. Missouri State Med. Assn., 1922, 19, 59), as follows:
1. The cancerous masses occupying the cervix are scraped or scooped out with a curette or, better still, with a very large, sharp spoon. This
may require a few whiffs of ether or chloroform, but in many cases a
preliminary injection of morphine renders this short initial step painless.
2. Do not lose time with attempts at checking the bleeding which
is usually abundant, but raise the foot end of the examining or operating
table and insert into the vagina a well lubricated Ferguson or other tubular speculum.
3. Pour into this speculum a tablespoonful of pure acetone, which
will check the bleeding immediately. Lower the speculum after about
ten minutes and permit the acetone and clotted blood to run out, and
fill th especulum once more with pure acetone.
4. The speculum is now held in place for fifteen or twenty minutes,
usually by the patient herself, after which time the table is lowered so
that the fluid will run out of the speculum. The latter is now thoroughly
washed out with cotton pledgets soaked in water, and then withdrawn.
No packing is left in the vagina.
There is absolutely no pain connected with the procedure, provided
the acetone does not touch the vulva. Even a single drop of acetone
upon the mucosa of the vulva would cause an intense burning which,
however, can be relieved at once by washing it off with water. It is for
this reason that a tubular and not a bi-valve speculum must be inserted
and that the amount of acetone used must not be so large as to run out
and over the vulva.
The treatment as outlined above is repeated every two days for at
least three weeks, except that the curettage is omitted. Later the intervals between treatments are lengthened to three or four days, and as the
condition responds to the applications, treatments are given only as the
case requires.
CONCLUSION
Th
)blei
ne problem of vaginal discharge is a very extensive one and necessitates a detailed discussion. The practitioner who realizes that discharge
is merely a symptom produced by a variety of pathologic conditions, will
Page 164 r
investigate into the underlying cause which may differ in every individual case, and vary his treatments accordingly. In the foregoing survey
only those methods have been discussed which have given satisfactory results in the hands of the author. Among these, there is a number of
original procedures which have stood the test of time and have won the
approval of other observers. This search into the therapy of vaginal discharge has also shown convincingly that the two most popular methods
of treatment, namely, vaginal douches and curettage, are the ones that
accomplish little, if anything. It is time to break away from these traditional remedies and practice newer methods that are better suited to the
needs of our patients.
CITY HEALTH DEPARTMENT
Vancouver, B.C.
STATISTICS-
Total Population (estimated) 	
Asiatic Population   (estimated)   I
-DECEMBER, 1926
Total Deaths  .  205
Asiatic Deaths   14
Deaths (Residents only)   159
Total Births   290
Male,       154
Female,  136
Stillbirths—not included in above   10
INFANTILE MORTALITY—
Deaths under one year of age  12
Death rate per 1000 Births   41.4
Nov.,
Cases
Smallpox          0
Scarlet Fever       37
Diphtheria          40
Chicken-pox        77
Measles         152
Mumps          19
Whooping Cough .... 1
Erysipelas     8
Tuberculosis    8
Typhoid Fever          3
 128,366
  10,100
Rate per 1000
of population
18.8
16.3
14.6
26.6
Diphtheria         7
Scarlet Fever  8
Typhoid Fever         3
US DISEASES REPORTED IN CITY
Jan.  1st, to
1926
Dec,   1926
Jan. 15 th,
1927
Deaths
Cases
Deaths
Cases D
eaths
0
0
0
0
0
0
26
0
7
0
0:-:
18
3
18
2
0
19
0
9
1
0
94
0
136
0
0
2
0
1
0
0
5
0
0
;0;"'
0
c7 '
2
4
0
12
8
12
3
—
0
2
0
0
0
tside city
included
in above
.
1
4
0
1
0
0
6
0
0
0
0
2
0
0
0
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Page 166
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