History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1930 Vancouver Medical Association Mar 31, 1930

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  Patient Types:
THE CHRONIC
They have worn holes in the carpets of many a waiting room and
frayed the physicians' patience to shreds.
Often, underlying the chronic conditions is bowel stasis and irrational use of harsh cathartics.
In such cases many chronics have been definitely benefited by a
period of "habit time" education together with other rational treatment.
The use of Petrolagar will materially shorten the period of bowel
re-education. A few of the advantages of using Petrolagar over plain
mineral oil are its palatability its more thorough permeation of the
feces, less danger of leakage, and it has no deleterious effect on diges
tion.
retrol
agar
Petrolagar Laboratories
of Canada Ltd.
907 Elliott St., Windsor, Ont.
Dept. V.M.  10.
.. Gentlemen:—Send me copy of "HABIT TIME" (of bowel movement) and
specimens of Petrolagar.
Dr	
Address THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published  Monthly  under  the  Auspices  of  the  Vancouver  Medical  Association  in  the
Interests of the Medical Profession.
Offices:
203 Medical and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abovs address.
Vol. VI.
MARCH,   1930
OFFICERS 1929-30
Dr. T. H. Lennie Dr. G. F. Strong Dr. W. S. Turnbull
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon.-Secretary Hon. Treasurer
Additional Members of Executive:—Dr. W. A. Dobson; Dr. A. C. Frost.
Dr.  W.
Coy
Auditors:
Trustees
Dr. W. B. Burnett Dr. J. M. Pearson
Messrs. Price, Waterhouse & Co.
SECTIONS
Clinical Section
Dr. J. R. Davies	
Dr.  S.  H.   Sievenpiper	
Physiological and Pathological Section
Dr. A. M. Menzebs	
Dr. R. E. Coleman	
Eye, Ear, Nose and Throat
Dr.  F.  W.  Brydone-Jack .Chairman
Dr. N. E. McDougall \ '■ Secretary
Physiotherapy Section
Dr. H. R. Ross Chairman
Dr. J. W. Welch Secretary
Pediatric Section
Dr.  C. F.  Covernton ^Chairman
Dr.  G.  O.  Matthews  Secretary
Library
Dr. C. H. Bastin
Dr. Wallace Wilson
Dr. S. Paulin
Dr. D. F. Busteed
Dr. W. H. Hatfield
Dr. D. M. Meekison
Dinner
Dr. W. T. Ewing
Dr. W. A. Gunn
Dr. L. Leeson
Rep. to B. C. Med. Assn.
Dr. A. Y. McNair VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
PROGRAMME OF THE 32nd ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on the Agenda.
1930
March
March
April
April
April
4th-^OSLER LECTURE—Dr. J. J. Mason.
18 th—Clinical Meeting.
1st—General Meeting:
Papers—Dr. L. H. Appleby; "Sodium Amytal."
Dr. G. O. Matthews; "Common Practices in
Infant Feeding—their Use and Misuse."
15 th—Clinical Meeting.
22nd—ANNUAL MEETING.
VANCOUVER HEALTH DEPARTMENT
STATISTICS, DECEMBER,  1929
Total Population   (Estimated)    . 240,421
Asiatic   Population   (Estimated)     .     9,33 5
Rate per 1000 of Poulation
Total   Deaths    1 . 233 11.41
Asiatic   Deaths    ... . 16 20.18
Deaths—Residents   only    s 210 10.28
Birth   Registrations    - . 332 16.26
Male       171
Female    161
INFANTILE MORTALITY—
Deaths under  one year  of  age	
Death  Rate per   1000  Births   	
Stillbirths—(not included  in  above)
December, 1929
Cases Deaths
Smallpox     '. 2 0
Scarlet   Fever 22 0
Diphtheria    38 0
Chicken-pox      33 0
Measles        4 '   0
Mumps    ~_ 20 0
Whooping-cough     18 0
Tuberculosis     6 12
Typhoid   Fever 1 0
Poliomyelitis   , . 1 0
Meningococcus-Meningitis 2 2
Erysipelas -~=     9 0
13
39.16
12
January, 1930
Cases     Deaths
February 1st
to 15th, 1930
Cases     Deaths
i
20
37
99
3
40
28
22
1
0
0
9
0
0
1
■■•.0.
0
0
0
25
0
0
0
0
3
11
14
38
3
19
16
11
1
0
0
9
0
0
1
0
0
0
1
0
0
0
0
Page 114 t.^^^jjv:
An Effective Allif-
in the Treatment of Pneumonia
Anything short of major calibre in a diathermy machine for the
treatment of pneumonia will prove disappointing. The Victor
Vario-Frequency Diathermy Apparatus is
designed and built specifically to the requirements. It has, first, the
necessary capacity to
create the desired physiological effects within
the heaviest part of the
body; secondly, a refinement of control and
selectivity unprecedented in high frequency apparatus.
In the above illustration the apparatus
proper is shownmount-
ed on a floor cabinet,
from which it may be
lifted and conveniently
taken in your auto to
the patient's home.
A REPORT from the Department of Physiotherapy
of a well-known New York
hospital, dealing with diathermy
in pneumonia and its sequelae,
states as follows:
"As a rule diathermy is indicated in acute pneumonia,
especially so when the symptoms are becoming or already
are alarming: temperature is
high, the patient is delirious, the
pulse is extremely rapid, cyanosis is deep, the respiration
rate is high, the breathing is
very shallow, and the cough
remains unproductive. Not infrequently in a pneumonia case
with such alarming symptoms,
after a few diathermy treatments an entire change of the
picture takes place: cyanosis
lessens, respiration becomes
deeper, the quality of pulse improves, the rate decreases, the
temperature is lowered, and the
cough becomes productive.
Auricular fibrillation that develops occasionally in similar
pneumonias or other types of
pneumonia where the toxemia
is great, has been changed to a
perfect normal rhythm after a
few diathermy treatments."
You will value diathermy as
an ally in your battles with
pneumonia at this season, aside
from the satisfaction derived
from having utilized every
proved therapeutic measure
that present day medical science offers.
A reprint in £ull of the article
above quoted, also reprints of
other articles on this subject,
will be sent on request.
Vancouver Branch:
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2012 Jackson Boulevard Chicago,111.,U.S. A.
"ORMERIT   VICTOR   TO^B    X-RAY CORPORATION
Motor Transportation  Bldg.,  570 Dunsmuir  Street. It Helps You
To Get Results
Out of our 22 years' experience as prescription specialists has grown an understanding
and appreciation of the value to the Doctor
of intelligent co-operation on the part of the
Pharmacist. That is one reason why we insist
that every medicinal used in our dispensary
must be of the highest quality obtainable.
eft©
Seymour
1050
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Pharmacy
LW
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Open
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In pneumonia
Optochin Base
For the specific treatment of pneumonia give
2 tablets of Optochin Base every 5 hours,
day and night for 3 days. Give milk with
every dose but no other food or drink.
Start treatment early
MERCK <Sl CO* Limited
412 St. Sulpice St.
Montreal EDITOR'S PAGE
An account of the interim report on Health Insurance by an appointed committee of the local Legislature has recently appeared in the
press. Doctors will be interested, for the medical profession has discussed this question in considerable detail for many years. There must
be a mass of information accumulated in the archives of the medical
associations, having a bearing on this subject.
Evidently the committee has viewed the matter thus far with a
favourable eye and as there are two doctors on the committee we may
presume that the views of the medical profession will be represented.
In a manner this question of health insurance somewhat resembles
the question of the regulations of the General Hospital in that the
medical profession, one may say the goodwill and cooperation of the
medical profession, are necessary to implement it, or them. Thus the
doctors take a justifiable corporate or collective interest in these and
similar questions and as one of the parties to an effective operation not
unnaturally believe that their views should have some weight.
Health insurance at the present time probably means an extension
to medical cases and to surgical cases for that matter, of benefits something on the lines at present granted to industrial accidents through the
Workmen's Compensation Board.
It will of course be a much more complicated affair to work out, as
to be really effective the insurance must embrace periods of unemployment.
Most countries having such arrangements have adopted something
in the form of the panel system which provides benefits for all people
whose normal earnings do not reach a given standard presumably whether
employed or not. Such a system one would think should be nation wide
in its application.
The panel system has this disadvantage, as far as the medical profession is concerned, in that it interferes in part with the principle the
profession has always maintained, that is the right of the patient to a
free choice of doctors. To an extent the choice is free, free among those
doctors who agree to do panel work and free in the sense that a change of
doctors can be made once every year if the individual so desires.
We believe that somehow or other better work is accomplished when
there is a minimum of interference with the personal relations of patient
and physician. Such a relationship has its drawbacks, it may be at times
abused, but on the whole we are satisfied that it works out to the best
interests of the community.
The experience of the Workmen's Compensation Board should be
invaluable in helping to solve this problem of health insurance. Here
the principle of free choice is for the most part fully at work and for
the most part too, we may believe it has proven satisfactory.
The doctors under such a system have very distinct obligations, not
only as to the quality of their work, not only as to their ability to under
pay 115 take such work, but as to their ability to press cases to an early convalescence and to a consequent reduction in the expense entailed on the
contributing parties.
We see difficulties in health insurance with regard to Laboratory and
X-ray work. Curtailment of these services is the last thing to be
sought. Cost reduction, so that fuller and freer use of these invaluable
adjuncts can be made, is the great desideratum. All doctors deplore the
cost of these examinations, not necessarily because it depletes the resources of the patient, but because it makes the physician hesitant about
some desirable, but not quite obvious, form of investigation.
We gather that the medical profession will see before a great time,
strange developments. The non-pay patient may even disappear out of
our hospital wards. Boards of directors will then sleep easier o' nights
and staff—staffs. will be such stuff as dreams are made of. Well, we
have brought things on ourselves, we have been so busy discovering and
inventing and prying hither and thither and producing cures and alleviations which have been heralded to the corners of the earth and prevenr
tions that but for the resources of nature should before this have made
the world safe for democracy and everybody else.
Now people are waking up and demanding a greater share of these
good things, finding life so desirable as to demand an indefinite extension.
It is up to the doctors to provide it, preferably for nothing,
but in any event for wages that will not induce them to retire too soon.
NEWS and NOTES
Several doctors have been ill during the past month, but we are
glad to report they are all making good progress towards recovery. Dr.
E. E. Day was confined to the hospital in the Medical-Dental Building,
suffering from the effects of a radical operation on the sinuses. It is
understood that he was completely recovered by Saint Valentine's day,
and enjoying life as usual.
We congratulate Dr. G. O. Matthews and Mrs. Matthews on the
birth of their first baby—a daughter—who arrived on the morning of
February 24th.
Dr. Ainley has been in the Vancouver General Hospital, and for a
time was threatened with pneumonia.   He is now better and has resumed
practice.
Dr. F. N. Robertson has also been seriously ill with pneumonia, and
while convalescing satisfactorily, he is still in the Vancouver General
Hospital.
The Mediterranean route to Vienna is again proving its popularity.
Dr. Grant Lawrence left on February 13 th, and Dr. Oliver Large on
February 24th for Vienna. Dr. Grant Lawrence will include London in
his return itinerary.   He expects to be back in Vancouver in June.
Page 116 The Tenth Annual Summer School will be held on June 24 th, 25 th;
26th and 27th. The Committee originally fixed upon September as the
date for this year's meeting but owing to strong representations made by
Dr. Bazin, President of the Canadian Medical Association, asking that
nothing should be allowed to detract from the success of the British
Medical Association meeting to be held in Winnipeg at the end of August, the Committee regretfully decided it must meet Dr. Bazin's wishes
and the only other possible date appeared to be the last week in June.
The Committee is meeting with considerable difficulty in securing suitable speakers owing to the meeting of the American Medical Association
being held about the same time. However, three first-class clinicians
have already been secured and it is hoped to publish the full programme
in the next issue of the Bulletin. The Committee took the opinion of the
Executive as to the effect of dropping the meeting for this year, but as
there will probably be no meeting in 1931 if the Canadian Medical
Association comes to Vancouver, the Executive felt that every effort
should be made to hold the School as usual this year. The Committee
hopes for the active support of the members to make this year's meeting
a success in spite of the counter-attractions of the Winnipeg meeting.
Dr. H. W. Hill, Director, Vancouver General Hospital Laboratories,
was appointed by the National Research Council of Canada in 1928 as
one of the four medical members of their Associated Committee on
Animal Disease and Nutrition. He recently attended the first meeting of
this committee held in Ottawa, February 11th, 1930, representing the
University of B. C. in connection with Contagious Abortion of Cattle,
Redwater and other diseases of stock, very damaging in themselves, and
some of them transmissible to man. Dr. Hill is also a member of the
National Research Council Associated Committee on Tuberculosis, which
met in Ottawa immediately afterwards.
MEETINGS
The regular general Meeting of the Association was held in the
Medical-Dental Building Auditorium on Tuesday, February 4th. Dr.
W. E. Scott-Moncrieff of Victoria was the speaker of the evening. He
gave a most interesting address on "The Importance of the Early Recognition of Glaucoma by the General Practitioner," which was illustrated
by lantern slides.    This paper will be printed later in the Bulletin.
Dr. G. F. Strong reported for the Special Joint Committee appointed
by the Executive to consider methods of closer co-operation between the
College of Physicians and Surgeons,' the B. C. Medical Association and
the Vancouver Medical Associations. This was in the nature of an
interim report. The first objective of the Committee was an attempt to
arrange for a compulsory fee as obtains in Alberta. This was, however,
found impracticable, and the Committee is now confining its efforts to
better co-operation with the B. C. Medical Association whereby it is
hoped to arrange for a reduced fee for Vancouver men some time in
1931.
Page 117 Dr. Lee Smith and Dr. E. C. McLeod were unanimously elected to
membership in the Association.
Dr. J. A. Gillespie reported for the Special Committee on the Hospital situation. This report, which was adopted by the meeting, contained
a resolution that a letter be sent to the Provincial Secretary informing
him that the medical profession of Vancouver was opposed to the new
regulations and that the Staff of the Hospital had passed a resolution with
only two dissenting votes asking the Board to modify them.
A special meeting of the Association was held on February 10 th to
consider certain statements made in the press by Mr. J. H. McVety
which reflected on the Association. Seventy members were present. The
Committee which had been appointed to draft a letter in answer to Mr.
McVety reported that after careful consideration, while submitting such
a letter for discussion by the meeting, doubted very much the advisability of answering Mr. McVety in this way. In the first place the
report of his speech was only a partial one as he assured the Association.
Secondly the Committee had no reason to believe that the published
statements represented the considered opinion of the Board. In the
opinion of the Committee, the Association, while holding firmly to its
principle, should pursue the course of amicable discussion for the present.
An extract from the drafted letter was read as follows:
"The Vancouver Medical Association has more than once been asked
to give the Press a statement of its position but has refrained from doing
so, feeling that this matter can be best adjusted by quiet and friendly
discussion. The Board, indeed, while it has not yet seen its way to grant
our request in the matter, has met us with the greatest courtesy and the
way is still open for amicable settlement."
The January meeting of the Clinical Section of the Association was
held at St. Paul's Hospital through the courtesy of the Staff of that
Institution. A large attendance was present. Dr. J. R. Davies was in
the Chair. Dr. F. P. Patterson showed several cases of fracture, particularly in relation to injury at the same time of nerves or blood vessels and
the complications which may ensue. The first case was that of a young
man suffering from fracture of the humerus showing non-union after
eight weeks' treatment. Injury to the brachial plexus must have occurred at the time of accident. The limb was then put up in elevated
position to afford maximum relaxation. In five weeks' time union had
occurred. The amount of recovery of function is problematical. The
injury to the brachial plexus was a physiological one due to over-stretching.
The next case was also an upper limb injury, the patient having
been struck by a falling object on the shoulder. An anatomical lesion
was present probably by an evulsion of the roots of the brachial plexus.
Recovery was not to be expected.
The third case was that of a musculo-spiral nerve injury with
fracture of the humerus.    The arm was splinted in the horizontal posi-
Page Hi tion with the forearm at right angles and a complete range of voluntary
power is now present.
Other cases were shown by Dr. Patterson illustrating the necessity
of looking for associated vascular or nerve injuries in cases of fracture.
The subject was discussed by many of the members.
Dr. T. H. Lennie presented a young man who had some time previously fallen from the sixth floor of a laundry into the elevator well.
Internal injuries and fractures of the pelvic girdle had been sustained.
This was followed later by weakness in the left leg. Foot drop was present
and anaesthesia over the outer part of leg with marked atrophy of the
gluteus maximus muscle.
Dr. Greaves of the Physiotherapy Department of the Vancouver
General Hospital spoke on the electrical reactions of muscles in these cases
demonstrating the types of apparatus used and the technique of their
application.
Dr. A. Y. McNair, Pathologist to St. Paul's Hospital showed the
stomach of a man dying shortly after admission of haemorrhage.
A large ulcer was present on the posterior wall of the stomach the edges
of which showed malignancy. The paucreas formed the floor of the
ulcer and the bleeding had occurred through an erosion demonstrated in
a large vessel.
Dr. C. W. Prowd of the X-ray Department spoke on the X-ray examinations in this case which had been made some considerable time
previously. He discussed the difficulties in diagnosis presented by an
ulcer located on the posterior wall of the stomach.
NOTICE
It has come to the notice of the Library Committee that some members of the Association have been borrowing books and journals from the
library without signing for them in the book provided for the purpose.
When we are aware of the whereabouts of the books removed from the
library, we are able to call them in when the need arises. Otherwise we
run the danger of disorganizing complete files, some of which are very
valuable and irreplaceable. The library is maintained for the members of
the Association and kept up to date to the best of our ability and
finances. Furthermore, it is operated under a few simple rules, and
essentially under the honour system. Please help us to keep it so, for if
books continue to get lost, a more rigorous supervision of their distribution on loan must be adopted.
The following books and journals are missing and cannot be located.
There may be others, but they cannot be determined without a great
deal of trouble.
American Journal of Medical Sciences.   Vols. 175, 176, 177, 178.
Physiology and Biochemistry in Modern Medicine, McLeod,  1926.
Nutrition and Diet in Health and Disease, McLester, last edition.
Diseases of the Skin, Sutton (only just purchased).
Edinburgh—Sterioscopic Atlas, Case IV.
Page 119 Way of Life—Osier.
Man's Redemption of Man—Osier.
Medical Follies—Fishbein.
Life of Madam Curie.
Oddly enough, while this notice was being penned, a book that was
posted as "missing" in 1921 was returned through the mail.
Please look around your homes and offices and see if you have any
of the foregoing list that have inadvertently become mislaid. We might
remind the members that books may not be borrowed for a longer period
than one week without renewal.
D. ML Meekison,
Secretary Library Committee.
CORRESPONDENCE
February 3, 1930
To The Editor,
The Bulletin,
Vancouver Medical Association,
Vancouver, B. C.
Sir:
In your issue of February, 1930, Dr. J. Ewart Campbell replies to
my letter to you of January, 1930.
No one who knows Dr. Campbell's standing or the relations between
us can imagine that I would for a moment accuse him of what we all
are sure would be impossible to him—dishonesty, whether deliberate or
not. Everyone who may read carefully my letter of January 30, 1930,
in response to Dr. Campbell's impeachment of our serological work,
must see that I took great pains to guard against saying anything that
might conceivably countenance such an imputation. If, in spite of my
pains, any reader can find even the smallest loophole for an implication
to that effect, I am very sorry.
As for the rest of Dr. Campbell's letter, since he himself says that
his own discussion of my statements is "beside the point," I am left
reluctantly in the position of "all dressed up, but no where to go,"'—
ready, even eager to meet relevant arguments, but no relevant arguments
to meet. The question at issue is not a personal one—whether Dr. Campbell or Dr. Hill is right; but a purely impersonal one—whether the Kahn
or the Wassermann corresponds the better with the clinical facts. This,
and this only, I take it, can be of any permanent scientific interest to the
profession, to Dr. Campbell, or to ourselves.
Dr. Campbell reiterates his belief concerning the shortcomings of
our Kahns and Wassermanns; and this belief is certainly of material
interest to the profession in general and to the laboratory in particular.
But if Dr. Campbell does not offer serious and adequate evidence for this
belief, it is obviously impossible for us either to disclose defects in his
evidence or train of reasoning, or to be convinced that his belief is correct.
Page 120 The evidence we ourselves possess and elsewhere have presented,
leads us to the conclusions we have stated. Until some one offers evidence (not beliefs) to the contrary, we must "e'en gang oor ain gait"
as best we may.
Our present tentative conclusions, already published in previous
issues, may be reiterated in condensed form here.
1. That neither Kahn nor Wassermann is perfect.
2. That both aid clinical diagnosis very materially.
3. That the evidence so far available, particularly that of the
League of Nations Conference, indicates that the Kahn shows greater
sensitiveness than the Wassermann, in clinically positive cases, averaging
in the League of Nations Conference results, 30% superiority.
4. That, despite the Kahn test's greater sensitiveness in clinically
positive cases, it is not (as the Wassermann is) correspondingly more
likely to present "false positives." In the League of Nations Conference
results, the Kahn not only averaged 30% better in picking out clinical
positives, but also its average for "false positives" was only about
one-eighth of the Wassermann average for "false positives."
I may add that a recent American publication (Ruth Gilbert, M.D.,
referee of the American Public Health Association Committee on Standard Methods for Kahn and Wassermann tests, Journal of the A.P.H.A.,
January, 1930), impeaches the European Wassermann as against the
American and suggests that the discrepancies found in the League of
Nations Conference would not be so great if the Kahn and American
Wassermann were similarly compared with clinical facts. We are awaiting with interest further information already promised on this angle.
Meantime we are proceeding with the laborious work of accumulating and tabulating data from the Venereal Clinic, kindly placed at our
disposal by Dr. Campbell, and hope to contribute further to the question
from Vancouver data later.
Yours very truly,
H. W. Hill, M.D.
Director, V.G.H. Laboratories.
Editor's Note: This correspondence has been interesting to clinicians
as a salutary warning against too great reliance on laboratory tests.
If later, further statistical information is available, we shall be glad
to publish it.'
LEADERS IN BRITISH MEDICINE
Comyns Berkeley
The President of the important section of Obstetrics and Gynaecology at the coming meeting of the British Medical Association at Winnipeg, 193 0, will be a man whose name and fame are known to many. Dr.
Comyns Berkeley has been an outstanding figure in his particular sphere
for over a quarter of a century and there are few graduates in medicine
Page 121 in the British Empire who do not know Berkeley and Bonney's "Difficulties and Emergencies of Obstetric Practice" or his "Textbook of Gynaecological Surgery." Born in 1865, he was educated at Marlborough and
Caius College, Cambridge. Entering Middlesex Hospital, London, in
1888 he has filled many offices there and is now Obstetric and Gynaecological Surgeon to that institution. In addition he is Consulting Obstetric Surgeon, City of London Lying-in Hospital; Consulting Surgeon to
Chelsea Hospital for Women; Consulting Gynaecological Surgeon
Eltham; Surgeon in charge of the Middlesex War Hospital, Clacton-on-
Sea, 1914-1918. He is editor of the Journal of Obstetrics and Gynaecology of the British Empire, and author of several other works on diseases
of women, some of which have gone into many editions. In 1895 he
married Ethel, youngest daughter of E. King Fordham, D.L., J.P. of
Ashwell, Herts.    His recreations are travelling and golf.
Alexander Murray Stuart MacGregor
The President of the Section of Preventive Medicine, a subject that
is one of increasing importance, is the Medical Officer of Health for
Glasgow, Dr. MacGregor. He was educated at Glasgow and Cambridge
(D.P.H., 1909) and before assuming his present position he served in
several hospitals in Glasgow. He is the author of "Immunity Phenomena in Cerebro-Spinal Meningitis," "Serum Treatment of Cerebrospinal Meningitis," "Studies in Epidemiology of Phibisis," and "Features
of Smallpox Outbreak in Glasgow, 1920." He holds the rank of Brevet-
Major, R.A.M.C., T.
CHRONIC INFLAMMATORY DISEASE OF THE BILIARY PASSAGES:  ITS DIAGNOSIS AND METHODS OF INVESTIGATION
By Dr. Clarence E. Brown
Read before the January Meeting of the
Vancouver Medical Association
Diagnosis is the solid foundation on which all sound practice is
builded. Without diagnosis, the treatment of the sick resolves itself into
the relief of symptoms only.
No other class of patient is so subject to the neglect of a thorough
investigation of his complaint as the chronic sufferer from gastro-intestinal disturbance and especially that caused by chronic biliary tract disease. Many of these unfortunate individuals go for years from one practitioner to another, not excluding the irregulars, seeking relief.
It will be well to consider some of the advances of recent years in
the science of biliary tract function and its disturbance from various
causes.
The gall bladder is an anomalous organ since it is absent in certain
mammals as the horse, the mule, the deer and the rat. It can be extirpated in man and experimentally removed in animals without any apparent influence on the liver function or bile formation. Through disease it
is frequently seen to be isolated from the rest of the bile tract and completely f unctionless.
Page 122 The gall bladder embryologically arises from the same group of
cells as the liver, duodenum and pancreas and is therefore closely related
to them anatomically and physiologically. The existence of a direct
lymphatic circulation between the liver and the outer coats of the gall
bladder, as maintained by Evarts Graham and others, has been questioned,
but at any rate there exists an abundant lymphatic supply between the
two organs. The gall bladder being an off shoot of the gastro-intestinal
tract contains a small amount of muscle tissue in its walls which has
definite contractile power as may be shown experimentally in animals.
The presence of this contractile power is suggested by the reduction in
size of the gall bladder as shown radiographically under certain conditions.
The cystic artery which supplies the gall bladder is a branch of the
hepatic artery. The cystic vein empties into the portal vein and this
anatomical arrangement may have some influence in setting up a possible
vicious circle of infection. Infection in the gall bladder wall reaching
the portal vein through the cystic vein, may be filtered out by the liver,
excreted into the bile and so returned to the gall bladder.
The Formation of Bile
The three chief constituents of the bile are the bile pigments
(bilirubin and biliverdin) the bile acids (glycocholic and taurocholic
acids and their salts) and cholesterol. The bilirubin is derived from the
haemoglobin and is formed in the endothelial cells belonging to the
reticulo-endothelial system. These cells are found chiefly in the spleen,
bone marrow and to a lesser extent in the liver (as the Kupffer cells).
They take up haemoglobin coming from the disintegration of the red
blood corpuscles, remove the iron free portion and form bilirubin. This
is carried by the blood stream to the liver, is taken up by the polygonal
cells and is excreted into the bile capillaries.
On reaching the bowel, bilirubin, through bacterial action, is converted into urobilinogen, some is excreted in the faeces and the remainder
is re-absorbed and carried to the liver by the portal vein to be taken up
by the polygonal cells and excreted again.
The bile acids appear to be specifically synthesized in the liver;
hence these are true secretory products of the liver activity. Through
their remarkable power of lowering surface tension the bile salts aid in
the emulsification and absorption of fats. The cholesterol in the bile
is derived directly from the blood serum and is a direct excretion of the
liver. As a constituent of the bile, it reaches the intestine and is again
absorbed, probably with the fats. Any loss of cholesterol to the body is
made up from the food.
Thus the bile, containing its three main elements, bilirubin, bile
acids and their salts, and cholesterol, is excreted through the polygonal
cells of the liver into the bile capillaries whence it passes into the bile
ducts.
McNee's conception of the structure of the liver lobule and the relationship to it of the portal vein, hepatic artery, and bile duct is represented diagramatically.    He represents the polygonal cells of the liver
Page 123 as a series of test tubes with the blind end towards the central vein and
the lumen opening into the bile duct. On the outside of the tube, and
between adjacent tubes, is a capillary network from the branches of the
portal vein and the hepatic artery. This arrangement brings the blood
in close contact with the polygonal cells of the liver.
Hepatic
vascular capillary
Kupffer ceils Mack)
Bile capillary
Bile
rial
vexn
Hepatic artery
Diagram of Liver Lobule.  (After McNee)
Bile is continuously produced by the normal liver, even in fasting
and continues to flow into the intestine. The gall bladder is not sufficiently large to store all the bile even when concentrated, excreted during the inter-digestive periods. There is a definite concentration of bile
as much as ten to fifteen times in the gall bladder through the absorption of water. Pressure exerted on the common bile duct by the sphincter of Oddi, or, as Carlson has pointed out, from the tonus of the
muscle wall of the duodenum, since the bile duct runs for some distance
obliquely through this muscle layer, prevents a continuous flow and
causes a backing up of the bile into the gall bladder. Food in the stomach and intestine leads to an increased secretion of bile. The continuous
secretion of hydrychloric acid in the stomach even during fasting, probably acts as a stimulus to the continuous flow of bile. Clinical and experimental evidence shows almost conclusively that the gall bladder
evacuates its contents most commonly after a meal, especially a meal of
fats and animal protein.
Acid chyme reaching the duodenum causes a flow of bile and Ivy
and Oldberg (1) have shown that a hormone mechanism is concerned
in gall bladder concentration and evacuation. A highly purified
"secretin" preparation from the upper intestinal mucosa, given intravenously to carefully prepared animals, caused a definite elevation of pressure in the gall bladder.    They named this substance "cholecystokinin."
Recently Garbat and Jacobi (2) have demonstrated that the instillation of various solutions, high up in the lower bowel, may also affect the
secretion and expulsion of  the bile.    Physiological  solution  of  sodium
Page 124 chloride, for example, may induce a drainage of the bile into the duodenum. The action may be the result of a direct stimulation of the cells
of the liver from absorption of the instilled fluids into the portal system,
or it may be a purely reflex nervous phenomenon.
Functional Tests of Value in Biliary Tract Disease
Of the many tests for establishing the degree of hepatic function
and especially that pertaining to the secretion of bilirubin, there is probably none which has been so useful as that introduced by van den Bergh.
It is comparatively simple and reasonably accurate. According to Greene
(3) the study of serum bilirubin is of clinical importance: (1) in establishing a degree of retention of bile in patients with obstructive jaundice;
(2) in furnishing a quantitative index for the degree of jaundice observed in various toxic or infectious types; (3) in following the course
of jaundice due to any cause; and (4) in demonstrating the presence of
latent icterus, as for example in pneumonia, exophthalmic goitre, pernicious anaemia, toxaemias of pregnancy and following the administration of chloroform or arsenical compounds. Following biliary colic the
serum bilirubion is elevated and the demonstration of latent icterus is of
diagnostic value.
The van den Bergh test gives a prompt "direct reaction" in obstructive hepatic jaundice and an "indirect reaction" in haemolytic jaundice.
Infective or toxic hepatic jaundice at the time of onset may give a
"biphasic reaction," but later a "direct reaction." The "direct reaction"
of obstructive conditions in the extra hepatic ducts and a similar reaction
in toxic hepatitis must be differentiated on clinical grounds.
The Rowntree-Rosenthal test of liver function depends on the
excretion of phenoltetrachlorphthalein by the liver. As the liver is an
organ with a large factor of safety and a large portion of it can be
removed and a remnant still suffice for normal function, the Rowntree-
Rosenthal test for hepatic function is probably of more value in the
later stages of liver pathology.
Roentgenography Following the Ingestion
of Phenoltetraiodophthalein
In 1923 Evarts Graham and Cole conceived the idea of applying this
ability of the liver to secrete the phthaleins in developing radiographic
study of the gall bladder. Combinations of the phthaleins with bromine
and iodine radicals were found to cast a shadow on the radiographic
film, the dye having been concentrated in the gall bladder. At present
the method in use, which is probably the least disturbing to the patient,
is the oral administration of phenoltetraiodophthalein. It is said
that there are no reactions in 99% of cases. Administration of the
dye is contraindicated in patients with pyloric obstruction and in
complete obstruction of the extra hepatic bile ducts. Visualization of
the gall bladder by the method of Graham and Cole depends, not only
on the hepatic secretion and patency of the ducts, but also on the capacity of the gall bladder to concentrate the dye.
The size of the gall bladder following the use of the opaque dye
depends on the state of digestion and the habitus of the individual.
Following a fat and animal protein meal it quickly decreases in size, at
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BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid (Anatoxihe-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine (SempU Method) least one-half. The shape of the shadow varies from circular to pyri-
form, usually the latter, and the outline is smooth and fairly well defined.
Normally. the gall badder may be seen anywhere from the tenth dorsal
spine to below the crest of the ilium and laterally from the mid-spine to
the right abdominal wall.
In a recent publication by Beilin (4) he states that following the
ingestion of the dye the shadow is pear shaped, distinctly visible, homogeneous in density and regular in outline. In fifteen hours there is increased density. At seventeen hours, subsequent to the meal, the shadow
is absent or reduced to at least one-half as compared with the thirteen
hour shadow. These findings are consistent in 98 per cent, of normal
cases.
Failure of the shadow to appear at thirteen and fifteen hours from
other than extrinsic causes, may be due to an obstruction of the hepatic
or cystic duct from inflammation or stone, failure of concentration
power, hydrops of the gall bladder, a fibrotic gall bladder usually containing stones, and occasionally large glands along the cystic duct. Failure
of hepatic function is very rare. Faint, as well as partial visualization,
failure of concentration and emptying functions are of definite pathologic significance. Acquired deformity is usually characterized by a
permanent, often faint, irregularity in outline and slight perversion of
function.    The deformities are a result of pericholecystic adhesions.
In regard to the Graham technique and cholelithiasis, he finds that
in 40 per cent, of the cases which went to operation, stones were found.
In 20 per cent, of the cases the stones were radio opaque and in 32 per
cent, the calculi were radio translucent. Cholecystitis was present in
10 per cent, of the cases showing stones. Surgical findings confirmed
the X-ray diagnosis of stones in 98 per cent, of the cases. In 70 per
cent, of cases in which the gall bladder showed no dye at thirteen and
fifteen hours there were cholesterol stones present. The calcium stones
are usually multiple and faceted; the periphery is increased in density,
whereas the centre is diminished in density. The cholesterol or nonopaque stones are seen as round or oval shadows of diminished density in
the gall bladder shadow; where small and numerous the gall bladder
shadow is mottled.
Achlorhydria may frequently simulate gall tract disease, in that the
gall bladder study reveals an absence of the shadow, which usually in-
dictates gall bladder. If the patient is placed on hydrochloric acid
therapy the shadow may then be revealed in a Graham gall bladder study.
The absence of the shadow in the first instance may be due to a relaxed sphincter of Oddi, or lack of tonus in the duodenal wall, allowing
the bile to pour into the duodenum, so preventing concentration in the
gall bladder.
In only two per cent, of Beilin's cases was the gall bladder found to
be diseased where cholecystographic study revealed a normal gall bladder.
In two per cent, of his cases that showed no filling normal gall bladders
were found. The causes of the erroneous findings were carcinoma of the
stomach, jaundice, active peptic ulcer and achylia.
Relative to the percentages quoted above, it is only fair to state that,
although most radiologists in discussing statistics in regard to the de-
Page 126 monstration of pathology in the gall bladder claim an accuracy of 93 to
98 per cent., the clinician cannot accept X-ray findings alone as sufficient
evidence, from his standpoint at least, to make a definite diagnosis and
clinical evidence should also be considered in the determination of the
best type of treatment.
Fractional Gastric Analysis
Achlorhydria is a fairly common finding in chronic biliary tract inflammation. Moynihan (5) reports in 22 per cent, of cases of gall
bladder disease there is an associated achlorhydria. In this condition the
pylorus is relaxed and there is probably a relaxation of the controlling
mechanism of the lower end of the common bile duct. In this way infection may be more liable to ascend the bile passages and so may account
for the frequency of chronic cholecystitis with achlorhydria.
A certain proportion of cases of cholecystitis may show a hyper-
chlorhydria and a duodenal ulcer is always a possible complicating factor
here.
In gall bladder disease there is frequently found an irritable condition of the stomach which is evidenced during the fractional meal by a
rapid emptying, this being effected in one-half to one hour in place of the
usual approximately normal period of one and one-half hours.
Meltzer-Lyon Method of Non-Surgical Drainage of Bele From
the Gall Bladder and Bele Passages
This method of obtaining bile from the gall bladder and bile passages has been in use for some years, both as a diagnostic aid and a method
of treatment. Bile obtained in this way is usually contaminated by
stomach and duodenal secretions and pancreatic juice. Pus cells in an
abnormal amount found in relatively pure bile and the finding of many
bacteria or intestinal parasites is of diagnostic value. I have noted the
presence of Giardia intestinalis in four cases during duodenal drainage.
Utilization of this method of non-surgical drainage as an aid to
treatment in bile tract infection has not met with the approval of a
large number of the profession. It is claimed by many that just as
effective results in the stimulation and elimination of bile may be obtained by the administration of cream or magnesium sulphate by mouth.
Other laboratory reports are of value in chronic cases in the establishment of a diagnosis. The blood count during an acute exacerbation
will show a Ieucocytosis. Bile in the urine gives important information
and examination of the stools for the presence of blood, bile, fats, undigested foods, etc., is essential.
Gastro-intestinal radiographic study, following the ingestion of a
barium meal or study of the colon following the injection of a barium
enema is of paramount value. Adhesions around the gall bladder to
the neighbouring parts such as the duodenum, pylorus, transverse colon
and hepatic flexure may be revealed by the presence of a deformed shadow
in these organs or in the gall bladder itself. Ulcerations in the stomach,
duedenum and colon, or, carcinoma of the stomach are also differentiated
by means of the radiographic study.
Page 127 Infection of the Gall Bladder
Infection of the gall bladder may be primary or secondary. Primary
infection is rare and is associated with the solitary cholesterin stone in
the gall bladder. Secondary infections are the common causes of gall
bladder inflammation and the routes of infection are the blood stream,
the bile and the lymphatics, or by direct extension from neighbouring
parts as the liver, stomach, duodenum, colon and kidney.
Wilkie (6) draws attention to the fact that certain organisms,
notably the bacillus-coli and the typhoid bacillus can grow in bile and
were erroneously thought to be the causative organism when found in
inflamed gall bladders. Rosenow, however, was able to cultivate a streptococcus from the walls of diseased gall bladders which on injection into
animals appeared to have a selective affinity for the gall bladder. A. L.
Wilkie has shown that cholecystitis/ is almost invariably an intramural streptococcal infection and has almost entirely confirmed Rose-
now's work. He has grown the streptococci in 85% of cases of chronic
cholecystitis from the cystic lymph gland. He also definitely proved
that the streptococcus is unable to grow in the presence of bile and that
in making cultures from the gall bladder wall no contamination with
bile must occur. Infection in the gall bladder, being intramural, takes
place through the blood stream and then spreads by the lymphatics. The
bile remains sterile.
Evarts Graham was the first to suggest the invariable existence
of hepatitis in cases of cholecystitis and according to Moynihan, no
doubt now remains that hepatitis if not the invariable, is yet the very
frequent antecedent of cholecystitis. The outer coats of the gall bladder are in a large proportion of cases more seriously affected than the
inner.
Infection through the bile stream may descend from the liver or
ascend by means of retrograde infection from the duodenum. This type
of direct infection through the bile, however, is probably not very
common. Infected teeth, septic tonsils and especially portal system infections, as in chronic constipation, colitis, infected haemorrhoids and
appendicitis, are probable sources of many cases of biliary tract infection. According to R. H. MacDonald (7) 90 per cent, of cases give a
history of constipation.
Pathology of the Gall Bladder
Once established the disease tends; to be slowly progressive and in
the diseased organ, crippled by fibrosis, gall stone formation is more than
likely. Whether the pathology involves the mucosa or the deeper layers
of the walls of the gall bladder, is probably not so important as the effect
of the pathology on the physiology of the gall bladder. It is the perversion of function which is the cause of symptoms. Following an
initial attack of inflammation, the gall bladder may have only a slight
disturbance of physiological function, but repeated attacks of cholecystitis produce enough damage to disturb this function considerably.
Active inflammation injures the concentrating mechanism of the gall
bladder. The changes in the walls interfere with the contractility and
emptying power of the gall bladder. Obstruction in the cystic duct
prevents completely, all gall bladder function.
Page 128 The gall bladder is concerned with cholesterol metabolism, namely
its absorption. Interference with this function results in the "strawberry" gall bladder.
Symptoms, Physical Findings and Diagnosis in Chronic
Biliary Tract Infection
Biliary disease is probably never harmless although the symptoms
may be very mild and cause little distress to the patient for months or
years. As stated, however, the disease tends to be slowly progressive and
as the physiological function is disturbed, there is a gradual development
of symptoms, especially referable to the digestive tract. Among these
may be mentioned, flatulence and fullness after meals, amounting sometimes to great distress, epigastric discomfort which may involve the right
side also or pierce through to the back, early relief of hunger during a
meal, a feeling of fullness after a small meal, sudden onset of nausea
sometimes accompanied by faintness, salivation, chilly sensations, acidity,
water-brash. The complexion of patients is often altered. Pain and
tenderness in the upper part of the abdomen are associated with local
tenderness and swelling of the liver, which may become palpable. The
gall bladder may be palpable and tender. The pain may be colicky in
nature and often radiates to the shoulder. The presence of all or most
of these symptoms over a period of weeks or months, their persistency as
well as their character makes them significant. Infections of the gall
bladder are common, and of all forms of dyspepsia that depending on the
gall bladder is probably the commonest.
In spite of this frequency, gall tract disease is comparatively rarely
diagnosed. Undiagnosed cases of chronic dyspepsia, which do not respond promptly to treatment call for a careful investigation. According
to Hurst, gall stones are found in about 10 per cent, of the bodies of all
people dying after the age of twenty. Since in most, if not all cases, the
formation of gall stones is preceded by cholecystitis and as cholecystitis
is often not followed by cholelithiasis, the former must occur at some
period in the lives of a considerable proportion of adults.
The diagnosis of typical cases of advanced biliary disease is not
difficult. Age of the patient, most often a woman of sedentary habits
with a tendency to obesity, chronic indigestion, pain under the right
costal margin radiating to the back and right shoulder, periodicity,
nausea, vomiting, eructation after meals, jaundice and clay stools, these
symptoms, all or in part, make up a picture that is definite. There are
many cases, however, which are atypical and in which the modern methods of investigation, as referred to above, are of value in the diagnosis.
Defferentlal Dlvgnosis
In the differential diagnosis, the investigation should be complete
enough to decide whether any other conditions which simulate -biliary
tract disease, may be present alone or as a complication. Peptic ulcer,
chronic appendicitis, caecal and ascending colon stasis, colitis, achlorhydria, gastric carcinoma, renal conditions; as calculi, pyelitis, ureteral
obstruction and abdominal adhesions, especially adhesions in the neighbourhood of the pylorus, require differentiation in the more obscure
cases.
Page 129 Lowsley (8) reports that many patients with right sided pain unrelieved by operations for appendix and gall bladder when investigated by
the urological department reveal the presence of upper urinary tract
lesions so frequently that the practice of having a cystoscopic examination made before any operation in so-called chronic appendix or chronic
cholecystitis, has become almost the rule. In this way many useless
operations have been avoided and unsuspected lesions of the right kidney
frequently discovered.
Coronary thrombosis and embolism have frequently been mistaken
for upper abdominal lesions, namely acute gall bladder colic or perforation of peptic ulcer. A careful examination of the heart including, if
necessary, an electrocardiographic study and the history of dyspnoea on
exertion should enable one to localize the pathology.
The writer regrets that nothing new is brought forward. The main
reason for the paper is to present a plea for a more sympathetic consideration of those patients who are complaining of the symptoms of
gastro-intestinal disturbance. The application of modern diagnostic
procedures together with a careful history and general examination of
these cases will lead to a much earlier diagnosis and a more definite
localization of pathology with a resultant treatment in a stage when
the latter is of definite prophylactic and curative value.
References
(1) Ivy, A. C. and Oldberg, Eric. A. Hormone Mechanism for Gall
Bladder Contraction and Evacuation. American Journal of
Physiology, Vol. 86, No. 3, October, 1929.
(2) Garbat, A. L. and Jacobi, H. G. Secretion of Bile in Response
to Rectal Instillation, Arch., Int., Med., 44; 455, September,
1929.
(3) Greene, Carl H. Journal A. M. A., Page 1476, November 7,
1929.
(4) Beilin, David S. "Roentgen Interpretation and Diagnosis," 1929.
(5) Sir Berkley Moynihan, British Medical Journal, Page 3496,
January 7, 1929.
(6) Wilkie, D. P. D., British Medical Journal, Page 481, March 17,
1928,
(7) McDonald, R. H., Journal A. M. A., December 7, 1929.
(8) Lowsley, O. S. and Turneur, F. P., Differential Diagnosis of
Pain in the Right Side of the Abdomen, A. M. A., Page 1614,
November 23, 1929.
CORONARY THROMBOSIS
By Dr. G. F. Strong
Read by invitation before a meeting of the
Victoria Medical Society, Feb. 3, 1930
Coronary thrombosis is one of the clinical conditions which has
emerged as an entity in the past few years. It is remarkable that a
condition now diagnosed with comparative ease could have escaped detection for so long a time. While sclerosis and thrombosis of the coronary
arteries and cardiac infract have been noted by pathologists for years,
Page 130 it is only within the last decade and a half that coronary thrombosis has
been understood and diagnosed at the bedside. One reason for this lag
was the confusion that existed between coronary thrombosis and angina
pectoris. Both conditions associated with pain under the sternum, they
were so confused as to be considered one and the same. We now know
that what we call coronary thrombosis was formerly described as exceptionally severe angina, or status anginosus. Sir Wm. Osier grouped
angina under three heads, mildest, mild, and severe, and amongst the
latter were undoubtedly instances of coronary thrombosis, since in the
autopsies on these cases instances of plugging of the coronary artery,
with pericarditis and rupture of the heart, were noted. Sir James
Mackenzie, in his last work on angina published in 1924, does not distinguish clinically the condition of coronary thrombosis. The condition
had been described as long ago as 1901 by Krehl, and had been noted by
Huchard in a pathological analysis of 185 cases even earlier. Then followed a long period of years in which this pioneer work received little
attention. In 1910 two Russian authors published three cases, two of
which were diagnosed, and they discussed the various features of the
condition which have now become so well known. Again there was a
long wait before further observations regarding coronary thrombosis
appear in the literature. Since 1915 there has been an increasing interest,
and our knowledge has increased in proportion.
The study of the coronary circulation has shown that the coronary
arteries are not end arteries, and that a very rich anastomosis is present.
It requires, therefore, the plugging of a fair-sized artery to cause an
infarct, and it is only when one of the main branches is suddenly closed
that instant death results. Some nourishment is no doubt carried to the
heart muscle by way of the thebesian vessels, and this accounts for those
patients who live with both coronary arteries affected. The occurrence
of a thrombosis presupposes some narrowing of the lumen of the vessel,
or interference with the blood flow, and in coronary thrombosis this narrowing is almost invariably due to sclerosis of the coronary arteries.
These may be sclerotic, as a part of a very general arterio-sclerosia, or
the sclerosis may occur only in the arteries of the heart. In fact, I have
seen an instance where a thrombus formed upon a single small atheroma
which was the only evidence of arterial change to be found anywhere
in the coronary vessels. It must be understood that the condition we are
discussing hede is the sudden type of coronary thrombosis associated with
a cardiac infarct, and is not to be confused with the condition of coronary sclerosis, a senescent process which may be complicated by a coronary thrombosis at any time, but which ordinarily presents a different
picture from the sudden attack.
An arteritis of the coronary vessels is considered by some to be a
possible cause for thrombosis, but there is little basis for this view. Clinically these patients seldom show evidence of infectious process preceding the attack, and pathologically, the changes noted in the walls of the
coronary arteries that are thrombosed are those of a degenerative rather
than an inflammatory nature. The actual changes that are noted are a
thrombosis of the sclerosed vessel with a resulting cardiac infarct, which
can be shown in the varying stages of infarcts as they occur in other
organs.    These infarcts result in scarring of the ventricular wall with
Page 131
mmm
TBS fibrosis and marked thinning. On the inner surface of the infarct there
is often an intra-cardiac thrombus. This thrombus may be only a small
roughened patch on the endocardium, or it may assume considerable size,
in which case fragments may be broken off, to cause peripheral embolism.
On the pericardial surface there is likewise a patch of localized inflammation, with resulting fibrin formation.
Coronary thrombosis is a disease of late middle life, occurring most
commonly in the decade from 0 to 70, and one reason for its apparent
increase is to be found in the fact that more people are surviving to
reach that age now than was the case twenty years ago. It is a disease
much more common in men than in women, various reported series showing an incidence of men to women of from 3 to 1 to as high as 4 to 1.
The cause of coronary thrombosis is not known. It is most probable that those factors which play a part in the production of degenerative disease of the vascular system in general are also to be blamed in
this disease. The infections of various natures cannot be held accountable. Focal infections or rheumatic diseases are not the cause, and syphilis does not produce coronary thrombosis. The much greater incidence
in men suggests again the time-worn idea of greater physical wear and
tear, and possibly the factor of tobacco, though there is nothing at all
conclusive. With the greater use of tobacco among women we may see
some change in this disease incidence in the succeeding years. Diabetes
is one of the causes of generalized vascular disease which is worthy of
mention. It has been pointed out recently that diabetics die with great
frequency of cardiovascular disease, and in a series of cases of coronary
thrombosis, a high incidence of glycosuria is reported. Angina pectoris
is a common, but by no means essential, antecedent of coronary thrombosis. The attack may occur without any warning of any kind, but
more often, on careful questioning, evidence will be brought out that
these patients suffered from slight substernal distress or occasional chest
pain, often not of sufficient severity to take them to their doctor.
Hypertension is the most common single etiological factor, and is undoubtedly present in a very large number of these cases. Even those
in which the blood pressure may be normal at the time of examination
will show evidence, such as retinal arteriosclerosis, suggesting that they
have had a previous hypertension. Heredity plays an important role in
this condition and should always be given careful consideration. There
is often a family history of arterial or cardiovascular-renal disease. The
type of patient is also worthy of comment. He is apt to be a stocky,
well-set person, somewhat over-weight, often of considerable strength,
enjoying life, and of unusually good health.
Description of Typical Attack
The patient has usually, though not always, been a sufferer from
angina pectoris. He has, therefore, been subject to some substernal distress varying from a slight constriction or sense of smothering to a severe
agonizing pain, usually brought on by exertion, and relieved by rest and
the nitrites. The attack of coronary thrombosis is not necessarily
brought on by exertion ,is of much greater severity, is not relieved by
nitrates, but requires large doses of morphia. The pain is usually substernal, its location and distribution may exactly duplicate that ascribed
Page 132 -
to the "angina," the difference being only in the severity. On the other
hand, the pain may be distinctly different, both in its original site and
in its distribution from the preceding anginal pains, so that the patient
may realize, not only from the increased severity, but also from the
difference in location, that the attack is distinct from what he has previously experienced. Death may occur at any time. Most cases of
sudden death in people of middle life are in fact due to coronary thrombosis. Death may occur so quickly that the patient has no time to
mention pain, o rhe may not apparently even experience that sensation.
Death may be deferred, and occur at a later period, from a variety of
causes, among which are an extension of the thrombus, a fresh thrombosis, a rupture of the infarcted area, or a cerebral embolism from a
fragment of the mural thrombus. The pain, as I have said, is agonizing
in character, and is usually accompanied by a fear of impending dissolution. The patient may be prostrated by pain, and shock is not an uncommon result, though occasionally he is unable to remain quiet and
walks the floor or rolls from side to side on his bed. Vomiting may
occur and this, coupled with the facts that the pain may occasionally be
under the lower end of the sternum, or even in the epigastrium, and
frequently comes on immediately after meals, has led to a diagnosis of
acute indigestion. There is no such thing as acute indigestion and the
term should be dropped. Most of these cases are instances of coronary
thrombosis, others being due to gall-stone colic or other upper abdominal
lesion. Examination at this time reveals a patient obviously suffering
very intense pain, he is pale and cold and of an ashen grey colour. The
pulse may be unaffected but the blood pressure usually falls. Later the
pulse becomes small and rapid and the blood pressure is apt to stay low
for some time. Occasionally pulmonary oedema will occur, almost
always a few rales are found at both bases. The character of the heart
sounds is usually changed and this may be an important feature, particularly in distinguishing the attack from an acute surgical lesion of the
upper abdomen. The first sound is muffled and may be almost inaudible.
Gallop rhythm may also occur at this stage.
During the next 24 hours important signs develop which makes
the diagnosis more certain, in fact, at times it is impossible to be certain
until these signs are present. The pain gradually lessens under the
influence of the opiate, and the patient may be comfortable but very
weak. Examination at this time shows that the pulse is still small and
rapid, blood pressure low, temperature elevated. The slight degree of
fever is a very important finding and must be carefully looked for. At
times the temperature by mouth may be normal while the rectal temperature will be found to be elevated by 1-2 degrees. At this time there is
usually a Ieucocytosis, both fever and Ieucocytosis being due to the
systemic reaction to the absorption from the cardiac infarct. Another
important sign, when it can be elicited, is a pericardial friction rub,
which -occurs during the first day or two after a coronary thrombosis.
Pericardial irritation usually occurs, but the rub may remain inaudible
because of the location of the thrombosis. Only in those instances where
the infarct is on the anterior wall of the heart will the resulting pericardial rub be audible. Irregularities may develop at any time after the
attack, extra systoles being most common, but almost any other of the
cardiac arrhythmias may develop.
Page 133
Tsmm The characteristic features, then, of the typical case are agonizing
substernal pain, shock, prostration, with the development in the first 24
hours of a moderate fever, Ieucocytosis, and often a pericardial friction
rub.
It is sometimes confusing to discuss coronary thrombosis and point
out the fact that it is not the same as angina pectoris, and yet make no
further comment. Angina pectoris is a symptom complex, a clinical
but not a pathological entity, consisting of substernal pain associated
with exertion or excitement. It is probably a result of coronary changes,
either spasm or organic narrowing, which reduce the blood supply to
the heart muscle at the time of increased requirements. The pain is
transitory, and the mortality from true angina pectoris is not high.
Coronary thrombosis, on the other hand, is a definite pathological entity,
due to perfectly clear-cut changes which we can detect, and has a very
high mortality rate. Just what percentage of people with an acute coronary thrombosis die we cannot know until more accurate autopsy figures
are available, but it must be in the neighbourhood of 75%.
Variation from the typical picture must be given careful consideration, because in coronary thrombosis, as in other clinical conditions, it
is not the typical case that causes trouble in making a diagnosis. Coronary thrombosis may occur without any pain. This has only come to
be appreciated very recently, and it will undoubtedly help to clear up
the diagnosis in some of those ill-defined conditions we have called acute
cardiac dilatation. It is amazing that an infarct of the heart muscle
may occur without the patient experiencing any pain, and yet I have seen
two such cases, one of which came to autopsy, and the other of which
is still under observation. The fact has been noted several times in
recent reports in the literature.
Another variation from the typical was noted in the following case,
which showed an unusual degree of dyspnoea. While some dyspnoea may
occur in coronary thrombosis, it is usually not a prominent feature, and
subsides rather quickly because of the enforced rest.
W. G., male, aged 56.    April 19th, 1928.
Severe precordial pain on April 17th, relieved only by large doses of
morphine. History of some slight substernal distress on exertion. Another attack of pain on the 19th at midnight. Pericardial rub heard all
over the precordium. Next day no rub, temperature 100°, leucocytes
15,600. Dyspnoea became a very troublesome feature, and continued to
be his major complaint until his death on July 16th, three months after
the attack. Dyspnoea was so marked that he almost fought for air. No
acidosis was present, nor were there other evidences of congestive heart
failure, as venous stasis or peripheral oedema. Respirations during the
last months were Cheyne-Stokes in character. Autopsy showed a cardiac
infarct as a result of thrombosis of left coronary. This infarct involved
nearly the whole of the lateral surface of the left ventricle, and had
resulted in a thinning of the wall to less than % a cm. There was a
large mural thrombus on the inner surface of the infarct. The extreme
weakening of the left ventricle, plus the encroachment upon its cavity
by the large thrombus, had so diminished the output of blood into the
aorta as to result in the extreme degree of dyspnoea.
Another atypical feature occurs in those cases simulating an acute
surgical abdomen.    The pain is epigastric and there is  tenderness and
Page 134 ^        J
rigidity in this region. When this condition occurs in a patient who has
had anginal symptoms, we can easily be on our guard and avoid mistakes,
but when, as may happen, the attack of coronary thrombosis occurs as
a bolt from the blue, the difficulties in the way of a differential diagnosis
are enhanced. It is in these cases that careful observation is so important,
and instances have been reported where a laparotomy has been performed, only to find that the cause of the pain was above the diaphragm. A
lowered blood pressure, a weakening of the heart sounds—especially the
muffled character of the first sound at the apex—may give us an inkling,
before the more definite signs, such as a pericardial rub, develop. Usually
after the first twelve hours the case becomes more clear-cut, and the
diagnosis is easily established.
Another fact worthy of note is that coronary thrombosis, when it
occurs in the course of congestive heart failure, is apt to produce a very
atypical picture. This has been well known, but has received little comment until recently. At autopsy on patients dying of congestive heart
failure, cardiac infarcts are occasionally noted. In these patients the
symptoms produced are not at all typical. In one case I had under
observation, a woman with congestive failure developed a ventricular
tachycardia from which she recovered. Subsequent autopsy showed a
cardiac infarct, the probable cause of the tachycardia.
Treatment
Unfortunately little can be said of the treatment of the acute
attack. Many of these cases die before medical aid can be summoned,
others are among those in which the newspaper comment notes the fact
that the doctor arrived too late to be of any assistance, but pronounced
death to be due to natural causes. The only drug of value in the early
stages is morphine, and it should be used without stint. A person of
medium size can be given one-third to one-half grain without danger,
and larger persons even larger doses. As much as a grain may be required in robust men to mitigate their extreme suffering. After the
pain has been relieved, the secondary symptoms must be treated as they
develop. Support of the circulation is necessary, and yet must be cautiously administered to avoid too great stimulation. Adrenalin in 5
minum doses by hypodermic repeated every two or three hours is certainly beneficial. Caffeine-sodium benzoate, up to 7% grains, by
hypodermic, will frequently be of value in combating shock. Needless
to say, absolute rest in a comfortable position, and with adequate external heat, is also required. If the pain returns, or restlessness or wakefulness are troublesome, more morphine should be given. So much for
the treatment during the first few hours. The use of digitalis early is
of questionable value, and to digitalize these patients at one stage of their
illness is to actually do them harm. To understand the use of drugs in
coronary thrombosis, we must keep in mind what actually happens in
the heart muscle. After the plugging of the coronary vessel, there is an
infarction of the ventricular wall with a resulting weakening, and further, there frequently develops on the inner surface of this infarcted area
a mural thrombus. Digitalis, by stimulating the heart, can cause two
accidents—a rupture of the infarcted area, or the dislodgement of a
fragment of the thrombus with resulting peripheral embolus. Later, that
is, after about two weeks, when the evidences of congestive heart failure
may develop, digitalis can be used, and should be administered as in any
Page 13 5 other cardiac condition in which it is indicated. Oxygen may also be
indicated at this stage, when it will give some relief to the dyspnoea and
cyanosis.
The treatment of coronary thrombosis after the initial stage is
mostly concerned with the treatment of the complication as they develop.
Sudden heart block with syncope may occur. This is best treated with
intra-muscular injections of adrenalin, minims 5 to 10, repeated as often
as necessary, or barium chloride in one-quarter to one-half grain doses,
three or four times a day, may be used. Another complication of coronary thrombosis which may be fatal, and which can be properly treated
only if it is understood when it occurs, is ventricular tachycardia. As
you know, paroxysmal tachycardia is not an uncommon cardiac irregularity, but those arising from an irritable focus in the ventricle are much
more serious than the more common auricular type. When ventricular
tachycardia occurs, it requires large doses of quinidine sulphate for its
control. The quinidine should be given in increasing amounts starting
with doses of 3 grains each, and increasing up to as much as 15 grains,
repeated three or four time a day, or oftener, until the rate is slowed and
the rhythm becomes normal.
The remaining points in the treatment of coronary thrombosis are
less impressive, but none the less important, matters associated with nursing care, attention to bowels, and diet. The patients need the utmost in
skilled care. Early they should be given enemata only, then mild laxatives to avoid either purging or straining. A fluid diet, changed after a
few days to soft or light, but always in small amounts to avoid any overloading of the stomach, is the most suitable. The patient should be kept
in the greatest possible comfort, both physical and mental, and should be
protected from worries. Visitors should be excluded except in the later
part of the treatment. Bed rest should be continued for six to eight
weeks at the very least, longer if complications have occurred.
I have not so far mentioned the value of the electro-cardiogram in
this condition. I deferred that comment, first, because the diagnosis can
be made in many cases without the aid of this valuable instrument, and
second, because it is not always possible to secure an electrocardiogram
during the first twelve to twenty-four hours, when these patients are
troubling us most. The electrocardiogram has its greatest practical value
in the study of these patients with heart pain, because it is by means of
the electrocardiogram that we can secure some idea of the integrity of
the heart muscle. When we remember that the electrocardiogram is
only a record of the spread of the impulse through the heart muscle,
we must keep in our minds the limitations of the method. The heart
tracing is no sure means of learning all about the heart, and- in no
case should the evidence of the electrocardiogram be considered superior
to that of sound judgment based on careful history and physical
examination. The electrocardiogram has a very great value, and as
I have said, it is in these patients that it is most essential, for often
it is the only means of diagnosing an obscure case of coronary thrombosis. The study of the electrocardiographic changes in acute coronary
thrombosis has developed from both experimental and clinical sides.
Observations on dogs after ligation of the coronary arteries gave
valuable information, and study of a series of clinical cases of coronary
thrombosis,  some of which were subsequently examined  post-mortem,
Page 136  has given this study further impetus. The important early change
in the electrocardiogram is a high take-off of the T-wave from
the descending limb of the R-wave, or a low take-off from the ascending limb of the S-wave. This results in a loss of the iso-electric S-T
interval, and in its place there is often a peculiar rounded hump where
the T-wave comes off the R or S. This change may occur early, even
within a few hours, and is apt to disappear after some days, leaving the
very sharply inverted T-wave, or some similar abnormality. Another
finding suggestive of coronary thrombosis is that in which all the waves
iri all leads are small. Suggestive evidences of this condition may also
be shown by a notching of the R-wave, or by the appearance of a prominent Q-wave in the third lead.
The electrocardiogram is also invaluable in differentiating the various irregularities that occur. Extra-systoles, of course, can be detected
clinically, but their origin may be determined by this instrumental
means. Heart block ,either in the form of delayed conduction, dropped
beat, branch block, or complete heart block, may occur, and can be
accurately studied. Most important from a practical standpoint because
it may be life saving, is the detection of ventricular tachycardia. When
this occurs in a heart already weakened by the damage resulting from
the coronary thrombosis, it is quite apt to produce fatal results, unless it
is given early and adequate proper treatment.
Conclusions
Coronary thrombosis is a clinical and pathological entity which can
be recognized at the bedside.
A knowledge of the characteristic symptoms and signs, and the recognition of the order in which they develop, may prove invaluable in
making a proper diagnosis in an emergency.
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Page 137 Wer^Much
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