History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1934 Vancouver Medical Association Nov 30, 1934

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 o.
The BULLETIN^'
OF THE
VANCOUVER MEDI6AL
ASSOCIATION I
Vol. XI
NOVEMBER, 1934
No. 2
111
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II
In This Issue:
HEALTH SERVICE FROM THE VIEWPOINT OF
THE GENERAL PRACTITIONER
TUBERCULOSIS  :: PREVENTION OF DISEASE
INFECTION CONTROL
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fflffl  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 Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XI NOVEMBER, 1934 No. 2
OFFICERS   1934-193 5
Dr. A. C Frost Dr. C. H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W. L. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L. Graham  . . _ -    Chairman
Dr. J. R. Neilson       Secretary
Eye, Ear, Nose and Throat
Dr. R. Grant Lawrence _.    Chairman
Dr. E. E. Day    —- —   - _ Secretary
Paediatric Section
Dr. E. D. Carder    — Chairman
Dr. R. P. Kinsman  _      Secretary
Cancer Section
Dr. A. B. Schinbein      Chairman
Dr. J. W. Thomson       Secretary
STANDING COMMITTEES
Library » Summer School
Dr. W. D. Keith Publications Dr. H. A. DesBrisay
Dr. C H. Bastin Dr MacDermot Dr. H R Mustard
Dr. A. W. Bagnall Dr jd £ R Cleveland Dr. J. W. Thomson
Dr. G. E^ Kidd Dr MuRRAy Bajrd Dr. C.E Brown
Dr. W. K. Burwell Dr. J. E. Walker
Dr. C A. Ryan Dr. J. W. Arbuckle
n. Credentials Hospitals
_       TW^     r DR.R.A.S!MPSON DR.T.H.LENNIE
Dr. J. W. Thomson Dr. j. T. Wall Governs
Dr. R W. Lees Dr. D. M. Meekison Dr r r Milburn
Dr. W. G. Gunn z"     „ _
Dr. S. Paulin
V. O. N. Advisory Board
Dr. I. Day &eP- io B- C. Medical Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees
m\
.  11
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m Treatment for High
Blood Pressure
Bioglan "H"—Ever since Sir Clifford Allbutt coined the
word hyperpiesia and described the disease known as idiopathic
or sometimes functional hypertension, high blood pressure, its
causation and treatment have received the constant attention
of all those interested in medical science. Let it be said at once
that in very few cases is it possible to indicate the exact aetiology.
As a matter of trial and error, however, certain lines of treatment have been found outstandingly effective. Among those
methods and occupying a foremost place is endocrine therapy
and Bioglan "H" has been found not the least useful of these
preparations. The chief active principle in Bioglan "H" is an
extract of pancreas which has been shown by several investigators to exert a permanent curative effect on cases of essential
hypertension or hyperpiesia. Reference should be made to an
article by Sir Humphry Rolleston in the British Medical Journal,
5th August, p. 223.
Bioglan "H"
Contains a hypotensive extract of the pancreas
Indications: Hyperpiesia (essential hypertension),
paroxysmal high blood pressure, early arteriosclerosis (not due to renal disease).
Made only in England by
THE  BOWSHER  LABORATORIES  LTD.
PONSBOURNE MANOR, HERTFORD
Representative: S. N. BAYNE
143 2 Medical-Dental Bldg. Phone Sey. 423 9 Vancouver, B.C.
References: "Ask the Doctor who has used it." VANCOUVER HEALTH DEPARTMENT
STATISTICS—SEPTEMBER, 193 4
Total Population (Estimated)    243 711
Japanese Population   (Estimated)  7 866
Chinese Population  (Estimated)    8 315
Hindu Population  (Estimated)    251
Rate per 1,000
Number Population
Total Deaths.                                                  163 g .
Japanese Deaths                                           10 1 j g
Chinese  Deaths                            6 g g
Deaths—Residents only    __                            141 7 0
Birth Registrations—
Male,' 13 8; Female, 143  __      281 14.8
INFANTILE MORTALITY— September, September,
1934 1933
Deaths under one year of age   6 4
Death rate—per  1,000 births    21.4 16.5
Stillbirths (not included in above)  5 7
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
October 1st
August, 1934 September, 1934 to 15th, 1934
Cases    Deaths Cases    Deaths Cases    Deaths
Smallpox            0             0 0             0 0 0
Scarlet   Fever        34             1 31              1 22 0
Diphtheria             2             0 10 0 0
Chicken Pox           6             0 8             0 10 0
Measles             2             0 0             0 0 0
Rubella             0             0 0              0 0 0
Mumps               3             0 12             0 16 0
Whooping-couph            13              0 11              0 5 0
Typhoid Fever          2             0 0             0 2* 0
Undulant  Fever.            0             0 0             0 0 0
Poliomyelitis           3              0 0             0 0 0
Tuberculosis             34           11  ■ 35              7 25
Meningitis   (Epidemic).—           0              0 0             0 0 0
Erysipelas              10 2              0 0 0
Encephalitis Lethargica           0             0 i    0             0 0 0
Paratyphoid               0             0 0             0 0 0
* Non-resident.
S. BOWELL & SON
DISTINCTIVE  FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
Page 22
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M  VANCOUVER MEDICAL ASSOCIATION
Founded   1898     ::    Incorporated   1906
Programme of the 3 7th 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 the evening.
1934.
October 2nd—GENERAL MEETING.
Dr. G. F. Amyot: "Infection, Its Spread and Control."
Discussion: Dr. E. D. Carder
Dr. H. A. Spohn.
October 16th—CLINICAL MEETING.
November 6th—GENERAL MEETING.
Dr. C. E. Brown: "Some Secretory Disturbances of the Stomach."
Discussion: Dr. H. A. DesBrisay.
Dr. A. Y. McNair.
November 20th—CLINICAL MEETING.
December 4th—GENERAL MEETING.
Dr. A. B. Schinbein: "Tumours of the Breast."
Discussion: Dr. J. J. Mason
Dr. B. J. Harrison
Dr. H. H. Pitts.
December 18th—CLINICAL MEETING.
1935.
January 8th—GENERAL MEETING.
Dr. W. E. Ainley: "The Relation of the Retina to Cardio-Vascular
and Renal Disease."
Discussion: Dr. W. D. Keith
Dr. Wallace Wilson.
January 22nd—CLINICAL MEETING.
February 5 th—GENERAL MEETING.
Dr. Murray Blair: "Physiological Observations in Obstetrics."
Discussion: Dr. W. S. Baird.
February 19th—CLINICAL MEETING.
March 5 th—GENERAL MEETING.
The Osler Lecture—Dr. Wallace Wilson.
March 19th—CLINICAL MEETING.
April 2nd—GENERAL MEETING.
Dr. F. W. Emmons: "The Surgery of the Presacral Nerve."
Discussion: Dr. J. J. Mason
Dr. F. Turnbull.
April  16th—CLINICAL MEETING.
April 23rd—ANNUAL MEETING.
Page 23
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I EDITOR'S PAGE
■
The recent meeting of the B. C. Medical Association was marked by
what is an innovation as far as British Columbia is concerned, in the fact
that at the end of the programme there was a meeting of the College of
Physicians and Surgeons of B. C. All the medical men present took part
in this meeting as members of the College, and the President of the Council
of the College, Dr. T. McPherson of Victoria, took the chair.
Reports were given of the year's work in connection with the affairs of
the College, and for the first time in the history of the B. C. Medical Council, members of that body had the opportunity to meet their constituents
and discuss Council matters with them.
This is not only an innovation, it is distinctly, we think, a forward step
and we are sure that the Council, as well as the members at large of the
College, will agree with us in this. Our readers will remember the reasons
why the Council and the B. C. Medical Association adopted a new modus
vivendi whereby the latter resigned to the Council the economic and other
functions which it had undertaken to perform and limited its own activities
to the scientific side of medicine. The reasons were largely financial, but
they were also reasons of convenience and expediency, and the promoters
of this change were also actuated by the desire to have the medical profession wholly included in the organization thus brought about, rather than
go on with the former arrangement whereby a minority paid an unduly
large amount towards medical organization. It was felt, and is still felt,
that much waste and overlapping could be prevented.
It is quite probable, however, that finality of organization has not yet
been reached. Finality is perhaps not the word, stability might be better.
There is still a lack of flexibility and the machinery creaks somewhat in
places. We know that nobody is more anxious than the members of Council
to remove these disabilities and we cannot, perhaps, expect that everything
can be so ordered as once, that all contingencies will be met. The tragic
and deeply regretted loss of Dr. Procter, the efficient and long-experienced
Registrar of the College, has further complicated things. We have now
neither a Secretary of the B. C. Medical Association nor a Registrar of the
College, and we are in a state of flux. Ordinarily, this would matter little,
we could take plenty of time over decision as to the best step to be taken
next, but unfortunately we are faced with a situation which is rather
urgent, and demands our most serious consideration.
We are assured that at the next session of the B. C. Legislature steps
will be taken to inaugurate some form of Health Insurance. What are we
doing and what should we do, to safeguard our legitimate interest in this
matter? It will not be enough, not nearly enough, at the last minute to
hurriedly organize some form of lobby.  This will get us nowhere.
We know that the Council is seeking the wisest and best way of solution
and we would not embarrass them in any way, but we should all welcome
any statement by them, or any step which would show that this matter is
in train. And we feel strongly that the first and most important step for
us to take is to organize solidly the medical profession of B. C. and that
includes all of them.
This organization cannot, we submit with all due respect, be done
properly unless we have a definite liaison officer to meet all the men on one
side and the Council on the other. We feel that since the Council has to
face the prospect of appointing a new official sooner or later it should
Page 24 take the step now, as the time between now and the session is all too short
to organize the profession, to obtain its pledges and support, and, indeed, to
keep the profession in touch with the developments that will certainly
arise.
This is a matter vitally affecting every medical man in the province;
indeed, it vitally affects the whole of the profession in Canada, and we
know that the Canadian Medical Association is watching the situation
closely. But in the nature of things it cannot take any step until it is
invited by us to do so, and the initiative is with the provincial organization.
We understand that in Alberta there is a trend back to the state of
things where the Council attends to the legal duties which are imposed on
it by Act of Parliament, while the Provincial Association resumes the economic activities formerly surrendered by it to the College. Might this not
be a step in the right direction? The Council cannot be expected, with its
limited number, and scattered membership, to do everything, and we have
no right to unload all our burdens on to its shoulders.
Lastly, there is the question of co-operation with our sister professions,
dentistry and nursing, not to mention the pharmaceutical profession. We
should, we feel strongly, be kept aware of each other's activities and should
discuss amongst ourselves very freely the whole question of Health Insurance in order that we may be capable of a reasonable and united effort and
not find ourselves faced with a situation which we cannot adequately meet.
These ideas are offered not in any spirit of criticism whatever. The
Council has proved beyond question the sincerity of its desire to do the best
possible for everyone, but we feel that this is a case where time is of very
essential importance, and we must not simply adopt an easy optimism, and
trust that it "will all come out right on the night," but must be ready to
drop ceremony and do what is in the best interests of all concerned.
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NEWS AND NOTES
A very important meeting will be held at the Auditorium of the Vancouver General Hospital on Monday, November 5th, 1934, at 8 p.m. The
guest speaker will be Dame Janet Campbell, D.B.E., M.D., M.S., of England.
Dame Campbell is an internationally known authority on maternal and
child welfare and is touring Canada, speaking in many important centres.
Her object is to arouse a greater interest in the problems of Maternal
Welfare and her qualifications for this task are unique. Since 1908 she has
been associated with national bodies dealing with Health and Education
and in 1919 she joined the Ministry of Health as Senior Medical Officer for
maternity and child welfare. Space will not permit of details about this very-
able woman, but it will be of interest to say that she has been closely associated with the Health Committee of the League of Nations, both as the
woman member of this committee and as President of the International
Committee on Infant Mortality. We are very fortunate to have her to
speak to us.
The meeting is being sponsored by several bodies, the Vancouver Medical Association, the Greater Vancouver Health League, the Graduate
Nurses' Association and the Health and Welfare Educational Group, of
which Dr. Amyot is President.
Dr. A. C. Frost, our President, will be in the chair, and Dr. Amyot will
introduce the speaker.
We invite a full attendance by members of the Association.
Page 25
1
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m The Radiological Society of North America will hold its next Annual
Meeting at the Hotel Peabody, Memphis, Tennessee, from December 3rd
to 7th, 1934, inclusive. The medical profession is cordially invited to
attend. Further information can be obtained from the Secretary-Treasurer,
Dr. Donald S. Childs, 607 Medical Arts Building, Syrcause, N.Y., U.S.A.
Dr. R. A. Seymour has left for Toronto to take a year's postgraduate
work in psychiatry.
The internes at the Vancouver General Hospital are rejoicing in the
possession of a new, comfortably furnished internes' room immediately
adjoining the Records Office. Dr. Haywood, Medical Superintendent of
the Hospital, has been kind enough to offer the use of this room to any
member of the profession who may have to wait for an operating-room
time, or may wish to consult records and take notes, or may for any other
reason need a quiet room for a while.  Books and journals will be available.
Our Librarian, Miss Firmin, is enjoying a holiday at the moment, which
everyone will agree is more than well-earned. The Bulletin is missing her
keenly, and if this month's issue is full of defects, we ask our readers to
attribute this to the loss of her guiding hand, and to possess their souls in
patience till next month.
SUMMARY
We are printing herewith a brief summary of the minutes of the annual meeting
of the B. C Medical Association. The important point is the resolution that was
passed looking towards a closer organic union with the Canadian Medical Association
with a view to adding strength to both the national and provincial bodies. Another
significant event was that at the close of this meeting Dr. T. McPherson of Victoria,
President of the B. C Medical Council, called a meeting of the College of Physicians
and Surgeons and after a brief address called for reports from certain Committees
that had been appointed by the Council during the year. It is impossible to report
at any length the minutes of this meeting, but the subject chiefly dealt with was
health insurance. Unfortunately the meeting began rather late and, as many members had to catch their train home, there was not as long a discussion as many would
have wished.
The annual meeting of the B. C. Medical Association was held in the
Elks' Hall, Kamloops, at 8 p.m. on September 18th, 1934, following two
days of scientific sessions. Most of those doctors who registered, eighty-five
in all, were present at this meeting.
The President, Dr. W. S. Turnbull, was in the Chair.
The minutes of the last annual meeting in Vancouver were read and
adopted.
Reports were heard from the following Chairmen of Committees: Dr.
H. H. Milburn on Ethics and Discipline; Dr. J. H. MacDermot on Health;
Dr. D. E. H. Cleveland on Publicity and Educational; Dr. G. F. Strong on
Programme and Budget. Dr. C. H. Bastin's Editorial Report, in his absence,
was read by the Secretary-Treasurer and ordered filed. The Secretary-
Treasurer's report and that of the Auditors were read and adopted.
New Business: Dr. MacDermot proposed the following resolution:
"That this Association goes on record as endorsing the principle
that the B. C. Medical Association should become an integral part
Page 26 of the Canadian Medical Association instead of being merely an
affiliated body if and when the Executive of the Associations of
other provinces take the same step. Further, that the election to the
Council of the Canadian Medical Association be carried out in such
a way that a better attendance may be secured and that these members of Council become automatically members of the Executive of
the Provincial Association."
This was seconded by Dr. Milburn and unanimously carried.
Dr. T. McPherson, Chairmna of the Nominating Committee, presented
the following nominations for the consideration of the meeting:
President, Dr. A. D. Lapp; Vice-President, Dr. H. H. Milburn;
Secretary-Treasurer, Dr. Ethlyn Trapp.
There being no further nominations from the floor, the Secretary-
Treasurer was instructed to cast a ballot for these nominees.
It was moved by Dr. H. Carson Graham and seconded by Dr. McPherson
that the time and place of the next annual meeting be left to the incoming
Executive. Carried.
Moved by Dr. C. H. Vrooman, seconded by Dr. Cameron McEwen, that
the usual banking resolution be passed. Carried.
Then followed the address of the President, Dr. W. S. Turnbull.
Following this address, Dr. W. J. Knox, the immediate past president,
presented to Dr. Turnbull the badge of the B. C. Medical Association in
recognition of his presidential year, a ceremony initiated two years ago by
the late Dr. A. S. Monro.
Dr. Knox moved a vote of thanks and appreciation to the President of
the Canadian Medical Association, Dr. J. S. McEachern, for his presence
and assistance at this annual meeting. This vote of thanks was seconded by
Dr. Lapp and unanimously and enthusiastically carried by the meeting.
Dr. A. D. Lapp was then installed as the new president, and took the
Chair. His first duty was to present to Dr. McEachern the vote of thanks
of the meeting, to which Dr. McEachern replied. It was then moved by
Dr. H. H. Milburn and seconded by Dr. W. S. Turnbull that Dr. McEachern
be made an honorary member of the B. C. Medical Association. Carried
unanimously.
The meeting then adjourned.
BOOK REyiEW
THE LIFE OF SIR ROBERT JONES.  By Frederick Watson.
To those of us who have had the privilege of working at his clinic in the
Royal Southern Hospital in Liverpool, the memory of the late Sir Robert
Jones is chiefly one of a kindly gentleman of great charm, wholly unpretentious, and with a marked sense of humour.
The story of his life as told by his son-in-law is also the story of the
early development of orthopaedic surgery. The pioneer in this work was,
however, Owen Thomas, the uncle by marriage of Jones, and with whom
he served his surgical apprenticeship. Thomas was the son of a bonesetter,
himself the eighth in direct descent of a line of bonesetters—"well-to-do
farmers and highly respected throughout Anglesey." Sensing that the day
of the bonesetter was past young Thomas was sent to medical school, and
standing as he did between past and present, he could apply to the inherited
lore and empirical skill of his forefathers, the wider learning of medical
Page 27 fim
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science. Adjoining his office Thomas had a blacksmith shop where he
fashioned splints to suit each individual case. He is quoted as saying, "A
man who understands my principles will do better with a bandage and
broomstick than another with an instrument maker's arsenal."
Jones was schooled in these principles and carried them on, soon drawing
patients from all over industrial Central England to his clinic; which
became, too, a mecca for visiting surgeons, notably Americans. He had his
great opportunity during the war and the years of reconstruction work
following. The story is known to all of how he preached the virtues of
the Thomas leg splint, until it came to form part of the front line equipment, and reduced the mortality rate for compound fracture of the femur
from 80 to 20 per cent.
The writer once asked Sir Robert Jones why he had not written a text
book on orthopaedic surgery, and he replied that he never seemed to be
able to find the time. It was only during the last years of his life that, in
conjunction with Lovett, he produced a work to make permanent and
available to all, the information he had gathered through his long years of
experience.
His biography is written by one who is not a member of the profession,
but this tends to add to its charm, since the author's relationship gives to it
an intimate touch, and it may be seen throughout the book that he makes
use of material available to him because of family ties. This volume is a
valuable addition to the library. G. E. K.
THE ROLE OF THE GENERAL PRACTITIONER
IN THE EARLY DIAGNOSIS OF TUBERCULOSIS
Abstract of an address by  Dr. F. M. Pottenger
Monrovia, Cal.
Dr. Pottenger's address was probably one of the most interesting of the
entire programme. He has a gift for epigrammatic statement, and this
always makes a speaker "easy" to listen to.
His address was, too, very encouraging to the general practitioner. He
shewed the immense importance, if tuberculosis is to be brought under
complete control, of the role of the physician in general practice, who sees
most tuberculous patients and sees them first. He stressed the obligation
that is on every one of us to see that these cases are recognised early; and
the fact that any competent physician can recognise early T.B.
Tuberculosis must be recognised early, if we are to eliminate it, or
bring it into complete control. Thirty years ago, deaths from T.B. were
200 per 100,000; today they are 65 per 100,000 of population, a reduction
of two-thirds.
This is almost entirely due to better diagnosis and treatment of early
cases.
Every patient with T.B. is a sick person, and an open case, for 4-5 years.
Therefore he is a source of infection for 4-5 years.
T.B. is not a virulent disease, only mildly infectious.
The curability of tuberculosis depends upon early diagnosis. Hence
the role of the general practitioner is of tremendous importance.
How early can a diagnosis of T.B. be made?
Any time after infection has occurred, i.e., after the first sensitization
Page 28 of body cells has occurred, i.e., four to five weeks after infection. This, of
course, is ascertained by the tuberculin test, which can be applied by any
general practitioner.
If we are going to do our best for the prevention of T.B. we must
bear in mind not only the cases that come to us, but the contacts. They
have been infected by someone else, and they have passed it on to others,
hence we must hunt for the contacts.
Tuberculin test. If this is positive, there is a focus somewhere in the
body. Early foci are not particularly dangerous, while small, in fact, they
give a certain immunity. As long as these early foci heal, we need not worry.
Next, take x-ray of chest. 80 to 8 5 per cent of T.B. appears first in
the lung.
One x-ray will not do.
A negative x-ray, or simply a calcified node, does not mean that we are
safe.
The suspected child must be watched. If there is normal growth, well
and good; if not to normal degree, or if child is listless and irritable, look
out.
If we find a shadow in the lung-field, the child should be put under
proper care. Up to fifteen, T.B. heals very readily.
Unfortunately, we too often miss the primary infection, and generally
our first diagnosis is of secondary, not primary, infection.
The first infection leaves a focus in glands. The centre of these caseates,
and does not always heal. Then secondary infections occur. There are T.B.
bacilli present in these glands.
If we have a large dose of bacilli coming into the body of one who has
already been infected, that patient very readily becomes very ill with a
■secondary infection.
N.B. The primary infection may not be accompanied by cough or
temperature, and unless routine x-rays are taken of the chest, nothing may
be suspected. It is with the secondary infection that we have temperature,
cough, "repeated colds"; sometimes gastro-intestinal symptoms; sometimes
dyspnoea on exertion.
Tuberculosis masquerades under many guises. When the symptoms
become definite, they fall into three groups mainly:
1. Toxic. Patient is tired, listless, lacks energy and appetite. There is
tachycardia on slight exertion, or none at all.
These symptoms are not pathognomonic of T.B.; they show merely a
nerve imbalance.
A slight rise in temperature is very common—and there are two types:
(a) Where temperature rises for a few days to 99° or 99*, subsides for a
few days, then rises again and so on.   These are due to reinfections,  (b)
Where temperature rises and remains at the higher level for quite a long
.time.  Here we have a focus present, for which we must search.
2. Associated with other parts of the body. There is here a visceral-
neurological upset.
"You cannot have a chronic injury of any viscus, without involving
neurons, and without its being reflected in other parts of the corresponding
segment of the body."
Page 29
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A considerable readjustment is necessitated by the chronic infection,
and the neurons "don't adjust."
The condition is apt to recur with fatigue or strain, and to be seasonal
to some extent.
Reflex pains are of great value; and referred pains too. Thus pain in
the area of the shoulder-girdle is of great value, especially when accompanied
by a lagging of muscles in that side, of reflex origin.
Hoarseness is frequently due to reflexes, is aggravated by strain, sometimes evanescent, always revealing. Similarly, flushing of the face, especially on the affected side, gives us a clue.
3. Definite local symptoms.  These are chiefly:
Haemorrhage;
Pleurisy and pleuritic pains;
Expectoration.
If a patient comes with hemorrhage, in the vast majority of cases this
will be from the lung.
Think first of tuberculosis.
So with pleuritic pain. Do not think of intercostal neuralgia, etc.—
think of T.B.
Pleurisy with effusion—most commonly tuberculous in origin.
If haemorrhage or pleurisy are combined with tiredness, or a little cough,
or limited excursion of one side, be very suspicious.
Expectoration. Never take the patient's word for it, when he says he
does not have any.  This is especially the case in children.
Give the patient a bottle, and ask for a 3 -day specimen.
Rules to follow:
1. Careful history.
2. X-ray.
3. Examine sputum.
Do not depend too much on this last. It takes 100,000 bacilli to the cc.
to be sure of seeing them. This is where laboratory work is important. The
sputum should be concentrated, as by centrifuging, then even 1000 per cc.
will be seen.
4. Always examine the chest bare. Watch the patient breathe.
The general practitioner should know the following (here Dr. Pottenger
became epigrammatic):
1. The general practitioner can make a diagnosis, as early as anyone.
Therefore he should.
2. If he fails, there is a lack of accuracy in his technique.
3. Nothing gives a patient greater confidence than a thorough examination; nothing is so destructive of confidence as a superficial one. We
must not fail through carelessness, through poor history-taking, through
improper examination, etc.
4. Do chest work, not as a specialist in chest diseases, but as an internist.
Be an internist, and practise the line you like best, but as an internist.
5. It's an individual that has the lung, not a lung that has the indi-
The day of specialism is on the wane.   (Yes, he said that.)
Do not be overshadowed by machinery or by mechanical methods.
The patient is a book that we can read.
Page 5 0 THE   GENERAL  PRACTITIONER  AS  PART  OF
THE NATIONAL HEALTH SERVICE
Following is a condensed report of the addresses made by Drs. Vaughan and
Gordon of Detroit at a special meeting of the Vancouver Medical Association held
on August 25th, 1934, with regard to the practicability of including the general
medical profession in the work of the health department, thus utilizing the medical
man both as a preventive and curative force in disease.
Dr. Henry F. Vaughan
Dr. Stuart Pritchard, a Canadian, now president of the board of the
Kellogg Foundation, holds the view that the family physician should function in preventive medicine in a fully organized way, as well as in the treatment of disease. It is to the advantage of the patient, the doctor, and the
state.
In Michigan, the study of health problems has been developed separately
from the state and municipal health departments. There they are fighting
for fully-developed health service in all counties. Their objective is to have
the family physician active in all diseases, including cancer, not alone
diphtheria, the one disease which was chosen as the first to be attacked.
An effort has been made to integrate the general practitioner into the
health programme in three ways:
1. Reach the public by a programme of education.
2. Secure the co-operation of the doctor in private practice through a
programme of education in methods, technique, etc., for members
of the profession.
3. A study of the factors of treatment, including hospitalization.
This programme takes time.   Since 1928 they have striven to have all
doctors who are interested give both preventive and curative treatment in
diphtheria. There has been no free clinic. All the work has been done by the
doctors in private practice. Eighty-five per cent of all school children are
now protected against diphtheria, and among the pre-school children, 5 0
per cent. Diphtheria is now a rare disease. In the last eight years much
progress has been made. The doctor is now a co-worker with the health
authorities.
The steps necessary to bring this about are:
1. Reach the doctor, who should be prepared, and taught the use and
application of toxoid, the Schick test, etc.
2. The doctor should learn the technique.
The group plan is used in co-operation with the health department.
Sixty public health committees have been formed, comprising at the present
time about 1200 doctors in Wayne County Medcial Society. The central
committee is in contact with all general practitioners, including those who
are not members of the Medical Society.  The methods used were:
A. A medical conference was held to interest all doctors.   The tuber
culin test in childhood was also studied. The doctor was prepared
by giving him a demonstration of the technique of inoculation,
etc.
B. Next there was education of the public:  (1), by urging the parents
to go to the Health Department; (2) by the use of popular lectures, radio, pamphlets, billboards, street cars, church announcements, etc;  this brings about 20 per cent returns;   (3)   home
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visitation; public health nurses visit homes (50 to 70 per cent).
The children are found by a follow-up of the birth records.
The mechanics of the programme of protection against diphtheria must
be worked out. The doctor agrees to do a certain work, say the application
of toxoid, at a stated price, say $1.00, with the understanding that the
patient pays the fee, and if the patient is unable to pay the fee, it is arranged
that the health department pays 50c. The use of the Schick test has been
dropped since July 1, 1934. Vaccination against smallpox is also arranged
for. There are also prepared lists of doctors willing to act in a curative way.
It is arranged that the mother sends the child to the doctor. Following up
birth records, when a child is six months old, public health nurses visit it,
the treatment is given, and follow-up methods instituted. One difficulty
is that a diphtheria patient may owe the doctor a bill. It was also difficult
to interest all doctors in the work. The entire cost of the programme is
less than the cost of treating diphtheria formerly. It is found that the
disease is reported earlier under this system, and further, the doctor receives
his pay, if only a small fee. Preventive medicine pays the physician better
than curative measures. Loss in three years has been $60,000, but the doctors
have received $300,000 for preventive procedures. This plan has spread to
smaller counties, and the.doctors are now doing all the work, under a full
plan as outlined by the public health department. The Kellogg Foundation
enables doctors to go to some medical centre and take a post-graduate course,
and in some counties the majority of the doctors have taken this course.
1. The local profession must be well-organized in general public health
measures.
2. The plan must not only include diphtheria, but other communicable
diseases, and ultimately cancer.
3. There must be a basic charge in medical service.
ii*
Dr. Gordon: The Control of Communicable Diseases
Dr. Gordon has recently spent twelve months in Europe studying the
above problem. The organization of the public health services are much
the same as here, with federal, state, and municipal bureaus.
In other countries public health laboratories are attached to the universities, and the service is of a high order. There is also excellent control
in hygiene, etc., in the rural areas. In Jugo-Slavia there is a full-time health
department in every important district. In Poland the health and relief
departments are in direct association with each other. The isolation procedures are much less rigorous than on this continent. In most cases the
head of the family may go out to earn his living, and the mother is considered more as the nurse in this country, and is also allowed to go out.
Placarding the house in contagious diseases is unknown in Germany. In
some others, children are excluded from school, and not rigorously quarantined. There is more hospitalization. The methods in use in the fever hospitals in London are of a very high order, as they attain much more centralization, while here the communicable disease department is a part of
the general hospital. Terminal disinfection is more thorough and complete
there.
Essential Features of Various Communicable Diseases:
Diphtheria is active in winter in Europe.   They had a relatively severe
Page 3 2 form of diphtheria of the laryngeal type, but this is becoming less and less
as control methods have developed.
Methods of Management in European Clinics:
Tracheotomy is rare, intubation more common. However, direct aspiration by suction, done through a bronchoscope, is practised extensively and
gives excellent results. It is interesting to note that the Von Boki Clinic
has a building dedicated to O'Dwyer. In the use of antitoxin, medium-
sized doses are given. In Germany as many as 2000 units may be given. In
Copenhagen, 200,000 to 600,000 units are often given. In Germany 20,000
to 60,000 units is the usual dose. If the case is very toxic, half the antitoxin
is given intravenously and half intramuscularly.
Prevention:
In some countries, particularly Austria and Germany, there is not much
enthusiasm shown for antitoxin, chiefly, no doubt, because of the Lubeck
disaster. They did not use toxin-antitoxin, nor toxoid, but used toxoid
antitoxin. In the U.S.A. much progress has been made. Toxoid is preferred.
It is being used even for adults; 2/10 of 1 cc. and increase gradually up to
3 doses, for immunization for adults. In most places two injections of
toxoid are used.
Scarlet Fever. In Europe Dr. Gordon learned much about aetiology.
There they are not so sure that the haemolytic streptococcus is the cause of
scarlet fever. Most men in Europe and in this country believe that there is
a group of streptococci, some of which cause scarlet fever. In some countries, viz. Roumania, they have a 22 per cent mortality. In England scarlet
fever streptococcus antitoxin is used much more, 8 5 per cent of all cases
being treated. In Roumania they use the convalescent serum, not the stock
serum. It is important to determine what kind of case one is dealing with,
whether severe or moderate. The toxic case is difficult. The rash is bluish-
red, there is cyanosis, the patient is much depressed, temperature is high,
often 105; a fulminating disease, with little sore throat, slight glandular
involvement, much toxaemia. Next is the severe septic type, with mottled
skin, much invasion of the tissues, the glands of the neck much enlarged.
A membrane is sometimes present in the throat, sinusitis may be present.
The toxic type is treated by streptococcus antitoxin. The septic variety,
most common here, does not yield results from the use of serum. In Detroit
they have adopted the method of whole blood transfusion from recovered
cases. In some European countries this method is rather commonly adopted.
Isolation in some Scandinavian cities is practised, in others none at all. A
study has been made of the incidence of the disease under these two conditions, and the curve of the chart is found to be the same. The isolation
period in Detroit is two weeks, in Chicago three.
Infantile Paralysis. In Europe they look to America for the lead in the
lines of treatment. In an attack the probable diagnosis is the most important
point, and this depends upon two things. There are two phases of the illness.
The patient develops acute symptoms from which he appears to recover,
when the symptoms reappear. This second appearance may be followed by
paralysis. If in the summer months, it is probably poliomyelitis. There may
be joint intestinal upset, if associated with vomiting and fever.
A. In tetanus, etc., the neck is definitely rigid, but in poliomyelitis,
while definite stiffness is present, if you pick up the child
by the shoulders, its head drops backwards. This definitely suggests poliomyelitis.
Page 33
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B. Stiffness in the spine. If the child is placed in a sitting position, with
the chin between the knees, and then is picked up by the knees,
the back remains rigid, but in poliomyelitis it becomes rounded.
Tremors are found by having the child hold out the hands with
the fingers spread.   Spinal puncture is necessary.   The cells are
increased in number from 30 or 40 to 700. A few cases may show
no increase; i.e., those where bulbar involvement is present, or in
the mild abortive type.
Treatment.  There is much difference of opinion concerning the use of
convalescent serum.   Dr. Gordon feels that there is a place for serum if
given before paralysis appears.   Serum was formerly given intraspinously,
but not at the present time, if meningeal symptoms are present.  Three cc.
may be given intramuscularly or intravenously.   Other measures may be
used, such as protection by splinting for four or five weeks.   No physical
therapy is used till after six weeks.  Use heat early, e.g., electric light under
the cradle.  Orthopaedic repair treatment may be used later.
In the question period, Dr. Vaughan stated that the method being so
successfully developed in Detroit was originated by twenty physicians in
one medical society, that is, the idea started there, and they began co-operative study with the health department. They used subtle methods to
interest the medical men, and the public, in the work.
1. They sent out a postcard calling all the men together to attend a
meeting held at a place at some distance from the district.
2. A question was included asking each medical man if he had any
complaint against the health department, for example, if the nurse
had taken any case away from him.
About 450 attended the meeting.  The question was also asked on this
card: "Are you willing to co-operate with the health department?"
Other modifications of this Detroit plan could easily be applied.
Dr. Gordon also answered some questions. One as follows, concerning
sub-clinical cases of poliomyelitis.
A. Symptoms of general infection, such as fever, vomiting, etc.  Many
terminate there, probably 75 per cent of all cases.
B. Those in which there is some slight involvement of the nervous sys
tem, probably 15 per cent.
C. Some with marked paralysis present.
Pooled serum of adults who had no poliomyelitis may be used. Poliomyelitis is probably not directly infective, as few double cases occur in one
family. The cases are probably not infective after one week from the
appearance of the paralysis. The incubation period is ten to twelve days.
The disease spreads by carriers, or from sub-clinical cases.
Scarlet Fever. Transmission of scarlet fever is more marked in the
winter months, and more in some cases than others. A shorter isolation
period is becoming more common, with no higher return of infected cases.
Three weeks isolation is as good as four. It is definitely proven workable to
allow two weeks period for adults.
Measles. There is a distinct value in convalescent serum. If used before
the third or fourth day it may prevent the development of the disease.
Encephalitis may occur on the eighth or ninth day after the appearance of
the rash, with drowsiness, headache, etc. The spinal puncture will show
an increased cell count and high sugar content.
Page 34 Whooping Cough. In the Faroe Islands, vaccine in whooping cough has
been helpful, in lessening the severity of the disease, and in immunization,
but it does not give complete protection against it. little is to be expected
from vaccine if the disease is established, that is in the treatment of the
disease.
VAT \ffl
mm
MALIGNANCY  OF  THE  LARGE  BOWEL-
James C. Masson, M.D.
Division of Surgery, The Mayo Clinic,
Rochester, Minnesota
With the exception of similar tumours in the body of the uterus,
malignant tumours of the colon are the most satisfactory from the standpoint of surgical treatment of all internal malignant growths. With this
fact in mind, physicians should be encouraged to try, more and more, to
make early diagnosis of such lesions; radical operation will cure a relatively
large number of otherwise doomed patients. Radium and roentgen rays, in
the hands of specialists, exert a wonderful influence for good on many
malignant tumours, especially epitheliomas and sarcomas of high grades of
malignancy. Most of the colonic growths are, however, slowly growing
adenocarcinomas which tend to metastasize late, and which are of a relatively low grade of malignancy (according to Broder's classification). As
a result, relatively few cures can be expected from irradiation. Surgical
removal should be advised in all cases in which operation of any type is
not contraindicated after adequate preparation. Such preparation includes
relief of obstruction, protection against peritonitis by intraperitoneal injection of vaccine prepared from streptococci and colon bacilli as advised by
Bargen, thorough emptying of the bowel, and keeping the patient on a diet
low in residue for four or five days before operating. It includes, also,
proper treatment for any existing anaemia, dehydration, renal insufficiency,
and so forth. This brings up an important further point. What one man
will consider a legitimate surgical risk, another man will not. If only
patients whose condition is diagnosed early, and who constitute good surgical risks, are operated on, a most satisfactory showing, both as regards
five-year cures and low mortality, would result. On the other hand, in a
series of cases in which operation is performed by equally good surgeons, but
which includes all cases in which there is any hope of cure, and many in
which palliation alone can be expected, the'death rate will be higher, but
the number of five-year cures, and the number of patients definitely helped,
will be much larger.
In considering diseases of the colon, it is rational to divide the organ
into a right half, that develops from the mid-gut and in which absorption
is a most important function, and a left half, which develops from the
hind-gut, and of which storage of fceces is the important function. The
symptoms of tumour in the proximal or right half of the colon, which
includes the cecum, ascending colon, hepatic flexure and half of the transverse colon, are different from the symptoms of tumor in the terminal or
left half, which includes the distal half of the transverse colon, the splenic
flexure, the descending colon and the sigmoid. New growth in the anal
canal again produces other symptoms.
* Read before the meeting of the British Columbia Medical Association, Kamloops, British
Columbia, September 17 to 18, 1934.
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*'i.i Dixon, in a review of the histories of sixty patients operated on at The
Mayo Clinic from 1907 to 1928 inclusive, and who lived five years or more
after operations on the right half of the colon, found that they had practically all lost weight, most of them many pounds; that they were all
anaemic, and that a tumour could be felt in the right iliac fossa. Patients
who have carcinoma of the right half of the colon have anaemia that is
much more marked than that of patients who have carcinoma of any other
part of the body. Anaemia that accompanies carcinoma of the right half
of the colon is to be definitely distinguished from the cachexia that develops
late in the course of extensive malignant disease, with multiple metastasis.
This anaemia is probably caused, as Alvarez and his co-workers have shewn,
and as Dixon believes, by the free absorption of products of bacteria, and
by the gradual loss of blood from the ulcerating surface. Occult blood is
almost a constant finding on examination of stools, but haemorrhages or
gross evidence of blood are rare. These malignant growths frequently become of relatively large size, without causing any obstruction, on account
of the content of this part of the bowel being fluid. That the growth alone
is not responsible for the anaemia is well shown by the marked improvement
in the blood picture following ileocolostomy. Besides anaemia, marked loss of
weight, and a tumour, these patients have, as a rule, marked loss of strength
and more or less marked gastro-intestinal disturbances, often suggesting
appendicitis, cholecystitis, pancreatitis, or even peptic ulcer. It is generally
on account of these two common symptoms that the patient first consults
a physician, and it is most unfortunate, as Jones has stated, that the individual "is too often given a tonic and sent on his way." Adequate examination of most of these patients at the time of their first visit to a physician
would disclose the presence of a new growth.
The marked improvement in roentgenography in recent years has been
a great help in localizing pathologic conditions of the gastro-intestinal tract.
In spite of the fact that obstruction rarely occurs in the caecum or ascending
colon, a positive diagnosis, as a rule, is possible early in the disease. The
most difficult tumours to localize are those in the caecal cap. Carcinoma of
the colon develops on the basis of pre-existing polyps, or from the .normal
secreting glands in the wall of the intestines. A causative factor of growths
in the caecum is no doubt irritation from the alkaline stream that passes
through the ileocaecal valve.
Fortunately, the right half of the colon lends itself well to radical
removal, not only of the involved bowel but also of the regional lymph
nodes. Because most of the malignant growths are slowly growing adenocarcinomas, a high percentage of cures can be expected, in spite of the
unfortunate delay so often experienced. Dixon, in the review previously
mentioned, showed that of 187 cases, in 123 there was no demonstrable
involvement of lymph nodes at the time of operation and that 66 per cent
of the patients lived five or more years. Furthermore, in 64 cases in which
lymph nodes were involved at the time of resection, 39 per cent of the
patients lived five or more years. In one case in which lymph nodes were
involved and malignancy of the lesion was graded 4, the patient lived more
than twenty-two years. As Dixon wrote, "it is an established fact that
malignant growths may be present in the colon for a considerable length of
time, remaining operable and not metastasizing."
The only prospect for cure of patients who have carcinoma of the right
half of the colon lies in radical removal. The surgeon is justified in assuming
considerable risk, for the outlook is hopeless unless the growth and the
Page 3 6 regional lymph nodes can be thoroughly removed. If the patient is in good
condition, it is generally advisable to remove the right half of the colon in
one stage, making end-to-side or side-to-side anastomosis between the terminal portion of the ileum and the middle portion of the transverse colon,
at the same time inserting a male catheter of large size into the ileum, a
few inches above the line of anastomosis, to allow adequate escape of gas.
On the other hand, if the patient is in poor condition, or such an operation
seems too hazardous, it is advisable to perform it in two stages; first, ileo-
colostomy should be performed, and two to four weeks later, the portion
of the bowel that has been isolated should be removed.
During passage from the caecum onward, the intestinal content gradually
changes from a fluid to a mass of some firmness of consistency; this change
results from rapid absorption of fluid by the wall of the right half of the
colon, through its entire length. The symptoms of malignant growths in
the left half of the colon, therefore, are very different from those of growths
in the right half. The contents of the left half of the colon, as I said before,
are more solid than those of the right half of the colon. The lumen of the left
half of the colon is smaller than that of the right half, and the walls are
more muscular. As a result, and projection into, or narrowing of, the lumen
will predispose to symptoms of obstruction.
Carcinoma of two distinct types occurs in the descending colon and
sigmoid. Probably the greater number of carcinomas in this region start
from polyps, and grow into the lumen considerably before the growth
extends back into the intestinal wall. Other growths start in the mucous
glands of the bowel and tend to encircle it, causing definite constriction of
the lumen; this is the so-called nakpin-ring growth. Of this latter growth
especially, symptoms of obstruction generally are the first intimation the
patient has that anything is wrong. In many cases, on account of back
pressure, patients often have general abdominal distress and frequently
tenderness in the right iliac fossa. In a review of 100 cases of carcinoma of
the left half of the colon, Bargen found pain was a complaint in 40 cases
and that in 15 of them the appendix had been removed shortly before they
came to the clinic. Frequently the history is that the patient has periodic
spells of partial obstruction, with intervals of weeks, or even of months,
when he is fairly free of symptoms; sometimes he has attacks of diarrhoea
and passes considerable mucus and some blood. Anaemia is seldom a symptom
of carcinoma of the left half of the colon. k Gross blood in the stools is
much more characteristic of a lesion of the terminal half of the colon than
it is of one of the proximal half.
Any irregularity in movements of the bowels should suggest to the
physician the need of thorough examination of the colon. Irregularities
which require attention are constipation of a type that suggests obstruction,
and diarrhoea, especially if mucus and blood occasionally are seen. Anaemia
that is not accounted for, and any indefinite abdominal pain should be
thoroughly investigated. Thorough rectal examination will demonstrate
any lesion in the anal canal, rectum, or rectosigmoid, and in this short
section of bowel more than 20 per cent of all carcinomas of the gastrointestinal tract, and more than 50 per cent of all carcinomas of the large
bowel are found. It is to be regretted that so many patients are under medical care for long periods, and complain of indefinite abdominal symptoms,
vet never receive thorough rectal examination.   Proctoscopic examination
Page 37
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N? should be made in all suspected cases. Lesions as high up as the middle of
the sigmoid are, as a rule, easily visualised.
If nothing is noted on digital or proctoscopic examination, roentgeno-
graphic examination following a barium enema should be made, and under
modern methods, applied by well trained roentgenologists, any deformity
in the large bowel, above the level of the pelvic brim, can, as a rule, be
recognised. Not only can the roentgenologist say that there is a deformity,
but usually he can express a very definite opinion as to whether it is
malignant or not.
In contrast to carcinoma, sarcoma may grow to large size and cause
no obstruction. In fact, the lumen of the involved portion is likely to be
larger than normal.
Treatment of malignant growths in the left half of the colon naturally
varies with the condition of the patient, the part of the bowel involved, and
the presence or absence of obstruction as a complicating factor. When
resection of the left half of the colon is advisable, except in rare instances
it is probably advisable to perform it in two stages. This is especially indicated if there is any obstruction, or if the bowel has not been well emptied.
The first operation consists in a colostomy or caecostomy, and in thorough
examination of the abdomen for evidences of metastasis. At the second
operation the growth is removed with a sufficient section of bowel and the
attached mesentery. Also the regional lymph nodes are removed, and end-
to-end or end-to-side anastomosis is performed. Many surgeons of large
experience utilise the Mikulicz principle of exteriorization of the growth
in many cases in which the sigmoid is involved. Rankin's modification consisted in using a three-bladed clamp and removing the isolated section of
bowel at the first operation; also the upper half of the clamp is opened in
about 72 hours to allow escape of gas and relieve obstruction. At a later
date the spur between the two loops of bowel is crushed with a long bladed
clamp, and if the stoma does not close in due time, plastic closure is made.
The method has met with general favor. The main objection to any type
of operation in which exteriorization is employed is that only a limited
amount of the mesentery and of the tissue that contains lymph nodes can
be removed; in such freely movable growths a classical resection is not a
very difficult procedure.
Many more malignant growths occur in the anus, rectum and rectosigmoid than in all the rest of the large bowel. On account of their situation, a diagnosis should be mare readily made, and treatment, as a result,
should be more satisfactory. Unforeunately, about 65 per cent of the cases
are inoperable when the patients are first seen at The Mayo Clinic.
The situation, size, and degree of malignancy, as well as the patient's
condition, must be taken into consideration in deciding on the type of operation best suited to any individual case. Local excision and posterior resection, with a resulting sacral anus, occasionally are justifiable, but more
radical operation, such as combined abdominal and perineal resection, or
posterior resection and colostemy, are more rational procedures. Either of
these major operations can be completed at one time, or divided into two
stages, depending on the condition of the patient and on the familiarity of
the surgeon with the special technic required for thorough, safe and rapid
execution of such operations.
I will discuss the technique as I show a few slides and a motion picture
Page 3 8 made for Dr. Claude F. Dixon, who is in charge of the surgical aspect of the
colonic service at The Mayo Clinic.
BIBLIOGRAPHY
1 Bargen, J. A.: Quoted by Dixon: Malignant growths of the left half of the colon: sur
gical   treatment.    Kansas   City   Southwest   Clin.   Soc.   Monthly   Bull.     10:4-7;   11
(March)  1934.
2 Dixon, C. F.: Unpublished data.
3 Jones, T. E.: Cancer of the colon and rectum: its diagnosis and treatment.   Northwest
Med.   32:326-331   (Aug.)   1931.
INFECTION:  ITS SPREAD AND CONTROL
By Dr. G. F. Amyot
Read before Vancouver Medical Association, October 2, 1934
The story of infection, its spread and control, is not a new subject, but
tonight it is my purpose to give you a new and "personal interpretation of it.
At the outset, may I say that I shall not burden you with pithy quotations
and statistics ad infinitum.
The germ theory of infection was brought into being and proved to be
a fact by the introduction of the microscope by Kircher in 1759 and
Leeuwenhock in 1775, and by the work of Pasteur, Koch and their disciples
during the last 40 years of the 19th century.
In discussing infection I think it is wise to have some idea of just how
extensive a field this covers. Some years ago Dr. H. W. Hill, director of the
provincial laboratories in Vancouver, made a survey of a million deaths
registered in the U.S.A. He found that 61 per cent of all these deaths were
due to some form of infection—not necessarily the acute communicable
diseases, but some form of micro-organism infection. He went further and
found that if he excluded all deaths where the cause was unclassified, those
from old age, accidents and malformations, that 86 per cent of the remaining deaths were due to some form of infection. As infection is an external
cause of illness and death, then we are justified in stating that theoretically
61 per cent of all deaths and 86 per cent of a group of three-fourths of a
million deaths where the cause is definitely a disease, are preventable.
From the above figures we realize that infection is not confined to the
acute communicable diseases but covers a long list of common illnesses not
usually thought of in this light. We have in this category such diseases as
tuberculosis, all forms; syphilis, all forms; gonorrhoea; bronchitis; rheumatic fever; endocarditis; endarteritis; boils; carbuncles; many skin infections; discharging wounds; typhoid; paratyphoid; undulant fever; Rocky
Mountain spotted fever; influenza, mild and otherwise; common colds;
pneumonia; tonsillitis; quinsy; infantile diarrhoea; dysentery, amoebic and
bacillary; puerperal fever; most heart conditions; nephritis; cholecystitis;
diabetes, and a long list of others.
Since we can accept the germ theory of infection as fact, we can
readily understand the causative agent of infection. Therefore the first
consideration in the study of infection is the cause, and the cause in this
case we shall call micro-organism (I am not going into the different types,
as we are all well versed on that topic, but will group them all as microorganisms). All the micro-organisms causing infection have not been
differentiated and isolated, but the general principles hold just the same.
These micro-organisms must exist in some definite place. It has been found
that these are parasites; that is, that they live and multiply only in living
human or animal bodies.   When they are removed from their natural en-
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vironment, the living body, they do not live in the majority of cases for
any great length of time, except a few micro-organisms which have particular characteristics, as the spore-formers of tetanus and anthrax. Spores
may live for long periods of time away from the body and will not multiply
until they again take on the vegetative form when they infect a new host.
Parasitic pathogenic micro-organisms do not increase or multiply in dirt,
filth, decaying vegetable matter, sewage or smells. They die quickly in any
unsuitable environment. The tubercle bacillus, although not a spore-
former, has a special structure which enables it to live in some places away
from the body for a longer period of time than most organisms. Even here
there is a gradual destruction of the bacilli.
Therefore we must conclude that the source of the mciro-organisms
which cause disease in man exists in man or animals only. Then, if man
or animal be the source or reservoir of these organisms—the soil where they
regenerate and multiply in millions—we must, if we are going to control
these diseases, find what particular living bodies are the source. We know
from experience that the most easily recognized source of these pathogenic
organisms is the typical case suffering from the particular infection; the
mild, atypical, missed case and carrier also come into the picture and will
be mentioned later.
These micro-organisms, to infect someone else, must leave the source
in some manner and be conveyed to the well population. These organisms
cannot walk, crawl, or fly, so depend on being carried by some other agency
in some fluid. This fluid we call a vehicle. The vehicle in the spread of
respiratory diseases is the discharge from the nose and mouth of the source.
In typhoid, dysentery, ets., the vehicles are the discharges from the bowel
and bladder of the source. In venereal disease, the discharges of the geneto-
urinary tract and the mucous membranes. Wounds, abscesses, etc., have as
vehicles the discharges, and so on through the list. In malaria the blood acts
as a vehicle.
There must be some mode of transmission of these vehicles containing
the causative agent, from the source to the well population, before we can
have a spread of the infection. The following are the main modes:
1. Contact,   (a) Droplet infection, loud talking, sneezing, and cough
ing,  (b) Articles recently soiled with vehicles; dishes, bed linen,
nursing articles,
nursing articles, (c) Hands and person.
2. Foods.  Milk and milk products, water, ice, meat and shell fish and
other foods.
3. Insects,   (a)  Biological; example, mosquitoes in malaria,  (b)  Me
chanical, flies.
4. Soil.  As containing the spores of tetanus.
5. Fomites. This last group is considered to be of very little importance
today.   It refers to articles soiled with discharges and retaining
living organisms for long periods of time.
The bacteriologist by his exacting studies has shown us that certain
micro-organisms or groups of organisms follow a definite course of procedure in infecting any individual, and that if we know the habits of these
groups we are aware of many weak points in the sequence of events through
which they must pass. To control or prevent the spread of these diseases
we must break this sequence of events as early and in as many places as
possible.  This can be done in a variety of ways.
Page 40 The first essential in controlling infection is to know the existence and
location of the case in its earliest possible stage. This also assumes that an
attempt will be made to diagnose the disease so the proper procedure can
be carried out from the beginning. It is wise to remember that practically
all persons having fever are suffering from some infection and therefore
Walt every fever is potentially infectious or communicable from the earliest
onset. If the army method of diagnosis of P.U.O. were applied to these
cases until such a time that it was possible to make a definite diagnosis, and
if P.U.O. were considered as always communicable until proved otherwise,
then control could be much more complete and effective.
As I have stated, the first essential is to know the source before action
can be taken. The public have placed in the hands of the health department
by law certain powers and duties to enable these departments to control, as
far as possible, the further spread of disease and establish methods of protecting the public from infection. These departments are also required to
promote health to the best of their abilities in their respective communities.
If these departments are to carry out their duties to the public it is
necessary that they know immediately the location of all sources of infection; that is, the case, the mild case, the missed case, and the carrier. This
is a big problem and can only be done by the complete and wholehearted
MEDICAL PRACTICE WANTED
Toronto physician wishes to obtain a practice in British Columbia,
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Reply to Box 798, Station F, Toronto, Ont.
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Enjoys a long-established reputation as a
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GARDENAL is more than a trade name, it implies a superior brand
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LABORATORY POULENC FRERES
OF CANADA LIMITED
Canadian Distributors: ROUGIER FRERES, MONTREAL
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Page 41 ft'IP;!':
ft
co-operation of every individual in the community. In other words, every
infection must be reported. One often hears the statement that the medical
practitioner is responsible for poor reporting. I do not think that this is
fair. I have found that the medical doctors on the North Shore are as close
to 100 per cent in this respect as it is possible to get and yet we do not have
all cases brought to our attention. The physician is only called to a few of
the cases. He will often see the first few cases of measles, for example, and
after that the neighbours treat their new cases in the same manner as Mrs.
Brown was told to treat hers by the doctor. I think that when cases are
reported to a health department that department should do more than
record the name, address, etc., in a book and forget about it. The health
department is in duty bound to try to instruct the parents and the patient
in proper methods of care to prevent the disease spreading to other members
of the family and the friends. If each case, when reported by the physician,
was first immediately reported as a fever or P.U.O., and then the proper
diagnosis supplied when available, much could be done in control. I shall
go farther and ask that each case be instructed immediately by the physician
and be told what precautions to take to protect others.
Following the discovery of a case of infection, we know we have a
definite source and must try to confine that disease to the one person. In
some cases we can actually start our control by destroying the microorganism in the source by the use of some special agent. This is done in
syphilis by the use of certain drugs; in malaria by the use of quinine, etc.
Unfortunately this is not possible in most of the common infections.
(To be continued)
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Page 42 McCOLLUM on
I Pasteurization
Dr. McCollum, universally recognized as one of the
foremost students in nutrition, says this tersely, clearly
and authoritatively:
"The evidences of animal experiment do not show any differences
between raw and pasteurized milks."
This is a very clear-cut statement regarding the
nutritional efficiency of raw and of pasteurized milk.
In this connection it might be well to point out that he
is not concerned here with problems of disease but rather
those of nutrition. The germs of tuberculosis and of
undulant fever have been repeatedly demonstrated in
raw milk through the use of animals.
RECOGNIZABLE CHANGES
"The actual changes in milk caused by pasteurization are an increase in insoluble calcium of about 6 tier cent, a reduction of iodine
content by 20 *ter cent, and considerable destruction of Vitamin C.
"Certain animals have a higher need for calcium than do infants
and it may be that raw milk would be better for them than pasteurized milk, but there is no evidence that this is true for children.
"There is no convincing, evidence that raw milk, even if it were
safe, is superior to pasteurized milk in infant feeding. Pasteurized
milk is probably better since it is more easily digested. The growing
practice by pediatricians of boiling milk or of feeding evaporated
milk to infants, shows that it is certainly satisfactory.
"The idea of splitting hairs over slight assumed differences is
absurd."
We do not remember to have seen a more simple and
direct summary of the effects of pasteurization upon the
composition of milk than is given in these sentences.
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
service phones:
Fairmont 1000     North 122     New Westminster 1445 H'H
0?,
ow pou see agarol
a?.
ow you see aomeimng els
I\ GOOD emulsion pours freely
—and Agarol does. You fill the
spoon for a dose, you don't scoop
it out of the bottle. Or if you
prefer, you place a close in a glass,
stir it a bit, and take it that way. A
pleasing drink it is, too. For children, you add it to milk—and they
like it.
■ Agarol is the original mineral
oil and agar-agar emulsion with
phenolphthalein. It affords easier
and more thorough mixing with
the intestinal contents. It offers
greater palatability, absence of oily
taste, and greater convenience in
use. Thereis no sugar in Agarol; no
artificial flavoring to get used to.
■ The treatment of constipation is
much less of a problem when you
rely on the dependable action of
Agarol for thorough softening of
the intestinal contents, for evenly
distributed lubrication of the
intestinal canal, and for gentle
stimulation of the peristaltic
function.
■ Try it. A request on your letterhead will bring you a complimentary supply.
AGAROL
FOR CONSTIPATION
Agarol is supplied in bottles containing 6 and 14 ounces.
The average dose is one tablespoonful.
WILLIAM R. WARNER & CO., LTD., 727 King Street, West, Toronto, Onh Tonsillitis
To alleviate pain, to maintain relaxation, freedom
of circulation and an even temperature to the
parts, the use of Antiphlogistine, thickly applied,
as hot as the patient can bear, generally proves
very satisfactory.
Because of its relaxant, decongestive, heat-retaining and plastic qualities, Antiphlogistine is a topical application of choice for the treatment of
tonsillitis in all its forms.
Besides being adhesive, Antiphlogistine
moulds itself to all contours; it retains
its heat and may be left in situ for more
than 12 hours.
ANTIPHLOGISTINE
Made in Canada
The Denver Chemical Mfg. Co.
153 Lagauchetiere Street W.
MONTREAL
Ml ;1'l
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Prokliman "Cilia
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IT is true, indeed, that excellent results have been reported
following the use of Sistomensin in patients suffering
from disturbances due to the menopause. However, in many
cases, it has been found much more effective to associate with
the ovarian hormones, substances capable of suppressing immediately certain of the more distressing symptoms.
PROKLIMAN "CIBA" combines the action of the ovarian
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cessation of menstruation.
Dosage: 2 tablets two or three times a day.
CIBA COMPANY LIMITED
MONTREAL
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Theocalcin
(theobromine-calcium salicylate)
Council Accepted
Give Theocalcin to increase the efficiency of the heart
action, diminish dyspnea and to reduce edema.
Dose: 1 to 3 tablets, three times a day, with or
after meals.
In 7l/z-grain Tablets and as a Powder.
Literature and samples upon request
MERCK & CO. LTD.
412 St. Sulpice St. Montreal
BILHUBER-KNOLL CORP., Mfrs., JERSEY CITY, N. J. physicians and Surgeons
AUTOMOBILE   GROUP   INSURANCE
Special Rates Have Been in Effect 18 Months and Many
Doctors Have Availed Themselves of This Saving.
WHY   NOT   YOU?
LOCKE & REE, General Insurance
407 Rogers Building' Phone Sey. 8488
Portable   X-Ray   Work   Now   Possible
IN THE HOME
A Convenience to All Doctors.   Totally Efficient and Shock Proof
For full details, phone or write
W. C. ECCLES
X-Ray Department, St. Paul's Hospital, Vancouver, B. C.
REST HAVEN
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A Medical Institution for the restoration of health,
situated eighteen miles from Victoria, overlooking the
Gulf of Georgia.
Modern facilities for the treatment of all classes of
patients with the exception of those suffering from
mental or contagious diseases. Hydrotherapy, electrotherapy, massage, and diet, under medical supervision.
Physicians referring patients or convalescents for
treatment are requested to send such reports and suggestions as may assist in their treatment.
*   REST HAVEN SANITARIUM
and HOSPITAL
SIDNEY, B. C.
m  THE PRESCRIPTION CHEMISTS
OUR ENTIRE ATTENTION
Is devoted to the rendering of a dependable and strictly
pharmaceutical service.
McGill & Ofmr,
FORT STREET (opp. Times)      Phone Garden 1196      VICTORIA, B. C.
WE HAVE BEEN PRACTICING IN
VICTORIA FOR THE PAST 67 YEARS
B.C. FUNERAL CO.
HAYWARD'S LTD.
Established 1867
'■'.: :   : ^€7°
Phones: E. 3614 and G. 7679
734 BROUGHTON STREET VICTORIA, B. C.
STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office.  Supplied
in one yard, five yards and twenty-five yard packages.
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C.
StM
W
Kul
■M Mi
Relative Values of Carbohydrates
Employed In Infant Feeding |
Continued down from 1911
1915
'' The infant with diarrhea and vomiting is given nothing
but tea for from twelve to twenty-four hours, no longer,
and then the albumin milk is commenced, not over 5 gm.
ten times a day, with 3 per cent, of a maltose-dextrin mixture. The amount of albumin milk is increased by 50 gm.
each day until the daily ration totals 300 gm. After the
weight has become stationary, carbohydrates can be_ added up to 5 per cent, of the maltose-dextrin mixture."
"Albumin milk is not so uniformly effectual in dysen-
teriform diarrhea as in cholera infantum. Whey seems to
act better, diluted half and half with oatmeal gruel. After
the starvation period he gives 50 gm. of the whey and increases by 50 gm. daily with equal amounts of oatmeal
gruel. As improvement sets in 3 per cent, of a dextrin-
maltose preparation can be added."—L. Langstein:
Cholera infantum and other severe diarrheas in infants,
Therap. Monatsh., V. 29, August, 1915; Abst. J.A.M.A.,
65:1814, Oct., 7, 1915.
1916
"Dextri-maltose, having a higher absorption tolerance
than the other sugars, is less likely to cause intestinal
disturbances when large amounts of it are given."—H. R.
Mixsell: A brief resumi of the role of carbohydrates in infant feeding. Arch. Pediat., 33:31-86, Jan., 1916.
1916
In cases of malnutrition and indigestion in infancy,
"The appetite improves rapidly, and the stools soon become normal in appearance, if the sugars are intelligently
prescribed. By this I refer to proper proportions of dextrin and maltose. When there is a tendency to looseness.
I have used the preparation known as 'dextri-maltose,
for the extra carbohydrates; . . ."—-1/. Ladd: Further experience with homogenized olive oil mixtures, Arch. Pediat.,
33:501-512, July, 1916.
1916
"For the addition of sugar, I usually use dextri-maltose,
which does not easily cause fermentation."—L. L. Mein-
inger: Use of Eiweissmilch, Arch. Pediat.,33:529-532, July,
1916.
1916
In the treatment of marasmus, "Three per cent of malt
sugar should be administered from the first, afterwards
running up to as high a per cent as the child will take."
—L. T. Roysler: A Handbook of Infant Feeding, C. V.
Mosby Co., St. Louis, 1916, p. 100.
1916
"Least irritating of all sugars, and more readily digested and quickly absorbed, is maltose."—H. Lowen-
burg: A Practical Treatise on Infant Feeding and Allied
Topics, F. A. Davis Co., Phila., 1916, p. 73.
1916
"Dextrin-maltose is valuable in cases where intestinal
disturbances are due to fermentation of milk sugar."
"Treatment (of sugar intoxication) consists in eliminating the latter (whey salts) as well as the sugars from
the diet temporarily, and when the symptoms have subsided, a different sugar in proper proportion should be
cautiously added; maltose and dextrin are preferable,
because they are not apt to produce fermentation, while
milk sugar is prone to set up fever and diarrhea."—E. E.
Graham: Diseases of Children, Lea b° Febiger, Phila., 1916,
pp. 179-201.
1917
'Tor children who are not gaining on a normal formula
with a sufficient amount of sugar of milk, or children who
vomit when sugar of milk is fed, or who are constipated,
the use of maltose instead of lactose often gives most
satisfactory results. This is readily accomplished by sub
stituting for the 4 or 5 per cent, of added sugar ofgauk an
equal amount of dextri-maltose or malted milk, which
latter gives, in addition to the maltose, some protein food
and an insignificant amount of fat. In many cases children who have failed to gain on other food will immediately show a marked gain as soon as this change is made."
—R. G. Freeman: Elements of Pediatrics, Macmillan Co.,
New York, 1917, pp. 101 and 192.
1917
"The carbohydrates most used in infant feeding are
the three soluble sugars and starch. The three soluble
sugars are lactose, or milk sugar, maltose, or malt sugar,
and saccharose, or cane sugar. Maltose is not used in its
pure form, on account of its cost. The various commercial
preparations of maltose are combinations of maltose with
various dextrins, but as in digestion dextrin is converted
into maltose, the chemistry is practically the same."
"The sugar which is not absorbed is broken down by
the bacteria of the intestine into a great variety of fermentation products, among them being lactic, butyric,
acetic, and succinic acids."
"Another effect of the excessive fermentation which
results from a relative excess of carbohydrate in the food,
is the formation of an excessive amount of gas. This may
cause abdominal distention, and, extending backward,
it may carry irritating acid products into the stomach,
and thus cause vomiting."
"Lactose is the sugar most likely to produce acute
symptoms. The stools are practically always green and
very irritating. Flatulence and colic are less prominent."
"The maltose-dextrin preparations rarely produce
acute exacerbations."—C. H. Dunn: The Hygienic and
Medical Treatment of Children, Southworlh Co., Troy, New
York, 1917, pp. 423, 424, 425, 428.
1918
"The sugars in the foods are milk sugar which is found
in mother's milk as well as in cow's milk, cane sugar and
malt sugar. Though milk sugar is a natural ingredient of
milk it is not well borne by babies when added to their
food; they digest cane sugar, the ordinary granulated
sugar, much better; malt sugar is the easiest digested by
babies."—C G. Leo-Wolf:Nursing in Diseases of Children,
C V. Mosby Co., St. Louis, 1918, p. 24.
1918
"Maltose (malt sugar) has the advantage of being
very easily digested; when part of the sugar given is
maltose, many children gain more rapidly in weight tha
when only milk sugar or cane sugar is used."—L. E. Hoh
The Care and Feeding of Children, D. Appleton £y Co.,
New York, 1918, p. 66.
1919
"In the administration of protein milk with its large
protein content, by adding to it sugar which is not easflyS
fermented (dextri-maltose), we produce, instead of pathologic fermentation, a condition of putrefaction whichj
changes the acidity of the intestinal contents to alkalinity, the peristalsis is decreased, the intestinal contents
pass slowly through the large intestines with absorption
of fluid and excretion of calcium and magnesium salts.
These minerals unite with fatty acids to form the typical
fat-soap-clay-coloured constipated stools  characteristic?
of protein milk feeding, and it is at this point that dextrimaltose should be added to the food."
"The majority of the cases were kept on protein milk
for a period varying from three to four weeks, and, in
many instances, contrary to the usual opinion, we were
able to keep the children on protein milk plus starch and
dextri-maltose, sufficient for their caloric needs for a
period of several months, in each instance accompanied-
by a substantial gain in weight and normal increase in
vigor and tissue turgor with comparative freedom from
digestive symptoms."—A. Brown and I. F. MacLachlan:
Protein milk powder, Canad. M. A. J., 9:528-587, June,
1919.
Continued down to 1934
MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ont.
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Westminster 288
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