History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1931 Vancouver Medical Association Mar 2, 1931

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   THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly By McBeath-Campbell Ltd., 326 West Pender St. 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. VII.
FEBRUARY, 1931
No. 5
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. "Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
Trustees
Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson
Auditors:   Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr.   S.   Sievenpiper Chairman
Dr. J. E. Harrison • Secretary
Eye, Ear, Nose and Throat
Dr. N. E. MacDougall  _ _ . Chairman
Dr. J. A. Smith  Secretary
Pediatric Section
Dr. H. A.  Spohn  -.—^- ---rg^-—-'- * Chairman
Dr. R. P. Kinsman    '-— —, Secretary
STANDING COMMITTEES
Library Orchestra Summer School
„„„„ r-.TT.-n, Dr.  R. P. Kinsman
£** R' S ^STEED ?' Jt £  ™AVIn Dr. W. L. Graham
Dr. D. M. Meekuon Dr. J. H. MacDermot Dr   q £> Brqwn
Dr. W. H. Hatfield Dr. F. N. Robertson Dr   t   l   Buttars
Dr. C. H. Bastin Dr. J. A. Smith Dr   c   h   Vrooman
Dr. C. H. Vrooman Dr  j  w  Arbuckle
Dr. C. E. Brown                                    Publications
Hospitals
Dr. J. M. Pearson Dr. J. W. Arbuckle
Dinner Dr. J. H. MacDermot Dr. J. A. Gillespie
Dr. L. H. Webster Dr- d- e> h- Cleveland Dr. W. C. Walsh
Dr. J. E. Harrison Dr. F. W. Lees
Dr. E. E. Day                                           Credentials yQN Advisory Board
,, .    ,    „   ^   ,, j   a        Dr. W. S. Turnbull Dr. Isabel Day
Rep. to B. C. Med. Assn.   Dr a ^ MacLachlan Dr. H. H. Caple
Dr. H. H. Milburn Dr. P. W. Barker Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS, DECEMBER,  1930
Total  Population   (estimated)    .- -	
Asiatic Population   (estimated)   	
  2 4 0,4 21
?P§L -'.  9,335
Rate Per  1,000 of Population
Total  Deaths   *    ^1
Asiatic Deaths —.    ''■
Deaths—Residents only  —   174
Birth  Registrations      342
Male       175
Female 167
INFANTILE MORTALITY—
Deaths under one year of age    14
Death Rate—per 1,000 Births   40.9
Stillbirths   (not included  in above)     7
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
January   1
November,  193 0
Cases    Deaths
December,  1930
Cases    Deaths
Smallpox   0
Scarlet Fever   2 8
Diphtheria      7
Chicken-pox       155
Measles     6
Mumps     _ 0
Whooping-cough         8
Typhoid Fever    8
Paratyphoid      0
Tuberculosis     2 0
Poliomyelitis  _,   J 3
Meningitis   (Epidemic)     0
Erysipelas     4
Encephalitis  Lethargica    1
In pneumonia
In: 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 & CO- Limited
412 St. Sulpice St.
Montreal
Page 99 JTHE PROFESSION RENDERS ITS VERDICT ON THE VICTOR SHOCK PROOF
These photos of a Model
"B" Shock Proof X-Ray
Unit show how one CooV
idge tube serves for all pO'
sitions in radiography and
fluoroscopy, both under and
over the table. The same
flexibility is realized with
the table in vertical and
angular positions.
"I Cannot Praise Kl;  jfjj
The Victor Shock Proof Enough"
THIRTY-THREE years ago I installed an x-ray machine, then
largely out of curiosity," writes a
Minneapolis physician. "The Victor
Shock Proof is my sixth
installation and I would
not change it for any other
x-ray machine of the pres-
ent time. .. .
"I cannot praise the Vic'
tor Shock Proof enough.
As a piece of mechanical
construction, it is a delight.
Quick and responsive to
every change in position,
anyone can operate it . . .
to one situated as I am this
This insulated low voltage
cable is the only electrical
connection to the unit proper. All high tension parts
are sealed in oil within this
shock-proof   head".
outfit is well-nigh perfect. Uniformity
in radiographic results is certain, tc
gether with remarkable clarity and
beautiful contrast. One can under'
take with assurance lateral
spine and all abdominal
work, and can do fine chest
work with flash exposure.
The unit is shock'proof and
with reasonable care should
last a lifetime."
A full appreciation of
the Victor Shock Proof
and its significance may be
gained through reading an
illustrated brochure we
have prepared. Won't you
write for a copy today?
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'i i i i i i i t i t i i i I l i i I 1 I i 1 I 1 l i I 1 1 I 1 I i l t t i I i i i i i : t l i i* EDITORIAL
The approaching session of the British Columbia Legislature brings
up again the now annual question of the licensure of various cults to
treat the sick. Once more we are faced with the question—shall we
oppose this or not?
There is much to be said on either side, and we confess to a feeling
of sympathy with those who argue that we should leave the responsibility
where it belongs, with the Legislature. Why, it may be asked, and with
reason, should we spend an enormous amount of energy and a great
deal of money, in doing what it is the obvious duty of the Legislature
to do, namely, to protect the public against untrained and ill-trained
people, who wish to be allowed to employ methods and treatment, which
are not based on any scientific knowledge? We are not, after all, the
guardians of public health—this is the function of the Legislature. Our
opposition puts us in an invidious position with the public, which
naturally considers it due entirely to fear lest our incomes be injured,
and our work taken away from us, if these gentry be given legal recognition. We know, of course, that this is not so, and that our motives
are not interested ones: we see, more clearly than any others can see,
the danger that such recognition of the uneducated would be to public
health. Through many years there has been built up a structure of
defense against disease, not yet complete, but soundly conceived, and
based on firm scientific foundations. This is endangered greatly by
anything which lowers the standard of education and training demanded
of those who treat the sick; and it is the knowledge of this that has
made us spend our time and our money fighting those who seek to
undermine our work.
But it is a wearisome, and as one often feels, a thankless struggle;
and, in one sense, we are not the ones who should be conducting it. We
have placed our knowledge and our advice at the disposal of the authorities; we have made all these things clear, ad nauseam. Should we rest on
this with a feeling that we have done our duty, and that no man can
do more?
We feel that we cannot. It is true that our position is unpleasant
and hateful—that we are weary of the misrepresentation and the misunderstanding that we meet—that this fight is not entirely ours. But
even so, we must continue it, to ensure that those whose duty it is to
protect the public adequately, fulfil this duty. For with our superior
privilege, of knowledge, comes a responsibility which we cannot evade.
We cannot simply sit tranquilly by as onlookers, saying that we are
not our brother's keepers. For after all, to some extent, we are. We
owe to the community a duty, a moral obligation, which we cannot
negatively discharge. We must with all the power that lies in us, protest
and keep on protesting against the passage of such legislation. We need
not, in this journal, labour the reasons for such opposition—every medical man, every scientifically trained man, knows them well—but we
must seize every opportunity to urge them on those whose ultimate
responsibility it is to see that only those who have adequate education
and scientific training shall be allowed to tamper with the human body.
Page 100 We should demand and keep on demanding, one of two things—
adherence to the present standard of scientific training for all who claim
to treat sickness, or the appointment of a Judicial Commission, which
shall make an unbiased and full enquiry into this whole affair, as was
done in Ontario. This latter was suggested at the last Session, and why
this simple method of solving the difficulty was not adopted, is one of the
mysteries of political life. Meantime, we must as individuals, and as
organized units, get behind our representatives, the B. C. Medical Council,
and support and strengthen them in every way. Above all we must
never give up the fight—our conscience will not allow us to do so.
Wearisome and expensive as it has been, it has been well worth while,
and it must go on till some finality is reached, some sane conclusion,
whereby, while no injustice is done to any, assurance may be given that
public health be not endangered. We cannot compromise or weaken in
this regard. The B. C. Medical Council may feel assured of the firm
support of every medical man in the province in this; they are our representatives, and we look to them to carry on the fight without faltering.
It has been brought to our attention that certain practitioners are
giving certificates of health for a smaller fee than that laid down in the
Schedule of Fees adopted by the Vancouver Medical Association. This
is very unfair to other practitioners and should not be done.
OBITUARY
Through the death of Dr. Thomas Alexander Wilson, which
took place at his home in Vancouver on Friday, January 16th,
the Vancouver Medical Association has lost one of its oldest
members.
Born in 1861, at Ottawa, Dr. Wilson was educated in the
public schools of Ontario where he later taught for some years.
Deciding to enter the practice of medicine, he went to Kentucky
and graduated in 1895 from the Hospital Medical College. On
the advice of friends he proceeded, in 1900, to take his
M.D.CM. from Queen's University.
Dr. Wilson was associated with Indian affairs from the
time he came to B. C. over thirty years ago. He spent six
years working among the Indians at Port Simpson, later moving
to Vancouver, where he continued his connection with the Indian
Department and was their medical officer in the Vancouver
district, until his death.
Dr. Wilson married, in 18 88, Dr. Belle Holland, who survives him. He leaves two sons, one, Dr. Ray H. Wilson, who
practises dentistry in San Diego, and Dr. P. M. Wilson of
Britannia Beach.
Page 101 MEETINGS
The first meeting of the Vancouver Medical Association for 1931
was held in the Auditorium on January 6th, and was exceptionally
well attended.
The report of the Dinner Committee was presented by the Chairman, Dr. L. H. Webster, and showed a substantial balance on the right
side.
A motion was introduced by Dr. Pearson for the purpose of securing the approval of the Association of the proposed action of the Publications Committee in engaging a business manager. It was explained
by Dr. Pearson in his introductory remarks that, while the Bulletin
was doing very nicely, thank you, there was a chance of its thriving
much more rapidly if it received proper sustenance in the form of additional advertising. The bulk of that now carried had come almost unsought and the surface of this field and source of additional revenue had
hardly been scratched. Increased advertising matter would enable the
Bulletin to increase its space for scientific matter, thereby increasing its
circle of interested readers and completing a virtuous circle (hitherto
unknown in medical parlance) would secure still more advertising. A
brief discussion followed, all of which was indicative of the accord of
the Association with the Committee's project. The motion was seconded
by Dr. J. H. MacDermot, and carried.
A motion was then brought before the Association by Dr. J. J.
Mason to provide for the formation of a Cancer Committee. The increase in cancer incidence and mortality, especially in British Columbia,
of which all are aware, was making it imperative that steps be taken to
systematize our observations and collection and arrangement of data on
cancer, which would then prove a source from which further knowledge
and advances could be gained. Dr. Mason's proposal was that what
would be in essence a Nominating Committee of about six members,
representative of the various branches of medicine and surgery, should
be assembled who in turn should select a committee—the Cancer Committee, who should arrange a two year programme of work in study and
assembly of data.
Among those who in speaking to the motion expressed their hearty
approval was Dr. J. W. Mcintosh, the newly appointed Medical Health
Officer for Vancouver, who had shortly before been welcomed back to the
Association meetings by the Chairman.
Dr. Mason's motion was carried unanimously.
The Chairman then introduced the guest speaker of the evening,
the Hon. Chief Justice Auley Morrison of the Supreme Court. In a
most pleasing manner His Lordship gave a very lucid exposition of
medico-legal relations, dwelling in particular upon the duties and responsibilities of the expert medical witness and the interpretation and
application of the term "insane" in reference to criminal acts and other
matters.
Page 102 WASSERMANN AND KAHN
REACTIONS FUNDAMENTALLY IDENTICAL
(From four articles by Eagle in the Johns Hopkins Hospital Bulletin,
November, 193 0, and the Journ. Expl. Med., November, 193 0).
With comments by H. W. Hill, M.D., Director, V.G.H. Laboratories,
Vancouver, B. C.
Of intense interest to physician, to serologist, and to immunologist,
the above articles indicate long steps forward in the understanding of the
Kahn and the Wassermann tests.
The conclusions reached, shorn of technicalities and detailed proof
(for which see the articles above listed) may be stated thus:
Syphilitic serum is distinguishable from "normal" (i.e. non-syphilitic) serum in that the former contains "reagin"—a hypothetical substance (somewhat of the order of the "amboceptors" and "agglutinins"
of Ehrlich's familiar nomenclature) having definitely recognizable features, based on its striking effects upon certain lipoid suspensions (the
"antigens" of the Kahn and Wassermann reactions.)
Normal serum, since it lacks this reagin, fails to produce these
effects.
A lipoid suspension prepared secundum or tern, "antigen," when
treated with normal serum is affected thus—each individual lipoid particle, suspended in the saline liquid, becomes irregularly coated with a
film of serum-globulin. Before the addition of the normal serum,
each lipoid particle presents to the surrounding liquid lipoid surface only.
After the addition of the normal serum, each lipoid particle presents to
the surrounding liquid but a fraction of its total lipoidal surface, the
rest of its lipoidal surface being now coated wtih a film of normal globulin which, of course, separates that part of the lipoidal surface so covered from the liquid. The lipoid particle therefore now offers to the surrounding liquid a "mosaic" surface, part original naked lipoid, part film
of normal serum globulin.
The normal serum globulin thus adsorbed on the lipoid particle is
unchanged; but the suspension as a whole no longer consists of lipoid
particles -f- saline liquid, but of lipoid-globulin particles -)- saline
liquid; and its colloidal properties now show changes corresponding with
this change in certain directions (cataphoresis, electric potential). But
there is no tendency to agglutination, precipitation, or flocculation in
the presence of small quantities of electrolytes (the basis of the Kahn
test); nor to complement fixation in the presence of fresh serum (the
basis of the Wassermann test).
Now, the original lipoid suspension, when treated, not with normal
but with syphilitic serum, is effected exactly similarly so far as the irregular coating of each lipoid particle with globulin is concerned. But
this film differs from that formed by the normal serum in that it is
not globulin only, but reagin-globulin. Whereas the film of normal
globulin was unchanged and therefore remained water-soluble, this film
Page 10} of reagin-globulin is water-insoluble. This suspension of lipoid-reagin-
globulin is subject to agglutination in the presence of small quantities of
electrolytes (the Kahn test), and absorbs complement from fresh serum
(the Wassermann test)—these reactions being due to the reagin-globulin
film, not to the lipoid particle, which acts only as the now inert carrier
of the film.
Thus, the complexities of the Kahn test, and the greater complexities of the Wassermann test, all tend to but one end—the demonstration, rather direct in the Kahn test, by agglutination and precipitation,
rather round-about in the Wassermann test, by complement fixation, of
the presence (and amounts), or absence, of syphilitic reagin-globulin.
Eagle suggests that since both tests thus determine a specific syphilitic
antibody, reagin, both reactions are after all "specific," not non-specific
as usually considered. (It remains true, however, that the specific antibody, reagin, is detected by the use of a non-specific substance, lipoid
("antigen") ; and to this extent these tests do depart from those more or
less parallel reactions where a specific antibody is detected by its corresponding specific antigen, as in the Widal reaction and its analogues.)
The action of cholesterin in increasing the sensitivity of the Kahn
test and the Wassermann test is shown by Eagle to be due merely to the
fact that the cholesterin adsorbs upon itself the lipoid particles, aggregating them in relatively large masses which then combine with the reagin-
globulin in greater quantities than when the particles remain in a finer
state of division; thus increasing agglutination in the Kahn test and the
absorption of complement in the Wasserman test.
COMMENTS
In view of the above conclusions from such clear cut experimental
evidence, it would now appear that the significances of the Kahn test
and the Wasermann test are not those of two different substances but
merely of two different techniques for determining, more or less accurately, the same substance, syphilitic reagin-globulin.
Hence it is worth considering whether or not the demand made
for performing both tests on all cases is now as logical as it seemed
in the past. The two tests, supposed obscurely to determine two different phases—to supply two different angles of view, so to put it—now
appear to determine only one. Both tests, it would now seem, arrive at
the same point—a more or less accurate determination of the reagin
present.
It would appear now more clearly that the Kahn test is more
simple and tends to be more nearly correct in this regard than most
Wassermann tests—and that the best Wassermann test can only hope to
duplicate or approximate the accuracy of a good Kahn.
Then why do both? If one has two pocket tape measures, one more
accurate than the other (and also more easily applied), why insist on
using both accurate and inaccurate tapes on all occasions? If a check
is needed, why not use the more accurate and simpler one twice, rather
than the more accurate first and then the less accurate and more diffii-
Page 104 cult one as a check upon it? What information can be gained in this
way regarding the actual measurements of the object? If the two pocket
measuring tapes are equally accurate, neither has the advantage in accuracy—and every one would use the most easily applied.
It would seem that the wide-spread Kahn-Wassermann debate was
after all chiefly concerned with a non-essential question—namely, which
test gives the higher percentage of positives; not with the really important issue,—which test best corresponds with the clinical condition of
the patient. That and that only can be the real concern of the physician.
That and that only is the real field for investigation.
Since both tests apparently estimate the same factor, reagin-globulin,
the Kahn being the superior in this determination, the real problem of
the future would now appear to be a careful study of the presence and
amounts—or absence—of reagin-globulin, and the clinical significance
(if any) of its fluctuations, when present. From this point of view,
the estimation of reagin-globulin at various stages in the progress of a
case of suspected syphilis might be thought of as more or less parallel
{mutatis mutandis) with the similar estimation of a Widal reaction or
even of a tuberculin reaction.
We are pretty well assured that a Widal reaction lasts long after
the germs responsible for it have disappeared from the patient's body.
We are inclined to believe that the tuberculin reaction and the syphilitic
reagin-globulin reaction visually disappear promptly, if and when the
germs have disappeared.
It would seem that Eagle has made a real contribution to further
progress in the study of syphilis by his illuminating researches.
ARTERIAL BLOOD PRESSURE, HIGH AND LOW
By Prof. Robert D. Rudolf, Toronto
The subject of blood pressure has been so much before the public,
lay and medical, in recent years, that it almost seems as if an apology
were necessary for again discussing it.
I will not waste time debating the factors that normally keep the
arterial blood pressure at its optimum point for the given individual,
(and, by the way, this point varies considerably in different healthy
people), but will merely enumerate them. They are, of course, the
systole of the heart, the elasticity of the arterial walls, the tonus and
degree of construction of the muscular coat of these walls, especially of
the arterioles, the total bulk of blood and the viscosity of the same.
If any of these factors increase the pressure tends to rise. Thus, when
the heart beats more rapidly or more powerfully the pressure rises, and
if the arterioles contract and so hamper the escape of the blood into the
capillary bed it also does so.
1. When we consider what may bring about any of these fundamental changes so that the pressure rises we find a maze of possibilities,
but it seems to me that the subject of aetiology of hyperpiesis, and so
of its treatment may be simplified if all cases of raised pressure be
grouped  into four  classes,   as  follows:   (1)   nervous;   (2)   toxic;    (3)
Page 105
B«*fcU-m^,ailr.'  'T'TnnffliiEnJ organic; and (4) essential. This last is the group into which are put
all those cases that cannot be accounted for, in fact, in which the cause
is not evident.
(a) Nervous Hyperpiesis. The blood pressure is very much under
the influence of the emotions. Most forms of nervous excitement tend
to raise it, either, probably, by increasing the action of the heart, or by
causing vaso-constriction, or by both. Possibly this is brought about by
an increase in the internal secretion of the adrenal glands. Even a
medical examination acts in this way and every physician knows that
a single reading of the pressure is quite unreliable and hence will leave
the cuff on and try the pressure a number of times or even on several
different occasions before corning to the conclusion that the pressure
is abnormal. Not long ago I was seeing an old gentleman with his son
who was a physician. The pressure during the hour that I was there
read at about 180 mm. systolic and I might have concluded that it was
really high if the son had not found it that morning to be 125 mm. But
not only will emotion raise the pressure but long-continued nervous tension will keep it up indefinitely, in fact as long as the stress lasts and
in the long run will produce organic changes in the vessel walls and
heart which may eventually cause death. This is no doubt the sequence
of events in many people who have for long lived at high tension and
eventually die of cerebral haemorrhage, heart failure or kidney involvement.
Most cases of so-called essential hyperpiesis probably really belong
to this class although many are probably toxic.
(b). Toxic Hyperpiesis. Various toxins can raise the arterial
blood pressure. It is usual to see it up in Graves' disease and in toxic
adenoma of the thyroid gland. M. C. Pincoffs recorded a most interesting case at the Association of American Physicians last year where a
young woman suffered from periodic attacks of high blood pressure
when the systolic readings would often be above 300 mm. A tumour of
one of the adrenal glands was discovered and upon its removal the attacks
of hyperpiesis completely disappeared.
In renal insufficiency there is a retention of products that should
normally be got rid of and the blood pressure tends to be high- Exactly
what these retained toxins are is not yet settled but Major has produced
much evidence that at least one of them is guanidin. R. G. Walter recently concluded after much experimental work that hypertension may
be due to the presence in excess of a specific amino-acid. This excess
may be due to retention resulting from renal disease, to over-production,
or more probably to some impairment of hepatic function whereby this
body is not sufficiently destroyed. It would seem that the toxins may
be ones that are normally present but are efficiently got rid of before
they become excessive or may be produced by abnormal changes in protein digestion, so that the normal amino-acids are broken down into
monamines and diamines and some of the former are pressor in action.
There appear to be three ways in which the body is protected from
the undue accumulation of toxins in the blood:   (1)  The mucous mem-
Page 106 brane of the bowel is normally resistant to their absorption; (2) the
liver rejects them after absorption; (3) and lastly, the kidneys can
excrete such as reach the blood. If any of these factors is in abeyance
toxaemia tends to occur, and hence the importance of attending to such
functions; also the need of lessening the protein intake when any of them
are faulty.
In the opinion of many, and I share it, alimentary toxaemia is one
of the commonest causes of raised blood pressure, and in every case, even
when some other cause, such as nerve tension, is evident, it is well to
lessen this probable source of trouble.
The late Professor Huchard, of Paris, used to teach that arteriosclerosis commences as a toxaemia, continues as a toxaemia and ends as
a toxaemia, and there was much truth in this, although it is not the
whole story. We must remember that in a toxaemia not only may the
blood pressure rise, but the toxins themselves will directly poison the
tissues of the circulatory apparatus as well as those of all the organs,
and hence may produce symptoms which are synchronous but not due
to the hyperpiesis.
(c). Organic Hyperpiesis. In true arterio-sclerosis the blood
pressure may or may not be high. It takes a very widespread sclerosis
to bring about such a rise. Some say that unless the splanchnic vessels
are involved it does not occur. Undoubtedly, if the arterial tree be sufficiently obstructed, a rise must occur on the proximal side of the lesion
as is seen experimentally when the abdominal aorta of an animal is
ligatured or compressed. Some years ago a young girl came to the
Children's Hospital complaining of cardiac distress. We found the
heart to be enlarged, and a rountine examination showed that there was
a loud systolic murmur at the base of the chest posteriorly, and that no
pulse could be felt in the abdominal aorta or its branches. The systolic
blood pressure was nearly 200 mm. An X-ray examination showed that
there was a large mass of tuberculous glands in the posterior mediastinum,
which was evidently compressing the descending aorta. Such a case
shows how a sufficient obstruction will raise the blood pressure, but a
degree of arterio-sclerosis sufficient for this seldom exists. If, however,
thickening occurs in some artery supplying a vital centre a general rise
in pressure of a compensatory nature quickly occurs. The late Professor Starling thought that such compensatory raising of the pressure
was a common cause. The vital centres must have sufficient blood for
the maintenance of life. Often when it is found to be hard to lower a
pressure by therapeutic means the case is of this nature.
(d). Essential or Idiopathic Hyperpiesis. As already mentioned, into this class are put all those cases in which the cause of the rise is
not apparent. These cases are mostly "benign," are not characterized
by any symptoms, and the high pressure is often discovered by accident
in the course of a general examination, say for life insurance.
Prognosis. When a rise in blood pressurs is found the question
arises as to its significance in regard to the probable duration of life.
Page 107
LJUHILESSBSHH This outlook depends largely on the cause of the condition. A rise in
the diastolic pressure is worse than when the rise is chiefly in the systolic.
The state of the kidneys, heart and retina all bear on the prognosis. The
dangers are heart failure, uraemia, cerebral or other haemorrhage and
acute oedema of the lungs, and the frequency is in this order. While a
persistent rise in arterial blood pressure is a serious thing, and insurance
companies fight shy of them as "risks," it is wonderful how long and
comfortably many of the systolic cases last, and it does not do to take
too grave a view of their condition. Especially is it important not to
terrify the sufferer, which will only make matters worse, and if the
anxious patient insists on knowing what the reading is then it is justifiable for the practitioner to deduct considerably from his findings. I
saw only the other day an elderly lady who was living in a state of
terror of a "stroke" (which, by the way was a family failing), since
a doctor when taking her pressure had looked very grave, but would not
tell her the result.
Treatment. In the treatment of any ailment, or rather ailing person, it is well to have some system of procedure, as in this way important measures are less apt to be overlooked than if the therapy be conducted in a haphazard manner. The routine that I always follow is
the following: environment, diet, specific treatment, and finally symptomatic therapy.
Of course in every case a diagnosis must be made of the condition
in so far as this is possible. In the case of hyperpiesis this has already
been partially done, but much more than a mere recognition that the
pressure is too high remains to be done. Is the rise due to nervous,
toxic or organic causes? Is it compensatory in type and hence a protective one for the damaged individual? How are the heart and the
blood vessels standing the strain, and of course what is the state of the
kidneys? Such questions all come under the heading of diagnosis and
should be as fully as possible answered before going further. When
no cause can be discovered the case is usually labelled "essential hyperpiesis," which of course is only a cloak for our ignorance.
Environment. Rest is of great importance in all cases, but the
degree of it depends upon the urgency. If the case be a bad one, and
especially if cardiac distress be present, complete rest in bed for several
weeks is necessary, and not only physical but mental rest, which is often
quite as important, and let it be repeated that apprehension is a great
source of nerve tension and hence the doctor should make as light as
possible of his findings with the sphygmomanometer. When an active
business man is merely put to bed and allowed to conduct his affairs
from there he is apt to fidget and gain no benefit from the physical rest.
All his worries should for a time be kept from him, which of course is
often a counsel of perfection. In patients who do not settle down to
rest well the free use of bromides is often useful.
Massage has its place in partially taking the function of exercise.
During sleep the blood pressure is usually lower than when awake,
but this is not always the case, and J. A. Williams, of Aberdeen, has
Page 108 shown that often, in disturbed sleep, rises occur that may be much
higher than are produced by moderate exercise and he thus explains the
not uncommon occurrence of sudden death during sleep.
In mild cases of hyperpiesis the patient may go on with his life's
work, and it is wonderful how much of the community's best work is
done by people who have blood pressures which exclude them from any
chance of being accepted for life insurance. All the same, a programme
should be arranged which will demand less physical and mental strain.
Often one can find on enquiry that some special work causes a special
strain on the individual, and this may be cut out without spoiling his
general efficiency. In these mild cases gentle exercise, especially of a
pleasant nature, will be of benefit, but the patient should be warned
to avoid anything that causes him circulatory distress. Short rests in
the horizontal posture during the day are valuable, especially after the
mid-day meal.
Diet. A general cutting down of the total diet is often advisable.
As regards the individual elements of the diet it has long been the custom to lessen the intake of purin-containing foods, such as meats (especially red meats), eggs, fish, and tea and coffee. Lately there has been
some doubt thrown upon the effects of a high protein diet and it has
been shown that such may be taken for a few days without any rise in
the arterial pressure, but this is different from the long continued excess.
Nuzum has proved that if rabbits are fed for months on a high protein
diet their pressure is higher than the controls, and recently Saile has
recorded that the average blood pressure in Trappist, Carmelite and
Carthusian monks, who are forbidden the use of meat, fish and eggs, is
considerably lower than that of the Dominicans and Franciscans who
are allowed meat four or five times a week. Generally speaking I believe that these patients are best on a lacto-vegetarian regime, although
an occasional indulgence in meat, fish and eggs will do them no harm.
Alcohol does not raise the blood pressure, but should be reduced or
barred on general principles. Tobacco has little effect on the pressure
and its moderate indulgence by those accustomed to it will do no harm,
and is in fact soothing.
The bowels should be gently open, and if they do not act so naturally the regular use of salines in the morning and an occasional mercurial
at night are indicated. There is some evidence that a limitation of the
intake of sodium chloride is useful and this should certainly be done
if there be any oedema.
The limitation of the diet is of special importance when it is suspected that the rise is of a toxic nature.
If a quieter life and regulation of the diet do not relieve the excessive pressure, small doses of iodide of potassium sometimes help, possibly
by increasing elimination.
Specific Treatment. An attempt should, of course, always be
made to remove the underlying cause of the rise in pressure and this is
often possible.   Where some nervous strain exists the relief of this may be
Page 109 all that is required. In toxic cases the careful dieting and free elimination above discussed may rank as specific. The cause, however, is often
unremovable, as in most instances of compensatory hyperpiesis, and then
all that can be done is to make the sufferer as comfortable as possible
under the circumstances. We must remember, moreover, that nature
often overcompensates. This is seen when excessive scratching for the
removal of some irritant causes damage to the skin; when an excessive
cough brings about pulmonary emphysema; when a slight gastritis causes
vomiting of an excessive degree, and so on. Nature is often a poor
doctor so far as the individual is concerned.
Symptomatic Treatment. In every case of raised blood pressure
the regulation of the diet and the manner of living are advisable, and
at least cannot do any harm, and many of these people require nothing
more and go on year after year in comfort, and in the end may die of
something quite unconnected with their hyperpiesis.
If the pressure remains high under such simple regime the question
arises of how far it is wise to further interfere with it, and here we may
divide all cases of hyperpiesis into two classes, (1) those without symptoms, and (2) those with symptoms.
In the cases without symptoms, where the individual would not be
aware of the raised pressure if the doctor had not found it in the
course of a general examination, I believe that as a rule we should not
actively interfere. The high pressure may be the optimum one for them
owing to some bodily abnormality, and if we lower it they do not feel
so well. A case seen not long ago illustrates this. An old ward patient
with hemiplegia had a systolic pressure of 180 mm. The hemiplegia
was of long duration and he was quite comfortable except for his somewhat hampered movements. We put him on benzyl benzoate and in a
couple of days the pressure was 130 mm., but he felt miserable. The
drug was stopped and the pressure soon rose, and with it his feeling of
bien etre. Another man was admitted with a failing heart and the
blood pressure was 100 mm. Under rest and digitalis the heart soon
regained power and the pressure rose to 200 mm., and he left hospital
feeling comfortable. He needed the high pressure for some compensatory reason. By the way, digitalis does not raise the blood pressure
unless it is low due to heart weakness and then it does so very efficiently.
Thus, to repeat, symptomless hyperpiesis that does not lessen under
careful dieting and the general regulation of the way of living, as a
rule should be left alone, as it is probably the optimum pressure for the
individual.    There is an exception to this which will be mentioned later.
But when high pressure is accompanied by symptoms the case is
different. It may be the lesser of two evils to lower the pressure for
fear that something worse will happen, and also in order to lessen the
distress. The symptoms that are common here are headache, dizziness,
irritability, breathlessness on exertion or even while at rest ("cardiac
asthma"), passing aphasia or even paresis and angina pectoris. Acute
pulmonary oedema may occur at any time.    As already mentioned, many
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Medical-Dental Building Vancouver of these symptoms may be really due to toxaemia rather than to a raised
pressure and may be largely reduced or removed by a reduction in diet,
free purgation and diuresis. In toxic cases that do not yield to minor
measures nothing in my experience equals the effects of a timely bloodletting. Often one sees the wonderful benefit that results from a spontaneous haemorrhage, and I can recall many cases where this vis medi-
catrix naturae did more than all our therapy, and therein lies a lesson,
and if nature does not act we can do so. In cases of the toxic type I
have never seen a venesection do harm, and usually it gives much relief.
The pressure usually falls gradually for several days after the removal of
blood and it is surprising how slowly it rises again. It may be months
before it does so and in some instances, especially in the high pressure
that sometimes occurs about the menopause, the fall may be permanent.
The little operation is always urgently required where there is pulmonary
oedema. In cases where venesection does not affect the high pressure it
is probably compensatory and the optimum one for the individual.
The vaso-dilators have their place occasionally in emergencies, such
as angina pectoris. For rapid effect, amyl nitrite or nitroglycerine are
the best, while for more prolonged action sodium nitrite, benzyl ben-
zoate, erythrol tetranitrate and lastly, mannitol hexanitrate are useful.
When the pressure is up owing to nervous influences the bromides and
luminal are often the best.
Very many causes of hypertension belong to the essential class in
that the underlying cause is obscure, and yet, if we can lower the pressure they feel better and no doubt the chances of complications are
lessened. Liver extract has been used with much success by some, while
others report less favourably. Possibly the differences may be due to
the different preparations employed. The drug which in our hands has
given the best results here is sodium sulpho-cyanate. It seems that the
substance had been tried by Pauli in 1903 on account of its chemical
resemblance to the bromides, and he noticed that the blood pressure was
lowered in addition to the sedative effect. J. B. Nichols states that he
has used it in cases of hypertension for fifteen years with good results.
He usually gives five grains thrice daily, and Arthur G. Smith, who was
associated with me in the work, and I began with this dose, but soon
found that equally good results could be obtained with half this amount.
It is interesting to remember that sodium sulpho-cyanate occurs in the
body normally an das much as o.l grm. is excreted daily in the saliva
and much more than this in some people, especially if they smoke. We
found that the normal blood pressure could be somewhat lowered by it
and that in cases of hypertension the fall was often great and very long
sustained after the drug had been stopped, and the relief of symptoms
was decided. The action is equally great in what seem like nervous and
toxic cases, and also in the so-called essential ones, but was less evident,
or absent, in organic cerebral conditions. Here, probably, the compensatory processes of the body prevent the fall.
As before mentioned, many patients need their high pressure, and if
it be lowered they feel miserable.    An instance of this was one that
Page 111 Dr. C. L. Taylor brought to my attention, where an elderly man with
arteriosclerosis and a blood pressure of 220/120 mm. was given 5 grains
of sodium sulpho-cyanate thrice daily for a few doses. Soon the pressure
fell to 170/100 mm., but he became mentally deranged and melancholic.
The medicine was discontinued and in a week the pressure was up again
and with it the mental condition cleared up. When given in moderate
doses, such as 2l/2 grains twice or thrice daily, there are practically no
untoward symptoms, although a few have slight gastric disturbance. In
very rare instances a skin eruption occurs in the form of dermatitis
exfoliativa, but this is so unusual that it need not deter one from the use
of the drug.
In conclusion, I would urge that every case of raised blood pressure
be carefully investigated, and, if possible, the underlying cause be found
and removed. In every case the environment and diet should be carefully regulated. In the nervous cases nerve sedatives are useful. In
the toxic ones the toxaemia can often be lessened by purging, diuresis,
and in stubborn ones often by the timely removal of blood.
In the many instances where the regulation of the environment
and the diet, etc., does not control the condition, and there are no
symptoms referable to the pressure, we should be very chary about interfering, although occasionally we can do so cautiously (best, I believe, by
the use of sodium sulpho-cyanate), with the object of lessening the strain
upon the circulatory apparatus. If upon such careful trial the patient
does not feel as well as he did when the pressure was higher such lowering treatment should be discontinued. He evidently requires the increased pressure to compensate for some abnormal condition.
II. Low Blood Pressure. Many apparently perfectly healthy
people have a pressure well below the average, and in the absence of
symptoms a systolic pressure constantly running between 100 and 110
nun. need give rise to no worry and requires no treatment. When the
pressure from some cause is below the average for the individual, general
tonics and especially strychnine are indicated. When the pressure is for
long below what it used to be, in anyone, tuberculosis and Addison's disease should be thought of.
In profound hypopiesis, as it occurs in shock and haemorrhage, intravenous injections of normal saline or a solution of gum acacia are of
value, but when haemorrhage is the cause, transfusion of blood is often
life-saving.
Adrenalin chloride or pituitrin will raise the pressure but the effects
are very transient. Ephedrin has proved of special value in these profound falls and the action lasts for hours. In the severe hypopiesis which
sometimes complicates spinal anaesthesia, 50 mgs. intravenously may produce a dramatic rise ■ which will enable the operation to be completed
with safety.
Page 111 CANCER
By H. H. Pitts, M.D.
Probably none of the ills which human flesh is heir to has been
responsible for more untiring research by innumerable workers in the
various scientific branches of medicine in almost every civilized corner
of the globe and the expenditure of, one may say, fabulous sums of
money, than has cancer. By the same token the fear of cancer in virtually every civilized man and woman over 40 is an ever present one,
and the merest suspicion of its presence is enough to cause one to "leave
all hope all ye who have this thing," to paraphrase the inscription on the
door of Dante's Inferno. Through all the years of effort by legions of
painstaking and persevering research workers, including in their ranks
many of the most brilliant minds of modern science, we are still wandering in the darkness of ignorance as to the true cause and definite cure of
this dread disease.
My time tonight is infinitely too short even to begin to enumerate
at any length the various theories advanced, each one of which has its
partisans, and so only the high lights of the more recent and more widely
accepted ones will be touched upon.
During our college days we had presented to us in the lecture room
Cohnheim's and Ribbert's theories and many others, points in each seeming all-sufficient, but weakening in some other aspect—but still these
theories have many adherents. The newer theories may be roughly
divided into two main groups, (a) Bacterial or parasitic;  (b) Cellular.
(A) Bacterial or Parasitic
Numerous bacteria, parasites and fungi have been heralded as the
aetiological factors in cancer, the most prominent supporters of this theory
in America being Nuzum, Scott, Glover and McCormack, with Blumen-
thal in Germany. Nuzum claims to have isolated anaerobic diplococci
and streptococci from human and mouse cancer, which, on reinoculation
into mice, dogs, but only once in man, will produce cancer. These
reproduced tumours, however, are difficult to identify and do not possess
all of the histological characteristics of true cancer.
Glover, Scot and McCormack obtained a bacillary organism occasionally showing spore formation, which, inoculated, after special cultivation, into animals, especially the chicken, produces Rous' sarcoma, and
in monkeys was said to have produced epithelial tumours of lip, tongue
and breast. A toxin was finally produced, an antitoxin and also an
agglutinating serum prepared. These experiments have not been satisfactorily confirmed, however.
Blumenthal causes vesiculation on the surface of a carcinomatous
growth by focussing the sun's ray through a lens and has found polymorphic organisms in the serum of these vesicles. Inoculation of this serum
into animals produces nodules which are, however, more of a connective
tissue type, but, with the addition of silica, more typical tumours are
Read before the Osier Society, April, 1930
Page 111
WP obtained.     He   is   not   entirely   certain   of   the   role   of   this   organism,
whether specific or merely a carrier for a specific invisible virus.
A (2) Combined Action of a Filtrable Virus Plus a
Chemical Agent
Gye and Barnard in England, in 1925, advanced the hypothesis
that cancer was caused by a filtrable virus and an element chemical in
nature—and from a long series of experiments elaborated the following
conclusions:
(1) Every malignant tumour contains an ultra-microscopic virus
or group of viruses which may be cultivated, demonstrated and micro-
photographed, the virus probably being contained within the neoplastic
cells.
(2) This virus alone, purified and cleared of all accessory substances, is not capable of producing a tumour by animal inoculation.
(3) When the virus is injected together with a culture of an
extract of tumour it produces a malignant tumour. This extract therefore contains a specific factor which renders the virus capable of attacking the normal cell, and transforming it into a cancer cell.
(4) The virus is in no sense specific, since one may produce a
tumour in an animal of one species with a virus taken from an animal
of another species.
(5) The specific or chemical factor, on the other hand, is strictly
peculiar to the species of animal from which it is secured.
(6) Hitherto the specific factor has been found in connective tissue
tumours of the sarcoma type. It is particularly abundant and resistant
in the Peyton-Rous tumours, while in other tumours it exists in a small
quantity and is very labile; in the latter case oxygen-free media must be
employed in order to demonstrate it.
Their work has given rise to a great deal of criticism owing to the
fact that it has dealt with sarcomatous growths rather than cancer.
Professor Gustave Roussy of Paris, at the International Symposium for
Cancer Control held at Lake Mohonk, N. Y., in 1926, said that the
proof of the inoculability of cancer will be clear only when an epithelial
tumour is produced in the same or different species of animal by a
medium altogether free from cellular elements, and summarized the present position in regard to the infectious theory of cancer as follows: "It
is clear that both early and recent workers have failed to prove the
specificity of the organisms they have isolated. The most variable
pathogenic agents have been demonstrated, these differing with each
worker, and as the tumours produced by inoculation are inflammatory
pseudo-tumours, one is led to believe that we are dealing with organisms
responsible for secondary infection."
B.    Cellular Theories
Tissue culture, according to the method developed by Alexis Carrel,
forms the basis for the bulk of the research along this line, and has very
considerably widened the field of investigation of  the cancer problem,
Page 114 especially for exponents of the cellular theory. The cellular theories
may be divided into two groups: (1) Cancer is due to a specific principle
elaborated by the cell itself; (2) Cancer is caused by abnormality of the
cellular glycolysis, these two divisions being the most recent of this
school of thought.
1. Cancer is caused by a specific principle elaborated by the cell
itself.
Carrel attempted to learn wherein lay the difference between malignant and normal cells of the same type. For his experiments he used
the Rous' chicken sarcoma. He was able to isolate two types of cells—
fibro-blasts (the fixed cells of connective tissue) and macrophages (the
mobile cells of connective tissue or of the blood). He inoculated fibroblasts in pure culture with the virus of the Rous' sarcoma and found
that they resisted it, showing that the aberrant element in sarcoma is
not the fibroblast. The macrophage constitutes the malignant element
of the Rous sarcoma and also of the spindle cell sarcoma of chemical
origin. These cells are fragile, die rapidly, and in dying liberate bodies
which Carrel calls "trephones," having the property of producing hyperplasia in neighbouring cells.. Thus the malignant element of the Rous
sarcoma, known as the virus, is propagated indefinitely.
Carrel claims that the virus is not a definite organism, but is produced only in the presence of cells, and is dependent upon the quantity,
activity and even the nature of the cells. In order to produce tumour
.growth, a number of conditions must be present: (1) A certain strength
of the chemical substance; (2) Cells in a given condition; (3) A certain
susceptibility of the organism.
However interesting these observations are, and however much they
may widen the horizon of the field of cancer causation, certain reservations must be made, for it does not seem fair to apply too dogmatically,
results of tissue cultivation in vitro to phenomena arising in the body,
where such intimate cell interrelationship exists.
2. Abnormality of cellular glycolysis as the cause of cancer. While
the cytobiologists, bacteriologists, biophysicists, etc., endeavour to trace
the cause of cancer to some factor in their particular field, the biochemist approaches it from a different angle, and Warburg of Germany
has tried to show this cause in disordered cell metabolism. Two phenomena are noted in normal cells insofar as their content in carbohydrate,
and especially in glucose, is concerned. (A) Glycolysis, which splits the
glucosa molecule and produces lactic acid. (B) Respiration, which on
the contrary results in the building up of carbohydrate, one or two
molecules of lactic acid disappearing for every molecule of oxygen consumed.
According to Warburg these are the key to the phenomenom of
living cell metabolism and are particularly pronounced in tissues of active
growth such as the embryo, or in cancer. In the latter, loss of the
normal rhythm between respiration and glycolysis occurs affecting cellular respiration. While normally there is a real synchronism between destruction and elaboration of glucose, in cancer it is lost, but the respira-
Page 115 tory rate is not necessarily affected. As to the cause of this phenomenon
Warburg believed that cancer originates in the absence of oxygen, the
above being the foundation of his theory. As all normal tissues possess
a double metabolic power (glycolysis and respiration) it must be assumed
that the constituent cells have gradually become specialized, some in the
phenomenon of respiration others in glycolysis. Should anything occur
to deprive the tissue of oxygen, be the cause mechanical, inflammatory
or otherwise, the only cells which persist are those capable of glycolysis,
and the survival of these cells is further favoured by the death of
neighbouring cells.
Such is the new conception of cell cancer.
It would appear that the present trend of thought in regard to the
cause of cancer is leaning more and more toward an intrinsic disturbance
of cell life, the causes of which are probably multiple. Recent work
tends to strengthen the proof that cancer is not due to a living agent
comparable to those responsible for the infectious diseases, nor does it
appear due to a virus; it is therefore not a communicable disease, and
this fact should be spread among the public. Cancer then appears to be
a special disease whose aetiological factor is still unknown, whose biological and morphological characteristics appear to be distinctly opposite
to those of inflammatory phenomena.
Whatever may be the method of development, the inflammatory
reaction persists only in the presence of the pathogenic agent which gave
it birth. It is thus for example that the nodular or ulcerous lesions of
syphilitic, mycotic or dysenteric nature come to a stop and heal, under
therapeutic action, which causes the causative spirochaete, fungus or
bacillus to disappear. Thus the inflammatory processes stop or even
regress as soon as the agent is removed. Cancer on the contrary appears
to result from the combined action of known and unknown causes which
produce in the cell disturbances of growth or function resulting in
quasi-fertility. This fertility which is transmitted to daughter cells
constitutes the essential characteristic of cancer cells; it is found in no
other morbid process. It matters little whether the occasional or determining agent disappears, be it chemical, physical or living, the new characteristics of the cancer cell will continue to follow the established
rhythm. The study of the latent phase of coal tar cancer in animals
is a good example of this fact.
Thus the two great morbid phenomena which attack the organism—
inflammation and cancer—appear to us today, from the biological point
of view, distinctly different one from the other. And perhaps it is
because we have mistakenly tried to bring them together that the
majority of investigations on the origin of cancer have, up to the present,
resulted only in failure.
Maud Slye of Chicago has done voluminous and interesting work
on heredity in mouse cancer and maintains that it plays an important
role in the causation of cancer, and in her laboratory has been able
actually to regulate the percentage of cancer incidence in mice by selective breeding.    She states also that apparently two factors are necessary
Page 116 to produce cancer: (1) an inherited susceptibility to the disease; (2) irritation of the right kind and degree, applied to the cancer-susceptible
tissues. For example, in mice that inherit susceptibility to spontaneous
breast cancer only, cancer does not occur from irritations other than
those applied to the breast tissue. If a mouse is a member of a noncancerous strain, a similar irritation would produce only scar tissue,
which would eventually be wholly or partly absorbed. She cites one
notable case of a mouse, a member of a strain carrying both carcinoma
and sarcoma, which when struck on the face by a cage door developed
both at the site of injury.
We certainly cannot lightly disregard the part that injury or
chronic irritation plays in cancer, for almost every day some instance is
brought to our attention, where the possibility of this factor being a
direct or contributing one in the existing lesion, gives us, at any rate,
considerable food for thought. Many examples are quoted, as you will
no doubt remember, from your lectures at college, of the marked incidence of cancer at special sites from a definite type of irritation, the
betelnut chewers of India (cancer of the cheek), carcinoma of the skin
of the abdominal wall in Thibet, where charcoal braziers are carried
beneath the cloaks in winter; carcinoma of the oesophagus in males in
China. Of course the question of whether or not the irritation is the
sole factor must be considered in these instances.
One so often hears the remark that cancer today is more prevalent
than say 20 or 30 years ago, and the usual explanation for this is that
we are living in an age of high specialization and marked progress, and
medical science has participated in this advance so that much more
adequate means of diagnosis is at our disposal and command. This,
however, is not the whole story, and I believe that cancer is actually
rather than relatively more prevalent today, and that the incidence in
younger persons is very definite.. Paget holds the view that if people
lived long enough they would eventually all have cancer, and he believed that the fact that the expected length of life has been prolonged
from 40 years in 1850 to 58 at the present time, may account for the
increase in both the morbidity and mortality of cancer. Statistics from
Holland ,to quote one example, give a mortality of 3.4 per 10,000 in
1867 and 11.2 per 10,000 in 1924. One might quote other statistics
from various countries ad nauseam, all would show definite increases.
I had intended primarily to incorporate in this paper the percentage
occurrence of carcinoma in the various sites most frequently involved in
the human mechanism, but decided, as I became more and more involved
in the maze of theories of causation, that I had much better let well
alone, and touch on only the more recent and more widely accepted
theories.
In conclusion, I wish to impress upon you further the present chaos
that exists regarding the aetiology, prognosis and treatment of cancer,
and the broad unexplored field that still lies open to the investigator.
Most assuredly, to him or her who is so fortunate as to discover the cause,
and a more satisfactory treatment, of cancer, the plaudits of all the world
would be little enough to mark the appreciation of suffering humanity
for its liberation from this ubiquitous monster.
Page 117
m&f British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin
in the interests of  the Hospital Clinical and Public Health Laboratories of  B. C.
Edited by
The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster;
Royal Inland Hospital, Kamloops;  Tranquille Sanatorium;  Kelowna  General Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above. Material for publication
should reach the Editor not later than the fifteenth day of the month of publication.
Vol. V.
FEBRUARY, 1931
No. 2
CONTENTS
Bacteriological Diagnosis Hill
"Distinctive Tastes" of Milk Hill
APPLICATIONS OF BACTERIOLOGICAL FINDINGS
TO DIAGNOSIS
By H. W. Hill, M.D.
Director; V. G. H. Laboratories
What does a positive report mean on a throat (or nose) culture
taken for diagnosis of diphtheria? What does a negative report mean?
What does a doubtful report mean?
Exactly similar questions may be properly asked regarding the same
sorts of report form suspected gonorrhea pus, whether of genito-urinary
origin or from an eye; in examinations of suspected tuberculous sputum,
suspected tuberculous urine, suspected tuberculous spinal fluid or other
suspected tuberculous material; also, in principle, in the various tests
for typhoid fever, undulant fever, etc.
Broadly the same sorts of question apply to all routine bacteriological reports,—and mutatis mutandis, to all laboratory reports on any
test of material from a patient.
Broadly also, the answers in all cases are of the same order,—a
positive report means that the specimen submitted showed the organism
or reaction suspected so far as accepted up-to-date methods applicable in
making rapid reports is concerned. A negative report means that the
specimen submitted, after a similar thorough examination, did not show
the suspected organism or reaction. A doubtful report means that a
thorough examination failed to yield conclusive evidence of the presence
of the organism or reaction sought, but gave indications, not conclusive,
Page 118 that it might be present."" In such cases obviously another specimen
should be submitted. Meantime, the strict truth has been reported; and
both the patient and the physician are protected thereby.
Simple, direct, inevitable as the above world-wide procedures in
reporting are—the concentrated wisdom of world-wide laboratory experience in its most concise form—the reasons for these forms of report
and the applications properly to be made of them in practice are not
always as clear to the non-laboratory professional man as to the laboratory professional man; and are therefore here recapitulated.
First. The laboratory obviously examines the specimen submitted,
nor the patient. In the patient may exist some clinical condition; a
proper specimen, properly collected, really representative of the particular discharge involved, should yield (if the stispected condition really
exists) the given organism or reaction responsible for that condition.
' Primarily then the laboratory is dependent upon the physician for a truly
representative specimen of the proper discharge, submitted in proper condition for examination, at the proper stage in the progress of the case.
From that point on, but from that point only, is the laboratory responsible. So obvious is this that its mere statement is sufficient to gain instant acceptance.
The laboratory examines the specimen by the best modern accepted
methods that will yield a prompt diagnosis; because, of course, the
physician must have a prompt return, in order to take action during
the period when such action will be of some use. Hence the aim of every
laboratory is to use those methods which will yield as high a degree of
accuracy as possible within a time limit which will make the return of
practical clinical value.
To illustrate—in diphtheria diagnosis, the actual scientific determination of the presence and degrees of toxicity and of virulence of
diphtheria bacilli found may be a matter of days or weeks, concluded
perhaps only after the patient is dead or well. Exactly the same might
be said of gonococcus or tuberculosis examinations, except that such
scientific proof may be still more time consuming. Such scientific
accuracy is impossible in practice, because of its really enormous expense;
and would be useless practically because of its extreme slowness. Fortunately, morphological methods, 95 to 99% accurate, are available in
diphtheria, in gonorrhea and in tuberculosis, and can be used promptly
and to advantage. As contrasted with the 50 to 75% accuracy of
purely clinical diagnosis these methods are quite remarkably efficient and
constitute a very real advance on older methods. But they are subject
to the disabilities of all morphological tests—the variability of the germs
sought and the resemblances between them and other non-significant
germs; therefore these methods cannot live up to the idealistic halo with
which the non-laboratory professional tends to endow them. It is a
matter of universal remark that it is the laboratory, man who is continually pointing out the disabilities of routine laboratory tests—it is
the non-laboratory professional who idealizes them and can hardly be
prevented from worshipping them.
*  In all  tests,  positive  and  doubtful  specimens  at  least  should  invariably  be  seen  by  at
least two expert workers, for check purposes.
Page 119 To illustrate further—a laboratory report of "diphtheria culture
positive" means this, and nothing more—that the specimen submitted,
when grown for 18 hours in the incubator on Loeffler's serum, yielded
organisms giving the morphology of diphtheria bacilli. The report does
not say, or imply, or desire to imply, that these germs are pathogenic,
toxic or virulent; nor that, granting them these features, the germs are
responsible for any of the patient's troubles—nor, again, that the patient
has any troubles at all, from them or from any other source. All these
are matters wholly for the physician to decide from his clinical examination of his patient. All that the laboratory can say is that the specimen
submitted showed the presence of the organisms reported. How they
got into the specimen in the first place, and what they may mean to the
patient are wholly matters for the physician to decide in each particular
case.
True, the laboratories of the world, from long experience and
slow, patient investigation of many hundreds of thousands of cases,
can offer certain guiding principles to the practitioner which he may
use in each case—rules so well and so long established that no practitioner
is justified in ignoring them.    Some of the more important ones are:
1. The finding of diphtheria bacilli in a specimen by the laboratory,
provided all proper technique was followed in collection, etc., of that
specimen, shows that the organism was present in the patient as well as
in the specimen.
2. The findings of clinical signs or lesions in the patient thus shown
to harbor diphtheria bacilli imply, but do not prove, that the diphtheria
bacilli found are responsible for the signs or lesions present. Obviously
if the diphtheria bacilli found are non-virulent, they cannot produce
lesions of any kind—and if lesions nevertheless be present, they must be
due to some other cause. (Virulence can only be determined in the
laboratory by special tests, the most rapid of which cannot be ready for
three days after obtaining the positive culture.)
Again, even if the diphtheria bacilli be shown to be virulent, this
further implies, but does not yet prove, that they are affecting the
patient, since it is true that the patient may be immune to diphtheria. If
the immune has no lesions, evidently any virulent diphtheria bacilli
proved to be present must be harmless to him, and he is a well "carrier."""
But if he has active severe lesions, and yet is immune to diphtheria, the
virulent diphtheria bacilli proved to be present must be none the less
harmless to him; his lesions must be due to some other infection, Vincent's, streptococci, etc. He is a "carrier,"'1' suffering from some intercurrent, non-diphtheria, infection.
Nevertheless, in actual practical everyday work, the examination
of throats, etc., for diphtheria bacilli has proved of immense service,
despite the occasional drawbacks,—why? Because the total of the
sources of error above noted in diagnosing diphtheria by culture are far
less than the sources of clinical  error—because,  therefore,  usually   (in
*  Dangerous  to  others  because of the  virulent germs  he  carries;   but  not  suffering  from
these germs himself.
Page 120 about 99% of cases) a "clinical sore throat 4/- diphtheria bacilli" is due
to the diphtheria bacilli found.
Negative reports on specimens submitted for diagnosis from clinically suspicious throats are dependent for accuracy first and chiefly on the
representative character of the specimen obtained; second, on the thoroughness of the examination given to the specimen; only for the second
of these two items can the laboratory be held responsible. A negative
report is universally understood to be inconclusive and in the face of
clinical or other reasons for suspicion should always be repeated.
This is particularly true in recovered cases where release from isolation is sought. The germs are doubtless reduced in number, may appear
on the surface of the throat only intermittently, and therefore are very
subject to lack of transfer to the media, or to transfer in very small
numbers; hence, they are not difficult to overlook.
To prove their absence from the patient is very difficult. Investigations by the writer in Boston, thirty years ago, showed that a single negative result in a case for release, if acted upon, resulted in releasing no
less than 30% of all the patients while still infective. The demand that
two consecutive negative cultures from both nose and throat should be
obtained before release cut down the number of infective persons released to 2 or 3%. The demand that three consecutive negative cultures from both nose and throat be obtained before release cut down
the number of infective persons released to one in 1,000, or thereabouts.
But note that even with three consecutive negatives, some of those released were still infective.
The principles thus painfully established in the now very familiar
cultural diagnosis of diphtheria apply in all bacteriological diagnostic
work, varying in detail with each disease, i.e., wth each specfic organism concerned—but yielding the same general story in all.
Above diphtheria is discussed in detail; later articles will deal with
gonorrhea, tuberculosis and typhoid.
■
Summary
1. Definite clinically suspicious symptoms of diphtheria call for
immediate antitoxin, whether a culture be taken or not, and without
regard to the returns from any culture taken, whether positive, negative
or doubtful. The rule in such cases is—first, antitoxin; then take a culture; and later be guided as to giving more antitoxin by the subsequent
developments of the case as well as by the cultural results.
2. Given a sore throat or nose not definitely clinically suspicious of
diphtheria, and a positive diphtheria report from it, the physician is
morally bound to assume that the patient has diphtheria; only conclusive proof that the germs are non-virulent or the patient immune to
diphtheria can justify any other conclusion. Since such proof to the
contrary can seldom be promptly available, immediate treatment of the
case with full therapeutic doses of diphtheria antitoxin is absolutely indicated.
Page 121 3. Negative results must always be discounted; while positive
results are about 99% correct; negative results for diagnosis are only
about 80% correct; and for release still less correct.
4. Suspicious or doubtful reports mean exactly what they say—
that while no final decision has been reached, the patient is not relieved
of the possibility of the infection suspected and "safety first" demands
treatment at once and another specimen, in the hopes that the latter will
prove conclusive. Such reports are not given in release cases, since in
such cases, the negative result hoped for is the only one on which action
is based.    Hence release cultures are reported positive or negative only.
(Occasionally of course, unsatisfactory results, due to overgrowth
or no growth or other accidents may be obtained in any bacteriological
culture.)
"DISTINCTIVE TASTES" OF PASTEURIZED MJLK
AND RAW MILK
At the Board of Trade Health Bureau meeting of Wednesday,
January 7th, 1931, twenty samples of milk—ten pasteurized milk, and
ten certified raw milk—externally unidentifiable except by a letter of the
alphabet attached to each, (corresponding with a written key), were
served out to ten members, with the request that each would
compare the two bottles handed to him in any way he pleased, but of
course using taste as one test, and state whether they were both pasteurized, both raw, or one raw and one pasteurized; and to state, in the
latter case, which was which.
The members, about thirty in all, collaborated in groups, so that as
a matter of fact 28 returns were made on the 20 bottles.
The returns, despite their paucity, have been considered worth classifying—as follows:
On the 10 pasteurized milks, 16 returns were made. 4 returns were
"doubtful"—these four judges would not decide. Of the other 12 returns, 7 stated (correctly) that the milk was pasteurized; 5 stated (incorrectly) that it was raw.
On the 10 certified raw milks, 12 returns were made. One return
was "doubtful"—i.e., the judge could not arrive at a decision. Of the
other 11 returns, 6 stated (correctly) that the milk was raw; 5 stated
(incorrectly)  that it was pasteurized.
Thus of 28 returns, 13 were correct, 10 were incorrect, and 5 were
non-committal.
This result was compared with the outcome of "deciding" which
samples were pasteurized, which raw, by the flip of a coin, taking the
first 2 8 consecutive flips.
In order to parallel the above results, the ten pasteurized samples
were subjected to the first 16 decisions of the coin, the 10 raw to the
remaining 12 decisions.    The coin-flips were correct as to the pasteurized
Page 122 milk in 6 instances out of 16; as to the raw, in 7 instances out of 12;
(The respective human decisions were correct in 7 and 6 instances.)
Hence the human judges were correct 13 times in 28 returns—and
so were the coin-flips! In other words, in this test, the opinions of interested, educated and intelligent citizens were worth on this subject no
more and no less than the tosses of a coin.
It is more than ever difficult now to believe that the "distinctive"
tastes of raw and pasteurized milk are distinctive to the "average citizen,"
as is so often stated.
The following are the actual results of the human judgments
obtained:
R
Pasteurized Milk
Certifie
d Raw Milk
P R
R
R P
R
P
P
P R
R R
R P
P
} }
P
R
P
?
R
?
P
P P
? R
Adjudged Raw
P
= Adjudged Pasteurized
} —
Adjudged
as Un
decidable
PROGRAMME OF THE 3 3rd ANNUAL SESSION
VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
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.
February      3rd—General Meeting:
Speakers—Dr. F. N. Robertson; "Some Unusual Uses
of Common Drugs."
Dr. Wallace Wilson; "Stenosis of the Mitral Valve."
17 th—Clinical Meeting.
3rd—General Meeting:
THE OSLER LECTURE—
Dr.  R.  E.  McKechnie;   "Reminiscences  of  Forty
Years' Practice."
17th—clinical Meeting.
7th—General Meeting:
Speaker—Dr.   C.   F.
Primipara."
21st—-Clinical Meeting.
28 th—Annual Meeting.
February
March
March
April
April
April
Covernton;   "Problems   of   the
Page 123 A.D. 1853 . . Mi . N°365.
Deodorizing Cod-Liver Oil.
LETT1ES PATENT to Sir James Murray, Knight,   Doctor of
Medicine, of Dublin, for the Invention of " Improvements ur
Deodorizing Cod liitm On, or Eskbbbikg it more Agreeable and
Easier to Use, either by itselp or mixed, and so as to be capable
of being Administered in larger Quantities and with ' greater
Success."
Sealed the 13th April 1858, and dated the 11th February 1853.
PBOYISI0NAL SPECTPICATION left by the said Sir James Murray
at the Office of the Commissioners of Patents, with his Petition,
on the 11th February 1853,
I, Sir James Murray, Knight, Doctor of Medicine, of Dublin, do
5 hereby declare the nature of the said Invention for " Improvements
in Deodorizing Cod Liver On, in Rendering- it more Agreeable and
Easier to Use, either by itseie or mixed, and so as fo be capable op
being Administered in larger Quantities, and with greater Success," to
be as follows: *— -", ^m
10 My Invention consists in treating the oil so as to impregnate it
most intimately with carbonic acid gas, by subjecting it to great
pressure and agitation and passing streams of this gas through it.
Mead's Standardized Cod Liver Oil needs no carbon dioxid gassing to render it
"more agreeable and easier to use" as set forth in this British patent of eighty
years ago. Moreover, Mead's Standardized Cod Liver Oil (also Mead's 10 D Cod
Liver Oil with Viosterol) are so pure, they need no flavoring. (Used for preventing
and curing rickets, and for vitamins A and D deficiencies.) Mead Johnson 8s Co.
of Canada, Ltd., Belleville, Ont., advertise these products only to the medical
profession and supply no dosage directions to the public.  536 13th Avenue West
Fairmont 80
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell J. H. Crellin W. L. Bertrand
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.
ESTABLISHED   NEARLY A
.CENTURY^SSs
B. C. STEVENS CO.
Phone
Seymour 698
730 Richards Street
Vancouver, B. C. 

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