History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1933 Vancouver Medical Association Sep 30, 1933

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of the
Vancouver Medical Association
News and Notes
made from
the finest quality Acetylsalicylic Acid so compressed
as to insure immediate disintegration in the
We commend VANASPRA to the profession as
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456 Broadway West Vancouver, B. C. THE     VANCOUVER     MEDICAL     ASSOCIATION
Published  Monthly  under  the  Auspices  of  the  Vancouver  Medical   Association  in   the
Interests of the Medical Profession.
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.  IX.
OFFICERS 1933-1934
Dr. W. L. Pedlow Dr. A. C. Frost Dr. Murray Blair
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. C. H. Vrooman; Dr. H. H. McIntosh
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
Clinical Section
Dr. W. H. Hatfield Chairman
Dr. W. L. Graham Secretary
Eye, Ear, Nose and Throat
Dr.   R.   Grant   Lawrence    . Chairman
Dr.   E.   E.   Day f Secretary
Paediatric Section
Dr.   J.   R.   Davies Chairman
Cancer Section
Dr. A.   Y.  McNair ..Chairman
Dr. A. B. Schinbein i Secretary
Library Summer School
Dr.  J.  W Thomson
Dr. C E. Brown
Dr. C H. Vrooman
Dr. J. W. Arbuckle
Dr. H. A. Spohn
Dr. H. R. Mustard
Dr.  W.  C.  Walsh
Dr. S. B.  Peele
Dr. T. H. Lennie
Dr. C F. Covernton
V.O.N. Advisory Board
Dr. I. Day
Dr.  J.  W.  Shier
Dr. H. H. Boucher
Fund — The President — The Trustees
H.   A.   DesBbisay
G. E. Kidd
J. E. Harrison
W. D. Keith
H. MacDermot
C H. Bastin
jrray Baird
A. W. Bagnall
E. H. Cleveland
J. G. McKay
N. E. MacDougall
P.  Patterson
G. E. Gillies
W. Brydone-Jack
Rep. to B. C. Med. Assn.
Dr. G. F. Strong
Total  Population   (Estimated)  247,251
Japanese Population   (Estimated) --  8,429
Chinese Population  (Estimated)  7,759
Rate per 1,000
Number    Population
Total   Deaths    !  150 9.7
Japanese  Deaths     3 4.2
Chinese  Deaths  7 10.6
Deaths—Residents only -  133 6.3
Birth   Registrations    :  264 12.6
Male     142
Female 122
Deaths under one year of age ;— 10
Death  rate—Per   1,000   births    .  37.9
Stillbirths   (not included in above)     5
August 1 st
June,  1933 July,  1933 to 15th, 1933
Cases     Deaths Cases    Deaths Cases    Deaths
Smallpox     i .. !         0             0 0              0 0             0
Scarlet  Fever         16             1 6             0 6             0
Diphtheria    i         10 2             1 0             0
Diphtheria   Carrier             0             0 0              0 0             0
Chicken-pox         204             0 41              0 8              0
Measles             2              0 0              0 0              0
Rubella              0-0 0              0 0             0
Mumps           77              0 7              0 10
Whooping-cough          8             0 10 3             0
Typhoid   Fever            0             0 2             0 10
Paratyphoid             0              0 0              0 0             0
Poliomyelitis              0              0 0              0 10
Tuberculosis            69           18 57           14 45
Meningitis   (Epidemic)             0             0 0              0 0             0
Erysipelas    .         6             0 4             0 10
Encephalitis   Lethargica            0             0 0             0 0             0
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Phone Seymour 698 730 Richards St., Vancouver, B. C.
There is considerable interest in knowing how large a proportion
of the common diseases are spread through milk. In order to determine this it is necessary to know the total number of diseases and
the number of these in which milk is concerned. The difficulty has
been to find all of the cases spread through milk. Since Massachusetts has made such a record in locating the outbreaks due to milk
the following table shows the percentage of the total reported cases
in the State accounted for by the milk borne epidemics:
* Septic  Sore Throat made reportable in  1914.
In considering the data given in the above table, it should be
remembered that the percentages given are smaller than they would
be if all of the cases caused  by  milk were known.
While Massachusetts offers the longest period of such comparisons
some other- states furnish higher percentages for short periods. During
the fiscal years from July 1st, 1924 to June 30, 1926, in California,
there were reported 2,630 cases of typhoid fever, of which 483 cases
or 18.3 per cent were traced to infection through milk. In 1898, Whipple in his book dealing with typhoid fever estimated that 25% of the
typhoid fever was spread through milk. Likewise in 1906, an attempt
was made to trace all cases of typhoid fever in the District of Columbia.
Of the cases where the source of infection could be traced with
reasonable certainty, 60.8% were assigned to milk. It should be
remembered that these two later percentages were developed before the
period when pasteurization had become sufficiently common to influence
the figures.
In this connection it should be noted that milk borne undulant
fever is probably now producing at least twice as many cases of human
disease as all of the epidemic milk borne diseases. In addition milk
borne tuberculosis has long been and probably still is our most
serious human affliction spread through  raw milk.
In the light of these findings it does seem strange that the attempt
has been made by some individuals to show that disease spread
through  milk  is  too  insignificant  to  be  considered  a  health  problem.
Sore Throat
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Manufacturers: Bilhuber-Knoll Corp., Jersey City, N.J. EDITOR'S PAGE
Listening one day recently to a very able speaker and clear thinker,
a couple of sentences he uttered struck us very forcibly as especially
applicable to the medical profession, though the speaker at the time
was making no reference to that section of society.
He said "The inspiration and traditions of the past are sacred, but
must not be allowed to usurp the place of the inspiration of the present."
Yet it often does—nations have fallen because they trusted to the inspiration and traditions of the past, instead of facing conditions as they
were. And a great deal of the trouble of our profession, and a great
deal of the grievance that the public feels against us as a profession,
is due to the fact that we are still, to a great extent, living in the past,
on an outworn tradition, instead of creating new rules of conduct to
fit new conditions of social order.
This reluctance to change is not necessarily laziness or selfishness
at all—it has, we firmly believe, a much more worthy basis; it is based
on traditions which are amongst the loftiest and most generous that any
profession has held—but we have reached a point where we should enquire
whether these traditions in their present form fit these times— and
whether we are being generous and noble, or merely "easy" and foolish.
For nobody has any real respect for the man or institution that supinely
submits to unfair treatment.
In the formulation of new rules of conduct, which will in their
turn become the tradition of our profession, we may, indeed we must,
keep the spirit of generosity and self-sacrifice that has made our profession what it is—but this spirit must assume a new form, more closely
consonant with conditions as they are. The word "charity" has assumed
new meanings, and has become a symbol for a form of socialized and
deputized giving, a collective generosity—so that personal and individual
charity on our part has become an impossibility, without injury to
ourselves and inadequacy as regards the recipients. Free medical service,
which once represented our gift to society, is now no longer practicable
or of real value—and we must express our liberality in other terms,
possibly of a more abstract kind—such as willingness to abandon our
individualism to a certain extent, to socialize our service largely, to
pool our resources for the common good, and to become to a degree
servants of the larger body, the state, rather than entirely personal
attendants of the individual person or family. This will require a considerable degree of self-sacrifice on our part, but it would seem to be
indicated by circumstances as they are.
Our speaker's other sentence was equally illuminating in this regard.
He said ""Whenever you find a man harping on the traditions of the past,
beware lest he is trying to make a profit out of it in the present."
There is very sound philosophy and sense in this, and it certainly is
true in our case—everybody, city, province and all sorts of eleemosynary
institutions wax really elequent in their panegyrics on the noble traditions of the medical profession, which has done so much for humanity
Page 217 without any thought of payment. Sitting in at a round-table conference
the other day, where some of us were urging the justice of the claim
made by certain members of medical staffs, for at least out-of-pocket
expenses in return for an immense amount of free work, we were
much impressed by the fervour of one lay speaker, who spoke of the
splendid work that the doctors of "his staff" had done for years.
He thought that it would spoil the whole relationship if money were
introduced into it. He told us solemnly that several of his staff had
assured him that if money were offered them they would resign.
We took leave to differ from this gentleman, and said we thought
he had misunderstood these doctors, that we knew of no doctor who
would refuse a fair fee for his work, if it were offered him. But he was
a very good example of the truth expressed in the quotation given above.
The truth is, we think, that the time is coming when medicine
must face the issue of socialisation of medicine to a greater or less degree,
and we may as well be frank and candid about it in saying that we
think that the sooner this is done the better both for ourselves and the
public at large. We feel that only esesntial changes should be made at
first—but these things should be done at once, and at our suggestion
and under our guidance. The profession is waiting for leadership in this
matter and will be prepared, we are sure, to go a long way in helping
to bring about the new state of things. Let us make no mistake about
it—the changes are coming—and the form they take, whether it be
pleasing to us or most unwelcome, will depend upon whether or not
we are ready and able to guide them. We believe that political parties
would welcome our guidance, if it were offered in concrete and practical
suggestions, and if they were convinced, as we could easily convince
them, of our sincerity and honesty of purpose. Whilst we may feel we
have certain grievances against the public, as represented by various
institutions, we must not forget that they too have certain well-grounded
causes for criticism of us—and we must be just as anxious to remove
these by constructive unselfishness, as we are to improve our own lot,
in fact, the latter consideration will fall to the ground completely if we
are not successful in the first part of the programme. The day of
individualism, with its selfishness and greed and gluttony culminating
in the present vast depression and misery, must go—and must be replaced
by a collective effort based on a much more unselfish spirit, and we
must do our share in bringing about the change.
In our last issue, we "pointed with pride" to the forthcoming
investiture of Dr. Dr. R. E. McKechnie with the Good Citizen's Medal.
We feel moved to comment again on the proceeding, as reported in the
daily press. R. E. in his remarks on the subject, took is as a compliment
to his profession, rather than to himself. While appreciating the kindly
spirit and loyalty which prompted these remarks, we feel that they did
Page 211 not accurately represent the true state of affairs, and we are afraid that
the responsibility is entirely R. E.'s own. He is merely reaping the reward
of a long life of public service, and we desire to inform him that he
cannot "pass the buck" to us.
Dr. Harold Caple was seen last week cavorting over the sands of
Savary, in a very becoming sun-tan, and very good spirits.
Others holidaying at this well-known summer resort were Drs.
Harold White, Medical School Officer, Dr. Day-Smith, Dr. F. N. Robertson, Dr. Walker Turnbull, and the Editor.
Dr. A. P. Proctor Junior is the latest addition (up to the time of
writing) to the line that forms "to the right." His marriage with Miss
Frances Griffin took place recently, and Dr. Eddie Day officiated as best
man. The contagion is apparently one of a long incubating period, but
we desire to warn Eddie that it very seldom fails to get its man.
Again we wish to comment with pleasure on the character of the
paper that appears in this issue. Dr. J. E. Walker is to be congratulated
on the amount and quality of work he has put into his study of the
cases which came under his notice at the Outpatients' Department.
The paper will repay a thorough reading, and we regret that it was impossible to publish it in one issue. We could not very well shorten it,
and our space is limited.
Calamus Scriptorious writes: "A prominent lady of this city was
given a Baby Shower recently (vide Province of late date). Having in
mind the usual meaning of a "shower," one wonders where the babies
come from. "Out of the everywhere into here," so to speak, or was it
the Maternity Clinic of the V. G. H.? Or—but let us not allow our
imagination to rove too far. As one stork remarked to another, "Is my
face red!"
We congratulate Dr. and Mrs. Murray Meekison on the safe arrival
of a daughter recently. Mother and child are both doing well.
Page 219 ANAEMIA
John Eden Walker, M.B.
This evening we are presenting a number of cases of anaemia, which
have been studied in the Outpatients' Department of the Vancouver
General Hospital under Dr. S. Sievenpiper and myself during the past
year or more, to illustrate especially the treatment of different types of
anaemia by means of liver extract and of iron.
In order to understand the action of these substances in the treatment of anaemia, one must first study the modern conception of the
pathology of this disease. Before shewing these cases, I should like to
spend a few minutes in presenting the theoretical aspect of the subject
to your attention. The accompanying diagram deals with the normal physiology of the maturation of the red blood cells, and its relationship to anaemia, based on a classification of this group of disease, from the standpoint
of changes as found in the bone marrow. The bone marrow is the
source of all the red blood cells in adult life. Before fifteen years of
age the marrow of all bones is engaged in cell production, after fifteen
only the spongy flat bones of the body and the heads of the femur and
humerus produce them. The endothelial cell, lining the intersinusoidal
capillaries of the bone marrow, is thought to be the parent cell. These
cells produce, by a process of mitosis, an indefinite number of megalo-
blasts which are larger than the mature erythrocyte and are nucleated.
These megaloblasts divide by the same process of mitosis into an
indefinite number of normoblasts which are smaller in size and are also
nucleated. The normoblast in turn extrudes its nucleus and becomes
a reticulocyte. Reticulocytes, when stained with certain vital dyes,
show rod-like bodies which are composed of the remains of the basophilic
cytoplasm of the normoblast.
The reticulocyte is the final stage of the immature cell. After it
reaches maturity, it is known as the erythrocyte. It will be understood
that in the normal state, it is necessary for comparatively few endothelial cells to produce megaloblasts, but in pathological conditions where
cells are urgently needed, the endothelial cells of the bone marrow serve
as a vast potential factory. Governing the maturation of the immature
red blood cell into the final product there is a complex mechanism.
Small htestme Bone   MaTTOW.
Endothelial Cell
A. HffieTpJastic
Small mm&m    NoTTnablast
' >to rn ELcK
eg. Pe Ti-iicioas Aiiae-mta,.
> cionoTTriabl&stic
e£J.Srmble r\cb}orhydric Anae-mia.
(biilaeTTi opoietic
eg-Acute Haemolytic  A-naewia.
ed. ReciATTent (iemovr/iage.
Delivered before a staff meeting of the Vancouver  General  Hospital,  May,   1933.
Page 220 From the normal stomach mucosa there is created a substance which
is called the intrinsic factor of Castle. When this intrinsic factor comes
into contact with an extrinsic factor, which is ingested into the stomach
in the food, a reaction takes place between the two, producing what
is called the haematinic factor. This haematinic factor is absorbed from
the small intestine, and stored in the liver, kidney, brain, and other organs.
As it is needed, this haematinic factor is carried to the bone marrow,
where its presence is required to allow the normal maturation of the red
blood cell from the megaloblastic level. In addition to this haematinic
factor there are other substances which control the maturation of the
RBC from the normoblastic level. The chief of these substances is iron.
Other minerals, of which copper is the most important, and vitamin
C, are believed to play a part in this control from the normoblastic
level onward. These substances are normally ingested into the stomach
and absorbed from the small intestine, to be stored in the body, or carried
to the bone marrow direct. In the past few years an attempt has been
made to classify the various anaemias from the standard of pathology
as it is found in the bone marrow. The marrow of the sternum has been
found to be the most satisfactory, from the view-point of this study.
The classification which I have illustrated above, serves in a broad way
to clarify the underlying pathology of the various anaemias. Bone marrow
is found to show two outstanding differences, those types of anaemias
where there is a decreased production of RBC in the marrow, that is,
a condition of hypoplasia, and those cases in which there is an increased
production of RBC in the marrow, that is, hyperplasia. Those anaemias
which show a hypoplastic bone marrow we will not speak of further.
Those types of anaemia which show a hyperplastic bone marrow may be
subdivided into anhaemopoietic and haemopoietic. Each of these
in turn may be divided into those cases which show a preponderance of immature cells at the megaloblastic leve
in the bone marrow, and those which show a preponderance of immature cells at the normoblastic level. The anhaemopoietic group: In this group of anaemias there is an increased number
of immature red blood cells present in the marrow, but for some reason
these are unable to progress through their various stages and enter the
blood stream. That is, there is an increased number of immature red
blood cells in the marrow but a deficiency of red blood cells in the circulation. In the haemopioetic group there is an increased number of immature red blood cells in the bone marrow, which are able to progress
through their various stages and reach the circulating blood, but for some
reason the cells, as they reach the blood stream, are destroyed or lost
faster than they can be produced.
How may we tell from looking at the blood smear to which type
of anaemia the case belongs? Can we tell from looking at the blood smear,
what we should expect to find in the bone marrow? We can answer
these questions by noting particularly the size of the red blood cells and
their haemoglobin content. Various methods of measuring the size of
the red blood cell have been devised, which I do not, however, intend
to discuss on this occasion. One might make the broad statement that
where the average cell is larger than normal and is well filled with hae-
Page 221 moglobin, thus giving rise to a colour index greater than one, the anaemia
is considered to be macrocytic, and the type cell in the bone marrow
will be the megaloblast. If the average size of the cells is below normal
or poorly filled with haemoglobin, thus giving rise to a colour index below one, the anaemia is considered microcytic, and the type cell in the
bone marrow will be the normoblast. These are broad statements and
will not cover every case of anaemia but serve as a general working
basis. We submit a list of the principal conditions that produce the
anhaemopoietic type of anaemia   (1)   with -megaloblastic bone marrow.
1. Pernicious anaemia.
2. Anaemia of Bothriocephalus latus infestation.
3. Anaemia following resection of small bowel.
4. Anaemia associated with intestinal stenosis.
5. Anaemia of cancer of the stomach.
6. Anaemia of dysentery.
7. Anaemia of T. B. of small intestine.
8. Anaemia following partial gastrectomy.
9. Anaemia following complete gastrectomy.
10. Anaemia of sprue.
11. Anaemia of chylous or fatty diarrhoea.
12. Anaemia of pellagra.
(2)   with normoblastic type of bone marrow.
1. Simple achlorhydric anaemia.
2. Nutritional anaemias.
3. Scurvy.
4. Tropical nutritional anaemia especially in pregnancy.
5. Fatty diarrhoea.
6. Pellagra.
7. Following resection of small intestine.
8. With intestinal stenosis.
This evening we do not wish to discuss the haemopoietic group
any further, but will dismiss it by saying that the pernicious anaemia
of pregnancy is believed to be an example of that form of haemopoietic
anaemia which shows a megaloblastic bone marrow. Chronic or recurrent haemorrhage is an example of haemopoietic anaemia showing normoblastic bone marrow.
It is the anhaemopoietic group which I wish to take up in more
detail. The outstanding example of anhaemopoietic anaemia showing
megaloblastic bone marrow, is true pernicious anaemia. An outstanding example of anhaemopoietic anaemia showing normoblastic bone
marrow is simple achlorhydric anaemia.
I wish to take up now the subject of pernicious anaemia with the
previous statements as an introductory background. The etiology of
pernicious anaemia: Pernicious anaemia may be due to one of three possible
causes (a) deficiency of intrinsic factor (b) deficiency of extrinsic factor
and  (c)  deficiency of absorption of haematinic principle at any location
Page 222 from the time it is produced, until the time it reaches the bone marrow.
The experiments of Castle have proved that the cause of pernicious
anaemia is lack of the intrinsic factor normally manufactured by the
stomach mucosa. The other two factors may play a part in some cases;
that is, the diet may be extremely deficient in extrinsic factor; or there
may be failure of proper absorption of haematinic principle from the
small intestine due to disease of this organ. What is the nature of these
three factors? We have no idea as to the composition of the intrinsic
factor. It would appear to be neither a vitamine nor a hormone, nor a
ferment. We have reason to believe that the extrinsic factor so far as
blood maturation is concerned is vitamine B2. Extrinsic factor is not
present in washed casein, in wheat glutin, in washed nucleo-protein or
in yeast nucleic acid, but it is present in beef muscle, and very strongly
so in autolyzed yeast. It has no properties which cannot be compared
to vitamine B2. The nature of the haematinic factor is also not known,
but it may be vitamine B2 altered in some way by the intrinsic factor.
It is of course notorious that the blood lesions and the central nervous
system lesions of pernicious anaemia may not parallel each other in severity in the same case. This has led to the idea that the factors
governing blood maturation and those governing the maintenance of a
normal central nervous system may not be exactly the same, although
very closely related. It has been suggested that the extrinsic factor concerned in the prevention of central nervous system lesions is probably
vitamin Bl. It is known that deficiency of vitamin Bl in the disease of
beri-beri produces peripheral neuritis. The analogy is obvious. Also it
has been shown in experiments on dogs fed upon diets lacking in vitamine Bl, that the central nervous system shows lesions similar to those
of pernicious anaemia. When we administer liver extract we are really
giving haematinic factor that has been absorbed from the intestine and
stored in the liver. We have found in our clinic that liver extract given
intramuscularly is at least fifty times as potent as when given by mouth.
This leads one to think that there must be either a destruction of the
principle of liver extract by the gastro-intestinal secretions, or else failure of absorption of this principle from the intestinal tract. It is extremely likely that in pernicious anaemia, there is, in addition to a deficiency of production of the intrinsic factor, also a deficiency of
absorption from the intestinal tract.
Our cases in the Out Patients' Department have
all been treated with liver extract, but preparations of
hog's stomach, in which the mucosa and the muscular layers have been
ground together and extracted, have been found equally potent, or more
so. During the past two years we have averaged fifteen cases constantly
in attendance, of which about three quarters have been given liver extract intramuscularly, for the past year, at weekly intervals. Some of
these cases had previously received liver extract in varying lengths of
time, from one to three years, by mouth. The intramuscular injection
has been given into the buttock or into the arm, whichever location the
patient prefers. The majority of our patients have experienced both forms
of treatment, and state that they prefer to take liver extract intramuscularly.  We are still maintaining several  patients  on liver  extract  by
Page 223 mouth for various reasons. In some cases the site of injection is painful
for only a few minutes; others have experienced pain for from two to
three hours, or from two to three days. The size of the dose up to a certain point, does not seem to influence the degree of discomfort following
the injection. We make a practice before starting a patient on intramuscular treatment, of doing a skin test, particularly when he has been
taking liver by mouth previously. In one patient who showed quite a
marked cutaneous reaction we started to desensitize him, but with the
first injection he collapsed for a few minutes. That is the only case which
has shown any reaction to intramuscular liver therapy. We have been
giving our intramuscular cases Lederle's liver extract. Three cc. of this
purified extract is derived from 100 grammes of liver. It has been estimated that in oral preparations of liver extract, the extract is only
equivalent to about 65% of the whole liver from which it is made.
Whether the purified liver extract used for intramuscular injection is
effective in the same ratio, I cannot say. In cases of relapse with low
red blood count and haemoglobin, using Lederle's preparation, it has
been the practice in this Hospital to give 5 cc every day for several
days, increasing the interval to about twice a week and finally
once a week. In patients whose blood has been brought to normal, one
must find what dosage is necessary to maintain the patient at his optimum
level. In our series, the patients have been on doses varying from 2 cc
a week to 6 cc a week. The average dose has been around 3 to 4 cc.
We started giving regular intramuscular treatment a year ago last April.
Last fall we tried to cut down the dose from 1 to 2 cc in each case but
found that the patients were not getting along so well and in the last
three or four months we have tried the opposite course and have put them
back on doses even higher than those they were previously getting.
I would like to say a word about the cost of liver therapy.
The cost to the Hospital of 3 cc of Lederle's liver extract is $1.17. The
patient on this dose would therefore have to pay $1.17 per week. The
same patient taking liver extract by mouth would require about three
vials per day, at approximately 25c per vial, which would amount to
$5.25 per week; more than four times as much as on the intramuscular
During the last couple of months we have been trying new cases
of pernicious anaemia on the Connaught Laboratories preparation of
liver extract for intramuscular use. This extract is not as concentrated
as Lederle's, in that 100 grammes of liver is represented by 10 cc of extract. If the potency of all extracts for intramuscular use derived from
100 grammes of liver is the same, then we would have to give 10 cc of
intramuscular Connaught Laboratories extract to get the same effect as
from 3 cc of Lederle's. From the few new cases that we had in the last
two months, we would think that the Connaught Laboratories preparation for intramuscular use is more potent than Lederle's preparation,
using as a basis of comparison the extract from 100 grammes of liver.
The cost of the Connaught Laboratories preparation to the Hospital is
45 c for 10 cc. The question of expense in the treatment of pernicious
anaemia is a very important one.
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ATEASPOONFUL by the measure
—three minutes by the clock, is
the efficiency story of Cal-Bis'Ma in
gastric neutralization. Sodium bicar-
bonate and magnesium carbonate for
quick neutralization, calcium carbon-'
ate and bismuth for prolonged action.
And, in addition, colloidal kaolin to
supplement the bismuth salts for
soothing and protecting the irritated
mucous membrane, and to adsorb
gases that may form in the stomach.
Well adapted for the alkaline treatment of gastric ulcer.
In nausea of pregnancy exceptionally
good reports are being received.
727  KING  STREET,   WEST,  TORONTO,   ONT. There must be a difference in the potency of the different extracts
which are on the market. Some authorities in England claim that the
extract from 15 grammes per week of liver is sufficient to maintain the
average patient. We can contrast this statement with our experience in
Vancouver, where the extract from 3 to 6000 grammes of liver has been
found to be necessary.
It may be asked why we should have started giving liver extract
intramuscularly when the extract is potent when given by mouth. The
reasons for this are twofold; first on the ground of economy; secondly
on the ground of better control of the patient. On the whole we are more
satisfied with the results of intramuscular therapy than when given by
mouth. We think that if sufficient quantities of liver extract are given by
mouth or intramuscularly the result should be the same, but we have
found that patients do not always take the full dose they are told to
take; that when they are feeling beter, or have felt better for some time,
they begin to omit a dose or take a smaller dose. On the other hand when
giving the extract by the intramuscular method, we know that the
patient is getting what he is supposed to be getting. Those patients who
have not been taking liver intramuscularly have been taking the Connaught Laboratories extract for oral use.
The treatment of pernicious anaemia cases does not consist wholly
in administering liver extract, though this is by far the most important
factor. Foci of infection should be eliminated. Mental hygiene is often
necessary. Iron therapy is sometimes indicated and complications if
present should be dealt with. Patients should be on a simple balanced diet.
We think that if they are getting a satisfactory dosage of liver extract, the so-called anaemic diet is not necessary as long as the diet is
balanced. We feel that this factor of diet has not been entirely satisfactory in the Out Patients' Department in all cases; many of them are
on City Relief and the rest have very limited incomes. We make a
practice of giving dilute hydrochloric acid in doses of one drachm t.i.d.
in a glass of water to counterbalance the deficiency practically always
present in the stomach. All authorities do not agree on the necessity of
this practice. Certain principles must be followed in the administration
of liver extract. Treatment must be continued indefinitely and in optimum doses. Patients in whom liver is discontinued will always show a
relapse in time. When we say an optimum dose, we do not mean one in
which sufficient liver extract is given only for the patient to hold his
own; his blood picture should be absolutely normal; his nervous signs and
symptoms should improve or at least show no retrogression, and his
general constitutional symptoms should be satisfactory. One should
never treat a patient with his blood count or haemoglobin as the only
guides. If a patient is allowed to lapse either through discontinuing liver
extract, or through insufficient liver extract being administered, on recommencing treatment it will often be found that larger doses than before are required to maintain him. There are two factors which definitely
inhibit the action of liver extract; these are the presence of foci of infection, and of arterio-sclerosis. Some workers have divided pernicious anae-
Page 225 mia into groups according to the amount of liver extract necessary to
maintain them. Those requiring the smallest doses were found to be
younger in age, having a shorter duration of the disease, showing less
chronic infection, and little arterio-sclerosis, and with less involvement
of the nervous system. Those requiring larger doses showed the reverse
of the above factors.
Most of our cases come under the second heading. We have fixed
the arbitrary interval of one week for administration of liver extract
intramuscularly, but we think that if one could give in one dose, as much
extract as would be taken daily, or weekly, by a pernicious anaemic,
for say, one month, his condition would show no deterioration. It would
seem that the liver extract is not destroyed or excreted by the body, but
is stored in the reservoirs of the body, of which the liver, kidney, brain
are the chief, and is released when required. In ordinary treatment
one should aim not only at meeting the daily requirements of the bone
marrow, but in filling up the reservoirs of the body as well, so that any
extra strain on the marrow may be adequately handled.
In handling patients in the Out Patients' Department we have a
limited staff, and a great many patients to see, so that we have tried to
develop an economy of effort in examining and treating those patients.
On admission we do a complete physical examination and complete laboratory survey. In following their course afterwards we try to .note
especially the following features; the condition of the tongue, foci of
infection, condition of the circulatory system, especially the presence
of arterio-sclerosis, an dthe condition of the nervous system. During the
past we have taken, at least once a month, red blood count, haemoglobin,
colour index and smear. Lately we have modified this to some extent and
are taking blood counts less frequently. We are depending more on the
examination of the smear by means of the microscope and by the eryo-
meter. This throws much less work on the laboratory and we feel gives
us the essential information.
Introduction to Presentation of Cases
In presenting some of the cases which have been attending the
O.P.D. during the past couple of years, we do not intend to show each
case in its entirety. We propose merely to show cases to illustrate certain
principles, or to bring out certain points that may be of interest. These
cases have all had full laboratory tests carried out on them, so that in
these cases where a full record of laboratory tests is not recorded, it may
be taken for granted that the necessary tests have been done; also in the
physical examination, negative tests are not recorded. Some of these cases
did not attend the clinic for anaemias for varying lengths of time after
their admission to the O.P.D., so that we have not been familiar with all
cases at their onset.
I. A case showing presence of normal amount of free HCL in
stomach contents. This is the only case we had attending the O.P.D.
which does not show achlorhydria.
Page 226 J.P. male, age 63 years. In August 1930 he was admitted to the
General Hospital for the period of a month. He gave a history of about
one and a half years duration: difficulty in walking, tingling and cold sensations in the hands and feet, great loss of strength, mental irritability
and poor memory. His nervous symptoms had become so pronounced that
he could hardly walk with the aid of two canes. On examination the
chief findings were in the C.N.S.; he had a staggering spastic gait; Romberg's sign very marked, Babinski (R & L) positive. Knee jerks were plus
plus, other reflexes not recorded. Vibration sense absent in both extremities.
Laboratory work. R.B.C. 2,900,000, haemoglobin 75%, colour index 1.3,
macrocytes plus 3, WBC 6000; poly's 57%, lymph's 41, stomach conditions free HCL 0,34,14,0.
Blood and spinal Kahn, negative. At this time there was much
doubt by the attending physicians as to whether this was a case of pernicious anaemia or not, on account of finding free HCL. However, patient
was started on liver therapy by mouth, y^ ampoule liver extract, (Connaught Laboratories) t.i.d. He continued on this dose from October 1930
to August 1932, during which time his blood counts could be considered
fairly satisfactory. He was able to walk a little better than on admission
but still had to use two canes; on the whole, he was a little better, but
not a great deal, as far as his nervous symptoms were concerned. His oral
dose of liver extract was apparently enough to keep his blood fairly
normal, but was not sufficient  to correct his nervous symptoms.
In September 1932 he first attended the clinic for anaemias. He was
started on Lederle's extract, 3 cc (100 grammes of liver) intramuscularly,
once a week. By November he was able to discard one cane, and by
December he was able to walk a short distance with no assistance. About
this time he also noticed a great improvement in the proprioceptive sensations in hands and feet. His tongue which had been sore from the start,
improved a great deal; the same may be said of his general strength. On
examination of his nervous symptoms February 1933, reflexes were about
the same, Romberg's sign much improved, he could walk a straight line.
His vibration sense was still absent in lower extremities but present in
upper. His blood picture has been normal since starting the liver extract
intramuscularly. During the last two months we have increased his
weekly dose to 6 cc, and he says that his walking ability and general well
being are improving all the time. Stomach contents in August 1932 and
February 1933 still showed free HCL present. We think that this case
is one of pernicious anaemia in spite of free HCL in the stomach, because
of his blood picture 2^4 years ago and the great improvement in his
nervous symptoms on adequate liver therapy.
of p
II.    Case showing combined sclerosis but blood picture not typical
oerntciotts anaemia.
J.S. male, age 54 years. About Ayz years ago he was feeling in his
usual good health. One winter morning he awoke and found that his legs
were weak and that he had no sense of balance. He had a general feeling
of weakness and later developed tingling in hands and feet, For about 1 y-z
Page 227 years he had various treatments but made practically no progress. During
this time he lost 20 lbs. in weight, and could walk only with great difficulty. In December 1930 he had his blood examined by his family doctor
for the first time, RBC, 3,200,000, haemoglobin 55%, colour index 84.
WBC 3,200. stomach analysis, no free HCL Blood Kahn, negative.
At a later date a spinal puncture was done with entirely negative
findings. There is no record of physical examination at this time, except that a note was made to the effect that the spleen was palpable.
He was put on ventriculin at this time and at once started to show improvement. In May, 1931 he first came to the O.P.D. at which time his
RBC were 4,450,000 haemoglobin 87%, colour index .96, leucopenia
with relative lymphocytosis. In September 1931, he first reported to the
clinic for anaemias. The symptoms at this time were numbness, tingling
and feeling of coldness in both extremities, weakness, and great difficulty
in walking. Examination at this time showed his knee jerks plus 4, Romberg marked, gait spastic, with inability to walk a straight line. Vibration
sense impaired over both lower extremities. He was started on liver extract (C.L.) per os, ampoules. 1—t.i.d. In December 1931 he reported that
he felt stronger, gait much improved, and tingling of hands improved.
At this time his dose was increased to 1^4 ampules t.i.d. (approximately
1200 grammes of liver) on which dose he continued until April 1932,
showing, during this period, a definite improvement. In April 1932, he
started on 3 cc of Lederle's extract intramuscularly, which was later
stepped up to 4^4 and then to 5 cc. At the present time symptoms have
all improved greatly; he can now walk a straight line, Romberg's sign
not marked, knee jerks are not nearly so exaggerated. Physical examination otherwise the same as a year ago. During all the time he has been
attending the O.P.D. his blood picture has never looked like pernicious
anaemia, except for an almost constant leucopenia. We consider this to be
a case of pernicious anaemia in spite of the absence of a characteristic
blood picture, and in spite of the sudden onset of his disease, which
apparently came on over night,—because he shows no free HCL in stomach contents and because he has a combined sclerosis which has improved
since he has been receiving liver therapy, previous to which treatment
there had been no changes in his symptoms for lyz years. It is probably
one of those cases in which the factor governing the maintenance of the
normal central nervous system has been very markedly upset while the
factor governing the normal maturation of RBC has not been upset to
an appreciable degree.
III. Case showing elevated blood pressure. Osier writing before the
institution of liver therapy, states that a low blood pressure is characteristic of pernicious anaemia and that high blood pressure is never
found. That is true, no doubt, in cases showing relapse; but as the
following cases show, is not true of those cases on adequate liver therapy.
(a) J. F. male, age 63 years. This patient was admitted to the
O.P.D. March 1930. History extended back to 1918 when he was confined
to bed for about six months, complaining of general weakness, numbness
and tingling of hands and feet, and attacks of vomiting. He improved
Page 228 from this attack and was fairly well until 1927 when he was again in
bed for three months with the same complaints; he recovered from this
attack with liver therapy. Since that attack in 1927 has been in bed
off and on and has never been really well. On coming to the O.P.D. in
March 1930 his RJBC were, 2,528,000, haemoglobin 75%; colour index
1.5; macrocytes plus 2, WBC 5,450 P. 70; L. 24. Stomach contents
showed no free HCL. Physical examination showed some degree of combined sclerosis. March 1930 to April 1932 given liver extract by mouth
and from that time on liver extract intramuscularly. The item of interest
in this case is however, his cardio-vascular system. This patient's blood
pressure while on liver extract intramuscularly varied between 170/90
to 210/110, the last reading being 170/100. His electrocardigram showed
left ventricular preponderance and ventricular extrasystoles. X-ray of
heart showed marked dilatation of aorta with heart not grossly enlarged.
There is quite a marked general arterio-sclerosis. His eye grounds a year
ago showed minute haemorrhage in right side. NPN normal.
(b) Mrs. B age 55. Patient has had symptoms of pernicious anaemia
for several years and had a typical blood picture on admisison. Her blood
pressure stays around 150/74.
(c) Mrs. R. Age 53. Has been on liver extract by mouth for the
past three years at least, and showed blood pressure between 150 90 to
170/90. We have two or three other cases showing blood pressure slightly
elevated; the remainder in our series either have normal blood pressure
or a little lower than normal while on liver therapy, but none of them so
far as we can find, have blood pressures below 100 systolic.
IV. Case receiving iron therapy as well as liver therapy.
J.F. This case we reviewed under III. This man was put on Frosst's
Ferro-catalytic capsule 1, t.i.d. January 12th, 1933. At this time his
blood count was as follows: RBC 4,600,000, haemoglobin 93%, colour
index 1, smear normal. He stated that he did not feel well. This was not
surprising perhaps, in view of the fact that he had a cardiovascular
condition. We thought we would try him with some iron as well as
liver extract. Ever since starting the iron he says that he has felt very
much better and has more energy. During the last few months various
authorities have stated that they do not consider liver extract alone a
sufficient treatment for pericious anaemia. They think that either whole
liver or iron should be administered as well. This idea sounds reasonable
because in view of the theory of the etiology of pernicious anaemia, one
would think that the people are more susceptible to failure of iron
physiology than normal individuals.
V. A case that has always received liver extract intramuscularly.
Mr. T.S. Age 52 years, was admitted to the V. H. G. Feb. 23rd, 1932
discharged April 18th, 1932. On admission his symptoms were as follows.
Indigestion 4 years, weakness 5 months, shortness of breadth, numbness
and tingling of hands, 3 weeks. A review of his past illnessess showed
Page 229 that he had typhoid fever in 1900, jaundice age 30, dysentery age 30. It
will be noted that these diseases are all diseases involving the gastrointestinal tract, and very probably have some bearing on his present condition. On physical examination the tongue was found to be smooth,
red and cracked, teeth showed marked caries, nervous system showed
absent ankle jerks, stomach contents no free HCL, platelets 55,000 per
cm. RBC 1,270,000 haemoglobin 22%; colour index 1.1; microcytes
plus 2, macrocytes plus 2. He was given Lederle's liver extract intramuscularly 5 cc Feb. 29th, March 2nd, March 3rd, and 4th at which
date his reticulocyte count was 50%. Following this the intervals between
injections were gradually lengthened to an interval of 5 days. By March
27th his reticulocyte count was 1%. On discharge from the Hospital
his RBC were 4,920,000; haemoglobin 80%; colour index .9. On coming
to the O.P.D. after discharge from the Hospital he was given three cc
once a week. RBC have never been below 4^4 million and haemoglobin
stayed between 90 and 100%; colour index usually slightly below 1.
He can now work in his garden for 6 hours a day, numbness and
tingling very much improved and his ankle jerks which on admisison to
Hospital were absent, are now obtainable.
VI.    Cases showing slight neurological si
We find it impossible to find any case of pernicious anaemia in our
series that does not show neurological signs. Most of them show marked
signs. We have, however, picked two cases to show this part of the picture
of pernicious anaemia to a comparatively slight degree.
(a) Mr. C. age 46. Admission January 1933. He states that he was
in excellent health until about three or four years ago. At this time he
noticed that he was becoming tired, weak and pale. For the past two years
has had a sore tongue and for the past year has had praecordial pain and
shortness of breath on exertion. For the past two or three months, numbness and tingling of the fingers, but no other symptoms of nervous
origin. Has had indigestion for past two months. On physical examination
his colour is pale lemon tint, marked pyorrhoea of lower teeth, nervous
system negative, except that tuning fork sensation is slightly diminished
over both upper and lower extremities. RBC 2,620,000; haemoglobin
80%; colour index 1.5; microcytes plus 4, WCB 4,500, poly. 71; lymph;
26, Van den Bergh .55 mgms., blood Kahn negative, barium series negative.
Fluoroscopic and radiographic examination of oesophagus and mediastinum negative. Oesophagoscopy negative. These examinations were made
because the patient has never been able to swallow a tube for stomach
analysis. He was started on Lederle's extract 3 cc once a week and increased to 6 cc. Symptoms and blood picture improved satisfactorily.
This is a case where the patient has evidently had pernicious anaemia
for at least three years, and yet has shown very little involvement of the
(b) Mrs. B. age 55. Was admitted to O.P.D. Feb. 6th, 1933,
with history that she has been anaemic for 30 years. She had been told
Page 230 that she had pernicious anaemia 16 years ago while in a Hospital
for a nervous breakdown. In the past 16 years has had to stop work at
least 15 times on account of weakness. For the past 7 or 8 years had
had numbness and tingling of feet. Three years ago she started taking
liver therapy but in the last year has had no treatment. Physical examination shows a pale lemonish colour, palpable spleen. Vibration sense
absent in lower extermities, central nervous system otherwise negative.
Laboratory work RBC 1,580,000 haemoglobin 46%; colour index 1.5
microcytes plus 4, WBC 7,700; poly 73; lymph 24. Stomach analysis—
no free HCL. Was admitted to the hospital and given Lederle's extract
intramuscularly, showing maximum reticulocyte response of 39%. She
returned to the O.P.D. March 23rd, 1933 with RBC of 4,850,000;
haemoglobin 81%, colour index .84. She has been kept on 4 cc of Lederle's extract intramuscularly weekly since March 23 rd. States she has
not felt so well for years. This patient has had a history of anaemia
for a great many years, possibly 16, and yet has very little evidence of
nervous system involvement.
IX.    Cases showing a palpable spl
We do not think the presence of a palpable spleen is of much importance in diagnosis. Many blood dyscrasias show a palpable spleen so
that it is of very little use in differential diagnosis. We do not think that
the percentage of cases of pernicious anaemia that show a palpable spleen
is as great as is commonly thought. In cases on maintenance doses we
never palpate the spleen, and in cases of relapse the percentage does not
appear to be very high, probably less than 50%.
X.    Cases showing reaction of WBC to liver extract therapy.
(A) Mr. C. On admission Feb. 2nd, 193 3, RBC 2,600,000; haemoglobin 75%; colour index 1.4; WBC 4.500; Poly. 71 Lymph 26. April
18th, 1933 RBC 4,670,000; haemoglobin 90%, colour index .9; WBC
8,850; poly 66; lymph 30. In this case, as his red blood cells became
normal so did his white blood cells become normal.
(B) Mrs. B. April 7th, 1933. RBC 4,500,000; Haemoglobin 85%;
colour index .94; WBC 9,825. One week later blood picture approximately the same; WBC 5,600 Poly. 47; Lymph; 51. We did not know
why her white blood count should have fallen without apparent reason.
(C) J. F. This man has been attending the clinic for three years,
and during that time has had only one white count which approached
normal, in spite of RBC never being below 4J4 million and haemoglobin
between 90%  and  100'/.
(D) Other cases show a normal white count with relative lymphocytosis in spite of normal red counts. We do not know what the significance of these white counts is, but we believe that sufficient liver
extract should be given to make the blood picture normal. These readings may mean that we are not giving sufficient dosage.
Page 231 XII. Cases showing that normal colour index and smear are more
important than high RBC count and haemoglobin.
(A) Mr. H. October 1932. Two weeks after starting treatment,
RBC 3,990,000; haemoglobin 100%; colour index 1.25; smear-macro-
cytes plus 3. March 193 3 RBC 4,620,000; haemoglobin 90%; colour
index .98; smear is normal.
In the first count this patient had haemoglobin of 100% but his
smear showed marked pathology. In the second count haemoglobin was
lower than on the previous occasion, but smear was normal. A single
haemoglobin estimation in this case would have been most misleading.
(B) Mr. S. January 1933. RBC 5,240,000 haemoglobinl06% colour
index 1.02; smear shews occasional macrocytes, slight irregularity in size
and shape of cells. April 1933, RBC 4,700,000; haemoglobin 90%; colour
index .96; smear normal. First estimation was taken after the patient
had been put on reduced doses of intramuscular liver. The rising colour
index and slight pathology as shown in the smear were, in our opinion,
sufficient reason to increase his dose of liver again. After stepping up his
dose we found the second estimation normal and well balanced.
(C) Mr. J. D. On admisison to O.P.D. September 1932, RBC
4,550,000; haemoglobin 108'. ; colour index 1.2;- macrocytes plus 2.
After treatment RBC 5,300.000; haemoglobin 105%; colour index .98;
smear normal. At the time the first count was taken this man.showed
very marked involvement of the central nervous system. If one had taken
merely the haemoglobin estimation one would have said that he showed
no signs of anaemia. Practically speaking, this man did not show anaemia,
but his smear showed marked signs of cellular pathology. The second
reading showed very little change in haemoglobin but there are now no
findings of cellular pathology. These cases serve to emphasize that the
examination of the blood smear is more important than the individual
RBC or haemoglobin estimation. It is for this reason that we have been
relying upon the appearance of the smear while keeping our cases on
their maintenance doses.
XIII. Cases showing comparison of effectiveness of liver per os
and liver extract intramuscularly.
Mr. F. M. Age 58. This patient was admitted to the V. G. H. on
August 14th, 1930, with history of numbness of hands and feet, with
difficulty in walking, of about 3J4 years duration. For a year previous
to admission had been on liver treatment but noticed that his weakness
and nervous symptoms were getting progressively worse. On examination, he was of a pale lemon tint, atrophic changes in the tongue, moderate oedema of the feet. Reflexes of the lower extremities were unobtainable
and his vibration sense was diminished in the legs. RBC on admission
1,070,000; haemoglobin 24%; colour index 1.14; WBC 4000; stomach
contents, no free HCL. On discharge from the Hospital, RBC 4,580,000;
haemoglobin 96%; colour index 1.05. While in the Hospital he was
getting two and then four vials of liver extract per day. In November
1930 to April 1932 he was kept on vials 3 to 4 per day. During that
time his blood was never really normal. His haemoglobin was always well
Page 232 up; but his colour index was generally higher than 1. He was undoubtedly getting an inadequate dose of liver, though three to four vials a day
is a fairly good dose (750 to 1000 gramnes of liver per day) In April
1932 he was started on 4 cc of Lederle's and then 5cc per week. After
a month of starting Lederle's extract intramuscularly RBC 4,510,000;
haemoglobin 96%; colour index 1. Blood has remained normal on 5 cc
for the past year. With regard to the nervous system there has been
marked improvement. Numbness and tingling improved a great deal and
he feels much stronger. He can walk a straight line very much better.
His knee jerks can be obtained with difficulty, whereas they were absent
on admission to the Hospital. His ankle jerks are still absent.
XIV.    Cases showing marked central nervous system lesions.
The majority of our cases showed marked involvement of the central
nervous system. Some of them were so severe, that before starting treatment they were able to walk only with the help of two canes, and then
some of them could hardly navigate. As a general rule, it takes longer
to improve the nervous symptoms than to improve the blood picture.
When one finds patients with absent or exaggerated reflexes, in many cases
these do not improve, but we have several cases where they have shown
improvement. One finds the greatest improvement in gait and sensory
disturbances though there have been cases where numbness and tinglin
have been very obstinate. The improvement in gait may be astonishing.
We have patients who could hardly walk with the aid of two canes before
starting treatment, but can now walk a short distance with no help
whatever. As we have said before, the severity of the blood changes may
or may not parallel the severity of the nervous changes.
(A) Mr. J.D. age 59. This patient was in apparent good health
until March 1932, when he noticed difficulty in walking, sense of girdle
constriction, numb feeling from the waist down, tingling in fingers and
marked weakness. These symptoms continued to get worse "in spite of
chiropractic treatment," until at the time of admission to O.P.D. September 1932, he could hardly walk with two canes and a second person's
On examination at that time his triceps and biceps reflexes were
equal and active plus 1; knee jerks plus plus plus; ankle jerks plus
plus; ankle clonus plus; Babinski positive; Romberg sign positive; vibration sense absent in the lower extremities; RBC 4,550,000; haemoglobin
108%, colour index 1.2 stomach contents—no free HCL. He was put
on Lederle's extract intramuscularly, 5cc a week. On April 20th, 1933,
7 months later, he states that he is feeling better. Last week he walked
38 blocks and worked all day in his garden. He can walk a short distance
with no assistance. He still has a great deal of numbness and tingling.
In spite of this marked improvement in his symptoms his reflexes and
vibration sense remained unaltered, except that ankle clonus was not so
apparent. His blood picture has become normal.
(B) Mr. F. B. Age 60 years. This man first came to the V. G. H.
June 1930 with history dating back to 1925. At the time of admission
he was practically bed-ridden. On examination his knee and ankle jerks
were absent on both sides; biceps and triceps equal and active; Babinski suggestive. RBC 1,600,000; haemoglobin 38%; colour index 1.2. He
remained in the Hospital from June 1930 to January 1931. From January 1931 to April 1932 he attended the O.P.D. and was on large doses
of liver extract by mouth, 4 to 5 ampoules per day. On this dose he
did not show much improvement in his nervous symptoms. In April
1932 he was started on intramuscular injections of liver extract, 3 cc
and later worked up to 5 cc. At the present time he says that numbness
and tingling is not much better but his gait is much improved; it is better
than at any time in the past three years. He can walk without canes or
assistance, whereas formerly he needed two canes. On examination
of his nervous symptoms there is practically no change in reflexes and
vibration sense, but there is a wonderful improvement in his gait.
We would like to say a few words on the inadvisability of trying to
cut down maintenance doses.
As we have indicated elsewhere, one must be very cautious about
cutting down the maintenance dose. If too little extract is being given
the poor results may become evident almost immediately, or not for
several months. For this reason we may give inadequate dosage for a long
time before this becomes evident. Last fall we tried cutting down the
dose on some of our patients, and we soon got the impression that they
were not doing so well. In giving liver extract (C.L.) by mouth, the
dose in milder cases may be only the extract from 250 grammes of liver
per day, but in Several cases larger quantities of extract, up to that from
1200 gramnes of liver per day are necessary. Most of our cases are from
50 to 70 years of age, with marked nervous lesions, and we find in some
of these, that the equivalent of 1000 grammes of liver per day by
mouth does not hold them any too well. Practically all of them received
or are receiving the extract from at least 750 grammes of liver per day.
Since giving liver extract (L) by the injection method, the dose has ranged
from the extract from 100 grammes of liver to the extract from 200
grammes of liver per week. Where patients do not respond as they should
to liver extract, one should keep in mind this question: Is our diagnosis
correct, or is the extract we are using not potent?
Another factor that has been discussed lately, is that of the need
of iron or whole liver in these cases.
It is possible that in some of these patients their iron reservoir
may become depleted, especially in relapse, and that more cases need iron
therapy in addition to liver therapy than is commonly supposed.
Since this paper was  written we have started  those patients  shewing  marked central
nervous system  lesions  on massive  doses  of  iron.
18 Years'
Page 234 INDEX
Anaemia, J. E. "Walker 219
Anaesthesia, Spinal,  W. N.  Kemp 37,   56
Annual   Meeting,    1933     ; 137
Appleby,   L.   H.   "Cranio-Cerebral   Injury" 85
Ascheim-Zondek  Trest,  E.   Gee   . 105
Biological   Products,   Karl   Meyer    33
Blood  Groups  in  Forensic  Medicine,  T.  Furuhata 203
B.  C.  Medical  Association  Constitution , 199
Brodie,   F.   J.   "Sub-Arachnoid   Insufflation" . 13
Burwell, W;  Keith,  "Metastases from Malignancy of Female Genital Tract"   164
Campbell, I.  Glen,  Osier Lecture on "The Eye" . 120
Cancer of Female Genital Tract," "W. K. Burwell  164
Cancer,  Chemistry  and  Metabolism  of,  H.   A.  DesBrisay   149
Clerf,  L.   H.   "Bronchial  Abscess,"   (Abst.)        7
Cleveland, D. E. H., "Salt free Diet in Tuberculosis" 75
Constitution  and  By-laws  of  B.  C.  Med.  Assn.   199
Coy, F. E., "Carrier's as Cause of Puerperal Fever" 148
Cranio-Cerebral   Injury,   L.   H.   Appleby    . !   85
Curtis,  E.  J..   "Thyroid  Disturbances  in  Children" 168
DesBrisay, H. A., "Some Points in the Chemistry and Metabolism of Cancer" 149
Eloesser,   L.,   "Infections   of   the   Lung,"   (Absts.)     26
Eloesser, L.,  "Surgical Treatment of Pulmonary T. B."   (Abst.)     31
Eye,   The,   I.   Glen   Campbell    i ; 120
Flothow, P.  G., "Relief of Pain on a Sympathetic Basis"  108
Furuhata,  T. "Heredity of the Blood  Groop  and  Forensic Medicine"   205
Gallie,  W.  E.,   "Obstetrical  Injuries  to Newborn,"   (Abst.)        6
Gee, Evelyn, "Friedman Modification of Zonlek-Ascheim Test of Pregnancy" 105
Gibson,    A.,    "Diary"       13
Gibson,   George  Herbert,   H.   B.   Maxwell 65
Harrison, ]. E., "Menorrhagia" _. 160
Hendry, W. B., "Problems of Pregnancy,"   (Absts.)    9, 10
Kemp,   W.   N.,   "Spinal   Anaesthesia"    37,  56
Leaves from Consultant's Note-Book, J. M. Pearson  49, 76
Lungs,   Infections   of,   L.   Eloesser    (Absts.)      26
Maxwell,   H.   B.,   "George  Herbert   Gibson"    65
Medical   Economics    (Ed.)     18,  81
Menorrhagia,  J.   E.   Harrison 160
Metastases from Malignancy pf the Female Genital Tract, W. K. Burwell 164
Meyer, Karl, "Biological Products in General Practice" 33
Middleton, W. L. C, "Transurethral Prostatic Resection"  70,  180
Narcotic   Drug   Act : . , 101
Obstetrical Injuries to Newborn, "W. B. Hendry,  (Abst.)    :—    6
Ootmar,  G.  A.,   "Typhoid   in  the  Okanagan"   72
Osier Lecture,  Dr.  I.  Glen Campbell  J 120
Pacific North West Medical Association Meeting  201
Pain,   Relief  of,   P.   G.   Flothow   108
Pearson, J. M., "Leaves from a Consultant's Note Book" 49, 76
Postgraduate  Tour,   "Dr.   Gibson's   Diary" 13
Pregnancy,  Problems of,  ~W.  B.  Hendry   (Absts.) 9,  10
Prostatic  Resection,   Transurethral,   Middleton . 70, 180
Puerperal Fever, Carriers as Cause of, F. E.  Coy , 148
Salt free diet in Tuberculosis, D. E. H. Cleveland 75
Spinal  Anaesthesia,  W.  N.  Kemp   37,   56
Subarachnoid   Insufflation,   F.   J.   Brodie    139
Summer School,  1932     3
Sympathectomy  for Relief of Pain,  P.  G. Flothow . 10
Thyroid Disturbances in Children, E. J.  Curtis  Ibi
Transurethral Prostatic Resection, W. L. C. Middleton 70, 180
Tuberculosis of Lung, Surgical Treatment,  L. Eloesser,   (Abst.)    31
Thyroid in the Okanagan, G. A. Ootmar 72
Walker,   J.   E.,   "Anaemia"    219
Page 23$ Preventing NUTRITIONAL ANEMIA
in Infants through a Normal
Nutritional anemia was present in 45% of the breast-fed and 51% of the bottle-fed
in a group of more than 1,000 infants studied by Mackay.1 Although this anemia was
of mild degree, it was sufficient approximately to double the morbidity among the artificially fd.
Anemia Prevalent
Commenting on this work,
the British Advisory Committee on Nutrition writes,
"This form of anaemia is
prevalent among infants, especially those living under
conditions of city life, and is
attributed to a deficiency of
available iron and possibly
also of copper. Its most important feature is susceptibil-
Cow's Milk, 14 oz.
Dextri-Maltose with
Vitamin B, 1 oz.
Daily Requirement *
1.01 mg.
0.166 mg.
It is generally agreed that breast milk and particularly
cow's milk are markedly deficient in iron and copper. But
when 1 OZ' of Dextri-Maltose with Vitamin B is added to
14 oz. cow's milk, properly diluted (as at 1 month), the above
increase in iron and copper results.
ity to infection, particularly a liability to colds, otorrhoea, bronchitis, and enteritis, and a tendency for infections to become chronic."2
Iron, incorporated in powdered milk, should be given as a routine to bottle-fed
infants, according to the recommendations of this committee in a report to the Ministry of Health. *r-ir  r\ r •       •    t
Milk Deficient in Iron
Stored in the liver of the full-term infant is a supply of iron and copper theoretically sufficient for the first six months of life. But actually the reserve is subject to
wide variation,1 probably because of variations in the iron content of the mother's diet
during pregnancy. Hill, for example, says, "If the mother is anemic herself, or if she
has eaten little iron-containing food during the last months of pregnancy, her off*
spring is born with an insufficient iron deposit. . . ."3
The trend is also toward
the introduction of iron-rich
solid foods at an early age.
The iron content of many
foods is variable, however.
Leichsenring and Flor4 found
that children's diets planned
to contain 5 and 8.5 ™g'
iron actually contained only-
3.25 and 6.5 mg., respectively. Pablum, higher than
most foods in iron and containing standardized amounts of this mineral can be administered as early as the
third month. Clinical studies by Summerfeldt5 show that Mead's Cereal (of which
Pablum is the pre-cooked form) is capable of increasing the hemoglobin percentage
of growing children.
* The desirable iron intake for children, according to Rose et al, is 0.76 mg. per 100 calories.    1.6 n-t;.\.___.J.L.. /». r-vjucrf
Infant of 1 month (3M lb-) and infant of 3 months (,UH lb.), both require 50 calories per lb.«        Bibliography on requa ■
Flease enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized person
Cow's Milk, 20 oz.
1.44 mg.
0.24 mg.
Dextri-Maltose with.
Vitamin B, IV2 oz.
°-855 ..;;
Mead's Cereal (dry), */4 oz.
or Pablum
Daily Requirement*
When 14 °z. of Pablum is fed to the 3-months-old infant
receiving 20 oz. cow's milk and 1V2 oz. Dextri-hialtose with
Vitamin B, a significant increase in iron and copper takes
.rsoou | *3**>JSil
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