History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1948 Vancouver Medical Association Jan 31, 1948

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Full Text

 THE
BULLETIN
Published By
The Vancouver Medical Association
EDITOR:
DR. j. H. MacDERMOT
EDITORIAL BOARD
DR. D. E. H. CLEVELAND
DR. H. A. DesBRISAY
Editorial and Business Office
203 MEDICAL-DENTAL BUILDING
VANCOUVER, B. C.
DR. J. H. B. GRANT
DR. D. A. STEELE
Publisher and Advertising Manager
W. E. G. MACDONALD
VOL. XXIV
JANUARY, 1948
No. 4
■• ft v."
m- '■>'■'■
Dr. G. A. Davidson
President
OFFICERS, 1947-48
Db. Gobdon C. Johnston
Vice-President
Db. H. A. DesBbisay
Past President
Db. Gobdon Bubke
Hon. Treasurer
Db. W. J. Doebance
Hon. Secretary
Additional Members of Executive: Dr. Roy Huggabd, Db. Henby Scott
TRUSTEES
Db. A. M. Agnew Db. G. H. Clement Db. A. C. Fbost
Auditors: Messbs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Db. Reg. Wilson Chairman Db. E. B. Tbowbbidge—Secretary
Eye, Ear, Nose and Throat Section
Db. Gordon Large Chairman Db. G. H. Fbancis Secretary
Paediatric Section
Db. J. H. B. Gbant Chairman Dr. E. S. James Secretary
Orthopaedic and Traumatic Surgery Section
Dr. J. R. Naden Chairman Dr. Clarence Ryan Secretary
Neurology and Psychiatry
Db. J. C. Thomas _Chairman Db. A. E. Davidson Secretary
Rlf$
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affile sI??.V'-flM
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STANDING COMMITTEES
Library:
Db. J. E. Walker, Chairman; Db. W. J. Dobrance, Dr. D. E. H. Cleveland,
Dr. F. S Hobbs, Dr. R .P. Kinman, Db. S. E. C. Tubvey.
Publications:
Dr. J. H. MacDebmot—Chairman; Dr. D. E. H. Cleveland, Dr. H. A.
DesBrisay, Dr. J. H. B. Grant, Dr. D. A. Steele.
,•■!(.> .lv-'-   •- - ■ ■ 0.*.'
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has received the A.M.A. seal of
approval.
ORTHO PHARMACEUTICAL CORPORATION (CANADA) LIMITED
TORONTO VANCOUVER MEDICAL ASSOCIATION
Founded 1898     :    Incorporated 1906.
Programme for Fiftieth Annual Session
(Spring Session)
February 17th    CLINICAL MEETING—St. Paul's Hospital, Nurses' Auditorium.
I March    5 th (Friday)    OSLER DINNER AND LECTURE—Hotel Vancouver, Banquet Room.
Osier Lecturer—Dr. Murray Blair.
March 16th        CLINICAL MEETING—Children's Hospital.
:4r'"f<
April    6th
GENERAL MEETING—Auditorium, Medical-Dental Building.
Speaker—to be announced.
April 20th CLINICAL MEETING—Place of meeting to be announced.
May   4th
ANNUAL MEETING—Auditorium, Medical-Dental Building.
Breaks the vicious circle of perverted
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tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian
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normal menstrual cycle.
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Full formula and descriptive
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Dosage:   l to 2 capsules
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Page 110 ■■wf
The rationale of
"ENZIFLUR"
therapy
As an Aid in the Prevention of Dental Caries
It has been suggested1 that fluorine may be adsorbed on the
surfaces of the enamel through the medium of the saliva. Investigations reveal that the fluorine may then combine with enamel
to form fluorapatite thus rendering the tooth less susceptible to
caries attacks. Recent clinical studies2 of 512 children showed a
decrease of 77 per cent, in the incidence of dental caries in subjects
receiving "Enziflur" — calcium fluoride with vitamins C and D.
Each "Enziflur" Lozenge supplies 2 mg. of calcium fluoride,
30 mg. of vitamin C and 400 Int. Units of vitamin D. Available in
bottles of 30 and 100 lozenges.
1. Leicester, H. M.: J. Am. Dent. A. 33:1004 (Aug.) 1946.
2. Strean, L P., and Beaudet, J. P.: New York State J. Med. 45:2183
(Oct. 15)1945.
M
ENZIFLUR
m
No. 805
AYERST,   McKENNA   &   HARRISON   LIMITED
Biological and Pharmaceutical  Chemists
MONTREAL CANADA
wvBk
465 VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
§: ■ city        - J|    •§■
STATISTICS—NOVEMBER, 1947
Total Population—Estimated jj j 339,350
Chinese Population-*-Estimated  .       5,980
[Hindu Population—Estimated  11 g
Rate Per 1000
Number Population
Total   deaths        400 14.3
Chinese deaths       17 34.6
Deaths, residents  only_i . I 378 13.1
BIRTH REGISTRATIONS:
Male I IH    407
Female        377
784 28.1
INFANT MORTALITY: November, 1947
Deaths under 1 year of age       15
Death rate per 1000 live births       25.5
Stillbirths (not included above)         7
December,
1947
17
19.7
10
CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY
November, 1947
Cases    Deaths
December, 1947
Cases     Deaths
Scarlet Fever	
Diphtheria	
Diphtheria Carrier.
Chicken Pox	
Measles	
Rubella
'lUDeua	
Mumps	
Whooping Cough
Typhoid Fever
Typhoid Fever Carrier.
Undulant Fever _
Poliomyelitis	
Tuberculosis	
Erysipelas-
Meningococcus   (Meningitis).
Infectious Jaundice	
Salmonellosis	
Salmonellosis  (Carrier)	
Dysentery	
Dysentery  (Carriers)	
Tetanus ■	
Syphilis	
Gonorrhoea	
Cancer (Reportable):
Resident	
Non-Resident	
1
0
25
98
3
21
3
2
1
5
0
45
6
2
0
1
0
1
0
0
65
218
94
14
0
0
0
0
0
0
0
0
1
0
0
0
15
0
2
0
0
0
0
0
0
0
0
0
0
12
1
0
36
61
7
27
8
0
0
2
0
54
5
1
0
1
0
0
0
0
0
0
97
44
0
0
0
0
0
0
0
0
1
0
0
0
13
0
1
0
0
0
1
0
0
4
0
0
0
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Page 111 LIVER   EXTRACT   INJECTABLE
(15 UNITS PERCC.)
FOR THE TREATMENT OF PERNICIOUS ANAEMIA
The potency of Liver Extract Injectable as prepared andi
supplied by the Connaught Medical Research Laboratories is
expressed in units determined by actual responses secured in thei
treatment of human cases of pernicious anaemia.
The high concentration of potency of this product makesi
possible a small dosage and less frequent administration.
Because of the low proportions of total solids in the product,
discomfort and local reactions occur very infrequently.
HOW SUPPLIED
Liver Extract Injectable (15 units per cc.) as prepared by the Laboratories
is supplied in packages containing single 5-cc. vials and in multiple packages
containing five 5-cc. vials. The larger package is for the convenience of
hospitals and clinics, and is also available to physicians.
CONNAUGHT MEDICAL RESEARCH LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. 7<4e ZdUori, Paae
It cannot be denied that medical science and the art of medicine have made outstanding progress in the last fifty years. Our knowledge of disease, its causes, diagnosis
and treatment, have advanced more rapidly in that time than in the hundred years preceding. Our hospitals are miracles of efficiency, and daily thousands of lives are saved or
prolonged, and suffering mitigated or dispelled, where fifty years ago, patients suffering
from the same diseases were doomed to an inevitable death.
Another department of medical practice in which great -advances have been made,
is the training of nurses. The fully-trained nurse of today is a highly-skilled, technically
expert woman, equipped to undertake procedures of which her predecessor of fifty
years ago had never heard, and for which she recived no training—anaesthetics, intravenous therapy, intricate surgical and medical techniques, and so on. Without her skilled
help and trained knowledge, much of modern medicine and surgery would be impossible.
This is all excellent, and as it should be. But there is a big question mark which faces
us, and grows ever more demanding of an answer: and it is "what of the patient?" What
of the sick man or woman of today, who needs medical and nursing care? And especially
the latter?
It reminds us of a well-known book on Hospital Management that was published
some years ago; on its front cover were printed the five functions of a hospital. Briefly,
they were as follows: First, to be a health centre for the community; second, to train and
educate doctors; third, to train and educate nurses. The fourth has slipped our mind—
but we remember very vividly that the fifth and last was "To take care of the sick."
There is a moral in this, and one that we would do well to consider. All medical
science, all nursing, all our advances in knowledge, have, really, only one justification,
and that is "To take care of the sick." Ail the other considerations are very important,
but they are secondary, as far as the practising doctor and nurse are concerned. But we
are losing sight of the first consideration, the patient. It is becoming increasingly difficult
for the sick man to obtain medical care that he can afford—hospital costs are rocketing
out of sight—a special nurse can hardly be found when he needs her—hospitals cannot
staff their wards.
Where is this all going to end? And is it not time that all concerned got together,
and made an earnest effort to find an answer to this very serious question?
Let us consider for a moment the nursing shortage. A very thoughtful and very
provocative article, published in a weekly known as the Commonweal, has recently
come to our attention—and it contains so much that must appeal to everyone who has
thought of this problem, that we feel it might be worth while to give a brief resume of
it. It is called "The Nurse and the Specialist" and is written by E. M. Bluestone, the
Director of Montefiore Hospital, New York. Whether Dr., Mr., Mrs. or Miss, we do not
know—but that does not matter.
This writer brings out clearly one or two facts. One is, that while "We are told by
the statisticians in the nursing profession, that we are graduating more nurses than
ever before," this is really a misleading statement. There are two things a graduate in
nursing can do—one of them is bedside nursing. In Bluestone's opinion, this is the only
activity that can be called "nursing," and we shall probably agree. The other activity is
specialisation by one who has had a three-year nursing training. She may specialise in a
hundred different ways, but she has ceased to be a "nurse."
It is the shortage in nurses (bedside nurses) that is serious. As to why nurses give
up nursing, to become laboratory, operating-room, industrial, public health, executive,
etc., specialists, there are probably a great many good reasons, economic security, special
Page 112
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M adaptability, and so on. Perhaps these are not impossible of solution—one very potent
cause is the lack of security that faces the bedside nurse. The author says of this nurse
"At her best she is a necessity, and that is why we want enough of them to go around
when the need is genuine. In fact, we ought to have a surplus, and should be willing to
pay for it through some form of unemployment insurance. It would be difficult to find a
profession that is more worthy of the benefits of social security than the profession of
nursing."
Would this be enough? The author does not think so—He or (she) thinks that
there are additional and deeper reasons. "After a certain point is passed, the more professional and the more educated the nurse, the less desirable she becomes at the bedside.
We have now before us the paradox of nurses who are too good for bedside nursing. Do
we need, and can we afford, a highly educated registered nurse for the sick on all occa
sions f
We must have bedside nurses: who can and will nurse, well and efficiently, the
sick patient. Have we set our sights too high, in our curriculum of training for nurses?
Do we, by our high standards or pre-training education, lose a great deal of competent,
excellent nursing material? Is our training curriculum too advanced or complicated?
(eight or ten lectures each in neurology, psychiatry and the like?) This writer thinks
so, and suggests some degree of lowering of academic requirements before training, revision of curricula, additional types of training, shorter and devoted entirely to training
for bedside nursing, and so on. This would staff our sick rooms and supply bedside nursing
in sufficient amount, without interfering with those who wish to take the more advanced
course, and at the end of them specialize in one of the many directions which our highly
specialised age has opened up. The writer ends:
"Our nurse-training programme, noble in conception though they have undoubtedly
been, have in actual practice overshot the mark and defeated our ends. We must try
again while benefiting from the mistakes of the past."
LIBRARY NOTES
HOURS—
Monday, Wednesday and Friday.  9.00 a.m. to 9.30 p.m.
Tuesday and Friday.- .  9.00 a.m. to 5.00 p.m.
Saturday L  9.00 a.m. to 1.00 p.m.
RECENT ACCESSIONS TO LIBRARY—
Transactions of the American Association of Genito-Urinary Surgeons.
Medical Annual, 1947.
Progress in Neurology and Psychiatry, Vol. I, 1946, and Vol. II, 1947, Edited by
E. A. Spiegel.
Gifford's Textbook of Ophthalmology, 4th ed., 1947, by Francis H. Adler.
Concepts and Problems of Psychotherapy, 1947, by Leland E. Hinsie.
Psychosurgery, 1942, by Walter Freeman and James W. Watts.
Their Mothers' Sons, 1946, by Edward A. Strecker.
Our Age of Unreason, 1942, by Franz Alexander.
A Textbook of Clinical Neurology, 6th ed., 1947, by Israel S. Wechsler.
Disease of the Nervous System, 5th ed., 1947, by F. M. R. Walshe.
An Introduction to Dermatology, 11th ed., 1947, by Walker and Percival.
Page 113 CORRESPONDENCE
Editor,
Vancouver Medical Association Bulletin,
925 Georgie St. W.,
Vancouver, B.C.
The Vancouver General Hospital is desirous of announcing to the medical profession that the Pediatric service in our Outpatients Department has been extended. I
would appreciate therefore, if you would give the following announcement publicity
for the next issue of the Bulletin.
"The Childrens Outpatient Department of the Vancouver General Hospital has
been expanded greatly in the past few months and patients may be referred for consultation daily by appointment. Clinic hours begin at 9.00 a.m.
"A fully qualified and experienced Pediatrician is in attendance each day at this
time and it is intended that the system of giving written reports to practitioners on
their patients shall be greatly extended."
Thank you very much for your consideration of this request and with kind personal
regards.
Yours sincerely,
R. A. Seymour, M.D.,
Asst. Director Medical.
•«»•'
The Editor,
Bulletin of the Vancouver Medical Association,
925 West Georgia Street,
Vancouver, B.C.
Dear Sir:
The Metropolitan Health Committee, School Health Division, has underway a
survey to study the problem of obesity in children. This will be an attempt to arrive at
conclusions regarding the causative factor in each case, be it glandular, poor food habits,
etc.
May we through the medium of your bulletin, request the assistance and cooperation of the practitioners of the district. When definite information is gained, it will
be made available to all who are interested. The plan of the survey is outlined as follows:
1. Students included will be those who are 30% or more overweight according to
the height and weight standards of Wood. There are approximately 500 students in the
survey to date. Two hundred of these will be plotted in retrospect on the Wetzel Grid
in an endeavour to get more information regarding the first tendency towards obesity.
If this proves profitable, grids will be obtained for the total number of students.
2. The study will include a physical examination, and a thorough inquiry into the
dietary habits, familial background and socio-economic status.
Since a complete physical examinations is not possible with the facilities at our
disposal and since we do not undertake any treatment, many of these children will be
referred to their private physician for these. The majority of them are probably already
attending the doctor.
In every case where a private physician is named, he or she will be contacted by
the School Medical Officer. It would be of great assistance if the doctor will make his
findings available to us. On the other hand, it is possible that we can assist in the treatment of the case in our follow-up. We have on our staff a well-trained nutritionist, who
is taking an active part in the study. If the doctor will indicate the caloric intake which
has been prescribed, she will outline a well-balanced diet designed for the individual.
It is planned to follow as many of these students as possible for a number of years,
in order that results of treatment may be assessed. In some cases of overeating an emo-
Pagell4
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"••Vfes-s- tional problem exists, and these students will be referred to the Mental Hygienist on
our staff.
Thanking you for your co-operation in printing this, I remain
Yours truly,
Stewart Murray, M.D., D.P.H.,
Senior Medical Health Officer.
Publication of the B.C. Formulary has now been completed and copies are available
for distribution to the medical and pharmaceutical professions. The bulletin was prepared by a point committee of the B.C. Medical Association and the B.C. Pharmaceutical
Association, and the publication has been financed by the latter group. Copies can be
secured on application to the new offices of the Pharmaceutical Association, 310 Dominion Bank Building, 207 West Hastings Street, Vancouver.
The provincial social assistance authorities, as well as municipal authorities in many
parts of British Columbia, have issued official advice that prescribing for patients in
receipt of social assistance or pensions must in future be confined to the B.C. Formulary
•unless special authority has been secured for prescribing elsewhere. Pharmacists throughout British Columbia have been advised by the provincial social assistance authorities and
by the majority of municipal authorities that their accounts will not be paid where it
is shown they have dispensed prescriptions outside the B.C. Formulary.
The following is part of a letter received from Mr. F. H. Fullerton, Manager of the
B.C. Pharmaceutical Association of B.C.:
UI know this point is a contentious one but on the other hand our own members
are faced with the alternative of either turning down descriptions or knowing they will
not be paid for them if they fill them, and therefore, from their point of view it is most
desirable that as many medical men as possible should know that the new Formulary is
available."
ANNUAL SESSION
BRITISH COLUMBIA SURGICAL SOCIETY
March 18th and 19th, 1948
The Session "will be held in the Vancouver Hotel.
Guest Speaker—Dr. R. M. Janes, Professor of Surgery, University
of Toronto.
There will be a series of sixteen, twenty-minute papers, followed
by discussion of a wide range of surgical subjects, including general
gynaecology, thoracic, orthopaedic and urological branches of surgery.
All scientific sessions are open to the members of the medical profession at large.   Every practitioner will be made most welcome.
A limited number of rooms have been reserved at the Hotel
Vancouver for out-of-town visitors. These may be had by direct
application to the Hotel.
Registration fee for the session is $5.00.
Page 115 Vancouver Medical  Association
President j ! _ Dr.  G. A. Davidson
Vice-President  Dr.   Gordon  C.  Johnstone
Honorary Treasurer Dr. Gordon Burke
Honorary Secretary Dr. W. J. Dorrance
Editor . Dr. J. H. MacDermot
msim
DUODENAL ILEUS (WILKIE'S SYNDROME)
§ ARTERIOMESENTERIC ILEUS
F. W. GRAUER, M.D.
Presented May 27, 1947
This syndrome has to do with extrinsic obstruction of the third portion of the duodenum in the region of the superior mesenteric vessels. Bloodgood was one of the first
to recognize the condition postmortem. Stavely, also of Johns Hopkins, did the first
duodeno-jejunostomy for this condition in the first decade of this century. \
The pathological background in the great majority of instances is related to a failure
of proper development of the mesentric attachments of the small and large bowels to
the posterior abdominal wall. This permits a hypermobile ptotic condition in which the
weight of the bowel is suspended by the superior mesenteric vessels and their branches
rather than the mesenteric leaves themselves. As a result the third part of the duodenum
becomes compressed between the aorta and spine posteriorly and the uperior mesenteric
vessels anteriorly.
In addition to this purely mechanical situation there may be developmental bands,
adhesions and in some cases an acquired pathological lesion such as lymph node enlargement at the root of the mesentery giving rise to obstructive symptomatology.
Wilkie's classical description of the symptomatology has associated his name with
this syndrome. "The patient is usually a female of somewhat spare build and of a vis-
ceroptotic type. She gives a history of stomach trouble for many years, usually since
childhood. She will state that she has always had to be careful of what she ate, otherwise
she suffered from epigastric pain and flatulence. Periodically she has had 'bilious attacks',
with nausea and vomiting. At the age of thirty or thereabouts the symptoms become
aggravated. Epigastric discomfort and flatulence follow all but the simplest of meals.
Walking and standing aggravate these symptoms; rest in bed gives a certain amount of
relief. In addition to the chronic flatulent dyspepsia so ^suggestive of a biliary condition
they suffer from what they term their 'attacks'. These are the typical popular bilious
attacks consisting of first a day of headache and nausea and epigastric discomfort, sometimes amounting to actual pain; this is followed by vomiting, first clear, then bilious.
This may last for a whole day, after which the patient feels completely relieved, although
relatives remark that she looks hollow-eyed and has a tinge of jaundice. Such attacks
tend to recur at intervals of from four to five weeks, and are ushered in by constipation.
In a few cases the nausea, headache, lassitude and epigrastric pain are the most pronounced symptoms, and vomiting is an occasional late symptom. In such cases it would
appear that a tonic pylorus resists the duodenal tension until at last it gives way, bile
regurgitates, is vomited, and relief is obtained. The persistence of such symptoms over
a prolonged period is apt to lead to a state bordering on, if not actually of, neurasthenia,
when the subjective symptoms complained of multiply by analysis and make diagnosis
more difficult."
Page 116
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lfe.fp!L The present case has to do with an example of an acquired type of dynamic duodenal J
ileus.    For brevity only the positive findings in the case history will be presented.
The patient is a white female, aged 30, married and has one child born in 1945.   She!
was admitted on Aprjl 4, 1947.
Complaints: A feeling of fullness in the upper abdomen after meals for the past four J
years.. Gas pains, fatigue and weight loss for the past year.    Nausea and vomiting after
larger meals on several occasions, associated with constipation since December, 1946.
H. P. I.: The patient was never one to enjoy robust health. About four years ago]
she began to suffer from a feeling of fullness in the epigastrium as though her stomach j
was not emptying. This would occur after even a very small meal, and when the meal i
was large she would develop nausea and vomiting of undigested food prefaced by crampy a
pains in the epigastrium. These attacks have become progressively worse. There has 1
been no haematemesis.  Her appetite has remained good but unsatisfied.
Past History: This patient has suffered from ill health since infancy.    She was born j
in 1917, was breast fed for a short time, was unable to nurse from a bottle and took
cow's milk from a cup.    She had frequent vomiting and diarrhoea with light colored j
stools which were bulky.   Her abdomen was large and buttocks wasted up to about the j
age of 6 years.    This history is very suggestive of cceliac disease.    At the age of 6l/z \
years she had a ruptured appendix which was treated by drainage only.   She became very j
ill until the age of 8.    At 9 years she had her appendix removed.    At the age of 10 an
incisional hernia was repaired.    During these years little food seemed to agree with her
and she became a nutritional problem.    She had intermittent bouts of constipation and j
diarrhoea until the age of 16.   At the age of 18 her menses began with a heavy flow and
irregularity which aggravated her anasmia.   She had a miscarriage at the age of 25 years.
Physical Examination: The patient is a fair complexioned, pale, lean female of slight
build.    Her best weight was 155 pounds four years ago.    Her present weight is  100 i
pounds.    The B.P. is 110/75.
Abdomen: The abdomen is scaphoid and soft.    There is mild tenderness under the \
right rectus above the umbilicus.    There is no muscle splinting.    The liver and spleen
are not palpable and there is no gall-bladder tenderness.    There is a small soft palpable |
mass in the mid-line at the level of the pancreas gland.   This could be the pancreas itself.
Otherwise examination of the abdomen including rectal and pelvic, is negative.
lymphs,
I
Laboratory: R.B.C. 3,800,000, Hb 80%, W.B.C. 6000, 56% polys, 38%
6% monos.
Fasting blood sugar 75 mgm%.
Gastric analysis Free HCl 5, Total 15 in 3 hours.
Urinalysis—normal.
G. I. X-ray series. This showed dilation of the second and third portions of the
duodenum with spasm of the first portion. There was a definite hold-up of barium at
the approximate site of the superior mesenteric vessels. This appeared to be an extrinsic
stenosis of the third part of the duodenum. At operation on April 10, 1947, the gallbladder was normal, there were no adhesions related to her previous operation. The peritoneum throughout had a peculiar slimy consistency. On raising the transverse colon,
the pancreas was of normal size but appeared a muddy gray color. The greater omentum
was quite atrophic and shrivelled to a small thin mass along with antimesenteric border
of the transverse colon. At the root of the superior mesenteric vessels was an aggregation of small pink soft lymph nodes embedded in fibrous connective tissue which gave
bulk to the root of the mesentery as it crossed in front of the duodenum. There were
no enlarged nodes elsewhere in the small bowel mesentery. The bowel itself appeared
normal except for a pale slightly thickened slimy serosa.
Page 117 Duodenojejunostomy was carried out bringing the first loop of jejunum to the right
side in front of the superior mesenteric vessels and joining it to the mobilized portion of
the third part of the duodenum to the right of the said vessels by lateral anastomosis.
Follow Up: The patient has had no further attacks of crampy epigastric pain with
lusea and vomiting. She is able to take a normal sized meal without discomfort. She
has some gas which is probably related to her low stomach acid.
Perhaps the most important single test for this condition is the X-ray finding of
stenosis and dilatation of the duodenum. Remembering that the pathological sequence
of partial obstruction is first increased peristalsis, then hypertrophy and finally dilatation, the finding of the latter justifies exploration and a short-circuiting operation.
TREATMENT OF CARCINOMA OF THE BREAST WITH
§ TESTOSTERONE THERAPY     |l
By W. M. TOONE, M.D., F.R.C.S., Edin.
(Read before the North Shore Medical Society, November,  1947.)
I was stimulated to enquire into the treatment of carcinoma of the breast with
testosterone when atending Sir John Fraser's Clinic in Edinburgh. This method of attack on carcinoma of the breast follows a line suggested by Herbst in Estrogenic Therapy of Prostatic Carcinoma. It is thought that control of glandular structures by sex
hormones is lost and carcinoma results. In this regard Mrs. Dawson has pointed out that
the curve of incidence of cancer of the breast is closely similar to the curve of incidence
of the menopause and concludes that a co-relation exists between the two. It has been
demonstrated that in a certain group, X-ray therapy has brought about a considerable
improvement. In this proportion of cases it was thought that by giving testosterone the
patient would be swung still more to the male side and that the temporary effect produced
by ovarian irradiation might be converted into a more permanent effect.
This work began in March, 1946, when I selected twelve cases which came to me in
practice. Ten of these cases had had radical mastectomies and there were two in which
the tumour remained. The last case followed died recently and so my report has been
delayed. All patients were given X-ray radiation to the ovaries. I have given 25 mgm of
testostone (Perandren)  twice weekly.
Mrs. M.—age 58. Radical mastectomy 1945, glandular and bone metastasis. This
patient had excruciating pain from bone metastasis and had morphine gr i frequently
during the day. After testosterone therapy her pain subsided, indeed she rarely had to
have morphine, her appetite improved and she died two months after treatment began,
in comparative ease.
Mrs. McW.—age 62. Radical mastectomy 1945. Glandular metastasis with severe
brachial neuritis. Pain much less severe—this patient died three months after onset of
testosterone therapy.
Mrs. A.—age 55. Radical mastectomy 1944, large ulcerating lesion from X-ray
burns. Glandular metastasis. No imprervement noted. Patient died two months after
therapy.
Mrs. I.—age 64. Radical mastectomy 1944. Bone and glandular metastasis. Pain
very severe. This was almost completely relieved by therapy. Patient died five months
after treatment started.
Mrs. S.—age 52. Radical mastectomy glandular metastasis. It was noted that the
glands diminished greatly in size and in some areas disappeared. This patient who was
going downhill rapidly lived for six months after therapy was initiated. The glands did
not return and she had a peaceful end.
Page 118
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mm*?.
MS Mrs. C.—age 56. Bone and glandular metastasis following radical mastectomy in <
1943. Considerable pain in lumbar region. Pain markedly relieved but patient died two j
months after therapy started. Sjl^^I
Mrs. C—age 80. Ulcerating scirrhous type of carcinoma. The ulcer healed com- <
pletely. Patient died of pneumonia ten months after having testosterone therapy.
Mrs. F.—age 60. Radical mastectomy 1944. Glandular metastasis, considerable- \
brachial neuritis. Pain relieved—patient died two months after therapy was initiated.
Miss C.—age 54. Radical mastectomy 1944. Glandular metastasis. No improvement with therapy.
Mrs. T.—age 49. Radical mastectomy 1944. Glandular and bone metastasis. Bedridden when seen and having considerable pain. Patient was able to sit in chair, and pain
was relieved after treatment. Patient died in ten weeks in comparative ease.
Mrs. M.—age 57. Radical mastectomy 1943 with glandular metastasis. Considerable
improvement seen in general condition but died two months after treatment.
The twelfth case proved to be very interesting. Treatment started in May, 1946,
and the patient died in October, 1947. This patient was 62 years of age and had had a
history of ulcerating breast since 1937. The ulcer was a deep suppurating wound two
hands' breadth in size covering the left breast and going into the axilla. There were
numerous palpable glands of both axillae, supra and infra-clavicular regions and many
nodules of the skin. There was a tremendous oedema of the left arm, the patient being
unable to use the left shoulder. She had complete paralysis of the lower limbs with incontinence of urine and faeces. Section taken at the edge of the ulcer proved it to
be an adeno-carcinoma and X-ray of the spine showed metastasis with collapse in the
lower dorsal region. Three months after the start of therapy the dirty ulcerating breast
was completely healed. Nodules in the skin disappeared and nearly all the many glandular
secondaries ceased to be palpated. Function of the limbs slowly returned and the patient
regained control of the sphincters. She was able to sit up in a chair for the first time
in two years. The voice became male in character and she was forced to shave her beard.
This improvement continued over a period of 14 months when she gradually started to
go down. Paralysis returned and she died 18 months after her first treatment.
Conclusions:
(1) In patients with metastasis from carcinoma of the breast testosterone therapy
combined with ovarian radiation alleviates pain considerably, especially in those who
have done bone metastasis.
(2) This treatment appeared to have hastened the end rather than prolonged life, but
the last days were more tolerable.
(3) It was not successful for cure in any case, although one patient lived 18 months,
and her breast tumour and secondaries disappeared. It may be that the benefit is
obtained because although testosterone is essentially an androgen it can also produce
an oestrogenic effect.
(4) I believe this form of treatment does produce an improvement but it is generally
only temporary in nature. It may well be used in the last stages of the disease for
relief of distressing symptoms and a more peaceful ending.
My grateful thanks are due to Ciba and Company who furnished the testosterone
to carry out this treatment.
References:
1. Personal Communication from Sir John Fraser.
2. Personal Communication from Dr. R. McWhirter.
Radiologist Royal Infirmary, Edinburgh.
Page 119 British  Columbia  Medical  Association
(Canadian Medical Association, Britsih Columbia Division)
President Dr. G. A. Davidson
President-elect Dr. Frank Bryant
Vice-President Dr.  Gordon C.  Johnstone
Honorary Secretary _ 1 Dr. W. J. Dorrance
Immediate Past President j Dr. Ethlyn Trapp
TREATMENT OF PSYCHONEUROSIS IN GENERAL
If ■- . PRACTICE    § Jf,
By V. GORESKY, M.D., Castlegar, B.C.
The attached paper will be of great interest to the general profession of B.C. and
we are grateful to Dr. Goresky for offering it to us for publication. It will, no doubt,
excite considerable discussion.^—Ed.
On finding that psycho neurotic patients with* and without** somatic disease
could densensitize themselves with help in two to five days, I began to investigate the
matter and used the following technique:
1. First, a rapport is established with the patient in a sitting position facing the
desk. All discussion is carried on in a friendly, personal manner, talking to the
patient on his own level as a personal friend and not as a superior. After rapport
is thoroughly established, a complete psychiatric history, especially with reference to all repressions, is obtained. He is asked to tell about all unpleasant
factors in his past and present life, especially those experiences that he does not
like to think about and tries to push away or "forget" when the memory of
them is recalled. Two hours or more are spent in eliciting all unpleasant details.
If one or two factors are held back it is immaterial as they will be desensitized
automatically along with the rest when he begins to feel improvement.
2. The patient is then told to go home and relive mentally and recall all past
unpleasant memories in every detail. He is asked to do this four to five times a
day for four to five days and then come back. He is also told how to correct any
interpersonal or environmental factors present; that is, how to solve any family
disturbances or problems in connection with his wife, husband, children or inlaws. Financial and occupational problems are also discussed and suggestions
made. The marital partner is then called in and interpersonal factors explained
and he or she is told what to do to provide a relaxing environment for the patient, and how to rule out in-law relationships or other interpersonal relationships. Every factor, and how to take care of it, is worked out in detail. In repressed experiences, the exact experiences are pointed out and how to desensitize
them is explained. In environmental factors, each one is pointed out and the
solution as to how best to carry it out is suggested. The exact wording to use so
that no one is hurt, or is hurt as little as possible, is suggested to the patient. The
solution provided must always be such that he will see that no one near and
dear to him has his feelings hurt. For this reason the exact wording or phrasing
must be suggested to him. If it is found that he is unwilling to do the "painless
surgery," the physician must do it himself, seeing his wife and explaning what
** Patients without somatic disease are those with mental symptoms only.
* Patients with somatic disease have both mental and physical symptoms or physical
disease.
Page 120 is necessary The choice of language is very important. The most personal ques
tion asked in one way, in a certain tone of voice, might be resented but if worded
differently it does not bother the patient. For instance, if a female patient is
asked if she is jealous of her husband and "nags him," she will deny it indignantly. If asked if she is hyperattached to and possessive with her husband, and
feels she cannot share his love with anybody else, even his mother or children,
that is quite readily admitted. The husband and wife are warned not to hurt
each other's feelings, and if they have done so to make it up at once regardless
of who is at fault.
In four to five days the patient usually comes back with conflicts, misconceptions,
obsessive reactions and most other mental and physical symptoms gone. Even migraines
and hysterical paralyses are relieved partially or completely. If the symptoms have not
cleared up, or are not clearing up in that period, the trouble is usually in environmental
or interpersonal factors. These are then examined in detail for the damaging factors. In
patients with poor insight, past unpleasant factors give a clue as to the present difficulties
by acting as sensitizations to them. These are located. Using the patient's somatic reactions as a check, they are gradually brought up to the patient's conscious mind in
such a way that their logic is irresistible to him. His own feelings tell him it is right.
Another method often used with a patient with high resistance is to get him to relax
and think back over his life, and to use especially that period between sleeping and waking to examine any thoughts which come up spontaneously. If they give a somatic or
psychic reaction, then he is told to desensitize these experiences also by going over them
four to five times a day for four to five days.
The patient is then instructed to keep going over all repressed material for the six
weeks that emotional re-education is carried on. He is frequently checked up on. After
the first ten days or so, he can reduce the number of repetitions of desensitizing to two
a day and progressively lessen the number of times he goes over the repressed material.
Finally, desensitizing once a week may be all that is necessary. After the first week, repressive factors do not cause any reaction.
For adjustment in environmental factors, a basic unit of father, mother, children
and the occupations and problems of each is used. A psychoneurotic in a home often
causes chain reactions such as peptic ulcer or hypertension in the marital partner, or bed
wetting or bronchial asthma in children. These were treated by adjusting family relationships and cleaned up in most cases.
Many patients who "could not carry on another day" were within four days able to
carry on their normal occupations easily and without upset. Later, as they are able, their
activities are increased to capacity as their abilities increase, but they are taught that
they have a ceiling. Find what it is and warn them not to exceed it. In six week's time
they learn how to adjust their activities, occupations and otherwise to their ceiling. Only
great physical or emotional strain will cause a slight temporary recurrence. With a little
Benzedine Sulphate—2.5 to 10 mgm., they can outface even these with a minimum of
disturbance. Patients with poor insight try to overdo things and can cause recurrences in
this way, but a little help puts them back on the track when necessary. These are few
and far between in this series of cases. Over one hundred cases were treated and fifty
histories kept. The patients are available for observation. The same ailment in different
patients can be caused by different combinations of past and present factors or of just
past or just present factors.
So far, one outright failure was met as far as cure is concerned because of an insurmountable interpersonal factor which meant divorce and children suffering. It was a
"shot gun" wedding to begin with and he hated his wife. Also, co-operation was poor.
Symptoms cleared in 80%, improved in 15%, while 5% were unco-operative. In
the 15% improved the failure to obtain complete cure was due to irreversible morphologic changes. In a diabetic of twelve years' duration, her insulin requirements dropped
from twenty to eight units of protamine zinc in twenty-four hours and her mental out-
Page 121 ook improved. Several cases of glycosuria associated with emotional conditions cleared
Lp completely. The syndrome frequently present in diabetes is a hyperattachment to a
parent or a marital partner with tension and quarreling in the home. In thyroid cases
mere was often a fear reaction producing mental conflict.
Emotional factors were located first, then treatment and observation of what happened in the various diseases carried out. A great deal of this work was done, of course,
[without financial remuneration. In nearly every case of chronic disease of unknown
origin improvement or cure, mostly cure, was obtained. The vast majority of chronic
cases of unknown origin fall under the classification of psychoneurosis, with somatic
disease. In fact, any chronic ailment seems to benefit to some degree from psychiatric
! treatment and, in my opinion, it should be used in them routinely. With this quick
technique it does not take long and some surprising results may be obtained. In addition
to psychoneurosis with and without somatic disease, it was found that in conditions like
divorce problems, delinquencies, sex perversions and even crimes which are due to obsessive compulsive reactions, this technique is of definite value. The underlying basis in
social misbehaviour is often a psychoneurosis and many apparently react quite well. It is
a field which will bear further investigation with this technique.
Discussion
Neuro-muscular nerve tensions are caused by some great insurmountable past mental
repression or present environment factor or a series of such small factors building up
cumulatively. In locating possible factors it is found that a mental conflict often gives
a clue to the type of environmental factor and vice versa. If one is present, searching for
the other along these lines and desensitizing the mental factor and correcting the environmental factors is the usual procedure. Mental conflicts act as sensitizations to the environmental conflicts. Further, it is found that most patients have symptoms involving many
organs of the body if they are looked for, but usually one organ is involved so much that
it overshadows the rest and claims the patient's whole attention to its symptoms.
Certainly, the best and quickest results are obtained in patients having a high intelligence, a higher education or more insight into themselves. Techniques are varied with
age, education and intelligence of the patient. In this series, this technique has given an
extraordinarily high rate of cures. The cures were permanent in those with good insight
and high intelligence. Those with poor insight got great temporary relief from symptoms,
but as in all psycho-therapy would not live within their limits. These patients would
permit environmental factors to build up and had to come periodically for readjustment
and education as to how to overcome these factors, until finally they learned their lesson
thoroughly in the hard way. In any case, they were much better treated on this field
than on the surgical or medical field. The improvement was much longer, the illness
slight and a few minutes talk was all that was necessary to relieve any recurrence of
symptoms. This was in spite of the fact that it was necessary to fight the battles of
psychiatry as well as treat every patient.
Children are treated best on a simple relationship level. The cause of the ailment is
the handling of the child by the parnt and rarely by the teacher. The cause is nearly
always found in the parents and psycho-therapy is given to them. It is a chain reaction.
Often the parents are psycho-neurotic or ill, or too busy to give the children the
emotional satisfaction they crave. The mother and father are taught to pick up their
children and pet them three to four times daily, giving plenty of praise and encouragement to avoid hurting their feelings and always to explain reasons for so doing when it
is necessary to do so. Only enough discipline is permitted to give proper training to the
child and this is rarely necessary as a reproof is generally enough for a hypersensitive
child. Reproof or discipline should always be followed within a few minutes by a demonstration of affection and an explanation as to why it was necessary. Bronchial asthma,
bed wetting, stuttering, various behaviour problems and stomach disorders such as poor
appetites, nervous diarrhoeas, etc. react in a startling fashion. In a few minutes to a few
hours symptoms start to clear up. The only psycho-neurosis in which there is any difficulty with this technique is in the hysteria group who have a fatal facility for blanking
Page 122
fpfll
Wa
j-; •■«.." :J
|p-; r / ..;
! *f out unpleasant memories. Uncovering psycho-therapy is used. This work is done on a
theory that apparently all psychoneuroses with and without somatic disease are due to
conditioned, reflexes caused by psychological stimuli. The stimulus may be in the past.
If it is of sufficient magnitude and is always present in the mind, as a repressed thought,
it may constitute what is called a mental conflict. It may be in the present with the past
factors acting as sensitizations, or it may be that a series of past and present stimuli act
cumulatively.
By reliving past experiences (that is, bringing out the repressions) the mind is
desensitized to them and some relief can be obtained (Freud & Bruer principle). Removing the stimuli by adjusting environmental factors completes the job, but once a pathway is established, emotional re-education or education in psychiatry is necessary to
teach the patient how to meet future situations which may act as stimuli to this type of
reaction. The most important part is to each the members of the family group to understand each other so as not to hurt each other's feeling and to make up quickly if they
do get into a quarrel.
Desensitizing the mind by reliving past experiences, raises the tolerance for the <
patient; that is, it requires a greater stimulus to set the reflexes in motion but it is very
questionable whether the reflex is ever completely eliminated. Therefore, emotional reeducation in meeting certain situations which might start th reflex operating is necessary.
Mental conflicts however, once desensitized, do not recur as it takes time to reestablish them. If they are acting as factors in creating tension then once they are desensitized the patient's resistance to environmental stimuli is raised to the extent that the
conflict contributed to his tension. If a conflict could recur, the patient could desensitize
it himself as before so there is no danger. Also by keeping in mind or remembering unpleasant experiences for a few days; i.e., not repressing them, the mind desensitizes itself
so they can't recur.
All emotions such as fear, worry, anxiety, hate, jealousy and conscience factors,
etc., can cause these stimuli as mental conflicts or as environmental factors, by causing
repressions of the past factors or some lack of expression in present ones. Translated into
occult or religious terms, any sinful or wrong thought or deed or fear is punished in the
man by this means. Through religious channels, therefore, cure may also be obtained.
Religious education and emotional re-education, faith and auto suggestion, confession
and psychiatric history, prayer and desensitization, may be considered as alternatively
similar psychologically and can be used optionally depending on the psychology or religious beliefs of the patient.
As mentioned, difficulty in treatment with this technique was only encountered in
the hysteria forms. In this group either better information has to be obtained from relatives or uncovering psychotherapy (narco-analysis or hypnosis)' practiced. In treatment
some autosuggestion and some desensitization is possible. In this series all cases so far
have been solved with uncovering psychotherapy and information from relatives, usually
the husband.
It is realized that most psychiatrists may claim that the percentage of relief from
symptoms is high. The percentage depends on the ability of the psychiatrist to establish a
proper rapport, to get the co-operation of the patient and, further, on his ability to
persuade the patient that his interest is personal. Embarrassing transfers of affection do
not occur in this technique, owing to the speed and the fact that the patient desensitizes
himself.
It is about two years since it was found that most patients could desensitize themselves sufficiently in two to five days to become symptom-free in psychoneuroses with
and without somatic disease, with a little help. Also, they could.analyze themselves with
their own somatic reactions as a guide provided they were taught and guided in the
process.
Page 123 Advantages of Techniques:
1. Speed—in two to five days physiological tension is released and the patient's cooperation assured.
2. Improvement can be promised within such a short time that the patient is more willing to co-operate and unless a patient is willing to co-operate reasonably it is not
possible to help him.
3. As the patient is partly his own confessor (although he may retain some factors)
little resistance is met and so narco-analysis, hypnosis, shock therapy, etc. need rarely
be used. To date there has been no great trouble in getting information necessary
from the patients.
4. Because of the speed and the patient doing his own desenstitizing, no embarrassing
transfers of affection are involved as in the longer techniques.
5. It can be used in more acute cases if necessary.
6. Less financial cost to the patient is involved.
Disadvantages: *mm
1. The technique is so simple that there is danger of quacks and other people without
sufficient medical and psychiatric training using it with incomplete results as to
re-education.
2. A physician without a sympathetic personality, knowledge of psychiatry and insight
as to possible causes of neuroses and have some practice in application may be unable
to apply the technique properly.
3. As with psycho-analytic techniques, the psychiatrist should put himself through this
technique before attempting to treat patients. This, if he is hypersensitive, will give
him greater insight into his own psychological reactions and, therefore, the patient's.
Comments:
The percentage of cures may seem high but of the first six cases treated with this
technique (two anxiety neuroses, one a reactive depression, one migraine which was
almost constant, one case of essential hypertension, one case of hysterical anaesthesia)
five lost their symptoms completely and one partially. This relative average continued
through the testing period on chronic ailments, many of which.were not known or
expected to be on the emotional field. Psychoneurosis without somatic disease such as
anxiety neurosis, obsessive compulsive reactions, depressions, etc., seemed to react quickest
and to give best results. Apparently the biggest single factor in creating psychoneurosis
is the impression that all people have and even are taught in schools that if an unpleasant
experience is undergone the way to get rid of it is to "forget it." The patients spend all
their lives trying to do this and their nerves get worse and worse until actual suffering and
mental, physical and asocial behaviour occur. By application of Freud's and Bruer's principle any repression, brought from the subconscious to the conscious repeatedly, disappears. By trying to remember unpleasant experiences till the conscious mind files them
away, and adjusting environmental and interpersonal factors in a home to make them
suitable by means of emotional re-education, a lot of suffering would be prevented.
Very few people have will power enough to repress every unpleasant experience
indefinitely and, even in them, efficiency is cut down. Even in the strongest minds the
ability to repress is governed by the sensitivity of the patient (the higher fhe I.Q. the
greater the sensitivity), the amount of unpleasant experiences or trouble and. the magnitude of these experiences. A sufficient amount of unpleasant experiences will break even
the greatest mind. In teaching, therefore, trying to remember unpleasant experiences
rather than trying to forget them should be the rule. If this fact is pointed out to a
psychoneurotic he immediately reverses his attitude towards his repressions. He reports
less difficulty in remembering them than in trying to repress them and improvement
follows in a few days. The type of symptoms, mental, asocial or physical, is not important. The Department of Mental Hygiene, Ottawa, states that 56% of all our children
Page 124
fjM- are slated for nervous troubles. This figure may be too low if chronic disease is added to
this score. The more complex life gets in a higher civilization the more traumas and
repressions multiply unless handled this way.
It was interesting to find that psychoneurosis with and without somatic disease
were found in introverts and mixtures of introvert and extrovert personality types.
Hysterical symptoms developed in extrovert personalities. This is in line with Pavlov's
work on conditioned reflexes in dogs. As one would expect, therefore, treatment of the
hysteria groups tends to fall mainly on the invironmental field whether interpersonal relationships or occupational while in the first two groups the treatment falls either on the
mental conflict field or both mental and environmental.
(With acknowledgment and thanks to Dr. G. A. Davidson and Dr. D. Williams for
their help and support in preparing this paser.)
CASE HISTORY
Mrs. R.B.
Age 40. First seen January 14th, 1947.
Symptoms:
Nervousness, hands and feet stocking anaesthesia, no feeling and no circulation in
the fingers from the palm down. She has cut her fingers with a knife and experienced no
pain or bleeding. Symptoms started over two years ago, at first sporadically, later more
or less constantly present. At first only the hands were affected, then the feet, and later
spreading to the face. Her back feels cold and clammy. She complained of sleeplessness,
tremor, migraine and specks before her eyes.
Past History:
She came from a large family and lived in a small town. Her father drank steadily
and heavily. She rather envied other children. She was chased by an Indian as a child. She
has always tried to forget this episode as she was badly frightened. It recurs in dreams
occasionally. She married quite young and had two children. Her first husband was
killed and she married again and moved to a different town to live. Her home burned
down and her husband developed tuberculosis. She had a hard time trying to live on
$40.00 a month. She was also frightened here by an Italian peeping through her window.
She has two children by her second marriage. Her youngest child, twenty-two months
old, is not walking and does not try to even pull herself up. Child developed spastic condition of limbs. Husband was in the Sanatorium, later returned and she had to go in.
Physical Examination:
X-ray of chest negative. Blood negative. Urinalysis negative. Intense tremor of
fingers and apparent deadness of half of hands.
Diagnosis:
Hysterical Anaesthesia.
Treatment:
Mental repetition of past repressions and unpleasant experiences. Anaesthesia began
to let up within twenty-four hours. Little environmental adjustment could be done at
the time. Later the child was treated successfully. In order to help maintain improvement
and make it permanent some adjustment in finances was made by the Social Welfare.
On January, 15 th, 16th, and 17th the hands cleared up. She was awake all night after a
house party and the condition of her hands returned temporarily. After the third consultation the hands stayed clear for days.
February 4, 1947—reports complete freedom from tension. Sleeps well. Condition
of hands good. Patchy recurrence once when she went to a ladies' meeting.
February 7th—reports hands turn bluish and whitish for a few minutes. She does
prescribed mental exercise and they clear up immediately. She can banish the anaesthesia
at will now.
Page 125 February 14th—husband sent to the Hospital with pleurisy. Anxiety made hands
blanch a little but she removed it voluntarily in a few minutes.
February 23 rd—she has had no recurrence since to date and feels she no longer requires treatment and feels capable of handling the matter herself now.
October 16th, 1947—recovery complete as no recurrences of anaesthesia since February 24th, 1947.
CASE HISTORY OF CHILD OF MRS. R.B. MENTIONED ABOVE
Baby L.B. Age 22 months.
Diagnosiss
Spastic muscles of back and legs. Baby unable to life itself in crib or walk. Saw
child first January 16th, 1947. Diagnosed as a condition following premature labour
and fear of walking in the child (hysteria).
Treatment:
Mrs. B. was advised to massage the muscles of back and legs but to also try and
teach the child to get up and overcome the fear complex and the fear of pain.
January 22, 1947—Mrs. B. reported she had gone into the bedroom and the child
had pulled herself up in the crib for the first time.
January 27, 1947—child gets up herself and tries to walk holding on to objects but
is still a little stiff.
February 4, 1947—child lifts herself easily and can walk if one hand is held. Stilt
a little stiff and uncertain about knee movements.
February 8, 1947—child took two steps alone.
February 14, 1947—child very active and walking quite freely with support and
sometimes without.
October 18, 1947—recovery complete and child normally active.
Comments on Mrs. R.B. and Baby L.B.:
The chief value of these two cases is to show that mental factors and environmental
are cumulative in their results. Reliving past factors was sufficient to relieve this patient's anaesthesia in spite of her child's ailment. In order to make it lasting the child's
condition had to be improved. In spite of financial troubles such as supporting a sick
husband and two children on $40.00 a month, recovery was possible. This was the patient
who led me to investigate other types of somatic disease. If emotional factors could
cause circulation to be cut off in such diverse places as hands, feet and face, then the
same thing could happen in any gland or organ or blood vessel in the body with disastrous results as in diabetes, hyperthyroidism, anginas, essential hypertension, etc.
CASE HISTORY
Mr. L.S.
Age 35. Teacher. Came to see me October 21st, 1946.
Mental History:
Brothers used to scare him as a child in,the dark by imitating wolves. Scared him
so that he was scarcely able to breathe. From 1914-1919, during school years, children
called him German and used to gang up to beat him up. Later he fell while mountain
climbing and held on to a ledge for some considerable time until rescued. During young
manhood he married and had difficulties with his in-laws. His wife died and this left him
with a sense of guilt in taking her away from home.
Page 126 Symptoms:
Later he developed an attitude of superiority to people in order to show how tough
he was, but he was always afraid that he might be considered weak and so was more
aggressive. He became chronically tired, unable to work or concentrate. He began to
drink heavily but it only relieved him temporarily. Gradually he became more tense and
nervous. Developed a fear of heights and driving in high places. He became more irritable.
Would find himself holding himself tense, even while writing on the blackboard, for fear
of falling. Dizzy spells came on. He had had gastric trouble for years, diagnosed as
mucous colitis. He developed fear of knives and started to hide them. He developed fear
of going insane and contemplated suicide. Heart palpitations made him miserable. He
saw mai^r doctors and was diagnosed as neurasthenic. Migraine constant.
Physical Examination:
Rapid pulse rate with extremely frequent extra systoles. Very nervous. Pain in
epigastrium. Otherwise negative. Tachycardia at times. X-ray—mucous colitis. Electrocardiogram normal. Urinalysis negative. Gastric analysis normal. Neurological examination negative.
Diagnosis:
Anxiety Neuroses.
Treatment: '^M
Mental repetition of all past repressions. All signs and symptoms and obsessions relieved in four days. Environmental factors cut down activities to just school teaching
temporarily. Mucous colitis cleaned up about the tenth day. Emotional re-education
carried on for five weeks.
Result:
January 4, 1947—completely cleared up in two weeks, gradually increasing confidence in himself. Extra systoles only under great emotional or physical strain. Has become more alert and ambitious toward his school work. Has more pep and again has
started to do a little Insurance business. Is returning to his University studies and can
do ten times the work he had been able to do in years. His constipation has cleared up
and bowels are looser and normal for the first time that he can remember. He was discharged from treatment on December 16, 1946, symptoms all cleared up.
January 26, 1947—some symptoms recur only if awake 36 hours working or under
excessive emotional strain, then an odd systole appears and cramps, pain and tenseness
occur in the epigastrium. This is only fleeting and if he rests up or the strain is relieved
he is back to normal.
Comments:
This case is a typical case with homicidal and suicidal obsessions. In four days it
clears up when the patient relives all the unpleasant experiences in his past life which he
tries to forget. Because an experience is unpleasant, and the training we get teaches up to
try to forget unpleasant experiences, this type of case results. The patient tries to block
off or blank out of his conscious all unpleasant memories. When the thoughts recur he
represses them and gets somatic symptoms for which he consults medical men who treat,
but cannot control the symptoms, because they are mental. In time the memories or
experiences create a confusion and come out in a distorted form. As the patient was highly
intelligent the cause of his symptoms was explained and that the symptoms were not
dangerous. Further, he was told that if he tried to remember all unpleasant experiences
and the symptoms became worse for a few days, not to worry about them but keep on.
In four days he feels as if a cloud has rolled off his mind and he feels better physically
than he ever felt before. Nerve tension is released and all symptoms disappear. During
moments of great physical or emotional stress, or when very tired, a slight warning
tension develops and he immediately takes measures to control it by rest or cutting down
his worries. The patient, by the way, is carrying on about five occupations at one time.
Page 127 One year later, October 16, 1947—patient feels fine and mental and physical improvement still increasing.
CASE HISTORY
Mrs. D.R.
Age 42. First seen on January 25th, 1947.
\Symptoms:
Nervousness, increasing since last baby;  melancholia;   depression;  loss of sexual
[desire; at times wishes she were dead; afraid of insanity; considers suicide by drowning
sometimes.
Previous History:
As a child—negative. Before marriage, as mother and father were going to Canada,
j forced their hand with pregnancy and married husband. Came to Canada a year later.
Husband had work at first but later they had to live on relief. Did not want children,
committed abortion. She has a large family—one girl 17 years old, last baby a few
! months old. Developed depression and melancholia during last pregnancy,  gradually
getting worse. Treated for nervousness since and afraid of having more children. One of
the girls, age 15, is a problem.
Mental Traumas:
Aside from being high strung and tense all her life, none till pregnancy before
marriage.
Maid-of-Honour for her sister in church. Mistook directions from her sister and
wandered into the wrong place during the Wedding March. She was in a near accident on
a bad road later. Domestic sexual difficulties increasing and husband rebellious. Cannot
go to the show or among people or listen to the radio as head aches too much and she
gets too upset.
Diagnosis:
Depression and migraine.
Treatment:
Being tired, this patient was asked to go home and relive all past unpleasant experiences in order to be able to give me a connected story in two or three days. Within
twenty-four hours improvement set in. Depression and migraine started to lift.
February 4, 1947—patient reported by husband to be joking and laughing for the
first time in many months. Emotional re-education was carried on for five weeks. The
patient's condition was explained to the husband and daughter and their co-operation
established.
Comments:
This patient was under treatment for migraine and depression for four years before
I saw her. She has five children and in spite of the responsibility of looking after them
and settling their disputes which make her nervous at times, she is adjusting satisfactorily
at to date, October 18, 1947.
Page 128 fyoMJcotuj&i Qene/uU ^o4^Uai Section
CARCINOMA OF THE COLON AND RECTUM
DR. A. T. HENRY
Carcinoma of the colon and rectum occupies a prominent place in the field of major
surgery. It carries with it a great responsibility because of its complications, for one
does not have only to contend with the area of tumour itself but with potential infection and associated obstruction as well as with debilitated patients due to delayed diagnosis. When we realize that between 10 and 15% of all cancer of the body arises in
this area it behooves us to attempt to arrive at earlier diagnosis than records in the
General Hospital would indicate. Particularly is this true in light of the diagnostic
measures which we have at hand. It would appear that at least 60% of these growths
are visible to the naked eye if they are looked for. Also as this is primarily a disease of
the fourth, fifth, sixth and seventh decades and as life expectancy is becoming more
^prolonged we can expect further increase in its incidence. However records indicate
thif disease to be present in the younger age group as well as in the later decades, and
one cannot emphasize the importance of a thorough and complete examination of all
patients with any irregularity of bowel habits. In this series 4% were below the age
of 45.
A review of the cases in the Vancouver General Hospital in the year 1944-45 showed
94 new cases admitted for treatment. This was out of a total of 637 cases of al' cancer
and out of a total of 25,431 cases admitted to the hospital in the year (15%). This
average is about the same as other years, for in a previous paper several years back I
quoted 104 cases out of a total of 970 in 1941 or 11%.
The age incidence was:
20-30  ; .  2
31-40  : 7_ ... 2
41-50   4
51-60   23
61-70  I  33
71-80   27
80 plus   4
Total . 94
In this group there were 51 males and 43 females, but over a long series it will be
found that it is pretty well divided between the sexes.
The sites of growth in this small series were:
Caecum      0
Ascending colon      7
Hepatic flexure  .     5
Transverse        6
Sp'enic flexure      3
Descending colon  |     5
Sigmoid   3 2
Rectum   3 2
Anus      4
The above figures show the great necessity for the use of the sigmoidoscope.
Page 129 The symptoms are all well known to us and include:—
1. Bleeding from the anus.
2. Irregularity of bowel action.
3. Pain—a late sign.
Bleeding is seldom severe even though constant. In fact the most severe haemorrhages I have seen have been from diverticula rather than carcinoma. The blood is usually
mixed with mucus and "may be a late symptom.
The irregularity of bowel action is related more to the growths in the sigmoid and
I rectum and is of two kinds. Firstly the slowly developing constipation due to narrowing of the lumen and secondly the so-called intermittent diarrhoea. The latter is not
I a true diarrhoea but rather a feeling of unsatisfactory elimination so that the patient
after defaecation has a desire soon to return to stool. This is due to the bowel trying to
I get rid of a foreign body not normally present. In taking a history, therefore, it is
important to separate a true diarrhoea with profuse loose stools to that of an urgency
' and only the passage of mucus and blood. Patients in general do not so distinguish
unless it is explained to them. Therefore if a patient calls up for something to stop his
i or her diarrhoea, one should be sure to find out the details and if it is more than a
transient condition be sure that he or she is properly examined.
Pain can be of two types. Firstly the intermittent colicky pain of a progressing
obstructive lesion found over the site of the growth and infrequent on the right side
because of the watery content of the bowel. The second is the constant dull nagging
pain found in rectal growths. In the advanced group with secondaries along the lumbar
glands we get the pain radiating down the back of the thighs very much as in the referred pains of disc lesions. This may become Very severe and mistaken for sciatica and
rheumatism and has in our hands been best handled with chordotomy. Dr. Turnbull has
done quite a number of these operations for us, both in inoperable cases as well as postoperative cases later developing these manifestations.
The records also brought out an interesting point in the number of hospital beds
held up in these cases. There was a total of 4330 days in hospital or an average of 47.5
days per case. The longest stay in hospital was 296 days. These number of days could
be greatly reduced if we had nursing-home facilities to look after these people. There is
urgent need for such facilities.
It was difficult to analyze a lot of the histories for statistical points due to poor notes
and in fact no histories at all. Some of this can be accounted for by shortage of internes
due to the war and also to overwork on the part of the doctors themselves and inability
to keep up with their charts. However, it would appear that the mortality rates in all
cases operable and non-operable were 35 deaths out of the 94 within a year or 37%.
These were divided into—
Non-operable—9 cases who were all advanced or complicated with such conditions
as uraemia and diabetes.
Operated upon—25. Of this group 16 died within 30 days, an immediate mortality
of 64%.
Some of the causes listed were:
1. Paralytic ileus—3.
2. Leakage at anastomosis—3.
3. Anaesthetic deaths—2 possibly 3."
4. Coronary occlusion.
5. Pneumonia and volvulus.
6. Perforation of growth and peritonitis.
7. Obstruction following caecostomy.
So much then for statistics. Let us now consider the more practical aspects of examination, diagnosis and treatment.
Whenever a patient presents himself with the symptoms and signs already discussed
you must verify with the following examination.
miU
mmf,
,-»■;.
:if'v
Page 130 1. Digital—Although important is probably the least so of all procedures. Remember you cannot feel piles and you may not feel the growth or polyp. One has seen many
a case in which a digital examination has not been done and of course that is unpardonable. The chief point I wish to make is not to be satisfied with a digital examination
only.
2. Sigmoidoscope—This is absolutely essential for everyone who bleeds from the
anal orifice. Because you see haemorrhoids and they look red do not be satisfied with
that for most people have them to some degree. Never do a haemorrhoidectomy without
having a sigmoidoscopic examination done. It is not pleasant for yourself or your patient
to have them return later with an obvious growth, and this has occurred on more than
one occasion. In probably 15 % of people an expert cannot get the sigmoidoscope beyond
the recto-sigmoid. If no growth is seen and you are suspicious, and you should be if
signs and symptoms are related, then use the X-ray.
The X-ray—Too often in my opinion the first thing that is done is to have an X-ray
examination. This is the wrong procedure. There are two reasons why. Firstly, when
you can feel and visualize a case why waste the time and money of your patient. Secondly, many cases come to you verging on obstruction and barium by mouth or barium
enema completes it. Therefore if you finally have to fall back on the X-ray use only
the barium enema, and be sure to have an understanding with your radiologist that
if fluoroscopically he runs into a hold up or obstruction, he stops and takes his picture.
Barium proximal to a constriction is a nasty and unnecessary complication, adding to
difficulty of a satisfactory operative procedure later.
One might just add a word by the way regarding the use of a sigmoidoscope.
Anaesthesia is seldom necessary except in small children or occasional painful rectal
conditions. It should be done either on a tilting table like the Buie table or in the knee-
chest or shoulder position. Personally I like the latter best because it allows better
sagging of the abdomen. As I have previously mentioned, if everyone had one passed
on himself there would be more respect paid to gentleness and consideration of the
patient. Actually it is an instrument that requires experience to handle and to know
what you see. It is one of our most valuable instruments and also one terribly neglected.
The average interne is not interested greatly in it until he gets into practice and finds
he knows nothing about it. If one passes the sigmoidoscope on enough patients the
normal becomes familiar, so that any suspicious lesion is picked up and can be verified
by another opinion if necessary.
Let us now consider the management and treatment of this condition. One has only
time in a paper of this length to touch on a few important details. Firstly let us consider the obstructive cases. As mentioned before, beware of a barium enema. A flat
plate is of considerable importance in distinguishing the site and if there is distension
and vomiting a primary deflation such as a caecostomy is most essential. Tubal suction
preceding this for a few hours will of course make it easier to do.
Before proceeding with the major part of some time of resection good pre-operative
attention is a must. Personally, if these people can be got out of bed I prefer it. Too
much bed and inactivity predisposes to weakness. Blood chemistry must be brought up
to as close a normal as possible. This includes blood transfusions and the use of amino-
acids and chlorides of ten. lowered by vomiting and diarrhoea. Use compound vitamins
especially the B's. The use of intestinal antiseptics such as sulfasuccidine for a few days
pre-operatively to cut down the intestinal flora is becoming generally accepted.
The use of anaesthesia. Many of these patients are elderly and suffer from disease
of. the circulatory system. Those especially with high blood pressure do not react too
well to spinal anaesthesia. Of the old anaesthetics ether intratracheally is the best.
More recently we have used curare with cyclopropane on some with excellent results.
Finally the various techniques of operation can be found in text books. One, however, might mention a few points. Even in the presence of secondaries in the liver
which are not too far advanced-1 believe the primary growth should be removed if
possible.  Aside from making the patient's end more comfortable, I feel that it retards
Page 131 the secondary growths. Anterior resection and end-to-end anastomosis is the operation
of choice, and it is amazing how growths below the pelvic floor can be mobilized and
brought up to allow this procedure. The question of preliminary colostomy such as the
Devine type with end-to-end anastomosis or whether one needs the colostomy is a debatable point. There are the two schools of thought. With proper preparation of the
colon and the post-operative use of antibiotic drugs I have had excellent results by
simple anastomosis using two layers of sutures and interrupted silk. It certainly saves
the patient a lot of time and money.
Late advances in low resection with preservation of the sphincters offer better results
surgically and socially than hitherto prevailed;
Lastly I would like to mention the use of the electro-cautery. Fulgurization has a
prominent place both in the treatment of early cases and of the late ones. It is amazing
for example in the former, particularly in elderly people, how the growth can be destroyed and inhibit that unfortunate constant irritable purulent discharge and constant
desire for stool. This may or may not be done in association with a colostomy. In the
early cases, and this includes a polyp, it is a comparatively simple procedure. Whether
a cancer arises in a predominantly sessile state or as a malignant change of a large polyp,
one can readily destroy the growth. A growth, shall be say, with a basal diameter of
that of a twenty-five-cent piece can be so treated with reasonable hope of a cure. A
number of these cases have been followed over a five-year period without recurrence.
One of course does not necessarily destroy the growth at one sitting. It may take several sittings to do so and recurrences, usually around the perimeter, may show up months
later but they can easily be handled in the same manner. In growths of larger size
involving half the diameter of the bowel one should not be very optimistic as to results
by fulguration, as in these cases lymphatic spread has to be considered. Obviously to be
sure in these cases complete excision is the only sure attempt at cure. I feel that with
experience one can rather well define the superficial type of growth amenable to fulgurization by vision through the sigmoidoscope. In the malignant polyp type it appears
more or less Uke an extension of a vine along the wall of the bowel as compared to the
perforating or ulcerative type of growth involving the bowel wall.
$Mg\
■BiRi
SURGICAL TREATMENT OF HYPERTENSION
M. ALBERT MENZIES, M.D.
The poor results of medical treatment of hypertensive vascular disease have focussed
increasing attention on surgery in the management of this condition. The two main
groups of surgical treatment are, first, surgery for known definite organic lesions causing hypertension; and second, treatment of essential hypertension by sympathectomy.
To dispose briefly of the first group this paper proposes only to mention some of the
more important of definite hypertension-producing lesions amenable to surgery. These
include unilateral kidney disease, brain tumour (or other cause of increased intracranial
pressure), coarctation of the aorta, pheochromocytoma, adrenal carcinoma, chorion-
epithelioma, hyperthyroidism, arrhenoblastoma, adrenal-like ovarian tumour.
In all these conditions the surgical treatment is to deal with the lesion in question.
In cases of unilateral renal disease, Ratliff reports improvement or cure in about 50%
after nephrectomy. Smithwick treated eleven cases of- pyelonephritis by sympathectomy
with 100% good results. Ratliff has studied a large series of cases; and he tel's us the
best hypertensive candidates for nephrectomy are "adult" chronic pyelonephritis, hydronephrosis, and calculous pyonephrosis. He found this type of surgery advisable in less
than 5% of hypertensive patients.
The main portion of this paper is devoted to treatment of essential hypertension by
sympathectomy.   Our ignorance regarding the etiology of this condition precludes a
Page 132
WrW
mm I
M
V ••j^r-'."-''.
mmmm J sound elaboration of rationale for any type of treatment. The theories backing up
sympathectomy bank heavily on prevention of neurogenic renal ischaemia by section of
the nerves. Also considered are decreased peripheral resistance from vascular relaxation
in the splanchnic bed and lower extremities; and reducd secretion of adrenalin from
emotional stimulus.
Sympathetic nerve section was first tried in 1925 for hypertension by Rowntree and
Adson. But it was not seriously considered and investigated until 1935. Since then the
pioneers Adson, Crile, Peet and Smithwick have led the way, aided by contributions of
Grimson and several others. Four main types of procedure are still mentioned in the
literature. Inf radiaphragmatic splanchnicectomy, done by Adson and Craig at the Mayo
Clinic, seems to produce more temporary results than other methods. Bilateral supradiaphragmatic splanchnicectomy has been performed by Peet in 1500 cases over a period
of thirteen years. His results are characterized by marked symptomatic relief and moderate blood pressure reduction. Smithwick combines these two procedures, with more
consistent lowering of blood pressure, accompanied frequently by sterilization in males.
Arrived at by experimentation, this is the most favoured operation to date, and Smithwick has reported on its use in 500 cases. Almost total sympathectomy has been tried
by Grimson, but most observers feel this probably is more extensive than necessary.
No one yet can say which will turn out to be the best procedure.
The mortality of sympathectomy is less than 3% in good hands. Peet describes his
method as a single operation lasting forty-five minutes to an hour and a half. He has
most patients up in one week; two weeks in hospital and four weeks rest at home; a
total of six weeks before the patient returns to work.
Several important criteria are considered in selection of patients for operation.
Smithwick bases selection on age, eyegrounds, diastolic blood pressure level, response of
blood pressure to sedatives (sodium amytal test), state of cardiac function and state
of kidney function (phenol sulphonephthalein test). Age should be under 53 and
preferably under 3 0, but may go up to 5 8 for incapacitating symptoms. Recent evidence
of coronary disease and renal failure are contra-indications. Peet prefers NPN under
40. In the absence of intractable cardiac decompensation, gross cardiac enlargement is
not necessarily a contra-indication. In fact many cases show striking post-operative
reduction in size of enlarged hearts. A cerebrovascular accident contraindicate operation
if severe brain damage has occurred, but not so in a patientjunder fifty who has completely recovered from the accident. Encephalopathy is unfavourable if mental changes
are marked and of long duration or mild but due to repeated thromboses. However, in
cases of mild, recent encephalopathy one may expect complete recovery post-operatively.
Of great significance is the patient with malignant hypertension. Recognized by
eyegrounds with papilloedema-and usually haemorrhages, exudates and angiospasm, high
diastolic blood pressure, usually moderate to severe renal damage and varying degree of
heart damage, the outlook of this patient with medical treatment is absolutely hopeless.
But if cardiac and renal damage are not far advanced, operation is indicated and may
give a very good result.
Peet's ideal case for sympathectomy is under 54 years of age, with a more or- less
continuously elevated blood pressure systolic over 170 and diastolic over 105 mm., NPN
'ess than 45, a well compensated heart and relatively normal cerebral function. He
makes notable exceptions in cases with incapacitating symptoms or in otherwise hopeless malignant hypertension.
Results of sympathectomy have been very encouraging. Life expectancy seems to
be increased in many cases of malignant hypertension, particularly if surgery is not too
late. Usually most marked is symptomatic relief. Peet reports headaches, nervousness,
insomnia and palpitation greatly or completely relieved in 86% of those still living
5 to 12 years after operation. This relief of symptoms does not seem to depend necessarily on significant lowering of blood pressure or improved heart or kidney function.
55% of his completely incapacitated patients were able to return to their former work
and 81.3% to some kind of work.
Page 133 Although less prominent than symptomatic relief, lowering of blood pressure has
been the usual result following sympathectomy. In 81% of those still living 5 to 12
years after operation in Peet's series, both systolic and diastolic levels were significantly
reduced. An increase was found in 6% and no change in 13%. Of the 81% good
results, one-fifth were graced by normal blood pressure levels. Including cases that died,
significant blood pressure reduction occurred- in 46.7%. Smithwick's more extensive
procedure improves this figure to 79.4%. With a preoperative grading into three types
according to pulse pressure, he has found the best results in type 1 (pulse pressure less
than half the diastolic pressure). Thus the best response to surgery is found in the
group least responsive to medical treatment.
Similarly in the ophthalmoscopic picture, the more advanced the ocular changes the
higher the percentage of improvement. Disappearance of angiospasm, haemorrhages and
exudates has been reported in 82% of cases; even blindness has been relieved by sympathectomy. In Peet's 21 malignant hypertensives still living, papi'lodema disappeared in
all cases and has never returned. Improvement or lack of progression of retinopathy
is the rule in the great majority of cases.
4 Cardiac enlargement has shown a significant reduction in 52% with striking hymp-
tomatic improvement. The electrocardiogram has returned to normal in a significant
number of cases. Paul White js study reported great frequency of marked post-operative
improvement in the electrocardiogram.
Improved renal function has been shown by return of urea clearance to normal in
45% and improved concentrating power in the same number of cases.
The generally typical picture of significant objective response and marked subjective improvement is illustrated by the results of Berwald and Devine. Adson's and
Smithwick's techniques gave them an average reduction of 78 mm. in systolic and 15
mm. in diastolic pressure, with objective improvement in 64% of cases and subjective
improvement in 92.5%.
During the past thirteen years essential hypertension has been treated by section of
splanchnic nerves and removal of part of the thoracolumbar sympathetic chain in at
least 2,500 reported cases. Usually either a single operation or two stages ten days apart,
operative mortality is less than 3% in skilled hands. Operation has resulted in a very
high frequency of relief from incapacitating symptoms. In a large percentage of cases
significant lowering in b'ood pressure has been obtained, along with arrest and even
reversal of retinopathy, cardiac, renal and cerebral changes. Patients totally disabled
for long periods of time up to four a*nd one-half years have been restored to normal
earning capacity. Malignant hypertension is not always hopeless, as excellent results are
frequently obtained by thoraco-lumbar sympathectomy.
Internist and surgeon alike emphasize assessment of progression of disease. Uncertainty of results requires presenting facts to the patient before advising operation. In
the words of Peet, "surgical treatment is a measure to be considered in management of
every case of essential hypertension, but to be used only when indicated. Evidence of
progression and activity of hypertensive disease is the indication for surgical treatment."
BIBLIOGRAPHY
Hinton, J. W., Thoracolumbar Sympathectomy in Essential Hypertension, N.Y. State ournal of Med., 44:
884, 1944.
Atchley, Dana W., Medical Treatment of Uncomplicated Hypertensive Vascular Disease, N.Y. State Journal of Med., 44: 2683, 1944.
Ay man, David, Present Day Treatment of Essential Hypertension, Med. Clin, of N.A.,  1141, 1944.
Berwald and Devine, Surgical Treatment of Essential Hypertension, Am. J. of Surg., 64:  3 82,  1944.
Peet and Isberg, Surgical Treatment of Arterial Hypertension, J.A.M.A., 130:  467,  1946.
Peet, Max Minor, Results of supradiaphragmatic splanchnicectomy for arterial hypertension, New Eng.
J. of Med., 236: 270, 1947.
Smithwick, R. H., Surgical treatment of hypertension—effect of radical lumbodorsal splanchnicectomy
on hypertensive state of 156 patients followed 1-5 years, Arch. Surg., 49: 180, 1944.
Page 134 Smithwick, R. H., Technique for splanchnic resection for hypertension, Surgery, 7:  1, 1940.
Smithwick, R. H., Some  circumstances under which lumbodorsal  splanchnicectomy appears  inadvisable,
N.Y. State J. of Med., 44: 2693, 1944.
Ratliff, R. K., et al., Nephrectomy for Hypertension with unilateral renal disease. J.A.M.A.,  133: 296,
1947.
Grimson, Keith S., Total thoracic and partial to total lumbar sympathectomy and coeliac ganglionectomy
in treatment of hypertension, Ann. Surg., 114: 753, 1941.
Bridges, Johnson, Smithwick and White, Electrocardiography in hypertension, J.A.M.A., 131: 1476, 1946
INFECTION AS RELATED TO MATERNAL MORTALITY
J. W. MILLAR, M.D.
In the past 15 years there has been a steady decrease in maternal mortality. In 1930
the rate for the United States was 6 per 1000 live births. In 1942 it was 2.5 per 1000.
The decrease has been in relation to all causes, but in recent years has been particularly
noticeable in the field on infection. This general decrease has been due to many factors
including education of the profession, education of the la/ public, better hospital facili-
ties and recent advances in medicine, notably the advent of penicillin, sulfonamides and
streptomycin. With regard to infection, it is noted that in 1941 38 percent of all
maternal deaths in the United States were due to infection.
A very interesting paper was presented by staff members of the Chicago Lying-in
Hospital last June reviewing maternal mortality between 1931 and 1945. Their statistics with regard to infection are most interesting. The mortality from all infection was
39 percent of the total, and included 32 deaths. Of these, 19 were due to genital infection and 13 due to extragenital infection. They have classified infections into two
groups:  (a) genital, and (b) extragenital.
Classification of Infections.
(a) Genital—arising within genital tract.
Organisms present in their series were represented as follows:
1. Haemolytic strept     9
2. Anaerobic strept.      4
3. Bacillus Welchii .    2
4. Others    I     4
Total    i  19
(b) Extragenital—those encountered in the same series were as follows—
1. Tuberculosis      4
2. Pneumonia      5
3. Meningitis        3
4. Diphtheria        1
5. Ruptured Appendix      1
A total of  13
deaths or 16 per cent.
Prevention is our main concern in further reducing mortality due to infection.
Prevention of infection, as always, should still be considered about the most important
factor in good obstetrical care. I have divided this into four phases.
1.   Good Pre-Natal Care.
When a woman's health is good she is much more able to resist and cope with any
infection to which she may be exposed.
Page 135 (a) Blood should be checked regularly during pregnancy.
An anaemic patient handles infection poorly.
(b) Elimination of foci of infection.
(c) B.M.R.—lowered metabolism means lowered resistance. At the Mayo Clinic
they say it impairs circulatory activity plus tone predisposing to thrombophlebitis.
(d) Chest X-ray—all patients should have a chest plate. In the past two or three
years in my practice five cases of pulmonary tuberculosis have been caught early
which otherwise would have been missed. Two of these only have required termination of pregnancy.
(e) Diet, vitamins and general health rules should be discussed with and understood
by the patient (e.g. no douches, no tub bath in last month, etc.).
(f) Leucorrhoea: never cauterize an eroded cervix during pregnancy; a parametritis
may easily follow.
2. Good Management of Labour.
(a) By nurses —caps and masks.
—good nursing technique.
—as few rectal examinations as possible. At each rectal examination
the post-vaginal wall is pushed up and wiped around the cervix
and may thus introduce bacteria.
—nourishment  and  good  sedation  to  maintain  and  conserve  the
patient's strength.
(b) By doctors—proper use of mask over nose and mouth as haemolytic streptococci
are often carried in the nose and throat.
—good case room technique. The commonest bad habit in Vancouver General Hospital is wearing masks over the mouth only.
This point is stressed repeatedly by Titus.
—isolation of infected cases.
—as few vaginal examinations as possible, and when done strict technique to be observed.
3. Good Obstetrical Judgment.
This means mainly early evaluation of cephalo-pelvic disproportions and thus the
avoidance of protracted exhausting labours with repeated examinations, the trauma of
difficult forceps, the need for late Caesarean sections. The elimination of high and difficult mid-forceps will decrease the extent of trauma and resultant infection.
Caesarean Section.
Peritonitis following Caesarean section stands high in the list of deaths due to genital
infection. The safest time for Caesarean section is before labour as an elective procedure.
The carefully conducted test of labour has increased the safety of Caesarean section.
Dieckman reports that Caesarean section still carried a mortality of 2-5 per cent in
larger clinics and perhaps higher than that in the country at large. Caesarean section as
a way out of trouble in the patient who fails to make progress after several days of
labour, and following numerous examinations, is a hazardous procedure. Davis states
"the criticism that too many Caesareans are performed in this country" is a valid one,
but even greater criticism should be levelled at the fact that too few are done at the
right time.
Disproportion at the inlet is met at the onset of labour and will be recognized early.
Disproportion in the mid-pelvis and outlet are not so easy and must be assessed early.
4. Good Care During Puerperium.
(a)  Good nursing technique.
Page 136 (b) Activity. An active puerperium is important. It is particularly important in
preventing thrombo-phlebitis of the pelvic veins, which process combines stasis and
infection. David states: "Bed rest has been indicted as the most important single cause
of embolism, so many patients are now allowed up on their second or third day. It is
likely that the pendulum has swung too far and that restricted bed rest and moderate
activity in bed may be the greatest aids to recovery as well as the greatest safeguards
in the prevention of thrombosis." At the Chicago Lying-in Hospital free movement in
bed is insisted on immediately following delivery and exercises are started early. Patients
are kept in bed eight or nine days.
Treatment.
i.   Parenteral fluids.
2. Transfusion and plasma.
3. Sulfonamides, penicillin and streptomycin—early and adequate dosage.
4. Extraperitoneal Caesarean section—the Waters operation where a late Caesarean section has to be done. As this procedure becomes more widely used the mortality from
late Caesarean section should drop.
PROVINCIAL DEPARTMENT OF HEALTH AND WELFARE
||g|j DIVISION OF V. D. CONTROL
Penicillin Treatment of Primary, Secondary and
Early Latent Syhpilis
The recommendations of this division in above type of syphilis is that 26 week sched«
ule of Mapharsen and Bismuth is treatment of choice. This schedule is sent out with
drug requests, or is obtainable at local health units, or this Division. Due to difficulty
in holding patients for 26 weeks, the following uses of Pencillin are also recommended
at discretion of private practitioner.
This schedule replaces all previous Pencillin Schedules forwarded except those for
Syphilis in Pregnancy, Neurosyphilis and Prenatal Syphilis.
I. Due to rapid changing recommendations in treatment of Syphilis with Penicillin,
"it is necessary to make further recommendations. It is now recommended that when
Penicillin is to be use«d, all cases of Primary, Secondary and Early Latent Syphilis be
hospitalized and treated with aqueous Pencillin, Mapharsen and Bismuth. (Syphilis in
pregnancy must not be treated by this schedule.)
II. Subject to the proper criteria, Penicillin will be supplied on request for a patient
reported on the Form Nl as having primary, secondary or early latent syphilis, providing
the patient's name is given as required under the Venereal Diseases Suppression Act.
The criteria for diagnosis is as follows:
Primary—To include those cases presenting the primary lesion of syphilis (the
chancre) which have not yet developed secondary manifestations. This diagnosis must
be confirmed by darkfield examination, blood test, or both. If blood test is negative,
the diagnosis of primary syphilis is not permissible without the demonstration of T.
pallidum by darkfield.
Secondary—-To include only those cases of early syphilis which show one or more of
the manifestations of systemic dissemination of the spirochete; for example, generalized
enlargement of lymph glands, cutaneous eruption, mucous patches, condylomata lata,
patchy alopecia, laryngitis, bone pains, febrile reaction, and so forth.    The chancre may
Page 137 or may not be present and if present may be in any stage of evolution. This diagnosis
Imust be confirmed by darkfield examination, serologic test, or both.
In early secondary syphilis and in addition to the manifestations listed above, ocular
or neurologic complications (iritis, neuro-retinitis, acute syphilitic meningitis) should
be specially recorded as "Syphilis, secondary, manifested by . . ."
Latent—Early latent—within four years.
Secondary symptoms have subsided and the active manifestations of late syphilis have
not yet supervened. There are no evidences of syphilis other than persistent positive
serologic tests of the blood, and history of exposure. The spinal fluid is negative. The
date of the negative examination of the spinal fluid should be stated in all cases. A
diagnosis (Latent-Tentative) is made in cases where the spinal fluid has not been
examined.
For further details you are referred to Pages 13 and 14 of "Procedures and Services
in Venereal Disease Control."
III. Plan of Treatment and Follow-up for Primary, Secondary and Early Latent
Syphilis  (excluding Syphilis in Pregnancy).
1. 1/ is\ always a hospital procedure.
2. Kahn, Complement Fixation, complete blood count, urinalysis and physical examination prior to treatment. In case of early latent syphilis a spinal fluid examination
is also to be done.
3. Aqueous Penicillin 50,000 units every two hours day and night for 90 injections.
Total 4,500,000 units.
4. Site of injection—upper outer quadrant gluteal muscle.
5. Arsenical Bismuth therapy during eight days in hospital.
1st day—Bismuth 1 c.c. intramuscularly.
2nd day—Mapharsen .04 g. intravenously.
5th day—Bismuth 1*4 c.c. Mapharsen .06.
8th day—Bismuth 2 c.c. and Mapharsen .06.
These dosages subject to change depending on the patient's tolerance and weight:
e.g. a man weighing less than 130 pounds, or any female, to have a maximum dosage of
Mapharsen .04 g.
THE ABOVE TO BE FOLLOWED BY:
6. Bismuth once a week and Mapharsen twice a week for 9 weeks unless contra-
indicated.
7. Kahn and Complement Fixation once a month for 6 months.
(a) If there is a persistent rising, titre of blood Kahn, we recommend the use of
consultative service from this Division. Please forward results of all laboratory tests
with this request.
(b) If serology is negative 6 months following therapy, check every 3 months for
one year, then every 6 months for a total of 5 years.
8. Spinal Fluid Examination at the Completion of Mapharsen and Bismuth therapy
if not done prior to treatment, and repeat at the end of 3 years and 5 years.
9. Cardiovascular examination 5 years from the completion of treatment if possible.
10. Warn patient regarding signs and symptoms of infectious relapse and to report
immediately if any appear.
11. Warn patient to report if pregnant.
Penicillin in Oil and Wax (Romansky Formula)
I. In event hospitalization being impossible, Pencillin in Oil and Wax is being supplied by this Division. It is, however, pointed out that P.O.W. is by no means as proven
in treatment of syphilis as aqueous penicillin and a good deal of thought should be given
before such treatment is carried out. Syphilis in Pregnancy must not be treated by this
schedule.
 ■■ ■•.-, .•
||;.M
II*^£ib«!i-l'e'*l'
Page 138 II. P.O.W. is supplied subject to criteria as noted in aqueous penicillin.
III. Plan of recommended treatment and follow-up using Penicillin in Oil and Wax
for Primary, Secondary and Early Latent Syphilis.
1. Kahn, Complement Fixation, complete blood count, urinalysis and physical examination prior to treatment. In case of early latent syphilis spinal fluid examination is
also to be done.
2. 600,000 units of P.O.W. intramuscularly for 10 consecutive days.   It is empha- \
sized that this injection must be given at same time each day for 10 consecutive days, j
Direction for use of P.O.W. must be rigidly followed.    In particular, syringes and =
needlesjnust be bone dry.   P.O.W. should not be refrigerated and it must be well shaken
before use.   If necessary to warm, this should be only slightly above room temperature.
3. Mapharsen and Bismuth Therapy during 10 -day Penicillin Series
1st day of Penicillin—Bismuth 1 c.c. intramuscularly.
2nd day of Penicillin—Mapharsen .04 g. intravenously.
5th day of Penicillin—Bismuth 1.5 c.c. Mapharsen .04-.06 gms.
8th day of Penicillin—Bismuth 2 c.c. and Mapharsen .04-.06 gms.
10th day of Penicillin—Mapharsen .04-.06 gms.
4. These dosages subject to change depending on the patient's, tolerance and weight:
e.g. a man weighing less than 130 pounds, or any female, to have a maximum dosage of
Mapharsen .04 g.
THE ABOVE TO BE FOLLOWED BY:
5. Bismuth once a week and Mapharsen twice a week for 9 weeks unless contra-
indicated.
6. Kahn and Complement Fixation once a month for 6 months.   Follow-up as in use i
of Aqueous Penicillin (III No. 7-No. 11 inclusive).
SUPPLY OF BLOOD DONORS — THE PROFESSION'S PART
Some months ago, in these columns, an appeal was directed to all doctors asking their
influence to help in keeping up the supply of blood donors. We were asked to impress on
the relatives and friends of patients who have been given transfusions of blood supplied
by the Red Cross, that it was their duty to volunteer, at once, to replace the amount
used.
The Red Cross Blood Transfusion Service has stated that the response to this appeal
was good, but that the supply of blood from this source is now noticeably falling off.
The physician or surgeon who carries out a transfusion can help, in a very real way,
to keep a healthy balance in the "Blood Bank" if he will make a point of remembering to
impress on the relatives that it is their duty to replace the blood which has been given
free by someone else.
SPEECH CLINIC
Treatment of
Articulatory and Voice Defects, Stammering
Kathleen Shaw, R.N.
2414 Main Street
FAirmont 7292
Page 139 Dr. D. E. H. Cleveland and Dr. Ben Kanee attended the session of the American
Academy of Dermatology and Syphilology in Chicago, December 6th to 11th.
Our congratulations are extended to Dr. L. H. Appleby, who was elected member of
the Western Surgical Society of North America. Membership is limited to 150 surgeons
in North America and Dr. Appleby is the third surgeon ever to be elected from Canada.
We would also congratulate Dr. Charles Gordon Campbell, who was awarded a
Fellowship by The American College of Physicians. Dr. Campbell is the only Canadian
to win one of the six fellowships awarded.
Dr. R. D. Thompson of Victoria has gone to London, England, where he plans to do
post-graduate work.
Deepest sympathy is extended to Dr. S. R. Harrison and Dr. H. W. Riggs on the
loss of their wives.
An article appearing in the press recently, which states "Infant Mortality rate here
sets record in World" was noted with interest by the medical profession.
Congratulations are extended to the following doctors and their wives on their recent
good fortune: Dr. and Mrs. C. G. Campbell, a son; Dr. and Mrs. N. D. Knott, a son;
Dr. and Mrs. R. C. Talmey, a son; Dr. and Mrs. B. W. Tanton, a son; Dr. and Mrs.
A. E. Trottier, a daughter; Dr. and Mrs. A. C. Walsh, a son; Dr. and Mrs. G. L. Watson,
a son.
We regret to record the passing of Doctor George A. Kelman of Fernie. Born and
educated in Scotland he received his M.B.C.M. at Aberdeen in 1887, and praticed in
Alberta before registering in British Columbia in 1932. Doctor Kelman retired from
active practice several years ago. Our sincere sympathy is extened to Mrs. Kelman and
family.
Dr. P. Barg, formerly of Essondale, is now doing post graduate work in Montreal.
Dr. R. J. Alexander has left Kamloops to commence pratise in Salmon Arm.
Dr. F. E. Coy who is with the Department of Veterans' Affairs has been transferred
from their Vancouver office to Victoria.
Dr. F. H. Davis has left Vancouver to go to the Allen Memorial Institute in Montreal.
Dr. G. R. Callbeck, formerly of Nelson, is now practising in Salmo.
Dr. L. L. Giroux has left Millardville to make his home in Dawson Creek.
Dr. W. J. Fowler has left Portland, Oregon and has gone to New York to do further
work in the Montefiere Hospital. ||i|
Dr. C. R. Salsbury, formerly resident of Victoria has accepted a position with the
Workmen's Compensation Board in Vancouver.
Dr. G. E. Sleath has left Bella Coola and has started practise in New Westminster.
Dr. G. A. B. Hall of Victoria is now residing in Phoenix,' Arizona.
Dr. A. J. Kergin of Prince Rupert has gone to Toronto to do post graduate work.
Dr. J. F. Cork has left Ladner and is now associated with the Vancouver General
Hospital.
Page 140
:*' ■'' >,'
kWM
mm Sincere sympathy is extended to Dr. R. S. Manson on the loss of his father.
Dr. A. W. Mooney has left Vancouver to make his home in Vanderhoof.
Dr. C. E. Cook has left Michel and is now practising in Edson, Alberta.
Dr. A. W. Perry of Victoria is doing post graduate work at the Lahey Clinic in
Boston, Mass.
Dr. J. A. Hay has left the Pacific coast and is now living in Foxwarren, Manitoba.
Dr. J. T. Cruise is now associated with Dr. L. A. C. Panton at Kelowna.
We regret to record the deaths of three of British Columbia's well-known medical
practitioners, and extend the profession's sincere sympathy to their families.
Dr. James R. Arthur, well-known Vancouver physician, who died very suddenly.
Born and educated in Ontario he came to B. C. thirty-five years ago, his death will be
keenly felt by the profession.
Dr. G. E. Bayfield, pioneer doctor and former superintendent of the Vancouver
General Hospital. Dr. Bayfield practised in the Peace River Country before enlisting
early in World War I and was well known up the coast when he served as doctor aboard
the Columbia Coast Mission ship. He recently retired after practising in British Columbia since 1904.
Dr. J. Scovil Murray, who was an active member of the profession. Born in New
Brunswick, he received his M.D.CM. at McGill and since coming to Vancouver from
Calgary in 1942 he has been practising with the Medical Clinic.
Dr. A. J. Kergin of Prince Rupert is at present doing post-graduate work in Toronto.
ARTHRITIS and ECZEMA
of endogenous origin
claimed to be allergic, may be
favored or induced by calcium
and sulphur deficiency, impaired
cell action, and imperfect elimination of toxic waste.
LYXANTHINE ASTIER
administered per os, brings about
improved cell nutrition and activity, increased elimination, resulting symptom relief, and general functional improvement.
Write for Information
L-17
Canadian Distributors
ROUGIER FRERES
350   Le  Moyne   Street,   Montreal
Nrnrn $c
t
2559 Cambie Street
Vancouver, B.C.
Page 141

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