History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1951 Vancouver Medical Association Jun 30, 1951

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 THE
ULLETI
OF
The Vancouver Medieal Association
EDITOR:
dr. j. h. MacDermot
EDITORIAL BOARD
DR. D. E. H. CLEVELAND    . DR. J. H. B. GRANT
DR. H. A. DesBRISAY DR. J. L. McMILLAN
Publisher and Advertising Manager
W. E. G. MACDONALD
VOL. XXVII.
JUNE, 1951
NUMBER 9
OFFICERS 1951-52
Dr. J. C. Grimson Dr. E. C. McCoy Dr. Henry Scott
President Vice-President Past President
Dr. Gordon Burke Dr. D. S. Munroe
Hon. Treasurer Hon. Secretary
Additional Members of Executive:
Dr. J. H. Black Dr. George Langley
TRUSTEES
Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommeb, Whiting & Co.
SECTIONS
Eye, Ear, Nose and Throat
Dr. N. J. Blair Chairman Dr. B. W. Tanton Secretary
Paediatric
Dr. Peter Spohn Chairman Dr. John W. WmTELAW-Secretary
Orthopaedic and Traumatic Surgery
Dr. D. E. Starr Chairman Dr. A. S. McConkey Secretary
Neurology and Psychiatry
Dr. F. E. McNatr Chairman Dr. R. Whitman Secretary
Radiology
Dr. Andrew Turnbull Chairman Dr. W. L». Sloan Secretary
STANDING COMMITTEES
Library:    ^%
Dr. A. F. Hardyment, Chairman: Dr. .1. L.JParnell, Secretary;
Dr. F. S. Hobbs, Dr. J. E. Walker, Dr. E. FranceWord, Dr. D. W. Moffatt
Co-ordination of Medical Meetings Committee:
Dr. J. W. Frost. Chairman Dr. W. M. G. Wilson Secretary
Sttmmer School:
Dr. Peter Lehmann, Chairman; Dr. B. T. H. Marteinsson, Secretary;
Dr. A. C. Gardner Frost; Dr. J. H. Black; Dr. Peter Spohn:
Dr. J. A. Irving.
Medical Econom ics:
Dr. F. L. Skinner, Chairman; Dr. W. E. Sloan, .Dr. G. H. Clement,
Dr. E. A. Jones, Dr. Robert Stanley, Dr. F. B. Thomson, Dr. R. Langston
Credentials:
Dr. Gordon C. Johnston, Dr. W. J. Dorrance, Dr. Henry Scott
V.O.N. Advisory Committee
Dr. Isabel Day, Dr. D. M. Whitelaw, Dr. R. Whitman
Representative to the B.C. Medical Association: Dr. Henry Scott
Representative to the Vancouver Board of Trade: Dr. E. C. McCoy
Representative to Greater Vancouver Health League: Dr. J. A. Ganshorn VANCOUVER MEDICAL ASSOCIATION
PROGRAMME FOR THE FIFTY-THIRD ANNUAL SESSION
Founded 1898; Incorporated 1906.
REGULAR MONTHLY MEDICAL  MEETINGS
FIRST TUESDAY—GENERAL MEETING—Vancouver Medical Association—T. B.
Auditorium.
Clinical Meetings, which members of the Vancouver Medical Association are invited
to attend, will be held each month as follows:
SECOND TUESDAY—SHAUGHNESSY HOSPITAL STAFF MEETING.
THIRD TUESDAY—ST. PAUL'S HOSPITAL STAFF MEETING.
FOURTH TUESDAY—VANCOUVER GENERAL HOSPITAL STAFF MEETING.
FIFTH TUESDAY—(when one occurs)—CHILDREN'S HOSPITAL STAFF MEETING.
Notice and programme of all meetings will be circularized by the Executive Office
of the Vancouver Medical Association.
VANCOUVER GENERAL HOSPITAL
Regular Weekly Fixtures in the Lecture Hall
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic,
edition, 1950.
ST. PAUL'S HOSPITAL
Regular Weekly Fixtures
TUESDAY—9-10 a.m 1 PAEDIATRIC CONFERENCE
2nd TUESDAY of each month—11 a.m ......TUMOR CLINIC
WEDNESDAY—9-11 a.m....... --J|-»- MEDICAL CLINIC
2nd and 4th WEDNESDAY—11-12 a.m OBSTETRICS AND GYNAECOLOGY
THURSDAY—11-12 a.m 1 -....PATHOLOGICAL CONFERENCE
(Specimens and Discussion)
FRIDAY—8 a.m  . CLINICO-PATHOLOGICAL CONFERENCE
(Alternating with Surgery)
ALTERNATE FRIDAYS—8 a.m SURGICAL CONFERENCE
FRIDAY—9 a.m DR. APPLEBY'S SURGERY CLINIC
FRIDAY—11 a.m INTERESTING FILMS SHOWN IN X-RAY DEPARTMENT
Page 212 SHAUGHNESSY HOSPITAL
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology.
Wednesday, 10:45 a.m.—General Medicine.
Wednesday, 12:30 p.m.—Pathology.
Thursday, 10:30 a.m.—Psychiatry.
Friday, 8:30 a.m.—Chest Conference.
Friday, 1:15 p.m.—Surgery.
BRITISH COLUMBIA CANCER INSTITUTE
Tuesday, 9:00 a.m. to 10:00 a.m. (weekly)—Clinical Meeting.
THE   BULLETIN
Publishing and Business Office — 17 - 675 Davie Street, Vancouver, B.C.
Editorial Office — 203 Medical-Dental  Building, Vancouver,  B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.
Closing Date for articles is the  1 0th of the month preceding date of issue.
Manuscripts must be typewritten, double spaced and the original copy.
Reprints must be ordered within 15 days after the appearance of the article in question, direct from the Publisher. Quotations on request.
Advertisements
Closing Date for advertisements is the  10th of the month preceding date of issue.
Advertising Rates on Request.
Office  Space  To   Rent M;
OWNER WILL FINISH TO SUIT TENANT
3605   E.   Hastings   at   Kootenay.     Situated   at
B.C.  Electric Terminal and 'within  5  minutes
of the
NEW BURNABY HOSPITAL
APPLY—3605 E.HASTINGS
Office—GLenburn  1388 Home—GLenburn 0208 M
ENJOY A REST
Retired nurses-have accommodation for one or two guests overlooking
the bay at White Rock.   Ideal surroundings to rest, relax or build-up.
Miss L McAulay, r.n. and Miss N. O'Neil, r.n.
299 Bishop Road, White Rock, B.C.
or Phone Mrs. Ferguson, BAyview 4477
Page 213 women
mm
are
always
demanding*
When growth, menstruation, pregnancy, convalescence or dietary
restrictions increase a woman's demands for iron ...
"Up to the age of menopause, women
require from two to four times more
iron than do men... Pregnant women
also have a higher requirement... iron
requirements are increased ... at
puberty (especially in girls) ..."
Goodman. L., and Gilman, A.: The
Pharmacological Baits of Therapeutics.
New York,The Macmillan Company, 1941,
p. 1110. 1115.
tKeznikoff, P . and Goebel, W. FL: J, Clin,
lnvetncafion  16:547,1937.
TSBOON Bmflrrmrfc iiiiiim^
Fergon®
SM/WOffMOI/S
0uicoiuie
For Hypochromic Anemias
BETTER TOLERATED: Fergon is only slightly ionized, therefore virtually nonastringent, nonirritating, essentially free of
gastro-intestinal distress.
BETTER ABSORBED: Fergon—stabilized ferrous gluconate—is
soluble and available for absorption throughout the entire pH
range of the gastro-intestinal tract.
BETTER UTILIZED: Comparative clinical studies show ferrous
gluconate to be better utilized than other forms of iron.t
Indicated in the treatment and prevention of anemias due to
iron deficiency; especially valuable in patients intolerant to
other forms of iron.
Average adult dose is 3 to 6 (5 grain) tablets; for children, 1 to
4 (2 Vz grain) tablets or 1 to 4 teaspoonfuls of elixir daily.
Supplied as 0.325 Gm. (5 grain) tablets, bottles of 100 and
500; 5 % elixir, bottles of 6 and 16 fl. oz.
New York 13f N. Y.    Windsor, Ont,
443 SANDWICH STREET WEST, WINDSOR, ONTARIO VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
CITY
STATISTICS—MAY,  1951
Total   Population—Estimated : 397 140
Chinese   Population—Estimated     6 282
Other—Estimated j  640
April, 1951
Rate per
Number 1000 pop*
Total  Deaths   (by  occurrence) ; I     365 11.0
Chinese Deaths _       20 38.2
Deaths, Residents Only I     312 9.4
BIRTH REGISTRATIONS—Residents and Non-Residents:
(includes late registrations)
Male . j     433
Female 1     384
April, 1951
24.7
INFANT MORTALITY—Residents Only:
Deaths under 1 year of age.^  15
Death rate per 1000  live births j !  25.2
Stillbirths   (not included in above item)  11
April, 1951
Scarlet Fever.
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
       April, 1951
t^gil Cases    Deaths
Diphtheria	
Diphtheria Carriers-
Chicken Pox	
Chicken Pox	
Measles	
Rubella	
Mumps.
Whooping  Cough.
Typhoid Fever-
Typhoid Fever Carriers.
Undulant Fever_^	
Poliomyelitis	
Tuberculosis	
Erysipelas.
' Meningitis	
Infectious Jaundice	
Salmonellosis——-	
Salmonellosis Carriers.
Dysentery	
Dysentery Carriers	
Tetanus ,	
Syphilis \
Gonorrhoea r
Cancer   (Reportable)—
Resident	
88
37
April, 1950
Cases      Deaths
103 59
Page 214 (CONNAUGHTj	
A new form of penicillin G . . .
I   ETHYL   TYROSINE
Since the advent of crystalline sodium and potassium penicillins, the
search for new salts of penicillin which exhibit unusual and useful properties has been intensively carried on. A number of such salts has been
developed in the Connaught Medical Research Laboratories. Of these
Penicillin G Ethyl Tyrosine has been selected by the Laboratories for distribution. This salt is a crystalline compound of penicillin G and the ethyl
ester of the naturally occurring amino-acid tyrosine. Penicillin G Ethyl
Tyrosine is exceptionally non-toxic, is stable and is but slightly soluble in
water. It exhibits prolonged penicillin activity when suspensions are
administered parenterally.
This new product of the Laboratories, Penicillin G Ethyl Tyrosine, is
available as a suspension in oil for parenteral use and in the form of conveniently small tablets for oral administration, as follows:—
In Oil with 2% Aluminium Monostearate
Vial of 10 cc, containing 3,000,000 International Units
In Tablet Form, for Oral Administration
Tube of   15 Tablets, each of   50,000 International Units
Tube of   15^Tablets, each of 100,000 International Units
Vial of 100 Tablets, each of   50,000 International Units
Vial of 100 Tablets, each of 100,000 International Units
□
CONNAUGHT   MEDICAL   RESEARCH   LABORATORIES
University of Toronto Toronto, Canada
Established  in  1914 for Public Service through Medical Research and the  development
of Products for Prevention or Treatment of Disease.
DEPOT FOR BRITISH COLUMBIA
MACDDNALD'S    PRESCRIPTIONS    LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. "Let us now praise famous men, and our fathers that begat us." It is a good thing,
now and then, to look back over the years, and do honour to the men who have worked
through them, and whose work has been good; who have contributed to the growth
of medicine, to the maintenance of high medical standards; and whose service to the
community in which they have lived has been constructive and helpful. Such men need
not be particularly "famous" in the ordinary sense of the word: their names do not
often appear in print—they do not advertise themselves, and the fame is often purely
local—but to hundreds, often thousands, of their fellow-citizens, they represent something which we all need to have—"a guide, a counsellor, a friend"—a man who can
help others to have happier, healthier and so better lives. In the words of the old essay-
writer from whom our opening quotation was taken, "these men maintain the fabric
of the world . . ."
We have been prompted to indulge in these reflections, by the complimentary
dinner that was given recently, by some of his many friends, to Dr. E. A. Martin of
North Vancouver, to celebrate his fiftieth year in the practice of medicine, most of it
in North Vancouver. To some of us, who have known Dr. Martin all these years, it
seems only a short time since he started practice there, and it is with something of a
shock that we realize how the time has sped.
In the fair land on the other side of Burrard Inlet, Dr. Martin has come to be
something of an institution, and one to be respected and consulted on any and all occasions. When he first went there, North Vancouver was more of an address for mail,
and a happy hunting ground for real estate agents, than a city, such as it has come to
be. But it was just as hilly as it is now, and getting about to see patients must have
been hard and wearisome. But Dr. Martin was strong and healthy, and devoted to his
work, and his record shews that mere Hills of Difficulty made no difference to him.
He has been a good doctor, a competent surgeon, and an able obstetrician—in other
words, he has been, all these years, a good general practitioner, a good "family doctor,"
and the large crowd of friends and patients who turned out to do him honour are
witness to the trust and confidence that he inspired by the way he did his work.
A man' who has lived through fifty years of medicine has seen a great many
changes, and the past half-century has been a specially interesting one. Fifty years may
not be long in the general time-scale, but a great deal has been packed into this particular section of Time. Surgery, medicine, obstetrics, neurology, psychiatry, public
health, to take only a few departments of Medicine, have completely changed the world,
have made life longer, safer, happier, healthier—and they have only begun. The past
fifty years have been a great adventure, and a man may count himself lucky who has
lived through them.
North Vancouver has grown a lot, too, since Dr. Martin first went there. It has
all the f acilitieis and trimmings of a modern city now—a good hospital, good roads,
schools, parks, fine houses, industries—a modern, up to date medical profession, and so
on. Some at least of these amenities are due to the pioneering work of men like Dr.
Martin. A growing population needs, besides jobs and industries, assurance of healthy
living conditions and adequate medical care—health and safety for children, good hospitals and public health institutions—and it was the faithful work of men like Martin
and McCaffrey, McLaughlin and Dyer, Carson Graham and others who went to live
and work there when conditions were not easy, that has made all these things to come
to pass. For this is not, of course, the work of any one man. But someone has to be
chosen as a prototype, and no better choice could have been made than that of Dr.
Martin. May he live long and happily to enjoy a well-earned leisure, happy in the sense
of work well done and the recognition of this by those among and for whom he has
worked.
Page 2t5 Hours during the summer months:
Monday—Friday    9:00 a.m.-5:00 p.m.
Saturday  9:00 a.m.-l :00 p.m.
Recent Accessions
Earnest, E., S. Weir Mitchell: Novelist and Physician, 1950 (Historical and Ultra-
Scientific Fund).
Marriott, H. L., Water and Salt Depletion, 1950.
Medical Research Council Memorandum No. 25—The Social Consequences of
Pneumoconiosis among Coalminers in South Wales by P. Hugh-Jones and C.
Montague Fletcher, 1951.
Sodeman, W. A.  (Editor)—Pathologic Physiology: Mechanisms of Disease, 1950.
Speed, J. S. and Smith, H. M. A.   (Editors)—Campbell's Operative Orthopedics,
2 vols., 2nd edition, 1949.
Surgical Clinics of North America—Symposium on Orthopedic Surgery, April,
1951.
Treves, Sir Frederick—The Cradle of the Deep, 1908 (Gift from Dr. W. D. Keith).
Wallgren, Avrid—Tuberculosis and other Problems of Pediatrics, Abraham Flexner
Lectures Series No. 10, 1950.
Wortis, J., Soviet Psychiatry, 1950.
The following journals are available now in the Library:
Acta Chirurgica Scandinavica.
Acta Medica Scandinavica (subscription renewed).
Acta Paediatrica.
Annals of the Royal College of Surgeons.
Antibiotics and Chemotherapy.
Boston Medical Quarterly.
British Journal of Ophthalmology (subscription renewed).
Journal of Investigative Dermatology  (gift of Dr. D. E. H. Cleveland).
Urological Survey.
Yale Journal of Biology and Medicine.
BOOK   REVIEW
HEADACHE AND OTHER HEAD PAIN by H. G. Wolff, IvI.D. New York: Oxford
University Press, 1948 pp. 642 illus.
This book was written in 1948 by Dr. Harold G. Wolff, Professor of Neurology
and Associate Professor of Psychiatry at Cornell University Medical College. Rarely
has such a book been needed more and even more rarely has such a need been filled so
adequately. It has elevated headache from the plane of "a symptom" to its proper status
as syndromes of many types, and has correlated those types usually described by specialists in many fields (e.g. eye, neurosurgery, neurology, ear, nose—sinuses, internists—
hypertension, dentists, etc.) into these syndromes.
The introduction is a general consideration of pain which is lucid and comprehensive:
and Chapter One describes the pain-sensitive structures within the cranial cavity.   The
Page 216 next eighteen chapters describe the various types of headache with a wealth of clinical
and experimental data that is condensed but in a manner which is easily read and
understood. The chapter on chronic post-traumatic headache is an excellent example
of observation and explanation. The final chapter on clinical differentation of headache's
should be read by all doctors.
Not the least value of this book is to show how complicated this subject is, how
most of our methods of treatment are palliative only, and how much more study of the
subject is required.
This reviewer cannot resist the temptation to advise those physicians who believe
so much in allergy and hormones as causes of headache to read pages 3 59-363.
The author writes well, his judgments are restrained and dispassionate. He merits
the accolade of having written a book that is valuable and as understandable to the
medical student, the general practitioner, the physician, the surgeon, as well as the
specialist. yM S.E.C.T.
GULF ISLANDS IMPROVEMENT BUREAU
Address all correspondence to the
Secretary at:
Saturna Island, B.C.
June 9, 1951,
Telephone Mayne 5 U.
Doctor W. G. Gunn,
435 West Broadway,
Vancouver, B.C.
Dear Doctor Gunn:
We have just been advised that Dr. Thomas E. Roberts, of Mayne Island has retired,
and possibly you are aware that Dr. Alan Beech, of North Pender Island, has also retired
through illness.
This leaves the above noted islands without medical aid of any kind, and this Bureau
would greatly appreciate your advice in replacing these gentlemen. We would appreciate
it very much if you could arrange to advertise these vacancies in your own publication,
and the cost of said advertisement would be born by the Bureau.
The Government gives an annual subsidy for taking care of these islands and full
information may be received on this point by writing the Secretary.
The populations of the Islands are approximately a* the present time: Galiano, 450;
Mayne Island,. 325; North Pender, 375; South Pender, 60; Saturna, 106.
Those positions would be ideal for a physician who wished semi-retirement, but
the combined area could be taken care of by a younger man with launch. Suitable
accommodation can be had for any applicant, and as the islands are steadily growing
in time there would be a lucrative practice.
Hoping to hear favorably from you in due course, and the writer can always be
contacted between the hours of 6 and 7:30 p.m. by telephone.
£§iiif |b^ Yours very truly,
J. M. Larnie,
Secretary-Treasurer.
Page 217 Vancouver Medical  Association
President j . Dr. J. C. Grimson
Vice-President . . Dr. E.  C. McCoy
Honorary Treasurer 1 Dr. Gordon Burke
Honorary Secretary. j . j , Dr. D. S. Munroe
Editor— j Dr. J. H MacDermot
SUMMER SCHOOL
Held May 28 th to June 1st   -   Hotel Vancouver
REGISTRATION LIST
DOCTORS:
Alton, J. A., Lamont, Aha.
Agnew, A. M.
Andreas, J. C, Wetaskiwin, Aha.
Armitage, T. F. H.
Baird, Murray
Beach, D. W.
. Becher, J. W.
Beevor-Potts, C. H., Duncan
Benwell, C. E.   (Essondale)
Berger, B., Port Coquitlam
Black, J. H.
Blair, Murray
Bostock, M. I.  (V.G.H.)
Boulter, "W. L.
Bridge, R.
Brown, Harold
Bryson, B. F.   (Essondale)
Buller, F.
Burke, Gerald
Burke, Gordon
Burwell, W. K.
Byrne, U. P.  (Essondale)
Campbell, E. A.
Caple, H. H.
Cates, B.
Caunt, T. G.   (Essondale)
Cawker, C. A.
Chou, L. Y.  (St. Paul's)
Christansen, H. F.
Chipperfield, L. S., New "Westminster
Chu, D.  (V.G.H.)
Chu, F. S.
Clarke, W. A., New "Westminster
Clement, George
Cooper, H. S.
Cork, J.
Cornish, A. L., New Westminster
Cowan, R.
Covernton, C. C.
Davidson, Doreen
Davidson, G. A.
Davis, R. L.
Day, I.
Day-Smith, F.
De Muth, O.
DesBrisay, H. A.
Page 218
DOCTORS:
Detwiler, R.  (St. Paul's)
Diamond, S.   (Royal Columbian)
Dobrey, A. N.
Dorrance, W. J.
Duffin, D.  (St. Paul's)
Duncan, A. C.
Eaton, C. M.
Edgar,  M. L.
Edington, W.  (Essondale)
Elliott, B. S.
Elliot, J. A.        |
Emmanuel, H., Penticton
Enns, C. F., Chflliwack <
Epp, D. L., Chilliwack
Evans, W.
Fahrni, Brock
Fahrni, G.
Farish, J. R.   (V.G.H.)
Fister, W. P.   (Essondale)
Foxgord,  R.
Friesen, L.  (Shaughnessy)
Frost, J. W.
Frost, A. C.
Frost, A. C. Gardner
Ganshorn, J.
Gillies, J. G.  (V.G.H.)
Gould, A. P.
Gould, C. E. G.
Gould, Grant
Graham, J. E.   (Essondale)
Graham, W.   (V.G.H.)
Grimson, J. C
Greenberg, A. B.
Gunn, W. R. L.
Harker, R., New Westminster
Harrison, J. E.
Harry, B. H.
Hart,  Reginald
Helm, E. V.—Port Alberni
Herrick, R.  (Essondale)
Herstein,  A.
Hicks, E. R., Cumberland
Hobbs, F. S.
Hough, E. K. (New Westminster)
Hunt, L. e DOCTORS:
Hutchins, L. R., Seattle
Hutton, G. H.
Jackson, J. M.   (Essondale)
Johnston, Gordon C.
Kaplan, S.
Keith, W. D.
Kelly, J.
Kennedy-Jackson, I.
Kergin, W. S., Prince Rupert
Kindree, L. C, Squamish
King, D. M.
Kinsey, F.
Kirkleride, R. A.  (V.G.H.)
Kirkpatrick, G. J.
Kliffer, E.
Komar, L.
Laing, J. W.
Lang, B. E.
Lang, J. W.
Lang, W. H.
Langley, George
Levine, M.
Levson, H.
Lewis, J. R.
Lindenfeld, B.
Lindenfeld, E.
Lyschak, R.   (Royal Columbia)
Maher, L. A.  (St. Paul's)
Malkin, A.   (SChaughnessy)
Mallek, J.
Marshall, M.   (V.G.H.)
Marteinsson, M. T. H.
Melgarde, C, Seattle
Milburn, H. H.
Moffat, D. W.
Morrison, M.
Moscovich, B.
Munroe, D. S.
Murphy, S. P.  (Shaughnessy)
Murray, Fraser
McConkey,  A.  S.
McCoy, E. C.
Macdonald, J.  R.
McDonagh,  J.  E.
McDonald, D. C.
McFetridge, S. A.
McGilvery, F. E. B.
Mcintosh, Hamish
McKay, B. K., Kamloops
McLaren, D.
McLaughlin, G. A., North Vancouver
McLean, Keith
McLean, Palmer
McLeod, E. C.
McMaster, S.
McNab, J. A.
McNair, A Y.
McNair, F. E.   (Essondale)
McPherson, M. M.
McNeil, C.  G., North Vancouver
McNeil, N.
DOCTORS:
Naden, J. R.
Neufeld, W. P.
Nicolson, G.  A.- (Essondale)
Palmer, R. A.
Parks, John
Parnell, J. L.
Paterson,  Donald
Patrick, H. L.
Patterson, F. P.
Paulin, S.
Peacock, E., West Vancouver
Perverseff, J. J.
Phillips, P., Princeton
Pinkerton, E. K.
Porter, J. A.
Pushman, D. R.  (St. Paul's)
Ragona,  P.
Reich, C. J.
Richardson, N. L.   (Essondale)
Robertson, C. E.
Robinson, G.
Robinson, H.   (V.G.H.)
Ross, A. C, New Westminster
Sadler, O.
Saxton, G.
Schom, C.
Schreiber, M., Port Coquitlam
Scott, Henry
Seldon, G.
Shallard, B.
Share, M.
Simpson, W. W.
Sinclair, J. A.
Slade,  C.
Stanley, R.
Smaille, W. D.
Spohn, Peter
Stevenson, T. K.  (V.G.H.)
Stevenson, G. H.  (V.G.H.)
Stocktonj  H.
Stoffman, I.
Story, Boyd
Stranks, G.   (Shaughnessy)
Strong, G. F.
Swanson,  A.  L.
Sylling, M.
Tait, W. M.
Telford, Lyle
Therrien, E., North Vancouver
Thomas, J. C.
Thompson, J. W.
Tolmey, R. C.
Tripp, A. J., Pender Harbor
Trowbridge, E. B.
Tuf teland, J. W.
Turnbull, F.
Verhoeff, D.  (Children's Hospital)
Walker, J. E.
Wall, M. D.
Wall, J. T.
Page 219 Walsh, W.  (Shaughnessy)
Wilson, W. A.
Warcup,  L.
Winbigler, H.
Warne, J.   (Essondale)
Willits, R.
Watson, G. L.
Wilson, J. W.
Watt, G. R., Nanaimo
Word, F. E.
Webb, Eric
Whittaker, K.
Yak, J.
Weaver, Howard
Yoshioka, J.   (Shaughnessy)
Whittaker, W. J.  (V.G.H.)
Young, A. K.
Williams, S. L.
Wilson, J. R.
Zeldowicz, L. R.
VISITING SPEAKERS
Dr. D. E. Cannell, Professor of Obstetrics
and Gynaecology, University of Toronto.
Dr. Donald Ross, Assistant Professor of
Psychiatry, University of Cincinnatti.
Dr. C. H. A. Walton, Assistant Professor
of Medicine, University of Manitoba.
Dr. Sheila Sherlock, Postgraduate Medical
School, University of London.
Dr.  Geraint James, Brompton Hospital
and Postgraduate Medical School, Univer-
Dr. R. B. Kerr, Professor of Medicine,
University of British Columbia.
Dr. Rocke Robertson, Professor of Surgery, University of British Columbia.
Dr. Lyon H. Appleby, f
Dr. John Balfour.
Dr. John Eden.
Dr. D. S. Munroe.
Dr. F. P. Patterson.
Dr. Frank Turnbull.
*• of Vancouver
sity of London.
SUMMER SCHOOL COMMITTEE
Dr. Peter O. Lehmann, Chairman. Dr. Peter Spohn.
Dr. B. T. H. Marteinsson, Secretary. Dr. J. H. Black.
Dr. A. C. Gardner Frost Dr. John Irving.
THE CANADIAN RED CROSS SOCIETY
British Columbia Provincial Division
May 31, 1951.
Dear Dr. Wallace:
We have been advised that the following resolution was unanimously passed at the
recent Annual Meeting of Central Council:
"This Central Council of the Canadian Red Cross Society hereby expresses its
thanks to the medical, dental, nursing and teaching professions for their continued assistance and advice in the work of the Society in its peacetime programme throughout the year."
We shall be grateful for your assistance in conveying the above message to the
members of your Association.
Yours sincerely,
(signed) C. A. SCOTT,
Commissioner
OFFICE SPACE FOR RENT
Excellent Location at Busy Intersection
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Page 220 THE MANAGEMENT OF THE MENOPAUSE
By DR. D. E. CANNELL
Professor of Obstetrics and Gynaecology, University of Toronto
This discussion would be better entitled "The Management of the Climacteric."
Cessation of menstruation is merely one of the mileposts on the road from the initial
decrease in ovarian function to the establishment of a new equilibrium. It is a series
of gradual but complex changes occurring in the female organism over a period of
years, which finally results in the cessation of ovulation and menstruation. Both the
well- and ill-informed woman faces this period of her life with some uncertainty and
apprehension. It is that time when children leave the parental roof and husbands not
too infrequently seek solace in other women's arms and charms. The tension of modern
urban life and competitive existence aggravates rather than ameliorates the disabilities
which may be associated with the menopause. The vast majority of women pass through
the climacteric with little or minor discomfort. Novak in studying 100 of.his own
patients found that 72 had not sought nor required medical help, 20 had required oral
therapy of one sort or another and 8 had been given hypodermic medication of some
type.1
The menopause occurs on this continent most commonly between 45 and 52. On
rarer occasions it may occur before 40 and any persistence of vaginal bleeding, cyclic
or otherwise beyond 55 must be considered pathological until proven otherwise. If
regular physical examination has any place in preventive medicine, it is in this group
of women. In my opinion regular examinations have some virtue in the early detection
or prevention of serious disabilities and all women at this time of life are entitled to
regular and systematic examination, advice, guidance and reassurance. The management
of the climacteric should be considered from two angles, for want of better descriptive
terms, I have chosen first, physiological symptoms and secondly, physical signs.
(1) Under Physiological Symptoms we shall consider—
(a)  Hot flushes.
(b )  Obesity—hypothyroidism,
hyperthyroidism.
(c) Depression.
(d) Arthralgia—osteoporosis.
(e )  Hypertension.
(2) Under Physical Signs—
(a) Alterations in menstruation
1. Rhythm.
2. Quantity.
(b) Alterations in sexual organs
1. Breasts.
2. Vulva.
3. Vagina.
PHYSIOLOGICAL SYMPTOMS
One must remember that at this time many preexisting conditions may be aggravated or magnified.2 It should be possible to explain sympathetically to patients the
exact significance of the menopause and to enable them to appreciate the changes which
are occurring in order to place them in their proper perspective. Reasonable, understanding explanation will in many instances do more to relieve patients than more
specific therapy.
Hot Flushes: These have been aptly termed by Farquharson as "sympathetic storms
of brief duration."3 They are present to some degree in almost all women passing
through the climacteric. In a sizable minority, variously estimated as from 15 to 50%
of patients, flushes are of such severity as to be disabling or at best very embarrassing.
They are due to the gradual diminution in estrogen secretion by the ovaries and the
Page 221 uninhibited.and sometimes excessive excretion of gonadotropins by the pituitary gland.
In many instances a proper assessment of their frequency by the patient will lead to
toleration and ultimately to relief. Where their occurrence is more troublesome and
frequent the administration of estrogens is specific, and all cases can be relieved by
some form of this therapy.4 Methods of administration vary, but hypodermic or implantation techniques are rarely required. Oral administration of a suitable form of estrogen
is capable of producing relief in 98% of cases. All such medication should be given
under the constant supervision of the physician in a systematic fashion.5 This should
follow as closely as possible the pattern of normal estrogen secretion. The dosage should
never be greater than 0.5 to 1.5 mgm. daily for 3 weeks—followed by cessation for
7 to 10 days, with a repetition (in gradually decreasing quantities) as long as required.
Except in rare instances this treatment should not be persisted in for more than 6 to
12 months. No patient with a familial history of cancer, vaginal bleeding or those with
benign or malignant tumours should be treated with estrogens.
Obesity: The tendency toward "middle age spread" is accentuated at the climacteric by decreased physical activity and increased intake of improper or excessive food.
The association of hypothyroidism at this time may be controlled by the use of thyroid
extract. Some authorities on the other hand, feel that hyperthyroidism may occur more
frequently during the menopause and require treatment due to excess production of
thyro-tropins by the pituitary.
Depression: Mild depression at the menopause is not infrequent. It is readily understandable in those women who believe that this marks the end of their active life.
Satisfactory explanation of the facts will usually correct these misapprehensions. Major
depressions are uncommon and usually suggest preexisting psychological disturbances
which have been accentuated by the stress associated with family or social difficulties
at this time. In such cases psychotherapy is indicated and the assistance of a psychiatrist
may be essential before relief is obtained. Estrogen administration in conjunction with
such treatment may be, but rarely is, required or helpful.
Arthralgia and Osteoporosis: Aggravation of arthralgic pains is not uncommon
but has little connection with any functional change associated with the menopause.
Osteoporosis due to calcium deficiency and the aging process is more common. Estrogen
therapy in these instances has little effect. Calcium may be helpful but the results are
frequently disappointing.
Hypertension: This in itself has little relation to the menopause but merely
represents one phase of advancing age. Some enhancement of preexisting hypertension
is not uncommon but its exact relationship to the menopause is uncertain. The usual
therapy for hypertension is indicated.
PHYSICAL SIGNS
Alterations in Menstruation: Minor changes in menstrual function can be anticipated at the climacteric. Gross changes should never be dismissed without investigation.
Many tragedies have occurred because patient or physician discounted them without
adequate consideration.
Rhythm: Shorter or longer intervals between menses are not uncommon as the
first factual indication of the onset of the menopause, so that conversely the periods
are longer or shorter than previously. No therapy beyond explanation of the significance
of these changes is required except where the flow is excessively prolonged. Intermenstrual spotting however, always necessitates investigation by biopsy or curettage.
Quantity: Excessive flow after 35 occurs in approximately 20% of women. It
must be emphasized that excessive bleeding is always abnormal and requires a definite
diagnosis. Dearnley reports that 31 % of her cases of cancer of the corpus uteri occurred
prior to the menopause and others have found a somewhat similar incidence in their
practice.6 Curettage will rule out this possibility in.most instances and is curative
in about 50% of the non-malignant lesions.7 It therefore follows that one should
utilize this procedure on any occasion where reasonable doubt exists as to the causative^
Page 222 condition. Where the bleeding is of such severity as to impair health, total hysterectomy
is to be preferred, in the absence of constitutional contraindications, to radium or x-
radiation, in the event that curettage does not provide relief.8
ALTERATIONS IN SEXUAL ORGANS
Breast: Decrease in size and firmness of the breasts is due to the loss of fat. The
concomitant occurrence of carcinoma of the breast at the menopause is due to the fact
that malignant disease is more frequent in this age group, rather than to any direct
connection with the changes of the climacteric. Careful visual examination and
palpation are essential features of physical examination and should require no additional
emphasis upon my part.
Vulva: Atrophy of the mons veneris and decrease in the pubic hair are usually
noted. The pathological changes associated with kraurosis vulvae and leukoplakia
require careful observation. The application of local estrogenic ointments- has been
beneficial in some clinics. In general oral administration is preferable and more satisfactory. The persistence of such lesions may and frequently does warrant vulvectomy,
both as a curative procedure and as a preventative of later malignant change.
Vaginas The atrophy and contraction of the vaginal mucosa is usually a gradual
process requiring little treatment. The amenities of the conjugal relationship may
necessitate some consideration on the part of the husband. In certain instances associated lesions of the uretha and bladder respond to the use of estrogen suppositories.
Prolapse due to injuries of childbirth, accentuated by atrophy and weakness of supporting
structures, warrant reparative procedures.
SUMMARY
On consideration of the whole topic therefore, one may sum up by saying that
rational explanation of the changes occuring in the female at the menopause suffices
to clear up most of the disabilities which occur at this time. In rarer instances the
sound and systematic application of estrogen therapy is indicated. As a corollary of
the latter statement, injudicious or prolonged hormonal treatment is condemned as
malpractice. It may occasion disastrous results by masking early symptoms of malignant
disease.
REFERENCES
1. Novak—Textbook of Gynaecology.
2. Hamblin—Facts About the Change of Life.
3. Farquharson—Personal Communication.
4. Perloff, W. H.—Am. Jour. Obs. and Gyn. 58, 684, 1949.
5. Curtis, Huffman—Textbook of Gynaecology.
6. Dearnley, G.—The Jour, of Obs. and Gyn. of the British Empire, 56, 819, 1949.
7. Foulkes, J. F.—The Jour, of Obs. and Gyn. of the British Empire, 56, 648, 1949.
8. Wilson, J. R. and
Daly, M.J.—Am. Jour. Obs. and Gyn., 60, 1088, 1950
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Page 223 THE DETECTION OF GYNAECOLOGICAL CANCER*
By DR. D. E. CANNELL
Professor of Obstetrics and Gynaecology, University of Toronto
The detection of gynaecological cancer is one of the most important considerations
in medical practice today. In speaking of early diagnosis it is essential to define clearLy
what is meant by the term "early." Considerable misunderstanding and controversy
exists in this regard. In subsequent discussion "early" will be used to refer to cancerous
lesions which are localized, rather than extensive. There seems to be little doubt that
where this interpretation of the term is applied, the cure rate is markedly improved.
No such relationship, however, can be found where "early" is used in a chronological
sense to denote the elapsed time from the first appearance of symptoms to the stage of
positive diagnosis or treatment.1
In this regard, in a study of 868 cases of carcinoma of the cervix at the Toronto
General Hospital and the Ontario Cancer Foundation from 1929 to 1944, Cosbie
found that the 5 year survival rate as applied to extent of disease was 73.75% for
Stage I, 48.36% for Stage II, 26.82% for Stage III and 7.61% for Stage IV. (Table 1).
On the other hand, in 1040 cases studied from 1938 to 1949 he found that the distribution of early and late cases showed no relation between the extent of disease and the
duration of symptoms. (Table 2). It appears obvious from this work that in carcinoma
of the cervix any improvement in treatment must depend upon early diagnosis and
therapy being instituted prior to extension of the disease beyond the confines of the
cervix. The application of these findings to other gynaecological cancers is more difficult.
Nonetheless, in principle, with the possible exception of ovarian malignancy, this is
the rule rather than the exception. The recent interest in carcinoma in situ has provided
a fertile field for investigation and confusion. It is not yet clear what relationship, if
any, this lesion bears to invasive carcinoma. Widespread differences in this regard have
been reported from different centres. The greatest incidence of direct relationship is
reported by TeLinde and Galvin in a study of 75 cases where subsequent examination
of the whole cervix demonstrated invasive carcinoma in 55.2 The detection of unsuspected carcinoma in clinically benign lesions is disturbing and somewhat difficult to
evaluate. Philpott,3 Shapier,4 Nieburgs and Pund5 and others report an incidence of
from 1.25 to 5.9 per 1000. This is in decided contrast to the experience of many
gynaecologists who have carried out routine pelvic examinations for long periods without encountering cervical malignancy in benign appearing cervices. The passage of time
and greater experience will answer many of these questions. However, it would seem
unwise and confusing at present, to designate carcinoma in situ as group O cancer of
the cervix until the relationship between such lesions and invasive carcinoma is definitely
determined.
In present day medicine the emphasis in diagnosis and treatment has been placed
upon mechanical, pathological and biochemical aids. These procedures are undoubtedly
of great assistance in establishing definitive diagnoses and no one would discount their
value. In the process, however, the clinical examination of the patient has been slighted
or in some instances disregarded entirely. The tendency to establish clinics and laboratories for the detection of carcinoma may well be a forward step in bur fight against
malignancy. On the other hand, no clinic nor laboratory, nor any number of them, can
replace the skill and diagnostic acumen of a sound general practitioner. It is with this
in mind that I have the temerity to emphasize those points in clinical examination of
the gynaecological patient with which we should all be familiar and to stress the need
for their more widespread employment in general practice. Yours is the opportunity.
Patients consult you first, and early diagnosis and progress in treatment rest in your
hands and upon your shoulders.
* Presented at the summer school of the Vancouver Medical Association, May 28-June 1, 1951.
Page 224 TABLE 1
(868 cases)
CARCINOMA CERVIX UTERI, 1929 - 1944
5 Year Survival
Cumulative Survival in % Number of Cases
71.75 80
54.63 244
41.28 347
33.64 197
TABLE 2
Survival in %
73.75
48.36
26.82
7.61
CARCINOMA CERVIX UTERI, 1938 - 1949
Relation of duration of symptoms prior to treatment to extent of disease on admission
Distribution
Early
Late
TOTAL
Number of
Cases
392
648
1,040
Under
3 Months
%
23.21
24.69
23.17
3 Months
To 1 Year
%
56.12
54.48
55.0
Over 1 Year Total in %
%
20.67 37.69
22.53 62.31
21.83 100.00
METHODS OF EXAMINATION
The detection of early malignancy in the gynaecological patient of necessity depends
upon regular examination of breasts, abdomen, pelvis and rectum. Careful history may
lead to suspicion, and, in the grat majority of cases careful physical examination will
suffice to establish a sound basis for investigation and treatment. That this work can
be better performed by our general practitioners than by clinics is apparent from the
long waiting lists which have been built up in any clinic which has functioned for an
appreciable length of time. In them, patients await initial examination from 6 to 12
months. The futility of expecting such centres to fulfill the purpose for which they
were established is apparent. On the other hand, practitioners can, by careful study,
satisfy themselves which patients should be referred for further investigation and thus
hasten their care, while ehrninating those who do not require treatment.
In order to do this, a complete history and physical examination are essential. This
should include, breasts, adbomen, pelvis and rectum. Little comment is required upon the
examination of breasts and abdomen. Pelvic examination requires more consideration.
Both inspection and palpation are necessary. In order to make a complete examination,
the introduction of a speculum is required. This should never be omitted. Many lesions
which are not distinctive on palpation will be deemed suspicious on visualization.6
The use of Lugol's solution is of assistance in demonstrating areas for biopsy if this is
required. The margins of such areas are the most suitable sites for biopsy. The use of
smear techniques popularized by Papanicolaou, Traut, Ayre and others has been widely
employed in recent years. One finds some clinics depending solely upon this procedure
in the detection of early malignancy. Its value as a screening procedure is unquestionable
though its more widespread utilization is presently hampered by the scarcity of capable
cytologists. On the other hand, biopsy of any suspicious cervical or endocervical lesion
is an office procedure which any practitioner can carry out without pain or difficulty
for the patient. Bleeding is readily controlled by a gauze pack which may be removed
in 12 to 24 hours. A combination of these two procedures should be utilized where
they are available. They are complementary and the smear alone should never be considered sufficient. In the event that cytological examination is not feasible, biopsy should
be employed. In some centres, greater accuracy is attributed to biopsy; in others, to
smears. All are agreed upon the fact that visual examination will detect suspicious
lesions which might otherwise be missed—and therefore add emphasis to the necessity
of the examination by speculum. Finally, careful bimanual examination combined with
or supplemented by rectal examination completes the investigation. "If we fail to put
our finger in the rectum, we often put our foot in it!" The rectal or combined recto-
Page 225 vaginal bimanual examination often gives information regarding the broad ligaments
or fornices which would otherwise not be attainable.
SMEAR TECHNIQUES
The original technique of Papanicolaou was that of obtaining material from the
cervical canal and vaginal pool by suction. This material was then placed on a slide,
fixed-, stained and studied. Better smears are now obtained by spreading the material on
a slide in the manner in which one makes a blood film. The distribution of cells is more
even and lends itself to more complete study. Ayre's technique of surface biopsy with
a spatula is widely employed in this country and has certain advantages and disadvantages over that of Papanicolaou. In Toronto, Robinson has advocated the spinning down
of such material with subsequent embedding in paraffin for microscopic study as biopsy
material. This is satisfactory from the pathologist's view but leads to cellular distortion
in the opinion of the cytologist.
BIOPSY
This should be taken at the squamo-columnar junction of the cervix. This may
be better defined by the use of Lugol's solution. Normal tissue stains a deep mahogany
colour, whereas abnormal tissue remains pink or white. Biopsies with a sharp punch
should be made at the junction of these areas and multiple specimens obtained. Cauterization of lesions is best postponed till the pathological report has been obtained to
prevent distortion if further specimens are required or delay in therapy, if malignancy
is discovered.
CURETTAGE
In all instances where bleeding or discharge are symptoms and no obvious cause
is determined, dilatation and curettage should be performed. The vaginal smear is of
great value in cervical lesions but of considerably less significance in fundal lesions.
Negative smears should therefore never be considered final in suspected carcinoma of
the fundus of the uterus.
COMPARISON OF RESULTS OBTAINED IN VARIOUS CLINICS
The use of smear and biopsy has its greatest value in the unsuspected malignancy.
There is a wide variation in the results reported in this respect but a substantial and
worthwhile percentage of early malignancy has been reported by various authors.
(Table 3).
A significant number of false positives and negatives have been reported by groups
skilled in cytological methods. An average of 10% of such errors may be expected.
The necessity, therefore, of confirmation by curettage or biopsy in the presence of
positive cytological opinion, is emphasized. Similarly negative cytological findings in
the presence of clinical evidence of malignancy should not be accepted without the
benefit of further investigation.
TABLE 3
Philpott 4000 cases— 9 unsuspected
Shapier 8000 cases— 9 unsuspected
Scheffey 5622 cases— 2 detected; 1 unsuspected
Kraushaar et al 2720 cases— 7 unsuspected W$
W.R.U 1600 cases—77 detected; 21.7% by cytology
Crawford, U. of T  211 cases—11 by cytology
SUMMARY
The earlier detection of gynaecological cancer depends upon the general practitioner. He must be prepared to investigate all women who present themselves for
consultation by taking a careful history and doing a complete physical examination.
The necessity of careful visual and pelvic examination is noted with particular emphasis
upon the vaginal speculum. Cytological study and biopsies are complementary adjuncts
in diagnosis. If the former is available it should be utilized; the latter is advisable in
any suspicious lesion.
Page 226 REFERENCES
1. Cosbie, W. G.—From a paper "Factors Bearing on the Prognosis of Cancer of the Cervix" which is
in the process of publication
2. Galvin, G. A. and
TeLinde, R. W.—Am. Jour. Obs. and Gynec, 57,  15, 1949.
3. Philpott, N.—Personal Communication.
4. Shapier, J.—Am. Jour. Obs. and Gynec, 58, 366, 1949.
5. Nieburgs, H. E. and |P?8|
Fund, E. K.—Am. Jour. Obs. and Gynec, 58, 532, 1949.
6. Henderson, D. N.—Canadian M. A. J., 63, 581, 1950.  WM
THE ACUTE ABDOMEN*
By LYON H. APPLEBY, M.D., F.R.C.S.(Eng.)
In a subject so vast, onee must select several points of high interest and develop
them, rather than to envelope the whole field. Nevertheless, the time is opportune to
once again emphasize the change that has come about in surgery and particularly among
surgeons in recent years. Gone is the surgeon-anatomist, whose chief stock in trade was
dexterity, whose skill outshone his knowledge and whose emphasis was on the purely
anatomical venture of surgery. Great strides have been made. The surgeon-physiologist
is with us and many situations, hitherto emergent, have lost their pride of place through
more rational thinking. It is twenty-five years since Lord Moynihan made his unappreciated statement: "We have made surgery safe for the patient, we must now make
the patient safe for surgery." Not so long ago the procedure was to ring up the hospital
and have the surgery made ready for a perforated ulcer; now we ring up and arrange
to have the perforated ulcer case made ready for surgery. The shortage of hospital beds
may lead to earlier evacuation of postoperatives, but it should never be allowed to infl-
ence the assessment of a case prior to operation. Preoperative restitutional care and
insurance against postoperative deterioration must never be hurried.
Widely as the dogma of preoperative assessment is accepted, perhaps in no situation
is it more generally applicable than in intestinal obstruction. I propose to discuss just
one phase of intestinal obstruction, bowel strangulation. While other types of obstruction may be acute, they are not necessarily urgent. However, strangulation obstruction
with the threat of gangrene has held its pride of place. I propose to outline a few points
by means of which strangulation obstruction may be recognized from other types, which
may not be found in the textbooks and which are gleaned from my own experience.
Small bowel obstructions all have colicky pain until the stage of complete ileus
is reached but, only in strangulation obstruction are colicky pain and tenderness both
to be found. The patient can best locate and demonstrate the area of tenderness and
frequently more accurately than may be elicited bv the surgeon. This point is important and will go a long way in differentiating early strangulation from non-strangulating obstruction. Everyone knows how tender a strangulated hernia may* be. The
combination of obstruction, colicky pain and localized tenderness means strangulation.
X-Ray of the abdomen in strangulation obstruction may be helpful sometimes in
a negative sense. The usual laddering and visible valvulae connivfentes seen in a small
bowel obstruction are less evident in strangulation. The pattern is less typical, owing
to associated effusion, the valvulae less distinct. Large bowel strangulation is a rarity
and, if the abdomen shows scars of previous surgery along with the above symptoms,
it is strangulation small bowel obstruction, until it has been proven to be otherwise.
Too many of these X-Ray pictures are taken at night and made subject to the interpretation of juniors and the inexperienced. They are important enough to be worthy
of seasoned consideration. The vast majority of the cases of acute abdomen are left to
the judgment of residents. In these days of intensive specialization, is it not strange
that there are no avowed specialists confining their work to acute abdominal emer-
Read before The Summer School Session, Vancouver Medical Association, May,  1951.
Page 227 gencies? The work of senior residents is excellent on the whole but subject to the
exuberance of youthful ambition. A leaven of solid maturity should be a safe diluent.
Auscultation of the abdomen is one of the most neglected fields of surgical
endeavour and a worthy subject promising fruitful research. Sporadic attempts have
been made by such men as Puestow of Chicago to interest surgeons in its possibilities.
In strangulation obstruction it may be helpful but a sound knowledge of normal peristaltic sounds is as important as a knowledge of histology is to the tissue pathologist.
There are three types of abdomens to auscultate in obstruction:
The Noisy Abdomen: As in strangulation obstruction, Richter's hernia and small
bowel obstruction.
The Quiet Abdomen: Obstructions associated with effusions of bile, urine, ascites,
blood or serous effusions. Less violent borborygmi are evident here.
The Silent Abdomen: As in complete ileus.
If the pain is synchronized with increased peristaltic sounds, it is presumptive evidence
of strangulation, and almost a certainty if localized tenderness is present as well.
Strangulation obstruction is urgent obstruction; the earlier seen the more urgent,
and should be operated upon at once. If, however, strangulation obstruction has been
present for twelve hours or more, it loses its place as an urgent operative case. Urgent
it still is, but the urgency is now one of restitution and fortification. A few hours so
spent is not time wasted but time invested. A human life may be a good dividend for
a few hours' investment in time. After twelve hours the bowel is already dead and a
few extra hours' restitutional care renders it neither more nor less dead. While this
applies to the gangrenous loop, it does not apply to the patient who is its host.
The assessment of viability is based upon tests of colour, gloss and the effect of
hot towels, but if a peristaltic wave will pass through the loop following proximal
stimulation the loop is viable no matter what colour it is, though spots of infarction
may be localized and subsequently perforate if not infolded.
Why is it not safe to do radical extirpative surgery in the presence of acute
obstruction? The main reason is the hypoproteinaemia incident to the obstruction, the
tissue oedema secondary to it and to excessive chlorides which may have been administered and which further oedema. It is not poor surgery or inaccurate suturing that
makes such things break down but a weak type of fibrin which is incapable of binding
the sutured bowel. Time to permit overcoming this hypoproteinaemia by exteriorization
of gas and liquid contents through an indwelling tube, caecostomy for instance, is
essential. Bowel loop exteriorization, colostomy, etc., is rarely needed. It is not the solid
but the liquid and gaseous contents which are lethal and they can be removed by intubation. I repeat, it is not poor surgery or poor suturing that makes a wound break
down, whether in the bowel or abdominal wall, but poor pre- and post-operative care
leading to its prevention. '^k
Intubation of a tense distended parchment-like caecum without spillage may be
at times difficult or impossible. I have utilized the following method: A loop of terminal
ileum is picked up, clamped off, opened and a glass tube passed along its lumen through
the ileocaecal valve into the caecum.Suction will at once cause the collapse of the
whole ascending colon, the hole in the ileum is closed and the tube intubation of the
caecum is then not difficult. A large mushroom catheter is sewn in and when the time
comes can be cut off, pushed in and passed by rectum, without the need of secondary
operations needed to close, such as transverse colostomies.
I think we use too much blood. The prime place for the use of blood is in blood
replacement, and probably in cases of associated hypoproteinaemia plasma or other parenteral administrations such as amino acids are better. Nevertheless, there is no substitute
for food by mouth in efficiency, whether in protein or potassium deficiency and restoration of normal bowel functions and solid food is worth everything else combined.
Probably in strangulation obstruction blood transfusion is called for because there is
associated blood loss. Bloody fluid in the peritoneal cavity in a case of suspected obstruction is suggestive of strangulation.
Page 228 I would like to say a few words about ileus, the type of silent abdomen, usually
postoperative, and almost invariably associated with some degree of peritonitis. Gas
pains are not normal; severe ones definitely mean that something is wrong. It is not
my purpose here to discuss the more commonly known remedies such as suction, Miller-
Abbott tubes, etc., but rather to confine myself, to a relatively new weapon, the PERISTALTIC ENEMA. I believe the PERISTALTIC ENEMA is destined to fulfil a major
role in bowel surgery.
The peristaltic enema is a two way ebb and flow proposition, utilizing only a small
quantity of fluids, usually 500 cc. are adequate. It operates under no pressure whatever,
runs into the bowel out of one can, circulates for a while, is expelled into another can
and then, as the peristaltic forces are developed, it is drawn in and expelled from can
to can, breaking down impactions of barium, liquifying hardened faeces, dependent upon
peristaltic force alone. Patients have no sensation of having an enema. It can be given
to and well tolerated by the seriously ill. It has no exhausting effects and the absence
of pressure permits its use in the presence of the most recent suture lines and can be
given to the most tender without pain.
Peristaltic enema machines were developed by Miss Stack, R.N. of Seattle, and the
enema requires from one to three hours to administer. Ileus is merely a temporary paralysis in the force of small bowel peristalsis and the whole purpose of this new enema is
the establishment of normal peristaltic movement. As an example: Case C, a right-sided,
colon resection, restored by ileotransverse-colostomy—developed low grade ileus unrelieved by usual measures. Peristaltic enema of alternating hot and cold solution threw
the small bowel into immediate peristaltic activity with complete and permanent relief.
Case A: aged 14 months, a bowel resection for intussusception; twenty-four hours later,
gross distention. Immediate relief was obtained with peristaltic enema. The enema has
thus been taken from the domain of the junior nurse and placed amongst the technical
procedures. Peristaltic enema machines now rank with Basal Metabolic and electrocardiographic machines, a new dignity indeed.
Perforated Duodenal Ulcer: A recent wave of conservatism in this traditional bastion of urgency has developed. It is completely impossible in many instances to gauge
the size of a perforation, the volume or nature of fluid or air leaks and the seriousness
of such a situation. Nevertheless, it has been known for years that many perforations
recover without operation. I believe that we can predict with reasonable accuracy which
perforations are safe to leave. There is something to be said for a prior knowledge of
the individual and the location of his ulcer, but we believe the following rules will not
be too far from the target. If the perforation is minimal with minor fluid leaks, occurring when the stomach is empty, associated with intense pain, in a healthy individual,
in privileged surroundings such as a large general hospital, then expectant treatment—
suction, posture, antibiotics, etc., may be employed with safety. I emphasize the intense
pain and scaphoid abdomen because these are due largely to high a#cid content spillage
and are frequently sterile. However, if the perforation occurs shortly after food or perhaps a beer orgy, with much air and fluid extravasated, less acute pain indicating a
lower acid content, with less scaphoid rigidity, then I believe that this type remains as
an acute surgical emergency. The man with the most intense pain and rigidity is the
one most likely to recover on expectant treatment. We have had seventeen such cases
treated without operation, sixteen of which were successful. One required subsequent
opening for fluid and pus collections but he recovered.
There is something gratifying about opening an abdomen, closing a recent perforation and watching the almost invariable recovery. Nevertheless, there are many instances
where patients present themselves with irretrievable medical conditions, cardiacs, diabetics, nephritics, etc., where it is highly satisfactory to have available such another
weighty weapon as conservative treatment when sudden disaster strikes. There is a place
for conservative treatment of perforation, sensibly assessed, in privileged surroundings
and in experienced hands.
Abdominal Pain: We point with pride to our physiologists, and to our laboratories
and comment upon the many glamorous achievements. Commonplace is our knowledge
Page 229 of blood diastase and organismal sensitivity, but patients do not come in concerning
these things. They complain of fatigue and we do not know too much about the type
of fatigue that a night's rest will not alleviate. They complain of insomnia, yet what
do we know about sleep that we did not know half a century ago? They complain of
anorexia, but what do we really know about appetite, hunger, nausea? They complain
about pain—do we know much about pain? Our research workers in the field of pain
have not kept pace. We have no means of calibrating pain or, for that matter, for determining that it actually exists. Today, pain is assuaged in much the same way as it was
a quarter of a century ago. Morphia still stands on its throne. The world awaits some
instrument of precision which will accurately measure the severity of pain. I shall use
ACUTE PANCREATITIS as an example of pain so severe that people die of the pain
rather than the toxicity. Standard treatment remains: Morphia q. s., and too often q. s.
means an amount sufficient to convert the patient into something like a vegetable. I
have seen two cases with the most dramatic effects from epidural anaesthesia in pancreatitis. The effects were so dramatic that it was obvious at once that when the pain
was assuaged, the patients were not as ill as they had appeared to be. Epidural anaesthesia
can be given at any level. The procaine can be mixed with oils or gelatins or other
substances which will prolong its action. An indwelling ureteric catheter into the
epidural space will give relief for as long as is necessary—weeks if need be. More of
such methods should be used and less morphia.
There is a tremendous and fruitful field developing in the use of intravenous procaine and tetracaine for the relief of pain, particularly traumatic pain, muscle tearings,
wrenched joints, extensive bruising, burns and what not. Thoracic pains of nervous
origin, pancreatitis, urinary stranguries, all respond well. While accidents have occurred
in its use, they are said to be minimal, and I have not experienced any.
A word about CORONARY THROMBOSIS—this is being missed less commonly
than hitherto. We have fallen into the trap too often not to be more wary. The mimicry
of abdominal disease by coronary occlusion can be very close. I believe, however, that
certain simple tests will help in the differentiation. Pain is a neurologic symptom and
follows a pattern governed by the neurological tree along which it is transmitted. Tenderness, however, is a sign which must be elicited by the surgeon. Once you have seen
the case, the relief of pain becomes mandatory. The withholding of morphia and other
pain relieving drugs in the fear that it might mask symptoms cannot be condoned.
In fact, it is of material and valuable assistance in establishing a diagnosis. If the pain
can be relieved and residual areas of localized tenderness can be no longer found within
the abdomen, then the case is probably thoracic in origin.f>;The best test that I know
to differentiate between the thoracic and abdominal origin of pain is a dose of
intravenous sodium amytal or pentothal, sufficient to abolish consciousness and relieve
pain. If such a patient resists and shows evidence of discomfort to abdominal palpation
under such circumstances, the case is almost certainly abdominal in origin. If they
permit abdominal palpation with no suggestive response, the case is probably thoracic
in origin. After all, the original truth serum and lie detector was just a confusing dose
of intravenous sodium amytal.
I should think that not one case is operated upon today for the urgent acute
abdomen for every ten so operated upon twenty years ago. The conservatism which has
spread over thoughtful surgery has so enveloped the mind of the surgeon with the need
for restitutional care prior to surgery, that in a previous address upon the acute abdomen
which I gave two years ago before the Intermountain Surgical Society at Ogden, Utah,
I was able to state that a beautiful passage from Dante's DIVINE COMEDY summed
up the present concept of the acute abdomen: "The mouse has fallen amongst less
hungry cats." Several colleagues have recently criticized me for my conservatism in the
acute abdomen. This makes me wonder whether, in these days of advancing "Spit and
polish,, types of medicine, Dante's cats may not be getting just a little bit hungry.
Page 230 POST-PARTUM HAEMORRHAGE
By DR. D. E. CANNELL
Professor of Obstetrics and Gynaecology, University of Toronto
William Vogt in his "Road to Survival" accuses the modern medical profession of
basing its ethics "upon the dubious statements of an ignorant man who lived 2000 years
ago." His chief complaint is that we believe it is our duty to keep alive as many people
as possible. A study of maternal mortality on this continent would provide him with
proof of this contention. He might, on closer examination, however, take comfort from
the fact that we have made little progress in preventing maternal deaths due to haemorrhage. Sepsis, toxaemia and haemorrhage still constitute at least two thirds of the
deaths attributed to or associated with pregnancy. Those due to sepsis have decreased
materially since the introduction of sulfonamides, and antibiotics. Those due to toxaemia
have been materially reduced with better obstetrical care. Haemorrhage which offers
the greatest possibility of improvement remains unchanged. This "red river of death,'*
as it has been aptly called, flows on uninterruptedly with occasional freshets bringing
it to flood level as the chief cause of maternal mortality.
The reports of Beecham,1 Dieckmann,2 Gordon,3 Greenberg,4 and Kerr,5 emphasize the general improvement in maternal mortality, without a corresponding decrease
in deaths from haemorrhage. It is admittedly difficult to ascertain from available mortality statistics the relative importance of post-partum haemorrhage as a factor in this
relation. It is suggested that in the United States that it contributes to deaths assigned
to toxaemia and sepsis, and alone through shock or blood loss is responsible for from
two to eight per cent of all maternal deaths.3 In Ontario from 1941 to 1945 haemorrhage accounted for from twelve to fifteen per cent of this mortality,6 while in Toronto from 1944 to 1947 post-partum bleeding was responsible for from eight to seventeen per cent of the total maternal wastage.7 It is obvious therefore that this problem
if properly appreciated and attacked will continue to cause individuals like Vogt greater
concern. It is and should be our purpose to see that this end is achieved.
GENERAL CONSIDERATIONS
It has long been taught that mismanagement in the third stage of labour is the
chief factor in the causation of post-partum haemorrhage. It is the purpose of this
paper to point out that proper prenatal care and management throughout labour, particularly in the late second and third stage will materially reduce this complication.
It is obvious that the pregnant woman who comes to term in good health and nutrition
without any significant degree of anaemia will face the hazards of labour, delivery and
the pueperium better than her sister who is in poor health and anaemic.9 The problem
of prevention and treatment resolves itself into three phases.
(1) Prenatal care.
(2) Management of labour.
(3 )   Prompt recognition and therapy if significant post-partum haemorrhage ensues.
PRENATAL CARE
Satisfactory prenatal care implies adequate attention to diet, correction of anaemia
and blood-grouping of all patients, including determination of the Rh. factor. One cannot agree completely with those enthusiasts who claim that all complications of pregnancy, labour and the Puerperium will be resolved with adequate dietary management.8
There can, however, be no question that patients with adequate diet are in better health,
as a general rule, than those with inadequate diets. It should be our aim to see that all
patients receive a satisfactory intake of protein, with a well-balanced diet containing
sufficient essential vitamin and mineral content for the patient's well-being. Correction
of anaemia is imperative, if necessary by transfusion, in the third trimester of pregnancy. All patients' bloods should be crossed and blood made available for transfusion
on admission to hospital. This entails considerable labour for the laboratory services but
may save lives when minutes count.
Page 231 MANAGEMENT OF LABOUR
Prevention of post-partum haemmorhage is to be preferred to any form of therapy
designed to treat it when it occurs. In this respect one should draw attention to the
fact that long and exhausting labours, without adequate sedation or maintenance of
fluid and caloric intake, are predisposing conditions to post-partum haemorrhage. The
avoidance of unwarranted interference with the normal course of labour, will materially
reduce the incidence of post-partum haemorrhage due to trauma. Awareness of, and
preparedness to manage uterine atony associated with multiple pregnancies, hydramnios
and toxaemia9 will permit their treatment before the complication becomes serious.
Adequate prophylactic use of blood transfusion in placenta praevia or premature separation of the normally implanted placenta will prevent or minimize serious post-partum
blood loss.
In particular it is necessary to revise our management of the late second, and third
stage of labour. Dieckmann2 has shown conclusively and among others has proven
satisfactorily to me that the following procedures will minimize or materially reduce
the instance of post-partum haemorrhage.
(1) Slow delivery of the anterior shoulder with a pause of thirty seconds before
delivery of the posterior shoulder.
(2) Administration of an oxytoxic 1 cc. of pituitrin or 0.2 mgm of ergotrate)
following delivery of the posterior shoulder.
(3) A pause of a further thirty seconds and then delivery of the balance of the
baby over a period of one to two minutes.
This permits normal separation of the placenta which will usually be found in
the vagina after delivery of the baby or be easily removed from the lower uterine segment by slight traction.
If there is little bleeding the placenta should be removed manually, if necessary,
in fifteen minutes, but at the most in one hour. If there is persistent bleeding with
retained placenta, manual removal is indicated at once. This is much preferable to
repeated attempts at expulsion by Crede's manoeuvre which frequently produces or
increases shock. The use of the uterus as a piston in the pelvis in expulsion of the
placenta is mentioned only to condemn it.
In the rush of modern obstetrics we are prone to forget some of the well-established methods of management of the third stage. The careful palpation and observation of the fundus for a full hour after delivery is a cornerstone of prevention which
is too often disregarded today. This period of twilight between labour and the puer-
perium has become a no-man's land of rush, uterine relaxation and neglect. If we are
to prevent tragedies it must be restored to its proper status in the course of labour. If
these principles are followed, together with the control of bleeding from lacerations
or episiotomies there need be little concern for the development of serious post-partum
haemorrhage.
MANAGEMENT OF POST-PARTUM HAEMORRHAGE
If in spite of all our efforts post-partum blood loss is excessive, any loss over 500
cc must be considered serious, treatment should be prompt and active. Intravenous
ergotrate, manual exploration of the uterus for retained secundines, massage and packing, are indicated, while intravenous fluids (saline, glucose and plasma) are being administered. The latter are only temporary measures while blood transfusion is prepared.
Our aim should be to replace the blood lost and this is always greater than one thinks.
At least 1,000 cc of while blood should be given in any instance where transfusion
is considered advisable. It should never be forgotten that saline, glucose and plasma
will not, and cannot, restore the patient who has lost any quantity of blood. This fallacy in treatment with resultant delay in transfusion accounts for many of the recorded
fatalities.
In rare instances hysterectomy may be required to control post-partum haemorrhage. This may be so in haemorrhage associated with toxaemia, tumour and placenta
Page 232 accreta. It requires a rare sense of timing to carry this out successfully but it is the
only therapy which will succeed in such circumstances.
DISCUSSION
The relative importance of haemorrhage as a cause of maternal mortality and morbidity has gradually increased over the years as toxaemia and sepsis are controlled.
Reduction in its incidence by adequate management in the prenatal period and care in
labour are essential if any marked improvement is to occur. Revision of management
of the late second stage with the slow delivery of shoulders and trunk in association
with the administration of oxytoxics will assist in the early easy separation and delivery
of the placenta with reduction in blood loss associated with this stage of labour. In our
clinic, unlike Dieckmann, we prefer ergotrate to pituitrin, because of the widespread
use of cyclopropane as anaesthetic agent. We feel there is a definite danger in the association of these two drugs, which may induce fatal pituitrin shock. The earlier removal
of the placenta by manual extraction where no bleeding is present and the immediate
removal of all placentae where haemorrhage is obvious will decrease the incidence of
serious post-partum bleeding. The immediate use of oxytoxics, exploration of the uterine
cavity, packing, intravenous infusions followed by transfusions, where haemorrhage
exceeds 500 cc, is indicated. A more widespread use of this procedure with amounts
of blood in excess of 500 cc is warranted in all cases of post-partum haemorrhage of
any severity. "Too little and too late" has been the characteristic feature of our blood
transfusion therapy. Too great emphasis cannot be placed upon the necessity of adequate
and speedy utilization of this life-saving procedure.
CONCLUSIONS
(1) The persistence of haemorrhage as a cause of maternal mortality requires
serious consideration if further progress in reducing maternal mortality is to continue.
(2) Revision in management of the late second and early third stages of labour
with particular reference to slow delivery of the shoulders, and manual removal of the
placenta in all instances before one hour elapses, has resulted in decreased blood loss in
such cases.
(3) Prompt control of bleeding, with replacement by transfusions of whole blood
in excess of the estimated loss is essential in' the management of this condition once it
occurs.
REFERENCES
1. Beecham, C.—Am. Jour. Obs. and Gynec, 53, 442, 1947.
2. Dieckmann, Wm. J. et al—Am. Jour. Obs. and Gynec, 54, 415, 1947.
3. Gordon, Charles A.—Am. Jour. Obs. and Gynec, 54, 1058, 1947.
4. Greenberg, E. M.—Am. Jour. Obs. and Gynec, 52, 746, 1946.
5. Kerr, Marion—Am. Jour. Obs. and Gynec, 55, 396, 1948.
6. Vital Statistics—Province of Ontario.
7. Vital Statistics—City of Toronto*
8. Ebbs, J. H.  and
Tisdall, F. F. et al—Canadian M. A J., 46, 1942.
9. Watson, Alexander M.—Minn. Med., 30, 945, 1947.
* Read before Vancouver Medical Association Summer School.
ERRATUM:
In "DRY BONES OF ANTIQUITY," published in April issue of the
Bulletin, Page 164—second para., AMERICAN as printed should be AFRICAN.
Page 165—fifth para.—sixth line, SIRIUS OF SOTHIC as printed should
be SIRIUS OR SOTHIC.
Page 233 THE DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
OF ACUTE PERICARDITIS*     J|
By D. S. MUNROE, M.D.
Pericarditis is a comparatively common entity and inasmuch as it may acute and
severe, it may constitute one of the acute medical emergencies. It is always a manifestation of important disease which may resut in several ways.
1. Primary disease of the pericardial sac, e.g. Acute sero-fibrinous pericarditis of
unknown etiology. ify*,
2. Secondary to Myocardial disease, e.g. Myocardial infarction. J||
3. As part of a pancarditis, e.g. Rheumatic Fever.
4. As a manifestation of some widespread pathological process throughout the body
or in some important organ and in which the pericarditis is only an incidental
if important process, e.g. Acute Disseminated lupus erythematosis, Chronic
glomerulo-nephritis.
Patients who ultimately are diagnosed as having Pericarditis may present with or
be presented with any one or more of five conditions:
1. A precordial adventitous sound snchronous with the heart beat.
2. Pain.
3. Dyspnoea.
4. Abnormalities in the Electrocardiogram.
5. Abnormalities in the x-ray.
It is proposed to review each of these possibilities: ||||
1. Those who present with a precordial adventitious sound synchronous with the
heart beat. In this instance, the first decision to We arrived at is whether or not the
adventitious sound is in fact due to pericarditis.   It could also be due to:
(a) Pleuro-Pericardial friction. This is usually heard along the left cardiac border
and is synchronous with respiration. It may in certain phases of respiration also be
synchronous with the heart beat. It is usually pretty clearly secondary to pleural
inflammation which in turn may be "primary" or secondary to manifest pulmonary
diseasesdisease. The associated clinical findings, x-ray, and especially the clinical course
of the patient will usually be sufficient to clearly establish this diagnosis. The condition
may of course progress and the patient may ultimately have both Pleural and pericardial
lesions, e.g. Tuberculosis.
(b) Mediastinal Emphysema or Pneumomediastinium. This condition in civil life
is rarely traumatic in origin except a sa complication of thoracentesis and even more
rarely due to rupture of the oesophagus or bronchus. In these instances, diagnosis is.
usually easy when consideration is made of associated symptoms and signs. In the
tramuatic case there will be the history of fractured ribs, subcutaneous emphysema,"
pneumothorav, hasmopneumothorax, and etc, while in the case of the ruptured viscus,
profound persistent collapse, haematemesis or haemoptysis, sudden onset of pnuemothorax
or hasmorrhagic pleural effusion, etc., in the absence of trauma will sooner or later make
the diagnosis clear.
Spontaneous Mediastinal Emphysema is one of those entities in clinical medicine
which, once having been observed, makes a lasting impression and is unlikely to be missed
on another occasion. The history is usually one of anterior chest pain or compression
corning on relatively suddenly and of varying severity. Like the pain of Angina, it
may be present only with exertion or be accentuated by exertion. On the other hand,
it may be constant. Dyspnoea may be associated. Perhaps the most characteristic
subjective complaint of the patient is that he (and his wife) may be able to hear and
feel a crunching in his chest. On examination, there is heard a highly characteristic
adventitious sound.   It is usually described as crunching, rasping or crackling and it is
*Presented at the Summer School, Vancouver Medical Association, May, 1951.
Page 234 usually systolic or systolic and diastolic in jime—i.e. to and fro* It is best heard when
the patient is in full expiration and when he is in the left lateral position. This sign,
originally described by Hamman, once heard is not likely to be forgotten. There is no
general reaction (fever, leucocytosis, alteration in the sedimentaton rate, etc) and serial
elctrocardiograms are normal. The x-ray may be diagnostic in showing a narrow line
of air along a cardiac border or in outlining a segment of the Aorta. Pneumothorax of
variable size may be present and subcutaneous emphysema may sooner or later be palpable. The condition clears in a few days but tends to be recurrent. The great importance of its recognition is that it may be so readily confused with pericarditis and in
particular with the pericarditis associated with myocardial infarction.
Having excluded these conditions, one can state that the condition is in fact due
to pericarditis and proceed with a Differential Diagnosis of that entity.
2. Those who present with pain. The term precordial pain is outmoded but in
relation to pericarditis the sense of that term is often to be taken literally. I think the
pain of pericarditis can be roughly divided into two types:
(a) On inconstant intermittent pain felt deeply in the anterior chest but only on
deep inspiration or when the patient is lying in a certain position (i.e. left lateral)
which position is specific for each patient. Ths type of pain most frequently occurs in
cases of myocardial infarction with or without an audible rub. It usually occurs on the
second to fifth days after the original continuous pain of myocardial ifarction has gone.
It may be of any grade of severity and patients have several times mentioned that it
was much worse than the original pain. It usually clears in a few days. Rarely if
ever is it accompanied by an effusion of significant amount. It is in my opinion a most
useful point in the early diagnosis of myocardial infarction. Not infrequently, suspected
cases of infarction present no confirmatory laboratory or Electrocardiographic evidence
when first examined. The development of this type of pain in such a case points
stronly to the diagnosis which will usually be confirmed by subsequent laboratory and
electrocardiographic studies.
(b) The second type of pain in acute pericarditis is steady, constantly present and
may be of any grade of severity but is usually not severe. It may be referred to one
shoulder, especially the left, if the pleura is involved in which case the pain will be
accentuated by deep respiration. It may also be epigastric especially in cases with
tamponade and consequent hepatic congestion and cases of pericarditis have not infrequently been at first considered to be some lesion below the diaphragm. It may be more
of a severe sense of oppression rather than a real pain.
Finally, it must be remembered that many cases of pericarditis are painless. Time
does not permit of a consideration of the type of anterior chest or epigastric pain which
occur with other conditions and with which the pain of pericarditis may be confused.
3. Those who present with Dyspnoes. Dyspnoea of considerable grade is not due
to pericarditis per se unless there is an effusion of at.least a moderate amount. Where
severe dyspnoea is the chief problem and where the possibility of pericarditis enters the
picture, the diagnosis usually will be between pricarditis with large effusion and acute
cardiac dilatation with severe acute heart heart failure. This situation is always an
acute medical emergency an dthere is no differential diagnosis which is more difficult
to make and none in which it is more important to be sure. The more important points
to be taken into consideration are:
1. History—a previous history of rheumatic fever or tuberculosis elsewhere might
be in favor of pericardial effusion. A previous history of angina would weight the
diagnosis in favor of recent myocardial infarction with acute dilatatin.
2. Fever of considerable grade would favor pericarditis.
3. Paradoxical pulse is more characteristic of cardiac tamponade but can occur
in acute cardiac dilatation. j|||
4. Low or very low systolic blood pressure with very small pulse pressure favors
pericardial effusion.
Page 235 5. A palpable apex beat is strong evidence against a large pericardial effusion.
6. Muffled heart sounds may favor pericarditis with effusion.
7. The electrocardiogram and x-ray may be of some value but often they are not—
to be discussed later.
The other numerous symptoms and signs (color, distention of neck veins, enlarged
liver oedema, etc., etc.) help little in this differential diagnosis.
8. Finally, paracentesis will settle the situation—but even this procedure may leave
one'in doubt and is not entirely without risk.
Pericarditis with massive effusion usually brings to mind an infective lesion—one
must however remember the occasional tamponade produced by rupture of a Dissecting
Aneurysm of the Aorta and by rupture of a myocardial infarct and by trauma, in which
cases the fluid will be bloody. Hasmapericardium may also be found in tubercuoious
pericarditis and in malignant invastion of the pericardium.
4. Those who present with abnormalities in the electrocardiogram—this is perhaps
poorly stated but it is not an infrequent occurrence for the electrocardiographic tracing
to be the first thing to brin gthe possibility of pericarditis into the diagnosis of a case.
It is common to have the tentative diagnosis of myocardial infarction suddenly shifted
to pericarditis although, of course, the two may co-exist.
The electrocardiogram may show no changes in pericarditis but usually it does
and the changes may be described as follows:
The earliest change is high take-off of the ST segment in leads 1 and/or 2 or
several leads without the presence of significant Q wavs. The shape of this elevated ST
is different from that see nin myocardial infarction in that the concavity is upwards as
inu the normal—it is not much changed in shape but its origin is above the iso-electric
line. There then develops a gradually lowering of the ST segments with flattening and
later inversion of the T waves in several leads. Q waves do not develop and R waves
persist. In the first two to four weeks, there are usually progressive changes to be seen
in serial tracings and complete recovery occurs after several weeks in the absence of
myocardial damage as in infarction.
Conduction defects in the form of prolonged PR interval, the Wenckebach phenomenon and prolonged QT interval may occur. They indicate a myocardial lesion and
thus weigh the diagnosis in favor of something which can give both pericarditis and
myocarditis—e.g. Rheumatic Fever. This point however is not absolute.
In pericarditis with developing effusion, any of the above changes may be present
early but the tracing soon becomes one of non-specific character in which the chief
changes are low potential and flat or inverted T waves throughout.
It is important to emphasize the different points in the electro-cardiographic tracing of infarction and acute pericarditis:
(a) the difference in the character of the elevated ST segments.
(b) The absence of reciprocal changes, i.e.—the absence of depression of ST2 as
seen in anterior infarction and the absence of depressed ST in precordial leads in posterior infarction.
(c) Absence of Q waves.
(d) Absence of change in R waves.
5. Those who present with abnormalities in the X-ray. It is not uncommon to see
a large heart shadow and wonder if pericardial effusion is present. Fluoroscopic and
X-ray examination can be of the greatest value in differentiating a pericardial effusion
from other conditions—in fact, X-ray study is perhaps the most important aid to the
diagnosis. However, frm the point of view of practical medicine, when it is most needed,
it often cannot be used. We have all had the experience of seeing a desperately ill patient
for whom it has been considered quite an impossibility to be fluoroscoped when sitting
and when lying. We are forced to resort to a portable film which, more often than not,
confuses the issue. Thus, perhaps the most important tool in the diagnosis of pericardial
effusion is of no value whatever in the individual case at the crucial time.
Page 236 The X-ray signs of pericardial effusion are very well known to all of you and need
not be detailed here. Perhaps the most important of these is the enlargement of the heart
shadow, the change in its contour with variation in position of the patient, and the
diminution or absence of cardiac pulsation when view with the fluoroscope.
These then are the five chief ways in which Pericarditis or Pericarditis with Effusion are likely to be brought to our attention. In any one case, perhaps only two or three
etiological types are possible or probable but it never does any harm to consider briefly
in one's mind all the causes of pericarditis. These are as follows:
I. Infective.
1. Rheumatic Fever—the patient is usually a child and nearly always under 30
or 35. Associated features include the joint manifestation of the disease, fever, heart
valvular lesions and moderate leucocytosis. The electrocardiogram in addition to the usual
changes of pericarditis very often shows AV conduction defects. An effusion of any
degree may be present. The fluid is serous. Salicylates affect the joint symptoms favorably promptly and they also reduce the amount of the effusion in many cases. Paracentesis is but rarely necessary.
2. Tuberculous—The process is usually much less acute but on occasion can be
quite as acute as that of Rheumatic Fever. An effusion of considerable amount is usually
present and this tends to be recurrent. Another tuberculous focus such as a lung lesion
or pleurisy with effusion is often present, j The tuberculin test is positive or becomes
positive. The fluid is serous or sanguinous and the organism can usually be recovered by
culture or guinea pig inoculation. The course is very chronic and constrictive pericarditis is a common complication. In fact, tuberculous pericarditis is the commonest cause
of chronic constrictive pericarditis.
3. Pyogenic—this may result from local spread as from en empyema or pneumonia
or it may result from hematogenous infection—(e.g. septicaemia from a boil or carbuncle) . The patient will usually present some superficial or deep focus with its attendant symptoms and signs. The course is hectic with high sustained fever or remittent
fever with rigors. The leucocyte count is high unless the infection is overwhelming.
The blood culture is likely to be positive. Pericardial effusion is likely to occur and the
fluid contains a large number of cells, mainly polymorphs, or is frankly purulent. The
infecting organism can be recovered from pericardial fluid. Local and general improvement is to be expected from appropriate antibiotic treatment.
4. "Benign" Pericarditis or Acute Non-specific Pericarditis or "Virus" Pericarditis
or Acute Serifibrinous Pericarditis of unknown cause—This condition was first recognized in 1927 and while not common its great importance is that it may so readily be
confused with myocardial infarction. It may occur at almost any adolescent or adult
age. It is commonly preceded within one month by an upper respiratory infection which
may have long since been forgotten. On the other hand, virus pneumonia and pleural
effusion have occurred in association. Pain is the predominant symptom, a rub is heard
as a rule and fever is variable in degree. Cardiac dilatation and/or pericardial effusion
may occur paracentesis is rarely necessary. The electrocardiogram usually shows the classical changes of pericarditis but there are no defects of conduction. Specific therapy is
of no value but complete recovery occurs in all. Diagnosis from other causes of pericarditis is by exclusion. The difficulty lies in excluding Rheumatic infection and myocardial infarction. This differentiation is most mportant because of the great difference
in prognosis.
II. Non-Infective.
1. Uraemia—this is a common cause of pericarditis. The patient usually has evidence
of far advanced renal or post renal disease. The more common types of renal diseases
are chronic glomerulonephritis and chronic pyelonephritis but pericarditis may occur
in any type of advanced bilateral renal disease whether this be primarily due to kidney
disease or disease of the lower urinary tract. Diagnosis is usually easy on clinical grounds
alone—hypertension, ophthalmoscopic changes, low fixed urinary specific gravity and
the history of chronic urinary trouble. The diagnosis is readily confirmed by an estimation of the NPN.
Page 237 There are three common misconceptions about Uraemic pericarditis:
1. It is painless. This is not always so—uraemic pericarditis may result in severe
pain.
2. It is always accompanied by a high NPN—this is not so—Uraemic pericarditis
may occur with an NPN under 100 mgms.%.
3. It is a harbinger of death—this is not always so—recoverey at least temporarily
may occur in cases where the azotaemia is post renal in origin if the cause can be removed.
There is commonly an effusion in Uraemic pericarditis but in only about one third
of cases is the amount sufficient to be detected by X-ray. Paracentesis is rarely necessary.
The fluid may be sanginuous.
2. Myocardial Infarction—pericarditis occurs in 25-50% of cases but is diagnosed
in a smaller percentage. It is unnecessary to review the findings in such a case—suffice
it to say that the occurrence of pericarditis in a suspected case of myocardial infraction
may absolutely confirm the diagnosis—or it may be the thin edge of the wedge in our
mental processes by which the diagnosis may be ultimately changed to one with more
favorable prognosis, i.e. Mediastinal emphysema, benign pericarditis, etc. Mention has
already been made of a characteristic sequence of pain in cases of myocardial infarction
with pericarditis.
3. Neoplastic—very rare—of academic importance only.
III. Others—
Collogen Diseases—Peri Arteritis Nodosa.
Acute Disseminated Lupus Erythematosis.
Rheumatoid Arthritis.
The presence of pericarditis in these is merely an incidental finding but it may be
useful in the diagnosis of the basic disease.
Thiamin Deficiency—this is rare in this country and rarely results in pericardial
effusion. Acute cardiac dilatation is more common.
Congestive Heart Failure—pericardial effusion may occur but is rarely of much
moment.
A secondary and often confirmatory method of diagnosis of the type of pericarditis
is by therapeutic test. Using salicylates, the therapeutic response in hreumatic fever and
the absence of response in all other types of pericarditis is of diagnostic value. The
appropriate antibiotic may yield a therapeutic response of diagnostic value in septic
pericarditis. ACTH and CORTISONE may prove to be of value as a diagnostic test in
severe rheumatic pericarditis with effusion.
Summary:
The diagnosis and differential diagnosis of acute pericarditis has been approached
by a consideration of the chief presenting symptoms and signs. A brief review of the
various types of pericarditis has been presented.
CANADIAN MEDICAL ASSOCIATION, B. C. DIVISION
Annual Meeting
Vancouver Hotel - October 3-5, 1951
Plan to attend . . . Make your reservations early ...
PROGRAMME will include—
Oct. 2nd, Afternoon—Sectional meetings, Vancouver Hotel.
Oct. 2nd, Evening    — General meeting of Association.
Oct. 3-5 —Scientific papers and round tables.
Oct. 3rd —Annual Luncheon, Vancouver Hotel.
Oct. 4th, Afternoon — Annual Golf Tournament at Shaughnessy Heights Golf
Club.
Oct. 4th, Evening     — Buffet Dinner and Dance at H.M.C.S. Discovery in Stanley
Park.
Oct. 5th, Evening     —Annual Dinner at Vancouver Hotel.
Page 238 Dr. R. Scott-Moncrieff of Victoria is taking a course in otolaryngology in St. Louis.
Along with Dr. Gordon Francis and Dr. Ron Taylor of Vancouver he will attend the
Canadian E.N.T. meeting in Quebec this month.
Dr. L. B. Pett of Ottawa addressed the Victoria Medical Society in June on "Conditioned Malnutrition".
Dr. K. C. Boyes, formerly of Woodfibre, and Dr. R. W. Lamont-Havers, acting
director of B. C. Health Service, have been awarded one year scholarships in the Eastern
States to study arthritis.
Dr, W. J. Knox of Kelowna has been awarded an honorary L.L.D. from Queen*s
University.
Dr. E. T. Feldsted of Vancouver has been named senior investigator for the B. C
Medical Research Institute.
Dr. Bede Harrison and Dr. C. P. Harrison of Vancouver have begun a joint radiology practice in New Westminster.
Dr. W. S. Wood of Vancouver has been awarded a medal in Obstetrics on graduation from McGill University.
Dr. D. K. Merkely of Regina will assist Dr. H. H. Pitts in pathology at St. Paul's
Hospital in Vancouver.
Dr. G. I. Norton of the Vancouver General Hospital has entered private radiology
practice in Vancouver with Drs. Turnbull, Dickey, Sloan &- McCurrach.
Dr. Gordon Stranks of Shaughnessy Hospital will be associated with Dr. W. M.
Toone in North Vancouver on July 1.
Dr. Jack Wame of the Crease Clinic at Essondale has begun private practice with
Dr. R. Stanwood in Vancouver.
Drs. L. Appleby, F. P. Patterson, Murray Baird and R. E. McKechnie of Vancouver
addressed District Four Medical Association in May. Dr. John Gibson of Penticton and
Dr. M. A. Crossland of Vernon head the new executive.
Dr. V. Guttormson of Kamloops has undertaken post-graduate work in California
for a year. f|£|
Dr. F. H. Mayhood of Vancouver has moved to Bowen Island.
BIRTHS
To Dr. and Mrs. Eric Webb of Vancouver, a daughter.
H. G. Weaver of Vancouver, a son.
H. K. Fidler of Vancouver, a son.
E. Christopherson of Vancouver, a son.
Morton Hall of Vancouver, a son.
/. G. Gillis of Vancouver, a daughter.
Harold Henderson of Kelowna, a son.
R. J. Cowan of Vancouver, a daughter.
N. B. Gregory of Ladner, a son.
R. D. Morrison of Hope, a daughter.
P. G. Ashmore of Vancouver, a son.
MARRIAGES
Dr. M. R. Earle of Vancouver to Hilda Bodkin.
Dr. Thomas MMar of Vancouver to Lorraine Donovan of Quebec.
Dr. Kenneth Morton of Vancouver to Joyce Fawsitt, psychologist at the Crease
Clinic.
Page 239 Ortho presents    .
Ortho-white
flat spring diaphragm
s. • for those cases where a flat
spring diaphragm is indicated.
Physicians have found that in some conditions a flat spring diaphragm
is preferred because it provides- a better support for the vaginal
wall. Also, some patients prefer the flat spring type for manual
insertion of the diaphragm.
Ortho-white flat spring  Diaphragms and Ortho coif spring
Diaphragms are individually packaged in an attractive,
convenient,   plastic   case   as   illustrated.   They   are
available in sizes 55 to 100 millimeters.
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ORTHO PHARMACEUTICAL CORPORATION
(CANADA) LIMITED Toronto
Ortho

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