History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1952 Vancouver Medical Association Jan 31, 1952

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 THE
ULLETI
OF
The Vancouver Medical 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
0MJi      Publisher and Advertising Manager
W. E. G. MACDONALD
VOLUME XXVIII
JANUARY, 1952
NUMBER 4
OFFICERS 1951-52
Dr. J. C. Geimson 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
i||f Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Eye, Ear, Nose and Throat
Dr. B. W. Tanton Chairman^ Dr. John A. Irving Secretary
Paediatric
Dr. Peter Spohn Chairman Dr. John W. WHiTELAW-Secretary
Orthopaedic and Traumatic Surgery
Dr. A. S. McConkey. Chairman Dr. W. H. Fahrni Secretary
Neurology and Psychiatry
Dr. R. Whitman Chairman   jf   Dr. B. Bryson j||LSecretary
Radiology
Dr. R. G. Moffat Chairman Dr. H. Brooke Secretary
STANDING COMMITTEES
Library :
Dr. A. F. Hardyment, Chairman; Dr. J.- L. Parnell, Secretary;
Dr. F. S. Hobbs, Dr. J. E. Walker, Dr. E. France Word, Dr. D. W. Moffatt
Co-ordination of Medical Meetings Committee:
Dr. J. W. Frost Chairman Dr. W. M. G. Wilson Secretary
Summer School:
Dr. J. H. Black, Chairman; Dr. J. A. Irving, Secretary; Dr. B. T. H.
Marteinsson; Dr. Peter Spohn; Dr. S. L. Williams; Dr. J. A. Elliott.
Medical Economics:
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
Published  monthly  at  Vancouver,  Canada.     Authorized  as  second  class  mail,  Post  Office  Department,
Ottawa, Ont. 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 invitee
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.
Programme of General meetings will be circularized monthly by the Executive
Office of the Vancouver Medical Association Programme of Clinical meetings will be
displayed weekly on bulletin boards prepared for that purpose and placed in the Vancouver General, St. Paul's and Shaughnessy Hospitals.
VANCOUVER GENERAL HOSPITAL
Regular Weekly Fixtures in the Lecture Hall
Monday, 8:00 a.m.—Orthopaedic Clinic.
Monday, 12:15 p.m.—Surgical Clinic,   ^p
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 Paediatric   Conference
2nd Tuesday of each Month—11 a.m Tumor Clinic
Wednesday—9-11  a.m Medical Clinic
2nd and 4th Wednesday—11-12 a.m Obstetrics and Gynaecology
Thursday—11-12   a.m . Pathological  Conference
(Specimens and Discussion)
Friday—8  a.m. Clinico-Pathological Conference
(Alternating with Surgery)
Alternate Fridays—8 a.m 1 Surgical Conference
Friday—9 a.m . „._.:__ Dr. Appleby's Surgery Clinic
Friday—11 a.m Interesting Films Shown in X-ray Department
Page 68 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.
B.C. SURGICAL SOCIETY
Spring meeting—April 25th, 26th, 1952.
THE  BULLETIN
Publshing and Business Office—17 - 675 Davie Street, Vancouver 2, B.C.
Editorial Office — 1807 West 10th Avenue, Vancouver 9, B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.
Closing Date for articles is the 10th 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.
Page 69 amf (%wde€0MJ&6cfat
Hi
Otorhinolaryngologists frequently express preference for
Neo-Synephrine hydrochloride to alleviate turgescence and
nasal congestion in colds, sinusitis and various forms of rhinitis.
"When considerable nasal obstruction exists, relief may be
obtained by the instillation of some shrinking agent into the
n©se... as for example Neo-Synephrine hydrochloride (^4 %) "*
A "desirable preparation of this type has been perfected
in Neo-Synephrine hydrochloride. It may be used for local
application in the nose in XA to 1 % solution."2
Neo-Synephrine's "desired effect occurs within from two
to fifteen minutes.. ."3
"Its action is sustained for two hours or more."3
Neo-Synephrine hydrochloride is notable for freedom from
sting and for effectiveness on repeated application. There are
few complaints of after effects such as burning and nasal congestion . ?. and little tendency to develop local sensitivity.1
Mfe
.SllffW*'
gP/wnft
j^y^
OlO
sttfy
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H^
EVER
IMS;
OF    CANADA    LTD.
WINDSOR,   ONT.
1. Tuft, I..- Clinical Allergy. Philadelphia, W. 8. Saunders Co., 1947, pp. 335-336.
2. Hansel, f. K.-. Allergy of (he Nose and Paranasal Sinases. St. Louis, C. V. Mosby Co., 1936, p. 769.
3. Keffey, S. P.: Choice of Sympathomimetic Amines. Cornell Conferences on Therapy, II, 1947, p. 156.
Neo-Synephrine, trademark res. U. S. & Canada, brand of phenylephrine
443 SANDWICH STREET WEST, WINDSOR, ONTARIO 4*e
Rapid Clinical Response
WITH
JJ
\
Chloromycetin
MEANS EARLY RETURN TO
NORMAL ACTIVITIES
Continuity of treatment with well-tolerated
CHLOROMYCETIN produces a rapid clinical
response in a wide variety of bacterial, viral,
and rickettsial diseases. Convalescence is
smooth, and an early return of the patient to
his normal activities may be anticipated.
nr
CHLOROMYCETIN
CHLOROMYCETIN
CHLOROMYCETIN
CHLOROMYCETIN
CHLOROMYCETIN
CHLOROMYCETIN
CHLOROMYCETIN
CHLOROMYCETIN
(chloramphenicol, Parke-Davis)
is supplied in the following forms:
Kapseals,® 250 mg., bottles of 16 and 100.
Capsules, 100 mg., bottles of 25 and 100.
Capsules, 50 mg., bottles of 25 and 100.
Cream, 1%, 1 ounce collapsible tubes.
Ophthalmic Ointment, 1%, lA ounce
collapsible tubes.
Ophthalmic, 25 mg. dry powder for solution,
individual vials with droppers.
Palmitate, Pediatric, 60 cc. bottles.
VC  A  Af
PARKE, DAVIS & COMPANY 1^
PE ** **«</
f0»
£&g*'
wmmmm
PREMARIN" with METHYLTESTOSTERONE
whenever 1^
estrogen-androgen therapy
is required
A steroid combination which permits
utilization of both the complementary
and the neutralizing effects of estrogen
and androgen.
Indicated — in fractures and osteoporosis
in either sex
— in  the  female   climacteric  in
certain selected cases
— in dysmenorrhea
— in the male climacteric
No. 879 —"Premarin"....,.^^..1.25 mg.
conjugated estrogenic
substances (equine)
Methyltestosterone. ...10.0 mg.
No. 878 — "Premarin"....-j|; 0.625 mg.
conjugated estrogenic
substances (equine)
Methyltestosterone 5.0 mg.
Bottles of 20 and 100
Ayerst, McKenna & Harrison Limited
Biological and Pharmaceutical Chemists
Montreal, Canada ^^^^^^B
I fir*"* ' VANCOUVER HEALTH DEPARTMENT
STATISTICS—NOVEMBER, 1951
Total population—estimated   397 140
Chinese  population—estimated           6 282
Other—estimated    |    ' ~ 540
October,   1951
Rate per
Number 1000 pop.
Total deaths   (by occurrence)  373 11.3
Chinese   deaths    '. . _'_     12 22.9
Deaths,   residents   only  324 9.8
Birth Registrations—Residents and Non-residents
(includes  late  registrations)
Male 	
October,   1951
Number
18 447
Female    1 -  459
906
27.4
Infant Mortality—residents only
October,  1951
Deaths  under   1   year  of  age .__     20
Death rate per 1000 live births -      31.2
Stillbirths   (not included in above item) - -     10
CASES OF COMMUNICABLE  DISEASES  REPORTED  IN  THE  CITY
Scarlet Fever _
Diphtheria '.
Diphtheria  Carriers -"—  —
Chicken Pox -"|fc~  58
Measles -'-   -  90
Rubella - | |     5
Mumps -  2 2
Whooping Cough     3
Typhoid  Fever  —
Typhoid   Fever   Carriers     1
Undulant  Fever ^ .  —
Poliomyelitis I     5
Tuberculosis-— _   42
Erysipelas '-     4
Meningitis *     2
Infectious   Jaundice   —
Salmonellosis ;     4
Salmonellosis  Carriers  —
Dysentery >  . i^>  10
Dysentery   Carriers  —
Tetanus —  —
Syphilis  25
Gonorrhoea.——-— . 149
Cancer   (Reportable   Resident) ,  57
Cases Deaths
October,   1951
60
69
Cases       Deaths
October,  1950
23
22
1
179
—
115
54
Page 70 -C CONNAUGHT >
Rapid and Prolonged . . . .
PENICILLIN G PROCAINE AND PENICILLIN G SODIUM
For Aqueous Injection
* The need for a penicillin preparation which gives initially high blood I
levels as well as a prolonged effect is fully met by Penicillin G Procaine andi
Penicillin G Sodium for Aqueous Injection. This product, as supplied byi
the Connaught Medical Research Laboratories, provides in each cc. of thei
suspended preparation 300,000 I.U. of penicillin G procaine and 100,0001
I.U. of penicillin G sodium. The soluble penicillin G sodium permits of the
rapid attainment (usually within 30 minutes) of a relatively high level of
penicillin in the blood, followed by the maintenance of lower blood levels
for about 24 hours, due to the effect of the relatively insoluble penicillin
G procaine.
This new product of the Laboratories is prepared as a stable dry
powder which requires no refrigeration. By the addition of an appropriate
volume of sterile water, a free-flowing aqueous suspension is readily and
quickly obtained. The aqueous suspension is ready for immediate intramuscular injection using a 20-gauge needle.
HOW SUPPLIED
1-dose vial—  400,000 International Units
5-dose vial—2,000,000 International Units
10-dose vial—4,000,000 International Units
D
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. As one studies the changing scene today, one is sometimes struck by a growing
tendency in our community towards the formation of associations and groups amongst
people who are technical assistants to professional workers: and, in many cases, are not
(themselves possessed of any great training or any but the smallest amount of scientific
knowledge. These we see first aid workers' associations, dental technicians' associations,
office workers' associationSj and so on, becoming strong and vocal and loudly asserting,
in many cases, their ability and right to undertake work for which they have not the
sufficient basis or clinical training. This, to our mind at least, presents a certain degree
of menace to the wellbeing of the community.
Nobody can, and probably nobody does, object to the formation of these associations. It is quite within their right to organize, and indeed could be a very valuable
and wise thing for them to do. But with numbers and organization goes a tendency
to form pressure groups, to enter the political field to some extent—and under our democratic methods, solid bodies of people forming a solid block of votes, have a definite
political value and a definite political weight.
And when they exert this pressure and this influence to gain for themselves the
Iright to do work for which they are not adequately trained, there is opened the way
[to a rather mischievous situation. One can see this in a recent agitation on the part
[of first-aid groups to be allowed to give parenteral and intravenous treatment, using
jmorphine, plasma and the like. There is no reason why certain first aid workers could
not be adequately instructed to do these things—but it depends on what we mean by
"adequate". True, registered nurses are often trained in these technical performances, but
[the basic and clinical training of a registered nurse is a far more complete and thorough
affair than any first aid worker receives—and the two cases are not parallel.
Again, we view with considerable misgiving the agitation among dental assistants
and technicians (perhaps we are not using the correct terms) to be allowed to do what
is really professional work, with nothing but a mechanical and technical training. In
spite of large display advertisements in the press, we do not think that they have a case
at all. The trained dentist, fitting plates, must have behind him a rigorous professional
training, and a knowledge and judgment based on that training—the man who has
merely learned how to fill a prescription for plates, and how to make them mechanically,
has none of these things, and should not be allowed, in our opinion, to practise dentistry.
The dentist's charge is not only for the plate, but for the skill and experience he alone
can provide.
It reminds one of Kim's jibe in Kipling's well-known story of that name: "A rat
found a piece of turmeric: said he "I will open a chemist's shop.' "
The danger is that public opinion, misinformed as to the true merits of the case,
and always prone to sympathize with the apparent victim of professional greed and
jealousy, which of course he is not, may become swayed in the wrong direction.
It is the old story. The only answer, and the best answer is, by adequate public
relations action, to provide the public with the true facts. It is not only medicine
and dentistry that are assailed—architects, engineers, lawyers, and all professional groups
are concerned. One has often thought that a Professions' Council or something of the
sort, would be a very good thing to have—that those who through various professions,
hardly learned by long and arduous training and labour, serve the public, might
by adequate public relations work, keep that public informed, for its own safety and
well-being.
The public cannot be blamed if, learning only one side of the question, it tends
to form opinions which we believe to be mistaken.   It should hear both sides, fairly
Page 71 presented.   And we should  make sure  that  the public  understands  clearly  that the
primary purpose of professional Acts, Medical, Dental, Legal, Engineering, etc., is to
protect, not the men who practise those professions, but the public, against irregular!
and improperly qualified practitioners.   This can only be done by laying down definite!
standards of training and education, and insisting that they be met in all cases.
Editor, The Bulletin,
Dr. J. H. MacDermot,
Vancouver Medical Association,
1807 West 10th Avenue,
VANCOUVER 9, B.C. B
Dear Dr. MacDermot:
Last year you generously included in your Bulletin a notice regarding the inaugural
Ball of our Medical Undergraduate Society. I have been asked by the Society to submit
the enclosed announcement in the hope that you might find space for it in an early
issue.
The success of last year's event was attributable wholly to the excellent support
that physicians and their wives gave to the students in what was actually a courageous
social venture. The students are keen to see that the Second Annual Medical Ball will
be equally successful.
I hope that it will be possible for you to help our students by including mention
of this event in your Bulletin.
Yours sincerely,
LAWRENCE E. RANTA,
Assistant to the Dean.
SECOND ANNUAL
MEDICAL BALL M
The Medical Undergraduate Society of the University of British Columbia is happy
to announce that plans are well advanced for the Second Annual Medical Ball to be
held on Friday, March 21, 1952, in the Ballroom of the Hotel Vancouver. The Society
hopes that the success of the inaugural Ball will encourage their many friends in the!
medical profession to lend again their splendid support, so that the bursaries established
from the proceeds of last year's event can be maintained.
Dinner will be served at 7:30 p.m. and dancing will proceed from 9:00 p.m. to j
1:00 a.m. Tickets at $9.50 per couple will be available at all hospitals. Reservations <
may be obtained through Mr. J. Treloar, ALma 3040-Y, 3727 West 20th Avenue.
VANCOUVER MEDICAL ASSOCIATION—SUMMER SCHOOL
to be held
May 26th to May 30th, inclusive
Salo
n
tun
-Hotel Vancouver
Information: Dr. J. A. Irving, Secretary, Summer School Committee
1807 West Tenth Avenue
Vancouver 9, B.C.
Page 72 Library Hours:
Mondays, Wednesdays and Fridays 9:00 a.m. to 9:30 p.m.
Tuesdays and Thursdays 9:00 a.m. to 5:00 p.m.
Saturdays   __._ 9:00 a.m. to 1:00 p.m.
\Recent Accessions
Alvarez, W. C, The Neuroses, 1951..
British Empire Cancer Campaign, 28th Annual Report, 1950.
Cecil, R. L. and Loeb, R. F., A Textbook of Medicine, 8th edition, 1951.
Cleckley, H. M., The Mask of Sanity, 2nd edition, 1950  (Nicholson Collection).
Custer, R. P., An Atlas of the Blood and Bone Marrow, 1949.
Farr, L. E., The Treatment of the Nephrotic Syndrome, 1951.
Kosmak, G. W., (editor)—Transactions of the International and Fourth American
Congress on Obstetrics and Gynecology, 1951.
Levine, S. A., Clinical Heart Disease, 4th edition, 1951.
Medical Clinics of North America—Symposium on Diagnosis in General Medicine,
Philadelphia Number, November, 1951.
Medical Research Council Report for the years 1948-1950; London H. M. S. O.,
1951.
Rankin, F. W. and Graham, A. S., Cancer of the Colon and Rectum—Its Diagnosis
and Treatment, 2nd edition, 1950.
Surgical Clinics of North America—Symposium on Minor Surgery, Nationwide
Number, October, 1951.
§ BOOK REVIEW
SOVIET PSYCHIATRY, by Joseph Wortis.   Baltimore: Williams and Wilkins, 1950,
pp. 314
This most interesting book was written by a man who has never been in Russia.
Nevertheless, it is apparent that he has done a tremendous amount of reading in order
to acquaint himself with the Russian literature in Psychiatry and he gives a fascinating
account of the attitude of the U.S.S.R. towards this subject—an attitude that is
definitely physiological and obviously markedly influenced by the work of Pavlov and
his school.
The Soviet psychiatrist believes that consciousness rests on a foundation of primitive
reflexes and physiological functions. To him "There is no underlayer of unconscious
idease derived either from biological drives or repressed from consciousness, to determine
man's behaviour.*' 5^
The Russians in many ways appear to have been taking a broad viewpoint in looking
at psychic disturbances. For some years they have stressed the point that a neurosis
should be regarded as a disorder involving the entire organism: and not merely the
psychic functions.
Page 73 Research would appear to be very active and the research worker would seem to bej
well treated. "While working for an advanced degree the aspirant is exempt from
military service, receives a salary, a book allowance equal to one month's salary, a two
month's summer and a twelve day winter vacation, and enjoys all the privileges of
regular staff members of the institute."
The chapter on Education and Research is well worth perusal.
In the U.S.S.R. there has been little interest in psychoanalysis since about  19361
Again one notes the emphasis on Physiology rather than the "dynamic unconscious"!
The viewpoint is nicely summed up in the following sentence ^Patients who are being
analyzed for two years and more become too submerged in themselves; they are conj
stantly stewing in their own juice and are torn away from reality."
The sections on "Child Psychiatry" and "The Importance of Work" are interesting!
In reading the book one gets some highlights on the methods of thinking and living^
adopted by the Soviets.
The book is recommended as an excellent contribution of great interest.
E . A. D.
OREGON ACADEMY OF OPHTHALMOLOGY
AND OTOLARYNGOLOGY
The Annual Spring Convention in Ophthalmology and Otolarygology will be
held in Portland, March 24 to 28, 1952, inclusive. An excellent program has been
arranged by the Oregon Academy and the University of Oregon Medical School. Otolaryngology sessions are scheduled on March 24, 25, and the morning of March 26.
Ophthalmology sessions will be held in the afternoon of March 27 and 28. Guest
speakers are:
DR. PHILIP E. MELTZER, Professor of Otolaryngology at Tufts College Medical
School, Boston.
DR. FRANCIS A. LEDERER, Professor of Otolaryngology at the University of
Illinois College of Medicine, Chicago.
DR. FREDERICK C. CORDES, Professor of Ophthalmology at the Universnj
of California School of Medicine, San Francisco.
Dr. WILLIAM HUGHES, Professor of Opthalmology at the University of Illinois
College of Medicine, Chicago.
Dr. Cordes will present the third E. Weeks Memorial Lecture in Opthalmology.
His subject will be "The Visual Prognosis in Diabetes."
Further announcements will be mailed early in February, 1952, and a complete
program will be sent to you by the middle of the month.
DAVID D. DeWEESE, Secretary
1216 S.W. Yamhill Street, Portland 5, Oregon.
The SPRING MEETING OF THE B.C. SURGICAL SOCIETY will be
held on April 25th and 26th, 1952. Dr. Warren Cole, Professor of
Surgery, University of Illinois, will be guest speaker, and he will
address a meeting which is open to the Medical profession on the night
of April 26th, in the Hotel Vancouver, Salon A.
Page 74 CANADIAN MEDICAL ASSOCIATION-B. C. DIVISION
October,   1951   — September,   1952
OFFICERS
President Dr. H. A. L. Mooney, Courtenay, B.C.
President-Elect ...Dr. J. A. Ganshorn, Vancouver, B.C.
Vice-President Dr. R. G. Large, Prince Rupert, B.C.
Honorary Secretary-Treasurer  ! Dr. W. R. Brewster, New "Westminster, B.C.
Chairman, General Assembly _ Dr. F. A.  Turnbull, Vancouver, B.C.
STANDING COMMITTEES CHAIRMEN
Constitution and By-Laws_J Dr. R. A. Stanley, Vancouver, B.C.
Finance Dr. W. R. Brewster, New Westminster, B.C.
Legislation '. Dr.  J.  C.  Thomas, Vancouver, B.C.
Medical Economics Dr. R. A. Palmer, Vancouver, B.C.
Medical Education Dr.  G.  O.  Matthews, Vancouver,  B.C.
Nominations | Dr. H. A. L. Mooney, Courtenay, B.C.
Programme and Arrangements Dr. R. C. Newby, Victoria, B.C.
Public Healths . - Dr.  G. F.  Kincade, Vancouver, B.C.
SPECIAL COMMITTEES CHAIRMEN
Arthritis and Rheumatism Dr. A. W. Bagnall, Vancouver, B.C.
Cancer Dr. A. M. Evans, Vancouver, B.C.
Civil Defence Dr. L. H. A. R. Huggard, Vancouver, B.C.
Emergent Epidemics.- Dr. G. F. Amyot, Victoria, B.C.
Hospital Service ! = Dr.  J.  C.  Moscovich, Vancouver, B.C.
Industrial Medicine ! Dr. E. W. Boak, Victoria, B.C:
Maternal Welfare Dr. A. M. Agnew, Vancouver, B.C.
Membership I Dr. L. H. Leeson, Vancouver, B.C.
Pharmacy Dr. D. M. Whitelaw, Vancouver, B.C.
EDITORIAL
Since Economics is to be conducted by the Economics Committee of the B.C.
Division of the Canadian Medical Association, it will be necessary for this organization
to be adequately financed. It has been estimated that a minimum fee of $30 will be
absolutely necessary for this purpose. Another $10, which had been previously collected
by the College for the Canadian Medical Association, will now be collected by the
B.C. Division making a total of $40 per annum.
This extra levy is partially offset by reduction in the fee paid to the College of
Physicians and Surgeons of B.C. Since they will be spared the cost of conducting our
Economics, their fees have been reduced from $50 per annum to $30.
The net increase in tax will therefore only amount to a matter of $20 per year.
The Council of the College of Physicians and Surgeons are to be commended on the
prompt manner in which they have made this reduction in their annual dues.
We may wonder why .we should pay this money to the B.C. Division. One can
think of several very pertinent reasons why it is essential to our own welfare.
In the first place, we, as a profession, have one of the most thriving and remunerative businesses in the province, and it would seem nothing short of madness for us to
neglect its financial aspects. ||§|
To do this we merely have to pay for an Executive Secretary and a small office
staff.
Page 75 Strangely enough, the long hours of meetings and negotiating will be carried on
completely free of charge by our elected representatives, and particularly those of our
Economic and Financial Committees.
In the second place, we want to remain free to conduct our various practices as
individuals, in our own way and in a manner which we know to be in the best interest
of the patient.
In order to do this we must be well organized, completely united, and as a group
financially able to protect our interests. In this way only can we continue to stem
the greedy tide of bureaucratic encroachment. This objective should be worth much
more than the tiny fee we are asked to pay.
The B.C. Division, unlike the College of Physicians and Surgeons, is purely an
organization of the Doctors in this province and has nothing to do with the Medical
Act.
Membership is entirely voluntary. If it receives the universal support it will be a
great success, and we will all benefit. If it receives inadequate support it will fail and
we will be at the mercy of anyone who cares to run our affairs for us. If the latter proves
to be the case then the responsibilities both severally and individually will be ours.
EET US AIM AT ONE HUNDRED PER CENT MEMBERSHIP.
G. C. T.
BRANCHES, AND HOW THEY WILL GROW
The rejuvenated British Columbia Medical Association is off to a strong start, and
is commencing to perform its major functions—except in one particular. There seems
to be some delay in the proposed organization of "Branches".
Those who conceived the new Provincial organization believed, until now, that
the wording of By-Law No. 3, under the title "Branches", would provide sufficient
information and incentive to set this part of the plan into action. In their discussions,
an Associatiqn was envisaged that would be vital and complete, working in close liaison
with all medical organizations within the Province. They did not foresee that the bare
words of By-Law No. 3 needed to be clothed, and then set out for display and acceptance by patient explanation.
Local medical societies can hardly be expected to favor affiliation with the Provincial body until they are persuaded that there is good reason for this action. If they
operate under a written Constitution and By-Laws they may have to adopt a new
By-Law to signify their relationship with the B.C.M.A. in a formal manner. It is just
at this point that inertia or misunderstanding can. develop.
Under the terms of By-Law No. 3 of the B.C.M.A. any organized medical society
representing the medical practitioners in a given geographical area of B.C. may apply
to the Association for recognition as a "Branch".   By this action the local society does?
not sacrifice independence.  Nor is there any financial obligation for either party in the^
affiliation. The duties of a Branch consist solely in sending to the Provincial Association
an annual list of members and officers of the Branch.   Privileges of a Branch are twofold—viz. 1. The right to apply to the Provincial Association for medical speakers oH
assistance in the development of a post-graduate course;   and 2. The right of direct
communication, through the Executive-Secretary, with the Board of Directors or withi
any of the Standing Committees of the Association.
The British Columbia Medical Association will grow strong, and become effective
whether the Branches come to represent all of the local medical societies or only some
of them. Neither membership nor voting strength in the annual mailed ballot elections I
is dependent on organization of the Branches. But good feeling and rapport, optimum
communication, and adequate personal contact with all of the members by the Executive-Secretary, do require development of Branches within the Association.
Page 76 Since the handling of Medical Economics has become one of the prime functions
of the Association, the position of Branches may be viewed in another important light.
Medical societies are sometimes beset by urgent local problems in the field of Economics.
On occasion they do not understand the application of general policies of the Division
to their local scene. They may have criticisms or constructive advice about the general
policies. In any of these .circumstances the lines of communication that are established
for the Branches will be a safeguard^ against misunderstanding and delay.
Local medical societies in British Columbia are urged to become officially recognized this year as "Branches" of the B.C.M.A. At the next Annual Meeting we hope
to read a cheerful report entitled ^Branches, and How They Have Grown".
F. T.
FINANCIAL ASPECTS OF THE B.C. DIVISION
The years 1950 and 1951 have been very busy and industrious years for the B.C.
Division of the Canadian Medical Association and plans were laid which will be carried
out during the year 1952.
At a special meeting held in November, 1950 the new constitution was adopted.
Plans were laid for the development of a general assembly and a nominating committee
was formed. The nominating committee nominated delegates and vice-delegates who
were to be elected to this general assembly. The election of these delegates was by
ballot and took place in the summer of 1951 and following this election a meeting of
the General Assembly was held in October of 1951 at the Annual Meeting of the B.C.
Division of the Canadian Medical Association. By the election of these delegates and
vice-delegates to the General Assembly from the membership of the Division it was
considered that the practising doctors in the province of British Columbia would be
represented and have their opinions brought forward for discussion and action and that
every member of the B.C. Division of the Canadian Medical Association would be well
represented and his medical affairs well taken care of. The General Assembly must
meet at least once a year and the affairs of the Division are reported at this meeting
when discussion of the reports of the various committees will take place. This assures
that every member will have a voice in the deliberation of the Assembly. The Board of
Directors of the B.C. Division of the Canadian Medical Association are elected by ballot
and on a voluntary basis. They must meet at least four times a year and, inasmuch as
they are elected by ballot, they are responsible to the members of the Division for their
actions. In British Columbia there are 1256 medical practising and there are 40 men
doing post-graduate work, making a total membership of 1296.
At the last Annual Meeting of the College of Physicians and Surgeons of British
Columbia a motion was passed instructing the Council of the College to take a vote
within the next two months to determine whether economics was to be handled by the
College of Physicians and Surgeons or by the B.C. Division of the Canadian Medical
Association. This vote was taken on the first of December and later counted on the
tenth of December. The result of this balloting was in favour of the Division. There
was a total of 1003 ballots of which 576 were in favour of the Division, 339 in favour
of the College of Physicians and Surgeons and 83 votes were not counted, as they did
not arrive on time. _
The duties of the B.C. Division of the Canadian Medical Association prior to this
balloting were social and educational and following the voting were enlarged to include
economics. In matters of economics are included all questions of tariff, Social Assistance
Medical Services, Medical Services Association, and all pre-paid medical care plans as
well as any other matter that has to do with the economic welfare of the practising
doctor. The administration and collection of the Benevolent Fund was previously
undertaken by the College of Physicians and Surgeons and this will now be under the
administration of the B.C. Division of the Canadian Medical Association.
Page 7? With the increase in the duties and responsibilities of the Division there is an
increase in the cost of the B.C. Division in carrying out these said responsibilities
During the year 1950-1951 the expenses of the B.C. Medical Association were met by
an administrative grant of eight thousand, four hundred and twenty-four dollars
($8,424.00) from the College of Physicians and Surgeons. This grant was sufficient
to pay all administrative and special expenses of the B.C. Medical Association. As of
March 31st, 1951 the Benevolent Fund amounted to seven thousand, two hundred and
fifty-five dollars ($7,255.00).||This fund will be turned over to the B.C. Division of
the Canadian Medical Association and will be administered by them and used for benevolent purposes only. The College of Physicians and Surgeons, in November of 1950,
found it necessary to increase their dues to the sum of fifty dollars ($50.00). This
increase in dues was necessary in order to make the necessary payments on the B.C.
Academy of Medicine, to defray the cost of the Economic Committee and other incidental expenses which had been gradually increasing. On the eleventh of January, 1952,;
the College of Physicians and Surgeons of British Columbia turned over to the B.C.
Division of the Canadian Medical Association the administration of economics for the
Medical Profession in British Columbia. At the same time they also agreed that they
would reduce the fees from fifty dollars ($50.00) to thirty dollars ($30.00) a year,
it being assumed that this reduction would allow the B.C. Division to collect an adequate
membesship fee to carry on the enlarged duties of the Division. The membership in the
Canadian Medical Association is ten dollars ($10.00) and this carries with it a subscription to the Journal of the Canadian Medical Association. This fee for membership in
the Canadian Medical Association is a separate fee entirely, from that of the College
of Physicians and Surgeons or the B.C. Division of the Canadian Medical Association.
The College of Physicians and Surgeons previously provided secretarial services, free
rent and gave the grant of eight thousand, four hundred and twenty-four dollars
($8,424.00) to the B.C. Division and this has now all been withdrawn since December
1951. In order to carry on its new duties, the B.C. Division will find it has to provide
a new secretary, extra office space, stenographic help, office equipment, travelling
expenses of the new secretary and for some members of the General Assembly, as well-
as for some members of the Board of Directors, printing, postage, paper and all other
associated expenses. These expenses are to be met by collection of dues from members
of the B.C. Division and also by asking any member who feels so inclined to donate a
founder's fee of one hundred dollars ($100.00). This founder's fee will include the
dues for the first year of membership in the B.C. Division. The amount required for
membership in the B.C. Division will be thirty dollars ($30.00) per year. When the
founder's fee has been collected and also the dues from the membership there should be
sufficient money to pay all expenses and to set up an office properly and equip it to carry
on the functions of the association.
The B.C. Division, since acquiring the duties of the Economic Committee on the
eleventh of January, has already had its sub-committee meeting with the members of the
Workmen's Compensation Board in order to establish a satisfactory schedule of fees
for medical services. This is a good indication of the degree of activity which the
Division is undertaking. A new secretary is a necessity and your Board of Directors
have already contacted Dr. Ferguson of Saskatchewan and are making the necessary
arrangements to have him undertake the secretarial duties of the Division. Dr. Ferguson's credentials are of the best and he has made a success in Saskatchewan as a
secretary there and I have no doubt will be equally successful when established in
British Columbia. It is desirable that every medical man in the province of British
Columbia who is practising should become a member of the B.C. Division of the Canadian Medical Association as "In unity there is strength" and let us be strong and
everyone join this Division. Let us all get together, join the Division, pay our dues and
there is no doubt but what the economics of the medical practitioner in the province of
British Columbia will be much benefited.
W. J. D.
Page 78 PUBLIC HEALTH AND MENTAL HEALTH NEWS
G. F. AMYOT, M.D., D.P.H.,
Deputy Minister of Health, Province of British Columbia
A. M. GEE, M.D.,
Director, Mental Health Services, Province of British Columbia
Through the medium of this page in the "Bulletin", we hope to present to the
physicians of British Columbia, news of any recent or forthcoming developments in the
Provincial Health Branch and Mental Health Services. These developments are usually
in the form of expansion of existing services, new services, new construction projects
such as hospitals, or changes in procedures in existing policies ranging for example, from
the reporting of communicable diseases to the securing of treatment for early psychotic
patients of favourable diagnosis.
In the field of mental health, the Mental Health Services under the Department of
the Provincial Secretary operate the following units:—
(1) The Crease Clinic of Psychological Medicine, Essondale, which is an active
treatment centre for psychoneurotic and early pcychotic patients whose prognosis is favourable and who will not need more than four months of treatment.
(2) The Provincial Mental Hospital, Essondale, which is in active and continued
treatment hospital for psychotic patients who require longer than four months
for adequate treatment.
(3) The Provincial Mental Hospital at Colquitz, Vancouver Island, where selected
male patients are sent from the Essondale unit.
(4) The Woodlands School, New Westminster, which is a residential unit with
hospital facilities for the care and training of mentally defective patients.
(5 )   Three Provincial Homes for the Aged, in Port Coquitlamj Vernon and Terrace.
(6) The Provincial Child Guidance Clinics which have stationary units in Victoria
and Vancouver and a travelling clinic which periodically visits other sections
of the Province. These are diagnostic and treatment centres for children with
behaviour problems or emotional problems. Full psychiatric, psychological and
social examinations are available.
Under the Health Branch, on the other hand, come such well known services as
the Division of Tuberculosis Control, the Division of Laboratories and the Division of
Venereal Disease Control. The Division of Tuberculosis Control is responsible for the
care and treatment of all tuberculosis patients either in its own sanatoria or tuberculosis
hospitals in Tranquille and" Vancouver, or in some instances by special arrangements
with general hospitals. In addition to having its own diagnostic clinics, the Division
was instrumental in having miniature X-ray equipment installed in thirty-four general
hospitals so that hospital admissions might be examined in the never ending task of
finding tuberculosis cases while they are still in the minimal stages.
The Division of Laboratories has steadily increased the number of tests it has
done over the years, so that last year it carried out well over one thousand tests a day
and distributed to physicians many biological products for use in the control of communicable diseases.
Physicians may obtain drugs for the control of venereal disease through the Division
of Venereal Disease Control, or your local health unit office. Upon request they may also
receive consultative advice.   The Division carries out a complete treatment program.
By means of the Province-wide system of local health units, each one of which is
under the direction of full-time Medical Director, both the health unit staff and the
Page 79 private physician are able to utilize these centralized services to greater advantage than
would otherwise be possible.
Throughout the years, there has been very fine cooperation between the medical
profession and the public health services with resulting benefits to the public at large.
If this series of articles is of use in continuing this cooperation by explaining some
of the developments in public health and mental health services as they occur, it will
have served its purpose admirably.
G. F. AMYOT
A. M. GEE
DR. K. SHIMOTAKAHARA
Obituary November 3 Otb, 1951
Dr. K. Shimotakahara died in Kaslo, B.C., on November 30th. He was
a graduate from the Chicago College of Medicine and Surgery in 1915. He
resided and practiced in Vancouver for many years before removing to Kaslo.
During his residence there he was highly regarded as a physician and a
citizen. The large attendance at the funeral and the wealth of floral tributes
gave impressive evidence of the esteem in which he was held.
F. M. A.
Dr. Takahara, as he was commonly known here, lived and practised in
Vancouver for many years. He was greatlyrespected, and greatly liked, by all
all his confreres in that city.   He had a most friendly andflikeable personality.
J. H. M.
AVAILABLE NOW
New modern Doctor's Office for Rent, on ground floor, 1
consulting room, 2 examining rooms, 1 lab... Will share waiting
room with other Doctors.
For Information—Call or Phone
MR.  FALK,
847 Dennian — Phone MArine 3433
Page 80 FOOD AND DRUG ALLERGY
AND ITS SPECIFIC MANAGEMENT*
m INTRINSIC ALLERGY lgg||;
C. H. A. WALTON, M.Sc., M.D., F.A.C.P.
FOOD ALLERGY
Allergy to food is probably common. It has been observed and described under
various names for centuries. "One man's food may be another's poison." But it is
only in the past third of a century that the concept of allergy to food has been
developed and placed on a scientific basis.
In general, clinical food allergy occurs more commonly in children but is. seen at
all ages. Allergic manifestations in infants and pre-school children are frequently
due to foods. As the child grows older, inhalants play a part more frequently, and
these tend to supersede the food sensitivities. As the child grows older his gastrointestinal tract matures and offers less opportunity for the absorption of large molecules
such as protein. However, food sensitivity does persist in many adults, especially in
such conditions as urticaria, migraine, gastro-intestinal allergy and asthma. Food allergy
is to be distinguished from certain food intolerances or idiosyncracies. Some foods,
because of their chemical make-up, may cause undesirable symptoms which act pharmacologically rather than allergically. The common intolerance of many people to cabbage,
onion, radish, cucumber, eggs, etc., is an example of idiosyncracy rather than allergy.
Food sensitivity may manifest itself in any type of allergic reaction. As
mentioned above, it accounts for a great many of the allergic reactions in infancy,
and throughout life it is the chief cause of urticaria and migraine. Food reactions
are characterized by a reaction time varying from one-half to twenty-four hours, in
contrast to the immediate reaction usually occuring with inhalants. Symptoms due to
food allergy may occur acutely at long intervals when they are due to rarely eaten
or seasonal foods. Chronic food allergy, of course, occurs when the food allergen is a
common one in the diet. Duration of symptoms may vary from half an hour to
several days and up to two weeks. Allergy to common foods is not continuous, but
periodic with rhythmically occuring refractory periods.
The most common syndromes produced by food allergy are gastro-intestinal
disorders involving abdominal discomfort, gaseous distension, crampy pain, diarrhoea,
pruritis ani, etc.; urticaria and angio-oedema; atopic dermatitis; headache; rhinitis and
asthma. As experience accumulates, food sensitivity is recognized more frequently in
adults with respiratory allergy.
Food allergens reach the reacting tissues following ingestion with subsequent
digestion and absorption or by inhalation and absorption, e.g. flour dust. They may
also reach the infant patient by breast milk.
The quantity and quality of the allergic foods determine not only the severity
but also the occurrence of symptoms. Symptoms may occur only when large amounts of
the particular food are taken or in the more sensitive when very minute amounts are
swallowed. It is also known that the length of time of storage and cooking influence
the reactions very materially. Individual tolerance to a given allergenic food varies
from time to time, and also with such circumstances as the effects of other foods,
condition of the intestinal tract, or infection. Fatigue, alcohol, emotional upsets and
excitement may be very important secondary factors. Food sensitive asthmatics are
often better in the warm months of the year.
The foods which most commonly are found to be responsible for food allergy are:
1. Cereals: Particularly wheat and oats and corn.
2. Eggs: Sensitivity to the white part of hens' eggs is very common.    It is probable
that egg yolk less often causes a true allergic reaction. ||||
•Fourth in a series of five addresses delivered at the Annual Summer School of the Vancouver Medical
Society, May, 1951, Vancouver, B.C.
Page 81 3. Milk is also a common allergenic food, and the lactalbumin fraction seems to be
the most important.
4. Meat sensitivity is less common.    Pork and chicken are the worst offenders.
5. Fish in one of its many forms is not an infrequent cause and, of course, fish products
such as fish glue, caviar and cod liver oil are included.    Fish reactions are apt to be'
very severe.
6. Vegetables when raw are more prone to cause trouble. The more frequent offenders
are beans, peas (including peanuts), potato, tomato and onion.
7. Fruits are frequent causes of acute seasonal urticaria, but may also cause chronic
symptoms, especially the citrus fruits, banana and apple.
8. Nuts are not infrequent offenders and may produce very severe symptoms, especially
urticaria and asthma.
9. Beverages: Coffee and tea are uncommon food allergens, but cocoa (including
chocolate) is a most important one. Beer is a quite common allergen and I have
seen a number of patients who will develop'asthma following its use.
DIAGNOSIS
The diagnosis of food allergy is often difficult. Food must always be considered in
all allergic problems. A knowledge of its characteristics and a very careful history
may suggest a diagnosis. Skin tests are seldom helpful and are most often misleading..
There are many technical reasons for this and perhaps the most important is that food
is greatly changed by cooking and digestion. Extraction methods are as yet not
entirely satisfactory. A negative skin test does not rule out a suspected food allergy,
and a positive reaction is of no importance unless confirmed by clinical trial. Too
many doctors and patients restrict a food permanently and needlessly because of a
positive skin test. Further, skin tests may be dangerous, especially with fish, nuts
and eggs.
As skin tests are usually of little value in diagnosing food allergy, it is necessary
to employ test diets. These diets are known as elimination diets. The ideal elimination
diet would be simply water, but in an effort to maintain nutrition during the test
period a diet is designed which eliminates most of the common food allergens and
provides subsistence on a limited list of foods which may be allergens but are unlikely
to be.
The best known elimination diets are those of Rowe and there are many modificai
tions of them. The principle is always the same. It is important to emphasize that
elimination diets are for diagnosis only. They should not be persisted in for more than
two or three weeks for fear of serious dietary defficiency. In general, it is desirable
to continue an elimination diet for a period of three weeks. If there is no improvement
in that time the diet should not be persisted with and immediate return to a full diet
permitted. If definite and even striking improvement occurs, it might be assumed
that the improvement has been due to the elimination of the many foods not permitted
in the diet. This, of course, is not proof but simply an assumption. In the event
of such improvement foods are then to be added back to the diet, one at a time, at
intervals of two to three days. When a previously eliminated food is added it is done
in an effort to provoke trouble, if trouble is going to occur with it. For this reason
the test food should be added in large amounts, larger than the patient would ordinarilj
eat. If no symptoms occur within two to three days it may be assumed that the fooi
is innocent. It then becomes a part of the original basic diet and another food is then
added. In this systematic way the diet may be gradually restored to normal and if
there are any foods which demonstrably cause symptoms it may be accepted that these
foods are true allergens. However, it would be wise not to accept a single test of this
kind, but the two or three or more suspected foods should be tried again after a symptom
free interval of a few weeks. If, again, symptoms are produced following the administration of the suspected foods this may be accepted as definite clinical proof. There
is a great danger in permitting patients to start on these elimination diets and losijj
sight of   them.     It  is  not  an  uncommon  experience  to  have  patients   report   to
Page 82 consultant who finds that they have followed some diet received elsewhere, for very
long periods of time, without really knowing that they are doing themselves grave harm.
It is apparent that if such limited diets as these are persisted in for any length of
time, serious dietary deficiencies may ensue. This is a particular danger in childhood. Not infrequently it happens that the suspected or proven food allergen is of
considerable dietary importance. Physicians must see to it that the dietary deficiency
is made up some other way. For example, in the case of milk, there are suitable milk
substitutes available on the market such as Mul Soy. If these substitutes are not tolerated
suitable vitamins and calcium salts are prescribed. The physician must be thoroughly
satisfied that the particular food does indeed cause the trouble, before permitting the
patient to continue permanent elimination of it from his diet. When a food is
demonstrated to be an offender there is little or no difficulty in persuading the patient
to avoid it permanently and there is little or no trouble in persuading the physician
that it is indeed a specific offender.
While a patient is on an elimination diet, it is important that he keep a complete
and accurate food diary. What is eaten at each meal should be recorded both qualitatively and in quantity. Any symptoms occurring day by day should be recorded
together with the medications taken to deal with those symptoms. Even without the
use of an elimination diet a carefully kept food and symptom diary is of the greatest
value diagnostically and should be used often. It has the drawback of being very
tedious to both patient and doctor. The physician's ingenuity is often taxed in handling
elimination diets and in helping the patient to elminate one or more specific foods.
The problem of substitutes of equivalent nutritional value, the problem of special
recipes and so on, would require much longer than the time available. It is necessary
to refer you to standard texts such as that of Rowe for detail. It is obvious that the
treatment of food allergy consists entirely of the removal of the demonstrably allergenic
food from the individual's daily diet.
There is disagreement as to whether or not it is possible to desensitize the patient
to food. It is impossible to desensit'ze by the hypodermic method as is done in the case
of inhalants. Inhalants are extracted in the respiratory mucosa via tissue fluids but not
digested. That is to say, in effect, the offending allergen is a watery extract of the
offending material made by the tissue fluid. In the case of foods or other articles which
are swallowed, digestion occurs in the intestional tract so that the materials absorbed
and which cause the' allergic reactions are products of digestion. They are not the
original substance nor are they simple aqueous extracts. An extract of food, therefore,
in its undigested or unprepared state, has no relation whatever to the digested material
absorbed and which acts allergenically in the patient. There is evidence, which I think
is convincing, that in some instances adequate desensitization is possible by giving
infinitely small quantities of the food orally in gradually increasing doses, to tolerance.
This seems to be particularly effective in the case of milk. If a solution of one part
of milk in several thousand parts of water is made and a tiny quantity of the diluted
milk given daily with very gradual increases over a period of months, it is possible to
achieve sufficient tolerance so that the patient can take small quantities of milk such
as the amount which appears in butter, or even the amount which would be used in
tea or coffee. Occasionally, the patient is able to take larger amounts and this, of
course, is a great comfort to him. Similarly with egg, desensitization can sometimes
be achieved. I suppose that the reason there is controversy in this matter is that
patients occasionally lose their food sensitivity, at least in a quantitative sense, and
perhaps the results achieved are attributed to spontaneous recovery. I do believe,
though, that in the case of milk, that an effort at desensitization is worth considering
in all patients, particularly children.
DRUG ALLERGY
Another class of ingestant which may produce important allergic reactions is that
of drugs.    Commonly used drugs such as aspirin, are found to act as allergens rather
Page 83 frequently.    While they are not proteins, they are believed to unite with a plasma
globulin to produce a hapten which acts as the specific allergen.
Drugs can be the specific cause of hay fever, asthma, urticaria, dermatitis, et<3
They must always be thought of and it is wise to eliminate all drugs from an allergic
patient for a test period. Being so commonly used they are very apt to be unsuspected
by patient and physician. Drugs of the aniline series are particularly prone to be
troublesome. Drugs of this series are also prone to affect the haematopoietic system,
producing such phenomena as agranulocytosis, thrombocytopoenia and acute haemolysis.
The classic example of this type is amidopyrine.
It is interesting to observe that while some asthmatics obtain relief from the usdj
of aspirin, others react violently to it.   Thus we have an example of the pharmacological
action of the drug compared to its possible allergic action.
Aspirin sensitive asthmatics are often very difficult to manage^ Their asthma is
often quite intractable and may indicate an intrinsic type of case. The mortality in
these cases high.    Aspirin sensitivity is not seen in children.
A group of drugs which has become important in recent years in the field of allergy
is the antibiotic group. The effect of penicillin in causing a serum sickness-like reaction
is now widely recognized. It is perhaps less widely known that the newer antibiotics,
namely, Aureomycin, Terramycin and Chloromycetin also do cause urticaria-like reactions]
almost indistinguishable from that seen with penicillin. It should be pointed out that
these drug reactions are somewhat different from the usual spontaneous allergy seen
with inhalants and ingestants. Thev resemble acquired sensitivity similar to anaphylaxis
artificially induced in the animal. There are many other examples of drug allergy such
as that seen with the use of liver, insulin, etc. The serum sickness type of allergy
occuring with penicillin, etc., is often temporary and may disappear permanently in a
few months.   That seen with liver may persist indefinitely.
A special note regarding Morphine is necessary. It is doubtful if morphine ever:
acts as a true allergen, but it does cause release of histamine which may account in part
for its often serious effects in allergic people. Its depressing effect on respiration and
the cough reflex add greatly to its danger. Morphine has killed many asthmatics, and
it should never be given to an asthmatic person on any account.
INTRINSIC ALLERGY
There  is   a  large  group  of  cases   manifesting  diseases  which   we   now  consider
allergic, such as asthma, atopic dermatitis, etc., which behave exactly as other allergic
problems do, but in which we are unable to make a specific etiological diagnosis.    Inj
my experience and that of others, this group represents approximately one-third of the
total.    Pathologically such cases are difficult, if not impossible, to distinguish from the
others.    They have been classified in different ways.    Rackemann introduced the term
"Intrinsic Allergy".     By this  term  he meant  that  extrinsic  allergens  could  not  bel
demonstrated and he presumed that the allergic reactions arose from allergens produced
within the body.    Such allergens might arise from a focus of chronic infection such as
might be seen in the accessory nasal sinuses or in dental abscesses.   Occasionally endocrine
factors appear to be important, particularly those related to the sexual function.   Again,
workers such as Harry Alexander in St. Louis, used the term 'non-allergic' for this
group, meaning, of course,  that they had not been able  to  demonstrate an allergic
factor.    This group is, indeed, very difficult to account for and exceedingly difficult
to manage.    I think that there is little doubt that if demonstrable sources of chronic
infection such as chronic hypertrophic  sinusitis  can be adequately  dealt  with,  some|
of these cases may do well.   Treatment resolves itself into the use of very radical surgery
which is successful only in a few skilled hands.    Too often, inadequate nasal surgery
leads to a grave aggravation of a seriously troublesome asthma.
There are cases in which there is much secondary infection in the bronchial tree.
Such cases may be primarily allergic asthma but manifest infection by purulent sputum
and perhaps by general physical symptoms.    In those cases in which infection appears!
to be an important factor, it would, of course, be proper to consider the question of
Page 84 vaccine therapy. Some workers believe that carefully prepared autogenous vaccines
are valuable. These vaccines are obtained by cultures taken through the bronchoscope
or from hypertrophic tissue removed surgically from the sinuses. That such vaccines
i are specific is evidenced by the fact that their administration will reproduce symptoms
and, indeed, there is some reason to believe that careful desensitization with these
vaccines will produce worthwhile clinical results. A number of other competent
observers believe that equally good results may be obtained using stock bacterial vaccines.
That these cases are indeed allergic is strongly suggested by the fact that some
of them manifest severe aspirin sensitivity. It is certain that aspirin can be classified as
an extrinsic allergen. There can be little doubt that it acts in a typically allergic
manner. Of course, the aspirin does not account for the primary disease. It is simply an
incident in the disease. Perhaps some day we shall have sufficient knowledge to acquire
diagnostic techniques which will indicate causes in these otherwise unexplained cases.
Intrinsic allergy can occur at all ages, although it is probably seen more often in the
older age group, particularly in those in whom the disease developed suddenly in late
life.    However, a word of caution should be given.    Because allergic disease develops
§fh late life it does not follow that it is intrinsic in type. Very often simple extrinsic
factors are demonstrable ^iri the older age group.    One should not succumb to the
„*emptation to classify a case as intrinsic because an adequate diagnostic survey has
not been made.
This vexing problem of intrinsic, infective or non-allergic asthma, or whatever
name one may call it, is important if only to emphasize that the management of allergic
disease involves the discovery of the offending allergen. As the offending allergens
are so often not discovered or are unsuitable for definite treatment, it follows that
nthis large group representing a third or more of the total becomes a problem of
symptomatic management only. With better medical attention, with more diagnostic
care and with newer techniques which we hope will develop, this group should become
smaller and smaller. I am afraid, however, that there is a tendency for it to become
too large. That is to say, it undoubtedly includes individuals who have demonstrable
and controllable extrinsic allergic factors which have not been discovered because of
inadequate diagnostic study.
In this discussion of intrinsic allergy I have perhaps rather over-stressed asthma.
I think that it is probable that intrinsic allergy, or whatever term is most suitable,
applies to other allergic manifestations including asthma. Certainly it includes allergic
rhinitis and it includes urticaria and some of the allergic dermatoses.
This is the group which is so often classified as psychiatric. Time does not permit
a discussion of the problem of psychiatry in allergic disease. I, personally, feel that
psychological causes are seldom if ever primary in allergic disease. There can be no
doubt that the severe, persistent and gravely disabling disease seen in many of these
cases does lead to psychological disturbances. One cannot be frequently and severely
dyspnoeic without becoming very disturbed and anxious. Individuals vary in their
capacity to stand severe disability very greatly so that some of those who are most
difficult to control do present striking psychological disturbances, but I think they can
be explained quite readily as secondary to the disease and not primary. When the
disease can be effectively controlled, whether one does it symptomatically by drug
therapy or by use of the new endocrine weapons such as ACTH or Cortisone, the
psychological disturbance rapidly resolves. Occasionally one sees highly unstable
patients who, among other things, have perhaps moderate asthma. It is understandable
that both doctor and relatives think that asthma is a manifestation of the individual's
neurosis. Very often in such patients the asthma is due to a readily recognized cause.
The asthma is controlled but the neurosis and its other manifestations continue. The
allergic patient, particularly the one who is suffering severely for a long time, deserves
sympathy and understanding. On rare occasions he may deserve special psychiatric
care, but continued attention must be directed to his primary disease.
Page 85 In concluding this discussion it is important to recall that allergy is a constitutional
diathesis and that allergic patients can and do have the other diseases to which non-
allergic people are heir.    In evaluating an allergic problem it is not only necessary
to consider the patient's psychological state and his allergic problem, but it is also"
necessary  to make  a  careful  differentiation from  manifestations  from  other  disease.
The management of allergic disease resolves itself into an attempt to find the specific
causes, which are often multiple, and into removing and otherwise controlling these
causes.    If and when this is not successful, as in perhaps a third of the cases (so-called
intrinsic allergy), symptomatic management then becomes the only method of treatment, available at present.    Symptomatic management is discussed in the fifth and last
of this series of addresses.
Division of Medicine,
Winnipeg Clinic,
St. Mary's & Vaughan,
Winnipeg, Manitoba.       Sgf|l
SYMPTOMATIC MANAGEMENT
II OF THE ALLERGIC PATIENT* ~||||,
ACTH AND CORTISONE — PRESENT KNOWLEDGE
C. H. A. WALTON, M.Sc, M.D., F.A.C.P.
*Fifth and last of a series of lectures on allergy delivered at the Annual Summer School of the Vancouver
Medical Society, May, 1951.
Throughout these talks I have attempted to show the value of the allergic theory
in the diseases under consideration. In many instances specific allergens can be
identified and appropriately dealt with either by separating them from the patient or by
specific desensitization. It should be the duty of the physician in charge in any of the
allergic diseases to make every effort to find the allergic basis for the patient's symptoms.
If he can do so the outlook for the patient is good. However, during the course of
investigation, even if successful, the patient must have symptomatic help. Further, there
is the large group of cases of perhaps a third or more in number, in which no specific
allergens can be found. In such cases one must resort to symptomatic therapy. There
is also the group of cases in which there are demonstrable allergens which cause trouble,
but in which all of the allergic agents cannot be found or dealt with satisfactorily.
These patients also require much symptomatic management.
1.    Treatment of Hay Fever or Allergic Khinitis
In the past few years valuable agents have been produced which are very effective
in more than 80% of cases of allergic rhinitis. These are the chemical substances
which can be classified as anti-histamine drugs. These drugs have many common
characteristics chemically and are similar pharmacologically. They vary in their
efficiency and in their toxic effect. The earlier drugs developed in this group continue
to be among the most valuable. Neo-Antergan, the first clinically efficient antihistamine, produced in the Pasteur Institute in France, is still one of the best. Pyri-
benzamine is closely related chemically and pharmacologically to it. Benadryl, the
first one available on this continent, is very effective but has the disadvantage of a
high proportion of toxic effects, the chief of which is its hypnotic property. Occasionally
this hypnotic property is valuable, but more often it is a nuisance. It is not possible
in the time available nor is it desirable to review for you the properties of all of the
many anti-histamine drugs on the market. All of you have had experience with some
one or more of them. Use the one that you are most familiar with. Dosage, of course,
varies with each product. Generally, an effective does lasts from four to six hours!
before symptoms return.    There is, of course, great variation in this.
Ordinarily anti-histamine drugs are given orally and are quite effective by this
means.    However, it should not be forgotten that the drug can also be used topically.
Page 86 In solution, Neo-Antergan and several of the others which are soluble, can be sprayed
in the nose with good effect. They can also be used as drops in the conjunctivae with
good symptomatic relief. These local effects are particularly valuable for immediate
effect and also can be used when the toxic effects from oral administration are
undesirable.
In a small proportion of cases in which the anti-histamine drugs are ineffective,
one of the several sympathomimetics may be used. Ephedrine locally is helpful but
unfortunately there is generally a severe reaction afterwards. Privine solution applied
to the nose and eyes is very effective but has the bad quality that in many instances
after prolonged use it will produce very severe and often intractable rhinitis medicamentosa. For this reason, in my opinion, Privine should never be prescribed, because
the patient will continue to fill the prescription without your knowledge and very
often serious harm will result. Privine in its more dilute form mixed with Antistine
in solution seems to have avoided the difficulties of the original Privine solution and its
use seems to be justified when other measures fail.
Although the causative agent may not be definitely identified, it is probably wise
when dealing with intractable and particularly perennial allergic rhinitis, to remove
feather pillows, substituting sponge rubber, and to minimize the amount of atmospheric
dust, particularly animal and household dust to which the patient might be exposed.
Occasionally it is possible for people suffering from pollinosis to leave the area in which
their particular offending pollen is prevalent for. its season. It is rare that a patient has
sufficient resources to accomplish this and other measures are therefore necessary.
2.    Bronchial Asthma
Whether or not specific dust allergens are demonstrated, I think that it is highly
important in all asthmatics to live in as dust-free an atmosphere as possible. Feather
pillows should be removed and foam rubber pillows substituted; animals in the house
should be forbidden; other notably dust producing environments such as grain elevators,
industrial atmospheres, etc., should if possible be controlled. Fresh paint causes severe
trouble in most asthmatics. Odors from cooking, particularly frying and burning
grease, are highly irritating. Pungent odors, irritating gases, strong perfume and
heavy local dust may precipitate trouble quite apart from any demonstrable specific
allergy.
The asthmatic patient is understandably anxious. He wants help as quickly as
possible. He is suffering from anoxia. A good rapport between doctor and physician
is of the greatest value. If the patient's confidence can be restored other measures are
apt to be more effective.
In this disease the sympathomimetic drugs, particularly Epinephrine, are still the
most useful and have been for more than a generation. Epinephrine or Adrenalin is
used hypodermically and the dose should always be small. In general, three to five
minims, that is a fifth to one-third of a cc. of the 1:1,1)00 solution of the hydrochloride
is adequate. It is very important not to give larger doses because of the great excitement
and tachycardia which are commonly produced as side effects. It is seldom that larger
"doses have any more beneficial effect on the bronchi and they always have an unfavourable effect on the patient as a whole. Small doses given frequently in different sites
are very much mo:e effective r>.nd less troublesome than one large dose. Long acting
or "depot-type" adrenalin has been disappointing. The mucate is not a long-acting
form. The preparation in oil is long acting but unpredictable and troublesome to
give. There is no reason why a stable and dependable patient cannot be taught to give
adrenalin to himself. This is no more difficult than teaching the administration of
insulin. Perhaps a member of the family could be taught to give the drug. I do not
think that any harm will result from this, although in dealing with depressed patients
or those who are unreliable, there is danger. I have known of suicide from overdosage
with adrenalin. Obviously, such risks occur with all drugs and should not prevent us
from using them intelligently.
Page 87 There are many forms of sympathomimetic drugs available. Ephedrine in the
form of the hydrochloride is effective orally as distinct from Epinephrine which is
only effective by the parenteral route. Ephedrine has the drawback in many cases of
causing a great deal of excitement and tachycardia. This is less troublesome in children
than in adults. Various synthetic analogues of this drug are also available, prescribed
in proprietary mixtures, associated with phenobarbital which cuts down the excitement,
and aminophylin. Such oral preparations are very valuable for milder cases. Another
drug of this series is Aleudrine. This drug is sold under the trade names Isuprel, Persol,
Norisodrine, Neo-Epinine and Isoprenaline. It is effective by inhalation, by injection
and sublingually. Norisodrine is generally administered in the form of an inhaled
powder. The others may be given by inhalation in the form of a fine spray of the
solution. The sublingual method is accomplished by means of tablets under the
tongue. These are all useful forms and are effective in the milder cases. Epinephrine is,
of course, useful also by inhalation but there is clinical reason to believe that if it is
used excessively, over a long period of time, the patient gets steadily worse and there
may even be damage to the bronchial mucosa. Whether this is true or not, one has the
distinct impression that excessive use of Epinephrine by inhalation leads to a more
severe form of the disease. All of the patent asthma sprays sold in drug stores consist
of Epinephrine in some form. As is well known, many asthmatics reach the stage
when adrenalin or one of its related sympathomimetic drugs is no longer effective. This
ineffectiveness is usually only temporary and other measures become necessary in
the interval.
Aminophyllin is an extremely valuable therapeutic agent in asthma. Given orally
it is of small value although when combined with Ephedrine it seems to be of some
use. Generally speaking, it is impossible to give a sufficiently large dose orally to obtain
an adequate effect without causing nausea and vomiting. However, it is exceedingly
valuable when given intravenously in cases of intractable asthma. The drug should
be given very slowly and well diluted. The average dose in an adult is 7*/> grains,
(half a gram) in a solution of at least 200 cc. of 5% glucose and water. It should
never be given directly from the ampoule. Serious accidents have occurred and even
fatalities reported. One cannot stress too greatly the necessity of dilution. This
fact, of course, limits its use usually to hospital and if in the home under difficulties.
However, there is a very useful though little known solution for this difficulty.
Aminophyllin dissolved, in a proportion of seven to ten grains in twenty cc. of distilled
water, can be administered per rectum with an effect which is very nearly comparable
to the intravenous route. This is a simple technique. The patient can carry it out
for himself with simple instructions. If it is considered more convenient, the drug
can, of course, be given in a suitable rectal suppository. A disadvantage of this method
is cost, which is several times that of the aqueous solution and the fact that the
suppositories tend to harden and become less soluble with time and storage. Occasionally
aminophyllin leads to extreme central nervous excitement and this may make its use
impossible in small children who are apt to show this peculiarity.
Potassium iodide is still the most useful expectorant in this disease. Given in
small doses of from three to five grains, two or three times a day, the thick glue-like^
mucus may often be expectorated with considerable ease and benefit to the patient.
It is not necessary to give the drug for any great length of time. Frequently the
patient can be taught to decide when to use it with effect. One should again sound a
word of warning that iodism may occur and in an allergic patient we sometimes see
a very severe iodide rash which may be most refractory to treatment.
The various asthma smokes, which are usually variations of stramonium leaf, are
effective symptomatically in moderate cases. They have the obvious objection of causing
a very unpleasant odour in the house and they soon leave the patient in need of other
measures.    In general, there is little or no place for their use in clinical medicine.
The severe cough which is so' troublesome in many cases, may respond satisfactorily
to sympathomimetic drugs and to iodides but occasionally it is necessary to use cough
Page 88 sedation and a simple syrup containing small amounts of Codeine, perhaps combined
with some expectorant such as Ammonium Chloride, is often very helpful. Codeine is
the one opiate used in small doses which appears to be safe in asthma.
Because of the patient's agitation and anxiety, sedation is also useful. Sedation
should never be carried to the state of making the patient unconscious or difficult to
rouse. He may be distressed but he requires to be alert so that he may fight his
difficult dyspnoea and not succumb because of lack of effort. Mild sedation, in the
form of barbiturates, bromides or chloral hydrate, is highly useful and can be used
rather freely with this precaution in mind. Asthmatics have died from large doses
of barbiturates and when given intravenously in the form of Sodium amytal there is
great danger.
As cyanosis is common, oxygen should be given freely. If a mixture of oxygen
and helium is available I think that it has considerable use when given skillfully and
not wasted.
Anaesthesia has been thought for a long time to help the severe intractable asthmatic.
Some anaesthetic agents are decidedly dangerous. Intravenous anaesthetics should
never be used and may lead to a fatal result. To date the only really safe anaesthetic
is ether. When given by inhalation with full oxygenation the patient not only sleeps
during the anaesthetic but is often easier afterwards. Ether can, of course, be administered rectally mixed with olive oil. Such administraton should be carried out by
those skilled in anaesthesia and with a nurse in attendance to watch the patient, because
it is desirable that a deep stage of anaesthesia he obtained. Carried out in this way
ether anaesthesia is sometimes useful. This form of treatment, of course, developed
because it was observed that asthmatics were often better after a major surgical
operation for a considerable period of time. There is much reason to believe, though,
that the anaesthetic is only part of the story. Apparently the surgical trauma is of
major importance. I have never seen a case of intractable asthma do as well from simple
ether anaesthesia as I have in several instances when major surgery became necessary
during intractable asthma. Often the patient had a remission lasting for many months.
Sometimes in a desperate situation one might almost wish that a surgical procedure was
necessary.
If the attack of asthma is prolonged fof more than a few hours, functional
emphysema develops. If the asthma persists for a long period the emphysema may
become permanent. It is highly desirable to anticipate this development and to teach
the patient correct breathing exercises with particular emphasis on proper expiration.
The asthmatic ordinarily attempts to limit expiration as much as he can with the result
that the sticky mucus tends to remain in his bronchi causing a semi-permanent bronchial
obstruction. If you have the good fortune to command the services of a physiotherapist
specially trained in the technique of proper breathing exercises, it is a great help to
have her teach such a patient and supervise his exercises from time to time.
It is perhaps trite to say that attention to the patient's nutrition is desirable. In
a severe prolonged case of asthma this is, indeed, often very necessary. The patient
should not be confined to bed. If he is more comfortable in a chair he should certainly
be permitted to use one. If he is able to go to the bathroom without too great aggravation of his dyspnoea, this should be permitted and in all instances ambulation and full
activity should be restored at the earliest possible moment. In this connection it is
particularly important to emphasize that children should not be invalided any more
than is absolutely necessary because of asthma. It is sad on many occasions to see a
child who, because of a severe asthmatic attack, has been confined to his home and even
perhaps to bed long after the attack has subsided, thus missing much school and
creating a form of invalidism which may be difficult to treat. mjM
Antihistamines are without value of any kind in the treatment of bronchial
asthma. The only exception to this rule may be in infancy. Of course, if there is
a concomitant allergic rhinitis antihistamines may be of indirect value.
Page 89 3. Urticaria and Angio-Oedema
Antihistamines are very effective symptomatically in at least 80% of urticarial
cases. Ordinarily it is sufficient to give them by mouth in doses appropriate to the drug
chosen. A favourable effect may last from four to six hours. If the case is very
severe and in particular when dealing with cases following the use of antibiotics in
which there is great disability and suffering, it is sometimes desirable to administer the
antihistamine drug intravenously. A most suitable form of this is Neo-Antergan.
Antistine is also available in this form. The drug should be given directly from the
ampoule in doses of 50 mgm. given through a small gauge needle and very slowly.
Fifty mgm. in this way will give most dramatic relief in most instances and it is very
much more effective both as to dosage and time than the oral route. If a hypnotic
effect is necessary the drug Phenergan is also available by the intravenous route and
is highly effective. The anti-histamine drugs also may be given rectally if desired and
this is valuable sometimes in small children, or in adults when vomiting occurs.
Epinephrine hypodermically is, of course, effective but it is seldom necessary to use it.
Ephedrine and its related drugs, by mouth, also is of some help but the occurrence of
excitement and palpitation usually is a drawback. Sedation is very important in this
disease because the psychogenic factors are often prominent. Small doses of phenobarbital
repeated at suitable intervals are often of the greatest help.
4. Atopic Dermatitis
This is not the occasion to discuss local applications in this disease nor am I
sufficiently familiar with dermatology to discuss the great variety of local applications
that might be used. Very often it is worthwhile to discontinue all the many applications that the patient has previously used, because of the locally irritating effects which
they often have. Itching or pruritus is a very common and distressing feature of atopic
dermatitis and if it can be relieved the skin will often benefit greatly. For this reason
it is desirable to try the effect of a suitable antihistamine drug. In somewhat more
than 50% of cases these drugs give such good relief in easing the itching that the
patient benefits considerably. Obviously in dealing with this disease known irritants
such as wool, soap, etc., should be removed from the patient's immediate environment.
Contact dermatitis is, of course, best dealt with by removing all possible irritants
from direct contact with the skin. Itching, again, can be often helped by the use of
suitable anti-histamine drugs. These cases are usually self-limited and local applications are only of temporary help. Soothing lotions and the use of such substances
as potassium permanganate, ferric chloride, etc., have definite value still.
5. Migraine
One almost hesitates to discuss the symptomatic management of this most distressing
illness. The attacks often come on without warning. Frequently it is impossible for
the doctor to reach the patient early enough to be of any real aid. The administration
of a suitable ergot preparation such as dihydroergotamine given early in the attack and
preferably intravenously will often have a dramatic and beneficial effect. Oral ergot
preparations are, on the whole, disappointing. The one known as Cafergone, which is
a form of ergotamine and caffein combined, is sometimes effective when given early
enough and in an adequate dosage. The patient who has a clear-cut aura can often use
such drugs early enough to abort the attack. Of course, rest and sedation are most
valuable at this stage. In a few instances the administration of a suitable antihistamine
drug when the attack is impending may be effective in preventing an attack. These
cases are not as numerous as we would like, but they do occur and are most gratifying.
The ordinary analgesic drugs are virtually useless in this disease. If vomiting is severe
the patient may need supportant therapy in the form of intravenous glucose saline.
6. Gastro-intestinal Allergy
In the recognition of gastro-intestinal allergy it is usual to find the cause* that is to
say, one would hesitate to make a- diagnosis of gastro-intestinal allergy allergy without
being able to demonstrate the cause.    The treatment, of course, is its removal.    If
Page 90 this reasoning is correct the patient might well be starved at the time of the attack and
limited only to water. The use of Atropine or some of the atropine-like drugs is often
very helpful in relieving symptoms, particularly the crampy pain which is so
characteristic.
7. Genito-Urinary Allergy
In the few genito-urinary allergies that I have seen, the administration of antihistamines has been effective. In these cases too, small doses of adrenalin might be
useful. It would also appear that in some instances of dysmenorrhoea adrenalin
and perhaps the anti-histamines have some use.
8. Motion Sickness
While this disease is not known to be an allergic phenomenon, it has been observed
that patients suffering from allergy who also suffer from motion sickness benefited
when they were given an antihistamine drug. The first of these drugs which was very
effective and which received world-wide publicity is called Dramamine. Dramamine is,
indeed, effective in the treatment of and prevention of motion sickness whether it be
in a ship at sea, a train, a motor car or an aeroplane. It is now known that all of the
antihistamine drugs have this same property in some degree and are effective in allergic
and non-allergic people alike. If your child vomits every time you take him for a
drive in your car, give him a tablet of Neo-Antergan or Pyribenzamine or some Benadryl
before you start and you will enjoy your trip very much more. In the case of your
friends crossing the ocean the same principles apply, and it would be wise to supply
them also with a few antihistamine suppositories so that if they forget to use their drug
and start to vomit the drug given rectally can restore them to reasonable comfort.
9. Desensitization reactions
When using potent extracts for the treatment of allergic persons there is always
a real risk of precipitating a severe general reaction. Such reactions are alarming and
some have been fatal. The prompt use of Epinephrine, tourniquets etc., is of course
necessary, but it is useful to remember that an intravenous injection of a suitable antihistamine (e.g. 50 mgm. of Neo-Antergan in 2 cc.) will frequently give rapid and
striking relief. An ampoule ready for instant use is now as important as Epinephrine
when carrying out testing or treatment in allergy.
ACTH AND CORTISONE
The recent advent of these two extraordinary substances has produced the most
amazing therapeutic revolution in medicine. Their extraordinary and unexepected effects
in producing beneficial results in the most diverse diseases, diseases which we thought
were quite unrelated in any possible way, have led to some startling results. Early in
their clinical trial it was noted by Thorn and others that one of the effects of the
administration of the adreno-corticotrophic hormone or of compound E, now known
as Cortisone, was to reduce the number of circulating eosinophiles to the vanishing
point. This phenomenon is, of course, the basis of the Thorn test. Four years ago
in Montreal Bram Rose and his associates demonstrated that tropical eosinophilia and
LoefHer's syndrome responded dramatically to ACTH. It is not surprising, therefore,
that Cortisone and ACTH should be used in various forms of allergic disease. This
is not the time to discuss the theory of their action nor give you in much detail the
wide experience that has accumulated in the past two years. In general, ACTH,
[which is a product of the anterior lobe of the pituitary gland, acts hy stimulating the
adrenals to produce a number of secretions among them Compound E or Cortisone.
Thus, the clinical effect of the two hormones is similar and when they differ it is
probable that the adrenal is producing other effective substances than Compound E.
I In fact it would appear that Kendall's Compound F is much more effective than
Compound E (Cortisone) in allergic disease. It is probable that Cortisone is not the
normal cortical secretion but that Compound F is. \
Generally, neither of these drugs would be justified for the treatment of such a disease
as allergic rhinitis, effective though they are.    They have, of course, also been shown
Page 91 to be effective in dealing with urticaria, atopic dermatitis, etc., but there is little
indication for their use in these diseases.
Cortisone used as a nasal spray has been of some value in our experience. One-!
hundred mgms. are suspended in about 15cc. of a normal saline solution or a 1:30001
solution of Zephiran and the resulting solution sprayed by means of a nebulizer into
the nose. Good symptomatic results may ocur for a short period. The spray has to bei
used every hour or two for a good effect, and it is extraordinary how polyps willi
sometimes shrink and almost disappear under such management. If nasal obstruction i
is chronic and polyposis severe ACTH or Cortisone in full therapeutic doses may bei
justified and then kept in control with a Cortisone spray. Experience only will tell if j
such management is ever justified to replace surgery.
The greatest use for the two drugs, of course, is in intractable asthma. There i
can, surely, be no excuse, other than clinical research, for using them in any other form
of asthma. Apart from the usual contra-indications which are known so well to you,
I would stress, in particular, heart failure and hypertension. Two of the major objections
to the use of the drugs may be fisted as firstly that they must be repeated at frequent
intervals, often under difficult circumstances, and secondly that they are much too
expensive for ordinary use. One might add that no one yet knows what continued use of
thesevsubstances would do to a patient over a long period of time. However, when one is
dealing with a case of intractable asthma, in the full meaning of that term, there can
be little doubt that one is justified in using either of these two endocrine substances.
Cortisone in a suitable dosage is sometimes dramatically effective in relieveing
asthma. Often, though, it is rather ineffective and disappointing. Fortunately, the
drug can be used effectively by mouth and this makes its use very much simpler and
certainly cheaper. If there is any doubt that it has not been effective by mouth then,
of course, it can and should be administered intramuscularly. Generally, three to four
hundred mgm. is given in the first day, and the dose gradually reduced over a period
of several days. It should not be continued indefinitely for fear of producing adrenal
atrophy. During its administration salt should be restricted, and it is desirable to
follow the effectiveness of the drug by daily eosinophil counts. Cortisone is also
effective when inhaled as an aerosol but there seems to be no practical advantage in
this method.
ACTH gives much better and more consistent results in the treatment of intractable
isthma. It, too, has a great drawback in the necessity of giving it parenterally at six hour
intervals. It has been found by experience that an interval longer than six hours
greatly reduces the effectiveness of the drug. It is our practice and the practice of
many centres to start with a dosage of 25 mgms. of ACTH subcutaneously every six
hours. This is given for a period of 48 hours or until the patient shows marked
improvement. The amount of the drug may then be progressively reduced, perhaps
to 15 mgms. then 10 mgm., and so on, but always at six hour intervals. In a favourable
case dramatic response will occur after 250-300 mgms. but not infrequently doses up
to 500 or even 700 mgms. are necessary to produce a satisfactory remission. During
the administration of ACTH the patient must, of course, be on a salt free diet, should
be weighed daily, and observed carefully for any toxic effects. Recently it has been
demonstrated that ACTH is more effective in smaller doses when given by continuous
intravenous infusion (5% glucose in water). This technique when practical seems to
give the best results and to be more economical.
The results are often, indeed, dramatic. A severely dyspnoeic patient breathes
normally, his emphysematous chest shows good breath sounds, his morale rises, he sleeps
well and suddenly a very sick patient becomes a well individual. Very occasionally
his euphoria may become abnormal and almost amount to a psychosis.
On occasion a patient will fail to respond to full doses of ACTH. Often the
initial eosinophil count is very low and drops little if at all. One can only presume a
failure to stimulate the adrenal cortex.     Such a  case may respond dramatically to
Page 92 Cortisone. In one case in which this occurred an operation for a prolapsed intra vertebral
disc also failed to benefit her. This seems to support the idea that major surgery exerts
its benefits on asthmatics through stimulation of the pituitary or the pituitary adrenal
axis. Her adrenal cortex failed to respond to ACTH stimulation or to the effects of
j surgical trauma.
It must always be remembered that the dramatic remission is usually short-lived.
The patient and his family must be warned that symptoms will recur and will recur
as severely as they were to start with, either in a few days or weeks or in a very rare
[case in a few months. The ensuing disappointment even when expected is very great
and may create a serious psychological problem, particularly if money is in short supply.
II believe that there is a place for the use of these substances in intractable asthma but
that place is limited and perhaps their greatest value will fie in the greatly improved
clinical knowledge of these diseases which we will derive. Even now, our understanding
of asthma and many other diseases has been greatly enhanced by the use of these products.
Our knowledge of the pathological physiology of many diseases will undoubtedly be
greatly helped by careful observation of the patient under treatment with Cortisone
or ACTH. It may be seriously doubted if ACTH or any of the adrenal cortico steroids
will ever become widely used as therapeutic agents in allergy but there is much reason.
to hope that their use will advance our knowledge greatly.
[Division of Medicine,
'Winnipeg Clinic,
St. Mary's & Vaughan Sts.,
Winnipeg, Manitoba.
MEDICAL OFFICE FOR RENT
Front accommodation is available for a general practitioner or
medical partnership in the new centre on the corner of Broadway and
Commercial Drive. Heating, ventilation and janitor services are
provided.
IP-'     ■ JfTHE
ROYAL   TRUST
Ht lilt-   COMPANY If   M. ».'■'
626 West Pender Street, MArine 8411
Vancouver 2, B.C.
Page 93 WYDASE IN OFFICE PRACTICE
Part of a series on its everyday uses
Registered ?'<§£££$
Treatment of Sprains
In the treatment of simple ankle sprains, Wydase added
to procaine
1. facilitates  adequate  diffusion  of  anesthetic.
2. reduces the number of injections required and
3. promotes rapid absorption of edema fluid and
blood from the site of injury.
Application of an elastic bandage maintains local pressure. Swelling subsides rapidly and early function is
thus encouraged.1
LYOPHILIZED Mm
W Y D A
Hyaluronidase Wyeth
**The Spreading Factor" facilitates absorption of injected fluid
. . . large clyses or small volumes of anesthetic or therapeutic solutions.
1   Britton, R. and Habif, D. V.: To be published.
JOHN WYETH & BROTHER (CANADA) LIMITED
WALKERVILLE ONTARIO

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