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Vancouver Medical Association
Contents
Shaughnessy Clinical
Meeting
Medicine and the Law
Laboratory Bulletin
ANNUAL MEETING
CANADIAN MEDICAL ASSOCIATION
JUNE 22—26, 1931
VANCOUVER, B. C.
Vol. VII.
MARCH. 1931
Meetings
General—Mar. 3rd
Clinical—Mar. 16th /.
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Vol. VII.
MARCH, 1931
No. 6
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. "Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
Trustees
Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. S. Sievenpiper Chairman
Dr. J. E. Harrison Secretary
Eye, Ear, Nose and Throat
Dr. N. E. MacDougall Chairman
Dr. J. A. Smith Secretary
Pediatric Section
Dr. H. A. Spohn \ ■- Chairman
Dr. R. P. Kinsman Secretary
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STATISTICS, JANUARY, 1931
Total Population (estimated) ' 242,629
Asiatic Population (estimated) 14,227
Rate per 1,000 of Population
Total Deaths , 200 9.7
Asiatic Deaths 14 11.6
Deaths—Residents only 186 9.0
Birth Registrations 337 16.4
Female 156
Male 181
INFANTILE MORTALITY—
Deaths under one year of age 21
Death Rate—per 1,000 Births 62.3
Stillbirths (not included in above) 9
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
February 1st
December, 1930 January, 1931 to 15 th, 1931
Cases Deaths Cases Deaths Cases Deaths
Smallpox 0 0 0 0 0 0
Scarlet Fever 53 0 26 0 18 0
Diphtheria 10 2 9 0 4 0
Chicken-pox 121 0 167 0 58 0
Measles 2 0 8 0 Jl 0
Mumps 21 0 34 0 40 0
Whooping-cough ii 10 0 11 0 2 0
Typhoid Fever 9 3 2 0 10
Paratyphoid —- 0 0 0 0 0 0
Tuberculosis - 7 13 17 17 9
Meningitis (Epidemic) . 0 0 11 0 0
Erysipelas . 3 0 7 0 3 0
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CT! t T 1 1 1 I t T 1 ! 1 1 1 1 1 1 t t I I 1 I t 1 1 t 1 I I I I 1 1 I I t t T t I I 1 t T T T T~ EDITOR'S PAGE
Recently, in the daily press, we saw an item to the effect that one
of our city fathers, Alderman Warner Loat, in discussing the question of
hospital accommodation, had intimated that doctors were a great deal to
blame, inasmuch as they sent patients to hospital unnecessarily.
We confess to a toral indifference as to Alderman Loat's personal
opinions—but, after all, he made this statement in his official capacity. It
is very much in line with a similar expression of opinion ascribed to a
minister of the Crown, who, in addressing a New Westminster audience,
made very much the same sort of statement.
The medcal man has been having a hard time of it lately. We
have, of course, our detractors and those who do not think well of us—
that is inevitable—but during the last year or so, we have been held
responsible for a great many of the evils that beset the body politic.
Beginning with the Hospital Survey Report, and ending with Alderman
Warner Loat, our iniquities and misdoings have been thoroughly exposed
and given a good airing. One begins to wonder whether it might not
be a good thing to do away with doctors after all. If we can believe
one speaker, we are responsible for the hospital deficit; another makes us
the scapegoat for hospital shortage—there is something rotten in the
state of Denmark, and everyone blames it on the doctor.
There is an old saying that the "bad workman quarrels with his
tools." A more colloquial rendering of this would be that he looks for
an alibi, or "passes the buck." This is a very human tendency—we all
do it at times.
In this particular instance, however, we take issue with these
speakers. We are getting tired of being blamed for things which are not
our fault. It should be quite obvious to any ordinarily intelligent man,
who will take the trouble to look into the facts, that neither the hospital
deficit nor the shortage of hospital beds can be held the fault of the
medical profession. Granted that occasionally a doctor sends a patient
to the hospital who might be treated at home, or granted that there
has occasionally been a doctor who tried to collect his fees from a patient
he has worked for in the hospital, and who has (horribile dictu) considered that he has at least an equal claim with the hospital. These are very
small factors. We deny emphatically that there has been unfair treatment of the hospital by the great bulk of medical men. Vancouver has
not provided hospital accommodation commensurate with its needs and
its growth. The failure to do so may have been due to causes which
the city could not control—it is certainly not our fault. Deficits are
not peculiar to Vancouver. Dr. Haywood has taken occasion to point
this out—we certainly are not responsible for them.
It might be a good thing if the medical profession could some day
have a chance to present its views and its side of this whole question
before the bar of public opinion. We feel that a good deal of this
unfair criticism of our profession would cease. In the meantime, we
desire to utter our small word of protest against the unthinking and
careless utterances of uninformed people, no matter what position they
occupy.
Page 125 NOTICES
An announcement regarding a class in tuberculosis for practising
physicians to be held at the Tranquille Sanatorium, appeared in a recent
issue of this Bulletin.
It has been decided to hold this class from May 25th to May 30th
inclusive. All phases of tuberculosis will be covered, particular attention
being given to special treatments such as pneumo-thorax.
The Sanatorium will refund travelling expenses to all men attending
this class. The class will be limited to ten men. In selecting the class
from the list of applicants, an attempt will be made to make it as representative of the various districts of the Province as possible. All men in
good standing in the B. C. Medical or the Vancouver Medical Associations are asked to regard this notice as an invitation to apply.
Those wishing to take advantage of this invitation are asked to
apply as soon as possible to Dr. A. D. Lapp, Medical Superintendent,
Tranquille Sanatorium.
The Annual Meeting and dinner of the Lower Mainland of B. C.
branch of the Association of Officers of Medical Services of Canada will
be held in the Messroom of the 18 th Field Ambulance, at 415 Cordova
Street West, Saturday evening, March 7 th, at 7 p.m.
All medical men who have held or are holding commissions in the
C.A.M.C. are urgently requested to be present, as the formation of a
medical section of the C.M.A. is to be discussed and arrangements made
for holding a sectional meeting in connection with the C.M.A. here in
June.
This branch has the distinction of having the largest enrolment in
the Dominion, and it is hoped that it may continue to. If you have not
been present at previous meetings, make a special effort this time and
also remind any of your friends.
Get in touch with the secretary as soon as possible so that arrangements may be made for catering.
Time: 7 p.m., Saturday, March 7th, 1931.
Place: 415, Cordova Street West.
Dress: Informal.
Tickets: $1.75.
H. H. Pitts,
Secretary- Treasurer.
Dr. R. E. McKechnie will deliver the Osier Lecture at a Dinner
Meeting of the Vancouver Medical Association, to be held at the Hotel
Vancouver on March 31st, at 7:30 p.m. Dress formal. Tickets $1.50.
Committees of the Association desirous of calling a meeting in the
Committee Room are asked to enquire beforehand from the Office
whether the room is already engaged, so as to avoid two Committees
being called for the same time.
Page 126 ADDITIONS TO THE LIBRARY
Medical Clinics North America. July, September, November, 1930.
United Fruit Co. Annual Report Medical Department.
Cornell University Medical Bulletin Urology. Vol. XIX.
Ministry of Health Report on Cancer Lip, Tongue and Skin.
Surgical Clinics North America. August, October, December, 1930.
Physiological Principles in Treatment. Langdon Brown, 6th Ed.
Osier's Medicine. 11th Edition, 1930.
Dietary Suggestions. Christie, Beams & Geraghty, 1930.
Bacteriology in Relation to Medicine. Vol. 7. Viruses and Bacteriophage.
Surgery of the Temporal Bone. Ballance, 1919. 2 vols.
Physical and Clinical Diagnosis. Andrus, 1930.
Annual Report of the Rockefeller Foundation for 1929.
International Clinics. Vol. 11. Series 40.
Roentgenology of the Chest. Sante, 1930.
Treatment in General Practice. Beckman, 1930.
Transactions of the American Proctologic Society. 1930.
Diseases of the Skin. Andrews, 193 0.
Transactions of Section of Ophthalmology. A.M.A., 1930.
Concerning Man's Origin. Sir Arthur Keith.
Intracranial Pressure in Health and Disease. 1929.
The volume of the Blood and Plasma in Health and Disease.
Rowntree and Brown.
Cornell University Bulletin. Vol. XX.
Coll. Papers School of Hygiene and Public Health. Johns Hopkins.
Transactions Section of Laryngol. Otol. and Rhinol. A.M.A., 1930.
Crossen's Gynaecology. 7th Edition, 1930.
Harvey Lectures. 1929-1930.
Leonardo da Vinci, the Anatomist. McMurrich, 1930.
Internal Secretions of the Ovary. A. S. Parkes.
Allergic Diseases. Balyeat, 1930.
Diet in Disease. Harrop, 1930.
Neoplastic Diseases. Ewing, 3rd Edition.
MEETINGS
The monthly General Meeting of the Association was held in the
Auditorium on February 3rd. Owing to the dense fog there was a small
attendance and on motion duly seconded and carried the presentation of
papers by Drs. Wallace Wilson and Dr. F. N. Robertson was postponed.
A letter from the Registrar of the College of Physicians and Surgeons was read asking for the opinion of the Association as to the action
to be taken in view of the proposed legislation coming before the Legislature re drugless healers and chiropractors. After considerable discussion the following resolution was carried: "That this Association is of
the opinion that the B. C. Medical Council should continue to oppose by
all means in its power any legislation which will empower drugless healers,
or other cults to practise without adequate examination in the fundamental subjects, scientific and otherwise, necessary to an adequate knowledge of disease, and that this Association urges the appointment by
the House of a Judicial Commission to examine into this whole matter."
Page 127 The January meeting of the Clinical Section was held at the Vancouver General Hospital on the 26th. Cases were presented by Drs. E. J.
Curtis, A. W. Bagnall, Wallace Wilson, W. L. Graham and F. N. Robertson. At the close of the meeting refreshments were served through the
courtesy of the Board of Directors of the Hospital. A full report of the
cases presented at this meeting will appear in a later issue.
The Committee authorized at the General Meeting of the Association on January 6 th to investigate the cancer question as it affects
the City of Vancouver has appointed an Executive Committee of which
Dr. J. J. Mason is Chairman and Dr. A. Y. McNair, Secretary. Several
meetings have been held and sub-committees formed to investigate and
study the question from different angles.
CLINICAL MEETING, DECEMBER 16th, 1930
Owing to the courtesy of the authorities at Shaughnessy Military
Hospital we are enabled to publish the following full report of the cases
presented at the meeting of the Clinical Section held at Shaughnessy on
December 16th:
Dr. J. Brown presented the following cases:
Case 1—G.S. Brought into hospital with ordinary symptoms of
hemiplegia. He could remember having no serious illness. Mother died
when he was quite young. Always had good health. Served overseas and
in 1919 appeared for Board at Whitley. Diagnosis D.A.H. Symptoms
noted were palpitation, shortness of breath and poor exercise tolerance.
Pulse 96 to 144 on exercise. A note made at that time stated there was
a cardio-respiratory murmur only. After coming back to Canada was
given a small pension for D.A.H. which was discontinued in about a
year because of greatly improved exercise tolerance. Carried on at his
own work until about July 5, 1930. Noticed during 1929 that he was
not standing up to his work very well, particularly during the last six
months. He complained of being tired and of shortness of breath. On
the morning of July 5 th was not feeling well and decided to stay off
work. Lay down on couch in the living-room, something apparently
happened and the next thing he knew he was off the couch with his
wife bending over him. He was not sure whether he lost consciousness or not but if so it could only have been for a few moments. That
day he was brought into hospital. Routine examination showed the
usual symptoms of right hemiplegia—right arm and right leg helpless.
The detailed symptoms will not be gone into as we are mainly interested
in the cause of the hemiplegia. On admission temperature was 99.2 and
since admission has been more or less irregular, varying from 99 to 101.
Heart examination revealed a distinct rough mitral murmur with moderate enlargement. B.P. 154/90. Arteries sclerosed excessively for his
age which is 44. Hemiplegia cleared up quickly, practically in two or
three weeks. Still had a little weakness of grip but was able to stand
and walk about a little with good control. This was for testing purposes only and he was kept closely in bed. Wassermann and Kahn negative. No history of rheumatism. Examination showed some enlargement of spleen. Diagnosis made of sub-acute bacterial endocarditis
Page 128
atuminF.suijjy with embolism. This diagnosis was made on the presence of a heart
lesion, continued irregular temperature, embolism and enlargement of
the spleen but up to date blood culture for the streptococcus viridans
has been negative. Blood count on admission was W.B.C. 6,600, R.B.C.
5,100,000, hemoglobin 95. Blood count taken three days ago showed
W.B.C. 9,000,000, R.B.C. 4,000,000, hemoglobin 76. This was not so
important in the actual count as in showing the direction towards which
the blood is tending, namely that of the usual anaemia. Mitral murmur distinctly heard, much the same as on admission last July, but no
new murmurs or sounds added. Diagnosis of sub-acute bacterial endocarditis made on these four symptoms. Other symptoms frequently
found were absent, such as petechiae, splinter haemorrhages, Kahn spots
on the retina, and so far a negative blood culture. Regarding the treatment of these cases or rather the lack of efficient treatment, I should like
to say a few words. Chemotherapy may be said to have failed. Various
remedies have been tried and reported on by numerous careful observers,
such as sodium cacodylate, arsphenamine, colloidal silver, mercurochrome,
acriflavine, and gentian violet. These must be considered to have failed.
Vaccine and serotherapy are, if possible, in a worse position. Auto-vaccine and anti-serum obtained from the blood of horses, immunized by
the patient's own streptococci has failed. Similar treatment to that
given in another streptococcal disease, namely scarlet fever, has also
failed. Finally transfusion from immunized blood has also failed. Lib-
man, who is regarded as the outstanding student, during the past 11
years, of these cases, reports six recoveries without any treatment but rest
and nourishment. The cases reported by him were diagnosed on splenic
enlargement, embolism, cardiac lesion, fever, petechiae, and positive
blood culture for the streptococcus viridans. He also believes that in
all probability a few cases spontaneously recover that are too mild to
be diagnosed. In fact the only conclusion we can come to so far as
results of research into various forms of treatment are concerned is that
the streptococcus viridans is extremely resistant to treatment.
Case 2—P. W. McD. A man 45 years of age who has always been
engaged in hard work. He passed fit into the army, went overseas, and
came back with a little chronic bronchitis for which he was pensioned
for a short time. Did not hear from him again until he was admitted
to hospital on the 1st of October, 1930, with double pneumonia. Had
been ill about five days before admission, complaining of chill, cough,
and pain in the chest. Routine examination showed double pneumonia
with typical signs, dullness, increased fremitus, bronchial breathing over
both bases, the larger area being on the left side. The morning after
admission temperature was 102 and the same afternoon 102/2- Heart
showed no enlargement, no murmurs, and sounds clearly cut. The morning of the third day temperature dropped to normal, with pulse still
120, in this respect differing from an ordinary crisis. Temperature remained normal for 36 hours, then went up to 100, next day 100.2, and
third day 100. During these three days the chest was carefully watched
for evidence of empyema, but no signs of this were discovered. On
October 7th temperature dropped to normal and remained so until the
15th, the pulse still running from 96 to 118. Heart showed .a real apex
beat about the nipple line and he still had some dyspnoea. On the night
of the 15th temperature dropped to 96, and no higher registration than
Page 129 this could be obtained by mouth, axilla, or rectum for about three days.
On the afternoon of the 17th he had a very bad turn and the nurse
thought he was dying. I saw him immediately and he had severe dyspnoea, very irregular pulse, pupils widely dilated. Taken down by
stretcher to the X-ray room, an X-ray of the heart was taken in the
horizontal position, the picture which you now see. This shows a greatly
dilated pericardial sac with a typical pear-shape. He was immediately
taken up to his room and I pushed a trocar into the fifth interspace
about an inch from the sternum and into the pericardial sac. A thick,
creamy-yellow pus began to ooze out. The suction apparatus was sent
for and 18 ounces of pus aspirated with considerable relief to the patient.
During aspiration the nurse, who was watching his pulse, with a hypodermic loaded with adrenalin handy, suddenly reported that his pulse
was regular. At the close of the aspiration of the 18 ounces the pupils
were down to normal. I do not know at what point during the process
they became normal. It would have been a rather interesting physiological question to determine whether the return to regularity of the
pulse and the contraction of the pupils occurred at the same time from
the relief of the internal pressure. The presence of pus in the pericardium brought up, of course, the question of surgical drainage and the
following morning I had Dr. Schinbein see the case and he advised no
interference at the present time until his condition might improve a
little. Two days after that I aspirated again, drawing off 13 ounces
of pus. Dr. McKee in the meantime reported that the organism was a
pneumo-coccus. The following day he had dyspnoea and the following
morning Dr. Schinbein opened the pericardial sac and aspirated 60 ounces
of pus. Tube and cigarette drains were inserted well to the back of
the sac and irrigation twice a day carried out for about fourteen or
fifteen days. Pulse dropped a little after the operation but not a great
deal—still 98 to 112. Patient, however, experienced very great relief,
and began to eat and sleep very much better. During this period of
drainage the chest was watched closely. Signs of dullness seemed gradually mounting on the left side—a pleural rub, which had developed
about ten days before, was very marked. This rub was also present on
the right side. Finally about the sixteenth day the pupils dilated again.
With a Potain aspirator I drew off 68 ounces of clear fluid from the left
side. Dr. McKee reported this sterile. After this aspiration there was
the first considerable drop in the pulse. A week later 64 ounces were
aspirated and again 42 ounces on December 1st. Since then he has been
able to take care of the fluid and needling this morning showed practically nil. During this period he developed phlebitis in the left leg. One
morning the calf was swollen and the next morning the thigh was considerably swollen. Dr. Schinbein saw him but considered it probably an
iliac phlebitis. However, under elevation it went down completely in a
week and the leg has remained normal since.
A few words about the capacity of the pericardium. A case reported
some seventeen years ago by Osier had 2,000 cc. removed. This was
clear fluid. The only experimental work regarding pericardial capacity
which I have been able to find is that done in 1929 by Williamson, who
states that 100 cc. could be injected without evident distention but
when the quantity recahed about 655 cc the pericardium either ruptured or was torn from its reflection at the great vessels. In this case
Page 130 altogether there was 91 ounces—2700 cc—of pus removed. This
amount, however, was evidently not all present at once. Lilienthal, in
his recent work, quotes a case reported by Matas, where a gallon of fluid
had been removed from the pericardial sac. Our patient, at the present
time, has gained weight, is doing well, sleeping well, getting stronger
and would look to be in a very fair way to recovery. He will, of course,
have an adherent pericardium and pleuro-pericardial lesions, but how
far these conditions will hamper the mechanical action of the heart is
questionable. His pulse is now from about 74 to 90. The apex appears
to be just within the nipple line, but what his future will be is a rather
interesting question.
Discussion on Case 1:
Dr. C. E. Brown. I think the diagnosis of sub-acute myocarditis
is almost positive in this case. I do not see how the brain lesion could
possibly be explained on any other basis. There were a series of cases in
Toronto (these were very mild) reported to have recovered. I have
never seen one recover myself.
Dr. Keith. I feel I would like to thank Dr. Brown for bringing
these cases up. I have nothing but agreement as far as the diagnosis of
the first case is concerned. We must bear in mind that arteriosclerosis
has practically nothing to do with high blood pressure. We used to
associate one with the other, yet he has no breaking of the artery in the
brain, but he has an embolus and in taking his blood pressure the pressure is not up very high.
What a change has occurred in medicine. It is not so many years ago
that aspiration of the pericardium was done to save a life in England.
In this particular case it was a young man and the opening of the pericardium saved his life and he was enabled to live for many years.
Dr. Vrooman. The capacity of the pericardium is of very great
interest. I drew off 43 ounces of clear fluid from a case of T.B. pericarditis and then a few weeks later drew off 30 ounces. X-ray very
comparable to the one shown tonight. Post mortem showed that effusion was due to T.B. pericarditis. Did not cause him very acute distress,
whether because it was pus or not is a question.
Dr. Gillespie. We had a very typical case about six months
ago in one of the hospitals—enlargement of the spleen, embolism, etc.,
seen in consultation with Dr. Pearson and Dr. B. D. Gillies. We could
not get the organism. Of course we gave a very doubtful prognosis, in
fact all pretty well agreed that the prognosis was very bad and very
little hope was held out; yet with rest and very small doses of novarsenol
benzol, even with .5 and .3, she had a very decided reaction. To the surprise of all of us she got better and today she is comparatively well. I
am doubtful, of course she had very good care and nursing (in one of the
private nursing homes), but I have always felt that there is a possibility
the novarsenol benzol had an effect because every time we gave it, even a
small dose, she was decidedly better and her temperature came down to
normal for about a week and then she got bad and we again administered
medicine. She was in hospital about three months.
Discussion on Case 2:
Dr. W. Wilson. There is one point in connection with large
pericardial effusions that it is well to bear in mind. When I watched that
Page 131 bottle filling up to 40 and 50 I kept hoping that that man had a good
heart muscle. If you have a bad heart and a pericardial effusion you may
have trouble from .a cardiac standpoint. In one case a man had a great
big flabby pericardium. He nearly died during the twelve hours following aspiration. He recovered from his acute symptoms, went out for
some months, returned and was again tapped. A second time he nearly
died. The third time he filled up he refused tapping. If you have an
acute pericardial effusion where the pericardial sac is not stretched then
there is not so much danger in taking off the fluid, but if a bad heart is
present then there cannot be too much care taken.
Dr. Appleby. I congratulate Dr. Schinbein on the result of his
case. I think I have seen only three such pericardial cases operated on.
(Dr. Appleby brought before the meeting the method of approach in
the cases which he had seen operated on.)
Dr. W. Wilson. There is the case of a boy who had a very large
pericardial effusion. He was tapped or a needle was put in and out at
the apex and also in the fifth and fourth space with no result. No fluid
was withdrawn although he obviously had a very large collection of fluid
and it appeared that the heart was pushed up against the anterior wall.
The boy was in acute distress. On opening the pericardial sac, however,
there was a large gush of fluid.
Dr. A. B. Schinbein. Unless you can sit your man right up I do
not think you will be able to get good drainage. When I opened this
pericardium I was right at the bottom. You would have to sit the man
up before you could drain anything. I think irrigation is to be commended in these cases. I passed a tube behind the heart and in that way
I kept, I think, the posterior part of the pericardial sac empty. I irrigated
every day with an irrigating can and very little pressure and washed it
out until we got clear fluid. There was a lot of pus present at first.
The approach was certainly very easy. I had a good big tube in behind
cigarette drains placed so that it would remain open.
Dr. J. Brown. I should have liked to hear some opinion expressed
as to the reason for the clear serum in the pleural cavity in view of the
presence of a large amount of pus on the other side of a comparatively
thin wall.
Dr. Vrooman. The only explanation would be a hypostatic condition due to heart weakness which is a very lame explanation. It is
hardly likely to have been inflammatory or to have been infected with an
empyema. It looks to me as if it was hypostatic.
Dr. J. Brown. There was a pleural rub extending outside the
nipple line around to the back on the left and also a pleural rub on the
right with a little fluid, and these rubs corresponded with the site of
the typical pneumonic signs. This would appear to militate against the
idea of a hypostatic effusion. The kidney function was normal.
Dr. W. A. Dobson presented the following Cases:
Case 1—C.H.T. This man at the age of 35 (1915) joined the
Infantry. He was then apparently very healthy, weight 165 pounds.
In Calgary stood his training very well. A few months later was in
France and soon complained that he could not take part in the ordinary
drill and marches and was removed from the Infantry to the Labor Corps. Remained in France 1915 to 1919. Discharged in 1919.
Weight then 135 pounds. Many cmoplaints but it was not considered
that he had anything really disabling him and he was discharged without
pension. He made a number of applications between 1919 and 1927, but
nothing came of them. We have on record a number of reports from
various employers in which it was always stated that although he seemed
to be quite earnest and sincere he was a total failure in his work. Admitted to hospital 1927. Examined in the ordinary way and nothing
organic found. He was labelled as a neurasthenic and put on a small
pension. At that time some apical abscesses were discovered on X-ray
and treatment carried out. Admitted again 1928, and pension raised,
also in 1929, and again two months ago. During all this time his complaints were of the usual neurasthenic type—headache, dizziness, stomach
trouble, insomnia and loss of weight. This time he complained of his
back more than any time previously. He walked in a stiff way. X-ray
showed very definite arthritis. ("Definite slight osteoarthritic change is
noted throughout the lumbar spine, there being small spurs at various
points. Otherwise the spine is negative.")
I bring this case up hoping to have some discussion on the possibility
and probability of what we have been labelling neurasthenia as being
arthritis during all these years. He compained of any slight jarring in
1915 affecting the spine and making it impossible to carry out his routine
work as a soldier. Now he shows a definite arthritis. Examination
shows the pelvis tilted forward obliterating normal lordosis. Bends forward till finger tips reach knees—returns very slowly and carefully.
Lateral and rotary movements one-third normal range. Tender on right
side of notch. Straight leg raising to 45 degrees right, 80 degrees left.
Towards extreme range complains of pain along back of right thigh.
That is all we found on examination.
DISCUSSION
Dr. C. E. Brown. Does the prostate show anything?
Dr. W. A. Dobson. Dr. Campbell examined him on many occasions and found it negligible.
Dr. Naden. It probably would not be an arthritis in a man of 3 5
years of age, if you could not find more clinically. In a man of this
age symptoms would be very acute.
Dr. Schinbein. In 50% of men over 45 years of age on X-ray of
spine you will find marginal lipping of the vertebra. Do not think that
because you find body changes that they are causing symptoms. This
whole problem of hypertrophic arthritis of the spine is unsettled and
personally I do not think that because you find a few lips on the dorsal
vertebrae that you should say that that man is incapacitated, because of
lipping.
Dr. Keith. You may have a man come in with symptoms of
irritation, pain and discomfort along the spine and you have him X-rayed
and you find that he has this lipping, and in a few months you see him
again and you find that he has no complaints, and comes back within a
few years again with the same complaint. Therefore that would favor
this having started away back.
Dr. Bagnall. Before the war a woman patient about 30 years
old had a good deal of pain in her back, and in the last three or four
Page 133 years I have seen her at intervals. At times after working hard or after
a lot of strain she would have marked symptoms. Now I have no doubt
that at that time she had arthritis, and as it became more or less anky-
losed, the condition became better. We had her teeth all out at the time.
Dr. Barker. I would like your ideas as to whether this man's
arthritis was the cause of his neurasthenia. In my experience I have seen
cases which are a good deal worse, where the patient grumbles a good
deal, but they do not as a rule show as many symptoms of arthritis as
this man. I think probably this arthritis is just a coincidence. I think
neurasthenia is the main condition.
Case 2:—W.H.L. This man went into eye, ear, nose and throat work.
He was quite successful in that and in 1914 joined up and went overseas.
Went to France from 1915 to 1919. In 1918 developed a tremor, particularly of the head and hands. A number of his associates have supplied certificates as to the onset at that time. On discharge this still
bothered him, more when he attempted to do any fine work. Was on
the boats for a number of years, then someone advised him to get into
the open and work. He did so and worked on the P. G. E. as a labor
man for a considerable time. Feels very sensitive about his condition.
Applied for recognition for. this condition on many occasions, but it
was considered a post-war disability and was not recognized until a
few months ago when he was admitted to hospital. Age 55. Mild
tremors of both hands and arms and occasionally very slight tremor of
the head. These used to be much worse. Worse when meeting strangers.
No tendency to exaggerate the symptoms, in fact attempts" to hide his
condition. When informed that the condition was considered genuine
he appeared to be very much relieved. Pupils equal. Convergence is
good. Vision good with glasses. Slight presbyopia. When following
page, movement left to right or right to left, there is a fine jerky movement of the eye, not present when eyes are moving in a vertical or rotary
direction. No hearing defect. He has been a little concerned about his
condition. After five years he began to become despondent. Has been
reading text books with the idea of finding out whether he has something
more serious. Much relieved when he found out that it was a functional tremor. There is nothing in this man's private life or habits that
would produce a tremor. He was under terrific strain from 1915 to
1919. Was a sensitive man and felt he could not take his old place in
the profession again and was naturally worried about it. He made one
or two slight attempts to get recognition and treatment, but it was
passed up until this year. In hospital where worries have been very much
lessened, where he has had a chance to relax and treatment, there has
been a very definite improvement. At rest tremor now is very slight.
Can grasp a thing lightly without tremor, but if he attempts to hold
anything tightly it comes on.
The Patdent says: "I suppose it is easiest to explain by writing a
letter. If you write a letter, you are alright for the first few words, and
then whatever you do you cannot control the hand—it will shoot out so
that nobody can read what is written. Same thing in moving a cup off
the table^—it will spill in spite of anything you can do. When lying at
rest there is no tremor at all. Only when you use some exertion it produces that. For four or five years, yes up to 1923 or 1924, I used to
Page 134
^«^ww—iprB'~-'^ ' ^w ** get, about three or four times a year, an attack of fever (not malaria)
running up to 103 and 104, and staying that way for ten days, and
then it would go away. That happened about every five months and
lasted up to 1923 or 1924. When sleeping, would wake up with a start.
No dreaming. As soon as I start to dwell on anything then it seems
to affect the muscles."
DISCUSSION
Dr. C. E. Brown. When we start to make a diagnosis of neras-
thenia on these patients we are starting at the wrong end. I think that
the more experience we get the more we see these patients to have organic
trouble. I think a basal ganglion condition in this case is quite a possibility. A syphilitic condition or something of that type may have something to do with this case.
Dr. W. A. Dobson. The practice here is that with all our cases
first on admission to hospital they go through other departments, surgical, intrenist, eye, ear, nose and throat, etc., and then they gradually
drift to the neurologist. Dr. Cathcart—who spent most part of a day
with him—felt that he had ruled out any organic condition entirely.
Dr. Cathcart is a very thorough man. However, our neurasthenics are
not started in the neurological department, but are shifted from other
departments.
Dr. C. E. Brown. Pathology has only just begun to be appreciated. Anyone could, however, find an organic lesion. It is only in recent
years this has been found. There is no disturbance of reflex, but none
the less it is an organic lesion.
Dr. W. A. Dobson. A great manly of our cases ten years ago
called neurasthenia have developed some other condition that may or may
not be at the back of it. Being labelled neurasthenia in the department does not mean that all other examinations are ceased. Very often
some organic condition would explain all the symptoms of ten years
previous.
Dr. A. B. Schinbein presented the following case:
V. O'B., Age 48. This man is pensioned for G.S.W. head and a
diagnosis of sarcoma of ilium with secondaries in chest has been made.
About 12 weeks ago he complained of pain to right of spine and running down his right thigh. A few weeks later reported to doctor, who
at that time could not make a diagnosis. On the 13 th of November
was admitted to this hospital. At that time he had a mass about the size
of a grapefruit in the posterior iliac region. X-ray showed: "In the ilium
on the right side extending from the lower part of the sacro-iliac joint
downward and outward there is an area nearly two inches in diameter in
which destruction of bone has taken place without any evidence of bone
production. The whole bone is not completely destroyed. The appearance might represent an inflammatory process or malignancy. An extreme degree of curvature in the lumbar spine is seen without evident
bony change." A mass in the right iliac region could be felt, and it has
increased since. He developed a mass in the left humerus, which has
gone on to spontaneous fracture. About three weeks ago he began to get
a swelling in the left lobe of the thyroid, which is quite firm, and in the
last week his voice has become practically nothing but a whisper. A
Page 13 5 few days ago I took a section from the mass in the right iliac region and
had Dr. Pitts report, as follows: "Macrosc. Exam. A number of very
cellular, greyish-white portions of tissue approximating to the size of a
pigeon's egg. They are grossly malignant. Microsc. Exam. Sections
show an extremely cellular type of growth, the cells being markedly
atypical. In some areas the cells are small, spherical, very deeply-staining, with no especial arrangement. In other areas, probably the majority,
the cells are polyhedral, many extremely large, frequently giant cell in
type, with innumerable mitotic figures and marked hyperchromatism.
Many of these cells are hydropsical in type, the cytoplasm being practically colorless. In parts there are fine trabecular fibrous strands running
through the sections, giving a somewhat alveolar appearance which, in
some instances almost resembles adrenal cortex, except that the cells are
so atypical. Many areas of degeneration are present and the tumour is
generally fairly well vascularized. Diagnosis: Metastasis from either an
adrenal or pulmonary carcinoma—because of the marked anaplasia of
the cells, it is almost impossible to determine which—the innumerable
giant cell formations, in a sense favor an adrenal source." He also has
another lesion in the upper end of the right femur and in the chest plate
which I have just shown there is one in the rib. The most common
malignant lesions that metastasize in bone, of course, are breast, thyroid,
prostate and the suprarenal. You will have to take my word for it and
also that of Dr. Campbell that this man has no enlargement of the prostate and that there is no irregularity or mass there. No evidence of any
malignancy of the breast. In the thyroid, left side, there is quite a hard
mass. You can feel no mass in the region of the left or right kidney.
I thought that this was probably a carcinoma of the thyroid with
metastasis in the bone but our section which we took from the mass in
the right iliac region the day before yesterday was reported on by Dr.
Pitts as I read before. I cannot tell you definitely, gentlemen, just what
the primary lesion in this case is. I do know that often a very small
malignant tumour in practically any part of the body may result in these
metastases being of very large size.
Dr. Pitts. This is extremely atypical and it certainly looks very
much to me like an adrenal carcinoma. I think that we can almost certainly rule out any thyroid trouble or any carcinoma of the prostate.
This picture is very, very, atypical and it is often very difficult to say
from which they originate. The query about this one is, of course',
whether to call this a carcinoma of the thyroid or in one of these other
places. As I say I think I would be a little bit inclined to put this down
as an adrenal carcinoma.
Dr. Riggs. It is very interesting from a thyroid standpoint. The
mass is very adherent to the thyroid cartilage or shoulder, so that it
evidently has either involved the whole of the inside of the larynx already
or there is a growth on both sides of the trachea involving both nerves
as his voice is completely gone. I have had a number of these cases in
which some have grown very rapidly and others have been of slow
growth like this one, but the voice does not go until the whole of the
thyroid is pretty well involved so that it presses upon the larynx. The
problem is, from an adrenal tumour will you be likely to get a metastasis
in the thyroid gland? It is not such a common place for it to metastasize. I do not remember ever seeing or reading of an adrenal tumour
Page 136 which metastasized in the thyroid and I should judge that any such
metastasis would be an extremely cellular one that would be quite soft,
as you sometimes see in thyroids of very rapid-growing medullary type.
This is extremely hard which is rather against an adrenal metastasis iii
the thyroid.
Dr. A. B. Schinbein. I should like to say that I do not think any
case of pain down the leg should be considered as sciatica until every
evidence of a new growth has been eliminated. I think this is a very
important factor in these malignant cases.
Dr. W. Wilson presented the following:
pathological specimen
A man in the early fifties, first seen by Dr. Schinbein in office
November, 1929. Had lost some weight. Complained of indefinite
gastric symptoms. Dr. Schinbein could find nothing. Gastrointestinal
tract negative to X-ray. Some sense of resistance in the region of the
pancreas. The man was sent into Hospital early in 1930, and he was
there till his death in November. During that time we had the interesting experience of watching a carcinoma of the head of the pancreas develop. The-man continued to lose weight. He gradually developed a
large mass in the right side of the abdomen going down well below the
umbilicus. I must say I did not diagnose what that tumour was. I
thought it was simply a cancerous mass in the abdomen. It was fairly
globular, almost the size of a small cocoanut. X-ray of G.I. tract negative. The man developed very profound jaundice followed by ascites.
The abdomen was aspirated. I have never seen a gall-bladder that approached this one in size. The large tumour extending down to the
umbilicus was this man's gall bladder. He suffered a great deal of pain.
Gall-bladder was not X-rayed. Note the tremendous size of the gallbladder and common and cystic ducts.
J. McF. For diagnosis. Polycythemia—true or secondary. 57 or
58 years of age. First seen in 1926. Had very marked bronchitis with
a great deal of purulent sputum with putrid odour. Could not sleep oh
left side because of constant coughing and expectoration of pus. X-ray
did not show much except very high diaphragm on right side and hilum
shadows possibly slightly enlarged. It at that time (1926) injected some
lipiodol through the cricothyroid membrane. The man complained of
no particular discomfort but the lipiodol was all in the neck tissues. I
had gone through the trachea. X-ray taken this month still shows a lot.
of that lipiodol present. It has spread out very considerably but there is
still a fair amount of lipiodol present in the man's neck. There was no
inflammatory reaction following it. I have had some cases where I have
injected lipiodol and got a good filling of the bronchus where I have seen
it a couple of years afterwards. You must expect, according to these
findings, that you will have lipiodol for some time in the spinal canal in
the case of spinal canal injections. At that time I did not repeat it and
the man went out of hospital shortly afterwards and went back to Dawson. He came down with shortness of breath, cough and dyspnoea several times but at no time have I any note of his colour or any increase
in his red blood cells. Some intestinal distress. Vomiting. Pathological
gall-bladder. About a year ago he came down from Dawson, and at
that time his picture was certainly different from that on his prior dis-
Page 137 ACUTE SINUSITIS
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Medical-Dental Building Vancouver charge from hospital. Purplish violet tinge all over his face. Dyspnoea,
headaches, weakness, generally miserable. During his period in hospital
now his red blood count has ranged from 6,000,000 the lowest, to the
highest which is 12,000,000. Hg. 110 to 170. We have bled him on
frequent occasions and gave him phenyl hydrazin hydrochloride. No
enlargement of the spleen. No enlargement of the liver to be made out.
No haemorrhages. The question is, is this a symptomatic secondary polycythemia? Very little sputum now. Purely dry cough. Certainly now
has nothing like the sputum one would expect from a man with bronchiectasis. When this man came in the last time I though "here is a
man with a symptomatic polycythemia due to his lung condition." Was
inclined to put him to bed and treat his bronchitis and see what results I
could get. No results until we started to bleed him and give him phenyl
hydrazin. Increased red blood cells—marked myocarditis, bronchiectasis.
This is a typical picture of ordinary polycythemia-vera. Headaches, dizziness and all the pictures that go with the polycythemia vera except enlargement of the spleen. There are three methods of treatment, but these
only give temporary relief. (1) Repeated bleeding. (2) X-raying of
the long bones. There is a definite risk in X-raying the long bones
because you may turn the case into an aplastic anaemia where the case
is then worse than when you first started. (3) Phenyl hydrazin hydrochloride by mouth in capsules. We have been treating this man with
various courses of .1 gram, three times a day. Kept watching his blood
count and stopped when he was between six and seven million because
action of the drug is cumulative. Then gave him a rest for awhile and
then bled him. Another point worthy of note in connection with the
giving of phenyl hydrazin is that it apparently deliquesces if you leave
it for any length of time in capsules. If you are giving large doses watch
your white blood count which is often fairly high at the start; twelve,
thirteen to fifteen thousand; and if you find that your white blood count
starts to climb you should stop the drug for a time.
DISCUSSION
Dr. Montgomery. In these cases there is a symptom that to me
is very marked. This patient is wearing an upper plate. If you look in
his mouth where the plate is pressing you will see a pale pink area of
almost natural color. If he was not wearing the plate the whole mouth
would be of a darker colour. At first it looks as if it is a thing that you
could not explain, but it is quite easy to explain. You will notice that
the mucous membrane is red on taking the plate out of the mouth. It
is a symptom that is almost pathognomonic. The reason for no congestion when wearing the plate is that the plate in pressing against that
area depletes it to a pale pink.
Dr. Pitts. There was a case two years ago of a woman 31 years of
age. The diagnosis was polycythemia. She was given phenyl hydrazin
and a short time after she suddenly died. On autopsy an aneurysm was
found.
(Dr. Pitts spoke a few words regarding the size of the gall-bladder
at the time of removal.)
Dr. Naden. In some cases where lipiodol was injected into the
spinal canal neuritis resulted. The lipiodol spread down around the
nerve trunks and caused it.
Page 13 8 Dr. McKee. Polycythemia vera, I admit, does exist. It is,
however, extremely rare. If you follow your cases for a long enough
period you will usually find there is some other cause. Since the war I
have seen six or seven cases which seemed to be nothing else but polycythemia. All of the others showed some other cause. A high count
(red blood cells) does not mean anything more than that for a year or so
you have to follow your case clinically as well as through the laboratory
and see if there is not some other cause.
Dr. Perry. There are characteristic eye grounds in these cases.
CERTAIN CONTACTS OF MEDICINE
AND THE LAW
The following are. the chief points in a very able address delivered
before the Vancouver Medical Association on January 6th, by the Hon.
Chief Justice Morrison. A large audience paid close attention to his
Lordship's remarks. At the outset Judge Morrison pointed out that the
functions of the Court and of a medical man are quite distinct. The
function of the doctor in ordinary life is treatment, the function of the
Court is to determine liability. When the doctor comes before the
Court, however, his function is to assist the Court, to which he is responsible, in arriving at the truth. It is obviously absurd for an unin-
structed judge or jury to decide on medical questions. It should be
remembered, however, that the medical problem in a trial is only one of
many and all the facts, medical and otherwise, must be taken into
account before a decision can be given.
Cases coming before the Court and in which the aid of the doctor
is necessary in order to enable the matter in dispute to be properly determined, are innumerable and increasing, as witness the growing number of
automobile accidents, insurance cases, cases of assisted abortion, and so
on.
Doctors come to the aid of the Court in one of two capacities,
either as assessors or as witnesses. The rules of the Court provide for the
calling to the aid of the judge and jury one or more doctors as medical
assessors. Whilst afcting as assessors medical men do not decide on the
facts, they merely give their opinion as assistants. Their advice may be,
and is, disregarded, but not often. They do not decide, that is the
responsibility of the judge or the jury as the case may be.
Medical men assist the Court best as witnesses in the witness box.
As witnesses they appear either as witnesses of fact or as experts. As
experts they give their opinion to explain the bearing which the facts
may have on a particular point. When called as experts they do not, of
course, pretend to depose as to the facts, but, owing to their special
knowledge, they are called to aid the Court in appreciating the value or
meaning of a fact not observed by them and they are permitted then to
express their opinion, which a witness to the fact may not do.
The medical witness must not be a partisan. He does not come to
give evidence pro or con, but to aid the Court. An expert witness is
called in to assist by virtue of his special knowledge. The significance of
an observed fact is often only of value when judged by an expert.
Page 139 The medical man who is called as a witness of the fact is often
placed in a most trying and invidious position. It is, of course, needless
to say he must not lend himself to the concealment of a crime nor to its
commission. Secondly, there is a rule that a doctor cannot refuse to
answer questions put to him, even though it affects his medical confidence. The duty of a doctor to preserve his patient's confidence is one
not lightly to be set aside, but a doctor, as a witness, is there to assist
the Court, he is not there to advance the interests of his patient exclusively. He is subject to cross-examination upon all matters relevant
to the issues in the case. He is subject to the rulings of the Court, for
it is in the public interest that he should be. In all cases where a person
is charged with infanticide, assisted abortion, murder, manslaughter,
concealment of birth, etc., the doctor who may have attended the patient
may be called by the Crown to give evidence against his patient at the
trial of the charge that is laid.
In divorce trials the doctor in attendance is often called by the
other side. As his position is most confidential, a delicate situation is
created, and one which might, in the hands of an unscrupulous patient,
be used to the detriment of the doctor by imputing a betrayal of that
confidence.
A medical man, when called as an expert witness, if he is not sure of
a fact should say so. The Court respects such a man. One thing is
certain; it is a great mistake to be cocksure and pretend to know too
much. If the doctor is not sure of a fact he should say so.
The medical man is not an advocate. Generally speaking the Bench
and the Bar trust a medical witness, hence the doctor may face his
duty with equanimity. No class of evidence is viewed more sympathetically than medical evidence, and the medical man may rely upon
this feeling on the part of both judge and jury.
Then we come to the great and important field of insanity. The
question of insanity is approached by the medical and legal professions
from different points of view. The misunderstanding, between the law
and medicine as to the bearing of the criminal law towards insanity is
to be deplored. The attitude of the criminal law towards insanity is
the question, not the insanity per se. To begin with, the law does not
define insanity. The two professions regard it from different viewpoints
to some extent. The lawyer bases his view upon the clear, simple, principle of the law that everyone is presumed to be sane and to possess a
sufficient degree of reason to make him responsible for his acts, until the
contrary is proved to the satisfaction of the jury which is trying the
case. The prosecution is not called upon to prove the sanity of the
person accused, for his sanity is presumed. The onus of proving insanity,
which is a matter of defense, is upon the accused. He must prove that
at the material time he was afflicted with a disease of the mind to such
an extent that it brought about such a defect of reason that he did not
know the nature and quality of the act he was doing or if he did know
what he was doing he did not know he was doing what was wrong.
The material time is the time of the perpetration of the act, and this
must be proved with particularity. The defence must prove first and
foremost that the accused was suffering from a disease of the mind;
secondly, that in consequence of that disease he was labouring under a
Page 140 defect of reason; thirdly, that that defect of reason so brought about was
of one of two particular kinds. That defect of reason when so found
must be clearly proved to be such as either (a) to prevent him from
knownig what he was doing; or (b) to prevent him from knowing
that he was doing what was wrong. The defence must prove that
either one of these conditions existed at the material time.
The third prerequisite illustrates the difference between the point of
view of the lawyer and of the doctor as to the criminal law. The doctor
who ordinarily examines a patient with a view of determining as to his
insanity may well come to the conclusion that his mind is diseased and
that therefore he labour under a defect of reason. Having arrived so
far he then decides upon the degree of medical attention and care to
which his patient is to be subjected. His responsibility is to his patient.
But where the patient is charged with having committed a crime the
public are interested and the question arises whether he is to be excused
from responsibility for what appears to be his criminal act, in which
case the criminal law insists upon further inquiry, because disease of the
mind alone, although a justification for treatment by the doctor, affords
no defence. He must prove that that disease of the mind at the material
time prevented him from knowing what he was doing when he committed the act; or prevented him from knowing that he was doing
what was wrong. Of course it is consonant with the principles of the
law and with common sense that he should be excused from criminal
responsibility if he was at the time in such a state of unreason through a
disease of the mind as not to know what he was doing. In this condition he cannot have known the nature and quality of his act. That
means, as an eminent judge has put it, that he thought he was peeling
an apple when in fact he was cutting a throat. In that case he did
not know what he was doing. And it may also be said that though from
a disease of the mind he is in such a state of unreason he knows what
he is doing but he does not know that he is doing what is wrong. To
illustrate this condition the learned Judge gives the case of the woman
who strangled her mother-in-law, laid the dead body on the hearth rug
and called in her neighbours to see how well she had done her work—
saying, "It was my duty to do it, and you see I have done my duty/'
In that case she knew what she was doing but did not know that what
she was doing was wrong.
The question of the conditions which have to be proved in order
that a person may be excused from criminal responsibility is a legal
question and for the courts, to be determined in accordance with the
principle of the criminal law. It is submitted by some high medical
authority that a person charged with a criminal offence should not be
held responsible when he committed the act charged under an impulse
which by mental disease he was powerless to resist. That of course raises
a fundamental difference as regards the third condition, rendering it
immaterial that the prisoner knew what he was about or that he knew he
was doing what was wrong. He might claim immunity notwithstanding
he knew what he was doing because he was acting under an impulse
caused by a diseased mind which deprived him of the power to resist or
desist. The Lord Chief Justice of England, in a treatise on this subject
dealing with the Report of a Special Committee and the expressed views
Page 141 of the British Medical Association thereupon, as set out briefly in the
foregoing remarks, says that the suggestion is, the ancient and dangerous
plea of the uncontrollable impulse, which in practice is so difficult to
distinguish from the impulse that is not in fact controlled. The doctrine
involves two propositions which are not of the same kind nor upon the
same plane. The first proposition is one of fact namely that there are,
as a matter of scientific imagination not of controversial speculation but
of actual experience, unfortunate persons in existence who though they
know what they are about and also know that they are doing wrong,
are nevertheless impelled by disease and irresistible impulse to commit an
apparently criminal act. The second proposition is of legislative morality or expediency, namely that these persons by reason of their number
or otherwise are of such importance as to require or deserve a fundamental revision of the criminal law."
Should such an alteration take place, which is not at all likely, it
would do away with the necessity for objection tests now applied by
judge and jury. It would do away with the necessity of considering
the evidence to ascertain whether the prisoner was aware of what he
was doing or that what he was doing was wrong. The test that would
be left would be whether he was guided by an irresistible impulse. It
can Veadily be seen the predicament of the jury called upon to try a man
under these conditions—conditions which would leave them with little,
if any, guidance. They would have to rely solely upon conflicting medical testimony. As to the prisoner's responsibility to the law, why have
a jury—why not also leave that question shorn of its objective tests to
the doctors?
This doctrine of uncontrolled or uncontrollable impulse has been repeatedly rejected in this country. As one eminent Judge has said, "If
an influence be so powerful as to be termed irresistible, so much the more
reason is there why we should not withdraw any of the safeguards* tending to counteract it. There are three powerful restraints existing, all
tending to the assistance of the person who is suffering under such an
influence; the restraint of religion, of conscience and of law. But if the
influence itself is to be held a legal excuse rendering crime dispunishable,
you at once withdraw a most powerful restraint, that of forbidding and
punishing its perpetration." This doctrine of uncontrollable impulse
has been considered, is so considered today, a most dangerous one, fatal
to the interests of society and the security of life.
Persons tried on any charge in any of our Courts have so many safeguards thrown around him, that the chance of any miscarriage of justice is so remote as to be entirely negligible.
The learned Chief Justice concluded his remarks by adding that if
the law were relaxed it might well be that in cases where there has been
no such evidence of mental disease antecedent to the alleged crime
mental experts would be found to say that the alleged crime itself
afforded evidence that it was committed under an uncontrollable impulse and that upon that ground the inference might be based that
there was no mental disease. If so the result might be to transfer to a
section of the medical profession the question whether a great number
of ordinary criminals should be held responsible to the law.
Page 142 . British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin
in the interests of the Hospital Clinical and Public Health Laboratories of B. C.
Edited by
The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster;
Royal Inland Hospital, Kamloops; Tranquille Sanatorium; Kelowna General Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above. Material for publication
should reach the Editor not later than the fifteenth day of the month of publication.
Vol. V.
MARCH, 1931
No. 3
CONTENTS
Bacteriological Diagnosis Hill
Bronchomycosis Ootmar
BACTERIOLOGICAL DIAGNOSIS OF GONOCOCCAL
INFECTIONS
By H. W. Hill, M.D.
Director, Vancouver General Hospital Laboratories.
This article elaborates, for the gonococcus, the general principles
laid down in the preceding article; but there applied to the diphtheria
bacillus.
For the gonococcus, as for the diphtheria bacillus, the tests ordinarily
made are those which can be made quickly—on the principle that the
physician, in order to act promptly, must know almost at once what the
result is; not weeks, or even days, later, but within a very few hours.
Hence, ordinarily, the report of the laboratory on gonococcus,
"smear positive," is based on the morphology (including staining) of the
organism found, as in the case of the diphtheria bacillus, but in part also
on its relationships to the epithelial or pus-cells present; the latter point
being quite as weighty in arriving at a decision as the former, since the
morphology of the gonococcus is not so distinctive as is that of the
diphtheria bacillus, and cannot be equally trusted, by itself, for the
recognition of the germ.
Strictly speaking, positive reports on smears for suspected gonococci
would be more logical if they read, "intracellular gram negative diplo-
cocci present, having the morphology of the gonococcus." This would
leave squarely to the physician, as in diphtheria, the decision as to
whether these organisms are reasonably to be considered significant or
not, his decision being then based, again as in diphtheria, on the actual
clinical conditions the patient shows.
Why cannot the laboratory be more certain of the gonococcus then
as above stated? The laboratory can—but only after an expenditure of
Page 143 time so great as ordinarily to make the results almost useless to both
physician and patient. Why not culture the specimen, as in diphtheria?
Because culturing gonococci from pus is difficult and uncertain at best;
and provided they do grow, they show themselves rather as resembling
staphylococci than as the typical biscuit-shaped diplococci of pus smears,
i.e., they show themselves in a form less identifiable than ever.
In brief, gonococci in culture lack three outstanding features by
which they may be recognized promptly and fairly definitely in smears
from pus—namely, their typical diplococcoid arrangement, their "biscuit" shape, and of course their relationships to epithelial or pus-cells.
Hence, even if the suspected organism found in the culture were in fact
the gonococcus, and if also it occurred as a pure culture, it would be less
readily recognizable in such culture than in the original pus specimen.
In order to demonstrate that such a slow-growing, now extracellular, and
staphylococcoidal organism is in truth the gonococcus, further and very
intricate tests must be made, depending upon its antigenic relationships,
and requiring for conclusive results an elaboration of the laboratory work
far beyond present practicabilities here.
Dr. A. W. Hunter has disputed this, but it is in accord with the
best literature available—Topley and Wilson—"Principles of Bacteriology
and Immunology, 1929"—Vol. 1, p. 337 (see text and plates).
In the supposed instances above offered, it was assumed that the
culture made from the pus proved to be pure. As a matter of ordinary
occurrence, pus from the urethra or the cervix, etc., or from the eye, is
not unlikely to yield a mixed culture; cocci, especially of various kinds,
are to be expected, some of which—e.g. Staph, aureus or albus—are
likely to outgrow any gonococcus present, and to add immensely to the
difficulties of the isolation of the gonococcus; which isolation must,
however, be accomplished if the conclusive antigenic tests are to be employed.
It will be obvious, then, that at the present time a report from a
gonococcus-suspicious smear of "smear positive" means only that, so far
as expert experience permits, the direct microscopical examination shows
organisms indistinguishable by such tests from gonococci; at the present
time here this is the only practicable method. Certainly cultural work is
possible, but only as the outcome of a very considerable special lay-out
and experience, and at an expense per specimen relatively very high.
A positive report on a gonococcus smear, although based only on
morphology (including staining) and cell relationships, would be practically conclusive of the presence of gonococci, if the pus examined originated in a clinically infflamed cervix or urethra. Even if the pus originated in the clinically inflamed eye of a patient, such a "smear positive"
report would call for immediate treatment as of a case of gonorrheal
ophthalmia, because delay for further cultural work might prove extremely serious. (This statement is closely parallel to that calling for
the giving of antitoxin in all cases of sore throat showing "diphtheria
bacilli positive," even where the clinical symptoms do not resemble those
classical of diphtheria.)
As in diphtheria, if the clinical symptoms are classical or even
clinically suspicious, prompt treatment should be initiated, without
Page 144 awaiting the laboratory report, or even if the laboratory report is nega
tive.
If a "smear positive" report is made for diagnosis from a urethra,
a cervix or an eye showing no clinical evidence of inflammation, the
question of the representativeness of the specimen submitted, already discussed under diphtheria, of course comes up. But, allowing this point,
there is no reason to believe that all infections with gonorrhea necessarily
yield severe clinical symptoms—indeed, gonorrheal ophthalmia is rare,
compared with the number of infections of the eye with gonorrheal pus
that must necessarily occur; suggesting a high degree of local immunity
to gonorrhea in the average eye, except perhaps in infants.
Assuming, then, that the specimen submitted is representative, this
report, "smear positive," from a clinically negative eye establishes two
things—first, the probable presence of trouble in some degree, since the
organisms were intracellular; and second, the presence of the typical
morphology and staining.
The absence of obvious clinical symptoms must then be accounted
for—exactly as in the case of "diphtheria bacilli positive" without sore
throat, etc. Is the condition a very early or a very late one? Is the
patient infected, but with non-virulent organisms? Is he infected with
virulent organisms, but is also immune? Or is he carrying a Micrococcus catarrhalis, etc., indistinguishable in morphology with certainty
from the gonococcus?
In diphtheria the question of virulence can usually be determined in
about three days; but this determination in the case of gonococci requires
conditions not to be found in most laboratories, and the time required
for its determiniation would make it wholly useless to the physician.
Therefore the three latter questions cannot be answered in any given
case promptly enough to meet the emergency. The only "safety first"
procedure, then, is to assume that the organism found may be significant,
and to treat promptly; after that, as in diphtheria, to await further developments.
The physician should not wait for a demonstration of virulence
from the development of severe lesions in the patient before instituting
treatment. Even in the absence of clinical symptoms, a report of "smear
positive" should call for at least prophylactic precautions, if not very
active therapeutic treatment.
What reliance may be placed on a gonococcus report "smear positive" for diagnosis?
Once more as in diphtheria, a negative report on a gonococcus
smear is reliable in proportion to (a) the representativeness of the specimen, and (b) the thoroughness of the examination in the laboratory.
Only for the latter is the laboratory responsible.
"The representativeness of the specimen" includes not only its
origin from the proper source, but also its being taken at the proper
time.
As to proper source, the eye, and the male urethra in acute stages,
present little difficulty. But in the female serious errors may arise. Thus
vaginal smears from young female children may be representative; but
from older females are useless. In the older female infected with gon-
Page 145 orrhea, the organisms must be sought, not in the vagina, but in the
cervix, in the urethra and its glands, and in the ducts of the various
vulvar glands. In metastatic infections (blood, joints, etc.) the particular material involved must of course be securea\
As to the proper time for the taking of a specimen for gonococcus,
in general the best time is at the earliest moment—certainly in acute
cases. In the more chronic cases, especially those under treatment, it is
sufficiently obvious that specimens must be taken from the freshest and
most abundant of such discharges as may be available, and as long as
possible since the last local treatment, several hours at the shortest.
In smears taken for release of the patient as "cured" or "non-
infective," the possible sources of error of a negative report, due to non-
representativeness of the sample, are multiplied many times over the
possible sources of error in the acuter stages. Hence smears for release
require redoubled care in the taking, as well as in the laboratory examination.
In genito-urinary smears from the male for release, account must
be taken of deep prostatic infection, of gonorrheal threads, of the small
numbers likely to reach the exit, of the intermittency of their escape.
The same sort of factors must be considered in smears from the
female for release. Urethra, cervix, ducts of vulvar glands and the
deep adnexa may all have been infected. All these must be "released"
individually, so to speak. Even in very young females where vaginal
smears may be used, the significance of a single negative for release is
almost nil, and experience shows that many negatives at considerable
intervals may be interspersed with or followed by positives.
Hence release of gonorrhea patients is even more time-consuming
and responsible a procedure than release of diphtheria patients. Since
three consecutive negatives are a minimum for reasonably accurate work
in diphtheria, double the number would not be unreasonable in gonorrhea (taken from a week to a month apart.)
Doubtful reports in gonococcus examinations mean, as in diphtheria,
that the best the laboratory evidence offers in the case so reported is inconclusive as to presence or absence of the gonococcus.
This inconclusiveness, always involved, as already reviewed, in all
examinations for gonococci when restricted to ordinary smears, becomes
acute if the smears yield organisms which are not definitely of the
classical type. Thus, the organisms may be gram-negative and intracellular but not biscuit-shaped, or diplococcoid, or may only present
these features in small proportion. They may be much smaller or much
larger than usual, or be accompanied by so many extracellular forms as
to confuse the picture. They may be diplococcoid and "biscuit-shaped,"
but not typically so.
Under these circumstances, the only thing to do, from the laboratory standpoint, just as in diphtheria, is to secure another sample, hoping
that in the second the picture will be more definite.
The only thing to do, from the clinical standpoint, is to consider
the "doubtful" report as having yielded no final information, but as a
strong indication that the gonococci may be present, and that appropriate
treatment should be installed, pending further evidence.
Page 146 Summary
1. Definite clinically suspicious symptoms of gonorrhea, whether
related to the genito-urinary apparatus or the eye, call for immediate
precautionary, if not full therapeutic treatment, whether a smear be
taken or not, and without regard to the results of any smear taken,
whether positive, negative or doubtful. In such cases, take pus for a
smear; then, without waiting for a report (unless this can be obtained
within a few minutes), treat; and govern later treatment by the subsequent clinical developments as well as by the smear results.
2. Given a genito-urinary or eye condition not definitely clinically
suspicious of gonorrhea, and a positive smear from it, the physician is
morally bound to assume that gonorrhea probably is present, and to treat
immediately on that basis. Only very strong evidence to the contrary
can justify any other conclusion.
3. Negative results, as in all bacteriological work, must be heavily
discounted, especially in face of good clinical evidence or even doubtful
clinical evidence—and second or third examinations should be freely
used.
4. Suspicious or doubtful reports from smears for diagnosis should
be taken at their face value—i.e., they indicate that the result of the
smear examination was not practically conclusive as to either presence or
absence of the suspected organisms, and that interim treatment at least
should be employed until further examinations or clinical evidence clear
up the diagnosis.
5. Smears negative for release should be accepted as indicating the
probable facts regarding the specimen submitted.
But smear negative does not mean patient negative, still less patient
permanently negative. Only the most careful collection of the specimens under the most favourable circumstances for the securing of positives, and the repetition of negative results many times, can make it
reasonably safe to say that the patient is negative. This applies particularly to females of any age, and to old deep-seated infections in any one.
BRONCHOMYCOSIS CASES IN B. C.
By G. A. Ootmar, M.D.
Director, Provincial Board of Health Laboratory
Kelowna General Hospital, Kelowna, B. C.
In 1913 a boy, who had been recently repatriated from the Dutch
West Indies (N. America), fell ill in Holland of a disease which had
all the clinical symptoms of tuberculosis. The disease ended rapidly fatal
and was registered as "tub. florida" (miliary tuberculosis) though
tubercle bacilli were never found in the sputum. The only fact that
struck us was that the sputum contained many fungi.
Some years later, 1918, in the Annates de I'lnstitut Pasteur, Besredka
gave a summary of the germs in infection of the bronchi and lungs and
mentioned, too, budding fungi.
In 1928 we received in our Laboratory in Kelowna a specimen of
sputum for examination which proved to contain many fungi—and as
the patient had been for some time in Southern California and in the
Page 147 literature it was mentioned that bronchomycosis was known in that part
of America, we suggested that the blastomyces found in the sputum
were the cause of the disease.
The disease points clinically to tuberculosis. Two types are known,
a mild and severe type (perhaps according to different species.) In the
mild type, which may become severe, there are no physical changes in
the lung,—even a Roentgenogram does not show any changes. This is
in contrast with the severe type, in which all clinical symptoms and
physical changes in the lung known for tuberculosis may be present. It
seems to us that the above mentioned case of 1913 was an unrecognized
severe case of bronchomycosis.
This year we were struck by the fact, that of 126 sputa we got
for examination in our Laboratory, four proved to contain yeast-like
bodies; two of the specimens came from the same community, and from
patients who were very nearly related.
We asked for other samples. The consistent presence of the yeast-:
like bodies in the sputum, with the absence of tubercle bacilli, leads us
to diagnose bronchomycosis.
The following interesting case is now in the Kelowna Hospital:
Mr. W. H. S., 65 years, patient in Kelowna Hospital, contracted
pneumonia in 1916 in the army, (temp. 104.4° on admittance to the
War Hospital) and was returned as a tuberculous suspect; but sputum
always negative. Had haemorrhages many times after the pneumonia.
Roentgenogram 1930 showed very little change. Dr. A. S. Lamb, who
examined him, was surprised to find no lesion to accord with his history.
November, 1930,—sputum positive for blastomyces. Fell ill December, 1930 with severe pain in stomach; was suspected to have peritonitis; symptoms alleviated after a week's illness. January, 1931, blastomyces in stool.
The organisms are Gram positive oval cells of the size of plus—
minus 2 by 8 microns; they grow on agar, do not liquify gelatin and
form gas in glucose, maltose, laevulose but none in xylose.
They form a special group, separated from the ordinary yeast.
Stokes, in the Journal of Tropical Medicine and Hygiene, August 1,
1930, mentions that MacKinney isolated 12 yeast-like strains from cultures from sputum, throat, mouth, stool and pus of human beings. Six
strains proved pathogenic for guinea pigs at times, three causing death,
three causing inflammatory reactions. Immune serum was prepared from
all these strains and each one of them agglutinated with the majority of
the sera from the other heterologous strains. When tested with immune
serum from commercial yeast with a titre of 1—120 these strains failed
to agglutinate in any appreciable dilution. These pathogenic strains,
therefore, can be separated as a distinct immunological group from the
commercial yeast strains.
Whether or not our cases showing blastomyces in the sputum are
due to contact infection, we do not know. All four cases proved to be
mild.
The isolation of the fungi from sputum and the repeated absence
of tubercle bacilli, leads to the diagnosis bronchomycosis in mild form.
Potassium iodide treatment may be installed, in mild cases, while in
severe ones treatment with autogenous vaccine seems to be of value.
Page 148 PROGRAMME OF THE 33rd ANNUAL SESSION
VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
GENERAL MEETINGS will be held on the first Tuesday and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on the Agenda.
March 3rd—General Meeting:
THE OSLER LECTURE—
Dr. R. E. McKechnie; "Reminiscences of Forty
Years' Practice."
March 17th—Clinical Meeting.
April 7th—General Meeting:
Speaker—Dr. C. F* Covernton; "Problems of the
Primipara."
April 21st—Clinical Meeting.
April 28th—Annual Meeting.
Massage & Medical Electricity
Medical Gymnastics
C. S. M. M. G., London, England
C. A. M. R. G. Montreal, Canada
MISS O. G. HARDING
Seymour 7613
825 VANCOUVER BLOCK
Vancouver, B. C.
Telephone Sey. 3334
MRS. E. M. PARR
Chartered Society of Massage and Medical Gymnastics, England
Canadian Association of Massage and
Remedial Gymnastics
Office Sey. 2855
Res. Doug. 4682Y
MISS BEATRICE GALLOP
C. A. M. R. G.
Graduate
McGill University School of Massage
and Remedial Exercises
419 VANCOUVER BLOCK
Vancouver, B. C.
Office Sey. 8683 Res. Doug. 1707R
MRS. ETHLA FABER
D. A. D. M. F. Copenhagen
C. A. M. R. G. Montreal
Physiotherapy
Certified by the General Danish Association of Physicians
214-215 VANCOUVER BLOCK
Vancouver, B. C.
HJa0frurorth & JflBaoirmorth JItit
COLLECTION SPECIALISTS
Telephone Sey. 3296—3297
407 RANDALL BUILDING, 535 Georgia Street West
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430-431 BIRKS BUILDING
Vancouver, B. C.
Office Doug. 908
MISS A. E. MARKHAM
Chartered Masseuse, England
Canadian Association of Massage and
Remedial Gymnastics
924 BIRKS BUILDING
Vancouver, B. C.
Phone Kerr. 1520R
MRS. L. H. EARLE
Canadian Association of Massage and
Remedial Gymnastics
6059 ELM STREET
Vancouver, B. C. VANCOUVER CRYSTAL POOL
BEACH AVENUE AT NICOLA STREET
AN INVITATION
is extended to .members of the medical profession to visit the
Crystal Pool at any time, to take a sample of the water for
analysis, and to investigate the rigorous standard of cleanliness and safety maintained by the management.
The purified warm salt water in the Crystal Pool is passed
through the filters one and a half times daily. At night, the
pool is completely filled, and any sediment is removed by a
vacuum cleaner.
All floors, mats and dressing rooms are sterilized daily. All-
wool bathing suits and towels are sterilized after use.
Attendants are constantly on guard for safety.
Dr. Underhill, as City Health Officer, made frequent unheralded visits to the Crystal Pool, and reported as follows:
"I have always found the Crystal Pool rigorously clean and
sanitary .... inspections have included not only tests of
the filtered and chemically purified water in the pool itself,
but unheralded visits to see the elaborate precautions
taken to keep the filters, apparatus, floors, dressing rooms
and laundry in perfect condition."
It was further stated in a Laboratory report that:
"Filtering treatment given by your plant in this case completely removes gas forming bacteria.
Further, the total number of bacteria are so reduced by
means of the filtering medium, that the number of colonies
per cc. remaining are no higher than those .found in some
samples of drinking water."
OPEN EVERY DAY
Weekdays, 1 p.m. to 10 p.m.
Sundays, 1 p.m. to 6 p.m.
For information regarding Book Tickets, Special Children's
rates, etc.
Phone Douglas 2376 ?^v
Pfc*^
ii
the BATTLE of the NUMBERS"
is the expression used by a prominent biochemist who recently visited
our Research Laboratory, in referring to the pseudo-scientific practice
employed by many manufacturers in stating the number of "vitamin
units" contained in their cod liver oil. "The problem seems to have
resolved itself," he went on to explain, "into a game of 'number, number, who has the largest number,' each firm trying to outdo all others
in having the largest number of units displayed on the bottle."
We have refrained from entering this "battle
of the numbers,'' not because Mead's Standardized Cod Liver Oil could not also be designated
by large numbers,— the data at the left give
proof of this—but because, as competitively
used, unit numbers hold little significance.
We are, therefore, holding ourselves aloof from
this Don Quixotic conflict until the smoke of
"battle" clears and numbers on the label of a
bottle of cod liver oil really mean something.
In the meantime, as from the beginning, we ask
the physician's confidence in Mead's Cod Liver
Oil on the basis of performance, knowing that:
(1) l/4th of 1% of Mead's Cod Liver Oil in a
rickets-producing diet will initiate healing of
rickets in rats in 5 days. (2) l/16th of 1% of
Mead's Cod Liver Oil in a xerophthalmia-
producing diet will cure xerophthalmia in rats
in 10 days. (3) Mead's Standardized Cod
Liver Oil is so pure it needs no flavoring.
There are in use at the present
time at least seven arbitrary
systems of designating cod liver
oil by "units" of vitamin D.
The size of these units varies
with each system, consequently the "number" of units is
small where the "unit" is large
|and large where the "unit"
is small.
This is illustrated by the fact
that if Mead's Standardized Cod
Liver Oil were to be designated
by one system, it would test
.15 unit. By a second system,
3 units. By a third, 15- By a
fourth, 40. By a fifth, 120. By
a sixth, 265. And so on.
In the matter of vitamin A
units, while the above confused
status does not exist (fortunately, due to the fact that there
is a U.S.P. standard), on the
other hand, there is such a wide
' latitude permitted in the interpretation of this unit, that there
may be a very wide difference
in "interpreted" potency between sample oils at the two
extremes of the permitted
latitude.
The physician can find assurance
in Mead's Standardized Cod
Liver Oil—without units—on
the basis of actual performance.
,r Supplied in 4-, 8-, and 16-oz. brown bottles in Iight-
*% proof cartons. Samples and literature on request.
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MEAD JOHNSON & CO. of CANADA, LTD., Belleville, Ont.
■■■■■■■mi Newfoundland Cod Liver Oil Exclusively
iiiniiiitiiiiiii ANNUAL DUES
Members are reminded that March
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with the Bylaws of the Association
the name of any man whose dues are
unpaid on that date must be removed from the role of the association.
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It is innocuous at therapeutic doses and of great clinical
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Offered in gradual dosages of from 0.005 gm. to 0.60 gm.
LABORATORY POULENC FRERES
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For literature and sample, apply to
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FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell J. H. Crellin W. 1 Bertrand
STEVENS'
SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity
for the bag or the office.
Supplied in one yard, five yards and
twenty-five yard packages.
ESTABLISHED NEARLY A
fcCENTURYjg ~
B. C. STEVENS CO.
Phone
Seymour 698
730 Richards Street
Vancouver, B. C. -f^h*-
Hollywood Sanitarium
LIMITED
tyor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Inference ~ IB. Q. Q^Siedical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C
or 5 15 Birks Building, Vancouver
Seymour 4183
Westminster 288
!KSW
History of Nursing in Pacific Canada
The Vancouver Medical Association Bulletin: March, 1931 Vancouver Medical Association Mar 31, 1931
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