History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1939 Vancouver Medical Association Feb 28, 1939

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 a
:*«o.
The BULLETIN
of the
VANCOUVER
MEDICAL ASSOCIATION
Vol. XV.
FEBRUARlT^VT Y O^N
%
No. 5
%*,
With Which Is^orfaqat&
Transactions^fJ^^P^s%^
'\>mi
Victoria Medical Society
the
Vancouver General Hospital
and
St Paul's Hospital
In This Issue:
NEWS AND NOTES
DAGENAN IN PNEUMONIA
HEPATIC AND GALL BLADDER DISEASE BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic  Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED WITH CASCARA AND
BILE SALTS PRODUCE BULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
45 6 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Stores) THE    VANCOUVER    MEDICAL   ASSOCIATION
BULLETIN
Published Monthly, under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices:
203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XV.
FEBRUARY,  1939
No. 5
OFFICERS  1938-1939
Dr. Lavell H. Leeson Dr. A. M. Agnew
President Vice-President
Dr. W. T. Lockhart
Hon. Treasurer
Dr. G. H. Clement
Past President
Dr. D. F. Busteed
Hon. Secretary
Additional Members of Executive: Dr. J. P. Bilodeau, Dr. J. W. Arruckle.
Dr. F. Brodie
TRUSTEES:
Dr. J. A. Gillespie
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommer.
Dr. Neil McDougall
SECTIONS
Clinical Section
Dr. W. W. Simpson Chairman     Dr. F. Turnrull Secretary
Eye, Ear, Nose and Throat
Dr. S. G. Elliott . Chairman     Dr. W. M. Paton Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Davies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard ~ .-Secretary
STANDING COMMITTEES
Library:
Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland,
Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davies.
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird.
Summer School:
Dr. A. B. Scheinrein, Dr. H. Caple, Dr. T. H. Lennie,
Dr. Frank Turnrull, Dr. W. W. Simpson, Dr. Karl Haig.
Credentials:
Dr. A. B. Schinrein, Dr. D. M. Meekison, Dr. F. J. Buller.
V. O. N. Advisory Board:
Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell.
Metropolitan Health Board Advisory Committee:
Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller.
Greater Vancouver Health League Representatives:
Dr. W. W. Simpson, Dr. W. N. Paton.
Representative to B. C. Medical Association: Dr. G. H. Clement.
Sickness and Benevolent Fund: The President—The Trustees. HMMIOTIM
(Squibb Estrogenic Substance)
SPECIAL PACKAGES AVAILABLE FOR USE IN
Amniotin has a regenerative effect on the type of nasal mucosa seen
in atrophic rhinitis ... an effect that has been found useful in the
treatment of this condition.
Amniotin in Oil for Intranasal Administration by the physician is provided in 5-cc. screw-cap vials containing 10,000 International Units per 1 cc....
may be applied to nasal mucosa on cotton pledgets or by means of an atomizer.
The insert accompanying this package outlines procedure for treatment.
Amniotin in Oil with Nasal Atomizer—An atomizer package for home
use under the direction of the physician. It contains a total of 20,000 International Units of Amniotin in 30 cc. of specially purified corn oil. It provides for
continuous treatment during the intervals between periodic visits to the physician's office or to the clinic. No printed matter accompanies this package.
Amniotin in Oil for Intranasal use is also supplied without atomizer in 30-cc.
bottles {total potency 20,000 International Units).
For literature write Professional Service Dept., 3 6 Caledonia Rd., Toronto
ERiSqjjibb & Sons of Canada, Ltd.
MANUFACTURING   CHEMISTS   TO   THE    MEDICAL   PROFESSION   SINCE    1858 VANCOUVER HEALTH DEPARTMENT
STATISTICS—DECEMBER, 1938
Total Population—estimated  259,987
Japanese Population—estimated. ;  8,685
Chinese Population—estimated ._  7,808
Hindu Population—estimated  335
Number
Total deaths    282
Japanese deaths        5
Chinese deaths        9
Deaths—residents only    242
BIRTH REGISTRATIONS:
Male, 174; Female, 175	
INFANTILE MORTALITY:
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths (not included in above)
--   349
Dec, 1938
..      17
..      48.7
9
Rate per 1,000
Population
12.8
6.8
13.6
9.6
15.8
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
January 1st
November, 1938 December, 1938 to 15th, 1939
Cases  Deaths       Cases  Deaths       Cases  Deaths
Scarlet Fever	
Diphtheria
40           0               39           0               13
0           0                 0           0                 0
73           0             105           0             139
4 0                 2           1                 1
5 0                 2           0                 4
4           0                 5           0                 4
21 0 31 0 44
10 10 0
0 0 0 0 0
.0           0                 0           0                 0
20 15 43 16 17
4 0 3 0 1
0           0                 0           0                 0
3 PROVINCIAL BOARD OF HEALTH,
EREAL DISEASE CONTROL.
North      Vancr.   Hospitals,
Richmond  Vancr.      Clinic  Private Drs.
0               0               49               31
0               0               60               16
0
0
Chicken Pox 	
0
Measles        	
0
Rubella    	
0
Mumps     	
0
Whooping Cough.
0
Typhoid Fever	
0
Undulant Fever __
0
Poliomyelitis    	
0
Tuberculosis .
Erysipelas        	
0
Ep. Cerebrospinal
V. D. C^
Syphilis	
Meningitis
lSES repo:
DIVISION
Burnaby
      0
EtTED T(
OF VEN
West
Vancr-.
0
0
0
Totals
80
Gonorrhoea     	
      0
76
/
BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
Descriptive Literature on Request.
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
stanley|n. bayne
1432 MEDICAL-DENTAL BUILDING
"Ask the Doctor Who Is Using It"
Phone: SEYMOUR 4239 VANCOUVER, B. C.
Page 121 *%Bi#F'4'
MB
OBESITY contributes to many diseases.
Overweight predisposes to such serious afflictions as diabetes, hypertension, arterio-sclerosis, heart disease, disorders of the kidneys and blood
vessels and lowered resistance.
Efficient reduction without drastic dieting or excessive exercise can be
accomplished with IODOBESIN, a potent combination of many glandular
substances.
IODOBESIN
For sustained pluriglandular reduction
MONTREAL, QUE.
Literature and samples from:
ANGLO-FRENCH DRUG CO.       - VANCOUVER MEDICAL ASSOCIATION
Founded 1898
Incorporated 1906.
GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8 P.M.—Business as per Agenda.
9 p.m.—Papers of the evening.
Programme of the 41st Annual Session (Winter Session)
1939
February 7th—GENERAL MEETING.
Dr. Murray McC. Baird: "Some Remarks about 'Rheumatism'."
February 21st—CLINICAL MEETING.
March 7th—OSLER LECTURE:
Dr. J. H. MacDermot: "The Layman and the Doctors."
March 21st—CLINICAL MEETING.
April 4th—GENERAL MEETING.
Dr. H. A. DesBrisay: Subject to be announced later.
April 18th—CLINICAL MEETING.
April 25 th—ANNUAL MEETING.
Some Medical Aspects of
ALL-BRAN
as an aid to elimination
1 Medical authority concedes that
"bulftf' provided by iood residue
assists efficient elimination.
2 Medical authority ascribes to
vitamin B\ the important property oi
improving the tonusoi the intestines.
Regular use of Kellogg's All-Bran
supplies helpful "bulk." This food
also contains vitamin Bi in appreciable quantity.
These facts provide a sound medical basis for recommending Kellogg's All-Bran as a valuable aid in
the prevention or relief of constipation due to lack of "bulk." All-
Bran is made by Kellogg's in
London, Ontario.
I^hr1
Page 122 Listening to the extremely interesting paper read by Dr. G. E. Kidd at the Association's
monthly meeting a few weeks ago, one was struck by several ideas which it might be worth
while to develop for a few minutes. (The paper will be published at an early date.)
First, one could not help seeing how much it meant to the author—how it had widened
his mental horizon, and how full he was of his> subject. His difficulty in giving the paper
lay solely in the matter of selection; he had such a wealth of material available that it was
hard to condense it within the limits of a short paper. Apart from this, one could almost
envy Dr. Kidd the obvious enjoyment and keen pleasure he getst out of' his subject—he is
full to bursting with this hobby of his—it enriches and fills his whole life.
This is the1 real value of hobbies—and it is this matter of hobbies which really is our
subject. Hobbies are rare things nowadays, it would seem; in these crowded, high-tension
days, the mere process of making a living takes up all our time. We "shun delights, and
live laborious days," and for what, and to what end? It is more vitally important' now
than ever that we should have hobbies—which, more than anything in the world, promise
us release and relaxation and return to sanity and "equanimity," that greatest of all mental
gifts. Hobbies are a "delight" we are very wrong to shun. They do more than give a
release from the tension of daily life: far more than that. They provide spiritual and intellectual satisfactions and pleasures that are inestimable. For there is a creative element in
the pursuit of a hobby, and the proficiency that this provides. In every man there is a
portion of the creative element that fills the universe, craving for expression and fulfilment,
and by far the simplest and most effective way of giving expression to this creative spirit,
is the adoption of a hobby. It is the putting out to usury of the one talent we may possess.
Nor is it merely a selfish satisfaction: for like all such things^ the effect of its impact
on one's environment is incalculable and immeasurable. Modern geology owes most of its
structure to the apparently aimless, much derided wanderings of a hobbyist, who wandered
round the river-beds and chalk-cliffs and valleys of southern England, and picked up
stones and flints, and peered into them, and thought about them and, made a hobby of
them, and learnt the age-long secrets they had to tell: and out of his hobby grew much of
our knowledge today of geology. Physiology, too, was the hobby of another Englishman,
a country parson in a small village, and he studied and experimented, and wrote one of
the most charming and readable books (in six volumes) ever written—all about physiology.
And one might go on with other instances.
There is no doubt that there is a joy and happiness to be found in a hobby that can be
found nowhere else, and we should all have one—and the busier we are, the more we should
have one. What it should be, what form it should take, is entirely) a matter of individual
choice. With some it may be stamp collecting, or book collecting,, or even butterfly collecting; with others, music and all its ramifications, its literature, its physical armoury of
instruments, its mathematical and scientific implications may be the subject; others find
more enjoyment in hobbies that take them out of doors: botany, gardening—even golf.
One thinks of Sir Frederick Banting's hobby of painting; and J. M. Pearson, a departed
member of this Association, had two hobbies: poetry and sculpture. There is no limit to
the range.
Lastly, as one of those who listened with the keenest delight to Dr. Kidd's address, we
feel grateful to him for his generosity in giving so freely from "the bonded storehouse of
his knowledge," and leading us out into fresh fields, into wider! horizons, shewing us new
possibilities for a fuller life. We need more talks like these to stimulate and refresh us, and
to encourage in us the desire to "go and do likewise."
A recent case in our courts will be of interest to our readers, whot will probably have
seen an account of the case to which we refer. Two medical practitioners of North Vancouver were sued by a patient for malpractice in the form of negligence; but after five
Page 123 witnesses had been heard for the defence, the lawyer for the plaintiff announced his withdrawal from the case, as it was evident that no negligence could possibly be proven. It
seems a pity that this could not have been found out sooner, thus saving Drs. Carson
Graham and Dyer considerable undeserved annoyance and unpleasant publicity. We congratulate them, however, on this public proof of their conscientious work, and the
thoroughness of their medical care.
A very significant event occurred recently when, at the instance of the Venereal
Diseases Division of the Provincial Health Department, a certain irregular practitioner
was prosecuted by the Attorney General's department, found guilty of treating venereal
disease, and punished by a fairly heavy fine. The significance of this is that, while hitherto
the Medical Council of British Columbia has been charged with the duty of prosecuting
any person who is guilty of infringing the Medical Act, here the Attorney-General has
recognised the fact that such infringement is a violation of the law of the land, and as such
should be a subject of concern to his department equally with any other infringement.
For many years it has been the opinion of leaders of medical thought that it is unfair and
unreasonable that we should be charged with the enforcement of the Medical Act, which
is only one of the Acts of the province, and that it puts us in an unfair light with the
public. We hail this as decidedly a step in the right direction, and congratulate the Honourable the Attorney-General and the Venereal Disease Division of the Health Department
of B. C. on their action in this matter.
NEW Si AND    NOTES
The annual meeting of the Eye, Ear, Nose and Throat Association of British Columbia
was held on January 7th and took the form of a dinner meeting at the Vancouver Club.
Drs. M. J. Keys, J. A. Stewart, N. C. Cook and E. H. W. Elkington came from Victoria;
Dr. E. D. Emery of Nanaimo and Dr. A. W. Bowles of New Westminster also attended.
The speakers from out of town were Dr. F. A. Kiehle, who spoke on "Some Aspects of
Glaucoma," and Dr. Richard Waldaple, whose paper, "New Methods and Results in X-ray
of the Larynx," was accompanied by lantern slides and case reports.
The same officers were re-elected: President, Dr. M. J. Keys; Vice-President, Dr. R. B.
Boucher; Secretary-Treasurer, Dr. L. H. Leeson.
Dr. G. C. Draeseke has returned from a trip to Mexico.
We regret to hear that Mrs. L. H. Leeson suffered a broken arm, through a fall at her
home. She is in the Private Ward Pavilion at the Vancouver General Hospital.
Congratulations are offered to Dr. and Mrs. Leigh Hunt on the birth of a son on
January 19 th.
Dr. D. E. H. Cleveland was the victim of what might have been a very serious accident when his car was struck by a hit-and-run driver on the highway near Cloverdale last
Sunday. Dr. Cleveland's car was overturned into the ditch, which was full of water. By
what seems a miracle, neither Dr. Cleveland nor Mrs. Cleveland nor either of their two
children, who were passengers in the car, were injured.
We offer our deepest sympathy to Dr. Fraser Murray on the death of his mother on
January 21st.
Dr. H. F. Tyerman of Nakusp is enjoying his annual winter holiday and Dr. George F»
Young is carrying on the practice during his absence.
Page 124 Dr. N. E. Morrison of Salmo is now associated with Dr. L .E. Borden in the practice
at Nelson.
We regret to record the passing of Mrs. R. W. Irving of- Kamloops on the 24th of
December. Funeral services betoken the respect in which the late wife of Dr. R. W.
Irving was held in that community. Dr. Irving was the recipient of many messages of
sympathy and the whole profession in British Columbia will be heartened to know that
our colleague is standing up well in his sorrow and will carry on his practice,, we hope with
many years of fine service to Kamloops and district.
Dr. John K. Kelly of Zeballos is out for a well deserved vacation. Dr. W. J. Elliott is
doing locum tenens for him.
Dr. H. A. Whillans went to Nelson when the late Dr. D. W. McKay became ill and is
remaining there temporarily to assist Dr. L. E. Borden in the practice.
* *      *      *
Drs. S. L. Williams of Nanaimo, F. R. G. Langston of New Westminster and Andrew
Turnbull of Victoria came to Vancouver to a largely attended meeting of the Committee
on the Study of Cancer on Monday, December 16th.
Drs. Thomas McPherson, Gordon C. Kenning and R. L. Miller of Victoria attended
a meeting in Vancouver on Thursday, January 5 th.
Dr. G. E. Bayfield of the Columbia Coast Mission called at the office.
* *      #      *
Dr. H. A. W. Brown, who has been doing special work with the Indian Affairs Branch,
is now resuming general practice at Fort St. John.
We record with regret the passing of Mrs. W. A. McTavish. The profession extends
sincere sympathy to Dr. McTavish in his sorrow.
Dr. N. B. Hall of Campbell River returned on December 18th from post-graduate
study in eastern centres. He was accompanied by his wife, and while away they spent a
short holiday in Jamaica.
At the request of Dr. C. T. Hilton of Port Alberni, Chairman of the Committee on
Maternal Welfare, British Columbia Medical Association, Drs. A. S. Underhill of Kelowna
and J. A. Ireland of Kamloops have been named to serve on the Committee as from District
No. 4 Medical Association.
Dr. and Mrs. Alan Hall spent a fortnight skiing on the slopes of Mt. Hood, Oregon.
Dr. Donald Beach of Langley Prairie was taken ill with pneumonia before Christmas
but we are pleased -to report that he has made a full recovery.
* *       *       *
Dr. E. J. Ryan, Superintendent of the Provincial Mental Hospital, is back at his post
following his recent study in New York.
Drs. M. J. Keys, F. M. Bryant and George Hall of Victoria have just returned from a
two weeks' golfing holiday in California. During the trip they motored from San Francisco
to Palm Springs, returning home from San Francisco by train.
Forty Years Ago.
Vancouver Daily Sun, January 20, 1899.—Citizens banquetted Dr. Alex. S. Munro on
the eve of his leaving to open practice at Atlin.
Page 125 Dr. J. F. Haszard of Komberley called at the office while at the coast.
Dr. and Mrs. John U. Coleman of Duncan are receiving congratulations on the birth
of a son.
Congratulations are being extended to Dr. and Mrs. G. L. Watson of Revelstoke on
the arrival of their first-born.
We are pleased to report that Dr. B. deF. Boyce of Kelowna is making satisfactory
recovery from a recent indisposition.
Dr. T. F. Saunders was unanimously elected a Life Member of the Vancouver Medical
Association at the general meeting held on January 3rd last.
Drs. H. S. Galbraith and D. W. Moffatt were elected to active membership in the
Association, and Dr. S. C. McEwen of New Westminster to Associate membership, at the
January meeting.
We offer our heartiest congratulations to Dr. and Mrs. J. Moscovich on the birth of
a son on January 4th.
Dr. D. M. Meekison has left for the Eastern States and Florida. He will be away a month
and will attend the meeting of the American Orthopaedic Academy at Memphis, Tenn.
Dr. H. H. Boucher will also attend the meeting of the American Orthopaedic Academy.
Dr. J. R. Neilson has left for the east. He will be away about six months and will do
post-graduate work in New York, London and Edinburgh.
Dr. B. H. Harry recently returned from Chicago, where he took a further three
months' post-graduate course in eye work.
Congratulations are in order to Dr. and Mrs. S. A. McFetridge on the birth of a
daughter on January 19th.
VANCOUVER MEDICAL ASSOCIATION BULLETIN and
the QUARTERLY CUMULATIVE INDEX MEDICUS       gj
The Bulletin announces with considerable pride and satisfaction that it has been
admitted to the list of medical journals and publications deemed worthy of inclusion in the
Index Medicus, that standard Index of medical work published by the American Medical
Association. This Index is too well known to need comment: it is the recognized authority
on this continent, and its standards of admission are high.
This is a signal honour to the Bulletin and we feel it as such, since it means that we
have attained the status which meets these standards referred to. But it would be a mistake
to suppose that this means that we have "arrived," and can rest on these laurels. What it
does mean is that it imposes on us the duty to see that we go on becoming a better and
better journal; that we are more careful than ever1 about the material we admit, about the
editing and arrangement of this material. It means that we must have accurate bibliographies, carefully prepared articles, and this imposes a responsibility on our contributors.
We have only begun, and while this is a good beginning, it must lead to better work on
our part, continual watchfulness, and adequate appreciation of our responsibilities.
Page 126 DR. D. W. McKAY—AN APPRECIATION
The medical profession has lost a widely known and respected member in the removal
by death of Dr. D. W. McKay, after a brief illness, at Nelson on December 28th.
Dr. McKay's professional training was broad and thorough. His studies embraced
psychiatry and mental ailments, and his aid was frequently sought in consultation in
dealing with the problems presented by this type of illness.
While on post-graduate studies he obtained his M.R.C.S., L.R.C.P. and D.P.H. degrees
in Britain and travelled on the Continent as well.
He served in the Canadian Army Medical Corps with the rank of captain during the
Great War.
His genial, kindly personality readily won him friends in every walk of life; and the
esteem in which he was held was evidenced by the large number who came in spite of bad
weather and road conditions to pay respect at the funeral service held in Nelson. The
burial service was conducted by the Masonic Order in New Westminster on January 3rd.
Dr. McKay was keenly interested in sports. As a student he excelled in athletics and
he retained his interest in sport during the whole of his professional lifetime, serving as
an official in various capacities at different times. At the time of his death he was President
of the B. C. Hockey Association. He gave generously of his time and privatd means to
the encouragement of sport and the training of young athletes.
In his professional duties his alert mind, his broad and thorough training, made his
opinion in diagnosis and treatment one to be respected. His going leaves the community
with a sense of loss and the recollection of a winsome personality whose memory will long
be cherished.
DR. J. MAIR ROBERTSON
Obht 28th December, 1938. Aet. 80.
In the passing of Dr. Robertson, medicine in Vancouver loses a very fine
old-time physician. Dr. Robertson was on old man when he died—but he had
been carrying on a busy general practice in full swing till shortly before his death,
and we think this a very happy way to live and die. He was in full possession of
all his faculties, and there was no period of invalidism or of decay to cloud the
end of his long and useful life.
Dr. Robertson had what is not common nowadays, a frank and unashamed
general practitioner's attitude towards medical practice. He even put "General
Practitioner" on his name plate—and there is no prouder title for a doctor. He
served all, rich and poor, to the best of his ability, and did always excellent work.
He was an honour to the profession to which he belonged, and a good citizen.
LIBRARY NOTES
"THE PHYSICIAN'S LEGACY," by Thomas Dover.
To the Library of the Vancouver Medical Association from Dr. W. W. Francis,
Librarian of the Osier Library, McGill University, has come a very interesting and
valuable gift. In commemoration of the Fortieth Anniversary of the Association, Dr.
Francis has given a copy of a little book by Thomas Dover, M.B., entitled "The Ancient
Physician's Legacy to his Country. Being what he has collected him/elf in Forty-nine
Years Practice: OR, An Account of the /everal Diseases incident to Mankind, de/cribed
in /o plain a Manner, that any Per/on may know the Nature of his own Di/ea/e." The
book is the 4th edition and was printed in London, for A. Betteswoth and C. Hitch, at the
Red Lion, in Pater-No/ter Row; and J. Brotherton, at the Bible next the Fleece-Tavern
in Cornhill in 1733.
Such a title page leaves very little for the reviewer to add. But the book itself, being
the outcome of many years' experience, is a delight to read.   Mr. Thomas Dover's cures
Page 127
* are sometimes very drastic, but according to the delightful letters from grateful patients,
so ingenously included in the book, must have been effective.
Sir William Osier, in his book "The Alabama Student," has written of Thomas Dover,
"Physician and Buccaneer," and both Dover and his famous powder were favourites of his.
The "Famous Powder" is a remedy for gout and he promises that in two or three hours at
the farthest, after taking, the patient should be perfectly free from pain.
Unusual interest attaches to this most acceptable gift, because it originally belonged
to Sir William Osier himself. Dr. Francis explains that it was a duplicate in Sir William's
library and was discarded by| him when he acquired a finely bound copy. The book was
given to Dr. Francis by Lady Osier, and by him to the Vancouver Medical Association in
honour of its Fortieth birthday.
PUBLICATIONS
W. E. Austin, M.D., Superintendent, Hazelton Hospital, Hazelton, B. C: "Simultaneous
Perforation of Multiple Peptic Ulcers."  Brit. Jl. of Surgery, v. 24, 1938.
R. G. Large, M.D., and H. N. Brocklesby, Ph.D., Prince Rupert, B. C: "A Hypoglycasmic
Substance from the Roots of the Devil's Club." CM.A.J., July, 1939.
MISSING!
Means, J. J.: "Thyroid and Its Diseases."  1937.
ITEMS FROM THE JOURNALS.
"Anatomical Variations in the Female Pelvis, Their Classification and Obstetrical Significance," by W. E. Caldwell and H. C. Moloy. Proc. R. S. Med., November, 193 8^
"The Place of Pathology Among the Medical Sciences," by W. W. C. Topley.   Lancet,
December 3, 193 8.
"Symposium on Traumatic and Industrial Surgery."  Am. Jl. Surg., December, 1938.
"Meulengracht Treatment of Bleeding Peptic Ulcer," L. J. Boyd and M. Schlochman.
Medical Clinics of N. A., September, 193 8.
OREGON ACADEMY OF OPHTHALMOLOGY
AND OTOLARYNGOLOGY    |||
The Fourth Annual Spring Post-Graduate Course in Ophthalmology and
Otolaryngology will be held in Portland, Oregon, the week of April 3rd to 8th,
1939. We atfe proud to announce that we shall be honoured by the presence of
two nationally noted guest teachers for the full week. They are Dr. John J. Shea
of Memphis, and Dr. Webb W. Weeks of New York. This course is sponsored
jointly by the University of Oregon Medical School and the Oregon Academy of
Ophthalmology and Otolaryngology. The programme is a diversified one: mornings are devoted to didactic lectures, afternoons are occupied with clinical work,
and at the evening sessions there will be classes in the Department of Surgical
Anatomy. Added features to this "Fourth" Course will be a course in cat's eye
surgery given by Dr. Weeks, and Teaching Moving Pictures which have proven
so popular at the American Academy meetings.
The Preliminary Programmes will be ready about March 1st. These, and additional information, can be secured by writing to Paul Bailey, Secretary, 929
Medical Dental Bldg., Portland, Oregon.
Page 128 JW'Tt ■
Vancouver Medical   Association
NOTICE!
A new card is being issued by the Social Service Department to relief recipients.
The Relief Administration Committee has been asked to circularize the members of the profession doing relief work, informing them that those who are in
general practice (that is, the family doctor) should sign on the left in the space
allotted, and in the case of the specialist, on the right, indicating the specialty
after his name. This should be done on the first visit after February 1st, 1939,
and the card should be examined by the attending doctor on each subsequent visit
to assure himself that the case is active.
When requesting special consideration for relief patients, it would expedite
matters if the doctor would state the diagnosis and direct all such information
to the Social Service Department of the City of Vancouver, Medical Section.
W. T. Lockhart, Chairman.
Dr. Murray McC. Baird will be the speaker of the evening at the General Meeting to be
held on February 7th. His paper is entitled "Some Remarks about 'Rheumatism'." Dr.
Baird says he will discuss "Aches and Pains!"
The Osier Lecture will be given at a dinner to be held in the Hotel Vancouver in the
Oval Room on March 7th.
The dates for the Annual Summer School of the Vancouver Medical Association have
been set for June 6th to 9th, inclusive. Summer School wjll, it, is hoped, be held in the
new hotel, where excellent lecture-room facilities are promised. The dates have been set
for early in June so as not to conflict with the Canadian Medical Association meeting
which will be held later in the month.
CLINICAL MEETING AT SHAUGHNESSY HOSPITAL
The regular clinical meeting of the Vancouver Medical Association was held at Shaugh-
nessy Hospital on December 20th. By good fortune this coincided with the annual visit
of Dr. Ross Millar, director of medical services of the Department of Pensions and National
Health at Ottawa. Dr. Millar was introduced by Dr. J. A. Jones and entered into the discussion of several of the cases presented during the evening. Dr. G. A. Minorgan outlined
briefly the work carried out at Shaughnessy Hospital and pointed out that ex-soldiers who
are now drawing the so-called "burnt-out pension" are not eligible for treatment at
Shaughnessy Hospital. Only those who have a pension for disability suffered overseas are
eligible for such treatment. Dr. W. L. Turnbull discussed amputation of the lower
extremities and illustrated his remarks by presentation of a number of patients wearing
artificial limbs of various types. A very full discussion by Doctors Millar, Schinbein,
Haig and W. L. Graham, as well as Mr. Blain, the artificial limb maker at Shaughnessy,
followed. All speakers emphasized close co-operation between the surgeon, patient and
limb maker for an optimal result in every case. Dr. F. H. Mayhood showed a case of
chronic arterial hypertension and discussed in some detail the etiology of the common
forms of this. He emphasized particularly the hereditary aspects of the disease. This
paper was discussed by Dr. C. E. Brown and Dr. Hatfield. Dr. A. B. Schinbein related
the history of four cases of carcinoma of the rectum which illustrated successively the
various combinations of a wise patient, a procrastinating patient, a good doctor and a
poor doctor. His presentation was discussed by Dr. Whaley. Dr. T. M. Jones, in the
absence of Dr. J. E. Campbell, related experiences at Shaughnessy with 41 cases of suprapubic prostatectomy, The mortality rate in this group was exceedingly low . The discussion
which followed, by Doctors A. W. Hunter, Wood and Drasch, was chiefly concerned with
the relative merits of supra-pubic prostatectomy and transurethral resection.
Page 129 SOME ASPECTS OF HEPATIC AND GALL BLADDER
| DISEASE
Dr. W. L. Graham
This excellent paper of Dr. Graham's, read some months ago, was held up, as it was felt that
figures obtained from his brother, Dr. Roscoe Graham of Toronto, should not be used
without the latter's permission, which he has very kindly given. The statistics and findings
here are of great importance, and are admirably summarized by Dr. Graham.
The subject of the diagnosis and treatment of diseases of the liver and biliary passages
is one of tremendous breadth, and it would not be of value if one were to attempt, in a
short paper, to cover the subject in detail; comprising as it does the many forms of not
only destructive diseases, but also obstructive conditions both within the liver itself, the
ducts and associated organs. The subject of jaundice and its differential diagnosis is
extremely difficult, requiring a firm basic understanding of the biochemistry of bile
pigments and of the physiological functions of the liver. The various laboratory tests
estimating liver function have not been of great help, as the liver has such a large margin
of reserve and such recuperative powers under proper treatment that only gross lesions
are determined—and these are frequently obvious clinically. The lesser degrees of damage
or dysfunction are not revealed, which may nevertheless be of real danger to the patient.
In dealing with the subject my remarks are confined to some of the newer ideas that
have been evolved within the past few years, but before doing so I would like to bring
particularly to your attention some general observations of treatment in cholecystic disease.
Within the past few years the confidence of the surgeon and the internist, in the results
of the treatment of gall bladder disease, has been somewhat shaken. The crux of the whole
matter lies in the statement of Evarts Graham that the patient with a damaged liver presents a questionable risk for surgery, biliary or otherwise. The warning, taken at its face
value, will mean, for all practical purposes, a surgical revolution. It will mean no more
simple surgery; from the standpoint of biliary surgery the corollary is that the surgeon
who proposes it must remember that hepatic disease of some degree is an invariable concomitant of all biliary tract disease and must regard all candidates as potentially poor
operative risks, regardless of how incongruous this inclusion may seem. Finally, the
catastrophes of biliary surgery, irrespective of the immediate cause, are primarily due to
delay in the institution of proper surgical measures. There seems to be no logical reason
for prolonged medical treatment of cholecystic disease. Such a statement does not mean
that we advise cholecystectomy on insufficient indication, nor does it mean, except under
certain circumstances, the performance of operation during an acute attack of cholecystitis. It seems only reasonable, however, not to allow pathological processes to progress
when non-surgical treatment often leads to' serious and occasionally fatal complications.
Obviously the surgeon who undertakes biliary surgery should be prepared, even in supposedly simple cases, for extreme technical difficulty, and be equipped to deal with the most
unexpected post-operative complications.
Moynihan's warning was wisely uttered when he said, "If; I might presume to offer
advice to the surgeon who has not had great and continued opportunities for practical work
I would suggest to him to leave the surgery of the gall bladder alone."
I shall not atiempt a differential diagnosis of hepatic and cholecystic disease. Suffice
it to say that according to pathological interpretation there are three ways in which
jaundice is produced:
(1) That which is due to an increased amount of serum bilirubin, that is, a hyper-
bilirubinasmia, and may be associated with a diminution of the ability of the liver to
excrete bilirubin. Examples of this condition are to be seen in haemolytic icterus and pernicious anasmia where there is an increased red-cell destruction.
(2) That which is due to a mechanical extra-parenchymatous biliary obstruction.
Back pressure and increased intra-biliary tension, thus caused, separate the cells and produce
a discontinuity of bile canaliculi and thereby permit the absorption of bile into the lymph
and blood.
(3) That which is due to a toxic or infective destruction of liver cells, as seen in a
hepatitis. This condition, through infection, produces a discontinuity of the cells lining
the bile canaliculi and permits the absorption of bile into the blood and lymph.
Page 130 The first classification is one of a generalized disease; the third is a localized infection
of hepatic tissue, and the second, which concerns us most in the discussion of this paper,
is a pathological and physiological change of the gall bladder and extra-biliary passages.
The diagnosis of cholecystic disease has always been difficult. It was not until comparatively recent years that we have had any adequate tests of gall bladder function and even
yet, it would not be wise to put too much stress on the emptying and filling of the gall
bladder without first taking into consideration the amount of hepatic insufficiency.
Before the discovery of the gall bladder dye test the diagnosis of early gall bladder disease
depended chiefly on the symptoms that were produced through a reflex mechanism. The
patient suffered from bizarre digestive disturbances, was found to have a pylorospasm
whose relief did not materially relieve the patient's symptoms. A very large percentage
were found to have an achlorhydria or at least a marked hypochlorhydria, and the differentiation from a primary achlorhydria was not always easy. It was found, however, that
these patients were not relieved by the addition of hydrochloric acid to their diet. Consequently, it was not until the onset of biliary colic, jaundice or an acute infective process
affecting the gall bladder that one was able to determine the seat of the pathology. With
the perfection of the dye test the discovery of gall stones was proven to be possible in 67%
of cases. However, it was very soon discovered that many people had gall stones without any
discomfort to themselves and that the presence of stones in the gall bladder was not an
adequate reason for surgical interference. It was also found that in absence of adequate
function of the gall bladder, so far as dye excretion, concentration and emptying were
concerned, a cholecystectomy did not always produce tli€| results expected. A dye test is
only confirmatory of clinical diagnosis. If a clinical diagnosis of gall bladder disease cannot
be made, an x-ray diagnosis is not sufficient. I shall deal later with the prognosis of
operative treatment of these conditions. Suffice it to say that we still have, despite our
improved laboratory facilities in the diagnosis of gall bladder disease, a very definite
clinical problem in the treatment of this condition. However, I do not think that one
could pass this point without urging one fact that should be obvious, i.e., the presence of
biliary colic or the presence of obstructive jaundice are incontrovertible arguments for
operative interference. They are not symptoms of biliary lithiasis but1 are complications
of this disease which, if not adequately treated, will go on to disturbed metabolism in the
normal tissues of the body and cause the very definite mortality that is associated with
complicated gall bladder surgery.
I have already pointed out that non-operative treatment has little curative effect in
the treatment of gall bladder disease, giving symptomatic relief to some patients but perhaps at the expense of normal physiological function.
The palliative treatment of biliary colic which was known so long ago has recently
been aided by the work of McGowan and associates, who discovered that morphine, when
given in therapeutic doses, tends to aggravate biliary colic rather than to relieve it. In
larger doses relief is obtained through the drug's effect on the general system. It was
found, in a patient who was suffering from the pain of angina pectoris associated with
biliary colic, that when amyl nitrate was administered both pains disappeared. Morphine
is known to be a stimulant of smooth muscle and its action on the sphincter of Oddi so
increases intra-ductal pressure that its effect was to increase the pain, whereas if amyl
nitrite, or more particularly nitroglycerine, were given, the sphincter relaxed and the pain
was relieved. They report pain resembling biliary colic in nine cases following cholecystectomy that was relieved by nitroglycerine—and of these nine two subsequently had
stones removed from the common duct.
May I distinguish here between cases in which the indications do not point to surgical
excision of the gall bladder and those in which they do.
(1) The silent gall bladder requires no treatment. Consequently, when the surgeon
does not believe that symptoms are attributable to gall stones, he should prevent the patient
from discovering that he has them. The knowledge of their presence may create a fear
and apprehension that may necessitate a cholecystectomy whether the surgeon feels it
advisable or not.
(2) Cases of gall bladder disease presenting the clinical symptoms of mild indigestion
are not fit subjects for surgery.  Many of these cases have non-functioning gall bladders
Page 131 as proved by the dye test which are either due to a closure of the cystic duct or to having
the gall bladder so packed with stones as to prevent normal function. The symptoms
appear to be due not to irritation of the gall bladder but simply to its lack of function,
and its removal will leave the patient in statu quo.
(3) All cases who have or have had gall-stone colic should have cholecystectomy performed, as it is quite clear from our accumulated experience that such colics tend to recur
in a very high percentage of cases. This group will contribute the serious complications
that threaten the life of the patient. Into this group naturally falls all those cases which
have or have had the various complications such as jaundice, acute infection, rupture or
gangrene, which permit no discussion as to the necessity of surgery.
(4) There is a large borderline group in which only experience and clinical acumen
are of help in our decision. They are the cases who suffer, not from definite colic, but
from a rather severe type of indigestion. In this group very careful studies are necessary;
coexisting gastric ulcer is not infrequent and may play a major role; faulty function of
the colon may prove an important feature. Such cases deserve more than the usual amount
of study and observation. Extensive attempts at medical management are advisable, as
even the most severe of these may, at times, be completely relieved. However, there does
remain a definite number in this group in whom persistent tenderness in the right upper
quadrant and failure to secure relief from medical management may necessitate a cholecystectomy. A dietary regime is necessary following operative treatment and particularly
necessary in the correction of habitual constipation.
There have been some new ideas in the etiology and treatment of various phases of gall
bladder disease in the past few years which I wish to discuss, namelyi the treatment of
acute cholecystitis, the subject of common duct drainage, the question of biliary peritonitis,
and the condition known as liver shock or liver death.
It requires sound judgment to choose the opportune time for surgical intervention in
acute cholecystitis. The treatment of this condition for many years has been one of
delayed intervention—I mean waiting until all acute symptoms have subsided, as evidenced
by the return to normal of the temperature and blood count, the disappearance of any
tender mass or abdominal rigidity. Various statistics have shown that the incidence of
gangrene or perforation approaches 20% in acute cholecystitis. This is contrary to textbook information; consequently, some ten years ago, in the hands of certain groups the
pendulum swung the other way and they advised immediate operative interference. This
change of front was based on the idea that obstruction caused retention of the infection
in the gall bladder and led to an acute cholecystitis. In the first place an acute oedema
occurred which was not infective and the condition was more properly known
primarily as an oedema of the gall bladder rather than an acute cholecystitis, so that from
a point of infection there was no danger in operating immediately, and the longer the
•operation was delayed the higher the incidence of infection and complications. The mortality in this procedure, however, ranged, according to available statistics, as high as 20%.
Cave in a recent article has reclassified operations in acute cholecystitis into three
groups, namely,/immediate, early and delayed—depending on the duration of the disease.
The idea must oe clarified that emergency and immediate operations are synonymous
terms: and that the duration of the disease should be dated from the onset of symptoms
and not from the admission to hospital. An immediate operation is one which is done as
soon as the diagnosis has been made; an early operation implies one that is done in the
interval between the first and seventh day; while the delayed operation indicates one that
has been done after the acute symptoms have subsided—and this* may be some weeks or
even some months later.
Finney reports 153 cases, 65% of which were operated upon the day of admission and
35% being observed for 48 hours or more before operation was performed. Amongst those
who believe in early operations, Branch and Zollinger of Boston report 253 cases, 15 % of
which were operated upon immediately because of definite signs of peritonitis or pending
perforation, with a mortality of 20%. The remainder of the 195 cases were treated conservatively for an average period of 4.7 days before operation with a mortality of 8.7%.
Page 132 From Toronto a group of cases was reported which showed a mortality rate of 16% in
immediate operations and 4.8% in the early group.
It seems, in the face of such evidence, that the early operation is advisable rather than
the immediate or emergency, if the above mortality rates are considered; and yet one must
remember that many of the immediate operations were operations of necessity because of
severe complications and were dated from their admission to hospital. It is felt that, if the
temperature remains elevated after 36 to 48 hours, the pulse rapid and the general appearance not improving, we should do a cholecystectomy or a cholecystostomy, and it might be
mentioned that in many cases a partial cholecystectomy is an operation of advantage that
is seldom used; it is of particular advantage in the gangrenous type of cholecystitis where
one removes the gangrenous area and drains the remainder of the gall bladder or its bed.
McKenty, of Winnipeg, reporting 76 cases of acute cholecystitis which he had operated
upon, did a partial cholecystectomy in 30, leaving the portion attached to the liver-bed
intact. He affirms that in the presence of sepsis this is a safer operation than a complete
cholecystectomy.
Yet one finds in a review of recent medical literature very few strong arguments against
the older plan of delayed operation. It is true that certain cases will go on to perforation or
local abscess formation, whose ultimate operative interference produces a high mortality
or a very stormy post-operative course; others will refuse operation resulting in a recurrence
of the; same condition, or a displacement of calculi that will cause a severe jaundice and
require, subsequently, more radical operative procedure which entails an increased mortality. Without available statistics, one wonders if the ultimate mortality might not be
lessened.
So one is left with the judgment that the problem of acute cholecystitis is probably too
complicated to be handled by any certain stereotyped policy. It would appear that this is a
disease par excellence to be treated by individualizing each case with regard to the optimum
time for operation.
Biliary Peritonitis.
Biliary peritonitis is said to occur in 1 % of acute gall-bladder cases. The source of the
bile may be from the gall-bladder itself or from the ducts as a result of trauma or disease.
In the great majority of cases of biliary peritonitis the source of the bile cannot be determined. It must be remembered that duodenal contents can be similar to bile in appearance.
The extent of the lesion or lesions, for they may be multiple, varies from a microscopic to
a widespread sloughing cholecystitis and is not necessarily located on the peritoneal aspect,
as a large retroperitoneal escape has been recorded. Localization is not likely to occur.
The actual site of the source of the bile may result from pressure necrosis at the site of
impaction of a stone even when local tension is not marked. Small stones are found not
infrequently between the trabeculae of a chronic gall bladder, and they produce minute
ulcers. In later stages a large calculus can be seen in contact with grosser ulceration.
Mechanical bursting is believed to be possible, for while in health the gall bladder is believed
to empty easily, practical experience shows that much patience must be expended to empty
this viscus completely. However, if the cystic duct be obstructed it is not likely that any
large extravasation would ensue. Some German observers feel that over-viscid bile itself
may obstruct the cystic duct completely, or, in a lesser degree, give the symptoms of gallstone colic in the absence of stone. The fortunate point is that in over 90% of cases the
site of perforation is in the gall bladder itself, either in the fundus or in the pouch of Hart-
mann; 3 % in the cystic duct, 4% in the common duct, and only 1 % in the hepatic ducts.
Biliary extravasation is a lesion of later life. The average age is 50 years. Women are
the more frequent subjects. The onset is usually sudden, with signs of an acute cholecystitis .
or biliary colic. It resembles, in many instances, duodenal perforation, but is not so acute—
and there is the absence of the board-like rigidity. Temperature and pulse are raised and
shifting dullness may be found. The quantity of fluid in the abdomen is often enormous,
partly because of the fact that the gall bladder has lost its concentrating ability but more
probably owing to the irritating effect the bile has on the peritoneum with its resultant
exudate. Jaundice is not common in this condition and is late and mild and then due to
absorption from the peritoneal cavity.
Page 133 Operation is the only treatment advisable and cannot be advised too early. Tapping the
abdomen has not been of value, although it may be done for diagnostic purposes. Suture of
the perforation, if it could be found, is obviously hopeless, and cholecystectomy is the most
satisfactory course. Drainage of the peritoneal cavity is necessary and particular attention
should be paid to the lesser sac and to the sub-phrenic space. Prognosis depends on the inf ec-
tivity of the bile and the promptness of intervention. It would appear that bile exalts the
virulence of the infection and diminishes the bactericidal properties of the exudate which
it produces.  Available statistics give the mortality rate as 50%.
Common Duct Drainage.
As has been mentioned before, in the operative treatment of chronic cholecystitis and
cholelithiasis there is a certain percentage of cases, estimated at from 10 to 20%, who have
residual symptoms. The three common causes of these symptoms are irreparable damage to
the liver and bile ducts or the reflex mechanism which is due to prolonged disease and can
be obviated only by earlier operation. The second cause is the association of constipation,
which is so frequently seen in disease of the biliary apparatus. The last cause embraces the
group in which the surgeon has failed to deal adequately with common duct lithiasis, and it
is this group I desire to discuss.
Wilkie first brought to our attention the fact that common duct stones are much more
frequent than had been realized. There are various factors that influence one in the diagnosis
of a stone in the common duct; neither pain, jaundice nor temperature alone is a sufficient
criterion. Regarding pain, it has been definitely proven histologically that there are no
functioning muscle fibres in the wall of the common duct. We are at a loss to account for
persistent biliary pain in cholecystectomized patients who subsequently have been proven to
have stones remaining in the common duct, unless we fall back on the theory of a spastic
condition of the sphincter of Oddi which is due to mechanical or infective factors, and the
resultant back pressure due to bile production causing distention of the duct, which results
in pain. The pressure of bile production has never been adequately determined, although
much experimental work has been done in this field.
So far as jaundice is concerned, it has been established, from reliable sources, that 33 %
of patients who have stones in the common duct have no jaundice and have had no history
of jaundice. At the same time, 40% of the patients who present themselves complaining
of jaundice have no stones in the common duct. In the consideration of painless jaundice
I hesitate to be dogmatic, but I feel that it is not true that painless jaundice may not be
due to a calculous obstruction of the common duct. I think that the surgeon should not
be too readily discouraged, for, even if no stone is found, it is not infrequent for him to
determine some operative interference that would be of benefit to the patient. This is
particularly true following dilatation of the sphincter of Oddi in the presence of a chronic
pancreatitis.
Until recently one has been loath to open the common duct: unless indications were
very definite. It would be impracticable to estimate the percentage of stones in the common
duct in lesions of the biliary tract unless the different types of lesions were isolated, whereupon the problem would become too involved. I might add that chronic cholecystitis and
cholelithiasis with a history of jaundice show an incidence of stone in the common duct
of about 18%'.
To overcome this method of investigation, which I feel is unsatisfactory, one might lay
down certain criteria for opening the common duct in order to avoid, to the greatest degree,
the possibility of missing a stone, and it has been agreed that the results of previous reports
do not place much reliance on palpation of the duct in determining the presence or absence
of stone.
It is felt that the common duct should be explored—I do not mean drained necessarily
—in all cases that:
(1) Those which give a history of jaundice or those which are jaundiced at time of
operation;
(2) Those in which the wall of the common duct is thickened;
(3) Those in which the common duct is dilated;
(4) Those in which the pancreas is enlarged or hard.
Page 134 There is no necessity whatever of establishing drainage to the common duct from which
stones have been removed unless trauma should be an inevitable accompaniment of removing the stone or we are dealing with an infection as evidenced by temperature or leucocytosis. A safety valve drainage after closure of the common duct may be provided either
by a cholecystostomy or by means of isolating the cystic duct and leaving it as the source
of drainage. This will to some extent prevent cicatricial stenosis of the common duct. It
is advisable, if closing the common duct, to incorporate a free omental graft in the suture
line.
Liver Shock.
The next complication I would like to discuss is the so-called liver shock or liver death.
I would not care to evaluate the different theories as to the etiology of the condition, but
in passing I would mention three or four:
(1) A sudden release of biliary obstruction rather than the obstruction itself is
responsible;
(2) Liver changes already present in biliary tract disease are aggravated at times by
operative measures which are supposed to relieve them, and then there is released
into the circulation a toxic substance which is presumed to be a water-soluble
foreign protein;
(3) When the function of the liver is below normal the kidney takes up the process
of detoxification, from which results damage to the convoluted tubules through
which foreign proteins are excreted;
(4) The liver syndrome is a single pathological process, of which the kidney pathology
represents the second stage.
Heyd, who first described the condition of liver-shock, has divided such cases into
three groups:
(1) The group of chronic cholecystitis without jaundice: Shortly after operation there
develops, without apparent cause, a rapidly rising temperature, delirium, and
vaso-motor collapse; this is followed by coma and death, the latter occurring
within 24 to 48 hours.
(2) Those cases which have been operated upon for the relief of obstructive jaundice:
Convalescence is satisfactory for the first few days, then the biliary drainage
diminishes in amount and becomes progressively more watery in character, and,
in spite of diminishing jaundice, the patient becomes delirious, then stuporous,
and finally comatose;
(3) There are conditions where patients are suffering from a diseased pancreas and
bile ducts without jaundice: After the common duct has been drained, they
progress satisfactorily until suddenly there is an increase in the pulse rate, a fall
in blood pressure, a suppression of urine and collapse.
Some writers deny the existence of this condition as a new or separate pathological
entity. If we admit its existence surely we should confine it to the first division, that is,
a chronic biliary disease without jaundice where death rapidly follows operative interference. The clinical picture here is that shortly after operation there is a peculiarly sudden
onset of hyperpyrexia, rising at times to 107 degrees, from no known cause. The skin
becomes cold and clammy, blood pressure falls, and cerebral excitation frequently occurs.
As the temperature continues to rise the patient becomes stuporous and finally comatose,
and succumbs within a day or two. In all these cases common fatal complications such as
peritonitis, haemorrhage, pneumonia and embolism can apparently be ruled out clinically.
In these cases the only significant finding at the post-mortem examination reported is
a microscopic degeneration of the liver of varying degree—and others state that these*
findings are not always present in sufficient degree to cause death and are merely an evidence
of profound intoxication.
It will follow that the other two classifications are composed of cases who have lived
sufficiently long post-operatively for other primary pathological processes to have developed and caused the clinical picture and subsequent death.
Page 13 5 It is interesting to note that Touroff feels that if a complete autopsy be done an adequate
cause of death will be found. In a review of 1360 cholecystectomies he found 4 cases that
had adequate post-mortem examination and which clinically had fitted into Heyd's first
group, and the causes of death were:
(1) A subphrenic abscess;
(2) Ligation of the common and right hepatic ducts;
(3) A gangrenous bronchitis;
(4) A hsemorrhagic pneumonia.
It will be well to appreciate, therefore, the dangers that lurk in individuals with a
damaged liver. I should deprecate, however, the too facile adoption of such terms as Liver
Shock or Liver Death to cover such deaths as appear mysterious or unexplainable. I should
suspect that some are not due to disordered hepatic chemistry but to a fulminating infection of a sort not readily discernible clinically that could be found at post-mortem. I feel
that the actual incidence of liver deaths, if such there be, has not been determined.
And in conclusion, taking gall bladder disease as a whole, the operative mortality rate
is given as 3.6%: this figure has been taken from a series of 610 consecutive cases published
by Wilson and his co-workers.
The results of gall bladder surgery reported are those dealing first with gall stones and
secondly with the degree of pathologic change in the gall bladder wall. When gall stones
are present, clinical results are satisfactory in 78% of cases as compared to 64% when they
are absent. When pathologic change in the gall bladder is marked and a cholecystogram
is a significant index, the clinical results are 88% satisfactory; when it is moderate, 76%
satisfactory; and when mild, only 57% satisfactory. These two results give weight to the
conclusion that patients with a really diseased gall bladder have an excellent chance of
symptomatic cure if that organ is removed. The problem resolves itself into one of accurate diagnosis.
The following statistics have been given to me from my brother's service at the Toronto
General Hospital and consist of analysis of 228 cases. I am indebted and grateful to my
brother for his permission to publish these statistics.
RESULTS OF CHOLECYSTOGRAPHY—201 CASES.
Pathological Findings
X-ray Report
Normal   	
No  concentration	
Concentration   poor	
Concentration   normal	
Emptying normal	
Emptying delayed	
No. Cases
Agree
Disagree
%
Accuracy
16
11
5
67
102
101
1
99.1
65
65
0
100
24
12
12
50
12
4
8
35
58
58
0
100
Report mal-f unction       192
Stones present.
       107
INCIDENCE OF SEX.
183
Failed to show 61
Total
cases—
Males _
Females
INCIDENCE OF THE PRESENCE OF BILIARY CALCULI
Total
No.
cases.
/
95.5
61.1
221
228
lculous cholecystitis        173
cases ca
No.  cases non-calculous  cholecystitis ! r	
Non-calculous cases operated on solely for biliary disease	
Non-calculous cholecystectomies incidental to associated diseases for which the opeartion
was  primarily  undertaken	
INCIDENCE OF JAUNDICE
Number of cases	
Stone in common duct =       30
Having no history of jaundice         5-
History of jaundice         8
Jaundice present - •       17-
Total cases with history of jaundice       31
Total cases with jaundice present       33—64
Deleting 25 cases of jaundice or history of jaundice due to common duct stone from
total group of jaundice or history of jaundice  39-
(Continued on foot of page 137)
228
-16.6%
-83.3%
-60.9%
Page 136 PUBLIC   HEALTH   SECTION
SYNOPSIS OF ADDRESS BY DR. STEWART MURRAY
Medical Health Officer of Vancouver.
January 3, 1939.
This short but very suggestive address of Dr. Murray's constitutes a new and we think a
very creditable departure from precedent, and one which we hope will be followed, as Dr.
Murray suggests, by other talks. We feel strongly that there is not nearly enough contact
between the twoi branches of medicinfe—therapeutic and preventive—and both suffer as a
result. The Bulletin welcomes, and intends to foster by every means in its power, closer
liaison between these two mutually complementary services, and it is our hope that we shall
be able to do something ot keep the way open for constant interchange of ideas and
knowledge. The facts and figures contained in Dr. Murray's paper are
of great value to the practitioner.
I thank you for the privilege of appearing before the Association. It is my hope that
on various occasions in the future some member of the staff of the Metropolitan Health
Committee may again have this honour. First, I wish to thank those members of the profession in active practice for their splendid co-operation in the past with the Health
Department. Secondly, on behalf of the Metropolitan Health Committee and its staff, I
wish to convey to the profession greetings and wishes for prosperity for 1939-. Thirdly,
to express the desire of the Committee and the staff for continued co-operation in protecting and promoting health work; and lastly, to point out some interesting facts to this
Association.
Health work, whether it be therapeutic or preventive, is all part of the same picture.
It deals, in the final analysis, with the individual citizen, and in order to obtain complete
success is dependent upon the concerted efforts of not only individual citizens but all
members of the medical profession. The local Department of Health has primarily as its
objective the safeguarding of the health of citizens as a body; however, in carrying out
its function, it can also serve as guide, advisor or assistant to the practicing members of
the profession, because of its peculiar relationship and responsibilities to the local government and the citizens. It is in this latter capacity that I wish to call to your attention
the following:
Vancouver is favoured with a general death rate of about 10 per 1,000. The five chief
causes of death are heart disease, cancer, arteriosclerosis, violent and accidental deaths and
tuberculosis. We could be of better service to the profession if they in turn would give
slightly more attention to the certification of the cause of death. Having been in practice,
I appreciate the fact that these small tasks are at times irritating, but if wholeheartedly
carried out,, much valuable, accurate information can be returned to the profession.
Our maternal mortality rate, 2.6 per 1,000 living births, is excellent, but even that
can be improved.
The stillbirth rate, while comparing favourably with other cities of similar size, can
be lessened. The same applies to the greatest cause of infant mortality—prematurity and
Common Duct
Explored
16 — 8%
13 — 27%
99 — 43.4%
No. with Stone
Common Duct
9 —   4.5%
9 — 18.7%
30 — 13.1%
  17.3%
GALL BLADDER DISEASE—(Continued from page 136)
No. of
Period Cases
January 1, 1929, to January 1, 1933       200
January 1, 193 3, to June 1, 193 3         48
June 1, 1933, to March 15, 1937       228
Of last group, 173 had stones in gall bladder and 30 stones in common duct
Table
Total number of cases 228; Total deaths, 11— 4.8%
Stones in common bile duct 30 cases; Deaths,   5—16.6%
Failure of liver function, 3 cases; post-operative pancreatitis, 1 case;
coronary thrombosis, 1 case.
Stricture of common bile duct 11 cases; Death, 1
(This death due to extensive suppurative cholangitis.)
Page 137 congenital debility. In this latter regard, may I refer you to the very excellent symposium
on prematurity in the current Journal of our Association by the Pediatric Section.
Communicable disease control offers a very interesting and productive field for joint
action by public and private health groups.
In 1938, scarlet fever was reported in approximately 485 cases. No deaths occurred.
Sufficient evidence has been produced from other centres to indicate the widespread use
of scarlet fever toxin for immunization. It is my hope that this year it will be made available to the private practitioner for use as is diphtheria toxoid. Reactions to the toxin are
unnecessary if administered carefully, and protection appears to last at least five years in
some 70% of individuals. In a recent Canadian survey of children 5—16 years of age,
78% were found to be susceptible, as measured by the Dick test.
In 1938, diphtheria occurred in 8 instances and 3 deaths resulted. In a three-month
period, September to November, 1938, diphtheria toxoid was obtained by only 66 Vancouver doctors. Gentlemen, in spite of the activities of the Health Department, there are
still probably 50% of children without benefit of this means of stimulating immunity, a
large percentage of whom are available to you in the course of your practice.
A similar opportunity in the preventive field is that of vaccination against smallpox.
Too small numbers of young citizens are done, and this allows for possibility of an epidemic
in view of our proximity to the Orient.
Whooping cough vaccine of the Sauer type would seem to indicate an excellent means
of prevention. Finances permitting, I would like to see this vaccine made available for all
infants and pre-school children. Now, we do constantly urge all parents to consult their
own doctors, who can administer it privately.
1       Measles in the past year have not been unduly prevalent, but we continue to work with
the Provincial Laboratories in making the convalescent serum available in selected cases
to private physicians.   The efficacy of the convalescent serum is well illustrated in the.
family of one of our confreres: M., 7 years: measles; R., 4 years: modified attack; F., 15
months: no attack, with no special precautions during the case in the home.
Undulant fever was reported in 11 cases. The joint effort of all members of the medical
profession with public health workers will be necessary in order to bring about 100%
pasteurization in order to eliminate this disease from the raw milk source. Approximately
75% of the milk sold is pasteurized, but the minority group using raw milk is very loud
in its efforts to prevent compulsory pasteurization of all milk. If each practitioner would
urge the use of pasteurized milk only, in time 100% would be reached.
In our Well Baby and Pre-school programmes, we consistently urge reference to the
family physician, and in no case is treatment given upon finding an abnormal condition.
Our school programme includes not only routine examination, but a scientific approach
to the classification of the physical status of the children. We not only study the child but
attempt) to learn of those factors in his environment which might be conducive to poor
health. In addition, we are carrying out surveys of lighting and ventilation in the schools
from the viewpoint of health.
Cancer.
In 1937, cancer caused 16.9 per cent of all the deaths in Vancouver.
You will remember that in 1931, largely through the request of this organization, and
the B. C. Medical Association, cancer was made a notifiable disease. This means that under
the regulations of the Public Health Act every case of cancer must be reported to the*
Local Medical Officer of Health.
Although the reporting of cancer has lagged during the past few years, a considerable
amount of information has been collected. It is very gratifying to learn of the progress
and interest that is being manifested by the Cancer Study Committee of the British
Columbia Medical Association. To them, I would like to offer what information and
facilities we can make available for the study of the cancer problem, and to the members
of the Vancouver Association in general I would appeal for better reporting of cancer
cases. Cancer notification forms are available in the Health Department, and if any of you
are out of these, a phone call will be answered by a supply in the return mail.
In conclusion, may I again thank you for your kindness and again urge your fullest
active interest in the newer fields of preventive medicine.
Page 13 8 British  Columbia  Medical   Association
(Canadian Medical Association, British Columbia Division)
President Dr. D. E. H. Cleveland, Vancouver.
First Vice-President £ Dr. F. M. Auld, Nelson.
Second Vice-President Dr. E. Murray Blair, Vancouver.
Honorary Secretary-Treasurer . Dr. A. H. Spohn, Vancouver.
Immediate Past President Dr. Gordon C. Kenning, Victoria.
Executive Secretary Dr. M. W. Thomas, Vancouver.
BRITISH COLUMBIA MEDICAL ASSOCIATION
The regular meeting of the Board of Directors of the British Columbia Medical
Association (Canadian Medical Association, British Columbia Division) was held in the
Hotel Georgia on Tuesday, January 24th, 1939, commencing at 4 p.m., and continued
following dinner.
Present: Dr. D. E. H. Cleveland, President; Doctors: W. E. Ainley; L. H. Appleby;
F. M. Auld, Nelson; E. M. Blair; G. H. Clement; P. A. C. Cousland, W. A. Fraser and
G. C. Kenning of Victoria; W. A. Clarke, F. R. G. Langston and G. T. Wilson of New
Westminster; A. C. Nash of West Vancouver; C. J. M. Willoughby of Kamloops; C. T.
Hilton of Port Alberni; A. C. Frost, R. Huggard, J. H. MacDermot, H. H. Milburn,
G. F. Strong, Wallace Wilson, A. H. Spohn and M. W. Thomas.
Dr. T. C. Routley, General Secretary of the Canadian Medical Association, attended
these sessions and contributed very considerably to the discussions and was very helpful to
this group in planning the programme for the remainder of the year.
The date of the Annual Meeting was definitely set for September 18th, 19th, 20th and
21st. The Committee on Programme reported that arrangements had already been made
for holding the Annual Meeting of the Association in the new Vancouver Hotel. It is proposed to enlarge the programme and develop its scope to meet the needs of all sections of
the membership and thus assure an even larger attendance at what should be one of our
most successful Annual Meetings. It is felt that the new hotel will provide even greater
comfort and better appointments for the meeting. At least eight speakers will be available, according to the announcement by Dr. Strong, Chairman of the Committee on
^Programme.
Dr. Milburn presented a report on the increase in membership in the Canadian Medical
Association. Already the enrolment shows an increase of 45% in new members over last
year. He was satisfied that the arrangement made for a reduction of 20% in the membership fee had accounted for part of this increase.
Dr. G. C. Kenning, Chairman of the Committee on Legislation, reported briefly on
-.action taken on several legislative matters during the recent session of the Legislature.
Dr. C. T. Hilton, Chairman of the Committee on Maternal Welfare, reported on the
'development of his Committee and outlined the programme whereby the Committee hopes
to assist the man in practice to carry out pre-natal care with greater ease and fuller cooperation of the patient.
Dr. W. A. Clarke, Chairman of the Committee on the Study of Economics, and Dr.
^Wallace Wilson, Chairman of the Committee on Economics of the Canadian Medical Association, led the discussion on many phases of medical practice.
Dr. C. H. Vrooman, Chairman of the Committee on Pharmacy, outlined the plans of
his Committee to co-operate with the Executive of the British Columbia Pharmaceutical
Association, particularly in the matter of proprietary medicines.
Dr. W. S. Turnbull, Chairman of the Committee on Hospital Service, suggested that
when Dr. Harvey Agnew of the Department of Hospital Service of the Canadain Medical
Association, visits the West in the near future, his Committee would attempt to hold a
conference on Hospital affairs. (Continued on foot of next page)
Page 139 Victoria  Medical   Society
Officers, 1938-39.
President Dr. P. A. C. Cousland
Vice-President Dr. W. Allan Fraser
Hon. Secretary Dr. W. H. Moore
Hon. Treasurer Dr. C. A. Watson
The Provincial Royal Jubilee Hospital
Victoria, B. C.
I CLINICAL CONFERENCE
A clinical conference was held at the Royal Jubilee Hospital on Friday, November 25 th,
1938, at 12 noon, under the chairmanship of Dr. G. A. McCurdy.
Dr. McCurdy welcomed two guests from out of town to the meeting—Drs. E. M.
Robertson and Ketchum.
Dr. E. W. Boak was then introduced and announced the subject of his) paper
"Spinal Cord Pressure—Symptoms and Diagnosis."
This is a large subject and many books have been written on it, so I will confine myself
to attempting to give you an outline of the causes in as brief a form as possible, including
the symptoms and examinations necessary for a differential diagnosis.
Spinal cord pressure may be either acute or chronic, and it is the latter we will discuss
chiefly.
Acute pressure may be due to:
Gunshot wounds;
Fracture of a vertebra from falls, crushes, etc.;
Haemorrhage into the cord;
Oedema (sudden) of a cord tumour;
Extrusion of nucleus pulposus.
Chronic pressure may be caused by:
1.   Tumours:
Extra-dural;
Intra-dural:  (a) intra medullary, (b) extra medullary;
Malignant;
Benign.
2.
Diseases:
Syphilis;
Hypertrophic pachymeningitis;
Tuberculosis—Pott's disease;
BRITISH COLUMBIA MEDICAL ASSOCIATION
(Continued from page 139)
Dr. Roy Huggard, Chairman of the Committee on Cancer, pressed for authority,
which was granted, to take immediate action in an attempt to obtain biopsy service, which
would be extended to cover the needs of the whole province.
Dr. J. H. MacDermot reported on behalf of the Editorial Board that the Supplement
containing papers read at the last Annual Meeting would soon be ready for distribution.
There had been some delay in collecting the papers for this publication. He announced to
the meeting that the Bulletin was now a recognized journal in that it was included in the
list of journals indexed in the Cumulative Index.
Page 140 Actinomycosis;
Chronic hypertrophic osteo-arthritis.
Paget's disease;
Spondylolisthesis.
Now let us consider the extra-dural tumours:
The benign ones include: Osteoma; osteo chronodoma; chrondoma; fibro-chrondoma;
giant-celled tumours; fibrous bands; cysts: dermoid, echinococcus and cysticercus;
lipoma; neurofibroma; endothelioma; hemangioma. All these tumours may cause
compression of the cord.
The malignant tumours include: Sarcoma; myeloma; endothelioma; hypernephroma;
metastatic carcinoma; also chrondoma, which arises from inclusion rests of the
notochord in sacrum and vertebra. These latter generally occur in the sacrum,
producing destructive bone change extending into the ilia and pelvis.
The malignant extra-dural vertebral growths are more common than the benign in
a ratio of 10—1.
The intra-dural tumours are more common than the extra-dural in a ratio of 2—1 and
are generally encapsulated. They are situated posteriorly and laterally as a rule, and rarely
anteriorly in relation to the cord. The greater number are found in the thoracic region,
next in the cervical area and the lowest number in the lumbar area.
Primary intra-spinal tumours are usually benign and operable, and are much more
common than was formerly thought.
Next come the intra-dural growths, and these are divided into extra-medullary and
mtra-medullary.
Extra-medullary—those tumours arising from the tissues surrounding the spinal cord
—show the following symptoms, which we may divide into three phases:
First phase: Involvement of nerve roots.
The outstanding symptom of involvement of nerve roots is pain, which is usually
characteristic and pathognomonic. It may precede the other symptoms by months or
years. It may be constant and intermittent, persist in a definite region and radiate over
the involved nerves.
In type the pain is lancinating, and is aggravated by coughing, sneezing, muscular
effort and straining at stool, and invariably wakens the patient from four to six hours
after he has retired. It is often very severe. This pain is apparently caused by the ball valve
action of the tumour, which is forced down by the superimposed cerebro-spinal fluid and
drags directly or indirectly on the sensory nerve roots. Craig states that ten per cent of
patients that he examined who had root pain have been operated upon for various thoracic
and abdominal lesions other than tumour.
Cervical tumours cause shoulder pain, neck rigidity and the pain is increased by
coughing and sneezing.
Pain fro mthoracic regional tumours often simulates intercostal neuralgia, gall bladder
disease, renal and appendicular colic.
Tumours of the cauda equina and filium terminale give symptoms of recurrent
sciatica, a positive Lasegue sign and diminished achilles reflex.
The second phase: The beginning of cord compression.
Neurological evidence of cord compression now becomes evident. The symptoms may
develop simultaneously with the existence of pain, or in a small percentage of cases
without pain.
Tumours situated antero-laterally cause progression of the symptoms and produce a
Brown-Sequard syndrome (a homolateral paralysis of the muscles below the lesion with
impairment of tactile and deep sensibilities on the same side, together with diminution or
loss of pain and temperature sense on the same side). If the post, columns: are first compressed, the deep sensibility is decreased and ataxia develops.
Sensory disturbances caused by tumour pressure on the cord are gradual in onset and
progress upward to a transverse level corresponding to the segment of the cord that is
compressed.
Page 141 At the caudal end of the cord it is difficult to determine whether there is a tumour of
the cauda equina, of the conus medullaris or of the sacrum, as the nerves pass out through
the anterior foramina of the sacrum.  The objective findings may be the same.
The third phase of cord compression is evidenced by extreme compression of the cord.
1. The paralysis is generally complete.
2. The sensory functions are abolished.
3. Trophic disturbances are present.
4. Loss of vesical and anal sphincter control.
Now we pass on to intra-medullary tumours. These rarely produce pain, but pass
directly into the beginning compression phase. Increased reflexes and loss of rectal and
vesical control appear early. The sensory and motor disturbances are progressive until a
definite transverse level is attained. The upper sensory level is less distinctly marked than
on cases of extra-medullary growths.
To summarize: In all cord lesions the symptoms are characteristic and are due to compression or destruction of the segment or segments on which the tumour presses. They
may not occur for some years after the root pains are complained of and) they vary with
the segment involved, consisting of motor and sensory paralysis and alteration of reflexes.
The direct spinal symptoms, from cord compression cause paralysis with atrophy and
reaction of degeneration of the muscles whose cord centres are involved. The tendon
reflexes centring in the segments are lost. Herpes zoster and other trophic disturbances may
occur. Anaesthesia may obtain with analgesia and thermic anaesthesia as well.
The indirect spinal symptoms, from compression of the long tracts of the cord, consist
of spastic paralysis with exaggeration of the tendon reflexes in the legs, anaesthesia, imperfect bladder and rectal control and a tendency to decubitus. At the onset, weakness with
rigidity appears and gradually increases to paralysis—paralysis generally at first on side
of tumour, motor paralysis extends from above downward and remains most pronounced
on side first involved. Anaesthesia occurs on opposite side first, except muscle sense. In
cervical lesions Brown-Sequard paralytic symptoms may appear. Sensation loss begins
below and ascends. Dissociated anaesthesia—characteristic of syringomyelia and intramedullary haemorrhage may occur in extra-medullary growth. A girdle sensation at
tumour level may appear. Local tenderness or sensitiveness of spine over posterior roots
involved only occur in posterior tumours and is generally the( only symptom referable to
the spine in intraspinal tumours. If tumour involves first dorsal segment or those above,
the ilio-spinal centre may be affected with a narrowing of pupil and a sweating of face and
neck on same side as tumour. In tumours of lumbar region the paralysis is atrophic in type.
In tumours of the cauda equina sensory symptoms predominate and are widespread.
At first pain on movement only, later persistent, then anaesthesia; muscular weakness
with atrophy develops slowly. Tendon reflexes, at first exaggerated, soon diminish and
are then lost. In lesions of the conus medullaris the signs develop more rapidly, sensory
disturbances may be dissociate—tactile sensation often being present, and pain is negligible.
Examination: A thorough physical examination must be made and often repeated, and
lumbar puncture, Queckenstedt test, spinal fluid examination, x-ray studies and lipiodol
injection are necessary before a diagnosis can be made. Then a neurological examination,
which must be thorough to the nth degree. The information obtained by a detailed testing
The following table gives an idea of the distribution in 451 cases, recently reported
from the Mayo Clinic:
Extra-dural Intra-dural
Portion of cord                                                                           Ext. Med. Intra. Med. Total
Cervical |        19                        29 19 68
Cervico-thoracic          8                        13 14 25
Thoracic  _ .      59                     111 49 219
Thoracio-lumbar       10                        25 18 53
Lumbar __       18                        32 5 55
Lumbo-sacral           5                          6 2 13
Sacral          13 5 9
120 219 112 451
Page 142 of the reflexes, muscular strength, muscular tonus, sensory acuity, gait, co-ordination and
balance will generally distinguish between degenerative diseases, which are usually bilateral,
and cord compression syndrome.
Spinal cord tumours are chiefly found in the third to sixth decades, but have been
diagnosed in babies as well as octogenarians.
The neuro-fibromata, of which 112 appear in this series, showed 81 intra-dural and 26
extra-dural and extended into the canal. Often these perineural fibroblastomata extend
from within the dura to the extra-dural space, producing the so-called "Dumb-bell"
tumours.
Endotheliomata (meningeal fibroblastomata) numbered 219, or nearly one-half of the
above group. These tumours are non-malignant, definitely encapsulated, and are easily
removed; most of them arise from the arachnoid and may extend to the dura.
Many of the extra-dural tumours, as well as those arising from the filum terminale,
are operable, but tumours within the)'spinal cord are rarely removable, but the cord may
be compressed by incision over the tumour in the midline. The tumour may then be partially removed, with resultant relief of pressure on non-involved fibre tracts.
Laminectomy and partial removal of non-encapsulated lesions may give relief from
compression in a variety of neoplasms, but should not be done for metastatic lesions as the
relief is too transient.
In closing, may I suggest that; one be not too hasty to do a laminectomy until every
path of diagnosis is explored, and if operation is decided upon the patient is gotten into the
best possible condition physically. The surgical mortality is about 4% and the time for
recovery depends on the character of the tumour and its duration.
Since 18 87, when Gowers and Horsley diagnosed and operated upon their thoracic
cord fibromyxoma, the progress in diagnosis and treatment has been steadily forward, and
especially the works of Elsberg and Frazier have given a tremendous impetus to this work
in America.
I hope this rather rapid survey of cord pressure may have served to bring to your attention the possibility of such a syndrome and for us ever to be on the lookout when patients
come complaining of intractable night pain or sensory and motor disturbance; if so, it will
have served its purpose.
Dr. McCurdy thanked Dr. Boak for his interesting paper.
Dr. Roberts was then called upon to give radiographic diagnosis of the tumours.
He exhibited films demonstrating the different things looked for in the spine radio-
graphically, when it was a question of differential diagnosis of spinal tumour. We look
for: (1) bone absorption; (2) increase in width of canal; (3) straight line of increased
density down the vertebral column.
The merits, advantages and disadvantages of the use of air and lipiodol injections were
discussed and films showing the true filling defect by the use of lipiodol were exhibited.
Dr. Roberts stated that he preferred the use of air first, then, if unsuccessful, the use of
lipiodol.
Dr. McCurdy thanked Dr. Roberts for his discussion.
General Discussion.
Dr. R. L. Miller asked about laboratory examinations (spinal fluid) being valuable as
an aid to diagnosis.
Dr. McCurdy stated changes in cerebral spinal fluid not noted until there are pressure
signs on the cord.
Dr. Maguire: Why is lipiodol not as popular as air for injection?
Dr. Roberts: In lipiodol foreign body is not absorbed for a considerable time, and
f.b. may be blamed for foci of infection.
Dr. Boak stated that there were no cases reported in literature proving lipiodol to be
an irritant. Air only gives information when block is complete.
Dr. Roberts: Air shows double contrast and is agreed to be the best method of procedure in many recognized institutions.
Page 143 Dr. Alcorn: To fill up spinal cord of a normal person, how many cc. air is required?
Dr. Roberts: Between 60/80 cc. air required to fill up spinal cord.
Dr. Gray asked Dr. Mitchell if he remembered a case of paraplegia due to injection of
lipiodol.
Dr. Mitchell replied in the negative and stated that lipiodol is absorbed after a long
period of time. Air injection very reasonable and should be tried before lipiodol. Stated
Dr. Boak gave a very good summary of the subject and agreed to the importance of neurological examination being emphasized.
Dr. Boak stated he had a case which he operated upon not long ago with query diagnosis: (1) secondary carcinoma of the fourth lumbar vertebra, or (2) old fracture occurring two years before. No primary growth could be found on complete examination.
Plaster cast and deep therapy improved condition. Was better for a time, then worse again.
Spinal exploration then decided upon. At operation dural adhesions right across cord were
found and freed and cord pressed to right by bony excrescence. Reflexes returned after
this treatment. The diagnosis is still questionable.
Dr. Roberts showed films demonstrating Dr. Boak's case.
Dr. McCurdy then again thanked Dr. Boak for his interesting paper and also those
taking part in the discussion.
The meeting then adjourned.
PATHOLOGICAL CONFERENCE
Pathological conference was held at the Royal Jubilee Hospital on Friday, December
2nd, 1938, at 12 noon, under the chairmanship of Dr. G. A. McGurdy.
Two guests were welcomed, Drs. Baines and E. M. Robertson, as well as members of
the staff, namely: Drs. P. A. C. Cousland, W. Maguire, R. L. Miller, G. Worsley, McKer-
chan, W. E. M. Mitchell, L. L. Ptak, O. C. Lucas, C. W. Buck, R. Scott-Moncrieff, D.
Smith, R. C. Newby, A. B. Nash, G. C. Kenning, D. M. Baillie, W. E. Alcorn and J. B.
Roberts.
Dr. McCurdy gave a brief summary on liver function tests, stating that discussion was
unsatisfactory on this subject from a practical angle, as the/ liver can be damaged from
85% to 95% without showing any insufficiency by testing, but there are a few tests used
which give an idea of the liver damage present. He then discussed different tests of value
and no value in diagnosing liver disease, stating that most literature on tests is by German
investigators and not easily obtainable in this country. Protein, sugar and dye tests were
discussed, also pigmentary function, the latter being demonstrated by slides showing
damage done to a unit of liver.
Dr. G. C. Kenning was then called upon to present a very unusual case of liver disease.
Dr. Kenning gave a brief outline of the history of the case:
The patient was examined in the office about one year prior to admission to hospital, when she was complaining of digestive disturbances, discomfort after meals, heartburn and flatulence. Examination showed no
evidence of enlargement of liver. There was a moderate hypertension. It was thought the digestive disturbance was cholecystic in origin.  X-ray examination was advised but not carried out.
Patient carried on for a while and then was seen twice at her home with acute attack of pain and
vomiting, which necessitated morphine. X-ray again was advised and carried out in detail. Complete G. I.
x-ray was negative. Examination of the gall bladder with dyfc showed no gall bladder shadow at all and
shadows suspicious of stone.  This report was regarded with suspicion because shadows were indefinite.
Patient continued to have digestive disturbance and another x-ray of gall bladder with dye was made,
this time in hospital. The report was non-functioning gall bladder probably containing stone. Once more the
patient carried on with diet. Eventually a third (investigation with dye was made (the third in one year),
and report revealed no shadow, the diagnosis being non-functioning gall bladder containing stone. Dr. Kenning
stated he then agreed that the patient might have stone. Examination in the office, prior to admission, revealed
blood sugar normal and N.P.N, also normal.
September 3rd the patient was operated upon and a perfectly normal gall bladder found with no stones.
Liver was found a little enlarged and nodular. There was a little fluid in the abdomen. Obviously the liver
was diseased.  A biopsy was taken.
Following the operation the patient went on reasonably well except for considerable oozing from the
wound necessitating a blood transfusion. During the second week it became obvious that fluid was forming
rapidly in the abdomen and leaking through the wound. Large quantities of fluid drained through the
abdominal wound. Gradually she became drowsy. Further blood chemistry was done. N.P.N. 40 mg. ten
days prior to her death.   An interesting point was the always very high red blood count.   September 13 th,
Page 144 capillary red count 6,500,000, Hgb. 111%. Venous count showed reds 5,500,000, Hgb. 110%. About this
time she began, to show albumen, granular and hyaline casts in the urine; before this the urine had been
quite normal. She became more and more cyanosed and N.P.N, was then found to bje 70%, the day before
death being quite normal.
Conclusion: One is inclined to regard with increased scepticism the significance of a lack of visualization
of the gall bladder in films taken following the administration of dye unless definite stone shadows positive
or negative are seen.
Dr. McCurdy thanked Dr. Kenning for his interesting paper and then reported on the
post-mortem findings:
P. M. summary: Heart and lungs essentially normal, although the heart might have been slightly
enlarged. Lungs absolutely negative.
liver was enlarged, weighing 2250 gms. The interior surface was slightly nodular. The remaining surface of the liver was smooth and dark brown in colour and fairly firm in consistency. The caudate lobe was
greatly enlarged. When sectioned, the liver presented some chronic venous congestion and a diffuse increase
in fibrous tissue. The lobuls were not well demarcated and the normal architecture was not preserved. The
gall bladder was filled with viscid black bile. The wall was slightly cedematous. The mucous membrane
appeared normal.  The biliary ducts were patent and appeared normal.
Pancreas somewhat increased in size and also increased in consistency.
Spleen weighed 400 gms. and was increased in size.
Oesophagus, negative.
Rest of P. M. examination essentially negative.
Stomach: In the first part of the duodenum there was a small acute ulcer. Otherwise G. I. tract was
negative.
Microscopic appearance of liver and spleen were shown by slides. Slide of section of
liver demonstrated marked engorgement and destruction of cells. Fibrous tissue not as
thick as usually found in ordinary biliary cirrhosis. Little functioning tissue left. No
obstruction of flow of bile. Slide of section of spleen showed walls thickened and filled
with blood, resembling almost a typical case of Banti's disease.
Dr. McCurdy then discussed blood examination and reason for high blood counts.
Dr. Roberts was then called upon for radiological aspect of liver function and examination of gall bladder.
Dr. Roberts stated that up to the year 1924 all examinations of gall bladder and liver
were done by direct method by showing shadow of gall} bladder itself. The Graham test
is now used, some workers claiming from 80% to 90% correct diagnosis. Films were
shown demonstrating the passage of the dye. One film was of a patient who took a very
small amount of dye and yet revealed stones, there being sufficient evidence to make the
diagnosis easily. Another film showed no definite shadow off gall bladder, but a second
examination showed stones present.  A third film revealed many stones.
Dr. Roberts agreed that negative gall bladder shadows should have examination
repeated for stones, if oral not satisfactory then the intravenous method should be adopted.
He also stated that in these cases one should be hesitant to report a mechanical obstruction
unless definite stone shadows are visualized.
The meeting then was thrown open for discussion of Dr. Kenning's case and liver
function as presented by Dr. McCurdy.
Dr. McKichen asked re the pain being so acute as to require morphine.
Dr. Kenning: Patient had symptoms of typical attack of gall bladder colic, but it was
subsequently found that there were no gall bladder stones. These attacks of pain might
have been pancreatic.
Dr. Mitchell stated he was sure cases of cirrhosis of liver are commoner by 5—6%
than realized. Present knowledge very embryonic. Disease the result of infection or poisoning (hepatic poison). Has three cases similar to the case described by Dr. Kenning and
feels sure each case one of catarrhal jaundice, the infection being due to damage to the
liver. He then discussed healed yellow atrophy as described by Boyd and is common in
cases of pregnancy damaging the liver. Stated that until there are better fiver tests we
would still be kept in the dark.
Dr. McCurdy: Volumes of experimental work being done on cirrhosis of liver and no
two are alike. Only satisfactory explanation given was cirrhosis resulting from inflammatory condition of intestine (chronic type).
Dr. McCurdy thanked Dr. Kenning for presenting this case and those participating in
the discussion.
The meeting then adjourned.
Page 145 V
ancouver
enera
Hospita
SOME POINTS IN THE TREATMENT OF PNEUMONIA
CASES  WITH DAGENAN (M. & B. 693)
Preliminary Report,
The Bulletin is glad to have the opportunity of publishing the attached preliminary
report on the use of Dagenan in the treatment of pneumonia, as we feel that the profession
at large will welcome the findings recorded here regarding treatment and management of
cases. This new remedy is producing spectacular results—and the staff of the Vancouver
General Hospital is to be congratulated on the care and thoroughness displayed in the still
somewhat experimental use of the drug.—Ed.
B. M. Fahrni, M.D., Vancouver General Hospital.
At the time of writing (January 15) twelve consecutive cases of pneumonia have
been observed and treated by the committee formed at the Vancouver General Hospital
for the investigation of the treatment of this disease with M. & B. 693. With the exception
of one fatal post-operative case who was not seen early, all patients have responded rapidly
to the drug, irrespective of the type of pneumococcus present. While the present series
of cases is too small to justify more than tentative conclusions, the patients concerned have
been carefully watched since the commencement of treatment, and certain observations
which have been made may be of interest or serve as a guide in the treatment of future
cases.
It will be noticed from the following table that of the twelve cases, six were of true
lobar type and six of lobular or bronchopneumonic distribution. The pneumococci in the
sputum of the former typed out specifically in every case except one, and while pneumococci were frequently found in the sputum of the latter group they could not be classified
as to type. If for the sake of classification it is desired to type the sputum, the specimen
must be obtained before commencing M. & B. 693, as the degenerative effect of the latter
on the capsules of the pneumococci makes specific typing difficult or impossible.
Case Day of
No.      Sex      Age    Sputum Type    Illness Admitted    Result
Temp. Pulse Resp. Temp. Pulse Resp.
Involvement        On Admission:   30 hrs. after drug:
1.
Fern.
23
Type I
5th
Recovered
Rt. upper Lobe
106°
112
32
99°
80
24
2.
Fern.
30
Type VII
3rd
Recovered
Rt. lower Lobe
103°
120
30
98°
96
24
3.
Fern.
75
Pneumo. present,
no specific type.
5th
Recovered
Broncho- both
bases
101°
100
54
100°
90
30
4.
Male
67
Type III
3rd
Recovered
Rt. upper Lobe
103°
130
32
99°
90
30
5.
Male
75
None found
2nd
Recovered
Broncho- Lower
half right
104°
96
32
99°
70
24
6.
Male
44
Type VIII
5th
Recovered
Lt. upper Lobe
Rt. lower lobe
103°
120
50
101°
104
30
7.
Fern.
19
Type I
3rd
Recovered
Rt. lower Lobe.
103°
114
42
99°
80
30
8.
Fem.
37
Pneumo. present,
no specific type.
3rd
Recovered
Broncho-
Lt. hilus to axilla,
Rt. hilus to base
100°
96
28
98°
70
20
9.
Male
59
Type XVII and
XXIX
4th
Died
Broncho- lower
half both lungs.
103°
110
40
103°
140
38
10.
Fem.
34
Type XXII
4th
Recovered
Broncho- right
base
Broncho- right
102°
120
32
102°
100
28
11.
Mlae
44
Pneumo. present,
5 th
Recovered
103°
98
28
98°
84
20
no specific type.
hilus to axilla
12.
Male
m
Pneumo. present,
no specific type.
3rd
Recovered
Upper div. right
lower lobe
106°
144
52
98°
104
24
Page 146 Dosage of M. & B. 693 (1 tablet M 0.5 gms.): With thei exception of Case 12 (age
"hl/z), all cases at the start received approximately the same dosage of the drug. Routine
treatment was as follows:
Tab. IV O.H. IV for 2 doses; then Tab. II O.H. IV until tern, normal (or 99°) —
usually in 24-36 hours; then Tab. II O.H. VI for 24 hours; then Tab. I O.H. VI
until physical signs are definitely clearing.
Administration: By reducing the dose as soon as the temperature and pulse approach
the normal figure, it was found in the later cases that the toxic symptoms of nausea and
vomiting were often obviated, whereas in all but two cases where the dose of two tablets,
four-hourly, was continued for several days, these symptoms were troublesome. The
tendency in the first cases treated was to discontinue the drug too soon or immediately the
temperature became normal. Where this was done there was a tendency for a secondary
rise of temperature, as occurred in Case 7, who received the drug for only twenty-four
hours. The second rise in temperature receded as Dagenan was again started, two tablets,
four-hourly. Case 1, who was quite ill for four days, with chills and a temperature of
106° on admission, responded rapidly, as seen in the table, and the drug was shortly stopped.
After five days of normal temperature with clearing of physical signs, she showed an
elevated temperature and developed an empyema which has been aspirated and appears to
be now disappearing with continued Dagenan therapy—one tablet six-hourly.
Children appear to tolerate this drug very well, the two cases treated receiving three-
quarters of a tablet and one tablet nine and four-hourly, respectively. However, there
were some nausea and vomiting when this dosage was continued more than twenty-four
hours without reduction.
For patients who have difficulty in swallowing tablets, these are readily powdered and
may be given in milk. Since the drug is quite insoluble in water, no form suitable for
parenteral use is on the market. The rectal route has not been satisfactorily investigated
as yet. Because of its rapid absorption, nausea and vomiting were not thought to be
sufficient cause to discontinue Dagenan; it was found thatt as long as the medication was
not vomited immediately, a satisfactory blood level of the drug could be obtained in the
nauseated patient, using the oral route. Equal amounts of sodium bicarbonate were given
with each dose of Dagenan.
Blood Concentration of M. &. B. 693: At the onset of the pneumonia a blood level
of 5—10 mg. of the drug per 100 cc. blood appeared to give a satisfactory response in our
cases. Later, when the patient was placed on a maintenance dose, a level of 3 mg. seemed
sufficient. The first estimation in our cases was done between twelve and twenty-four
hours after starting the drug. In several cases, the high blood concentration suggested
that the dose recommended above is unnecessarily high.
Toxic Symptoms:
1. Cyanosis was marked in three cases, disappearing as the drug was lessened.
2. Nausea and vomiting were present in eight of the twelve cases, occurring most
often after the administration of 6 to 7 gms. of the drug, i.e., about the end of the
first twenty-four hours, though Case 7 vomited after the first dose of four tablets.
3. Case 5 developed a generalized raised erythematous, pruritic rash, of the type not
uncommonly seen with prontylin. This patient had) received 29 gms. of M. & B.
693 and the rash disappeared two days after discontinuance of the drug.
No serious effect on the W.B.C. was noted in any patient.
Patients with relatively high leucocytosis responded most dramatically.
Summary: It was noted that in practically every case clinical improvement paralleled
that of the temperature chart. In some cases physical signs suggested clearing of the lung
process as early as twenty-four hours after commencing Dagenan, and x-ray plates of
the chest taken at forty-eight and seventy-two-hour intervals in two patients corroborated
these findings of rapid resolution. In case 7 resolution in the lung occurred rapidly, but
left thickened pleura and a continued temperature, of 99°. In the lobar pneumonias which
Page 147 F
had advanced to the stage of consolidation on admission, the oxygen tent was necessary
only eighteen to forty-eight hours; the remainder of this class required this measure for
less time or not at all. The majority of the bronchopneumonias did not necessitate oxygen
therapy.
Perhaps the most striking cases in the series are the seventy-five-year-old patients, one
of whom (Case 5 ) appeared acutely ill on admission, and it was felt that his heart would not
stand the strain of an attack of pneumonia. The rapid improvement in this case following
the administration of M. & B. 693, together with the results of the remaining cases, makes
us feel that we have at hand a chemo-therapeutical agent which is effective in pneumococcal infections of the lung. At a later date we hope to present figures which will justify
our present expectations.
BLOOD SEDIMENTATION TESTS
Although this laboratory procedure enjoys a very considerable degree of popularity,
the exact physical or physico-chemical mechanism responsible for the variation in the rate
of settling of the red corpuscles in various diseases is not definitely known. While it was
originally used as a differential diagnosis chiefly in lower abdominal inflammatory processes, viz., appendicitis and salpingitis, it soon became apparent that it could not be
entirely depended upon in this respect, and indeed, while in many conditions consistently
high rates are the rule, they cannot in themselves alone be regarded as significantly diagnostic. As Osgood says, "It should be regarded as a somewhat different and sometimes more
sensitive criterion of bodily reaction to injury than are fever and leucocytosis. Hence is
chief value is not in differential diagnosis but iri following the progress of the individual
case."
The three most widely used methods are the Cutler, Westergren and Linzinmeier.
The techniques are essentially similar, differing mainly in the size and calibration of the
tubes, the amount of blood used and the intervals at which readings are taken. All employ
the use of a sodium citrate solution which is first drawn into the syringe before the venipuncture is performed. In the Cutler and Linzinmeier methods, after thorough mixing of
the blood and citrate in the syringe it is expressed into the tubes, while in the Westergren
method it is expressed into a watchglass or other small receptacle and then drawn up into
the pipette. Readings are taken at 5-minute intervals for one hour1 in the Cutler method,
and at the end of one hour in the Westergren, although Westergren himself recommends
one, two and twenty-four-hour readings. In the Linzinmeier method the time is recorded
for the red cells to settle from the mark "0" to the mark "18" on the tube, the normal
time being 1200-1400 minutes (20-23 54 hours) for men, for women 800-1000 minutes
(13*4-16% hours), while any reading less than 200 minutes denotes a pathological process. The Cutler method is also known as the Graphic method, as the readings are reported
on a graph chart in the form of curves or lines, as follows: Horizontal line (normal or
absolute quiescence) ; diagnonal line (quiescence), diagonal curve (slightly or moderately
■ active process), vertical curve (moderate to markedly active).
It will be readily noted that there are certain disadvantages in these various methods,
chiefly in the time factor, especially in a laboratory where steady pressure of work obtains,
the 5-minute intervals readings by the Cutler method almost entirely occupying the tech-
nicians time for the full hour, and further, the apparatus has to be carried to the bedside
and set up immediately. This latter procedure is also true of the Linzinmeier and Westergren methods. It was with the purpose of overcoming this what one might call "slavery to
time" that Osgood carried out some 40,000 comparative (i.e., with the various methods)
sedimentation tests, using a modified Westergren method in which the same apparatus was
used, but with oxalated in place of citrated blood, and readings at 15 and 45 minutes. He
found that this procedure was productive of as useful information as the other methods,
the apparatus could be set up at the convenience of the technician in relation to pressure of
more emergent work as the blood was oxalated, and other portions of it could be used for
Page 148 blood chemical estimations, blood counts, etc., and further, the tests were accurate within
a three-hour period after venipuncture.
It is this modified Westergren method that we have adopted in the Vancouver General
Hospital laboratory, and it has now been in use some 18 months, replacing the Cutler
method f ormely in use. This change was made with no disparagement of the latter method,
but solely because of the great saving in time, and the convenience of the former. There
was some concern, I believe, consequent on this change, because of the change in the method
of reporting. As is well known now, the readings are reported as a fraction, the numerator
being the upper level of the column of red cells in the pipette at the end of 15 minutes, the
3-4
13-15
Rates in
denominator at the end of 45 minutes.   Normal is usually considered
women are 3—4 mm. higher than men in the 45-minute period and children 5—10 mm. A
relatively efficient method of translating these findings into terms of the Cutler graph
is as follows:
15-minute reading less than— corresponds to horizontal or diagonal line.
45-minute reading greater than — corresponds to diagonal curve.
45-minute reading greater than — corresponds to vertical curve.
Generally speaking, rates of 15—30 in the 45-minute period should be considered as
suggesting slight increase; 30—50 moderate, and 50—100 as severe, while over 100 means
an extreme increase.
Time and space do not allow for the enumeration of the various pathological processes that produce rapid sedimentation rates, but in pneumonia it is usually higher than
in any of the other infectious diseases, often over 100 mm. in the 45-minute period. However, even in a physiological process such as pregnancy, very] high rates are obtained, as
high as 30 mm. in 45-minute period in the second to fourth months; 45 mm. in the fifth
and sixth, but even up to 80 are not unusual; seventh an average of 50 mm.; eighth and
ninth months, 60 mm., while below 30 and over 100 mm. are unusual, and even normal
readings are obtained at any time during pregnancy. In the first five! days of the puer-
perium the rates may range from 40—120 mm., but following this gradually returns to
a more normal rate by the end of the second month postpartum. Thus it is evident that
pathologic processes are not the sole initiators of rapid sedimentation rates.
In tuberculosis, hcemorrhage, blood dyscrasias, malignancy, necrosing benign tumours,
extensive suppuration, etc., rapid sedimentation rates are the rule but may vary considerably in degree. In some conditions, viz., polycythemia vera and extensive hepatic disease, a
decrease or even a complete absence of sedimentation is the finding. A further point of
interest is that the 15-minute readings in the modified Westergren method are more
significant in the very rapid rates, while with the slower rates the 45-minute readings are.
Variations in room temperature, alterations in the plasma viscosity, the number, size
and haemoglobin content of the red blood cells are considered to have a definite effect on
the rate but not to any significant degree. A number of workers have endeavoured to
make corrections for low haemoglobin and red counts, but it is, generally considered that
this lends itself to no definite rule.
Temperature curves and leucocytosis are fairly characteristic for various types of
disease but this is not true with sedimentation rates, and to date no typical curves for
certain pathologic processes have been elaborated. It must be remembered that an increased
sedimentation rate does not necessarily mean disease nor does a normal rate preclude the
possibility.
In conclusion, it may be suggested that, with a test that is affected to such a degree by
so many factors, too much reliance must not be placed on it alone, but it should be considered and weighed with other laboratory findings, clinical data, etc., as one of the pieces
to be fitted into the jigsaw puzzle of diagnosis.
Page 149 An Unusual Type of Allergy—Involving the Capillaries
White female child, age 7, admitted in September, 1938, to the Pediatric Department
of the Vancouver General Hospital.
Complaints on Admission:
1. Generalized abdominal pain for the past five weeks, sharp, spasmodic, intermittent in character,
with an interval of several days between attacks.
2. Dull aching pain down the vertebral column, localizing somewhat behind both knees, also present for
the past five weeks, continuous in character and not influenced by strain or fatigue.
3. Recurrent oedema of one or both legs, arms and face, fleeting in nature, lasting from one to three
days.  The legs in particular would swell to two or three times their normal size.
4. A red spotty rash, co-existent with the cedema and covering the same area.
Past History: Recurrent sore throats with fever over the past two years; measles; pertussis.
Family History: Irrelevant.
Examination on Admission: Temperature 100.4, pulse 108, respiration 28. Patient well developed, well
nourished, lying quietly in bed; did not seem acutely ill.  The face was puffy, pale and pasty.
Tonsils hypertrophied and definitely infected. Fauces and pharynx red and injected. There were many
brownish red maculopapular haemorrhagic lesions over the extensor and flexor surfaces of both arms, over the
buttocks, both legs and over the soles of both feet.
Generalized slight tendterness could be elicited over the entire abdomen. At this time there was no
definite cedema of extremities.   The spleen was not palpable.
Laboratory Findings: Rumpel-Leede tourniquet test was positive. Urine: albumen plus 2, red blood cells
plus 3, white blood cells plus 2.   Specific gravity 1010, no casts.
Blood count: R.B.C., 3,500,000; W.B.C., 7250—67% lymphocytes; platelets, 700,000; coag. time, 2
minutes; bleeding time, 2 minutes; sedimentation rate, 4/25; Kahn and Widal, negative; blood chemistry:
normal except for the albumin-globulin ratio which was 2.87/3.68.
Progress Notes: During September the patient suffered from several sudden severe
attacks of abdominal pain which in all cases were followed by blood in the stools.
Every few days would appear a fresh shower of petechias involving at times almost the
whole body, at other times perhaps one limb or part of a limb. On one occasion, following
a transfusion, the arm to which had been applied the tourniquet became massively swollen
and 24 hours later was covered with large and small ecchymotic patches. This! swelling
only remained two days.
Throughout the month of September the urine consistently showed a low specific
gravity, albumen and blood, but a urine concentration test revealed normal kidney function.
Treatment: Frequent blood transfusions; large doses of the so-called anti-hemorrhagic
vitamine P (Citrine); calcium gluconate—high vitamines, and for a time a salt-free diet;
lastly, tonsillectomy was performed on October 11th.
Gradually there was an amelioration of symptoms. The showers of petechia; became
less frequent, the1 abdominal colic disappeared, the R. B. cells disappeared from the urine
and the stools became normal.
On discharge, October 15 th, the only positive finding was a trace of albumen in the
urine. The child was well and happy, and we present her as a case of anaphylactoid! or
vascular purpura, and we hope that the infected tonsils may have been the causative
sensitizing factor.
The use of vitamine P (Citrine) is still very experimental and in our judgment had
little bearing on the happy outcome in this case.
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Page 150 Protection Against Typhoid
Typhoid and Typhoid-Paratyphoid Vaccines
Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly
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The preventive values of typhoid vaccine and typhoid -
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progressive faVms. . . . Cool, fresh
milk arrives in a hurry . . . and it's
Carnation milk, hermetically sealed, sterilized for utter safety, almost
before the sun has set on the morning's milk . . . that is part of the
quality-background of a product
that has earned noteworthy acceptance in the field of infant feeding.
A BOOKLET FOR PHYSICIANS
—Write for "Simplified Infant
Feeding", an authoritative publication treating of the use of
Irradiated Carnation Milk in
normal and difficult feeding cases
. . . Carnation Company Ltd.,
Toronto, Ontario.
IRRADIATED
CI    IRRADIATED    \    JF l^|
arnation IVlilk
A CANADIAN PRODUCT - "from contented cows"
IRRADIATED^
-p§^§« RAPIOSimiUM
(Standardised Vitamins A and D)
IN GENERAL PRACTICE
In Prophylaxis
The daily ingestion of Radiostoleum acts as an effective safeguard against attacks
of invading organisms in epidemics of acute infections.
In Treatment
If infection has supervened, the administration of Radiostoleum in massive doses
aids in reducing the virulence by building up the patient's resistance.
In Convalescence
The administration of Radiostoleum makes good depleted reserves, stimulates
the jaded appetite, restores vitality, reinstates normal metabolic processes and
hastens the return to normal health.
Stocks of Radiostoleum are held by leading druggists throughout
the Dominion, and full particulars are available from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse Toronto 2, Ont.
-R.stm/nan/RQS
flfoount flMeasant XHnbertahfno Co. %tb.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. P. HARRISON W. R. REYNOLDS neumonias
(whatever the type)
focus your local treatment on
Antiphlogistine
applied as a poultice over the entire thoracic wall
THE DENVER  CHEMICAL MANUFACTURING CO.
153 Lagauchetiere St. W.
Montreal
Made in Canada. OLEUM PERCOMORPHUM (Liquid)
10 and 50 cc. brown bottles in light-proof cartons. Not less than
60,000 vitamin A units, 8,500 vitamin D units (International) per
gram. 100 times cod liver oil* in vitamins A and D.
OLEUM PERCOMORPHUM (Capsules)
Especially convenient when prescribing vitamins A and D for
older children and adults. As pregnancy and lactation increase
the need for vitamin D but may be accompanied by aversion to
large amounts of fats, Mead's Capsules of Oleum Percomorphum
offer maximum vitamin content without overtaxing the digestive
system. 25 and 100 10-drop soluble gelatin capsules in cardboard
box. Not less than 13,300 vitamin A units, 1,850 vitamin D units
(International) per capsule. Capsules have a
vitamin content greater than minimum requirements for prophylactic use, in order to
allow a margin of safety for exceptional cases.
OLEUM „J\
*COMORPH$*i
50S6 I
FOR GREATER
ECONOMY,
the 50 cc. size of
Oleum Percomorphum is now supplied with Mead's
patented Vacap-
Dropper. It keeps
out dust and light, ■
is spill-proof, vm~i
breakable, and delivers a uniform
drop.  The 10 cc.
size of Oleum Per- *
comorphum is.
still offered with
the regulation
type dropper.
USeS ' For the prevention and treatment of rickets, tetany, and selected cases
of osteomalacia; to prevent poor dentition
due to vitamin D deficiency; for pregnant
and lactating women; to aid in the control
of calcium-phosphorus metabolism; to promote growth in infants and children; to aid
in building general resistance lowered by
vitamin A deficiency; for invalids, convalescents, and persons on restricted diets; for
the prevention and treatment of vitamin A
deficiency states including xerophthalmia;
and wherever cod liver oil is indicated.
*U.S.P. Minimum Standard
MEAD JOHNSON & CO. OF CANADA, LTD.
Belleville, Ont.
ETHICALLY MARKETED
We purposefully selected for
these products classic names
which are unfamiliar to the laity,
or at least not easy to popularize.
No effort is made by us to "merchandise" them by means of public displays, or over the counter.
They are advertised only to the
medical profession and are supplied without dosage directions
on labels or package inserts.
Samples are furnished only upon
request of physicians.
// You Approve This Policy
Specify MEAD'S
Vbase enclose professional card when requesting samples of Head Johnson products to cooperate Jn preventing their  reaching unauthorized persons- The Doctors' Busy Season
—and Georgia Pharmacy is
ready for instant service,
with full stock, seven qualified pharmacists, and a
prompt delivery system.
Day or Night   —  Phone Sey. 2263
OMMAU
MIOMT
GEORGIA PHARMACY
w.oionQtAmm&&3Pmmr strut
(Hmttt $c if amrc IGtfr
Established 1191
VANCOUVER, B. C.
North Vancouver, B. C. 1 Powell River, B. C. Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
ROY  WRIGLEY  PRINTING au|^3fei>a  PUBLISHING  CO.  LTD.

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