History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1933 Vancouver Medical Association Jun 30, 1933

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 VOL. IX.
JUNE, 1933.
No. 9
**
X
JL-ff
JO
35
THE BUJ^pN
of the *'
Vancouver Medical Association
Menorrhagia
Thyroid Disturbances in Children
Metastases in Cancer of Female Genital Tract
News and Notes
PACIFIC NORTH-WEST MEDICAL ASSOCIATION
Hotel Vancouver.       July 4, 5, 6, 7, 1933.
PUBLISHED MONTHLY AT VANCOUVER. B.C. BY McBEATH"CAMPBELL LTD.. 326 WEST PENDER STREET
ANNUAL SUBSCRIPTION $1.50 No Counter Prescribing
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Your prescriptions are carefully filled at saving
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Vancouver Drug Company
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Head Office:
456 Broadway West Vancouver, B. C. 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. IX. JUNE,  1933. No. 9
OFFICERS 1933-1934
Dr. W. L. Pedlow Dr. A. C. Frost Dr. Murray Blair
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. C. H. Vrooman; Dr. H.' H. McIntosh
TRUSTEES
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. H. Hatfield Chairman
Dr. W. L. Graham , Secretary
Eye, Ear, Nose and Throat
Dr.  R.   Grant   Lawrence    Chairman
Dr.   E.   E.   Day    :  - - Secretary
Paediatric Section
Dr.   J.   R.   Davies Chairman
Cancer Section
Dr. A. Y.  McNair Chairman
Dr. A. B. Schinbein Secretary
STANDING COMMITTEES
Library Summer School
Dr.   H.   A.   DesBbisay Pr- J-  W Thomson
Dr. G. E. Kidd Dr-  C- E- Brown
Dr   J   E   Harrison Publications Dr. C. H. Vrooman
Dr. W. D. Keith Dr. j. H. MacDermot ?"' J„W.  ^"T*
Dr. C. H. Bastin 1)r.  ,^urray baird °r"  £ £ ^OHN,
Dr   A   W   R.rvAit t^     „   r   u   - Dr. H. R. Mustard
DK.  J\.   W.  BAGNALL £)R-   J).   £.   H.   CLEVELAND
Hospitals
Dinner Dr.  W.  C.  Walsh
Dr. J. G. McKay                                   Credentials g S. B. Pehle
t^    m t-  >,    ^ Dr. T. H. Lennie
Dr. N. E. MacDougall          1)r.   K  P.  pATTERSON Dr. C. F. Cover^ton
Dr. G. E. Gillies                     r^   s   pAUIIN
Dr. F. W. Brydone-Jack V.O.N. Advisory Board
Rep. to B. C. Med. Assn. J£; ] ^Shjer
Dr. G. F. Strong Dr. H. H. Boucher
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS, APRIL,  1933.
Total   Population    (estimated)    _
Japanese Population   (estimated)
Chinese   Population    (estimated)
Total   Deaths    	
Japanese Deaths ..
Chinese Deaths ~_
Deaths—Residents
only
Birth
Registrations
Male 128
Female    136
Rate per
203
3
8
179
1000  of
247,251
8,429
7,759
Population
10.0
4.3
12.5
8.8
13.0
INFANTILE MORTALITY—
Deaths under one year cf  age 	
Death Rate—per  1,000  births
St.i.bi.ihs   (not  included  in  above)
12
15.4
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
May 1st
March,  1933 April,  1933 to  15th,  1933
Cases    Deaths Cases    Deaths Cases    Deaths
Smallpox      0             0 0             0 0             0
Scarlet   Fever        9              1 7             0 5             0
Diphtheria         0             0 0             0 0             0
Diphtheria   Carrier         10 0              0 0              0
Ch.cken-pox        154              0 141              0 78             0
Measles          3              0 2              0 0             0
Mumps      80             0 90             0 77             0
Whooping-cough      31              0 23              0 3             0
Typhoid    Fever        4             0 2              0 3              0
Outside cases 1  Ouside case
Paratyphoid          0              0 10 0             0
Tuberculosis      118            10 84            11 34
Poliomyelitis    _____     10 0              0 0             0
Meningitis   (Epidemic)        0              0 0             0 0             0
Erysipelas           3              0 3              0 10
Encephalitis   Lethargica        0              0 0             0 0             0
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ESTABLISHED   NEARLY A
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Phone Seymour 698 730 Richards St., Vancouver, B. C.
Page 155 Investigation of an Outbreak of
Typhoid Fever in Warsaw
Almost exactly ten years after a typhoid epidemic in Warsaw and
Winona Lake a second epidemic began. The first case was reported
August 28th, and was followed by approximately forty cases and
two  deaths.
The official report on this epidemic by the State Board of Health
is as follows:
"An outbreak of typhoid fever consisting of fifteen cases resident
in Warsaw and Winona Lake caused an investigation of the milk
supply on September 8th and 9th, 1932. Representatives of the State
Board of Health assisting Dr. O. H. Richer, City Health Officer
of Warsaw, Indiana, investigated the patients' source of Milk. In
every   case,   patients   were   either   regular   or   irregular   customers   of
the Dairy of Warsaw, operated by It was later
shown   that  approximately  25  persons  who  were  transient  in Winona
Lake and who used milk from the Dairy became ill after
leaving   Winona   Lake.
"Warsaw has a city ordinance requiring all milk sold within the
city  to  be pasteurized.  A  thorough inspection of  the equipment  and
methods of the Dairy was made. Feces and urine specimens
were taken  of  members of  the immediate family  and no
typhoid carrier was identified. Samples were taken from the dairy
water supply and the examinations showed no trace of contamination.
Recording thermometer charts showed many discrepancies and irregularities in respect to both temperature to which the milk was heated
and in the length of the holding period, indicating incomplete pasteurization. The verbal statement and the records of showed
that he was buying and selling more than 100 gallons "of milk daily.
The pasteurizer capacity was only 100 gallons and the recording
thermometer charts showed that not more than 100 gallons of milk
were  pasteurized   daily.
"It  was  later  learned   that  the operator's   nephew had
worked in the dairy during the summer. Examination of his body
discharges indicated  him  to be a typhoid carrier.
CONCLUSIONS
"The typhoid fever epidemic of Warsaw, Indiana was caused by
one, or a  combination of  all  of  the following  items:
"1.    A tyhoid  carrier working in the Dairy.
"2.    Incomplete pasteurization of milk by the Dairy.
"3.    Sale of raw milk for pasteurized milk by the Dairy.
Associated Dairies Limited
DISTRIBUTING RICH, SAFE, CLEAN MILK
PHONES:
Fairmont 1000—North 122—New Westminster 1445 __£-_£
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MERCK 8C Co. Ltd., 412 St. Sulpice St., Montreal
Selling Agents
Manufacturers: Bilhuber-Knoll Corp., Jersey City, N.J. EDITOR'S PAGE
It is with great pleasure that the Bulletin.draws its readers' attention
to certain articles that it has been publishing recently. These articles represent original thought and work of a high degree of excellence, done
by some of our own members, and such work is of the greatest value,
as shewing the keenness and interest that are so essential if our profession
is to go ahead. It is not the importance of the particular piece of work
that matters: what matters is that a man practising in a small country
town should be so alive and keen on his work that he takes the trouble
to think to a conclusion the problem of puerperal septicaemia as it affects
his own practice. He does not only think, but follows Hunter's advice,
and tries: the result is a short paper in the May issue by Dr. Coy of
Invermere, which makes us all sit up and think in turn. How far is the
nurse a potential danger in the handling of maternity cases? The suggestion may lead to the clearing of several doubtful points.
Again, Dr. Brodie's paper on Subarachnoid Insufflations represents
an actual piece of work done by himself, from which he can and does
draw definite conclusions: it is a highly finished product, and its roundness and completeness add greatly to its value.
So also with Dr. Curtis' paper on Thyroid Disturbances in Children.
This is particularly gratifying, in our opinion, since he has done what
should be done more often, namely, made use of the material which lies
so abundantly to our hand in the hospitals of Vancouver. Dr. Curtis was
not content with the ex cathedra statements of the great ones of thy-
roidology, if there is such a word: he again obeys the immortal Hunter,
and tries for himself. The result may not be of world shaking significance.
That does not matter a scrap; after all, one never knows just which log
in the jam is the key-log, the loosening of which will break up the whole
mass and set the drive free. It is the fact that we have men who will
have a vision and then follow it where it leads them.
Dr. Burwell's short paper, too, on lymphatic paths of metastasis,
is an excellent bit of work, it summarizes, in a form that makes for
great convenience and usefulness, our knowledge of lymphatic paths,
and will be very welcome to all of us who have to consider treatment
and prognosis in the cases of cancer.
We are making rather a point of these papers, some may think too
much so, but we think not. It augurs well for the future of medicine in
Vancouver. For these men are not alone. We have from time to time had
other work to publish which reflects the same keen interest in research,
and without research, continuous and everlasting, medicine would never
be the magnificent thing it is. No man may say that one piece of research is more important than another. Many of the greatest discoveries
have come through some seemingly small and relatively unimportant
observation—all of it is of inestimable value—so that we congratulate
these men, and ourselves in that we are able to help them to make themselves vocal.
Page 156 Have you read the advertisements in this number? We urge you to
do so, and as far as you possibly can patronize our advertisers. They alone
make this journal possible, and they are all carefully selected. Their advertisements will be of interest to you and may be profitable.
The forthcoming meeting of the Pacific North-West Medical Association is going to be a red-letter event in the medical history of Vancouver. It takes the place this year of the Summer School, which has
generously suspended its operations for 1933, in order to give the P. N.
W. M. A. every opportunity.
The programme this year is a most excellent one. It is entirely
British, and except for one speaker, entirely Canadian. The one exception,
Dr. Kinnier Wilson of London, is well known to Vancouver medical men,
who will not forget the addresses he gave here a few years ago. Those
of us who heard these know that we are sure of a most delightful and
profitable time when he returns in July.
The rest of the programme is equally good. It is very well-balanced,
and has something for everybody; nor is it,as sometimes happens, a
specialist's programme. It is carefully designed to meet the needs of the
general practitioner, i.e. the bulk of the profession, though there is plenty
for the men in special practice as well.
We are glad to see that the Committee has, except for clinics, left
the afternoons alone. It is very difficult, admittedly, to please everybody
in this matter, but we believe that, on the whole, the plan followed here
is the best one, and the least upsetting to the man who has to keep
one eye on the stove, while he listens to the preacher over the radio.
The only proper way to attend one of these meetings is to go to another
town for it. Anyway, the month of July is the best that could have
been chosen, it is not a busy time for most of us, and we can take a
few days off.
We feel strongly that every man in the Province who can possibly
come to this meeting will be well repaid. The Committee in charge,
with Dr. B. D. Gillies, this year's President, at the head of it, has worked
hard to make this a success. They have provided a programme that will
be as good as a post-graduate course. They promise us some entertainment
in the way of golf, and a Dinner which is to be especially memorable.
Sister professions are to be invited to send representatives, and speeches
will be short and good: one or two of the speakers are men of renown
in this regard, and it is for us to get behind them and reward their
efforts in the only way that they would want a reward, namely to take
advantage of the service they have rendered us and enjoy the meal of
good things they have provided. Let us make this the best meeting the
Pacific North-West has ever known.
Oh yes, about fees. Well, $12.50 (if you pay before June 30) or
$5 a day, is, we think, very reasonable, even in these hard times, which,
we are assured on all sides, are rapidly coming to an end. We have to
have a holiday of some kind, why not make this part of it?
Page 157 IMPORTANT NOTICE
The B. C. Medical Association will hold a Dinner at the Hotel
Vancouver at 6:30 p.m. on Monday, July 3rd, at which all members of
the College of Physicians and Surgeons are urged to be present.
At this Dinner the speakers will be Members of the Council of the
College of Physicians and Surgeons who are authorized to present to the
meeting a report of the activities of the Council since the re-organization
of the B. C. Medical Association on January 1st, 1933; also selected
speakers fom the B. C. Medical Association.
Immediately following the Dinner, the ANNUAL MEETING of
the B. C. Medical Association will be held.
NEWS AND NOTES
Dr. Murray McCheyne Baird has at last taken the step, and will join
the great majority about the beginning of June. We learn that he has
chosen Thursday afternoon for the fateful event but this is probably
due to the fact that he is used to encountering hazards on this particular
day of the week and feels that it will be in keeping.
Dr. Lavell Leeson admits that he intends to follow Dr. Baird's
example but is very much more reticent about the exact date. The only
facts we can gather about this are that it will be somewhere between
June and August.
A casual visitor to the maternity pavilion some three or four weeks
ago would have seen Dr. Roy Huggard gazing adoringly through one
of the nursery windows on the third floor, while Dr. W. G. Gunn was
gazing equally adoringly through another at the- far end of the corridor.
These two gentlemen are to be congratulated on the arrival of two beautiful examples of the genus boy.
Dr. A. C. Frost has been spending a short and well earned holiday
on the Island with Mrs. Frost. We understand that they have played an
average of thirty-six holes of golf a day and they are looking very fit
on their return. The Bulletin congratulates Mrs. Frost on her very fortunate escape from serious injury in the motor accident of a month or so
ago.
Dr. H. B. Maxwell, who used to practise in Vancouver some years
ago and has since b^en practising on Vancouver Island and the lower
mainland is leaving for England shortly where he intends  to take up
Page 15S practice and hopes to remain, he says, for the rest of his natural life;.
We shall all miss him very keenly as everyone who knew Bertie was
very fond of him for his genial and kindly spirit. Mrs. Maxwell accompanies him and his two boys will follow later on.
Dr. J. J. Mason recently spent a couple of weeks on the  Island
holidaying. He looks very well and fit since his return.
Dr. J. C. Haramia who has been away at Hazelton for the past
three months has now returned to Vancouver.
We congratulate Dr. Harry Milburn on the miscellaneous collection
of objets d'art that he accumulated at a recent golf tournament. One's
only fear is that nobody will again believe that his handicap should be
22.
A team of golfers from Seattle and Victoria invaded the city recently and have gone home with the scalps of the Vancouver braves
who are grimly waiting for next year to take their revenge. The game
was played at Shaughnessy Golf Course and everyone had a delightful
time.
We are very glad to see that Dr. F. N. Robertson has completely
recovered from the very painful effects of an accident to his eye some
weeks ago: which confined him to bed for several days.
Dr. J. L. Turnbull has returned from Savary Island, where he has
been for some weeks. He looks ten years younger and in some mysterious
fashion has accumulated a coat of tan. This will be no surprise to those
who know Savary Island, but looks rather novel to those of us who are
living in the land of perpetual rainfall that Vancouver has proved itself
to be for the past year or so.
Dr. J. A. (Okey) Smith goes about these days with a happy smile
on his genial face for has he not succeeded in adding half the medical
population of Vancouver to the membership of Shaughnessy Golf Club?
Thereby doing them a good turn, as well as fulfiilling his duties as
chairman of the Membership Committee.
Page 159 MENORRHAGIA
By J. E. Harrison, Vancouver.
A modern, thorough understanding of the principles involved in
the production of menorrhagia (profuse or prolonged menstrual flow)
presupposes a rather full acquaintance with the new physiology of menstruation and endocrinology, in both of which rapid advances have been
made during the last few years by laboratory experiment and clinical
study. Ideas on these subjects are, at the present time, in such a state of
flux, that it is perhaps unwise for us to have dogmatic views of any
kind in this relation. Many of our former convictions have, as in so many
other branches of medicine, gone the way of all flesh, and have been
replaced by newer, more or less proven theories and beliefs, which in
turn are paving the way to still more amazing unplumbed truths.
Not so very long ago investigation of a case of menorrhagia was
confined chiefly to the examination of the pelvic organs with a general
search for constitutional diseases, and treatments were perhaps mainly
operative efforts. To-day, however, although attention is still directed
toward local pelvic abnormality and general disease, we are, or should
be, endocrine-conscious.
May I first mention briefly the causes of menorrhagia which are
most familiar to us. Menstrual haemorrhage, its amount and duration,
may depend, in general, upon the functional state of the uterus and
active or passive pelvic hyperaemia. The factors controlling the amount
and duration of the flow then may be (1) the contractility and tonicity
of the uterine muscle, (2) the degree of active or passive engorgemeent
of the pelvic blood vessels, and (3) the coagulability of the blood.
Loss or decrease of contractility and tonicity is associated with a
hypoplastic state, congenital or acquired, general and uterine asthenia,
subinvolution and fibrosis as related to chrome metritis following puerperal and other infections and myomata or polypi. Hyperaemia may be
active or passive. Active hyperaemia results from infections and displacements of the genital organs. This, of course, includes all types of metritis,
parametritis and endometritis, salpingitis, oophoritis, acute or chronic;
also the congenital and acquired displacements. Passive hyperaemia is
caused by cardiac, pulmonary, hepatic and nephritic disease. Coagulability of the blood may be altered by blood dyscrasias, such as purpura.
Uterine or ovarian cancer and lues are also found frequently to be causes
of menstrual haemorrhage.
The principles of treatment of these pathological states are familiar
to us all. General toning up of the asthenic and non-contractile types,
through regulation of diet, proper exercise, sleep, rest and suitable medication. Hot vaginal douches and possibly diathermy may be used. Curette-
ment may occasionally be performed as a stimulating measure to promote
contractility of the uterus, or to secure material for histologic study: for
often only by such means may insidious malignant growths be discovered.
Curettage will be found to arrest haemorrhage in 50% of cases but at
Read before the Osier Society of Vancouver.
Page 160 best is usually only a temporary measure. Many of these types of menorrhagia which have in the past fallen into this classification are found now
to be benefited by suitable endocrine therapy, of which more will be
said anon. Certainly the more radical forms of treatment should be postponed until these measures have been tried. In some cases, especially those
associated with great irregularity of haemorrhage, x-ray radiation or
radium implantation may be indicated, and should be used in many
instances in preference to surgery. Radical surgical procedures, particularly in these types of bleeding, are becoming less popular.
Treatment of active hyperaemia resulting from infection and displacements of the genital organs, shows also a modern tendency to conservatism and expectant management, displacing many surgical methods
of a decade or so ago. The handling of those cases of menorrhagia caused
by general constitutional diseases is obvious, and may be specific or pallia-!
tive.
Let us. direct our attention, for a moment, to some of the newer
conceptions of the physiology of menstruation, and how they affect the
treatment of menorrhagia. The * periodicity of the menses probably depends upon the time-duration of ovulation and the life-duration of the
expelled ovum. When the ovum is not fertilized, but succumbs, we may
look upon the result as an afertile or menstrual abortion. The menstrual
decidua becomes detached, menstruation begins, resolution of the corpus
luteum ensues and another Graafian follicle develops. During the last
few decades, research workers have been endeavouring to find out how
far the regulation of the female sexual cycle is dependent upon the
influence of hormones.
In the normal menstrual cycle the Graafian follicle develops and
matures during the first half of the intermenstrual period-from 14-18
days. It can now be taken as definitely proved that the ripening follicle
elaborates an oestrus-inducing hormone or rather a group of closely
related chemical compounds to which is given the name of follicular
hormone. The chief function of this hormone is to stimulate the development of the secondary sex organs of the female, such as the uterus,
vagina and mammae. The concentration of this oestrus-inducing hormone
in the blood increases during the first half of the intermenstrual period
and attains a maximum about two weeks prior to the onset of the next
menstruation. This rise in concentration in the blood is paralleled by a
rise in the excretion of the hormone in the urine. After rupture of the
follicle on approximately the 15th day the concentration of the hormone
drops rapidly to a low value, followed about nine days later by a short
rise just before menstruation. Accompanying this appearance of the follicular hormone in the early part of the intermenstrual period, there
is growth and development of the endometrium characterized by an increase in blood vessels and stroma. This is sometimes called the interval
type of endometrium. If growth and rupture of the follicle are followed by normal development of a corpus luteum, the latter generates another hormone whose main purpose is to stimulate the uterus to prepare
a decidua suitable for the recption of a fertilized ovum. These further
changes, under the influence of the corpus luteum hormone are often
Page 161
===== ca.led pseudo-pregnant or true pre-menstnial changes, and comprise the
corpus luteum phase of the cycle. If pregnancy takes place the corpus
luteum phase continues, and facilitates the retention of the fertilized ovum
and protects the developing embryo. When the corpus luteum does not
develop properly, on account of failure of ovulation or follicle rupture,
these final changes do not occur in the endometrium, but if there has
been follicle growth and production of adequate amounts of follicular
hormone, there develops the so-called interval type of endometrium, and
bleeding occurs which may simulate menstruation.
It is obvious, then, that the maintenance of a normal menstrual
cycle depends upon adequate development of corpora lutea, and demands
a reasonable supply of both hormones.
These processes occurring in the mature ovary have been shown by
Evans and others to be dependent upon the secretory activity of the
anterior lobe of the pituitary body. Aschheim and Zondek showed that
a substance is found in large quantities in the urine of pregnant women
which is either identical, or closely related chemically with the gonad
stimulating hormone of the anterior pituitary lobe. They believe that two
separate components or hormones, which they call Prolan A and Prolan
B, are essential for the control of the ovarian cycle. "A," for the production of mature follicles and follicular hormones and "B," for luteini-
zation and production of the premenstrual phase.
Neither the preparation of these two components in pure form, nor
their separation, has yet been accomplished, but it has been found that
administration of small quantities stimulates the follicular hormone, while
in larger quantities the dominant effort is that of Prolan B. According to Weisner, this is because the "A" principle becomes inert rapidly,
even on standing, and its maximum effect is reached long before that of
the "B" element. For this reason the administration of Prolan, or similarly,
anterior pituitary lobe extract, in large dosage gives a definite luteinizing
effect. This has been also noted by other workers.
When we consider that experimental removal of the Graafian follicle or corpus luteum is followed in from 48-72 hours by sometimes
profuse uterine bleeding, we can "readily see the application of hormone
therapy of this kind. Any influence which will tend to promote a normal
follicular development, with its accompanying secondary changes, normal
ovulation, and a normal corpus luteum phase with its associated premenstrual uterine changes, will in all probability produce a normal menstrual period.
The particular gynaecological problem which invites the application
of such observation is that of functional uterine bleeding. Novak made
some interesting observations on this condition. He believes the immediate
disturbance to be in the ovaries, the historical picture showing an absence
of corpora lutea or other lutein elements, with the persistence of unruptured Graafian follicles. On the basis of this he assumes that the
ch'ri'-teristic "hyperplasia of the endometrium" and the associated uterine bleeding are due to absence of progestin or corpus luteum principle,
Page 162 and a relative excess and persistence of the folliculin effect. The endometrium in these cases confirms this impression for it presents a picture
of over-grown interval endometrium. The administration of extract of
corpus luteum or the luteinizing hormone contained in anterior pituitary
lobe, then, should convert the hyperplastic non-secreting endometrium
into a pregravid or normal premenstrual one, thus completing the cycle
and causing cessation of bleeding. Novak used a preparation of anterior
pituitary substance in a series of fifty-one cases of this type, many of
them recurrent, often with a history of several previous curettements, and
in 44 of these bleeding was checked satisfactorily.
Adequate stimulation of the ovary, of course, by either follicular
hormone or corpus luteum hormone or Prolan may not produce a typical
response in the presence of local or ovarian disease.
That the substance called Prolan which is found in large quantities
is pregnancy urine, is not identical with the anterior pituitary sex hormone, is shown by the fact that it has no effect in an animal from which
the pituitary gland has been removed. It is looked upon, therefore, as an
activator, stimulating the gland itself to produce more of its sex hormone. Prolan is supposed, according to most recent investigation, to be
elaborated in the chorionic portion of the placenta during pregnancy.
Collip found that what he calls a second placental principle was similar
to anterior pituitary extract. He names it H.P.L. or anterior pituitary-
like hormone of the human placenta and he has proved it to be of
exceptional value in menorrhagia. The dosage employed is from 1-2 cc.
injected subcutaneously daily or every 2 days. In the simpler types of
menorrhagia, treatment for one week before the menses are expected,
reduces the flow. The more severe types may require treatment for three
months or longer before normal periods are established.
From these remarks it may be seen that gradually there is being
established, by means of laboratory experiment, a number of facts concerning the physiological effects of active principles purified to a greater
or lesser degree and derived from ovarian tissue, pituitary glands, placentae, and pregnancy blood and urine. Knowledge of the physiology of
any one of these hormones, does not, however, help us greatly to understand the exact manner in which some or all of these principles harmoniously interact, or to what extent hypo-or hyper-activity of any one gland
may affect the activity of the others. The exact manner in which, therefore, an active principle of placental or pituitary or ovarian origin may
restore a case of excessive menstrual bleeding to somewhat normal functioning, must remain for the time being an unkown quantity.
This little treatise on menorrhagia would not be complete without
mention of the role played occasionally by hypothyroidism, and even some
cases of toxic goitre. Excessive bleeding is the menstrual disturbance most
frequently associated with hypothyroidism, amenorrhoea rarely, if ever,
occurring when the thyroid gland alone is deficient in function. In
patients of any age whose menorrhagia cannot be attributed to pelvic
pathology, a basal metabolism test should be made and even though this
Page 163 Meeting of Pacific North-West Medical Association
July 4th, 5th, 6th, 7th,
Hotel Vancouver, Vancouver, B. C.
President—Dr. B. D. Gillies
GUEST SPEAKERS
Dr. A. T. Bazin, Professor of Surgery, McGill University, Montreal.
Dr. C. H. Best, Professor of Physiology, University of Toronto.
Dr. Wm. Boyd, Professor of Pathology, University of Manitoba.
Dlr. J. G. Fitzgerald, Dean of the Faculty of Medicine, and Director of the
School of Hygiene and Connaught Laboratories, University of Toronto.
Dr. A. H. Gordon,  Professor of Medicine, McGill University, Montreal.
Dr. A. T. Mathers, Associate Professor of Medicine, University of Manitoba, Winnipeg.
Dr. S. A. Kinnier Wilson, 14 Harley St., London, England.
Dr. D. E. S. Wishart, Junior Demonstrator of Oto-laryngology, University
of Toronto.
Tuesday, July 4th—
8:00- 9:00 a.m.—Registration.
9:00- 9:40 a.m.—Dr. A. T. Mathers, "Medico Legal Problems."
9:45-10:25 a.m.—Dr. Wm. Boyd, "Tumours of the Neck."
10:30-11:10 a.m.—Dr. A. H. Gordon, "Migraine."
2:00 p.m.—Surgical Clinic, Dr. A. T. Bazin.
8:00- 8:40 p.m.—Dr. D. E. S. Wishart, "Vertigo."
8:45- 9:25 p.m.—Dr. Kinnier Wilson "Visceral & Affective Epilepsy".
9:30-10:10 p.m.—Dr. J. G. Fitzgerald, "Some aspects of the Problem
of  Meningococcic  Meningitis."
10:15-10:55 p.m.—Dr.   C.  H.  Best,  "Recent  Work  on  Carbohydrate
Metabolism."
Wednesday, July 5th—
8:30- 9:10 a.m.—Dr. A. T. Bazin, "Acute Osteomyelitis."
9:15- 9:55 a.m.—Dr. A. T. Mathers, "Psychoneuroses-."
10:00-10:40 a.m.—Dr. C. H. Best, "Recent Work on Fat Metabolism."
10:00-11:00 a.m.—Dr. D. E. S. Wishart, "Mastoiditis in Children."
10:45-11:25 a.m.—Dr. Wm. Boyd, "Why Does a Patient Recover from
Infection?"
2:00 p.m.—Medical Clinic, Dr. A. H. Gordon.
8:00- 8:40 p.m.—Dr.   A.   T.   Bazin,   "Tumours   of   the   Colon   and
Rectum."
8:00- 9:25 p.m.—Dr. J. G. Fitzgerald,"Recent Work in Staphylococcic
Infections."
p.m.—Dr.  Kinnier Wilson,  "Cerebral Tumours."
H. Gordon, "The Diagnosis of Disease with Coincident Enlargement of the Liver and Spleen."
Tests from the
9:30-10:10
10:15-10:55—Dr. A.
Thursday, July 6th—
8:30 -9:10 a.m.—Dr.
9
9
10
15- 9:55
00-10:00
00-10:40
C.  H.  Best,   "Liver  Function
Physiological Point of View."
a.m.—Dr. A. H. Gordon,
a.m.—Dr. D. E. S. Wishart, "Sinusitis in Children."
a.m.—Dr.   Kinnier   Wilson,   "Hysteria   from   the   physiological side."
10:45-11:25 a.m.—Dr. A. T. Mathers, "Sleep and its Disorders."
2:00 p.m.—Golf Tournament, Shaughnessy Golf Course.
7:30 p.m.—DINNER.
Friday, July 7th—
9:00- 9:40 a.m.—Dr. J. G. Fitzgerald, "The Nature of Antigens."
9:45-10:25 a.m.—Dr. Wm. Boyd, "The Pathology of the Breast regarded as Disordered Physiology."
a.m.—Dr. A. T. Bazin, "Lesions of the Breast."
p.m.—Neurological Clinic, Dr. Kinnier Wilson.
Information:
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Paulson Medical-Dental Bldg.
Spokane, Wash.
by June 30, $12.50. Any individual day $5.00.
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should be given before more radical measures are contemplated. Definite
hypothyroidism may occur in the presence of an apparently normal
BMR.
I sincerely hope that my few remarks tonight do not leave you   more
hopelessly entangled than ever in the maze of endocrinology.
METASTASES FROM MALIGNANCY INVOLVING
THE FEMALE GENITAL TRACT
K. M. Burwell, Vancouver.
The question of metastases from malignancy involving the female
genital tract is far too comprehensive for me to even scratch the surface
in the time allotted for it. In addition, one cannot even think of any
primary malignant growth in this or any other organ without wondering
how great a swath it will cut. All of us are well acquainted with the
organs and tissues involved in cancer spread by continuity and contiguity; most of us recall the blood supply without any great difficulty;
but fewer are well acquainted with the lymph circulation; and is not
this the greater menace? However, to cover this tonight is not possible,
sufficient will it be for us to pass through the genital tract step by
step, and point out certain salient characteristics in metastasis from a
growth of a particular part; to mention some interesting findings, which,
although not so common, are none the less worthy of note.
The Vulva
Metastasis from squamous—celled cancer of the vulva is early and
exists long before palpability. The inguinal and femoral glands are most
frequently involved. Stoeckel believes that when surgery is indicated
the iliac glands should be removed as well.
Dissemination in melanoma of the vulva is so rapid that Erichsen
does not believe in local treatment if the primary growth is larger than
a filbert. Florini's case, reported in 1932, involved the clitoris and at the
time of excision was not marked by any inguinal adenopathy. Eight
months later the patient died, and at autopsy metastases were found in
the abdominal nodes.
Adenocarcinoma of the gland or duct of Bartholin metastasizes early
to the inguinal glands.
Whether rodent ulcer is malignant or not is still under discussion.
Crossen does not consider it so. At any rate the lymph glands and viscera are never involved.
Primary cancer of the urethra is very rare. Metastasis to the inguinal
glands occurs in about 20% of cases. Dr. Arbuckle had such a case last
year and should be able to give first-hand information on this subject.
Read before  the  Cancer  Section  of  the  Vancouver  Medical Association  on   February
27th, 1933.
Page 164 mm*
The Vagina
Cancer of the vagina secondary to cancer of the uterus, rectum,
bladder or external genitalia, is far more common than the primary form.
Gellhorn and Fleischmann report metastastic hypernephroma of the vagina arising respectively from the kidney and left suprarenal gland.
The paravaginal tissues are early involved with resultng fistular
development and extension to the broad ligaments, ureters, and ovaries.
Glandular metastases depend on the situation of the growth; if near the
vulva to the inguinal glands, and from, the remainder of the vagina to
the hypogastric, external iliac and sacral promontory nodes.
Fallopian Tube
Many ccses considered to be primary are really secondary, reaching
the tube by direct extension from an ovarian or uterine growth, or by
way of the lymphatics, abdominal ostium or viscera.
Metastases from carcinoma of the Fallopian tube are in the direction
of the uterus, ovary, or regional glands. Stein, of New York, recently
reported a case of primary chorionic cancer of the Fallopian tube with
metastasis to the liver and abdominal nodes but none to the lung. The
patient died from haemoperitoneum.
The Ovaries
Adenocarcinoma of the ovaries is the most malignant of all ovarian
tumours. The omentum is the favorite site of metastasis; nodules are frequently found in the intestine.
The papillary variety of adenocarcinoma is almost always cystic
and tends to proliferate. These metastasize by way of the perivascular
lymphatics and to the regional glands (late); especially the retroperitoneal
and inguinal ones. Peritoneal implants from rupture of the capsule may
fill the pouch of Douglas. In Hoffmann's case tumour metastases were
found in the liver and thyroid gland and gave symptoms of Basedow's
disease.
As I have metioned in dealing with the tube, the growth found may
be secondary to a primary growth elsewhere; and in this case always
resembles the parent growth, whether or not it arises in the colon, liver
or breast. In Hempel's case the origin was in the pylorus; in Reichel's the
uterus. Marken's case followed linitis plastica, Goinard's was from the
rectum, and Bennett's from the jejunum.
Last spring you will recall Dr. Mason bringing before the Clinical
Section of this Association at the Vancouver General Hospital a case of
Krukenberg tumour of the ovary. The presentation of the case and the
discussion which followed was sufficient to warrant no further mention'
of this clinical entity.
Chorionic cancer may occur at the site of an ectopic pregnancy or
result from malignant evolutionary changes in an embryoma.
Page 165 Sarcoma of the ovary is very malignant and metastasizes early by
continuity, contiguity, and by way of the blood stream to the viscera,
peritoneum and pleura.
The Cervix
A thorough study of this subject is not within the scope of this or
any other single paper. The space given over to it in the larger textbooks and the necessity of knowing the anatomy and histology of the
tissues involved, make it almost necessary to enumerate the issues one
by one.
The study of autopsy specimens has been very illuminating, at times
discouraging, and again hopeful. Sampson's twenty-seven cases showed
that twenty had extended beyond the uterus, of which twelve had metastasized to the parametrium and iliac glands. In this same series the
pelvic lymph nodes were studied in nineteen cases, of which nine showed
metastases. Schauta made a very thorough study of sixty cases and noted
that in 43.3% the glands were entirely free. Kundrat's analysis of eighty
cases showed only four in which the glands were involved with the parametrium free.
Certain general points are worthy of mention. There is no demonstrable relation between the size of the primary growth and the occurrence of metastases. A large lymph node is not necessarily metastatic,
while a small one is not necessarily free. There is about the same proportion of free glands found in inoperable cancer as there is involved
glands in operable cases, which is about one-third. Cancerous glands are
frequently not much enlarged, firmer than normal, sometimes hard as opposed to septic soft glands.
The seriousness of malignancy of the cervix is due to the complex
lymphatic system in the parametrium about it; for it is directly to the
parametrium, utero-sacral ligaments and sides of the rectum that all
lymphatic channels lead. As regards the blood stream, cancer spreads less
frequently in this way than does sarcoma.
Let us now note the extension to the various organs of the body.
Growth beyond the internal os to the body of the uterus occurs only late.
The tubes and ovaries are rarely involved, and even then only in advanced
cases. As may be readily understood, direct extension to the vagina is
frequent, and involvement may also take place by implantation, by retrograde lymphatic spread, or by direct extension along the lymph node.
At times one finds the deep tissues involved, forming submucous lumps
and areas of induration which later ulcerate.
The proximity of the bladder and rectum necessitates not infrequent
involvement. The presence of the cul-de-sac of Douglas protects the rectum for some time against'invasion. Direct extension occurs along the
vaginal walls and may eventually lead to obliteration of the cul-de-sac.
The parametrium is the blood-vascular-lymphatic-hilum of the cervix. About one hundred and twenty ganglia are present in the paramet-
Page 166 B_L!*__
rium. There are three groups of parametrial nodes; one where the artery
crosses the ureter and which is often first involved; the small lymph
nodes; and nodes along the wall of the main vessel. Kundrat found in
seventy-six cases operated upon by Wertheim in which the parametrium
was involved on one or both sides, that there was 71% in which the
glands were entirely free from metastases. This a little higher percentage
than in G. Winter's series. As a result of necrosis and sloughing a zone
of cellular infiltration may develop which cannot be distinguished clinically from malignant infiltration; thus not all parametrial infiltration is
malignant.
The pelvic lymphatics are not involved as often as previously considered. The parametrial glands may escape entirely; the cancer cells
lodging in the iliac or sacral nodes. Other glands as the sacral, superficial and deep lumbar, inguinal and colic glands may be invaded from
time to time. Schauta considered the glands to be in four stations; parametrial, promontory, intermesenteric, and coeliac. The acceptance of his
operation shows how relatively infrequent is involvement of the latter
stations.
The ureters in their terminal portions are frequently obstructed by
compression from infiltration or by direct extension from the growth.
Mjetastases to distant organs are only found in advanced cases. Prone
are the liver and spleen. MacCormac autopsied one hundred and nine cases
noting visceral metastases in only 20%. In the some series, kidney lesions
occurred in 43.5%   (hydro-and pyonephrosis).
Extension by the blood stream reproduces the parent growth wherever the cells may lodge. The lungs are frequent sites. Fournier reported
two very interesting cases of left supraclavicular cancerous adenopathy
in cancer of the cerivx treated surgically; the route probably was by
way of the hypogastric nodes through the prevertebral, lumbar and mediastinal nodes to the neck.
This aspect of the subject would not be complete without reference
to the question of radium. There is no real evidence to prove that radium
causes metastasis; rather does it serve to prolong life to such an extent
that at times quiescent cells in a lymph node, lying dormant for years,
suddenly proliferate.
Corpus Cancer
Cancer of the body of the uterus as opposed to cervical cencer is
more circumscribed, less infiltrative, and shows a diminished tendency
to lymphatic extension. The lymphatics draining the body run along the
upper border of the broad ligaments in close relation with the ovary and
tube, and then accompany the ovarian vessels over the brim of the pelvis
to reach the chain of lumbar lymph glands lying on either side of the
spinal column. Other lymphatic vessels run with the round ligaments to
the inguinal glands. At times cells are carried in the uterine discharges,
lodging and growing in the vagina to produce secondary growths from
Page 167
zss which metastases may  be found in  the liver  and  omentum.  Strachan
found vaginal metastases in five of thirty cases.
Chorionic cancer of the uterus spreads to various organs through
the blood stream by erosion of the vessel; especially prone being the brain
and lungs. Occasionally the growth perforates the uterus leading to intraperitoneal haemorrhage.
Sarcomata of the uterus metastasize relatively later than carcinor
mata. The endometrial type is much more malignant than the fibro-
muscular form on account of the earlier infiltration to the perimetric
tissues and the more frequent metastases to other organs; especially the
lungs, more rarely to the iliac glands.
THYROID DISTURBANCES IN CHILDREN
By E. Johnston Curtis
In September 1932, Dr. Helmholz of the Mayo Clinic spoke on
"Thyroid Disturbances in The Child," before the Summer School. The
title of this paper is the same. Far be it from me to re-hash what so able
a paediatrician has told you. This paper will deal with our findings in
children who have an enlargement of the thyroid as we see it in Vancouver.
This paper is the result of mere curiosity, which was aroused some
time ago by the insistence that Jimmy Jones or Mary Jones had goitre,
and he or she should be treated for the condition. I carried on for a long
while in the,time-accustomed manner: with each visit came another "repeat" of the old prescription for sodium iodide. There was no consideration of the patient's age, hereditary influence, living conditions, presence
of parenteral infections, or of the actual state of the thyroid gland itself.
After a time I began asking myself questions—is this thyroid really
enlarged? If it is, then by what means or standards am I gauging its
size? Soon I found myself saying that if he or she had more fat or was
not so under-nourished the gland would never have been noticed or given
me any concern. Seldom was the so-called thyroid enlargement noted
first by the parents (12% were first noted by the parent and all these
were in younger children.)
Some cases returned at very long intervals, dissatisfied because the
medicine had not made the gland disappear. Some were disgusted and
did not return. Many more kept returning because the child was "still
nervous." Others returned because of repeated parenteral infections. I
was always remarking on the cold blue fingers.
This went on so long that it was felt that it would be worth while
to begin a systematic study of the questions presenting themselves. Broadly speaking, were we doing the right thing by treating every individual
in the same manner?
Read at a meeting of the Vancouver  Osier  Society,  March  22,   1933.
Page 168 *•_*__-_
I have found nowhere anything which satisfactorily tells me what
constitutes an enlargement of the thyroid in children. Marine, however,
states that the thickness of the isthmus is a good indication of enlargement. There it ends. One is taxed in this problem when it is realized that
83% of our cases were more than 5/? underweight. I now know from ex^
perience that slight degrees of enlargement are difficult to determine. It
seems to me that the gland need not only be visible but must also be
enlarged to palpation and that its consistency must be different to the
indefinite, soft, jelly-like mass that a normal gland presents. In the adipose
individual inspection means little.
Then the personal equation of the examiner plays an important role.
The Out-patient Department of the Vancouver General Hospital, at
the suggestion of Dr. Carder, set aside a period each week for the observation of these cases. This history and findings of the 156 cases I consider fairly accurate as there have been two of us handling them. There
is thus more uniformity of opinion than if the material been taken from,
say, six doctors. I am indebted to Dr. Grant for his patience in sticking
to a definite scheme and an often uninteresting repetition of things for the
past three years. I shall not try to bore you with percentages. (These
cases had about three hundred distinct courses of treatment.)
As ever, girls predominate in number, but it is interesting to note
that boys are increasingly affected. The youngest seen was three years
of age. 50% of the cases were less than twelve years old. The frequency
of foreign parentage—"the dregs of Europe"—is very noticeable. Is it
generally because of their less hygenie mode of living or their diet? Allen
of Winnipeg and others have found the incidence in cabbage-eating
families much higher.
Is Greater Vancouver a goitrous district? Dr. Lamont gives me the
information that he held special thyroid investigation clinics involving
7000 children. In these he found 24% had a palpable thyroid. The district
was from Cambie St. east. It is interesting to note that that side of the
city is not supplied wih Capilano water. He also states that the prophylactic use of iodine tablets furnished by the schools is a negligible quantity for the whole city. In this 24f < , the number of boys and girls was
equal—ranging between the ages of 6 and 11 years. The incidence of
thyroid enlargement, "goitre," given in the school annual reports for
the city  (1931)  is approximately 5%.
However I would question whether we can consider our childhood
community as goitrous in the same sense as the Ohio workers—in that
iodine deficiency is the cause of goitre. True, we know that the iodine
content of the water supply is negligible. It is to be noted that these
cases were born on the prairies of already goitrous mothers, and the growing child lived east of this coast line for at least six years. Half can be
considered goitrous families. The mothers all nourished their babies at the
breast. No mother or infant had cod liver oil among these prairie folk.
McCarrison's animals on an iodine-free diet in clean cages did not
develop goitre; those in dirty cages did. When those in the dirty cages
Page 169 were given iodine or cod-liver oil goitre did not develop. Is there anything in the fact that today so many babies are receiving cod liver oil that
it will be a preventative of goitre as well as of rickets? Is the iodine
present in the cod liver oil in an amount sufficient to prevent goitre,
or is it the vitamin content? Is this an argument for the use of cod liver
oil rather than Viosterol in infant feeding?
McCarrison again has proved that diets deficient in vitamin content,
particularly vitamin B, are capable of causing goitre in a type hitherto
unproduced experimentally, and in no way related to iodine intake.
The living conditions of these children were found to be good in
few instances, the vast majority were poor. Do the children in our better
homes get goitre? My impression is that they do not with anything like
the same frequency.
A sufficiency of iodine (that is, if we consider lack of iodine the
cause of goitre) becomes an insufficiency in the presence of such un-
hygenic conditions as noted above. Does the same necessarily apply whenever an extra load of energy is required; as, for instance, during or as
a result of repeated parenteral infections or persistent nutritional or developmental difficulties? A large number of these badly nourished youngsters gave a history of such difficulties in their infancy and pre-school
periods.
It is known that metabolism is increased where malnutrition exists.
I take it then, that an extra demand is made on the thyroid and the
result is a compensatory enlargement. Surely the elimination of causes
which produce the malnutrition is quite sufficient to influence for the
better this thyroid enlargement and its symptoms.
Half the cases gave a history of repeated infections, many came with
active infection, and half had decayed teeth of no mild degree. Does the
dental decay mean an upset mineral metabolism and thus an added load
for the thyroid?
We are dealing, it must be remembered, with a growing organism,
the metabolism demands of the child are large and, with added stress, the
thyroid must work overtime.
We have seen numbers of cases with bad tonsillar infection greatly
improved by their removal. The elimination of a pyelitis produced a
normal child within a short time. The drainage of an infected maxillary
antrum slowed all the increased metabolic processes, and in a reasonable
course of time all signs of thyroid disturbance disappeared following the
clearing up of chronic chest conditions. Heart disease, acute and chronic,
nephritis, diabetes, we have seen these influence the consistency and size
of the thyroid..
In the latter, the linking of the endocrines is readily realized. It is
important to remember that there is a very striking interdependence between the various glands of internal secretion, and that disturbances in
metabolism,  in  diseases  associated  with   pathological  conditions  of   the
Page 170 hypophysis may not necessarily be ascribable to that gland, but may be
due to an alteration in function of another gland (thyroid, adrenals)
resulting from a diseased pituitary.* I have seen two cases of Frohlich's
syndrome in which the thyroid was very much enlarged and in both cases
the thyroid gland practically disappeared with the use of pituitary substance.
The relationship of the sex glands and the pituitary you heard last
month. These things I point out to emphasize that interrelationship.
This following discussion is based on 8.7% considered as non-goitrous, 16% not treated (puberty), 75.3% treatment in some form at all
times.
The 91.3% of glands which we have considered as enlarged we
divided into—small 32%, moderate 43.7%, and much enlarged 15.6%.
The symptoms most marked were nervousness and tremors; the pulse rate
was increased in 50% of the cases; headaches, warm, moist skin occurred
with about the .same frequency (55%); eye signs were present to some
extent in 20% of the cases; dyspnoea and vertigo in 30.8%. The glands
which were enlarged were described as 21.4% hard (all were taking
iodized salt on admission) firm 39.4%; soft 49.2%. The lobes were
unequal in 36%, and nodules were definitely made out in 7.5'r .
From a general review of the symptoms and results of treatment I
feel that 18% of the cases were hypothyroid although on admission only
6% were considered so. Of the remaining (those that were not hypothyroid), 22% were considered as severe types of thyroid enlargement
(2 of these were considered to be cases of Graves' disease.)
Symptoms of hyperthyroidism in children are much the same as
in the adult, but the seyerity of the signs is not as marked. Rapid pulse,
nervousness, tremor, exophthalmos, polyphagia, dyspnoea, hyperhidrosis,
loss of weight, enlargement of thyroid, are present in varying degrees but
on the whole are less marked.
For a period we were using an organic compound of iodine instead
of the old-time sodium iodide. It was noted we were getting nowhere,
many became worse, many were helped by stopping its use. Then we
turned to the use of thyroid extract with so much effect that it is
now in almost universal use.
Dr. Helmholz considers that these cases must all have been hyper-
thyroid, drawing his conclusion from the therapeutic test. Why, then,
have only 6% shewn a low BMR on admisson? He explains this for
us by saying that the standards used for children have never been
satisfactory—that from the rates obtained at the Mayo clinic (Dr. Booth-
by) we now have something authentic, and this, he claims, proves that
our determinations were too high. However, as I said, many of the
children became hypothyroid clinically and by the BMR test.
It is to be noted that 30% were taking iodine on admission. Half
of these had taken it before the enlargement was noted. We found in
*    Gerling—Chemistry  in  Medicine—p.   252.
Page 171
ass many of these who were getting iodized salt on admission, or were given
sodium iodide or organic iodine as treatment, that when the use of iodine
was discontinued they became hypothyroid, and not infrequently the
BMR would become 10 or less (10 or 12% became minus BMR). In
all, however, when the iodized salt was stopped, there was improvement.
It is interesting to note what happened when these enlarged thyroid
cases were given iodine or iodized salt. The gland became hard or firmer,
and almost invariably enlarged. Tremors, nervousness and pulse rate increased in the majority. 77% became generally worse. In 65% of the
cases the pulse rate increased. When later the iodine was discontinued
73% improved generally. In 70% the pulse rate decreased.
Turton, in the 'Lancet', 1927, states that it is not difficult to cause
considerable distress by the use of iodine in the goitre of childhood.
For the past year those cases which we decided to treat have been
treated with thyroid substance. This was because of (1) the lack of
results from iodine, (2) the harm done by iodine (3) the fact that the
gland, when iodine was being taken, became nodular, (4) the fact that
the BMR findings were very inconsistent.
With thyroid extract 92.1% showed general improvement. In 82.9%
pulse rate decreased or remained the same (the remainder increased because of definite hypothyroid state.)
It is to be noted only small doses of thyroid substance have been
used, anl I feel that the efficacy of thyroid substnce is yet to be proven.
Only in one case did the BMR increase to any degree on thyroid
substance; this was not a hypothyroid condition. A girl of 8 years (now
10 years) had been given iodine in various forms—always the gland
enlarged, and she became highly nervous. Her condition was definitely
toxic. Then with gradually increasing doses of thyroid substance it was
discovered that not only did the thyroid decrease in size and become soft,
but she became markedly improved. When the BMR was taken the gland
could not be seen and could hardly be felt. The BMR was -(-40. This
will show the discrepancy in the metabolic rates.
It is known that thyroid extract in relatively small doses does not
have any effect on the BMR of a normal child other than a stimulative
oflfect on growth.* This leads to the question whether the BMR should
be the criterion of the effect of thyroid substance.
To me the BMR has some significance: I feel that the plus values
mean little, if anything, but the negative values will certainly indicate
a hypothyroid condition. For example: a plus 10 has no significance to
me, but a minus 10 is indicative of less thyroid secretion than in the
normal. From this experience the enlarged gland, then, would be expected
to reduce in size on thyroid therapy—become softer, and there would
be general improvement.
* American Journal Diseases of Children,  February,  1928.
Page 172 Puberty
If we segregate those girls of 12 years or over who secured no
treatment (169), we find that they gained weight as did the whole
group; that the pulse rate which was increased in the majority, decreased
in 35%; the thyroid gland remained the same size in practically all;
headaches were more frequent; the BMR increased in all and on the
whole the symptoms were the same or worse in 36%.
I think one finds that as puberty appeared in the mother so it appears
in the daughter. If the mother's menstrual history first began at 15 years
rather than at 13 years, the daughter may be expected to act in the same
way. That the thyroid enlarges at this time there is no doubt. However,
I question whether in the normal girl—that is, where no previous diseases etc., have existed and where the previous endocrine balance has
been good, the thyroid will be physiologically enlarged for a period of
more than 3 or 4 months. The persistent enlargement means that some
mechanism has gone wrong elsewhere.
Among the children of the Children's Aid Society there is an appreciable number of adolescent girls (approximately 100) which I like to
consider as a control group. The physical health and incidence of illness
is extremely low. Here only 4% have developed goitre and it is interesting
to note that they had used iodized salt extensively.
Summary
1. Measurement of the neck is unsatisfactory.
2. In estimating the size of the thyroid,  consider the child as a
whole, do not just look at the thyroid.
3. There is not one cause for goitre,—there are many.
4. Having a child with thyroid enlargement, clear up pathological
processes elsewhere and you will be surprised at the results.
5. Thyroid enlargement is not always due to an iodine deficiency.
A deficiency is relative only.
6. The BMR test by the usual standards is of very questionable
value. As regards Reid's formula, I cannot give an opinion.
7. Enlargements of the thyroid are associated, more frequently than
is generally suspected, with a hyposecretion.
8. Iodine is of doubtful value in prevention, or in the treatment
of the enlarged thyroid which is secreting normal thyroxin.
9. Iodine given to such a child may do more harm than  good.
Iodized salt in the home should be thrown on the garbage heap.
Page 17r 10.    Hyperthyroidism   does  occur  in   children,   but   the   signs
are
much less marked than in the adult. The pulse rate is more reliable in
these cases than the BMR.
1.    Many children at puberty get well without treatment.
12. Remember  that  the youngster who  is  a live wire may wear
out his thyroid.
13. If treatment seems indicated, is it not better  to use thyroid
substance?
Conclusion
It appears that a lack of iodine leads to a lack of thyroxin, because
of a lack of the wherewithal to make it.
A lack of thyroxin causes an enlargement of the thyroid gland in
response to an undersupply of this substance. When the gland has already
enlarged, the giving of iodine may result in the formation of more
thyroxin than is necessary, at least for a time. At any rate the gland
is stimulated by iodine to produce thyroxin and so is kept active.
It would seem logical under such conditions to provide thyroxin
rather than iodine, for this would give the gland rest and stimulate
functional activity. When there is hyperfunction of the thyroid, the
provision of liberal amounts of iodine may do distinct harm because of
overproduction of the hormone thyroxin which stimulates metabolism
to a marked degree.
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