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The Vancouver Medical Association Bulletin: August, 1930 Vancouver Medical Association Aug 31, 1930

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  Patient Types:
THE CONVALESCENT
During the period of convalescence Petrolagar is prescribed with
great success. It mixes thoroughly with bowel content, mechanically
protecting the delicate membrane as does the natural mucus.
Petrolagar avoids any apprehension or anxiety as to bowel function
during the days when the patient is slowly regaining strength.
Petrolagar is an emulsion of 65% (by volume) mineral oil with
the indigestible emsulsifying agent agar-agar.
Pelrelaga
r
II
Gentlemen:—Send me copy of "HA-
Petrolagar Laboratories SSSfff &&£.ffl0Vement) and
of Canada Ltd. Dr	
907 Elliott St., "Windsor, Ont. Address   	
Dept. V.M.  10. THE  VANCOUVER   MEDICAL  ASSOCIATION
B U L L EfT I N
Published Monthly  under  the Auspices of  the Vancouver Medical Association in the
Interests of the Medical Profession.
Offices:
203 Medical and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. VI.
AUGUST, 1930
No. 11
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair. Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow •
Dr. W. B. Burnett
Auditors:
Trustees
Dr. W. F. Coy Dr. J. M. Pearson
Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr.   S.  Sievenpiper Chairman
Dr. J. E. Harrison Secretary
Eye, Ear, Nose and Throat
Dr.  F.  W.  Brydone-Jack Chairman
Dr. N. E. McDougall Secretary
Pediatric Section
Dr. C. F. Covernton	
Dr. G. O. Matthews	
-Chairman
—Secretary
STANDING COMMITTEES
Library
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to B. C. Med.
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Publications
Dr. J. M. Pearson
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland
Credentials
Dr. W. S. Turnbull
Dr. A. J. MacLachlan
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Summer School
Dr. W. T. Ewing
Dr. R. P. Kinsman
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Dr. J. Christee
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Hospitals
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Dr. J. A. Gillespie
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Sickness and Benevolent Fund — The President — The Trustees We Recognize
Our Responsibility
For over 22 years the Georgia Pharmacy has
maintained the confidence of Vancouver
Doctors by carefully carrying out their instructions in the preparation of prescriptions
from the highest quality medicinals. We
recognize our responsibility.
efl©
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Sole distributors in Canada
MERCK & CO. Limited     Montreal
412 St. Sulpice St. EDITOR'S PAGE
Through a regrettable oversight, we omitted, in the last number
of the Bulletin, to acknowledge our indebtedness to the Osier Society for
the two excellent papers by Drs. W. L. Boulter and H. A. Rawlings
which we published in that number. Our readers will get an idea from
these of the calibre of the papers read before this Society, the members
of which are drawn from the younger generation of medical men practising in Vancouver.
The Society has, we understand, been in existence for two or three
years and meets at regular intervals to hear original papers read by its
members, two of whom speak at each meeting. We have been privileged
to read several of these papers and wish to pay our tribute to the marked
excellence of the work done in their preparation and selection. The
Osier Society is to be congratulated on the sincerity and high idealism
which its members have shown from the beginning, and believing that
they are doing constructive and valuable work, we wish this Society
long life and ever-increasing success and prosperity.
In one of Kipling's "Soldiers Three" tales, the immortal Mulvaney
says, "Sure, the only thrue way to wisdom is through folly, for I've
thried it."
In this is contained, very concisely, a great deal of the history of
mankind, and the emphasis is on the word "only." It is the answer to
Utopias and to dreams of perfect legislation, which shall make everybody good and wise; and, perhaps, even Mussolini will prove not to have
been the best friend to the true growth of his people.
All of which is inspired by our reading of Dr. Chisholm's thoughtful article in last month's Laboratory Bulletin, to which we hope all our
readers have given the thought and attention it deserves. Occasionally,
(this is by the way) we hear a scoffer say that much of the Bulletin is
wasted because it is not read. We should hate to think that this were
so—and no part of the Bulletin is better worth reading, as a rule, than
the Laboratory's contributions. Dr. Chisholm's article is full of "meat,"
to use a homely but forcible expression. He has put his finger unerringly on the cause of the popular misunderstanding, we had almost
written mistrust, of the Public Health service. It is that there has, till
now, been a confusion of curative with preventive medicine, through
the employment of practitioners of medicine as part time medical officers.
It would be equally absurd, as he points out, to expect the captain and
crew of a ship, charged with the navigation of the ship, to spend part of
their time erecting the lighthouses, buoys, etc., on which they must
depend. For, as Dr. Chisholm points out, the medical man's whole training, his whole bent of mind, is along therapeutic lines, and preventive
medicine is entirely different—parallel, but never converging or mixing
with the curative branch. More and more, the fact is being realized,
that the foundation of scientific medicine, as we look forward to it in the
days that are to come, must be Preventive Medicine, broad-based,
scientifically conceived and administered.    The methods by which this
Page 228 must be done are well understood by the leaders in Preventive Medicine,
Dr. Chisholm outlines them, but the principle is beyond doubt. It is
the only justification for medicine, in the final analysis. Merely to patch
and tinker with damaged and worn-out machinery is, in the long run,
so hopeless and forlorn a task, that one would weary of it—but medicine
means far more than this. It is to heal the sick before they become too
sick, to prevent the disease, that we may not need to cure it, to teach
right methods of living, rather than to help the sufferer to an easy
death. We have tried the ways of folly long enough, and it is time that
we set our feet on the way of wisdom, as shown us by such articles as
that of Dr. Chisholm.
NEWS AND NOTES
Very few adverse criticisms of this year's programme have reached
the Committee responsible for the arrangements so we may conclude
that the 1930 Session of the Vancouver Medical Association's Summer
School was appreciated by those who attended. The registration this
year was thirty short of our highest attendance. This falling off is probably due to the fact that a number of men from the Interior of the
Province intend to take the trip to the British Medical Association at
Winnipeg. There was a larger atendance than usual of men from across
the line and these were apparently well satisfied with the medical fare
provided, but, as usual, the lack of social entertainment in connection
with the School was regretted by our American friends. As the School,
however, is primarily run for educational purposes, and is not in
any sense a "Medical Convention," as the term is understood nowadays,
the absence of the usual social functions is explained.
Through the courtesy of the B. C. Medical Association the Committee was enabled to obtain three speakers from the East under the
grant for Post-graduate instruction made to the Canadian Medical
Association by the Sun Life of Canada. The men in the distant parts of
the Province, who were unable to make the trip to Vancouver, will have
the opportunity of hearing addresses by other speakers sent West under
the same auspices in the latter part of September.
The report adopted by the Vancouver Medical Association on June
17th, outlining the terms upon which closer co-operation with the Provincial Association would be acceptable to the local Society was presented to the members at the Annual meeting of the B. C. Medical Association on June 25 th and was adopted without any discussion, and the Executive of the Provincial Association was empowered to discuss details
and complete arrangements on its behalf with the local Society. A joint
meeting of the two Executives was held on July 10 th when progress was
made and a resolution carried that a joint committee, composed of three
members from each Executive, be appointed to work out the necessary
details.
Page 229 A group of men from Vancouver attended the meeting of the
American Association for the Study of Goitre which was held in Seattle
and Tacoma on July 11 - 12.    Among those making the trip were:
Dr. L. H. Appleby
Dr. C. E. Brown
Dr. J. Brown
Dr. V. E. D. Casselman
Dr. R. E. Coleman
Dr. E. C. McLeod
Dr. Hugh Macmillan
Dr. H. W. Riggs
One of the most interesting papers was that given by Dr. O. Kimball, formerly of Cleveland but now of Detroit. He stated that in a
survey of school children in Detroit made in 1924, forty-two per cent,
were found to have endemic goitre while on a recent survey only one-
third of one per cent, were found to be affected in this way, showing the
great value of iodine prophylactic therapy. In thirty-six hundred cases
of mental defects, eight per cent, were found to be due to congenital
hyperthyroidism and these were composed of cretins and also the Mongolian type of idiocy, which he considered to be a foetal form of thyroid
deficiency developing in the sixth to seventh week of foetal life. In none
of these cases were they able to raise the I.Q. beyond the age of eight
years, even in those cases where thyroid extract was given early.
Dr. Henry Wackenroder has resumed practice after a visit to the
Mayo Clinic.
We congratulate Dr. W. J. and Mrs. Dorrance on the birth of a
son who put in an appearance on July 5 th.
We also extend our sincere sympathy to the Doctor in the recent loss
of his mother.
Dr. J. A. Gillespie has returned from a trip during which he visited
Montreal, Toronto, New York, Chicago and other Eastern Medical Centres. As Chairman of the Hospitals Committee of the Association, Dr.
Gillespie reports that in accordance with the report adopted by the
Association and printed in the May issue of the Bulletin, the Committee
felt it wise to wait until the report of the Hospital Survey Commission
was received and all parties had been given an opportunity to discuss
same, before taking any action. This report was not received for distribution until June 19th. A sub-committee has been appointed to consider the report and bring in recommendations to the full Committee.
This Committee is now at work, but owing to the absence of some of
the men during the vacation season, there has been unavoidable
delay. While the Committee regrets this delay and is anxious to get
the matter finally settled, it is convinced that the attitude of the medical
profession is as firm as ever in its opposition to the hospital regulations,
and the Committee has every reason to be hopeful that a final solution
of this question, which will be in line with the wishes of the Medical
Page 230 Association and the whole medical profession,  will be reached  in  the
early Fall.
LIBRARY NOTES
Recent Additions to the Library
Yearbook American Coll. of Surgeons for 1930.
System of Bacteriology in relation to Medicine.    Vols. 1 and 2.
Otosclerosis, 2 vols.    A resume of the Literature to July, 1928.
Transactions of the American Ophthalmological Society for 1929.
No. 3 Canadian General Hospital (McGill), 1914-1919. Fetherstonhaugh
History of Biology.    Nordenskiold.
Gastric and Duodenal Ulcer.    Hurst.
Harvey Lectures for 1928-1929.
Minor Surgery.    Foote and Livingstone, 6th edition.
Transactions Amer. Assn. G. U. Surgeons for 1929.
Medical Clinics North America, for January, March and Mjay, 1930.
Classification of Bright's Disease.  Russell, Med. Research Council Report.
Diet and the Teeth.    Mellanby, Medical Research Council Report.
Transactions American Proctologic Society for 1929.
Polycythaemia Erythrocytosis and Erythraemia.    Parkes Weber and Bode.
Surgical Clinics North America, for February, April and June, 1930.
Physiology.    Starling, 5th edition, 1930.
Report of Henry Phipps Institute for 1929.
Transactions American Laryngological Association for 1929.
Medical Annual, 1930.
Section Laryngology A.M.A., 1929.
Mouth Infections.    MacNevin and Vaughan, 1930.
After Treatment of Operations.    Lockhart Mummery, 5th edition, 1930
Report of Commission on Med. Education and related Problems in Europe
Transactions American Laryn. Rhinol. and Otol Society for 1929.
The Operations of Surgery Rowlands and Turner, 2 vols., 7th edition
Transactions of the American Otological Society for 1929.
Mayo Clinic Volume, 1930.
Trauma Disease and Compensation.    Fraser, 1929.
International Clinics.    March, 1929.
An Autobiography.    E. L. Trudeau.
Diseases of the Blood.    Paul Clough, 1929.
Tuberculosis Among Children.    Myers, 1930.
Dorland's American Illustrated Dictionary.     15 edition, 1929.
Bulletin Ayer Clinical Laboratory, 1930.
Skin reactions and blood chemistry of Normal men and Clinical
Patients.    Petersen and Levinson, 1930.
The Story of a Surgeon.    Sir John Bland Sutton.
Heredity in Man.    Gates.
Memoirs of Adami.   By Marie Adami.
Diagnosis and Treatment of Venereal Disease.    Harrison.
Clinical Atlas of Blood Diseases.    Piney and Wyard.
William H. Welch Medical Library.    Opening Exercises.
Opium Addiction. Report of New York Committee on Drug Addiction, 1930.
Medical and Surgical Yearbook of Physicians Hospital of Platsburgh. V. 1.
Page 231 CARCINOMA OF THE LARGE BOWEL
Being an address delivered before the Vancouver Medical Association
Summer School by Dr. George T. Wilson, of Toronto
The large bowel is divided arbitrarily into the caecum, ascending
colon, hepatic flexure, transverse colon, splenic flexure, descending colon,
iliac colon, pelvic colon or sigmoid, rectum and anal canal. Most of these
segments are more or less fixed to the posterior abdominal wall, but the
transverse colon and sigmoid are each suspended by a meso-colon containing blood vessels, lymphatics and glands. The lymphatics are more
numerous in the proximal half bowel than the distal and this is what is to
be expected seeing that the latter is for the most part a storehouse. In
general, the lymphatics accompany the venous return, but it is important
to remember that when the usual passage of lymph flow is obstructed, the
next most accessible route is taken up.
About fifty per cent, of carcinomata of the large bowel occur in the
colon and the other fifty per cent, in the rectum. About two-thirds
of the new growths occur in the recto-sigmoid area. There is a general
increase in the incidence of cancer from the caecum to the rectum, but
there are more in the caecum than in the transverse colon. The relatively fixed areas of the bowel are more prone to become the seat of carcinoma
than the mobile portions, possibly because these are more subject to
trauma. About five per cent, of all carcinomata in man are in the
rectum. There are about the same number of carcinomata in the large
bowel as in the stomach.
The average age of people suffering from carcinoma of the colon is
about fifty; while in carcinoma of the rectum the average age is five to
ten years higher. There is recorded a case of carcinoma in the transverse colon in a child of three. Men are more commonly affected than
women.
We still know very little about the cause of cancer. A history
of long continued constipation preceding the onset of the disease is
the exception, and in the majority of instances the individual has been
particularly free from bowel disturbances. Chronic ulcerative proctitis
or colitis do not. seem to have much bearing on its production, and
although haemorrhoids are a common physical sign of cancer in the
rectum, the growth does not develop in haemorrhoidal tissue. Diverticulitis does not appear to develop into a carcinoma.
There are two main types of carcinomata occurring in the colon,
the polypoid and the stenosing or ring carcinoma. In the former a
mushroom-like mass of variable size grows from one side of the bowel
into the lumen which may be completely filled by the tumour; while in
the latter, the carcinoma cells encircle the bowel wall and the accompanying fibrosis gives the appearance of a ring-like constriction to the
tube. The polypoid type of growth may occur in any part of the large
bowel but it is more common on the right side.    The ring carcinoma
Page 232 is almost Confined to the region of the sigmoid. In the sigmoid and
rectum the polypoid type of adeno-carcinoma is prone to develop colloid
changes, in which event a wide area of the bowel is apt to be involved.
It tends to spread to the peritoneum where it produces miliary nodules
or bulky masses of gelatinous tissue, but the glands are not early enlarged. In the rectum, besides the cauliflower-like mass protruding into
the ampulla, there is the local patch of new growth which ulcerates,
leaving an excavated area on the rectal wall with a hard indurated edge.
Occasionally a solitary polyp in the usual place in the lower third of
the rectum becomes carcinomatous; while it is estimated that fifty per
cent, of intestinal polyposis develop carcinoma. The carcinoma commences in the intestinal mucosa and generally invades the other coats
of the bowel, but for a considerable time the disease is a local one, and
it is probably true that the initial glandular enlargement is always of
an inflammatory nature. Liver metastases are late. Above the tumour
but the early evidences of a growth in the large bowel are extremely
and in the late stages, thinned. The caecum may be so distended and
weakened from a distant obstruction that perforation occurs. The
growth itself may ulcerate into an adjoining coil of intestine or the bladder or into the loin, giving rise to symptoms closely resembling a perinephric abscess.
The signs and symptoms of a carcinoma of the large bowel differ
considerably in the different regions. In the right half of the colon
digestive disturbances and anaemia are often outstanding symptoms and
indeed the appendix has frequently been removed for a carcinoma of
the transverse colon. In the left half, obstructive signs are predominant;
but the early evidences of a growth in the large bowel are extremely
variable. Previous constipation is uncommon, so that when a man past
middle age for the first time notices that there is some change taking
place in his bowel movements a new growth should be suspected. In
some, the first intimation of anything wrong is an attack of pain with
the passage of a considerable quantity of blood, and this may pass off
leaving the patient quite himself again and with the feeling that everything is well. Some have indigestion with mild crampy pains particularly after meals when peristalsis is stimulated and there may be evidence
of slight abdominal distension. Others have periods of constipation
followed by diarrhoea, and in another group there is continuous diarrhoea
with variable amounts of mucus often stained with blood. The blood
may be either mixed with the stool or lying upon it. Occult blood, in the
absence of ulceration in the stomach or duodenum, should make one
suspicious of a new growth. On the other hand, its absence is not a
test of any value. Pain in the lower back and down the legs is a late
sign and is due to invasion of the posterior abdominal wall, but pain in
the back accompanied by a distressing flatulence may be an early sign.
Tenesmus is a most important symptom, particularly in growths about
the recto-sigmoid, and if there is frequently the feeling that the evacuation has been insufficient, the probability that a carcinoma is present is
very great. In carcinoma of the anterior wall of the rectum pain in the
perineum is common.   Abdominal distension form ascites usually means
Page 233 that the peritoneum has been invaded by the growth, although pressure
on the main lymphatic trunks may produce it. In the late stages there
may be metastases in the lungs and brain and the cervical glands. In
about five per cent, of the cases the first symptom is acute intestinal
obstruction.
The physical signs are variable, but here again we are interested
chiefly in the early changes. The abdomen must be carefully examined
for any alteration in its contour and this requires a great deal of time
and patience if important signs are not to be overlooked. Sometimes
one finds that nothing abnormal can be either seen or felt at the first
examination, and at a subsequent visit a well marked spasm of the bowel
can be clearly seen and felt. Frequent examinations therefore, in suspicious cases, should be made and the best place to make such is in a
hospital. There may be a well-defined tumour present when the patient
first presents himself for examination. If this is in an accessible area
of the bowel, the enlargement is readily recognized, but if it is situated
at either of the flexures or in the vicinity of the recto-sigmoid, it may
readily escape detection. The liver should be carefully palpated to
determine if possible its size and consistency, and whether there are any
nodules upon its surface. The anal region must be inspected for evidence
of haemorrhoids, as these are frequently associated with a carcinoma of
the rectum. A rectal examination must never be omitted. It is best
carried out with the patient lying upon the left side with the knees
drawn well up and the buttocks over the edge of the bed. The gloved
finger should then be swept around the whole of the rectum, bringing
the front of the finger against each part in succession. If, during this
examination, the patient is asked to bear down, it is often possible to
recognize a growth of the lower sigmoid, as it gets pushed down in
front of the upper part of the rectum. In the female a vaginal examination should invariably be made. But the physical examination may be
entirely negative and yet the suspicion persists that some form of obstruction is present. The problem may be further elucidated by an X-
Ray examination after the adminstration of barium. An opaque enema
should be given and its upward passage observed with the fluoroscopic
screen and subsequently plates should be made. In addition a barium
meal may be given and plates taken and by a combination of the two
a correct diagnosis can be made in quite a high percentage of cases.
The most difficult area to examine is the recto-sigmoid because of the
mobile sigmoid overlapping the growth. If the first examination shows
everything clear it need not be repeated, but if in doubt as to whether
spasm is responsible for the abnormality, another enema should be given.
If the barium meal and the opaque enema stop at approximately the same
place, it leaves no doubt about the true cause of the obstruction. It is
always advisable to have the enema precede the meal, as the latter in the
presence of a sclerosing type of growth, may cause an acute obstruction.
In addition it may be difficult to get rid of the barium.
Sigmoidoscopic examination is a valuable aid in obstructive lesions
in the rectum and lower sigmoid, but it must be done by one accustomed
to making such examinations, as it is not free from danger. It is readily
carried out with the patient lying upon the left side with the knees drawn
Page 23* well up and the buttock slightly elevated. The bowel must be well
washed out previous to the examination by several enemata. No anaesthetic is necessary but the instrument must be passed up gently and under
direct observation. If the growth cannot be seen it probably means that
it can be removed by some form of operation without a permanent
colostomy. If still in doubt .there must be no hesitation in advising an
exploratory laparotomy.
The main condition which must be ruled out in an obstructive
lesion of the colon is a diverticulitis. Diverticula may occur in any
portion of the gastro-intestinal tract but the common place for them to
give symptoms is in the sigmoid. Inflammation of an acute and chronic
character is quite a common complication, and in the latter type may
be sufficient to produce a marked narrowing of the canal which, even at
operation, is difficult to differentiate from a carcinoma. In each there may
be blood and pus in the faeces, and the only reliable method of differentiation is by a barium enema. In the left iliac foss a chronic
volvulus of the sigmoid would have to be ruled out and here, if
seen during an exacerbation, the distended loop can be both seen and
felt. Occasionally a portion of the loop gets caught in a hernia.
In the right iliac fossa a hyperplastic tuberculous mass would have to be
taken into consideration as well as actinomycosis. The former may present other evidences of tuberculosis, but if not, the fact that the patient
has had the tumour for a long time and still looks well would be against
malignancy. The latter has a hard wooden feel and is very apt to be
associated with fistulae discharging pus with the characteristic sulphur
granules. In elderly people faecal impaction may closely simulate a
neoplasm but is readily ruled out by repeated enemata. As previously
observed, an exploratory incision is always justifiable in cases of doubt
and should be strongly urged under these circumstances.
The treatment of a carcinoma of the large bowel varies with the
situation of the growth among other things, and for convenience of
description we may divide the bowel into four divisions:—
Group I.—includes the caecum, ascending colon and hepatic flexure.
Group II.—includes the transverse colon, splenic flexure, descending
colon and iliac colon.
Group III.—includes the sigmoid or pelvic colon.
Group IV.—includes the lower-most part of the sigmoid and rectum.
Except in cases where acute obstruction is present, before any operative procedure is carried out in any of the groups, the general condition
of the patient should receive careful consideration and any abnormality
corrected as far as possible. Any toxaemia present is largely due to the
absorption of noxious products in the bowel on the proximal side of the
growth, and these must be got rid of by frequent enemata and mild
aperients, such as paraffin oil. If the opening in the growth is narrow,
very little of the irrigating fluid may pass at first, but if persisted in,
Page 235 success is usually attained, particularly if assisted by small doses of morphia
and rest. In any resection of a growth in the colon where distension of
the bowel proximal to the resection is liable to be a factor, some provision must be made to prevent it. In group I. this is done at the time
of resection, while in the others, it is the first stage in the removal of
the growth. The anaesthetic is important and spinal anaesthesia is unquestionably the best, provided the operation is not unduly prolonged,
in which event the effects may pass off before the work is completed.
In debilitated patients a blood transfusion is most helpful.
Group I.
After exposing the growth by a suitable incision the abdomen is
examined for glandular involvement and more distant metastases in the
liver. If there are no visible implants in the liver and it is felt that the
tumour can be safely removed, the next step is its mobilization and it
is very important that this should be thoroughly done. The outer leaf
of the peritoneum is divided and the caecum, ascending colon and hepatic
flexure, together with the terminal ileum, turned inwards along with their
vascular supply. Towards the upper end the situation of the duodenum
must not be forgotten. The small bowel is divided with the cautery
five or six inches from the ilec—caecal valve and the colon cut away a
short distance to the right of the middle colic artery and the intervening
mesentery with any visible glands is removed. Near the middle colic
artery the bowel narrows considerably so that if the small bowel is
divided by removing more from the anti-mesenteric border, the two
apertures may be very nearly the same. Inasmuch as the ileo-colic artery
supplies the terminal portion of the small bowel it is always safest to
remove the last portion of the ileum. When the two ends are nearly
the same size an end to end anastomosis should be carried out. The
field is carefully packed off and the ends brought together without any
tension. The fat is carefully dissected back from the cut edge of the
colon so as not to interfere with the placing of the sutures, and there
must be no doubt whatever about the circulation to the end of the colon.
If, at the conclusion of the anastomosis, the wall of the intestine does not
bleed when lightly pricked with a needle, the circulation is not sufficient.
The fat pads which were stripped back should be tacked down over the
suture line which may be further re-inforced by a cuff of the omentum.
Leakage is due to necrosis of the edge of the bowel from lack of blood
supply or to distension from obstruction by swelling at the anastomosis
about the fourth day. The former can only be obviated by scrupulous
attention to the vascular supply; the latter is prevented by providing
a vent in the area of the bowel proximal to the suture line. At the
conclusion of the anastomosis then a piece of small bowel about a foot
away is lifted into the wound and a catheter tied in by the Witzel method.
It is then drawn through a small hole in the omentum and stitched at a
convenient spot in the wound. It is always well to put a drain of rubber
tissue down to the site of the anastomosis and a small drain in the bottom
of  the  abdominal  wound  often  prevents   the  incision  from  breaking
Page 23 6 down. The catheter comes away readily in a week or ten days and the
fistula always heals spontaneously. In the after treatment the main
essential is rest to the bowel and this is best accomplished by withholding
all fluids by mouth for three to four days, sufficient morphia to keep
the patient comfortable and a continuous intravenous injection of
glucose in saline.    For an average man 3000cc. daily are sufficient.
When there is a considerable discrepancy between the ends to be
anastomosed, some other plan should be adopted. The end of the colon
may be invaginated and the open end of the ileum anastomosed to the
side of the colon or both ends may be invaginated and a side to side
anastomosis carried out. By the latter method one can be more sure of
the integrity of the blood supply and if the openings are made near the
invaginated stump, there will be no trouble whatever from pocketing.
Its disadvantage lies in the fact that there is more suturing to go wrong
and it requires a longer time to perform.
Group II.
In the treatment of cases in this group, a preliminary drainage on
the proximal side of the growth is a necessity but what constitutes the best
method is debatable. Many are of the opinion that a caecostomy is
sufficient, but if by that is meant bringing out the caecum and tying in
a good sized tube and dropping it back, then we believe that such is
not of much value, for in the great majority of cases the bowel contents
pass on to the seat of the obstruction and very little comes out through
the opening. True, a considerable quantity may be removed by irrigation, but even this is often unsatisfactory. If it works well, however,
it has the advantage of closing spontaneously when its usefulness is over.
On the other hand an opening in the caecum can be made an effective
one if a good sized button of the wall is withdrawn from the wound and
sutured to the abdominal wall. It has the disadvantage in requiring a
further operation to close it. Through the caecal opening the large
bowel should be frequently irrigated, combined with the use of rectal
enemata. Some prefer to include a mild antiseptic in the washings, but as
the effect is mainly a mechanical one, normal saline is as good as anything.
This procedure should be carried out for ten days or a fortnight prior
to the operation for excision. Such an opening, besides serving as a
vent to prevent distension of the bowel on the proximal side of the
anastomosis and thus diminishing the danger of leakage, aids very
materially in lessening the toxaemia from which many of these patients
suffer. In addition it has a beneficial effect upon the bowel wall and
helps to lessen the fixity of the growth which, in the early stages, is
always due to an inflammatory reaction.
Having first both patient and the large bowel in as healthy a state
as possible, the removal of the growth may be proceeded with. It is exposed by a suitable incision and a general survey made to determine
whether it is removable or not. Besides an examination of the tumour
to see if it can be mobilized, the liver should be searched for metastases.
Occasionally there are multiple tumours in the colon.    Even if there
Page 237 are undoubted secondaries in the liver, if the general condition of the
patient warrants it, excision gives more relief than a palliative operation
in those instances where the growth is resectable. Mobilization of the
tumour is then commenced and it may have to be dissected from the
stomach and adjacent coils of small bowel, or, in certain instances, a
piece of either may have to be taken away with the growth in the colon.
Adequate mobilization is most important and in this segment of the
bowel it is the phrenico-colic ligament which firmly holds the splenic
flexure to the diaphragm which interferes mostly with freeing the bowel.
When this ligament is divided the bowel carrying its blood supply with it
is readily mobilized. In the vicinity of the transverse colon the attachments of the omentum above and below are severed and the growth, including a segment of its mesentery, if present, is then removed with the
cautery. If there is a great deal of fat in the mesentery the peritoneal
coverings should be lifted off so as to expose the vessels, as by so doing
the integrity of the blood supply to the bowel on either side of the resection can be more adequately determined. If th middle colic artery
has to be tied, then the hepatic flexure should be removed as well because of its liability to slough. Two procedures are now open, an end
to end anastomosis may be done, or both ends closed and a side to side
opening made. If the lumen of the proximal and distal segments are
nearly tjbe same, the former type of union may be carried out, otherwise
the second should be done. In neither instance must there be any
tension upon the suture line, and before the anastomosis is begun the
ends should lie against each other without any tendency to pull widely
apart. On the whole, side to side anastomosis is the safer plan as there
the danger of leakage from a small area of necrosis at the suture line
is eliminated. As previously remarked, if the opening is close to the
invaginated stump there will be no danger of pocketing. The disadvantage lies in the fact that it takes longer to perform. Should the abdomen
be opened for an acute obstructive lesion about the splenic flexure, and
if the general condition of the patient is fair, the growth may be sidetracked by an anastomosis between the transverse colon and sigmoid.
Then in a fortnight or so the tumour, if resectable, may be removed,
indeed, such a procedure is advocated as the method of choice by some
surgeons.
Group III.
It is in carcinoma of the sigmoid that the Mikulicz type of operation
is particularly suitable. The afferent and efferent loops after removal
of a segment of the meso-sigmoid are stitched together and the growth
is withdrawn through the abdominal wound. The peritoneum is then
sutured to the loops and the rest of the wound closed. Forty-eight
hours later the growth is removed, close to the level of the abdominal
wall, with the cautery. Subsequently a clamp is applied to the spur-
parating the loops and left on until it comes away, usually in five or
six days. If the spur has been divided sufficiently deep, many of these
fistulae close spontaneously, but if not, they may be closed by separating
the bowel edges from the abdominal wall without opening the peritoneum
and suturing them transversely. In a suitable case this type of operation
is a very satisfactory one and is the safest method of resection.    But the
Page 238 prime essential is a meso-sigmoid which will allow the growth to be
brought out of the wound without tension, so that anything which
prevents that is a contra-indication. Usually a fixed growth is a dangerous one to bring out of the wound in this fashion, as the necessary
manipulation is sure to traumatize the bowel, the proximal loop of which
often harbours infective organisms under these conditions and they may
readily enough initiate a fatal peritonitis. Any undue tension is sure to
interfere with the vascular supply and produce gangrene of the loop. A
very fat abdominal wall is in itself usually a sufficient reason for deciding
against the Mikulicz operation. On the other hand preliminary drainage
of the proximal colon, with frequent irrigations of the obstructed loop,
will greatly increase the number suitable for this procedure in that it will
decrease the fixity of the tumour and get rid of the infection in the bowel
wall. The best place to make the artificial opening is the transverse colon,
as thereby the whole faecal stream can be diverted and the maximum
degree of rest is thus given to the sigmoid and adjacent colon. When
carried out for the Mikulicz operation this type of colostomy does not
prolong the convalescence as it can be closed at the same time that the
sigmoid opening is being dealt with. Recently Rankin has reported
recurrence in the abdominal wall in twelve per cent, of such cases, but
if the tumour is not allowed to come in contact with the abdominal
wound and thus permit of cell implant, it is probably true that this complication would not ensue. Gangrene of the withdrawn loop is not
necessarily a serious complication either, and in many of these instances
the general peritoneal cavity does not become infected. In contradistinction to the Mikulicz type of operation for a carcinoma of the
sigmoid, is resection with end to end suture over a tube. This is the
operation of choice of many surgeons and when everything goes satisfactorily it is the ideal in that the patient is quickly restored to health.
But the danger of leakage is great, particularly about the tenth day
and the operation has a higher mortality that the Mikulicz plan. It
should always be preceded by some form of preliminary drainage of the
proximal colon.
Group IV.
The treatment of a carcinoma of the recto-sigmoid has been considerably clarified during the past decade and it is now quite generally
recognized that in this area the only logical procedure is the establishment
of a permanent colostomy and the complete removal of the lower sigmoid,
rectum and anal canal. The main contention at the present time is
whether this should be done by the perineal or the abdomino-perineal
route. Miles is the most outstanding advocate of the abdomino-perineal
route, while Lockhart-Mummery is a powerful protagonist in favour of
excision by the perineal route. Theoretically, the former type of operation is best, in that all obviously involved tissue can be removed, but the
main objection is the high mortality. This, in the hand of Miles himself,
is twenty-five per cent., and is certainly much higher than that in the
hand of most surgeons doing this type of work. It is thus a very
formidable operation and one which few patients are prepared to face.
On the other hand, Lockhart-Mummery reports a large series of excisions
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Medical-Dental Building Vancouver by the perineal route with a mortality of only three percent. In this
connection however, it is only fair to observe, as Mr. Grey Turner
points out that the surgeon with a very low mortality may only be
operating on the easy cases; so that it is very difficult to appraise
properly the various mortality statistics. That the abdomino-perineal
operation is attended with a great deal of shock there is no doubt, but
it is also true that if the growth is high up in the rectum and on the
borderland between operability and non-operability, the removal by the
perineal route is likewise associated with considerable shock, and quite
a high mortality. Quite apart from these considerations, if there are
enlarged glands above the brim of the pelvis, these can be removed much
better by the abdominal route. On the other hand in the perineal type
of operation, during the preliminary left inguinal colostomy and exploration for distant metastases, the exact position of these glands can be
noted and their removal made certain subsequently. Often times the
choice of method is made because the surgeon feels that he can do one
type of operation better than the other. An intimate knowledge of the
anatomy of the perineum is essential for the perineal operation if the
resection is to be done well. It is not difficult to remove long segments
of the bowel by this route even up to two feet.
PROGNOSIS AND RESULTS:
As in carcinoma in many other parts of the body, the prognosis in
cancer of the large bowel is quite variable. In growths of the right side
of the colon, the immediate mortality is less than after resections of the
left side, but recently Rankin reports rather better results from left
sided growths. In left sided tumours he reports forty-eight per cent,
alive after three years, and in right sided, forty-seven per cent, after
three years, and thinks that any mortality under ten percent is excellent.
Grey Turner's mortality was nineteen per cent, and there is no doubt
that the average is considerably higher than that—naturally the older the
patient, the higher will be the mortality. But again we wish to point out
that the mortality figures vary with the boldness or timidity of the
operator. In carcinoma of the recto-sigmoid Miles reports recurrence
in thirty per cent, of the cases while Lockhart-Mummery claims fifty per
cent, free of recurrence after five years, but recurrence may take place
ten years after the operation. Miles on the other hand, claims recurrence
by the perineal route in over ninety per cent, of his eighteen cases.
Within recent years the treatment of carcinomata of the large
bowel by radium has been receiving considerable attention. Neumann
and Croyn of Brussels have been devoting much time and energy in
attempting to find a cure in growths of the rectum and it has been
taken up by many others. A review of radium therapy in rectal carcinomata has been published in the last edition of the British Journal of
Surgery by Gordon-Watson and it is evident from his observations that
surgery still offers the best prospect of cure. It is useful, however, in
inoperable cases, particularly where the growth is situated posteriorly,
in which event the coccyx and a portion of the sacrum should be re-
Page 240 moved to allow of direct implantation of the needles. But the cancer
cell in the rectum, unlike that in the cervix uteri and mouth, is particularly resistant to the effects of radium and up to the present time the
results have been disappointing.
It is difficult to get an accurate estimate of the percentage of
patients suffering from carcinoma of the large bowel in whom the
growth is inoperable when first seen by the surgeon, but it is probably
true that in the vast majority symptoms are present for a year before the
surgeon is consulted. Radical removal in the early stages of large bowel
cancer is attended with excellent results, so that the only hope of improving our mortality statistics rests with the physicians who first see
these patients, and until it is recognized that a person past middle age,
who commences to have some irregularity of his bowels, has a carcinoma, until it is proved otherwise, there will be little chance of improvement in the treatment of carcinoma of the large intestine.
THE DIAGNOSIS AND TREATMENT OF
PEPTIC ULCER
By Dr. William Fitch Cheney
Clinical Professor of Medicine, Stanford Medical School.
Peptic ulcers vary as to position. They may be situated on one or
other side of the pylorus or upon the lesser curvature of the stomach.
The ulcers vary also as to size and depth. Hence it is not surprising
that different cases may show different disturbances of the gastric function. There are also a number of complications which may at times still
further confuse the picture. The methods of examination upon which
diagnosis depends are four: Clinical history, physical examination, gastric analysis and x-ray.films and fluoroscopy.
1. As regards clinical history the characteristic features are chron-
icity, or long duration of symptoms; periodicity, or the tendency to
spontaneous remissions and exacerbations lasting for days, weeks or
months; rhythmicity, or the occurrence of symptoms at a more or less
definite time, an hour or two or more after meals, relief temporarily by
the next meal and then recurrence; and fourth, the character of the
symptoms, with pain predominating, belching, heart-burn, water brash,
nausea and at times vomiting and all the discomforts commonly described
as "sour stomach." But these symptoms vary as to the time of occurrence after meals, and as to their kind and severity in any given case.
While pain is the most common manifestation, this varies in its site,
intensity and radiation. Nevertheless peptic ulcer usually presents a
history highly suggestive, though never by itself diagnostic.
Delivered  before  the  Summer  School  of  the Vancouver  Medical
Association, June,  1930.
Page 241 2. The most noteworthy fact about uncomplicated peptic ulcer
is the absence of any objective signs on physical examination. Tenderness is characteristic, over the epigastrium or right hypochondrium; but
this is what the patient feels and not what the examiner discovers.
There is no tenderness palpable as in appendicitis or neoplasm. In fact
the discovery of a palpable mass always makes the diagnosis of ulcer
dubious.
3. Gastric analysis affords us evidence more valuable than any
other, except possibly X-ray. The fasting contents in peptic ulcer are
commonly increased in amount, have an abnormally high total acidity
and free HCl, and frequently give the reaction for occult blood. After
a test meal, the characteristic finding is hypersecretion and hyperchlor-
hydria. This is not an absolutely certain condition in every case, but
statistics show that it occurs in 80 or 90 per cent, of all peptic ulcers.
4. X-ray examination is very valuable but not infallible and must
always be considered in connection with all the other evidence, never
relied upon without corroboration. The signs it affords are the outline
of the stomach and duodenum and a possible filling defect; the rate of
peristalsis, usually excessive in the presence of ulcer; the patency of the
pylorus and the stomach's emptying time.
Complications that now and then change the character of the evidence and so confuse the picture are the following:
1. Pyloric obstruction, due to cicatricial contraction in the
healing of an ulcer in that region, but often due rather to inflammatory
swelling and oedema around the ulcer. The new symptoms that suggest
this complication are repeated vomiting of retained food, progressive loss
of weight and pain that occurs more or less continuously and not with
the usual rhythmic relation to meals. The sign that best indicates pyloric
obstruction is visible peristalsis over the stomach, elicited by inflating
the stomach by carbonic- acid gas (having the patient drink a dram each
of soda bicarbonate and tartaric acid in separate solutions). Flicking
the abdominal wall over the stomach with the end of a towel will
sometimes suffice to bring out these peristaltic waves. When obstruction
has occurred, the gastric analysis shows a decreased secretion of acid;
and after lavage to remove accumulated food-refuse, X-ray films demonstrate the retention of barium for long periods after it is taken.
2. Haemorrhage from an ulcer may take the form of slight but
persistent oozing, colouring the vomitus a reddish brown or appearing in it as brownish flecks; or it may give rise to the vomiting of a
larger amount of bright red blood, preceded by faintness and weakness;
or the first attack may be so large as to prove fatal, though this is a
rare event. In any history of ulcer there may be one or several attacks;
but this is always a complication and not a part of the routine course.
The blood from an ulcer may never be vomited at all, but pass on down
the bowel and be discharged in the form of a dark, tarry stool; or
there may be both hematemesis and melaena in the same attack. The
Page 242 patient's story of one or the other of these events, with the background
of a chronic disturbance of digestion furnishes proof enough at the
time of what has happened. It is not wise to attempt any thorough
physical examination, or to give a test meal or to resort to X-ray examinations for at least one or two weeks after haemorrhage has occurred.
At the moment it is better to be content with the history and with inspection of vomitus and stool.
3. Perigastric adhesions are the result of an ulcer approaching so
close to the peritoneal covering of the stomach that a localized plastic
peritonitis is produced. In such event there is a history of increased
frequency and intensity of the pain, which becomes so severe it may
require opiates for its relief. Also there is frequently radiation of the
pain to the back, under the shoulder blade or near the spine, opposite
the pain in front, due to adhesions to the pancreas or gall-bladder or
liver or some other viscus. The history suggesting these adhesions is
therefore change in the intensity, the constancy and the radiation of the
pain. On palpation there is found increased tenderness in the epigastrium or hypochondrium, with rigidity and spasticity of the abdominal wall. The gastric contents show higher acidity because of the
reflex hypersecretion from peritoneal involvement, and the X-ray films
may demonstrate an out-pocketing defect, warning of threatened perforation. Certainty in the diagnosis of adhesions is not always possible,
but usually the picture is clear.
4. Perforation of an ulcer is manifested by intense pain and extreme shock; there is a sudden severe pain and there is profound faint-
ness and weakness. Other organs perforating into the peritoneal cavity,
such as the gall-bladder or appendix, may give a similar picture; but the
previous history of long-continued stomach trouble usually identifies
the cause as a duodenal or gastric ulcer. Examination of the patient
shows a tender, board-like abdomen, with pallor, perspiration, rapid
and weak pulse and subnormal temperature. The immediate indication
is for surgery and laparotomy will determine more accurately the site
and degree of perforation.
5. Cancer of the stomach undoubtedly does develop at times upon
an ulcer base; though the frequency of this occurrence is much disputed.
The history that suggests this change is loss of appetite which has previously been keen; more constant pain, coming on almost at once after
food is taken; loss of weight and strength and colour. The fact that
the patient has longer history of disturbance of digestion than is usually
associated with cancer, does not avail, because the malignant change
may be recent but the ulcer history goes back for years. Palpable
tumour over the gastric area should always suggest cancer rather than
ulcer. Gastric analysis usually shows a falling secretion, but free
HC1 may remain high even after malignant change has occurred. The
character of the filling defect in the gastric wall, shown by X-ray,
usually completes the diagnosis.
Treatment: The average case does well with ambulatory treatment, without detention in bed and without loss of time from work.
Page 243 The plan that has been found most serviceable is the use, first, of a
simple diet and the following list is the one given at the outset:
7 a.m. Two soft-boiled or poached eggs, thoroughly toasted bread
or Zwieback or toasted soda crackers with butter; a glass of milk or a
cup of cocoa made with milk and cream. 10 a.m. A glass of milk
(about a half pint). 1 p.m. Beef, mutton or chicken, picked into
shreds while raw or chopped fine, then made into a meat ball and cooked
rare; toast, Zwieback or crackers with butter; a glass of milk. 4 p.m.
A half pint of milk. 7 p.m. A bowel-full of well-cooked rice with
butter or cream and sugar; or shredded wheat biscuit toasted crisp, with
butter or cream; or toasted bread or Zwieback or crackers; with any of
these a glass of milk.
With this diet the patient is instructed to take one tablespoonful of
olive oil just before each meal; and one to two hours after each meal,
depending upon the time his distress begins, to take also one level tea-
spoonful of the following powder: Bicarbonate of Soda, 2 ounces; magnesium oxide and bismuth sub-carbonate, of each one ounce. After a
week or two on this plan, the average case is free from discomfort. If
this is so then a second and more liberal diet list is given, such as the
following:
May Eat: Eggs, soft-boiled, poached or scrambled lightly; tender
beef, mutton or chicken, chewed thoroughly; sweetbreads or brains;
any kind of fish, cooked as desired, including oysters cooked in any
way except fried; cocoa made with milk and cream; milk as much as
desired, with cream; no vegetables except baked or mashed potatoes,
unless prepared as a puree; soups of any kind if not highly seasoned,
cooked with rice or barley or vegetable, but strained clear after cooking; cream soups made from milk and the puree of vegetables; any
cereal, provided that it is cooked soft and husks and coarse particles are
removed by the puree sieve; white bread thoroughly toasted, soda
crackers, Zwieback, shredded wheat biscuits, served with butter or cream;
cream cheese; cooked fruits such as baked apple or pear, or apple sauce,
or stewed dried fruits if put through the puree sieve; for dessert, rice
pudding, corn starch, blanc mange, custards. Avoid course foods, such
as hard-boiled or fried eggs; tough meats or meats cooked too long;
or pork, veal or ham; vegetables such as corn, string beans, peas or
spinach, unless prepared as a puree; coarse cereals such as oatmeal or
cracked wheat, unless strained through a puree sieve; all hot breads and
fresh fruits; all irritating foods such as very salty, sour, peppery or
highly seasoned dishes of all kinds, including salt fish, pickles, salads,
acid fruits and drinks and highly seasoned soups; and all stimulating
drinks such as coffee, tea and all alcoholic liquors.
With this second list from which the patient may select, he is instructed to continue the glass of milk at 10 a.m. and at 4 p.m. and the
alkaline powder two hours after each meal.
If a patient fails to improve on the plan suggested or if the condition from the outset seems unusually severe, then rest in bed is advised,
Page 244 with milk and cream equal parts, two to four ounces every two hours
from 8 a.m. to 10 p.m., with the alkaline powder on the alternate hour.
After one week, if all goes well, foods on the first list are gradually
added. After two weeks in bed it is usually possible for the patient
to be up and about again resuming the first diet and plan described. But
if even on this plan improvement does not ultimately occur, then surgery
must be considered.
The various complications of peptic ulcer call for special treatment
differing from the original plan. When pyloric obstruction has been
diagnosed, it is not necessary to consider at once a gastro-enterostomy;
but better to try first treatment to overcome inflammation, oedema
and spasm, which are often more responsible for the obstruction than is
cicatricial constriction. A plan to meet this emergencv includes (a)
rest in bed; (b) daily morning lavage with warm solution of bi-carbonate
of soda to keep the stomach clean; (c) a diet of equal parts of milk
and cream, two to four ounces every two hours from 8 a.m. to 10 p.m.;
(d) the alkaline powder of soda, magnesia and bismuth, one level tea-
spoonful on the alternate hour; (e) tincture of belladonna, ten drops
in a tablespoonful of water, three times a day; (f) warm moist compresses to the abdomen; (g) gradual reutrn to the first diet list recommended; or (h) if no clinical improvement follows, then ultimately
gastro-enterostomy.
The treatment of haemorrhage from peptic ulcer will be considered
on detail in a later lecture on "Hematemesis—its Significance and Its
Treatment." .
For the cases diagnosed perigastritis, the proper treatment includes rest in bed, milk and cream diet, alkaline powder, warm applications to the abdomen and careful observation for fear of sudden perforation.
If perforation does occur, laparotomy is indicated and should be
done as early as possible.
B. C. MEDICAL ASSOCIATION NEWS
The Annual Meeting of the B. C. Medical Association was held at
the Hotel Georgia on June 25th, 1930.
The meeting opened with an address from the retiring President,
which was brief but very much to the point and omitted no essentials.
Following the general business, such as presentation of the minutes of last
Annual Meeting, which were adopted as read, the Auditor's report, reports
from Standing and Special Committees and the appointment of a nominating committee who proceeded to nominate officers for the coming year
and a subsequent election of officers, the feature addresses of the evening
were delivered.
Page 245 Dr. J. G. Fitzgerald, Professor of Hygiene and Preventive Medicine
at the University of Toronto, spoke on "Some of the Possibilities of the
Future in the Practice of Medicine" and Dr. Oskar Klotz, Professor of
Pathology at the University of Toronto, spoke on "Medical Meander-
ings in the Tropics."
These addresses were greatly enjoyed by all present, the speakers
being authorities in their subjects with their wide range of experience
and at the same time admirable raconteurs.
The officers for the ensuing year are as follows:
President Dr.  G.  L. Hodgins of Vancouver
President-elect Dr. T. McPherson of Victoria
Vice-President Dr. H. H. McKenzie of Nelson
Secretary-Treasurer Dr. W. T. Ewing of Vancouver
Members of Executive at large:
Dr. G. K. McNaughton of Cumberland.
Dr. G. E. L. Mackinnon of Cranbrook.
Dr. S. G. Baldwin of Vernon.
VANCOUVER HEALTH DEPARTMENT
STATISTICS, JUNE, 1930
Total   Population    (estimated) ~.
Asiatic   Population   (estimated).
Total   Deaths   	
Asiatic  Deaths	
Deaths—Residents   only   	
Birth   Registrations   	
Male      197
Female   177
INFANTILE MORTALITY—
Deaths under one year of age :	
Death   Rate—per   1,000   Births	
Stillbirths   (not included  in above)	
Cases of Contagious Diseases Reported in City
  240,421
  9,33 5
Rate Per   1,000 of Population
156 7.89
             13 16.94
136 6.8 8
374 18.93
32.09
5
May, 1930
Cases Deaths
Scarlet   Fever    13 0
Diphtheria     13 1
Chicken-pox      68 0
Measles        2 0
Mumps    :  43 0
Whooping-cough    : 136 0
Typhoid   Fever        2 0
Paratyphoid        2 0
Tuberculosis      10 19
Poliomyelitis         0 0
Meningococcus  Meningitis 1 0
Erysipelas         6 0
Smallpox        2 0
June, 1930
Cases Deaths
0
0
0
0
0
2
0
0
15
0
0
0
o
22
14
51
4
21
64
2
0
8
0
1
4
0
July 1st
to 15th, 193 0
Cases     Deaths
2
11
9
1
1
18
0
0
4
0
0
Page 246 British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin
in the interests of the Hospital, Clinical and Public Health Laboratories of B. C.
Edited by
A. M. Menzies, M.D., of The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster;
Royal Inland Hospital,  Kamloops;  Tranquille Sanatorium;  Kelowna General Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.    Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Vol. IV.
AUGUST, 1930
No. 7
"THE EPIDEMIOLOGY OF TUBERCULOSIS"
By H. W. Hill, M.D.
The University of British Columbia, Vancouver, B. G.*
The epidemiology of tuberculosis is a very ambitious subject to
attempt in a twenty-minute talk, but I shall do my best to bring out a
few of the main points as I see them.
Epidemiology, I take it, is the sociology of disease—the natural history of a given disease, not in the patient, but in the community.
Etiology mainly deals with the immediate causes of disease as they
operate in the body of the victim; epidemiology deals with the remoter
causes, operating outside the body; those which allow the immediate
cause to impinge on the body of the victim. Etiology studies the disease
in the patient, in the pursuit of cure. Epidemiology studies the disease
outside the patient, in the pursuit of prevention. Epidemiology is not
in this aspect a laboratory subject, despite the great assistance laboratory
work can and has given to it. Epidemiology as I conceive it must be
studied chiefly out amongst the people. It is only amongst the people
that the sequences of human events and the interplay of human life and
activities, which permit and control the incidence of the immediate
causes of disease, can be threaded out.
Studying the epidemiology of tuberculosis in this way, as far back
as we can, and correlating it with studies in other more recently affected
races, its natural history in our own white race indicates that there have
been three outstanding features of the disease. These are a great decline,
beginning many long years ago, in the number of cases—this decline beginning long before modern preventive measures were even thought of
as possible or called for; a great rise in the age of tuberculosis deaths,
correlating with the decline in cases; and, a present-day prevalence of
infection almost co-extensive with the present day population.
We may, I think, safely deduce that tuberculosis, when invading a
new population, reaches a vast number of the population, is very fatal,
* Presented at the Salt Lake City meeting of the Western  Branch of the  (International)
American   Public   Health   Association,   June,   1930.   (Abstract).
Page 247
gfjHfPljangmgg attacks and kills the young children chiefly, and then bit by bit, as time
goes on, kills fewer and fewer people, at gradually increasing ages, until
at last it reaches the stage with which we are so familiar amongst our
own people; wide-spread infection, a relatively very low incidence of
fatal attacks, and these attacks chiefly in older adolescents or younger
adults.
Can we explain these features of tuberculosis and weave them into
a coherent story?   I shall attempt to do so.
First let me say that epidemiologically, as well as etiologically, clinically and therapeutically, tuberculosis presents all the features presented
by any ordinary acute infectious disease such as measles or scarlet fever,
typhoid or mumps—except of course that it is long drawn out. Only
in this feature of chronicity, not in any other, does tuberculosis depart
from the family resemblances common to all acute infections.
Let us compare it epidemiologically with measles. Measles is an
acute disease, the infection of which reaches, as does that of tuberculosis,
approximately 100% of our white population. Also it attacks chiefly
children, as does tuberculosis when first introduced into a race. Also
nearly every one infected suffers disease as a result of that infection,
again like tuberculosis when first introduced. Our race has suffered both
diseases for centuries. Why has tuberculosis died down, while measles is
as prevalent as ever? Why have we now an obvious ability to meet and
overcome, without disease, the very widespread infection of tuberculosis,
while such an ability to meet and overcome, without disease, the equally
widespread infection of measles is so rare as to be almost a curiosity?
I believe this striking difference is due to the difference in fatality.
Tuberculosis in early days attacked chiefly young children, as measles
does now, but tuberculosis killed its child victims as measles does not.
In brief, tuberculosis sought out the susceptibles of the race, and eliminated them by early death, before the reproductive age was reached.
Measles seeks out its susceptibles also, but does not kill them—they survive to reproductive ages. To the extent that tuberculosis eliminated
from reproduction the strains of whites susceptible to it, it left the
insusceptible strains to propagate and replace the susceptible strains. But
measles fails as a rule to kill the susceptibles it finds. They as a rule
recover and go on to reproduction, thus perpetuating, not their acquired
immunity of course, but their original natural susceptibility. Were
measles 100% fatal, the susceptible strains (i.e., most of us) would be
completely eliminated during childhood, and only the relatively very few
insusceptibles would survive to carry on the race. In a very few generations, under this rigid system of elimination, the susceptible strains
would disappear. As it is, however, the non-fatality of measles prevents
it from eliminating itself, and we continue to suffer from it, to the extent
of 95% of us, because we continue to be born, 95% of us, susceptible
to it.
But tuberculosis, by attacking at first chiefly the lower ages, and
killing off these its victims, has done just that elimination of susceptible
strains which measles has failed to do. It has not of course worked on
the basis of 100% efficiency, but it has succeeded in eliminating susceptible strains to such an extent that only one in thirteen of us now
Page 248  dies of tuberculosis, instead of one in seven, as it was forty years ago, or
one in four, as the much older records indicate, for still earlier times.
Why was this elimination of susceptibles and lessened incidence of
fatal cases accompanied by a rise in the age of death?
Obviously, I think, this was due to the gradually lessening opportunity for infection as cases diminished. When tuberculosis existed in
almost every family, as it must have done to give the high death rates
of earlier days, and as it does now amongst recently infected peoples,
every child born ran a great chance of early massive infection from an
open case. As cases became rarer the child would not so immediately
encounter them; and today, when we have but one or two open cases
per thousand of the population at any one time, many a child grows to
adolescence before encountering dangerous massive infection. Hence even
the susceptible, who die on infection, now escape to later years because
they do not encounter dangerous infection until later years.
So far I think I have accounted for our present low incidence of
deaths from tuberculosis on an hypothesis that has the advantage of
accounting for the undoubted coming down of the disease before modern
methods of control went into effect at all. Doubtless, modern methods
have hastened the decline, but they are far too recent, too inefficient
and cover too small an area to take all the credit.
But the most important and practical point remains to be made. It
is this; that if the above hypothesis be correct, it is inevitable that tuberculosis will increase again—there are indeed definite indications that it
is already increasing—and only much more strenuous methods than are
in vogue now, more strenuous and much more widely applied, promise us
any hope of stopping the rise.
Why should there be a rise? Because susceptibles are now surviving to reproductive ages as they did not when tuberculosis was more
common, and the children now being born are therefore in larger percentage born of these surviving susceptible strains. Exposed sooner or
later to massive infection, these susceptibles will add to our present
death rates from tuberculosis as insuscepibles would not. This is as I
see it the great problem that confronts those who have to do with
tuberculosis today—the probability that we have reached the bottom of
the curve, and are about to ascend it again.
If this hypothesis of the epidemiology of tuberculosis be correct,
the past history of tuberculosis in the human family has been of necessity
a series of waves, waxing as susceptibles increased, waning as they were
suppressed by the disease itself; waxing again as susceptibles again increased in proportion as the previous waning of the disease allowed them
to survive.
We are then at the trough of the last wave. The hopeful thing
is that we are for the first time in human history able through modern
knowledge to prevent the heretofore inevitable rise, on the very verge of
which we seem to be.   It is now or never, it seems to me.
And the method? The prevention of spread from existing foci,
i.e., the open cases.
This, as I see it, is the great objective of preventive tuberculosis
work today.
Page 249 ■^w^
• i
>        1    \  \   \   v   \   \
I ■   *    , \ \ \ \
\    \ \ • \
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IDhere
as
The physicians of this country evidence
an almost" unanimous preference for
Dextri-Maltose when modifying Protein
Milk, as well as cow's milk formulae
IDhereas ISlHI
The cases requiring Protein Milk are
difficult to feed, representing sick
babies with severe nutritional upsets.
Therefore,
Se it resolved SICl
That, in the feeding of healthy babies,
as a modifier of cow's milk, the physician's carbohydrate of choice is
*Dextri~CDaltose
MEADS
iWUUW
lijJlJj)JjJjJJJ///'/j{tl
ipextri-maltose with vitamin b" is now also available to physicians who are interested in its appetite^nixgrovth^nmulating
Properties, please write for samples to mead joh nson s. co.. of Canada, ltd., belleville. ont.. specialists in infant diet materials.
m Rest Haven Sanitarium and Hospital
MARINE DRIVE, SIDNEY, B. C.
(Near Victoria)
(Visited by Qualified Physicians)
Rest   Haven,  is  situated   amid   natural  beauty.    Particularly   convenient   and  desirable  for
Rest—Recuperation  and  Convalescence.
There is boating, salt water fishing, and golf.
Private room accommodation $28.00 and $35.00 weekly;
Semi-private  $21.00  and   $25.00  weekly.
Direct   patients   to   Rest   Haven  via   the   Steveston-Sidney   ferry,   MOTOR   PRINCESS.
From   Victoria  by   the   Vancouver   Island   Coach   Lines,   Ltd.,   at   the   Broughton   Street
Station.    Private car will  meet  boats  if  desired.
FOR   RESERVATION  AND   FURTHER  INFORMATION
WRITE OR TELEPHONE MEDICAL SUPERINTENDENT OR  MANAGER-
SIDNEY 95 — 61 L.
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. £.
66 5 Granville St.
151 Hastings St. W.
One Phone:
Seymour 8033
Connecting all three stores.
Brown Bros. & Co. Ltd.
VANCOUVER, B. C.  new-*-
Hollywood Sanitarium
LIMITED
tyor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference t T>. Q. oftCedical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288

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