History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1928 Vancouver Medical Association Oct 31, 1928

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OCTOBER, 1928
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Page 2
*fTi^$%&)£?TA
si^ THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under  the Auspices of the Vancouver Medical  Association  in  the
Interests of the Medical Profession.
Offices:
529-30-31  Birks Building, 718  Granville St., 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. V.
OCTOBER,  1928
No.   1
OFFICERS, 1928 - 29
Dr. T. H. Lennie Dr. W. S. Turnbull Dr. A. B. Schinbein
Vice-President President Past President
Dr. G. F. Strong Dr. J. W. Arbuckle
Secretary Treasurer
iS       HTRUSTEES ^'M0;:; > > >1jMta^
Additional members of Executive:—Dr. A. C. Frost and Dr. F. N. Robertson
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Auditors:    Messrs. Price, Waterhouse & Co.
I     l^^^^^H SECTIONS ;-J^H| •' ' ■ •: jH} 7 1
Clinical Section
Dr.  L. H.  Appleby —JE. 1 Chairman
Dr. J. R. Davies  M JBL K Secretary
Physiological and Pathological Section
Dr.  C.  E. Brown   _„.—„——_— ~ Chairman
Dr.  R.  E.  Coleman —S Secretary
Eye, Ear, Nose and Throat
Dr. W. E. Ainley g ..-...„. || _ , Chairman
Dr. F. W. Brydone-Jack I JE —Secretary
Physiotherapy Section
Dr. H. R. Ross  I —S- HL.—^—1 Chairman
Dr. J.  W. Welch  X S- Secretary
Pediatric Section
Dr.  E.  D.  Carder   ....—_ S Chairman
Dr. G. A.  Lamont  PPfl Secretary
'   ||i||:    STANDING COMMITTEES ^^M        fl
Library Orchestra Summer School
Dr. D. F. Busteed Dr. A. M. Warner Dr  h> r< Storrs
Dr. C. H. Bastin Dr. W. L. Pedlow j)R   g# j)   Gillies
Dr. W. A. Bagnall Dr. J. A. Smith rjR.  l. H.  Appleby
Dr. Lyall Hodgins Dr. L. Macmillan dr   ^ -jv Ewing
Dr. S. Paulin Publications Dr. J. Christie
Dr. W. A. Wilson Dr. J. M. Pearson Dr. J. T. Wall
Dinner Dr. J. H. McDermot
Dr. E. M. Blair Dr. D. E. H. Cleveland Hospitals
Dr. L. Leeson Credentials Dr. H. H. Milburn
Dr. H. H. Pitts Dr. J. T. Wall Dr. A. S. Monro
Rep. to B. C. Med. Assn.   Dr. D. D. Freeze Dr. F. P. Patterson
Dr. Stanley Paulin Dr. W. A. Dobson Dr. H. A. Spohn
Sickness and Benevolent Fund           The President       The Trustees VANCOUVER MEDICAL ASSOCIATION
Founded 1898
Incorporated 1906
^^H   PROGRAMME OF THE 3 1st ANNUAL SESSION    §^H
GENERAL MEETINGS will be held on the first Tuesday and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
from October to April inclusive. Place of meeting will appear on the
Agenda.
1928
October      2 nd-
October     16 th-
November   6 th-
Nfovember 20 th-
December    4th-
December 18 th-
-General  Meeting:
Papers—Dr. J. J. Mason: "Genital Prolapse."
Dr. W. B. Burnett: "The Technique of Version."
-Clinical Meeting:
-General Meeting:
Paper—Dr. John Minor Blackford of Seattle:   'The
Clinical Side of Gall Bladder Disease."
-Clinical Meeting.
-General Meeting:
Papers—Dr. B. D. Gillies; Dr. G. E. Gillies: "Peptic
Ulcer, its Medical and Surgical Aspect."
-Clinical Meeting.
1929
January
January
February
February
March
March
April
April
April
8th-—General Meeting:
Paper—Dr.   Ralph   C.   Matson,   Portland,   Oregon:
"Surgical Treatment of Pulmonary Tuberculosis."
22nd—Clinical Meeting.
5th—General Meeting:
Paper—Dr. R. P. Kinsman: "Focal Infections in Infancy and Childhood."
X-ray films to be shown by Dr. H. A. Rawlings.
19 th—Clinical Meeting.
5 th—General Meeting.
The OSLER LECTURE—Dr. H. M. Cunningham.
19th—Clinical Meeting.
2nd—General Meeting.
Paper—Dr. F. P. Patterson: Subject to be announced.
16th——Clinical Meeting.
23 rd—Annual Meeting.
Page 4 fvmmm
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the reasons for satisfied Victor users everywhere. The
combination of Victor Quality and Victor Service is to
protect and justify your
investment in X-Ray and
Physical Therapy apparatus.
Local Victor Service
is available at:
Vancouver Branch:
VICTOR
A RECENT incident served to prove how our nation-wide
service organization can respond to a severe test:
The Victor office at Washington, D. C, was informed by
the Navy Department that service was desired on Victor
X-ray apparatus installed on the Airplane Carrier U. S. S.
Lexington, then lying at San Pedro, Calif., 3000 miles away.
Quick action would be necessary, as the ship might be sent
to sea any moment. The message was flashed to the manager
of the Victor Branch Office at Los Angeles, and on the same
day a trained service, man reported at San Pedro, leaving
them with their outfit operating at 100 % efficiency.
For years the Victor organization in its publicity has repeatedly referred to Victor Service as one of the advantages
enjoyed by users of Victor products. While the use of the
word sendee is relied upon by many organizations to perform miracles toward winning favorable consideration for
a product, any gratifying results can emanate only through
the actual rendering of the service, when the need for it is
urgent and the situation unusually difficult.
Letters in our files from physicians and institutions in all
parts of the United States and Canada commend the Victor
organization on making good its claims for Victor Service.
Motor Transportation Bldg.  570 Dunsmuir Street
X-RAY CORPORATIONS
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and complete line of X'Ray Apparatus
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A GENERAL. ELECTRIC
ORGANIZATI O N Idealism
In Business
Our idea of a Pharmacy is that it should
be an institution, dedicated to the health of
the community and inspired by the spirit of
responsible helpfulness to Doctor and Patient.
We have honestly tried to live up to our
ideal for over twenty years.
Ph$rmgey
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Night
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Say it with Flowers |jj
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty :■     .§   EDITOR'S PAGE   ^Hmp
With this issue we begin a new volume of the Bulletin, the fifth.
On forty-eight occasions this little publication has appeared with more
or less punctuality. It has contained current information on affairs
medical and such occasional papers and addresses as have been available
and which appeared to be of sufficient interest.
To serve as a means of communication between the members and
to link them more closely together; to enhance the status of the Society;
to stimulate interest in its work; to carry to outside points information
of its activities; these were the objects for which this paper was founded
and which those who have since been responsible for its appearance have
endeavoured to make effective.
How far they have succeeded, it is not easy to say. Perhaps those
in immediate charge know least about its success—or failure. In this
instance they have not, as in the case of commercial publications, the
verdict of the subscription list to guide them. Without cost, without
request, those on our mailing list receive their copy month by month.
The rest is silence—for the most part. Are our "readers" really readers
or merely perfunctory glancers and consignors to the fire or the waste
paper basket? Or is there even perchance a collector or keeper among
them? We fear not. From an occasional library it is true comes a
request for back numbers "to complete our fyle." But librarians are
odd folk and as specimens, out of the way publications from remote
regions have their value.
At times we are quoted or reprinted in a journal of wider publicity
and greater circulation, which is of course, very gratifying and encouraging to the editorial soul. It has more practical value too in that it
enables us to solicit the publication of original matter with more confidence and more success. For we work in a circle, original writers or
writers of papers requiring more than usual research and preparation or
reporters of unusual cases are dubious of publication because of our
limited circulation while our circulation is the more limited because of
the difficulty in securing important contributions.
To those who have generously overlooked these limitations and have
given us material which might well have merited a greater scope, our
sincerest thanks are due. We hope that this self-sacrificing encouragement of home industries will not be entirely without its recompense.
In one way, in a small way, material success has been achieved.
Financially our balance has always been on the right side. We are
gratified to be able to say that our small but select body of advertisers
stays with us. Some of them have done so from the beginning. We
hope that they receive value for their money, that those who read their
advertisements purchase their goods. We repeatedly urge them to do
so for our interests are mutual. If these advertisers ar^l satisfied that
is probably as near an indication as we can get as to the successful accomplishment of our desire.
Our readers will miss this winter the regular publication of contributions from the Laboratories of the Province which has ben a promi-
Page 7 nent feature for the last two years. We hope that these may be resumed. Valuable as they were to our readers, the value to the laboratory
workers was double. Like that of mercy, to him (or her) that gives
as well as to those who receive.
And so, after this brief unveiling of the editorial hopes and apprehensions we ring up the curtain upon this our fifth year, believing still
that there is justification for our effort.
*        *        *
^^^^^1 ' IH ANNUAL DUES ^^B •' ^B 1 £' ■l^U
We take this opportunity of reminding our members that according
to Bylaw No. 5 of the Constitution and Bylaws of the Association a
bank draft will be presented to all members whose annual dues are
unpaid on October 31st. Some members annually object to the presentation of such drafts. The remedy is obvious—send a cheque for
your dues now.
NEWS AND NOTES
Dr. Geo. E. Seldon has returned from a hurried trip east where he
went for the purpose of attending the meeting of the Canadian Medical
Council.
The scenic beauties of Jasper Park were recently enlivened by the
presence of a trio of golfers from the medical ranks of Vancouver, since
Drs. B. D. Gillies, Boucher and Colin Graham elected to spend a holiday
there. Dr. L. H. Appleby also spent a week at Jasper and has now gone
South for a short further holiday.
The first of the Vancouver General Hospital staff meetings for the
present season was held on the night of Tuesday, September 11th. Some
clinical material was to have been presented, but owing to the amount
of business requiring discussion, the former had to be postponed. The
question of the supply of internes was the principal subject discussed.
The difficulty in obtaining an adequate number of internes is becoming
a serious problem, and ways and means are being sought to overcome this.
*      *      *
Dr. L. W. McNutt has left for a course of post-graduate study in
eastern clinical centres.
Dr. A. W. Hunter attended the annual meeting of the American
Urological Association at Del Monte, Cal. Dr. Hunter was away about
10 days.
Page 8 The Study Club, for which the name of The Osier Reading Club
has been tentatively adopted, has completed its plans and programme for
the coming season. Meetings will be held monthly. Each member is
expected to prepare a paper, two of which will be read at each meeting.
It is intended to invite other members of the Vancouver Medical Association to be present from time to time to hear and lead a critical discussion
upon papers which deal with topics in which they are individually interested. It is anticipated that some of the papers read will be published
in the Bulletin.
-j* j* j>
•• %> %*
Interest in the new Medical and Dental Building has perceptibly increased since building operations have commenced. It is anticipated
that excavations will be complete about September 25 th, and as cuttings
for the concrete have already been completed, construction will proceed
forthwith. The building is expected to be ready for occupation about
September, 1929. 159 applications for space have already been received,
and it is thought that by the time the building is completed it will be
fully allocated. The building contractors, Messrs. Carter, Hall and
Aldinger have the new Hudson's Bay Company's store on the list of their
recent creditable performances.
Dr. Frank P. Patterson is leaving for the east to spend a few weeks
visiting clinical centres in Toronto, New York and Chicago.
Evidence of the keen interest taken by many members of the profession in Vancouver in keeping fresh their anatomical knowledge is shown
by the success Dr. H. Wackenroder has encountered in his efforts to enlist
their support in a movement towards securing improved facilities for
dissection. Over fifty doctors have joined him in requesting that the
Vancouver General Hospital take steps to provide a room in one of the
buildings where dissection can be carried on under conditions of at least
comparative comfort and convenience, with reasonable necessary facilities.
If such arrangements can be made it will make it possible for those who
desire it to have in Vancouver opportunities for anatomical study such
as many at present must travel to eastern cities and pay considerable fees
to obtain. Beyond this, it is particularly desired to emphasize, the ultimate benefit, as in all branches of special study, will be to the patient
who profits by his medical attendant's increased and refreshed familiarity
with human anatomy. That the shortest and most certain road to such
familiarity is by making repeated dissections is too obvious to require
emphasis here.
#
It is reported that the Library Committee is encountering difficulty
in locating two volumes of The Lancet of recent date, taken from the
Library. As in the first instance a most important regulation—that requiring that all books and periodicals taken out must be signed for—
was ignored when these volumes were taken, it is evident that any appreciation of what is due from any person availing themselves of the
privileges of the Library to the others is lacking.    Without an apprecia-
Page 9 rJlnygaftBWgMhfe!
tion of the spirt of co-operation which must exist among all users of the
Library it will be impossible for this department to function properly.
A case of comminuted fracture of the knee-joint in Annex 7 at the
Vancouver General Hospital will be of particular interest to those who
believe there is still room for improvement in the mechanical appliances in
use in treatment of fractures. A new mechanical splint for use in
fractures of the tibia and fibula has been devised by Dr. J. R. Atkinson,
and has been tried already in a sufficient number of cases to prove its
value.    It is at present to be seen in use in the above case.
Dr. Roger Countryman, at one time on the Interne staff of the
Vancouver General Hospital, was a recent visitor in Vancouver and New
Westminster with Mrs. Countryman and their two small children. Dr.
Countryman now practises in St. Paul. Mrs. Countryman was before
her marriage Dr. Dorothy Trapp, of New Westminster.
Dr. C. Murray Blair left on September 26th to attend the meeting
of the American College of Surgeons in Boston, at which he will read a
paper.
^^M    SPECIAL MEETING, SEPTEMBER 5th   l|f;
The Autumn Post-graduate Tour of speakers sent out by the Canadian Medical Association has recently ended. As our readers know, these
tours are now an established institution, and are made possible by the
generosity of the Sun Life Assurance Co. of Canada, which makes an
annual donation of $30,000 for this purpose. These tours are proving
of great educational value to the medical professiorjbf Canada.
The team, composed of Dr. A. T. Bazin, Dr. A. H. Gordon and Dr.
Gordon Bates, spent one evening in Vancouver, on September 5th. The
meeting at the Vancouver General Hospital Auditorium was very largely
attended, a hundred and fifty medical men being present, and the papers
given were of a very high order. The speakers avoided the mistake,
which is too often made by visiting lecturers, of giving a mass of more
or less elementary matter, which should be taken as known by men who
are in actual practice. Instead, they embarked at once on the latest
developments in the subject with which they were dealing, and gave a
real post-graduate lecture.
Dr. Gordon Bates was the first speaker, and dealt with venereal
disease, from a Public Health standpoint. His lecture was closely followed, and he made some points of great importance. In dealing with
syphilis, he stressed the wide prevalence of the disease, and its destructive effect on human life and health. As a killer of mankind, this
disease ranks higher even than pneumonia, and is, he showed, the rightful
"Captain of the Men of Death."
Page 10 Dr. Bates went exhaustively into the diagnosis of the disease. In
this connection, the Wasserman test, and others similar to it, have immensely increased ouf powers of diagnosis. He gave many instances to
show the importance of examining a whole family, where one member has
the disease He dwelt at some length on the necessity of spinal fluid examination, if one's estimate of the case is to be of value. No case should
be considered cured till a normal spinal fluid is shown as well as a normal
blood.
Again, as regards treatment, Dr. Bates went at length, for which
we are grateful, into the routine that his own clinic follows—the necessity for thoroughness, constant checking by blood and spinal fluid tests,
and the dangers of incompleteness. He reminded us that lack of finality
in treatment will lead inevitably to later nerve lesions, which will fill our
hospitals and asylums in days to come,—and emphasized the duty that
is incumbent on every medical man to do his share in the proper solution
of this tremendous problem—an economic as well as a medical problem.
Dr. Bates dealt with the various spirochaeticides, mercury, arsenic
and bismuth, and at some length with sodium thiosulphate, one of the
newest remedies. This is of especial value in its power of liberating the
arsenic-fast blood cells, so that treatment with arsenic resumes its
potency. Hitherto, this has been one of the chief bugbears of the
physician, who was halted in his tracks before he had been able to
eradicate the disease.
Turning to gonorrhoea, he gave much valuable matter for our consideration, dealing especially with the problem of abortive treatment,
and considering the disease from a social and Public Health standpoint.
Dr. Bazin was the second speaker, and gave a most exhaustive talk
on surgery of the gall bladder. He dealt first with the pathology of
gall bladder infections. He reminded his hearers that cholecystitis, and
the presence of stones, are merely incidents in a serial of biliary infection
—that the story does not end with the liver, its ducts, and the gall
bladder—that, just as important, the pancreas sooner or later is involved
—that evidence is accumulating which shows that diabetes may be the
subject of the final chapter—that there is reason to believe that even
the spleen is one of the links in the long chain which starts with the
deposit of a special streptococcus, identified by research workers, as the
specific organism in many oral and intestinal infections, in the wall of
the gall bladder. For it is here that the infection commonly begins, and
not in the bile, though certain germs, notably typhoid, do appear in the
bilestream first.
The speaker traced fully the course of the infection. As regards
stones he regards these, in the case of the ordinary cholesterin stone, as
the result of the budding off into the lumen, of the lipoid projections
which characterise the strawberry bladder, described so well by Boyd
of Winnipeg. Round these the stone forms. Other stones are formed
round a bacterial nidus in other ways.
Page   11 ijSll
■■■■■HI M—yi mi TIT—Bri   t
Dr. Bazin went fully into symptomatology and diagnosis, especially
from a clinicaB standpoint. His chief criteria may be summed up as
follows:
(1) A history, more or less prolonged, of distress immediately after
food-gas and discomfort. The larger the meal, the worse the discomfort.
Little or no relief by soda. Where there is obstruction of the ducts, a
fatty meal will aggravate the distress.
(2) Pain in the epigastrium, radiating to the back beneath, or opposite the right scapula—occasionally, but seldom, to the shoulder proper.
The last is not attributable to the gall bladder itself, but further involvement.
(3) Tenderness, especially on deep, "hook-up" pressure over the
site of the gall bladder, and at Mayo-Robson's point.
(4) X-rays, of course, as at present used, are of supreme value,
directly and indirectly. In this connection, he urged the use of the flat
plate first, as this shows stones with calcium. If this is negative, the
dye by mouth, as this is effective in 80% or more of cases, and if this
fails, by intravenous injection.
Treatment: The two main points in the speaker's presentation of
this, were as follows:
The incision is of importance, and where thorough access is necessary, should be vertical. Thorough exposure and complete relaxation
are essential.
In practically every case, the speaker prefers cholecystectomy to
simple drainage. His conception of the pathology makes this the logical
conclusion. The common duct must be carefully explored in every case
for stones and gravel, and failure to palpate them does not justify carelessness in this respect. A fine ureteral stone forceps should be used,
and other methods such as irrigation.
The flabby and obese should be prepared by diet and exercise. In
jaundice calcium is of very great value, as the lactate orally, or the
chloride by vein.
The greatest care must be taken to avoid aberrant common ducts,
and accidental injury of a normal duct.
Dr. A. H. Gordon dealt with some cases of hypothyroidism. In a
delightfully witty introduction, he deprecated guessing as a method,
either of diagnosis or treatment, in cases which suggest thyroid deficiency.
The diagnosis must be made according to carefully defined principles,
and all the desiderata must be supplied. He gave several case reports,
which simulated various diseases, and which had been treated for vears
mistakenly, where careful examination, according to a clearly-defined
plan, showed that the real trouble was a lack of thyroid secretion.
One of these cases simulated pernicious anaemia, almost exactly,
except that the blood picture was a typical, and the basal metabolic rate
was low—this giving the needed clue.
o o
Page 12 Another had been treated for a long time for chronic nephritis,
and with the white, thick skin, the sluggishness, and apparent oedema,
did suggest this condition. But the urine was more or less normal, and
a metabolic rate far below normal, cleared up the case.
Another suffered from pericardial effusion, and was tapped repeatedly. Here again, lack of a typical history, and a thorough clinical
examination, including a basal metabolic rate reading, showed the true
cause, and appropriate treatment brought relief.
Other cases suggested nervous system lesions, Addison's disease, etc.
The profound weakness and easy fatigue, the slowness, almost stoppage at
times, of speech, the falling of hair, the oedematous looking skin, each
one obsessed some observer, to his undoing. But the one thing common
to all these, was the low basal metabolic rate, and the speedy improvement in nearly every case, when thyroid extract or thyroxin was given
cleared up all doubt.
Dr. H. White moved a vote of thanks, which was very heartily
passed.
:** «
^ia B. C. MEDICAL ASSOCIATION NEWS ^H
Dr. C. R. Marlatt has resigned the position of Medical Superintendent of the Powell River Sick Benefit Society, effective December 1st.
Dr. Marlatt, who has been practising in Powell River for the last nine
years, will continue there in private practice.
We understand there is a vacancy for Medical Superintendent of
the Powell River Sick Benefit Society. Any of our members interested
may forward applications to the Executive Secretary, B. C. Medical
Association, 927 Vancouver Block, Vancouver.
The fourth extra-mural post-graduate tour throughout British Columbia has just been completed and it will be interesting to the Canadian
Medical Association and the Sun Life Assurance Company to know that
it was an unqualified success.
Lectures were given at Cranbrook, Grand Forks, Kelowna, Vancouver, Chilliwack, Nanaimo, Victoria, Prince Rupert and Prince George.
Outside the larger centres of Vancouver and Victoria tremendous mileage
was covered by the doctors h|| their anxiety to attend the meetings, and
this, plus the enthusiasm and keen appreciation of the addresses, must
have been gratifying to the distinguished speakers selected for us. It
was indeed an honour to have Dr. A. T. Bazin and Dr. A. H. Gordon of
McGill University and Dr. Gordon Bates of Toronto with us. Dr.
Theo. H. Lennie, Vice-President of the B. C. Medical Association and
Dr. Howard Spohn accompanied the speakers on their tour. The Annual
Meetings of the East Kootenay, West Kootenay and Okanagan Medical
Page 13 Societies were held concurrently with the post-graduate meetings. Dr.
F. W. Green of Cranbrook was elected President of the East Kootenay
Society, Dr. H. H. McKenzie of Nelson President of the West Kootenays,
and Dr. A. L. Jones of Revelstoke President of the Okanagan Medical
Society.
We welcome back our Executive-Secretary, Mr. C. J. Fletcher, who
has just returned home from the Mayo Clinic and hope he will soon be his
genial self once more.
•Je -K -Jc
"Twenty Years Ago in Vancouver"
From the Vancouver Daily Province, Aug. 23, 1908
"The B. C. Medical Association elected Dr. C. J. Fagan, Victoria,"
"president; Dr. Glen Campbell, Vancouver, vice-president; Dr. J. D."
"Helmcken, Victoria, treasurer; Dr. C. Eden Walker, Westminster, sec-"
"retary."
* * *
We regret to say we are losing the services of our stenographer, Miss
W. Forsyth, at the end of the present month. While regretting the loss
she will be to the Association we congratulate Miss Forsyth on her approaching marriage to Mr. A. Finnie, which is to take place on November
9 th. Miss Forsyth has given splendid proof of her ability and efficiency
in the way she has handled the office work of the Association during
Mr. Fletcher's absence, and we extend to her our very good wishes for the
future.
NEUROSYPHILIS
Address delivered before the Vancouver Medical Association  Summer
School, June, 1928, by Dr. F. H. McKay of Montreal.
Syphilis is an old disease. While the exact period in which it was
first recognized remains largely a matter of conjecture, it is definitely
accepted as one of the several devastating plagues which swept over
Europe during the middle ages. Since that time, it has been the subject
of more intensive study, with not a little speculation, than probably any
other disease. And yet it is a striking fact that the three great epoch-
making events in its history should have been crowded into the short
space of five years.
The discovery of the Spirochaeta pallida by Schaudinn and Hoffman in 1905, the formulation of the complement fixation test by Bordet
and Wasserman in 1906, and the preparation of salvarsan by Ehrlich
in 1910 indicate the most productive period in its history, and constitute
the basis of a surer knowledge of its pathogenesis and treatment. In
the discovery of the spirochaete in the brain substance of undoubted
paretics by Nogouchi in 1913 and their later recognition in the spinal
cord pulp of typical tabetics, we establish beyond doubt the relation between the causative organism and the so-called parasyphilitic diseases.
Page 14 The term parasyphilis is being gradually dropped from our nomenclature, in the firm knowledge that tabes and paresis are as definitely
syphilitic manifestations as are the skin lesions of the secondary infection.
Not so firmly established, however, is present day opinion on the
course of development of these late infections, or why it is, that one
individual will bear the brunt of the attack in his cutaneous system,
while his fellow, showing little or no evidence of cutaneous reaction,
develops after many years, signs of nervous involvement.
The striking affinity of the spirochaete for tissues, embryologically
of ectodermic origin is obvious, but what factors are effective in deciding
which of these systems—the cutaneous with its immediate reaction or the
nervous with its much later response—must bear the brunt of the attack,
is still a matter of conjecture.
Many explanations have been advanced, some of which predicate a
difference in the strain of the organism. Certain authorities teach that
we are really dealing with entirely diffe'rent strains of organisms and have
set up the neurotropic theory which implies that one special strain
alone, is responsible for syphilis of the nervous system. This theory takes
its origin from the observation that following a common source of infection, tabes or paresis may be fairly constant developments. There is,
however, little to commend this theory and in the light of wider knowledge it would appear to be of questionable importance.
Then again, the belief that this long period of time may be consumed in the actual progression of the organism along the perineural
spaces, by which it is believed to gain access to the central nervous system, is without sufficient foundation.
It is much more probable that the question is one of a defensive
reaction on the part of the host.
It is a well recognized fact that the milder types of primary and
secondary infection are those most often followed by cerebral syphilis,
while, conversely, individuals showing well jnarked cutaneous manifestations seldom develop late parenchymatous changes in the brain or cord.
I am more and more impressed as time goes on by the statement of
patients who aver their innocence of infection.
It is further recognized that this class is the one which receives
least attention and consequently inadequate treatment at the outset and
that this treatment may be a cause rather than a deterrant of cerebral
involvement.
In this connection it is interesting to note that in certain semi-
civilized races, amongst whom syphilis is rampant, cerebral syphilis was
unknown until treatment by salvarsan was instituted. McArthur working among the natives of Bechuanaland, showed that neurosyphilis made
its appearance with the advent of salvarsan treatment.
Now what bearing have§these observations upon the pathogenesis
of neurosyphilis?
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Page 17
mmmmmmss* p» «■^sSStKL.
The theory is suggested—and at present it is the most probable
and logical theory—that coincident with the primary infection, defensive
anti-bodies are produced in the serum of the host and that even in untreated cases these are frequently successful in preventing disaster to the
central nervous system.
The effect of a few salvarsan injections is to interfere with the
activity of the anti-bodies and thereby permit the organism to gain a
hold in the deeper tissues, while simultaneously they destroy the organism in the blood stream and superficial tissues and even obscure the
picture by bringing about a negative Wasserman.
Subsequent involvement of the nervous system after such abortive
attempts at treatment is fully recognized and not difficult of interpretation. Syphilis is essentially an infectious disease and its invasion of the
human economy awakens a tissue reaction similar in all respects to that
of other infections. Recovery and cure depend largely upon the efficiency
of this reaction which, as we have noted frequently, suffices to overcome
the infection before irreparable damage to nervous tissue is done. This
then means only one thing, that treatment by salvarsan if instituted at
all—and few would be bold enough to belittle such treatment—should
be intensive and prolonged enough to destroy all the organisms within
the tissues of the host. It is probable that inadequate treatment is worse
than none at all.
There is now no doubt that the spirochaete is harboured in the
tissues of the nervous system during the intervening period between the
secondary invasion and the clinical appearance of neurosyphilis.
Fordyce states that he found evidence of nervous system involvement as shown by the serology in 25% of all cases of primary syphilis,
and believes that the late cases—paresis and tabes—are due to long
persistence of the infecting organism "in loco."
However, with his further "dictum" that neurosyphilis never
follows a normal spinal fluid, whether brought about by treatment or
by the natural tissue reactions, I cannot agree as I have seen more than
once the development of full fledged paresis, subsequent to a normal
serology.
Improvement in the treatment of early syphilis :has been made particularly since the appearance of salvarsan and we have had every right
to expect that the spectacular disappearance of the primary and secondary
manifestations of the disease under salvarsan treatment, should be reflected in a lowering of the incidence ratio of neurosyphilis. This unfortunately is not the case and every treatment clinic of the present
day reports that the incidence of cerebral syphilis is on the increase.
This state of affairs must be laid at the door of inadequate treatment and if there is one lesson to be learned from such a state it is that
the early treatment of generalized syphilis should be intensive and complete.
Page IS As to symptomatology, one might expect that with each clinical
group as outlined in our classification table, one should find a clear cut
symptom-grouping, but as a matter of fact, this is not always so. While
it is recognized that certain signs and symptoms speak for one or other
of these types, it is often impossible to classify clinical types from signs
alone.
For instance, the presence of epileptic seizures points to meningitis
of the vertex so falling within the category of meningovascular syphilis,
but how often do we see an epileptic attack usher in and accompany
general paresis.
Paralyses of cranial nerves speak for meningitis of the base but we
know too, how frequently these are found in tabes.
Optic atrophy may be an indication of gumma pressing on the optic
tract or it may stamp the course of tabes or paresis, and at this point I
wish to make passing reference to certain statements occasionally appearing in the literature, to the effect that optic atrophy is curable.
I have not yet seen a case of optic atrophy influenced, least of all
cured, by any special treatment, but incipient atrophy due to pressure
from gumma or basal meningitis would theoretically appear amenable
to treatment. The atrophy, however, associated with tabes or paresis
and so due to primary neuronic degeneration is progressive and in no
way affected by any recognized therapy.
Then again, the mere presence of a mental disorder does not always
mean that we are dealing with paresis of the insane and here I would
like to stress this point, for too often an irreparable injustice is done to
the patient by jumping at the diagnosis of paresis when really he is
suffering only from an associated psychosis or a simple syphilitic psychosis which yields as readily to proper treatment as any other syphilitic
manifestation.
I
Certain patients with meningeal infiltration of the base may show
mental disturbance indistinguishable from that of paresis and it is readily
seen how the pessimistic attitude which usually accompanies the diagnosis
of the latter would endanger the chances of recovery from the former.
Occasionally it is necessary to apply the therapeutic test and administer a course of treatments before certain psychosis occurring in the early
course of syphilis can be definitely allocated.
It is not uncommon to find such mental symptoms as impaired
memory and concentration, depression, character-change and inattention
to duty in meningovascular syphilis disappear entirely after one course
of antisyphilis treatment—a feature of meningovascular syphilis never
observed in the treatment of true paresis.
Of all the signs which serve to stamp the neurosyphilitic, whether of
the meningovascular or parenchymatous  type, irregularities in  the size
Page 19
mm ttfrSfrfflrcn
and function of the pupil take a paramount place. We are usually
taught that the Argyle-Robertson pupil is the stamp of syphilis and
while this is not entirely true, as any lesion of the midbrain inflammatory
or otherwise may cause this phenomenon, yet it occurs so frequently in
syphilis and so seldom in other diseases that its place of importance in
the diagnosis of syphilis is fully justified.
Nor is the typical Argyle-Robertson pupil necessary, for after all,
the finding of an irregular pupil or unequal pupils or of one completely
fixed to light and accommodation, is just as important and more frequent. This is particularly true in meningovascular syphilis where a
slight irregularity or inequality so often blazes the trail of a spirochaetal
infecton.
Now, the question may be asked—"After all, what difference does
the type of infection make so long as we are sure the patient has cerebral syphilis?" The answer is one of prognosis and the determination of
the attitude of the attending physician. The diagnosis of meningovascular syphilis spells hope and energy to the physician which is almost
invariably translated into therapeutic success. The diagnosis of parenchymatous syphilis too frequently blots out that hope and dampens
enthusiasm.
Vascular syphilis like vascular disease of other origin has too its
manifold symptomatology but if we remember that the symptoms are
those of arterial disease, such symptom-complexes as monoplegia, hemiplegia, speech defect, Jacksonian convulsions, cranial nerve defect, etc.,
can be easily interpreted and readily allocated. Any of these groupings,
particularly hemiplegia and monoplegia occurring in young patients,
free from obvious arterio-sclerosis, suggests syphilis as the likely cause.
Very significant of meningovascular syphilis are successive attacks
of mild and transient palsies whether of the speech mechanism, ocular
movements or one or both extremities.
The signs of gumma are those of brain tumour of other origin.
Consideration of the subjective symptomatology would involve a discussion of all known neurological symptoms. It is sufficient to point out
that many of our neurasthenics are but the bearers of disguised and early
neurosyphilis. Headache of a migratory character may be the only
symptom for months while insomnia alone may hold the stage for a
year or more. General apathy, impaired concentration, loss of interest
in one's work, reduced energy and general inefficiency may be long in
evidence before some definite objective sign appears to direct the observer's attention along the right road.
Of parenchymatous syphilis I will have little to say. Here the
neuronic element of the brain and cord is interfered with and when we
consider that this element, if destroyed, cannot revive—its highly specialized characteristics rendering it incapable of regeneration—we are not
surprised at the failure of therapeusis in a well establshed pathology.
Whether in parenchymatous syphilis a patient develops tabes or
paresis is entirely a matter of accident.
Page 20 When the infection strikes most heavily upon the cerebral field we
are face to face with that most horrible of all syphilitic processes—general
paresis of the insane. Relatively fortunate is he who has the disease
process confined to the cord, for at least his cerebral functions remain
intact while the ravages of the disease may be stayed, though not cured
in the sense that pre-existing damage can be repaired.
If, then, any neurological symptom, subjective or objective, may be
attributed to syphilis and if the differential diagnosis of cerebral syphilis
involves a consideration of all other degenerative and inflammatory diseases of the central nervous system, is there any sheet anchor on which
the physician can depend in the time of need?
If so, it is to be found in the examination of the spinal fluid. The
serological findings not only give us corroborative evidence in diagnosis
but are the criteria by means of which we measure progress or regression
in treatment. Their investigation should be a routine procedure and if
at any time positive, treatment should be continued until all phases are
rendered negative. Positive serology is an expression of the meningeal
involvement that accompanies the infection, but unfortunately, with the
exception of paresis, is not a constant finding.
From 25 to 30% of clinically established cases of tabes have normal
cerebro spinal fluids. Meningovascular syphilis in even greater proportions is accompanied by negative serology.
Conversely, in those cases of so-called latent syphilis, positive
serology in the absence of all clinical findings indicates persistent infection and frequently relegates to its proper basis a mild recurring headache or a troublesome insomnia.
Involvement of the meninges is first indicated by an increased lymphocytic count, which may vary from an average of 16 to 40 in tabes,
to excessively high counts in paresis.
Coincident with the increased cytological phase the globulin content
is increased, again showing the maximum increase in paresis, and peculiarly resistant to treatment in all forms.
The specific Wasserman test shows a positive reaction in about 60%
of meningovascular, 70% of tabetic and 100% of paretic cases.
The colloidal gold which is closely paralleled by the colloidal mastic
test, is positive in well over 90% of paretics, 75% of tabetics and 50%
of interstitial syphilis. Contrary to the generally held opinion, the type
of curve, which is but an expression of the intensity of the reaction,
does not suffice to differentiate the types of the disease.
Definitely paretic curves, while suggestive of paresis, are found in
over 40% of all cases of neurosyphilis, a figure which in itself nullifies
its pathognomonic importance. Moreover, it is not infrequently found
in disseminated sclerosis, brain tumour and encephalitis.
Page 21 The paretic curve indicates a stronger reaction with the colloidal
gold, and for this reason is more frequently found in paretic fluids
which, as we have seen, present maximum reactions in 100% of cases.
So constantly positive to all phases is the fluid in general paresis,
that I have come to regard positive serology as essential to the diagnosis
of paresis, and seriously question such a diagnosis in the presence of
normal fluid.
^^9     I    9   TREATMENT   ^^^^^nffl
Reference has already been made to the incidence of neurosyphilis,
which may be conservatively placed at 25% of the whole.
Ample proof is forthcoming to establish the fact that this involvement takes place in the early months or years of the general infection
and gradually progresses over a varying period of time to the establishment of subjective or objective signs.
Some investigations furthermore tend to show that the infection is
active from the outset as evidenced in some or all of the abnormal
phases of the spinal fluid, thus invalidating the once commonly held
belief that reinfection of the nervous system occurs many years after the
primary infection.
Also, it has been intimated that destruction of the parenchymal
elements of the central nervous system is irreparable and unaccompanied
by subsequent regeneration. It is evident, then, that treatment to be
most effective must be instituted at the earliest possible opportunity—
preferably in the latent or silent period, immediately following invasion
of the nervous tissues.
The difficulties attendant upon diagnosis in this stage of the disease
can be obviated only by the frequent, I might say, universal use of the
Lumbar puncture needle. If we may expect infection in 25% of all
cases, it is not asking too great a sacrifice on the part of the other 75%
to subject themselves to Lumbar puncture for the general betterment
of the whole.
The efficacy of treatment, and consequent prognosis, depends in great
measure upon early diagnosis which when established is the signal for
therapy sufficiently intensive and prolonged to completely eradicate all
abnormal serological findings.
Treatment may be continued for years without much evident amelioration in the serological pathology, only to show at a subsequent
examining a normal fluid. I have been impressed with the suddenness with which abnormal findings in the spinal fluid may disappear.
Much controversy as to the relative merits of various methods of
treatment has been indulged in during the past few years and it is not
my intention to add to this plethora or unproved assertion. Rather do
I wish to outline as briefly as possible the methods by which the best
Page 22 results have been obtained in the Neurological Treatment Clinic of the
Montreal General Hospital.
Here, it has been found, that the ordinary intravenous injection of
neosalvarsan (novarsenobenzol) given at weekly intervals and alternating with intramuscular injections of mercury salicylate, has been as
highly efficacious in the treatment of meningovascular syphilis as any
of the other more elaborate methods. The use of the intraspinal technique
of Swift and Ellis or one of its modifications is reserved for these cases
which show no clinical or serological response to intravenous therapy.
The question may be asked "Why not employ intraspinal therapy
from the outset?"—the answer to which embodies the following reasons:
On the whole, continued or persistent intravenous therapy gives
maximum results in the great majority of cases of interstitial neurosyphilis. The technique is so much simpler and the inconvenience to the
patient so much less, that it is the method of choice, especially in outdoor
clinics.
The treatment of tabes is conducted is conducted along much the
same lines though better results have followed the drainage procedure
advocated by Gilpin and Early. This consists in drawing away spinal
fluid until pressure of 30 to 50 mm of water is registered, from % hour
to 1 hour before the administration of neosalvarsan. I am convinced
that this procedure is sound and hastens recovery in well established tabes.
The rationale of this procedure consists not only in the greater
difference of potential between the vascular and the spinal fluid pressures but also in the increased vascularity following upon dilitation of the
intramedullary or intracerebral blood vessels, effected by the lessening of
pressure in the subdural space—a sort of Bier treatment to the cerebrospinal system.
Tabes, especially those cases with definite meningeal involvement,
may almost invariably be prevented froni further progress, and if seen
in its earlier stages, even cured.
The most hopeless cases are those showing but little meningeal involvement with neuronic degeneration of the posterior columns, evidenced by advanced clinical signs and normal or almost normal spinal fluid.
It is, however, in the treatment of general paresis that the greater
strides have been made in the past few years.
The hopeless prognosis, formerly associated with the diagnosis of
this most fearful of all syphilitic processes, has within recent months
given place to a note of optimism, heretofore unknown.
The first ray of hope followed upon the work of Wagner von
Jauregg who initiated the malarial treatment, and in reviewing the results
of many workers who have followed up his lead, one can have no doubt
that paresis has been given a "set back" by this measure. While admittedly, it is too early to dogmatize as to permanence and perforce one
must speak in terms of remission rather than cure, the high percentage of remissions following directly upon treatments is, at least, encouraging.
Kirby, whose experience has been quite full, has had in a series of
106 cases, remissions ranging from 12% in the demented cases to 67%
in the manic cases. The same note of optimism is struck by all workers
with experience in this field. An average of full remissions, reported
from a number of clinics, ranges from 25% to 35%, while incomplete
remissions give a much higher average.
No definite opinion is possible as to the rationale of induced fever
in the therapy of the disease, though it is interesting to note the ex^-
perimental work of Schomberg & Rule on the thermal death point of
the spirochaeta. They found that the organism was biologically destroyed at a temperature much lower than that necessary to devitalize vegetable micro-organism. Clinically, too, the best results are obtained where
the temperature reaches the higher levels.
The next important advance in the treatment of paresis is contained
in the development and production of the arsenical compound, tryparsa-
mide. This drug^ which was introduced by Jacobs and Heidelberger in
1915, studied experimentally by Browne & Pearce, and applied first to
the treatment of paresis by Lorenz and Laevenhort, is, at present, the
most valuable adjunct to our armamentarium against paresis. Administered intravenously in 3 grm. doses weekly for 10 to 12 weeks, interspersed with mercurial injections, it has been productive of results
heretofore impossible, and certainly most encouraging. It is easily borne
by the patient and although one must mention its possible edverse effect
on the optic nerve, this cannot be accepted as a real contra-indication
when balanced against its clinical value.
Some cases of optic atrophy have been reported and it is essential
to check up the vision of the patient during its administration, with
which precaution the   drug is safe and well borne.
The immediate effect on the patient is one of subjective betterment
and physical improvement follows, often with startling rapidity. On the
other hand, serological improvement is often slow, and may show little
evidence of modification until 50 to 70 injections have been given.
Meanwhile however, improvement takes place in the mental and physical
status, and remissions of varying duration permit the resumption of social
and economic activity.
While, as before intimated, we should guard against too optimistic
an attitude in any measure pertaining to the treatment of paresis, a fair
experience with this drug has led the writer to regard the future with,
at least, some measure of hope.
Summarizing the relative value of malarial and tryparsamide therapy,
Reese of the Wisconsin Psychiatric Institute, where the drug was first
employed, concludes that 'Tryparsamide on the whole is of greater
value than the malarial treatment. In the former, benefit was noted in
60( ( of the cases treated, while the latter gave beneficial results in only
30%.    The  former  is  immediately  followed  by  marked  physical   im-
Pagc 24 provement while the latter is weakening and cannot be employed in
emaciated patients. Properly controlled, tryparsamide is not harmful
to the visual apparatus."
As may be surmised, the best results are obtained in a combination
of induced malaria followed by tryparsamide administration. When the
physical state of the patient permits, this procedure is followed in most
clinics at the present time.
While the immediate and spectacular effects of the arsenical preparations rightly occupy a principal place in our present day therapy,
the stabilizing effect of mercury should never be lost sight of. As an
adjunct it still remains the sheet anchor of treatment directed toward
enduring recovery.
In conclusion, may I once more refer to the desirability of early
recognition of involvement of the central nervous system to which end
the frequent use of the lumbar puncture needle is essential and finally
express the hope that through the medium of these newer therapeutic
agents, with others still to follow, the feeling of pessimism and despair
that heretofore has stamped the diagnosis of paresis may be "on the turn."
J*
A  CLINICAL  EVENING  AT  SHAUGHNESSY
About fifty members of the Vancouver Medical Association, taking
the dog days in Vancouver, were the favoured guests of the Medical
Staff of the Shaughnessy Military Hospital on Tuesday evening, August
14th, at a very interesting clinical meeting. An unusual series of cases
was presented and the meeting concluded in true Shaughnessy fashion
with refreshments, which seemed to be very much appreciated.
The first case was presented by Dr. Dobson—a man who had a
25% disability, discharged from the army on account of nephritis,
who for 8 to 10 years had been unable to hold a position, presumably on
account of nephritis. It was finally determined that the man's disability
was really mental and not due to the nephritis at all. This case serves
to manifest what possibly is very often overlooked, the importance of the
mental factor in the treatment of various physical conditions.
The second case shown by Dr. Dobson was a civil engineer who had
been vomiting from 5 to 25 times a day since 1921. In 1922 the blood
Wassermann being negative the spinal fluid was examined and a positive
Wassermann found and the case was diagnosed cerebro-spinal syphilis.
Prognosis at that time was given as from 1 to 2 years but the patient is
still living and apparently not failing very rapidly. The striking feature
of this case is the persistent vomiting.
The third case was that of a veteran discharged with pension on
account of shellshock. In 1922 persistent headache developed and a
diagnosis of brain tumour was ultimately made.    There were no local-
Page 25
MM izing symptoms but a decompression was done with great relief, the
spinal fluid pressure dropping from 55 to 20. The patient still suffers
much and a sub-temporal decompression on the other side will probably
be done. It was believed that the tumour was of rather recent development and not in any way connected with the original condition which
was diagnosed as shellshock.
The first case presented by Dr. Schinbein was one simulating
Buerger's disease in a man of 68 years of age who had seen two years of
service and was discharged on account of pain in feet and leg. Patient
had been in and out of hospital with his legs discoloured purple when
down and white when elevated with an eczematous condition developing
in the skin. The right foot and leg became worse than the left and an
ulcer finally developed on the sole. There was no femoral pulse in the
right leg. Amputation was done at mid-thigh with equal anterior and
posterior flaps and the healing has been complete. The left leg still
gives a femoral and popliteal pulse but this is lost in the dorsalis pedis
artery. The man showed a general condition of arteriosclerosis though
the blood pressure is only 148/90. There is definite myocarditis with
enlargement of the heart. The non-protein nitrogen is normal and the
kidney function fair. Sympathectomy in Buerger's disease was mentioned but authorities agree that in the face of occluded arteries it
offered very little help.
Dr. Schinbein showed a patient from whom he had removed the
largest pyonephrotic kidney he had ever seen.    This patient had from
1918 intermittent pain in the left side of the abdomen from a day to a
week's duration. X-ray for stone was negative and the spine was clear.
In 1923 an attack lasted six weeks and patient was then free until 1926.
In bed over two weeks. Pain recurred in May, 1928, and patient was
operated this summer. X-ray showed a free colon, the kidney was not
outlined and the urine showed pus. At operation 60 ounces of pus
were removed. The tumour extended from the costal margin to Pou-
part's ligament from the umbilicus into the flank. The ureter immediately below the kidney was not distended, the condition apparently having
developed from a kink of the ureter or an aberrant vessel. Healing was
by first intention in spite of the infected field.
Dr. Schinbein presented a patient who had trench fever in France
with a pleurisy and after six months was invalided home.    He worked
1919 to 1920. He was still bothered with pain in the left side and
weakness. A diagnosis of T.B. was made and in January, 1928, he was
admitted to the Tuberculosis Pavilion at Shaughnessy. He showed persistent fluid in his abdomen and it was felt that he had a T.B. peritonitis.
His red blood count was 4,600,000, with 85% haemoglobin, with 5,000
white blood cells. Tubercle bacilli were not found in the sputum. Non
protein nitrogen was 3 3, Wassermann negative. Exploratory laparotomy
was done and the only pathology found was cirrhosis of the liver. The
organ was very small and nodular. Since operation patient has been
comfortable for 2 to 3 weeks but is losing ground. Novasurol with ammonium chloride was given but made no difference in the ascites. The
Talma operation—transplanting the omentum into the abdominal wall
Page 26 to give collateral circulation, was not done. A striking feature was the
absence of collateral circulation through enlarged veins of the chest and
abdomen and absence of haemorrhoids in the face of an advanced cirrhosis of the liver.
Dr. Wallace Wilson presented a case which had been diagnosed as
pernicious anaemia. Patient was 46 years of age with 3%j|million red
cells, haemoglobin 56%. Negative Wassermann with a high hydrochloric acid content of the stomach. Patient, in his own words, "sleeps
al the time." Pain in the legs, slow speech, dull mentality, hair is
brittle, skin dry, pouches under the eyes, lips thick. He has worked
until this spring, but had simple employment. The basal metabolism
rate of minus 48 only confined the diagnosis of myxoedema. The
prognosis under thyroid treatment is excellent. The patient's service
medical record noted repeatedly the dull mentality and the condition
undoubtedly goes back to his service years.
The second case presented by Dr. Wilson was a "falling down"
case. The condition had been diagnosed as a gastric neurosis on account
of the persistent attacks of pain and vomiting. X-rays have been negative three times, but the trouble increased. Finally an x-ray showed a
duodenal ulcer and the patient improved very much on a Sippy diet.
Lately there has been a complaint of difficulty in bringing up gas from
the stomach and in swallowing, particularly solid food. The most
recent x-ray showed an apparent obstruction of the oesophagus in its
lower part, diagnosed on the x-ray as a carcinoma on account of the irregularity of the obstructed portion of the tract. Dr. Cunningham
examined the tumour with an oesophagoscope and found a hard red mass
which on section proved to be an adenocarcinoma. The x-ray difference
from cardio-spasm depended upon the irregularity of the obstructed oesophageal wall, in the latter condition a smooth sided funnel is found.
Dr. Wilson presented a third case for diagnosis. The patient has
had intermittent attacks of bronchitis since the war which have allowed
him to work only at intervals. He had lost 25 pounds in weight in four
years, had a persistent cough, with an occasional haemoptysis. Physical
examination has been negative except for dullness between the scapulae
and harsh high pitched breath sounds. The temperature since being
under observation has passed 99° only three times in spite of profuse expectoration. The spleen is definitely enlarged. Tubercle bacilli have
never been found. Patient is dyspnoeic when prone. Asthma is not
suggested even though there seems to be some inspiratory obstruction.
Veins on the left side of the neck are larger than on the right. X-ray
films show a mushroom-shaped opacity 2 to 3 inches across, standing out
from the left hilus into the upper portion of the lung and a smaller
similar opacity on the right side with definite mottling of the adjacent
lung tissue.
Dr. McCullum in discussing the x-ray film considered a diagnosis of
Hodgkin's disease, new growth or tuberculosis. Dr. Vrooman pointed
out that a malignancy would probably have killed the patient within a
year, whereas he has been under observation for four years and has been
Page 27 ill since the war. He also mentioned that in Hodgkin's one would expect
glandular enlargement in addition |to the enlargement of the spleen.
He considered the condition a chronic fibrotic tuberculosis.
Dr. Wilson showed a case of myocarditis with fibrillation which
has shown a remarkable recovery. Patient has been in the hospital
many times since 1923. He has been tapped repeatedly for ascites but
is now up out of bed for the first time in months and feeling fairly well.
Diuretics have been of no help in this patient. % gr. thyroid daily may
have toned up his metabolism and aided diuresis.
The last case presented was a patient of 36 years of age. In 1916
in France he developed in the course of a week a tumour on the left side
of the neck. In 1918 this tumour was treated with x-ray and a diagnosis of Hodgkin's disease was made. It disappeared leaving only small
glands. Microscopic sections confirmed the diagnosis. Patient has
worked off and on since. He was treated intermittently with x-ray
until 1923. Since that time he has been gradually slipping. The axillary glands have become enlarged and are painful at times. The spleen
is enlarged. A constant temperature with daily exacerbations, secondary
anaemia (2l/2 million red cells, 40% haemoglobin). Blood transfusion
was of no help. X-ray shows chest and mediastinum clear. Liver
extract has been used experimentally without benefit.
In closing Dr. Procter, who presided, expressed the pleasure of the
staff of Shaughnessy Hospital in being able from time to time to entertain the Association. Dr. Pearson voiced the thanks of the Association
for the courtesy and hospitality of the Shaughnessy staff in presenting
such extremely valuable clinical material. —G. B.
•J* J* •!*
"Jr* *%% %»
I H        HOSPITAL SERVICE    ;^R?« I
Dr. G. Harvey Agnew, Secretary of the Department of Hospital
Service of the Canadian Medical Association is at present in Vancouver.
The following is a copy of the report of his Department presented at the
Annual Meeting of the Association in June last:
I REPORT OF THE DEPARTMENT OF HOSPITAL SERVICE H
The Department of Hospital Service, the youngest of the many
activities of the Canadian Medical Association, has been organized because
of the tremendous need for such work among the smaller hospitals in
Canada. We have, at present, no national hospital organization to link
up the various provincial hospital associations, and, in fact, in some
provinces, no provincial hospital associations exist at all. A great many
of our smaller institutions, especially those in smaller centres, are building without proper advice; they are purchasing equipment and supplies
which may be unnecessary, of poor quality and obtained at a higher price
than necessary; they are often inadequately organized and frequently cannot cope with the local situation. The need for the closer study of
certain hospital problems was emphasized in the recent report of the
Committee on Hospital Efficiency. Thanks to the generosity of the
Sun Life Assurance Company the establishment of this Department has
now become possible.
In operation but four months, we can already report considerable
progress.    The organization of the department and the planning of the
Page 28 scope of our work has entailed considerable thought and effort. An Advisory Board is being formed, composed of representative hospital authorities from all parts of Canada. It has been considered advisable to include
laymen as well as physicians on this Board. Hospital problems are being
studied by visiting as many of our institutions as possible and discussing
the local situation with superintendents, staffs and governors. By the
end of the year, we hope to have visited the majority of the hospitals in
each province.
Our chief activity will be to act in an advisory capacity on the
many problems which arise in the course of| hospital administration.
This will be by correspondence and, where deemed advisable, by personal
visit. We hope, also, to be of considerable assistance to the existing
provincial hospital associations and to aid in the formation of such
associations where they do not already exist.
To this end we are now building up a reference library on hospital
topics. Hospital Administration has become a very highly specialized
field in the past few years and we shall find such a library of inestimable
value in working out the many details of the requests coming ||o this
Department. We shall pay special attention to those contributors to
hospital literature which are most applicable to Canadian institutions.
Arrangements have been made with the American Medical Association,
American Hospital Association, the Hospital Library and Service Bureau
and the American College of Surgeons to work in close co-operation for
mutual benefit and to prevent overlapping.
A number of special studies have already engaged our attention.
The exodus of recent graduates to other countries and the resultant dearth
of internes here has prompted us to undertake to find appointments for
our students among our own hospitals. We have found many more
vacancies than applicants and hope in subsequent years, by approaching
the students at an earlier date, to retain a still higher number in Canada.
We are also making a study of the laws of each province with respect to responsibility for indigents, the extent of government and municipal aid, etc. We hope, also, to bring to the attention of the government, many anomalies and impositions in the customs regulations which
might well be corrected in the interests of the hospitals.
At present there is no complete nor trustworthy list of Canadian
hospitals. We have found the greatest difficulty in completing our own
list from the available data which have been culled from many sources.
We are, therefore, very pleased to announce that we, in co-operation
with the Federal Department of Health, hope to publish shortly, a complete and thoroughly up-to-date list of our Canadian Hospitals.
From the very first announcement, a most gratifying response has
been evident. A tangible proof that this work will meet a great need is
the fact that already, in four months, over one hundred and fifty requests
for advice or help have been received. We have reason to hope, also,
that our Department can be very instrumental in developing a very close
harmony and interchange of viewpoint between the medical staffs and the
Boards of Governors (Can. Med. Assn. Jnl., Sept., 1928).
Page 29 VANCOUVER HEALTH DEPARTMENT
STATISTICS, AUGUST, 1928
Total   Population   (Estimated) 142,150
Asiatic Population   (Estimated)    ^^K  10,940
Rate per 1,000 of Population
Total   Deaths     131 10.88
Asiatic  Deaths    I  15 16.19
Deaths—Residents   only   —  1 85 7.96
TOTAL   BIRTHS            261 21.68
Male       134
Female   127
Stillbirths—not  included   in   above I   9— 6
INFANTILE MORTALITY—
Deaths under one year of age  6
Death Rate per  1,000 Births  22.99
CASES OF INFECTIOUS DISEASES REPORTED IN CITY
September  1st
July,   1928
Cases     Deaths
        11 0
Smallpox     11
Scarlet Fever  .  6
Diphtheria     37
Chicken-pox      2
Measles     2
Mumps     3
Whooping-cough      6
Typhoid  Fever      2
Tuberculosis      16
Erysipelas       4
Poliomyelitis      3
0
Diphtheria          16 1
  3 0
  2 0
  2 0
  3 0
Scarlet Fever
Smallpox	
Typhoid   Fever
Poliomyelitis   __
August,
1928
to 1
5 th, 1928
Cases
Deaths
Cases
Deaths
7
0
3
0
2
0
5
0
25
2
14
1
5
0
1
0
1
0
0
0
3
0
1
0
0
0
1
0
6
0
0
0
15
9
6
—
4
1
3
0
10
2
2
1
t eluded
in Above.
12
2
4
0
1
0
0
0
0
0
1
0
6
0
0
0
5
2
1
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