CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
'Serum therapy ; Acute osteomyelitis ; Gall bladder pathology.' -- Title page
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THE VANCOUVeA<MEDICAL 0 % ASSOCIATK sP •^U BULLETIN Published monthly at Vancouver, B. C. Subscription $1.50 per year «/ Serum therapy cAcute Osteomyelitis Qall gladder Tathology SEPTEMBER, 1927 *3- Tublished by e!Mc(U3eath Spedding Limited, IJancouver, "23. Q. >K IVhy an Emulsion A SIMPLE demonstration shows the Physician at once why Petrolagar is preferable as an intestinal lubricant. Mix equal parts oi Petrolagar and water in a tube or glass. In another tube or glass, try to mix equal parts of plain mineral oil and water! Deshell Laboratories of Canada Ltd. 245 Carl aw Avenue TORONTO, Canada r% DL w iiliificatiin of mineral n't tncrcaws the flffiCteftcy *| an inlesliial luttrican t—mixes in- limalcly with intestinal content. and the ientieiKy to leakage is lessened. Petrolagar Page 3 66 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. Stanley Paulin All communications to be addressed to the Editor at the above address. Vol. 3 SEPTEMBER 1st, 1927 OFFICERS, 1927 - 28 Dr. W. S. Turnbull Vice-President Dr. G. F. Strong Secretary Dr. A. B. Schinbein President TRUSTEES Dr. A. W. Hunter Past President Dr. A. C. Frost Treasurer Dr. J. M. Pearson Auditor Dr. W. F. Coy Dr. W. B. Burnett Representative to B.C. Medical Association Dr. C. H. Vrooman SECTIONS Clinical Section Gordon Burke , , '. j . ' ; I L__H1_Chairman L. H. Appleby 9 - i Secretary Physiological and Pathological Section J. E. Campbell 1 Chairman F. J. Buller : Lill . . Secretary Eye, Ear, Nose and Throat Section E. H. Saunders Chairman W. E. Ainley 1 -1 -..Secretary Genito-Urinary Section G. S. Gordon i - Chairman J. E. Campbell " . Secretary Physiotherapy Section . H. R. Ross - ; Chairman J. W. Welch _ j i : Secretary STANDING COMMITTEES Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. 1 L Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Library Committee C. H. Bastin W. C. Walsh W. A. Bagnall D. F. Busteed Orchestra Committee J. A. Smith H. A. Barrett L. Macmillan H. C. Powell Dinner Committee D. D. Freeze C. H. C. Bell T. H. Lennie Credit Bureau Committee Dr. D. McLellan DR. L. Macmillan Dr. J. W. Arbuckle Credentials Committee Dr. F. W. Lees Dr. E. J. Gray Dr. W. F. McKay Summer School Committee Dr. G. F. Strong Dr. W. D. Keith Dr. H. R. Storrs Dr. R. Crosby Dr. B. D. Gillies Dr. L. H. Appleby VANCOUVER MEDICAL ASSOCIATION Founded 1898. Incorporated 1906. THE 30th ANNUAL SESSION GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m., from October to April. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m., from October to April. Place of meeting will appear on Agenda. General Meetings will conform to the following order:— 8:00 p.m.—Business as per Agenda. 9:00 p.m.—Paper of Evening. + * * VANCOUVER HEALTH DEPARTMENT STATISTICS — JULY, 1927. Total Population (Estimated) 137,197 Asiatic Population (Estimated) 10,576 Rate per 1000 of Population Total Deaths 139 11.87 Asiatic Deaths 14 16.9 Deaths—Residents only 91 7.11 TOTAL BIRTHS 272 20.26 Male 144 Female 128 Stillbirths—not included in above 14 INFANTILE MORTALITY— Deaths under one year of age '_. 11 Death Rate per 1000 births 45.52 CASES OF INFECTIOUS DISEASES REPORTED IN CITY August 1 to 15, 1927 Cases Deaths June, 1927 Cases Deaths July, 1927 Cases Deaths Smallpox Scarlet Fever Diphtheria Chicken-pox Measles Mumps Whooping Cough. Typhoid Fever ... Tuberculosis Erysipelas Epid. Cerebrospinal Meningitis. 0 7 13 98 44 3 8 1 20 7 3 0 1 0 0 1 0 0 1 12 0 3 0 7 23 3 14 1 3 1 14 7 0 0 0 1 0 0 0 0 1 11 0 0 0 2 4 0 0 2 1 0 15 ■ -.4. 0 0 1 0 0 0 0 0 0 Cases from outside city—included in above Diphtheria Scarlet Fever Typhoid Fever __. Epid. Cerebrospinal Meningitis . Page 3 68 2 0 2 0 1 1 11 1 '%' 0 1 1 1 0 1 1 0 0 Section of X-Ray Department, Montreal General Hospital. Installation by Montreal Branch of Victor X-Ray Cotporation of Canada, Ltd. Victor Service in Canada ' I HE Victor X-Ray Corporation has assumed a respon- sibility to the medical profession which does not end with developing and manufacturing X-Ray and Physical Therapy apparatus of the most approved type. It is a tenet of the Victor code that the operator of a Victor machine has the right to receive technical aid when he needs it. So, a nation-wide Victor Service Department was organized years ago and direct branches established in the principal cities of the United States and Canada, where Victor trained men are always available. No matter where a Victor machine may be installed Victor service stands ready, on request, to inspect it or to render such technical assistance as may be required. Victor alone maintains so comprehensive a Service Organization. Victor X-Ray Corporation of Canada, Ltd, 524 Medical Arts Building, Montreal 2 College Street, Toronto Motor Transportation Bldg., Vancouver Medical Arts Bldg., Winnipeg Victor is as old as the X-Ray. Adequate service can be rendered only by an organization of proved stability and performance. Whether your X-Ray needs are small or large, for limited office work or for the specialized laboratory, Victor Service can help you in the selection of equipment best suited for the desired range of service. XrRAY Diagnostic and Deep Therapy Apparatus. Also manufacturers m^ of the Coolidge Twbe ^ PHYSICAL THERAPY" High Frequency, Ultra-VioIet, Sinusoidal, Galvanic and Phototherapy Apparatus ^, Vancouver Branch: Motor Transportation Bldg., 570 Dunsmuir St. Page 3 69 EDITOR'S PAGE Biographies of medical men are becoming more numerous. Lister, Paget, Osier, Horsley, to mention some of those which come readily to the memory, and now the late Sir James Mackenzie has found, if not his Boswell or Trevellyan, certainly his admirer anxious to emphasize and perpetuate the lessons which may be drawn from his life. We may say at once that a very readable and interesting book has been produced. The title of "The Beloved Physician" is perhaps a trifle fulsome; the matter of the work less so than the title might lead one to fear. Indeed, considerable reticence is shown in the account of the purely personal and private life of Mackenzie. The author has before him, we take it, always the view, which he considers this man's great ability, powers of observation, experience, clearness of vision and logical attitude of mind, gave him of the science and the art of medicine, and the conclusions to which they led him. The work is evidently intended for popular or, at all events, lay consumption, and the familiar description or translation into a sort of "lingua franca" of the more technical part of Mackenzie's work on the heart must have cost the author an amount of application which one would would think the results will hardly repay. Nevertheless, as it is done, we must say that it is well done, and the popularization in no way detracts from its readability by the professional eye. We suppose that most of us will agree that a very great mind was lost to medicine when Mackenzie passed away as the result of an ailment affecting that part of the human body which his own work had done so much to illuminate. Probably posterity will acclaim his as one of the great and original minds working in his chosen field. A mind groping after something imagined but found difficult of expression. This imposing edifice of modern medicine, these gorgeous towers and cloud-capped pinnacles of bacteriology, of pathology, of surgery, of electrical science, of biochemistry and biophysics, was it, is it sound at the foundation? Mackenzie early in his carrer asked some pertinent questions of the leading inhabitants of this edifice and received what seemed to him very ambiguous answers. Particularly he wanted information about the heart and and specifically about the heart in pregnancy. Little was forthcoming and that little mainly concerned with the accepted views of the significance of murmurs. Doubtless, also, he encountered, as he might easily encounter today, the same vagueness of information concerning very ordinary and commonplace signs and symptoms in other fields of enquiry. At any rate, failing this assistance, he set himself the task of observing and elucidating phenomena about the heart, not, we take it, because he found here a very special field of enquiry, but because it offered a concrete and readily available opportunity for such work. Possibly at first he did not consciously realize that he was using these observations on the heart as an example of what might and should be applied to other organs and other diseases but he certainly had not travelled far along the road before he realized that much of re- Page 370 search in medicine consisted in trying to sustain an isolated brick of fact in mid-air, without a satisfactory wall either below it or on either side. Finally, Mackenzie recognized that in a sense it was his misfortune to have accomplished this epochal work concerning the heart. The world of science, the world of medicine, the popular world dubbed him "eminent cardiologist" but lost sight of, indeed, mainly never realized, that all his work was merely as the demonstration of a principle and of a method. Doubtless many, as the experience of years has accumulated, have felt vaguely that, despite all the brilliancy of discovery in and out of the laboratories of medicine, all is not right with our method, when to possibly more than one half of the complaints for which we are consulted, we are unable to give even a name and in more than one-half of the remainder a name only which characterizes some prominent symptom. But, with the lassitude of years, the problem is handed on to a younger generation still under the spell of the text book and the mechanical part of the craft and so quite unable, for the most part, to appreciate that there is a problem, much less to attempt its solution. Not so Mackenzie. When he realized the position, gathering up his remaining energy, he deliberately renounced his eminence, his leadership and his ease, and set himself once again to the task. And what was the task? To elucidate the meaning of the early symptoms in the diseases common among the people. To enforce his belief that the bedside is the real laboratory, the general practitioner the real research worker, the beginning, not the end of disease the problem, continuity of progress the result of maintained observation, and the true aim of medicine the anticipation of the advanced results which fill our hospitals and on which so much of the energy and enthusiasm of physician and surgeon is now lavished. NEWS AND NOTES Dr. Charles L. Scudder, of Boston, who was one of the lecturers at the Washington University Extension course in Seattle, stopped over in Vancouver on his way home and gave a very interesting address before the Association at a special meeting on Monday, July 25 th. Dr. Scud- der's subject was "The Operative Treatment of Fractures." Dr. J. Bakes, Primarius of the Surgical Clinic at Brunn, Czechoslovakia, has been staying in Vancouver on his way to Northern B.C. on a big game hunting expedition. While in the city Dr. Bakes spent considerable time at the Vancouver General Hospital and gave an interesting talk on some phases of gall bladder disease. A joint luncheon meeting of the B.C. Medical and Vancouver Medical Associations was held at the Hotel Georgia on Monday, August 15 th, when the Hon. Dr. J. H. King was the guest of honour. At the close of the luncheon Dr. King gave an address on the activities of the Federal Department of Health, a report of which appears in another column 6f this issue. Dr. A. Primrose and Dr. Duncan Graham, who are touring British Columbia this Fall under the Canadian Medical Association's scheme for extra-mural post-graduate instruction, are expected to arrive in Vancouver on September 7th. Special meetings will be arranged for that date to hear addresses by the visitors, of which due notice will be given. Columbia University, New York, announces special eight-week courses for medical graduates in general medicine, dermatology, pediatrics, gynaecology, neurology, ophthalmology, pathology, surgery, and bacteriology, to be given at the Mount Sinai Hospital from October 17th to December 10th. Dr. A. C. Frost, Treasurer of the Vancouver Medical Association, wishes to draw the attention of members to the fact that the annual dues for the current Association year were payable on April 1st, 1927. Will those members who have not yet paid up send cheques as soon as possible in order to avoid the issue of drafts, as provided for in the bylaws of the Association. The Trustees are still hoping for replies from a large number of members to their letter of June last on behalf of the Sickness and Benevolent Fund. Dr. Gordon Burke, who has been engaged in post-graduate work in Eastern centres for the past two months, returned to Vancouver on August 20th, and has resumed practice. Drs. A. C. Frost and W. T. Ewing, with Dr. W. A. Clarke of New Westminster, left at the end of August for Chicago and Rochester, and expect to be away about a month. Dr. Robert Crosby, who has spent several months in Europe returned home on August 21st and has resumed practice. Dr. W. J. S. Millar has returned to the city after three months post-graduate study and has resumed practice. LIBRARY NOTES The Library is situated in 529-531 Birks Building, Granville Street, Vancouver, B.C. Librarian: Miss Firmin Hours: 10 to 1,2 to 6 A LIBRARY GIFT The tradition of giving to the library is gradually being built up. The first large gift of books the library ever received was from the New Page 372 York Academy of Medicine. Then Sir T. Lauder Brunton gave us a great number of volumes. Sir Wm. Osier sent us a one-hundred-dollar cheque as a contribution towards a library building, and the other day Dr. H. C. Moffitt presented the library with a one-hundred-and-fifty-dollar cheque —being the whole of his expenses, travelling, etc., in connection with the Summer School. That the Library Committee is elated over this thoughtful contribution, goes without saying. The example of Dr. Mof- fitt's gift and the interest that it indicates in medical education here should stimulate every member of our Association to take a vital interest in the library and its development. Not content with merely giving, Dr. Moffitt must look over the library, so on June 25 th, at nine o'clock, Doctors Bagnall, Busteed and Keith were on hand to meet him and showed him over the library. The arrangement of the books and Journals in our limited space seemed to appeal to him and the relegation of the older tomes to the storage warehouse was commended. Dr. Moffitt, like all those interested in medical libraries and medical education, brought up the question of having our own building for library and meeting purposes. He thought our immediate efforts should be to secure a building near the General Hospital, as probably the most central location for the library, an old thought with all those who have been associated with the library and the abortive efforts made by our Association in this direction in the past. I think this suggestion of Moffitt's is most timely and our library committee and executive should take initial steps at once in this matter. A shade of the late Doctor William Osier will probably arise one of these days and ask us what happened to the contribution he gave us for our library building. Dr. Moffitt said of medical education here, knowing that there was some talk of establishing professorships for the primary subjects before a complete medical curriculum was introduced in our University: "Why not begin on the clinical end first?—clinics could be given at the hospital right away. Get to work with the material you have at hand and the rest will come in due time." This, I personally feel, could be done under the jegis of our Association at once.—W. D. Keith. SOME RECENT ADDITIONS TO THE LIBRARY "Certified Milk." Proceedings of the 19th and 20th Annual Conferences of American Association of Medical Milk Commissions. "History of Medicine." Greene Cumston. "History Taking and Case Recording." Corscaden. "Massage." J. B. Mennell. "Abnormal Psychology." MacDougall. "Surgical Clinics of North America." Feb., 1927. Cancer number (1). "Surgical Clinics of North America." April, 1927. Cancer number (2). "Treatment of Fractures.^ Scudder. 10th Edition revised. 1926. "Pediatrics. Abt. In eight volumes 1921-1927). Page 373 I II "Transactions of the Ophthalmological Society of the U.K. Vol. 46. 1926. 'Applied Refraction." Homer E. Smith. 1927. 'Medical Clinics of North America." March, 1927. Boston number. 'Medical Clinics of North America." May, 1927. Heart number. 'Public Health Reports." U.S.A. Part II. for 1926. Vol. 41. 'Clinical Neurology." I. Wechsler. 1927. 'History of Med. Dept. of U.S. Army in the World War." Vol. XI. Surgery. 'Cancer Control." Report of International Symposium (1926). 1927. 'Medical Annual." 1927. 'Diseases of Hip, Knee and Ankle Joint." Hugh Owen Thomas. 2nd Edition. 1876. 'Dental Education in United States and Canada." Carnegie Foundation. 1926. 'Mayo Clinic Volume" (1926). 1927. 'Report of Henry Phipps Inst.," 1927. 'International Clinics," June, 1927. 'Surg. Clinics N. America," June, 1927. 'Symptom Diagnosis," Barton & Yater, 1927. 'A Guide for Diabetics," Campbell & Porter. 'Primer for Diabetic Patients," Russell Wilder, 3rd ed. 'Food, Nutrition and Health," McCollum & Simmonds. 'Meaning of Disease," W. A. White, 1926. 'Pneumoconiosis," Pancoast & Pendergrass, 1926. 'Kidney Disease," Floyd, 1926. ..;■■ . 'Cavernous Sinus Thrombophlebitis," Eagleton. nu 'Diseases of Women," Crossen, 6th ed., 1926. ■Surgical Technique," Printy. 'The Mind and Its Disorders," Stoddart. 'Forensic Psychiatry," East. 'Some Famous Medical Trials, Parry. «| 'The Ego and the Id.," Sig. Freud. 'Epidemic Diseases of the Central Nervous System," McNalty. SOME POINTS IN THE PATHOLOGY OF THE GALL BLADDER An Address to the Summer School of the Vancouver Medical Association, June 24th, 1927, by Dr. Wm. Boyd, Prof, of Pathology, University of Manitoba. I shall confine myself, in this lecture, to two topics, the structural changes produced in the gall bladder in disease, and the mechanism by which gall stones come to be formed. I shall, however, be unable to refrain from making at least a passing allusion to the function of the organ under consideration. Structural changes.—Before we can hope to form any conception of the pathological gall bladder we must first gain some idea of its normal Page 374 EH appearance. To my mind by far the most satisfactory method of attaining this end is to look at the mucosal surface under water by means of a low-power binocular dissecting microscope, using the brilliant light of an arc lamp as an illuminant. The picture disclosed to our eyes is a remarkable and beautiful one, the entire mucosal surface is divided into polygonal spaces by tall, graceful membranes, delicate as gossamer, and swaying with every movement of the water. Compare such a picture with the flat, featureless prairie presented by the inner surface of the urinary bladder. On morphological grounds alone it is at once evident that the latter is a mere reservoir, whilst in the former an active interchange of substances must take place through the lining membrane. This view is confirmed by a consideration of histological sections of the normal gall bladder, which show what appear to be a number of delicate villi, really mucosal folds cut on edge, each villus covered by columnar epithelium with the scantiest of stroma containing blood vessels and lymphatics, a structure evidently designed for secretion or absorption. The pathologist is dependent on the kindness of the surgeon for normal specimens of this kind, for in autopsy specimens the villi appear as mere scraggy scarecrows denuded of epithelium. For many years it was thought that the interchange through the villi was in the nature of a secretion, and that cholesterol in particular was poured into the bile by the gall bladder epithelium. In 1921, however, the work of Peyton Rous and McMaster showed in the most convincing way that the chief function of the gall bladder was one of absorption and concentration of the bile which it contained. My own work in 1923 seemed to suggest that cholesterol was one of the principal substances absorbed, a similar conclusion being reached by Torinoumi working in Aschoff's laboratory in the following year. Before leaving the subject of the normal gall bladder, I must refer to the interesting work of Boyden on the alteration of the mucosal pattern as the organ passes from distension to collapse. In complete collapse, produced by feeding an animal on a diet rich in fat, the lumen becomes nearly filled with large fungiform projections showing a peculiar globular distension, a condition much more favourable to absorption than is the state of dilatation. When we study the pathological gall bladder under the dissecting microscope we find a picture very different from the normal. The most extreme change is seen in hydrops of the gall bladder, where the organ becomes greatly distended as the result of blocking of the cystic duct by a calculus. Here we find an absolutely flat, featureless surface, devoid of a single elevation. It is evident that in such an organ absorption must be seriously impaired, may, indeed, be entirely abolished. In an ordinary chronic cholecystitis the folds are enormously thickened. The cause of this thickening is revealed by histological examination. It is due in part to cedema, in part to great collections of inflammatory cells and proliferated connective tissue cells, and in part to wide dilatation of the lymphatics which is a feature of at least the earlier stages. These inflammatory changes are by no means confined to the Page 375 mucosa, but are also evident in the fibromuscular and in the subserous coats, changes which lead to a general thickening of the gall bladder wall In an. acute inflammation the entire wall is diffusely infiltrated with inflammatory cells. In the more subacute form plasma cells may form a striking feature of the picture, just as they do in the appendix. In the chronic cases the cells in the deeper layers are more focal in their arrangement, being collected into little groups. In these cases active fibroblastic proliferation may be going on, with the subsequent formation of dense fibrous tissue. In course of time this scarring may become so extreme that the mucosa is entirely replaced by a network of interlacing trabecular. Despite statements to the contrary the normal gall bladder does not possess true glands. The furrows between the ridges may, however, be so deep as to suggest a simple tubular gland, an appearance known as the Luschka crypts. In chronic inflammation these invaginations of mucous membrane may become very pronounced, so marked, indeed, that glandlike structures may be found in the depths of the muscular coat, and may be mistaken by the unwary for an adenocarcinoma. I have noticed that the epithelial cells lining these deeper formations differ from those covering the surface in that they are quite clear as if they contained mucin. It may be that such structures behave like true glands and produce an abundance of mucus when the wall is inflamed. For the purpose of gaining an insight into some of the fundamental features of gall bladder pathology, I have found a study of the condition known as the strawberry gall bladder of peculiar value. The name is rather an objectionable one; it should rather be termed the lipoid gall bladder or liposis of the gall bladder. With the naked eye small yellow granules, not unlike the seeds of a strawberry, can be seen scattered over the mucosal surface, but it is under the dissecting microscope that the true picture is revealed. In severe cases the fragile folds of mucosa are loaded down by dense yellow material, much as the branches of a delicate birch tree may be weighed down by a load of snow. In the milder cases only a fold here and there is picked out, like a mountain ridge retaining but an occasional patch of the winter's snow. This yellow material can be shown by microchemical methods to be an ester of cholesterol, a lipoid which forms the most important constituent of the vast majority of biliary calculi. The distribution of this lipoid can be studied by a variety of methods, of which the two most useful are the polarizing microscope and the use of a fat stain such as Scharlach R. or osmic acid. The polarizing microscope serves to distinguish between cholesterol and neutral fat, for the former is doubly refractive and, therefore, appears as brilliant particles, shining with a silvery radiance which is accentuated by the surrounding darkness, when viewed under crossed Nicol's prisms, whereas neutral fat, often present in large amount in the deeper layers of the gall bladder, remains invisible. It must be remembered, however, that all that glitters is not cholesterol, and fibrous tissue may appear faintly white, though not brilliant. Page 376 For a study of the finer distribution of the lipoid the use of a fat stain is necessary. The bright red globules and granules are found principally in the epithelial cells of the surface and in the underlying stroma of the folds or villi. These deposits are sometimes extraordinarily heavy. In a few of my preparations I have been able to demonstrate the lipoid within connective tissue cells of inflammatory origin in the deep layers of the wall. From a consideration of this distribution of the cholesterol it is hard to believe that it is in process of excretion. The conclusion is forced upon one that it is being absorbed, probably by the lymphatics, a conclusion which is confirmed by experimental evidence. The amount of cholesterol which may collect in the strawberry gall bladder is remarkable. In a series of quantitative estimations I found that the lipoid was increased 40, 50, and even 60 times. Fowweather and Collinson in a recent number of the British Journal of Surgery found an increase in the cholesterol of the gall bladder wall in 45 per cent, of calculus cases. This brings up the point that the lipoid increase is by no means confined to the strawberry gall bladder. I have found at least some traces of lipoid microscopically in about half of the cases of chronic cholecystitis. When we enquire, what causes this remarkable deposition of cholesterol, we find ourselves taking the difficult step between structure and function. I think myself that it must depend on the presence of inflammation in the gall bladder wall. In every case which I have examined there has been at least some evidence of inflammation, although often very slight. Indeed, I have hardly ever found lipoid deposits in a gall bladder showing very marked inflammation. Long-standing inflammation leads to obstruction of the lymphatics, which, in turn, must interfere with the process of absorption. Apparently, when the inflammation reaches a certain grade the cholesterol simply disappears. In one of our cases the greater part of the gall bladder was thickened and had evidently been inflamed for some time. No lipoid could be seen with the dissecting microscope. The remaining part was much thinner, the mucosa was comparatively unaltered, and it contained heavy deposits of cholesterol. In addition to the factor of inflammation it is extremely probable that an increase in the blood cholesterol and, therefore, the bile cholesterol has something to do with these lipoid deposits. Fowweather and Collinson found a high blood cholesterol in 47 per cent, of their cases of cholecystitis and calculus. We must remember, however, that a high blood cholesterol is often only a transitory phenomenon, so that it may no longer be present when the gall stones are discovered. Of this transitory increase, pregnancy is a good example. A second is convalescence after typhoid fever. A third is rapid loss of fat in a stout subject. The fat, female, forty person is in danger of an occasional high blood cholesterol. Reviewing our knowledge of the morbid anatomy of the inflamed gall bladder, we find that we may recognize three principal conditions. First, acute cholecystitis, characterized by infiltration of the entire wall with acute inflammatory cells and the outpouring of a purulent exudate Page 377 into the cavity of the viscus. Second, chronic cholecystitis, in which the wall is again infiltrated with inflammatory cells, this time of a chronic character, with fibroblastic proliferation, subsequent fibrosis, and serious interference with the delicate absorbing mechanism of the organ. And, third, the condition we may term the lipoid gall bladder, also dependent in part upon chronic inflammation, although of a slighter nature, and distinguished by deposits of cholesterol in the mucous membrane and to a lesser extent in the deeper layers of the bladder wall. You will notice that I have avoided all discussion of the question of the etiology of cholecystitis. This is because once I started I would hot be able to stop. If, however, I could have engaged in such a discussion. I would arrive at the following conclusions. First, that streptococci of low virulence are the most common cause of cholecystitis. Second, it is probable that bacteria reach the gall bladder both by the blood and the lymph stream, sometimes by one path, sometimes by the other. When they travel by the lymphatics they may come from the liver, from the first part of the duodenum, or from the appendix. The work of Prof. Evarts Graham has shown us the importance of lymph spread infection from the liver. Origin of gall stones.—Let us turn now to the second of my topics, the origin of gall stones. The first and in some ways the most important step is a recognition of the fact that there are several different kinds of calculi, which have quite different methods of origin. For a full realization of the importance of distinguishing between the different kinds of calculi we are indebted especially to the work of Aschoff and Bacmeister. Two main types of stone may be recognized, the metabolic or aseptic stone, and the inflammatory or septic stone. The metabolic stone is large, oval, single, white, composed entirely of cholesterol, and, therefore, known as the cholesterol solitaire. Aschoff calls this a metabolic stone because it is apparently formed solely as the result of disordered liver metabolism. Cholesterol is kept in solution by the bile acids, but the solubility is dependent not only on the amount but on the relative proportion of the acids. Any disturbance in the acids, any increase in the cholesterol, may be followed by precipitation of the latter. The stone is distinguished by its radiate structure, as opposed to the concentric structure of the septic or inflammatory stone. Frequently it gives rise to no symptoms, and is only found by accident at autopsy. It is a silent stone, and, as a rule, the gall bladder shows no evidence of inflammation. It may, however, become impacted in the neck of the gall bladder, and the acute stasis which results is apt to be followed by infection. Should the stone then roll back into the bladder and allow the bile to reenter, a deposit of bilirubin calcium is laid down upon the cholesterol solitaire, with the result that what is termed a combination stone is formed, a combination of the metabolic and the inflammatory types. There is this great difference between a pure cholesterol stone and a combination stone; the pure stone is solitary whilst the combination stone, being partly infective in origin, is nearly always associated with the septic type of multiple calculi. The formation of a pure cholesterol stone is favoured by such factors as high blood choles- Page 378 terol (and, therefore, high bile cholesterol), and by stasis in the gall bladder. We have seen, however, that although a high blood cholesterol conduces to the formation of a cholesterol solitaire, yet it by no means follows that it will be high at the time the stone is removed. Before leaving the subject of the metabolic stone, mention must be made of another variety, much less common and more difficult to understand. I refer to the pure pigment stone. These are multiple, about the size of a grain of rice, black in colour and of a hard brittle consistence. They contain no cholesterol. These are the stones which so frequently complicate hemolytic jaundice, but other factors concerned in their origin are, as far as I am aware, still unknown. We come now to the commonest variety, the infective or septic stone. These are the facetted, cholesterol-pigment-calcium stones which on section present not a radiate but a characteristic concentric arrangement of laminaj. All the stones of one family are about the same size, but there may be two and sometimes even three families. In addition, there may be one or more large combination stones. If the crystalline material is removed by means of chloroform or ether, a protein framework is left which shows the same concentric lamellation as the stone. This is never seen in the pure cholesterol stone. It is evident, therefore, that they are formed in a medium rich in protein, whilst the cholesterol stone is formed in a medium poor in protein. This provides us with a clue to the way in which these stones originate. As the result of inflammation of the gall bladder, a mixture of pus, mucus, bacteria, and epithelial debris is poured out. During an acute attack the gall bladder is more or less a closed cavity, but as the swelling at the neck subsides bile again enters, and around the little nuclei of organic matter are deposited layers of cholesterol and bilirubin calcium. In this manner the family of facetted septic stones is formed. There is, however, another way in which we may study the formation of stones. So far we have only considered the contents of the gall bladder; we have still to consider its wall. If a series of lipoid gall bladders are examined by means of frozen sections and the Scharlach R stain, masses of cholesterol will occasionally be found which so heavily weigh down the villi that the latter appear to be attached by a mere pedicle to the surface of the mucosa. Should one of these masses become detached it will form an ideal nucleus for the formation of a stone. It is possible, indeed likely, that at least some stones may be formed in this way. Chauffard in his book on biliary lithiasis agrees with this suggestion, and thinks that multiple-facetted stones usually originate in the mucosa. At the time of operation the gall bladder wall may no longer present a strawberry appearance, but this, as we have seen, tends to disappear as the wall becomes more extensively fibrosed and thickened. In conclusion, brief reference must be made to the condition known as the stasis gall bladder, the Stauungsblase of the Germans. It is a fact well known to surgeons that a patient with gall bladder symptoms may be found at operation to have neither cholecystitis nor calculi. These cases have been studied by Continental workers, more particularly by Aschoff, Berg, and Westphal. Atonic and hypertonic varieties have been Page 379 described. In the atonic variety the gall bladder wall is thin and lax, in the hypertonic it is thick and the bladder is distended. In both there is stasis of bile and a tendency to the formation of stones. Westphal has shown that the hypertonic, or, as he calls it, the hyperkinetic variety, is due to vagal spasm of the neck of the gall bladder and the sphincter of Oddi, a condition which is frequently present in the early stages of pregnancy. This may be a factor of importance in determining the formation of calculi in pregnant women. SERUM THERAPY Notes of an address by Dr. J. G. Fitzgerald, Director of the Con- naught Laboratories, Toronto, delivered before the Summer School of the Vancouver Medical Association, June 23rd, 1927. Dr. Fitzgerald said that he grouped the known sera into four classes: (1) True antitoxic sera of which there were five used in the treatment of diphtheria, tetanus, scarlet fever, botulism and more lately erysipelas. These sera contained substances directly antagonistic to the toxin produced by the infecting organism in the case. (2) Bactericidal sera, the best known of which was the anti-men- inococcic, the serum produced from the pneumococcus Tl and the antityphoid serum of Chantemesse. (3) The anti-virus sera of which the anti-poliomyelitis is the best known. (4) A doubtful and questionable category containing the antistreptococcic and anti- staphylococcic sera. The action of bacterial vaccines is very uncertain and it is exceedingly difficult to demonstrate their effect, if any, scientifically. It was also impossible to give the proper indications for their use and, while not definitely discountenancing the employment of vaccines, the lecturer deprecated their indiscriminate application. Anti-diphtheritic serum was the first discussed. Though actually introduced by von Behring, the first large clinical test was made by Roux (who is still living and active) in 1894. There are a few general principles concerning its application. One of the most important is that of early employment. It is still the practice of some to wait two, three or more days for a laboratory report before beginning treatment and still many patients died on account of this delay. It is to be remembered that the laboratory does not make the diagnosis, that is a clinical matter. If there is reason to suspect the presence of diphtheria, the course is clear—serum treatment must be begun at once. It is to be remembered that the mortality in cases where the treatment is commenced on the fourth day is six times that when it is begun on the first day of the disease. Prior to the introduction of antitoxin, out of every three cases (Continued on Page 385) Page 3 80 The British Columbia Laboratory Bulletin Published monthly September fo April inclusive 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 Donna E. Kerr, m.a., 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 Columbia 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. Volume 2 SEPTEMBER, 1927 No. 1 CONTENTS Eykman Water Test Ootmar Resistant Spores in Milk Plates Kilpatrick Temperature of Dilution Water for Milk Counts Dowsley Difference in Function of the Two Kidneys R. E. C. EYKMAN WATER TEST G. A. Ootmar, M.D., Kelowna, General Hospital Laboratories. One danger of infection with the organisms of cholera, typhoid fever, dysentery, etc., lies in using water which is contaminated with excreta from diseased persons or carriers. We know how difficult it is to look for microorganisms in the water, also that a negative report may mean nothing. For years attempts have been made to find ?.n easy method of determining the contamination of water and other liquids with excreta. Bacillus coli communis is held to be an indicator—the presence of this organism being a reliable test for contaminated water. Such water must be considered dangerous on account of the possibility of an associated infection with the above-mentioned pathogens (not mentioning the possibility that B. coli itself or related strains, might also be dangerous to health). Freudenreich (in the Centralblatt fur Bakteriol: Bd. XVIII, page 114) found that pure water contains no B. Coli while contaminated water carries appreciable numbers. Contaminated water inoculated into lactose broth and incubated at 37°, gives strong fermentation within 12-24 hours. This fermentation does not occur with bacteria ordinarily found in the water, even if Proteus vulgaris is present. Page 3 81 In this way, he was able to trace Bacillus coli communis in 0.00,001 cc. of canal water, while in 100 cc. of pure water they were not found. Petruschky and Pusch (Zeitschrift f. Hyg: und Infectionskunde: Bd. XLIII, page 304) added equal parts of water to peptone broth and incubated at 37° C. When the mixture remained clear there were no B. coli communis present; if it became milky, B. coli could be isolated in a plate culture. Still the difficulty remained, however, that there are many bacilli related to B. coli which do not originate in the intestines; thus the reactions of B. coli alone could not be used as an indication that the water had been contaminated with excreta (feces, etc.). Eykman made use of the fact that B. coli still grows at a temperature of 46° C. and ferments glucose, producing indol in sugar-free media containing peptone. He mixed 8 parts of the water with 1 part of a sterile solution made up of glucose, 10% peptone and 5% NaCl, and put the mixture in a sterile U-tube with one end closed. Usually after 24 hours, but certainly after 48 hours, the mixture will become cloudy, and gas forms if B. coli, originating from the bowel, are present. (Indol is not formed on account of the presence of glucose.) In the microscopical examination of the contents of the fermentation tube, we find non-motile bacilli, some with slight motility; and cocci; and when plated, we find for example butyric-acid-producing bacteria. From a scientific point of view, one cannot say that B. coli is the only bacillus originating from the intestines which ferments glucose at 46° C. because there are many others which do the same; but hundreds and hundreds of tests prove that water contaminated with feces always shows a positive fermentation at 46°; while pure water does not. Besides, the other bacteria which cause fermentation at this temperature are nearly always found to belong to the intestinal flora. Rainwater always gives a negative result, even when it has been taken from a gutter. At 37° O, the special media described above may also show fermentation, mostly after 24 hours. In this case bacteria belonging to the colon group are found which lack the property of growing at 46° C. and which belong to a strain which does not originate in the intestines. Other experimentors, as Bulin from the Hyg. in Prague, modifies Eykman's test by using mannite instead of glucose, but from a practical point of view, as the Eykman test is so easy to perform and as it is verified by the many tests made in Dutch East India (where it is a standard method) we may consider it a very valuable test in tracing water contaminated with feces. RESISTANT SPORES IN MILK PLATES M. Kilpatrick, M.A., Vancouver General Hospital Laboratories. History.—Spores were first noticed in the milk plates May 19, 1927. These spores reappeared on June 14th, and persisted for a period of three weeks. Page 3 82 Source.—Since the spores were only found in the agar, the other media being quite free from them, we were forced to conclude that the spores came from the crude agar. Utensils used to make agar are used for this purpose only. This explains why the other media had not been contaminated. The aluminum pot in which the agar is boiled was thoroughly cleaned and sterilized in the autoclave for 30 minutes at 15 lbs. pressure. Swabs were then taken from the pot and planted. Abundant spores were present in 48 hours. It was thought that if a new tin of crude agar were used the difficulty might be solved. A new tin of Bacto agar was opened; a supply of Bacto agar from the University of B.C. was obtained. Parallel tests were then made from three sources. 6 tubes of sterile broth inoculated with U.B.C. agar. 6 tubes of sterile broth inoculated with Old V.G.H. agar. 6 tubes of sterile broth inoculated with New V.G.H. agar. These tubes were sterilized for 20 minutes at 15 lbs. and then incubated. In 24 hours there were spores present in every tube. Resistance of Spores to Heat.—Agar slant cultures of spores were made and these were sterilized in duplicate at: (a) 15 lbs. pressure for 20 minutes. Result: Growth in 24 hours in both tubes. (b) 15 lbs. pressure for 30 minutes. Result: No growth in 48 hours. (c) 15 lbs. pressure for 45 minutes. Result: No growth in 48 hours. (d) 15 lbs. pressure for 60 minutes. Result: No growth in 48 hours. Numerous other tests were then made on crude agar, from the three sources, and on the utensils used. It was found that half an hour at 15 lbs. pressure killed all spores except, occasionally, those from the agar which originated the trouble. These resistant spores were, however, killed in three-quarters of an hour. Present Procedure.—All utensils and test tubes are sterilized for 20 minutes at 15 lbs. pressure. The crude agar is also sterilized for one hour at the same pressure. After the spores have been eliminated by the above procedure, the media itself is sterilized completely by 15 lbs. pressure for 20 minutes. This technique has been, so far, completely successful. TEMPERATURE OF DILUTION WATER FOR MILK COUNTS Gertrude Dowsley, B.A., Vancouver General Hospital Laboratories. It was suggested that high milk counts obtained during the summer might be due to the use of water dilution bottles kept at room temperature and that the use of dilution bottles kept at ice-box temperature would appreciably lower the counts. To determine the importance Page 3 83 of this factor, a series of counts have been made. A sample of milk was placed in a dilution bottle at ice-box temperature and a similar sample of the same milk placed in a dilution bottle at room temperature. Both bottles were then placed in the ice box and plated 4 or 5 hours later. The accompanying results show that in 7 out of the 10 samples, the count obtained from the room temperature dilution bottle was lower than the count from the ice-box temperature dilution bottle. The differences, however, were small in consideration of the errqr of the method. Therefore, the milk count was not found to be affected to any appreciable extent by the use of the room temperature dilution bottles rather than the ice-box temperature dilution bottles. Date Source Ice-box Temperature Room Temperature July— (Official Count) (Exp erimental Count) 5, 1927 804 2,700 1,900 7, 1927 809 182,000 197,000 11, 1927 814 112,000 110,000 15, 1927 823 315,000 341,000 18, 1927 829 166,000 164,000 19, 1927 840 1,760,000 1,930,000 21, 1927 844 24,90.0 22,000 25, 1927 864 79,000 60,000 26, 1927 870 248,000 121,000 28, 1927 883 142,000 122,000 DIFFERENCE IN FUNCTION OF THE TWO KIDNEYS The following series gives the range of the specific gravity in simultaneous samples from the right and left kidney at two-hourly intervals. This recent case of Dr. A. W. Hunter illustrates again the independent manner in which kidneys may vary their rate of function. Our attention can not be drawn too often to just such cases. Since the great bulk of clinical information consists of isolated estimation of bodily functions, there is a very powerful and constant tendency to create the impression that such isolated readings represent stationary states rather than points in a moving panorama as they really are. RIGHT KIDNEY LEFT KIDNEY Time Volume Sp. Gr. Volume Sp. Gr. 10 a.m. 192 cc. 1006 210 cc. 1006 12 noon 100 cc. 1005 46 cc. 1005 2 p.m. 95 cc. 1006 100 cc. 1006 4 p.m. 60 cc. 1007 100 cc. 1004 6 p.m. 90 cc. 1008 62 cc. 1009 8 p.m. 90 cc. 1010 70 cc. 1009 —R. E. C, V.G.H. Page 3 84 (Continued from Page 3 80) one died. The matter of dosage is also of great importance. In many instances the dosage as ordinarily employed may be quite inadequate. In the Blegsdam Hospital at Copenhagen, they have lately shown a mortality of under one per cent. Immense doses are used, especially in cases not received within thirty-six hours of onset. From 40,000 to 200,000 units may be given within twelve hours. In the treatment of tetanus early recognition is again of the utmost value, or even in injuries or operations where there is reason to fear the possibility of its occurrence, the administration of 1500 units as a prophylactic measure. The first signs are those of pain and stiffness at the site of injury. This may occur long before there is any sign of trismus and is the ideal time at which to commence treatment. The lecturer favoured the use of the specific anti-serum intrathecally, getting the serum to the place where the toxin is becoming fixed. He recognized that either through the introduction of a foreign protein or because of the preservative used in the serum a good deal of spinal irritation might be set up. 5000 units may be given intraspinally, slowly, well diluted and warm. At the same time a little may be given intravenously and a large reservoir, of say 20,000 to 30,000 units given intramuscularly for slow absorption. • For treatment of scarlet fever anti-sera had been used in Russia for many years. The heart blood of fatal cases had been used for purposes of obtaining the cultures from which horses were inoculated. The Dicks in 1924 were able, by means of their cultures, to reproduce typical scarlet fever. In botulism, two types of antitoxin were used as two types of toxin had to be combatted. Amos of Johns Hopkins Hospital has recently introduced a special serum for use in erysipelas. This is reported to give fairly satisfactory results in certain cases. The Connaught Laboratories are now supplying this serum for use in this small group of cases. The dose is from 50 cc. to 100 cc. It is to be remembered that in the vast majority of cases of erysipelas no such treatment is required, the tendency of the disease being towards resolution. In the treatment of meningococcic meningitis, if the specific antiserum is used within the first 24 hours, about 80% of the patients will recover. It is very necessary that the serum (which is given intrathecally) be used as early as possible after the removal of as much cerebro-spinal fluid as can be obtained. The mortality among untreated cases is very high, about 75% going on to a fatal termination. Light general anaesthesia is used for lumbar puncture and the serum, which is warm, is given slowly. There is no need to wait for a laboratory diagnosis. In suspected cases, if the cerebro-spinal fluid removed is turbid, give the serum at once, and, further, it must be remembered that in about one- fifth of the cases it is difficult, if not impossible, to demonstrate the presence of the organism. Page 383 Regarding anti-streptococcic serum, Dr. Fitzgerald said that they were now trying out in Toronto what they hoped would be an improved serum made from strains of streptococci isolated from septic uteri. The serum from convalescent cases of anterior poliomyelitis is probably of value and there is also good basis for the use of the anti-serum for Type one pneumococcus. Unfortunately, cases of Type one are not very numerous and there is no serum for Types two and three and the use of any serum here is unwarranted. ACUTE OSTEOMYELITIS Notes from an address delivered before the Vancouver Medical Association Summer School, June, 1927, by Dr. C. L. Starr. A number of years ago, on going through the statistics of the hospital, we found we were having very poor results in our cases of acute infections of bone. A careful study of the problem, however, in a way, relieves us of the responsibility for the results we were getting. I found the patient was generally admitted to the hospital three weeks or so after the disease had started. That meant the infection had had an opportunity to spread, and we could not do very much to prevent it spreading and while we could remove certain portions of necrotic bone, we did not prevent the possibility of these things recurring in after years, and we had the experience of having bone infections lighting up again years after apparent subsidence. I had an experience in which I opened up a bone eleven years after suppuration had ceased. I opened into an abscess cavity and from that cavity we drew staphylococci after eleven years, so it seemed hopeless to improve the condition unless we could get at the origin. So I became interested in the acute stage. I do not intend to touch the great importance of operative procedures in the late stage. Now for a moment let me recall some of the anatomical features as they relate to bone growth and development. First, circulation; the circulation of the shaft of the long bones, where the bulk of these acute infections takes place. The nutrient vessel enters a little to one side of the centre of the shaft and divides into a number of branches which spread in two directions towards the two epiphyses and from that the entire blood supply is received. These vessels anastomose with the second source of blood supply, that from the periosteum. This anatomy is important because the bone will survive if either of these two sources of blood supply is intact. If it were not so in every fracture of the long bone where you have a complete tear of the nutrient vessels you would have a death unless it could be supplied from the periosteal vessels. That is the reason why we have no gross difficulties with the blood supply in fractures which are complete. Either one of these sources of blood supply is sufficient to keep the bone nourished, but there is a third supply— from the epihyses. Page 3 86 The attachment of the periosteum is an important factor. The periosteum goes down the shaft of the bone and buries itself in the epiphysis, so that you can take a child's bone, in the early stage of development, and you can twist it and you will always separate the shaft from the epiphysis and the periosteum. The importance of this is that that attachment of the periosteum to the epiphysis beyond the epiphyseal line, makes it probable that the neighbouring joint will escape infection. Care must be taken not to cut across this bar and open the capsule between the periosteum and the synovial membrane and thus make an entrance for infection into the joint. In days gone by more joints have been infected by poor judgment on the part of the surgeon than by direct spread of the infection. One other point—the relation of the epiphyses to the joints. You will recall that in practically all of the long bones, with one exception, the attachment of the ligaments of the joint is to the epiphysis. The one exception is the hip joint, and there the epiphsis of the head of the femur is inside the capsule so that if you have an infection in the head of the femur and the infection spreads along the line of least resistance, then it will be opening directly into the joint. That is the only joint in which it will do so. There is one point and that refers to the cortex of the shaft of the long bones. When we speak of the infection spreading from the cancellous tissue through the cortex to and underneath the periosteum, it rather startles us, because we think of the cortex as it appears in the middle of the shaft. These conditions occur, in practically 95 per cent., in cases of small children. You must also remember that the cortex is of the normal thickness in the middle of the shaft—one-quarter to three-eighths of an inch in thickness—and we think of the difficulty that any infection will have in spreading through that cortex, unless we also remember that the cortex at the epiphyses is not of that character at all. It thins out, and by the time it reaches the epiphyseal line it is practically of tissue- paper thickness. This helps us in accepting the fact of the possibility of the spread of infection in that way. The etiological factors in all acute infections of bone are of two types: a primary focus of infection elsewhere in the body, such as mouth and tonsils, and much more frequently, some local infection of the skin, as boils and infected wounds. The organisms most commonly found is the staphylococcus with some strains of streptococcus. The infection comes from the skin surface in pretty much all cases and with us we have found that the infection comes from the feet. So many children get sore feet either from the so-called stone bruising or from badly fitting boots and the starting point is probably there. It is easy of demonstration. If you take a rabbit and inject into the vein of the ear a virulent staphylococcus you can pick it up in the cells of the medullary area of the cancellous tissue of the bone two hours afterwards. If you do not put in a very large dose and examine again in two hours they are gone. The phagocytosis is so great that it will take Page 3 87 care of any ordinary infection. If that is true, and we have a bacterium in all of these cases, either you must have a lowered resistance to disease, in which you expect to find a focus of infection, or an increased virulence thrown into the blood stream that cannot be taken care of and you find the organisms are not being phagocyted. It happens usually on the diaphyseal side of the epiphyseal line. It makes no difference whether the nutrient vessels point towards the knee or ankle in determining which end will be the site of location of that infection, but I think that the question of traumatism is an important factor. If you get a twist or wrench of the epiphysis, naturally that particular area will have lessened resistance to the infection than the parts not traumatized. These infections are carried in and are found most frequently in the growing child. You rarely see them after the epiphysis is united, around the 19th to 20th year. Occasionally you see them, but not often. With that factor, if you ask whether it starts on the diaphyseal side of the epiphyseal line, I do not know. It is simply a fact that this does happen. We have had more or less difficulty because the commonly accepted method of the spread of the infection has been a question of debate and possibly not everyone is of the same opinion even now. (Dr. Starr then showed a series of slides.) Continuing Dr. Starr said: From our autopsy specimens, from microphotographs andf rom our experimental work in growing animals we can demonstrate that the infection will spread along the epiphyseal line to the cortex and periosteum; it readily strips the periosteum with increasing tension as pus is formed and we can demonstrate that with increasing pressure the infection spreads backwards through the Haversian canals at different levels, giving rise to the spotting character in •many of these infections. Now we come to the X-Ray. Roentgen ray findings are always negative in the early stages, and must not be relied upon in making a diagnosis. Now taking this as the background of our etiology, the thing that naturally comes to our minds is what signs and symptoms we shall have and whether we can make our diagnosis from that standpoint and the first thing is pain. Pain is always present, moderate at first but increasingly severe with each hour that passes and located in the neighbourhood of a joint. Now I emphasize the neighbourhood of a joint. Some people cannot distinguish it from a septic arthritis, but it is in the neighbourhood of the joint and not within the joint and you can move it gently backwards and forwards without any exacerbation of the pain. The contour of the joint is not changed. In the early stage there is no sign of fluid in the joint itself. So we have 1. Pain in the neighbourhood of the joint 2. Elevation of temperature to 103-5 Page 3 88 3. A marked Ieucocytosis. Now, if you have these signs, and, in addition, a localized tenderness, and the tenderness is in the neighbourhood of the location of the epiphyseal line, the most tender spot will localize the worst area of infection, whether on the inner or outer side of the long bone. If you make pressure on the bone and grope around say on the inside, where the infection is most marked, then the child will cry out, thus satisfactorily locating for you the fact that the infection is nearer the inside than the outside. With these signs in the growing child, the question of diagnosis becomes simple and there are only one or two things you can mix it up with. The most important is septic arthritis, and here you may have the same symptoms without the same maximum tenderness on the epiphyseal line, the differentiating feature is that you can get movement in the osteomyelitic condition and not in the septic arthritis. The X-Ray is of no value in your diagnosis. You must make your diagnosis from the history and symptoms. The question of suppurative acute rheumatic fever may be a difficulty, but here, in the acute rheumatic fever with an arthritic manifestation, you will find that the signs are obviously joint signs and not neighbourhood joint signs. It is true you have some pain, some fever and a Ieucocytosis, but you do not get the excruciating pain you do get in the other condition. Once you have made your diagnosis it is much safer to cut down through the periosteum to the bone, over the area of greatest tenderness. Make the incision towards the centre of the shaft and not towards the joint so as to be sure not to cut across the epiphyseal attachment. If you find, with your incision, that you get no pus, you will find an cedema and then you may run into pus underneath the periosteum. If you find pus underneath the periosteum a drain there may be all that is necessary, but I am satisfied now that that is not enough. Take out a little strip of the cortex so that any infection remaining in the medullary tissue will find a way of escape and that to the outside. As long as you have this you will run no fear of infection into the deeper tissues. If you fiind no pus, you should lift up the periosteum for half to one inch both ways to see if you have missed the points of greatest tenderness, and then, feeling that you have not done enough, make 2-3 drill holes from the cortex obliquely downwards to the epiphyseal line, and then if you do not get free pus I,at least, have never failed to get a culture from the bone itself in the debris which I have withdrawn from my drill holes. If you get that I think you are perfectly safe to leave it there, but you would be using poor judgment to continue your excision until you reached your medullary canal, which is unquestionably suggested in all the textbooks, even of today. One recent System of Surgery says that the surgeon who fails to continue his cutting through the cortex until he reaches the medulla Page 3 89 has not fulfilled his entire duty. My feeling is that he has overstepped his duty by a long way and the patient would have been better left with drill holes only. Now, with the separation of the periosteum from the cortex, that portion of the shaft from which the periosteum is stripped is separated from its blood supply, and it will sequestrate down to the point from which the periosteum is stripped. We now have a series of cases (about 25 or 26) which we have carried through a definite infection, and that is all that was done, and all recovered health within a month's time, and without sequestra. My judgment is that once you have an opening made so that it will drain, you cannot as well determine the line of sequestrum as nature will, and once it starts to separate you cannot hasten the process; you are building up new bone and by the time the sequestrum is separated, the involucrum is quite easily cut through and you can enlarge the opening sufficiently to take out the sequestrum, and you should have it entire, and I always do that with the tourniquet. Then swab out the cavity with iodine, and crush the soft surfaces of the involucrum against one another and put it in a splint to support it. My feeling is that as time goes on you will have a gradually increasing number of cases that will get well without any sequestrum, and that has been my object in presenting a subject of that sort to any person good enough to listen to it, and, I think, will do for the osteomyelitis cases what we have succeeded in doing in the Province of Ontario, by missionary tours through the country. I hope we can look forward to the time when our practitioners generally will diagnose acute osteomyelitis within twenty-four hours. It is very easy in the first 24 hours and very difficult afterwards. If we can accomplish that we will save the children in the future from these long-drawn-out bone infections. B.C. MEDICAL ASSOCIATION NOTES A large number of medical men had the pleasure of hearing the Hon. Dr. J. H. King give an address at the Georgia Hotel at a luncheon meeting arranged by the B.C. and Vancouver Medical Associations. Dr. H. E. Ridewood, of Victoria, was in the Chair and introduced Dr. King, who is the Minister of Health for Canada. Dr. King gave a succinct report of the activities of the Federal Department of Health. This is a new department, having been inaugurated in 1920, and has many functions of great importance to the national life. The first function to which he referred was that of quarantine. Canada, in uniformity with thirty-four other countries, has a very complete system of quarantine, and maintains four stations, the one at Williams Head being well known to British Columbians, and described by Dr. King as one of the best in North America. Page 190 Another great department of his work is that connected with immigration, especially as regards selection of those who are fit, mentally and physically. Until last year examination of immigrants was conducted entirely at the port of disembarkation in Canada, but Dr. King's Department has been able to persuade the Government that examinations should be conducted at the ports of embarkation and Dr. King gave some very interesting figures as to the greater efficiency thus obtained. For instance, in 1925, Dr. Laidlaw of Alberta reported that of the 1920 insane patients in Alberta, 79% were foreign born, costing an annual sum of $250,000 to Alberta alone. The same percentage obtains throughout the West, whereas in Ontario, where immigration is small, only 39% are foreign born. Examining 20,000 immigrants in Great Britain, the Department discovered 10% of these to be unfit, whilst previously, of 115,000 landed in Canada and examined there, only half of one per cent were discovered to be unfit, owing to examinations being performed hurriedly and inadequately. The Department proposes to send twenty-five Canadian doctors to Great Britain and Ireland to conduct thorough examinations before immigrants are allowed to proceed. This is obviously kinder to the immigrants as well as infinitely better for Canada. Dr. King then touched on the Food and Drugs Act, which, he stated, is one of the best in any country. Under this Act inspectors are employed throughout Canada. A laboratory is maintained at Ottawa and dealers guilty of fraud or substitution are prosecuted. Dr. King then took up the Opium and Narcotic Act which has recently been amended in concert with other countries under the League of Nations programme. There are at present 8,000 addicts in Canada and the number of these is decreasing rapidly under strict administration of the Act. Dr. King uttered a serious warning to the medical profession which, led astray at times by a mistaken sentiment of pity, is guilty none the less of breaches of this law. He stressed the necessity for institutional treatment of addicts and emphasized the intention of his department to enforce the law in this regard to the utmost of his ability. Other functions of the Department are sanitary service on the Great Lakes of the St. Lawrence with a view especially to prevention of typhoid. This work is productive of much good. Inasmuch as matters of health are primarily in the control of the Provinces, the Federal Government has to exercise great care not to infringe on provincial prerogative. Accordingly, the Dominion Council of Health has been organized, composed of Provincial Health Officers and representatives of the Federal Board and this Council meets every six months at Ottawa with a view to unifying administration in health matters. Dr. King paid a warm tribute to the Provincial Health Officers and their work. Other public bodies of semi-official standing are those connected with Mental Hygiene, Child Welfare, Red Cross, Tuberculosis, Venereal Disease and the St. John's Ambulance. Grants are made by the Govern- Page 391 ment to each of these bodies and the Federal Department keeps a certain amount of control to prevent overlapping and waste of effort. There has been a great awakening in public health matters throughout Canada in recent years. Universities are educating public health nurses, and the medical profession is awakening to a friendlier and more co-operative view of public health service. Canada, Dr. King said, was in the forefront of the nations as regards public health, though she is a young country, and small in population. He concluded by urging the medical profession to keep in touch with the development in public health. This is especially important, as he pointed out, in Vancouver which is a great and growing port and is faced with problems of great magnitude which have been thrust upon it rapidly and with little preparation. Dr. King received a great ovation at the end of his speech and a vote of thanks was proposed by Dr. R. E. McKechnie, seconded by Dr. A. B. Schinbein, President of the Vancouver Medical Association. Dr. McKechnie drew attention to the responsibility that lies on the medical profession as educated men who have received most of their education at the public cost, to repay to some extent this obligation by doing their share of public service and he pointed to Dr. King as a noble example in this field. INDEX TO VOLUME III.—1926-1927. Albuminuria, Routine tests for : i :... 113 Annual Meeting t . £ . 256 Antipodes, a Trip to the \ S 55 Arbuckle, Dr. J. W., "Eclampsia" I . 147 B.C. Laboratory Bulletin - 1 113, 149, 180, 215, 381 B.C. Medical Association Notes 23, 54, 86, 121, 142, 195, 219, 241, 281, 320,355, 390 Blood Chemistry in Nephritis . . 178 Book Reviews 119, 144, 192, 243 Boyd, Dr. wm., "Gall Bladder Pathology" 374 Brown, Dr. C. E., "Poor Surgical Risks" 248 Campbell, Dr. J. A. E., "The Mechanism of Growth" , 284 Champion, Dr. B. H., "Some Observations at the Mayo Clinic" 78 Clinical Meetings g" 1 105, 141, 179 Coleman, Dr. R. E., "Dose for Glucose Curve" , 81 "Fatal Case of Diabetic Coma" 151 "Poor Surgical Risks" 313 and Donna M. Kerr, "Analysis of 223 Consecutive Glucose Curve's" 18 0 Diabetic Coma, Fatal Case of 151 Diphtheria Cultures - . 272 Eclampsia, Aetiology of \ 1 111 Eclampsia, Treatment of . : 147 Electricity, Nature of 210 Endocarditis and Rheumatic Feyer 348 Eykman Water Test 381 Fitzgerald, Dr. F. ., "Serum Therapy" Freeze, Dr. D. D., "Poor Surgical Risks" 252 Page 392 Gall Bladder Pathology 374 Gellhorn, Dr. G. E., "Vaginal Discharge" : _ 157 Glioma, Cystic—a case report 79 Glucose Curves, Analysis of 223 Consecutive l . 180 Glucose Curve, the Dose for 81 Golf . 271 Greaves, Dr. G. A., "The Nature of Electricity" 210 Growth, Mechanism of . 284 Haemorrhage, Antepartum 339 Health Department Statistics (see Statistics) Hill, Dr. J. W,, "Diphtheria Cultures" 272 Hunter, Dr. A. W., Presidential Address , 107 Hypertension, Treatment of 177 Kerr, Donna M., "Sodium bicarbonate for Intersitial Administration" 21 Kerr, D. M., and Coleman, R. E., "An Analysis of 223 Consceutive Glucose Curves" 180 Ketosis, Carbohydrates in 191 Kilpatrick, M., "An Unknown Organism Causing Fatal Meningitis in Infants" 150 Kilpatrick, M., "Delayed Typhoid Bacteremia" . 84 Laboratories, Vancouver General Hospital 20, 51, 81 Library Notes 1 85, 109, 143, 192, 209, 242, 372 Lister, Lord . 243 Lugol's Solution, effect of on Hyperplastic Thyroids 146 Malcolm, M., "Routine Tests for Albuminuria" : 113 Moffatt, Dr. C. D., "Cystic Glioma," a case report j 79 Medical Education, Osier Lecture 220 Mechanism of Growth ! Meeting, Annual 256 Meningitis, Unknown Organism Causing Fatal Meningitis in Infants 150 MacArthur, W. P., Lt.-Col., "Typhus Fever" 303 McEachern, Dr. M. T., "A Trip to the Antipodes" 55 Mackay, Dr. W. F., "Referred Pain" - - 122 McKechnie, Dr. L. N„ Obituary . . 41 McKechnie, Dr. R. E., "Address on Lord Lister" 3 243 McKee, Dr. C. S., "Blood Chemistry in Nephritis" 178 MacLeod, Dr. J. J. R., "The Place of Physiology in Medicine" 275 McNeill, Dr. N., "The Vienna School of Medicine" ' 321 Nephritis, Blood Chemistry in 178 News and Notes 9, 41, 72, 105, 140, 176, 239, 270, 336, 371 OBITUARY:— McKechnie, Dr. L. N 41 Elliott, Dr. J. E i 33 5 Rothwe 11, Dr. E. J - 355 Wilson, Dr. D. H 104 Wilson, Dr. T. H 176 Oille, Dr. J 348 Ootmar, G. A 3 81 Osier Lecture, "Medical Education" 220 Osteomyelitis, Acute r j— 386 Pain, Referred pain in connection with some disorders of the abdominal viscera 122 Pearson, Dr. J. M., "The Treatment of Hypertension" 177 Pipes, Ethel C, "Carbohydrates in Ketosis" 191 Pitts, Dr. H. H., "The Effect of Lugol's Solution on the Hyperplastic Thyroid"— 146 Pitts, Dr. H. H., "Tonsil and Appendix" - 51 Physiology, place of in medicine - 275 Poor Surgical Risks 248, 252, 313 Page 393 Presidential Address Prowd, Dr. C. W., "Analysis of Radium Treatment in 600 Cases" Radium Therapy—analysis of 600 cases Referred Pain in connection with disorders of the abdominal viscera. Rheumatic Fever and Endocarditis , , Royle, Dr. N. D., "Ramisection" Schinbein, Dr. A. B., "Poor Surgical Risks" Seldon, Dr. G. E., Osier Lecture, "Medical Education" Serum Therapy Sodium Bicarbonate for Interstitial Administration" i Starr, Dr. C. L., "Acute Osteomyelitis" s Summer School, Abstract of Proceedings (1926) .. 9, 43 Statistics, City Health Dept 26, 39, 91, 127, 165, 172, 204, 236, 268, 300, 332, Thyroid, Hyperplastic, effects of Lugol's solution on ! Tonsil and Appendix _ Turnbull, Dr. W. S., "Aetiology of Eclampsia" Tuberculosis, significance of sputum examination in reference to. Typhoid Bacteremia, Delayed. Typhus Fever, Old Time Epidemics of_ Vaginal Discharge Vancouver General Hospital Laboratories (see Laboratories) Vienna School of Medicine.. Vrooman, Dr. C. H., "Significance of Sputum Examinations in Reference to Tuberculosis 21 386 73 368 146 51 111 337 84 303 157 321 337 339 104 176 PRESCRIPTIONS filled exactly as written Phones: Seymour 1050 -1051 Good Bad Indifferent The condition of affairs described on page 803 of the C.M.A. Journal, July, 1927, certainly is astounding — one would scarcely conceive of such a wide variation in Liquid Extract and Tincture of Nux Vomica. Our safeguard against such a variation is simply to purchase standardized Liquid Extracts and Tinctures solely from manufacturers whose integrity is unquestioned. liladoivalcli DEPENDABLE PRESCRIPTION SERVICE NIGHT AND DAY The Ou?l Drug | Co., Ltd. Jill prescriptions dispensed bu, qualified Druggists. IJou can depend on the Ou?l for Accuracy and despatch. U?e deliver free of charge. 5 Stores, centrally located. We would appreciate a call while in our territory. (1 VanfXB^ay Supplies *VDQ[? <> There are over 30 Direct Branches now estab' lished by the Victor X'Ray Corporation throughout U. S. and Canada. These branches maintain a complete stock of supplies, such as X'Ray films, dark room supplies and chemicals, barium sulphate, cassettes, screens, Coolidge tubes, protective materials, etc., etc. Also Physical Therapy supplies. The next time you are in urgent need of sup' plies place your order with one of these Victor offices, conveniently near to you. You will ap* predate the prompt service, the Victor guar* anteed quality and fair prices. Also facilities for repairs by trained service men. Careful attention given to Coolidge tubes and Uviarc quart? burners received for repairs. VICTOR X-RAY CORPORATION Main Office and Factory: 2012 Jackson Boulerard, Chicago Motor Transportation Bldg. Vancouver, B.C. Victor X-R-P Safe A lead-lined steel cabinet for storing films and loaded cassettes. Write SUPPLY SALES DIVISION for price and detailed information. Duality Dependability Service Quick-Delivery «,» Price Jpplies to Ml ■*> */ or 4, 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. E. 665 Granville St. 151 Hastings St. W. Phones Sey. 988 and 672 Phones Sey. 9513 and 1391 Phone Sey. 1370 Brown Bros. & Co. Ltd. VANCOUVER, B. C. Page 397 I STEVENS' Safety Package STERILE GAUZE Soft Pure Absorbent STERILIZED BY 20 lbs. STEAM PRESSURE The Stevens Safety Package is designed to enable the gauze to be withdrawn from the carton without removing the whole roll. READY FOR USE IN THE OFFICE HANDY FOR THE BAG 2i B.C. STEVENS CO. LTD., AC . . 730 Richard Street, • «■ Vancouver, B.C. wee kof CLINICS Electro-Physiotherapy Post-Graduate by NOBLE M. EBERHART, M.D. HOTEL GEORGIA, VANCOUVER, B.C. SEPTEMBER 19-24, 1927 An unusual opportunity is afforded the Medical Profession of British Columbia, to attend a distinctly advanced course of Lectures and Clinical demonstrations by a recognized authority on the subject. Further information upon request from B.C. STEVENS COMPANY LTD. 730 Richards St. VANCOUVER, B.C. Tetanus Antitoxin <™> P. D. & co. ^ 1 =r Potent—Refined—Concentrated Cj HROUGH years of biological research we have developed certain refinements in -*■ the manufacture of Tetanus Antitoxin that enable us to offer to the medical profession a product which, we feel confident, stands alone in point of quality. Tetanus Antitoxin, P. D. & Co., is supreme in these important particulars: small- ness of volume, rapidity of absorption, water-white clearness, and fluidity. And still another point,—on account of the small content of protein and total solids, the risk of producing serum sickness or other form of protein disturbance from its use is slight. Tetanus Antitoxin, P. D. & Co., is supplied in a dose of 1500 units in bulb and syringe containers for prophylaxis, and in doses of 3000, 5000, 10,000 and 20.000 units in syringe containers for treatment. Parke, Davis & Company [United States License No. 1 for the Manufacture of Biological Products^ TETANUS ANTITOXIN, P. D. & CO., HAS BEEN ACCEPTED FOR INCLUSION IN N. N. R. BY THE COUNCIL ON PHARMACY AND CHEMISTRY OF THE AMERICAN MEDICAL ASSOCIATION Page 399 jjflte, ~*33J-»~ Hollywood Sanitarium LIMITED tyor the treatment oj Alcoholic, Nervous and Psychopathic Cases Exclusively Reference •» <\&. Q. dMedical ^Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Westminster 288 ?■©>»
Periodicals
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: September, 1927
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