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History of Nursing in Pacific Canada
Vancouver Medical Association
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m Tlhe Bf LLE of the I Vancouver. M ED IC A L AS S 0 CI AT 10 N m Vol. XVII. FEBRUARY, 1941 With Which Is Incorporated Transactions of the Victoria Medical Society the VancouveiiGenercd Hospital and St Paul's Hospital No. 5 !hi ;1 iii JTiis Issue: Page NEWS AND NOTES -Mi-—m_- j$jjj0. ■ llll^ ^.J^^^^L^.,^19 TREATMENT OF PYOGENIC SKIN INFECTIONS— D. e||I. Cleveland, M.D jji-__- |jjt|---|^^p>- -T^Ki__r-0^^^l22 NEPHRECTOMY WITH BILATERAL RENAL TUBERCULOSIS-^ Earl* R. Hall, M.P. ;^fe -^11 - -l^^.— ife'-^l^^P-" -"-M^- 126 NITROUS FUME POISONING—Dept. of Pensions and National Health_f§28 SHOCK—G. A. McCurdy, M.D,|fr :gjf|l|i--. ^^^^^^tf^^'-13"1 THE DOCTOR AND HIS PATIENTS—Arthur E. Hert2le& :J^_ili38 mi iii jiP - a 111 % ♦If <» *3 $1 m m ,*=■■ If nu1 — an ideal adjuvant in| Respiratory Congestions Sample and literature on recjuest THE DENVER CHEMICAL MFG.CO. 153 Lagauchetiejre St. W.,Montreal Made in Canada ill THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C. EDITORIAL BOARD: Dr. J. H. MacDermot Dr. G. A. Davidson Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XVII. FEBRUARY, 1941 No. 5 OFFICERS, 1940-1941 Dr. D. F. Busteed Dr. W. M. Paton Dr. A. M. Agnew President Vice-President Past President Dr. W. T. Lockhart Dr. R. A. Palmer Hon. Treasurer Hon. Secretary Additional Members of Executive: Dr. G. McDiarmid, Dr. L. W. McNutt. TRUSTEES Dr. F. Brodie Dr. J. A. Gillespie Dr. F. W. Lees Auditors: Messrs. Plommer, Whiting & Go. SECTIONS Clinical Section Dr. Karl Haig Chairman Dr. Ross Davidson Secretary Eye, Ear, Nose and Throat Dr. J. A. McLean Chairman Dr. A. R. Anthony Secretary Pediatric Section Dr. R. P. Kinsman Chairman Dr. G. O. Matthews Secretary STANDING COMMITTEES Library: Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies, Dr. W. A. Bagnall, Dr. T. H. Lennie, Dr. J. E. Walker. Publications: Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson. Summer School: Dr. H. H. Caple, Dr. W. W. Simpson, Dr. Karl Haig, Dr. J. E. Harrison, Dr. H. H. Hatfield, Dr. Howard Spohn. Credentials: Dr. A. W. Hunter, Dr. W. T. Ewing, Dr. A. E. Trites. V. O. N. Advisory Board: Dr. E. Riggs, Dr. W. C. Walsh, Dr. R. E. McKechnie II. Metropolitan Health Board Advisory Committee: Dr. H. Spohn, Dr. F. J. Buller, Dr. W. T. Ewing. Greater Vancouver Health League Representatives: Dr. G. O. Matthews, Dr. M. W. Simpson. Representative to B. C. Medical Association: Dr. A. M. Agnew. Sickness and Benevolent Fund: The President—The Trustees. ?!':* •' : fsarc* m If f M It ;•» cAnnounce IMUNOVAX &R£ (Oral Immunizing Vaccine) Modern Cold Therapy Numerous Investigators* have demonstrated that the incidence of respiratory infections can be reduced, their severity lessened and duration shortened by the administration of a freshly prepared oral vaccine. IMUNOVAX E.B.S. is an oral vaccine in tablet form, containing the anti-body-forming material derived from the freshly killed bacilli of — 15 billion pneumococci 7.5 billion streptococci 125 million H. influenzae 125 million M. catarrhalis in each tablet The advantages of this simplified oral treatment over the injection method are apparent. DOSAGE Dosage and Administration: One tablet, one-half hour or more before breakfast each day for seven days, with water. Then one tablet twice each week throughout the season in which respiratory infections are prevalent, to maintain immunity. During epidemics daily doses should be given to maintain maximum immunity. ■fcl. Thomson, D., Thomson, R., and Thompson, E. T.: Immunization by the Oral Route in Respiratory Infections. With Special Reference to Influenza, Colds, and Their Complications, Brit. M.J., 1:258, 1936. 2. Kolmer, J. A., and Amano, K. W.: Specific Prophylaxis of Pneumococcus and Streptococcus Meningitis: Vaccine Prophylaxis, Arch. Otolaryng., 15:547, 1932. 3. Kolmer, J. A., and Rule, A. M.: Oral Immunization of Rabbits against Pneumococcus Pneumonia and Septicemia, Proc. Soc. Exper. Biol. 8s Med., 30:107, 1932. 4. Ross, V.: Oral Immunization of Humans against the Pneumococcus, J. Immunol., 27:307, 1934. 5. Rosenow, E. C, and Heilman, F. R.: Streptococcal Vaccines in the Prevention and Treatment of Respiratory Infections, Am. J. Clin. Path., 8:17, 1938. THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED TORONTO MANUFACTURING CHEMISTS CANADA SPECIFY E. B. S. ON YOUR PRESCRIPTIONS VANCOUVER HEALTH DEPARTMENT STATISTICS—DECEMBER, 1940 Total population—estimated 269,454 Japanese population—estimated . Chinese population—estimated ~ Hindu population—estimated Number Total deaths . 330 Japanese deaths 9 Chinese deaths 10 Deaths—residents only 288 BIRTH REGISTRATIONS: Male, 230; Female, 206 | 436 INFANTILE MORTALITY: Dec., 1940 Deaths under one year of age 16 Death rate—per 1,000 births 36.7 Stillbirths (not included in above) 9 9,094 8,467 339 Rate per 1,000 Population 14.5 11.7 13.9 12.6 19.1 Dec, 1939 10 30.7 5 / CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY November, 1940 Cases Deaths December, 1940 Cases Deaths Jan. 1-15,1941 Cases Deaths Scarlet Fever . 26 Diphtheria 0 Chicken Pox . 52 Measles 201 Rubella 13 Mumps J 12 Whooping Cough '. 3 Typhoid Fever : 0 Undulant Fever 5 Poliomyelitis ! 0 Tuberculosis 21 Erysipelas 2 Meningococcus Meningitis 1 Paratyphoid Fever 0 0 0 0 0 0 0 0 0 0 0 16 0 0 0 21 0 82 442 17 3 O 0 0 0 36 1 5 0 0 0 0 0 0 0 0 0 0 0 11 0 0 0 0 0 81 710 18 7 0 1 0 0 16 0 4 0 0 0 0 0 0 0 0 0 0 0 0 2 0 Syphilis Gonorrhoea V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH, DIVISION OF VENEREAL DISEASE CONTROL West North Vane. Hospitals & Burnaby Vancr. Richmond Vancr. Clinic Private Drs. 0 0 1 1 20 16 0 0 2 0 64 20 Totals 38 86 & < * BIOGLAN THE SCIENTIFIC HORMONE TREATMENT "Bioglan products differ in that they are derived from original material." A Product of the Bioglan Laboratories, Hertford, England. Represented by STANLEY N. BAYNE Phone: MAr. 4027 1432 Medical-Dental Bldg. Descriptive Literature on Request Vancouver, B. C. ; t Page 117 I P> 81 ffS Is £ J, "11 I in \w ill i^tW I :> ' w ' i '•ii li ■: ■;■?.*. «S®9 SK&> :»§*& ^?^§i : VS5* 48 m%% & M M, •*^ n £i * * y #* m | if in ii £% *> £+ i^ AYERST,JJcKEBHA-i HARRISON LIMITED BMafical <md fiftatmacMtttic^ljSAptitiifo MONTREAL HELP WIN THE WAR CANADA BUY WAR SAVINGS CERTIFICATES VANCOUVER MEDICAL ASSOCIATION Founded 1898 . . . Incorporated 1906 GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m. Place of meeting will appear on the Agenda. General meetings will conform to the following order: 8:00 p.m.—Business as per Agenda. 9:00 p.m.—Paper of the evening. Programme of the 43 rd Annual Session February 18—CLINICAL MEETING. Programme of the 43rd Annual Session (Spring Session) March 4—SPECIAL LECTURE. Dr. Henrik Dam of Copenhagen. March 12—OSLER LECTURE. Dr. G. F. Strong. March 18—CLINICAL MEETING. April 1—GENERAL MEETING. Symposium on Cancer—Conducted by Department of Cancer Control of the Canadian Medical Association. April 15—CLINICAL MEETING. April 22—ANNUAL MEETING. CANADIAN MEDICAL ASSOCIATION jg|| 1941 I MEMBERSHIP 1941 FEE OF $8.00 INCLUDES JOURNAL OF C.M.A. TO BE PAID THROUGH THE OFFICE OF THE REGISTRAR College Dues for 1941 j $15.00 C. M. A. Membership, 1941 8.00 This will make your cheque total for 1941 $23.00 New Members are reminded that prompt response will assure receipt of the January number of the Journal. THE JOURNAL SPEAKS FOR CANADIAN MEDICINE THE C.M.A. MEMBERSHIP FEE INCLUDES THE JOURNAL. !Rit What are you using on your patients with Gonorrhoea? Sulphathiazole Squibb and our series shows it's the best drug yet. '•». m *m And we don't have half the reactions we had with Sulphapyridine. Vfi y "As a matter of fact we have a large series of cases treated with Sulpha- thiazole Squibb and have obtained cures in over 90% of them." "What dosage do you use?" "3 grams or rather 6-7.7 grain Tablets Squibb, the first day, followed by 8, 8, 6 and 6 Tablets on the succeeding four days." "And if the patient is not apparently cured on the 6th day?" "It is highly unlikely that prolonging the therapy will produce results and we feel it is better to change the drug. As a matter of fact, if the discharge continues after the third day, we become pretty pessimistic about obtaining quick results with oral therapy." "Have you used Squibb Sulphathiazole on non-specific urethritis?" "Yes, and obtained excellent results in the few cases we have treated, using the same dosage schedule we follow in G.C." *We wish to thank the Canadian clinicians whose as yet unpublished observations are embodied in this advertisement. When writing for SULPHATHIAZOLE specify SQUIBB Used continuously in the Dominion since December, 7939. For literature, write 36 Caledonia Road, Toronto ER: Squibb & Sons of Canada, Ltd. MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858 !» »r.' »»j THE EDITOR'S PAGE During its present "Winter Session, the Vancouver Medical Association has been fortunate in hearing on two occasions, and consecutive at that, from the major Health Departments of the Province. The first occasion was Dr. Stewart Murray's address last month, as M.H.O. for Vancouver. This appeared in the last issue of the Bulletin. In January, we heard from Dr. G. F. Amyot, Medical Officer of Health for the Province of British Columbia. Most unfortunately, his excellent talk was all extempore, and hence cannot be reproduced for our readers' benefit. This is a great pity, as it was well worth hearing—thoughtful, seasoned and provocative of thought, as was evidenced by the discussion: the sort of talk which we are accustomed to hear from Dr. Amyot. His talk was in the nature of a reminder of the necessity for close and harmonious relation? between all branches of medicine. The apparent line of cleavage between the therapeutic and preventive branches of our craft is more for working purposes, than any essential barrier. The two groups must cross and recross this line continually, and there is no trespassing in such invasions. There is no sharp division, and must never be one, between the two. Dr. Amyot, more perhaps than anyone in his position, has made every effort to avoid such divergence, and to bring the two branches into co-operation and harmony—and from what he said the other night, it is his carefully considered and deliberate intention, to continue this policy. Most of his hearers were actively practising medical men, i.e., therapeutic rather than preventive, and we think it is safe to say that they welcomed Dr. Amyot and his remarks very heartily, and in essence agreed entirely with him. It depends a great deal, of course, on the point of view—and one cannot help being biased to a certain extent by one's daily work and daily environment—but that is just why we feel that these meetings are of so much value, in that each side has a chance hitherto never afforded, of hearing and seeing what the other side thinks and feels. If there has been divergence, and difference of opinion, it is because till now we have largely been working in separate compartments: each side becoming more and more specialized and less and less conscious of the other part of his work. Because the two are, or should be, really inseparable, and there is no doubt that in the long run, both therapeutic and preventive medicine will succeed most fully by a judicious intermixture of the two elements for each. As one listened to Dr. Amyot, as he sketched the growth and gave the details of Preventive Medicine in British Columbia, and stressed the importance of a right relationship to the "practising" or therapeutic side of the profession, one could see how close the two things really are. One or two of the men who discussed the address brought this out. For example, in most, if not all, of the now recognized divisions of Preventive Medicine, Tuberculosis, Venereal Disease, etc., while now these are definitely controlled and operated by the Health Department, the agitation and education which led to the public recognition of their importance and the necessity for their organization, were initiated and for a long time handled by medical men in the active practice of the profession, who, together with laymen who saw the importance of the matter, labored in season and out of season, often for long years, and often against rebuff and discouragement, till they were able to convince governments of the necessity, the vital necessity, for better and more definitely organized management under the government's control. Dr. Amyot made much of the intention of "government" to maintain and expand these services. We none of us can fail to applaud this intention, since we ourselves urged it for so long, and worked for it. We hope that other departments, Cancer, Food Control, Mental Hygiene, Maternal and Child "Welfare, to mention only a few, will similarly be recognized Page 118 a r W. s **;H 'II I «# W • s 1 fit »: * ;,.■!' If * Hi.. at .1 j •« as vital to the welfare of the community, and be handled by the community, and not left, as they so often are, to private enterprise, with the overlapping and confusion that so often arise. Dr. Amyot referred, and we hope the British Columbia Medical Association will take note, to the suggested advisory council which he had accepted in principle some months ago, at the dinner which was given in his honour when he first took up his present duties. We cannot doubt that such a council would be of value, and might be of much assistance both to Dr. Amyot, who has time and again shown his sincere desire to work with us, and to ourselves, who have so often felt that we should like and should have some opportunity from time to time to express our views in matters of Public Health and Preventive Medicine and to offer our help in questions of Therapeutic Medicine. Such a council, carefully chosen, might do very much to advance the cause of health and the prevention of disease in our state, and that is what we all want. NEWS AND NOTES Dr. J. W. Vosburgh, who has been serving with the Air Force, has been forced to relinquish his appointment owing to an unfortunate illness. Doctor Vosburgh has now recovered and is taking up medical practice. Formerly Doctor Vosburgh was at Stewart, and latterly on the staff at Essondale before joining the Services. »t »?. •%. **. *r *r *v *v Dr. F. E. Coy of Invermere has joined the Active Force in the R.C.A.M.C. During Doctor Coy's absence in the Army by arrangement Doctor W. B. Clarke is carrying on the practice. * * * * Dr. R. J. Wride of Princeton is now serving in the R.C.A.M.C., A.F. *^ *t S% Jj. Dr. J. P. Ellis of Lytton wants to arrange with someone to carry on his practice. He, too, has decided to enter the Medical Services. •t *t *4. A if *r "if ** The sympathy of the profession is extended to Dr. and Mrs. H. L. Turnbull and family in the sudden passing of their son, the late Mr. W. E. Turnbull. * * «- * Dr. and Mrs. F. E. Saunders are receiving congratulations on the birth of a son on January 26th. sj- s{- ss- >C- Doctors W. L. Turnbull and C. G. Morrison who are on the staff at Shaughnessy Hospital are now registered with the College of Physicians and Surgeons. 3^ 55" 5f »f Dr. R. B. Shaw of Nelson visited the Coast recently. * *- * * Dr. B. L. Dunham of Nelson, who has been associated with Doctor Shaw, is leaving to join the R.C.A.M.C., A.F. Dr. F. P. McNamee of Kamloops has joined the Naval Medical Services. 55* •? *r *s* Dr. W. Roy Walker of Penticton is joining the R.C.A.M.C, A.F. Page 119 Dr. A. Marshall and Dr. A. C. McCurrach, until recently on the staff at Tranquille Sanitarium, are now with the Naval Medical Services at Esquimalt. *B" "if *P *T Dr. L. Giovando of Nanaimo is reported to have had some fine fishing in the Port Alberni district. Major C. A. Watson of No. 13 Field Ambulance has been moved from the Nanaimo area and is now at the Gordon Head Camp near Victoria. Dr. H. R. Christie of Rossland and Dr. W. Laishley of Nelson are taking a prominent part in the Interior Bonspiel. Dr. Gordon Wilson, who received his early education in this Province and was an interne at the Vancouver General Hospital, is now working with the Trail group. Among those who attended the Special Luncheon which was addressed by Dr. Charles Walter Clarke, Executive Director of The American Social Hygiene Association, were: Lieut. Col. R. A. Hughes, D.M.O., M.D. No. 11; Wing-Commander E. E. Day, P.M.O., Western Air Command; Major T. Miller, District Hygiene Officer; Dr. G. F. Amyot, Provincial Health Officer; Dr. E. Therrien, President, North Shore Medical Society; Doctors W. A. Clarke, J. T. Lawson and G. T. Wilson of New Westminster; Dr. A. N. Beattie of loco. The luncheon was largely attended. Dr. W. H. White of Penticton was a recent visitor in Vancouver. BRITISH COLUMBIA MEDICAL ASSOCIATION The regular meeting of the Board of Directors of the British Columbia Medical Association was held on Wednesday evening, January 22 nd, following Dinner at the Hotel Georgia. Those present included: Dr. Murray Blair, President of the Association and Chairman of the Board of Directors; Doctors G. F. Amyot, F. M. Bryant, P. A. C. Cousland and Thomas McPherson of Victoria, D. F. Busteed and D. E. H. Cleveland of Vancouver, W. A. Clarke and G. T. Wilson of New Westminster, P. S. McCaffrey of Agassiz, C. T. Hilton of Port Alberni, E. D. Emery of Nanaimo, and H. H. Milburn, R. A. Seymour, A. H. Spohn, Ethlyn Trapp, Wallace Wilson, W. M. Paton of Vancouver and M. W. Thomas, Executive Secretary. LIBRARY NOTES RECENT ACCESSIONS TO LIBRARY Neoplastic Diseases, 4th ed., by James Ewing. Medical Clinics of North America, December, 1940—Symposium on Fractures. Surgical Clinics of North America, January, 1941—Symposium on Pain. The Unseen Plague—Chronic Disease, by Ernest P. Boas. Hugh Young, A Surgeon's Autobiography. The Endocrine Function of Iodine, by William Thomas Salter. Transactions of the Section on Laryngology, Otology and Rhinology, A.M.A., 1940. Transactions of the Association of American Physicians, vol. 55, 1940. Year Book of General Medicine, 1940. The Bulletin wishes to offer to Dr. R. W. Garner of Port Alberni, its sincere apologies for a mistake made in the January numjber. In recording the obituary of the late Dr. E. L. Garner, by an inexcusable oversight, we used the initials R. W.; and can only express our regret at this carelessness, and our hope that it has not occasioned Dr. R. W. Garner any inconvenience or unpleasantness.—Ed. Page 120 :*!' 1* %- ml *i *** fi'U i-t British Columbia Medical Association (Canadian Medical Association, British Columbia Division) President Dr. Murray Blair, Vancouver First Vice-President Dr. C. H. Hankinson, Prince Rupert Second Vice-President P ____Dr. A. H. Spohn, Vancouver Honorary Secretary-Treasurer . Dr. Walter M. Paton, Vancouver Immediate Past President JDr. F. M. Auld, Nelson Executive Secretary Dr. M. W. Thomas, Vancouver CORRECTION: The Circular letter which reached you as an enclosure with the January Bulletin should have read: "C.V."—"CONVERSATIONAL VOICE AT 20 FEET."—and not "W.V.—Whispered Voice." Members are asked to note: 1. C.V.—Conversational Voice at 20 feet. 2. Standard eyesight testing charts will arrive in a few days and may be had by doctors on application to the Official Administrator, National War Services, 525 Seymour Street, Vancouver. Members are asked to please use the standard eye-sight cards, and thus avoid variation in records. Actual figures should be used rather than vague terms such as "good," "fair," etc. Defective vision is the principal cause of rejection of recruits by Army Medical Officers. Please record vision with and without glasses. 3. When placing a recruit in Category "D", please state length of time of temporary unfitness. This is necessary. With few exceptions, the forms are completed satisfactorily. VENEREAL DISEASE AND NATIONAL DEFENCE Dr. Charles Walter Clarke, Executive Director of the American Social Hygiene Association, speaking to members of the British Columbia Medical Association at a luncheon meeting recently, emphasized the seriousness of the venereal disease hazard in war time. Out of a twenty-seven-year experience in the field of venereal disease control which included service in the commissioned ranks in France in the Great War, duties in Geneva under the auspices of the League of Nations, and more recently membership on an advisory committee to the United. States Army and Navy, Doctor Clarke outlined the steps necessary to avoid the increase in venereal disease associated with a state of war. The source of venereal disease among members of the Forces is almost always to be found in the civilian population. It is the duty of physicians in civilian practice to assist in reducing to a minimum this source. Prostitution in its various forms, and in particular that which is highly organized commercially, constitutes an "alien fifth column' which undermines the efficiency of the war effort by spreading venereal disease to members of the Forces, to potential recruiting material and to workers in key industries. Doctor Clarke urged strict enforcement directed against bawdy houses, pimps, procurers, madames, and the lengthy retinue of less obviously associated citizens who exploit diseased young women for their personal gain at the expense of their country. It is gratifying to know that many of the suggestions made by Doctor Clarke, relative to a closer co-operative effort between the Department of National Defence, members of the British Columbia Medical Association and the Provincial Board of Health, were already in actual operation in British Columbia. Page 121 College of Physicians and Surgeons President Dr. L. H. Appleby, Vancouver Vice-President Dr. W. A. Clarke, New "Westminster Treasurer Dr. w". E. Ainley Members of the Council—Dr. J. Bain Thom, Trail; Dr. Thomas McPherson, Victoria; Dr. Gordon C. Kenning, Victoria; Dr. Osborne Morris, Vernon. Registrar—j Dr. A. J. McLachlan Executive Secretary Dr. M W. Thomas MEDICAL ECONOMICS The Canadian Medical Association and Problems of Medical Economics The book which has been passed to the members of the profession with the compliments of the Canadian Medical Association is a worthy compilation—firstly, it has bound together the series of Articles by Mr. Hugh H. Wolfenden—secondly, it deals with matters of vital importance to our members. The foreword by Dr. Wallace "Wilson, Chairman of the Committee on Medical Economics of the Canadian Medical Association, presents this valued book as a challenge to Medicine to do some long-range planning. Doctor Wilson says in reference to Mr. Wolfenden's Articles: "What he has written should be read, reread and kept for reference. ..." Vancouver Medical Association TREATMENT OF PYOGENIC SKIN INFECTIONS D. E. H. Cleveland, M.D. A brief presentation of this subject does not permit consideration of any but those conditions which are common and familiar to all. Diagnostic and pathologic features will receive but little attention, since our subject is that of therapy. While it is my aim to place before you the practice of the most competent dermatological authorities, it is impossible to go into this exhaustively, and I shall confine my references to methods with which I have had personal experience. Superficial Infections. Impetigo Contagiosa. This may be due to either streptococcus or staphylococcus, more frequently the former. It is a self-limited disease if not properly handled. Ammo- niated mercury in an ointment base is used successfully in the streptococcal cases, but in those due to staphylococcus it is of little or no use. Do not use higher than 2.5% concentration. Wash the face morning and night with plain toilet soap—not medicated soap. Light shaving is permitted, the razor being dipped frequently into 10% lysol solution, as well as the brush at the end of shaving. The lysol should always be rinsed off carefvlly and not transferred to the face. After washing, the face is sponged with Page 122 if 1 Bfeft 1 111 m m g 1/5000 bichloride solution, which lessens the risk of spreading or inoculation of new areas by fingers, etc. The ointment, made with a soft base having a low melitng-point, is applied lightly to individual lesions every three hours. It is gently wiped off with toilet tissue before each fresh application. Washing, sponging and final application of ointment is done at bed-time. This treatment is continued until when lesions are wiped dry no droplets of serum reappear. This commonly takes two or three days. The ointment application is then continued thrice daily for another day or two. About 1 % of patients are intolerant to white precipitate. In these and the staphylococcal cases the crusts may be mechanically removed, the lesion wiped with benzol and 25% silver nitrate painted on. A single application is often curative. Gentian violet is specific for staphylococcal impetigo and equally good in streptococcal. The originators of this treatment recommended 5% gentian violet in 20% alcohol. Crusts are removed first, and it may be necessary first to check an excessive flow of serum, with a pledget dampened with adrenalin, 1/1000. The dye is painted on and allowed to dry, the involved area covered with lint thickly smeared with borated vaseline, and left undisturbed for 48 hours. Two or more treatments are sometimes necessary. Pieces of lint soaked in 1/1000 acriflavin emulsion applied over the area, secured with a bandage and changed daily, is another efficacious treatment. In the staphylococcal impetigo sometimes sen in small children, with profuse serous exudation, sponging hourly with 0.5 to 1 % resorcin solution is often successful. Moist dressings must not be used, and no other dressings are necessary except as mentioned above. The parts should not be exposed to open sunlight or other sources of ultra-violet. Medicated soaps must not be used. The patient must be ordered strictly to keep the fingers away from the lesions, and wash carefully after applying treatment. Ecthyma is similar to impetigo but involves deeper parts of the skin, usually on the extremities. The treatment is similar to that of the streptococcal impetigo, but 5% ammoniated mercury ointment may be used twice daily, and the parts lightly bandaged. Intertrigo, usually due to staphylococci of low virulence, is not suitably treated with ointment. Gentle cleansing with plain toilet soap and water and powdering with zinc stearate and talcum is generally sufficient. The addition of a tenth portion of liquid paraffin gives the powder a slightly more adherent quality and is better proetction against sweat, urine and other irritant discharges. Bockhart's Impetigo or superficial pustular folliculitis and other widespread superficial infections are treated with warm permanganate baths once or twice daily. One teaspoonful of potassium permanganate crystals is dissolved in a cup of hot water and added to a warm bath deep enough to immerse the parts affected. After fifteen to twenty minues in the bath and drying, 2% ammoniated mercury in vaseline is rubbed in and talcum dusted over. Sycosis Vulgaris frequently commences on the upper Up, and is due to streptococci in a nasal discharge. Attention to the source of this discharge is a necessary part of the treatment. The face, after shaving and washing with precautions described under impetigo, should be bathed or fomented with liquor calcis sulphurata or a similar lotion diluted with 2 to 4 volumes of hot water for five minutes. An ointment whose active principle is oxyquinoline sulphate is then rubbed in. The treatment is repeated at bedtime. If daily shaving is not possible, hairs which are loose and lift out easily may be removed daily from the nodular and pustular lesions. No attempt must be made to extract them forcibly. A few patients do not tolerate oxyquinoline sulphate in any concentration and it must be replaced with ammoniated mercury ointment. Treatment must be continued for two or three weeks after pustules have ceased to appear, and resumed at once on any sign of recurrence. In resistant cases weekly fractional doses of X-rays are a valuable addition; heavier dosage sufficient to produce a temporary depilation may be necessary, and in rare cases permanent depilation is the only cure. Page 123 L Vaccines and toxoid are rarely of any use. Direct sunlight or other sources of ultra- I violet are apt to aggravate the symptoms without producing any curative effect. The j disease is often a most resistant one, lasting for years and taxing the resources of the most skilled and exprienced. Onychia and Paronychia. These infections of the nail-bed and nail-fold respectively are often coccogenic—usually streptococcal—and are commonly spoken of as whitlows or run-around. Evulsion of the nail, too often practised, is rarely necessary. The part should be soaked daily in 1/5000 bichloride solution, 5% ammoniated mercury rubbed in twice daily, and X-ray treatment of appropriate dosage administered. If there is free pus under the nail, it may be evacuated through a drill hole and moist dressings applied. Deep Infections. Furuncle. Incision and drainage is not indicated except when the boil is "pointing" and a fluctuant collection of pus is readily apparent. Probing and attempts to extract hairs or forcible attempts to extract an adherent slough are purposeless and dangerous. Sufficient drainage should be maintained to keep the incision open until the necrotic slough or "core" separates spontaneously. A small hot moist dressing proportioned to the size of the boil of weak lysol solution may be used, but poultices of the various popular types are to be eschewed. Large moist pads are not recommended generally; they may produce a dermatitis or spread a crop of satellite lesions. When the incision is ready to close, a small dry medicated pad secured by elastic adhesive is a good dressing. In its incipient stages the boil can usually be aborted. Experimental lancing, squeezing and other such interference should not be permitted. A hygroscopic dressing such as saturated solution of magnesium sulphate or 12% sodium sulphate may be used. Rest of the part is important. In boils about the lower part of the face the patient should remain in bed, be forbidden to talk and given no food which cannot be taken through a tube. An arm should be kept in a sling, and walking or other use of a lower limb forbidden when a boil is present in these parts. No active use of skeletal muscles should be permitted when a boil occurs on the neck or trunk. If the correct dosage of X-rays is applied sufficiently early, a boil may be aborted, but if the critical point has ben passed the inevitable suppuration and "pointing" will be hastened. In either case time is saved, discomfort and inconvenience minimized. The destructive effect of X-rays on lymphocytes and liberation of antibodies is believed to be the explanation of the favourable results with X-ray therapy. In localized furunculosis weekly administration of fractional dosage of X-rays is the most satisfactory treatment. Since areas of localized furunculosis are usually in certain sites characteristic of the occupation, recreational activities or other habits of the patient, attention to the local conditions at fault is essential. The special form of activity implicated must be abandoned for a time and means taken to avoid pressure and friction and contact with soiled, greasy and sweat-soaked clothing, often coated with epithelial debris forming an excellent culture-medium for micro-organisms. Bandaging, if unavoidable, should be light and frequently changed. If possible, frequently changed and boilable articles of clothing such as cotton shorts, or lengths cut out of cotton stockings, should be used instead of bandages. Bathing the part daily with warm water and castile soap is desirable. In the case of the large, flabby indolent bags of seropurulent material sometimes seen on the upper trunk and back of the neck, incision is not advisable. Many are thin-walled and rupture or leak spontaneously through small fistulous openings. Those on the neck usually have thicker walls, and are often connected by fistulous tracks beneath the surface of the skin. Aspiration is sometimes useful and when they are discrete the injection into the aspirated cavity of 60% alcohol through a fine needle until blanching occurs will often hasten their closure and prevent refilling. Compresses of Alibour solution— a solution of copper and zinc sulphate in camphor water—diluted with four volumes of hot water, should be applied for twenty minutes several times daily. The entire involved area should be sponged over twice weekly with iodized alcohol—1% w/v solution of Page 124 1* i - / ml :m iim iodin crystals in 70% alcohol. Air-cooled ultra-violet, better still dry heat supplied by an incandescent bulb in freely circulating air, or best of all sunlight in open air— avoiding an erythema—often proves valuable. X-rays appear to be less generally useful in the very superficial trunk-involvement, where they sometimes seem to aggravate, although they are almost indispensable in the more deeply-seated lesions on the back of the neck. Carbuncles seldom offer opportunity for abortive treatment, although this can be accomplished successfully by properly timed and appropriate dosage of filtered or unfil- tered X-rays. The radical surgical treatment of fully developed carbuncle is familiar, and adequate in most cases. The indolent slowly burrowing lesions in which the urgent requirements have been met by surgery and which yet continue to smoulder in various foci should have fractional X-ray treatment. Hydradenitis Axillaris. So-called boils of the axilla are usually not boils at all but abscess of the sweat-glands. They do not form necrotic cores but burrow under the surface forming intercommunicating sinuses. Surgical treatment is usually contraindi- cated. X-rays have practically a specific effect even where their use is delayed until after some lesions have been opened surgically and spreading thereby favoured. Frequent bathing with mild antiseptic and astringent solutions such as Alibour's is to be employed at the same time. Tradition supports the belief that excessive carbohydrate intake has something to do with furuncles, carbuncles and related pustular infections. While diabetes and boils or carbuncles are not associated as often as one might expect recent investigations lend some support to the traditional view. Hydration of the tissues is a directly predisposing factor of pyogenic infection, and is favoured by high carbohydrate intake and alkaline-ash-diet. Dehydration is favoured by a swing of the acid-base equilibrium to the acid side by high protein diet, hydrochloric acid by mouth, acid fruit-juices (plums, prunes and cranberries), reduced carbohydrate and intravenous dextrose. In furuncles and other skin-gland infections bromides and iodides should be avoided, as they have a supposedly irritative effect on these structures, and it also must not be forgotten that such lesions are often wholly accounted for as allergic reactions to these halogens. Vaccines and toxoid have resulted in many more disappointments than successes! Remedies such as tin, manganese, calcium sulphide and vitamin-rich compounds such as yeast are of no proven value and not to be relied upon. As will be observed from the above remarks X-rays have an important place in the therapy of the pyogenic skin infections, particularly the deeper ones, including the pyogenic complications of acne vulgaris, but their use should be regarded as a part of or adjunct to intelligent dermatological therapy. Reliance upon X-rays or other physical agencies as the sole method of treatment, even when such treatment has been properly administered and after the diagnosis has been correctly made—which is not always the case—often results in disappointment because other necessary treatment has been omitted, and these modalities are unjustly discredited. Erysipelas. Since this is a self-limited disease with a favourable prognosis except in the extremes of age or in the debilitated subject, good results with comfort and convenience are often attained by the use of simple measures. Such are the use of compresses wet with iced saturated solution of magnesium sulphate in mild or doubtful cases. A few super-erythema doses of ultra violet, or an erythema dose of X-rays divided over two or three daily exposures, give excellent results. Since the quartz-lamp can readily be brought to the patient's bedside it is more generally used. The use of sulphanilamide for erysipelas has been standardized by Bellevue and other large hospitals. It has been convenient and most efficacious in our practice here. For patients of twelve years and over 100 grains are given in divided doses during the firs^ 24 hours, and the daily dose reduced by 20 grains in each successive 24-hour period until Page 125 \ v i 40 grains are given on the fourth day and this dosage is maintained if necessary until the temperature has remained normal for 24 hours. In younger patients suitably reduced doses are used in a similar manner. Sulphonamide derivatives have a place in the therapy of pyogenic skin infections, but we must make a plea against hasty and unthinking resort to them on all occasions. The dangers attendant upon their use contraindicate their exhibition in comparatively trivial, superficial, easily controlled conditions. There is no satisfactory evidence as yet that they are of any value as topical remedies. In deep-seated streptococcal and staphylococcal infections their use may be life-saving. The choice between sulphanilamide and sulphathiazol should not be haphazard. Valuable time is sometimes wasted in using sulphanilamide in staphylococcal infection. There is always time to stain and examine a smear for the predominant organism, later to be checked if possible by examination and cultures of pus from deeper parts and the blood. A complete blood-count and urinalysis should be made at the outset and repeated daily during the use of the drug, and frequent estimation of the blood-concentration of the drug made. In the less serious conditions lower concentrations give satisfactory results with correspondingly less risk to the patient. At the- same time, regardless of dosage, symptoms of intolerance whether from idiosyncrasy or allergy should be watched for, and their significance properly interpreted and assessed. St Pauls Hospita NEPHRECTOMY WITH BILATERAL RENAL | TUBERCULOSIS M § j| Earle R. Hall, M.D. The problem of renal tuberculosis when localized in one kidney is usually solved by nephrectomy. When this condition is found in cases having bilateral involvement, operative treatment is nearly always contraindicated. Some instances of this may occur, however, when surgical intervention will prove to be of considerable benefit. The following case for presentation is one of this type, having bilateral renal tuberculosis, and showing a decided improvement following the removal of one kidned. Mrs. H. V., age 50, was first seen in September, 1940, with the following history: Previous Illnesses: Fourteen years ago—Pneumonia—No chest trouble since. Thirteen years ago—She was ill for several months, complaining of swelling and pain involving the left breast. She also had intervals of recurrent pain in the back—aching across lumbar region, not radiating and not of the colicky type. This illness was also associated with frequency and dysuria at times. Apparently no definite diagnosis, beyond a statement of the possibility of kidney stones, was given to her. Her symptoms gradually subsided and she returned to apparent normal health. Previous Cystoscopies: Thirteen years ago with the above illness—examination was reported negative. Does not know if Pyelograms were made. Previous Operations: Age 21—Appendectomy and partial ovarectomy. Previous X-Kays: 1. Of vertebral column in childhood—negative report. 2. Of chest—few years ago—negative report. Menses: Ceased 6 years ago, following a gradual diminution in the amount of flow. Menstruation was regular with no dysmenorrhea. There has been no recurrence. Marital: Married—never pregnant. Present Complaints: 1. Abdominal pain; 2. Frequency and dysuria recently; 3. Loss in weight. Onset and Course: She was in apparent good health with no complaints until about 7 weeks ago, when she began to feel "generally miserable" and thought she had influenza. The bowel was very sluggish, and there was a gradual onset of frequency of micturition Page 126 r. m - »'i! i'M ilw •'«!. —every 1 l/z hours during the day, but never more than once or twice during the night. Following the onset of frequency, she developed considerable dysuria. At the commencement of urination there was severe pain felt at the bladder neck region and extnding through the urethra. This became so great at times that it was difficult to expel any urine. Following medical advice and treatment the dysuria disappeared, frequency diminished, and micturition returned to normal. About 3 weeks ago, she developed abdominal pain described as "gas pains." There was also some abdominal distention. She states relief was obtained at times by massage of the abdomen. There was no nausea or vomiting. Following medical advice she obtained relief, and was free of pain until a few days ago, when there was return of abdominal pain with distention. The pain become more severe and was present also at the back—across the lumbar region, with greatest intensity at the right. The pain, when experienced, is steady with occasional sharp twinges, and appears generalized— radiates over the entire abdomen, and posteriorly to the lumbar areas, especially on the right. With recurrence of this pain the bowel became very sluggish. She has lost weight during the past few months, and feels generally weak. Micturition has been normal since improvement a few weeks ago. There has never been any hematuria. Examination: Patient was seen by me for the first time in September, 1940, lying in bed at St. Paul's Hospital, having recently been admitted by her physician. The patient did not appear ill, except for a somewhat sallow complexion. Temperature and pulse rate were" normal. Abdomen: Abdomen somewhat distended and tympanitic—no points of tenderness, Bi-manual palpation showed some definite tenderness localized to the right kidney region. Cystoscopy and Pyelography—Local Anesthesia. "Bladder mucosa appeared pale. The trigone was normal except for some slight aedema surrounding both ureteral orifices. Bladder capacity was good. Catheter entered left ureter and passed without obstruction. Catheter entered right ureter, but met definite obstruction about 77 cm. within and could not be passed beyond this point though various size instruments were used. There was good secretion of urine from the left kidney but no urine seen from the right. Injection -of dye on the left caused no pain, but a very slight amount on the right produced pain extending along the course of the ureter to the kidney region." Report of Pyelograms: "Marked areas of calcification in both kidney fields. Right ureter apparently obstructed opposite the sacro-iliac joint, but a small amount of dye passes up the ureteral course to the renal pelvis which is not clearly outlined. Left kidney shows normal pelvis, but upper and lower major calices show defects consistent with tuberculosis."—Dr. C. W| Prowd. Bladder Urine: Alkaline. Specific Gravity: 1010. Albumin +. Sugar: Negative. Microscopic: W.B.C. ++. Smear Positive for Tbc. Urine from Left Kidney: Cloudy. Microscopic: R.B.C. ++; W.B.C. ++. Smear Positive for Tbc. There was no reaction following cystoscopy, and two days later a second cystoscopy to obtain good visualization of the right kidney was carried out under spinal anaesthesia. At this time the bladder showed not change, and the catheter on the right would not pass beyond the previously encountered obstruction. There was no urine from the right kidney. Dye was injected to fill the right renal pelvis. A left pyelogram was also made. Report of Pyelograms: "Left pyelogram was similar to that obtained previously. Right pyelogram showed enlargement of pelvis with distortion and defects of calices which were also enlarged. This was marked at the upper major calyx which was blunted and much deformed. The right ureter was filled with dye showing a striking beaded appearance. Findings indicate bilateral renal tuberculosis."—Dr. C. W. Prowd. Page 127 h- Urines Obtained at Second Cystoscopy: Bladder: Direct smear Positive for Tbc. Left Kidney: Direct smear Negative for Tbc. Animal Inoculation and Cultures of Urine Obtained at First Cystoscopy: Madder Specimen: Positive for Tbc. Left Kidney Specimen: Positive for Tbc. N..P.N.: 23 mg.? Blood Count: Haemoglobin: 60%; R.B.C.: 3,480,000. Patient was feling improved and she was discharged from hospital for some sustaining treatment while surgical intervention was being considered. On October 22, 1940, she was readmitted to St. Paul's Hospital. She had been complaining of aching and pain at right kidney region and some frequency. Urine: Acid. Specific Gravity: 1018. Albumin: +++. Microscopic: W.B.C. +++•; Pus Clumps +++; R.B.C. +. Oct. 23, 1940—Avertin and Ether Anaesthesia. Right Nephrectomy. The kidney showed a fairly large abscess involving the upper pole and almost total obstruction of secreting tissue throughout the organ. Pathological Report: Pyelonephritis; Pyonephritis; Tuberculosis of Kidney. Post-operative Course: She sustained operation well and recovery was uneventful. Temperature was normal on the 3rd day and remained so during her hospitalization. N.P.N.: (3 days after operation) 25 mg. Urine: (3 days after operation) Acid; Specific Gravity: 1017; Albumin: +; Sugar: Negative. Microscopic: W.B.C. +. She was discharged from hospital on the 19th post-operative day, at which time urine examination was normal. Comment: From the examination of this case it was evident that there was tuberculosis involving both kidneys. The right kidney was non-functioning and almost completely destroyed by the infective process. The pyelogram on the left side showed a normal appearing kidney, except for some slight involvement at the upper and lower minor calices. The urine from this kidney was fairly clear and its function well within normal, as also borne out by the low N.P.N, values. However, tbc. bacilli, while not consistently found, were easily obtained from this side. Following deliberation, it was decided that her general health would be much improved by removal of the ureter and infected right kidney. This did not entail great risk, and it was considered that the infection in the left kidney might then become arrested following a general improvement in her health. This subsequently proved to be so and urine examinations before hospital discharge showed a tremendous improvement. Since leaving hospital, she has made steady progress in her general health. NITROUS FUME POISONING Division of Industrial Hygiene Department of Pensions and National Health Nitrous fumes are a VIOLENTLY POISONOUS mixture of yellow, brown and brownish-red gases. Even though the fumes have an unpleasant, irritating odour, breathing of them can be tolerated. The fumes are much heavier than air and, therefore, in a badly ventilated space, was collect at floor level. The composition of the fumes will depend upon the processes by which they are developed and in certain processes the nitrous fumes evolved may be of an explosive, as well as a poisonous, nature. The fumes arise when nitric acid is exposed to air and when this acid comes into contact with organic matter such as wood, paper, etc. Nitrous fumes are also evolved when nitric acid comes into contact with metals. Among further sources of nitrous fumes are electric arcs and explosions. Page 128 '■■ •»* 11m- :SK 1 *!:-. Mf!' mi m In Industry The following types of workers are most likely to be xposed to the danger of nitrous fume poisoning: 1. Aniline makers 2. Arc welders 3. Artificial leather workers 4. Blasters (dynamite—mining—tunnelling) 5. Bleachers 6. Calico printers 7. Chemists and chemical workers. 8. Collodion makers 9. Damascening workers 0. Dye makers 1. Electro platers 2. Etchers .3. Explosive workers. .4. Galvanizers 5. Hat workers 6. Metal cleaners .7. Metal refiners [8. Mercury fulminate workers L9. Miners 38. Welders 33. Mixed acids handlers Moving picture operators Nitrators Nitric acid workers Nitrobenzene makers Nitrocellulose markers Nitroglycerine makers Nitrous acid workers Photo engravers Picklers (metals) Picric acid makers Pyroxylin plastic workers Sulphuric acid workers (Chambers Process) Synthetic ammonia workers (Haber Process) Tetryl makers Tetra-nitro-aniline makers Torch cutters (metals) Tunnellers Poisoning by Nitrous Fumes Poisoning by nitrous fumes occurs as a result of breathing the fumes. When the fumes are allowed to escape, air currents carry them through the atmosphere which is being breathed. These fumes have an irritating effect upon the breathing passages and the lungs and seriously damage the tissues of these organs. In addition the fumes may be absorbed into the blood stream through the lungs, and poison the whole body. It must be remembered that some individuals are more easily poisoned than others and that workers who feel that they have become accustomed to the fumes are not immune from poisoning. Acute Poisoning.—Since breathing of nitrous fumes can frequently be tolerated without discomfort, a worker may not have any warning that he is being poisoned. However, the symptoms of acute poisoning usually do not develop for some hours after the fumes have been inhaled. In from six to twenty-four hours after inhalation of the fumes the lungs may become congested with fluids. Death may result a few hours after the worker realizes, by his symptoms, that something is wrong. It must be stressed that an individual who has ben affected by an exposure may lose the preliminary symptom of violent, spasmodic cough when removed from the exposure and may seem to be normal for some hours before the serious bronchial and lung conditions begin to appear. Consequently, workers developing a violent cough on exposure must be removed at once and placed at rest and under observation. Chronic Poisoning.—Chronic poisoning by nitrous fumes occurs as a result of continued daily breathing of air containing small quantities of the fumes. The fumes absorbed in this way cause injury to the breathing passages and the lungs with the result that the worker may have a chronic cough, headaches, loss of appetite, constipation, corrosion of the teeth and inflammation of the mouth, nostrils and eyes. When a worker notices such signs he should report to a physician at once and should inform the physician of his exposure to nitrous fumes. Cases of nitrous fume poisoning should be reported to the employer and to the Provincial Departments of Health and Labour so that adequate steps may be taken to protect other workers. Page 129 *ir *».j»sg*i The effects of nitrous fumes on the body are insidious and it cannot be too strongly stressed that even a slight exposure to these funus may result in death. The fumes may have a delayed action on the body and a worker can feel perfectly well for some hours after the exposure before the serious effects begin to appear. Treatment. Acute Poisoning. No matter how slight the exposure to the brownish-red nitrous fumes, precautions should be taken to avoid the effects of poisoning. If the worker suffers from a feeling of oppression in the chest, or from a cough after exposure,— (1) The worker should be removed to the open air and kept warm; (2) a physician should be called without delay; (3) if coughing continues and difficulty in breathing occurs, before the arrival of a physician, oxygen should be given; (4) artificial respiration should be avoided unless breathing has ceased. Chronic Poisoning. If a worker suffers from a chronic cough, corrosion of the teeth, inflammation of the mouth, nostrils and eyes, headaches, loss of appetite and constipation, a physician should be consulted without delay. Prevention. Responsibility of the Employer. 1. To isolate processes evolving nitrous fumes and to insure that such processes are carried out in closed vessels, wherever practicable. 2. To remove nitrous fumes by exhaust ventilation at the point of origin when the material requires to be used in open vessels. 3. To provide adequate ventilation, in addition to exhaust hoods, for all workrooms in which nitrous fumes may be encountered. 4. To insure that ventilation equipment is operating satisfactorily by having workroom air tested for nitrogen dioxide routinely. Ten parts of nitrogen dioxide per million parts of air (by volume) is now considered the maximum safe concentration. 5. To insure that no worker may enter a tank or enclosed space until thorough ventilation has been carried out. Persons required to enter tanks or enclosed spaces which have contained nitrous fumes should be protected by a safety-felt and by the presence of another worker on the outside. 6. To provide protective clothing and goggles for workers required to handle nitric acid. 7. To insure frequent periodic medical examination of all workers exposed to ntrous fumes. Such examination should be carried out by a physician familiar with nitrous fume poisoning. Health records of nitrous fume workers should be kept and medical advice as to transfer of an affected worker to more innocuous duties must be) acted upon promptly. 8. To insure that workers who have been exposed to nitrous fumes and who are suffering from a cough receive medical attention immediately. No worker who has become affected by the fumes should be allowed to return to work without a physician's order. It must be remembered that nitrous fumes have a delayed action. 9. To insure that all those who may have occasion to be exposed to nitrous fumes are made aware of the poisonous nature of the fumes. Workers must be encouraged to report early symptoms of the poisoning. Responsibility of the Employee. 1. To carry out, in detail, all safety measures which are advised for protection against nitrous fume poisononing. Page 130 :*'i rLS K « ^.' 2. To make use of ventilation equipment, gas masks and clothing supplied for protection against nitrous fumes and nitric acid and to report to the employer when such equipment is not in good order. 3. To remember that nitrous fumes are yellow, brown or brownish-red in colour, are VIOLENTLY POISONOUS, and that breathing the fumes is dangerous even though they may not be found irritating at the time. 4. To report immediately, both the employes and physician, any signs of irritation after exposure to nitrous fumes. Victoria Medical Society Officers, 1939-40. President Vice-President Honorary Secretary Honorary Treasurer Dr. A. B. Nash Dr. D. M. Baillie Dr. O. C. Lucas Dr. P. A. Cousland SHOCK Paper presented by Dr. G. A. McCurdy, Pathologist, Royal Jubilee Hospital, Victoria, B. C, before the Victoria Medical Society, on January 6, 1941. The purpose of this paper I am to present this evening is to try to outline to you the pathogenesis of shock and to indicate some recent methods of treatment. I will not attempt to discuss in detail the various theories which have been brought forward to account for its occurrence. By shock I refer to secondary shock, and I want to emphasize that secondary shock is not a condition seen only by the surgeon, but is a condition which the internist sees in states of intoxication, which may be metabolic or bacterial in origin, and in cases of cardiac disease whether valvular, vascular or functional in origin. The obstetrician may also encounter it in cases associated with marked loss of blood, prolonged labour, or in the toxaemias of pregnancy. It is also seen by the radiologist in patients who have had prolonged irradiation therapy and who develop irradiation sickness. Its occurrence with burns frequently makes it come to the notice of the paediatrician, and the orthopaedist sees it associated with fractures. It would be possible to continue through all the specialties and note further examples of shock. Thus shock is a condition which almost any physician or surgeon, whatever his specialty, is frequently required to treat. In many conditions which are not associated with trauma or operative interference, shock may develop insidiously, and may go unrecognized unless the physician is "shock conscious." Clinical Signs. Every surgeon is only too familiar with the clinical signs and symptoms of the patient who is passing into secondary or surgical shock. Meakins1 has recently summarized the development of shock in these words: "The first evidence is an unusual degree of weakness and listlessness soon to be followed by tachycardia and a small pulse volume. The blood pressure at this time is well sustained or even elevated. This is apparently a compensatory suspense, of temporary duration. In rapid succession the skin becomes cold and moist, the face is drawn and the expression anxious. The skin Page 131 and mucous membranes become livid with a pale and mottled cyanosis. There are also rapid and shallow respirations, great thirst and vomiting by which the thirst is further aggravated and there is also oliguria and often diarrhoea. Finally there is loss of sensitivity, coma and death. The blood pressure at a relatively late stage rapidly falls and usually indicates an "irretrievable state'." Pathogenesis. With this clinical picture in front of us I will now try to describe to you the sequence of events which apparently take place during the development and final termination of the shock process. The first change which has been demonstrated is loss of normal capillary tone and permeability. The former results in dilatation of the capillaries, thus increasing the volume of the vascular system and decreasing the blood pressure; the latter allows the plasma to escape from the capillaries; thus, at the same time, the blood volume is diminished and the cellular constituents of the blood are normally concentrated. This occurrence is called hoemoconcentration and is indicated by a rise in haemoglobin, red blood cell count and haematocrit reading, and due to the fact that the damaged capillaries allow crystalloids to pass through their walls more easily than they allow the passage of the plasma proteins, the latter are also concentrated. This may be demonstrated by determining the plasma protein or by estimating the specific gravity of the plasma. Nature attempts to compensate for these serious developments in two ways. First, steps are taken to restore blood volume by discharging blood from the spleen and by absorption of fluid from other sources, e.g., the tissues and from the gastro-intestinal tract. The next step at compensation is an attempt to diminish the volume of the vascular bed by contraction of vessels. This apparently is brought about by a stimulation of the carotid sinus by the fall in blood pressure, which activates the sympathetic system, which in turn causes the adrenal medulla to secrete adrenalin. This secretion causes vaso-constriction of arteries and arterioles in the non-vital areas, e.g., skin and gastro-intestinal tract, so the blood is shifted to the vital areas and the blood pressure rises. Possibly a great number of cases of incipient shock reach this stage and, owing to Nature's compensatory mechanism, do not progress any further. If the exciting causes are very severe and are either not removed or vigorously treated, the process which I have just described becomes progressively worse, the capillaries become more permeable and atonic and respond with difficulty, or not at all, to stimuli which normally cause them to contract; more plasma escapes, the blood volume and its oxygen capacity are seriously reduced, and an increased degree of anoxaemia results so that the oxygen supply to the tissues becomes inadequate and tissue anoxia develops. Tissue anoxia, by causing faulty cellular metabolism, leads to the formation of toxic metabolites which collect and further add to the capillary damage. As the process continues, the changes become more marked until the point is reached when nature has done all she can. The vascular bed is so constricted that further vaso-constriction is impossible, the damaged capillaries fail to respond to stimulating agents and become more permeable and more fluid is lost and further reduction in blood volume results. The blood pressure begins to fall rapidly and the patient is doomed. The above processes, up to a certain point, are reversible, but beyond that point they become irreversible, and no matter what therapy is instituted, nothing can be done to save the patient. The condition is really one of acute circulatory failure caused by capillary damage. To understand what is happening to the capillaries, in the light of what knowledge we have, a few words on capillary physiology and pathology are indicated. Though capillaries are microscopic vessels, they have an enormous total volume. Landis2 gives the total capillary surface as 68,000 square feet. In other words, the total surface of the capillary endothelium of an average adult is sufficient to line a pipe three miles in length and one foot in diameter. This enormous surface area makes it very easy for the passage of large quantities of fluid from the vascular system to the tissues. Any disease affecting the permeability of the capillaries may result in vast quantities of fluid leaving the vascular system in a very short time. It has been shown that if the human Page 132 M !i •11:,- ..." »*. '!!' *W fil # capillary endothelium is as permeable as that of the frogs (and there is no reason to suppose that it is not) it would be possible for the total plasma volume of man to filter through the capillary walls in a matter of 10 seconds at a capillary pressure of 10 mm. of Hg. Of course this does not happen, because under normal circumstances there are a number of forces acting to keep the fluid within the capillaries, but it illustrates how quickly fluid can leave the vascular system if some of these forces fail to act. Capillary tone is independent of adjacent arteries and veins; even an arteriolar pressure of 100 mm. Hg. fails to dilate a constricted arteriole. The capillary endothelium however is very sensitive to changes in oxygen tension and to metabolic products and apparently during normal function these agents are responsible for capillary tonus. The capillary endothelium is also very susceptible to toxins and poisons of all types, e.g., chemicals, poisonous drugs, anaesthetics, products of protein cleavage, etc. The normal response of capillary endothelium to noxious agents is: first, loss of tone, which causes the capillary to dilate, and, secondly, its permeability is increased, causing fluid to escape. According to Moon , an agent or condition which is injurious to capillary endothelium increases its permeability. The following diagram illustrates the normal rhythm of capillary blood flow, and you will appreciate the delicate control which directs the blood to the point where it is needed most and, when the needs are met, the flow to that part is shut off, thus conserving the nutriment and oxygen for those parts which need it most. Functional activity of tissues Contraction of capillaries Bloodless tissue State of rest Consumption of oxygen. Liberation of wastes Arterial blood: Nutriment Oxygen Hormone (Pit.?) fit II' Endothelial: Relaxation Dilatation Permeability Fig. 1. Normal Capillary Reaction. (After Moon3) The following table illustrates how the capillaries respond when noxious agents are brought in contact with them. Agents or conditions injurious to capillaries Capillary Endothelium Pathological results Dilation Permeability Stasis Oedema Effusions Hasmoconcentration Fig. 2. Reaction of Capillary to Noxious Agent. (After Moon3) Tage 133 hw: JK'^:!* f/kf Now, when we correlate the intimate changes which occur in of shock with those which occur in the body generally, we have picture of how shock is brought about. Figure 3 illustrates this. Neurogenic factors Neurologic lesions Emotional reactions Heat stroke (?) the capillaries in cases a fairly comprehensive Agents or Conditions injurious to capillaries Clinical Trauma, burns, surgery Intoxications Metabolic Bacterial Drugs Poisons Pregnancy Prolonged labour Intoxication Abdominal Obstructions Perforations Pancreatitis Peritonitis Thrombosis Serum sickness I Capillary Atony t \ Tissue Anoxia N Pathology \ Reduced blood volume I Reduced volume flow \ Reduced delivery of oxygen Permeability Haemoconcentration Congestion Petechiae Stasis Oedema Effusions j Haemorrhage Loss of fluid Cardiac inefficiency Myocardial coronary occlusion Endocardial valvular Functional heart block Circulatory obstruction arterial, venous Sympatho- Adrenal Hyperactivity Epinephrin Asphyxia all causes \ P! >3> f Fig. 3. Correlation between clinical occurrence of shock and its Pathological Physiology. (After Moon4) Etiology of Shock. The nature of shock is fairly well understood, but a lack of agreement exists as to its etiology. When a person receives an injury of such a nature as to cause shock, a great number of changes take place. First of all, the physical impact which produces the injury initiates a series of afferent nerve impulses which may cause marked vasodilatation. If these impulses are strong enough the person may pass directly into primary shock. Secondly, the nerve endings in the injured area are stimulated and keep up a series of depressor impulses which also act by producing vaso-dilatation and may further reduce the blood pressure (sometimes such afferent impulses raise the blood pressure). Thirdly, according to the nature and extent of the injury there will be a greater or lesser amount of fluid lost into and around the injured tissues. Fourthly, as a result of the entry into the blood stream of capillary toxins, liberated from the injured tissues, the capillary endothelium will be damaged with a resulting loss of tone and an increase in permeability. An analysis of the literature which has accumulated on this subject shows Page 134 > mw 4». .% 1 '■•■' II' I n 8-* I ill that each one of the above processes has been considered the most important cause of shock. Thus O'Shauglinessey and Sloame5 have adduced proof of the neurogenic theory. Blalock, et al.G have shown to their satisfaction that local fluid loss is the most important factor in shock. Cannon and his co-workers7 hold the theory that generalized capillary damage is the major cause of shock. A detailed criticism of the various theories concerned with the development of shock is beyond the scope of this paper. However, it may be said that a large percentage of the experimental investigations of shock are open to the following criticism: First, many of the experiments were poorly controlled; secondly, the effects of anesthesia and haemorrhage often overshadowed the development of shock; thirdly, the duration of the majority of experiments made it clear that the investigators were dealing with primary shock and not secondary shock at all. Moon8 in an effort to overcome many of these objections, devised a technique of producing shock which surmounted them. He produced shock by aseptically removing muscle from a dog, mincing it and under light anaesthesia introducing the minced muscle into the peritoneal cavity of a second dog. The dogs invariably developed shock some hours later and died 10-36 hours after implantation of the muscle into their peritoneal cavity. The dogs thus treated developed the typical secondary shock as it is seen in man. The same results were obtained with a variety of other agents which cause capillary damage. These experiments are, of course, in favour of the traumatic toxaemia theory, but they do not necessarily exclude the other factors mentioned above as being important contributing causes. Before leaving the etiology of shock, I would like to mention the part played by the adrenal cortex. Very few believe that secondary shock is due primarily to exhaustion of the adrenal cortex. However, there is a growing literature which describes the part which the adrenal cortex plays in shock and of how it may become depleted of its store of hormone, thus causing a state of exhaustion which may help to prolong shock. The physiologists have shown that an animal deprived of its adrenal cortex develops a condition which closely parallels true secondary shock, i.e., gradual fall in plasma volume, haemoconcentration, diminished blood flow, fall in blood pressure, rise in blood urea and potassium, vomiting and diarrhoea9. Selye10 found that in cases of mild shock the cortical cells of the adrenal lose their lipoid granules during the first 24 hours; later the granules reappear and the adrenal increases in weight. Weill and Brown11 have shown that following major operations the excretion of cortical hormone or cortin in the urine is greatly increased. This observation complements Selye's observations in animals. Selye and Dosne12 have shown that cortin behaves in the body as a stabilizer; an example of this is that it counteracts both the hyperglycaemia following insulin administration. It is rational to believe that if a relatively large proportion of the cortical hormone is used up a condition of cortin deficiency will develdp and aggravate the condition of the already shocked individual. How the administration of cortin influences th ecourse of shock will be referred to later. Diagnosis and Prognosis. The physician confronted with the classical pictures of shock does not need any laboratory or other help to aid him in diagnosing the condition. However, in many cases shock develops insidiously, and if the doctor is going to help the patient the condition must be diagnosed early, i.e., before the classical picture manifests itself. The earliest sign to appear is haemoconcentration. One may determine this by doing a red blood cell count, haemoglobin estimation, haematocrit determination or estimating the specific gravity of whole blood or plasma. One should test for the presence of haemoconcentration just as soon as it is suspected that shock may develop. During the development of shock the blood should be frequently checked to note the response of the patient to treatment. A patient undergoing any operation which may be followed by shock should have tests for haemoconcentration performed as soon as he reaches the ward, as this reading will serve as a check on subsequent determination. Haemorrhage which is often present in cases of shock will confuse the findings and the readings will have to Page 13 5 s- be interpreted with caution. Moon13 regards the red blood cell count as the quickest and easiest method of determining haemoconcentration and states that in cases of moderate shock, the increase in the red blood cell count is usually between 20-50%. More severe degrees of shock may be accompanied by an increase of over 100%. The increase in the red blood cell count is paralleled by similar rises in haemoglobin and haematocrit readings. Scudder14 places great reliance on blood potassium studies in shock. Potassium exists almost entirely within the cells, thus in cases associated with cell destruction or alterations in the permeability of the cell membranes will be associated with a rise in plasma potassium. Even in cases of haemorrhage, despite the dilution of the blood, plasma potassium rises. Thus it is a very useful index to shock. Scudder makes the statement that "One common denominator in the phenomena of shock, whether produced by tissue abuse, loss of fluids, haemorrhage, injections of toxins, destruction of adrenal cortex or stimulation of the sympathetic system, is a rise in plasma potassium." He noted no survivals in cases which had an increase of plasma potassium of over 100% or a decrease of over 25%. Other changes in the blood chemistry such as a rise in the blood urea, and fall in the blood sugar and oxygen carrying power are not of much diagnostic or prognostic imhportance. Treatment. Treatment in cases of shock must be instituted early; treatment should be commenced even before shock has had a chance to manifest itself. By anticipating the development of shock one can often prevent it from occurring, or if it does develop, it will be much milder and the patient's chances of recovery are ever so much increased. This fact was brought out very strikingly during the war of 1914-18, when it was shown that in a series of similar wounds, if treatment was instituted within three hours after the injury, the mortality was 11%, if the treatment was delayed 9 hours, the mortality rose to 37%, and with longer delays the mortality reached the high figure of •78%. The lesson learned from these observations can be applied to the treatment of shock due to any cause. Since shock is due to loss of blood volume, the first indication is to restore the blood to its normal volume. This, however, is extremely difficult to do. Crystalloid solutions either isotonic or hypertonic have been used without avail. Usually there is a temporary response, but the effect is very evanescent. Gum solutions, particularly gum acacia, have been used with some benefit, though often with a great deal of harm to the patient. Up to a very short time ago, the most useful agent for restoring blood volume was the transfusion of whole blood. Recently concentrated serum has been advocated for the treatment of shock, - and Best and Solandt10 have reported great success with its use in experimental shock. The use of concentrated serum is restricted because of the difficulty of obtaining it for routine use. We hope that in the near future larger amounts will be made available for general use. If treatment is to be effective, it must be started early, and as transfusion of blood is the treatment of choice, must valuable time is often lost in trying to find a suitable donor. Under the best of circumstances* usually an hour elapses between the time the pall is put in for a donor and the time the donor's blood is ready for transfusing the patient. Sometimes the time is much greater and when the blood is available the patient has passed beyond the point where it will benefit him. Of course, the patient can be given intravenous saline solutions with glucose while the search for a donor is being made, but as these solutions pass out of the capillaries so quickly the patient's tissues soon become waterlogged and the nutrition of the tissues is interfered with. Recently there have been a number of papers published on the use of serum or plasma in cases of shock and severe haemorrhage (Levinson16, Best and Solandt15, Strumia, Wagner and Monaghan17. The advantage of using serum or plasma lies in the fact that they can be used without preliminary cross matching tests; thus no time is lost and the fluid contains the serum proteins which are so necessary in holding it within the vascular system. Serum or plasma possesses a second advantage of a very practical nature in that either Page 136 i m i J|ih Hi II*.1 I* if if may be stored almost indefinitely without deterioration. In this latter respect they differ from preserved whole blood, which deteriorates very rapidly and after 11-14 days has to be discarded. In cases of shock uncomplicated by haemorrhage, plasma or serum may be preferred to whole blood, for repeated transfusions of whole blood will add to the haemoconcentration by the introduction of large quantities of cellular constituents, an extra burden will be placed on the heart due to the greater viscosity of the blood. In cases of shock with haemorrhage, the plasma or serum can be given with benefit and the anaemia treated later when whole blood is available. The efficacy of serum alone has been demonstrated very forcibly by Levinson et al.1Q. They bled dogs in successive stages, taking 30% of the calculated blood volume at the first bleeding and replacing that with an equal amount of blood serum. Then, during the next half hour, 20% of the blood volume was removed and that replaced with serum, and so on until 80% of the calculated blood volume was removed and replaced with serum. At this time the control dogs were dead, as were those which received normal saline solution, Ringer's solution and lactate solution. They also demonstrated that by still further successive bleedings 150% of the calculated blood volume could be removed and replaced with serum and have the animals survive in good condition. These experiments make it clear that serum or plasma make very good substitutes for whole blood, and I hope before long supplies of serum or plasma will be made available for hospital use. The use of adrenal cortical hormones in shock is advocated by an increasing number of investigators. Selye et al.18 has shown that administration of cortin to rats in surgical shock prevented to a great extent the hypochloraemia, decrease in blood volume, and haemoconcentration. Desoxycorticosteroneacetate, on the other hand, showed little beneficial effect. In fact, if the administration of Desoxycorticosteroneacetate were pushed, harmful effects resulted. Selye also found that in cases which were subjected to prolonged pretreatment with cortin, cortical atrophy resulted and no cululative effect longed pretreatment with cortin, cortical atrophy resulted and no cumulative effect occurred. He concluded that pretreatment was not only useless but may be definitely harmful. Pretreatment might have a place in cases which are shocked before operation but to have pretreatment prolonged interferes with the normal function of the adrenal cortex. One last form of special therapy must be kept in mind and that is the administration of oxygen. Since the oxygen carrying power of the blood is reduced in shock, a varying degree of anoxaemia is invariably present. To counteract this, oxygen must be given. This is just as important in shock as it is in pneumonia. Conclusion. In conclusion, I wish to emphasize the following points: 1. Shock is a condition frequently found in medical as well as in surgical practice. 2. It is easily diagnosed if the physician becomes "shock conscious." 3. Haemoconcentration is one of the first indications of shock. 4. Shock results from capillary damage and unless treated early a vicious cycle sets in which leads to irreversible changes and death. 5. Treatment consists in promptly restoring the blood volume, preferably by whole blood, serum, plasma or concentrated serum, as well as general supportive measures. 6. The use of cortical hormones is advocated. REFERENCES: 1. Meakins, J. C: Canadian Medical Association Journal, 43:201, 1940. 2. Landis, E. M.: American Journal of Medical Sciences, 193:297, 1937. 3. Moon, V. H.: Journal of Laboratory & Clinical Medicine, 26:117, 1940. 4. Moon, V. H.: Journal of American Medical Association, 114:1312, 1940. 5. O'Shaughnessy, L., and Sloame, D.: British Journal of Surgery, 22:589, 1935. ibid 25:900, 193 8. 6. Blalock, A., and Cressman, R. D.: Surgery, Gynaecology & Obstetrics, 68:278, 1939. Page 137 7. Cannon, W. B.: "Traumatic Shock," Appleton, New York, 1923. 8. Moon, V. H.: Archives of Pathology, 24:642, 1937. 9. Best, C. H., and Taylor, N. B.: "Physiological Basis of Medical Practice," William Wood & Co., Baltimore, 1937. 10. Selye, H: Endocrinology, 21:169, 1937. 11. Weil, P. G., and Brown, J. S. L.: Canadian Medical Association Journal, 43:8, 1940. 12. Selye, H., and Dosne, C: Proceedings of the Society for Experimental Biology & Medicine, 42:580, 1939. 13. Moore, V. H.: Annals of Internal Medicine, 8:1*633, 1934-35. 14. Scudder, J.: "Shock, Blood Studies as a Guide to Therapy," J. B. Lippincott, Philadelphia, 1940. 15. Best, C. H., and Solandt: British Medical Journal, 1:799, 1940. " Canadian Medical Association Journal, 43:206, 1930. 16. Levinson, Neuwelt, and Nicheles: Journal of the American Medical Association, 114:455, 1940. 17. Strumia, M. M., Wagner, J. A., and Monaghan, J. F.: Journal of the American Medical Association, 114:1337, 1940. 18. Selye, H., Dosne, C, Bassett, L., and Whittaker, J.: Canadian Medical Association Journal, 43:1, 1940. B. C. CANCER INSTITUTE The December meeting of the B. C. Cancer Institute was held in the Institute on the evening of January 6th. The meeting was well attended and, under the chairmanship of Dr. J. W. Thomson, papers were read by Dr. Thomson on the "General Surgical Principles in the Treatment of Cancer"; Dr. G. H. Clement on the "Surgical Principles in the Treatment of Secondary Glands in the Neck." Dr. Tchaperoff discussed the radiological aspects of the subject. Active discussion was stimulated by the presentation of these papers. The January meeting will be held on January 27th and members of the profession who are interested in problems relating to cancer are cordially invited to attend. THE DOCTOR AND HIS PATIENTS . By Arthur E. Hertzler Author of "The Horse and Buggy Doctor" Reprinted from the Abstract published in "Coronet." (Continued from January issue) When an officer of the civil law performs a marriage ceremony, he makes no pretenses of being holy but guarantees that his job is legal. It seems to me that a phonograph could be rigged up so that a nickel in the slit would pronounce the words with as much feeling as Hizzoner. A stamp could be affixed for a dime; total cost fifteen cents. That would be quite a saving for folks whose total assets are a shoestring. I think the whole scheme as followed by society is wrong. We doctors should perform the marriage ceremony. When a couple of candidates appeared before us, we could get a complete history to see what led up to the present complaint. If the young man were enamoured only of the young lady's shape, we would try to get the angle from which the view was obtained. Thus we could forecast the probable course of the marriage. Many women do not reproduce their kind. If we study this class we may find that their failure is a matter of choice, or of circumstances beyond their control. Single women fall into several groups. The most outstanding is that which enters into celibate life at an early age for religious reasons. The next group enters it without any definite avowal; most commonly where some member of the family requires care. Next is the vast army of career women, whose primary purpose in life does not fit in with matrimony and a family. The final is that group left single by circumstances. Widows should be classed here. Page 138 fi WW I? m & i *t» ■; 1 •' 'ill : ;: n"" II Many of these women accept their fate silently. What heartaches they may conceal, no one knows. But some of them become a problem for the doctor, because they find their conflict with biological forces annoying, even difficult or wholly confusing. They complain of fatigue and sleeplessness. A wise doctor understands, asks no. questions, prescribes the proper sedative and thereby makes a friend. No doctor should make a comment in such an instance. Nature is angry with them because they have failed to reproduce. The doctor should advise them to continue on their jobs with increased energy and industry. The best antidote against the sex urge at any age is work and yet more work. This applies particularly to celibate women. DREAM OF PARADISE (THE HONEYMOON AND AFTER) Love which leads to the altar is a complicated phenomenon. It carries mutual honor and respect. This implies that the parties bring to the altar a degree of civilization beyond that of the great common herd. It is a mysterious combination of a spiritual something which began as a gentle whisper, and sex. Therein lies the trouble. When I see a young couple starting on their honeymoon with no more sense than their elders, I feel like crying out to them to watch their step. I am not concerned here with cases of love at first sight which require somebody to climb out of bed at two a.m. to marry them. Tomcat stuff. The most vicious idea ever promulgated is that sex satisfied represents the pinnacle of love. The fact is, as anyone should know, love is one thing, sex another. Satiety is a dangerous thing at any stage of the matrimonial journey. It is particularly perilous because in the beginning it may cause one to fall over the cliff into the valley of disgust from which there is no rescue. Satiety loosens the temper and shows the unvarnished elements in their ugliness. Nobody but a nasty old doctor would think of such things. He remembers an instance where a bride left her newly-acquired husband at daybreak and went home to mother. "I did not know one had to do that and I'm not going to do it!" Explanations from the fond mother that everybody does it. That girl was crying for a protector. If she had been a heifer, and. I a farmer, I would have said, "Don't put her in, boys, she isn't ready yet." The shock is severe, and lasting. Even intelligent young women who are fully informed hesitate to undress before a strange man. Sure, I know how little their days as a lover will provide scenery which will help them identify the stranger without pants as the same man who last night was the lover at the garden gate. Many a home has been lost in the early days because some erotic old fool has told the bride that sex is the consummation of love. Brides now have more sense than their mothers. Even the bride has a general notion what marriage implies and is prepared to meet it. Although aversions may develop during the first night, they are usually psychic and capable of correction. An example: a womlan told me that her husband was an ideal lover; had done everything one could expect from a future husband during his courtship. To be in his arms was bliss indeed. Her thoughts did not reach beyond this; she was too happy. Had he just held her in his arms the first few5 nights, until she could have had time to realize exactly what marriage meant, which she knew theoretically of course, all might have been well. The result was a frigidity she was never able to overcome. Where was the remedy? There was none. She loathed her husband sexually but loved him as a man. He was woefully ignorant of why his bride was nervous. One thing should be particularly emphasized: if there is pain, the young bride should see her doctor and take her husband along. Most likely the! trouble is caused by a spasm of fright, and a statement of that fact, reinforced perhaps by a little sedative, will relieve it. The couple should go to the doctor together. Failure to do so might cause a fissure which will widen in the ensuing years. Page 139 Farmer boys know that before turning a cow into a lot, certain preliminary psyio- logical processes are necessary. Often I have heard brides say in spiritual agony: "If he would only hold me a while as he used to do!" She knows what she needs, but she is too embarrassed to tell her husband. I am confident that many rows start because of that great feature of our national life, the double bed. Such articles of furniture are shown to be overwhelmingly preferred by housewives in national market polls. The fundamental fact behind this preference is that many women want only to be held and loved. Certainly the ladies have a right to indicate when they want only to be held and loved, and when they want to go further. But holding, just as a manual exercise, becomes uninteresting to the husband. Double beds lead to morning indulgences, which often mean excesses. The only thought in the minds of the couple upon arising in the morning should be bacon and eggs. If we could get the word "obey" out of the marriage contracts and instead insert the provision that the bride shall always be master of her own person, the changed point of view would, I am sure, work much good. But to achieve it, the whole scheme of things must be altered. With the adjustment period comes another problem. It is vulgar for a young couple to produce a baby in regulation time. And it might be premature—as many first babies are—much to the delight of the neighborhood dowagers who scent a delicious scandal. How to have babies presents difficulties. How not to have them brings even greater problems. Societies exist for the promulgation of such knowledge. Many couples know more about it than the doctor. Here the doctor is silent; not through fear, but because the law decrees that the doctor can't know anything. Don't blame him; the laws are what people make them. The early months of the marriage, in which prevention of conception is practiced, are more hazardous than later years because complete adjustment has not yet been reached. Complicated indeed is the life of a young couple as they go forth to make a home. It seems plain that their chief trouble lies in the fact that love and sex are confused. Mutual respect is indispensable, and to this must be added love. Sex, a necessary end, is not a part of love. Excessive indulgence does more than anything else to drive love away. But the advent of a child may excite love when only sex existed before. THE STRUGGLE FOR PARADISE (THE HAPPY AMERICAN HOME) It would be pleasant for us doctors if we could assume that connubial bliss would respect the status quo. We get one factor fixed—and behold! Something else turns up. The question of children is one of the most usual causes of domestic unhappiness. Many a doctor has made a friendship that lasted until his dying day by showing sympathetic understanding and avoiding a blunt diagnosis. He tells the lady that he finds her afflicted with a slight touch of pregnancy; only slight. She may be mad at the doctor. If she is merely surprised, that is no concern of his. If really angry, she will direct her remarks in a direction which will not hurt him. But if she is frightened, the doctor can reassure her by calling attention to the fact that many women have recovered from a like condition. To couples whose wish is not anticipated by nature, a baby is desired. When denied a baby of their own, many couples seek to fill the void by adopting a child. This involves many hazards, which I do not like to discuss. If I were to adopt a child, I would insist on knowing his antecedents. How did it happen the child was placed for adoption? If this information were not forthcoming, I would play safe and buy a dog. To most couples there comes a day when their own baby arrives, and with it arrives a crisis. Only when a woman produces here own baby is there a readjustment of the endocrines. She comes out a different person than when she conceived. Many con- Pa^ 140 IT*- '» 14] i< ■'" 1 wv m M .% «« ?»< Pi jr* siderate husbands do not realize that as long as a mother is nursing her child, her sex instinct is satisfied. They need to be told. Somehow the idea is getting around that the relation of husband and wife has something to it besides procreation. Our finest couples are anxious to do the right thing by themselves and their children, and produce no more than they can properly care for. The right to limit the size of one's family has not been widely recognized. How to select the number? The average family desires two or three. If people could decide, many would have none. The most desirable families produce the fewest children; the lower classes produce big broods. Suppose I get real bold and ask what would happen if doctors were allowed to sterilize people after they have had the desired number of children? What effect would it have on the home life of the people? Occasionally I have had to rmove a tumor of the uterus, which operation leaves the patient spiritually and sexually unchanged but makes pregnancy definitely impossible. These people bloom out with a happy smile. I have seen hundreds of such women, and naturally they make an impression on a doctor's mind. The race must be perpetuated. The fates do not care whether or not married people are happy. That does not seem right. Just when people are most in need of guidance, they are left to the teaching of a fool ancestry. TRAGEDIES IN PARADISE Things are much more impressive when witnessed at two o'clock in the morning than when read about in the evening paper. Sit with a young doctor beside a girl less than fifteen years old. Through the long weary night this girl laboured to produce her child. No one was present except the husband and the doctor. To hieghten the nervousness of the doctor, a bad storm was raging and a few blocks away his own father lay dynig. The father died, alone, almost at the moment the baby was born. While in the process of delivery, the patient's husband flopped to the floor in a dead faint. The new mother, seeing this, screamed and tried to get out of bed. A large basin of bichloride solution stood on a chair by the bedside. This the doctor doused over the new papa, who at once recovered and started to crawl out of the room on all fours. As he went through the door the doctor threw his obstetrical forceps and scored a perfect hit. The man was insane, which the doctor had known a couple of years previously. Child wife, worse than a widow because her husband still lived. He had his "rights." The town slept, of course, except for the doctor. Another patient; fourteen. Labour lasting thirty-six hours. As the baby was born the mother of the patient gleefully exclaimed: "Me a grandmother at twenty-eight! Did you ever know of one younger?" I knew the proper language, and what is more I used it. The husband was an unemployed gentleman of sixteen. He took one look at the baby and disappeared. He has not been heard from since, and that was forty years ago. These are examples of what I mean by domestic tragedies happening to persons who are not morally guilty. Child marriages are hereditary, and represent the first step toward sex murders. Most of the men in these cases are sexually irresponsible. Society looks on, helplessly. To the pervert, the sex fiend, the hopeless moron, sterilization is a protection. To sterilize, it is necessary only to clip a tube no larger than a knitting needle. The patients are still free to exercise all their lustful functions. But they cannot produce children. On the other hand, outright castration means the removal of sex glands, and all desire, in most cases. If one wanted to lessen human suffering, he would be doing these patients a service by castration. It would relieve them of an eternal urge that nearly, sometimes actually, drives them insane. Page 141 t**- Common tragedies in large families result from this cause. Some member of the family might be far from normal. A man whom I had known for many years angrily declared that his wife had had a baby which was not his, because he was impotent. I tried to convince him that his notion of impotency was all in his mind. But he established a good case for himself. I knew he was a man who believed his Bible from "kiver to kiver," so I tried the immaculate conception idea on him. To my mind he rejected it categorically, declaring that both he and I knew better. As a final effort I reminded him that people catch diseases from public closets, and they might catch pregnancy the same way. The possibility appealed to him. As he arose to go, he remarked: "Do you reckon it could have been one of them New Deal fellers?" I assured him it could not, because that bunch were too impotent for any good. He was satisfied. Some of these incidents are doubly tragic, because many of them could have been prevented. Even if not preventable, the suffering might be lessened if those about them would extend a sympathetic and helping hand instead of leaving the entire problem to the doctor. PARADISE LOST (HELL WITH THE LID OFF) When a farmer introduces a gentleman cow and a lady cow, at the invitation of the lady, and afterward the gentleman goes off and eats grass quite disdainful of the lady's charms, the farmer makes a record in his book and calls it a day. The farmer does not say when he introduces the two that it "is for better or for worse." He has studied his blood lines and he knows it will be for the better. Just because Ferdinand goes off into the south pasture and eats grass in a pout, the farmer does not have a moral fit and call it a divorce. He knows Ferdinand will be back for the same reason he was present in the first place. The stock breeder uses intelligence because he knows he must. The humans receive no attention at all from persons of intelligence. All they get is an assurance that the husband and wife become legally single again following the fracture of the marriage bonds. Whether or not a mumbled ceremony preceded the honeymoon does not alter in the least the biological nature of the transaction. A learned judge tells me that nine-tenths of the divorce cases in his court have a biological basis. I think doctors could sure some of it. We doctors, if handed this divorce problem, would compile case-histories and facts. We would inquire into the premonitory signs. That is, disturbances which occurred before the patient knew he was sick. "When did you first feel that you were in love? When did you first feel that you were in love? When did you first notice the object of your affections? Was it cleverness on her part or her cute shape which first upset you?" To the girl, I would ask only one question: "How high did the water splash when you fell in?" Questions establish causes. "Which one of you first verbally kicked the other in the face? When did you first hear of the word 'incompatibility,' and what does it cover?" and a lot of other pertinent questions. "In the second place," one would inquire, "have you ever seen an incompatibility pill, and calculated its diameter, and compared that with the diameter of your esophagus? Suppose it got stuck and you could not get it up or down? Suppose it tastes worse than you expect?" Then we would hand them a list of previous cases. These reports would cause the patients to pause a second, which would do more good than all the weeping and arm- waving. "Here are the terminal results of the last thousand cases I operated on. Look here—what they wrote down as 'freedom' turned out to be only a delusion." Quite likely the patient would say: "Gosh, they're all failures. Even though my marriage may be a failure, divorce is a greater one. I believe I will try bromides a little longer." Page 142 I m m : i It II i • ■ fi m P" Hl.; Imagine where surgery would be if we operated on a patient just because he says he is sick, without any inquiry as to whether he really is sick, or as to how he came to be sick, and then forgot him as soon as the wound was sutured. As old age approaches, we take a renewed interest in sunsets. To the observant old doctor, among the most beautiful pictures about us are the serene old couples who have fought life's battle together. Try as we may, we cannot control the outcome. We can only steel ourselves to take what comes, and hope that our own sunset is beautiful. We have in old age the last leg of the tripod which holds the hope of a new world. The first is the love of a child who knows only love, not sex. Next the love of a single woman who shows us sex can be sublimated in a noble cause, and now finally love which comes after sex as such has died. When one observes an old couple gradually fading into the beyond, with nothing to bind them but that fine sentiment which seems to be but a return of the love of a child, he sees the highest state of which man is capable. Leave me a picture of the mother and her child; a picture without lust; one which reveals the humanizing effect of suffering and love, and I can construct for you, and myself, the outlines of a real Christian civilization. REPRINTS... The Roy Wrigley Printing & Publishing Company Ltd. will have the type standing on all articles in The Bulletin until the 25th of the month of issue, and will furnish reprints at the following prices: Reprints With Cover 100—4 pages 200— $ 8.00 10.00 11.25 13.50 15.25 23.50 es _ $10.75 12.00 15.50 19.75 20.00 27.50 Reprints Without Cover 100—4 pages $ 4.25 200— " 300— 400— 500— 1000— 100—8 pa 200— 300— 400— 500— 1000— 100—16 pages $12.00 300— 400— 500— 1000— 5.25 6.25 6.75 7.50 11.75 100—8 pages $ 6.50 200— 300— 400— 500— 1000— 8.00 9.25 11.00 12.75 19.25 100—16 pages $ 9.00 200— 300— 400— 500— 1000— 16.00 19.50 22.50 23.25 32.00 200— 300— 400— 500— 1000— 10.50 12.00 13.50 15.00 21.00 Roy Wrigley Printing & Publishing Co. Ltd. 300 WEST PENDER STREET Phone: SEymour 6606 Page 143
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: February, 1941
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