CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
'The Osler Lecture ; Laboratory bulletin.' -- Title page
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Patient Types: | THE HOSPITAL CASE Confined to the bed, weak and nervous the hospital patient under your care is hardly a fit subject for the old-fashioned drastic purge. Petrolagar has many advantages in maintaining bowel function. It is palatable. It mixes easily with bowel content, supplying unabsorbable moisture with less tendency to leakage. It does not interfere with digestion and is prescribed in preference to plain mineral oil. Petrolager restors normal peristalsis without causing irritation, producing a soft-formed consistency that provides real comfort to bowel movement. Petrolagar is composed of 65% (by volume) mineral oil with the indigestible emulsifying agent, agar-agar. Felrol agar Petrolagar Laboratories of Canada Ltd. 907 Elliott St., Windsor, Ont. Dept. V.M. 10. Gentlemen:—Send me copy of "HABIT TIME" (of bowel movement) and specimens of Petrolagar. Dr Address 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 and Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Dr. J. M. Pearson Dr. J. H. MacDermot Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the abovj address. Vol. VI. APRIL, 193 0 OFFICERS 1929-30 Dr. T. H. Lennie Dr. G. F. Strong Dr. W. S. Turnbull President Vice-President Past President Dr. E. M. Blair Dr. W. T. Lockhart Hon.-Secretary Hon. Treasurer Additional Members of Executive:—Dr. W. A. Dobson; Dr. A. C. Frost. Trustees Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson Auditors: Messrs. Price, Waterhouse & Co. SECTIONS Dr. J. R. Davies Dr. S. H. Sievenpeper Dr. A. M. Menzies. Dr. R. E. Coleman Physiological and Pathological Section Eye, Ear, Nose and Throat Dr. F. W. Brydone-Jack Chairman Dr. N. E. McDougall Secretary Physiotherapy Section Dr. H. R. Ross Chairman Dr. J. W. Welch . Secretary Pediatric Section Dr. C. F. Covernton . Chairman Dr. G. O. Matthews Secretary Library Dr. C. H. Bastin Dr. Wallace Wilson Dr. S. Paulin Dr. D. F. Busteed Dr. W. H. Hatfield Dr. D. M. Meekison Dinner Dr. W. T. Ewing Dr. W. A. Gunn Dr. L. Leeson Rep. to B. C. Med. Assn. Dr. A. Y. McNair VANCOUVER HEALTH DEPARTMENT STATISTICS, FEBRUARY, Total Population (Estimated) Asiatic Population (Estimated) 1930 Total Deaths . Asiatic Deaths Deaths—Residents only Birth Registrations Male 167 Female 170 INFANTILE MORTALITY— Deaths under one year of age Death Rate per 1,000 Births Stillbirths (not included in above)- Rate per 1000 of 218 20 190 337 240,421 9,355 population 11.82 27.93 10.30 18.27 22 65 7 .28 Cases of Contagious Diseases Reported in City January, 1930 Cases Deaths Smallpox Scarlet Fever Diphtheria .. _ Chicken-pox Measles Mumps Whooping-cough ! Typhoid Fever Tuberculosis uj Poliomyelitis Meningococcus Meningitis- Erysipelas 20 37 99 3 40 28 1 22 0 0 9 0 ■ "0"-1 1 0 0 0 0 0 25 0 0 0 February, 1930 Cases Deaths 3 21 30 62 30 39 16 0 0 11 0 0 3 0 0 '■' i' fr<K 18 ~& 0 Ma to 15 Cases 2 4 14 17 5 25 18 2 10 0 1 2 rch 1st th, 1930 Deaths 0 0 0 0 0 0 0 0 0 0 0 Say it with Flowers Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs, Roots, Wedding Bouquets. Florists' Supplies and Funeral Designs a Specialty Three Stores to Serve You: 48 Hastings St. £. 665 Granville St. 151 Hastings St. W. One Phone: Seymour 8033 Connecting all three stores. Brown Bros. & Co. Ltd. VANCOUVER, B. C. Page 13 8 /ol aefheiatinja- Aeat im/Ai/i tAe tissues N?^h $ Anything short of major calibre in a diathermy machine will prove disappointing. The Victor Vario-Frequency Diathermy Apparatus is designed and built to meet every requirement. 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Limited Montreal 412 St. Sulpice St. A STUDY OF A PERSONAL SERIES OF HYSTERECTOMIES AND MYOMECTOMIES Being the Osier Lecture delivered before the Vancouver Medical Association, March, 1930, by Dr. J. J. Mason Mr. President and members of the Vancouver Medical Association: It is a little over 16 years since I was accepted as a member in this Society. It seemed fitting that, after having honour upon honour bestowed upon me during that membership, culminating in the request to deliver the Osier Lecture, I should render an account of my stewardship, in some particular at least, in the class of work that I have been engaged in. With this in view I have reviewed every hysterectomy and myomectomy done since I came to Vancouver, in all 379 cases,—this does not include cases in which small myomata were shelled out in the course of an operation for other pelvic pathology—and tonight I propose to discuss the surgical technique of these operations and some of my end results. It goes without argument that before an operation be undertaken a complete written history of the patient should be obtained by the surgeon, and a complete examination, with a written record of every system, should be made. If there be the slightest doubt of these findings, an internist should be asked to survey the patient or, if necessary, help obtained by a specialist in the system that needs clarifying. If teeth, tonsils, or other pathology need attention, and the case be not urgent, by all means let it be done before the major undertaking. If the blood be low from prolonged or severe haemorrhage a blood transfusion should precede operation. A tentative diagnosis eshould be made and written down and a diagram made of the supposed pathology. The decision to operate should only be arrived at after careful study of all elements in the case. The same pathology in one patient may be treated best by surgery, and in another by non-surgical measures, depending upon many factors that are discovered during the history taking or general examination. Be careful of the woman who is very anxious to have an operation. Again, in the case that is obviously hopeless, hesitate. A famous surgeon once said that he liked the patient to do her own dying. If the case be deemed operable the preparation of the surgeon is worth considering. To get good results in any branch of clean surgery we must have an aseptic conscience. The care of the hands, with the avoidance of contamination with infective discharges, should be a matter of daily concern. The preliminary scrub of the surgeon is often poorly done, the elbows are not reached and he walks from the scrub room to the operating theatre with hands low, getting the drip and the run-down from the contaminated elbow region. The apron is splashed with water and a sterile gown put over it which remains sterile only as long as the drops of water do not wick through from the apron. Strict technique in scrubbing and proper masking of the operating room personnel is necessary. These and many other points are elementary but all make for clean surgery. The strength of the chain of surgical technique is only as strong as its weakest link. The anaesthetic is worthy of consideration. We used to follow Crile's anoci association technique, but recently we have used only inhalation with occasionally local, and never spinal, anaesthesia. Fortun- Page 139 ately in Vancouver we have an excellent corps of anaesthetists who relieve us of any worry in that branch of the operation. Ether plus oxygen, or nitrous oxide with ether or chloroform, plus oxygen, have been variously used at the discretion of the anaesthetist. If any of you have not seen intra-tracheal ether used in a difficult case you have a surprise coming when you note the relaxation obtained. Preliminary morphine and atropine are given unless contra-indicated. The routine surgical technique we adopt is as follows. As soon as the patient is wheeled into the operating room she is put in stirrups in the lithotomy position with the hips at the end of the table and vulvar and vaginal preparation is done with equal parts of tincture of iodine and alcohol on swabs held by an artery or dressings forceps, paying attention to the folds in the vagina and vulva. The bladder is catheterized with a soft rubber catheter. A bimanual examination is done and the pre-operative diagnosis confirmed or disproved. A weighted vaginal speculum is placed in position and the cervix drawn down for inspection. If there be difficulty in drawing down the cervix by means of a tenaculum on the cervix, a toothed forceps on either side of the broad ligament close to the cervix, a manoeuver of Curtis', will bring it lower. The cervical canal is iodized with a cotton applicator. If a diagnostic curettage -be indicated it is done and the pathologist's opinion immediately obtained. If a biopsy be indicated and has not been previously done, a section is taken with the scalpel being careful to get the section to include, if possible, normal and abnormal tissue. The cut area is immediately cauterized thereby avoiding any risk of dissemination if cancer be present. If it be decided to operate from below, the operation is then done. If the operation be done from above, the patient is released from the lithotomy position and prepared for the abdominal operation. The surgeon re- scrubs and is gowned and re-gloved. We wish to urge in all cases, even if it has been definitely decided to operate from above that the surgeon do this preliminary examination under the anaesthetic. It fortifies or disproves pre-operative diagnosis, it empties the bladder, and it surgically prepares the vagina and lower cervix which are always contaminated. It takes but a few minutes, the patient does not need to be draped, nor the surgeon gowned. If a vaginal hysterectomy be indicated the routine technique is as follows. The cervix is drawn down. The anterior vaginal wall is grasped with thumb forceps about midway from urethra to cervix in the median line and the vagina cut through with scissors which are then insinuated, first above towards the urethral meatus and the anterior vaginal wall incised, and then backwards to the cervix, extending this incision which now circumscribes the cervix. The vagina is stripped off the bladder and the bladder off the uterus. The peritoneum in the anterior cul-de-sac is opened and an exploration of the fundus uteri made with the finger. The fundus is then drawn through this anterior peritoneal opening by successive bites with towel forceps curved on the flat. The round ligaments are separately tied and clamped and cut on both sides, then the rest of the broad ligament on the one side and then on the other side, the uterus being removed. If one wishes, long straight forceps can be applied on each broad ligament from above and from below close to the uterus, after first opening the posterior cul-de-sac, the Page 140 — so-Called Mayo technique. The round ligaments are first sutured together, the peritoneal cavity closed and the broad ligaments tied or sutured together. Whatever plastic on the vagina is indicated is then done. The sutured round and broad ligaments are usually sutured to the subpubic tissues, especially if it is felt wise to support the bladder. Drainage is practically never used. If only a vaginal myomectomy be indicated and that myoma be present on the fundus, the anterior vaginal wall is alone incised without circumscribing the vagina around the cervix. The routine abdominal operation on the uterus is as follows: The patient is placed in a fairly high Trendelenburg position. The surgeon stands on the patient's left and the incision is made from the pubes to the navel or above, one-half inch to one inch to the left of the median line. Bleeding points are caught and tied with No. 0 plain catgut, taking care not to grasp more tissue in the forceps than is necessary. Towels are clipped around the skin edges. The anterior sheath of the left rectus is incised well down to the pubes taking care not to injure the pyramidalis. The inner edge of the rectus sheath is stripped off the rectus to the linea alba and vessels from the muscle to the sheath clamped in two places, cut and tied. The rectus is then drawn over to the left exposing the posterior rectus sheath and peritoneum. We try to avoid grasping the anterior fascia with artery forceps both on entering and leaving the abdomen as wherever a clamp is placed a potential necrotic area is produced, inviting infection. The posterior sheath and peritoneum are carefully opened. At times the upper ends of the deep epigastric vesels require clamping and ligaturing. As soon as the peritoneum is opened, if the patient be well anaesthetized and in good position, air rushes into the cavity carrying the intestines toward the upper abdomen. The gallbladder, liver, foramen of Winslow, pylorus, kidneys and appendix are quickly examined. The pelvis is carefully palpated and the uterus delivered or grasped with the surgeon's left hand and held up and forward while the tubes and ovaries are visualized. The bladder is orientated as well as the sigmoid and rectum. If a pack be required care should be taken that it is not too hot, that it is moist, and the omentum should be pulled down over the intestines placing the pack on the omentum, thereby traumatizing less the intestine. Self-retaining retractors are practically never used. Good anaesthesia, a resourceful assistant, a long incision, the Trendelenburg position, all help to render superfluous the need of self-retaining retractors which must injure the tissues. Gentleness and strategy overcome many difficulties in the surgery of the abdomen and render the patient more comfortable later. All adhesions must first be separated, keeping close to the uterus and working down and out. A proper orientation is ever necessary. If a myomectomy be indicated place the uterine incision, if possible, so that there will be something to peritonize it. In the anterior wall the bladder can be mobilized easily and used, or, if necessary, the round ligaments can be stretched to cover the incision. In the posterior wall it is a little more difficult but the sigmoid can often be used to advantage. In doing a myomectomy the incision is deepened to the myoma and enucleation done, endeavouring to tie the feeding vessels- and to approximate the walls with catgut, chromic No. 1, only tying tight enough to close all dead spaces. If the endometrium be opened it should first be closed. A Page 141 button-hole suture of chromic catgut No. 1 closes the uterine incision with, at times, the sacrifice of some of the peritoneal flap and a running suture peritonizes all. It is surprising what large myomata may be removed, preserving the uterus to the patient's great advantage. If the myoma be in the broad ligament enucleation can first be started by splitting the broad ligament between the round ligament and Fallopian tube. If the myoma be low down the bladder should be mobilized early to prevent injury. In doing uterine surgery the position of bladder and ureters must constantly be kept in mind and if there be doubt the ureters must be demonstrated. For years we have given the patient methylene blue gr. 5, p.o., the day before the operation as a guide in case of injury to bladder or ureters. Fortunately so far we have never seen blue. It is a continuation of a suggestion of Crile who used to use it preliminary to hernia operations. The routine technique for a panhysterectomy and the removal of both tubes and ovaries is as follows. The surgeon elevates the uterus with his left hand and it is first, of course, taken for granted that all adhesions have been separated, and the assistant retracts the right abdominal wall. The surgeon elevates or puts on stretch the right infundibular pelvic ligament and with a No. 2 chromic gut suture on a Kelly needle he first catches the peritoneal edge of this ligament and then transfixes the broad ligament below the ovarian vessels, finding a clear space to pass the needle. The vessels are tied with the ligament lax. The right round ligament is next similarly handled. A hysterectomy clamp is next placed at the uterine cornua extending down to the clear space below the appendages and the round ligament and broad ligament are cut through. If the tumour be large and the infundibular ligament difficult to put on stretch, or the vessels difficult to visualize, a finger is shoved through underneath the ovarian vessels and forced through the anterior part of the ligament first above and then below the round ligament and the vessels and round,- ligament separately clamped, cut and tied. We endeavour, if possible never to transfix a vessel with a needle, thinking that thereby we lessen the risk of embolism and phlebitis, and make our field of operation easier to work in. Ligatures are left long on the round ligament and usually on the ovarian vessels. The anterior reflection of bladder on to uterus is cut across and the left appendages similarly dealt with. The bladder is stripped down well on to the vagina. At times it is necessary to clip a few fibres in the centre line. One cannot separate this anterior flap too superficially as fortunately the bladder always shoves off with this peritoneal reflection. This separation is extended far enough out on either side to carry the ureters out of harm. The loose tissue along the side of the uterus is clipped down to the uterine vessels which are always seen and felt before tying or clamping. The posterior reflection is then less easily stripped down. If the hysterectomy be done for carcinoma the uterine vessels are tied well outside but with first a definite view of the course of the ureter. If there be no cancer the uterine vessels are clamped in two places and cut between. Bearing in mind the blood supply of this lower lateral uterine area, a clamp is placed from before backwards on either side, taking in these vessels. The fascia surrounding the cervix is then carefully cut through with the scalpel using the two cornual uterine clamps to elevate the uterus and the latter is Page 142 MM gradually shelled out until the vagina appears. This is opened and the cervix circumscribed, placing clamps on the opened vaginal wall in front and behind in order to prevent any spill from the vagina which is often full of blood that has been squeezed out of the uterus in the previous manipulations. At times it is necessary to place one or two forceps on bleeding vaginal vessels. The lateral clamped lower uterine or upper vaginal vessels are tied and the vagina closed with a No. 1 or No. 2 chromic gut. The cardinal vessels, uterine and ovarian, are all doubly tied. The ligaments are sutured into the stump of the vagina after first being sure that all oozing has been completely controlled and the vaginal stump and opened broad ligaments are completely peritonized, by means of a pursestring suture of No. 1 chromic gut on a Kelly needle. All pads are accounted for, any clots removed, the sigmoid tucked back into the cul-de-sac, omentum drawn down, and the abdominal wall closed. If a supravaginal hysterectomy be done the endometrium lining the cervical canal may be removed. The stump of the cervix should be mattressed carefully in order to prevent opening later when the catgut absorbs, with possible post-operative haemorrhage about the tenth day. We always save the ovaries and tubes if healthy and a good blood supply can be maintained to the ovary, no matter what the age of the patient, unless the uterus be malignant or questionably so. We practically never drain through the vagina, always closing it snugly but being careful to see that no oozing is left to produce a haematoma. In closing the abdominal wall we endeavour to keep the peritoneal edges rolled out using a running suture of No. 1 chromic gut coming back uniting the muscle to the linea alba and tying at the starting point. A doubled No. 1 chromic gut closes the fascia, a No. 0 plain gut the superficial fascia and skin clips the skin. We never use stay sutures. We endeavour to deal gently with all tissues, avoiding clamps on muscle or fascia, knowing that devitalized tissue is a potentially infected tissue, avoiding too tight sutures, making rigid haemostasis, etc. During the operation the anaesthetist gives submammary saline or saline and glucose. Post-operatively, if necessary, we give an intravenous of 10% glucose and if necessary a blood transfusion. In doubtful cases where the patient has lost much blood before coming into hospital she is pre-operatively transfused, or grouped, and o donor chosen ready to transfuse as soon as the operation is over. Our post-operative care is very simple. Morphia is ordered p.r.n. for two or three days. The Trendelenburg position is followed for 12 hours. The catheter is used only if necessary, but often enough to avoid overdistention, and if it has to be used it is continued after the patient voluntarily voids, once daily, immediately after voiding, until the residual urine is less than half an ounce. An enema is given on the third to the fifth day and every two days thereafter. The clips are removed on the seventh day and the wound overstrapped. Headrest is given on the eighth to the tenth day and the patient allowed out of bed usually on the twelfth day. Following a suggestion of Walters, for some years we have been using thyroid extract, beginning the third day and continuing until the patient leaves the hospital, as a preventative of embolism. The patient is examined in the office one month after operation and as often later as necessary. Cancer cases are watched carefully for years. Page 143 Page 144 — < I O i m CO Miss D. Mason acknowledges indebtedness to Spalteholz "Anatomy," and Kelly Noble's "Gynacology" in Figs. 1—6. Page 146 We have classified the pathology that necessitated the operation under the following heads. (a) Myomata, with complica tions including adenomyo- mata (b) Cancer of Cervix Uteri (c) Cancer of fundus uteri in cluding one case of Deci- duoma (d) Chronic infective uteri which included cases where curet- tings or biopsy were suspicious or cases associated with chronic infected appendages, etc. (e) Fibrosis uteri (f) Complete inversion of the \ uterus ) (g) Purpura 175 cases requiring hysterectomy 73 cases requiring myomectomy 22 cases 18 cases ?! 86 cases 3 cases 1 case 1 case (A) Hysterectomy was done in 175 cases for Myomata Uteri. The vast majority of myomata uteri require no treatment. To urge surgery for a symptomless myoma is reprehensible. That a small myomatous uterus is more likely t obecome malignant than a normal uterus we doubt very much. There was no instance of sarcomatous degeneration in this series of cases and Dr. Harry Pitts tells me that only once in his series at the Vancouver General Hospital has he encountered sarcomatous degeneration in a fibroid. We have had one case of sarcoma of the cervix uteri but in that case no myoma was present. The association, however, of carcinoma of the cervix or body is more common, but not more so than one would find in otherwise normal uteri. The fear of carcinoma starting in the remaining cervix where a supravaginal amputation has been done, we believe, is real. For years, in doing the supravaginal operation we coned out the cervix thoroughly, carefully mattres- sing the stump. A few post-operative haemorrhages about the tenth day, when the catgut softened and the cervical ring sprang apart requiring a suture of the cervix per vaginam, have modified our technique. At present, if the cervix be not absolutely normal we do a pan-hysterectomy wherever feasible and, if not we cauterize the cervix thoroughly either before, at, or after the operation. If the cervix be coned out a more resisting catgut should be used. We advise radium or X-ray treatment for myoma in women (1) who are surgically handicapped and who cannot be made safe risks; (2) who are near the menopause where a diagnostic curettage has eliminated cancer; (3) where there is no submucous myoma which may be breaking down; (4) where there is no appendage disease and (5) where the tumour is not larger than a four months' pregnancy. With the present safety and thoroughness of surgery we believe that radiological measures should be placed on the defensive. To radiate young women and thereby destroy the gonads is no better than the old treatment of thirty years ago, bilateral oophorectomy. We wish to report briefly two cases where originally the patient Page 147 was in good shape for surgery but after ineffective radiation the hazard was greatly increased. (1) Mrs. , aet 46. Fifteen years before she had had a partial bilateral oophorectomy for excessive bleeding. Recently X-ray treatments had been taken without benefit. The operation was extremely difficult because of marked infiltration and excessive vascularity extending through the abdominal wall and involving the broad ligaments, bladder and intestine. (2) Mrs. , aet 52. We saw her two years before with a prolapsed myomatous uterus, bleeding excessively, and advised a vaginal plastic and pan-hysterectomy. Six months after radium she came back complaining of increasing weakness and pain and a very offensive uterine discharge, as well as her regular prolapse. She said she was ostracised by her family because of the discharge. At operation the peritoneum, bladder, uterus and tubes were very oedematous with pus dripping from the congested tubes. A marked odour was noticeable as soon as the abdomen was opened. In stripping off the bladder necrotic areas filled with pus were uncovered in the uterine wall. Naturally the operation was extremely hazardous, but she made a good recovery. In young women with symptom-producing myomata a hysterectomy is seldom necessary. A myomectomy is usually possible. In this series of cases we seldom found an uncomplicated myoma. The common complications were old salpingitis and oophoritis, endometriomata of the ovaries, papillary cysts of the ovaries, infected cervices, tuberculous salpingitis, parovarian cysts, prolapsus uteri, red degeneration of a myoma with occasional necrotic areas in the centre of an old degenerated tumour, carcinoma of the cervix and body and a fairly frequent association with gall-stones. Myomata are often associated with pregnancy but seldom act as a complication. If the myomata be low down in the early months nature usually carries them away from the lower segment as the pregnancy advances. In only one case in this series was the pregnancy sacrificed. Mrs. , aet 42. Examination showed a huge myomata extending half way between the ensiform and the umbilicus. She was running a temperature of 101, had acute pain (a red degeneration taking place), and a pregnancy of a couple of months' duration riding on the very top of the myoma. The cervical canal was fully 12 inches long. In two cases an inguinal hernia was repaired from the inside by withdrawing the sac and pursestringing the opening. Surgical sequelae in this series of hysterectomies for myomata ended in three deaths. In detail: (1) Mrs. , aet 36. Operation November 18, 1921. Examination showed myomata uteri extending to the umbilicus with a parovarian cyst, size of an orange, undergoing papillary degeneration. Supra vaginal hysterectomy and bilateral salpingo-oophorectomy were done, a very easy operation. Convalescence was normal until sudden exitus from pulmonary embolism on the seventh day. Post-mortem findings showed a clean abdomen, slight haemorrhage in the muscular layer of the abdominal wall and pulmonary embolism. (2) Miss , aet 53. Operation May 7, 1928. Two years after the menopause she had slight uterine bleeding and noticed the abdomen Page 148 enlarging. Examination showed multiple myomata extending to the navel and a small suspicious nodule in the right breast. At operation cholelithiasis and a dermoid cyst of the left ovary, very adherent to the sigmoid ,as well as the large adherent myomata were found. Supravaginal hysterectomy and left salpingo-oophorectomy were done. Much post-operative vomiting and distention with dilatation of the stomach requiring lavage supervened, with exitus one week later. Post-mortem findings showed carcinoma of the breast, cholelithiasis, fatty infiltration of the liver, slight haemorrhage in the cul-de-sac, likely from the sigmoid, intestinal distention but no definite obstruction and no evidence of peritonitis. The pathologist gave intestinal toxaemia as the likely cause of death. (3) Mrs , aet 57. Operation October 30, 1929. Menopause at 45. Recently she complained of a blood stained uterine discharge with much pelvic distress. Examination showed a large woman, blue lipped, dyspnoeic, oedematous, with four plus albumen in the urine, plus sugar, triple plus W.B.C., a blood pressure of 90/218 and multiple myomata packed tight in the pelvis and extending almost to the navel. She was referred to an internist who hospitalized her and after a few weeks had her sugar free with albumen down to two grams to the litre and blood pressure 90/160. He advised against surgery. She was allowed home but her pelvic distress was marked and she and her husband urged radical measures. In the meantime the blood stained vaginal discharge had recurred. At operation multiple myomata undergoing calcareous degeneration and a very adherent tubo-ovarian cyst were removed. The operation was without incident and quickly and easily done. Her heart began to race shortly afterwards, stupor developed and exitus of cardiac origin occurred four days later. This case should not have been operated but I know of no other treatment that would have helped. From the standpoint of morbidity there was very little of moment. There was one case of incisional hernia in a woman, Mrs. A. W., aet 46, stout, with a previous history of lues, who was given an enema the first night post-operative, without orders, causing the patient marked strain. The hernia was later repaired and a cholecystectomy done for cholelithiasis. One woman, Mrs. — —, aet 40, six months after operation developed a primary (apparently) carcinoma of the lung. Another case, Mrs. , aet 54, developed an infarct in the right lung with pneumonia following, but she later made a good recovery. A Mrs. , aet 62, for whom a vaginal hysterectomy, along with a genital plastic was done for bleeding myomatous prolapsed uterus on June 1, 1921, developed carcinoma of the stomach in 1925. (1) Miss , the evening after operation, got out of bed and walked across the ward without untoward incident. (2) A Mrs. — —, six years after a vaginal hysterectomy for myoma and prolapse, came back complaining of slight vaginal bleeding of one month's duration. A small granulation was present at the vault of the vagina, easily destroyed by the cautery with the patient in the knee-chest posture. Page 149 Night or Day, Sundays or Holidays, graduate pharmacists at Macdonald's Prescriptions are ready to supply emergency items from the largest and most complete stock of pharmaceuticals in Western Canada* ©fl© Ulac&malu1'! Medical-Dental Building criphons RINITY 6226 OPEN ALL NIGHT TWO SPEEDY MOTORCYCLES Free delivery from 8 a.m. to 11 p.m. PUBLIC HEALTH S2 BIOLOGICAL PRODUCTS Diphtheria Antitoxin Diphtheria Toxin for Schick Test Diphtheria Toxoid (Anatoxme-Ramon) Scarlet Fever. Antitoxin Scarlet Fever Toxin for Dick Test Scarlet Fever Toxin Tetanus Antitoxin Anti-Meningitis Serum Anti-Pneumococcic Serum (Type 1) Anti-Anthrax Serum Normal Horse Serum Smallpox Vaccine Typhoid Vaccine Typhoid-Paratyphoid Vaccine Pertussis Vaccine Rabies Vaccine (Semple Method) CONNAUGHT LABORATORIES University of Toronto TORONTO 5 - CANADA ill (3) Mrs. — —, at examination previous to operation showed a large hydronephrosis of the left kidney due to an impacted myoma in the pelvis. Six months later pyelography showed the kidney almost normal. (4) Mrs. , aet 74, showed only bladder symptoms, and a diagnosis of stone in the bladder had been made by the X-ray. Cystoscopy negatived this diagnosis and at operation a calcareous myoma was found which had buried itself in the bladder wall. It was easily removed. (5) Mrs. , aet 54, operation February 12, 1926, showed coincident myomata uteri and carcinoma of the cervix uteri. Pan-hysterectomy and bilateral salpingo-oophorectomy, with cauterization of the opened edges of the vagina from above, has so far prevented a recurrence. (6) Mrs. — —, aet 4, complained of profuse menses for 12 years. She showed Hgb 30% and a red cell count of 2,500,000. A submucous myoma was removed per vaginam on January 11, 1929, with improvement for a couple of months. Then there was recurrence of bleeding. At operation there were dense recent adhesions with about a half ounce of thick pus in the cul-de-sac below an adhesion of the rectum to the uterus. The rectum was as thick as the wrist and all tissues were very friable. The cause of the infection was apparently a so-called abdominal 'Flu' one month before the operation which the patient did not mention until later. A supra vaginal hysterectomy and bilateral salpingo-oophorectomy were done. Proctoscopic examination a few months later showed a polypus or granulation the size of a bean at about the recto-sigmoidal juncture which was easily removed by the cautery through the proctoscope. Pathological examination showed it to be innocent. She has been well since then. (7) Miss , aet 44, operation March 9th, 1929, came in for advice, complaining of constant bleeding for six weeks. The cervix was open with a submucous myoma presenting. On general examination we discovered a lump in her breast of which she was unaware and which had the appearance of carcinoma. We thought the myoma could be easily removed per vaginam but encountered marked adhesions and did a hysterectomy from above and at the same sitting a radical breast amputation. The pathologist confirmed the diagnosis. She made a normal convalescence. Cholelithiasis is a frequent accompaniment of myomata uteri. Occasionally a cholecystectomy is done with the hysterectomy bus usually it is reserved for a later operation. It is a common finding when palpating the gall-bladder during a pelvic operation to find it very tense, so tense at times that it feels as if a little more pressure might cause it to rupture. Often these gall-bladders are free of adhesions with the foramen of Winslow open. Are they all pathologic? We do not think so, as many of these women, when carefully quizzed, have no symptoms. We have occasionally been impressed with the disparity in size of the two kidneys as if one kidney did most of the kidney function. We have not noticed any marked difference in the post-operative subjective menopausal symptoms in women of forty or over when the ovaries have been left or removed. In younger women, where hysterectomy is necessary, there is no question that the ovaries should be left if the case be not malignant. If the Fallopian tubes have to be removed we are careful to preserve the blood supply to the ovaries by making the amputation close to the tube. Vaginal hysterectomy is done in the cases associated with prolapse where Page 150 ■■Mi extensive vaginal plastic is required and the tumour is not too large to remove from below. During this same period of 16 years there were 73 myomectomies performed without mortality or morbidity. The incidence of pregnancy following in these cases is small, five, but many of these cases were in unmarried women or women in or near the forties where there was prejudice against losing the uterus entirely. A few were done in older women in association with operations for vaginal prolapse where we wished to save at least some of the uterine body for a support for the bladder. (B) Hysterectomy was done in 22 cases for carcinoma of the cervix uteri. The gynaecologist meets the terrible scourge of cancer only too frequently. For some reason or other we seldom see carcinoma of the cervix uteri in its early stages. There is nothing more depressing in our work than to see an otherwise healthy woman present herself with the history of irregular vaginal bleeding and on bimanual examination to feel the characteristic irregular nodules which are so hard to describe. In early carcinoma of the cervix, although seldom seen, we believe that radical surgery will give better results than radiological measures. We are aware fully of the excellent statistics reported by some Radium Clinics and we will all agree that radical surgery is absolutely out of place in the vast majority of cases when first seen. However, in the early cases that often require a biopsy for diagnosis we believe that radical hysterectomy with cauterizing of the vaginal incision from above will protect the patient better than radiological measures. In the borderline case, or advanced case, radium at times seems to be life-saving. In this series of cases we have in a few attempted what we would now say was doomed to fail, being persuaded to do a radical operation by physicians who have not had what they thought was sufficient benefit in similar cases treated by other means. If a radical operation has been done inspection of the vault of the vagina should be- carried on for years. If a granulation shows it should be cauterized or radium placed against it. We will briefly review this series of 22 cases. They were without operative mortality. There was marked morbidity in one case, Mrs. , aet 28, who was operated January 25th, .1927. She had been bleeding for four months and had a pre-existing old pelvic infection with the cervix studded with pus sacs. The cervix was very large and nodular, but not breaking down, and clinically we did not think it was malignant. Section showed carcinoma and surgery was chosen instead of radium on account of the old infection. A pan-hysterectomy was done cauterizing along the course of the ureter on the left side where infiltration was taking place. After operation the abdominal wound broke down and later a uretero-vaginal fistula formed with rapid extension of growth in the pelvis, uninfluenced by radium or X-ray. This case should not have been operated but any other treatment would have been equally ineffectual. She lived about 18 months. Of the other 21 cases 14 are alive but four have been operated in the last two years and are not safe, nor for that matter are the others safe. A few of these cases are worthy of comment. (1) Mrs. , aet 45, operation May 15, 1922, had her menopause at 33. She had been bleeding for two months before examination. The cervix was nodular with a bleeding area, the fundus was small and Page 1 51 movable. Biopsy was not definite. A pan-hysterectomy was done and the pathologist reported both adenocarcinoma of the body and epithelioma of the cervix. She has since had a cholecystectomy done for cholelithiasis and empyema of the gall bladder. On June 30, 1926, she presented a definite recurrence in the scar, at the vaginal vault, which radium cleared up magically. Intensive prophylactic X-ray exposures have followed. Examination last week showed no evidence of the disease. (2) Mrs. , aet 53, operation May 30, 1922, had been bleeding for seven months. She had the menopause seven years before. The cervix was as large as an orange with one gland in the left broad ligament. Wertheim hysterectomy was done with cauterization of the vaginal incision. She was well until early in 1929 when an obscure upper abdominal illness caused her death. A post-mortem was not made but very likely a metastasis occurred although pelvic examination was negative. (3) Mrs. , aet 38, operation September 18, 1922, at examination showed the anterior lip of the cervix occupied by a bleeding cancer. Radical operation was done with cauterization of the vaginal incision. Some years later a radical breast amputation was done. She is now in good health. (4) Mrs. — —, aet 46, operation October 15, 1923, had been treated with radium six months before outside the city for an early carcinoma of the cervix. It recurred and a radical operation was done. Recent examination shows no exidence of the disease. (5) Mrs. , aet 63, operation April 14, 1924, showed on examination the posterior lip of the cervix destroyed with carcinoma and extension down the posterior or vaginal wall for fully one inch, all freely movable. Radical operation was done. Examination recently shows negative findings. (6) Mrs. — —, aet 37, was operated May 3, 1926. She presented herself at the office with an early cancer of the breast which was radically removed and on general examination a suspicious cervix was encountered that had not given her any symptoms. A biopsy, at the time of the breast operation, disclosed carcinoma. Radical operation was done and she is now well. (7) Mrs. , aet 50, had a pan-hysterectomy May 15, 1928. Twelve years before we had operated on her for pus tubes which were causing an arthritis that cleared up after the tubes were removed. Examination showed a nodular bleeding cervix with biopsy positive for carcinoma. She is still normal. She had never been pregnant. (8) Mrs. , aet 52, operation September 14, 1926, had had a trachelorrhaphy and suspension some years before with negative pathological findings in the cervix. Examination showed carcinoma involving the right lip of the cervix and expending to the vaginal wall. Panhysterectomy with cauterization of the vaginal incision was done. Examination January 14, 1930, was negative. We would have liked to have presented a record of all the cases of carcinoma of the cervix that we have seen but the labour involved was too great at the present time. (C) Hysterectomy was done for carcinoma of the fundus uteri in 18 cases with no operative mortality. Three later died of a recurrence Page 152 « and we think the remainder are still alive although there are two cases we have been unable to trace. A few cases are worthy of comment: (1) Mrs. , aet 74, operation June 19, 1924, had been bleeding for one year, on and off. Diagnostic curettage showed adenocarcinoma. A pan-hysterectomy and bilateral salpingo-oophorectomy were done without untoward incident. Fairly recent examination shows her well. (2) Mrs. , aet 49, operation June 8, 1925, pan-hysterectomy and bilateral salpingo-oophorectomy being done. Diagnostic curettage showed adeno-carcinoma. She developed acute lobar pneumonia, postoperatively, but under the care of an excellent internist recovered and, we think, is now well. (3) Mrs. , aet 52, operation October 15, 1926, pan-hysterectomy and bilateral salpingo-oophorectomy being done. She had been treated outside the city 18 months before for bleeding uterus, by radium and X-ray. The bleeding still continued. Examination showed the cervix absorbed and blood coming from the interior of the uterus. Pathological examination showed extensive adenocarcinoma of the fundus. December 14, 1927, a definite nodule was felt in the left vaginal fournix. Radium absorbed it and examination a few weeks ago shows no evidence of metastases although I feel sure there will be later. (4) Mrs. , aet 37, operation March 21, 1927, is the only operative experience we have had with deciduoma malignum. She had one child in January, 1923. Her menses had been normal and were regular on December 26—30, 1926. There was a stain on January 2, and a few clots and a stain followed for three weeks. After that no staining. She presented herself at the office saying she had a recurrence of the cystocele for which we had operated some years before. Examination showed apparently a suburethral cyst, the size of a Japanese orange, prolapsed out of the vagina. The uterus was forward and enlarged to the size of a two months' pregnancy, and felt so. She also showed a cyst in the right lobe of the thyroid gland. On March 11, the anterior vaginal wall was incised and an apparent haematoma was enucleated in which were three cyst-like bodies the size of a small grape. Dr. Allen McNair reported deciduoma malignum. On March 21, ten days later, a pan-hysterectomy was done. The uterus was filled with a mass of chorionic cysts. The pathological report was hydatidiform mole which had become malignant and the microscopic appearance of the tumour was duplicated in the small haemorrhagic tumour removed from the vaginal wall and which could be safely assumed to be a metastatic tumour. She is now well. On only one occasion previously was hydatidiform molar pregnancy radically treated, thinking to find deciduoma and in that case it was absent. The teaching that a hydatidiform mole is of great potential malignancy is not borne out by our cases treated conservatively, for in fully 18 cases this is the only one in which metastasis occurred. (5) Miss , aet 50, operation May 7, 1927, had had irregular bleeding for two years previously. Examination was difficult on account of a stricture of the vagina. Under anaesthetic the stricture was dilated and a diagnostic curettage showed adeno-carcinoma. Pan-hysterectomy and bilateral salpingo-oophorectomy was followed by intensive X-ray treatment. She is still well. Page 153 (6) Mrs. , aet 54, operation March 18, 1929, pan-hysterectomy and bilateral salpingo-oophorectomy being done. She had the menopause three years before and now had had irregular bleeding for three months. Diagnostic curettage showed adeno-carcinoma. The pathologist reported fibromyoma as well as carcinoma. She was well on December 9, 1929. In doing a hysterectomy for carcinoma of the fundus, and for that mater in all uterine surgery, care should be taken that tenaculae be not placed in the uterine wall. It also goes without argument that in all radical uterine cancer surgery the liver must be first proved to be free from metastasis. (D) Hysterectomy was done in 86 cases for so-called precancerous lesions and in cases associated with chronic metritis, with chronic infective lesions in the pelvis. There were two deaths in this series, both of which I feel, should not have occurred. It was impossible to obtain post-mortem in either case but we will present briefly their case history and operative findings. (1) Mrs. , aet 36, was operated on December 30, 1927. This was the only pan-hysterectomy death. On examination she presented a bleeding eroded cervix with a left lateral tear and a fixed retroverted uterus. A pan-hysterectomy and appendectomy were done. The pathologist reported chronic endocervicitis, endometritis and chronic appendicitis. She developed distention and vomiting which, however, subsided. The wound was clean. The pulse kept rapid and mental symptoms developed. She told her friends before operation that she was going to die. To our minds it was likely a peritonitis, but where from we do not know, as autopsy was refused. (2) The other case was Mrs. — —, aet 42, operation February 4, 1929, at which supra vaginal hysterectomy and left salpingo-oophorectomy were done for irregular bleeding and odorous leucorrhoea. The pathologist reported hyperplasia endometritis and a luteal cyst of the ovary. She developed distention, the abdominal wound did not heal and opened and had to be resutured. The cervix opened and bled. Blood transfusion improved her but distention continued and she died two weeks post-operative. Autopsy was refused. Both cases had possibly some peritoneal contamination. There were also two cases in this series that required suturing the cervix from below, 10 days later, for bleeding from the stump. They later did well. The remaining cases recovered without any untoward incident. Many of the cases were for lesions that the pathologist thought were malignant, or potentially malignant, but which later examination proved to be inflammatory. Five cases were associated with tuberculous salpingitis, one was an old infected ectopic and one was associated with cancer of the ovary. (E) Hysterectomy was done in only three cases of so-called fibrosis uteri, as these cases, uncomplicated, are more safely treated and with less distress by radium, which is 99% efficient. (F) Hysterectomy was done in one case of inversion of the uterus, which bears comment. Mrs. — —, aet 37, operation November 11, 1928, a supravaginal hysterectomy being done, saving both tubes and ovaries. Delivery took place November 5, 1928, at 11 a.m. Labour was Page 154 slow, associated with inertia. Marked post-partum haemorrhage followed and the vagina was packed and repacked. On the morning of operation, when we first saw the patient, there was a complete inversion of the uterus. Haemoglobin was 42%, 2,000,000 red blood cells, blood pressure 40 70. At operation from above, after vaginal preparation, and after ineffectual atempts at reduction from below, a unique picture presented itself. The tubes and ovaries were inverted as well into the uterine funnel. The uterus was reinverted by using the round ligaments as tractors and after one of these tore off, the cornua of the uterus was caught with tenaculae and gradually reduced. The uterus was markedly congested and the peritoneum was cut and split in many places, potent sources for intestinal adhesions and obstruction, even if the disabled uterus did not develop infection, so a supravaginal hysterectomy was done, and the patient recovered without incident. (G) The case designated purpura should not have been done. Mrs. — —, aet 41, operation July 20, 1922, under local anaesthesia, a supra vaginal hysterectomy being done. She had a haemoglobin 18%, and 637,500. red cells, 2,000 leucocytes with 20% polys and 80S lymphs, even after three transfusions on July 2, July 17, and July 19. She bled from every cut surface and died that night. A discussion of our records in which we have done hysterectomy and myomectomy. There were 115 panhysterectomies, including 24 vaginal hysterectomies with a mortality of 1, a percentage of .87. There were 191 supra vaginal hysterectomies with a mortality of 5, a percentage of 2.6. There were 73 myomectomies with no mortalities. Totalling 379 cases with a mortality of 6, a percentage of 1.58. This lecture would not be complete without a few minutes' contemplation of some of the attributes that made Sir William Osier the most brilliant and best loved physician of his age, if not of all time. Under the early influence of a saintly mother he learned to respect divine and natural laws. Biblical teachings moulded his early life. He could well say with Sir Thomas Browne "there are two books from which I collect my divinity, besides that written one of God, another of His servant nature, that universal and public manuscript, that lies expansed unto the eyes of all; those that never saw Him in the one have discovered Him in the other." The world's classics were his everyday companions. He always kept before him the 'master word'. He expressed himself to the university students in Toronto, at the time of the amalgamation of Trinity and Toronto Universities, as follows,—"I propose to tell you the secret of life as I have seen the game played and as I have tried to play it myself. It is the open sesame to every portal, the great equalizer in the world, the true philosopher's stone which transmutes all the base metal of humanity into gold. With the magic word in your heart all things are possible. The miracles of life are with it. It is directly responsible for all advances in medicine during the past twenty-five centuries. And the master word is Work, a little one, as I have said, but fraught with momentous consequences, if you can write it on the tables of your heart and bind it on your forehead." Morley, the famous English historian, Page 155 to a similar audience in the same city, gave vent to a similar exhortation when he said "Believe me when I tell you that the thrift of time, in future years will reward you with an usury of profit beyond your fondest dreams, but that the waste of time will alike dwindle you in moral and intellectual stature beyond your darkest reckoning." His powers of observation he constantly cultivated, keeping a notebook ever ready. During his last illness with pneumonia and empyema, he daily recorded his symptoms and signs. When Sir Thomas Horder was called in consultation Osier handed him the daily record of the case to date. He was ever a 'public health crusader' focussing the public mind on the terrors of typhoid and tuberculosis and the means of prevention. His contributions to medical literature were voluminous. Many of his medical writings are classic as literary contributions apart from their scientific worth. His public addresses to nurses, students and nonmedical bodies will be often quoted in future years. There is one attribute that stands out very prominently in his life and that is his constant attendance at medical meetings and his loyal support of local, national and international societies. He preached the value to the individual practitioner, the general profession and the public of a local medical society and a library. Permit me to quote from his address to the profession at Nottingham, England, when opening their new Club and Library,—"How common the experience to enter a cold, cheerless room in which the fire in the grate has died down, not from lack of coal, not because the coal was not alight, but the bits, large and small, falling away from each other, have gradually become dark and cold. Break them with a poker, get them together and what a change in a few minutes. There is light and heat and good cheer. What happens in the grate illustrates very often the condition of the profession in a town or county. Singly or in cliques the men have fallen apart, and as in the dead or dying embers there is neither light nor warmth, or the coals may be alive and bright, but covered with the ashes of discord, jealousy and faction. Like the poker bringing the elements together the medical society is the most important single factor in the promotion of that unity and good fellowship which adds so much to the dignity of the profession. " He loved the young physician. As Harvey Cushing writes: "He became the friend of all he met. He knew the workings of the human heart metaphorically as well as physically. He joyed with the joys and wept with the sorrows of the humblest of those who were proud to be his pupils. He stopped to lift them up to the place of his royal friendship and the magic touchstone of his generous personality helped many a desponder in the rugged paths of life. He achieved many honours and many dignities, but the proudest of all was the unwritten title of 'the young man's Friend'. The spirit of Sir William Osier walks among us now and will continue to do so as long as we as individuals and as an Association respect divine and natural laws, hold close to the master word, keep our powers of observation keen, our records full, render to the community our best endeavours in matters pertaining to public health and continue loyal and helpful to the rapidly increasing number of young physicians who are in our midst. With his spirit amongst us we can have no fear of the future of our profession. Page 156 British Columbia Laboratory Bulletin Published irregularly in co-operation with the Vancouver Medical Association Bulletin, in the interests of the Hospital, Clinical and Public Health Laboratories of B. C. Edited by A. M. Menzies, M.D., of The Vancouver General Hospital Laboratories Financed by The British Columbia Provincial Board of Health COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital, Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New "Westminster; Royal Inland Hospital, Kamloops; Tranquille Sanatorium; Kelowna General Hospital; and Vancouver General Hospital. All communications should be addressed to the Editor as above. Material for publication should reach the Editor not later than the seventh day of the month of publication. Vol. IV. APRIL, 1930 No. 3 CONTENTS Controlling Scarlet Fever Outbreak Ootmar Why Do We Examine Urine? (Continued) Matheson Co-operation is the Keynote of Success. This is true in laboratory work as well as in other lines of endeavour. Just as a physician may find it next to impossible to diagnose and treat disease successfully unless he has the fullest co-operation of his patient, so also a laboratory may find it next to impossible to give satisfactory results unless it has the fullest co-operation of the physicians requiring specimens to be examined. Fortunately most physicians realize that hospitals and laboratories are established mainly for one purpose, viz.: for the proper diagnosis of disease in, and treatment of, the patient; and this being also their own object, they are always read to co-operate with such institutions in working towards a common objective. On the whole, there are very few misunderstandings between physician and laboratory, but in a large institution almost daily are found potential causes for such difficulties, and it is only by careful checking on • the part of a competent and experienced staff that many serious errors are avoided. Any rules and regulations regarding the examination of specimens at the laboratory, are made, not with the object of working a hardship on anyone, but with the prime object of more accurate and uniform results, leading to the best treatment of the patient. We wonder if physicians realize how much unnecessary time may be taken up in the laboratory when specimens are received in an improper manner, with requisitions improperly made out or perhaps no requisition, label, or mark of identification at all. We often wonder also, if physicians appreciate fully the efforts that are put forth by the laboratory, in order to give a satisfactory service during the whole 24 hours of each day. As concrete suggestions we shall give a few simple rules, which, if followed, would assist materially in accuracy and efficiency at the laboratory. SUGGESTIONS 1. Make out a requisition, preferably on the regular laboratory form, for each specimen to be examined. 2. Write legibly on the requisition, giving all the details possible. Page 157 3. Use the proper containers fo rsending specimens to the laboratory, e.g., sputum bottles for sputum. 4. Make requirements fit in, as far as possible, with the period when the largest number of the laboratory staff is on duty (i.e., in the Vancouver General Hospital, from 8 a.m. to 4 p.m.), avoiding Saturday afternoons, Sundays and holidays. Real emergencies of course will be taken care of at any time. 5. If a doctor wishes a report given to a patient or some one other than his deputy, he should always send a note to this effect or phone to the laboratory, as no such information is given out from the laboratory without the doctor's order. NOTE—Sputum bottles, agglutination outfits, sterile swabs, tubes, slides, etc., may be obtained at the laboratory at any time without charge. CONTROLLING SCARLET FEVER OUTBREAKS By Dr. G. A. Ootmar Medical Health Officer, District of Kelowna, B. C. The recent epidemic of scarlet fever in Kelowna, which was stopped short by the immunization clinics which the Provincial Board of Health allowed us to organize, did not give us many cases to study; but two years ago an epidemic of scarlet fever in the district, gave us valuable experience about the haemolytic streptococcus. We found that swabs taken from tonsils and posterior nasopharynx, showed the haemolytic streptococcus, while swabs from the palate and buccal mucous membrane were free from this organism. In November, 1929, a case of scarlet fever was reported to me, and swabs from the throat showed haemolytic streptococci. A single finding of haemolytic streptococci in the throat certaintly does not allow a diagnosis of scarlet fever, as the same organisms are also found in anginae and pharangitides. But the repeated finding of haemolytic streptococci is certain proof that clinches the diagnosis of scarlet feveri while the disappearance of the haemolytic streptococci in two or three successive swabs proves that the case no longer is infectious. In practice, we did not release a child from quarantine until the throat swabs were negative on two successive occasions (culturing on blood agar plate, plus 5% horse serum). On the other hand, if haemolytic streptococci are not found, this is certainly against a diagnosis of scarlet fever. Up to the present, we do not know of any ready method to differentiate between the scarlet fever streptococci and the ordinary haemolytic streptococci. But it might be of interest to record that in cases where the haemolytic streptococci were found, and the patients confined to bed or room, it took much longer to get the throat clear, than when the patients were allowed to be outside. It might be ,perhaps, that reinfection takes place, and if so, it would be interesting to investigate as to whether or not children in isolation hospitals would remain positive for a longer period than those nursed at home, where chances of reinfection are so much smaller. During our immunization experiences against scarlet fever there were some occurrences which I think important enough to be mentioned. We performed the Dick test on 1,3 89 children and adults. Out of these tests, 804 were found to be positive. There were three cases in Page 158 «us which, during the inoculations, the child fell ill with sore throat, fever, rash; all symptoms which may occur in individuals markedly susceptible to scarlet fever toxin. But in these cases, haemolytic streptococci were repeatedly found in the throat. The Dick test which had been positive some weeks before, was now negative. Were these scarlet fever symptoms and the change in the Dick test due to the one or two inoculations against scarlet fever? If so, it would be reasonable to suppose that others who did not have any clinicial symptoms from the injections and had one or two inoculations would have turned negative too; but eight of such children were again given the Dick test and were found to be still positive. The repeated finding of haemolytic streptococci and the change of the Dick test from positive to negative suggest that, during the inoculations, cases of scarlet fever occurred, although of a very mild type. Perhaps the mildness of the attacks were due to the partial immunization induced by the few inoculations. WHY DO WE EXAMINE URINE? By J. E. Matheson, M.B. Vancouver General Hospital Laboratories. In the February issue of the B. C. Laboratory bulletin an article appeared on urinalysis. In that article I mentioned two general reasons for examining urine; the first being to determine the functional ability of the kidney and to determine the presence of lesions, if any, in itself or along the urogenital tract. The urinary findings in such conditions were given. The other reason for examining urine is to determine the functional ability of other organs of the body; organs that produce a change in the urine without a pathological change necessarily being present in the kidney, i.e., diabetes, etc. True, in many diseases, abnormal and even pathological materials are found in the urine; and the continued presence of such substances may, and frequently does in time, cause pathological changes in the kidney itself. But there are conditions, e.g., diabetes mellitus, in which the main lesion is in another organ of the body (pancreas), and results in the appearance of sugar and other substances in the urine without gross and severe lesions being present in the kidney. Sugar is, without doubt, the most usually encountered abnormal content of urine that occurs .as a result of disturbance of function of an organ other than the kidney. One must not forget that there does occur a condition, renal diabetes, in which the sugar found in the urine is not a result of altered metabolism but the result of a lowering of kidney sugar threshold which allows sugar to escape even with the blood sugar level within the normal range. In true diabetes, however, the kidney threshold for glucose tends to rise. In severe diabetes, acetone bodies also are encountered in the urine. These substances result because of the failure of the body to completely reduce the fat to carbon dioxide and water, the process being halted at an intermediary point, at which the reduction has only proceeded to that of these acetone bodies. In the normal body the bulk of the aceto-acetic acid is oxidized to acetic acid and carbonic acid and then further to carbon dioxide and water. The diabetic is unable, in part or even entirely, to complete the last two steps of fat metabolism mentioned. Page 159 In primary disease of the liver or disease associated with the biliary tract with obstruction to the flow of bile, bilirubin and biliverdin appear in the blood and subsequently in the urine. Unless the amount of bile in the tissues is extremely small it can always be demonstrated in the urine. The polyuria one encounters in those cases of internal glandular secretion disturbance of the pituitary gland is of importance in differential diagnosis. Other facts ascertained, historical and physical should remove any doubt from one's mind. The examination of the urine is of importance in differentiating acute yellow atrophy of the liver from phosphorus poisoning. In the latter, the urine is highly acid and concentrated. Leucin and tyrosin crystals usually found in acute yellow atrophy are seldom seen in phosphorus poisoning. Ureau and uric acid, although low at first, rise to normal again in cases of phosphorus poisoning. Of the other poisonings which one sometimes sees, the abnormal findings in the urine are usually the result of toxic damage to the kidney proper, e.g., mercurial poisoning. The presence of albumin, tube casts, etc., can be demonstrated. Here it might be well to mention those cases showing an abnormal constituent of the urine, namely albumin, found consistently in pathological urines but not having, in this particular type of patient, the same clinical significance that is usually -attached to it. There do occur a few cases in which large amounts of albumin are found in the urine in apparently healthy people, particularly adolescent males. These cases have been discovered accidentally and the condition given a variety of names because of inadequate and unsatisfactory explanation, e.g., orthostatic, essential, physiological albuminuria. Albuminuria and other urinary abnormalities without tube casts are of importance in the differential diagnosis of still other conditions, e.g. myocardal degenerations. One recalls that the secretion of urine depends on, among other things, the pulse pressure. It is obvious that, in a case, say of auricular fibrillation, with poor cardiac output and consequent inadequate pulse pressure, the urinary secretion will be low. Any one of the many conditions with heart failure may show albuminuria, and the microscopical examination of the urine rules out primary disease of the kidney. In febrile conditions, albumin is not infrequently encountered. I do not refer to the albumin encountered in such conditions as scarlet fever where the albumin is associated with a definite lesion of the kidney. The majority of albuminurias in febrile conditions are not the result of associated kidney conditions, and recovery is complete. Only a small percentage show the late pathology of a pale granular contracted kidney. Many other conditions cause slight degrees of albuminuria, for example, goitres, burns, cirrhosis of the liver, obstruction to the portal circulation or inferior vena cava, and numerous tumours in or associated with organs of the peritoneal cavity. From time to time we pick up extraordinary and uncommon abnormalities in urine. Recently the Bence-Jones protein was demonstrated in urine from a case of multiple myeloma. However, these are rather in the class of medical curiosities, and as such have not the same importance as the routine test. Page 160 a?iu5r|iSi* ^rifi/MmtfM <!&££?, INSURED AGAINST IMITATION The Antiphlogistine Container in its present form, was adopted after years of painstaking research. Drawn of special alloyed metal with neither seams nor joints and hermetically sealed by an easily removable metal cap and ring, it maintains the hygroscopic potency of its ingredients and preserves them against deterioration even under the severest climatic conditions, and on the other hand, it furnishes a distinctly convenient method for heating the contents. Rigid laboratory control guarantees uniformity of therapeutic action. That more and more doctors are today turning to Antiphlogistine is convincing proof that it meets the exacting requisites of the modern practitioner for a safe and efficient poultice and dressing. THERE IS ONLY ONE Beware of inferior substitutes! The Denver Chemical Mfg. Co., 153 Lagauchetiere Street, W., Montreal. Dear Sirs: You may send me, free of all charges, one trade size package of Antiphlogistine for trial purposes. M.D. Address - City State 536 13th Avenue West Fairmont 80 Exclusive Ambulance Service FAIRMONT 80 ALL ATTENDANTS QUALIFIED IN FIRST AID "St. John's Ambulance Association" WE SPECIALIZE IN AMBULANCE SERVICE ONLY R. J. Campbell J. H. Crellin W. L. Bertrand VITAMIN D (Antirachitic, antispastic) ... In concentrated form Cod-liver Oil contains more vitamin D than any other natural available product, but always in association with vitamin A and, of course, with the characteristic taste of the oil. Now a synthetic vitamin D preparation is available—one that has only the physiologic effect of this particular vitamin. It is II1 ■' |H VIOSTEROL in Oil -100 D This product has 100 times the vitamin D potency of high-grade cod-liver oil. It is administered by drops instead of by spoonfuls; is bland and tasteless; can be mixed with different foods. A suitable dropper is supplied with every package. The dose ranges from 10 to 20 drops (3 to 7 minims) a day, or in exceptional cases 25 or possibly 30 drops. Specify on your orders and prescriptions: "Parke, Davis &. Co.'s Viosterol in Oil--100 D." I I PARKE, DAVIS & COMPANY WALKERVILLE, ONTARIO WINNIPEG. MANITOBA MONTREAL, QUEBEC j You Physicians Who Play Golf, You KnowThere's aClubforEvery Stroke [LMOST any player can swing around the course with a single club, dubbing drives, lifting fairway sods and bringing home a century mark or more for the final score. But the finished golfer needs a club for every shot—a studied judgment of approach or putt before the club is selected. Similarly in artificial infant feeding. For the normal infant, you prefer cow's milk dilutions. For the athreptic or vomiting baby, you choose lactic acid milk. When there is diarrhea or marasmus, you decide upon protein milk. In certain other situations, your judgment is evaporated milk. Dextri-Maltose is the carbohydrate of your choice for balancing all of the above "strokes" or formulae and aptly may be compared with the nice balance offered the experienced player, by matched clubs. To each type of formula (be it fresh cow's milk, lactic acid milk, protein milk, evaporated or powdered milk), Dextri-Maltose figuratively and literally supplies H the nicely matched balance that gets results. MEAD JOHNSON & CO. of Canada, Ltd., Belleville, Ont. Rest Haven Sanitarium and Hospital MARINE DRIVE, SIDNEY, B. C. (Near Victoria) (Visited by Qualified Physicians) Semi-Private Wards Surgical Wards Private Rooms Maternity Wards Rates as low as $21.00 Weekly. Beautiful for situation. For further information apply to: MEDICAL SUPERINTENDENT, SIDNEY, B. C or the Manager Miss R* A* Backett, r, n. Masseuse Rooms 503 - 504 Birks Building Phone Trinity 2004 Sun Ray with Quartz Lamp Cabinet Baths and Shower Swedish or Weir Mitchell Massage Specializing in Physio-Therapy Patients may be visited in homes (Qualified Physicians invited to visit) —— ~H«©^ aStf-»~ Hollywood Sanitarium LIMITED tyor the treatment 0} Alcoholic, Nervous and Psychopathic Cases Exclusively ''Reference ~ ^B. Q. ^Medical ^Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Seymour 4183 Westminster 288 w®«= ?I«V
Periodicals
W1 .VA625
English
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Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: April, 1930
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