CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
'Osler lecture ; Narcotic drug act ; The Kahn test.' -- Title page
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PETROLAGAR (DESHELL) IS ADVERTISED ONLY TO PHYSICIANS Petrolagar (Ptaii) No 1 Blue Label The palatable emulsion of pure mineral oil and agaragar is indicated in the ordinary cases of constipation and as a follow up in severe cases when -Petrolagar Phe- nolphthalein has been previously used. Petrolagar (Phenolphthalcin) No. 2 Red Label Phenolphthalein % gr. to the tablcspoonful, is indicated in severely constipated individuals who have used drastic purgatives. We recommend reducing to Plain after one or two bottles. Petrolagar {Alkaline) No. 3 Green Label Contains magnesia calcined and is indicated in hyperacidity and acidosis, and is extremely useful in gastric ulcer where constipation is present. Useful in Pyorrhea and acid-mouth. Petrolagar (Unsweetened) No. 4 Brown Label Indicated for those who do not like sweets and may be prescribed safely for Diabetic patients. It is bland like the other numbers- and while unsweetened, is unusually palatable. The principle of lubrication and bulk calls for the usage of Petrolagar Plain in all cases unless special considerations indicate one of the other forms. Deshell Laboratories of Canada. Limited, Dept. V., 245 Carlaw Avenue, Toronto, Canada. Please send without obligation, copy of Habit Time and samples of Petrolagar. Dr. Address _"* Page Two THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the Interests of the Medical Profession. Offices: 529-30-31 Birks Building. 718 Granville St., Vancouver, B. C Editorial Board: Dr. J. M. Pearson Dr. J. H. MacDermot ' Dr. Stanley Paulin All communications to be addressed to the Editor at the above address. VOL. 2. APRIL 1st, 1926 No. 7 Dr. J. M. Pearson Auditor Dr. A. C. Frost OFFICERS, 1925 -26 Dr. J. A. Gillespie President DR. A. W. HUNTER Past President Vice-President DR. H. H. MILBURN Secretary Treasurer Dr. G. H. Clement Dr. a. B. Schinbein TRUSTEES Dr. W. F. Coy Dr. W. B. Burnett Representative to B. C. Medical Association Dr. A. J. MacLachlan SECTIONS Clinical Section DR. W. L. Pedlow .--... Dr. F. N. Robertson Physiological and Pathological Section DR. C. H. Bastin - ' -_ Dr. C. E. Brown - Eye, Ear, Nose and Throat Section Dr. Colin Graham ...... Dr. E. H. Saunders Genito-Urinary Section Dr. G. S. Gordon ...--. Dr. J. A. E. Campbell Physiotherapy Section Dr. H. A. Barrett - Dr. H. R. Ross - Chairman Secretary Chairman Secretary Chairman Secretary Chairman Secretary Chairman Secretary COMMIT PEES Library Committee Dr. Wallace Wilson Dr. A. W. Bagnall Dr. W. D. Keith Dr. W. F. McKay Orchestra Committee Dr. F. N. Robertson Dr. J. A. Smith Dr. L. Macmillan Dr. A. M. Warner Dinner Committee Dr. G. F. Strong Dr. W. A. Dobson Dr. L. H. Appleby Credit Bureau Committee Dr. Lachlan Macmillan Dr. D. G. Perry Dr. G. A. Lamont Credentials Committee Dr. Lyall Hodgins Dr. R. Crosby Dr. J. A. Sutherland. Summer School Committee Dr. G. S. Gordon Dr. Murray Blair Dr. w. D. Keith Dr. G. F. Strong Dr. H. R. Storrs Dr. R. Crosby I ii wm VANCOUVER MEDICAL ASSOCIATION. Founded 1898. Incorporated 1906. Programme of the 28th Annual Session 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 p.m. Place of Meeting will appear on Agenda. General Meetings will conform to the following order:— 8.00 p.m.—Business as per Agenda. 9.00 p.m.—Paper of Evening. 1926. APRIL 6 th— General Meeting. Urological Evening. DRS. B. H. CHAMPION, G. H. Clement, G. S. Gordon, and A. W. Hunter, APRIL 20 th- "Problems in Urological Diseases." ANNUAL MEETING. CITY HEALTH DEPARTMENT. VANCOUVER, B. C. STATISTICS — FEBRUARY. 1926. Total Population (estimated) Asiatic Population (estimated) Total Deaths 135 Asiatic Deaths 19 Deaths (Residents only) 102 Total Births—Male, 114 Female, 120 234 Stillbirths—not included in above 5 INFANTILE MORTALITY— Deaths under one year of age 20 Death Rate per 1000 Births 85.5 CASES OF INFECTIOUS DISEASES REPORTED. 128.366 10,100 Rate Per 1000 of Population per Annum 13.7 24.5 10.4 23.8 January Cases Deaths Smallpox 2 0 Scarlet Fever . 10 0 Diphtheria 20 1 Chicken Pox 8 0 Measles 10 0 Mumps 19 0 Erysipelas 2 0 Tuberculosis 18 9 Whooping Cough 2 0 Typhoid Fever , 1 0 February. 1926 Cases Deaths 0 18 25 30 11 281 1 6 7 0 Cases from Outside City- Diphtheria Smallpox Scarlet Fever - Typhoid Fever -included in above: 5 1 3 1 0 0 4 0 5 1 0 0 0 0 1 0 0 0 1 7 1 0 0 0 0 0 March lsf to \5th 1926 Cases Deaths 0 0 5 0 9 1 30 0 4 0 167 0 3 0 6 2 6 0 0 0 0 0 0 0 Page Four Imminently 'Practical Because of its acknowledged leadership physicians and engineers who have de' vised improvements in X'ray apparatus automatically submit their ideas to the Victor organization first. If these improvements are incorporated in Victor apparatus the roentgenologist knows that they meet a real want and the searching clinical tests to which all Victor apparatus is submitted. It has never been the Victor policy to adopt a principle or an improvement simply because it is new or different. There must be a need for it. Thus is to be explained the eminently practical character of Victor X'ray apparatus. that they have successfully withstood VICTOR X-RAY CORPORATION: 2012 Jackson Blvd., Chicago, III. 33 Direct Branches—Not Agencies—Throughout U. S. and Canada VANCOUVER: VICTOR X-RAY CORPORATION OF CANADA, LTD. 910 Birks Building J ^ XrRAY Diagnostic and Deep Therapy ^Sr Apparatus. Also manufacturers . L of the Coolidge Tube A \z PHYSICAL THERAPY High Frequency, Ultra'Violet, Sinusoidal, Galvanic and it. Phototherapy Apparatus EDITOR'S PAGE. In this issue of the BULLETIN we present to our readers the annual Osier Lecture delivered before the Vancouver Medical Association by Dr. E. D. Carder. The subject chosen this year was "The Thymus," and as will be seen recent researches in this still uncertain region have been ably set down pro and con. The lectureship itself was established some years ago in memory of the late Sir William Osier, who took, we like to think, a special interest in our Society, of which he was long an honorary member. While Sir William, as far as we know, never visited this portion of Canada, not infrequent letters attest this interest and an occasional material contribution was of manifest assistance in the early and struggling days of the young Association. To recall to memory these specific benefactions, as well as those more general in which we, in common with medicine the world over participate, and to give to later adherents living interest in his work and personality, are some of the reasons which led to this foundation. Notwithstanding the exceptional recognition of his services which was bestowed on Osier during his lifetime, he has left the world still his debtor. Considerable natural ability and immense industry were combined with a generosity in distribution remarkable even among a profession esteemed unusually generous. We note with interest a recent editorial in the Journal of the Canadian Medical Association, discussing the possibility of the erection of a permanent memorial to Osier at or near the place of his birth. We can give this project our endorsation. Monuments to our citizens of public spirit or public benefactions are not too common in Canada, certainly not in the West, where, perhaps, we have been too busy pioneering. It is true that a great deal of Osier's success and reputation was acquired outside of the Dominion, but nevertheless, as a perusal of Cushing's "Life" will show, his native country lay very close to his heart. Let us then praise famous men, and in this instance we may at least be sure that no books, no lectureships, no monuments or other memento mori are ever likely to be written, established or erected in memory of anyon who so singularly and completely merits them, as Osier. Pending a more complete review of the Opium and Narcotic Drug Act, 1923, and the amendments of 1925 recently received, we extract the following as of particular interest. Section 15 of the original Act reads—as if affects physicians—"If any person charged with an offence under Section 6 of this Act pleads or alleges that the drug in question was required for medicinal purposes, or was prescribed for the medical treatment of a person under professional treatment by the accused .... the burden of proof thereof shall be upon the person so charged." To this a sub-section is now added: "Except in the case of a drug addict Page Six or habitual user of drugs suffering from a diseased condition caused otherwise than by the excessive use of any drug, it shall be no defence to a physician charged with an offence under Section 6 of this Act that he did give, sell or furnish any drug to such addict or habitual user for self-administration." Apparently no cure can now be attempted which entails self-administration of the drug. Preparations for the Victoria meeting of the Canadian Medical Association in June next are already well advanced. A partial provisional programme is published in the current number of the Journal of the Association. We .hope to give a fuller notice of this meeting in a subsequent issue. Dues for 1926-27 are payable April 1st. yours for 1925-26? NEWS AND NOTES. Have you paid The regular monthly meeting of the Association on Tuesday, March 2nd, took the form of a dinner, which was held at the University Club. About eighty members were present at the dinner, and more came in afterwards in time for the. business meeting. We have been informed that the dinner was a success both financially and gastronomically. Dr. H. E. Young and Dr. Cyril Wace, of Victoria, were present as guests of the Association, and before the business meeting commenced these gentlemen were given an opportunity of explaining to the Association the history, aims and objects of the Solarium for Crippled Children shortly to be established on Vancouver Island, near Victoria, under the auspices of the Women's Institutes of B. C. This institution will provide treatment by the Rollier system, and will certainly be a valuable addition to the therapeutic resources of this part of the Dominion. The minutes of the previous meeting were read by the Secretary and adopted. Dr. W. L. Pedlow then gave notice of his intention to move an extraordinary resolution at the next general meeting to restore the wording of Section "C," By-Law No. 1, of the Constitution of the Association, to that which obtained before the meeting on December 10th. Dr. E. D. Carder, who had been chosen to give this year's Osier Lecture, then read his paper entitled "The Thymus," which appears in full in this number. Dr. A. W. Hunter has resigned his position as Pathologist to the Vancouver General Hospital in order to devote more time to genito-urinary work. Dr. Hunter, however, still remains a member of the Visiting Staff of the Hospital. Dr. Harry Bell, lately Anaesthetist at St. Paul's Hospital, has joined the staff of the Vancouver General, where he is giving anaesthetics in the Eye, Ear, Nose and Throat Section. We are pleased to report that Dr. Harry Milburn, who has been suffering from sinus infection for some considerable time, has been recuperating on Vancouver Island, and hopes soon to resume practice. The monthly Clinical Meeting of the Association was held in the Auditorium on Tuesday, March 16th. Dr. Gunn presented a case of pernicious anaemia of special interest on account of the difficulty in obtaining a suitable donor for blood transfusion,, although patient's blood was in Group 4. Dr. Coleman discussed this feature of the case and suggested that probably one- third agglutinin was present in the patient's blood. Dr. Walker (hospital interne), presented the history of a case of profound anaemia apparently of a secondary type, in which the Van den Bergh test showed a high degree of bilirubin to be present in the blood. This patient had progressed steadily under rest, HC1. and high caloric diet. Drs. Pearson, Keith, Sutherland, and Hodgins discussed the case. Dr. K. Shimotakahara showed an interesting case in a Japanese baby for diagnosis thought possibly to be a congenital amaurosis. He also presented a case of T.B. peritonitis in a man. Dr. F. Brodie presented the history of a case of recent accident with fracture in the region of the fifth cervical vertebra with injury of the cord, causing complete paralysis below the level of the clavicles with analgesia and loss of protopathic sense up to the same level, but with retention of epicritic and joint sense. Dr. Brodie's diagnosis of the case was an injury of the fore part of the cervical cord at site of the fracture, but not including the columns of Goll. Dr. J. M. Pearson presented a case of very old and large varicose ulcer of the right leg, which, owing to the patient being forced to take rest following a hemiplegic attack, was now healing in a satisfactory manner under the application of mild boracic ointment only. VANCOUVER GENERAL HOSPITAL LABORATORIES. R. E. Coleman, M.B. Assistant Director, V. G. H. Laboratories. The Wassermann (complement fixation) test for syphilis has been officially superseded by the Kahn (precipitation) test for syphilis in the U. S. Navy (J. A. M. A., Jan. 16. p. 210), and in the State of Michigan (J. Mich. Med. Soc, Oct., 1925). The former change went into operation Dec. 30, 1925, the latter Oct. 15, 1925. , Hereafter the U. S. Navy Medical Dept. will regard the Kahn precipitation test "as the standard test in the serum diagnosis of syphilis and yaws," and require that "it be so employed Page Eight : as a routine." Other tests are now purely optional, but if employed, must be employed only "in addition to the Kahn test." Standardized antigen for the Kahn test is supplied by the C. O, U. S. Naval Medical School, Washington, D. C. In Michigan, the simplicity, accuracy, rapidity, and close correspondence in results with the Wassermann test are the features given as reasons for the change. The evry earliest Canadian work on the close correspondence of the two tests in clinical diagnosis was published by our Serologist, Mabel Malcolm (C. M. A. J., March, 1924), (presented to the C. P. H. A., Edmonton, June, 1923). The V. G. H. L. has long contemplated a change to a quantitative serological reaction for syphilis, and the Kahn test offers just such a reaction, yielding a very high rate of agreement with the clinical findings and with the Wasserman. We will welcome expressions of opinion from those physicians who have used the Wassermann test extensively in the past regarding such a change here, following a "transition period," during which both tests would be done and reported on every specimen, so that each physician might see for himself in his own practice the close correspondence, indeed practical identity of the two tests. The Laboratories are undergoing a much needed spring housecleaning and the first complete re-painting in nine years. Everything has been kept running, despite ladders in the gangway and fresh paint everywhere. B. C. MEDICAL ASSOCIATION NEWS. In view of the doubts in the minds of many men regarding the exact status of the medical man prescribing narcotics, it will be of interest to publish the following extracts from a letter received by the Secretary from Dr. John Amyot, Deputy Minister of Health, Ottawa:— "There is nothing in the law to interfere in any manner with the practice of physicians in prescribing narcotics where such drugs are required for medicinal purposes, or for the relief of pain and suffering in the case of incurable diseases, or afflictions, etc. "Section 6 of the Act simply provides that it is unlawful for a physician to give, sell or furnish, or to prescribe narcotic drugs for a person unless such drugs are actually required for medicinal purposes, or prescribed for the medical treatment of a person under professional treatment by such physician, etc., or in other words, the drug must be required for legitimate medicinal uses, and not simply furnished to a drug habitue or others to be Page Nine administered by themselves at their convenience, for the gratification of the appetite due to the habit. "Section 15 of the Act places the burden of proof upon the physician where charged with an offence under Section 6 of the Act; in other words, if a physician is charged with supplying or prescribing narcotic drugs, for other than medicinal purposes, the onus is upon him to establish the fact to the satisfaction of the court, that such drugs were actually required for legitimate medicinal purposes, and were not supplied to an addict solely to gratify his addiction, which practice is not considered as being for medicinal uses, as defined under Section 6 of the Act. "Section 8 of the Amendments, Chapter 20, as passed at the last session of Parliament, simply provides in clear language the expressed intention of Parliament, as to the meaning of 'medicinal purposes' as referred to in Section 6 of the Act. In other words, this amendment makes it quite clear that any physician who gives, sells or furnishes (prescribes) narcotic drugs to a drug habitue solely for the gratification of the appetite, cannot plead that he was treating a patient in the ethical sense of a patient, or in other words, prescribing the drug for medicinal purposes. An exception, however, is made under the amendment in the case of a drug habitue who may be suffering from some diseased condition or affliction existing, other than from the excessive use of narcotics, but in such cases the physician must not prescribe for the patient any amount of narcotics in excess of that actually required to allay the pain and suffering of the patient due to any diseased condition which may exist aside from the craving for narcotics caused by the prolonged or continued use of such drugs. "Under the Act as it stands, there is nothing whatever to prevent any physician from prescribing narcotics at any time when in his opinion, as a physician, the drug is actually required for legitimate medicinal uses. He, and he alone, is the sole judge under the law, as to when the drug is required, and the amount necessary, etc. Parliament simply passed a law to prevent unscrupulous physicians trafficking in these drugs under the pretence of practicing medicine." Copies of the Opium and Narcotic Drug Act and Amendments thereto are in the possession of the Secretary, and of the Vancouver Medical Association, and may be seen at either office. LIBRARY NOTES. (The Library is situated in 529-531, Birks Building, Granville Street, Vancouver. Librarian: Miss Firmin. Hours: 10 fo 1, 2 fo 6.) SIMPLE GOITRE. To have a master surgeon like Sir James Berry express his views on endemic goitre, views gleaned from 40 years of obser- Page Ten vation and investigation in many countries, is enough to make one sit up and take notice, particularly as his conclusions are so definite and so diametrically opposed to the general medical opinion of Canada and the United States. Those of you who have time should read "The Hunterian Lecture," published in the Lancet of February 6th. Sir James has nothing to do with the theory that lack of iodine is the cause of this malady. "Balderdash" might express his feeling as to this theory. Though he gives us no definite experiments to back up his views, yet his whole lecture ought to stimulate all of us to renew our activities in pursuit of the influences which result in this very common condition. W. D. K. CORRESPONDENCE. To the Editor Vancouver Medical Association BULLETIN: During the past few months there have been many hundreds of cases of mumps among Vancouver school children. Most cases have been of a very mild type, affecting chiefly the sub-maxillary glands, the parotid being little or not at all affected. In many cases a slight swelling of the parotid gland is shown by the filling up of the sulcus between the mastoid process and the ramus of the jaw. There is little or no rise of temperature and seldom any pain. The swelling begins to subside in two or three days. These mild cases have in a great many instances been followed by others in the same family of the usual type of mumps. The exclusion period for cases of either type of mumps, and for contacts with same, is three weeks. HAROLD WHITE, School Medical Officer. ABSTRACTS. GASTRIC ACIDITY IN ACNE VULGARIS. Frank Crozer Knowles and Henry B. Decker. Arch, of D. « S. 13:215. (Feb.). 1926. That there is a relationship between mild pathological conditions in the gastro-intestinal tract and acne vulgaris has long been a popular belief among both physicians and laymen. There appears to be considerable clinical evidence in favour of this view. It is referred to among etiological considerations in all standard text-books and in articles appearing in the journals. Until recently, carbohydrates and fats in the diet were regarded askance, and considering the pronehess of adolescents to over-indulge in these substances, it seems but a natural reaction on the part of the orthodox medical attendant to order their restriction. Lately, Page Eleven mum however, the idea has been gaining ground that variations in gastric acidity play an important part in acne. This is probably due to the frequest observation that in cases of hyperchlorhydria, congestion of the "flush area" and rosacea—usually confused with acne—is present. Hitherto study of these associated conditions has been chiefly or entirely clinical, hence the vagueness of the references above referred to. In a prliminary report read before the 1925 annual meeting of the American Dermatological Association, Knowles and Decker state they have made gastric analyses in twenty-five cases of acne vulgaris. They feel that as far as they have gone, clinical observations have been borne out, but they have failed to find that any relation exists between the severity, type and duration of the acne vulgaris and the gastric acidity. An interesting discussion on the paper was participated in by eminent dermatologists, and is reported in full. This paper is of special interest in emphasizing the close relationship which exists between dermatology and internal medicine, and which must be recognized if therapy in a multitude of dermatoses is to be anything more than empirical. D. E. H. C. * * * VARICOSE VEINS. A report by C. Kosinski (entitled "Observations on the Superficial Venous System of the Lower Extremity," appearing in the January, 1926, number of the Journal of Anatomy) of dissections made at University College, London, throws some light on the possible cause of varicose veins in the leg. It is demonstrated that in about 13% of cases, the small saphenous vein, instead of opening into the popliteal, winds upwards and inwards, and ends by joining the great saphenous in the upper third of the thigh. The direction of blood flow is always from the small to the great vein. This added volume of blood thrown on the unsupported great saphenous is probably responsible for varicosities there. The writer argues that there being evidence of a hereditary tendency in from one-half to three- quarters of cases of varicose veins of the leg, this hereditary factor may be expressed in modes of arrangement of the superficial veins. It is suggested that the close association of the veins with the nerves of the leg may be responsible for the. aches and discomfort which accompany varicosities. At one stage in the development of the human embryo, and in all mammals of a lower order than man, the small saphenous is the main superficial vein of the hind limb, emptying into the internal iliac through the gluteal. In these the great saphenous is short, terminating in the femoral vein in the lower part of the thigh. Varicose veins of the leg are found in no mammal other than man. G. E. K. Page Twelve "THE THYMUS." Being the Osier Lecture read before the March Meeting of the Vancouver Medical Association by Dr. E. D. Carder. TOPOGRAPHY.—The thymus gland may consist of one, two or three lobes. It is bi-lobed in about 80% of cases. In the late foetus and the stillborn it is of the cervico-thoracic type, the lateral surface convex and bulging against the mesial surface of the lungs. The lungs rarely extend at all on its anterior surface and the thymus rarely extends at all on the anterior surface of the right ventricle of the heart. On the other hand, the thymus in infants who have breathed has a typical form and reJations similar to those in young children. It is elongated and moulded so that its anterior, lateral and posterior surfaces bear the impress of all the organs with which it is in contact. The change from the broad or foetal type to the elongated and moulded thymus found in the live-born and young infant bears a direct relation to the establishment of respiration and is dependent upon the expansion of the lungs. In some cases the thymus may extend posteriorly to such an extent as to press upon the structures behind it. This may be due to an unusually large thymus or to a very narrow superior thoracic aperture which will not permit the thymus to protrude into the cervical region when compressed by the expanding lungs. This last phase is extremely important when one tries to determine whether or no a thymus is dangerous. It is also important when considering the position of the diaphragm and also the position of the head when taking a Roentgenogram. STRUCTURE.—The thymus is made up of several lobules. Each lobule may be divided into a cortical and a medullary portion, the general arrangement bearing a strong resemblance to that of a lymphatic gland. The medulla is characterized by the presence of peculiar concentrically striated bodies—Hassall's corpuscles —whose precise origin and significance are still matters for discussion. (Schaefer.) It is yet doubtful whether we are to look upon the thymus in its fully developed condition as a lymphoid organ. Hammar believes that not only in origin but throughout life the thymus has the character of an epithelial organ. Mosher, on the contrary, says: "Except for Hassall's corpuscles—which are peculiar to the thymus—-the tonsil, the thymus and the intestinal lymph glands are identical." The matter is unsettled, but is a question not only of morphological but also of physiological importance. If the thymus cells are in truth epithelial throughout the life of the organ, we may with reason look for an internal secretion in the specific sense. On the other hand, if the cells be regarded as lymphoid, then we shall expect to find that the functions of the thymus are allied to, if not identical with those of the lymphatic glands. (Vincent.) Page Thirteen FUNCTION.—There is much contradiction in the deductions of various experimenters who have attempted to determine thymus function. Its interrelationship with the endocrine system is suggested by Crotti's observation that it undergoes hyperplasia after thyroidectomy, and that thymectomy is followed by thyroid hypertrophy. Hyperplasia of the thymus is frequently associated with Graves' disease. Jaffe demonstrated that in old rats double suprarenalectomy was followed by regeneration of thymuses that had previously involuted. Hyperplasia of the thymus is found often in Addison's disease. Riddle claimed that in the thymus of birds was a substance indispensable to the production of the egg-envelope. Uhlenhuth states the thymus contains a substance capable of producing tetany, and it has been suggested that a function of the parathyroids is to inhibit this activity. Parke and McClure, in a very careful series of experiments on dogs from which they removed the thymus, express the opinion that the thymus is not essential to life in a dog; that its removal produces no detectable alteration in the hair, teeth, contour of the body, muscular development, activity, or intelligence of the experimental dog; that extirpation of the thymus causes no alteration in the organs of internal secretion unless there be changes produced in the short period immediately following thymectomy. They point out that in evaluating the results claimed by other investigators to follow thymus extirpation the greatest importance must be given to the fact that the symptoms and pathologic changes which have been ascribed to deprivation of thymus function are almost, without exception, the symptoms and pathologic changes which occur in laboratory animals as the result of confinement, improper food, unhygienic conditions, bacterial and parasitic infections. Does involution of the gland occur spontaneously, independently and merely coincident with the development of the secretion of the gonads, or is there a causal relation between them? Its persistence is stated to cause failure of the gonads and genitalia to properly develop—like Barrie's Peter Pan—while the converse is claimed equally strongly. Swale Vincent says: "Castration causes enlargement of the thymus and interferes with normal involution of the gland, therefore involution is due to development of the reproductive glands." Olkon claimed that by injecting thymus extract into animals one could produce reduction in weight, spasm of muscles, convulsions, and sometimes death. His own work was repeated by Miller and Freeman, first with intraperitoneal injections in the same doses, and then with much larger doses, without producing any symptoms. Miller and Freeman also prepared a protein ex- Page Fourteen tract of normal thymus glands, and of hypertrophic thymus from cases dying of so-called status lymphaticus. Inoculation of these extracts into the skin of children with enlarged thymus with symptoms, gave entirely negative results. Porter says: "The subcutaneous injection of thymus extract seems to act without effect other than that produced by the injection of any protein solution of like strength. Partial thymectomy (one lobe) in young rats caused within 15 days a marked hypertrophy of the remaining lobe, while in older rats this effect was not produced. This is put forward as emphasizing the functional importance of the gland before puberty. In a review of 24 articles on the physiology of the thymus, based mainly on animal experimentation, and appearing from 1904 to 1924, Mr. C. L. Short, of Harvard Medical School, stated the conclusions drawn from these articles as follows:— 1. The thymus is not necessary for life. 2. Thymectomy has no effect on the growth and development of the skeleton and organs. 3. Castration delays the involution of the thymus. 4. A substance contained in the thymus causes convulsions. 5. Thymic hyperplasia follows double suprarenalectomy. 6. Thymic hyperplasia in thyrotoxicosis is secondary. 7. In birds a relationship exists between the thymus and the egg- producing mechanism. 8. So-called thymic death probably bears no -relation to the state of the thymus gland. 9. One, if not the primary, function of the thymus is to produce leucocytes. 10. The thymus may also have an antitoxic function. In spite of its colorless position in the physiological scale, the thymus is of clinical importance principally on two counts — hyperplasia of the gland with symptoms, and in connection with the condition known as status lymphaticus. Hyperplasia of the Thymus.—To accuse an organ of being hyperplastic, one must have a normal standard by which to judge. Dr. A. B. Bratton presents figures as to the average weight of the thymus collected at the Pathological Department of the London Hospital. His data were obtained from autopsies on 337 persons aged one day to 16 years, who died from accidents, burns, asphyxia or under anaesthetics, or- the immediate results of these, not later than the day after. No sign of disease other than the above named causes of death was found at autopsy. (It is well established that the thymus undergoes pathological involution in states of disease, hunger and overwork.) These 337 cases are divided into groups and averages struck of the actual weights of the thymus, and of the percentages that such weights bear to the body weight. Briefly they are these, omitting decimals:— Still-born and under 2 days 11 gms. .34 2 days and under 3-12 days 19 gms. .45 3-12 days and under 6-12 days | 23 gms. .42 6-12 days and under 1 year 22 gms. .35 1 year and under 2 years 26 gms. .26 2 years and under 6 years 24 gms. .25 6 years and under 11 years 29 gms. .13 11 years and under 16 years . 27 gms. .08 To sum up: the gland grows rapidly during the first two years of life (particularly the first three months)—changes little until the seventh year (if anything decreasing slightly), when it begins again to increase, to fall slightly after the eleventh year. In comparison with the whole body the thymus grows faster during the first six months of life, after this decreases rapidly; after the fifth year the relative decrease continues at a slower rate. He draws two conclusions: First, the weight of the normal thymus at any age is so variable that it is practically impossible to say in any individual case whether it is too large or too small. Thus the mean or average weight at five years is about 25 gms., but the coefficient of variation of the weights of which this is the mean, is about 35—so that a range from 16 to 34 gms. makes it impossible to say that any one thymus is abnormally large unless it weighs fully 42 gms., or too small unless it weighs less than 8 gms. Second, until normal fluctuations in the weight of the thymus, and in the relation of the thymus to the body weight have been determined, it is impossible to recognize and exclude cases of status thymicus gravimetrically: indeed we know of no gravimetric evidence that such a condition as status thymicus exists. When is a thymus enlarged, and how, in the absence of suggestive symptoms, is the diagnosis to be made? The freedom with which the term "enlarged thymus" is used in the voluminous literature on the subject is exceeded only by the absolute lack of definiteness as to the standard in the writer's mind. First—Physical Examination. Blackfan and Little regard light percussion disclosing dullness in the second costal interspace anteriorly, extending over 7/8 inches to the left and over Yt. inch to the right of the midsternal line, and continuous with the cardiac dullness below, as evidence of a positive or enlarged thymus. Disappearance of this dullness with extreme dorsiflexion of the head, they consider as confirmatory evidence. Mosher. of Boston, in 110 cases subsequently confirmed by X-ray, states that 25% of these were diagnosed by physical examination. This method is obviously so unreliable and uncertain that it must give place to the X-ray as a diagnostic means. Page Sixteen Second. The radiographic interpretations in the literature are, in the majority of instances, equally indefinite, but I shall quote Wasson, of Denver, whose investigations have apparently been most painstaking and careful. In a recent article on "Radiography of the Infant Chest," he says:— "After making these investigations, noting all observations in detail and watching carefully the technic of each experiment, I came to some definite conclusions. Thus at birth the shadow usually attributed to the heart is that of the heart, the right border of the heart shadow is formed by the superior and inferior venae cavae, the left border of the heart is formed by the left ventricle. The two auricles and the great vessels form the base of the heart shadow. These great vessels, venae cavae, aorta and pulmonary artery, form a shadow triangular in shape which quickly narrows as it passes upwards, and at its narrowest point is less than the transverse diameter of the shadow of the spinal column. "If the thymus is present in any considerable size it will be found to overlap the base of the heart and to pass upward, obscuring the shadow just described of the great vessels. The shadow of this thymus is again triangular in shape with its base overlapping the base of the heart, and especially the auricles. Its transverse diameter at its broadest point, which is usually the third interspace, may be two or three times the diameter of the shadow cast by the thoracic spine. This shadow of the thoracic spine is taken by measuring the transverse diameter of the vertebral bodies. "If the shadow of the thymus is no greater than that cast by the great vessels, it is a very small thymus. "The thymus lies anteriorly against the upper sternum and manubrium, and posteriorly upon the auricles, great vessels and trachea. "Some writers have described a large thymus which is enlarged only in its antero-posterior diameter, but I have never seen such a one nor can I conceive of such a thymus except under most unusual conditions. I have made an arbitrary classification of the size of the thymus into three classes. "The first is the small thymus which does not increase the transverse diameter of the mediastinal shadow, or in other words, is only 1/3 greater than the width of the bodies of the spine in the second interspace. "The second is a moderate sized thymus which has twice the diameter of the body of the thoracic vertebra in the second or third interspace. "The third, where the thymus is three or more times the width of the vertebra, or the large thymus." This is at least an enunciation of a definite and reasonable working basis. A careful technic is essential. The child must be fiat on the back, the body held in median position with no tilting, the head held in semiflexion (Blackfan claims that the thymic Page Seventeen shadow becomes greatly diminished in size, or disappears altogether when the head is in extreme dorsal flexion). According to Gerstenberger it is necessary to examine the gland under the fluoro- scope as a check on the film findings, because of the influence of the movements of the diaphragm. He found if a film were made at the end of expiration when the diaphragm is high, that the thymic shadow is large, and if the film is made at the end of inspiration, the thymic shadow is small. Pfahler always films the child while crying, just at the end of a cry, because the thymus then enlarges. Mosher, of Boston, states that crying does not alter the size of the thymus. Again we ask: what constitutes an enlarged or hyperplastic thymus? Peterson and Miller, in a series of 120 new-born babies, state that 43% had enlarged thymus glands. They give no criteria by which they distinguished between normal and abnormal, therefore one cannot judge the merit of their report. Liss, in his series of 119 cases at birth, found 42% showed thymic shadows measuring more than 3 cm., which he regards as pathologic. This is a very arbitrary ruling on account of the difference in individual babies; 3 cm. might be normal for one baby and abnormal for another, relatively smaller. Blackfan and Little, in a series of 60 babies varying in age from five hours to one year, found 50% had enlarged thmuses without symptoms. Now to accept these figures and interpret these so-called enlarged thymus glands as pathologic, means that we have a congenital anomaly in about 50% of our new-born babies. This is too great a strain upon one's imagination and becomes a reductio ad absurdum. Liss, in commenting on his series, says: "The striking revelation in this study was the fact that in a group of average normal infants at birth, 42% showed the presence of a shadow, suggesting a thymus measuring more than 3 cm., and this without symptoms. As the work progressed retrogression in size of the shadow took place, the greatest change within the first few months, a steady change as the year went by, so that with our limited material (119 cases) spontaneous disappearance of this shadow took place in the majority of cases. Some, however, persisted to the second year." This natural retrogression or involution would seem to suggest that possibly we should not too readily interfere with a gland (doubtless serving some useful purpose in the body) which is causing no symptoms and which, for all we at present know, may be a normal organ. Regarding older children. At the Throat Department of the Massachusetts General Hospital, a series of 5000 children from 1 to 16 years showed on X-ray examination 7% of that age with a persistent enlarged thymus. Page Eighteen Disproving the statement that 50% of children have enlarged T.B. glands which give a broad mediastinal shadow indistinguishable from the shadow given by an enlarged thymus, a series of 90 X-rays taken at the Peabody Home for Crippled Children—a T.B. Sanatorium—showed a broad mediastinal shadow in exactly 7% also. Blood counts made on children shown by the X-ray to have an enlarged thymus, showed a slight lymphocytosis, but not enough to be diagnostic. After X-ray therapy of the thymus there was no change in the blood count. Is the term "enlarged thymus gland" a desirable one, then, in a pathological sense, or should we say "symptom producing gland"? Blackfan and Little—to quote from their cases again—took a series of X-ray plates in 60 apparently normal babies without symptoms. These plates were compared with a series of 200 plates previously taken in babies with diagnosis of enlarged thymus glands. From this comparison they conclude that 50% of all their series had enlarged thymus glands. We may infer, therefore, and in fact do know that given two babies with the same sized thymus, one may have alarming symptoms and the other no symptoms whatever. Benjamin, in 225 cases of enlarged thymus, states that $% only showed symptoms referable to it. The symptoms associated with a symptom-producing thymus gland are:— 1. Dyspnoea—continuous or paroxysmal. 2. Choking and coughing—important if associated with dyspnoea—most frequent during and after nursing, and often occurring at night. 3. Stridor—This is the dominant feature of the clinical, picture. It may become apparent a few hours after birth or not appear for some weeks or even months. Both phases of respiration are affected, but inspiration more than expiration. The degree of stridor is variable. Rarely is the larynx obstructed or the cry much altered in cases where the stridor is continuous. On the other hand, where stridor is paroxysmal, dyspnoea may become intense and respiratory interference so great that extreme cyanosis is present. Congenital laryngeal stridor is a condition often confused. In this the noise is entirely inspiratory—there is never cyanosis nor is it paroxysmal. Bliss mentions another symptom—the position of the baby's head. He says that after excluding such abnormal conditions as meningism, meningitis and the muscular hypertension of marasmic infants, if we find a baby holds its head extended backwards, our attention should be attracted to the thymus gland, because the baby is inferentially attempting to ease its respiration by opening Page Nineteen more freely the upper aperture of the thorax, relieving pressure on the trachea. Blackfan and Little showed that the upper thoracic opening in an infant could be widened antero-posteriorly 1/8 inch by forcible dorsiflexion of the head. The Differential Diagnosis of a Symptom-producing Thymus.—The following conditions may have to be differentiated:— 1. Congenital heart lesions. A congenital heart lesion severe enough to produce dyspnoea and cyanosis can usually be diagnosed by the stethoscopic examination. 2. Congenital atelectasis. The cyanosis in this condition generally improves when the baby cries vigorously—with an enlarged thymus it increases. 3. Anomalies of the larynx—are best differentiated by laryngoscopic examination. 4. Laryngeal diphtheria—history—fever—culture^ 5. Asthma. 6. Retro-pharyngeal abscess. 7. Enlarged mediastinal glands. There seems to be no criterion whereby enlarged mediastinal glands can be positively diagnosed from enlarged thymus of slight degree. So experienced and authoritative a radiologist as Dr. Baetjer, of Johns Hopkins, is of the opinion that most of these moderate grade shadows in the upper mediastinum are due to lymphadenitis rather than enlarged thymus. The irregularity of the mediastinal mass is suggestive of glands—the very young age of the patient is more suggestive of thymus. In case of doubt the therapeutic administration of the X-ray will bring about an involution if the enlargement is due to the thymus. Treatment. 1. Thymectomy has been performed successfully, but as a therapeutic agent it has been abandoned on account of the technical difficulties and the high attendant mortality—17 out of 50 operated on—a mortality of 33%. (Parker.) 2. X-ray. Friedlander, in 1907, was the first to report the case of a child with enlargement of the thymus treated successfully by X-ray. The treatment was suggested by experimental work of Heinicke, who found that X-ray exposure had a profound influence upon lymphoid tissues in guinea pigs, rabbits, and dogs. 3. Radium. For radium Pfahler claims these advantages: (1) It can be applied without annoyance or struggle on the part of the child, and therefore involves no risks on the table; (2) the radiation can be kept definitely in place; (3) the action of radium is more rapid and usually one application is sufficient even in the severest forms; (4) radium is portable and makes treatment, when necessary, possible at home. Page Twenty On the contrary, Hardy reports a series of 18 cases treated with radium, six of which developed untoward symptoms attributable to it. Moreover, it is not as generally available and is expensive. X-ray, then, is the common therapeutic means employed. The technique used by various radiologists varies slightly in detail, but practically yields the same dosage. That in use at the Vancouver General Hospital by Dr. Mcintosh is 7 milliamperes —an 8-inch spark gap—4% minutes exposure through a 3 millimeter aluminum filter at a distance of 10 inches, equalling a ^ skin dose, over the anterior surface of the thorax in the thymic area, with the abdomen protected. This dose is repeated if necessary, but not sooner than two weeks. This repetition depends on the clinician's views as to discontinuing treatment on the subsidence of symptoms regardless of the size of the gland, or to continuing until the gland has retrogressed to so-called normal. Some comments may be, perhaps, fitly made at this juncture. Are these symptoms due to pressure? The majority of observers believe they are. Yet only a small proportion of so-called enlarged thymus glands present symptoms, and autopsies daily disclose very large thymuses even as large as 65 gms. in children who, during life showed no evidence of pathological change in the organ.. v It is true that the upper thoracic aperture in infants is small, often not more than 2 cm., yet when one regards the soft jellylike thymus, whose histological structure is such that it cannot enlarge suddenly any more than the tonsil, it is difficult to believe that it could exert any degree of pressure on the relatively firm trachea. It is conceivable that it might be forced up and jammed into the narrow space between the sternum and vertebral column and exert pressure enough to influence the vagus or recurrent laryngeal nerve. The fact that prompt relief is obtained coincidental with the reduction in size following X-ray therapy, is not absolute proof of this theory, because we do not know what other changes in the gland are produced by exposure to the Roentgen ray. De Buys and his associates at New Orleans, reporting on a series of 120 new-born, says: "Up to the present we have been unable to arrive at a definite standard as to the size, shape and position of the gland causing symptoms, some patients having all the effects of a hyperfunctioning thymus and on examination showing only a very slight enlargement, while other cases in the series with marked enlargement of the gland show no clinical manifestations." Should every so-called hyperplastic thymus in an infant— regardless of its producing symptoms or not—be subjected to X- ray therapy? There are those who advocate it on the ground that such a gland is a potential danger and a menace; that the X-ray exposure is a harmless procedure and without known unfavourable Page Twenty-one sequelae, and, in fact, that such a routine properly falls within the category of preventive medicine. There are others, however, who take a conservative stand. The function of the thymus is not yet proven. The ultimate effect of premature retrogression or hastening of its involution by X-ray, is not as yet known. The effect upon contiguous tissues (the innocent bystander, so to speak) may not be altogether harmless. Therefore only those glands producing symptoms should be treated. It is superfluous to add that the treatment should be administered only by a competent radiologist. Status Lymphaticus.—The association of sudden death with enlargement of the thymus has long been noted, but it is now conceded that persistence of the thymus in these circumstances is merely one of a series of anatomical imperfections occurring in the same person. This condition of status lymphaticus, as it was termed by Paltauf in 1889, is characterized by persistence or enlargement of the thymus, hyperplasia of all the lymphoid structures of the intestine, viz., Peyer's patches, the solitary follicles and mesenteric glands—hyperplasia of the lymphoid follicles of the spleen, though not invariably—hypoplastic deficiencies, i. e., defective development of the muscular coat of certain arteries, particularly of the aorta and vessels of the brain. The faucial tonsils may share in the general lymphatic hyperplasia—though the superficial regional lymph nodes are not involved, and are negligible from a diagnostic standpoint. Enlargement of the thymus, per se, does not imply the existence of a status lymphaticus and may be present without it. The association of sudden death with status lymphaticus has been so persistently emphasized that its broader significance has been lost. "As a matter of fact," says Symmers, "sudden death in subjects of status lymphaticus is a tragedy rarely enacted, but when it does occur the rapidity of the blow and the dramatic circumstances in which it is delivered are exceedingly impressive. An apparently healthy child dies during the administration of an anaesthetic, during or after an uncomplicated tonsil and adenoid operation, or during a simple circumcision. Not every individual with the stigmata of status lymphaticus drops dead if pricked with a needle, though some do succumb to trivial injuries. It is also true that certain subjects of status lymphaticus are highly susceptible to infection, notably cerebrospinal meningitis, diphtheria and enteric, and that in them infection is apt to pursue a rapid and often a fatal course. On the other hand, the majority of such subjects, it is safe to assert, are not only capable of withstanding injuries, both slight and severe, but infection as well." Norris, of New York, has described the physical characteristics of these cases-;—the angelic type of child, well-nourished, velvety skin, arching limbs and narrow waist—in the male adult a body of fine proportions, almost feminine in type, and magnificently muscled, frequently specimens of physical beauty. If this Page Twenty-two be true, it possibly affords one explanation why a good many of us have escaped sudden death. Emerson, in the alcoholic wards at Bellevue Hospital, states that of 1000 patients suffering from effects of attempted suicide and from cocaine, morphine, etc., 22</ showed clinical characteristics of status lymphaticus. Symmers says it is relatively frequent among neurasthenics and epileptics. Stating that it is scarcely conceivable that status lymphaticus occurring so often among such a diversity of individuals of unstable emotional qualities should be accidental, he further says: "It seems reasonable to assume that congenital hypoplastic blood vessels are under indifferent vaso-motor control, and that this is not without influence on mental poise." It was pointed out by Virchow that in chlorotic girls the aorta is hypoplastic and the genitalia, notably the uterus, of the infantile type. Not only are these deficiencies common to status lymphaticus in the female, but it is a matter of observation that chlorotic girls present a skin of fine texture, graceful outlines and the subcutaneous body fat well present. Their vaso-motor system is easily disturbed, and emotional disturbances notoriously common. In short, the anatomical signs and symptoms of chlorosis suggest that this form of anaemia is an incidental phenomenon in girls with status lymphaticus. Sudden Death in Status Lymphaticus. The oldest theory as to the cause of these deaths is that it is due to compression of the trachea by an enlarged thymus gland. As a matter of fact the enlargement of the thymus in these cases has usually remained undiscovered until autopsy, and curiously enough there is no record that any such child was subject to thymic asthma or stridor during its lifetime. At Bellevue Hospital, Symmers states they have never been able to implicate the thymus as a mechanical factor in the production of death, the anatomical signs of tracheal compression and of death from suffocation never having been found, though carefully sought for. Moreover, while some of the secondary symptoms may possibly be those of pressure, at death itself the picture is not one of choking. Another theory is that the thymus suddenly liberates a death-dealing toxin. Repeated and most painstaking experiments on animals have so far failed to give any proof of this theory. Mosher says there is, to him, a striking similarity between a death from acidosis and a death from status lymphaticus, and expresses the opinion that some fault in the chemistry of food with the production of histamine or a similar compound will eventually be found to be at the bottom of the condition. He cites the rapidly increasing role that acidosis is playing in the toxaemias associated with certain forms of intestinal pathology, such as intestinal obstruction, burns, etc. Symmers has a more attractive theory. He says deaths in status lymphatic conditions are of two varieties. One is mechani- cal and follows haemorrhage into the brain—the other is obviously an intoxication. First, sudden death following haemorrhage into the brain: In slightly over 40% of all cases, the vascular system in subjects of status lymphaticus is hypoplastic, particularly the aorta and vessels at the base of the brain. Hypoplasia of the cerebral vessels is of profound importance from the standpoint of sudden death, not only in death ensuing spontaneously, but in subjects who have been exposed to a degree of injury which in normal individuals would be insignificant. These results he confirms by autopsy findings. Second, sudden death referable to intoxication: He says again: "The histology of the lymphoid tissues is of fundamental importance in the interpretation of those cases of sudden death into which the element of intoxication enters. The lymphoid tissues are most abundantly developed in youth, which is in keeping with the observation that the danger of sudden death in status lymphaticus is greatest during the same epoch. It is likewise significant that in this condition those lymphoid tissues which display the highest degree of hyperplasia are to be found in the mucous membrane of the gastro-intestinal tract in which situation they are actively engaged in the process of filtration and are constantly subjected to the destructive action of a great variety of substances, both chemical and bacterial." In children suddenly dying with all the physical attributes of status lymphaticus, microscopic examination of the lymphoid tissues throughout the body almost invariably shows myriads of necroses in the germinal follicles. The release of nucleo-proteids formed by the destruction of innumerable germinal follicles follows. These acting as foreign proteins sensitize the individual and when, later, the lymph nodes are again subjected to the action of destructive substances—such destructive substances being introduced by the injection, say, of antitoxin or manufactured in the process of shock induced by anaesthesia or the prick of a needle— then again nucleo-proteids are released and death occurs as an anaphylactic reaction. An ingenious and attractive theory. Nevertheless we must admit that the actual factors in the cause of death in these cases are at present unknown. It has been a routine for the past two years at the Massachusetts General Hospital, among others, to X-ray the chests of all children from 1 to 1 6 years of age who were scheduled for tonsil and adenoid operation. Five thousand cases were examined thus, and 7% showing a large mediastinal shadow were considered to be suspicious thymus cases and were given four X-ray treatments at 10-day intervals. Of these, two cases which showed enlarged thymus and received the regulation treatment, gave trouble—one during the giving of the anaesthetic (ether) and one after the completion of the tonsillectomy. The symptoms in both cases were those of extreme shock. Both recovered. Page Twenty-four In the Vancouver General Hospital at present all outdoor cases coming up for tonsil and adenoid operation are X-rayed with the same object. In view of the fact that it is generally conceded that status lymphaticus death is not a pressure death, and that the thymus in this condition simply shares in the generalized hypertrophy of the lymphoid structures of the alimentary canal, and further that a hypoplastic condition of the circulatory system is a relatively frequent feature, is it not a pertinent question to ask just what security against such tragedies is afforded by X-ray treatment of the thymus alone, apart from the fact that having discovered such a condition we may play safe by refusing to operate? I regret that this paper presents nothing original and possibly little that is conclusive. Indeed it would be presumptuous on my part to make any such claims when an investigator like Hammar has studied the thymus for 20 years and has not yet arrived at proved conclusions. 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Periodicals
W1 .VA625
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: April, 1926
Text