CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
'Tracheotomy in children ; Inflammation of nasal sinuses ; Laboratory bulletin ; Medical economics.' -- Title page
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i OFTHE Vancouver Medical Association Contents Tracheotomy in Children Inflammation of Nasal Sinuses Laboratory Bulletin Medical Economics Meetings General Meeting, March 1st Clinical Meeting, March 15 th Cancer Section, March 29th Vol. VIII. MARCH, 1932 No. 6 Published monthly at Vancouver, B. C, by McBeath-Campbeix Ltd., 326 Pender Street West Subscription, $1.50 per year. I MICROSCOPES Slides, Counting chambers Laboratory Glassware etc. STAINS Bacteriological Histological REAGENTS Qualitative and Quantitative Diagnostic Preparations CHAS. H. ANDERS, Chemist GORDON M. CLAY, Associate Chemist THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the Interests of the Medical Profession. Offices: 203 Medical Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Dr. J. M. Pearson Dr. J. H. MacDermot Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. VIII. MARCH, 1932 No. 6 OFFICERS 1929-30 Dr. C. W. Prowd Dr. E. Murray Blair Dr. G. F. Strong President Vice-President Past President Dr. L. H. Appleby Dr. W. T. Lockhart Hon. Secretary Hon. Treasurer Additional Members of Executive:—Dr. A. C. Frost; Dr. "W. L. Pedlow TRUSTEES Dr. W. D. Brydone-Jack. Dr. J. A. Gillespie Dr. J. M. Pearson Auditors: Messrs. Shaw, Salter & Plommer SECTIONS Clinical Section Dr. J. E. Harrison Chairman Dr. A. M. Agnew ■■ Secretary Eye, Ear, Nose and Throat Dr. J. A. Smith . Chairman Dr. A. O. Brown 1—Secretary Pediatric Section Dr. C. A. Eggert Chairman Dr. S. S. Murray Secretary STANDING COMMITTEES Library Orchestra Summer School Dr. D. M. Meekjson Dr. J. R. Davies Dr- c- e- Brown Dr. "W. H. Hatfield Dr. F. N. Robertson Dr- T- L- Butters Dr. C. H. Bastin Dr. J. A. Smith Dr- c- h- Vrooman Dr. C. H. Vrooman Dr. J. E. Harrison Dr- J- w- Arbuckle Dr. C. E. Brown Dr- H- a- Spohn Dr. H. A. Spohn ,, . Dr- H- R- Mustard Publications TT ... , Hospitals Dinner Dr- J' M> Pearson Dr. W. C. Walsh Dr. J. H. MacDermot jjr p ^ Lees Dr. J. E. Harrison Dr. D. E. H. Cleveland Dr. a. ^. Bagnall SR- ^* >H< J*™ DR- F- J- Buller Dr. N. McNeill , , Credentials V.O.N. Advisory Board Hi . „ „ ,, , . Dr. A. J. MacLachlan Dr. Isabel Day Rep. to B. C. Med. Assn. Dr a | McNair Dr h r Caple Dr. H. H. Milburn Dr. T. L. Butters Dr. G. O. Matthews Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT STATISTICS, JANUARY, Total Population (Census, 1931) Asiatic Population, Estimated 1932 246,579 1 15,000 Rate per 1,000 Population Total Deaths Asiatic Deaths Deaths—Residents only Birth Registrations Male 143 Female 153 INFANTILE MORTALITY— Deaths under one year of age Death Rate—per 1000 births :. Stillbirths (not included in above) CASES OF CONTAGIOUS DISEASES REPORTED 214 21 190 296 10.2 16.3 9.1 14.2 Smallpox _ Scarlet Fever Diphtheria Chicken-pox 3 8 Measles . 285 24 21 1 0 56 0 0 3 0 December, 1931 Cases 0 20 7 January, 1932 Mumps Whooping-cough Typhoid Fever Paratyphoid Tuberculosis Poliomyelitis Meningitis (Epidemic) Erysipelas Encephalitis Lethargica Deaths 0 0 1 0 0 0 1 1 0 21 0 0 0 0 Cases 13 9 8 60 2222 80 23 2 0 57 0 1 4 0 Deaths 2 0 0 0 1 0 1 0 0 11 0 1 0 0 9 30.4 10 IN CITY February 1st to 15th, 1932 Cases Deaths 15 1 6 14 621 39 6 1 0 22 0 0 5 0 BILLON'S « N0VARSEN0BENZ0L A dependable product uniting these important factors in arsenical therapy: —Therapeutical activity —Innocuity of administration —Uniformity in chemical and physiological particularities —Great solubility LABORATORY POULENC FRERES OF CANADA LIMITED Canadian Distributors: ROUGIER FRERES, 350 Le Moyne St., MONTREAL 7 ?Q. 1 0 0 0 1 0 0 0 0 1 0 Page 106 Pasteurization of Milk "The Lancet", one of the, two leading medical journals of Great Britain, in the issue of December 13, 1930. page 1315, contains, in the correspondence section a letter, from which we print the following excerpts: "Sir: In view of the importance of Milk in the diet of both children and adults, it is necessary for the known facts regarding the safety of this article of food to be placed before consumers and all concerned. Experience has shown that where pasteurization (the heating of milk, under conditions which ensure the destruction of harmful bacteria, yet leave the vitamins unimpaired) is generally practised, infection traceable to milk recedes almost to vanishing point. This fact has led no fewer than 21 cities in the U. S. A. to ordain the compulsory pasteurization of milk. The signatories, while expressing no opinion on the principle of compulsion, are emphatically agreed that the time has arrived when, in order to increase milk consumption and diminish the risk of milk infection, pasteurization should be universally recognized as the immediate practical method of ensuring safety. They are further of opinion that while no effort should be relaxed to improve milk at the source, the entire milk supply—excepting "Certified Milk"—should be pasteurized." We are, Sir, yours faithfully, Dawson of Penn. Robert Hutchison Charles Porter Thomas Horder A. Bostock Hill James Fenton John Robertson H. Charles Cameron John MacMillan Lord Dawson of Penn is Physician-in-Ordinary to His Majesty the King and to the Prince of Wales. Sir Thomas Horder is Physician-in-Ordinary to the Prince of Wales. Sir John Robertson is Professor of Hygiene and Public Health, Birmingham University. Dr. Robert Hutchinson is Physician to the Hospital for Sick Children, Great Ormond Street. Dr. A. Bostock Hill is an Emeritus Professor of Hygiene and Public Health, Birmingham University, Past President of the Royal Sanitary Institute. Dr. H. Charles Cameron is Physician, and Physician-in-charge of the Department for Diseases of Children, Guy's Hospital. Dr. Charles Porter. B. Sc, M.R.C.P., Medical Officer of Health, Marylebone. Dr. James Fenton, D.P.H., Medical Officer of Health, Kensington. Dr. John MacMillan, D.P.H. Medical Officer of Health, Woolwich. ASSOCIATED DAIRIES Limited DISTRIBUTING RICH, SAFE, CLEAN MILK Phones: Fairmont 1000—North 122—New Westminster 1445 "URGENT" to us means "At Once!—Now!" Phone us from the patient's home for medicine or sick room necessities* ©fl® Seymour 1050 Qeovgxa Pharmacy Granville atCJeor&ifc^ Open All Night A Doctor's Income— depends upon his presence "on the job" Accidents or sickness may at any time prevent this and insurance against these possibilities is a prime necessity. 11 '4 %§^#2§B§ ®tl® HnBlfi ■J.C. ALBERT MITCHELL will take care of this, as well as your Auto, Fire or Burglary Insurance. 744 West Hastings Street Vancouver, B. C Seymour 3838 VANCOUVER MEDICAL ASSOCIATION Founded 1898 Incorporated 1906 PROGRAMME OF THE 34th 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 meetings 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. 1931. November 3rd—GENERAL MEETING. Papers: Dr. H. A. DesBrisay: "Syphilis in Medical Practice." Dr. W. T. Lockhart: "Treatment of Syphilis." D. A. L. CREASE of Essondale will discuss the treatment of Degenerative Types of Neurosyphilis. Discussion: Dr. J. E. Campbell; Dr. W. L. C. Middleton. November 17th—CLINICAL MEETING. December 1st—GENERAL MEETING. Papers: Symposium on Fractures to be arranged by Dr. A. B. Schinbein and Dr. D. M. Meekison. Discussion: Dr. F. P. Patterson; Dr. J. A. West. December 15th—CLINICAL MEETING. 1932. January 5th—GENERAL MEETING. Papers: Dr. C. S. McKee: "The Interpretation of Blood Pictures." Dr. Murray McC. Baird: "The Clinical Aspect of Some Blood Diseases." Discussion: Dr. W. H. Hatfield; Dr. A. Y. McNair. January 19th—CLINICAL MEETING. February 2nd—GENERAL MEETING. Papers: Dr. H. Dyer: "Tracheotomy in Children." Dr. C. Graham: "Inflammation of the Accessory Nasal Sinuses in Children." Dr. E. E. Day: "Indications for Endoscopy." Discussion: Dr. J. A. Smith; Dr. H. R. Mustard. February 16th—CLINICAL MEETING. March 1st—GENERAL MEETING. The Osier Lecture: Dr. F. P. Patterson. March 15th—CLINICAL MEETING. April 5th—GENERAL MEETING Papers: Dr. J. W. Thomson: "Emergencies in Abdominal Surgery." Dr. A. W. Hunter: "Diagnosis and Treatment of Some Urological Emergencies." Discussion: Dr. G. E. Gillies; Dr. Lee Smith. April 19th—CLINICAL MEETING. April 26th—ANNUAL MEETING. Page 107 F" EDITOR'S PAGE Our readers will be interested in an article that appears in this issue, written by Dr. R. E. Coleman, who is chairman of a Committee on Economics, appointed by the Vancouver Medical Association recently. It is significant that Committees on Economics are very active just now in all Medical organizations. Gradually, it has been forced on our reluctant attention that all is not well with our profession from an economic point of view; and it is a hopeful sign that we are at last awake to this fact. Dr. Coleman's article is very suggestive, and will be provocative of thought and discussion. Wisely, we think, he does not attempt, at least at this stage, to consider treatment. He adopts the scientific course of first attempting to make an accurate diagnosis. To do this, he inquires into history, symptoms, and pathology. He asks us to consult with him on the case, to give our opinions and views; later, it is hoped, remedies will be suggested. There is much sound sense in this paper. Dr. Coleman is in a favourable position from which to view the problem. His is a detached view, to some extent; he is not a practitioner of clinical medicine, and is not hampered by personal considerations. Thus he has the onlooker's view of the game, traditionally a superior one. He has, we know, spent much time and thought on this matter, he is in close touch with the members of the profession, and, being himself disinterested, disarms by this fact, any suspicion that might unworthily arise, and receives . the confidences of many. Some who read this paper, and all of us should read it and carefully think over it, may feel somewhat disappointed that it is not more "practical," that it does not suggest the lines, at least, along which a cure may be found. We take it that this vagueness is deliberate on the part of the writer. He wants to make us think for ourselves. He desires, we know, that there should be the freest possible criticism of his ideas, destructive if necessary, but preferably constructive. He is not, he apsures us, at all thin-skinned, and will welcome the wound given by a friend, as gladly as he would endorsement of his ideas. This journal will give every opportunity it reasonably can, for discussion in its pages. The question is—not are we getting out of' our work all we can— but are we getting all we ought, to get? Readers will notice that Dr. Coleman does not merely refer to the monetary rewards of medical practice. He refers too, and in this we are in thorough accord—to the other results we should strive for in our daily work, leisure, hobbies, culture, (a much abused, but irreplaceable word), time to ourselves, time for post-graduate work, time to invite our souls. "Il faut cultiver notre Jardm" says a famous Frenchman. Are we doing it? or do we merely dig it over, and plant the same old crops, year after year, to the weariness and exhaustion of the soil? Or do we grow any flowers and things of beauty, to rest our eyes and refresh our souls, in addition to the homely and useful foodstuffs that we must have? For we owe more to ourselves than a living—we should make for ourselves a life, a very much wider, and a very much rarer thing. Page 108 Dr. Coleman has done us a service—not only in his choice of subject —but in his manner of approach. It is for us to welcome this paper, to read, mark, learn, and inwardly digest it—to make suggestions and criticisms, to invite further discussions on the subject—and ultimately profit by it. NEWS AND NOTES With reference to a paragraph which appeared in the North Shore Press, North Vancouver, on February 2nd, purporting to be a health article written by Dr. Grant Fleming and published by the Canadian Medical Association, the matter was immediately taken up by the Registrar of the College of Physicians and Surgeons here with Dr. Routley, Secretary of the Canadian Medical Association. He at once wired as follows: "With reference to article appearing columns six and seven, page two, North Shore Press, February 2nd, this was not prepared by Health Service Canadian Medical Association. Ap- . pears to be deliberate attempt at misrepresentation. Legal advice being sought as to how Association may secure redress." In addition a letter has just been received from Dr. Routley in which he says in part: "I can scarcely believe that any of the members of our profession in British Columbia would think for a moment that * the article came from the Canadian Medical Association. As a matter of fact not one line of it is taken from the the regular weekly Health Service which we are sending to the Press. I do hope you will give the widest publicity to the facts as incorporated in my telegram." Certain stalwarts in our ranks are nursing sick arms and feeling very sorry for themselves. We understand that they have declined to accept an invitation to appear before Mr. Justice Murphy to testify to the advantages of vaccination. The marriage of Dr. Taylor Henry to Miss Marguerite Neilson took place at Chalmers Church on January 27th. In extending our congratulations to the happy couple, separately and collectively, we take occasion to point out that there are a dozen or more desirable and more or less youthful and comely bachelors still at large in the professional ranks. We might recall the fact, well known to miners and others, that when a strike has been made, thorough working of the ground in the immediate neighborhood is often well rewarded. It will be four years before another leap year comes around: in the meantime " a fair field and no favours." We are glad to report that Dr. E. H. Funk, who has been seriously ill, is now convalescing. Dr. Miller Tait also is making a good recovery from pneumonia. Page 109 Dr. Lyon H. Appleby has left for Santa Barbara to attend the convention of the Pacific Coast Surgical Association. This explains the phenomenal prolongation of the hibernation season among Californian bears recently commented upon by southern naturalists. Our sympathy goes out to Dr. "Danny" McKay, who has been enduring erysipelas with fortitude if not patience. Dr. McKay was heard to say [Deleted in the interest of public morals:—Ed.] The name of the local doctor who has become a true believer in miracles (see a recent copy of the Province) and thrown away the crutches upon which he has spent about a year as the result of a visit to the corner drugstore where he received the most pleasant surprise of his life in the discovery of a new remedy—"a natural clay with marvellous curative powers, containing an extraordinary percentage of Iron as Oxides,"—would be greatly appreciated at the editorial office. If the manufacturer of this marvellous nostrum is not already an advertiser in the Bulletin, we intend asking our friend, the local doctor, to act as our advertising agent on a special mission to the aforementioned benefactor of humanity. SPINAL FLUIDS The Provincial Board of Health Laboratories, 763 Hornby St., Vancouver, B. C, is now ready to do, on requisition, Colloidal Gold Reactions on spinal fluids. At least 3 cc. should be supplied (to include Kahn, etc.) On spinal fluids sent in for bacteriological work, (menin*gitis-epi- demic, tuberculous, streptococcus, pneumococcus, etc.) routine (cell count, sugar, globulin, chlorides, etc.) will be done, on requisition, also. Spinal fluids from suspected poliomyelitis and encephalitis cases will, on requisition, be given a "routine" examination. In reply to numerous questions, charges are not made for any examination of material ( including the above) from any patient suspected of any communicable disease; the only charges made are for certain water, milk, sterility, etc. tests. TRACHEOTOMY IN CHILDREN Dr. Harold Dyer Unless parents welcome the preventive treatment of diphtheria with more enthusiasm than they shew for vaccination against small-pox it is certain that the general practitioner, if still allowed to treat sick children, will sometimes meet cases of laryngeal diphtheria with very urgent symptoms of respiratory obstruction. When he does he must be prepared to get air into the lungs quickly either through the obstructed larynx by intubation, or through an opening into the trachea below the vocal cords which are practically always the seat of obstruction. I venture to relate details of the last five urgent cases of this type. Minute details are given of the after treatment following the first sensational relief; because danger to life may become imminent at any moment till the child is Read before Vancouver Medical Association. February 1932. Page 110 breathing again comfortably through the natural air way and has done so for several hours without any sign of spasm of the cords or lung complication. There seemed to me so little in books to help one during this anxious period. As I had made notes of what happened directly after these cases had recovered or died, these notes and the conclusions drawn from them are presented to you for the help of those who meet such cass for the first time under similar circumstances and for criticism of those who have dealt with them in larger numbers or more effectively. The first one met with, in B. C, was in a small boy aged 2 years 6 months. The details of his early treatment show that we have travelled "some" since then. He had been ill 4 days when I saw him at 5 p.m. On August 11, a doctor had given him 500 units of anti-toxin early in the day. Later in the day another doctor had given him 2000 units and sent him back to his home, across the inlet. At 5 p.m. pulse and colour good. Resps. 27, insp. and exp. stridor well marked. Marked recession of lower chest and a little cough. Both tonsils and post-pharyngeal wall had patches.of white membrane. At 9 p.m. the dyspnoea was worse and 9000 units were given. At midnight the child had become restless and anxious looking. He cannot sleep nor lie still but is pawing the air for breath. Recession very marked. R.30-36. The boy was put on the kitchen table and chloroform given by a doctor. The lower end of the cricoid was identified with the forefinger of the left hand and fixed. An incision of Y^ to Y\ inch was made below this; trachea felt and a small stab incision made. It was not large enough to admit the tracheal dilator or tube. Very little bleeding but on air entering the slit dypsnoea soon became less urgent. The opening in the trachea was dilated with dissecting forceps, and a tube inserted. August 12, much better but much yellow mucus plugs the tube, (this tough mucus and the difficulty of dealing with it is not much emphasized in the text book account of the operation.) When you watch your cases for many hours after the operation you will find this mucus a constant cause for anxiety by blocking up the inner tube and also making a tough valvular flap over the lower opening of the outer tube which necessitates the removal of that tube almost every hour or two. August 13, better, but yellow mucus still plugs the tube. Both tubes removed at 5 p.m.. Much obstruction or spasm, child terrified dyspnoea severe, tube replaced. Child has been vomiting. Tube removed again during the night by the father but had to be replaced. August 14th, given 2-oz. milk, 2 hourly. Some of this came through the tube when drinking, but by feeding into the back of the throat with the head well back this was prevented. At 4 p.m. the tube was taken out and the boy settled down after anxiety and dyspnoea. In November 1922, I had my next case, a girl of 5. One of a family of seven children ranging from 6 months to 13 years, living with their parents in a small house. The children all had measles and about the sixth evening this child got a croupy cough which got worse all night. At 1 p.m., next day, I saw her and took a swab of the throat. At 8 p.m. I saw her again, the stained smear from the swab having looked suspicious to me. She looked very ill, R54: p. 156, so I gave her 10000 units Page 111 of antitoxin. All night she struggled for breath in a small back room on a low couch-bed. About 1 a.m., she was given 5 mins. of adrenalin and another 10 minims at 1:30. The child now seemed to be sleeping in spite of the stridor. She seemed to be breathing with less effort and less rapidly. I prepared to go home and had put on my coat in spite of the mother's anxiety, when I noticed that the respirations had fallen to 14 and were gradually ceasing as the child gave up the effort to keep going. The child was obviously dying, livid and blue lips. Heart auscultation showed it to be still beating but below 40 to the minute. Tracheotomy was performed with great haste. The father, a butcher by profession, held the head back over the pillow with one hand, with the other holding an ordinary electric globe of low candle power on an extension cord. The cricoid was identified with the forefinger of the left hand and the trachea below it rapidly cut into. Much purulent yellow matter poured out and was coughed out in a shower over everything around. Finally a thin cast of the trachea was pulled out with forceps. The child's colour instantly improved. Respiration restarted and continued. The father and myself looked after the child till a nurse arrived 8 hours later, the father being alone with the child in the house with only his wife and six other sick children for 3 or 4 hours. The tube was removed in 48 hours and did not need replacing. All the rest of the family had prophylactic treatment but one child had a mild attack of diphtheria. My next case, which occurred in 1925, is a painful record of disasters. The case was that of a boy aged 6, who was subject to attacks of bronchitis and pneumonia. He went to a school concert in thin clothes on a cold wet evening in April. Next day he had lost his voice and developed a clanging, croupy cough with spasms of obstruction to breathing. When seen the next day his fever was not high, P. 20, tongue clean, no cervical adenitis, has very big tonsils which do not appear inflamed. The spasms of coughing and laboured breathing recurred at intervals for six days, on the 6th morning he had passed the best night since the onset, because of Tinct. Camph. Co. repeated till asleep. He then had a severe attack of suffocation and was taken to hospital where he improved a little with steam tent and adrenalin. Two hours later he had a severe attack of unconsciousness from which he was rallied with oxygen. Taken to the operating theatre he was given ethyl chloride against my wish and ceased to breathe after a few inhalations. The trachea was opened as quickly as possible. Much purulent mucus escaped but there was no coughing and hardly any bleeding. A tracheotomy tube was inserted but artificial respiration and oxygen failed to restore respiration. Cultures of the interior of the trachea showed diphtheria. From this abortive tracheotomy I have learnt two essentials: (I.) Insist on chloroform as the anaesthetic or else use none at all. (II.) Choose a sensible helper whether trained or untrained; the "last straw" occurred when the boy on the table had ceased to breathe either from lethal dose of Ethyl Chloride or from respiratory spasm and the highly trained graduated nurse hesitated about giving me the knife because it had not been in the sterilizer for the official length of time. Page 112 The next case will only be mentioned briefly to compare it with the cases needing operation. It was that of a boy 4% years, who developed laryngeal diphtheria on the 6 th day after measles. He had all the ordinary signs of laryngeal obstruction except that the stridor was almost entirely inspiratory. A nurse and myself stayed with him almost continuously for 24 hours during which time we prepared several times to open his wind-pipe, but he ultimately coughed up a lot of stuff which he at once swallowed, about 27 hours after he had received 10000 units of antitoxin. The dyspnoea ceased from that time though the loss of voice persisted for another day. The last case was in February, 1927. Had had measles 5 weeks before but became ill again nearly a week previously. Last evening he seemed better and ate some supper but the difficult breathing and croupy cough had become worse on the morning of the day I first saw him, Saturday, February 5, at 1:3 0 p.m. (a typical day and time to meet with such a case.) A small boy with double stridor, cervical adenitis and both tonsils and uvula covered with a thin white film of membrane, T.99: P.20: R.40. He was given 20000 units one hour later and a nurse sent for. On arrival she refused to attend it without a prophylactic dose of serum. As she had once had diphtheria and twice had serum, the second time followed by severe urticaria. I got her to take the next ferry back to town. Another nurse arrived at 4:30 p.m. by which time the boy was more distressed, with much inspiratory suction of the diaphragm and attacks of air hunger. Till 6:30 p.m., I watched him when he seemed less restless and there was less stridor though resps. were 48. On my return at 7:15 p.m. he was lying as the nurse said, quietly asleep his face shaded by the sheet of an impromptu steam tent. He was breathing about 25 to the minute, livid in the face, with a slight convulsive gasp at the end of each breath. In fact he was just giving up the struggle for existence. He was carried, limp and flaccid to the kitchen table and a beer bottle put under his neck. With no anaesthetic nor cleansing of the surface the lower end of the cricoid was identified and the trachea opened below it through an incision ^4 inch long. Much coughing and bleeding but tube easily inserted and the boy was soon back in bed, breathing easily with steam kettle near, and with the edges of wound vaselined but no dressing and the tube tied in with string. February 6th, seen at 9 a.m., 2 p.m. and 7 p.m. Resp. became more difficult and stridor more marked through the tube as the day passed; at 7 p.m. he seemed in much distress and pulled out the tube which had been frequently removed and cleaned without relieving him. The mother was hastily sent to the fowl house to pull out some tail-feathers from the roosting hens. These were boiled and were inserted into the trachea both with the tube in position and out. Much mucus was coughed out and finally a tough green lump which had blocked the trachea and the tube. February 7th. Patient had a good night. By 6 p.m. difficulty of breathing was again very great in spite of several removals of the tube by Page 113 the new nurse. The tube was replaced and the trachea stirred low down with feathers. After much violent reflex cough tough membranous plugs were forced out and later much thin yellow purulent matter. As the time was now overdue for all membrane to have separated, and as there was some air getting through his larynx and also sputum which he swallowed after coughing, I left the tube out as it seemed to be irritating the trachea. The result justified this procedure as the boy recovered, to the relief of all parties concerned. These last 5 cases of laryngeal diphtheria have taught me more than many such cases in my interne hospital work, now many years ago. One thing is that the only safe course is to stay right "in touch" with these cases till the spasm and obstruction to breathing has completely ceased, whether tracheotomy has been done or not. Next to watch by the bedside continuously when the obstruction is severe. The respiratory centre seems to fail rapidly at the end. Probably the child at last falls to sleep exhausted, and with sleep, voluntary efforts stop and as asphyxia deepens the child slides quietly out of existence in its sleep. This moment when apparently sleep is present but in reality coma has supervened and the respirations have lessened in noise and frequency, is the crucial moment, I think, for operation, because: (1) The little child lies limp like a drowned kitten and can be put into any position with no frantic struggles nor terror to add to the difficulties. No anaesthetic is required. The trachea can be easily felt and quickly opened. If the worst happens and the trachea is not opened or, being opened the tube cannot be got into it, or if the wound is flooded with with blood and the child dies unrelieved on the table one feels that at least one did not hasten the child's end, and, most important of all the nerve racked parents have realised that it is a forlorn hope as they see the limp and apparently dead child lying motionless and silent and accept death as the inevitable. (2) I do not think the danger of heart failure is at all real. The heart beats vigorously in the early days of diphtheria till respiration fails and starts beating vigorously again as soon as oxygenated blood reaches it. There is probably little absorption of toxins from membrane in the larynx or trachea. (3) The child after hours of terror and misery wakes up to find itself resting in comfort, no longer with the awful feeling of suffocation and obstruction in the throat. With their first conscious cough they seem to realise that the hole in their throat is the only way by which they can get air into their lungs. For the first few hours they do not try to pull out the tube nor toss about wildly as all children do after an anaesthetic nor is there the serious complication of vomiting to be dealt with. Later when the tube gets plugged with mucus and obstruction is again felt the child may pull out the tube but in that time the tube will have worn a channel for itself and also for a little Page 114 air to get in and out when it is taken out to be cleaned or pulled out by the child. Feathers are still a necessity to me to keep the tube clean. Occasionally they must be pushed beyond the end of the tube into the trachea to excite an explosive cough and so clear the tube, but when this fails the tube must be taken out and cleaned. Sod. Bicarb, solution has been used to moisten the feathers and clean the tube. (5) After antitoxin has been given the spread of the membrane is arrested. It will ultimately loosen and separate even if the process causes increased temporary obstruction by its passage upwards through the larynx from the trachea. At any moment until the child has lapsed into unconsciousness a violent coughing or vomiting effort may clear the windpipe so effectively that almost natural breathing and good air entry may replace the struggle for breath of the few hours before. The anxieties to parents and doctors and dangers to the child for at least two days after tracheotomy are so great that, if there is any chance that they can be avoided by waiting, it is worth doing so till the last moment when there is no alternative. You are then fighting with your back against a wall, which is probably when most people are able to do their best work. At first the breathing will settle down quietly after the violent coughing and expulsion of blood and mucus caused by the intake of cold air and, generally, some blood into the air passages. Soon however, cough with increasing frequency and diminished effectiveness, will let you know that the child feels some obstruction to breathing and is trying to clear it away. Now is the time when much depends on the nursing. The attendant must stand by with a moist swab ready to catch the tough yellow stuff which is shot out of the tube only to be sucked back by the indrawn breath. Much depends on the skill and alertness with which this is done. After a time the coughing fails to expel the secretion and the child gets restless and tries to pull out the tube. Soon the dreaded moment arrives when the outer tube must be taken out to be cleaned. The inner tube which has been coughed »r taken out and replaced is taken out and cleaned. The outer tube is then pulled out followed generally by a burst of coughing and expelled purulent matter which should be wiped away before it has time to be sucked back. While the tube is out the inner tube can be re-inserted as it is effective in keeping open the track of the outer tube and as an airway. The outer tube is often very dirty, the lower end being often caked with dried yellow stuff which has to be scraped off with a small knife or scissors and then cleaned with Sod. Bicarb, solution and replaced. Occasionally it may be necessary to keep the opening patent with tracheal dilators while a feather is pushed down the trachea and twisted to dislodge loosening membrane. The dilators should however, be used as little as possible for a struggling, angry or frightened child. As soon as air is getting into the larynx through the hole in the top of the outer tube keep the tube out if possible as it is a source of irritation to the trachea. This happened in my last case when much thick discharge con- Page 115 tinued to block the tube at intervals although a whisper of voice had returned when the tube was out and after cleaning. The tube was removed with great misgiving but the thick purulent secretion soon ceased and air passed more freely through the larynx. There is a small oval hole in the top of the tube, which is, of course, useless at first. If much membrane has been coughed out via the tube, or when enough time has elapsed since the antitoxin was given to expect the vocal cords to be clearing, the opening of the tube is covered by holding a damp plug over the incision. This directs air through the oval hole into the larynx and so gets the vocal cords used to the air passing through them and minimises the chance of spasm when the tube is taken out. Often a husky cry or slight success in attempting to whisper will give one the clue that air is passing through the larynx as well as through the tracheal opening. Also the alae nasi will begin to work even with the tube uncovered, or dry cotton will be blown back and forth in front of the nose or mouth or with the cough and expulsion through the tube some of the stuff seems to get into the mouth and be spat out or swallowed. The wound should be dressed at once with vaseline, oil or any antiseptic ointment available in the house. The discharge is very septic and irritating to the skin which it will soon make very sore. The tube can be tied in with any piece of string or tape, boiled if time permits. Elaborate aseptic preparations must often be sacrificed to the need for speed. Have the instruments boiled if there is time; if not, use them straight out of your bag. The germs with which you are likely to infect the wound are harmless compared to those which will be sprayed out from the trachea opening over the wound and every person and thing near. Of intubation I know nothing. I once tried to do it in hospital under favourable conditions without success. I have watched skilled men do it in hospital but cannot imagine going away from a private bouse and leaving the child with nothing but an intubation tube between it and suffocation. Even the supporters of intubation admit that tracheotomy may become suddenly necessary if various probabilities happen. Also I have known, personally, of two children who could not do without the tube die after many weeks of terror and suffering. Dr. K. Gordon, of the London Fever Hospitals, used to teach an easy and effective method of operating, which I have never seen improved on. The lower end of the cricoid cartlage, which can be identified in the neck of the smallest infant, is located by the tip of the left forefinger. The finger is never allowed to leave this land-mark being held firmly pressed on it from above, the nail pointing downwards toward the sternum and overhanging the edge of the cricoid. This point is never left till the windpipe is opened. A small deep cut is made directly downwards from the edge of the nail in the middle line and about ^ to 1 inch long. The rings of the trachea may now lie exposed but if not they can be felt with a finger of the right hand. The bleeding should be checked if there is spare time (which is unusual.) A sharp stabbing cut Page 116 is made just below the nail of the left fore-finger and downwards. This can be done confidently in a poor light and in a wound obscured with blood. The only possible failure that I know of is that caused by a blunt knife cautiously used. This may go through the tracheal rings and push the lining mucous membrane or even the diphtheritic membrane covering it in front of the blade without dividing it. This happened to me once in a children's hospital and only the quick thinking of the anaethetist saved a disaster. Chloroform is the anaesthetic to use if any is required. It acts quickly, lessens spasm and so aids respiration. The blood is saturated with C02 so the risk of chloroform poisoning is almost nil. There is not much mucus and rarely vomiting after a short anaesthesia. There is no part of the human body the treatment of which by the general practitioner is not considered a gross presumption by the specialists for that area. The general practitioner will, however, acquire a status and dignity equal to the elite when he assumes the title of "Specialist in Emergencies." It is for this reason that I have ventured to bore you with the minutiae of the treatment required for the somewhat important emergency of a child choking to death. As such cases will almost always occur in the houses of the poor and can rarely be removed to well equipped hospitals for scientific treatment the specialty in this work will probably not become overcrowded. INFLAMMATION OF THE NASAL SINUSES By Dr. Colin Graham I have selected sinusitis in children as the subject of my paper this evening, for the reason that our results in chronic cases are so unsatisfactory, and the great majority could be checked so easily before they reach this unhappy state. Prevention is so easy and cure so difficult. The rhinologist cannot be critical of the general practitioner for overlooking infection of the sinuses in children, for it is really only in the last decade that specialists in this field have been alive to its importance and the frequency of its occurrence. A word first of all about the development of the sinuses. The antrum at birth is a cavity about the size of a small bean, situated above the inferior turbinate and internal to the orbit. The frontals are about the size of a small pea until the sixth or seventh year, when they begin to expand fairly quickly. The ethmoids are all present at birth, but the sphenoid is a mere depression in the bone and does not reach its full size until about the sixteenth year. The usual causes of sinusitis are acute rhinitis and influenza, a surprising small percentage date back to the acute contagious diseases. Quite Delivered before the Vancouver Medical Association, February, 1932. Page 117 a number come from swimming. There is here a difference of opinion as to whether it is a water-borne infection or not, some claiming that this plays only a small part, and that the infection is from bacteria present in the patients nose and throat. My own experience leads me to believe that most of these cases are caused by children bathing while they have some slight upper respiratory infection but that a severe infection of the sinuses can develop even with the nose and throat in their normal condition. A series of unusually severe cases which I once saw in a period of three weeks of fine weather, all giving a history of having been bathing in a pool a day or two previous to onset, supports this conclusion. Besides the local factors, there are, of course, those of the general system: poor living conditions and defective diet, improper clothing, lack of fresh air and sunshine, endocrine disturbances. A good deal of attention has been given to vitamins. In white rats a lack of A leads to purulent sinusitis; in human being it predisposes to sinusitis, but more so in children than in adults as the latter have a fair amount of it stored in the glandular fats. It is said that a preponderance of B over A leads to hypertrophic rhinitis, and the mucous membrane of the sinuses no doubt would be involved also, a condition unfavourable to the clearing up of infection. We see three types of cases: those tending to the hypertrophy just mentioned, those tending to atrophy of the mucous membrane, and those in which, in spite of a prolonged discharge, the membrane shows surprisingly little change; when the sinusitis has cleared up there is a healthy Schneiderian membrane. The factors favouring healing in untreated cases in children are good general health combined with good living conditions and care; the mucous membrane of the sinuses in children is naturally in a healthier condition than in adults, all of whom have had one or several mild or severe infections in the sinuses in the course of tbe upper respiratory inflammations of which we have all been the victims; the natural opening of the antrum (most cases in children are in the antra) is, relatively to the size of the cavity, many times larger than in adults; the drainage is, therefore, better. The unfavourable factors: the child runs about, taking no care to avoid all the things in his daily life which would be detrimental to his recovery; in his treatment he will not tolerate anything which causes much discomfort; infection of the ears with resultant otitis media and possibly mastoiditis is an ever present source of anxiety and a deterrent to methods of treatment which might be highly beneficial to the sinus condition itself. In surgical treatment we also encounter obstacles and problems which give us serious concern. Among the complications in younger children are mastoids, enteritis, cardio-renal affections, tonsillitis, meningitis and encephalitis. In older children not so frequently enteritis and mastoiditis, but arthritis, cervical adenitis, and bronchitis. When you see a child (and I might add that it applies equally well to adults) with a loose cough consisting of only one or two mild expulsive efforts at a time and there is a nasal tone to the voice, think at once of sinusitis with bronchitis as a complication. Page 118 An Important Announcement HALIVER OIL Abbott A new product having 60 Times the vitamin ffA' potency of Cod Liver Oil. Equal in Antirachitic Potency to Viosterol 250 D Ji.,a>. *»»OTTS ONE Abbott Laboratories offer to the medical profession the richest known source of Vitamins A and D—Haliver Oil (halibut liver oil) with Viosterol 250 D. So potent is this new product in Vitamins A (60 times the A content of cod liver oil) and D (equal to Viosterol 250 D) that ten drops once each day are .equivalent to three teaspoonfuls of high grade cod liver oil plus the Vitamin D value of ten drops of Viosterol each day. Small size of dose eliminates disagreeable features of cod liver oil. ONE 5 cc. bottle of Haliver Oil equals 300 cc. of Cod Liver Oil in Vitamin A Potency ONE You can start prescribing Abbott's Haliver Oil with Viosterol 250 D today for the prevention and cure of rickets and other skeletal defects; to promote growth; build resistance against nutritional and respiratory disorders; for pregnant and lactating mothers; and wherever cod liver oil or viosterol have been used in the past. It has been demonstrated that the interrelationship between Vitamins A and D makes both advisable for patients suffering from a deficiency of either. ONE 5 cc. bottle of Haliver Oil equals 5 cc. of Viosterol 250 D in Vitamin D Content Your druggist is stocked or can obtain Abbott's Haliver Oil with Viosterol 250 D in a few hours from his jobber. .Available in 5 cc. vials with .special droppers, and in boxes of twenty-five soft gelatin capsules. Daily dose to infants, 8 to 10 drops, or more; older children, 15 drops; adults, 20 drops or 2 capsules, or more. 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Nu-Kor Belt iM^c one Complete line of surgical belts, fitted by expert Corsetieres For further information call Sey. 7258 Office 445 Granville St. Vancouver, B. C. Diagnosis: The interference with general health may be slight or quite serious. Of the local symptoms the main one, of course, is nasal discharge, either mucopurulent or purulent; nasal obstruction; possibly some deafness; in the acute cases there is seldom great pain; in frontal sinusitis it rarely aproaches the severity it can attain in adults. Examination of the nose will show discharge in various places; particularly significant is to find it exuding around the middle turbinates. It is usually possible to get a good view of the child's naso-pharynx and pus can be seen coming from above the tips of the inferior turbinates, suction often gives valuable evidence. Transillumination is almost worthless in younger children and of very little value in the older, although here it may give some information in frontal sinusitis. The antra usually transilluminate well even in the presence of a definite infection, on account of the thinness of the bone through which the light passes readily. Radiographs do not give a great deal of help; my experience is that if you cannot make the diagnosis without them, you cannot make it with them. However, if cost is not a consideration it is always a satisfaction to make the examination complete. One may say that a discharge lasting into weeks is not simply an acute rhinitis which is slow in clearing up—it will not clear up because the one or more of the sinuses are involved. In the case of a unilateral discharge, one must not forget the possibility of a foreign body. In the latter case the discharge is usually of a thick dirty character with, very often, an odour, and the other side of the nose looks healthier in comparison to the depressed side than it does in a case of unilateral sinusitis. I have spoken of discharge as a prominent symptom and also of the unreliability of transillumination. There are exceptions to all rules. A boy of about 13 was sent in to me by the family doctor to see if I had left a piece of tonsil in an operation I had done a few years before, to account for a mass of glands on the left side of the neck. There was no tonsil tissue remaining and I felt satisfied that my snapshot diagnosis of T.B., which I had made from his general appearance when he came into the office, was correct. The nose and the nasopharynx were healthy looking and absolutely free from discharge. Transillumination however showed the left antrum dark, and it proved to be filled with foul pus. Attention to the antrum very quickly cleared up all the symptoms. Except for an occasional case of acute frontal sinusitis in children over 12, or an occasional orbital abscess suddenly demonstrating the presence of an ethmoiditis, most of the cases have reached at least the subacute stage when they come to us; they have a cold in the head which will not clear up, and it is very frequently because interference with hearing has been noted that we are consulted. I have said that very few of the chronic cases can be traced to the exanthemata. I think that the reason lies in the greater care given to these cases; they are kept in bed and then carefully watched for a time after they are allowed up, whereas following flu or mild upper respiratory infections they are soon turned out of doors. To my mind this is the clue to a very important point. More attention should be paid to Page 119 the common cold in children; if the discharge drags on, put the child back in bed, where it will be quiet and in an even temperature and keep it there until it is evident that it is well on the mend. I had a case recently which illustrated this very well. Following a cold the child had a nasal discharge for several week with no signs of it abating. The right side was clean but under the left middle turbinate was a stream of yellow pus from the antrum. In a very short time the nose was clean, in spite of the presence of large adenoids, the treatment consisting of little more than keeping the child in bed. I give these cases plenty of fluids and some alkaline treatment, drops of a fresh argyrol solution in the nose for a few days—if carried on longer it only seems to cause irritation—and drops of ephedrin in oil. To be effectual the medicine must reach the region of the middle turbinates, so the head must be thrown well back when the drops are instilled. Inhalations are frequently useful. If there are adenoids or diseased tonsils—and if tonsils are present in such a case they practically always are diseased—remove them as soon as one feels that the inflammation has reached the point of safety—that is, when it is merging into the chronic. While the child is under the anaesthetic I wash out the antra for observation of the character and amount of discharge. With proper supervision and after care this is sufficient to clear up the case in which pathological changes in the tissues have not advanced too far. However, it is not uncommon to get a history that the tonsils and adenoids had been removed on account of the nasal discharge, but without any material improvement. I wish to emphasize here the importance of following up these cases after operation. If the symptoms do not clear up promptly, treatment for sinusitis must be instituted, and the case not allowed to drag on into the chronic state when it is a curse to the child, the parents, and the rhinologist. Now when the case has become definitely chronic and the removal of tonsils and adenoids has failed to help, the trouble begins. We must use some cleansing treatment and nothing short of the bulb syringe or the douche bag is of much value. They do not entail much danger to the ears if the patient is carefully instructed and gradually trained. I have only had acute otitis as a complication a few times and these I could not attribute to the treatment, as they nearly all occurred during an intercurrent acute rhinitis, at which time the douche is stopped and the child forbidden to blow the nose vigorously. I have found nothing more satis- facory than the Nichols syphon douche, which even young children can be taught to use, but the process of teaching must be very gradual, at first a mere trickle of solution and the amount slowly increased. After douching, the membrane, cleared of all its protecting mucus, must be coated with some bland oil spray. If the syringe is used instead of the douche, the child is made to lean well ovet the back of a chair or placed face down on a table with the head extended beyond the edge, the tip of the nose and the ears being in the same vertical plane. Climate is another help we can call in to tide us over until Nature decides to get busy on the case. Many of these cases are comparatively free from symptoms as long as they are in the dry belt in the upper country. When these local measures, combined with attention to general health and hygiene, fail to give us results, we are forced to resort to surgery. A Page 120 radical operation is not to be considered before the second dentition on account of the mutilation of tooth buds. Again, radical intranasal surgery with ruthless removal of a large amount of turbinate tissue cannot be entertained; it is true this will clear up the sinus in most cases and the immediate result is a very happy one, but the final result is nasal discomfort and irritation for the rest of the patient's life. When one has seen a few horrible examples of this type of surgery, one is inclined to wish that access to the inferior turbinates had not been made so easy. One should start with the most conservative surgery which one feels will serve the purpose and this usually involves no loss of turbinate tissue whatever. The inferior turbinate is pried away from the lateral wall of the nose as if one were lifting up the lid of a box and the opening into the antrum made entirely underneath this structure. If this procedure is not successful, one must use more drastic measures. A series of two or more operations in any field seldom brings the surgeon any kudos, as you well know. No matter how carefully the whole subject is explained at the outset to the most intelligent of parents, it is of no avail if the first conservative operation is not successful, and furher interference is necessary. Such cases are truly a severe test of the patience of all concerned, and it is hard to resist the temptation to take a more reckless course. Nevertheless, the preservation of satisfactory nasal function is a duty which cannot be emphasized too strongly. A good deal could be written on the subject of the relation of nasal obstruction and discomfort to nervous irritability with all its reactions on the temperament of the patient and his enjoyment of life. If I have appeared to stress the difficulties of the rhinologist it is only that I may impress on you the importance of keeping the possibility of sinsuitis in children in mind. The general practitioner sees most of these cases. Prompt and insistent action on his part can do so much to prevent the development into the chronic state which means such a serious menace to the patient's health and comfort for the rest of his life. MEDICAL ECONOMICS (I.) The Reality of an Economic Problem To-Day Dr. R. E. Coleman Medical economics as dealt with in this and subsequent articles wLl cover those problems whose solution will insure that medical practice shall be an all round success; to the patient, to the practitioner, to the community and to the advancement of medical science. Theory would predict and experience has shown that failure of any one of these factors eventually affects all of the others. Of the whole chain of factors involved in this huge field the weakest link at present is that of income and for that reason will be chiefly dealt with. It is proposed to show that no other of the infinitude of medical problems, ethical, technical, social or scientific, needs more earnest attention at the present time. Economics really means the scientific correlation of all the factors involved in any device or mechanism for achieving a result; the principle Page 121 of all economics whether medical, military, mercantile, international or biological is the same—to secure a maximum of the desired results from a minimum of necessary expenditure. Economcs therefore differs from our ordinary conduct of affairs, in that it asks for a maximum of required returns, not of miscellaneous by-products; at a minimum of necessary expenditures, not a random, blindfold waste of time, energy and money in needless directions. Medical economics will necessarily therefore apply the general principle of securing maximum returns from medical activities with a minimum of expenditure of medical effort. Briefly we must cut our present waste of time, energy and money; and secure better returns to our patients and ourselves for less outlay. Are we physicians wasteful in output for the returns secured? Do we reverse the above mentioned principle of economics, and act.rather as if we wished to secure a minimum of required results from a maximum or unnecessary expenditure, instead of the scientific converse already advocated? For instance do we spend so much money on our initial training that most of us can never hope to get the cost back again in the limited number of years that we can look forward to as income producing? The medical graduate has been likened to a costly machine representing a large capital investment and a high running cost. The older physicians will think of other resemblances between themselves and machines, i.e. the frequent extension of working days and weeks to the physiological point that automatic reactions of the physician can alone be relied upon. If a business man were to plan such an investment he would do so with the object of making a profit. He would also calculate the probable life of the machine so that he could determine his "sinking fund"; that is, the amount of money he would have to put aside each year, so that when his machine was worn out he would have the money to buy another machine. Does any physician here in Vancouver operate such a sinking fund on his own investment? Since the machine would be expected to require power and oil, etc., he would also want to know what the maintenance cost would be. The human machine uses up materials also. Then too he would expect that parts of the machine would break and wear out from time to time and these items would have to be paid for, as well as the lost earnings during the shut down. The human machine is also subject to temporary breadowns. He would also pay some insurance company to assume the risk of partial or complete loss of the machine. ..We can insure the human machine against accidents and death. After carefully checking these items—profit on the investment, running costs, repairs, sinking fund and risks—the business man would estimate what would be the minimum hourly rate he would have to charge for the use of the machine. Does the average physician's fee even attempt to meet these requirements? If, as often happens, such a calculation sets a selling price that the market will not support, the machine is not purchased. How many parents planning to finance a medical course for their son would proceed with their sacrifices if they made such calculations? In actual life errors are often made in such calculations with the result that no profit is made on the machine. The business is then said to be a failure and the product goes off the market. Is our costly medical machine going to prove any ultimate exception? Sometimes too the salesman in selling a machine persuades Page 122 the purchaser that certain items of cost are negligeable, and that the market is good for the calculated price when actually the contrary is the case. The results in the end are the same as when the business man himself makes the mistakes. Is this not a true picture of those who sell the present investment in the preparation for the practice of medicine? How many recent medical graduates were not undersold on the cost of their preparation and oversold on the selling price of the market? That is, does the average selling price warrant the average investment? It was stated above that the various factors, such as profit to the patient, to the physician, to the community and to science, were interdependent, and that a progressive failure of any one factor would when of sufficient magnitude, eventually affect all of the other factors. If then, it is as suggested that there has been a failure to yield an average financial profit to the physician, how might such a failure be expected to affect the other factors and is there evidence that these effects are already demonstrable? In the field of business, after the investment has been made, if it is determined that no profit is being made, attempts are made to reduce the costs. One common expedient is to increase the quality and selling price of the profitable articles and decrease the quality and selling price of the unprofitable articles. (Is this not what the medical profession has done with regard to its technical, versus its thinking processes? Would anyone familiar with the actual practice of medicine care to compare the skill with which the average appendix is removed with the skill exhibited in the diagnosis? The same general trend is also apparent in the relative sale of surgical and diagnostic literature. Is any general practitioner without recent references in surgery and on the other hand how often does a general practitioner ever buy a reference book on diagnostic procedures after ten years in practice? Again if the early diagnosis of pulmonary tuberculosis yielded the same fee as an appendix operation how many open cases of this condition would we have walking about? Or in the case of a laboratory report how would the accuracy of the average interpretation compare with the average accuracy of the technician's reports?) In the field of business it is the common experience that when the cost of an article is reduced below the point at which its quality can be maintained, the consumer complains and the good worker loses interest in his product. If the selling price of the Rolls Royce motor car were forced down so far as to force a reduction in quality it is probably that the workers would feel even more badly about it than the consumers. (With regard to medicine today is not the public complaining bitterly and are not the general practitioners and internists bemoaning the financial, physical and emotional limitations as applied to careful diagnoses?) These and many other phases will suggest themselves to the hearer as strongly indicative that after all the practice of medicine follows the same sequence of economic events as is found in ordinary business. In the field of medical science a careful study shows the same factors at work. The emotional values here are so marked, however, due to antagonism to any correlation between scientific research and economics, that a detailed analysis will have to be presented later but the following Page 123 high lights are significant. In such industries as the automobile business research is provided for out of the reserves of the business and is eventually passed on to the consumer, each consumer contributing his part. How much scientific research is being carried on today out of medical reserves? Does the average consumer absorb any such costs in his fees? It is common knowledge that by far the most of it is carried on out of taxes and the financial reserves of unrelated industries, through endowment, etc. These are very dangerous systems as will be shown later. The present situation of our own University is a striking illustration. When we turn to the bearing of physical and emotional reserves on medical science we find the same thing. During the last fifteen years the entire medical profession of Vancouver has furnished but three active members of the B. C. Academy of Science. This in spite of the fact that there are known to be a number of physicians in practice here who had a good grounding in the sister sciences, and would, if they had the spare physical and emotional energy, be very glad to keep in touch with these sister sciences by this, the only means available here of doing so. Also in the field of scientific research here in Vancouver a number of researches have been carefully considered, but without exception they have been wrecked early, on the rocks of lack of financial, physical and emotional reserves. Thus we find that there is much in common knowledge which strongly indicates that the unsatisfactory economic position of the medical profession here in Vancouver has already reacted adversely on the patient, the practitioner, the community and the advancement of science. Though the individual factors have been very lightly touched upon a careful study of these individual factors over a number of years indicates very strongly that the more each one of them is investigated the more real and serious each one becomes. Analysis of the group problems, supplemented by personal investigation of individual cases in the different fields of medical or salaried practice, has shown that the weakest point in the whole system practice whether general practice, specialty practice, or private practice, has always been found to be the lack of information on the part of the individual physician and of the public, concerning the nature of the costs of modern medical services. We very truly say to the industries that if they will spend a little of their financial reserves in scientific research they will receive ample financial returns. These same individuals might with equal truth reply that if we would spend a little of our scientific reserves in scientific research into medical economics we would receive ample returns in scientific opportunities. In view of the above discussion it would seem that the various factors of medical activities are inseparably interrelated and that the present failure of the economic factor threatens all others. It therefore becomes the duty of the present generation of physicians to concentrate on this factor with the same intensity with which previous generations have concentrated on scientific and altruistic factors. For this purpose the same course should be pursued as was pursued in the past, namely by concerted study by the younger men. The older practitioners have some of the necessary data and general information but they lack the time and energy to study and correlate it. The younger men have both the time and energy to collect the data and to study the problem. Further the younger men of today are those whose very future depends upon the Page 124 results. I therefore urge that every young physician take some phase of this huge problem and for the next three years concentrate all of his spare energies on it. I myself have been studying the problem for years and for the last seven years a detailed study has led to the following conclusions. First, there is no phase whether scientific, altruistic or selfish that will not yield to analysis. Second, the whole problem resolves itself into one of relative values. Third, our own problem is but one phase of the general social structure to which the following quotation from Rene Descartes applies. "If ever the human race is to be raised to the highest practicable level intellectually, morally and physically, the science of medicine will perform that service." The reason for this is that in our costs we will eventually have to include certain physiological costs which only the medical profession is capable of appreciating and even the medical profession will be able to appreciate these factors only after careful study. What then will be the nature of our ultimate objective? It would seem at present that our objective will be accomplished when the physicians' fees or salary as the case may be are based upon time, divided by total cost plus profit. To determine the hourly charge rate the total anticipated number of hours actually spent with patients during the year will be divided by the total costs plus profit for the year. As I said above the financial costs will be hard to calculate but the physiological costs will be tremendously harder. Yet if these physiological costs are not calculated the time will come when the equation will again be as far out of equilibrium as it is now. Bay. 4234 L MRS. KATE PEGRAM C.A.M.R.G. Medical and Surgical Massage Electricity Remedial Exercises 1645 11th AVENUE WEST Vancouver, B. C. Office Sey. 2855 Res. Doug. 4682Y MISS BEATRICE GALLOP C. A. M. R. G. Graduate McGill University School of Massage and Remedial Exercises 419 VANCOUVER BLOCK Vancouver, B. C. Remedial Institute Our work conducted under supervision of trained instructors, endorsed by members of medical profession. Doctor's close contact with patient maintained by progress charts for medical reference TRINITY 1550 n. s. McDonald "Physical Culture" 804 Pender St. W. MISS ADA MARKHAM Chartered Masseuse, England. C.A.M.R.G. Canada wishes to announce that she has removed her offices from 924 to 931 Birks Building, Vancouver. Page 125 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 The Provincial Board of Health Laboratories 763 Hornby Street, Vancouver, B. C. Financed by The British Columbia Provincial Board of Health COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital, Victoria; Vancouver General Hospital; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster; Royal Inland Hospital, Kamloops; Tranquille Sanatorium and Kelowna General Hospital. All communications should be addressed to the Editor as above. Material for publication should reach the Editor not later than the fifteenth day of the month of publication. Vol. VI. MARCH, 1932 No. 1 UNDULANT FEVER IN THE OKANAGAN VALLEY By G. A. Ootmar, M.D. Director: Prov. Board of Health Laboratory, Kelowna, B. C. Since the Okanagan Central Laboratory started in 1925 we have performed as a routine, in suspected cases of Typhoid, agglutination tests for Typhoid and Para A. and B.; later for Para C. also. Notwithstanding the clinical diagnosis pointed definitely to Typhoid in several cases, the agglutination tests were negative through the course of the disease, even when different strains of the bacilli were used for the tests. One day, after trying to get a culture from a patient's blood, we obtained a very slow growing colony on blood agar, barely visible in 5 days. Subsequently these organisms grew readily on glucose agar and showed many coccoid forms, mixed with tiny rods, gram negative, non- motile, non gas- or acid-producing in glucose or lactose. The agglutination tests were as follows: Miss L.—May, 193 0— B. typhosus, B. para A and B—negative, 1/20 to 1/640; B. Melitensis—positive, 1/20 to 1/640. Investigating, we found that though the patient consumed raw milk, this milk was supplied by a dairy farm on which no cases of abortion in cows had ever occurred. This was our first experience with Micrococcus Melitensis and certainly not a very encouraging one as no source of infection was found. A short resume of the history of the disease and the germs may may proceed the history of our laboratory tests. Undulant fever, a specific infectious disease of the human, is caused by several varieties of organisms called Brucella. After Bruce, in 1887, isolated Micrococcus Melitensis from a man who died of Malta fever, and Bang, in 1896, isolated the causative agent of bovine contagious abortion, it was 20 years before Alice Evans (Journal of Infectious Diseases, XXII., 1918) discovered that Melitensis Bruce and abortus Bang are similar—nearly identical; that these organisms were not to be differentiated even by agglutination tests. The similarity of the two organ- Page 126 isms is indeed much closer than that between the organisms of typhoid and paratyphoid or of human and bovine tuberculosis. (J3. abortus prefers less oxygen than Melitensis.) In symbosis with a fast growing oxygen consumer, (B. colt) B. abortus grows well on Drygalski's medium. After some subculturing it grows more like an aerobe. Though these two are so closely similar, one gets the impression in reading several articles that there is not yet a general understanding as to their relationship. The French seem to suppose that the pathogenicity of Melitensis is greater than that of abortus. The symptoms of the disease are variable. Sometimes they resemble those of typhoid, sometimes the patient is suspected to suffer from malaria. When the symptoms resemble typhoid, they are milder as a rule and are spread over a longer period. The name of the disease suggests this. The long waves in the temperature chart, caused by the risings and fallings of the temperature, gave the disease the name of "undulant" fever; the usually more gradual onset of the disease makes it differ from typhoid and makes it difficult to fix the date of the beginning of the disease. The extreme weariness, the tiring easily, sometimes comes on gradually, sometimes, as in one of our patients (agglutination 1/640) only in the afternoon. He started to work in the morning, but was compelled to stop in the afternoon. Some complain of chills at regular intervals. The fact that sweating often takes place when the temperature falls often suggests malaria to the physician since the triad of symptoms —chills, fever and perspiration—are highly characteristic of this disease. Blood tests showing the absence of plasmodia and the presence of Melitensis are of course conclusive. (It is perhaps not impossible that some of the cases of "typho-malarial fever" recognized during the American Civil War may have been cases of Undulant fever). Influenza may be suggested by the complaints of pain and aches all over the body—the pain sometimes located in the back of the neck; while complaints of pain in the joints may lead to an erroneous diagnosis of Rheumatism. The disease is contracted through the use of raw milk, or the handling of placentae or fetuses from infected cows or even in the act of milking. Sometimes the virus enters the body through accidental wounds, incurred during the slaughtering of animals; or through wounds infected by articles soiled with the excretions of cows (saliva, feces, urine, etc.). In March, 1929, there appeared in an Okanagan Valley paper an advertisement for the sale of cattle from a big ranch. The advertisement read: ". . . . The cattle listed above are a nice type of Jerseys. There has been abortion in this herd but it would seem that the cows are starting to carry their calves the full period. All cattle tested for T. B. . . ." The animals were sold all over the Valley and it was after that date that the cases of undulant fever increased to such a number that in a manner of speaking one rather preferred to perform an agglutination test for Melitensis first, in suspected atypical cases of typhoid; doing the Widal for typhoid in the second place. Page 12? In 1930 we found a herd infected with contagious abortion on a farm. The historia morbi, for which we are indebted to Dr. A. S. Underhill, of Kelowna, follows: June 20, 1931—Boy. Age 9 years—living on the above mentioned farm. Came in complaining of headache, general malaise, and a tender spot on lower part of left breast. Had been quite well the day before. Temperature—102.4. Pulse—115. Head and neck—negative. Chest—a small red spot about the size of a flat bean on left breast, quite tender. Lungs—normal. Heart—normal. Extremities—a scar about half an inch long just above left elbow, just recently healed and no signs of inflammation around it. Said it was a barb-wire wound. June 21, 1931—He was irrational part of the night of June 20. A fair day, June 21. In the evening he had a convulsion and when I was called was irrational. Temperature—105.4. Pulse—160. Had restless night. June 22, 1931—Feeling better this morning and quite rational, but I decided to move him to Hospital. Temperature—102.1. Pulse— 135. Resp.—32. Blood count—7,200. Urine—normal. June 23, 1931—Seems a little better this a.m., although still very toxic. Had a fair night. Temp, was up to 103.3 last night, but down to 102.4 this a.m. Towards evening became irrational at times. Complaining of pain in right ankle. June 24, 1931—Not as good a night. Temp, up to 103.3 again. Restless this a.m. A red spot similar to the one on the breast appeared on lateral side of right ankle. Ankle not swollen. Complains of pain in right knee. Abdomen slightly distended and somewhat tense. Very little diaphragmatic breathing. Some tensing of all muscles and neck stiff. Respiration rate increased, and grunting with breathing. Chest still clear. June 25, 1931—Had a very poor night. Restless and irrational. Widals for Paratyphoid B. (1/20) show some agglutination in the lower dilutions—not typical. Some agglutination to B. Melitensis, (/80). Very toxic and irrational most of time. Pulse weak and rapid. Pericardial sack distended, 20 cc. of pericardial fluid withdrawn. (Later B. Melitensis was found in this fluid). A definite pleuritic rub now found at right base. Rales at base of left lung. June 26, 1931—Gradually getting worse. Very toxic and irrational and infection evidently general. Complains of being sore wherever touched, all muscles tense, abdomen almost rigid. Definite signs of pneumonia left base. Blood count now down to 4,700. Pulse very weak. Temperature, pulse, and respiration all up. Temperature finally reached 106.2 (rectal) before he died at 8:20 p.m. In September 1931, the mother of the ill-fated boy came into the Hospital with an "abortion." As a routine we have performed agglutination test for Melitensis in cases of human abortion to test the possibility of a relation between human abortion and a positive agglutination test for Melitensis. Dr. W. Knox kindly forwarded us in all cases of "human abortion" samples of blood to our laboratory and did also in the above mentioned case—in which the agglutination was positive (1/80). Page 128 It was not the first case in which we found a positive agglutination in human abortion and later on when we have done more tests we hope to publish the results of this investigation, together with the ones we started on domestic animals, as dogs, etc. As soon as the attention of the medical men had been drawn to this disease the diagnosed cases of undulant fever found in all countries of Europe and in America and Canada increased considerably. In the Report of the Twelfth Annual Meeting of the National Dairy Council of Canada (Winnipeg, March 18-19, 1931) we read on page 19— "This has become the "bete noir" of many dairy farmers. Many dread it more than tuberculosis. The Health of Animals Branch are assisting owners of herds in the control and elimination of this disease by making examination of blood samples, etc." We do not suppose that the examination of blood samples is sufficient or will eliminate the disease. Mr. Fred Smith, my assistant, to whom I am very much indebted for careful research, when performing test, in 1929 found that by testing the whey of the milk, there was sometimes a positive agglutination in the milk with a negative one in the blood and we therefore decided to do both milk tests and blood tests on the same animal at the same time. The following history of a cow shows how even the milk of the several quarters may differ. A cow bought January 2, said to be in calf had to be sired February 21, 1929. A dead calf was born September 29. Placenta lost October 9th. Sired January 29, abortion April 16. Sired May 22, was in season again October 26. It is not known if any abortion took place as this cow was in the pasture. Sired October 26. In season February 23, 1931. The farmer asked for a blood test, which was done February 27— positive for Melitensis up to 1/40. December 6, 1931, another blood test was taken. Negative for abortion. Milk of three quarters negative, positive in right hind quarter (1/50). The agglutination tests were done with different quantities of serum corresponding to dilutions. 1 in 25 = 0.08; 1 in 50 = 0.04; 1 in 100 M 0.02; 1 in 200 = 0.01; 1 in 500 = 0.004. Retained placenta is one of tbe symptoms of contagious abortion, but abortion itself has been regarded as the main symptom, though many times it does not appear and when it occurs it disappears after one or two abortions—giving the farmer the wrong idea that the "cow got over the disease." (See the above mentioned advertisement). Kelowna has a bylaw making compulsory the pasteurization of all milk from Grade B. farms. When an application came to sell raw milk from a Grade A farm we performed tests on 10 cows with the following results. No. 1—positive in blood up to 0.004. Positive up to 0.02 in 3 quarters, in one positive 0.04; No. 2—positive in blood up to 0.02, positive up to 0.02 in two quarters, up to 0.08 in one—while negative in the fourth; No. 3—negative in blood. Positive in all quarters ( in one very slight) up to 0.08; No. 4—(not milking) positive in blood; Page 129 E No. 5—negative in blood and also in 3 quarters, in one positive up to 0.004; The bull (2 years on farm) negative in blood; The farmer himself positive in blood up to 0.02. The two cows, No. 3 and No. 5, were both negative in blood, but positive in three or more quarters. Though there seems to be a wide variation in human susceptibility, the fact that nothing definite is known about the variability of the pathogenicity of the organism decided us not to allow the milk of these cows to be sold unpasteurized. The patient reader of this article will perhaps ask for what reason we tested the bull and also why we tested the non-milking cows. There is a widespread belief among the farmers that the bull carries the germs —that heifers are free before they become pregnant. As the organisms are not found in the uterus except during pregnancy and a few weeks after delivery, it was highly improbable that the bull would be positive— notwithstanding that he sired 4 postive cows. When the cases of contagious abortion increased, some farmers took measures to have their herds treated. This treatment consisted in: (a) Injection with killed bacteria. Whereas in our Laboratory we barely have time to attend to all routine work, Mr. Smith was so kind to give his few spare moments to this research. In order not to take too much advantage of his offer, we only tested two cows, which had aborted several times and which were injected in 1930, fourteen days after the last abortion. Cow B—negative in blood and in milk of all quarters. Cow L, No. 1—had two abortions treated 2l/z years ago. Positive in blood up to 0.02. Negative in all quarters. (b) Injection with living bacteria. The fact that the cows fail to show the symptoms of abortion after one or two abortions suggests that if living organims were to be injected (prior to conception or during pregnancy) they might stimulate the formation of antibodies. We tested two cows thus: (Injected, 1930) Cow L., II.—Positive in blood up to 0.004; Positive in all quarters up to 0.004; Cow L., III.—Positive in blood up to 0.004; Positive in the two forequarters up to 0.004; Negative in right hind quarter; Positive in left hind quarter up to 0.04. One and one-half years after this treatment the cows showed positive reactions. We must object to the use of the living organisms for control of the symptoms of abortion, since it may make the animals carriers of the infection. It is of the utmost importance from a health standpoint that this treatment should no longer be allowed. Conclusions Faced with the seriousness of the situation, the time has now arrived, in my opinion, to perform, in all cases where test for typhoid and paratyphoid are required, an agglutination test for undulant fever also. According to our experience it is highly imperative that infectious abortion of animals be included with the diseases dealt with under the Animal Contagious Disease Act in Canada; consequently becoming a notifiable disease. Page 130 MEAD JOHNSON & Co. of Canada, Ltd., Belleville, Ontario TheT onic Up-To-Date Fresh liver and spleen . . . for bloodbuilding Cod liver oil for its food value Malt extract . . . for its nutritive influence Hypophosphites .... for remineraliztttion combine to make WATERBURVS COMPOUND Plain or with Creosote and Guaiacol the preparation of choice as a tonic and reconstructive at every age period, at every season of the year. Its palatability is unusual—no oily taste or odor. A bottle of each form is at your service. 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The Vancouver Medical Association Bulletin: March, 1932
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