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History of Nursing in Pacific Canada
Vancouver Medical Association
'Syphilis in general practice ; The treatment of syphilis ; News and notes.' -- Title page
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STRAND THEATR.65-BLDG. wmc^mmmcmADA ANDERS' VITAMIN CREAM A compatible balance of Vitamins A. B. C. D. E. in a natural colloidal suspension with 50% biologically tested COD LIVER OIL Made up fresh everyday Costs patients $1.00 for 8 ounces 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 abovi address. Vol. VIII. DECEMBER, 1931 No. 3 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- Dr. A. M. Agnew_. ..Chairman —Secretary Eye, Ear, Nose and Throat Dr. J. A. Smith i Chairman Dr. A. O. Brown , Secretary Pediatric Section Dr. C. A. Eggert Chairman Dr. S. S. Murray Secretary STANDING COMMITTEES Library Dr. D. M. Meekison Dr. W. H. Hatfield Dr. C H. Bastin Dr. C H. Vrooman Dr. C E. Brown Dr. H. A. Spohn Dinner Dr. J. E. Harrison Dr. H. H. Pitts Dr. N. McNeill Rep. to B. C. Med. Assn. Dr. H. H. Milburn Orchestra Dr. J. R. Davies Dr. F. N. Robertson Dr. J. A. Smith Dr. J. E. Harrison Publications Dr. J. M. Pearson Dr. J. H. MacDermot Dr. D. E. H. Cleveland Credentials Dr. A. J. MacLachlan Dr. A. Y. McNair Dr. T. L. Butters Summer School Dr. C E. Brown Dr. T. L. Butters Dr. C. H. Vrooman Dr. J. W. Arbuckle Dr. H. A. Spohn Dr. H. R. Mustard Hospitals Dr. W. C Walsh Dr. F. W. Lees Dr. A. W. Bagnall Dr. F. J. Buller V.O.N. Advisory Board Dr. Isabel Day Dr. H. H. Caple Dr. G. O. Matthews Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT STATISTICS, OCTOBER, 1931 Total Population—Census 1931 24 5>3 ° 7 Asiatic Population (Estimated) i 15,000 Rate per 1,000 of Population Total Deaths Asiatic Deaths Deaths—Residents Only Birth Registration Male 193 Female, 188 INFANTILE MORTALITY— Deaths under one year of age Death Rate—Per 100 births Stillbirths (not included in above) CASES OF CONTAGIOUS DISEASES REPORTED 181 16 159 381 13 34.1 8.7 12.6 7.6 18.3 IN Smallpox —~ — Scarlet Fever Diphtheria - Chicken Pox Measles 1 Mumps Whooping Cough Typhoid Fever Paratyphoid Tuberculosis Poliomyelitis Meningitis (Epidemic) Erysipelas Encephalitis Lethargica September, 1931 Cases Deaths 0 0 8 0 0 0 0 0 0 1 5 3 2 16 ■"' 4-' h'# 58 •~9 0 3 0 17 0 0 0 0 October, 1931 Cases Deaths 0 24 6 18 14 20 14 2 0 68 1 0 0 0 0 0 1 0 0 0 0 0 0 17 0 0 0 0 CITY November 1 st to 15th, 1931 Cases Deaths 2 5 7 20 19 13 12 1 0 38 1 0 2 0 The oral administration of Pyridium in tablet form affords a quick and convenient method of obtaining urinary antisepsis when treating gonorrhea and other chronic or acute genitourinary infections. Pyridium quickly penetrates denuded surfaces and mucous membranes and is rapidly eliminated through the urinary tract. In therapeutic doses Pyridium is neither toxic nor irritating. Pyridium is available in four convenient forms: as tablets, powder, solution or ointment. Write for literature. MEI|§f«jlilil ;4|^5i^}pie^f^i|MDNTREAL Page 43 Before and after the baby comes— SQUIBB Viosterol / Palatahility, small dosage, high potency, make it invaluable for pregnant and nursing mothers The necessity for providing mothers with Vitamin D during pregnancy and lactation is twofold: 1. To help protect the infant against rickets. 2. To safeguard the mother against dental caries and other harmful effects of faulty calcium metabolism. Proof that a highly potent source of Vitamin D, like Squibb Viosterol in Oil-250 D, may give human milk the power to help prevent bone deformities in Infants, has been offered recently by Gerstenberger. He found that by adding Viosterol to the diet of wet nurses under his care, he could make breast milk markedly anti-rachitic. Under ordinary circum- stances, human milk contains practically no Vitamin D. Viosterol in Oil-250 D has these distinct advantages as a Vitamin D supplement to the diet of pregnant and nursing mothers. Base of administration—The dosage is small and is accurately regulated by a standard dropper enclosed in the package. Palatahility—It does not cause digestive upset because of the small amount of oil taken. Specific, rapid action—Viosterol has 250 times the anti-rachitic potency of standard cod-liver oil, as shown by biologic tests. Thus it assures prompt, certain results. In protecting expectant and nursing mothers with Viosterol in Oil-250 D, take one extra precaution. Specify Squibb's! Squibb Viosterol in Oil-250 D is prepared by a special process which keeps the solution from turning rancid and protects it against loss of anti-rachitic potency. Tell mothers always to ask for Squibb's— the Viosterol in the blue bottle. mmmm^mm MANUFACTURED UNDER LICENSE FROM THE WISCONSIN alumni research foundation and accepted BY THE COUNCIL ON PHARMACY AND CHEMISTRY, A. M. A. You expect . . . from us the purest, freshest Drugs, immediate service, any hour of the day or night. You receive . . . from us the purest, freshest drugs, immediate service, any hour of the day or night. Seymour 1050 Georjjpa Granville a.t Qeort^ia^ Open All Night REST HAVEN SANITARIUM On Marine Drive, near Victoria, B. C. Practicing Physicians and Surgeons are invited to send their chronic or convalescent patients to Resthaven. High Blood Pressure and Diabetic Diets prepared and administered by competent Dietitian. Your instructions carefully carried out. Qualified physician and nursing staff in attendance. Write, Telephone or Wire Manager, Rest Haven, Sidney, B. C. Telephone Sidney 61L. or 95 — Rates are no higher than Hospital Rates — 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 Sth—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 16th—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 2nd—GENERAL MEETING. The Osier Lecture: Dr. F. P. Patterson. March 16th Apri -CLINICAL MEETING. April April- 6th—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. 20th—CLINICAL MEETING. -ANNUAL DINNER. Page 44 EDITOR'S PAGE In responsive c tures: ii a recent issue of Life appears a cartoon which will sound a hord in any medical man's breast. It consists of two pic- n the upper one a doctor, standing by the bed-side of a sick child, is saying to the father and mother, who are hanging on his words, "The crisis has passed." In the lower, the father is making out the monthly cheques, and is saying to his wife: "We can pay all the bills this month, dear, except the doctor's." There is nothing new about this, though, appearing as it does in Life, one remembers the days somewhile ago, when that purveyor of wit and humour was rather bitterly anti-medical in its attitude. But at the same time it makes one think again. It would be interesting if one could get a true record, complete and detailed, of the amount of work done by the medical man, for which he could and should be paid a fee, but for which he never is—and to the doing of which, without remuneration, he has become more or less resigned. We do not here refer to ordinary "charity" work, or even, for the purposes of this writing, to the unremunerated work done for the charges of the city and province, whose every other need is paid for in cash. The work we refer to is the endless number of reports, certificates, affidavits and so on, which we are evidently expected to fill out and sign, as a matter of course, and with regard to which we never hear any mention of payment. A man dies, leaving his widow more or less penniless. The bill for his care is no longer collectable, and his doctor abandons any hope of that. But there was a small insurance policy, enough to give him a good funeral, and pay the undertaker's charges, only, in order to secure this money, the doctor must give a certificate. The notary who witnesses his signature charges and receives a small fee—how often does the doctor charge or receive a fee for this service? Then the widow applies for mothers' pension. Again, there are reports to be made; needless to say, no payment is made for this. Or we send a patient to the City Relief Office. Straightway comes a polite request for reports, and from time to time we are expected to make other reports. And other instances might be given. The point is, that all these reports are vital. On them turns the whole question of the payment of money due. Making these reports, writing these certificates, takes up our time and calls on our knowledge and training, which are our living, the only commodity we have to sell—why do we not insist on a fee? In justice to ourselves, our wives and families, we should do so. Many of our financial troubles are our own fault, the remedy for them lies in our own hands, and here is one thing that gives us a starting- point: but it is only one. It is time that organized medicine took up, seriously, the whole question of medical economics. We should not only survey the field, and pass pious resolutions. We should be prepared to go to governmental bodies, and state our case—not graspingly or unreasonably, but as a matter of ordinary honest and common fairness, we should make it plain that we are awaking to a sense of our own reasonable dues—and that we are determined to insist upon them. Pan 45 NEWS AND NOTES The North Pacific Surgical Association meets in Vancouver on December 4th and 5 th. The officers of the Association have kindly extended an invitation to the profession here to be present in the Hotel Vancouver, on Friday, December 4th, at 8:30 p.m., to hear Dr. William Boyd, of Winnipeg, speak on "Intracranial Tumours." The Paediatric Section entertained Dr. Clifford Grulee and Dr. J. I. Durand at dinner at the Hotel Georgia, on November 2nd. At the dinner Dr. Grulee and Dr. Durand discussed the formation and constitution of the newly formed American Academy of Paediatrics which had arisen out of the White House Conference on Child Welfare. The Annual Dinner of the Vancouver Medical Association was held at the Hotel Vancouver, on November 14th. The Committee in charge very wisely had reduced the price of the tickets in view of the prevailing depression and its wisdom was attested by the attendance, which was the largest on record, 166 men being present. The programme went with great smoothness and everyone appears to have had a good time. A particularly pleasing feature was the presentation to Dr. A. P. Proctor of the "Prince of Good Fellows Degree" and from expressions of opinion heard on all sides no more suitable choice could have been made by the Executive nor one more gratifying to the members at large. Dr. H. H. Pitts and his committee are to be congratulated on the success of the dinner. Pari passu with this event there was in progress a very successful dinner and whist drive at the Georgian Club arranged by the doctors' wives, with an attendance of eighty. In reference to the notice that appeared in the last issue of the Bulletin regarding the new Nomenclature of Diseases, Mr. Fish, of the Records Department of the Vancouver General Hospital, has asked us to say that copies of this book may be obtained from him at a small charge. Many of our members will no doubt feel that they should have a copy in order to conform with the system advocated. Dr. R. E. McKechnie has been honoured by election to the Council of the Royal College of Physicians and Surgeons of Canada and represents British Columbia on the Council. Dr. G. F. Strong was invited to address a meeting of the King County Medical Society, Seattle, on November 9th, when he gave a paper on "Hypothyroidism." Dr. Alfred W. Bowles (McGill, 1919) who has been associated in practice with Drs. Gunn, Hackney and Shore, of Calgary for some years, has opened offices in the Westminster Trust Building, New Westminster, and will specialize in Eye, Ear, Nose and Throat work. Dr. Bowles recently spent two years in Europe in postgraduate study. The Royal Commission to enquire into the question of Chiropractic and Drugless Healing will open on November 30th. The Commisisoner Page 46 appointed is Mr. Justice Murphy. The B. C. Medical Association is associating itself with the Council of the College of Physicians and Surgeons in the heavy work which such a Commission will necessarily entail. Dr. E. L. Reid, Ear, Nose and Throat specialist, formerly of Nelson, has opened offices in the Vancouver Block. Dr. A. W. Hunter was chosen President-Elect of the Western Branch of the American Urological Association at the Seventh Annual meeting ir San Francisco. The 1932 meeting will be held at Portland, Ore., July 1st and 2nd, 1932. The November General Meeting was held in the Auditorium of the Medical-Dental Building on Tuesday, the third of the month at 8 p.m. Dr. C. W. Prowd, President, was in the chair and seventy-seven members attended. The following men were unanimously elected to membership: Drs. C. E. Davies, H. A. DesBrisay, A. K. Haywood, J. R. Naden and C. A. Ryan. SYPHILIS IN MEDICAL PRACTICE H. A. DesBrisay, M.D. Vancouver, B. C I am to speak on syphilis, a rather time-worn subject—time worn, but still most absorbing—full of many unsolved and perplexing problems. My remarks will be in the nature of a very brief review of a vast subject, and reiteration of some well known facts. Syphilis, it is generally agreed, was brought from the Island of Haiti, by the sailors of the Columbus Expedition, to spread over the old world like a conflagration on a fresh unresisting soil. This then new enemy to mankind roused mediaeval medicine from its stupor, so in a sense we owe syphilis a somewhat doubtful debt of gratitude. Although the progress of medical science was rapid from that time, and although syphilis has been attacked as possibly no other disease, it still remain a public health problem of great magnitude, and always a problem to every physician. With the discovery of the spirochaeta pallida in 1905 and then that of the direct spirochaeticide—salvarsan—hopes were high for its eradication. One or two doses would often apparently cure. There seems no doubt but that the inadequate treatment that followed the introduction of salvarsan produced a mere postponement of infectivity and hastened severe relapses. At any rate there has been no special decline in the amount of syphilis; and now after a four hundred year start, the disease is firmly established. Our problem as medical men is to recognize syphilis in all its stages, to unearth it and prevent its sprea.d. Do we realize its prevalence? How often we are tempted to feel that it is impossible for certain individuals to have the disease. "Why," one says, "I have known this man and his family for years and syphilis is out of the question. There is no history of such a thing. Anyway, someone took a Wassermann and it was negative." I wish to emphasize first the incidence of syphilis, second, the unreliability of the history, and third, that the blood reaction is to be looked Delivered before the Vancouver Medical Association, November, 1931. Page 47 upon as only one corroborative sign. I wish to show how these facts have to be considered in our daily struggle. Now syphilis, a venereal disease by circumstance, (because the spirochaete is an anaerobe and grows best in dark corners) is a subtle disease, often lying dormant, forgotten or unknown, its effects appearing in later years as a result of the insidious gradual destruction of tissue. Osier's statement that in the late stages syphilis may simulate almost any condition met with in medicine, is a byword, but we may almost amend this to say—may simulate almost any condition, and yet show a negative Wassermann. The Prevalence of Syphilis—In the Laennec Clinic in Paris, dealing with general medicine, 15% to 18% of the women and 21 °/o to 28% of the men had syphilis (1). In private practice it is usually found that at least 5% of patients can be proven to have syphilis. To this consideration must be added the number of syphilitics who pass through our hands without detection of the disease and the large army who never seek medical advice. There are in the United States alone, according to Hazen, about eight million syphilitics, or about one in eight or ten. (This figure of course is partly due to the large negro population). It is said that one death in nine is due to syphilis and that syphilis costs the United States five billion dollars annually. Now let us look into the value of the history of syphilitic infection. The primary lesion often escapes the patient's notice and frequently the secondary manifestations are so slight as not to be observed. In an article written (2) in conjunction with Dr. J. H. Stokes, we pointed out that of 255 patients with late syphilis, 52.5% did not know they had acquired syphilis, and 41% were not aware of having had any venereal disease. 27.5% only could give a history of a genital sore, and only 10% could give a history of secondaries. The history is found to be unreliable in at least 25% of men, and 6Q(% of women. The Value of the Wassermann Reaction. The Wassermann and Kahn reactions, while probably the best single tests of luetic infection, after the dark field examination, that we have at our command, are not absolutely specific and a blood test does not prove the absence of the disease. In the previously mentioned article we noted that approximately 30% of late syphilitics, even though untreated, had negative blood Wassermanns, and that of the total number of untreated and partially treated cases, as high as 55% may show negative blood tests. Neurosyphilis especially, shows the greatest percentage of negative blood Wassermanns, seventeen out of 225 patients (7.5) were serologically negative, but still symptomatically progressive. Visceral lues shows the highest percentage of positives. A single positive reaction in the absence of other clinical proof of syphilis should never be blindly accepted as proof of the disease. To understand our cases better as we study them and treat them, let us keep before our eyes the pathologic picture of syphilis, essentially the same in all stages—the perivascular cellular infiltrations of the exudative stage, later the obliterative endarteritis with necrosis, and often areas of gummatous formation of the degenerative stage, followed by connective tissue overgrowth of the productive stage. Page 48 To some extent the pathological pictures tally with the various clinical stages. The chancre is a type of local tissue reaction (3), differing fundamentally in no way from the thousands of lesions produced in miniature during the secondary features, nor from the gumma, except that in the latter we have an additional factor of allergy, with tremendous local hyperplasia and coagulation necrosis. The relatively mild reaction to the spirochaeta pallida is the reason for the insidious course and the latency (or better, concealment). It seems as if there were almost a tissue indifference on the part of the host to the organism (a sort of passive resistance, which may however occasionally win out in the end). In most cases no violent storm is roused, no proper antibody formation, as we know it in bacterial disease, produced, and therefore immunity to syphilis, as we accept the term, does not exist; making the prospects for a curative vaccine or serum seem hopeless. Syphilis is a constitutional disease long before the time of the primary lesion. Pearce and Brown have shown that even castration within 48 hours following inoculation of the rabbit's testes with the spirachaeta pallida, will not prevent the general infection of the animal. We must constantly remember then, that a patient probably has a generalized syphilis two days after infection. The course of the disease after this distressingly short period of grace depends upon several factors: (3) (I.) The organism, of which there are probably several strains; (II.) the host; (III.) accessory factors, constitutional, infections, trauma, etc., and (IV.) treatment. Although it is customary to divide the course of syphilis into three stages, we cannot speak of the various manifestations in terms of time. There is ever an unpredictability in any individual case. Why does one man, twenty years or more after infection show little or no obvious effects, and why does another poor soul come in with a definite myelitis two months after infection? What reasons underlie the diffuse, malignant cases such as Warthin and others have reported, where practically all tissues, especially the myocardium, suffer vascular damage unto death? The host with his physiologic defense of unknown amount is probably the largest factor. The defense mechanism is apparently resident chiefly in certain tissues, as the skin and bones and viscera, and this physiologic defense depends upon the presence of organisms in the tissues. These organisms may apparently be absolutely latent for a time as seen in the heart of congenital syphilis, which, while rich in spirochaetes, may yet function perfectly, with no visible signs of degeneration: such latency is, no doubt, responsible for occasional spontaneous cure, and the mildness of some cases. Let us take care then, that we do not upset the patient's immunity balance with rash and insufficient treatment. Remember that allergy may be artificially produced by inadequate therapeutic attack. Miraculous symptomatic results may be followed by structural explosions. The secondary stage represents a tremendous shower of spirochaetes throughout all the body tissues. Lumbar puncture at this time frequently shows at least a meningeal involvement (4) (5) of the nervous system, and yet the eruptive lesions, as pointed out, may be so slight as to escape notice in some 90% of cases. The response of the bodily tissues to the Page 49 invaders is usually effective in killing off the greater part of these, and the few remaining are held partly in subjection as it were, to await their time, in nooks and corners of the nervous system or other organs, (landlocked organisms) but by their presence producing local tissue changes (premature senility). The seeming years of immunity have been purchased at a great price. I shall not attempt to describe in any detail the protean manifestations of syphilis, but I do wish to emphasize the necessity of having a suspicious mind when examining patients. Kolmer's maxim is "always suspect syphilis, but be slow to diagnose it." I shall try to illustrate the necessity for alertness, by citing a few facts and mentioning a few cases. The primary lesion may be insignificant, masked or almost inaccessible to examination. I recall one case of urethral chancre with no external lesion, but in which the thickened penile lymphatics and the inguinal bubo led to its detection. (Cherchez le bubon). Secondary Syphilis, easily overlooked, is illustrated in the case of a middle-aged married man who showed on the palms of the hands recurrent secondary lesions, which had been diagnosed as the desquamation of scarlet fever. Another example is that of a young man with an erythematous scaly, and slightly moist eruption in the gluteal folds, which I thought was an eczematoid dermatitis, until a confrere demonstrated living spiro- chaetes from the lesion. Latent Syphilis, (concealed syphilis), showing no outward signs, is a problem which may necessitate repeated blood tests, provocative tests, and lumbar puncture. These cases are often of conjugal origin, where the disease is first found in the marital partner. Indeed, it is this type of case that brings the percentage of innocently acquired syphilis up to about 20%. The wife or husband, and the children of every luetic, should have a complete investigation, and not merely a blood test (3). While a patient may be considered non-infectious toward the fifth year of the disease there are exceptions, and Eberson and Engman have shown that infection may lurk in the semen of the latent syphilitic. The late skin lesions are frequently ignored. A patient seeking relief for poison ivy exhibited also on his skin a typical tertiary syphilide, which he had been aware of for months, but he paid no attention to it, because it had caused no distress. Complete examination of such a patient usually shows no central nervous system involvement. It is a peculiar fact that late syphilis of the skin and bones, and often of the abdominal viscera, appears to protect the nervous system. ■ Here it may not be amiss to briefly touch on the tertiary skin lesions, the nodular, squamous and ulcerative types. We look for several characteristics—serpiginous border, induration, destruction of tissue, with peripheral extension, scarring and pigmentation. A characteristic lesion wrongly diagnosed is shown in the follow- Female—age SO—nodulo-ulcerative syphilide of the neck, which had been diagnosed as cancer and been treated by X-Ray for several weeks. Under anti-luetic treatment it healed rapidly. Lues of the mucous membranes may be easily mistaken for a malignant growth, as in the following case: Page 50 Female—age 40—ulcerative, destructive, fungating lesion of the pharynx, diagnosed epithelioma. Blood Wassermann four plus. Within two weeks after treatment was begun, the lesion had practically disappeared. Gastro-intestinal. A not infrequent initial complaint is stomach trouble. Gastric symptoms, even after the definite crises of tabes have been excluded, are present in about 25% of cases with late syphilis. From reliable reports it is shown that more than 10% of tabetics have needless operations (usually abdominal) performed at least once, because of mistaken diagnosis. In addition to neurosyphilis as a cause, these gastric symptoms may of course be due to involvement of the abdominal viscera. Syphilis of the stomach itself is an occasional finding. Stokes, in examination of 200 cases of lues whose complaint was stomach trouble, found 4% who had definite gastric syphilis. 70% of the 200 cases, however, had neurosyphilis. The Liver suffers insult in all stages of syphilis. Irgang and Sola found with the Van den Bergh test evidence of hepatic involvement in 25% of untreated cases, although none presented symptoms that could be interpreted as hepatic. It is a point of interest that we frequently see patients with duodenal or gastric ulcer and syphilis, perhaps latent, whose gastric symptoms improve greatly under antiluetic treatment. It is not suggested that peptic ulcers are caused by syphilis but merely that the lues is a further aggravation and retards healing. Case—Mr. G., age 52—Typical history and findings of duodenal ulcer of three years duration. Blood Wassermann positive. On ulcer treatment alone patient had considerable distress. He neglected the taking of anti-syphilitic treatment for another year during which time he had periodic distress. Within one week of the beginning of anti-luetic treatment, his pain and all discomfort had disappeared. Syphilis of the intestines is so rare as scarcely to be considered. Even the old textbook syphilitic stricture of the rectum is very uncommon (7). Cardio-vascular syphilis is considered to be the cause of 15%— 25% of organic heart disease. 50%—75% of syphilitics in the late stages have at least an aortitis. Aortic insufficiency in a patient of 40 or over should be considered as due to lues unless proven to be caused otherwise. Fully 75% of these cases have a syphilitic origin. Whereas patients with rheumatic heart disease may have had symptoms for years, those with syphilitic lesions have but rarely suffered for three years from symptoms, the two most important being a sense of substernal oppression and paroxysmal dyspnoea. Case—Mrs. W., age 45—Complaint—dyspnoea and substernal pain of three years duration following influenza. Examination showed a pulsating tumour in the third left intercostal space anteriorly. X-Ray showed a bilateral irregular shadow, diagnosed as lymphosarcoma. The patient also had a nerve deafness, and a four plus Wassermann reaction. Death occurred suddenly the evening of the examination. Autopsy revealed a rupture of one of the two dissecting aortic aneurysms present. A myocarditis due to syphilis is rather a delicate diagnosis to make during life, but as Warthin showed, it must be fairly common. Warthin reported the autopsy findings in eight cases of sudden death (8). In all, there was pathological evidence of an acute exacerbation of a previously latent myocardial syphilis, and spirochaetes were demonstrated in the affected areas. - L'/r Syphilis may attack blood-vessels anywhere in the body. I recall a patient whose only complaint was nose bleed. An aneurysm of the septal vessel was picked up by an alert nose and throat man; the Wassermann reaction was four plus. Page 31 Late syphilis of the genital tract, male and female, may occur. Un- dubted cases of syphilis of the prostrate are on record. Once, upon being asked to see a patient having a stormy post-operative course after a salpingectomy, I recognized a woman whom I had seen two years before with a florid secondary syphilis, and to whom I had given only four doses of neosalvarsan. Her blood was still strongly positive, and the pathological report of the Fallopian tubes was "picture of syphilis." Neurosyphilis. We must remember that in its eary stages this is most likely to be overlooked. Lumbar puncture is the key-note to the diagnosis. Lost pupillary reflexes and absent knee-jerks but represent the scars of the preceding inflammation. In such a case, the onset was probably years before, in the secondary or early tertiary stage, when the involvement was meningeal, with the first clinical evidence a rise in the cell count of the spinal fluid. At this time the blood Wassermann was probably positive, and the spinal fluid Wassermann negative, and a few years later both positive. In later years very likely the spinal fluid only was positive, and still later, perhaps thirty or forty years after the initial infection, we may see the serological findings completely negative, and yet the disease still progressive, or much earlier with partial treatment. For practical purposes we may think of neurosyphilis as following somewhat the different stages mentioned in considering the pathology, although of course the various processes go on side by side with one feature predominating. Thus in the secondary or early tertiary stages, the cellular exudate predominates to give the meningeal form, a disease of the twenties. When the obliterative endarteritis is the feature, we find the clinical signs of vascular neurosyphilis, such as sudden hemiplegias in young adults in their thirties. When the degenerative pictures predominate there may be symptoms and signs from the gummatous lesions, as cerebral gummata or myelitis. The type corresponding to the overproduction of connective tissue is seen clinically as tabes, paresis and tabo-paresis, a disease of the forties or later. Case—Meningeal Form—Female, single, age 27—Complaint, headache and neck- ache of one year's duration. Examination, by a neurologist showed no abnormal neurological signs. ■ The blood test was positive. The spinal fluid Wassermann was negative, but the globulin test was positive and the cells numbered 222 per cubic millimeter. Case—syphilitic myelitis—Male, age 54—No history of venereal disease. January 1st, patient went to bed with a "cold in the head" with slight fever, followed by numbness and gradual weakness of the legs, progressing to complete paralysis within three weeks. Examination—Eye reflexes normal; fundi normal. Spastic paralysis of both legs, and paralysis of the bladder with complete anaesthesia from the level of the third dorsal nerve down. The blood reaction was negative. In the absence of any evidence of syphilis the condition looked like a non-specihc myelitis, but the spinal fluid Wassermann reaction was strongly positive. This patient made an almost complete recovery after seven months of mild antisyphilitic treatment. Case—late tabetic stage—Male, age 64—History of luetic infection 37 weeks before with treatment by mercury pills only. Examination showed every evidence necessary for the diagnosis of tabes including a Charcot joint of the right ankle. The blood Wassermann was negative. The spinal fluid Wasserman was negative, the cells were normal, but the globulin test was positive. This is an example of a man who has developed enough immunity to weather the storm for nearly forty years, and is now negative serologically, but who shows the scars of battle. Congenital Syphilis may be early, or retarded in its appearance, or latent. The latter is the type so often overlooked until some infection or accident brings the disease to light. It is scarcely possible to miss the case with the typical triad of signs, but it is not uncommon to find only one stigma in a congenitally syphilitic child. A gradually developing nerve-deafness as part of an active neurosyphilis is not infrequently seen. Similarly, failing vision, due to optic atrophy, may be Page 52 the first apparent symptom. A child may appear before you as a fully developed tabetic or paretic, as in the following case: Male, age 14—Had always been apparently healthy and was rather precocious in school. He suffered a so-called "nervous breakdown' at fourteen. Examination revealed Argyll-Robertson pupils, exaggerated deep reflexes, and the typical mentality of a paretic. The blood was positive, and the spinal fluid showed the Wassermann positive and a paretic gold curve. There were also stigmata of congenital syphilis. It is to be noted then, that a history of infection and the blood Wassermann report are really of less importance than careful examination, especially neurological, ophthalmic and spinal fluild examinations. However, the blood Wassermann and Kahn reactions are extremely valuable, and should be done routinely, All pregnant women should have a blood test by the end of the third month. Treatment is of little use after the eighth month. The Wassermann reaction of the umbilical cord, and for the first six months of infancy, is often unreliable. In cases of gonorrhoea, follow up Wassermanns may unearth syphilis in as high as 10%—20% of cases. The provocative test, according to O'Leary adds 10%—20% to the acuteness of the Wassermann test. A negative Wassermann, found after treatment has begun, tends to keep the patient away. A syphilitic is improperly treated until he has had a spinal fluid examination (unless he is over 65). In the early case, according to Stokes, one may wait for six months after infection and intensive treatment. Remember that even in the early cases, and in the latent, there are many who show no neurological signs, and yet have characteristic changes in the spinal fluid. A patient with a normal spinal fluid during the first year of infection, seldom developes neurosyphilis, and the patient with latent syphilis, whose spinal fluid is normal after the fifth year, practically never developes central nervous system lues (9). Note, however, that neurosyphilis may be clinically progressive in the presence of a normal spinal fluid. Remember that negative serologic findings are not uncommon in the vascular type of central nervous system syphilis; also recall that 75% of all paralyses of the pupils are luetic, and that one Argyll-Robertson pupil is worth 90% in the diagnosis. I shall not attempt to go into the relative merits of the Kahn and Wassermann reactions, but by way of cheering up the oft-abused laboratory man, let me quote Kolmer, who says: "Although all tests are capable of yielding false reactions because of technical errors, the incidence of these is remarkably low in expert hands, and probably not as frequent as are the clinical errors in the diagnosis of syphilis." Let us then, not lean too heavily on the laboratory. Why, in spite of modern treatment, is syphilis still such a menace? The answer lies in missed diagnosis, insufficient treatment, and difficulty of complete cure. The chief reason for insufficient treatment, according to investigations, is that we do not give the patient sufficient information. The second factor is painful intramuscular injections. The third, is neglect on the patient's part, and the fourth is cost. We are apt to forget in our syphilitics that they need often mental and moral support, conservation and strengthening of their physical mechanism. There is an old saying: "It is much more important to Page 53 Government, Municipal, Public Utility, and Industrial Securities The successful investment of funds is more easily attained with the aid of experienced investment specialists. Professional men frequently find it impossible to give time during regular office hours to the consideration of their own affairs. Our representatives will be glad to make appointments at whatever hours are most suitable to clients or prospective clients. Nesbitt, Thomson and Company Ltd. 728 Hastings Street West Vancouver, B. C. 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When doing your Xmas shopping take advantage of our LOW WINTER RATES Single Rooms Double Rooms Twin Beds $2.50 $3.00 $3.50 4.00 4.50 5.00 - from $5.00 320 Rooms—All With Bath or Shower EXCELLENT COFFEE SHOP - REASONABLE PRICES SPECIAL GARAGE FACILITIES 1111E11111111 b E11111 ^ E11B111111111111111! 11 * 51111111 ■ 1111111111111111111111111111111 i 11! 111111111111 OPEN LETTER TO THE B. C. DOCTORS: During this trying period of depression it behoves us to do some straight thinking when we make our purchases. When making a purchase we can make it answer a two fold purpose: namely, the buyer's, and at the same time to assist in keeping a B. C. Employee on the payroll. We therefor ask your consideration when, placing your order for Christmas Greeting Cards this year and providing quality and price are equal, purchase a B. C. Greeting Card. If your regular dealer does not have them, phone Trinity 1311, or call at LIMITED 566 Seymour Street Vancouver, B. C. iiiiiiiiiiiiiiiiiiiiiiiniiiiiiiiiiiiiiiiiiiiuiiiiiiiiiiiiiiiiiiiiiiiiiiniiiniiiiiiiiiiiiimiiii know what sort of a patient has a disease, than what sort of disease a patient has." Public Health talks, and propaganda have been the means of earlier recognition of cancer and tuberculosis. Why not in syphilis? For obvious reasons it is difficult to put the subject before the public clearly. The laity associates syphilis with hushed-voice discussions, and cannot divorce it from the seventh commandment, a punishment for sin. When shall we tell a patient that he or she has syphilis? That is an individual problem. When told, the patient should be given a clear understanding of the condition. Syphilis should be explained as a disease, like any other, to be thought of and attacked, apart altogether from any moral side-issue, a venereal disease by accident. Summary Syphilis then stands as a challenge to every medical man. Expect syphilis in at least one case in twenty. Do not place any reliance on a negative history. Do not expect a single blood test alone to make the diagnosis. Remember a syphilitic is improperly treated unless he has had a spinal fluid examination. Bibliography J. H. Stokes, "The Third Great Plague." J. H. Stokes and H. A. DesBrisay, Can. Med. Assn. Jnl., Vol. 14: 715. J. H. Stokes, "Modern Syphilology." Wile & Marshall, Arch. Derm. & Syph., Vol. 3: 272—278. Stokes & McFarland, Am. Jnl. of Syph., 1922: Vol. 6, 395—409. J. H. Stokes and P. W. Brown, Am. Jnl. Med. Sc, Vol. 164: 867. Buie, L. A., J. A. M. A., Vol. 81: 1357—1361. 8. Warthin, A. S., Am. Heart Jnl., 1925. 9. Hopkins, H. H., Arch. Derm, and Syph., Vol. 24: 404—408. I. II. III. IV. V. 1. 2. 3. 4. 5. 6. 7. THE TREATMENT OF SYPHILIS Dr. W. T. Lockhart, Vancouver The treatment of syphilis departs from the usual method of dealing with parasitic disease in that we treat the disease or rather the cause of it, instead of being concerned primarily with enabling the patient to survive the immediate effects of the parasitic invasion. The early symptoms of syphilis are quite trivial, if there is no accompanying bacterial infection. The primary sore is a simple papule. The lymph node hyperplasia is of moderate degree and painless. The secondary eruptions give rise to no subjective symptoms. Only rarely is there any fever or malaise. Our whole responsibility for treatment lies in the knowledge of the very dangerous results which follow on the trail of chronic syphilis, the slow persistent fibrotic changes, chiefly involving the vascular system and leading to ischaemia and cellular depletion of the organs or tissues involved. Any scheme of treatment to be completely effective, must have for its object the destruction of all the infecting parasites. Failing that, if it should prove to be beyond our power, there remains the possibility Address delivered before the Vancouver Medical Association. November, 1931 Page 54 of supporting or increasing the natural immunity reactions of the host, to the end that he shall become a carrier only and live out a life of the ordinary duration without suffering illness or disability. The physician who has been employed in the treatment of syphilis during the last twenty years must have experienced repeated disappointment, and may be inclined to be sceptical as to the attainment of the first objective except under very special conditions, but the second is within his competence in the great majority of cases with which he has to deal. The terms "acute" and "chronic" are ambiguous and in discussing methods of treatment it is more convenient to consider syphilis as being either early or late, according to the duration of the infection, early referring to the first few months of the disease before the parasite has become domiciled and has settled down to live with and on the tissues of the host, with occasional ructions perhaps, but on the whole peaceably. Late syphilis includes all uncured cases where immunity of greater or less degree has been established. The treatment of early syphilis is based upon two definite objectives. First, to heal all open lesions in order to limit the danger of transmitting infection and secondly to exterminate the remaining parasites in the body of the host. The first is a duty to the public, which has no means of protecting itself in the ordinary way by segregation and quarantine during the period of infectivity. The physician in charge should see to it that his patient is instructed in the proper measures to prevent the spread of infection and should carry out such specific treatment as will limit the dangerous time as quickly as possible. The second objective, the complete destruction of the parasites, is a much more difficult matter and the amount of treatment required has been increased from time to time as experience has shown that cases thought to be completely cured, ultimately have relapsed. The difficulty of determining cure and cessation of treatment is very great. All symptoms disappear long before any instructed person would dream of regarding the patient as being free from infection. The various complement fixation, precipitation and flocculation tests, delicate though they are, may show no sign, and yet experience has shown that the parasite may be present still and capable of redistributing itself in the host. It has been shown by experiment with rabbits (1) that infective elements linger in the lymph nodes after the serum tests fail and proof has been given by successful inoculation of healthy rabbits by material from glands. It would no doubt be possible to apply such a test in man but no facilities for making use of it are available at present. In default of any absolute index of cure we are compelled to treat to the full extent of what experience has shown to be necessary to sterilize the greatest possible percentage of cases, and then to keep the patient under observation for a sufficiently long time to render it improbable that relapse will ever occur. Such treatment is bound to be far more than is required in some and will be less than necessary in a few, in order to attain our objective, but at present it is the only trustworthy criterion we have. Page 5 5 The amount of treatment required varies directly with the time that has elapsed since infection took place. Primary sero-positive syphilis requires more treatment than primary sero-negative and when secondary symptoms are present, still more treatment should be given before putting the patient on probation. The drugs used in the majority of clinics in Great Britain and America are one of the arseno-benzol compounds and either mercury or bismuth with courses of potassium iodide in the later stages. (2) Some of the German clinics use salvarsan alone in early syphilis (2); while some in France pin their faith entirely on bismuth. Owing to differences in action it seems to be wiser to adopt the bi-metallic treatment. It is believed that the A B C is changed in the body to a substance which attacks and destroys the spirochaete. Hg. has been shown to have little or no destructive effect on the parasite but is believed to operate by strengthening the natural resistance of the host. Both spiro- chaeticidal and resistance building powers are attributed to bismuth but in the former at least it is less potent than the arsenical preparations. The plan of treatment for early sero-negative syphilis which I have used for the last twelve years consists in administering a course of approximately 6.0 grms. of 914 intravenously together with 8 to 10 grs. of Hg. intramuscularly usually the salicylate. The commencing dose of 914 is 0.3 or 0.45 grms. repeated on the fourth or fifth day. If there is no evidence of intolerance the dosage is increased by steps to 0.9 the later treatments being given at weekly intervals. The Hg. is usually given three or four days after the As., but where it is inconvenient for the patient to attend twice a week, he is given both on the same day. This course of treatment is followed by a rest of about one month during which the patient takes K.I. by mouth in gradually increasing doses up to sixty to ninety grains a day. The bimetallic course is then repeated and in sero-positive and secondary syphilis a third similar course is given. The patient after completing treatment reports in three, six and twelve months for examination and serum test and is advised to continue reporting annually. For the last three or four years I have substituted Bi. for Hg., giving 0.2 grms. of the metal each week, carrying it on into the rest interval twice a week, so as to give a total of about 3.0 grms. to the course. On a few occasions I have substituted sulphur salvarsan or silver salvarsan for the 914 but the great majority of treatments have been given with 914. This plan, of course, is modelled on the War Office scheme as instituted by Col. Harrison only that during active hostilities the soldier got only one course as a rule and that a somewhat shorter one than the above. After the Armistice I extended the course in my clinic to approximately 6.0 grms. and ten grains, and where opportunity permitted, gave another course or part of one in the cases of infection of long duration. My civil cases have not been very numerous, but so far, any relapses which have occurred have been in patients who failed to complete their treatment or else were irregular in attendance. Page 56 Among working people, particularly those whose occupation takes them away from the city, such as sailors, loggers and the. like, it is often impossible to carry out a prolonged course of treatment according to a definite plan. One frequently has to substitute less effective forms of treatment such as Hg. rubs or pills and it is difficult to get these people to take even these systematically. One of the very serious difficulties in the adequate treatment of syphilis is the associated expense. Our by-law (3) lays down a fee of $15.00 for an intravenous injection of salvarsan and if one is giving twenty to forty of these in addition to Bi. and other incidentals, the ordinary youthful citizen, male or female, cannot possibly pay. I suppose that all of us take advantage of clause (6) and try to adjust the fees to the patient's earning capacity, but it would be very much better to adopt Stokes' suggestion and make an annual fee to cover all expenses of treatment. This would at least emphasize the length of time that is required. The respective merits of concurrent or consecutive administration of As. and Bi. is still a subject of debate. In the early years of the salvarsans the prevalence of neuro-recur- rence was so marked that many practitioners reverted to the use of Hg. instead. It seems reasonable to infer from the known action of the drug that the rapid sterilizing effect of salvarsan inhibited the production of imr munity substances which would have taken place in response to the presence of a generalized infection. Under the administration of Hg. this response is but little interfered with and a high degree of natural immunity is established. Salvarsan penetrates the meninges with difficulty and the effect of giving this remedy alone is tantamount to depriving the central nervous system of a large part of its natural protection without furnishing anything in lieu of it. Hg. or Bi. supplies this lack, and is a sufficient reason for giving one of them together with the As. in at least the primary attack on the spirochaete. For the full argument I would refer you to Moore and Keidel's thesis (4) in support of consecutive, and Col. Harrison's (5) in support of concurrent administration. During treatment the toxic effects of these metallic poisons has to be guarded against. Individuals differ in susceptibility and a constant watch must be kept for symptoms of intolerance, remembering that the dangers of As. lie in damage to skin or liver, and Hg. or Bi. to the kidneys. Prior to instituting specific treatment a complete physical examination should be made and a history taken. Previous attacks of dermatitis or an ichthyotic or seborrhoeic type of skin suggest caution in the use of arsenic while any kidney dysfunction, unless of syphilitic origin, might be a handicap in the use of Hg. or Bi. Before giving the arsenical injection it is advisable to have a look at as much of the skin as can be conveniently exposed. Any erythematous flush of arms, throat or thorax or complaint of pruritus should be a signal to withold the drug pending developments. Any icteric type of Page 57 the conjunctivae, however slight, should be accepted as a warning to change the remedy and give Bi., instead of As., until a Van den Bergh test can be made and the question of the integrity of the liver settled. Before commencing the administration of Hg. or Bi. it is a good thing to have the mouth cleaned up, and to see that it is kept clean during the progress of treatment. A mouth wash of chlorate of potash or H2Oa may be prescribed. The urine should be examined for albumen prophylactic against vomiting to have a light meal Less serious complications sometimes occur. Nausea is common I instruct my patients to hold the nose and breathe through the mouth to avoid it and as about two hours before the injection is given. In some clinics the arsenical is dissolved in 20cc. of an alkaline 40% solution of glucose, but among our well fed people, I don't think that is necessary (6) (7). Nitritoid crises are rare since the preparation of the arsenicals has been thoroughly standardized. I have not seen one for ages and have got entirely away from giving a preliminary atropine or adrenalin injection, although it is well to have the latter at hand in case of need. Where symptoms of poisoning due to any of these metals do occur, one should give sodium thiosulphate 0.5 to 1.0 grm. I.V., daily, together with such adjuvant treatment as may be required, and if the symptoms are at all severe, the patient had better be taken in to hospital at once. Apart from signs of active intolerance, the patient may appear to do badly under treatment. He may become anaemic, spiritless, or lose weight. Specific treatment should be intermitted for a time and cod liver oil and haematinics, such as Easton syrup, with extra food given instead. Or the specific treatment may be manifestly ineffective, symptoms of generalized syphilis such as secondary rashes, making their appearance even while intensive treatment is being given. Here it is probable that the patient is incapable of transforming the A. B. C. into the derivative named arsenoxyl, which destroys the spirochaete. (8) It is in such cases that non-specific protein injections, or pyro-therapy and in suitable cases, thyroid extract, are likely to be of value, together with a change to silver or sulphur salvarsan. The persistently positive Wassermann may come in here also but we are on debatable ground. One is not quite sure of the exact significance of reagin. To those who believe that it is merely evidence that syphilis has passed that way, it is a matter of indifference but to those—and I think they are in the majority—who believe it is evidence of the presence of active foci of specific infection, it should be dealt with by the measures just enumerated. When the diagnosis of early syphilis has been missed or the disease insufficiently treated, there may be an asymptomatic period during which the patient appears to be perfectly healthy and the fact of his infection is discovered only by accident. This stage is commonly referred to as latent syphilis. The propensity which latent syphilis has of coming to light as the result of local trauma or intercurrent illness, is well known. A fractured bone which refuses to unite, an ulcer of the stomach, an Page 51 open wound that will not heal, or a delayed convalescence from an ordinary illness, any one of a multitude of abnormalities may lead to an investigation which discloses a history and stigmata or symptoms of syphilis. Specific treatment will usually transform the patient's condition and he recovers his ordinary health in a most gratifying manner. When he has been restored we are confronted with a problem. Shall we proceed forthwith to treat him intensively over a period of years, or shall we rather "Let sleeping dogs lie." The question is, "Are the dogs really sleeping?" or are they carrying on nefarious activities sufficiently below the surface that we do not recognize the effects until irreparable damage has been done. One can only generalize. If the patient has a considerable portion of his life before him and is sound except for his specific infection it would be preferable to treat him thoroughly in the hope of establishing a static immunity which will last him for the remainder of his life, but if he has had his infection for twenty or thirty years and shows no evidence of involvement of vital organs, such as cardio-vascular or neurosyphilis it would probably be better to temporize and keep him under observation. Recent pathological investigations by the late Professor Scott Warthin and by Professor Levaditi (9) (10) appear to confirm those published nearly twenty years ago by Mr. J. E. R. McDonagh (11) that in addition to the adult spirochaetes, there are resting forms of the type of spores. If this be accepted it goes far to explain many obscure phenomena of the disease, including latency. The rapidity with which the chemo-therapeutic remedies rid the host of all the spirochaetes in the external lesions in the course of a few hours contrasted with the months of continuous administration which fail to dispose of them completely, points to the existence of resistant forms of the parasite, apart from any immunity to arsenoxyl which they may ultimately develop. The value of K.I. in the treatment of syphilis has been attributed to its power to cause absorption of fibrous exudate which prevents the effective contact of the arsenical with the parasite, but if spores do exist it may well be that the iodides have a more direct effect similar to that which they have on diseases due to spore-bearing plants such as actinomycosis, blastomycosis and sporotrichosis. Clinically K.I. has been known to be a valuable remedy for generations but when chemo-therapy came into vogue it was almost forgotten. Latterly it has found a place again in most systems of treatment more particularly in late syphilis. I believe that it should be given periodically during all stages of the disease in association with the chemo-therapeutic and resistance-building remedies. When the incomplete immunity characteristic of latent syphilis ultimately breaks down the symptoms complained of may be referred to some particular viscus but it is commonly found that the damage is wide-spread and involves other important organs as well. The locus of permanent infestation varies, whether by accidental implantations during generalized infection or on account of the special affinity which the particular strain of parasite has for the cellular tissue of the organ in which it takes up its abode. Page 59 In neurosyphilis it seems probable that the parasite finds a refuge in part of the neural axis after having been driven out of the rest of the body, for it has been shown that the specific remedies penetrate the meningeal envelope with difficulty. Treatment in neurosyphilis therefore must be continued for a much longer period than is necessary in cases where infection of the central nervous system has not taken place. Vascular infection of brain or cord has been shown to occur in a large proportion of cases and it is clear that many of these must resolve without developing symptoms of degeneration. Only about 10% of syphilitic infections ultimately become tabetic or paretic, (lib). ■ Investigation by Fildes, Parnell and Maitland, confirmed by others, showed definite changes in the C. S. F. in 20% to 30% of primary syphilis and in 40% of secondary syphilis, (12) the first observable change being a pleocytosis with a positive Wassermann reaction appearing much later on. Dr. Redvers Ironside in discussing the prophylaxis of neurosyphilis says: (13) "It is a commonplace of every neurologist who sees many cases of neurosyphilis, that cases of late neurosyphilis give a history of little or no treatment of the primary disease, Erb has emphasized it for a decade. I myself observe it every week." Dr. David Lees, (13) also, "The whole subject of the prophylaxis of neurosyphilis is dependent on the efficient treatment of early syphilis—A great deal of work still requires to be done to educate the profession as to the minimum amount of treatment which is essential in every case of syphilis." What has been said in reference to neurosyphilis applies with equal force to cardio-vascular syphilis. The frequency of heart disease as a cause of death in vital statistics raises the question as to how many of these had their origin in a degenerated myocardium, the result of spiro- chaetal infection. You will remember the micro-photographs shown here some years ago by the late Professor Scott Warthin showing spirochaetosis of the cardia, and his opinion as to the frequency of the condition. Gummata and fibroses of almost any other viscus or tissue of the body are fairly frequent and can be dealt with successfully, but the outlook in late cardio-vascular or neurosyphilis is gloomy in the extreme and emphisizes the need for adequate treatment of the primary infection, in order to prevent their incidence as far as is humanly possible. One caution in regard to commencing treatment in late syphilis where chemotherapy either has not previously been employed or where it has been in obeyance for a number of years. Do not commence treatment with an arseneo-benzol compound! Take a preliminary canter for a few weeks with Hg. or Bi. before administering the arsenical and even then begin with small doses, so as to avoid the danger of serious reactions of the Herxheimer type. During the war a fatal case of haemorrhagic encephalitis occurred in my clinic, although the patient had been started on very small doses of arseno-benzol. Since then I have made a practice of first giving Hg. intravenously for two or three weeks, before starting with the arsenical, of late years I have substituted Bi. intramuscularly, as it is more suitable for ambulant patients and is believed to be more effective. For those who prefer Hg. the cyanide 0.005 to 0.02 grms. in 1% solution intra- Page 60 venously on alternate days is effective and non-irritating. Hg. CLg ay be given intramuscularly at the expense of causing a little pain. m Given intravenously, even very dilute, it is apt to thrombose the vein. When giving soluble Hg. one has to keep in mind the possibility of a haemorrhagic colitis in addition to the usual toxic symptoms in mouth or kidneys. In the treatment of any variety of late syphilis it is best to soft-pedal the arseno-benzols and to make use rather of Bi. and K.I. with the combinations Bismarsen or in selected cases Tryparsamide as alternates. Just a few words in reference to congenital syphilis—the infected infant or child is treated on the same lines as adults except for the smaller dosage. Treatment of infants with florid symptoms should commence with a few weeks of Hg. in order to avoid a possibly fatal Herxheimer reaction. The arsenical used, either 914 or sulpharsen may be given intravenously or intramuscularly in a dose of 0.05 grams of 914 to an infant of two or three weeks gradually increased to 0.1. Older children in proportion up to a maximum of 0.45 at puberty. Sulpharsen is given in dosage of about one third as much as 914. Hg. may be given by the mouth gr. % to gr. l/2 of Hydrarg. c Creta powdered and placed on the tongue before giving the bottle. Or it may be given by inunction of the ointment, a pea sized portion rubbed into the axillae, back or belly, daily, changing the place each day. Or Bi. may be given intramuscularly from 1/10 the adult dose in infants to one half in older children. Cod liver oil should be given to all of them. Far and away the best method, however, is to treat the potentially ccngental syphilis in utero by systematic specific treatment of the mother throughout pregnancy. It is now acepted that every pregnant woman who has been infected with syphilis should receive treatment throughout pregnancy, even if she has had intensive treatment and has been presumed cured prior to the pregnancy occurring, and this holds for every pregnancy she may have subsequently. Where this is carried out, an infant free from syphilis may almost be guaranteed. In the few cases I have had, every child has been born ,and has remained uninfected. The oldest is now five years old without having shown any symptoms of syphilitic infection. Physicians in charge of the large lying-in hospitals are unanimous in extolling the efficacy of pre-natal treatment. The only complaint they make is that so often knowledge of the mother's infection comes too late for it to be of service in saving the infant. It is incumbent on every physician who treats a young woman of child-bearing age to warn her insistently of the necessity for further treatment in the interest of her child, should she ever become pregnant. With the exception of mental defectives, there are very few women who would place secrecy ahead of the welfare of their babies if they were fully informed of their danger. The directors of pre-natal clinics have a responsibility also for even if treatment is not commenced until the fourth or fifth month of Page 61 gestation, the infant appears to stand quite a good chance of escape where the maternal syphilis is of some years duration. The question of the prophylaxis of acquired syphilis is still unsettled. The application of 30% calomel ointment prior to coitus would probably prevent infection in the majority of exposures. (14) Experimental work on animals has shown that the infection is diffused very rapidly and applications of the ointment or other antiseptics after intercourse is quite useless. Contraceptive jellies, if used in quantity, would have some preventive effect. Stovarsol and the new compound of Bi. and arsinic acid synthesized by Levaditi (15) given per orem are stated to be effective in rabbits, as is also the intramuscular injection of Treparsol, but (16) confirmation when applied to man is still rather doubtful and in any case the public would require a lot of education before making use of such elaborate measures. This is really a matter of very great inmportance for unless some measure of effective prophylaxis is discovered and applied the extremely casual sexual relationships of the younger generation are going to distribute the disease as widely as in Northern Russia, where it is reported that 90% of the villagers are infected. References 1. Levaditi et al, Medical Annual, 1929, p. 464. 2. "Treatment of Syphilis and Gonorrhoea"—Professor Pinkus, Berlin, Br. Jnl. Ven. Dis., Jan., 1927. 3. Constitution and Bylaws, B. C. M. A., 1922. 4. Johns Hopkins' Hospital Reports, Vol. 39. 5. Research Committee of Privy Council—Special Report, No. 132. 6. "The Treatment of Syphilis," Col. L. W. Harrison "Practitioner," Feb., 1931. 7. Dr. Cole in J. A. M. A., Sept., 1931. 8. Levaditi, Am. Jnl. of Syph., 1930. 9. Quotation—Medical Annual, 1929, p. 464. 10. Quotation—Medical Annual, 1929, p. 464. 11. "Treatment of Syphilis," J. E. R. McDonagh. lib. "Clinical Neurology," Wechsler. 12. Research Committee of Privy Council—Special Report Series. 13. Dr. Redvers Ironside—"Proohvlaxis of Neuro-syphilis," Br. Jnl. of Ven. Dis., Oct., 1927. 14. Kolle and Evers, Medical Annual, 1927, p. 481. 15. C. Levaditi, Br. Jnl. of Ven. Dis., Jan., 1928. 16. Quotation Medical Annual, 1929, p. 467. 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"CHART OF CARBOHYDRATE HYDROLYSISs MILK SUGAR GROUP Lactose** (Milk Sugar) Dextrose* CANE SUGAR GROUP Saccharose** (Cane Sugar) Dextrose* Erythro- dextrin*** MALT SUGAR GROUP Starch Amylodextrin*** Achro- dextrin*** itose** Dextrose* end prod- :ose is all dex- 'hich means quicker ition than end prod- 'from other carbohydrates. ♦Monosaccharides.^? DTsaqfEharide ***Polysaccharide Of the monosacchariaesyiextrose, the end product of maltose, is converted into glycogen more easily than levulose or galactose. Therefore, maltose, which splits into two molecules of dextrose, may be absorbed with much less digestive energy than either lactose or saccharose. 8 Morse, J.L.&Talbot,F.B.Boj/onMe<i.ci*S«rg.y;., 159:852. RELATIVE ASSIMILATION VALUES OF VARIOUS CARBOHYDRATES^ Average per 100 gms. body weight 1 MALTOSE 1.50 2 DEXTRIN + MALTOSE - 1.32 3 Glucose + dextrin 1.32 4 Glucose + sucrose 1.32 5 Glucose 1.04 6 Sucrose + maltose j(C^\ 0.98 7 Fructose + glucose... __lQ7NAo.98 8 Sucrose + dextrin..^^V^T^JjIo.76 9 Sucrose. /.C.} J.rJ..j/o.76 10 Fructose y^T^S*.. J^A- - - - 0.5 11 Glucose + lacrose^A.. \Z*^- 0.26 12 Lactose....yV^-^Al.... 0.16 13 Galactose._%JS^J.^f 0.1 These authors have a^^stated: "Maltose, fructose, glucose, starch a\adextrin lead in nutritive value, followed by galactose, mannose, ara- binose, xyiose, lactose, sucrose and glycogen. 2 lH. Ariyama and K. Takahasi: Biochem. Z.. 216:269 (1929) and *J. Agr. Chem. Soc, Japan 5; 674 (1929). RATE OF SUGAR ABSORPTION IN NEWBORN* % °/o IHCHEASt IN BLOOD SVGA* C2&- SJ/S45 4 FLOOD, R. G , J A.M A. MALTOSE OR LACTOSE IN INFANT FEEDING- Answer—The superiority of one form of carbohydrate over another in artificial feeding of infants has been much discussed during recent years. It is generally accepted that cow's milk without modification is not a satisfactory infant food. So far as the carbohydrate is concerned, about one-fifth to one-eighth ounce per pound of infant's body weight is required daily. To supply this amount it is necessary to add carbohydrates in some form. Admitting that lactose is the sugar sy human milk, it does not follow that it i) he/ajgaUvb^ tolerated in another medium, such as c o\ r's (milk. generally believed that lactose is mori • axltiS sucrose—that it must be fed with a cei U in aofbug caution, as fermentative upsets are lit ely to foljj amounts' approximating that found in iiuman fed; There is cause for disagreement among clinicians, as it is important to consider the other food elements; i.e., the amounts of fat and protein fed as well as the medium in which they are fed. For example, when lactic acid milk is used, more added carbohydrate seems to be tolerated than when sweet milk mixtures are fed. Sucrose has the advantage of being much cheaper and is always available. Evidence has not been presented that it should not be used in infant feeding. With its general use in large infant welfare clinics where supervision is a matter of routine, there is less to be said against it as far as clinical results are concerned. The complaint that it is too sweet is not often encountered when the usual amounts are fed. The dextrin-maltose preparations possess certain advantages. When they are added to cow's milk lixtures, we have a combination of three forms of carbo- lactqfce, dextrin and maltose, all having differ- n the intestinal tract and different absorp- /rates. JB^cause of the relatively slower conversion of iftrins tppnaltose and then to dextrose, fermentative esses/are less likely to develop. Those preparations ainirfc Relatively more maltose are more laxative tnan those containing a higher percentage of dextrin (unless alkali salts such as potassium salts are added). It is common experience clinically that larger amounts of dextrin-maltose preparations may be fed as compared with the simple sugars. Obviously, when there is a lessened sugar tolerance such as occurs in many digestive disturbances, dextrin-maltose compounds may be used to advantage. 5 Queries and Minor Notes, J. A. M. A., 88:266. MEAD JOHNSON & CO., OF CANADA, LTD. .BELLEVILLE, ONT., Specialists In Infant Diet Materials REPRINT from THE "DAILY HERALD," LONDON, ENGLAND "WEEK END PLATFORM" February, 1931 Tainted Milk "Murders" "Health Minister on Typhoid Outbreak" "The deaths that have occurred from paratyphoid in Essex are murder" said Mr. Arthur Greenwood, Minister of Health, when opening a new model dairy, on Saturday, at Croydon. "Until we get a pure supply of milk you may take it that we are acquiescing day by day in the murder of honest citizens and children," he added. "In the outbreak of paratyphoid in Essex we have had a few hundred cases and several deaths, but we have got down to the farm where it originated." "It originated in a farm worker there, and infection appears to have spread through the milk produced at that farm." "That is a lesson we ought to take to heart. It seems utterly futile for the community to spend its hundreds of thousands of pounds on institutions that treat disease which common sense should prevent." Dr. Chas. H. Mayo, Rochester, Minnesota, has this to say, "It is within the province of the Board of Health of any community to insure GOOD AND SAFE MILK." "The protection of the public can be insured by pasteurization." "IT IS THE ONLY SAFE WAY." ASSOCIATED DAIRIES Limited Distributing PROPERLY PASTEURIZED SAFE — CLEAN — MILK Phones : Fairmont 1000—North 122—New Westminster 1445 The B.C. Pharmacal Co. Ltd. Take this opportunity of thanking the members ofB. C. and Vancouver Medical Assns. for their support during the year now closing and wish them all THE COMPLIMENTS f§§l OF THE SEASON -»91 ROJOCREAM HEATH/;-- SURE LAXATIVE Rolocream Health Oats flj Especially valuable to the Medical Profession due to its corrective properties. Our special electric sterilizer, through heat waves, detrinizes Rolocream Health Oats and makes it easily digested and assimilated. (latter & ^mxxxn, J&tk Established 1893 VANCOUVER, B. C. North Vancouver, B. C. Powell River, B. C. DIGIFOLINE "CIBA" Digitalis—100% of it Contains all the therapeutically desirable constituents of digitalis leaves— Free from irritant substances of the saponin group— Promptly and uniformly absorbed from the gastro-intestinal tract— Liquid Ampoules Tablets CIBA COMPANY LIMITED MONTREAL Messrs. Macdonalds Prescriptions, Ltd. - Vancouver, B. C. Messrs. McGill & Orme, Ltd. - Victoria, B. C. keep a full range of "CIBA" specialties. WE SPECIALIZE IN AMBULANCE SERVICE ONLY R. J. Campbell J. H. Crellin VV. L. Bertrand STEVENS' SAFETY PACKAGE STERILE GAUZE is a handy, convenient, clean commodity for the bag or the office. Supplied in one yard, five yards and twenty-five yard packages. B.C. STEVENS CO. Phone Seymour 698 730 Richards Street Vancouver, B. C. -*-*»!= df& ^e^mpeT®* !I^BH~ NEW WING Hollywood Sanitarium ■H §j§§ LIMITED 0? tyor the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively Inference I IB. Q. oMedical Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Seymour 4183 Westminster 288 !«aw
Periodicals
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: December, 1931
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