CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
'Early recognition of glaucoma ; Laboratory bulletin ; Health insurance.' -- Title page
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Patient Types: THE CHILD Never too young to learn the golden rule of "Habit Time." Much too young to learn the cathartic habit. When irregularities of diet or neglect cause constipation, Petrolagar assists the necessary regimen of bowel education. Children like the taste—it's just like pudding sauce. Petrolagar is composed of 65% (by volume) mineral oil with the indigestible emulsifying agent, agar-agar. letrol agar Petrolagar Laboratories of Canada Ltd. 907 Elliott St., Windsor, Ont. Dept. V.M. 10. Gentlemen: BIT TIME" specimens of Dr. —Send me copy of "HA- (of bowel movement) and Petrolagar. Address THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the Interests of the Medical Profession. Offices: 203 Medical and Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Dr. J. M. Pearson Dr. J. H. MacDermot Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the abovi address. Vol. VI JUNE, 1930 OFFICERS 1929-30 Dr. G. F. Strong Dr. C. Wesley Prowd Dr. T. H. Lennie President Vice-President Past President Dr. E. M. Blair Dr. W. T. Lockhart Hon. Secretary Hon. Treasurer Additional Members of Fxecutive:—Dr. A. C. Frost; Dr. "W. L. Pedlow Trustees Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson Auditors: Messrs. Shaw, Salter & Plommer Clinical Section Dr. S. Sievenpiper Chairman Dr. J. E. Harrison Secretary Eye, Ear, Nose and Throat Dr. F. W. Brydone-Jack Chairman Dr. N. E. McDougall - Secretary Pediatric Section Dr. C. F. Covernton Chairman Dr. G. O. Matthews Secretary Summer School Clinics Vancover Medical Association Programme June 24, 25, 26, and 27, 1930 All meetings will be held in the Ballroom of the Hotel Georgia Fee, $10.00 Phone during Sessions: Trinity 5881 Speakers: Dr. W. F. Cheney, Prof, of Clin. Medicine, Stanford University, San Francisco. Dr. J. G. Fitzgerald, Prof. Hyg. and Prev. Med., University of Toronto. Dr. Oskar Klotz, Prof. Path, and Bad., University of Toronto. Dr. D. B. Leitch, Prof. Paediatrics, University of Alberta, Edmonton. Dr. K. G. McKenzie, Dept. of Surgery, University of Toronto. Dr. Henry R. Viets, Neurologist, Harvard Medical School, Boston. Dr. George E. Wilson, Assoc. Prof. Clin. Surgery, University of Toronto. TUESDAY, JUNE 24th 8 a.m.—Dr. W. F. Cheney: "Gastric and Duedenal Ulcer, Diagnosis and Treatment." 9 a.m.—Dr. George E. Wilson: "Fractures." 10 a.m.—Dr. Oskar Klotz: "Arteriosclerosis." 11 a.m.—Dr. Henry R. Viets: "Signs and Symptoms of Structural Disease of the Nervous System."' 12:30—LUNCHEON: Speaker—Dr. J. G. Fitzgerald: "Can We Say Goodbye to Diphtheria?" 8 p.m.—Dr. K. G. McKenzie: "The Diagnosis of Spinal Cord Tumours." 9 p.m.—Dr. D. B. Leitch: "A Practical Discussion of Ketosis and Acidosis." 10 p.m.—Dr. J. G. Fitzgerald: "Why Vaccines and Sera." WEDNESDAY, JUNE 25 th 8 a.m.—Dr. George E. Wilson: "Infections of the Hand." 9 a.m.—Dr. D. B. Leitch: "Anorexia in Childhood." 10 a.m.—Dr. W. F. Cheney: "Methods and Value of Gastric Analysis." 11 a.m.—Dr. Oskar Klotz: "Coronary Disease of the Heart and Angina Pectoris." 2 p.m.—Dr. K. G. McKenzie: Clinic. B. C. MEDICAL ASSOCIATION MEETING 6:30 p.m.—DINNER (Informal) Hotel Georgia. Tickets $1.5 0. Speaker. Dr. J. G. Fitzgerald. 7:30 p.m.—Business Meeting: President's Address; Secretary-Treasurer's Report; Reports from Chairmen of Standing Committee; Election of Officers, etc. THURSDAY, JUNE 26th 8 a.m.—Dr. H. R. Viets: "The Diagnosis and Treatment of Epidemic Cerebrospinal Meningitis." 9 a.m.—Dr. W. F. Cheney: "Significance of Ascites and its Treatment." 10 a.m.—Dr. George E. "Wilson: "Internal Derangements of the Knee." 11 a.m.—Dr. D. B. Leitch: "A Simple Classification of Gastro-intestinal Disorders." 2 p.m.—GOLF TOURNAMENT. 8 p.m.—Dr. K. G. McKenzie: "The Diagnosis and Treatment of Intracranial Haemorrhage." 9 p.m.—Dr. Oskar Klotz: "Tumours of Bone." 10 p.m.—Dr. H. R. Viets: "The Diagnostic data obtained by examination of the Cerebrospinal Fluid." FRIDAY, JUNE 27th 8 a.m.—Dr. Oskar Klotz: "Surgical Tuberculosis." 9 a.m.—Dr. Henry R. Viets: "Infectious Diseases of the Nervous System other than Epidemic Cerebrospinal Meningitis." 10 a.m.—Dr. D. B. Leitch: "Problems associated with the Nursing Infant." 11 a.m.—Dr. K. G. McKenzie: "The Diagnosis, Localization and Surgical Treatment of Brain Abscess." Lecture I. 2 p.m.—Dr. Henry R. Viets: Clinics. 8 p.m.—Dr. W. F. Cheney: "Significance of Haematemesis and its Treatment." 9 p.m.—Dr. K. G. McKenzie: "The Diagnosis, Localization and Surgical Treatment of Brain Abscess." Lecture II. 10 p.m.—Dr. George E. Wilson:' "Carcinoma of the Large Bowel."* a (When is Diathermy of Q)alue in HJour (Practice ? l^H YOUR decision to use diathermy in the treatment of any condition will, of course, be based on recognizedmedical authority. Many physicians have become interested as a result of observing the many references to diathermy in current medical literature, and no doubt intend to investigate for themselves when opportunity presents. But a busy practice affords little of the time required in searching the files of the medical library, and so it is put off indefinitely. A preliminary survey of articles on diathermy, published during the past year or so, is available to you in the form of a 64-page booklet entitled "Indications for Dia- Victor X-Ray Corpn. of Canada Ltd. X-EAY CORPORATION 2012 Jackson Boulevard Chicago,111.,U.S. A. FORMERLY VICTOR lffi6JSj~-RAY CORPORATION thermy." In this booklet you will find over 250 abstracts and extracts from articles by American and foreign authorities, including references to more than a hundred conditions, in the treatment of "which the use of diathermy is discussed. If you number yourself among the physicians who have not yet adopted diathermy in practice, and desire to investigate this form ot therapy in view of reaching your own conclusion as to its value in your practice, you will find this booklet a convenient reference. A copy will — _ — __ be sent on request. Dlathem ^M^r^-^z^ W Join us in the General Electric Hour broadcast every Saturday night on a nationwide N. B. C. network. General Electric X-Ray Corporation 2012 Jackson Blvd., Chicago. Not being a user of diathermy in my practice, please send your 64-page booklet "Indications for Diathermy." .State. Phone Prescriptions To Us We Deliver Anywhere It will often save the time of patients who call at your office if you phone their prescription to us. We will have it prepared, ready for them when they call or we will deliver it direct to their home. Seymour 1050 Ceovgva Pfiarinacy Granville at Qeoi'^iz^ Open All Night in cystitis and pyelitis TRADE MARK PYRIDIUM Phenyl-azo-alpha-alpha-diamino-pyridine hydrochloride (Manufactured by The Pyridium Corp.) For oral administration in the specific treatment of genitO'Urinary and gynecological affections. Sole distributors in Canada MERCK & CO. Limited Montreal 412 St. Sulpice St. EDITOR'S PAGE A recent President of this Association, in his valedictory address, took occasion to dwell on the necessity for union and cohesion amongst the members of the profession. The truth and wisdom of his remarks are being emphasized today. At no time in the history of the medical profession has there been a greater need for unity and intelligent organization of its forces. Nor is this said in any selfish spirit. It is not the good of the profession alone that we seek or should seek, though we are entitled to maintain our rights—but the community as a whole stands to gain or lose largely in the course of the next few years, as events now happening tend in one or the other direction. The control and guidance of these developments are largely in our hands, if we choose to assume them. And, we cannot but feel, it is our duty, and we should regard it as a privilege, to assume this control. We shall, no doubt, be misjudged and misinterpreted—this has been the case already—but we may not shirk the burden for this reason. Consider the question of Health Insurance, now in the realm of practical politics. The Commission investigating this matter has already gone so far as to bring in a report favouring Health Insurance. In this preliminary report, no mention is made of the medical aspect of the matter. Its next report will undoubtedly deal with this. It is for us to see that the Commission is given every fact we can supply—that its views of this are formed along sound lines, not for our sake only, be it said. We must look at this subject from a new angle, new to us, that is. Hitherto our whole conception of medical practice has been along individualistic lines, and and for most of us, along therapeutic lines mainly. We must consider sickness and its cure from a community standpoint, and with an emphasis, hitherto unknown, on preventive medicine. We take leave to say that the great majority of our members is ready and willing to take this view—provided, and this is only fair and reasonable, that our rights are respected, and our opinions given due consideration—and there is no doubt that this will be done. Or again, consider the matter of hospital management and practice, that has caused so much heartburning and unhappiness in the last few months. Here is another very dangerous threat to our well-being. Here again, we must consider the matter from the broadest and most unselfish standpoint. Our advice, our demands, must be based, not only on what we consider our rights in the matter, but on what we feel will be for the best interests of the sick. Only so can we justify ourselves. To do all this requires the wisest and most intelligent organization. It requires loyalty, too, on the part of all of us. One wonders, often, how far the majority should rule, and to what extent the minority should be conceded rights. Undoubtedly, a minority has rights, and is extremely useful as a brake on hasty action, but ultimately, we cannot but feel, the majority is always right. To quote Kipling, "The game is more than the players of the game, And the ship is more than the crew." There are trying months ahead of us—it is useless to deny it, and dangerous to ignore it. More than ever before, we need cohesion, we need Page 185 unity, we need patience and tolerance—but above all, we must show sincerity of purpose and firmness. We must do more than satisfy ourselves. Mens conscia recti is very comfortable for the ostrich-minded person, but it is not enough. We must gain and keep public sympathy and support or we are in danger of losing a very great deal—and the community will suffer with us. The Buie tin has been asked by the Executive to publish the following letter from the Chief of Police. April 25th, 1930. The Secretary, Medical Association, Vancouver, B. C. Dear Sir: My attention has been called to the practice of some of the medical profession when called in to attend cases of alleged sudden death or suicide, of ordering the removal of the bodies before notifying the police. As you no doubt know, under the Coroner's Act, it is the duty of every legal qualified medical practitioner who was last in attendance during the last illness, or on the death of any person who died from other than natural causes, to notify the Coroner or Police that such person has died from other than natural causes. I shall be pleased to have the kind co-operation of the Medical Association in this respect. Faithfully yours, (Sgd) W. J. Bingham, Chief Constable. NOTICE The Annual Meeting of the B. C. Medical Association will be held in the Ballroom of the Hotel Georgia, Vancouver, B. C, on Wednesday, June 25th. Dinner, 6.30 p.m., Business meeting 7.30 p.m. The speaker at the Dinner will be Dr. J. G. Fitzgerald. NEWS AND NOTES A Committee of the Vancouver Medical Association, with which are associated members of the Executive of the B. C. Medical Association, is hard at work drafting a programme of entertainment for the Overseas visitors to the British Medical Association meeting when they arrive in Vancouver in September. Dr. H. W. Hill, Professor of Bacteriology and Public Health at the University of British Columbia, has left for the East to attend the Convocation of the University of Western Ontario. This University, of whose faculty Dr. Hill was formerly a member, will bestow upon him the honorary degree of L.L.D. Dr. J. R. Davies has been holidaying and recuperating in the Interior of the Province. Page 186 GOLF The golf tournaments at Seattle and Vancouver were the same old enjoyable events as ever. The weather man did himself proud in both places. Of course Captain Houston guaranteed the weather in Seattle and it was so. The arrangements for the day and the evening's entertainment were perfect. Never before had we experienced such a demonstration of hospitality, each Seattle player making his opponent feel that he was his special guest. Only one cloud in the sky,—they took us into camp to the tune of 88 to 53. The officers of the Seattle Golf and Country Club not only came to the dinner to welcome us on behalf of the Club, but furnished no small part of the entertainment. When Mr. Sterritt sang "Roamin' in the Gloamin' " as only he and .Harry Lauder can sing it and we all joined in the chorus, Mr. Pattullo thought he was back among the heather on his native heaths in Forfarshire. We were sorry that they and the other officers of the Club could not have been with us in Vancouver as we put on the pipes and Highland dancing for their special benefit. Dr. Bill Bowman was there with tricks newer and better than ever, and the tramp doctor who played the ukelele on the whisk-broom with the occasional fracture of a string gave us the real laugh of the evening. Already we are planning for our next year's trip to Seattle. At the return match in Vancouver not even one cloud in the sky. The men of the north came through and piled up the handsome score of 80 to 60 in favor of the local team. The battle over, Miss Alexander in full Highland costume called everyone to the dining-room to the skirl of the pipes. Later Miss Donalda Thomson, Champion Highland dancer of Western Canada, and her little sister Phyllis, set the blood tingling with Highland dances. Bill Bowman arrived at the last minute disguised as a Chinaman. We missed Woodward of Seattle and Geo. Hall of Victoria. Dr. Mc- Micking, however, took on the duties of Captain of the Victoria team. But where was Tommy McPherson? The story is told that Tommy went to bed early that night in Victoria and he dreamed a dream, and behold! Charlie Covernton and he, both wearing the kilt, contested the point as to which one should be deemed the best Highland dancer. At the end of the Sword dance and the Highland Fling the count was even, but Tommy finally won out as Charlie never heard of the Pigeon Wing. The history of this battle would not be complete were it not narrated how when Bill Murray and Boyd of Victoria were 5 down and 6 to go, they waded in and took the remaining 6, or the episode of Lauchie Macmillan in the stone pile, how, when he had battered away and finally got out, his opponent mentioned the count of 12 for that hazard. "No, just six," Lauchie explained, "the other six were the echoes." When boat time came there were some narrow squeaks. All made it except one, who spent the night in a nice comfortable bed in Vancouver. And it is told that as he was drawing the coverlet up under his chin he was heard repeating softly under his breath: Too late I stayed; forgive the crime, So swiftly flew the hours. How softly falls the foot of time, That only falls on flowers. Page 187 Moving pictures of the Seattle game were shown on the screen. It was only when we were thus able to see ourselves as others see us that some of us were vividly reminded of the flight of time. Dr. Wheaton of Bellingham, acting as trimmer, played for Vancouver in Seattle and for Seattle in Vancouver. His voice was the big bass violin in the choruses. LEADERS IN BRITISH MEDICINE N. Bishop Harman The President of the Section of Ophthalmology is known not only for his high professional standing but also for being Treasurer of the British Medical Association. Born in 1869 he was educated at the City of London School and St. John's College, Cambridge, where he was Scholar and Research student. He married Katherine, daughter of Arthur Chamberlain, J.P., Moor Green Hall, Birmingham, and has three sons and two daughters. He is Lecturer in Ophthalmology and late Dean of the West London Post-Graduate College; Senior Ophthalmic Surgeon, West London Hospital; Ophthalmic Surgeon to the Belgrave Hospital for Children; Ophthalmic Consultant London County Council Education Department and the National Institute for the Blind; Member of the Government Committee on Causes and Prevention of Blindness, 1920-22; Late Chairman of Hospitals Committee; C.N.O., South African War. His publications are: Congenital Cataract; Preventable Blindness; Analysis of 4,283 Cases of Blindness; The Eyes of Our Children; Aids to Ophthalmology. THE IMPORTANCE OF THE EARLY RECOGNITION OF GLAUCOMA BY THE GENERAL PRACTITIONER An address delivered before the Vancouver Medical Association By Dr. W. E. Scott-Moncrieff, M.D. Ed., F.R.C.S. Ed. Lieut.-Col. Indian Medical Service (Retired) By some, it would seem, the eye is looked upon as a mechanical affair, a sort of camera, not part of the human body; though in the body, not of the body. 1. By the public, who, for defective vision, go more often than not to the Optician—I beg his pardon—the Doctor of Optometry—or even make their own selection from a pile of glasses in a fifteen cent store or pawnbroker's shop. Patients are frequently surprised, occasionally even somewhat annoyed, when I enquire and make a note of general condition and name of the family doctor. 2. Then the general practitioner, in the diagnosis, prognosis and treatment of disease neglects the eye as I hope to show later. 3. Lastly, the eye specialist is apt to become narrow in his view and get out of touch with general medicine, to forget that the eye is not only in the body but of the body. Page 188 I shall convince you if I can. 1. That blindness is from some aspects, sometimes, nay often, worse than death; for the blinded individual sometimes; for the family often; for the community almost always. 2. That glaucoma is comparatively frequent; that it almost always affects both eyes; that when recognized early, and treated, much can be done and, when not diagnosed and treated early, little can be done; that when left alone glaucoma invariably destroys sight; that glaucoma is frequently not recognized, with disastrous results. 3. That medical education in ophthalmology is defective. 4. That the attitude of the general practitioner towards ophthalmology is wrong. 5. Finally I must suggest remedies for these defects. 1. That blindness is in some cases worse than death, often for the family, almost invariably for the community (and also by the way for the doctor). For the doctor—a patient who has gone blind can be worse than a patient who has died. I was once asked to a garden party for the blind—I went—and met a number of my failures and as the details came back to my mind I wondered—had I shown bad judgment in treatment or a lack of operative skill in this or thas case? You general surgeons can't meet your failures at a garden party—at least not in this world! Grant me that total blindness is a much greater calamity than is generally realized and I will spare you a recital of the instances and arguments I have collected in support of my opinion. My second point—that glaucoma is nearly always bilateral—that it is relatively frequent—that it often escapes recognition—that when recognized early much can be done and, when not diagnosed and treated early little can be done and that, when left alone, blindness is inevitable. I will show some lantern slides of case records from India, Edinburgh and Canada. Slide 1*. 30-1-16—Bilara—cases seen: Cataract, over ripe blind 11, 1 - 3 in 2 persons Cataract, operable 19 19 Glaucoma, absolute, 11, 11, 11, 1, 11, 11, 11, 11, 11, 11, 11, 1 22 eyes, in 12 persons Glaucoma, operable 5 5 Shrunken, 1, 11, 1, 1, 5 eyes in 4 Cornea, op. total 11, 1, 1, 11, 11, 11, 11, 11, 11, 11.—18 eyes in 10 Cornea op. partial, 1, 11, 1 4 eyes in 3 Staphyloma — — Uveal Disease, 1, 11 3 eyes in 2 Couched, 1, 1, 2 eyes in 2 Total cases seen 76 Operated cases later in this book—140. This was at Bilara. At the big Jalore gathering I did not record the inoperable cases, but we did 63 operations in 5 days. Remarks and comments on Slide 1. It is a facsimile of the first page of a private case book of ophthalmic operations I kept when I was Residency Surgeon, Western Rajputana States in 1915-16. The largest *This and other slides referred to in text we're shewn by the speaker during his address. Page 189 . of these States is Marwar of which Jodhpur is the capital. "Marwar" means literally "the land of death"—an extremely interesting country! It might also be called the land of blindness. About one in every 170 persons is blind, i.e., blindness is about seven times as common as in the U. S. A. The Residency Surgeon administers the State Medical Department and inspects the dispensaries throughout the State. The area of Marwar is about a tenth of that of British Columbia. The population is two and a half million. Due notice is given of these inspections. Operable cases are brought in to Jodhpur when possible, and otherwise are operated on in the verandah of the dispensary. The slide shows the sorting out of the blind into operable and inoperable cases. Bilara is in a fairly populous district on the railway, therefore a good place to visit; also the small game shooting is good! Jalore, the other place mentioned, is reached by horse or camel back from the railroad 30 miles distant. It is full of temples, sacred monkeys and eye diseases. What is to be learnt from this record? Note the comparative prevalence of glaucoma as a cause of blindness. "This is India" you may say. Well! Careful statistics from the U. S. A., France and Germany show that 10% of blindness is due to glaucoma. Note that the disease is a bilateral disease. Next note that glaucoma, if not treated, inevitably destroys sight; 22 eyes totally and incurably blind—only 5 operable and these probably too far advanced for lasting cure. Look now at the cataract cases—19 out of 22 eyes operable, only 3 inoperable. Now many of these 19 operable eyes had been blind for years; the subsequent operation records show this. In acute glaucoma if an eye has been blind for a few days only it is going to be totally blind; in chronic glaucoma if an eye has become damaged to the extent of only being able to count fingers that eye is doomed. Blindness from cataract is temporary and curable. Blindness from glaucoma is permanent. Slide 2. Woman aged 69. Right eye blinded 12 years ago by glaucoma following shock from a fall. In August, 1928, left eye typical subacute glaucoma controlled to date by miotics and general treatment. Tested regularly, tension and visual field normal. Comment: Note that attack followed a shock. The question of miotic or operative treatment is one for specialists but, whichever is adopted, general treatment is always important. Slide 3. Woman aged 46. Was sent by an optometrist to a physician and while under treatment for nervous breakdown in a Sanatorium left eye became blind from glaucoma. Had an abdominal operation; three days later right eye typical subacute glaucoma; trephining operation. Cured. Comment: Disease bilateral—attack in first eye missed, nothing can be done; attack in second eye recognized early, treated early, cured. Slide 4. Woman, age 76. Right eye blind one year; diagnosis was that "a broken artery formed a clot of blood." Left eye in 1928 subacute glaucoma; miotic and general treatment failed to control the condition. After consultation I trephined the eye, wounded the lens Page 190 and subsequently extracted it. useful vision. Following a stormy time she now has Comment: Disease bilateral; in first eye diagnosis was wrong; my operative technique was faulty; the ultimate result was surprisingly good. Slide 5. Woman, aged 63. Following a major operation under local anaesthesia, acute glaucoma both eyes. Vision of both eyes gone in two days. Comment: Disease bilateral; preceded by shock and mental strain. Slide 6. Woman, age 45. A nurse. Only complaint slight blurring of vision at times; anterior chamber slightly shallow; pupillary reaction a trifle sluggish; left eye visual field contracted almost to fixation point; typical cupping of discs; tension plus; trephining operation done. Right eye enlargement of blind spot shown by Bjerrurn's screen test; sluggish pupil; tension slightly plus; eye trephined. Result in both eyes very good. In left eye visual field much improved. Comment: Disease bilateral. Note the mildness of the symptoms. Glasses were changed several times, but glaucoma was not looked for. Do not miss glaucoma because one or more of the cardinal signs are absent. In this case the ophthalmoscopic examination and perimetry were invaluable. Photographs a year after operation. Eyes appear normal til lid is raised. Then one sees the oedematous bleb—not so large actually as it appears to be in the photo. The small peripheral iridectomy can be seen in right eye. ^mmemtKZ ■t> ., r^-'.r^sL Page 191 Slide 9. Boy, age 7. At three months right eye seen to be bigger than left; typical case of buphthalmus; mother was told that nothing could be done. At l'/2 years both eyes trephined and advance of disease arrested but right eye is blind. Comment: Disease not diagnosed or else wrong advice given and no treatment till too late to save sight of right eye. Photograph shows the enlargement of the right eyeball. Slide 10. Elderly woman. Got what she thought was one of her periodical bilious headaches. Her doctor fortunately thought of glaucoma and it was glaucoma. Operation on both eyes; in one trephining, in the other iridectomy. Both retained very good vision till her death seven years later. Comment: The history of periodical headaches might very readily have led to a wrong diagnosis. Severe headache in an elderly person should always suggest glaucoma. Slide 11. Woman, age 49, a domestic help. In 1919 left eye painful and red and became quite blind. The doctor, though living quite near, was not called in. On June 6, 1921, left eye was trepKjiied for recurring attacks of pain. Three days later acute congestive glaucoma occurred in right eye and this, in spite of the prophylactic use of pilocarpine and eserine. On 29th right eye was trephined. Last Christmas, i.e. %y2 years later, I heard that she sees as well as ever with her right eye. Comment: This case shows how extraordinarily casual people can be over loss of sight in one eye. The onset following shock of operation is also noteworthy. Including the above there are 30 cases of glaucoma in a special file I started a few years ago. In 15 of these glaucoma was not recognized and treated in the first eye till permanent damage had occurred. In all but three of these fifteen cases the first eye became totally blind. In three cases both eyes became blind. In two more cases total blindness will occur. Some of these cases were missed through sheer carelessness on part of the patient, some because not looked for, and some from a wrong diagnosis. These are very small figures but I can vouch for their accuracy. Most of these individuals are alive now—a living proof of my contention that glaucoma is frequently missed. Page 192 Look again at S.ides 2 and 11. There in the same living person we have the striking contrast between untreated and treated Glaucoma. The left blind, untreated vessels, eyeball hard as a stone. The right treated eye; normal in appearance till the lid is raised, and there one sees the iridectomy coloboma and the oedematous bleb encroaching slightly on the cornea; the vision is normal. One could scarcely imagine a more striking picture. A general impression obtained from a small number of carefully observed cases can be more useful than the drawing of conclusions from bald statistics. Show a student a group of individuals totally blind from untreated glaucoma and throw in a few cases such as Nos. 3 and 11 above. He will be so impressed that he will study glaucoma and make himself fit to suspect, even if he may not be able to diagnose it's existence when he meets with it in general practice. My fellow specialists who are present will have no difficulty in recalling experiences similar to my own. Point 3. That the education of the medical student in Ophthalmology is defective and Point 4—that the attitude of the general practitioner, to the ophthalmologist is wrong. These may be taken together, the one follows on the other. The general practitioner is also a student of medicine. The undergraduate all through his medical course studies conditions that threaten life, such as intestinal obstruction, appendicitis, peptic ulcer, middle meningeal haemorrhage, asphyxia. He studies these conditions in the Dissecting Room, Wards, Outpatient Department and P.M. Room. In regard to conditions that affect eye-sight, how different!—two lectures or demonstrations a week for several weeks in the special Eye Department. In the Dissecting Room how much dissection of the eye is done? In this connection I came on the following passage in Samuel Pepys Diary—in 1667 I think, when his eye-sight was failing—"To an alehouse: Met Mr. Pierce the surgeon and Dr. Gierke, Waldron, Turber- ville my physician for the eyes and Lowre to dissect several eyes of sheep and oxen, with great pleasure and to my great information. But strange that this Turberville should be so great a man and yet to this day had seen no eyes dissected, or but once, but desired this Dr. Lowre to give him the opportunity to see.him dissect." This would be more or less true in the present day-.--;.- ,.- What is there in the teaching of ophthalmology that takes the place of the post mortem room and the post mortem specimens, as used in other branches of Medicine and Surgery?. \ In many general hospitals the eye cases go direct to the eye department; in a few, I believe, they first go through the general out-patient department. Then so many don't go to a General Hospital at all; they go direct to an Ophthalmic Hospital where they are only seen by men specializing or aiming at a higher medical qualification. How often are eye cases shown in clinical examinations in medicine and surgery? What would be the feelings, and language, of the student if he were examined on any but; the simplest eye cases? I know that '. i Page 19) Ophthalmology is much better taught now than it was in my student days. Young graduates tell me that if a student looks for it he can get plenty of instruction in ophthalmology but he has to go after it; he is not, so to speak, forcibly fed. The general practitioner's attitude towards eye diseases. There is, I contend, a neglect of the study of eye diseases. Most general practitioners have books and monographs and read articles in the journals on abdominal conditions that threaten life. How different as regards conditions that threaten eye-sight! How many of you have a book on glaucoma? How many of you read or have the chance of reading articles and case reports on glaucoma and other conditions that threaten eyesight? Glaucoma is just as serious a disease as appendicitis—worse in a sense, because glaucoma, untreated, always ends in blindness—appendicitis may, even if untreated, end in recovery—the one threatens sight and the other threatens life. A child has a belly ache, you always think of appendicitis. An elderly person complains of mustiness of vision or increasing presbyopia; how many of you think of glaucoma? Again, compare doubtful peptic ulcer with a case with vague eye symptoms. You think nothing of having an expensive gastro-intestinal X-Ray examination made, but how often is the vague eye case examined with the ophthalmoscope? accurate, and costs nothing. I have known doctors send such patients to an optometrist for a change of glasses. A doctor is called in to see a case of abdominal pain, he makes light of it; fails to diagnosis appendicitis; does not think of it; almost unthinkable in these days!—the patient dies; dreadful! Well! for appendicitis—substitute glaucoma—and for death blindness and you have what happens not infrequently. The cases I have quoted bear this out. Dr. Scudder, at the American College of Surgeons meeting here, in Vancouver, last year, used an analogous argument with respect to the treatment of fractures. He said that while disease, which threatens life receives full consideration, the same cannot be said of injuries which cause deformity and loss of function. As a result, from coast to coast, there are hundreds of persons partially or wholly incapacitated. He remarked, that while a case of appendicitis will bring the surgeon down to hospital at 2 a.m., in a fracture case he will probably wait till next morning. You may wonder why, in the title of this paper, I have talked of the recognition and not the diagnosis of glaucoma. It is not a very good title. What I really mean to convey is the importance of recognizing or rather of realizing that any case of failing vision may be a case of simple glaucoma and any case of severe headache, especially if there is also vomiting, may be a case of congestive glaucoma. Listen to what Elliot says in his book "Glaucoma a Handbook for the Practitioner." "In the great majority of instances it is an easy matter to make a correct diagnosis in a case of glaucoma. The danger of a failure to do Page 194 so does not arise from any inherent difficulty, but rather from the surgeon's forgetfulness of the possible occurrence of the disease in his practice." You all know the parallel columns of signs and symptoms of glaucoma and iritis, very important, but it is also important to bear in mind that some of the signs may be absent. Do not diagnose glaucoma from any one sign or symptom alone. Do not miss glaucoma because one or several of the signs are absent. It is in simple non-congestive glaucoma that the chief difficulties arise and it is in these cases that perimetry, as well as the indispensable ophthalmoscopy, is indispensable. These points are well brought out in Slide 6. I say perimetry, not the use of the perimeter, because an expensive cumbersome instrument is unnecessary. The visual field can be measured by the observer's hand or, in greater detail, by the use of black board or cloth. The ophthalmoscope is the most useful, the most accurate and the most neglected diagnostic instrument we possess. There is no time now to elaborate this statement. It is so important a question that it merits a paper and discussion all to itself. You will find in your Bulletin of September, 1925, an abstract of an address entitled "The Importance of Ophthalmic Aspects of General Medicine," by Dr. Edward Jackson, the distinguished Ophthalmologist of Denver, Colorado. Read this and read also the recently published book by Maitland Ramsay, "The Eye in General Medicine" and think again before condemning as untrue and extravagant this opinion regarding the ophthalmoscope. Why is glaucoma so often missed? Man has two eyes with overlapping visual fields and in Glaucoma it is the nasal field, in one eye only, that is usually first affected. Even a slight impairment of vision is evident to the one eyed man, whereas a very considerable loss of vision either direct or indirect may escape notice or only be discovered accidentally by the two eye man. One might go the length of saying that if an individual is going to get glaucoma 'twere better for that individual to be born blind in one eye, for then his glaucoma will be detected early, when all can be saved, instead of late, when nothing can be saved. Partial loss of vision, in one eye only, does not interfere with mode of life in many instances and this is a chief factor in the comparative neglect of eye affections by the patient. Even total loss of vision in one eye is not a great calamity. The reason for this is anatomical and physiological, i.e., the visual fields overlap. If man had not two eyes but one, I venture to think that the study of the eye would be more thorough in every respect from first to last. Another point—glaucoma, like early cancer, is usually not painful, and it is pain more than any other symptom that brings the average patient to the doctor. How do I propose to improve matters? As regards the place of ophthalmology in the medical curriculum I make only one suggestion. In the near future our university will have a medical faculty. Let the ophthalmologists see to it that their all-important subject is well taken Page 195 DO NOT HESITATE to make use of our free delivery service anywhere in the Vancouver City Limits anytime between 8 a.m. and 11 p.m. Phone your prescription to us from the patient's home when making your calls—for our quality drugs —reasonable charges and good service will be appreciated by your patient. Tllacaoi\ala>* Medical-Dental Building IiJMITED: ipli< Tescnpiions TRINITY 6226 OPEN ALL NIGHT TWO SPEEDY MOTORCYCLES Free delivery from 8 a.m. to 11 p.m. PUBLIC HEALTH BIOLOGICAL PRODUCTS Diphtheria Antitoxin Diphtheria Toxin for Schick Test Diphtheria Toxoid (Anatoxine-Ramon) Scarlet Fever Antitoxin Scarlet Fever Toxin for Dick Test Scarlet Fever Toxin Tetanus Antitoxin Anti-Meningitis Serum Anti-Pneumococcic Serum (Type 1) Anti-Anthrax Serum Normal Horse Serum Smallpox Vaccine Typhoid Vaccine Typhoid-Paratyphoid Vaccine Pertussis Vaccine Rabies Vaccine (Semple Method) INSULIN Price List Upon Request CONNAUGHT LABORATORIES University of Toronto TORONTO 5 - CANADA Depot for British Columbia MACDONALD'S PRESCRIPTIONS LIMITED Medical-Dental Building Vancouver care of. Since 1879 the British Ophthalmologists have been fostering the teaching of the subject in the Old Country. I would suggest that your eye, ear, nose and throat section should look into the matter. The annual reports of the Council of the British Ophthalmologists have been published for years in the British Journal of Ophthalmology. Some of your senior eye specialists probably have the back numbers of the Journal, if not I can let you have them. On the part of the general practitioner I would plead for greater attention to eye diseases and to the eye as a diagnostic factor, the avoidance of treating eye diseases with insufficient knowledge and experience and without consulting the specialist. The general practitioner, especially the man who practises up country, might well take a G. P. course in ophthalmology instead of in abdominal surgery. Such a course is an excellent training in accuracy of observation and diagnosis. Let him add to his income by doing refraction work. I personally know four doctors in the interior who do this. To the young intending specialist I would say—a universally held opinion—"do not specialize too early." Before going off to New York or Europe, go into general practice and specialize gradually," preferably in a district where there are no specialists." To the young specialist I would also say; consult the senior men more, offer to assist them at their operations. Do not be in a hurry— take a long view. "The young man in a hurry who thinks he knows all about his special subject runs a risk of being a danger both to himself and the community among whom he practises." That is from Maitland Ramsay's book. To the senior specialist I would say, welcome the junior man. Do not resent his appearance. Let there be a fair field and no favour. Pass on work to him when occasion offers. Invite him to attend your operations. To all specialists, and this applies not only to eye, ear, nose and throat men, I would say "try at every opportunity to bridge over the gap between specialism and general practice." Glaucoma is now looked upon not as a disease of the eye, but as the result in the eye of a constitutional disease. It is a "sick eye in a sick body." In the research work now being done biochemistry, endocrinology and capillary osmosis are playing an important part. The decompression operation that is done on the glaucoma eye does not cure the disease, but it provides a safety valve and so prevents the destruction of the optic nerve—if done in time. Personally I always enlist the help of the physician in the treatment of a glaucoma patient and sometimes I find it difficult to get his ready co-operation and also that of the patient, both being accustomed to look upon an eye condition as a local affair. The last two headings on my case report form are—"General Health" and "Family Doctor." Very important for the specialist, the physician and the patient. Page 196 HEALTH INSURANCE [The following is the brief handed to the Chairman of the Commission on Health Insurance which represents in a condensed form the views of the medical profession and may be used as a basis for discussion at a later date.] The question of Health Insurance has engaged the earnest attention of the medical profession in British Columbia for many years. It has been realized that there is a demand, chiefly on the part of the wage- earning class, and the man of moderate means, for the inauguration of some scheme whereby the cost of illness may be more evenly distributed. As we see it, the following are the main factors in bringing about this demand for a change. 1. The cost of medical care is, under present conditions, borne almost entirely by the sick individual and his family. In this connection it is true that in many industries, commercial organizations, etc., aid is given by the employer. Also organizations are formed by groups of working men and women, whereby they contribute to a fund, for purposes of meeting the costs of illness. (C.P.R., H.B.C., etc.) Even with these, however, there is not adequate provision made for meeting all costs—and families are not included. 2. The cost of medical care, in its fullest modern form, is an excessive burden to the working man. Modern methods of diagnosis have multiplied greatly and are costly. This is no reflection, as we take it, on modern medicine. These methods of diagnosis and treatment are of extreme value, are life-saving, time-saving and are altogether desirable. They should be available to all. 3. These two facts lead to two evil results—either (a) the workman has to be content with inferior service, or (b) he has to accept charity. He resents both, and both are bad for the community. With (a) time, health, often life, are lost—efficiency is impaired, the community as well as the workman suffers. Mortality is higher among the working classes than it should be. The workmen hesitate to seek treatment early, on account of cost and time lost. He cannot afford such things as periodic health examinations, prophylactic care for his children, (teeth, tonsils, toxoid, etc.) As regards (b). This is an extra burden on the taxpayer, already overloaded. Moreover, it is unnecessary, as where a man is earning a wage, a proper system of insurance would enable everyone to pay his share towards his own protection. 4. There are many causes for illness. Some arise from individual neglect, carelessness, errors against health laws, etc.— (the individual). Others arise from the conditions in which the working man works, in industry—(the industry). Others from conditions of housing, sanitation, community life— (the community). Page 197 ,\Wi There is only partial recognition of these facts in our present system. 5. There is no adequate system of prevention of disease. Experiments already tried show that a vast amount of disease is preventable. Therefore, it should be prevented. This is especially true of maternal mortality and morbidity—of children's disease, of infectious disease (especially T.B.), of industrial diseases, heart disease, degenerative diseases, of insanity, and mental defects. We do not feel that there is any criticism of the methods of medical practice. Other things being equal, we feel that the working- man prefers to have the right to choose his own medical attendant, just as the wealthy man has. He wishes to have access to complete treatment, modern methods of diagnosis, hospitals where necessary, specialists, etc. The method of practice in vogue has grown up through many generations, and is, we believe, the best in every way, except in the matter of cost. The patient chooses his own doctor in whom he has confidnce. This doctor is, however, in competition with others, and must show his fitness and maintain himself in this state of fitness. This is for the good of the community. The doctor is paid for the work he does, and this we believe to be the best plan. Experience has shown that the vast majority of medical men can be depended on to be reasonable. In. ordinary practice, charges are based on a list of fees, and this can be used always as a check on charges made. The medical profession would support and endorse any system which would improve the health of the community, lessen disease, and prevent illness as far as this can be done. We have examined into the systems of health insurance existing in various countries. We find that while they have caused some improvement in certain ways, notably in the opportunities given for better preventive work, they are yet very imperfect and defective and are criticized for these reasons both by beneficiaries of the Act, and by doctors and others who work under them. Considering the British National Health. Insurance Act as an example,' we find the following main defects. 1. It is too limited in its application, as it embraces merely the wage-earner and not the family. .bi»».. u.r 2. It is too limited in its scope and provides merely.a..;pretence of medical care. This is mainly due to the fact, that the amount collected is so small that it'is impossible to give any adequate medical service. The surgery, ■ ISfeofca'tfory, X-ray and hospital treatment are omitted and thus good medical Work cannot be done in this connection. The method of payment of doctors is, in our opinion, a wrong one, namely by means of a capitation fee. We believe that this is.the wrong method of payment for almost any work and especially medical work. The doctor like any other worker should be paid a fair fee for what he does and speculative element should be removed entirely. If a complete service was given, we believe that the capitation fee necessary would have to be very much larger than it is in Great Britain and the method of payment is not used in any other department of human activity. Page 198 Work under the Act is limited to the panel of doctors and while it is true that any medical man may put his name on the panel, yet we believe that a sick man should have access to any doctor he wants, without restrictions as under our present system of practice and should be free within reasonable limitations to change his doctor if he is not satisfied. We feel that if any system-of Health Insurance is introduced into British Columbia, it should be based on the following main principles. First as Regards Scope— The plan should be a complete one. The aim should be to give complete medical care. This would include hospitals, specialists, nursing, modern methods of diagnosis and treatment of all kinds necessary. This should be the ideal to be aimed for, though at the beginning, it might be necessary to apply certain limitations in order to render the Act workable at the outset. Thus we can conceive that it might be necessary at first to exclude certain chronic and institutional diseases, and perhaps to limit the range of payment or the time during which compensation is given, for practical reasons. Further, the Act should include the family as well as the wage- earner. This is essential, only in this way can we hope to attack with any success, the problems of maternal mortality and morbidity and the question of child welfare, and other similar problems. It would be necessary for the married man to pay more than the single man, but we believe that the method of payment could be so adjusted that thsi would not be too great a burden on the family. Second as Regards Method of Administration— There should be as little dislocation as possible of our present system of practice. The features that have worked well and satisfactorily the method in vogue in such countries as Denmark would be of great should be retained—and change made only when necessary. Thus all registered medical men should be eligible to practice under the Act, and there should be the freest possible choice of doctor by patient and of patient by doctor, as is the case at present. The doctor should be paid for the work done on the basis of a fee list comparable to that of the Workmen's Compensation Board, and based on the fee list of the B. C. M. A. As regards allocation of payment for the costs of illness. This should be divided amongst the three parties responsible, as shown above, the individual, industry, and the state. The exact proportion to be determined. The Act should be applied compulsorily to all whose income falls below a certain figure. We would sugges that at first the setting of this figure be regulated so as to include those individuals who earn the lower wages, these being the ones who are really in need of aid, e.g., one thousand for single, twelve hundred or fourteen hundred for married men. This could later be enlarged to include others with rather better wages, when the Act was found to be workable. One of the most essential parts of any scheme as we see it, is the establishment of an adequate system of preventive medicine, of health to maternity and children. In connection with the former, a study of Page 199 work, social service work, and so on. This is especially true with regard value. Establishment of systems of pre-natal and post-natal care, by properly trained workers, will do much to lessen our present excessive maternal and infant mortality. In this connection, we feel that this work should be done by salaried workers, doctors and nurses, and their work should be kept completely separated from therapeutics and diagnosis. We feel that this work should be under the control of a Commission analogous to the Workmen's Compensation Board and should be administered entirely by it. Lodges, Benevolent Societies, etc., should be absolutely barred as carriers under the Act. Experience in Great Britain has shown that the admission of these bodies as carriers has been very detrimental and has done more to prevent development of the Act than anything else. There should be no possibility of exploitation for a private profit, and all funds collected should be administered by the Commission for the good of the insured. Hence, insurance companies should not participate in any scheme that may be devised. The experience of the Workmen's Compensation Board has shown that a Commission can operate the Act far more economically than can be done in any other way. As regards tuberculosis and other institutional diseases, these we feel, should be omitted from the Act, at first at least, and handled as at present. Similarly with chronic cases at first. As regards the really indigent. These should be greatly lessened by such an Act. Everyone in the country should be registered, as was done in war-time, and made to pay his share. In certain areas, there are large numbers of people of scanty and uncertain income, who yet could be made to pay a share towards their own protection. As regards hospitals. The introduction of a Health Insurance scheme would go a very long way towards settling the hospital problem, and toward enabling the hospital to reduce its fees to the "pay" patient, who now pays more than he should. The method of administration will vary in different areas of the country. Mining and lumbering areas will, perhaps, best be served at first by a contract system, such as prevails at present. Rural areas will require special consideration, on account of mileage, etc. Considerable study has been devoted to this matter of Health Insurance by various organizations in the United States, notably the Pennsylvania Health Insurance Commission, in 1929, and the American Association for Labor Legislation. The latter prepared a tentative Health Insurance Act based on the results of their investigation and drew up certain standards of considerable interest. We feel that their arguments are well worth perusal. In drawing up any Health Insurance Scheme, we believe that the Workmen's Compensation Act could very well be used as a model. This Act is working efficiently and economically and is accepted, on the whole, as satisfactory by all who are connected with its operation. It follows the principles set forth above, as adapted to the system of medical practice already in vogue, and hence caused no upset or confusion when first adopted. Page 200 British Columbia Laboratory Bulletin Published irregularly in co-operation with the Vancouver Medical Association Bulletin, in the interests of the Hospital, Clinical and Public Health Laboratories of B. C. Edited by A. M. Menzies, M.D., of The Vancouver General Hospital Laboratories Financed by The British Columbia Provincial Board of Health COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital, Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster; Royal Inland Hospital, Kamloops; Tranquille Sanatorium; Kelowna General Hospital; and Vancouver General Hospital. All communications should be addressed to the Editor as above. Material for publication should reach the Editor not later than the seventh day of the month of publication. Vol. IV. JUNE, 19?0 " No. 5 CONTENTS 1. Summer Schedule, Wassermann and Kahn Tests, V.G.H. Laboratories 2. Gastric Analysis - Matheson 3. Hypoacidity In Pulmonary Tuberculosis Darling 4. Scarlet Fever Experiences Ootmar NOTICE Re Wassermann and Kahn Tests Vancouver General Hospital Laboratories Because of the shortage of Laboratory workers during the holiday season, June, July and August of this year, it is necessary for the Bacteriological Department to make special arrangements to cope with the routine work. Beginning June 1st and ending August 31st, the days for receiving requisitions for Wassermann and Kahn tests will be Sunday, Tuesday and Thursday up to 6.00 p.m. By this arrangement it is hoped to avoid dropping one or other of the two tests during the summer, a course of action which was necessary last year. Requisitions for Wassermann and Kahn tests should be in the Laboratory not later than 6.00 p.m. on Sundays, Tuesdays and Thursdays. The tests will then be completed by 1.00 p.m. on the following day. The co-operation of Attending Doctors to meet this re-arrangement is requested. R. A. Seymour, M.B., Acting General Superintendent, Vancouver General Hospital. GASTRIC ANALYSIS J. E. Matheson, M.B. Vancouver General Hospital Laboratories A necessary prerequisite to the proper understanding of the results obtained in a "gastric analysis" is the understanding of the physiology of gastric secretion and digestion. Two types of stimuli mainly, result in the secretion of gastric juice, psychical and chemical. The former acts through sight, smell and thoughts of food, the latter produced by water and food extractives, Page 201 i 1 broth, etc., coming in contact with the gastric mucosa. Pavlov's famous experiments on dogs with gastric and oesophageal fistulas demonstrated these points as well as the variations in quantity produced through stimulation with various kinds and quantities of food; In the dog, meat caused a copious secretion of gastric juice, even when no portion of food reached the dog's stomach. Normal gastric juice is a thin, watery, pale colored fluid, acid in reaction, specific gravity 1001-1010. The acidity is due to free hydrochloric acid. The other most important constituents are the enzymes, pepsin, rennin, and lipase. The acid has the power of combining with the protein of the food forming "combined H.C.L." which is truly a chemical combination rather than a mere absorption of acid by food. This fact accounts for the different reactions obtained in the two. The germicidal powers of the gastric juice are due to the H.C.L.; also, because of the part it plays in the formation of pepsin from pepsinogen, hydrochloric acid is obviously a very essential product of the gastric mucosa. Further, the pepsin, when formed, requires an acid medium to work in, being inactive in neutral or alkaline solution. Other acids, however, may be used to produce the proper acidity needed for the pepsin to act. In order to examine the stomach of a patient, then, we must study its response to stimulation. The easiest way to study its maximum response under controlled conditions is to have the patient take definite food mixtures, and then, in order to follow the subsequent steps of digestion, and to determine whatever changes may take place during this process, fraction analysis are done. Thus one is able to follow the whole cycle of changes which takes place. In the actual test, samples can be taken every 15 minutes or every half hour for three hours. The acidity is determined in terms of N/100 sodium hydroxide required to neutralize the free and combined acid present, various indicators being used to demonstrate the respective end points. The results are then calculated as for 100 cc. of the given sample. It is readily seen that since the "combined acid" is a definite chemical combination of acid and food, this latter combination will have a different hydrogen ion concentration from that of the free acid and will therefore show a different end point and will require a different indicator. So the results are given separately for the free acid and the combined acidity. The following graph shows the results plotted in the form of curves. Curve one is that of the normal stomach. ( Curve two is delayed di- ■ gestion. Curve three is tardy hyperacidity. Curve four is continued secretion in obstruction. Curve five is acidity in gastric carcinoma. " The test meal used (the Ewald test meal) consists of two pieces of toast and eight ounces of tea llmt br&. '•1% *'A. Page 202 After the passage of the Rehfuss tube the residuum is removed from the stomach before any food or water is taken. It should be remembered that the tip of the tube should reach the lower pole of the stomach and should remain there throughout the whole test. The residuum, in the normal stomach will be about 50 cc. Its total acidity averages about 30, free acidity 18.5. At the intervals decided upon (15 minutes or half hourly periods) 5 cc. samples are withdrawn, a small quantity of air being blown down to clear the tube for the next sample. The stomach will normally be empty at the end of the 2% hours. In order to have a representative sample for analysis the stomach contents are thoroughly mixed by aspirating back and forth several times, before the sample is taken. A single examination gives no information concerning gastric digestion as this process is a continually changing one and we must examine several consecutive specimens to get any idea of the trend of changes that are taking place. In those cases showing a low acidity, considerable fermentation of the carbohydrate in the diet may occur with the formation of lactic and other organic acids. In the examination for lactic acid we get a rough estimate of the amount present. This examination will be done routinely in this laboratory on all specimens showing low inorganic acid content. HYPOACIDITY IN PULMONARY TUBERCULOSIS George Darling Tranquille Sanatorium Laboratory The occurrence of hypochlorhydria and achlorhydria in the tuberculous is a complication frequently overlooked and, paradoxically, is commonly referred to by the patient as "acidity." These conclusions are the result of basic findings on a series of gastric analysis performed at Tranquille sanatorium. A common complaint from the tuberculous patient is indigestion and acidity. When a neutralizing agent is prescribed such cases often experience an aggravation of their symptoms with increased distress. To determine the gastric contents a series of analyses were instituted, and 32 have been tabulated to date. This is a small number but the findings are significant. Patients complaining of "acidity" were found to be suffering from a diminished secretion or entire absence of jfree hydrochloric acid. Ten were definite cases of achlorhydria; 13 revealed hypoacidity; 1 hyperacidity and eight only were interpreted as being within normal limits. Analysis on two cases of achlorhydria were repeated after an interval of some months, during which time diluted hydrochloric acid had been administered internally. One showed slight improvement in the secretion of free H.C.L.; the other remained as before. All cases with diminished secretion were given dilute hydrochloric acid aftre meals. Improvement was noted in some, while in others the symptoms of indigestion and flatulence were enhanced. On consulting the literature it would appear that achlorhydria in the tuberculous has been the subject of scientific study. Todd claims absence of free hydrochloric acid is to be found in pulmonary tuberculosis. Bonney asserts that irrespective of fever, the Page 20} hydrochloric acid may be reduced in amount or absent altogether at any period of the disease, although, as a rule, in early phthisis this constituent of the gastric secretion is normal in amount. Rosenthal has found the hydrochloric acid absent in both incipient and advanced cases, notwithstanding an apparently normal appetite and digestion. Wells, DeWitt and Long in their "Chemistry of Tuberculosis" state that although there is some evidence of decreased gastric motility and secretory activity in phthisis, and also low pancreatic activity, the alimentary tract seems able to handle, in an entirely normal manner, even excessive quantities of food. Pottenger is of the opinion that if there is abnormal secretion in the stomach there is apt to be abnormal secretion in other parts of the gastrointestinal tract from the same cause. In early tuberculosis increased acidity, probably of reflex origin is quite common. During the late stage of the disease, especially when toxemia is marked, a deficiency of hydrochloric acid is the rule, although this condition often alternates with normal amounts of acid, or with hyperacidity. When suffering from hypochlorhydria Pottenger recommends that patients be urged to eat sparingly until the condition is corrected, and to eat food that is stimulating to the gastrointestinal tract. If the condition is chronic he prescribes dilute hydrochloric acid, with a liberal diet which will stimulate secretion. Laboratory findings on the 32 cases mentioned are appended. Gastric Analyses in Pulmonary Tuberculosis Achlorhydria— Free H.C.L. Total Acidity Case Classification Degrees Degrees Blood 1 Advanced 0 0 0 2 Advanced 0 0 0 3 Moderately advanced 0 30 0 4 Advanced 0 10 0 5 Far advanced 0 5 -f- 6 Far advanced 0 0 -j- 7 Advanced 0 5 0 8 Moderately advanced 0 0 —{- 9 Far advanced 0 0 0 10 Far advanced 0 0 -f- Hypochlorhydria— 11 Advanced 15 30 0 12 Far advanced 25 35 0 13 Far advanced 15 20 0 14 Far advanced 13 30 0 15 Far advanced 7 13 0 16 Far advanced 8 30 0 17 Far advanced 10 15 0 18 Advanced 20 35 0 19 Moderately advanced 10 20 0 20 Moderately advanced 25 30 0 21 Moderately advanced 18 28 0 22 Far advanced ___* 10 18 0 23 Moderately advanced 15 30 0 Page 204 Normal— 24 Far advanced 35 55 0 25 Far advanced 33 53 0 26 Far advanced 37 55 0 27 Incipient 42 54 0 28 Moderately advanced 55 65 0 29 Moderately advanced 34 50 0 30 Incipient 35 56 0 31 Advanced 48 72 0 Hyperacidity— 32 Far advanced 75 86 0 A Rehfuss stomach tube was employed in each case, and gastric contents withdrawn every fifteen minutes over a two hour period. The figures given represent the maximum reading of free hydrochloric acid and total acidity. References: Todd, J. C. Clinical Diagnosis Bonney, S. G. Pulmonary Tuberculosis Wells, DeWitt, Long Chemistry of Tuberculosis Pottenger, F. W. Clinical Tuberculosis SCARLET FEVER EXPERIENCES Dr. G. A. Ootmar Director, Public Health Laboratory, Kelowna, B. C. M. H. O., Kelowna District. In a previous article I gave some of our experiences with scarlet fever outbreaks and would now add further findings from our immunization campaign. Scarlet fever is now accepted as a toxic infection, due to a certain streptococcus which localizes in the pharynx, secreting a toxin which, when spread through the body, produces the symptoms of scarlet fever. Dick, or rather "The Dicks" introduced intradermically, a diluted streptococcic toxin which analogically with the toxin of diphtheria led to the preparation of scarlet fever toxin and active immunization with same. In 1906, Gabritschewsky used a four-day-old broth culture heated to 60 degrees, which killed the streptococci and left the exotoxin intact. After adding 0.5% phenol, he injected 0.25 cc. in children under two years of age and one cc. in children above 10 years. In fifteen per cent, of those injected, reactions were found which resembled scarlet fever, more or less. These reactions never occurred in children who had scarlet fever, nor were any reactions shown when a vaccine was used which was made from streptococci found in erysipelas. It is to the merit of the Dicks that they gave us a measure which expressed the value of the toxin in skin units or "Dick doses." A standard scarlet fever toxin is one of which one-tenth cc. in a 500 cc. Page 205 dilution gives a Dick reaction. This corresponds to 5,000 skin-test units per cc. In Kelowna, the scarlet fever toxin injections for establishing active immunity, (five injections for total immunity) were given at intervals of a week. In total 3,888 inoculations were done. But not all the children or adults took the five inoculations. The Christmas holidays interfered, also thirty below zero weather prevented the pre-school children from attending the clinics. In a preceding article (B. C. Laboratory Bulletin, April, 1930) I stated that the Dick Test did not change from positive to negative after the second inoculation; but fourteen days after the fifth and last inoculation, all the children on whom the Dick Test was done again, showed a negative reaction. I am now able to add some additional information gathered from further study of our series. After we finished our inoculations, there were still some cases of scarlet fever. A total of 19 cases occurred, all in children who had not been inoculated at all, or only inoculated twice. The cases were very mild and sometimes were even doubted that the disease was really scarlet fever. But the haemolytic streptococci which were found repeatedly and the positive Schultz-Charlton skin-blanching phenomenon banned every doubt. The Schultz-Charlton phenomenon can be called a reversed Dick test. Serum of a person who has had scarlet fever when injected intradermically in one-tenth cc. doses into a patient showing the scarlet fever rash, produces a white spot or local blanching in the red rash. The serum of persons suffering from scarlet fever in the early stages lacks this property. We made further tests to see if the serum of a person with a negative Dick would produce the Schultz-Charlton phenomenon in a scarlet fever rash; and found that such serum reacts just as well as the serum of a scarlet fever convalescent. (It would be worth while to investigate as to whether such a serum, i.e. one able to produce localized blanching of the rash, is also capable of neutralizing the streptococcus toxin; in other words, whether a mixture of toxin and serum would give a negative Dick test to a person who had previously yielded a positive Dick.) To find out if there were any pseudo-reactions in the Dick test, as are sometimes found in the Schick test, I heated a tube of Dick-toxin for one hour at 100 degrees C. But the proteins which give pseudo-reactions are not destroyed as tests showed, since both the heated and unheated toxin yielded positive reactions on inoculation into the skin. There is a striking converse parallelism between the reaction of Dick and of the Schultz-Charlton; that means, that the blood of a person with a negative Dick test is able to give a positive Schultz-Charlton in a scarlet fever patient. The more the antitoxin develops in the blood of a person who suffered from Scarlet fever, the more the Dick becomes negative—and the more his serum has this positive blanching influence on the rash of a patient with scarlet fever. Page 206 VANCOUVER HEALTH DEPARTMENT STATISTICS, APRIL, 1930 Total Population (estimated) Asiatic Population (estimated) 240,421 9.335 Total Deaths Asiatic Deaths Deaths—Residents only Birth Registrations .—.____ Male 209 Female 211 INFANTILE MORTALITY— Deaths under one year of age Death Rate per 1000 Births :. Stillbirths (not included in above). Rate per 1000 of Population 180 8 168 420 11 26.19 21 9.11 10.43 8.50 21.25 Cases of Contagious Diseases Reported in City March, 1930 Cases Deaths Smallpox 3 0 Scarlet Fever 12 0 Diphtheria 19 0 Chicken-pox 53 0 Measles 10 0 Mumps - 45 0 Whooping-cough ~ 48 0 Typhoid Fever 1 0 Paratyphoid B. - — — Tuberculosis . 19 21 Poliomyelitis 0 0 Meningococcus Meningitis __ 2 1 Erysipelas 9 0 April, 1930 Cases Deaths May 1st to 15th, 1930 Cases Deaths 21 25 20 59 6 54 69 0 4 14 0 0 7 0 0 0 0 0 0 0 a i 21 o o 0 1 7 10 41 1 33 89 1 2 8 0 0 2 Say it with Flowers Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs, Roots, Wedding Bouquets. Florists' Supplies and Funeral Designs a Specialty Three Stores to Serve You: 48 Hastings St. E. 665 Granville St. 1 51 Hastings St. W. One Phone: Seymour 8033 Connecting all three stores. Brown Bros. & Co. Ltd. VANCOUVER, B. C. Page 20/ Jj Dextri*Maltose for Modifying Evaporated Milk In sections where fresh cow's milk is not readily available, physicians often rely upon evaporated milk for infant-feeding/ Dextri-Maltose is as important for modifying evaporated milk as it is for fresh cow's milk, supplying the correct proportion of carbohydrate without nutritional upset to the baby* The assimilation limit of Dextri-Maltose is twice that of cane or milk sugar* Dextri-Maltose is absorbed high in the intestinal tract, so that it is least likely to cause fermentative diarrhea and nutritional disturbances* DEXTRI-MALTOSE NOS. 1, 2 AND 3, SUPPLIED IN 1-LB. AND 5-LB. TINS AT DRUGGISTS. SAMPLES AND LITERATURE ON REQUEST, MEAD JOHNSON & CO. OF CANADA, LTD., BELLEVILLE, ONT. Rest Haven Sanitarium and Hospital MARINE DRIVE, SIDNEY, B. C. (Near Victoria) (Visited by Qualified Physicians) Semi-Private Wards Surgical Wards Private Rooms Maternity Wards Rates as low as $21.00 Weekly. Beautiful for situation. For further information apply to: MEDICAL SUPERINTENDENT, SIDNEY, B. C. or the Manager Miss R* A* Backett, r. n. Masseuse Rooms 503 - 504 Birks Building Phone Trinity 2004 Sun Ray with Quartz Lamp Cabinet Baths and Shower Swedish or Weir Mitchell Massage Specializing in Physio-Therapy Patients may be visited in homes (Qualified Physicians invited to visit) IPS foti&ffi&V&'&ff^nW*'*'*'™*!*******'. m ^KywAwwWftWgS i 536 13th Avenue West Fairmont 80 Exclusive Ambulance Service FAIRMONT 80 ALL ATTENDANTS QUALIFIED IN FIRST AID "St. John's Ambulance Association" WE SPECIALIZE IN AMBULANCE SERVICE ONLY R. J. Campbell J. H. Crellin W. L. Bertrand 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. ESTABLISHED NEARLY kCENTURY.*' ~ B.C. STEVENS CO. Phone Seymour 698 730 Richards Street Vancouver, B. C. 1 i ! —j — SSfe -•-*©»= Boe^j^fe^T^ie *r !I^PH- Hollywood Sanitarium j* ., | LIMITED tyor the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively ''Reference ~ IB. G- oMedical ^Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Seymour 4183 Westminster 288 «®«p TKSV
Periodicals
W1 .VA625
English
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Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: June, 1930
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