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History of Nursing in Pacific Canada
Vancouver Medical Association
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The BULLETIN OF THE VANCOUVER MEDICAL ASSOCIATION Vol. X. MARCH, 1934 ite M NEWS and NOTES THE BONE MARROW REVIEW \ ur y PUBLISHED MONTHLY AT VANCOUVER. B. C, BY WRIGLEY DIRECTORIES LIMITED, SOO WEBT PENDER STREET -■ VANASPRA made from the finest quality Acetylsalicylic Acid so compressed as to insure immediate disintegration in the stomach. 2Vz DOZ. IN GLASS VIALS, BAKELITE CAP. VANASPRA 5-GRAIN PLAIN. VANASPRA COMPOUND No. 202. VANASPRA COMPOUND No. 303 with CODEINE. We commend VANASPRA to the profession as of the highest standard at less than half the price of other makes. Western Wholesale Drug Limited 456 Broadway West Vancouver, B. C. 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. H. MacDermot Dr. M. McC, Baird Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address Vol. X MARCH, 1934 No. 6 OFFICERS 193 3-1934 Dr. W. L. Pedlow Dr. A. C Frost Dr. Murray Blair President Vice-President Past President Dr. W. T. Ewing Dr. W. T. Lockhart Hon. Secretary Hon. Treasurer Additional Members of Executive:—Dr. C. H. Vrooman; Dr. H. H. McIntosh TRUSTEES Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie Auditors: Messrs. Shaw, Salter & Plommer SECTIONS Clinical Section Dr. W. H. Hatfield |l _i|_ —..__ Chairman Dr. W. E- Graham si. Secretary Eye, Ear, Nose and Throat Dr. R. Grant Lawrence-^HI; Chairman Dr. E. E. Day , Secretary Pediatric Section Dr. E, D. Carder || Chairman Dr. B. P. Kinsman j|^ E^l$£i!|| Secretary Cancer Section Dr. A- B. Schinbein Chairman Dr. J. W. Thomson Secretary STANDING COMMITTEES Library Summer School Dr. H. A. DesBrisay Dr- H- a- Spohn Dr.G.E.Kidd „ ... .. Dr. H. R. Mustard t-_ rr u Publications Dr T W Thomson Dr. J. E. Harrison i.k. j. w. ihum.uk Dr. W. D. Keith Dr. J. H. MacDermot Dr. C. E. Brown Dr. C.H. Bastin Dr. Murray Baird Dr- J- E- Walker Dr. A. V. Bagnall Dr. D. I ft Cleveland Dr- Ji p ArbuckLE Hospitals Dinner Dr. W. C. Walsh _ _ , Dr.S. B. Peele Dr. J. G. McKay Credentials Dr t h Lennie Dr. N. E. MacDougall _ _ _ „ r>D r F rnvFBNTON r_„ r -c r- Dr. F. P. Patterson ur- *-• r- ^overnton JJr. Cj. fc. Gillies Dr. S. Paulin V.O.N. Advisory Board v _. 4 t> r- i, j a Dr.F. W. Brydone-Jack Dr. I. Day Rep. to B. C. Med. Assn. „ T „„ c Dr. J. W. .Shier Dr. G. F. Strong Dr. H. H. Boucher Sickness and Benevolent Fund — The President — The Trustees (SiotfAMU HORMONE PRODUCTS formerly known as VIT-ALEXIN REPRESENTING A GREAT ADVANCE IN ENDOCRINE MEDICINE For the Medical Profession: A CONDENSED EXPLANATION OF BIOGLAN PRODUCTS BIOGLAN is a unique combination of specifically active hormones obtained by the most modern methods from original material in a sterile non-irritant base of unquestioned purity for intramuscular injection. In the series of compounds known as the BIOGLAN products we offer the most modern physiological principles especially directed to restore and preserve endocrine balance. Perfect co-ordination of endocrine activity is a primary essential for the maintenance of normality. Like so many normal phenomena, it is never noticed or appreciated until the disagreeable consequences of its loss are made manifest. Endocrine imbalance shows itself in a great diversity of apparently unrelated states. Mental and physical sluggishness, lack of concentration, reduced resistance to disease, obesity, impotence, sexual frigidity, menstrual disorders, sterility, habitual abortion, muscular weakness, and debility may all be evidence of lack of internal secretory equilibrium. Such a wide variety of conditions to be treated makes flexibility of formula a paramount consideration. To achieve this object The Bowsher Laboratories, Ltd., ransack the animal kingdom to extract by the most up-to-date methods all the worth-while active principles which modern science has revealed. A leaflet fully descriptive of the various formulae will be forwarded to any registered physician on application. Depots in Canada, Australia, India, China, Philippines, Malaya, Jamaica, Irish Free State, and on The Continent. The Bowsher Laboratories LIMITED BIOLOGICAL and RESEARCH Ponsbourne Manor, Hertford, England S. N. BAYNE B. C. Representative Phone Sey. 4239 143 2 Medical-Dental Bldg. Vancouver, B. C The Bowsher Laboratories Specialize Solely in Hormone Research VANCOUVER HEALTH DEPARTMENT STATISTICS—JANUARY, 1934 Total Population (Estimated) 243,711 Japanese Population (Estimated) 7,866 Chinese Population (Estimated) 8,315 Hindu Population 251 Rate per 1,000 Number Total Deaths Japanese Deaths Chinese Deaths Deaths—Residents only ___ - - Birth Registrations only Male 164; Female 136. umber Populat 191 9.2 6 9.0 8 11.3 172 8.3 300 14.5 INFANTILE MORTALITY— Jan., 1934 Deaths under one year of age 8 Death rate—per 1,000 births 26.6 Stillbirths (not included in above) 7 CASES OF CONTAGIOUS ^DISEASES REPORTED IN CITY December, 193 3 Cases Deaths Smallpox 0 Scarlet Fever 180 Diphtheria 0 Diphtheria Carrier 0 Chicken Pox 73 Measles 1 Rubella 0 Mumps 43 Whooping-cough 11 Typhoid Fever 1 Undulant Fever 0 Poliomyelitis 0 Tuberculosis 40 Meningitis (Epidemic) 0 Erysipelas 1 Encephalitis Lethargica 0 Paratyphoid I . 0 January, 1934 Cases Deaths February 1st to 15th, 1934 Cases Deaths Nmm $c ®-fjmttfi0tt 2559 Cambie Street V ancouver | B. 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LABORATORY POULENC FRERES OF CANADA LIMITED Canadian Distributors: ROUGIER FRERES, Montreal VANCOUVER MEDICAL ASSOCIATION Founded 1898 Incorporated 1906 PROGRAMME OF THE 36th ANNUAL SESSION GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m. Place of meeting will appear on Agenda. General meetings will conform to the following order: 8:00 p.m.—Business as per Agenda. 9:00 p.m.—Paper of Evening. 1934. March 6th—GENERAL MEETING. The OSLER Lecture—Dr. J. G. McKay. March 20th—CLINICAL MEETING. April 3rd—GENERAL MEETING. Papers: Dr. Murray Baird: "Erythema Nodosum in Relation to Tuberculosis." Dr. D. E. H. Cleveland: "Drug Eruptions." April 17th—CLINICAL MEETING. April 24th—ANNUAL MEETING. flfoount pleasant IHnbertaktrtG Co, %tt>. KINGSWAY at 11 th AVE. Telephone Fairmont 58 VANCOUVER, B. C. R. F. HARRISON" W. R. REYNOLDS Page 103 PUBLIC HEALTH || BIOLOGICAL PRODUCTS Diphtheria Antitoxin Diphtheria Toxin for Schick Test Diphtheria Toxoid (Anatoxine-Kamon) 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, B. C. EDITOEgS PAGE The first monthly payment for relief cases is, we understand, now being made—and we rub our eyes and wonder if we are seeing things. Truly, the amount is not very large, but that, we know, cannot be helped. We understand how desperately scarce money is for relief, and how really difficult is the task set to those who are administering relief moneys. And we feel that they are doing their best to be fair to everybody. The whole history of our dealings in this matter with City and Province have shewn us once again, and perhaps we needed the lesson, that we shall only advance, in all such negotiations, by the steps of compromise and mutual give-and-take. Where this spirit, of candour and generosity and reasonableness, is present, much can be gained: and if it is absent, no permanent victory will ensue. One is appalled, as one studies the face of the world today, at the tragic absence of trust and confidence between men and nations. Everywhere is suspicion and fear and complete, mistrust—and one asks oneself where it is all going to end. And yet, in the final analysis, all business dealings, all our social structures, all our economic and financial relations, are based on one thing, and one thing only—the personal honesty and honour of the people concerned. With these assured, contracts are merely formal records of fact, and are otherwise superfluous—without them, contracts are useless and as perishable as the dust. Perhaps our reflections on this subject are rather too weighty and sententious—and are carrying us too far afield—but in these days of terrible strain, where the air is absolutely supercharged as with electrical potential of fearful danger, it is well to emphasize, where we can, the virtues of patience and trustfulness and perfect candour. In our various negotiations of time past, as we look back at them, any gains we have made have been secured along these lines, of frank and amicable discussion—while our failures have been too often due to haste and lack of patience, and of trust in the essential honesty of the other party concerned, as well as to disregard, perhaps, of their point of view. "Peace," says the poet, "hath her victories no less renowned than war." We are beginning to think that he has understated the case—and to realise that the victories of peace are the only true victories, while those of war are very transitory and questionable. Our profession is facing a test in this regard in the next year or so. We are assured by the government, through the Hon. G. M. Weir, that health insurance is to be introduced at the earliest possible date, and we shall do well to think very carefully over this, and what it means and may mean to us, for good or ill. There is no partisanship whatever in the opinion we express that we are fortunate in the fact that Dr. Weir and the Hon. Geo. Pearson will be largely concerned in piloting the new craft through the legislative sea, with its dangers of storm and wave. Dr. Weir, while engaged in politics, and therefore necessarily identified with a party, is, we are quite aware, concerned for the welfare of all parties equally, and the same may be said of Mr. Pearson. The latter has the additional advantage of having been closely identified with the work that has been done in this province, in the study of the question of Health Insurance, and he is fully seized both of the importance and urgency of the problem, and of the difficulties and dangers that must be overcome. We are confident that these men and their colleagues will take a long enough view of the case: considering not only immediate expediency, but Page 104 all the implications of the future that their present policy must involve: and will safeguard the best interests of all concerned to the best of their ability. As for us, we have no special case to urge, beyond striving to see that any scheme adopted goes far enough to bring about a real insurance, of improved health and lessened disease for the nation at large: and as the interests of the sick are best preserved, so will ours also. There has been a tendency in the press reports on the matter to emphasize the fact that any measure of health insurance will greatly relieve the hospital burdens of the province. This will be a great advantage, but is not, to our minds, the outstanding need. It is the burden of sickness on the individual that needs relief, and we should concentrate our attention on this aspect of the matter. NEWS AND NOTES At the time of writing, our worthy President is being congratulated on being a member of the rink that won the McLennan cup in the recent curling tournament. Our ignorance of the correct nomenclature may have led us astray—if so we apologise: perhaps bonspiel is the correct word. We understand his "stanes" are being re-bored and fitted with new valves in preparation for a much bigger event in prospect: and we wish him luck. We congratulate Dr. J. A. Smith on his recent election to the captaincy of the Shaughnessy Golf Club. We note with pleasure that he is returning to active play after his recent absence on account of illness. And it was also a pleasure to see Dr. Fred Brydone-Jack out on the links again a week ago. Beyond a certain dignified reserve in his general bearing, he appeared as efficient as ever. Dr. and Mrs. J. J. Mason recently returned from Honolulu—the doctor looks extremely well, and we are glad to welcome him back. So also with Dr. T. B. Anthony, who was on the same boat, and has resumed practice. Dr. W. L. Graham has returned from his trip East. It is with great regret that we record the sudden death of Dr. S. Petersky, a very well-known member of the profession in Vancouver. Dr. Petersky was addressing a meeting of the Liberal Association at the time of his death, on Health Insurance, a matter in which he had been vitally interested for years, and on which he had spoken on several occasions. Dr. Petersky was also closely connected with the Vancouver Institute, of which he was secretary and president at various times. He was a public-spirited man, quiet and unassuming in his manner, but always ready to testify to the faith that was in him, and pertinacious in seeking that which he felt to be the right thing. He was proud of the ancient race to which he belonged, and was a good Jew, faithful to his people, and always awake to their interests, being an active worker in many Jewish organisations. We extend our sincere sympathy to his widow and family. Page 105 It is with great pleasure that we record the fact that Dr. J. W. Arbuckle's son, Billie, is recovering from a most serious illness: the patient is well on the way to recovery—and we rejoice with his family. Dr. McLean, President of the Regina Medical Association, was in town recently on his way to California, and spent some time discussing with Dr. Vrooman the matter of relief in medical cases: and explaining the methods adopted in Regina. Dr. W. M. Paton is away in California for a month's holiday. The Osier Dinner will be held in the Oval Room of the Hotel Vancouver on Tuesday, March 6th, at 7 p.m. The Osier lecturer is Dr. J. G. McKay, and his subject "Psychiatry." THE 1934 SUMMER SCHOOL The Vancouver Medical Association Summer School will be held this year on June 26th, 27th, 28th and 29th, in the Hotel Vancouver. The Committee in charge has secured the following speakers: Dr. F. W. Lynch, Professor of Obstetrics and Gynaecology in the University of California, San Francisco. Dr. Lynch's subjects will be: (1) Retro-position of the Uterus; (2) Prolapse of the Uterus; (3) Fibroids; (4) Peritonization and Internal Obstruction. Dr. C. E. Dolman, Clinical Associate in the Connaught Laboratories, Toronto, will devote three lectures to a discussion of staphylococcal problems. His fourth lecture will be on some subject connected with his recent research work. Dr. Naffziger, Professor of Surgery at the University of California Medical School, will give lectures on the four following subjects: (1) Neuralgias peculiar to the head and face, coupled with atypical neuralgias; (2) Some phases of Peripheral Nerve Injuries (illustrated by a movie); (3) Exophthalmos of Thyroid Disease; (4) Fracture of the Spine with Cord Injury. Dr. Max Cutler, of the Tumour Clinic of the Michael Reese Hospital, Chicago, will discuss the question of Cancer in connection with radium treatment. Dr. W. C. Alvarez of the Department of Internal Medicine of the Mayo Clinic, has sent an interesting list of subjects connected with the gastrointestinal tract on which he will be prepared to lecture, but a selection from these titles has not yet been made by the Committee. Dr. C. A. Aldrich, Paediatrician, of Winnetka, 111., is the speaker selected in this branch of medicine. His subjects will be announced later. Two or three of the speakers will give clinics and in addition Mead Johnson and Davis and Geek will demonstrate movie pictures of surgical procedures, etc. We are assured that all the speakers are keen, interesting men, so that given a good attendance the success of this year's Summer School should be assured. Page 106 LIBRARY NOTES Reviews The Life of Edward Jenner, M.D., F.R.S., by F. Dawtry Drewitt. Jenner, whose name stands for so much in preventive medicine, is a far-off figure to the physician of today. Dr. Drewitt in his short biography brings us close to the man Edward Jenner and makes us realize that even as a boy he was very much interested in natural history and a keen observer of nature around him. Then we learn that he was a disciple of John Hunter and, what is more to the point, was a great friend of Hunter's and kept up an active correspondence with him for many years. He could very readily have chosen city practice with its opportunities for hospital appointments and large income, particularly with his training and medical associations. However, he loved the country, with its closer touch with his fellow man and nature. Thus it was that he settled in the small town of Berkley in the heart of Gloucestershire. Small-pox flourished in this country from time to time. Is it any wonder then that he got his mind fermenting on the well known local observation that those infected with cow-pox (milk-maids) never took small-pox. Applying this practically, he was able to show that a person inoculated with cow-pox and subsequently inoculated with small-pox, did not take the latter disease. Thus was given to the world, through the revealing mind of an English country physician, one of the greatest contributions ever made to preventive medicine. Every physician should spend an hour or two reading this interesting book, for it has many lessons of inspiration for us all. W. D. Keith. We present herewith the paper read by Dr. B. D. Gillies on "The Bone Marrow." It is only fair to say that the paper, excellent as our readers will agree that it is, is greatly handicapped in its presentation by the fact that the slides and illustrations, of which Dr. Gillies made such free use, and which conributed very greatly to the completeness, and therefore the interest of the paper, must o|%ecessity be omitted. But the Bulletin felt that this paper should be published, nevertheless, and Dr. Gillies kindly agreed to let us have it, though it represents a sacrifice on his part, since the delivery of it depended so much on the constant reference to illustrations. THE BONE MARROW By Dr. B. D. Gillies, Vancouver, B. C. Hidden aw» in the most inaccessible portions of our anatomy, distributed and protected as is no other system, is, after the blood, the muscle and bony systems, the largest and until a very recent date the least studied organ of the body. I refer to the bone marrow. Read before the Vancouver Medical Association, February, 1934. Page 107 I have chosen to speak of it tonight for two reasons, one because my interest was drawn to it over twenty-five years ago on account of several articles of Pappenheim's which appeared in Folia Hcematologica, in which he forecast many facts we now know in blood cytology, and secondly because I know so little about the subject. During the past four or five years the interest of scientific workers has increased to such a degree that last year the Journal of Laboratory and Clinical Medicine devoted two consecutive numbers completely to blood and bone marrow study. On account of these facts I felt that a paper, discursive in the extreme, fragmentary from beginning to end, might yet be of interest to our association, and be, to a small degree, helpful to our members interested in clinical work. Custer states that the marrow has not been studied either efficiently or sufficiently during the course of routine autopsy work, and that this is shown by an analysis of the postmortem services of two of the foremost teaching hospitals of this continent. During the years 1927, 1928 and 1929, 2618 autopsies were performed in this service; the bone marrow was examined 47 times, or in 1.7 per cent of the cases. In twenty-five of these the marrow of but one bone was observed ; in several instances simply grossly. For the most part the histological descriptions merely confirmed the gross diagnosis of hyperplasia or no^^l mality, and no mention of cytology is made. Does it not seem incredible that this stupendous organ which plays such an important part in immunity and protection against infection, this birthplace of cells whose life history in the circulating blood is but three to four days, whose function is to provide these cells in normal number and do so rhythmically, and to be on the alert to increase the supply whenever called upon, should be treated with such profound indifference? This, however, is but one of its several functions of which we shall speak. I propose to deal with the subject first by speaking of the physiology of the bone marrow, and if time permit, also very shortly of its pathology. It is suggested by Custer that the femur, rib, sternum and vertebra as a group are preferable bones for marrow study. In the event that such an extensive survey is not considered necessary in an individual case, the femur and vertebra are recommended as the choice of bones for examination. The former to determine the response of the blood-forming organs to stimulation, by metamorphosis from fatty to red marrow; the latter for study of cell content. As all of us know, during intrauterine life the marrow is entirely red, but later yellow (or fatty) marrow makes its appearance. Passing now from the anatomical distribution of the bone marrow and having some idea of its active response to stimulation, let us deal at once with the bone marrow functions. I shall borrow much from a paper by Askanazy which appeared in the Journal "Sang" in 1930. The bone marrow is an organ weighing 2600 grms., the largest in the body after the blood, the musculature and the bony system. Formerly this organ was supposed to have only a mechanical function. It was thought that as the bones of birds contained air to make them lighter, so the bones of vertebrates in general contained marrow for the same reason. Function and structure must be considered together. In the present instance it is most convenient to consider first the structure. The bone marrow is not a single tissue but a collection of tissues living together and collaborating in various ways, in the spaces between the bony trabeculae. Page 108 Hi I In order to get a clearer view of the blood-forming functions of the bone marrow, and incidentally also to clarify certain clinical conditions, it is necessary to delve a bit in the embryology of blood formation, for, as we are all aware, blood exists and functions before the bone marrow has developed. Development of red blood corpuscles: As a result of the work of Doan, Cunningham and Sabin, it may be stated with fair confidence that in mammals and birds, both in the embryo and in extrauterine life, the red blood corpuscles develop intravascularly from the endothelial lining of minute blood vessels; the white corpuscles develop extravascularly and pass actively through the lining wall of the capillaries into the circulation. The above and what immediately follows I have taken from Wright's Applied Physiology. (Then followed a description of the formation of blood in the embryo and the changes occurring in the developing cells from the primary cell, the megaloblast, erythroblast, normoblast, reticulocyte to the erythrocyte. These changes were illustrated by various slides and plates. The structure of the marrow, vascular arrangement and methods developed to simplify the study of these developments were also dealt with.) To return to the article by Askanazy:— He goes on to analyze successively the function of (1) the endosteum, (2) the fatty marrow, (3) the reticulum and the vessels, (4) the hematopoietic parenchyma, and (5) the lymphatic follicles. (1) It is only gradually that the need to distinguish the endosteum has become apparent. The endosteum is a fine fibrillary membrane which covers the bony trabeculae and regulates the life of the trabeculae. It possesses a fibroplastic, osteoplastic and osteoclastic power and is seconded in its task by the blood vessels belonging to it. Here are cells which are effaced in the normal skeleton of the adult, but which construct and destroy bone by mechanical and histiochemical means. The endosteum is the internal continuation of the periosteum. Its function can be widened, especially in cases of osteosclerosis. It is specific osteogenetic tissue which can make osteoclasts but not megakaryocytes. The endosteum is more concerned with bone pathology but it is necessary to name it and to remember its particular place in the scheme of the vital reactions of the tissues contained within the bone. (2) The fatty marrow, occupying a large space, has received more attention than other elements of the marrow. It increases in amount from early childhood, developing centripetally in the interior of the extremity bones, where only the upper third or quarter of the humerus and femur still contain red marrow during extrauterine life. Some fatty cells are every- wheap? found among the "noble" cells in the normal state. Although fatty marrow does not differ morphologically from other adipose tissue in the organism, it does differ fromJt in chemical composition. The mother cell of the fat cell of the bone marrow is the cell of the reticulum. This origin has had an influence on it, but in general, one can say that the fate of the yellow marrow, normally and under pathologic conditions, is that of adipose tissue in general. The yellow marrow is a storage depot for fat; because of its localization in the skeleton it fulfils first a mechanical function in decreasing the weight of the bony system, and together with the red marrow, allowing greater size to the bones. A further mechanical function is replacement of hematopoietic tissue after this has become superfluous. It increases greatly the intraosseous pressure, which is so important for the exportation Page 109 of the blood cells. The pathologic process of gelatinous atrophy shows that the fat cell can revert to the reticular cell and that it contributes to the local and general alimentation of the organism. On the other hand, it can become enriched with fatty matter and lipoids, and accumulate lipotropic substances such as cholesterin. In a state of hyperplasia, it can create an adiposity that is dangerous to the hematopoietic cells. It can stifle the red marrow. The yellow marrow stands in two relations to the organs outside the skeleton; a relation to the adipose tissue in general and a relation to the endocrine glands, which influence the metabolism of adipose tissue. (3) The tissue of the reticulum, which, in a state of repose, occupies a very inconspicuous position, has been given today a higher place in biology than the bone marrow itself. The stroma of all organs, heretofore neglected, is today the subject of intense study. By stroma, is meant the interstitial tissue of organs, with or without the blood vessels. When the interstitial tissue and the vascular apparatus are thought of together, one speaks of the reticulo-endothelial apparatus. The meaning of this term has been becoming too vague. The important part of the reticuloendothelial apparatus is to be found in what was called the blood filter at the beginning of this century, i.e., the liver, spleen and bone marrow, the rest is accessory. Two fundamental facts are: (1) This filtration system is attached to the endothelial cells and to the cells of the reticulum of the three organs in question, not to the cells of their parenchyma. (2) This system correlates organs which have, in other respects, widely differing functions. In Gaucher's and in Niemann-Pick's diseases the reticular cells become filled in an extraordinary manner with organic substances elaborated or accumulated because of an altered metabolism—in Gaucher's disease (which used to be called splenomegaly)—cerebrosids, and in Niemann-Pick's disease—lipoids. These substances distend the reticular cells so as to cause atrophy of the "noble" cells with resultant osteoporosis. Some cases of diabetes with lactaemia manifest mild degrees of this surcharge of lipoids in the reticular cells. This pathologic state can be reproduced by feeding animals on lipoids or by injecting lipoids intravenously. While the reticular cells filter and cleanse the blood by retention of pigments without harm to the marrow, lipoid infiltration can attain degrees which imperil the existence of the "noble" cells, as when the rays of radioactive substances become fixed in these cells and exert their deleterious influence on the haematopoietic tissue. Among the beneficial actions of the reticular cells is that of engulfing and transforming diseased and senile erythrocytes, also that of manufacturing hemosiderin used in erythropoiesis. They also act as the living principle of defense in infectious diseases, particularly specific infections. Studies in the histogenesis of tubercles, of the nodules of glanders, of granulomatous foci, foci of leprosy, etc., in the bone marrow, show the importance of the action of the reticular cells. In cases of grave infection, especially if acute, they succumb with the " noble " cells, but if the reaction is latent and productive, it is from the reticular cells that the specific cells are formed (the epithelioid and giant cells of tuberculosis, the epithelioid cells of glanders, Sternberg's cells in lymphogranulomata, etc.). It is highly probable that they fight against the specific virus and it is possible that they participate in an essential manner in the elaboration of antibodies which take origin in the bone marrow. o Page 110 The reticular cells and the cells of the vascular endothelium collaborate. The slowed down current in the large vessels with thin walls favors exchange, and nowhere is this exchange more lively than in the bone marrow. The first storage depot in point of time for foreign particles passing out from the blood is the endothelium of the vessels, but more often these particles are found in the reticular cells. The nature of the foreign substance, its dispersion and its crystalloid or colloid character, makes a difference. Lipoids, for instance, are stored by preference in the reticular cells, they are rarely found in the vascular endothelium. Just at this point I would like to draw attention to a paper by Hal Downey which appeared in the Journal of the Iowa Medical Society in 1932. The reticulo-endothelial tissue is the mother tissue of all cells, the so- called myeloid cells, i.e., the cells of the bone marrow regenerate from a parent cell which we call the myeloblast and that in turn comes from a reticulo-endothelial cell. It was over 25 years ago that Pappenheim put forward the theory of a mother cell from which all other cells develop. The hematopoietic cells represent the parenchyma of the bone marrow. The quality and quantity of the work of this parenchyma is extraordinary. The red cells, the white cells and blood platelets spring from them. The red cells are the sole carriers of oxygen. The different white cells have different functions, some of which are not yet fully understood, as, for instance, the function of their granulations. In man's normal state the erythrocytes, cells without nucleus, are unsuited to reproduce themselves, and take their origin solely in the bone marrow by mitosis of erythroblasts which have persisted from embryonic life. Their formation by the aid of marrow cells without haemoglobin can be observed physiologically in special conditions and pathologically in cases of extreme need (anaemias). Two physical principles regulate erythropoiesis: atmospheric pressure and the sun's rays. It depends, further, on diet (vitamins, meat, liver, iron). More than any other activity of the bone marrow, erythropoiesis is concerned with the multiple relations existing between the bone marrow and a number of anatomic systems of our organism. Its relation to the blood is illustrated by the activation of erythropoiesis by venesection and by multiple anaemias resulting from quantitative insufficiency, of any origin. A more subtle correlation is shown in splenomedullary relations. In laboratory animals the spleen is always haematopoietic; in man in the normal state in extrauterine life, the spleen shows only minimal vestiges of erythropoiesis, but in case of need the spleen can come to the aid of the bone marrow in haematopoiesis, particularly in young persons; this is seen in infectious spleen, in pernicious anaemia, and in anaemias resulting from destruction of the marrow in the bone. This extramedullary haematopoiesis, in the liver and spleen, is seen only where the parenchyma is smothered and atrophied by proliferation of a non-haematopoietic tissue. A further regulatory influence of the spleen on the bone marrow is seen after splenectomy-—an inhibitory influence. Krumbahr denies this inhibitory effect. This appears from the fact that after splenectomy there may be an overaction of tissues forming red blood cells and red cells containing Jolly's bodies in the blood. This latter is not explained unless as due to loss of some maturation factor. The monocytosis and eosinophilia are explained by the suppression of a blood filtering organ. In infections diseases the spleen and the bone marrow react promptly and together; in the leukaemias their col- Page 111 laboration is almost constant. There is a correlation with the endocrine glands. The thyroid animates erythropoiesis; this is not seen so much in hyper-thyroid as in hypo-thyroid states. In the latter, there is increase of the fatty marrow at the expense of the red marrow. Injection of thyroidin brings about temporary increase in red cells in the blood, and thyroid- ectomized animals do not develop hypererythraemia at high altitudes. The anaemia of the myxedematous is well known. Well known also is the influence of insufficiency of the pituitary and the suprarenals on anaemias. The role of the ovaries in states of haemorrhagic diathesis is familiar. The influence of the pancreas on erythropoiesis is still disputed. These relations between myelopoiesis and the endocrine glands may be direct or perhaps by way of the autonomic nervous system. This nervous apparatus has an important place in the functions of the marrow in directing the circulation. All these correlations show that erythropoiesis is subject to many controls and modifications, but an automatic regulation is suggested by the exact manner in which the function develops. There is the rapidity with which the parenchyma proliferates in the marrow of the extremity bones when marrow of the bones of the trunk cannot supply an emergency demand for cells quickly enough. A few days suffice to bring about this extension of haematopoietic terrain in case of large loss of blood or of acute infectious disease. I do not see how we can rule out a chemical influence being at work in many cases. The Leukopoietic Function:—Leukocytosis is a function of the bone marrow. It has a specific character, i.e., a single category of leukocytes, characterized by one of the specific granulations, is elaborated and animated by a corresponding irritation. This shows the reason for the predominance (40%) of neutrophil myelocytes in the normal leukopoietic marrow, since the neutrophil leukocytes are in a majority of the blood, and the reason for the small percentage of eosinophil myelocytes (3%) in the marrow—this is the percentage of eosinophil leukocytes in normal blood. This parallelism cannot of course be constant. The marrow expels almost its whole store of leukocytes at once in case of emergency demand, and the proliferation of leukopoietic tissue must go more slowly. Under certain conditions the marrow calls on fresh recruits for the production of myelocytes, the myeloblasts. These cells, without granulations, are rarely seen in the normal marrow, they are numerous in the fcetal marrow. They are frequently found in considerable numbers in pathologic states. Experiments have shown that vegetal substances provoke a local neutrophilia and that extracts or particles of intestinal worms give rise to a local eosinophilia. A phytogenic (neutrophil) leukocytosis and zoogenic (eosinophil) leukocytosis may thus be distinguished. But this function of the marrow has not yet been explained. At present we interpret the mobilization of the myelocytes in question by decrease of the surface tension of these cells under the influence of substances in the blood which react on their surface. The cell moves in a direction away from that on which its surface has undergone diminution of tension. This gives a key to the explanation of leukocytosis following injections of solutions of various salts, and allows better understanding of the leukopoietic function of the marrow in leukocytoses in general. The functional explanation of the leukaemias will not be obtained until we understand the etiology of this, almost neoplastic, proliferation. As to the pathologifistates in which the leukopoietic function Page 112 is inhibited, a more exact counting of the leukocytes in the circulating blood is necessary; one speaks of both leukopenia and aleukia. The number of leukocytes, with or without lymphocytosis, can be lowered in the blood when leukopoiesis is altered under the influence of roentgen rays, radioactive substances or poisons such as benzol. In certain malignant infections this inhibition of leukopoiesis is manifest by a leukopenia or &n agranulocythaemia where the poisoned myeloblasts are no longer able to form granulations. In other forms of leukopenia there is no insufficiency of the marrow but hyperactivity, and the number of leukocytes decrease in the peripheral blood because they are being stored in the internal organs, especially the liver and lungs—a phenomenon of anaphylactic and of haemoclastic shock. Finally, in certain infectious diseases, such as typhoid and influenza, the leukocytes do not leave their site of origin, because the action of chemotaxis is checked by these microbic toxins. In the past twenty years much has been learned on the thrombopoietic function of the marrow. Under this term the author includes the formation of megakaryocytes and of blood platelets. Two different sorts of giant cells are found in the skeleton—the osteoclast, a large cell with distinct multiple nuclei of osteogenetic origin, and the megakaryocyte, a large cell with a single large polymorphous nucleus, of hematopoietic origin, and characterized by specific metachromatic granulations in its protoplasm, except for a small peripheral hyaline zone. These megakaryocytes are always found with haematopoietic tissue. Until Wright in 1905 discovered that these cells gave birth to blood platelets (now almost completely verified), their function was thought to be purely phagocytic—in infectious diseases they have been seen to contain leukocytes or red cells in their protoplasm. They are found only in the marrow of animals whose blood contains platelets. They increase in the marrow when platelets are numerous, as in myeloid leukaemias, posthaemorrhagic anaemias, certain phases of infectious fevers and especially in Vaquez' disease, where thrombocytosis in the blood is marked. They decrease in thrombopenia, as in pernicious anaemia, myeloblastic leukaemia, myelophthisic anaemia. Changes in the megakaryocytes may be in their number or in a pathologic condition affecting their granulations. The megakaryocytes have the function of throwing platelets into the circulation. It appears that the role of platelets in the blood will be explained on physiochemical grounds. A tendency to multiple haemorrhages is manifest in patients with thrombopenia, which seems to indicate that the function of the platelets is to guarantee the normal colloidal state of the vascular endothelium, the permeability of which increases as the platelets decrease. On the other hand, the platelets play a role, in the blood itself, in the phenomena of immunity. There is yet much that is hypothetical about all this (i.e., the function of the platelets). The lymphatic tissue of the bone marrow.—Fifteen years ago this author demonstrated that one third of the people in Switzerland had lymphatic follicles in the marrow of the femur and a pupil found still more in the marrow of the vertebrae. It is uncertain whether this should be considered physiologic of pathologic, but up to the present it has been impossible to associate any disease with the presence of these follicles. They are found only with arterial capillaries and it seems probable that they filter the lymph, here as elsewhere. In cases of metastatic anthracosis black pigment was found in these follicles. In patients with extreme degrees of active blood regeneration, secondary Page 113 foci of blood formation may appear in the liver and other organs which are not structurally suited to a tissue as soft as developing marrow. The absence of the bony supporting framework allows the rhythmic dislocations of the organ to dislodge tissue that would otherwise be immobilized. It is suggested that the abnormal and immature cells which enter the blood stream in leukaemia come from the metastatic foci in other organs than the bone marrow or lymph nodes, and that when such foci are absent the patient shows the characteristics of aleukemic leukemia. Likewise the areas of blood formation in the liver may be the source of nucleated red blood cells which appear in the peripheral blood in pernicious anemia, rather than the bone marrow. Under normal conditions, the structure and physiology of the bone marrow (as well as that of the lymph nodes, which have similar characteristics) prevent the release of immature cells into the blood stream. The fixation of young cells by viscid intercellular matrix and the liberation through liqui- f action as a process associated with the maturation of each cell is common to the development of both erythrocytes and leukocytes. Bone marrow cells are not normally in contact with blood plasma and if put into plasma or serum they undergo very definite changes. There is a marked change in reaction when the cells are displaced from the relatively acid tissues to the relatively alkaline plasma or serum. The change is exactly the same as that experienced by the immature blood cells in leukemia when they enter the blood stream. Beside the change in pH there is the change in surface tension. The action of enzymes is probably not a factor under these conditions. It is believed that the adult cells, in fluid, enter the peripheral circulation by localized temporary solution of the thin protoplasmic layer of capillary walls. The fluid pressure on each side would be sufficient to prevent extravasation of blood into the tissues. (There followed here an exhibition of several slides illustrating the development of the leucocytes.) It has been demonstrated that there is a rhythmic delivery of granulocytes from the marrow into the blood stream. Shaw has shown that the afternoon rise is but part of a diurnal rhythm with a second rise about midnight. As clinicians we are interested in these facts of normal delivery and we have knowledge of many substances that by chemotaxis induce an abnormal delivery inducing a leucocytosis. Our knowledge, however, does not extend so clearly to the factors that produce maturation and in many cases this is the process over which we would wish to have control. Bacon considers that an increased activity of the marrow comes from altered body proteins. One might venture to speculate that the resistance of the patient may not depend on the power of the granulopoietic tissue to respond, but on the power of the tissues producing the maturation factor to respond. In liver we have a maturation factor as far as erythropoiesis is concerned. No doubt there is a similar factor in the body to regulate maturation of granulocytes. This factor or factors must be sought in certain organ extracts as well as in specific dietary factor; may be vitamins. The whole structure of the marrow will be found in a relatively uniform state under normal conditions. This means that the relative proportions of erythropoietic to granulopoietic tissue as well as the proportions of the different levels of maturation within the two groups is relatively constant. It can be roughly estimated that from three to twenty times more tissue is devoted to the production of granulocytes than to the production of Page 114 erythrocytes, or, in other words, the volume of granulopoietic tissue is from nine and one-half to twelve times that of the spleen. In contrasting this with the great excess of erythroid over myeloid cells in the blood stream the reverse in the ratio must be correlated with the greater length of survival of the erythrocytes in the blood stream. It would seem from this that the granulopoietic organ is manufacturing an extremely fragile and delicate product. The mere loss of granulocytes for seven days is incompatible with life. They are one of the chief sources of immunity. They are thought to be the source of complement in the plasma, complement is probably the most important single factor in destruction of bacteria and the defense of tissues. They may be the chief source of supply of the various types of immune bodies such as bacteriolysins, hemolysins and precipitins. If a similar maturation factor such as is contained in liver and the mucosa of the stomach, which causes such active maturation of erythroblastic tissues, were at our disposal to cause maturation of the above mentioned cells, who knows but that many of the acute infections would lose their terrors. The Monocyte:—Until recently the nongranular cells of the blood were all classified together as lymphocytes, the transitional or large mononuclear of Ehrlich or as it is now more frequently designated, the monocyte, receiving little attention from physicians. That the monocyte is closely related to the I primitive cell" of the connective tissues similar in all morphologic and other characteristics to the primitive cells of the lymph node and bone marrow has been clearly demonstrated. Doan and Sabin noted the appearance of large numbers of monoblasts in the bone marrow of rabbits experimentally infected with bovine tuberculosis. These cells after maturing were then rapidly transformed into typical mono and multinuclear epitheloid cells arranged as tubercles. Hyperplasia of monocytic tissue is as possible and frequent an occurrence as myeloid or erythroid hyperplasia, and when it occurs, is reflected quite as quickly and directly, qualitatively as well as quantitatively, in the peripheral circulation. Tie monocyte-lymphocyte ratio is of distinct prognostic significance^ tuberculosis, the quality of the individual cells in each of the categories being equally important, while tuberculolipoids have a very strong irritative or stimulative effect upon the monocytes. Very many other substances also call forth this response in a greater or lesser degree and many types of general tissue reactions involve the monocytes. yLet us pass on to a short consideration of the pathological conditions of the bone marrow. It has been pointed out that the marrow of the long bones contains red marrow frequently in adults. In a certain percentage of persons ^SPUs development of red marrow may be so great as to be microscopically indistinguishable from the findings in pernicious anemia. Microscopic exar|§nation shows the differer^e in the nature of the erythropoiesis. Fahr examined the constituents, especially the iron content of the spleen, liver and lymphatic portal ring in cases with transformation into red marrow in the long bones with the same in pernicious anemia. He selected cases with tuberculosis as suitable. In tuberculosis the entire marrow of the femur is frequently transformed into red marrow. In spite of the distinct statements of recent authorities that red marrow is present in an extraordinarily high percgjjitage of long bones of adults, text books continue to state the contrary. The author has found complete transformation of red into yellow marrow in the long bones of adults to be the exception rather than the rule. 'age 115 A remarkable tendency to formation of red marrow in tuberculosis cannot be denied. It does not appear probable from the author's observations that this tendency is connected with the appearance of tubercles in the marrow. In ordinary pulmonary tuberculosis tubercles appear very often in the bone marrow, but typical tuberculous changes are, on the whole, slight. In 100 cases of tuberculosis he found tubercles in the liver in 68, in the portal ring in 65, in the spleen in 60 and in the bone marrow in 17. There is no reason to assume direct irritation of the marrow as cause for appearance of red marrow. For the new formed cells, leukopoiesis is chiefly responsible in tuberculosis. On this point the author's findings agree with those of other research workers. Red marrow can arise on the basis of erythropoiesis (pernicious anemia) and on the basis of leukopoiesis. Pernicious anemia is a process in which erythropoiesis suffers the greatest disturbance; in tuberculosis the disturbance in leukopoiesis dominates the picture, but the erythropoiesis does not behave normally. In the progress from the slight deviations from normal in the erythropoiesis in tuberculosis to the severe disturbances in pernicious anemia the spleen-liver relation in respect to iron content shifts more and more in favor of the liver, as the iron content of the portal ring and the erythrophage content at this site undergo great increase. Downey, in the same paper to which I have already drawn your attention, speaks of the "leukemic" process affecting the red cells so that practically the only division of the myeloid system affected is the line of reds, the normoblasts and the mature reds. Some cases of polycythemia, the so-called erythremias, are of that type. Certain cases of myelogenous leukemia begin as a polycythemia and terminate as chronic myelogenous lukemia with anemia. As to the influence of blood transfusion on the function of the bone marrow, Bogdanov, Beljajena and Majenz found that post-operative complications, infections and icterus, exert an inhibitory effect on bone marrow function. After transfusion of blood the red blood cells increase, but it is not until the third or fourth day that the irritative (stimulative) effect; on the bone marrow begins really to be seen. If operation is performed immediately after the transfusion, the stimulative influence is checked before it gets fully started and the full effect of the transfusion is not obtained. Operation should be done about one week after the transfusion. Myeloma. In 1848 Bence Jones first called attention-to a peculiar protein substance found in the urine in a case of skeletal disease. In 18 82 Kuhne recorded the second case in which this substance was found, but in 1973 von Rustitzky published a case with similar morphological findings but without the protein material in the urine. It is he who first applied the term myeloma to the disease. The nature of the disease is still the subject of lively controversy. The literature shows four distinct modes of manifestation of lymphomyeloma: (1) The commonly accepted picture of Kahler's disease with multiple skeletal tumors and no striking changes in the blood; (2) similar cases with growths both in the bones and other tissues, with a small number of plasma cells in the peripheral circulation; (3) destruction of bone less striking, diffuse infiltration of the marrow and many other tissues and a high percentage of plasma cells in the blood, and (4) generalized diffuse infiltration of the marrow, large numbers of plasma cells in the blood Page 11 5 and histologic changes in the viscera reminiscent of lymphadenosis (lymphatic leukemia). The question as to whether this classification can throw light on the etiology is a difficult one. The histology of myeloma is not very complex. There are two forms: (1) tumours of lymphatic origin (lymphomyelomata) ; (2) tumours composed of leukocytic cells of the granular series. In some cases nodules composed of the characteristic cells are not discovered till the bones are opened, although the compact tissue is always decreased, sometimes to paper thinness. The bone destruction results from the tumour growth itself, not from osteoclasts. A mass may extend through the compact bone into the surrounding tissues where it pushes aside rather than infiltrates the adjacent structures. The bone marrow even close to the growth shows no microscopic changes. In some cases no growths can be found outside the skeleton. Grandular enlargement and splenomegaly are uncommon, but may occur. It has been stated that it does not occur in children and the duration of the disease is longer and the growth slower than has been supposed; complete latency is perhaps very long. There is seldom any explanation for the improvement that not infrequently takes place in the advanced stages, nor for the diminution of pain. There is no associated fever. Irradiation should be tried and also Coley's bacterial toxins. Carcinosis of the bone marrow on the other hand may produce great irritation of the bone marrow and show marked blood changes such as pronounced anemia with high color index, many normoblasts and largely increased numbers of white cells in the circulating blood with lymphocytes predominating. In some of these cases the primary growth is extremely difficult to detect. Puhr maintains that epulis and the giant cell sarcoma of the long bones, the so-called brown tumours of osteitis fibrosa, are both progressive hyperplastic processes of one and the same system, the reticulo-endothelial system. Epulis originates in the reticulo-endothelium of the bone marrow of the alveolar process, and giant cell sarcoma of the bone marrow in that of long bones. Paralysis of the bone marrow is spoken of in the literature and the conditions resulting therefrom are as follows: 1. Agranulocytosis, which, by the way, is a very incorrect nomenclature and ought to be discarded in favor of the term neutropenia. 2. Essential thrombopenia; 3. Aplastic anemia, a chronic disease of erythropoiesis; 4. Hemorrhagic aleukia, a chronic disease of leukopoiesis; 5. Amyelia, acute paralysis of bone marrow. Infections of severe grade and benzol poisoning and irradiation have been indicted as some of the causes of the above mentioned conditions. The action of the x-rays is an action on the leukopoietic function of the bone marrow rather than on the leukocytes in the blood, and the effect may be stimulating or destructive according to the dose. In conclusion you may ask me why I have dealt at such length (and apparently stressed unnecessarily) with the origin and development and the types of cells seen in bone marrow. Recntly the term Erythron, suggested by Boycott, has been introduced to comprise the circulating blood and the cells from which they arise. If our knowledge of these immature cells, which may Page 117 break through into the circulation, is too meagre; if our acquaintance with the sign posts that they rear to guide us is so slight that we pass them by unrecognized; if, I say, such is our position in so-called blood diseases, we are like a pilot in charge of a valuable craft who cannot read his chart while passing through dangerous waters. Not only himself but his charge may be wrecked. If more support were needed I will quote from Lovell Gulland in his Harveian Oration on the Circulating Fluid, who "looks forward to the time when the differential count will be more important than the auscultation of the heart," but that day will come in its fullness only when "the knowledge to interpret such data properly is ours." I maintain that such time will come when, and only when, our knowledge of the normal histology and pathological changes of the bone marrow are as familiar to us as our old time friends the neutrophil and eosinophil. WHAT IS GOING ON IN THE WORLD By H. L. M. in The American Mercury for March, 1933 (Continued from January issue) But then the health department of his town began to go into the medicine business, and in a few years his practice was as good as ruined. Half a dozen free dispensaries of one sort or another were opened in his bailiwick, and nurses on the city payroll began to rove the streets in municipal Fords, seeking prospects. One of his chief sources of income, in his palmy days, had been his obstetrical practice. He delivered babies at $20 a head, and took in enough at the business to pay his rent. But now the city nurses began pouncing on his patients at the first sign of divine retribution, and by the time those patients came to term they were installed luxuriously in some tax-supported maternity hospital, and having the time of their lives. My friend, of course, could not remonstrate with them, but it was at least ethical for him to make some discreet inquiries. "The nurse told me," he was commonly informed, "that I could get a professor to help me—and it wouldn't cost a cent." In a few years the practice of this laborious and worthy man was ruined, and he fell into grave difficulties. All of his more thrifty patients left him; there remained only a few dead beats to whom rooking the doctor was half the fun of being ill, and a rather larger body of insolvent morons who avoided the dispensaries in fear that the medical students supposed to lurk there would slaughter them to get their bones. Presently my friend became ill himself, and what remained of his once comfortable income ceased altogether. His colleagues, including some distinguished specialists, attended him gladly and without charge, for such is the fraternal custom of the craft, but the incidental expenses of his illness were heavy, and after it had gone on for a couple of years his reserves were almost exhaustd. When he died at last he left next to nothing. This was the net reward of a quarter of a century of hard and useful work. This was the natural fruit of state medicine, urged by fanatics and paid for by fools. In so far as the first and third recommendations of the committee contemplate a further extension of that malignant folly, they deserve all the damnation that the embattled doctors have been heaping upon them, but I think it is only fair to add that there are some reservations accompanying them that take a good deal of the poison out of them. One is the reservation Page 118 that, in a community of any size, there ought to be, not one large group of physicians and surgeons, dentists and nurses, pharmacists and morticians, but a series of groups, and that something resembling free competition between them ought to be maintained. The other is the reservation that the whole scheme ought to be tried out on a voluntary basis, and for a considerable time, before any move is made to saddle its costs upon the public. In this last reservation, alas, there is no sign of any tenderness toward the taxpayer; he is to be allowed to escape, it appears, only until the details of the group scheme have been worked out to a sufficiency of decimals, and it is in smooth running order. But all the same, he is indubitably given that humane time of grace, and while it lasts he will have some chance to put up a defense and maybe to fight his way to security. A few years ago his prospects under the circumstances would have been dismal indeed, for the tide was roaring against him and the public-school pedagogues were showing all other varieties of uplif ters how easy it was to take him. But since then he has begun to protest and revolt—to such an extent, indeed, that even the pedagogues are being chased away from the trough. Thus the advocates of free medicine for all have brought their goods to what seems to be a falling market, and by the time they close with their victim and try to get his signature on the dotted line, he may be ready to soak them in the kishkes and make off unscathed. No one, back in the Golden Age of prehensile altruism, would have regarded such a miracle as possible, but in these iconoclastic days it is actually coming to pass. The doctors, in their combat with the visionaries of the committee, are handicapped by the fact that they are themselves largely responsible for the situation which gives its soarings whatever plausibility they may have. On the one hand they have not offered sufficient resistance to the evil tendency, so apparent since the turn of the century, to make medical care more and more expensive, and especiaHylpospital care. And on the other hand they have given far too much encouragement to the baleful proliferation of free service. If now, with depression in full swing, these costs begin to be prohibitive to larger and larger numbers of patients, and they go flocking to the dispensaries for the treatment that they can't afford to pay for, it is certainly not surprising to find the professional do-gooders, who are always eager for more power, reaching out eagerly for the whole business, and proposing to reduce the doctors to the estate and dignity of hirelings working for them, and at their direction. I do not believe that the doctors, taking one with another, have profited to any considerable extent by the vast increase in the cost of medical care. The averaget|JQCome among them is probably not much more today than it was twenty years ago: if it has grown at all, then it is only to the extent that other professional incomes have grown. The general practitioner, indeed, is probably worse off today than he was then. Nor has most of the excess gone to the specialists. It has gone to the hospitals, and they have got it, not in the character of institutions for the care and cure of the sick, but in the character of luxurious hotels for the entertainment and flattery of the sick. Their luxuriousness is naturally most visible in the gaudy quarters and elaborate attendance provided for the rich, but it runs all the way down the line to the wards and dispensaries, and the cost of lodging a free patient has increased at almost the same rate as the cost of lodging a pay patient. In most hospitals of any pretensions caring for the former now actually costs more per diem than the average American hotel gets for a room, a bath and Page 119 three meals. But this luxury, great as it is, is not enough for the patient who has to give any thought to his social dignity. He must buy more if he would keep up with the Joneses—and not infrequently that keeping up with the Joneses precipitates him into such a financial disaster that he is the rest of his life recovering from it. A substantial part of the increased cost, of course, is due to improve-r ments in the art of medicine. Not a few of them call for expensive apparar tus, and all of them call for kinds of skill that cannot be had for nothing. It is obviously far more costly to make a series of x-ray plates and cardion grams of the heart than it used to be to do the whole job with a stethoscope, or even with the naked ear, as was the custom when I was young. A Wasserr mann may not cost as much as a permanent wave, but it at least costs more than no Wassermann. And it is plainly more expensive to cut out a gangrenous appendix and nurse the patient back to health than it used to be to give him a dose of Glauber's salts and send for a clergyman. But all of these costs are very easily exaggerated. They run, at most, to a great deal less than the costs of mere comfort and convenience. A large part of them, even in the case of pay patients, are performed by persons who a^e notoriously underpaid—for example, hospital internes and student nurses,-.— and all of them may be obtained by any reasonably prudent person at vejry moderate rates. What runs up the bill is the elaborate attention and entertainment that commonly go with hem. Theoretically it should be cheaper to treat a patient in a hospital than in his home, but actually, as everyone knows, it is immensely more expensive. He is housed in a building that commonly represents an investment of millions, he is boarded and lodged as comfortably as in a first-rate hotel, and in addition he is looked after day and night, in his special capacity of invalitd, by a staff of persons who, however little they are paid in cash, must still be housed, fed and somenow clothed. It all runs to a formidable sum, even for a light illness. People will not go to a hospital that has the name of being run parsimoniously; they prefer the gilded hell which offers all the latest luxuries, from sunbaths on the roof to bedside radios. They like to think that they have had the whole woifjts; it somehow caresses their amour propre, and gives them a standing with the neighbors. Years ago, patients emerging from surgery used to devote their talk mainly to their sensations on going under the ether: now what they talk about is the cost of the adventure. And even those who pay nothing, I am informed, get pleasure out of the thought that the bigwigs who looked after them, if paid at all, would have been paid a lot. What is to be done about this I do not know, and neither, apparently, does the Committee on the Costs of Medical Care. The scheme it proposes would not really diminish those costs; it would simply tend to load them, in the long run, upon the taxpayer, and so encourage their infinite ip.crease. The doctors themselves, realizing the gravity of the situa.iipn, have attempted to meet it in various American cities by setting up hospitals, or parts of hospitals, for patients of the so-called middle class—that is, for patients who are able to meet a reasonable expense when they are jll, and do not want to accept charity, but are yet too poor to maintain themselves for months on the scale of a bootlegger at Palm Beach. The tran^-Atlantic steamship companies showed the way here when they began to operate one- cabin boats—comfortable enough for any rational person, and yet much less expensive than the fashionable liners. Page 120 But the middle-class hospitals have been anything but roaring successes, save maybe in a few places. The very fact that they are relatively cheap sheems to be the chief objection to them; the normal American, when he is sick, is eager for the best attention that he can get, and the general habit of mind of the country, apparently surviving the depression, makes him believe that the best is necessarily the most expensive. So he goes in for a swell room and special nurses, and the quarters that were established to save him from bankruptcy are occupied by patients who ought to be in the wards. His doctor, I daresay, tries often enough to dissuade him, for the money that he wastes will usually have to come out of the doctor's pocket, but persuading him is not easy. Indeed, it will probably take a few more years of the depression to convince him that he is living, in sickness even more than in health, a good deal beyond his means, and that he will continue in difficulties until he goes back to the simpler life of his fathers. The report of the committee makes much of the lack of hospital faculties in the more remote parts of the Hinterwald, and indeed of the lack of any decent medical care at all. Of the 3072 counties in the United States only 1765 have hospitals, and probably a quarter or a third of these are no more than crude dressing-stations. In the more backward States there are considerable areas in which no competent medical man is in practice; the people, when they are sick, have to travel many miles for treatment. Naturally enough, such isolated and usually benighted persons are easy prey for quacks, which swarm in every rural section of the United States. And it is in the country towns, too, that nine-tenths of the patent medicines consumed in the country every year—about half a billion dollars worth—find a market. All this, of course, is unfortunate, but that anything can be done about it is very doubtful. The committee is somewhat vague on the subject: it hints that the States ought to provide medical service where it is lacking, but does not go into much detail. A few unusually enlightened rural communities have induced doctors to settle in them by offering guaranteed incomes to competent men, but it must be plain that such communities are too intelligent to be numerous. The rest, I daresay, must go on trusting to patent medicines and the chiropractors until God Himself sends them relief. Certainly, it can't be easy to tempt a medical man of any dignity to live in an American country town, with its complete lack of civilized contacts, even if the bait be economic security. Moreover, that security can never be really secure so long as the Methodist shaman survives. In this direction the doctors have let themselves be hustled and run amuck by the public health brethren. The public health business tends more and more to fall into the hands of professional uplifters, and they spend a great deal more time discussing what ought to be done than what can be done. Their chief postulate seems to be that it is the bounden duty of the state to take care of every citizen who can't or won't take care of himself, and they are always eager to pour out the taxpayer's money to that endl But there is really no such duty. The really helpless and friendless sick, of course, must be cared for, if only to keep them from shocking the well by lying in the gutters, but the public responsibility does not go half so far beyond that simple business as uplif ters appear to think. (To be continued) Page 121 STj Trs. Pepys did not take many baths—but ^* f-L. no one did jn tjjg 17th Century. Cold houses, lack of even tub-and-sponge facilities, made bathing an ordeal. The desirability of cleanliness was recognized,-as Pepys' comment indicates—but the practice of cleanliness did not begin until bathing was made pleasanter. Parke-Davis has applied much the same reasoning to vitamin therapy—/. e., by making vitamin therapy pleasanter, its field can be substantially broadened. And to make it pleasanter, you have Parke-Davis Haliver Oil products. It is a well-known fact that adults are more squeamish than children about taking cod-liver oil, and preparations containing it. Their aversion to fish oil is completely obviated by the high potency of Haliver Oil. All the adult patient has to do is to take one or two tiny, tasteless capsules, instead of those distasteful teaspoonfuls. Haliver On. Plain 32,000 vitamin A units (U. S. P. X), or 43,000 vitamin A units (International); and 200 vitamin D units (Steenbeck), or 540 vitamin D units (International) tergram. PARKE, DAVIS & COMPANY WINNIPEG WALKERVILLE MONTREAL The World's Largest Makers of Pharmaceutical and Biological Products CORAMINE CIBA THE SAFE AND DEPENDABLE CIRCULATORY and RESPIRATORY STIMULANT Clinical results—the ultimate criterion—definitely establish the outstanding value of CORAMINE "CIBA' for use not only in temporary emergencies, but also where a relatively prolonged action is desired. You will find it invaluable in such conditions as pneumonia, influenza, senile debility, myocardial involvements, accidents from anaesthesia and poisoning by various drugs or gases. LIQUID AMPOULES CIBA COMPANY LIMITED MONTREAL Messrs. Macdonald's Prescriptions Ltd., and Messrs. Georgia Pharmacy Ltd., of Vancouver, B. C, and Messrs. McGill & Orme Ltd., Victoria, B. C, keep a full range of "CIBA" specialties. For the Failing Heart wm Theocalcin Bh (theobromine-calcium salicylate) Council Accepted Give Theocalcin to increase the efficiency of the heart action, diminish dyspnea and to reduce edema. Dose: 1 to 3 tablets, three times a day, with or after meals. In 7 Yz-grainlisTablets and as a Powder. Literature and samples upon request MERCK & CO. LTD. 412 St. Sulpice St. Montreal BILHUBER-KNOLL CORP., TAfrs., JERSEY CITY, N. J. In the Affections of the I Respiratory Tract I where it is desired to stimulate the circulation of blood and lymph through the affected parts, Antiphlogistine is a valuable adjuvant to the treatment. Applied externally, it not only relieves the congestion, but promotes comfort through its anodyne and analgesic actions. Its heat-retaining property renders it of special value in the general treatment of affections of the lower as well as of the upper respiratory tract. Standard works and textbooks recommend Antiphlogistine for the relief of these conditions. Send for Sample and Literature. ANTIPHLOGISTINE MADE IN CANADA The Denver Chemical Mfg. Cd. 153 Lagauchetiere Street W. MONTREAL one s Dietetic Kitchen... Where individual requirements are catered to— Where meals are cooked the Health Way— Where cooked vegetables retain their vitamines— Where raw vegetables can supply a full course meal, from cocktail, soup, main dish, side entree and salad, to pie and pudding. -♦• 789 West Georgia Street, Vancouver, B. C. Phone Sey. 2021 E. I. MUSGRAVE, Manager A POST-OPERATIVE SUPPORT THAT STAYS IN PLACE Spencer Garments correct posture; straighten Lordosis back-lines; uplift and smooth out sagging abdomens. CORSETS AND SURGICAL BELTS SPENCER CORSETS (CANADA) LIMITED MARGARET LESLIE, Manager Phone Seymour 7258 445 GRANVILLE STREET VANCOUVER, B. C. S. BOWELL & SON DISTINCTIVE FUNERAL SERVICE Phone 993 66 SIXTH STREET NEW WESTMINSTER, B. C. FORT STREET (opp. Times) Phone Garden 1196 VICTORIA, B. C WE HAVE BEEN PRACTICING IN VICTORIA FOR THE PAST 67 YEARS B.C. FUNERAL CO. I HAYWARD'S LTD. Established 1867 Phones: E. 3614 and G. 7679 734 BROUGHTON STREET VICTORIA, B. C. 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 73 0 Richards St., Vancouver, B. C pH74 CHARTS CAN'T EXPLAIN IT It takes personal observation in practice to evaluate properly the good effects of Alka- Zane in systemic acidosis — threatened or actually present. The clinical thermometer will show how fever abates when Al ka-Za ne is an ad junct of the treatment in influenza and other febrile diseases. The pregnant woman will curtail her story of uneasiness and discomfort, when Alka-Zane is administered during the puerperium. Certain skin diseases will show a marked tendency to improve, when Alka-Zane supplements the treatment. Albumin will diminish in the urine when Alka-Zane is given in nephritis. These are just a few examples where Alka- Zane may prove of evident usefulness in the treatment of diseases in which acidosis is a complicating factor. Tritwfii supply sent on request. Please use letterhead. ALKA-ZANE -for acidosis Alka-Zane is supplied in bottles containing I1 ? and 4 ounces. The dose is one teaspoonful in a glass of water. Alka-Zane is an effervescent salt of the carbonates, phosphates and citrates of sodium, potassium, calcium and magnesium. It is free from lactates, sulphates and tartrates, and sodium chloride. A teaspoonful in a glass of water makes a zestful, refreshing drink. WIU3AM R. WARNER & CO., LTD. 727 King Street, West, Toronto, Ontario Effective and Dependable fi^HHltS General Stimulation I without IB After-Depression KOLA ASTIER GRANULATED ^."at.,.. ITOR A^ n m 4 i** FReREStfigf ^ Restrainer of Tissue Waste Anti-Neurasthenic Heart Regulator Muscular System Stimulant for A large percentage of the cases treated by the general practitioner are of an asthenic type and call for the use of some supportive and stimulant treatment. In all materia medica there is no drug that is so admirably adapted to such a class of cases as Kola—the seed, or nut, of the Sterculia Acuminata. The stimulation of Kola is peculiar in that it is tonic in effect and that, unlike that of ordinary stimulants, it is never followed by after-depression. Its co-operating tonic action maintains its beneficial stimulation. In KOLA ASTIER GRANULATED, the physician has available to him in convenient form a skilfully prepared standardized extract, containing all the active principles of the Kola Nut: Caffeine, Theobromine, Kola-Red and Tannin. Kola Astier is not habit forming. Cardiac Adynamia Neurasthenia Post Influenzal Asthenia Post-Operative Shock Senile Involution Mental and Physical Overstrain Convalescence Write for Sample and Literature ROUGIER FRERES DISTRIBUTORS FOR CANADA 3 50 Le Moyne Street Montreal, Que. z:jja&Sf*^ i for sick as well as normal babies Dextri-Maltose/ Carbohydrate of Choice "As to the kind of extra carbohydrate to be added, whether lactose or maltose, I believe dextri- maltose *" b,f f^t-t^r ■" p^naral in cases of fat in- digestion{[infantile atrophyH'—C. H. Dunn: The Jlygienic arid m eaicai i realment of Children, South- worth Co., Troy, New York; 1917, V. 1, p. jlS. In discussing the treatment ofCdeeompositioa Feer says: "The period of repair may De snort- ened by giving suitable additional food; the best, probably, being buttermilk to which carefully regulated proportions of dextrin and maltose preparations or malt soup are added."—E. Feer: Text-Book of Pediatrics, J. B. Lippincott Co., Phila., 1922, p. m. In the treatment of( infantile recommends the following: trophyS Fischer i ne carbohydrate should be increased by gradual addition of dextri- maltose. "Malt soup or dextrimaltose (Mead's) should be added in teaspoonful or more doses to each feeding until the point of carbohydrate tolerance is reached."—L. Fischer: Diseases of Infancy and Childhood, F. A. Davis Co., Phila., 1925, V. 1, p. 285. Grulee, discussing treatment ofiQeeompositionl. observes: "As a rule it is best to star^wi?Ii™7"to 23^ or 3 ounces of albumin milk to the pound weight in 24 hours; the sugar to be added is in the form of a maltose-dextrin mixture. One should never delay too long in adding this."—C. G. Grulee: Infant Feeding, W. B. Saunders Co., Phila., 1922, p. 265. Referring to the^fTypotrophic infantjHerrman writes: "In mild cases, the aaaiuon ot dextrimaltose instead of cane or milk sugar may be sufficient to obtain a gain in weight."—C. Herrman: The treatment of nutritional disorder sin artificially-fedinfants, New York M. J. 114:158-160, August, 1921. In discussing artificial feeding irCJatnrepsiajHess states: "The carbohydrates are usually aaaed in a slowly fermentable form, such as the maltose and dextrin compounds, which are usually started by the addition of four grams per kilogram (1/15 ounce per pound) and increased until eight grams or more per kilogram (J^ ounce per pound) of body weight are added."—J. H. Hess: Feeding and the Nutritional Disorders in Infancy and Childhood, F. A. Davis Co., Phila., 1928, p. 278. Concerning the treatment ofCmarasmus_> Hill says: "When the stools have becomesmootn and salve-like, carbohydrate, in the form of dextrimaltose, may be gradually added up to the limit of tolerance."—L. W. Hill: Practical Infant Feeding, W. B. Saunders Co.. Phila., 1922, p. 281. ".^Spasmophilic baboon bottle feeding should receiveaTTffflTeTHTmoTint of milk—a pint, or at the most 24 ounces in the 24 hours—to which cereal gruel and some form of sugar is added, preferably one of the malt dextrin preparations; also the early addition of other foods than milk to the baby's diet."—M. Jampolis: Infantile spasmophilia, Interstate M. J. 25:652, Sept., 1918; abst. Arch. Pediat. 35:691, Nov. 1918. With reference to the treatment oj^liarrhea^Lust writes: "After several days, 2% to 3% 01 a maltose- dextrin preparation may be added (Dextri-Maltose). This is preferable to the easily fermentable lactose or cane sugar."—F. Lust: The Treatment of Children s Diseases, J. P. Lippincott Co., Phila., 1930, p. 145. "The treatment of artificially fed children in the first of these groups consists in putting them on a low fat dietary, and giving them carbohydrate in the form of one of the less ferment- ali______ii_^iy___ii5Ctsii, dextrimaltose."—L. G. Parsons: C Vastina disorde^aof early infancy, Lancet, 1:687~ 6§i, April h, 1924. Pearson and Wylligjajiiscussing the treatment of milder cases oCnanition sayp"Regulation of this disturbed organismanBalance is obtained by the addition of carbohydrates, while fat and casein are reduced. For this purpose dextrimaltose and flour are better than the ordinary sugars, since they are more slowly absorbed and have greater efficacy in their powers of controlling the flora in the large intestine."—W. J. Pearson, and IV. G. Wyllie: Recent Advances in Diseases of Children, P. Blakistons Son & Co., Phila., 1930. v. 116. Regarding the treatment of thc^narantic infanj Raue states: "After the intolerance to -.U^.it has been overcome a carbohydrate, preferably Dextrimaltose, may be added."—C. S. Raue: Diseases of Children, Boericke & Tafel, Phila., 1922, p. 1,27. In discussing the treatment otatrophyyThursfield and Paterson, state: "If the baby continues to improve, the next step in the treatment is to add to the milk one of the less fermentable carbohydrates, such as dextrimaltose; . . ."—H. Thursfield, and D. Paterson: Diseases of Children, William Wood & Co., 1929, p. 105. "I also find dextrin-maltose an excellent addition to albumin-milk when the first objec£j£i]iaiifi8i has been achieved and a gain iiCweight is desirecQ in this way I have succeeded in reeding aioumin- milk far beyond the period usually advised, with highly gratifying results."—F. L. Wachenheim: Infant-Feeding; Its Principles and Practice, Lea & Febiger, Phila., 1915. p. 158. "Dextri-maltose has been substituted for lactose not infrequently, when the tolerance for the latter continues low."—J. H. West^L^j^QL^Aioh starch evaporated milk feeding for th^^arasmic bab\]%Arch. Pediat. 48:189-193, March, 19317 "Malt sugar is indicated "•H] r>thrr< fnil tp prn- duce a sufficient gain, or whenfinalassimilation of taQ is evident."—0. H. Wilson: 7 he roleoj caroonyaraxes in infant feeding, Southern M. J. 11:177, March, 1918; abst. Arch. Pediat. 35:hh7, July, 1918. MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ont. Please enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized persons SBm 5)6 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 &mt?v & if atma Sift. Established 1893 VANCOUVER, B. C. North Vancouver, B. C. Powell River, B. C. j?^gss^_ag^^t^'£^^^^.gas{^5^^^^^ Hollywood Sanitarium Limited For the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively Reference—B. C. Medical Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Seymour 4183 Westminster 288 Sc^S^cs^Si^^5^^ai^?^?5iis5?^c^as®
Periodicals
W1 .VA625
English
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: March, 1934
Text