CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
image/jpeg
THE ULLETI * 0F The Vancouver Medical Association EDITOR dr. j. h. MacDermot EDITORIAL BOARD DR. D. E. H. CLEVELAND DR. J. H. B. GRANT DR. H. A. DesBRISAY DR. J. L. McMILLAN Publisher and Advertising Manager W. E. G. MACDONALD VOLUME XXX. JANUARY, 1954 NUMBER 4 OFFICERS 1953-54 Dr. D. S. Munroe Dr. J. H. Black President Vice-President ♦Dr. George Langley Hon. Treasurer Dr. E. C. McCoy Past President Dr. F. S. Hobbs Hon. Secretary Additional Members of Executive: Dr. R. A. Gilchrist Dr. A. F. Hardyment TRUSTEES Dr. G. H. Clement Dr. Murray Blair Dr. W. J. Dorrance Auditors: R. H. N. Whiting, Chartered Accountant SECTIONS Eye, Ear, Nose and Throat Dr. W. M. G. Wilson Chairman Dr. W. Ronald Taylor Secretary Dr. J. H. B. Grant. Paediatric .Chairman Dr. A. F. Hardyment Secretary Orthopaedic and Traumatic Surgery j Dr. W. H. Fahrni Chairman Dr. J. W. Sparkes Secretary Neurology and Psychiatry Dr. A. J. Warren Chairman Dr. T. G. B. Caunt Secretary Radiology Dr. W. L. Sloan Chairman Dr. L. W. B. Card Secretary STANDING COMMITTEES Library Dr. D. W. Moffat, Chairman; Dr. R. J. Cowan, Secretary; Db. W. F. Bie; Dr. C. E. G. Gould ; Dr. W. C Gibson ; Dr. M. D. Young. Summer School Dr. S. L. Williams, Chairman; Dr. J. A. Elliot, Secretary; Dr. J. A. Irvine; Dr. E. A. Jones; Dr. Max Frost; Dr. E. F. Word Medical Economics Dr. E. A. Jones, Chairman; Dr. W. Fowler, Dr. F. W. Hurlbubt, Dr. R. Langston, Dr. Robert Stanley, Dr. F. B. Thomson, Dr. W. J. Dorrance Credentials Dr. Henry Scott, Dr. J. C. Grimson, Dr. E. C. McCoy. V.OJN. Advisory Committee Dr. D. M. Whitelaw, Dr. R. Whitman, Dr. H. A. Henderson, Dr. R. A. Stanley Representative to the Vancouver Board of Trade: Dr. J. Howard Black Representative to the Greater Vancouver Health League: Dr. W. H. Cockcroft Published monthly at Vancouver, Canada. Authorized as second class mail, Post Office Department, Ottawa, Ont. Page 133 Clinical experience has clearly demonstrated the effectiveness of PLEXONAL in the treatment of anxiety neuroses and insomnia particularly in the presence of over-activity of the sympathetic nervous system. Sedative dose: | 1 or £ tabs. 2 or 3 times daily. Hypnotic dose: 1 to 3 tabs, at bedtime. SANDOZ PHARMACEUTICALS DIVISION OF SANDOZ (CANADA) L MONTREAL a 286 ST. PAUL ST. SANDOZ HOSPITAL CLINICS VANCOUVER GENERAL HOSPITAL Regular Weekly Fixtures in the Lecture Hall Monday, 8:00 a.m.—Orthopaedic Clinic. Monday, 12:15 p.m.—Surgical Clinic. Tuesday—9:00 ajn.—Obstetrics and Gynaecology Conference. Wednesday, 9:00 a.m.—Clinicopathological Conference. Thursday, 9:00 a.m.—Medical Clinic. 12:00 noon—Clinicopathological Conference on Newborns. Friday, 9:00 a.m.—Paediatric Clinic. Saturday, 9:00 a.m.—Neurosurgery Clinic. ST. PAUL'S HOSPITAL Regular Weekly Fixtures 2nd Monday of each month—2 p.m. Tumour Clinic Tuesday—9-10 a.m Paediatric Conference Wednesday—9-10 a.m Medical Clinic Wednesday—11-12 a.m Obstetrics and Gynaecology Clinic Alternate Wednesdays—12 noon Orthopaedic Clinic klernate Thursdays—11 a.m Pathological Conference (Specimens and Discussion) priday—8 a.m. Clinico-Pathological Conference (Alternating with Surgery) Alternate Fridays—8 a.m Surgical Conference Friday—9 a.m Dr. Appleby's Surgery Clinic Friday—11 a.m. Interesting Films Shown in X-ray Department SHAUGHNESSY HOSPITAL Regular Weekly Fixtures Tuesday, 8:30 a.m.—Dermatology. Monday, 11:00 a.m.—Psychiatry. Wednesday, 10:45 a.m.—General Medicine. Friday, 8:30 a.m.—Chest Conference. Wednesday, 12:30 p.m.—Pathology. Friday, 1:15 p.m.—Surgery. BRITISH COLUMBIA CANCER INSTITUTE 2656 Heather Street Vancouver 9, B.C. SCHEDULE OF CLINICS—1953 MONDAY—9:00 a.m.-10:00 a.m.—Nose and Throat Clinic. (TUESDAY—9:00 a.m.-10:00 a.m.—Clinical Meeting. 10:30-12:00 noon—Lymphoma Clinic. (THURSDAY—11:00 a.m.-12:00 noon—Gynaecological Clinic. DAILY—11:45 a.m.-12:45 p.m.—Therapy Conference. Page 137 Pediatric -to-uAe; Eryfhrocsn m»|fr fat _•*« Stearate (Erythromycin Stearate, Abbott) SUSPENSION A sweet, cinnamon-flavored suspension with the cocci-killing effectiveness of Erythrocin. That's Pediatric Erythrocin Suspension. Little patients like it. Pediatric Erythrocin Suspension is ready for instant use. No mixing required. This new form of an effective antibiotic maintains stability for at least 18 months—whether or not the bottle has been opened. Prescribe odd or even ounces, as indicated. ESPECIALLY INDICATED in otitis media, bronchitis, sinusitis, pharyngitis, tonsillitis, scarlet fever, pneumonia, erysipelas, pyoderma ... when children are sensitive to other antibiotics or when the organism is resistant. . . when the organism is staphylococcus, because of the high incidence of staphylococci resistant to other antibiotics. Like Erythrocin Tablets, Pediatric Erythrocin Suspension is specific in action—less likely to alter the normal intestinal flora than other oral antibiotics, except penicillin. Can be administered before, after or with meals. Pharmacies have Pediatric Erythrocin Suspension in 2-fl. ^przi—v oz. bottles. Won*t you try it? (jOuj&otU Abbott Laboratories Limited • Montreal The dawn of a new era in therapeutics A drug so extraordinary in activity that it warrants the introduction of a new word to medical terminology—"neuroplegic"—is a drug which has necessitated the strictest control and clinical investigation. Clinically, we have but touched the fringe of the potential indications for its use but now that Largactil is being made generally available, the Medical Profession will undoubtedly be informing us of the many fields in which it is helpful. Largactil creates a condition which is described as a "pharmacological foboromy" and its known indications are: psychomotor disturbances, the relief of pain, and as an adjuvant in anaesthesiology. We would suggest that physicians interested in this drug, write for complete documentation. Largactil is supplied as: Tablets, 25 mg., tubes of 20, bottles of 100, 500, 1000; ampoules—5 cc. 5 mg. per cc. for intramuscular injection; ampoules—2 cc. 25 mg. per cc. for intravenous use. LARGACTIL (CHLCRPROMAZINE) 204 Youville Square, Montreal POBLEnC Page 139 o the most complete o the most potent o the most economical • TABLETS • ELIXI NOW WITH VITAMIN I In geriatrics W a pleasantly palatable elixir Particularly suitable for pediatric use ROUGIER FRERES, 350 le moyne street, montre Page 140 GREATER VANCOUVER PUBLIC HEALTH Metropolitan Health Committee Dr. Stewart Murray, Sr. Medical Health Officer, City Hall, Vancouver, B.C. Population (Estimated) I Vancouver 3 90,3 2 5 Burnaby Municipality 61,000 North Vancouver City 16,000 North Vancouver District Municipality 16,000 West Vancouver Municipality 14,250 Richmond 19,186 | University Area 3,800 District Lot 172 1,469 TOTAL 522,030 ***** EDUCATION OF DEAF CHILDREN The recent visit to Vancouver of Dr. Edith Whetnall, F.R.C.S. (Eng.) was a stimulating experience to all who have anything to do with deaf children and their rehabilitation. Dr. Whetnall is Consultant in Otology to the London County Council and is Director of the Audiology Unit at the Royal Ear, Nose and Throat Hospital, I London, and was most generous with her time while here. Dr. Whetnall's method of training these deaf children depends primarily on the training of the infant and very small child to use the small amount of hearing with i which he was born. She has found that only a very small proportion of deaf children are absolutely without some hearing. Children born deaf do start to babble at the normal age when they are close to the mother's voice and can hear her. However, when they start to toddle and are removed from the sound of her voice they cease making these sounds. Combining these observations with the knowledge that normal children prepare for speech by a preliminary period of listening to it, and also the fact that there is likely a time of readiness for learning speech just as there is a time when other new ventures are learned more easily, Dr. Whetnall has adopted a new method of dealing I with deaf children. This new method depends on finding the deaf child when he is very young. As soon as mothers suspect that the baby is deaf she brings him to the doctor. Various methods are used for testing the hearing of these children for sounds, but they are not intricate or expensive procedures. When it is established that the infant or child is deaf the training is centred around the mother as well as the child. These babies are fitted with hearing aids and the mothers are instructed in the methods of talking to them in order to develop a pattern of listening as near as possible to that of the normal child. By following this procedure Dr. Whetnall has found it possible to develop normal speech in a large majority of children with severe hearing handicaps. Along with this training one must give special training in speech and lip reading and in her experience these babies accept the hearing aids well and in many cases can continue their education in the regular school system. In view of the success of Dr. Whetnall's work it becomes imperative to start our training of these handicapped children at the earliest age possible, and all who come in contact with deaf children are urged to consider carefully the possibility of doing more [towards their rehabilitation. Page 141 <CONNAUGHT> ANTI- MEASLES SERUM Concentrated and Irradiated Human Serum FOR MODIFICATION OR PREVENTION OF MEASLES Human serum prepared from the blood of healthy adults so as tc involve a pooling from a large number of persons provides an economical and effective agent for the modification or prevention of measles. Modification is often preferable since it reduces to a minimum the illness and hazards associated with measles, but does not interfere with the acquiring of the active and lasting immunity which is conferred by an attack of the disease. On the other hand, complete prevention of an attack of measles is frequently desirable, and can be accomplished provided that an ample quantity of serum is administered within five days of exposure to the disease. Serum supplied by the Connaught Medical Research Laboratories is concentrated to one-third the volume of normal adult serum and is irradiated so as to minimize the occurrence of homologous serum jaundice. HOW SUPPLIED Irradiated Anti-Measles Serum, pooled and concentrated, is distributed by the Laboratories in 5-cc rubber-stoppered vials. CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto, Canada Etublithed in 1914 for Public Service through Medical Research tad the derelopmeac of Product* for Prevention or Treatment of Diieaie. DEPOT FDR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. From time to time, as we read in the press, there arise from different groups in Canada emphatic demands for a system of National Health Insurance, to apply to everyone—on a non-paying basis. As might be expected, the most urgent of these demands come from Labour Groups—since these represent people whose income are in the lower income brackets, and on whom medical care, in the modern sense of the word, imposes a burden which is often too heavy for them to carry, without hardship and some deprivation. The C.C.F., too, is quite vocal and explicit in support of such a scheme. Actually, we sometimes feel that the burden of medical costs is often even heavier in the case of the office-worker, the worker in stores, the teacher, the man of moderate means generally, than it is on the labour groups, since these, just because they are groups, can generally find relief in a group medical plan. But the more we think of it, the less do we feel that a blanket scheme of Health Insurance, medical and hospital care, ostensibly without cost at the time, is any answer to the problem. In the first place, it would have to be paid for out of taxes. The experience of such countries as Great Britain, New Zealand and others, shows that the cost of such a system of Health Insurance is not only heavier than was ever expected, but it is quite unpredictable—the operating costs are much too high, abuses are too easy, efficiency is too low, and the quality of service is not of the best. Canada can look at these examples and take due warning. Perhaps some of these disadvantages are avoidable, or can be mitigated, though we doubt it very much. But even granting this, there are certain other considerations which demand our attention. Presumably hospital care would be an integral part of any such scheme. The experience of B.C. does not encourage any optimism when we contemplate any extension of this as a public service, though it is supposed to carry itself. Hospital beds in many parts of B.C., notably the larger centres, are away below requirements, and yet year by year the B.C.H.I.S. has lost money—and if more hospitals are built, and they should and must be built, we are going to be presented with some pretty big bills and deficits. If this service is to be paid entirely out of taxes, who is going to pay these taxes? Perhaps we shall have to make up our minds to accept the fact that hospital service I cannot be met entirely by direct taxation through premiums, any more than roads can | be built out of automobile fees, or university students given their training on their fees alone. We read that Ontario hospitals lose thirty million dollars a year. If the Government assumes the cost of hospitals, what about the tax-structure of the country? Canada has enormous military bills to pay. It has a tremendous programme of social services, pensions, grants in aid for health, for hospitals, and it is contemplating gradual extension of health grants. Our taxes are already nearly at top level—they cannot go very much higher. It is very easy for those who are not in positions of responsibility to clamour for free medicine, free hospitals, free dentistry, and so on. But these things will not be free, and we must try to find a scheme that will give us full value for our money. All this does not mean that there is not a problem that we have to solve, and a very serious problem. The present methods of distribution are not satisfactory or equitable, and need considerable changes. And no group in the community realizes this more fully than does the medical profession. And this body has done, and is doing, and will continue to do, something about it. At some cost to itself, and at the risk of some of its most cherished traditions, it is more and more committing itself to prepaid medical plans, at prices that the man in the lower income-brackets can afford. It is exploring, as fast as it can, methods of extending such coverage to everyone in the Page 143 community who wants it. In B.C. at least, this latter will become an actuality in the very near future. Hospital care in B.C. is available now to all, at what is really a very low rate—j and as the difficulties of administration are overcome, and as more beds are providedJ this will afford a positive answer to some at least of our health problems. Of course, this means that the individual has to pay his share of the cost as hej goes. This is as it should be—it helps to curb abuse, to keep costs down and so on.) Moreover, it means a gradual change, less revolutionary and abrupt, and so very much safer and better, than the arbitrary imposition of half-baked systems of state medicine, with bureaucratic control. The way in which the distribution of medical costs is de-| veloping now, one step at a time, gradually and progressively, if somewhat too slow and] unsatisfactory from the point of the demagogue and doctrinaire, will in the long run mean a sounder and healthier plan. The Federal Government, with its grants towards health, hospitals, laboratories, etc., is contributing its share, as are the Provincial Gov-^ ernments with their Public Health Divisions, their laboratories and the rest. Lastly, there is the medical profession, working steadily along sound lines, to remove old evils and injustices and to improve national health, while it seeks to avoid precipitate andl unwise action, which, however tempting at first sight, is only too apt to lead to disaster] in the long run. Library Hours Monday to Friday. 9:00 a.m. to 9:00 p.nu Saturday 9:00 a.m. to 1:00 p.m. Recent Accessions The British Medical Directory, 1953. Official History of the Canadian Medical Services, 1939-1945, v. II* Clinical Subjects. The Alaska Vagabond, Doctor Skookum by John Michael Hewitt, 1953. Acute Injuries of the Head by G. F. Rowbotham, 3rd edition. The Surgical Clinics of North America: Orthopedic Surgery, Dec., 1953. Analgesia and Anesthesia in Obstetrics by J. P. Greenhill, American Lecture Series, 1952. Verse or Worse: Remarked the red corpusle to the white: "Ye Gods, you don't half leucocyte!" —London Opinion. Page 144 BOOK REVIEW Correlative Cardiology: An Integration of Cardiac Disease by Carl F. Shaffer, MJ)., F.A.C.P., Associate Professor of Clinical Medicine, Bazlor University College of Medicine, and Don W. Chapman, M.D., F.A.C.P., Associate Professor of Medicine, Bazlor University College of Medicine. This publication, according to the authors, is designed to correlate the phases of anatomy, physiology, pathology and abnormal or pathological physiology that pertain to the diagnosis of cardiac disease. Its purpose is to enable comprehension of the manifestations of the normal and abnormal cardiovascular system through simple, concise statements correlated with diagnostic illustrations. The book is divided into chapters with titles such as Anatomy, Nomenclature, Special Diagnostic Procedures, Cardiac Medications, Congenital Anomalies, Myocarditis, [Syncope, etc. The subject matter is set out in a highly systematized or classified manner under headings, sub-headings and further sub-divisions, after the style of Letheby Tidy or Hey Groves. This makes for clarity and conciseness and the book becomes a very [readable and comprehensive summary of the various aspects of cardiology. For instance, the chapter on congenital heart disease consists of twenty-six pages, yet the commoner anomalies of the heart and great vessels are lucidly presented together with numerous diagrams to illustrate murmurs, direction of shunt, etc. The section of thirty-two pages devoted to Coronary Artery Disease goes into such considerations as the present state of knowledge as to the importance of cholesterol metabolism, the mechanism of cardiac pain and the concept of coronary artery insufficiency as well as the usual presentation of clinical features, management, etc. In a detailed examination certain criticisms could be levelled. For instance, the statement that in hyperthyroid heart disease "irradiation of the pituitary gland is effective in approximately one quarter of the patients" may well be regarded today [as irrelevant. Also in the treatment of cor pulmonale there may be some hesitation in taking the risk of using 100% oxygen and then correcting the resultant acidosis by a solution of sixth-molar lactate intravenously. Nevertheless, detractions such as these are relatively insignificant and overall the exposition is that of generally accepted current principles. This book is practically a complete synopsis which, in its form and scope, should be very acceptable and especially useful to the undergraduate as well as to the practitioner who wishes to revise and recapitulate the subject of cardiology as a whole. WESTERN SOCIETY FOR REHABILITATION REHABILITATION CENTRE 900 West 27th Avenue Vancouver 9, B.C. BAyview 3111 The President and Board of Directors are pleased to announce the Official Opening of the two final wings to the Rehabilitation Centre on March 11, 1954, at 4:30 p.m. In order that the services and facilities of the Centre may be brought to the attention of the medical profession in British Columbia, a special Open House will be held on March 11th from 11:00 a.m. to 4:00 p.m. Refreshments will be served from 12:00 noon to 1:30 p.m. An interesting programme, including demonstrations in rehabilitation techniques, kill be arranged. A detailed schedule of the programme will be posted in the local hospitals for your prior information. The President and Board of Directors extend a cordial invitation to the physicians [in the province of British Columbia to participate in this Open House programme and \o attend the Official Opening Ceremony commencing at 4:30 p.m. Page 145 CANADIAN MEDICAL ASSOCIATION BRITISH COLUMBIA DIVISION 1807 West 10th Ave., Vancouver, B.C. Dr. G. Gordon Ferguson, Exec. Secy OFFICERS 1953-1954 President—Dr. R. G. Large Prince Rupert President-Elect—Dr. F. A. Turnbull Vancouver Immediate Past President—Dr. J. A. Ganshorn Vancouver Chairman of General Assembly—Dr. G. C. Johnston Vancouver Hon. Secretary-Treasurer—Or. J. A. Sinclair ! New Westminster PRINCIPAL DELEGATES TO THE BOARD OF DIRECTORS Victoria Dr. J. F. Tysoe Dr. E. W. Boak Nanaimo Dr. C. C. Browne Prince Rupert and Cariboo Dr. J. G. MacArthur New Westminster Dr. J. F. Sparling Dr. D. G. B. Mathias Kootenay Dr. S. C. Robinson Yale Dr. A. S. Underhill Vancouver Dr. Ross Robertson Dr. R. A. Gilchrist Dr. J. Ross Davidson Dr. R. A. Palmer Dr. A. W. Bagnall Dr. P. O. Lehmann Dr. Roger Wilson Chairmen of Standing Committees Constitution and By-laws Dr. Carson Graham, North Vancouver Finance Dr. J. A. Sinclair, New Westminster Legislation . . Dr. J. C. Thomas, Vancouver Medical Economics Dr. P. O. Lehmann, Vancouver Medical Education— Dr. Charles G. Campbell, Vancouver Nominations Dr. R. G. Large, Prince Rupert Programme & Arrangements Dr. Myles Plecash, Penticton Public Health _Dr. J. Mather, Vancouver Chairmen of Special Committees Dr. J. H. MacDermot, Vancouver _Dr. F. W. B. Hurlburt, Vancouver Archives Arthritis and Rheumatism Cancer Dr. Roger Wilson, Vancouver Civil Defence Dr. John Sturdy, Vancouver Ethics ©r. Murray Baird, Vancouver. Hospitals Dr. F. A. Turnbull, Vancouver Industrial Medicine Dr. W. S. Huckvale, Trail Maternal Welfare Dr. A. M Agnew, Vancouver Membership Dr. L. Fratkin, Vancouver Nutrition Dr. J. F. McCreary, Vancouver Pharmacy Dr. B. T. Shallard, Vancouver Public Relations Dr. A. W. Bagnall, Vancouver GRADUATE TRAINING A programme of preceptorship training for graduates of the Faculty of Medicine] University of British Columbia, is being arranged through the co-operation of the Sectior of General Practice, B.C. Division of the C.M.A. This will be inaugurated in Mayj 1954, and is on a voluntary basis. The Faculty of Medicine will graduate its first clas< in mid-May and preceptorship appointments will normally occpy two weeks to one month between graduation and the beginning of internships. A list of physicians who would welcome service as preceptors is being assembled and interested physicians are invited to contact Dr. J. L. Coltart, Chairman, Section ob General Practice, Academy of Medicine, 1807 West 10th Ave., Vancouver 8, B.C. SCIENTIFIC SESSION SECTION OF GENERAL PRACTICE The session will be held at Harrison Hot Springs on March 19 and 20. For reservations and further information please apply to: DR. T. BRIDGE 3 379 Ekingsway, Vancouver, B.C. Page 146 NEW REGISTRANTS December 2nd, 1953 RUEBSAAT, Helmut J., Nelson, B.C. (Assoc, with Dr. H. H. Smythe) December 7th, 1953 _NUTTAL-SMITH, John Columban Reginald, The Burris Clinic, P.O. Drawer 120, Kamloops, B.C. December 14th, 1953 JOHNSTON, Alfred James Meredith, Office: 1216 Douglas St., Victoria, B.C. Home: 1633 Davie St., Victoria, B.C. December 16th, 1953 ANDERSON, Lewis Sutherland, Director, West Kootenay Health Unit, 1145 Cedar Ave., Trail, B.C. December 16th, 1953 FELIX, Cornelis Henricus, St. Joseph's Hospital, Victoria, B.C. December 16th, 1953 GAERBER, Bernard Joseph, No. 418 - 925 W. Georgia St., Vancouver, B.C. Certified Specialist in Psychiatry, Royal College of Physicians & Surgeons of Canada, Dec. 1, 1952. CHANGE OF ADDRESS AND ADDITIONS TO REGISTER December 16th, 1953 JAMESON, Winifred, 50 Foul Bay Road, Victoria, B.C. December 16th, 1953 KARLSSON, Ragnar, Chemainus, B.C. December 16th, 1953 MACLEAN, Neil Bruce, 605 Fifth Avenue, New Westminster, B.C. December 16th, 1953 MacKINNON, Geo. Lawson Cleburne, 925 W. Georgia St., Vancouver, B.C. December 16th, 1953 RALLING, Antony, 320 -2nd Avenue, Prince Rupert, B.C. December 16th, 1953 SAMUELS, Victor, No. 827 - 736 Granville St., Vancouver, B.C. Certified Specialist in Paedriatrics, Royal College of Physicians & Surgeons of Canada, Dec. 2nd, 1953. December 16th, 1953 SHAW, Harry, Powell River, B.C. December 16th, 1953 WEST, Raymond Owen, Rest Haven Hospital, Sidney, B.C. Page 147 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D.P.H., Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D., Director, Mental Health Services, Province of British Columbia BIOPSY SERVICE A Provincial Biopsy Service operated by the Health Branch, Department of Health and Welfare, in cooperation with hospitals having recognized Pathology Departments and employing certified pathologists, has been in operation in this province since January, 1949. This Biopsy Service has been a most successful service and has done much to improve cancer control in this province. The service has also been operated adrninis- tratively most successfully, owing to the excellent cooperation of the pathologists and hospitals concerned. The Biopsy Service has expanded rapidly, and in the most recent year, 13,059 individuals had specimens referred under this service. The first nine months period of this year has again shown a marked increase and indications are that the $34,000 allowed under Cancer Control Funds for this service will be over-expended. It is emphasized that the Biopsy Service is financed by the Cancer Control Program of the Health Branch of the Province of British Columbia, and thus is not to be interpreted as a tissue service. There are indications, however, that physicians and hospitals are regarding this Biopsy Service as a tissue service. This statement is based on information gathered by pathologists in the hospitals responsible for this work when it is noted that a total of 679 appendices, 62 tonsils and 30 hernial sacs were examined in the first six months of 1953 by six of the hospitals doing the examinations for the Biopsy Service. It is thus requested that physicians and hospitals take the necessary steps to review this matter and use this Biopsy Service as it was originally intended, namely, for the examination of tissues suspect of malignancy. It is fully realized that a tissue service is a desirable and useful service in the majority of instances. The possibility of establishing a tissue service is being investigated by interested groups in this province, but before such a service is established it will be necessary to determine, first, if the recognized pathological departments in the seven general hospitals could carry this increased load, and, second, ways and means of financing same would have to be established. STAFF NOTES PROVINCIAL MENTAL HOSPITALS Dr. A. E. Davidson, Mr. C. B. Watson and Mr. F. Matheson attended the Fifth Mental Hospitals Institute held at Little Rock, Arkansas, in October. Miss Barbara Leslie attended a Rorschach Workshop at Asilomar, California, in August. Dr. G. H. Stephenson has returned from one year's postgraduate study in psychiatry at the University of Toronto. Dr. Carl Derkson commenced a year of postgraduate study in psychiatry at the Allan Memorial Institute in Montreal in September. Dr. Pauline Gould commenced a year of postgraduate training at the University of Toronto in September. DIVISION OF T.B. CONTROL Dr. W. Coburn attended a course in Internal Medicine for General Practitioners at the University of Washington School of Medicine in May. Dr. M. L. Allan attended the Eighth Annual Postgraduate Course at the American College of Chest Physicians, Chicago, during the latter part of September. Page 148 Dr. W. J. McLaren took a Postgraduate Course in Diseases of the Chest at the American College of Chest Physicians, New York, in the early part of November. He also spent an additional two weeks observing various thoracic surgery centres in New York and Boston. Dr. D. Campbell attended the Joint Meeting of the Pacific Northwest Trudeau Society and the Pacific Northwest Chapter of the American College of Chest Physicians in Seattle in November. DIVISION OF VENEREAL DISEASE CONTROL Dr. W. S. Maddin attended the meeting of the American Academy of Dermatology and Syphilology in Chicago in November, and in addition visited treatment centres in Toronto, New York, Detroit and Ann Arbor. INTERNATIONAL CONGRESS Canada will share with the United States the honor of being host to the XVIIth International Congress of Ophthalmology, which will meet in Montreal, Sept. 9-11, 1954, and in New York, from Sept. 12th to 17th, 1954. Inquiries regarding the Congress as a whole should be addressed to the Secretary-General, Dr. William L. Benedict, 100 First Avenue Building, Rochester, Minnesota, U.S.A. Inquiries relating solely to the Montreal portion of the Congress may be mailed to the Associate Secretary, Dr. G. Stuart Ramsey, Physical Sciences Centre, McGill University, Montreal. DOCTOR WANTED This opening has new building. Single or married—living quarters in back of building for single doctor or house can be obtained for married doctor. Car available. Also Drug Store for sale two doors from medical building. This location 25 miles from Vancouver. Apply to: MR. POWELL No. 8 Beecher Ave., Crescent Beach, B.C., Telephone - Newton 143X3 FOR RENT Corner location 18th Avenue and Dunbar, suitable for Doctor and Dentist. Vacant January 31. Apply to: Mrs. Allen KErrisdale 0729-Y Page 149 THE TREATMENT OF CANCER OF THE TONGUE BY RADIOTHERAPY AND BY SURGERY 1 'f|# by SIR STANFORD CADE K.B.E., C.B., F.R.C.S., M.R.C.P., F.F.R. Sergeon, Westminster Hospital London, England Paper given at the Refresher Course on Malignant Disease held at the British Columbia Cancer Institute Vancouver October, 1952 Cancer of the tongue is dirninishing in incidence and today accounts for about 4 per cent of all cancer incidence. There is also a change in the sex incidence of the tumour; whereas 50 years ago it was rare in women, about 10 to 15 per cent of the total incidence, it occurs now much more frequently, namely in 30 per cent of cases in England and Wales and in some countries, namely Scandinavia, the incidence in women has risen to nearly 50 per cent. The disease remains a formidable problem, and unless controlled by treatment results in serious interference with speech, difficulty in swallowing, increased salivation, distressing foetor, infection, necrosis, haemorrhage and oedema. Its course inflicts on the patient a martyrdom unsurpassed by cancer in any other site. Till the advent of radiotherapy the control of cancer of the tongue could be achieved only by surgical means, that is by the removal of part or the whole tongue— a procedure more akin to medieval torture than a therapeutic measure. Radiotherapy in successful cases leads to disappearance of the tumour healing of ulceration and a return to normal with little physical deformity or functional disability. Not all cancers of the tongue are sensitive to radiation and not all regressions are permanent, so there is still a need for surgical treatment in some cases or in some stages of the disease. Surgery also remains the first and most efficacious method of treatment of the metastases in the cervical lymphnodes. It should also be pointed out that radiotherapeutic control of cancer of the tongue is not an easy and simple method, but requires skill, experience and training of the staff as well as specialized and often expensive and elaborate apparatus and the co-operation of hospital physicists. The method is not devoid of dangers, chiefly from overdosage, and may result in radium burns, necrosis, haemorrhage and severe pain. Nevertheless radiotherapy is the greatest advance in treatment of lingual cancer and has altered the entire management of these cases. CHOICE OF TREATMENT It is now generally accepted that for the primary growth the method of choice is radiation and for the cervical metastases surgery. But there are cases where surgery is still indicated in the treatment of the tongue and conversely radiotherapy to the lymphnodes. A wise choice of treatment is based firstly on a knowledge of the disease, that is a clear and accurate conception of the pathology, clinical manifestations and natural history of cancer of the tongue; secondly, on technical skill and specialized knowledge of radiotherapeutics, including the biological effects on normal and abnormal tissues, experience of the relative effects of different dose-rates, overall treatment time and total dose needed to achieve regression of the tumour with the least damage to the adjoining normal tissues, the jaw bones, the mouth floor, the mucous membranes, the skin. Finally there is need of elaborate, costly and varied types of apparatus and a technical knowledge of their use. DIAGNOSIS Firstly, it should be established that the disease in question is, in fact, cancer and not some other pathological condition: trauma, sepsis, specific infections, tuberculosis, syphilis. There occur also in this site degenerative processes, leukoplakia, chronic super- Page 150 ficial glossitis, hyperkeratosis, which are accepted as precancerous states and which require assessment. The differential diagnosis between these various states is outside the scope of this paper, but it is necessary to emphasize that the safest, quickest, most certain way of establishing a diagnosis is a biopsy and histological confirmation. Prolonged periods of observation, time consuming anti-syphilitic treatments, are always against the patient's interests, risky and uncertain. When the possibility of cancer is considered, immediate biopsy is the answer and no other method of diagnosis has so much to offer for so little risk and inconvenience. Here, as much as in any other site of cancer, and more productive than in many, "look and see" is better policy than "wait and see". A further advantage of histological examination is the grading of the cancer from the keratinising low grade more favourable type or grade I to the embryonic, anaplastic highly malignant grade IV. There is therefore firstly the diagnosis of the presence of cancer and next the precise grading of it. But in addition accurate diagnosis should include the estimation of the exact site and extent of the lesion. This, too, influences the choice of the method of treatment: is the lesion small and localized? is it extensive but still localized to the tongue? or has it transgressed to adjoining structures, the floor of the mouth, the jaws, the tonsillar pillars, the pharynx? No estimation of the disease is complete without a knowledge of the extension of the growth to the lymphnodes and the extent of such involvement. WHEN TO EMPLOY RADIOTHERAPY For the primary growth, the treatment of choice is implantation of radium needles in the anterior part of the tongue or teleradium in the posterior part behind the V and in the vallecula. It is the method of choice in all cases with the following exceptions when partial or total excision of the tongue is indicated: (1) in radium failures; (2) in the presence of advanced postsyphilitic changes, such as glossitis with fibrosis due to syphilitic endarteritis; (3) when the disease has spread to the extrinsic muscles of the tongue, to the mucosa covering the gum and the underlying bone. In such cases radiotherapy is likely to have palliative effect only. Specially is surgery indicated in cases of radiation failures. Primary failure is seen occasionally in cancer of the tongue as in other sites, such as the uterus or even skin cancer, when there is little if any effect immediately after the treatment; or recurrence may develop a short time after an initial disappearance of the growth and complete healing. Surgery in such cases consists of the removal of the affected part of the tongue with an adequate amount of apparently normal tissue beyond the growth. It is preferable to carry out such resection with diathermy than with a scalpel; not only is bleeding controlled, but the operation is done with greater accuracy. If the alveolus of the mandible is involved, partial resection of the jaw should be done at the same time. RADIOTHERAPY There is no doubt that radium has given much better results than X-ray therapy in the treatment of cancer of the tongue. Whatever the explanation, be it difference in the wave length and hence difference in biological effect, or increase in total dose, or the different effect on the normal surrounding tissue, clinically there is no doubt that the achievement of radium by far surpasses that of X-rays in this anatomical site and this type of tumour. It is possible with radium to give a very high dose to the tumour, varying from 6000r to 8000r with little damage to the rest of the mouth, hardly any general effect on the patient and equally little risk of local radium necrosis. The method of radiumtherapy depends on the actual site of the lesion. In tumours of the anterior part of the tongue, the method of choice is the insertion of radium needles or seeds. More recently needles containing radioactive cobalt 60 have been used with equal effect. Needling of the tongue can be done by a single plane implant for small lesions, a two plane or volume implant in bulky tumours. When the disease involves the posterior or pharyngeal portion of the tongue, the vallecula epiglottis, or glosso- palatine folds, teleradium is the method of choice. The 10 gram radium unit has proved a very useful weapon in a good proportion of patients. The prognosis in posterior lesions is nevertheless much worse and the use of curved cobalt 60 needles or of a powerful Page 151 telecobalt unit will probably give better results. Although convention X-rays at 200-| 250 K.V. have little effect on cancer of the tongue, supervoltage X-rays at 2 to 4 million volt holds out promise and may give as good results as teleradium. Treatment by inter-j stitial radium for anterior lesions is completed in 6 to 7 days; with teleradium it takes 5 to 6 weeks to deliver a similar dose to the lesion. But by this protracted fractional] treatment, the skin reaction is minimal and the discomfort from the mucosal reactions in the pharynx are less severe and more bearable. The total dose is the same by both methods, viz. 6000r to 8000r, to the tumour. TREATMENT OF THE CERVICAL LYMHNODE AREA Surgery: In the absence of enlarged cervical lymphnodes, it is now accepted in most important clinics that an expectant policy is justifiable. Prophylactic treatment by radiotherapy is not practised, and prophylactic block dissection has been abandoned in all cases where it is possible to keep the patient under routine observation. If the cervical lymphnodes are enlarged, the best treatment is a wide dissection— the so-called block dissection of the neck. The indications for this operation are quite definite and are as follows: (1) The primary lesion should be healed. (2) The glands, although enlarged, should be mobile and strictly operable. (3 ) The general health of the patient should permit operation. If a block dissection is decided upon, it should consist in the removal of the deep fascia from the mandible above to the clavicle below, and from the midline in front to the edge of the trapezius behind. It should include the sterno-mastoid muscle, the omohyoid, the posterior belly of the digastric muscle, the submaxillary salivary gland and the internal jugular vein. With this sheath of deep cervical fascia will be removed all the lymphnodes along the main vascular bundle and in the anterior, posterior and submaxillary triangles. A bilateral block dissection is indicated if the contra-lateral lymphnodes are enlarged. The removal of both internal jugular veins can be done with safety at an interval of 10 days or more. The spinal accessory nerve has to be cut if the dissection is to be complete. The disability following a block dissection of the neck is surprisingly small. The mortality of the operation is 1.5 to 2 per cent. Radiotherapy: If the lymphnodes are fixed to the main vascular sheath, or if the cellular tissues of the neck are invaded by disease, block dissection is contra-indicated and the neck should be treated by radiation. As in the case of the primary growth in the tongue, so in the lymphnode metastases, better results have been achieved by radium than by conventional X-rays. Although external radiation, by teleradium is the usual method, there is a group of patients where interstitial radium is indicated; when the mass of lymphnodes is large, a two plane or volume implant can be carried out. SUMMARY From a series of 500 cases of cancer of the tongue treated by radiumtherapy in a period of 26 years, the following conclusions are drawn. In early cases of cancer of the anterior part of the tongue, without any cervical lymphnode invasion when first) seen, 65 per cent of five-year survival has been obtained. In all cases, including thej most advanced, 21 per cent survived five years. The problem of cancer of the tongue remains still formidable and both earlier diagnosis and better treatment are necessary if the results are to be improved. Radium remains the method of choice for the primary growth, and surgery for the lymphnode involvement. The palliative value of radium is important, but in the advanced cases, although healing of the primary lesion is often j achieved, the expectation of life remains limited to less than 3 years in most cases. 1 Page 152 J THE USE OF SYMPATHOMIMETIC AMINES IN THE : TREATMENT OF SHOCK | | | By DR. J. G. FOULKES Head of Department of Pharmacology, U.B.C. Any discussion of drug therapy must necessarily revolve around two key points: (1) What is the nature of the derangement to be treated? An understanding of the underlying pathogenesis of a diseased condition is essential to the definition of rational therapeutic objectives, that is to a determination of what changes are required in order to correct the disordered function. (2) To what extent can the therapeutic objectives thus defined be met by available pharmacological tools? An adequate understanding of the actions of a drug is necessary to know whether or not its use can be expected to aid in overcoming a particular pathological condition. These principles may seem self-evident, and yet the breadth of our ignorance in both of these areas often requires us to rely on an empirical rather than on a rational basis for therapy. The past five years have witnessed a number of important advances in the pharmacology of the sympathetic nervous system, with the introduction of agents whose place in our therapeutic armamentarium is yet to be fully ascertained. Among the sympathomimetic agents, nor-epinephrine has probably received more attention recently than any other. Actually, nor-epinephrine is not a new compound, its structure and basic actions having been known for nearly fifty years. Renewed interest in this compound has followed the relatively recent discovery that it is produced in the body and in fact is the major mediator of sympathetic nerve activity, comprising 80% or more of the material released upon sympathetic nerve stimulation (the remainder consisting of epinephrine). Both of these substances are also present in the secretion of the adrenal medulla, but their relative proportions are reversed. The presence of 10-15% or nor-epinephrine in extracts of the adrenal medulla was overlooked for many years, until its chemical separation became possible through the technique of partition chromatography. While both epinephrine and nor-epinephrine are pressor compounds, their administration leading to a rise in blood pressure, nevertheless, there are a number of important diqerences in their cardiovascular actions. These can be appreciated most readily by a brief description of their effects on the heart and the peripheral circulation during continuous infusion. The actions of epinephrine on peripheral vessels is mixed. While the vessels of the skin and the splanchnic bed are intensely constricted, this effect is more or less counterbalanced by dilation of the vessels of the skeletal muscles, so that the total peripheral resistance is relatively unchanged. The cardiac stimulating actions are therefore primarily responsible for the pressor response which results when epinephrine is administered in this fashion. Nor-epinephrine (Arterenol, Levophed), while less potent in some of its vasoconstrictor actions, is more uniform. Its vaso-dilating actions are minor and its over-all net effect is predominantly vaso-constriction with a rise in total peripheral resistance. Its cardiac stimulating action is almost as intense as that of epinephrine in isolated preparations, but in intact patients these are largely mitigated by reflexes arising from presso-receptors, which actually lead to a bradycardia by way of the vagal efferents to the heart. Thus the pressor response to nor-epinephrine is dominated by its peripheral vaso-constrictor actions. These divergent actions serve to emphasize the point that the blood pressure is always the resultant of two components, cardiac action and peripheral vascular resistance, and an increase or decrease in either may be responsible for raising or lowering the blood pressure. This reciprocal relationship is further illustrated by the actions of isopropyl nor-epinephrine, a closely related amine with a marked vaso-depressor action. This compound causes a predominant vaso-dilation with a marked fall in total peripheral Page 153 resistance. Although its cardiac stimulating actions are, if anything, more intense than those of epinephrine and nor-epinephrine, and are unopposed by reflex modulation, the net effect is one of a substantial fall in blood pressure. Current interest in sympathomimetic agents has been particularly aroused by thff proposal that they may be efficacious in the treatment of shock. An evaluation of this possibility requires a brief consideration of some of the salient features of the various conditions grouped under the heading of shock. Broadly speaking, the principal feature which these conditions share in common is a persistent hypotension, the proximate cause of which may be either cardiac or peripheral. The obvious common sense approach when faced with this situation, is to consider means of raising the blood pressure. The use of vaso-constricting drugs offers a convenient means to this end. However, this approach requires careful examination before it can be accepted as rational. Is the blood pressure a reliable measure of circulatory adequacy? Is hypotension, per se, the principal threat to life? The answer to this latter question must be qualified by saying that it depends on the degree. The crucial responsibility of the circulation is to provide oxygen and nutrition to the tissues. Its ability to do so is determined directly by the rate of flow of blood through the peripheral circulation, and while adequate flow depends upon a sufficient head of pressure, pressure is not the sole deterrninant of blood flow. The flow of blood through any tissue is determined by the resistance to flow offered by the tone of its small vessels as well as upon the head of pressure under which the blood is delivered. If vascular tone is reduced by vaso-dilation, the pressure required to maintain a given flow through that tissue is also reduced. Actually, hypotension which is primarily peripheral in origin, that is due to vaso-dilation, is often well tolerated if not too drastic, even over fairly prolonged periods of time. For instance, high transection of the spinal cord in the cervical region gives rise to a condition known as spinal shock. This condition is characterized among other things, by peripheral vaso-dilation and a fall of mean blood pressure to levels of 30-40 mm. Hg., whch may persist for twenty-four hours or longer with no permanent deleterious effect. Similar tolerance to prolonged hypotension experimentally is manifested by animals subjected to continuous stimulation of the carotid sinus. This is the type of hypotension which is deliberately produced under controlled conditions for certain surgical procedures by means of the administration of ganglionic blocking agents. In sympathectomy and in adrenergic blockade by drugs, a similar hypotension of peripheral origin is produced which can be well tolerated, in the supine position at least. The absence of reflex control in these conditions may jeopardize the cerebral circulation if the erect position is maintained. The advantage of ganglionic blockade is that a pressor response can still be produced and maintained by the more peripherally acting sympathomimetic amines. The same thing is true of the shock which may occur in spinal anesthesia and one wonders whether this condition is truly as grave as it is sometimes considered to be. In contrast to these examples are those cases of shock which follow a marked reduction in circulating blood volume, such as that which occurs following hemorrhage, burns, certain types of trauma, surgical procedures, and other related conditions. The loss of circulating fluid leads to poor venous return, poor cardiac filling, and a primary reduction in cardiac output. Compensatory reflex tachycardia commonly occurs, but the heart cannot put out more blood than is returned to it. Compensatory reflex vasoconstriction is fairly intense (although not maximal) and during the initial stages, blood pressure is often maintained at fairly normal levels, while the rate of flow through the tissues is reduced as a result of the reduced cardiac output coupled with compensatory vaso-constriction. If under these circumstances, blood pressures as low as 30-40 mm. Hg. are allowed to persist for several hours, the shock becomes irreversible. While blood pressure may be restored temporarily, it cannot be maintained and the shock cannot be overcome, even after complete restoration of the lost circulating blood volume. Even the transfusion of relatively large amounts of blood is to no avail. We have already seen that in spinal shock, such levels of pressure may be tolerated for long periods of time. It is not the low pressure which causes shock to become irreversible, but the reduced peripheral flow of blood through vital'organs. The exact mechanism of irreversible shock Page 154 is still not fully agreed upon, but the peripheral compensatory vaso-constriction appears to play an important role in its development. A number of investigators have reported that complete blockade of the sympathetic nervous system offers a highly significant degree of protection against the development of irreversible shock due to bleeding or trauma in experimental animals. Animals are subjected to shocking procedures and allowed to remain hypotensive for several hours, whereupon the volume of the circulating | fluidis restored to normal levels. In control animals, survival rates range from 10-30%. | In animals pre-treated with sympathectomy, ganglionic or adrenergic blockade, and ! subjected to the same or equivalent procedures, recovery commonly runs as high as 80-90%. It should be emphasized that in these experiments, the shock is carried to the stage of irreversibility by maintaining a predetermined degree of hypotension. Animals subjected to adrenergic blockade, reach this point with a smaller degree of blood loss than do untreated animals. But untreated animals will survive a degree of blood loss greater than that which can be tolerated by animals subjected to adrenergic blockade. Adrenergic blockade is not of therapeutic value in animals already carried to the irreversible stage of hemorrhagic shock. The point to be emphasized is that it is not the hypotension which leads to irreversibility, but the reduced flow of blood through vital tissues. A considerable amount of experimental evidence has now accumulated which indicates that the release of ferritin (so-called VDM), especially by the anoxic liver, may play an important role in explaining these findings. This substance appears in the blood stream at about the time that shock becomes irreversible, and the liver loses its capacity to inactivate this material. Arterialization of the portal vein to the liver decreases the mortality of shock procedures. In animals pre-treated with sympathetic blockade, VDM does not appear in the blood during the maintenance of a degree of hypotension which would otherwise lead to irreversible shock, and the liver retains its capacity to inactivate this material. VDM acts primarily to dilate capillary beds, and to render them unresponsive. The dilated beds lead to pooling of the blood, and the reservoir thus created may soak up large quantities of transfused blood and render the restoration of effective circulating blood volume exceedingly difficult to accomplish. Capillary anoxia may lead to further fluid loss directly into the tissues. In shock, hepatic blood flow is substantially reduced and when the irreversible stage is reached, the resistance to flow in the hepatic bed remains high in spite of restoration of normal circulating blood volume. These facts force us to recognize that the rational therapeutic objective in hypotension or shock is the maintenance of a flow of blood adequate to sustain the viability of such crucial organs as the liver, the kidney, the heart and the brain. While a minimal head of pressure is required for this purpose, particularly in the case of the heart and brain, the level required is apparently not large. In simple hypotension, the work required of the heart falls more rapidly than does coronary flow. There is a fair margin of safety in the cerebral circulation between the level of flow required to maintain normal consciousness, and that which will produce irreversible neuronal damage. We have already seen that in the case of the liver and kidney, vaso-constriction in the presence of an inadequate cardiac output, jeopardizes rather than enhances the flow through these organs. As a matter of fact, even with a normal or elevated cardiac output, excessive vaso-constriction alone, if prolonged, may give rise to irreversible shock. Acute decerebra- rion in animals is associated with a marked sympatho-adrenal discharge, and within a few hours fatal shock develops. Shock can be prevented and survival greatly prolonged in such animals by sympathectomy or adrenergic blockade. Large infusions of pressor sympathomimetic amines alone will also precipitate shock in experimental animals, an outcome which can be prevented by adrenergic blockade. It is well known that factors such as pain, cold, strong emotions and asphyxia, all of which tend to produce reflex vaso-constriction, also tend to potentiate the development of shock from hemorrhage of trauma, and for a given degree of fluid loss, tend to make traumatic shock more severe than that due to simple hemorrhage alone. Experimentally it has been shown that this potentiation in the case of strong afferent stimuli can be prevented by blockade or interruption of the nervous pathways involved. Page 155 All of these considerations make conservative medical scientists very wary of claims for beneficial effects of sympathomimetic amines in shock, particularly where the condition is the result of loss of circulating blood, and where fairly intense reflex vaso-j constriction is already present. In the case of hypotension due to primary vaso-dilation (spinal anesthesia, spinal shock, ganglionic blockade, certain types of central lesions,! overwhelrning sepsis), the use of moderate amounts of suitable vaso-pressor agents may be rational. Such patients are considerably more susceptible to blood loss than are persons with intact and functional vascular innervation. Also direct myocardial depression as in j barbiturate poisoning may be assisted by sympatlK>niimetic agents because of their direct cardiac actions. In most of these cases while probably not required for the prevention of irreversible shock, or as a life saving procedure, unless the hypotension is really profound, the restoration of normal blood pressure leads to a subjective improvement. The patient I is more alert and feels more comfortable and treatment may prevent the nausea, malaise j or impairment of consciousness which often accompanies hypotension. Similar immediate j effects may be seen upon the administration of such agents to patients in shock with reduced blood volume, but the crucial question here is: what is the effect on survival? This question can only be adequately answered on the basis of carefully controlled clinical investigations, where individuals with comparable degrees of shock are compared. | There are many clinical reports on the use of sympathomimetic agents in patients with shock. Some of these present apparently dramatic results. A recent report describes a case of perforated ulcer, in a profound state of shock with classical symptoms, which j failed to respond to fluid replacement but responded beautifully to nor-epinephrine infusion. The nor-epinephrine had to be continued for over twenty-four hours before the blood pressure became self-supporting. Its use permitted an operation which otherwise would have been considered to be out of the question. However, this represents a single case. Single cases are never very impressive to a person familiar with the vagaries of biological material and the principles of statistical validity of data. Unfortunately, all of the clinical reports thus far available consist entirely of small series of cases in which the system of controls leaves much to be desired. None that I know of involve any very sizeable group of comparable cases in which treated patients were alternated with controls. In controlled animal experiments, there is no evidence that mortality is reduced in traumatic or hemorrhagic shock as a result of the administration of synipathornimetic amines. In a recent review, Frank cites unpublished data showing that nor-epinephrine does not prolong survival in experimental hemorrhagic shock, and does not improve hepatic blood flow during shock. Many of these same considerations apply to several recent reports advocating the use of sympathomimetic amines in the treatment of shock associated with myocardial infarction. The use of nor-epinephrine in this condition may seem paradoxical but it should be kept in mind that (1) all sympathomimetic agents increase coronary flow, (2) nor-epinephrine causes relatively little increase in cardiac irritability in animals with intact reflexes. The cause and nature of the shock which develops in myocardial infarction is still the subject of controversy. Some investigators claim that fluid loss occurs. Others deny this and claim that cardiac incompetance is primary. Others state that reflex vaso-dilation is responsible. At any rate true shock in the presence of infarction is a very grave condition. It is not surprising that several of the reports of the use of sympathomimetic amines stress the production of successful pressor responses, but play down the relatively meager survival value of the treatment. In all these reports, the treated cases are compared with general statistics rather than with control cases whose comparability is determined. The pooled data from several such reports suggest survival of as many as 30-40% of patients presenting this syndrome treated with nor-epinephrine as compared with about 20% in other types of therapy. For a difference in mortality of this magnitude, the number of cases as yet is rather small for any far reaching conclusions. Incidentally, one group of workers employed mephenteramine (Wyamine) rather than nor-epinephrine. This and several other agents such as Neosynephrine possess properties which are very similar to nor-epinephrine. They differ primarily in requiring larger doses, having a longer duration of action, but developing tachyphylaxis (that is Page 156 becoming relatively less effective with repeated or prolonged use). The dramatic results seen in some instances, suggest that in certain cases at least- shock due to myocardial incompetence or reflex vaso-dilation may be sufficiently profound to represent an acute threat to life, and that the actions of nor-epinephrine may aid in tiding the patient over this crisis. In a recent discussion of this general problem, Dr. Mark Nickerson, an outstanding authority in the field of the pharmacology of the sympathetic nervous system, summed up his impression as follows: "I have been unable to find in the literature any report of controlled experiments in which any pressor agent administered in any dosage schedule in any type of shock, has improved the survival rate. I am forced to conclude that the available evidence fails to demonstrate any beneficial effect of vaso-constriction in protection against the development of irreversible shock." This statement is debunking of a high order, and stresses the critical approach which the medical scientist must maintain toward new therapeutic claims. It points out that the case for these agents in the treatment of shock where reflex vaso-constriction is already present, has not been proved. It does not disprove these claims, or preclude the possibility that further experiments and properly controlled clinical investigations will ultimately jurtify some of the hopes now placed in them. Some of the isolated clinical reports have been very suggestive. Nor-epinephrine has been studied far less extensively than epinephrine. The differences in action between these two drugs could conceivably provide a basis for some hope that nor-epinephrine may offer rational treatment in early shock due to fluid loss. For instance, nor-epinephrine is far less toxic than epinephrine, and much larger amounts are required to produce experimentally irreversible shock. Lands, who is associated with the company which produces nor-epinephrine has suggested that whereas epinephrine dilates the extensive vascular bed of skeletal muscle and therefore diverts large amounts of blood to this relatively unimportant bed, its presence may further compromise flow to vital organs. The release of epinephrine from the adrenal medulla is an integral part of the sympatho-adrenal discharge which is set up by cora- j pensatory reflexes. Conceivably, the restoration of blood pressure by nor-epinephrine might relieve the drive to this discharge and therefore reduce epinephrine release. Further, by closing down skeletal muscle vessels as well, the vital visceral organs may be placed in a better position to compete for a larger share of the available cardiac output. As yet we know very little of the effects of nor-epinephrine on specific vital vascular beds (such as the liver). These points remain to be decided by future studies, both experimental and clinical, before the degree of confidence which can be placed in this type of therapy will be apparent. We do not know whether nor-epinephrine can be of assistance in overcoming shock when the "irreversible" stage has been reached, or whether any i beneficial actions which it can be expected to exert will be useful only if applied early in the condition before irreversibility develops. We cannot as yet be sure that such therapy may not actually be harmful rather than beneficial to some patients. I would suggest therefore that its use be reserved for clinical investigation or for patients who are in profound shock, who fail to respond to extensive fluid replacement or other therapeutic procedures, and whose prognosis is therefore very grave under any circumstances. BIBLIOGRAPHY I. SHOCK: (1) Wiggers, Physiology of Shock, 1950—Commonwealth (Book) (2) Zweifach, An. N.Y. Acad. Sci., 55: 370 (1952) (Symposium) (3) Frank, N.E.J. Med., 249: 445, 486 (1953) (Review) (4) Macy Symposium—1951 EL CLINICAL USE OF SYMPATHOMIMETICS IN SHOCK: (1) Moyer et al., Am. J. Med., 15: 330 (1953) (2) Gootnich et al., Circulation, 7: 511 (1953) (3) Calenda et al., Am. J. Med. Sci., 226: 399 (1953) (4) Braude et al., Arch. Int. Med., 92: 75 (1953) (5) Kurland et al., N.E.J. Med., 247: 3 83 (1952) (6) Miller et al., Arch. Int. Med., 89: 491 (1952) (7) Hellerstein et al., Am. Ht. J., 44: 407 (1952) (8) Luger et al., J.A.M.A., 146: 1592 (1951) Page 157 in the COMMON COLD when others fail.. • CORICIDIN controls In a study of 5,734 patients with the common cold treated with CORICIDIN ". . . relief of symptoms was 72.7 per cent"*. Side effects were mild and their incidence was only 1.5 per cent greater than with the placebo. CORICIDIN contains CHLOR^TRIPOLON Maleate the antihistamine effective in smallest dosage—combined with acetylsalicylic acid, phenacetin and caffeine. CORICIDIN (antihistaminic-antipyretic-analgesic) A surpassingly potent drug—always on hand for immediate use— CORICIDIN controls when others fail. CORICIDIN Tablets in bottles of 25, 100 and 500 tablets. ♦Manson, M. H.; Wells, R. L.; Whitney, L. H.; and Babcock, G. Jr.: Internat. Arch. Allergy & Applied Immunol 1:265, 1951. \CK£tUfa CORPORATION LIMITED (~s Montreal Page 160 Dr. C. E. Robinson has resigned as Medical Director of the Canadian Arthritis and Rheumatism Society, but continues to act as consultant on a part time basis. His duties have been assumed by Dr. R. W. Lamont-Havers. Dr. Harold S. Robinson has been appointed full time Director of Medical Research for the Canadian Arthritis and Rheumatism Society. A Tissue Committee of the Vancouver General Hospital has been formed to review all cases in which normal or tissue with minimum pathological changes has been removed. It is headed by Dr. T. K. McLean. Dr. Ben Kanee and Dr. John Nelson of Vancouver collaborated on a paper on trends in venereal disease control at the American Dermatological Society in Chicago in December. Dr. J. S. D. Burnes is now working with Dr. W. H. Sutherland of Vancouver. Dr. Anson McKim is on the staff of the Willow Chest Centre. Dr. E. Warshauski is now studying surgery in England. Dr. Stewart Murray of Vancouver has been elected vice-president of the American Public Health Association. VWUSUAt RSLIEF ?0£ DISTRESSING SYMPTOMS OF COLDS AND FOR PAW CORICIDIN WITH , CODEINE i CORICIDIN with Codeine y% gr. or yA gr. Each coated tablet contains: Acetylsalicylic acid 0.23 Gm. (3% gr.) Phenacetin 0.15 Gm. (2% gr.) Caffeine (alkaloid) - - - 0.03 Gm. ( % gr.) Chlor-Tripolon maleate* - 2.0 me. (1/30 gr.) Codeine phosphate 0.016 Gm. (% gr.) or 0.008 Gm. (% gr.) * Brand of chlorprophenpyridamine maleate W(eto/t4_ CORPORATION LIMITED *—"^ Montreal Page 161 Doctors who received specialist qualifications in the recent Royal College exams are /. W. Anderson, D. S. Burr is, J. L. Danto, John Dick, Lewis Herberts, E. C. Hoodless^ R. M. Jameson, Elda Lindenfeld, G. A. McLaughlin, Jamil Mashal, J. M. Murray, J. G.j McPbee, R. E. Robins, J. A. Rankine, W. D. Smaill, N. R. Stewart, G. H. Thompson and Michael Turko. Graduating class of the University of B.C. will spend a month with general practitioners t>f Vancouver at the end of their term on a preceptorship basis. Semi-Private Pavilion of the Vancouver General Hospital is now being renovated to accommodate the pediatrics ward and the Health Centre for Children. The main operating room of the hospital is now in action on the top floor of the main building after two years of temporary quarters. Dr. J. H. Keogh is now studying radiology in the Deaconess Hospital in Boston. Dr. A. M. Inglis is now in London, England, engaged in orthopedic studies. BIRTHS To Dr. and Mrs. Adam Waldie of Vancouver, a son. To Dr. and Mrs. K. C. Boyce of Vancouver, a daughter. To Dr. and Mrs. T. L. Colder of Vancouver, a son. FOR RENT Doctor's office in new building—25th Avenue and Macdonald Street. Immediate Possession. MONTREAL TRUST CO. 466 Howe Street MArine 0567 NEW MEDICAL BUILDING To be erected at 873 W. Broadway, just a few steps from General Hospital. Offices planned to suit, Elevator Service, Ample Parking. For Full Particulars PEMBERTON'S 418 Howe Street TAtlow 9172 Page 162
Periodicals
W1 .VA625
English
Vancouver : University of British Columbia Library
Vancouver, B.C. : McBeath Spedding Limited
Images provided for research and reference use only. Permission to publish, copy, or otherwise use these images must be obtained from the Digitization Centre: http://digitize.library.ubc.ca/
Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: January, 1954
Text