Volume 2 1931 32 by Joanne Paterson

University of Western Ontario

MEDICAL JOURNAL

VOLUME II. Published by the

Undergraduate Body of the University of Western Ontario Medical School

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Univers·ty of Western Ontai•io

MEDI CAL .JOURNAL Published Quarterly by THE UNDERGRADUATE BODY OF THE

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The University of Western Ontario VOL. II

MEDICAL

JO URNAL

Surgical Treatment of Pulmonary Tuberculosis

No.1

_... J

MURRAY SIMPSON, M.D., M.Sc., F.R.C.S. (Edin.)

Consulting Thoracic Surgeon, Queen Alexandra Sanatorium and compres ion of the diseased lung have definitely proved REST to have been of great value as therapeutic agents during the treatment of pulmonary tuberculosis; a a result, collapse therapy has earned an important place in the treatment of that disea e. Various types of collap e therapy have been employed and each has its definite indications. The mo t commonly used procedures are: (1) Artificial pneumothorax. (2) Hemidiaphragmatic paralysis. (3) Paravertebral thoracopla ty and antero-lateral costectomy. ( 4) Pneumolysis. (5) Multiple intercostal neurectomy. Second to artificial pneumothorax, hemidiaphragmatic paralysis is the mo t universally used procedure. To the patient and to the physician presenting him for surgical collapse the following questions concerning hemidiaphragmatic paralysis are of vital interest. (1) What amount of pulmonary collapse results? (2) What degree of rest follows? (3) What is the effect on the contralateral lung? ( 4) The risk and disability incident to the operation? ( 5) Indications? ( 6) Technique? (7) Results? PULMONARY COLLAPSE The value of collapse, as demonstrated by the results of artificial pneumothorax, is beyond doubt. Interruption of the phrenic and accessory phrenic nerves causes an immediate paralysis and subsequent rise of the corresponding one-half of the diaphragm. When the phrenic nerve is interrupted in its entirety, half of the diaphragm becomes immediately paralyzed in 1

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

路-

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every part from centre to periphery. The paralysis i a complete at the periphery and at the oesophageal entrance as at t he vault and is not affected by time. The degree of paralysis depends upon the success achieved when sectioning the phrenic and it accessory branches. Partial elevation occurs immediately but complete rise is not present until the end of four to six months. The subsequent rise of the diaphragm depends upon the mobility of the diaphragm previous to operation. Adhesions in the costophrenic angle tend to limit the elevation postoperatively. The height to which the diaphragm rises varie from one to nine centimetres; the average is about four centimetres. In a erie of one hundred case performed personally, the rise equalled about fo ur and one-half centimetres. The rise of the diaphragm decreases the capacity of the lung by one-fifth to one-third of its original volume. (About 400 to 800 cc.'s.) There is an immediate decrease of about 32'}"o in vital capacity; t he tidal air decreases and the oxygen consumption remains practically unchanged. 1 As a result of the compression of the lung due to the elevation of the paralyzed diaphragm, the maximum unit of blood are r eceived to the lung and this increased blood aids the lung and pleura to realize the utmost of their power of re istance, defence and repair. The collapse also permits the apposition of the walls of moth-eaten and thin walled cavities and the. fibrosis of other lesions. Ascent of the diaphragm is not always necessary for a satisfactory clinical result, although it i usually true that the higher the diaphragm the better will be the clinical result. DEGREE OF I !MOBILIZATION

Practically all of the expan ion of the lung in a vertical direction, even of the apex, depend upon the descent of the diaphragm. Following complete phrenic interruption, the diaphragm does not move on ordinary respiration. In forced respiration or sniffing the paralyzed side moves paradoxically. The absence of the piston-like action of the diaphragm decreases re piratory movement by about one-third. The restriction of movement prevents rapid dissemination of toxic products and bacteria from the lesions as it retards lymphatic circulation to the lung. Secondly, as a result of the decreased movement of the lung, peripheral intravascular resistance is low, and t here is lessened cardiac labor. EFFECT ON CONTRALATERAL L NG Concerning the effect of hemidiaphragmatic paralysis on the cont ralateral lung, O'Brien states in a recent review of 700 cases performed by him, "A large percentage of my cases have had bilateral lesions and my own observations have been that in a good percentage of these

SURGICAL TREATMENT OF PULMONARY TUBERCULOSIS

the disea e in the contralateral lung has been healed along with that in the ide on which operation was performed, showing that no so-called 'added burden' had been placed on it. I have not been convinced that any of these measures have been the direct cause of spread or activation of disease in the other lung. In 70 ro of my operative cases the lesions in the contralateral lung improved." 2 Alexander states, "My experience with hemidiaphragrnatic paralysis has not led me to the conclusion that it is responsible, except rarely, for activation of tuberculou lesions in the contralateral lung." 3 No ill effect , definitely attributable to the operation, were observed in the contralateral lung in our series. R ISK AND DISABILITY INCIDENT TO THE OPERATION

The review of the literature for the past five years gives a total of 4,697 cases of phrenicectomys; there were, in this entire group, 57 (1.2 %) complications directly attributable to the operation and of these 26 (0.5 % ) were fatal. The complications were hemorrhage, pulmonary embolism, and pneumonia. 4 Statistics of Nuveau, Barne and others show that a tuberculous patient with a cavity and po itive sputum has only a five per cent. chance of living longer than five years--therefore, an occa ional complication should not influence the consideration of operation.~ Head 6 tate , "Blocking or extraction of the phrenic nerve are in experienced hands absolutely afe procedur es. They entail neither an operative mortality nor morbidity." No com plications resulted in our series. E FFECT ON ADDITIONAL T REAT 1:ENT

Hemidiaphragrnatic paraly is doe not interfer e with any f urther collapse procedure which may be contemplated at some future t ime. Reinforcement of artificial pneumothorax with diaphragmatic paralysis le sens the chance of effusion. The operation causes t he media tinum to be more yielding from loss of anchoring support. It is usually a complementary procedure to thoracoplasty lessening the length and number of the lower ribs to be resected. Bot h intercostal neurectomy and pneumolysis are both benefitted by primary phrenicectomy. INDICATIONS

The ( 1) (2 ) (3 )

indications may roughly be divided into three groups: Select ion. Necessity. Complementary to some further surgical collapse. O PERATION OF SELECTION

Head, in a recent publication, states, "In a disease as chronic and as seriou as pulmonary tuberculosis, and in which re t and collapse have pr oven so valuable, the conclu ion cannot be escaped t hat t his

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

remedy should be applied as completely and as effectively as po sible regardless of the fact that the patient might get well without it. For the past eighteen months we have been proceeding upon the principle that every case of unilateral tuberculosis should be treated surgically." 7 The indications for selected cases are: (1) Ca es which are not doing well under ordinary rest treatment but which are not considered ufficiently advanced for use of pneumothorax. (2) Ca es in which pneumothorax has been attempted and found impossible on account of pleural adhesions. (3) Before releasing artificial pneumothorax as an insurance against reactivation. ( 4) For economic rea ons. The ideal case is one that is unilateral, yet results have shown that selected bilateral ca es improve. Moth-eaten and thin walled cavities and basal lesions how the greatest amount of improvement. OPERATIONS OF NECESSITY

In this type of case, omething must be done to help the patient out of a difficult situation, or to relieve specific symptoms without expecting a cure. ( 1) Severe hemoptysis. (2) To stop incessant coughing. (3) To relieve the heart from embarra ment caused by extensive displacement produced by the pull of the fibrosed lung. ( 4) To abolish dy pnea and pain resulting from a scarred lung and diaphragmatic adhesions. COMPLEMENTARY TO FURTHER SURGICAL PROCEDURES

(1) Pneumothorax. (2) Thoracoplasty. (3) Intercostal neurectomy. CONTRAINDICATIONS

(1) Patient with soft, exudative, rapidly spreading lesions. (2) Lesion is so small that one is optimistic enough to think that it will heal on rest in bed only. (3) When collapse could not help because of complications, or consolidation. TECHNIQUE

The technique employed is that de cribed by Alexander . Local anesthetic is employed and even during complete evulsion of the nerve the patient ha not complained of evere pain. The patient is placed upon his side, in order that the omohyoid muscle be di placed from the operative field. An incision, usually about one inch in length, is made about an inch above and parallel to the clavicle at the outer border of the ternomastoid muscle. The platysma is incised and the deep cervical fascia is separated with blunt curved scissors. The calenus anticus muscle is exposed and in the

SURGICAL TREATMENT OF PULMONARY TUBERCULOSIS

majority of subjects the main phrenic will be found lying upon that muscle or near to its medial or lateral border. If phrenicectomy is to be performed, the nerve is anaesthetized and then a portion of it r e ected; careful search must be made for the acces ory nerves which are present in up to 80 % of cases, these mu t then be re ected also. If phrenico-exairesis is to be performed, the nerve is injected, sectioned and t he distal portion of it must then be pulled from the neck and chest; at least eight to nine centimetres must be obtained in order to ensure complete paralysi . The platysma is then sewn with chromic and the kin with intradermal sutures. The patient need miss no meals and requires hospitalization for only twenty-four hours. RESULTS

The operation gives beneficial result in from 75% to 85% of ca es. The majority of moth-eaten and thin walled cavitie will close, following hemidiaphragmatic paralysis. Severe hemoptysis is promptly checked as a r ule. Ince sant coughing is relieved to a considerable extent. Practically no ca es are made wor e by the operation. CONCLUSION

I wish to emphasize that in hemidiaphragmatic paralysi there is at our disposal a procedure which will aid t he t uberculou pat ient who needs some help in handling his infection. Bed rest doe not eem sufficient to enable the patient to fibro e hi le ion and yet one hesitates to ad vi e pneumothorax; it i in this type that t he mo t spectacular re ults are obtained. There i practically no risk t o the operation, it entails only a twenty-four hours tay in the ho pital and it i completed in one tage. REFERENCES lWerner-O'Brien-Arch. of Surg. 20'Brien-Arch. Surg. 21-2-1930. SAJexander-Annals of Int. Medicine, Oct. '30. â&#x20AC;˘Berry-Arch. Surg. 21-2-1930. SO' Brien-Arch. Surg. 21-2-1930. 6 Head-S. G. and 0 ., Oct., 1930. 7Head-S. G. and 0., Oct., 1930. Alexander-Surg. Syn. and Ob., Sept., 1929.

GOLDEN RULES OF SURGE R Y

Remember never to make promi e of any kind, and particular ly as to the results and the exact length of time it will require to get a cure, because a wound may suppurate in spite of all our precaut ions. Remember that consent is necessary to make an operation legally permis ible. Remember that about one-half of all strangulated hernias which have r esi ted taxis without relaxation will slip back under complete relaxation brought about by an anaesthetic. Never give a positive diagnosis of an obscure abdominal tumor until you have examined the patient after purgation and under ane the ia.-Bernays.

Acute A nterior Poliomyelitis F. W. HUGHES, M.D., F.R.C.P. (Can.)

Staff of Medicine, London General Hospital years this disea e has been shown to be infectious, and I Nhasrecent been produced in monkeys by the virus obtained from the nose of patients suffering from the disease. The organi m has not been definitely isolated, but a great deal of proof has been offered as to its existence. The virus is found in various parts of the body, such as the lymph glands (pharyngeal and mesenteric), tonsils, nasal fos ae, and the ganglia of the spinal root . It ha also been found in the secretions from the nose, inflamed eyes and ears. It is rarely detected in the spinal fluid or the blood of man. It is quite po ible that it is harbored in immune individuals (carriers), and often in adults--probably in the nose. Thus the disease may be spread often causing sporadic cases. The method of spread is not definitely known. Many per on , no doubt, may have the disease in an abortive form, never developing paralysis. The e case may be a factor in transmitting the di ease. In acute anterior poliomyelitis, hyperplasia of the lymphatic glands, of the spleen and inte tinal lymph nodes occur. Of particular interest is the infiltration of lymphocytes around the blood vessels entering the fissures of the cord. The most marked cord lesions are found in the anterior gray matter-parenchymatous, va cular and interstitial, which later produce necrosis of the anterior horn cells, partially by pressure from hyperemia, and partially by toxic action. This cau es a lower neuron paralysis. Microscopically, there i perivascular proliferation of round cells along the blood vessel of the leptomeninges le ening the blood supply to those parts of the cord. These essel often rupture, causing small clots and edema. The function of the ganglion cells is interfered with by edema, hemorrhage, cell proliferation cau ing degenerative changes in the cells them elves. Children under five years are most susceptible to the di ease but no age is exempt. No doubt, many case are so mild that they escape notice, or are not diagnosed. The prodromal symptoms vary considerably and are sometimes completely lacking. There is generally fever , moderate or fairly high, acompanied by pain in the head, sometimes frontal, more frequently at the back and in the neck. The child is irritable and cries when moved and especially when the head is bent forward. The neck and pine are more or less rigid. Drowsiness is evident though the mind is fairly clear and the eyes bright. The pharynx and the nasal mucous membrane may be reddened. Occasionally there are gastro-intestinal symptoms, diarrhea and vomiting. Frequently there i a remi sion in the symptoms which may not have been noticed, and then with increased fever a flaccid paralysis suddenly appears. The reflexes vary much from exaggeration to 6

ACUTE ANTERIOR POLIOMYELITIS

absence. The Kernig sign is generally present. Not infrequently paraly is is the first symptom noticed by the parents, though careful questioning often reveals that orne slight febrile symptoms may have occurred. One case in the series recently wa stricken with paralysis of arm and leg on the b路eet and no symptoms had been noticed before. Fever, with its general accompaniments, stiffness of the back of the neck, retraction of the head, pain on bending the spine forward, and irritability should demand a spinal tap. A cell count of o er ten is suspicious, and in poliomyelitis the count may range anywhere from 20 to 2,000 or more. One of our cases had a count of over 4,000 after t wo spinal punctures. Usually the count is 100 to 200 and the fluid is not generally turbid, whereas in cerebral spinal meningitis the fluid is often turbid. A lower count (20 to 40) occurs in lethargic encephalitis and brain abscess. Early in the disease the polymorphonuclear leucocytes are in exces and later, 36 to 48 hours, the lymphocyte predominate.. This increase lasts for about two week . (Ruhrah. ) The fine web-like clot of fibrin (Welbach's mantle) een in tuberculous meningitis is ab ent in poliomyelitis. The protein content is generally somewhat increased (100 to 150 mg. in 100 c.c.), and the sugar content generally shows no variation from the normal. Special attention should be given to the number and differential count of cells, protein content, sugar content and ab ence of T .B. bacilli. The paralysis may appear in the first few hour , or as late a a week. As a rule, the first paralysis is the maximum, but the extent of the paralysis is very variable. The most common situation is one or both legs, one or both arms, or a leg and an arm. In severe cases the trunk muscles are involved and possibly those of the neck, and death may occur from respiratory failure. The order of frequency of paralyzed muscles is: anterior foot muscles, quadriceps, glutei, ham string , and deltoids. The paralysis is accompanied by atrophy and flaccidity of the muscles. Sensory disturbance is rare and loss of control of the phincters is unusual. Early diagno is is very essential that treatment may be begun before permanent damage is done to the vital nervous structures. As soon as suspicious symptoms occur, especially in an epidemic, a lumbar puncture hould be done and the cerebro- pinal fluid examined. When we remember that increased pressure is cau ed by the mechanical increase in cells and tissue in the cord, we can readily see the great therapeutic advantage of removing some of the spinal fluid. Frequently headache, pain in the back and stiffness in the neck are greatly relieved by the withdrawal of 10-50 c.c., depending on the pre sure of the fluid and the size and age of the patient. This procedure may be repeated in 12 to 24 hours. Recently convalescent serum has been used in treatment with some success. It may be given intraspinally, intravenously, intraperitonally or intramu cularly. It may be given intra pinally immediately after the cerebro-spinal fluid ha been withdrawn while the needle is

UNIVERSITY OF WESTERN O NTARIO MEDICAL JOURNAL

in situ, always remembering to introduce a quantity of serum less than the amount of cerebro-spinal fluid withdrawn. If 20-100 c.c. of serum are given, part intravenously, part intraspinally or by muscle or into the peritoneum before the paralysis sets in, good results generally follow. Smaller doses may be repeated in 12-24 hours, after each spinal tap. The erum must be given before erious damage is done to the cell of the anterior horn. If the paralysis had occurred, the muscles mu t be placed at rest in a perfect state of balance, as overstretched mu cles rarely if ever regain their full function; they must be kept warm and, when the soreness has left, a light massage, gradually increa ed, i useful. Later defects are treated by orthopedic proces es. Electricity is of doubtful value.

Hypodermoclysis The injection of quantities of fluid into certain locations, especially under the breasts, is highly unde irable both from the point of view of the patient's comfort and because of the danger of producing local tissue sloughs. As is well known, fatty tissue characteristically are provided with a relatively poor blood supply; when the blood supply is disturbed, infection tend to occur and extensive slough may even result from mere pre sure in the absence of infection. Care should be taken, therefore, to avoid the injection of olutions into ti sues rich in fat. Muscular tissue is al o unsuitable for the reception of solution; it is relatively dense, and fluids permeate it very slowly; furthermor e, if sloughs should occur, due to pressure effect , the re ult would be disastrous. Ea ily disten ible, loose, areolar connective tissue is preferred. The sites of election for injection are the axilla, and the outer a pect of the thigh between the kin and the fascia lata; the e site provide con iderable areas of ea ily distensible, loo e areolar tissue, and the capability of ab orption from the e area i ordinarily sati factory. Half a liter of fluid can be accommodated without undue discomfort in either axilla or in either thigh. - Am. J. of S ., Vol. X II; 186.

â&#x20AC;˘

Therapeutics in Allergic and Related Conditions of the Respiratory Tract L. WHITTAKER, '32 is the purpose of this paper to indicate some of the trends in the I Ttreatment of two clinical condition , hay fever and asthma. Insofar as there has been so much written regarding their etiology, it is difficult to discuss treatment without some reference to it. GENERAL PROPHYLAXIS

In patients known to be subject to allergic conditions or to have a history of allergy in the family, it is well to do all that can be done to improve the general health by means of a well-balanced diet, exerciseÂˇ short of fatigue, removal of foci of infection, a voidance of chemical and mechanical irritants, and extremes of temperature. It is also well to avoid sensitization to horse erum, e.g. by the injection of anti-toxin as advocated by Kolmerâ&#x20AC;˘. SPECIFIC PROPHYLAXIS

Specific prophylaxis includes an investigation into the cause of the allergic reaction. This may be found by testing intradermally with alcoholic solutions of various substances, e.g. pollens, foods, orris root as in perfumes or powders, epidermals of horses, cats and dogs, and dusts of houses. When the exciting cause has been determined, several courses may be pursued. It may be possible to avoid contact by a change of residence, by abstaining from certain foods, and by eliminating the causative factor from the environment. If this cour e is found impracticable, it is necessary to desensitize the patient. In the case of pollens, this may be simple. According to the modified W alker 1 method, the skin is first tested with varying dilutions of the allergen. The first dose is that below the one which gives a reaction. Then injections are made at intervals of five to seven days over a period of 14 weeks until six minims of a Yl.oo dilution are administered. The short interval method of Duke 2 consists of administering doses of glycerolated pollen antigen beginning with two and a quarter units and giving the smaller concentrations once or twice a day and later at intervals of 24-48 hours up to 3000 units in the 25th dose. This latter method is advised because it is more rapid and less liable to cause reactions. It has been e timated that 90 per cent of the cases of hay fever will re pond to this treatment and following three years of such, the condition clears up permanently. One c.c. of Yl.ooo epinephrin may be administered if there is a reaction. In the case of epidermals from horses and cats, the desensitization is fairly satisfactory. Occasionally it is found that chronic infections of tonsils and sinuses or the normal bacteria in the respiratory tract are the cau e of the reaction. In this instance, testing with the various 9

UNIVERSITY OF WESTERN O NTARIO MEDICAL JOURNAL

bacteria and the employment of autogenous vaccines may prove helpful. This treatment is carried out with gradually increasing doses, beginning with an interval of five to seven days and subsequently increasing t he intervals according to the procedure of Pinnes and Miller. 8 Where no causative factor is found, it may be possible to increa se t he immunity of the patient by injections of non-specific protein bodies. Varying degrees of success have attended the use of such substances as typhoid, autogenous and stock vaccines, tuberculin, milk a nd pept one in the experience of Tobey. 4 LOCAL PROPHYLAXIS

Local treatment may be necessary following the desensit izat ion of the patient. In this connection polypi, polypoid turbinates, chronic sinuses should be investigated and treated according to the findings of Hastings. 1 0 The procedure of Sluder 6 , which has been subsequently modified by Bird 7 , is worthy of note. The rationale is to block the afferent tracts from the nose and thus prevent the exciting causes f r om stimulating the ordinary responses. This method advocated the injection of both nasal nerves and Meckel's ganglia with 80-95 per cent. alcohol. Cauterization of the sensitive areas of the nose has also been a dvised by Tobey, and air filters have been suggested by Kolmer , in the treatment of allergy. IMMEDIATE OR SYMPTOMATIC THERAPY

At the time of an attack various drugs are indicated. With asthmatic conditions, five to fifteen minims of 7'1. 000 epinephrine, hypodermically, is efficacious (v. case report). Its action may be augmented by the administration at the same time of one-half to t hree-quarters of a grain of ephedrin. Either of these drugs applied locally may relieve hay fever. Atropine is efficacious with hay fever where there is excessive secretion (v. case report) . Excessive thirst, dizziness and delirium with tachycardia are danger signals in its use. Mor phine with or without atropine is of doubtful value. The great danger with chronic conditions as asthma is that the patient may develop habit. P otassium iodide 'may be used along with belladonna in the treatm ent of asthma with beneficial effects according to Osler. 9 With hay fever, cocaine in epinephrin applied locally may be helpful in some cases but here again the danger of habit-formation should be considered. A host of other drugs have been tried and with a measure of success, but these noted are sufficient for the average patient. Case 1.- Male, 70 years of age, has been troubled for years with asthma, which is aggravated at varying seasons of the year , but is able to breathe easily and rest in bed or walk about if he receives seven minims of ?{ 000 epinephrin and one-half grain of ephedr in every two or three hours. Other drugs which have been tried have not given relief. Case 2.- Female, 29 years of age, has been troubled f or t he past

THERAPEUTIC

IN ALLERGIC CONDITIONS

three years with hay fever which begins towards the latter part of August and continues to the middle of September, but has complete relief of symptom one hour after the administration of 77 ;; grain of atropine. The effects are maintained for approximately eight hours. SUMMARY

The therapeutics of allergic conditions in the re piratory tract have been reviewed. Prophylaxis include avoidance, de en itization and care of local pathological conditions in the nose and throat. Of the drugs to control symptoms, epinephrin, atropine and ephedrin are especially noted. BIBLIOGRAPHY lWalker, I. C.- One Hundred Ca es of Hay Fever--J.A.M.A. 90-750-Mar. 10, 1928. 2Cchiff, N. S.-Long and Short Interval Treatment-Ann. Int. Med. 3-690--Jan. 1930. 3 Piness, L., and Miller, H.-Specific Protein Reactions in Eye, Ear, Nose and Throat-Ann. Otol. Rhin. and Laryng. 38-691- 1929. â&#x20AC;˘Tobey, H. G.-Allergy-Arch. Otolaryng. 12-799-Dec., 1930. 5Kolmer, J. A.-Treatment of Allergy-Arch. Otolaryng. 12-804-Dec., 1930. &Sluder, L.-Ann. Clin. Med.-May, 1925. 7Bird, H.-Hay Fever, Its Control Through Efferent Interception-Ann. Int. Med. 3-850-Feb., 1930. Feinberg, S. rtL-Two Cases-Ann. Int. Med. 3-1035--April, 1930. 9McCrea-Osler-Practice of Medicine (Eleventh Edition)-1930, p. 631. lOHastings, H.-Allergic Conditions in the Nose and Throat-Ann. Int. Med.45-799-May, 1930.

MUCOUS COLITIS In many textbooks on Medicine, no causes are given for mucous colitis. 0 ler says that true mucous colitis, a secretion neurosis of the large intestine, is met with in nervous and hysterical patients. Walter Jehn (Deutsche Medizinische Wochenschrift, 1924) reports the case of a young woman, 27 years old, who was neuropathic and inclined to vasomotor disturbances. While still weak, after an intestinal infection which was supposed to be typhoid fever, the patient suffered a severe psychic shock through the breaking of her ecret engagement, for which mental relaxat ion wa impossible because she had no one to whom she could talk about it. Gradually, the manifestations of an anxiety state became evident and a definite mucous colitis developed. Thi did not respond o customary treatment. It was only when the attending physician came to suspect a possible psychic factor in the condition of the patient, and directed his inquirie accordingly, that he found the casual connection. Hypnotic treatment, second grade, gradually controlled the affection and the patient was discharged, relieved of her trouble.

Building Resistance to Colds W.

WALLACE MORRISON,

M.D.

New York City THE CAUSE OF COLDS

I T has been established quite definitely by the recent investigations of Shibley, Mills, and Dochez 1 , that the actual cause of the contagious cold is the entrance into the body of a filtrable virus. The portal of entrance i most probably the nose and throat. The contributing cause of colds is undoubtedly a lowered resistance of the body to such infection. It is thus evident that colds may be prevented in two ways : either by avoiding infection, or by building up there istance of the body. Because it is almost impossible for most people to avoid infection at all times, let us discuss the various measures which may be used to increase resistance. THE METHODS OF BUILDING RESISTANCE

(a) The Diet.-This factor is of very considerable importance in adults as well as children. The diet must be 路aried, and a reasonable balance maintained between the amounts of protein (meat , fish, eggs, cheese), fat (butter, oil, shortening), and carbohydrates (sugar, bread, starchy vegetables). Mineral alts are es entia!, and are pre ent in vegetables, fruits, and e pecially milk. All of the vitamins are probably necessary; pre ent knowledge indicates that vitamin A is perhaps most needed to resist infection ; it is present in milk, cream, cream cheese, butter, egg-yolk, and especially in cod liver oil. The diet of the growing child hould contain a quart of milk a day, one egg, an ounce of butter, the juice of a large orange, and cod liver oil or one of the newer cod liver oil concentrates, to contain all the needed vitamins; many adults would do well to include these foods in their diet. For proper intestinal activity a reasonable amount of roughage in the form of raw and cooked fruits, the green vegetables and leafy salads mu t be taken daily. At least six glasses of water hould be imbibed daily. If the diet and the fluid alone do not prevent constipation, the use of mineral oil, alone or combined with agar, is preferable to the repeated taking of cathartics. (b) Exercise and Rest.-Everyone not performing a reasonable ;mount of vigorous physical labor daily should take some active exercise in the open air, or with the window widely open. A bri k walk is an excellent tonic; the simple setting-up exercises u ed in gymnasium and physical training schools the world over are a good sub titute when other exercise cannot be taken. Proper rest is also an essential ; fatigue, whether from work or play, distinctly lowers resistance. Seven or eight hours of quiet sleep with the windows open will be required by all children and most adults. (c) Fresh Air, Day and Night. Everyone ought to spend at least one hour daily in the open air. The rooms in which we work and leep, especially, ought to be well ventilated but not draughty. Rooms t hat are too hot and too dry have a very decided effect on t he resistance 12

BUILDING RESISTANCE TO COLDS

of the mucous membranes of the respiratory tract; a temperature of 68 to 70 degrees Fahrenheit is best; some means for proper humidification of the air, such as water pans on heat radiators, is very important indeed. (d) Tonic Baths.-For those whose resistance i lowered by chilling of the body, tonic baths will often lessen the susceptibility to colds. The cold or cool morning tub or shower, or the cold air bath, followed by a bri k rub with a rough towel is advisable. (e) Sunlight and Light Bath .-Everyone ought to let the sun shine on the skin every day, while out of doors, or through the open window, since ordinary window gla s filter off the desirable actinic rays of the sun. In bad weather and in the smoky sunlight of large cities, the use of artificial sunlight is helpful. There are a number of "sun lamps" which may be safely used at home; the skin must not be burned, and the eyes should always be protected from the strong light by smoked goggles. True ultra-violet radiation baths probably aid in building resistance; they should be given only under the direction of a phy ician to avoid harm and to secure the best results. (f) Vaccines.-In some persons a more or less definite resistance to colds may be built up by the use of vaccines. These are either stock, or preferably, autogenous vacines prepared from the germs which are no doubt the secondary invaders of the re piratory tract, active especially in the later stages of the cold. Such vaccines must be used with care, and should be given only by a physician who understands the control of the dosage, etc. It i an interesting pos ibility that in the future some specific method of immunization against the filtrable viru , the actual cause of colds, may be developed. (g) Remedying of Diseased Condition of the No e and Throat.There are a number of local abnormal conditions of the nose, such as septal deviations, hypertrophy of turbinates, subacute and chronic sinus infection, arious forms of chronic rhinitis, etc., and of the throat, such as chronic tonsillitis, hyperplasia of the adenoid, chronic pharyngiti , etc., which undoubtedly act as predisposing factors in the su ceptibility to colds. For the remedying of these, the help of the physician, and very often of the otolaryngologist as well, is ab olutely e sential. (h) Remedying of Di eased Conditions El ewhere in the Body.The presence of any of a number of diseases such as nephritis, diabetes, various forms of heart disease, pulmonary and other forms of tuberculosis, anemia, chronic focal infection, etc., most certainly lowers the resistance and predisposes to cold . For the prompt discovery and treatment of these condition the physician must be consulted. A "health examination" twice a year is a most excellent means of finding the pre ence of such di ea es, and i to be very highly commended from the standpoint of the general health and of increasing the resistance to colds. REFERENCE 1

Shibley, G. S., Mills, K.C., and Dochez, A. R.-Studies of the Etiology of the Common Cold-J.A.M.A., 95:21, 1553, Novem. 22, 1930.

â&#x20AC;˘

Case Report of a Septic Thrombus of the Leg with Ulcerations JEAN CAMPBELL,

'33

woman 56 year of age, on admission to Victoria Hospital, had an ulcerated area on the lateral aspect of the left leg f rom the ankle to the knee, three and a half to four inches wide, from which t he uperficial muscular layer had been removed by the attending surgeon, piece by piece, as necrotic changes became evident. The cut ends of the muscular fibres were cO\Âˇered with a gluey, greenish-grey exudate; the skin around the margin was undermined, an inch or more hanging loosely, with pocket of pus beneath. The patient looked toxic and had a temperature regularly irregular, ranging from 98 to 101 o F ., pulse 119 to 130, and respirations 23 to 25 per minute. She was dehydrated and nauseated, having taken no food, according to the history, for seven days before com"ng into the hospital. Catheterization had been necessary daily for the past six week , and the urine showed albumen, casts and pus. The patient had had a mild sore t hroat six weeks previously when she suddenly developed a severe pain in the left leg, and within a few hours a dark purplish bleb formed, extending from the ankle to the knee ; when this was opened, more than a pint of dark sanguinou fluid came away, and the mu cles beneath were black. The affected muscular ti sue was removed, but thick purulent exudate formed over t he whole area, with necrosi and undermining of margins. Hot boracic compresses were used, and drainage instituted. The exudate was decreasing and a thin white line of advancing epitheleization could be seen on the medial border, when the patient became nau ' eated, vomiting all food taken, and finally refusing food altogether, so she was brought to t he hospital. There was a past history of a cystitis for which she had been treated for years, and a mild myocarditis. With two interstitial injections of saline, forced fluids for a month a nd a half, efficient drainage, and good nursing, her condition improved.

DISCUSSION

The etiology is apparently an embolus lodging in the anterior tibial artery at its origin and causing moist gangrene in that part of the leg upplied by it. This area extends from one inch above the lateral maleolus. The embolus is usually a fragment of ,-egetations from the valve of the left heart. However, it might have been a fragment of a blood clot formed in a diverticulum of the left heart from an aneurysm, or upon the surface of a rough atheromatou aorta. There is no history of trauma or burn to account for the localized a rea of tissue damage. The di colorations of tissue and the formation of blebs a nd the "crackling" obtained on palpation of blood in the tissues 14

SEPTIC THROMBUS OF THE LEG

re emble gas gangrene, but this condition is easily ruled out a it is so rapidly progressive and so quickly fatal. SUMMARY

This ca e illu trates one of the emergencies of general practise. The usual symptoms are a harp tabbing pain at the lodgment of the embolus, with a dull ache along the course of the blood vessel below it, and lo of pulsation in the artery di tal to the obstruction. To complete the diagnosis, the heart is examined for murmurs indicative of vegetative growth upon the valves of the left heart. If diagnosed within a few hours of onset, embolectomy is re orted to, the artery is cut down on and opened and the embolus removed, the wall being repaired with fine sutures. If treatment is commenced later it mu t be one of removing the dead tissues as they are formed . T wish to thank the attending physician, Dr. D. A. Cameron, for hi help and aid in reporting this interesting case.

DEHYDRATION Dehydration should never be allowed to develop in surgical patients to a point at which it becomes clinically recognizable. The earliest changes in the direction of dehydration con ists in minor deg1路ees of blood concentration accompanied by a dimini hed and relatively concentrated urinary output. The blood concentration can be mea ured roughly by means of hemoglobin determinations, by blood counts, or by hematocrit reading ; the urinary concentration is manifested in a high pecific gravity which a sume a rather con tant level. The phy ical ign con ist of dryne s of the kin, parching and cracking of the tongue and general dryne s of the oral cavity, and, in everer degrees, of enophthalmus, fever, restle ne s and delirium. Dehydration kill patients by interfering with the migration of the erythrocyte through the mailer capillarie of the parenchymatous organs, and thus preventing tissue respiration; the tissues die as a result of slow and progre sive asphyxia. Dehydration is characteri tically accompanied by the development of acido i , because both respiration and excretion are di turbed; carbon dioxide fail to be excreted in normal amounts from the lung , and fixed acid , principally in the form of acid pho phate , are incompletely excreted by the kidney . -Am . J. S., Vol. XII; 173

X-Ray T reatm ent of H erpes Zoster J. G.

BOYES,

M.D.

Plainfield, New J erseu THERAPY to the Roentgenologist and Clinician alike is X -RAY most often discouraging but we believe that in the treatment of herpes zoster we have found at least one condition which responds very readily. Heretofore, the milder lesions became chronic, often accompanied by intercostal pain or neuritis, la ting in orne cases a matter of months or even a year. In the literature on this subject we found many forms of treatment for the local lesion and for t he pain which often follows . Quoting from one article, a doctor state , "Shingle , particularly in persons past middle life, not uncommonly may have a sensitiveness for several weeks or months in the area which previously was the site of eruption. This is really a form of neuralgia, and though often distressing, entirely disappeara in time even in the absence of treatment. Relief is afforded, however, by the taking of acetyl salicylic acid in a dosage of 13 Gm. (5 grains) after each meal and before retiring, with or without application of dry or moist beat or mentholated ointments. Shingle are cau ed by an infection of the nerve root and mo t cases run t heir course in from two to six weeks." Dr. W. Jo eph, a German physician, during the last influenza epidemic, noted frequent occurrenes of herpes zoster following this disease. In several patients the pain were felt for five weeks or longer and were assumed, in these cases, to be caused by the toxins of the influenza bacillus. The clinical aspects of the dermatitis were the same as when it appears alone. The di ease was unusually painful. Dr. Hill, in his article, states that he i convinced that herpes zoster i an infectious disea e and the persons suffering from it should be isolated. Herpes zoster may give rise to either varicella or herpes in susceptible per ons. The cutaneous lesion of herpes zoster and varicella are very similar. Investigation of the spinal cord hould be made to discover whether there is a imilarity in the cord lesions of the two diseases. An attack of varicella does not confer immunity against herpes zoster. Further investigation is required to discover whether an attack of herpes zoster will confer immunity against varicella. Another author is of the opinion that it is impos ible by means of medication to entirely relieve the pain, and it does not cease spontaneously. Herpes zoster and its associated neuritic pain i probably due to a virus infection of the po terior root ganglion. The injection of the ganglia supplying the infected skin segment i o:~e procedure often followed by success but the technique is difficult and the treatment dangerous in that the ganglia alone must be injected with alcohol. Dr. A. S. Hyman, of Nev; York, reports three patients wit h herpes 16

X-RAY TREATMENT OF HERPES ZOSTER

zoster who subsequently developed angina pectoris. He states that the characteristic burning pain experienced in herpes zoster resembles, in many respects, that of angina pectoris. Herpes zoster and angina pectoris exhibit identical area of altered skin sensitivity. There is a po ibility of a common etiologic background in both herpes zoster and angina pectoris of the neurogenic type. Of the twenty-six patients that have come to us for x-ray therapy treatment, fifteen were female and elev路e n male. The age varied from eighteen to seventy-nine: one patient below the age of twenty, two patients between twenty and thirty, five patients between thirty and forty, five patients between forty and fifty, four patient between fifty and sixty, and nine patients over sixty years of age. From this it would seem that the disease, as we find it, is more common in females and in older people. The period between the on et of the disease and the initiation of treatment varied in the e ca es from a few days to three weeks, but u ually patients were seen about one week or ten days after the onset of the eruption. The locations of the eruptions varied considerably. One patient had areas extending from the shoulder down the course of the nerves to the dorsal and palmer surfaces of the hand ; two were treated with lesions in the lower abdomen over the pubes and about the buttocks; one with lesions in the right temporal region, right frontal regions and involving the right eyelid; and several cases showed lesions in the abdomen near the umbilicus, extending around from the lumbar region. The majority of the lesions followed the intercostal nerve . The last three ca es howed almost identical lesions involving the upper portion of the left brea t, left axilla and back with two small areas under the axillary region, which is a rather peculiar incidence. No cases were treated with lesions in the lower extremities. The number of treatments given over the skin area varied from one up to five, the average number of treatment per patient being 2.5. In only one case, so far as we know, have these lesions not responded to x-ray therapy. This particular patient, a man of seventytwo years of age, had had herpes nine months previous. Surrounding the left ide of the body, at about the region of the ninth intercostal space, there was scar tissue extending from the back to the front about one to one and one-half inches in width. He apparently had had a very marked eruption with marked inflammation resulting in these scars. His pain had never entirely di appeared. Five x-ray treatments were given over the spine. After the first treatment, he reported some relief but the pain again returned and was not relieved by further treatment. It is possible, in this case, that the lesion was produced by the pressure from a productive osteo-arthritis. An x-ray examination was advised but this was not made and no further x-ray treatment was given. In milder cases patients get some relief the same day or at least within twenty-four hours. In more severe cases they may not get relief until after the econd or third treatment. Since these treatments are given within periods of four to five days, it is only a very short

UNIVERSITY OF W ESTERN ONTARIO MEDICAL JOURNAL

time until the patient is r elieYed to a cer ain extent from the malady and ultimately the lesion entirely clears without ~car formation, prodding the treatment i begun at the on et of the di ea. e. The subsequent neuralgia which ha often followed this le ion, we believe, is entirely absent. While there are many varied treatment for herpes zoster, we have found x-ray therapy a very adequate treatmen an beli â&#x20AC;˘e that it entirely relieves t he ub equent neuriti and mf often follow the malady for a period of time after the eruptions heal.

STATUE OF JOHN Hl'. "TER Presented by the Queen to 0 f Universjty &Iuseum

Control of Cancer and Purchase of Radium·:· BERNARD MOONEY,

M.D.

Edmonton, Canada

HEN I was asked by Dr. Bow, the Chairman of the Cancer Committee, to prepare a resume on the above subject, it seemed to me that a logical consideration would entail, first, what step are being taken to control cancer and, secondly, to examine briefly in what way the use of radium would amplify the pre ent mode of treatment. The following are facts acquirea by a review of the available literature, impressions gained at well known clinics ano hospitals and by personal experience. CONTROL OF CANCER

Cancer, a colloquial term used to include all forms of malignancy, is now generally believed to be on the increase and to be attacking the white race particularly. It is unnecessary to labour these points, easily verified by statistics and e tablished by current medical experience. As a result, far-seeing people the world over, both lay and medical, are devi ing ways and means to combat this dread disease. In Sweden, Denmark, Belgium, France, Germany, Austria, United States, some of the South American republics, and in Canada, cancer has become more or less a national question. The problem is fundamentally the same wherever the white race exists, but, compared with some of the European countries, Canada is rather behind in organization and equipment. As a concrete example, the attitude of Sweden ' is presented: The Radiumhemmet was founded in 1910 by John Berg. First it functioned as a private undertaking; in 1911 it was given over to the Cancer A ~sociation. Since 1913 the institution has been supported jointly by the Cancer Association, government, city, and the University of Stockholm. (1) Organization.-This consists of a radiotherapeutic clinic, radiotherapeutic polyclinic, radium division, Roentgen division, operating room, division for charting and following up, phy ical laboratory, and anatomic-pathological division. (2) Working Method and Working Problems.-The institution as a whole ha h •o main purpose . First, the study of the effect of radiation in tumor by means of sy tematic treatment in humans; and econd, a study of the radiation effects on the normal organism and on t umors by means of animal experiments. Another purpo e of the institution is to organize po t-graduate medico-radiological instruction. The instruction in medical radiology in Sweden dates back to 1908 when for the first time a private course wa created at the Seraphim hospital. In 1914 a regular voluntary *Read as a part of the report of the Alberta Cancer Committee at the meeting of the Alberta Medical As ociation, in Winnipeg, August 25th, 1930. 19

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

course was given at the Caroline Institute in Stockholm. Since 1916 a similar course has been given in Lund, and another since 1919 in Upsale. Dating from 1924, the course in radiology has been obligatory for all students. (3) Results.-In the first t years, from 1910 to 1920, 7,500 cases were treated at Radiumhemmet; during the following five years, 11,000, making a total of 18,500 cases. Of these, 13,000, that is 70 7c , were malignant tumors. With regard to the results obtained, the cancers are di vided into five large groups." The author then goes on to give more detailed results of the treatment, and one is impressed with the care with which records are kept and the surprisingly high percentage of cures. The League of Nations has appointed a Cancer Commission, the scope of which is outlined by its secretary, Dr. Tomanek, 3 as follows : "First, the commission desires to make a comparative study of the methods and results obtained in the treatment of uterine carcinoma. This particular disease has been selected becau e this type of carcinoma, in contradistinction to other forms, has been for a long time the subject of a very wide and intensive research. Secondly, the commission proposes to make a very comprehensive study of the propagation and the etiology of so-called occupational cancers. It is the purpose of the commission to pay particular attention to carcinoma of the lung occurring in workers in the cobalt mines in Schneeberg. Thirdly, the commission proposes to send questionnaires to all cancer workers throughout the world. These questionnaires will detail the different carcinoma problems under consideration which may be studied with the help of the League of Nations and which give promise of early and successful solution." Dr. Tomanek took occasion to remark that the League of Nations lays particular stress, not upon the theoretical investigation but upon the more practical handling of the fight against cancer. "The commission further proposes to give lectures, exhibitions of instructive cases, and to acquaint the members of the commission with the organization and statistics of cancer treatment in all the prominent clinics throughout the world." Australia has recently inaugurated a cancer campaign and within the last two years has purcha ed ten grams of radium for her hospitals. South Africa is commencing a similar movement. In Canada and the United States the question of cancer control is rapidly engaging public attention. On and adjacent to the Atlantic coast, where centres of population are located, concentrated endeavor is in evidence. Worthy of particular notice is the educational effort of the American Society for the Control of Cancer. The Canadian Medical Association, through its hospital department, directed by Dr. Agnew, has collected data on the radium available in Canada. The Provincial Government of Quebec has purchased a considerable quantity of radium and an emanation plant i in operation in Montreal. The trustees of the Toronto General Hospital recently announced their intention to

CONTROL OF CANCER AND PURCHASE OF RADIUM

purchase a substantial quantity of radium and to establish a centre for the treatment of cancer. Saskatchewan has appointed a Cancer Commission under the direction of the Minister of Health, Dr. Munroe. The commission is empowered to organize cancer clinics, conduct an educational campaign, and provide radium and x-ray equipment. The executive of the Alberta Medical A ociation appointed a Cancer Committee under the chairmanship of Dr. Bow, the Deputy Minister of Realth, at the beginning of the year, and this meeting is now to receive the report of that committee. As far as I am a ware, cancer has not been made a notifiable disease but the weight of well considered opinion is now demanding that this be done. The only available statistics on cancer are those based on death certificate , whereas, autopsies show that a large number of patients die with cerebral, pulmonary or abdominal carcinosis in which no such condition was suspected. The cause of death as stated in the death certificate may be in error from 30 to 40 per cent. â&#x20AC;˘ This may a tonish statisticians but it does not surprise pathologists. It is now generally agreed that cancer in its early stages can be successfully treated, and that surgery, radium and x-ray treatments, either singly or in combination, are the methods of choice. Granting this, the great need is early diagnosis. The public should be taught the early signs and symptoms of malignancy and the necessity of consulting a physician if they recognize such signs or if they are in doubt. This educational campaign will have to be fairly intensive, without relaxation, and the medical profe sion will have to be included in it to some extent. In analyzing the reasons for the fatal delay in the diagnosis and treatment of cancer, Herbert L. Lombard and Mary P. Cronin, in an article entitled "Why Do People Delay ?"â&#x20AC;˘ drew the following conclusions: The delay between the first symptom and the first consultation with a physician, for individuals with cancer, coming to state-aid cancer clinics in Massachusetts, is six and one-half months. Males delay longer than females except for skin cancers. The greatest delay is in cases of cancer of the kin and the shortest delay is among those patients having cancer of the uterus. Thinking the condition a minor malady is the largest single cause of delay. Among the males this reason is considerably greater than among the females. The greatest single cause of delay, between consultation with the physician and treatment, is because of poor advice on the part of the attending physician. Forty-five per cent. of the cancer patients had a medial delay of six months after consulting a physician, while "forty-five per cent. received treatment within a short time following diagnosis. In a few words, cancer control, in the light of our present information, resolves itself into a more thorough utilization of existing knowledge.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

From an economic standpoint the cancer propo ition is more or le a local affair. The average patient is unable to meet the present costs, and I use the word advisedly, of successful surgical and radiological treatment, but whether aid should come from philanthropic or public funds or a combination of sources depend on local conditions. It is estimated that eighty per cent. of patients with malignant disease are unable to bear the costs of present-day treatment. PURCHASE OF RADIUM

It should be clearly understood that radium is only one of the radiological methods used in the treatment of malignancy. It is still a moot question whether x-ray machines or radium will produce the shorter wave length. It is quite possible that x-radiation, in the near future, will surpa s radium as regards cost of production, shortnes of wave length, convenience, shorter time of application, and so forth . Experiments in this respect are in progress. At present all authorities agree that both are necessary. A second point that should be studied i the relation of surgery to x-ray and radium in the treatment of cancer. Profe ~sor Regaud of the Pasteur Institute and Director of the Radium Institute of Paris, one of the highest radiological authorities in the world, states: "Radium and roentgen ray cannot and should not be divorced from surgery in the modern treatment of cancer. If, in spite of this, I limit my remarks to radium therapy alone, I do not wish to leave the impression that such therapy at the Radium Institute of Paris is considered more important" than other methods of treatment of cancer." The que tion might be asked : Has radium justified itself in the treatment of cancer? The question can be an wered most satisfactorily by quoting from one or two authoritative sources. The ixth annual report of the British Empire Cancer Campaign, dated August 7th, 1929, state in part as follows: "The International Conference on Cancer convened by this Campaign was held last July . It proYed an even greater success than was expected. Over 500 delegates and members attended from all parts of the world. At this conference a special section was devoted to radiological treatment. As a direct result of data submitted by the delegates, it immediately became apparent to all that radium was destined to play an important part in the successful treatment of cancer in the near future. At the same time it became more obvious that the supply of radium available in this country was hopelessly inadequate. Steps were immediately taken to a scertain what would be the best way, materially, to increase the supply, and to organize its distribution to the best po ible advantage. "It was decided that an International Radium Fund, to raise money for the purchase of a large quantity of radium, should be launched. The British Government impressed by the report of the Raleigh Committee on the supplies of radium, approved of the launching of the Fund and agreed to contribute pound for pound up to the sum of one

CONTROL OF CANCER AND PURCHASE OF RADIUM

hundred thousand pounds. Within a short time the sum of over a quarter of a million was subscribed. There is no doubt that, so far as can be seen, sufficient radium will soon be available for present requirements. "One of the outstanding features of the Cancer Conference was the production of overwhelming evidence that radium is a most potent agent in the successful treatment of cancer in certain situations, notably the mouth and throat, the womb and the breast." Dr. Albert Soiland, 7 speaking at the annual convention of the Radiological Society of North America, last year at Toronto, said: "It is significant that every medical institution where radium has been available long enough for demonstration of its value in cancer is increasing its supply as rapidly as possible. The reason for this is that those working in such institutions have had convincing proof of the efficacy of radium in larger amounts than were formerly used." Stanford Cade, F.R.C.S., Assistant Surgeon to Westminster Hospital, London, in his recent book, "Radium Treatment of Cancer," states: "Until recently the principle underlying the treatment of cancer was the elimination of the growth by excision with the knife or diathermy. The vital question for each individual case was : 'Is it removable?' The answer varied with the size of the growth, the skill and courage of the surgeon, the general condition of the patient and the presence of recognizable metastasis. Even in its widest sense the measure of operability depended on the question : 'Is the lesion removable?' and not on the question : 'Is the removability of the lesion going to cure the patient?' In the past ten years rapid progress of radium therapy has changed the conception of operability, and for the disappearance of the cancerous lesion it is no longer imperative to rely entirely on the scalpel. What has radium added to the older methods of treatment? No one claims it as a specific for malignant disease. It has a limited use, but wider than that of surgery alone. In certain situations it has replaced the knife. In others it bas added to it a possible means of prolonging life. One fact stands out very clearly: no patient, however 'inoperable,' should remain untreated." REFERENCE Forssell, Gosta-The Radiotherapeutic Clinic of the Cancer Association in Stockholm, "Radiumhemmett," its Organization, Working Methods and Therapeutic Results.-Acta Radiologica. 1928. IX 315-369. 3 Vienna Letter.-The Establishment of a Cancer Commission as a Part of the League of Nations. Am. Jour. of Roent. and Radium Therapy. Feb. 1929. P. 183. â&#x20AC;˘Wood, Francis Carter-Bulletin of the American Society for the Control of Cancer. May, 1930. P. 1. â&#x20AC;˘Lombard, Herbert L. and Cronin, Mary P.-Cancer in Massachusetts. "Why Do People Delay?" The Commonwealth, Mass., Dept. of Public Health. V. 16, No. 4, Oct., Nov. and Dec., 1929. I will be pleased to furnish statistics to anyone interested. 7 Soiland, Albert-Some Economic Aspects of the Cancer Problem-Radiology, March, 1930, p. 240. Cade, Stanford, F.R.C.S.-Radium Treatment of Cancer. Introduction, p. 1. Macmillan Company of Canada, 1929. 1

Dr. Moses, M. 0. H. ARTHUR

HILL,

'32

HE underlying pr inciple of the sanitary and medical regulations of T the laws of Moses is the prevention rather than the cure of disease. Moses was cent uries ahead of the medicine of his time; in fact, when we consider that modern medicine is increasingly laying the emphasis on prophylaxis and is slowly breaking away from the pharmacopeal traditions of the past, we may well wonder at this man, one thousand years before Hippocr ates, t hrowing overboard with one magnificent gesture the whole materia medica of Egypt and adopting for his people some public healt h measures. Prevention and t reat ment of disea e, to be sound, must be based upon a true knowledge of etiology; indeed, the methods one uses to combat disease a r e an indication of one's knowledge of their cause. Thus in Africa wher e disease is attributed to evil spirits, incantations and charms ar e pr act ically t he sole means used to ward off sickness. Judging Moses' understanding of the etiology of disease in general by his prophylact ic measures, we find that he attributed human ailments to the following causes: (1) Infected meat, or meat coming from questionable animals, and other articles of diet considered unsuited for food . (2) Lack of proper rest and nourishment. (3) Unsanitary conditions due to overcrowding and lack of cleanliness. (4) Improper ment al and spiritual attitude toward life and society in general. ( 5) Contamination, direct or indirect, from sources such as: (a) body discharges; (b) clothing, utensils, furniture, buildings, etc., used by a diseased person; (c) contact with dead animals ; (d) articles brought into the camp from a possibly diseased source. There are, no doubt, ot her indications of a scientific etiological sense which could be worked out but the e are sufficient to show that Moses' medical knowledge was based upon personal observation, painstaking recording, independent thinking, and untiring work. Some of the general regulations laid down to govern the people as a whole demonstrate how these principles were worked out in practice. Both while on the march and in camp, the order and position of the various tribes were definitely indicated. The Tabernacle was to occupy the central posit ion, while the camp was arranged round about it, at some distance, in the shape of a large rectangle with one end open, facing east. Each tribe was allotted its own position in the camp, the open nature of which prevented overcrowding and its attendant evils. On several occasions later on, Moses was able, with singular 24

DR. MOSES, M. 0. H.

ease, to isolate whole families from the rest of a tribe; so it appears that not only were the tribes separated from each other but families and households within the tribes had definite locations with open spaces between them. The advantage of such an arrangement as a purely sanitary measure are obvious. One of the outstanding characteristics of the Mosaic code was the provision for the observance of the Sabbath. At this early date, the custom of resting one day in seven was peculiar to J;he Hebrews, although it later spread to the Babylonians and other adjacent peoples. It was simply a day of rest, a day of cessation from all labor but that of preparing food, and even that had to be cooked the day before. This primitive Sabbath must not be confused with that which the rabbis, hundreds of years later, loaded up with all kinds of burdensome ritual, and which must have been one long, nervous strain, rather than a rest. The land was also to receive its Sabbath; one year in every seven it was not to路 be cultivated and the farmers were to gather only that which grew of itself. This sabbatical year provided a holiday for the owner of the land as well as for the land itself. This practice of observing frequent days and months of rest no doubt contributed considerably to the general well-being of the Israelites. The rational of Moses' dietary regulations is becoming more apparent every year, as our knowledge of dietetics increases. We have for years recognized that the Hebrew prohibited pork long before the dangers of tape-worm, trichina and hydatid had been associated with the pig, but until recently we paid little attention to the fact that the Hebrews could not eat hare nor handle its carcass. Within the last decade it has been discovered that the handling of rabbits infected with B. tularense, as well as the eating of this flesh, may give 路rise in the human to tularemia, an acute febrile disease. Why they were forbidden the flesh of carnivorous animals and birds of prey is not so apparent as yet. Of the clean meats which the Hebrews were allowed to eat, the law provided that none should be kept in their dwellings even though cooked, for more than twenty-four hours--a necessary precaution in a hot climate. The prohibition of the eating of blood had a religious significance, but may there not be here a recognition of the fact that the blood is the vehicle of all manner of infection? We know today that epidemics of typhoid fever have resulted from the consumption of oysters from infected beds. Had Moses observed this and therefore forbidden the Israelites to eat shell-fish? The only fish which the Hebrews were allowed to eat were those which had scales. These had to be cleaned before they were eaten and the removal of the scales entailed the removal of any fungus growth adhering to them. For one week every year, during the Feast of the Passover, the Hebrews were allowed no leaven at all in their houses; every last trace of it was to be removed. This necessitated a thorough scouring of the kitchen and its utensils and a renewing of all food supplies. Again,

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

at another season of the year, the Feast of Tabernacles was kept, when everyone left his home and lived for one week in a booth built with boughs. This provided for the airing and cleansing of all Jewish houses at least once a year. The occasions were legion on which an Israelite was required to bathe the entire body and wash all his clothes. E verywhere the keynote is cleanliness, to a degree little realized even today; this is especially true of the regulations governing the individual's sexual life. When we try to calculate the amount of water the Hebrew family used during its everyday existence, not to mention those special occasions which demanded extra cleanliness, we can understand why the water supply was as important to them as it is to us. Moses seemed to realize that the only final disinfectant was fire. All parts of the sacrificial animals were carefully burned with fire, either on the brazen altar or outside the camp. All contaminated clothing which could not be washed clean with water was to be burned. To protect the nation from possible infection from the spoils they took in warfare, it was provided that only that which wa first passed through fire could be brought into the camp. Instances of a like character could be multiplied. The rules for the prevention of the spread of infection through body discharges are interesting to study, as also are the thorough-going regulations for the control and eradication of venereal disease. As one author puts it, no modern state has yet had the courage to enact a moral code comparable to that of Moses. The practice of circumcision is believed to have had a directly beneficial effect upon the sexual life of the Hebrews; its value is evident in a climate where sex appetite is prone to develop early under any conditions. In this code, too, are found the earliest known medical legal provisions as well as a simple kind of workmen's compensation. There is one section of the Mosaic code without which any account of its medical features would be inadequate. This is the section that deals with the control of leprosy. Here, for hundreds of years, obscured by archaic terms and a widespread ignorance of the Old Testament among medical men, have lain hidden all the important principles of our modern system for the prevention of the spread of communicable diseases. Aaron Brav, a Jewish surgeon in Philadelphia, has worked out the regulations governing lepro y very carefully. I shall give a summary of them here. The word translated "leprosy" in the English Bible is "tsaraath" in the Hebrew. This word does not mean leprosy as we understand it, but denotes a group of contagious diseases with skin manifestations transmitted by contact. The Hebrews did not differentiate between the various types of skin rashes but treated them all in the same manner-by isolation. The principle diseases for which we practice isolation today have skin eruptions for their main diagnostic feature,

D R. MOSES, M . 0 . H.

such as smallpox, scarlatina, measles, erysipela , and leprosy; it i probable that some of these were included in the group "tsaraath." Any infectious disease with skin manifestations wa reportable to the sanitary officers--the Levites---who had to decide what disposition should be made of the patient. The priest , upon being notified, went to inve tigate the case and, if the diagnosis was clear and a contagion ' â&#x20AC;˘as present, the case was con idered dangerous. The pat ient was officially declared infectious or unclean and he was at once isolated in a special place outside the camp or city. This place, called in the Bible an "unclean place," was really a properly orga nized isolation camp. Every patient with "t araath" was labelled "unclean" or "infectious," presumably by some kind of a placard. Such was the disposition of a case where the diagno is was clear. Where the diagnosis was doubtful, the patient was placed under temporary detention for seven days, when the pr iest came to make another examination. If the changes after the first seven days did not warrant definite diagno is he was kept separate for seven more days, after which time in nearly all cases a definite diagnosis was made. He was either declared infectious and sent outside t he city to the isolat ion camp, or he was found clean, free from contagion, and set free. Qua rantine of suspected cases was thus pract ised for not less than even or more than twenty-one days. The mode of life of the patient in the isolation camp is not described, but it is assumed that the authorities supplied t heir ordinary needs, as well as medical attention, or else they could never have been reported cured. There is indirect evidence from II Kings, Chapt er 7, that the so-called lepers were supervised by men called " Shearim" or watchmen. When the affected individual appeared to be cur ed, he was reported to the sanitary officer who went out to the isolation camp to examine him. Since the leper could not enter the city, it is again reasohable to assume that someone, especially appointed to supervise the camp, r eported the case. If the priest found that the man was cur ed he was removed from the camp to the city after a public religious ceremony bad been performed. The patient had .then to bathe and shave t he entir e body and wash his clothes and was still detained in some public isolation ward for seven days longer to make sure there would be no r ecurrence. On the seventh day he again bathed and shaved his entire body and ashed his clothes, and if he still appeared sound, another public religious ceremony was performed and he wa s sent back t o his family, cured. One form of "tsaraath" seems to have been like a vegetable mould or parasite. Articles of clothing which had come in contact with a so-called leper had to be submitted to the prie t . If found diseased, they were burned forthwith. If doubtful, they were washed and re-examined at the end of the week, when they were eit her burned or pronounced clean. When t he wall of a house were attacked, the parts

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

affected had to be torn down and carried to a refuse heap outside the city. The remainder of the wall wa thoroughly scraped, the craping themselve being carried from the city, and the broken places rebuilt with fresh material . If these means proved insufficient, the whole house was demolish d and the debris removed from the city. Modern science may ha\·e di covered impler met hods of disinfection but certainly nothing more thorough or effective. I olation was also practised for gonorrhea and any other disease which was accompanied by a di charge, apparently f rom any part of the body. So we find in the Mosaic code that: (1) Certain communicable disease with skin manif estations were recognized. (2) Isolation was enjoined for the patient and quarantine for the contacts. (3) The diagnosis and treatment of these conditions by health officer was provided for. (4) The need for terminal disinfection and scrupulous cleanliness wa emphasized. Moses is seldom thought of as a medical man, yet he gave to the Israelites a code of public health regulations which even today are strikingly rational in spite of their great age. The health and longevity of the Jews a a nation, as noticed by many observers, is largely due to their observance of these laws during the past thirty-five hundred years. Modern medicine has many refinements to offer in t he way of diagnosis and treatment but as far as the broad principles of public health are concerned, we cannot go very far away from those laid down by the Hebrew law-giver. BIBLIOGRAPHY • lThe English Bible. 2complete works of Flavius Josephus-Whiston. 3History of Medicine, p. 38-Neuburger. •Evolution of Medicine, p. 28-0sler. GMedical Men in the Time of Christ, p. 14-Wilson. GEncyclopedia Britannica-"Prostitution." ?Biblical Medicine and Hygiene-Murphy, H. H.-C.M.J.A. 22-2-262-Feb., 1930. BRelation of Jews and Judaism to Medicine-Friedenwald-Am. Med. N.S. XII-9-615. OTreatment of Contagious Diseases-Brav.-Am. Med. N.S. XII-9. toMoses as a Sanitarian-Williams-Bost. Med. & Surg. Journal. CVI-1-6-Jan. 1882. UHistoric Faith in the Light of Today-Colgrave and Shortt.

A man who tands firmly on both feet in time of danger, and keeps his mouth hut, will always be sufficiently brave.-Frank J. Mather, Jr.

A thought embodied and embrained m fit word walks the earth a living being.-Whipple.

On the History of Syphilis MARSH

W. POOLE, M.D. Detroit

ยงIR JAMES Y. SIMPSON is best known and remembered for his discovery of chloroform as an anaesthetic. During his lifetime, however, his greatest diversion was found in delving into historical and archaeological subjects with the result that he published many papers in scientific journals and the transactions of different societies. Many of these essays were later edited by Dr. John Stuart, secretary of the Society of Antiquaries of Scotland, in two volumes, under the title of "Archaeological Es ays." Many of these are of considerable interest to a medical reader because of Sir James' leaning toward such subjects, while others, of course, are of interest only t o an antiquarian. The following paragraphs have been to a great extent abstracted from the fascinating paper "Antiquarian Notices of Syphilis in Scotland." The disease syphilis was entirely unknown to the ancient Roman and Greek physicians as there is no reference to it to be found in any of their works. AI o, the physicians who observed the malady, and the authors who described it in the latter part of the fifteenth century and the early part of the sixteenth, refer to it as "morbus ignotus" or "morbus novus," proving that it was entirely unknown to them prior to that time. Columbus arrived at Palos, in Andalu ia, on his return from his first visit to Hispaniola on March 15, 1493, after landing in Lisbon on March 6 to visit the Spani h king at Valparaiso, while his lieutenant Pinzen was driven in at Bayonne; thus there were possibly left two or three separate points of spread of the disea e from the contacts made by their sailors. The cases that appeared did not attract much attention from physicians or the public until their attention became focu sed on it when it appeared as a serious epidemic in the city of Naples, following that city's occupation by the troops of Charles VIII of France from February 22, 1495 until May 20, 1495, on which date the victorious army commenced its homeward march, the last of them reaching France by the end of the following year (1496). Presumably Charles' soldiers pread syphilis among the inhabitants of the regions along their homeward path and carried it to their own homes in France, while his auiliaries carried it to the Swiss, Germans, and Flemings. The extremely rapid rate of spread of this new disease throughout Europe has led many to presume that in the days of its early epidemics it was carried by different methods from the one by which it is now propagated. The early writers and observers themselves entirely overlooked its true nature and considered its spread as being pestil29

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

entia! in type. Swediaur pointed out that it was not until after the year 1500 that anyone appreciated the fact that it was a venereal disease, being spread by coitus a a rule. In this connection it is interesting to note that in Aberdeen, the Town Council on April 24, 1497, issued an edict aiming at preventing the spread of "the infirmity cumm out of Franche and strang partis," that "all Iicht weman be chargit and ordanit to deci t fra thar vice and sy:ne of venerie," the penalty being that of having "ane key of het yrne one thair chekis." The canny aldermen, however, were later mi led by the opmwns of others and fell into the common error in regard to the "seiknes of Nappilis." In October, 1497, the Edinburgh council passed "ane Grangore Act," grandgore or grangore being the name by which syphilis was generally known in its early days in Scotland. In this they refer to it as a contagious siclrnes , the sufferers being segregated and sent to t he island of Inchkeith in the Firth of Forth. They further stipulated that anyone presuming to treat the condition had to go and remain with the patients at Inchkeith to prevent spread of contagion by a third person. The penalty for violation of this rule was banishment and branding on the cheek by the iron. So completely was the true nature of yphilis overlooked that physicians unhesitatingly gave case reports and descriptions of the new disease as they observed it in public officials, priests, nuns, reformers, and even the rulers of the day; for example, in 1500, Peter Pinctor mentions among the more illustrious patients that he had treated the head of the Church. Also, in 1519, Ulric Rutten, one of the strongest supporter of the Reformation, publi hed "De Guiaci Medicina, etc., Morbo Gallica," and in it de cribed his own case, his own sufferings, how he was cured by guiacum after being salivated eleven times, and finally he drew the conclusion that the disease was caused by "some unholsome bla tes of the ayre." The laity and the phy icians overlooked the primary lesion of lues; their attention being caught by the econdary lesions-the skin eruptions, the bone lesions and pains, the ulcers of the throat, the eye (symptoms) and (the) constitutional symptoms. In fact, in 1498, Montagnana advised moderate coition as one of the means of cure for a sick bishop under his care, listing under the points in treatment

"coitus ve1路o sit temperatus." The reigning monarch of Scotland, King James IV, during this period, has left several extremely intere ting contributions due to the fact that he had interests which were quite foreign to his duties as the ruler of the kingdom. We learn that he was something of a dentist, dabbled in physiology, chemi try, as well as medicine. He introduced a rather unique method of obtaining patient which was by paying them to submit to his treatment. His usual compen ation apparently was eighteen shillings, to which fact we owe our knowledge of his

THE HISTORY OF SYPHILIS

activities because of the items which appear in the public accounts where payments were noted as having been made as follows: "Item, to ane fallow because the King pullit furtht his twtht, eighteen shillings." "Item, to Kynard, ye barbour, for tua teith drawin furth of his hed by the King, eighteen shillings." Naturally yphillis soon came under his notice and various expenditures were charged for monies which were given to those suffering from the disease; for example: 22 Februar 1497-8 "Item, the 22nd day of Februar giffin to the eke folk in the g1路angore at the tounn end of Gla go, two shilling ." April 1498 "Item, giffin to the seke folk in Lithgw as the King cum in the tounne, two shillings eight pence." The poets, too, were soon familiar with the "pockis" and made many allu ions to it in their various poems. Probably the earliest and most noted of these was the Scotch poet James Dunbar, who was attached to the court of James IV. The after-effects and the consequences of the disease he described in some verses addressed to his patroness, Margaret, queen of James IV, as follows :

"Sum that war ryatouss as rammis Arnow maid tame lyk ony lammis, And settin doun lyk scarye crockis, A nd hes forsaikin all sic gammis That men calllibbing of the Pockis." "Sum thocht thame selffis stark lyk gyandis, Ar now maid weak lyk willow wandis, With schinnis scharp, and smalllyk rockis, And gottin thair bak in bayth thair handis, For ower oft libbing of the Pockis." and he closed the verses with this earnest advice,

"B e ware with that perrelous play That men call libbing of the Pockis." A later poet, Sir David Lindsey, in speaking of John Mackrery, the king's "fule," refers to him as getting-

"Jn his maist triumphant gloir For his reward get the Grandgoir." Naturally, too, historians have left their contributions and it has been recorded that the laird of Colzean wrote to the laird of Bargany, maliciously suggesting to him that yet he might lose "sum uther joynt of the Glengoir as ye did the brig of your neise." There are, of course, many other passages and excerpts which are more or less similar in nature and it seems somewhat unneces ary to extend them any further at this time as they only throw corroborating evidence of the place that the new disease played in the lives of these rugged old Scots, rich or poor, priest or layman, king or serf.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

MEMBERS OF EXECUTIVE

Hospital Ca1npaign Committee

Chairman

RAY LAWSON, ESQ. Vice-Chairman

GORDON J. INGRAM, ESQ. Vice-Chairman

~bttortal O all medical men in Western Ontario and particularly to those T who have graduated from the University of Western Ontario, the situation at the London Victoria Hospital regarding facilities as a clinical hospital has for some time been apparent. It has been universally conceded among the profes ion, a well as by the University authoritie , that the rebuilding of Victoria Hospital after a period of fifty-six years of active public service is not only desirable but an immediate necessity. The Board of Trustees of Victoria Hospital, after weighing many factors, not the least among which is the fact of business and financial depression at the present time, have nevertheless been compelled at this time to launch a campaign for $1,000,000 to rebuild the hospital. The chief factor in this decision is the fact that, contingent on rebuilding operation being immediately commenced and the whole amount being rai ed, the Provincial Government of Ontario has made a grant of $200,000 towards the building fund; similarly, the London City Council has made an additional grant of $300,000. In complete agreement with the University authorities, the Trustees of the late Dr. Meek e tate have set aside $100,000 towl;).rds the establi hment of a modern laboratory in memory of the late Dr. Meek's son; there has also been set aside for endowment of the laboratory in the new Hospital the sum of $100,000 and it is estimated that the accumulated interest on this amount by the time the laboratory is finished will amount to approximately another $20,000, which will be used for equipment, etc. Finally, the late Colonel Gartshore, in addition to his many munificent gifts toward the Victoria Hospital during his lifetime, left provision in his will for the payment of $50,000 toward the erection of a new Hospital, under certain conditions. It can thus readily be seen that, of the $1,000,000 required, a total of $650,000 is already assured, conditional, as stated above, on an immediate launching of a public campaign to raise the balance and to meet the provisions of the terms of grants. The rebuilding plan involves replacing practically all the existing building , with the exception of the major operl:}.ting department as established by the late Colonel Gartshore. It is the intention to build the new Hospital to the plan shape of the letter H. The buildings will be demoli hed as units and rebuilding will immediately replace the demolished unit prior to proceeding with work on the second unit of the same building, thus until the present buildings now comprising Victoria Hospital have been replaced. Then such additions as are included in the specifications and plans to provide further accommodation will be proceeded with according to schedule. At no time during the building operations will the services be interfered with to any great extent, certainly not in any measure to render them incomplete or inadequate. As the rebuilding of Victoria Hospital means that all groups in the Cit y of London and vicinity are to be asked to financially support the building program which will take practically five years to complete, 33

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

and in keeping with the fact that the new Hospital will in every sen e of the term be reorganized a a community hospital, the Trustees of the new Board propose to have the charter amended to provide for the enlarging of the present Board from five to fourteen members and to immediately identify the new Hospital as the City's own Hospital, it is proposed to have the name changed to "London General Hospital." As the War Memorial Children's Hospital is a separate unit, it is also proposed to apply for a separate charter for thi institution and, in serving the interests of all counties in Western Ontario, it will then be in a position to make a broader appeal for financial aid from these sources. As already mentioned above, it is estimated that the Hospital will take five years to rebuild and, in appealing to the public for contributions towards the building fund, a special concession has been made in t hat the contributors may spread their payments over a five-year period and, if desired, can make their first payment one year from the date of the campaign, which will be conducted in this City during the week December 7th to 14th. This appeal is not limited to the citizens of London but should have a peculiar significance to communit ies outside the City. From a review of past figures of Victoria Hospital, it i at once apparent that over 25 % of the total number of patients have been from the adjacent counties in Western Ontario, particularly from the County of Middlesex. The new Hospital will continue to erve this enlarged community and its services will be available to all, irrespective of wealth, race or creed. There can be little doubt that such an appeal will meet with most heartY and spontaneous response from the well wishers of Victoria Hospital; with such a nucleus available, it would appear apparent to all thinking men that, merely from a business standpoint, leaving out the urgent humanitarian considerations, the move to launch this project has not been ill-timed but has been due to force of circumstances, leaving the Board of Trustees no other alternative. It now remains to be een how quickly the total objective can be arrived at and if every individual well wisher will put his or her total energies behind this campaign, the balance of the $1,000,000 will be raised in record time. The individual contributor should not lose sight of the fact that the new London General Hospital will be owned and controlled by those who help to build it. ITH this issue of the University of Western Ontario Medical W Journal another volume has been tarted and one year has been added to the life of the Journal. We are one year old and, we trust, a year wiser. At any rate, what we want to impress upon you is this, that this is a good time for the renewal of your subscription. The clerical .work required for making out statements and reminders of subscription that have run out is con iderable. The subscription manager is enclosing with this i sue a pink slip which, filled out and the sum of one dollar attached, will insure you receiving the complete volume, which is quite important if you preserve the files of the Journal. The business office will appreciate it if you will send in your check for another year's subscription; or, while you are about it, better make that check for $5.00, which will bring you the Journal for five years. Will you sit down and make out that check? Thank you. Now, don't forget to mail it at once.

' .

The University of Western Ontario VOL. II

MEDICAL JOURNAL

No.2

â&#x20AC;˘ Anatomical Considerations 1n Exophthalmos H . ALAN SKINNER, M. B.

Associate Professor of Anatomy Unive1Âˇsity of Western Ontario Medical School ARIOUS explanations have been offered at different times to account for the occurrence of exophthalmos in such conditions as Basedow's or Graves' disease. None of the theories have been universally acceptable although there is more or less truth in all of them. The more likely explanations eem to be those which have some foundation in anatomical fact and it therefore may be of interest to review the anatomical consideration involved in this question. Among the explanations which have been advanced are the following: contraction of the orbital mu cle (Muller's muscle) ; increase in retro-orbital fat; venous congestion behind the eye; orbital oedema; relaxation and elongation of the orbital muscles; dilatation of the orbital blood ves els. The exophthalmos in Graves' disease is said to disappear after death, and examination of cases in which the exophthalmos had been prominent in life has so far revealed no post-mortem findings which would account for the condition. One of the frequent explanations offered is that it is caused by Muller's muscle. To the average doctor Muller's muscle is something he has never seen, t herefore he is apt to believe in its powrs. A clear understanding of the actual anatomy may be of assistance in arriving at a proper conception of the situation. In a great many animals the orbital wall is not a complete bony wall, particularly externally. In such animals as the dog, rabbit or pig the external wall is deficient, and its place is taken by a muscular sheet which serves to separate the orbital fossa from the temporal fossa. This mu cular sheet is continuou with and part of the periorbital fascia. In man a portion of this mu cle persists in the region of the inferior orbital tis ure where muscle fibres are found bridging the bony gap. These fibres are the remains of the orbitalis muscle of the lower animals and in man this muscle was described by Muller and is known as the orbitalis or Muller's mu cle.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

The e muscle fibres are smooth muscle and innervated by the sympathetic. Toxic conditions in the thyroid gland are presumed to cau e a reflex irritation through the cervical portion of the ympathetic. Contraction of Miiller's mu cle wa then suppo ed to tighten the periorbital fa cia, causing protrusion of the eye. A second set of smooth muscle fibres wa described by Miiller and this has aided in increasing the confu ion regarding Muller's muscle. Two lamellae of smooth muscle fibres are noted in connection with the levator palpebrae superioris muscle. These mooth mu cle fibres are attached to the kin of the lid and to the fornix of the conjunctiva under the lid. Their function is to wrinkle the skin and fold it away as the eyelid is raised, and, in the ca e of the conjunctiva fibres, to prevent the conjunctiva from wrinkling by keeping it continuously taut. These mooth muscle fibres, which are innervated by the sympathetic, were de cribed by Muller, and are accepted by many people in error as being :rt'l iiller's muscle. These fibres do, however, play a part in Graves' disease. Toxic stimulation from the thyroid causes sympathetic irritation. This is effected in the upper lid by a slight retraction so that the white shows above the iris. This retraction is caused by the abnormal pull of the smooth muscle components of the levator under the toxic stimulation. Clinically this fact is made u e of in von Graefe's sign. This is a jerky lowering of the upper lid when the patient is a ked to follow an object downward with the eyes. This is of cour e due to the abnormal tone of the smooth mu cle fibres which do not let the lid down smoothly. The retraction of the upper lid produced by these smooth muscle fibres undoubtedly increa es the effect of exophtholmos by contributing t o the staring appearance by increa ing the amount of eye white exposed. Apart from this fact, however, these fibres play no part in the production of exophthalmos. Turning next to a consideration of the ascular theories there is little practical evidence to upport them. Venous congestion in the orbit itself is difficult on account of the free communication of the veins with out ide vessels. It does occur in case of cavernous sinus thrombosis where the normal outlet into the cranium is completely blocked. In such ca e the collateral circulation is sometimes insufficient to drain the orbit and exophthalmos then occurs as a result. Hesser (1913) considered it impossible for the exophthalmos in goitre to be explained on the basis of venous congestion. In attempting to explain a condition such as exophthalmos care should always be taken to determine as clo ely a possible the conditions which exist normally. In this instance it eem important to determine what factors are normally concerned with maintaining the position of the eyeball. The four rectus muscles which pa s forward from a po terior in ertion around the optic foramen all tend to pull the eye back into the

ANATOMICAL CONSIDERATIONS IN EXOPHTHALMOS

orbit. Thi backward pull mu t be neutralized by some forward pull, and it is generally accepted that this is accomplished by the superior and inferior oblique muscle which antagonize retraction by the recti. In addition the po ition of the eye i partly maintained by a fascial sling which stretche across the orbital cavity from side to side. Some muscle fibres have been described in connection with this fascial sling. The e are pre umably mooth muscle fibres. The inferior oblique muscle is al o involved in this arrangement and probably plays some part in taking up slack in this sling. The possibility that a portion of the inferior oblique muscle is formed of smooth mu cle fibres should not be overlooked. If this were so then the action of the inferior oblique may be partly an involuntary function in maintaining the forward position of the eye. If the sympathetic nervous system is involved in the matter then irritation of the cervical sympathetic might disturb the _muscle balance in favour of the forward pull and cause a forward displacement of the eyeball. Whatever the explanation of the exophthalmos in goitre may be, it eems likely that the sympathetic nervous mechanism is involved in it. Muller' mu cle, situated in the inferior orbital fi sure, cannot account for the extreme protrusion so frequently observed. Some other muscular arrangement must be at fault. It seem likely that the derangement is an accentuation of some norm I muscular function which is concerned with the maintenance of the po ition of the eyeball in the orbit. From this standpoint the inferior oblique seem most favourably situated to produce the effect.

SHOULD COD LIVER OIL BE FLAVORED? It i a well-known fact that young infant shy at aromatics. Older patients often tire of flavored medication to the point where the flavoring itself becomes repellant. Thi is particularly true if the flavoring i of a volatile nature or "repeats" hours after being ingested. Physicians have frequently u ed the term "fresh," "natural," " weet,'' and "nutlike" in commenting upon the fine fia or of Mead' Standardized Cod Liver Oil. They find that most patients prefer an unflavored oil when it i as pure a Mead's. Physicians who look with disfavor upon self-medication by laymen are intere ted to know that Mead's is one Standardized Cod Liver Oil that is not adverti ed to the public and that carries no do age directions on carton, bottle or circular. 'lead Johnson & Company, Belleville, Ont., Can., Pioneers in Vitamin R search, will be glad to send samples and literature to physicians only.

Duodenal Ulcers Which Have Healed by Removal of a Chronic Appendix DR. W. A. ELGIE

Chatham, Ontario HAVE in the pa t two years removed a chronic appendix in three cases with the sole object, in each ca e, of attempting to heal an accompanying duodenal ulcer. The diagnosis wa made in each case from typical duodenal ulcer symptoms which were confirmed by x-ray examination. They were again confirmed at operation. The duration of the ulcers varied from five to almo t fifty year . None of the ca es gave a history of having had acute appendicitis, nor were they aware of any appendiceal involvement except a little tenderness on manipulation in the lower right iliac fossa. Each one had tried varied types of diet and medical therapy with un atisfactory results. The symptoms always returned. Two were able to carry on with their usual occupation but the third had been unable to do any work for the past year. I advised the removal of the chronic appendix after aU other foci of infection which were demonstrable had been eliminated. To this they consented and the operation was performed. In each ca e ulcer symptoms disappeared. They have gained weight, and have been able to eat a full and varied diet. Each feels he is cured. The first has remained well for two years, the second a year and a half, and the third has been well for nine months. The following ca e hi tories will gi' e more complete details.

No. 1 W., male, aged 64, manufacturer. He had complained of indigestion as long as he could remember (probably fifty years). For the past twenty-five years he has had typical duodenal ulcer symptoms, including two hemorrhages. His earlier symptom were seasonal, relief during the summer and winter months, only to on et during the spring and fall. For the past three year they had been continuous, and hi general health was failing. He has lost seventeen pounds in weight. The x-ray showed a large . crater ulcer of the duodenum with a great deal of deformity suggestive of con iderable car tis ue. The appendix was not visualized but was slightly tender on manipulation around the caecum. I advised appendectomy with no tomach surgery. At operation, a right rectu incision was made long enough to view the duodenum, which showed a large rna s of malignant looking tissue with a few adhe ions to the gall bladder and posterior side of the diaphragm which were left undisturbed. The appendix was very short, about one inch long, had no appendiceal omentum, and was almost of a grizzly hardness, sugge tive of repeated attacks of appendicitis. This CASE HISTORY

DUODE NAL ULCERS WHICH HAVE HEALED

was removed very close to the caecum in order to get enough normal tissue to tie it. The convalescence was very stormy, the touching of the appendix seeming to liberate a very deluge of infection. The temperature ran up to 105 and the pulse to 120, staying there for seven days. The duodenal ulcer symptoms were very much aggravated. The patient each day had a small duodenal hemorrhage, which recurred daily for five days following the operation. On the second day he developed an ilius which lasted for five days, after which peristaltic action was re tored and the bowels started passing very offensive green liquid stools mixed with pus. This la ted for seven days, but the temperature and pulse fell to normal two days after the ilius passed. From then his convale cence was very rapid and he left the hospital in fourteen days. He was put on a full diet a soon as feasible after the operation, and has continued eating anything, including pickles. This operation was performed two years ago, and the patient now weighs ten pound more than at any time previously. He states he feels better now than he has for the past fifty years. CASE HISTORY

N0 . 2

S., male, age 24, farmer. He had duodenal ulcer symptoms at 19 years of age. At first they were seasonal, relief in the spring and fall months, and return of ymptom in the summer and winter months until two year ago when they became continuous. He tried all medical and diet therapy con cientiously, but his relief was transient and he never felt well, although able to carry on his usual occupation. A gastro-intestinal x-ray examination showed a very small penetrating ulcer on the superior border of the duodenal cap. The appendix was long, constricted in its middle and having a bulbous end, and was lying parallel to and adherent to the terminal ilium. The remainder of the tract showed no pathology. At operation, a right rectu incision wa made long enough to view the duodenum, and the ulcer was demonstrated without any surrounding complications. The appendix about six inche long, tightly adherent to the terminal ilium, had a particularly tight band at its middle, segmenting it into two halves, with a large fecolith in the tip end. The appendix was dissected free to its base and tied with No. 2 twenty day chromic cat-gut, and no purse string suture wa used. The abdomen was closed in the u ual manner. The patient' !:Onvalescence was entirely uneventful except that his temperature remained about 100 for five days, after which it subsided to normal. He went home on the tenth day. The ulcer symptom were not aggravated in this case. He was put on a full diet as soon as feasible after the operation and he has been eating anything for the pa t one and one-half years. His weight has increased over fifteen pounds, and there are no further ulcer symptoms.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL CASE HISTORY

No.3

D., male, aged 36, farmer. He give a history of indigestion for five years, followed by ten years of typical duodenal ulcer symptoms. A gastro-intestinal x-ray examination showed a large crater ulcer of the duodenum. The appendix, about five inches long, was curled around the base of the caecum to the lateral side. At operation, a right rectus incision was made long enough to view the duodenum, which howed a moderately large ulcer, but no surrounding pathology. The caecum with the appendix curled around it were adherent by bands of adhesions to the iliac fossa. The appendix had three fecoliths, one at the tip, one at its middle, and one near the base. It was dissected out and tied close to the caecum with chromic cat-gut, a fine plain cat-gut being used for a purse string suture. The abdomen was closed in the usual manner. His convalescence was quite stormy, the temperature rising to 101 and the pulse to 110 and remaining there for five days. During this time he was quite delirious and remembers nothing about it, so I was unable to determine if the ulcer symptoms were aggravated or not. At the end of five days his delirium subsided, temperature and pulse became normal, and he was put on a full diet. It is now nine months since the operation. He has had no further ulcer symptoms, is able to eat anything, and has gained twenty-seven pounds in weight. Our ideas are only intellectual instruments which help us to penetrate phenomena. We should drop them when they have served their turn, even as one scraps a history grown rusty from long usage. - Claude Bernard. There is a short rule for obtaining the confidence of your community-deserve it.-Oliver Wendell Ho lmes. In analyzing history, be not too profound, for often the causes are quite superficial.-Eme?路son. Wisdom provides things necessary, not SUJ?erfiuous. -Solon. Forget the hours of distress, but never forget what they taught thee.-Gessuer. He who is wedded to tradition has turned his mind against progress.-A. B. Jamison. The work of science is to substitute facts for appearances, and demonstrations for impressions.-Ruskin.

The Psychiatry of the Greeks and Romans •

MURRAY

L. BARR, B.A., '33

fundamental principles upon hlCh modern Psychiatry rests T HE were e tablished over two thou:::and years ago by the physicianphilosophers of Greece. Their clinical descriptions of many types of mental di ease were acurate and complete. Progress which has been made since then has been due to two fac.or : first, the application of the microscope to the study of organic disea e of the brain and, second, the establishment of the psychoanalytical school and the application of psychologcial principle to the study of the psychoses. There follows a running commentary on some facts related to psychiatry in the Grecian era which have been gleaned from the literature. The records them ·elves are fragmentary, '·hich renders their presentation in a connected manner difficult to an inexperienced hi torian. The early Greek thinkers had no records to fall back upon. They ·ere, in truth, original ~·orkers. Until their time it was believed that upernatural agencies, over \Vhich man had no control, were respon ible for all types of mental disea e. Epilepsy, for example, was called the Morbus Sacer, or Sacred Disease, becau e of its supposed divine origin. It was Pythagoras of Samos (582-50..., B.C.) who first dispelled the darkness of the hollow mysteries of the temple by the light of rational thought. He was closely followed by Hippocrates, the Father of Medicine (460-377 B.C.) who, in the ollowing word , prote ted the divine origin of epilepsy : "It i · thus with the disease called Sacred : it appears to me to be nowise more di ine nor more sacred than other di eases, but has a natural cause from which it originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it i not at all like to other di ea es ... " (E.1: ·act from a paper pre ented to the 0 ler Society of London at their January meeting.) Hippocrate recognized the brain as the organ in which mental proces es took place and laid down the principle that mental disea es were due to changes occurring in that organ. The term "melancholia" is a surviving witness of his humoral theory of pathology which he applied to mental a well as other diseases. Melancholia means "black bile." and Hippocrates belie,·ed that the subject of melancholia suffered from an exces of his fluid which rendered the brain too cold. In this enlightened age a close bond existed between medicine and philosophy. As a consequence, p ychotherapy played a prominent part in the treatment of the in ane. EYen the more highly educated of the laymen of today regard the "lunatic" as an Irresponsible cr ature to be isolated from society, sup ied with the b re neces ities of life and 41

UNIVERSITY OF WE TERN ONTARIO MEDICAL JOURNAL

restrained by physical force, if neces ary. The Greek philosopherphysicians regarded all mental patient a being acce ible, to a greater o~ lesser degree, to reason, and took a sympathetic interest in their personal welfare. Their sympathie , it eems, carried them at times to extremes, for love was advocated by many Greek writers a a valuable therapeutic agent. Aretaeu recorded the case of a certain per on who, supposedly the victim of an incurable mental di ease, succumbed to the great biological urge "and when the physicians could bring him no relief, love cured him." Soranu , renowned for his wisdom, wrote in protest, "It has been recommended to render in ane per on acces ible to love; but this passion is often enough the cau e of their malady ... It is absurd to think that love, which is one fury, can drive out another." The therapeutics of Plato, who was a contemporary of Hippocrates, were representative of thi period. He regarded drug as the last weapon in the physician's armamentarium to be u ed in the fight against di ea e. With the rise of Roman ci ilization, Greek culture was transplanted to the new medium which proved to be too rich and artificial to encourage a healthy growth. Neverthele s, in the writings of Horace, Lucretius, Cicero, Pliny and Cel us something may be learned of the state of psychiatry at that time. Horace, as might be expected, touched upon the ubj ect of in anity with satyrical humor. There wa once a Qvaker who addre ed his spouse in this manner: "All the world i queer, ave me and thee, and sometimes methinks thee a little queer." Horace assumed a imilar attitude and classified hi friend according to their types of fooli hness. In his writings there occur a phrase "go to Anticyra" which has the same significance as the catch phra e "go to Bedlam" which wa current some years ago in England. In the time of Horace, hellebore was the favorite drug in the treatment of insanity and the plant from which it was derived grew in abundance on the i land of Anticyra. The island became a type of open-air sanatorium to which patients were taken to be dosed on the spot. Horace commented that ince the covetous man wa both fool and a madman, it was a marvel that the i land was not overrun with such fellows. Since Horace, as a man of letter , wa little intere ted in the scientific a pects of insanity, recourse mu t be had to other writers for an acount of the state of p ychiatry a a cience when Rome wa in the ascendant. The records left by Pliny and Cel us are mo t fruitful, tho e of Lucretius and Cicero les so. From the e sources we learn that three men stand out above their colleagues in the treatment of mental di ea es in the fir t century, B.C. The e men were Asclepiade , a contemporary of Caesar and Cicero, Themi on, his disciple , and Cel u , who lived to practice in the Christian era. A clepiades, according to Pliny, wa born in A ia Minor about 120 B.C. He studied medicine and philo ophy in Greece, where he came under the influence of Epicurus. The teachings of Epicurus are apparent

THE PSYCHIATRY OF THE GREEKS AND ROMANS

in the faith which Asclepiade placed in open air and plea ant relaxation as a means of promoting health. A clepiades arrived in Rome at the age of twenty-four and soon became widely known as the result of a fortunate incident. While out walking one day he met a funeral proce sion. To the trained eye of the physician, the supposed corpse showed certain signs which indicated that a prematurial burial was about to take place, so Asclepiades stopped the proces ion, ordered that the "corp e" be returned to "it " home, and in tituted treatment. An uneventful recovery took place, the individual having been in a tate of coma. Pliny did not sympathize with this legitimate adverti ing and accused Asclepiades of playing to the gallery. Asclepiade was an ardent advocate of phy iotherapeutic methods in the treatment of in anity and endeavored to produce sleep in disturbed cases by the use of massage. He made use of drugs only as a last re ort and cautioned again t using too large do es of poppy or henbane "le t it be not in our power afterwards to wake the person whom we desire to sleep." Asclepiades wa the first to attempt a classification of mental di ea es ba ed upon the pre ence of hallucination and illu ions on the one hand, and delu ion on the other. This active and productive worker, who has been called the Father of Psychiatry, was killed by a fall at the age of 90, thus winning a wager with a friend that he would die a natural death. Themison need only be mentioned in this brief review. None of hi writings have been preserved but it may be inferred from the records of his contemporaries that he closely followed his teacher, Asclepiades, in the u e of physiotherapeutic method . In addition, he bled hi patient so freely that he ha been called "Themison the Phlebotomist." Aurelius Cornelius Celsus was born in Rome and wrote a most important series of eigh book , in the third of which wa a chapter entitled "A Treatise on Madnes : Of Several Kinds of Madness and their Causes." This work may be regarded as an epitome of all that was known on the subject of insanity at the time of Celsu , and is the most important ingle treati e on the subject of insanity which has been pre erved from the ancient writers. His treatment wa decidedly enlightened, consisting of a dietary regime, physiotherapeutic application , and mental diver ion. In his own summary he set forth the following rule : "Mad people ought to be trongly exercised, to have much friction or rna age, to eat neither fat, fie h nor wine, to eat lightly after purging ... they hould neither be left alone nor among trangers ... they ought to travel in other countries, and if their judgment returns, take a journey into distant part once a year." Galen, born in Pergamo in 131 A.D., was the la t of the great路 medical men in this Golden Age of human history. This worker was the chief agent for the transmi ion into modern times of the medical knowledge of the ancient . His vivisection experiments upon animals

UNIVERSITY OF WESTERN O NTARIO MEDICAL J OURNAL

opened up an entirely new field in the tudy of disea es of the mind. Hi out tanding contribution to p ychiatry wa the differentiation between mental abnormalitie secondary to omatic di ea es, and those due to primary brain disturbances. Had he taken but a ingle tep farther forward he would have freed him elf from the prevailing errors and establi hed a rational p ychopathology. But even Galen dared not throw into the discard the humoral theory of Hippocrates. With the death of Galen the fire of scientific enthusiasm wa all but extingui hed. A few coal , yet alive, were pre erved by the Arabs and in the monasterie of Europe, to be fanned into flame many many centuries later with the scientific renais ance. Any knowledge of the insanities which has since been acquired over and above that po e sed by the phy icians of Greece and Rome ha come from the research laboratories of psychology, biochemi try and histology. Devoted scientists, working in these fields, and men with the ability to correlate and generalize will finally achieve the complete solution of psychiatric problems.

In the J.A.M.A. of January 30, 1932, there i an interesting case report of a traumatic le ion of the abdomen. On April 11, 1930, a youth aged 18 had a piece of timber dri en through his abdomen, from side to side, in an automobile accident. He was unable to sit down but was surpri ingly free from pain. Omentum, inte tine and hemorrhage, were evident at both the entrance and exit of the timber. At operation two feet of inte tine were removed and the patient reacted well. On April 20 evere pain , chill , and high fever occurred. Swelling and tenderness were marked over the parotid. On the 25th, the gland was opened and drained, exuding thick pu . The next day there was abdominal pain, nau ea and vomiting. On the 27th there was a severe hemorrhage from the neck, and transfu ion were given. On the 28th, fecal vomiting developed and an entero ;tomy was done. The econd hemorrhage from the neck occurred on April 30. No radial pul e was felt. A transfusion succeeded in reviving the patient. Within a week a third hemorrhage occurred which could not be arre ted. A a last re ort the external carotid was ligated. Thirteen transfusions and gallon of aline infusion were given. Thi proved effective and he is now free from all aches and pains, and has but a few scars to tell the tale. Put off your imagination a you take off your overcoat, when you enter the laboratory; but put it on again, as you put on your overcoat, when you leave the laboratory.-Claude Bernard.

Custom i often only the antiquity of error.-Cyprian.

Congenital Atelectasis S. L. V ALERIOTE, '33 case of atelecta is is reported because of (1) the T HErarityfollowing of the condition, (2) the high mortality, (3) the inadequate treatment. CASE REPORT

Baby K. was admitted to the nur ery from the labor room of St. Jo eph' Ho pital, Guelph, on July 26, 1931. A few hours following delivery, the breathing of the babe was noticed to be irregular, rapid, and shallow, with intermittent cyano i . On examination no movement of the right che t was ob erved, and the apex beat was not palpable. There was dullne s in the right lower chest and normal cardiac dullness was absent. The breath sounds were absent in the right lower chest and the apex beat was heard about two inches to the right of the sternum at about the fourth interspace. The radiologist reported that "the flat antero-posterior film of chest shows marked displacement of the mediastinum to the right, giving a typical picture of pulmonary atelecta is." (Fig. 1.) Four days later, the x-ray plate showed a somewhat greater displacement of the media tinum. Immediately after birth, the nose and throat were cleared of any vaginal discharge. The child failed to give a lusty cry and inspirations were produced artificially. With the on et of the intermittent cyanosi , oxygen inhalations were started, but were of little u e. The child lived for three weeks. DIFFERENTIAL DIAGNOSIS

1. Congenital Enlargement of Thymus Gland.-In this condition the delivery of the baby usually is not difficult. The breathing is abnormal from the tart, and the skin, lips and nail are cyanotic. In piratory stridor is distinctly audible. X-ray plates of chest show an enlarged thymus. 2. Cerebral Hemorrhage.-The delivery in this case is usually difficult. The babe is restless and may have evident sen ory and motor disturbances. The fontanelles may bulge. Cyanosis is present from birth and is continuous. Lumbar puncture usually confirms the diagno is. The cerebrospinal fluid may be red or yellow, due to hemolysis of red blood cells. 3. Congenital Heart Disease.-The delivery i not necessarily difficult in the e cases. There may or may not be a heart murmur. Cyano i is constantly present from birth, and is increased by crying. The heart is nearly alway enlarged, particularly to the right. 4. Infection.-The most probable infection i pneumonia. In this ca e the temperature is usually elevated and the babe is toxic. There 45

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

is bronchial breathing and impaired re onance, with persistent cyanosis. X-ray plates of chest help con iderably in the diagno i . The enlarged thymus will be hown clearly if it is present. The displacement of the media tinum al o will be hown clearly, and this condition is important in atelectasis. The temperature was normal in the above ca e, hence infection would be contraindicated.

Fig. I.-Marked di placement of media tinum to right giving typical picture of atelecta i .

POST-MORTEM

On post-mortem examination, the x-ray finding were verified and the extent of the atelecta i wa found to be greater than previou ly supposed. The three lobes of t he right lung were completely collapsed

CONGENITAL ATELECTASIS

and were liver-like to the touch. The left bronchus was twisted on it elf. The lower left lobe was found in the left apex and was also collap ed. The upper left lobe was found in the left lower chest and wa emphysematous and covered with blebs. The radiologist injected the bronchial tree with a weak solution of barium and reported that there wa no oclusion or gro s abnormality of the bronchi and the bronchial tree. The heart and thymus appeared normal. (Fig. 2.)

â&#x20AC;˘

EFT Fig. II.-Injection of bronchial tree with barium. No occlusion or grosa abnormality of bronchial tree.

DISCUSSION

Phy iology.-The respiratory movements immediately after birth produce important changes in the lung , both anatomical and physiological. The alveoli dilate and the lung expands little by little. This increa e in size is not accompli hed as in a balloon; the lung "opens" like a lady's fan, according to Sir Arthur Kieth.' It has been shown by Henderson 2 that inflation i a low procedure and that large atelec. tatic areas persist in the lungs for everal days or even weeks. If the atelecta i i extensive or persi tent, death will follow because of the

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

a phyxia, unless adequate means are employed to remedy the cause. Etiology.--According to Hess, 3 the causes of congenital atelectasis may be inherent or extraneous. (a) Inherent Cau es: 1. Lack of development of the central nervous system especially the re piratory centre. 2. Congenital malformation of heart or re piratory tract. 3. Disea es of air pa ages. 4. Injuries to skull, or cerebral hemorrhage. 5. Enlarged thymu . (b) Extraneous Causes: 1. The aspiration of vomitus or vaginal ecretion. 2. The occurrence of general or local infection. TREATMENT However simple or difficult the diagno is may be, the treatment appears to be one of the greatest problems in atelectasis. In the routine treatment, the nose and throat are cleared, deep inspirations are stimulated by hot and cold baths, gentle inflation is tried by means of a soft rubber catheter, and oxygen inhalations and emetics are u ed. Modern methods of treating atelectasis may have beneficial effects, and should be tried because of the high mortality in spite of any treatment. According to Coryla ,â&#x20AC;˘ oxygen-carbon dioxide mixture may be of value if the gases are used in the proper proportions. Pneumotherax was another method suggested in the above case; the beneficial effects would result from the correction of the di placement of the heart, with the possibility of the kink in the bronchus being removed, or of a plug being expelled from the bronchi. SUMMARY 1. A case of atelectasis is reported because of the rarity of the condition and because of the high mortality due to inadequate method of treatment. 2. The differential diagnosis is usually easy with the invaluable aid of the x-ray. 3. The encouragement of modern and more radical forms of treatment may reduce the high mortality rate. I wish to thank Dr. A. E. Broome, Radiologist, of Guelph, for his valuable assistance and also Dr. R. Cramer and Dr. L. M. Stuart for their permission to report this case. BIBLIOGRAPHY tK.ieth, A.-Further Advances in Physiology. Henderson, Y.-Physiology of Atelectasis (J.A.M.A.; 93:96, July 13, 1929). 3 Hess-Premature and Congenitally Diseased Infants (1922). 4 Corylass, P. N.-Atelectasis, Asphyxia and Resuscitation in Newborn (Am. J. Obs. Gyn.; 21:512, April, 1931). 2

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Obesity and Weight Reduction R. GRANT JANES, '26 Marquette, Michigan

in recent years, has decreed that women should maintain F ASffiON, slender figures. So important does this seem to the female sex, t hat dieting has become an almost universal procedure. We should therefore prescribe a diet which will be suitable for reducing purposes, but not harmful to the individual. Various firms, usually opportunists taking advantage of the "fashion of the hour", have advertised numerous preparations. Many of these supercede normal glandular function with deleterious effects; others at many times the cost give results similar to those obtained by using Epsom salts. Many women and girls resort to ridiculous measures of their own, such as intermittent fa sting, or by selecting certain foods and abstaining from others without any logical rea on. Again, there is the eighteen-day diet, given much newspaper publicity, which is deficient in many ways. CAUSES OF OBESITY

What cau es obesity? Many theories have been suggested, such as endocrine disfunction, hereditary background, changes in body metabolism, decreased energy output, and over-indulgence in food. According to Newburgh, there is only one basic cause of obesity and that is over-eating, in other words, the last two causes enumerated above. To use his phraseology, "the a vailable energy of the diet exceeds the transformation of energy on the part of the individual." Many fat people are emotionally unstable and eat to allay their nervousness. Despite statements of obese patients to the contrary, close check on their caloric intake invariably discloses excessive consumption of food. We know that decreased thyroid function approaching the lower limit of normal is conducive to a gain in weight. We have evidence, too, that dysfunction of the pituitary gland, particularly the anterior lobe, may result in a gain of weight. It is thought that the hypothalamus has centres for fat metabolism; ca es of obesity following encephalitis are reported to support this theory. In obesity we find that if the B. M. R. is calculated on the basis of ideal rather than actual weight, it is us ually much above normal. Following a period of reduction, we find that the B. M. R. has dropped considerably as in all cases of starvation. HARMFUL EFFECTS OF OBESITY

Excess body fat seems to be a factor in the causation of cardiova cular-renal disease, hyperten ion, diabetes and gall-stones; certain 49

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

minor ailment are at time due to obesity, namely eczema, varico ities, exce sive perspiration and fatigue. We recognize it adverse effect upon longevity. Fat people are poorer urgical ri k and are prone to develop po t-operative hernia and pneumonia. Migraine, sterility, and amenorrhoea may in some case accompany obesity. Foster tated that :fifty per cent of patients with hypertension are obese. Forty to sixty per cent of all obe e per on have abnormal tolerance to glucose. Alterations in the amount of fie h occur naturally at puberty, t he menopause, menses, and pregnancy. SAFEGUARDS IN REDUCING

How, then, is reduction afely accomplished? Numerous method are used by different physicians, but all must adhere to fundamental rules. First, the body must be kept in nitrogen equilibrium. The nitrogen output is approximately 0.16 grams per kilogram of ideal weight. The creatinine coefficient of Folin is used by some a an index to muscle mas con umption. Thi nitrogen output may be covered by the ingestion of one gram of food protein per kilogram of ideal weight. Should the diet consist only of protein and its inseparable fat content, some of the protein 路will be diverted to carbohydrate for its antiketogenic property. Therefore some carbohydrate must be given, not to avoid acido~ i s, but to act as a protein sparing food, and indirectly to prevent nitrogen los . The amount of carbohydrate adequate for thi purpo e equals 0.6 grams for every gram protein. A diet may be planned on this basis, giving 1.0 gram protein per kilogram of body weight, plus 0.6 grams carbohydrate per gram of protein. To make the meal more palatable some fat may be added. The caloric deficit in the diet is made up by burning the excess body fat. One can estimate by the loss of weight, the amount of body fat consumed. Compare this with the amount of carbohydrate taken and the ketogenic-antiketogenic ratio can be calculated. Should acido is develop, the carbohydrate content of diet wo ld have to be raised. However, experience has shown that the ratio may go as high as three or four to one, and only a transitory acidosis, at the mo t, develops. Therefore, we may practically rule out fear of acidosis in weight reduction. However, if a ratio of 1.5 to 1 is approximated, so much the better. Protein supplies a high specific dynamic action, increase resistance to di ea e, prevent mu cle wasting. Since the oxidation of one hundred grams of fat produces one hundred and seven cubic centimetres of water, this fact must be taken into consideration. Sometimes a patient reducing teadily will cease to lose for a time. This may be due to water retention with tendency to alkalo is, but will soon be followed by a diw路e i and udden drop in weight. Aside from the safeguards above mentioned, the diet must be so planned a to include adequate amount of the various vitamins, and alts a iron, calcium, pho pborous. If necessary, Tyrode's solution

OBESITY AND WEIGHT REDUCTION

made without dextro e may be u ed to supply deficiency of salts. Vio terol may be added if required for calcium metabolism. Some form of useful labor or exercise enables the individual to burn up the excess fat. Thyroid tablets hould not be administered except where the B. M. R. sinks appreciably below normal, and should be withdrawn immediately that the rate reaches normal or lightly above. METHODS OF REDUCING

C. J. Barborka of the Mayo Clinic uses the following method in dietary restriction. Allow twenty to thirty calories for each kilogram of expected weight. Allow one gram protein for each kilogram of expected weight. Apportion the carbohydrate and fat so that the ketogenic over antiketogenic ratio approximates a 1.5 to 1. Then having established the carbohydrate, protein, and fat ratio for the expected weight, leave the carbohydrate and protein as calculated and reduce the fat to such an amount that the total intake will be from seven hundred and fifty to nine hundred calories. Another more simple and practical, but les accurate, method is to explain to the patient that he or she must eat about two and a quarter ounces protein daily in the form of meat, fish, sea foods, or the equivalent in egg, milk or vegetable protein. Thi will include the inseparable fat. Make up the remainder of the diet with fat and carbohydrate food, watching the weight so that reduction produces at a rate of about two pounds per week. Instruct the patient to include such articles in the diet as will supply the proper vitamin and mineral requirements. There eem to be little difficulty in controlling the amount of fat, the carbohydrates seeming to be eaten more in exce s. Fats eem ea ily curtailed. Test urine occasionally for ketone bodie . The rate of reduction may be varied, two pounds per week being adequate, but as much as five to eight pounds in odd weeks in very obe e people may be lost without harm. If perseverance is maintained, that longed-for sylphlike figure may be obtained. The feeling of hunger soon di appears and new and better habits in eating are learned, which add years to the ends of their lives. If hunger is troublesome, more of the low caloritic value vegetables may be substituted to fill the stomach, a hunger pains eem to be due to its being incompletely filled. There is evidence, too, that the feeling of satiation may be due to the attainment of the optimum rate of change of food calories through optimal amounts of food. BENEFICIAL EFFECTS OF REDUCTION

According to Evans and Shang, many benefits may be accredited to the lo s of excess fat, as loss of dyspnoea, increased vigor and sense of well being, relief of headaches and minor skin ailment , and depression of elevated blood pressure. Tuberculosis is a contraindication to reduction, but not nece sarily myocardial weakne s.

UNIVERSITY OF WESTERN ONTARIO MEDICAL J OURNAL SUMMARY

1. Cau es and ill effect of obesity have been given. 2. Questionable method have been cited. 3. Procedures for reduction have been outlined. 4. Maintenance of average weight can be attained safely and like the control of infectious disease hould be practised to promote the good health of the individual. REFERENCE Barborka, C. J.-Obesity and Its Treatment. (Proceedings of the Staff Meetings of the Mayo Clinic; 6, No. 9 :128, March 4, 1931.) Evans, F. A., and Stang, J. M.-The Treatment of Obesity with Low Caloric Diets. (J.A.M.A., 97:1063, October 10, 1931.) Newburgh, T. H.-Causes of Obesity. (J.A.M.A., 97:1659, December 5, 1931.) Bureau of Investigation, J.A.M.A., 97:1554, November 21, 1931. MacLeod's Physiology and Biochemi try in Modern Medicine. (C. V. Mosby Co., St. Louis, Md., 1931, 6th Edition.)

A BRIEF HISTORY OF SURGERY Surgery, like the other master sciences, had its beginning in the remote past. From ancient Egyptian papyri and Babylonian and Hindu writings we learn that variou in truments had been devised and operation performed in an almo t prehi toric era. Thu wounds were dre ed, broken bones splinted, absce e opened and limbs amputated. A sharpened flint was the earliest known instrument used in cir:cumcision. In India, surgery reached a high degree of development, probably the highest attained in antiquity. As early as the fifth century A.D. more than 120 varieties of surgical instruments were in use and operation were performed for ve ical calculi and cataract. During the first fifteen centurie of the Christian era, surgery experienced many vici situde . The Greeks and Romans knew how to control hemorrhage by twisting blood vessels, and operations were done for hernia. A distinct tep backward was taken when surgery and medicine were separated and the practice of surgery relegated to barbers and bath-keepers. It was not until the days of Ambroi e Pare that surgery began to take on a scientific aspect. The work of John Hunter, Lord Li ter, and 路 following that of Pare, combined to lift surgery into modern scientific status. Nor must we forget men like Simp on who through their discoveries did much to lessen human mi ery. Surgery even today is rapidly moving forward. Brain and chest s urgery have only recently come into their own, while cardiac surgery is still an unproven field. May we not all pay tribute in our thought at least to those who down through the ages have forged the framework upon which surgery, a we know it today, ha developed, and ever trive to make more complete that great alleviator of human sufferingurgery.

A cute Intestinal Intoxication DR. T. F.

RUSSELL,

'31.

H amilt on General Hospital.

CUTE intestinal intoxication i a di ea e of early childhood, occurring most commonly in the late summer and early fall months. The condition i al o known a toxico is, cholera infantum, and ailmentary intoxicat ion. It is characterized by evere diarrhoea, loose greenish stool with mucus, coviting, drow iness, and severe toxaemia. The diarrhoea causes dehydration by eliminating large amounts of fluid through the gastro-intestinal tract. The vomiting causes los of hydrochloric acid in the vomited gastric juice and brings about an upset in the acid-base equilibrium of the blood which re ults in an acidosis. Probably the most marked feature i the evere dehydration which is best shown by the very dry, or in the more acute ca es, the "doughy" feel of the skin of t he a bdomen. At autop y the hcte tine are usually normal, but the lh路er may show degenerative change . Many organisms have been named a cau atiYe agent , but at pre ent it is generally con ider ed t hat the imading organi.-m belongs to the dy entery group. The treat ment of this condit ion ha been changed f rom time to time, but no specific treatment ha been di co,路er d. It i difficult to obtain accurate stati tic路 r garding the ..:ucce of the ,路arious forms of treatment, becau e it i well kn0\\'11 t hat the everity of the infection varie from year to year as is t he ca e in other epidemic di eases. The treatment is sym ptomatic and involves combatting the vomiting and diarrhoea and correcting the dehydration and the up et of acid-ba se equilibrium which they produce. In hospital practice, the patients are usually seen in a fairly advanced stage, when their toxic appearance is very striking. In the early, but very acute case the lo s of tissue may not be as marked, but thesyes and cheek are sunken, the fontanelles are depres ed, and the skin of the abdomen is hot and dry. In many cases the skin feels doughy and this seems to indicate a poor progno is. The more advanced cases show a marked loss of weight; the face pre ents the appearance of an old man, and the skin is very dry. When the acidosis is severe t he breathing i deep and rapid, and the lips are cherry red. It is found that in the majority of cases, these infants have been weaned at birth or have been brea t-fed for only a short time. Many patients come from homes in which, due either to carele ness or t o poverty, sanitary conditions are very poor. It might be well t o empha ize here the importance of urging mothers to breast-feed their babies, and the necessity of cleanline s, especially in the care of milk. COMPLICATIONS

In treating these cases it is of the utmost importance to examine them thoroughly in order to ascertain if there i any complicating condition. Thi i e pecially true if there is a prolonged fever fo r which no cause can be as igned. Otitis media, pneumonia and pyelitis are the most frequent complications. 53

UNIVERSITY OF WESTERN O NTARIO MEDICAL ~OURNAL

Otitis media is the most common. Re tie sness with turning of the head from side to side, a whining cry and a septic temperature point to this condition, and the auriscope confirms the diagno i . Pneumonia is evidenced by the increa ed re piratory rate, movement of the alae, cyanosis, unequal expansion of both sides of the chest, and fever. Rales are usually pre ent, but may be absent or extremely hard to discover. The areas of rales are usually patchy and tend to move from one location to another. Pyelitis can only be diagno ed by the examination of the urine. TREATMENT

The essential factor is to get the ca es as early as pos ible and to institute drastic treatment at once. It is a mi take to delay treatment in the hope that they will clear up spontaneously. Two main objects must be kept in view; first to combat the dehydration and, second, to combat the acidosis. For these purpo e fluids must be pushed to the limit. Blood i , of course, the be t, because it is the normal body fluid and i of special value in restoring the acid-base equilibrium. A direct transfusion of 10-15 c.c. per pound of body weight should be given at once into the internal saphenous vein at the ankle. The tran fusion may be repeated after 24 hours, often enough to counteract the toxaemia, a shown by clinical observat ion. Following the transfusion, fluids should be given subcutaneously, intraperitoneally or intravenously. The fluids used are physiological aline or glucose solution depending on the method of administration. Dr. Alan Brown, of Toronto, advi es the use of both saline and glucose. Ten c.c. of normal saline or 5 per cent. gluco e olution per pound of body weight is administered subcutaneou ly under the kin of the abdomen two or three times daily as indicated by the severity of the diarrhoea or dehydration. Only aline may be u ed intraperitoneally, because 5 per cent. gluco e may set up irritation and cause intestinal distension. About 20 c.c. per pound of body weight 111ay be given in this manner. There is orne difference in opinion regarding the advisability of intraperitoneal injection. It is claimed by some that there is little absorption from the peritoneum of an acutely ill infant. Fluid may be given through the anterior fontanelle into the longitudinal sinu and this has many advantages over other methods of adrnini tration, although there are possibly some dangers connected with it. It is particularly valuable in the severe, acute cases because t he fluid reaches the blood stream directly without delay of absorption, and because a much higher concentration of glucose may be used. Ten c.c. of 10 per cent. solution per pound of body weight may be used. It must be pointed out that 1 minim of a 'l'J ooH atropine solution should be given immediately following the injection of fluid to prevent oedema of the lungs. Admini tration of fluids by the above methods i continued until the baby can take sufficient fluid by mouth to prevent dehydration. All food by mouth mu. t be topped for 24 to 28 hours depending on the amount of vomiting. As much fluid is given by mouth as can be

ACUTE INTESTINAL INTOXICATION

retained without vomiting. For thi purpo e 15 per cent. gluco e in water, or in barley water, may be u ed. Perhaps the be t olution i. C.O.G., consisting of two parts of orange juice, three part of 10 per cent. glucose, and one part of odium citrate. This olution supplie water, antiketogenic sub tance , and nutrition; it is very palatable and babie will take it when they refu e other fluids. One to two ounces per hour i given in mall amount . In ca e in which vomiting is a prominent feature, ga tric lavage with odium bicarbonate solution (one tea poonful to a pint of water) i u eful. There ~s some diver ity of opinion a to the value of stimulants but they appear to be u eful. The be t drugs for this purpose seem to be Caffeine Sodium Benzoate gr. ~. Epinephrine m. 1 to 5, Spiritus Frumenti m. 5 to 10, or Cm路amine m. 10. Brandy given twenty minutes before feeding eem to stimulate the appetite in some ca es. If, at the end of 48 hours, the infant i free from toxaemia and vomiting, milk feedings are commenced. It doe not seem to make much difference what feeding i u ed, although the best re ults seem to be obtained by the u e of traight milk and barley water, protein milk, or lactic acid milk. The important point is to begin with very small amount and to give the mixture well diluted. For example, for a three-month -old baby begin with a one ounce feeding of dilute lactic acid milk every three hour , and a the food tolerance increa e , the feeding may be slowly increased in amount and in trength. Too rapid increa e should be carefully avoided. The C. O.G. may be given between feeding to increase the fluid intake but hould not be given for an hou r before each feeding. If the vomiting tends t o recur, stop the miE< feeding and continue as before. The treatment of the complication is very important and i , of course, governed by their nature. In otiti media, paracente is of the drum should be performed a oon as the condition is diagnosed. No great amount of pu may be obtained but the infant receives immediate relief and the temperature drops. Pneumonia i treated by the usual methods. Large dose of Potassium Citrate are given if pyelitis is diagno ed. SUMMARY

1. Acute inte tinal intoxication is a disease of infancy, een in the late ummer and early autumn months, which manifests itself by diarrhoea, vomiting, and extreme toxaemia. 2. The recognition and treatment of complicating conditions such as otiti media, pneumonia, and pyeliti is very important. 3. Treatment consi ts of tran fu ion of whole blood, the admini tration of fluids inter titially, intraperitoneally, or intravenou ly, giving by mouth, C.O.G., and stimulant . When toxaemia di appear , begin with very small feeding and gradually increase them in amount and trength. Treat complication when they arise. REFERENCE Summerfeldt, Dabe, Brown.-Can. Med. Assoc. J ournal XXV, 288, 1931.

An Unusual Neuro ..Pituitary Syndrome ALLAN

D. RIDDELL, '33

morbid conditions of the pituitary gland are Âˇimilar to other T HE endocrine disturbance inasmuch a they are subject to the same discordance of opinion among inve tigators. This gland is unique in that its variou yndromes, perhaps, have no equal in the field of endocrinology. Hyperpituitarism has been recognized since 1886, when it was described by Marie1 â&#x20AC;˘ Frohlich 2 in 1901 was one of the fir t to recognize ihe common syndrome which bears his name. It is also known as dystrophia adiposagenitalis. Various other conditions of the pituitary have been described, and include such disturbances a diabete insipidus, Dercum's disease, and Simmond's syndrome. Although Frohlich's syndrome is easily recognized, the diagnosis may be difficult when it i complicated with other nervous conditions. In view of this, the following atypical syndrome may be considered. CASE REPORT

D., male, aged 14, the eldest of four children who are alive and healthy, gives a history of ce sation of growth in height, exces ive increase in weight, tremor in both hands, with intention, increase in ize of his breasts, undeveloped genitals, drowsines and extreme sensit iveness to any stimulus. These symptoms have developed in the past f our years. The tremor was more marked in the right hand than in the left. It has gradually increased and is more noticeable in the morning just after rising. The abdomen increased in size, the fingers were stubby and the feet were small. There was marked drowsiness and difficulty was experienced in awakening the patient. Upon being awakened, however, he appeared normal. He was clum yon hi feet and stumbled ea ily. Bladder control was partially lost in the early part of last summer, but this occurred only with exercise and the patient did not wet the ued at night. The parents have noticed that this boy always has had a better appetite than the other children and that he would eat more than an ordinary adult. He had trouble with his eyes one year ago while in a warm room at school. He noticed that objects appeared mailer and were blurred, but his sight returned to normal when he went outside. The upper thoracic vertebral region was tender about two years ago. His birth was normal and up to four years ago he was healthy, with no history of infectious diseases or injuries. He learned to walk at 18 months and previous to this crept in a peculiar manner with the right foot dragging beneath the body. He had been quieter than his 66

AN UNUSUAL NEURO-PITUITARY SYNDROME

playmates and is most friendly to those who pay attention to him. Examination.-The patient is 4 feet 10 inche in height and weighs 138 pound . This is approximately 28 pound overweight. He is able to pursue the ordinary routine of life except for the inconvenience caused by the tremor of his hand. This is most troublesome as an intention tremor when he wi he to pick up a gla of water or ornething of the sort. There is erythema of the face and a female distribution of fat and hair. No abnormalities are noticed in the pupil reaction or in the visual fields. There i slight tremor and twitching of the tongue but there is no deviation from the mid-line. The speech is slow and hesitant. The thyroid gland is not palpable. The lungs and hearts reveal no abnormalities. There is an upper thoracic vertebral tenderne s on pressure in the region of the second vertebra but no abnormality can be palpated. The breasts are distinctly of the female type in appearance. The abdomen is pendulous and the liver edge is just palpable. The genitals are small and there is limited pubic di tribution of hair. Nocturia is present and the amount is the same as that voided during the day. The knee jerk and the Achilles reflex are increased. The Babin ki, Gordon, Oppenheim and arm reflexes are negative. Mentality appears normal for a boy of his age. X-ray reports indicate an enlargement in the region of the pituitary gland ugge tive of tumor growth. Treatment.-Pituitary extract and thyroid extract in tablet form have been administered for three months and there has been orne increase in height but no alleviation of the other symptoms. The parent3 con idering the cost of the treatment, and being disappointed in the results, did not consider it worth while to have the treatment continued. DISCUSSION

According to the x-ray reports we believe that tumor of the pituitary constitutes the pathology in this ca e, but this doe not seem to be consistent with the other findings of the ca e. Practically all ca es of adenoma of the pituitary gland show unmistakable symptoms of brain tumor, i .e., blindne s or approaching blindness, headache and vomiting according to the work of Frazier3 â&#x20AC;˘ None of the e ymptoms are present in this case. Malignancy is ruled out a it runs a more acute cour e with very definite symptoms. The more probable explanation is that advanced by Rheinâ&#x20AC;˘, stating that the disturbance of the hyphophy i ha been brought about by a congenital hydrocephalus. It is po ible that hydrocepha us may cause hypophyseal disturbances with or without evidences of pre sure on the olfactory or optic nerves. In addition to this, the cerebellum or even the pons may suffer disordered functions, in all of which structural changes may or may not be pre ent in the sella turcica. The hydrocephalus is idiopathic and cau es a cy tlike deformity of the third ventricle or distension elsewhere in the cerebro pinal circulation. The symptoms may vary from a mild disturbance to

UNIVERSITY OF WESTERN O NTARIO MEDICAL JOURNAL

complete mental unbalance. Thi pre sure is also very likely the causative factor in diplegia. Brain and Strau " di cuss the etiology of hydrocephalus and, according to their finding , it is probably due to a blocking of the cerebrospinal fluid in this ca e. This may be caused by a cerebral tumor or a meningeal inflammation. If there is no tumor, then inflammation in the region of the foramen of Munro is likely the cause, and specifically may be an arachnoiditis. This may have originated intrauterine or shortly after birth. In support of the theory that the entire condition is of congenital origin we have the fact that the patient showed a weakne s as early as the "creeping stage," at which time the dragging of the right foot beneath the body indicated some cranial le ion. Pituitary extract and thyroid extract have been u ed in treatment and although they usually timulate an increase in growth they do not alleviate the other symptoms. If at a later date definite pressure , ymptoms develop ugge tive of a slow-growing benign tumor, operative t reatment may be resorted to as advised by Ro e and Carliss6 • At pre ent, however, no treatment is advi able. If the patient ha no further progres ive symptom , then he may expect practically a normal span of life. His mentality may cease to expand in a few years, but otherwise his faculties should be normal. SUMMARY

1. X-ray reports indicate a pituitary tumor but clinical investiga-

t ion favor a congenital hydrocephalus as the causative factor for the This seems to support the fact 1)ituitary dystrophy and the diplegia. t hat laboratory findings hould be merely corroborative and secondary in importance to the clinical finding . 2. The theory of the congenital hydrocephalus a the causative factor for the pituitary dystrophy and the diplegia i supported by the creeping attitude with the right foot dragging beneath the body. 3. Medicinal treatment, with pituitary and thyroid extract, seems t o benefit growth only. 4. Operative interference is advisable only when definite pressure ymptoms appear. 5. At present no treatment is advisable in this ca e, and considering t he evidence available, it would seem that no serious consequences might develop. I am pleased to acknowledge the kindly advice of Dr. S. M. Fisher and his permission to submit this case report. BIBLIOGRAPHY •Marie, P.-Two case reports of Acromegaly (Brain; 12:59, 1890). "Cushing, H.- The Pituitary Body and its Disorders (P. 43, 1912). 3 Frazier, C. H.-Series of Pituitary Pictures (Arch. of Neur. & Psych.; 23:656, April, 1930). •Rhein, J. H. W.-Hypophy eal Press. Sympt. due to Hydrocephalus (Arch. Neur. & Psych.; 13:71, January, 1925). Brain, W. R. and Strauss, E. B.-Recent Advances in Neurology (MacMillan Co., 1929). 11 Wakeley, C. P. G., and Hunter, B.-Rose & Carliss' Manual of Surgery (P. 880, 13th Ed., August, 1930). 7 Dorland, W. A. 1.-Amer. Med. Dictionary (14th Ed., 1927).

I ,

The Pathology of Diabetes·=· W. I. WAITE, M. D. CCORDING to Warren 1 few disea es definitely associated with any one function show as wide a range of pathological changes, or as frequent ab ence of demonstrable pathological le ion , as does diabetes. The pathological lesions in the pancreas may be quantitative or qualitative. The quantitative changes are: In the normal pancreas the number of island cells is believed to vary from 250,000 to 1,750,000. In diabetes, the pancreas in Warren's series of 259 cases showed an apparent decrease of 51 per cent. The qualitative changes are: 1. HYALINIZATION.-Hyalinization of the islands of Langerhans is now considered the mo t typical pancreatic le ion in diabete mellitus. The nature of this process is not a yet fully understood. This change doe not usually begin until after 40 years of age. At this time also hyaline changes begin in the mailer blood vessels especially those of the pleen, which organ, incidentally, lies in the same vascular circuit a does the pancreas. Fifty per cent. of all diabetes, according to Warren, show hyaline changes. A striking feature of hyalinizat ion is the unequal involvement of the islands in the same pancrea . Some may be completely converted into hyaline rna e , while others may be spared. Still others show varying degree of transition between the e extreme . Hyalinization of the i land now i considered to be due to the production of interacinar ub tance by fibroblasts and po ibly by endothelial cells. Diabetes a ociated with hyalinization of the i land is likely to be mild, due to the fact that there is a relatively slow progress of the lesion. 2. FIBROSIS.-Fibrosis is the next most frequent change and, like hyalinization, tend to occur in older individuals. Occasionally, the same pancreas will show both hyalinization and fibrosis of the i lands. The fibroblastic proliferation begins at the capsule and follows the vessels into the insular tissue. Frequently, this change is associated with arteriosclerosis of the pancreatic ve els and it is usually accompanied by interacinar or interlobar fibrosi . 3. LYMPHOCYTIC lNFILTRATION.-Lymphocytic infiltration is a pathological change occurring in and about the islands and found, usually, in the young. This type of change is a sociated with severe diabetes of short duration 1 . 4. HYDROPIC DEGENERATION.-Hydropic degeneration is another pathological process found in the island cell , involving the .replacement of the specific granules by vacuoles and the cytoplasm by a watery fluid, leaving the nucleus alone within the di tended cell membrane. The h·iking feature about this change i that it appears to be the result of exce ive overstrain rather than injury. Hydropic changes are pronounced in preliminating cases of diabetes of relatively short duration.

• Read at the meeting of the Interne ociety, Victoria Hospital, November, 1931. 59

UNIVERSITY OF WE TERN ONTARIO MEDICAL JOURNAL

Insulin by reducing functional overstrain has reduced greatly the number of cases developing hydropic degeneration. 5. ISLANDS APPARENTLY NORMAL.-Of particular interest is the fact that a considerable proportion of diabetic patients show no demonstrable lesion in the islands. Of a series of 300 cases 27 per cent. showed islands which were normal. Pathologists have advanced three different hypotheses to explain this phenomenon. (1) The islands may be normal and insulin may be produced, but it is either defective in quality or is neutralized by some substance in the body. (2) The diabetes may be of other than insular origin. (3) The insulin may be formed by normal islands, but through failure in transport the insulin is not brought into the blood stream and so not distributed as required by the body. 6. FATTY INFILTRATION.-Fatty infiltration or lipomatosis of the pancreas as a whole has been considered as characteristic of diabetes. The amount of the pancreatic fat is closely related to that of the normal body fat and probably represents the degree of fat storage rather than being associated with the diabetic process. 7. ARTERIOSCLEROSIS.-Arteriosclerosis of the pancreatic vessels in a marked degree is not common, occurring in only five per cent. of cases. Consequently, arteriosclerosis as a cause of diabetes is not important. 8. ABSCESSES, CALCULI, AMYLOIDOSIS AND CARCINOMA.-These are unusual pathological findings in the pancreas and are not characteristic of diabetes. ABNORMAL CARBOHYDRATE METABOLISM One of the results of the altered carbohydrate metabolism is the abnormal distribution of glycogen. Glycogenic infiltration of the epithelium of Henles' loop now is considered a constant pathological finding in diabetes. Increased glycogen has been found also in the fibres of the heart muscle. The nuclei of the liver cells show marked infiltration while the liver cell itself contains but little glycogen. Insulin serves to increase the amount of glycogen in the liver cell and to lessen the amount stored abnormally. A diabetic progressing favourably on insulin and dying from some cause other than diabete or sepsis shows almost the same distribution of glycogen as the normal individual. The storage of glycogen in muscle fibres is found to be decreased as a result of abnormal carbohydrate metaboli m. Likewise, the amount of glycogen stored in the skin, which i u 路ually quite large, is lessened. Sepsis developing in cases treated with insulin will reduce the amount of glycogen stored and thus account for the lowered carbohydrate tolerance. ABNORMAL FAT METABOLISM In diabetes there is a frequent occurrence of lipemia and hypercholesterolemia. This deposition, when present, is marked in the spleen and reticulo-endothelial system. In the skin evidences of abnormal fat metabolism are found in the

THE PATHOLOGY OF DIABETES

Xanthomata that are frequently seen. A reduction of fat in the diet u ually results in the di appearance of the Xanthomata. Xanthomata are an indication that the lipoid content of the diet needs lowering. As cholesterol is eliminated mainly by the gall bladder, it is natural to expect an increased evidence of di ea e of the gall bladder in diabetics and statistic show this to be the ca e. In orne ca es, gall stones predispose to acute attacks of pancreatiti with eventually sufficient injury to the i lands of Langerhans to cau e diabete . Evidences of disturbed fat metabolism are al o found in the liver. Some authors consider an enlarged and fatty liver a a regular finding in diabetes.

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ACIDOSIS AND COMA Acidosis and coma are allied with abnormal fat metabolism. Instead of dealing with localized and readily demonstrable deposits of lipoid sub tance a in the skin and gall bladder, we have to deal with widely di tributed abnormal end products of fat metaboli m which, unlike the fats themselves, are oluble in the body fluids and hence diffusible, thereby exerting a con iderable effect on the arious cells of the entire hody. This diffu ibility greatly affects the picture, making it general instead of local. A tubular nephritis, due to toxic injury of the epithelial cells, is a frequent finding in acidosis and still more impairs renal function, causing increa ed retention of acetone bodies, thus setting up a vicious circle. 'fhe showers of casts o often found in the urine in acidosis are due to this nephritis. The development of acidosi depend largely on the depletion of the glycogen stored in the body. When the glycogen reserves are large, le fat ha to be metaboli ed and the combustion of such fat as is utilized is more complete. Thus the glycogen-forming effect of insulin i of great value in treating acidosis. The culmination of acido is i coma in which the pathological changes are very few indeed. Before the introduction of insulin, coma repre ented the triumph of the uncomplicated diabetic proce s over the organism. But now, the advent of coma in ca es treated by insulin mean that the diabetic proce is receiving outside aid in its struggle, and this aid is usually sepsis. The only typical pathological changes found in a case of acidosis progres ing to coma and death are those characteristic of prolonged acido i , a tubular nephritis with evidence of toxic injury to the liver cells. ARTERIOSCLEROSIS AND GANGRENE Arteriosclerotic changes are prone to develop at an earlier age in diabetic individuals than in other . The out tanding type of lesion is the Atheromatous change. The intimal type of involvement in the mu cular arteries should lead us to suspect that such arterie come from a diabetic. Gangrene is one of the eriou complications of diabetes both from the nature of the lesion itself and from the wide path it opens to septic

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

inva ion of the body. Arterial occlusion in the typical diabetic gangrene is a gradual process, a progre ive encroachment on the lumen of the artery by intimal thickening, not infrequently showing heavy deposits of lipoid substance. Hence, t here is t ime for collateral circulation to develop. Moist gangrene results and all too oft en leads to generalized epsis. THE HEART A natural sequence of the prevalence of arteriosclerosis is the f requent occurrence of myocardial injury due to coronary disease. Postmortem report indicate that cardiac infraction is t hree times as frequent in diabetic individuals. However, the diabetic process is usually present 10 to 12 years before a fatal heart lesion develops. In the coronary arteries al o, intimal changes of the at heromatous type predominate. Another erious myocardial inj ury not infrequently encountered is t hat of multiple abscesses. DIABETES AND INF E CTION It can be ea ily understood t hat where the pancreas is being severely taxed and hardly able to pr oduce ufficient insulin to supply t he body needs, and often requiring the help of dietetic control or extraneous insulin, that any slight infection or toxemia may be sufficient to injure the island cells. Hence, it is often noticed t hat ther e is a severe drop in the sugar tolerance of diabetic during the course of any infection. The quick recovery of the patient after the infection has sub ided indicates that the damage to t he island cells does not go on to necr osis. P neumonia exacts a heavy t oll among diabetics and for that reason it is necessary to be car eful with r egard to colds and upper respiratory infections. The pyogenic infections often end fatally when associated with diabetes. All blisters and abrasions should be treated very carefully and kept as aseptic as possible. Staphylococcus albus, usually considered of little significance, may be dangerous to t he diabet ic, often setting up pyemia and multiple abscesses. DIABETE S IN CHILDREN Lymphocytic infiltration is consider ed t he most characteristic lesion of the islands in children, suggesting str ongly t he action of some toxic agent. The necrosis of island cells as a result of functional overstrain will set up a mild reaction sufficient to account for t he infiltration of lymphocytes. Diabetes in children is usually sever e, but as a rule it becomes less severe with the passage of time. This may be due to the fact that in children the regenerative power s of t he pancreas are at their height, enabling the organ to replace t he inj ured cells more radily. Hydropic degeneration, hyalinization, fibro i and arteriosclerosis are rare in the diabetes of childhood. The ab ence of these makes the outlook more hopeful since the progre s of the disease may be held in check by satisfactory treatment. BIBLIOGRAPHY 1

Warren, S., Pathology of Diabetes (Lea & Febriger, Phila, 1930) .

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Complete Heart..Block with Case Report J.

MARTIN LEBOLDUS,

'32

this condition in which none of the auricular impul es reach the I Nventricle, two rhythm , one for the auricle and one for the ventricles, mutually independent, are generated in the heart. The former, which originates in the sino-auricular node, ha a normal rate, while the latter, which originates omewhere in the atrioventicular bundle, has a rate of about 30 per minute. The sino-auricular node and junctional tis ues, the latter consisting of the auriculo-ventricular node and bundle, constitute the pecial tissue of the heart which are concerned with the initiation and the propagation of the heart beat. The S. A. node i situated at the junction of the superior vena cava and the right auricle. The A. V. node i ituated at the posterior and right border of the interauricular eptum near the mouth of the coronary sinus. The A. V. node is continued in the A. V. bundle which runs horizontally forward and to the left to the membranous interventricular septum, at the anterior part of which it divid ~ into right and left branches. Both these branches are continuous with an arborization of fibers under the endocardium of both ventricles, known as Purkinje fibers. The S. A. node initiates the normal heart beat. From here the impulse pread out uniformly over the auricular walls to the A. V. node from which it spreads down both branches of the A. V. bundle to reach the ventricles. Clinical heart-block is due to some defect in the conductive system between the auricles and ventricles. STAGES

1. In its slightest degree the inter y tolic interval is delayed, i.e., the period between the contraction of the auricles and the contraction of the ventricles is longer than one-tenth econd. The rate and rhythm are regular. 2. In the next tage the stimulu from the auricle does not always reach the ventricle, re ulting in an occa ional dropped beat. 3. In a still more advanced stage the dropped beat become more numerous and show a periodicity, e.g., the ventricle may respond only to every other auricular beat resulting in a 2:1 rhythm. This may later become 3:1, giving a bigeminal or trigeminal pulse. These three stages are all example of partial heart-block, due to different degrees of decrea ed excitability of the A. V. node. 4. Finally comes the stage of complete heart-block in which there i a complete di ociation between the auricular and ventricular beat , due to the complete blocking of timuli from the auricles to the ventricles. The auricles still respond normally to the S. A. node impul e 63

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

while the ventricles respond to stimuli originating in the A. V. bundle at the rate of about 30 per minute. ETIOLOGY

The etiological factors of heart-block may be grouped under three headings : 1. In children and young adults-due to rheumatism, chorea., or the actions of the toxins of acute infectious diseases such as diphtheria and influenza. 2. In adults-due to degenerative changes in the genetic system as a result of syphilis or arteriosclerosis. 3. The effects of drugs, such as digitalis. SIGNS, SYMPTOMS AND DIAGNOSIS

Some of the points about to be mentioned here have already been discussed. 1. Pulse rate, usually about 30 per minute. This is not affected by rest, posture or exercise. 2. Auscultation of apex beat with simultaneous palpation of the jugular veins in the neck reveal the dissociation of the auricular and ventricular beats, the normal rate of the auricles and the ventricular bradycardia. Often faint, muffiled sounds may be heard in the long diastoles. These are due to auricular systoles. 3. Stokes-Adams syndrome-the loss of consciousness with convulsions. This tendency to syncopal or apoplectiform attacks is most common in the transition stage when the heart is passing from a partial to a complete block, i.e., during the intervals when the ventricle is attempting to set up a rhythm of its own. These attacks of faintness, convulsive seizures, or even temporary lo s of consciousness are due to the cerebral anemia as a result of the ventricular standstill. Until such time as the ventricle is enabled to set up its own course, the StokesAdams syndrome will occur, and may result in a fatal termination. 4. The electrocardiagram in complete heart-block shows that the deflection or auricular complex occurs at the normal rate, while the A. R. S. or ventricular complex occurs at a rate of about 30 per minute. The P .-R.interval exceeds 0.2 seconds, which is definite evidence of delayed conductivity in the A. V. bundle. 5. The polygraph in complete heart-block shows a prolonged A. C. interval with complete dissociation of the "a" and "c" waves. The normal A. C. interval is one-fifth second. TREATMENT

The most encouraging results are obtained when the lesions in t he A. V. junctional tissues are due to either a syphilitic or acute inflammatory process. The majority of the lesions, however, are of a sclerotic nature, in路 which case the treatment should be aimed at the factors producing the bradycardia. The most dangerous period is that during which the transition from partial to complete heart-block is taking place, in other words,

; '

COMPLETE HEART-BLOCK WITH CASE REPORT

the occuuence of the toke -Adam yndrome. The only efficient drug during these emergencies i epinephrine. The effect of epinephrine on the Stoke -Adam syndrome wa fir t de cribed by Danielapolu and Danule cu in 1916. Since then, however, attempt have been made at the prevention of the e syncopal and convul ive attacks. Barium chloride in 30 mgm. do e four time daily, admini tered orally, was introduced by Cohn and Levine. Barium chloride acts by increa ing the irritability of the heart muscle directly. Other drugs which may be u ed are atropine, the nitrite and digitali . CASE REPORT

J., male, aged 67. Thi patient with a clinically negative past hi tory though with some evidence of hypertension and arteriosclero is, wa , in February 1930, suddenly struck by a feeling of dizziness and yncope which la ted about 10 econd . The attack became more frequent and increased in duration, but he never lo t con ciousness completely. These attack were quite often preceded by what the patient described a a sen ation of heat. Quite frequently this heat ensation was the only manife tation. Patient wa admitted into the ho pital on July 26, 1930. For the next three or four week he pa ed through a ,路ery critical stage of hi illne . He had frequent period of confusion and of emi-con ciousne , having 100 in one particular morning. He did not demon trate the typical Stoke -Adams yndrome. Since the definite e tablishment of hi pre ent condition of complete heart-block, the patient is feeling rea onably well, though all the time confined to bed. Inspection.-The patient i a fairly well nouri hed male. The che t i bilaterally ymmetrical. The left praecordia shows no prominence. The apex beat is lightly vi ible ju t out ide the nipple line. Pulsations out ide the praecordial area are visible in everal location : (a) in the epiga trium to the left of the xiphoid proce s. The pul ation are y tolic in time. The e pul ation may be due to a dilated and hypertrophied right ventricle; (b) in the neck lateral to the ternocleidoma toid , due to pul ation in the jugular vein , which are due to the di ten ion of the right auricle with blood. The jugular pul ations correspond in time with the auricular systole , with a larger pul ation at irregular intervals due to the ynchronou auricular and ventricular contraction . The pul ations ocur at the rate of 66 per minute; (c) in nearly every uperficial artery in the body, e pecially in the brachials. The pul ation are sy tolic in time and occur at the rate of 21 per minute. Palpation.-The apex beat is ju t out ide the nipple line, four inche from the mid-sternal line in the fifth intercostal pace. The impulse of the beat is localized and weak, and the rate and rhythm regular. There are no palpable thrill and there is orne evidence of thickening of the radial and brachial arterie . The radial pulse is fulL

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

Percussion.-Thi reveal left ventricle dilatation and hypertrophy. The left border i 41f2 inche from the mid-sternal line in the fourth intercostal space, the left nipple being 3% inche . The right ide of the heart could not be percu ed beyond the right border of the ternum. Au cultation.-In the region of the apex beat, the fir t ound i weak, while the econd sound is not audible. In the region of the pulmonic and aortic valves no sound can be heard. The optimum

ELECTROCARDIOGRAM --

"~th

------

Analysis of above record - Auricular rate 60, \~ entricu iar rate 25, rhythm irregular, Departures from normal (Lead I, Lead II, Lead ill) Four Auricular beats to one Ventricular no temporal relation between them. Interpretation- entricular bradycardia due to complete A.- V. block.

location for au cultation i at the xipho ternal junction where both fir t and second sounds are audible. For every first sound beat there are on the average between three and four second ound . The latter ound , which are faint and muffled, are due to auricular contraction and are heard during the long pau es between t he ventricular sy tole . At irregular interval the contraction of the auricles and ventricle coincide, when the first ound is accentuated, which coincidence i ynchronous with the large pulsations of the jugular vein in the neck. Blood pre sure on December 29, 1930: ystolic, 200; diastolic, 60; pul e pressure, 140. Pul e rate ventricular sy tolic 21, auricular sy tolic 66. The Was erman is negative.

C OMPLETE HEART-BLOCK WITH CASE R EPORT

l \

In recapitulation, the patient' condition on admi ion to the ho pital was one of partial heart-block. At that time the auricular and ventricular beat exhibited a 2:1 ratio. Since that time the condition of complete heart-block ha become establi hed. Thi man left the hospital on February 27, 1931. He is now an inmate in a House of Refuge. On inquiry regarding hi condition, the following, in part, is t he reply received: "Jan. 6, 1932. He had one heart attack about two

ELECTROCARDIOGRAM .

-·

.--.,i•--Jii;1Jii-~, ,.._.,~:-- ~--

---r

- -

"';.-.

._,.....- --

1(----

- - _____.. -

~ ..A...~-~-;-

~.,~~:=-li-.,-.a ,

--- -

._......

- .

•

- --

Analysis of above records-Auricular rate 76, \ 'entricular rate 3 rhythm regular, conduction time from Aur. to ent., 0.36 sec. Departures from normal (Lead I, Lead II, Lead III)-Two Auricular beats for each entricular complex with a prolonging of the PR interval and widening of the base of R in all leads. Main spike down in Ill. The P is 3 mm. in height. Interpretation- Ventricular bradycardia due to 2:1 partial heart block. The right bundle branch shows the mo t involvement (right bundle branch block). The passage of the impulse from Auricle to Ventricle is markedly delayed.

month ago which confined him to bed for a few day . At the present time he i up and around. Thi man walks miles each day." Treatment.- This patient received atropine ulphate gr. 7~ 0 ( 4) dur ing his attacks on first entering hospital. After his seizures were under control he received Sod. nitrite gr. 11 twice daily from Augu t 2, 1930, to February 27, 1931. Thi patient did not receive epinephrine at a ny time becau e of his hyperten ion. SUMMARY

1. Apparently the only etiological factor in thi ca e are hyperten ion and arterio clero is. 2. The typical Stokes-Adams yndrome wa never demonstrated.

UNIVERSITY OF WESTERN ONTARIO

MEDICAL

JOURNAL

3. The pulse rate is exceptionally low-average 21. 4. The prognosi i above average. Willuis, 1926, in a report on 65 patients placed the average length of life after clinical examination at 14 months. The life expectancy is less in left, than in right, bundle branch block. BIBLIOGRAPHY Mackenzie--Diseases of the Heart. 249, 1925. Price--Diseases of the Heart. 19 , 1927. Heatherly-Modern Methods in Heart Disea e. 80, 1924. Cohn, A. E., and Levine, S. A.- The Beneficial Re ults of Barium Chloride on Adams-Stokes Disease. (Arch. Int. Med.; 36, 1, 1925.) Willins, F. A.-A. H. Tour, 1, 5, 576, June, 1926.

~bttortal ORDER to keep abrea t with the field of medicine, every pracI Ntitioner of today mu t read carefully the current medical literature. On the trength of articles contained therein he may in titute a new cour e of treatment or adopt a new type of urgical procedure. Each doctor in practice i confronted every day with ca e which vary somewhat from the text-book picture. If he is exacting he will keep on record a hi tory of each ca e, with hi ob ervations, his treatment and his re ults. In the cour e of time, the accumulated evidence will confirm hi judgment in future ca e . Thi doctor now reache the state where he can contribute to the medical profe ion pictures of pathological proce e upported by his own ob ervation . Evidence such as this is the foundation of facts in medicine. We would urge every doctor in every field to make careful ob ervations, to keep diligent record and to write hi ob ervations for orne medical publication. We would al o impre upon every medical tudent that now i the time when he hould begin to keep hi record and write hi ob ervations, not only becau e they are invaluable to him, but also that he might make use of th m in medical publication which are now becoming acce sible to the tudent who desire to publish. McGILL MEDICAL UNDERGRADUATE JOURNAL In November, the number of tudent body publication wa increa ed by the appearance of the McGill Medical Undergraduate Journal. It is a journal of 64 pages, to be published quarterly, and each is ue is to contain a sympo ium on orne ubject.

Editorial

The first i ue i called the "Medical Education Number," which deals with medical education in variou part of the world. There i al o a plendid article on Artificial Pneumothorax in Pulmonary Tubercui.:> i , a baffling ca e report with the solution hidden el ewhere, and two literary efforts which mu t have been in erted by the "Printer' Devil." The Journal offer great po ibilities and will surely become an important part of the McGill Medical Body. To the organizer and editor , we appreciate the tremendou ta k that they have undertaken, and extend to them our best wi he for their uccess.

CREDO QUIA IMPOSSIBLE The human race has an inherent belief in charm , taboo and incantation . Probably the fir t u e the aborigines made of their ability to converse wa to tran mit from one to another the healing powers of herbs and berrie ; certainly the olde~t hieroglyphic belonged to priest and deal with the art of healing by the use of specific concoctions but always acompanied by elaborate rituals. The coming of the scientific age has not as yet over hadowed the superstitiou beliefs of the layman o that he i till impre sed mostly by the pectacular, such as gland rejuvenation and quack cure-all , thus making it much ea ier to sell the piau ible impossible than the po sible in medicine. He excu e prejudice and ignorance with such expressions a "faith" and "moral rectitude." The rna ses of the people till maintain an attitude of "Credo quia impo ible" in regard to cientific matter in general, and modern medicine in particular, a good example of thi being the State of California which claim the be t educated population in the world, yet, in 1920 and again in 1922 tried to pa san anti-vivi ection bill tating that "vivi ection experimentation, surgical or phy iological, on man or any lower animal, with or without anae thetic, and whether painful or not, for cientific experiment be banned from the State"-at the arne time expres ly permitting farm operations without anae thetic uch a dehorning, gelding, playing, caponizing, branding, etc. Thi narrowmindedne would not only ha e prevented the production and testing of vaccine but also would have made impo sible uch te t as the Widal and Wa erman. Al o, about 1922, a bill was passed, with di a trous results, making vaccination and inoculation optional and to which may be attributed directly the great increa e in mallpox and which allowed typhoid carrier to work a cook and yphilitics to barber. The only olution of such condition i the wider spread of scientific knowledge which will bring in its wake a broader view and tolerance for new and u eful cientific discoveries.

UNIVERSITY OF WESTERN ONTARIO MEDICAL J OURNAL )

RECENT ACCESSIONS TO THE MEDICAL SCHOOL LIBRARY MEDICINE--

Associations for Research in Nervous and Mental Diseases. Epilep y and the Convulsive State. 1931. Association for Re earch in Nervous and Mental Di eases. Intracranial pressure in Health and Disease. 1929. Bellingham-Smith & Feiling: Modern Medical Treatment. 2 vols. 1931. Cawadias: Modern Therapeutics of Internal Disea es. 1931. Von Economo: Encephalitis and it Treatment. 1931. Imperial Cancer Research Fund, England. Scientific reports. v. 9, 1931. Kolmer, Boerner & Garber: .. pproved Laboratory Technic. 1931. Jackson: Selected Writings. v. 1, Epilepsy. 1931. Nervous and Mental Di ease Publishing Co. Monographic series. Poynton & Schlesinger: Recent Advances in the Study of Rheumatism. 1931. Rowntree & Snell: Addi on's Di ea e. 1931. Strumpell & Seyfarth : A Practice of Medicine. 3 vols. 1931. Travis: Speech Pathology. 1931. SURGERY-

American Medical A sociation. Primer on Fra ctures. 1931. Boehler: Treatment of Fracture . 1930. Buie: Protoscopic Examinations. 1931. Cheatle & Cutler: Tumours of the Breast. 1931. Greig: Clinical Observations on the Surgical Pathology of Bone. 1931. Henry: Exposures of Long Bones and other Surgical Methods. 1927. Rose & Carless: Modern Surgery; 13th edition. 1931. OBSTETRICS AND GYNECOLOGY-

Berkeley, Andrews and Fairbairn: Midwifery; 4th edition. 1931. Cro en & Crossen: Disea e of Women; 7t h edition. 1930. Eden and Roland: Widwifery; 7th edition. 1931. Frank: Gynecology and Obstetrical Pathology. 2nd edition. 1931.

PHARMACOLOGY AND THERAPEUTICs--

American Medical A sociation: New and Non-Official Remedies. 1931. American Pharmaceutical As ociation: ational Formulary of Unofficial Preparations. 5th edition. 1926. Burn: Recent Advances in Materia Medici. 1932. Lipowski: Moderne Pharmakotherapie. 1930. Magnus: Lane Lectures on Experimental Pharmacology and Medicine. Squire: ompanion to the Briti h Pharmacopoeia. 19th edition. Squire: Pharmacopoeias of the London Hospital . 9th edition. 1924. BIOCHEMISTRY-

Barger : Application of Organic Chemistry to Biology and Medicine. 1930. Dhar: Chemical Action of Light. 1931. Hill: Muscular Movement in Man. 1927. Levene and Bass: Nuclei Acid. 1931. Onslow: Principles of Plant Biochemistry. 1931. PHYSIOLOGY-

Evans: Recent Advances in Physiology. 4th edition. 1930. Handbuch der ormalen und Pathologischen Physiologie, v. 15, pt. i and ii. Roger: Traite de Physiologie Normale et Pathologie, v. 8. MISCELLANEOUs--

Annals of the Pickett-Thomson Research Laboratory, v. 7. Collected Papers of the Mayo Clinic, Rochester, Minn., v. 22, 1931. Da Costa: Papers and Speeche . 1931. Keith: Ethnos or the Problem of Race. 1 31. Keith: New Discoverie Relative to Antiquity of Man. 1931. Powers: The F oundation of Medical History. 1931. Reid: The Great Physician. 1931. Scammon: The Development and Growth of the E xternal Dimensions of the Human Body in the Fetal Period. 1929. Walmsley: The Heart. 1929. Williamson: Handbook of Di ea es of Children. 1931. NEW CURRENT SUBSCRIPTIONS--

Journal of Scientific Instrument . V. 1-7 and current . Nutrition Ab tracts and Reviews. V. 1 and current. Quarterly Journal of Pharmacology (British). V. 1-3 and current.

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The University of Western O ntario VOL. ll

ME D ICAL JOU R NAL

No.3

Cardiac Pain and Its Significance GEo. C. HALE, M.D.C.M., F.A.C.P.

Professor and Chief of the Department of Medicine University of Western Ontario the most frequently encountered complaints of pain in P ROBABLY the practice of medicine are headache, abdominal di comfort, and

praecordial pain. A patient with headache will have difficulty in persuading the doctor to take hi complaint seriou ly; the patient with abdominal pain will have difficulty in avoiding being the ultimate recipient of one or more laparotomy cars; but the individual with pain over the heart may leave the doctor in a quandry. He cannot brush it aside like a mere headache, nor can he operate to sati fy his curiosity as to the cause. He knows it may be neurotic, on the one hand, or on the other, the fir t evidence of a erious if not fatal malady. The heart, like the hollow abdominal vi cera with mu cular walls, does not respond to all stimuli that would be painful to superficial tissue . But experiment and ob ervation have shown that these hollow muscular organs, when over-distended or contracting under abnormal conditions, are capable of producing impulses which, carried by the nervous sy tern to the central nerv.ou sy tern, are, a it were, interpreted to the brain as painful en ation ari ing in those areas supplied by the cerebro pinal nerves concerned. The exact course of the afferent ympathetic fibers of the heart is not certain. It can, however, be fairly accurately surmised to be ympathetic ganglia and thence by rami, gray or white, to the posterior root of the first cervical to the fifth dorsal spinal路 nerves. This accounts for the pain of angina pectoris being referred to the throat, the arm, and the praecordial area. Clinical experience would suggest an even lower distribution to account for the epiga tric pain so common in myocardial infarction. Actual proof of, at least, part of this anatomical theory is hown in the relief of anginal pain by the removal of the middle and inferior cervical and first thoracic sympathetic ganglia on the left side. Pain, then, of organic cardiac di ea e may have a very wide and confusing distribution. That of functional origin, however, is usually confined to the praecordial area. The rea on for functional or nervous cardiac pain would be an interesting psychological study. Why should 71

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

certain neurotic individuals complain of pain over the heart while others have symptoms referable to the abdomen. This is probably as difficult to answer as the que tion why one nervous per on, when excited, ha diarrhoea while another has frequency of micturition. Suggestion probably plays a part due to a family history of heart disease, the recent death of a relative from this cause, or a consuming terror of heart affections, just as other neurotics may have a complex regarding cancer, tuberculosis, or lues. Of all the organs of the body, the heart is probably most intimately associated with psychic life. We speak of broken hearts, great-hearted per on , the heart jumping into the mouth, and in polite virgins of an earlier period the more intimate physiological urges were always referable to the heart. Slam the door of a roomful of nervous women; several will place their hand over their heart, but not one will clutch her abdomen. It may be granted then that cardiac pain is common, and that it may be psychic in origin or due to organic di ease. Our problem is to differentiate between the e two types. In the vast majority of per ons under middle age, cardiac pain, to have significance, must be accompanied by structural or functional signs and symptoms of organic di ease. For example, ca e of mitral stenosis, auricular flutter, or vascular hypertension with cardiac hypertrophy, frequently complain of pain, but the clinical picture enables us to make a diagnosis of organic di ease, the prognosis of which depends on this clinical picture and is not influenced by the pre ence of pain. If the patient has pas ed middle life, shows definite signs of organic cardiac di ea e, and . suffer from pain, the latter may have more meaning; but the physician is already warned by the evident clinical picture and is not liable to o erlook its possible significance. The difficult problem, however, is the person past middle age, especially a male, with a hi tory of cardiac pain and no structural symptoms to indicate organic heart disease. Here a timid physician, keeping on the safe side, may produce a confirmed cardiac neurasthenic and a careless optimist may be instrumental in hastening death. To those who cavil at the ambiguity of the term "middle age," it may be answered that middle age is a period which varies physiologically in individual and families. P ychologically it is the age when a man starts planning to go to bed at a rea onable hour because he has a hard day before him. A cia ical attack of angina pectoris may be accepted at its face value, even from the hi tory alone, if it is reliable. The evident agony, the fear of impending death, the distribution of the pain, even with an unchanged pulse and without sign of tructural change in the heart, force us to this diagnosis. But what then? What do we mean by the term "angina pectoris"? In earlier writings one comes across analyses of post-mortem findings of patients dying from this condition, showing how some cases presented

CARDIAC PAIN AND ITS SIGNIFICANCE

evidence of coronary artery disease while in others nothing cotild be found to account for the symptoms. The former group we now recognize as instances of coronary occlusion with perhaps myocardial infarction, and presenting a somewhat different clinical pictuxe of the attack. The latter still remains as angina pectoris, i.e., a clinical entity which disappears with death. What is the difference between this type of cardiac pain without pathogical cause, which results in death, and the type which we call cardiac neurosis? This question can be answered only when there is an acceptable reply to the query as to whether functional disease can actually cause death. There it no doubt that certain individuals and races have a definite aptitude to spasm of unstriated muscle. It has been brought to my notice on several occasions by physicians who have had experience in Eastern fields of medicine; that in China, although cardiac disease of all types is extremely common, a case of angina pectoris is unknown and the spasmogenic aptitude very rare. If this is true it does not depend on a racial characteristic of superficial calm. A Chinaman may get very excited and chatter vehemently when you accuse him of losing your shirt, but he does not worry about it. You maintain an air of stately calm but you lose your temper and cause your unstriped muscles to go into spasm. Probably no satisfactory answer will be given to the problem of angina pectoris until a large group of cases have had a sympathicectomy performed with relief of symptoms, a subsequent life of normal expectancy, and negative autopsy findings as regards coronary artery disease. There is, however, another clinical picture similar, and yet dissimiliar, to angina pectoris, more insidious, anti hence more dangerous. This is the syndrome of coronary occlusion, and comes about in the following manner. In certain individuals, at an undeservedly early age, intimal proliferation occurs in the visceral arteries to a degree unsuggested by the appearance of the larger vessels. E ssential hypertension is a fairly frequent cause. If the coronary arteries are the greatest sufferers, the blood flow through them is decreased and the nutrition of the myocardium may be endangered. Symptoms are then readily produced by over-exertion, over-fatigue, lowering of the blood sugar by .diet, or lowering of the blood pressure by artificial means. Quite f requently dyspnoea comes on so insidiously that it is more remarked by others than by the patient himself, who ascribes it to lack of condition. The pain or discomfort is often epigastric and associated with eructations of gas, suggesting gastric disease. This also is true in cases of coronary occlusion with infarct, as shown by numerous reports in the press of persons dying from so-called acute indigestion. A common history is that of a man seized with acute epigastric pain during a banquet and the cause attributed to the heavy meal, neglecting such contributing factors as a rise in blood pressure from the excitement of making a speech or over-indulgence in alcoholic beverages.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

路Sudden death does not always occur, however, as a result of myocardial infarct, nor is the pain always severe. The cardiac di comfort may be anything from a feeling of pressure over the sternum to a severe pain. It is liable to last for hours or days, and again unlike angina pectoris, the patient is more comfortable moving or even walking about. After twenty-four to thirty- ix hours there is a fever and leucocytosis, and there is a periodical friction rub in about twenty-five per cent. of cases. The reason that a friction rub is heard in only one-quarter of instances of true infarct is because the lesion may be near the apex, on the posterior part of the heart, or on the endocardial a 路pect of the heart wall. During the acute attack there is often a drop of blood pressure which may remain lowered and suggest a les favourable prognosis than where there i a sub equent ri e. This lowering of the blood pressure probably explains why amyl nitrate and other drugs of this group fail to relive the pain, as they do in angina pectoris. In fact, it is a question whether their use is not contra-indicated. One may say then that cardiac pain may be due to coronary artery disease and pre ent a clinical picture which, with adequate laboratory aid, should be recognized; that it may be due to angina pectori which, in spite of lack of evidence other than the hi tory or presence of the attack, must be gravely con idered; and it may be merely of functional or nervous origin, in spite of the presence of certain evidence of structural change, e pecially in young persons. It is in these ca es that t he electrocardiogram is mo t helpful. But this, with other laboratory aids to diagnosi , must be interpreted in conjunction with the clinical picture to be of real value. To those unfamiliar with the electrocardiograph one may explain briefly that it records the electrical impulses generated by the contraction and relaxation of heart muscle. By means of the three leads, that is by three circuits: (1) from right to left arm; (2) from right arm to left leg; (3)from left arm to left leg--a triangular aerial is, as it were, thrown about the heart. Each ide of the triangle picks up the electrical impulses in its vicinity. The e impulses cau e a deflection of a beam of light in the instrument and a re graphically recorded on a moving film. As long as the muscular contractions arise in the proper place, travel in an orderly manner to their destinations without delay, the electrocardiogram will be normal. There might be a narrowed coronary artery, but until it is unable to carry sufficient blood to nourish adequately that part of the heart mu cle which it upplies, the electrocardiogram may be normal. Thi , however, i no guarantee that the artery may not shortly become too narrow to be efficient or that a thrombosis may not occur. Again the cardiac contractility is influenced by drugs a shown by the effect on the electrocardiogram of digitalis therapy or by the drinking of a glass of iced water. But in spite of the possible errors or

CARDIAC P AIN AND ITS SIGNIFICA N CE

fallacies the electrocardiogram still remains the most reliable source of information regarding the condition of the coronary arteries of a heart which, clinically, reveals no evidence of structural disease. I n the absence of physical signs, or electrocardiographic evidence of disease, one's judgment as to t he organic origin of cardiac pain is inevitably influenced by the question of ex, age, and family history. Coronary thrombosis is many time more common in men than in women; statistics have been given suggesting a ratio of three to one. With regard to the age of the patient one must remember that although the greate t incidence of coronary thrombosis is between the ages of fifty-five and sixty years, seventy per cent. occur before the sixtieth year, and that there are almost as many ca e between thirty-five and forty-five as there are between sixty and eventy year . One must be careful about excluding this condition becau e the patient is under forty years of age. Here one may be aided by the family history, for undoubtedly precocious arteriosclerosis of visceral arteries is frequently the result of a familial diathesi . On being confronted, then, by a patient complaining of cardiac pain one might with advantage adopt the following routine. Inquire regarding in tance of cardiac deaths particularly in relatives who died young, not forgetting that this family history may have produced a morbid fear in the patient's mind. Question him about the illne e he ha had and if po ible exclude yphili by t he Wa sermann te t. Encourage him to talk about himself in or der to gauge his reactions towards life in general with its worries and responsibilities. Tr y to find out whether a ny previou symptoms or illn esses were con equent to some psychic cause, and di appear ed with the removal of such cause. Que tion car efully about the cardiac pain, its time of occur rence, its relation to either physical effort or worry, and especially the date of its first appearance. Attacks of intermittent cardiac pain over a period of many year without physical signs are not likely to be organic in origin. Make a careful physical examination with the patient itting up, lying down, and also on his left side, and te t his response to effort. If nece ary, and po ible, have an elect rocardiogram ma de. Occa ional mistake in diagnosis are inevitable, but only inexcusable if they are t he r esult of carele s methods of investigation.

ST. BARTHOLOMEW'S HOSPITAL CHAPEL from an antique illustration In his "Brevarium Bartholomei," the fir t book on medicine connected wit h t he oldest ho pital in London, J ohn Mirfield ob erves t hat a person may be pre erved from plague infection by smelling and wallowing musk, aloe , wood, torax, calomint, amber and ot her aromatics.

Spontaneous Pneumothorax LORNE WHITAKER,

B. A. '32

B rant fo rd

condition of spontaneous pneumothorax is an interesting clinical T HEoccurrence and one which pre ent an etiological problem to t he clinician. The following ca e report i condition for the purpose of discu sion.

Fi.~~:.

elected as exemplifying the

L. M., male, aged 27, suffer ed from coryza for six weeks. On November 15, 1931, f ollowing t hree days of general malai e, weakness and lassitude, the patient had a evere pain in t he right chest 76

SPONTANEOUS PNEUMOTHORAX

which began in the afternoon. This pain became aggravated and radiated to the posterior thorax below the right scapula. He had a paroxysmal cough, which continued intermittently for two hours. Following this he vomited three times within an hour. Treatment wa instituted for pleurisy, although there was no rise in temperature. Acetyl salicylic acid grs. v and codeine grs. ss were given every two hours for the pain. The right side was strapped with adhe ive and mustard pla ter and an electric pad were applied. The pul e rate ranged from 100 to 110. The temperature remained below 99 degrees Farenheit. Sedative cough mixture relieved the cough. The patient was more comfortable the following day. Within two days the cough subsided. The analge ic was continued for five days. The adhesive pla ter was removed on the sixth day. On the seventh day a con ultant examined the patient. This was done in view of a history of similiar attacks and consequent possibility of acid-fast infection. There was slight diminution of the breath's sound of the right ide, but nothing ufficiently definite to indicate a pathological condition in the lung. The pulse wa persi tently rapid and there was positive Von Graef' sign. An x-ray examination of the chest, and a basal metabolism te t were advised. The patient had the above inve tigation carried out on November 22, 1931. The x-ray record (Figure 1) read as follows, "The radiographic examination of the che t made from stereoscopic films shows that there is considerable thickening of the root hadows and peribronchial thickening. Apices are clear. There is quite a large pneumothorax at the right base, extending upwards to the level of the third interspace in front. In the absence of any hi tory it i probable that this condition is due to tuberculosis. There is little evidence to support this suggestion." The basal metabolism te t showed a rate of plus 38. A second x-ray examination, on December 23, 1931, (Figure 2) read as follows, "The radiographic examination of the che t shows that t he spontaneous pneumothorax on the right side has become absorbed." In the interim the patient had a strongly positive reaction to a Von Pirquet test. The patient again i ited the consultant on December 29, 1931, who found some moisture in the right chest and suggested that an afternoon and evening temperat ure chart be made for a week before allowing the patient to resume hi work. The temperature remained within normal limits, o the patient returned to hi work on January 5, 1932. Since that time he has shown teady improvement and has gained 12 pounds since fir t examination. ETIOLOGY

1. Age. 0 ler pecifies adult life; Norris and Landis 2 early life because of its frequent relationship to tuberculosis; Stein9 , 20-30 years ; Hirschboeck12, 15-45 years. 1

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

2. Sex. Males are more frequently ubjects than females, the ratio being given as 4 to 1 by Hir chboeck'~, and 75 to 23 by West 10• 3. Site. The right side is more frequently affected acording to Thompson 11, while Hirschboeck' ~ affirms that it occurs with equal frequency on either side. A limited number of cases have been reported in which the condition was bilateral, Hirschboech' 2 •

Fig. 2

4. Tuberculosis. Undoubtedly this condition forms the etiological background in the majority of ca e of pontaneou pneumothorax. Osler', Palmer and Taft8 , and Stoloff• assert that 90 per cent of these cases are found in patients with pulmonary tuberculosis. Biach (Quotation by Hirschboeck' 2 ) is a little more conservative and puts the figure at 77 per cent. In children the incidence of tuberculosis as a causative factor

SPONTANEOUS PNEUMOTHORAX

is much less, accounting for only 40 per cent. of the cases, Stoloff4 • It occurs in 5 per cent. of all tuberculosis patients, Norris and Landis 2 • In the present instance the patient does not give a history which would indicate such a condition. He i , however, a lim, wiry individual with what might be termed the phthisic habitus. He ha a brother with active tuberculosis in a sanatorium in England and gives a history of having worked four years in a sanatorium himself. It would thus seem that the odds are in favour of tuberculo is as being the causative factor, either directly or indirectly. 5. Other causes given include: pneumonia, gangrene, emphysema, hydatid disease, pertussis, congenital defect, lung ab cess, bronchiectasis, foreign body, lung apoplexy, empyema in order of frequency given by StolofP. Osler1 includes haemorrhagic infarct. A thma i cited as a cause by Biach (Quotation by Hirschboeck 12 ) and Thompson 11 • Perforation of the adjacent air-containing viscera and caries of bone are regarded as cau es by Biach (Quotation by Hir chboeck 12 ) . In children it may occur with crofula, mea les, diphtheria or be congenital, Page7 Other rare occa ions are new growths and ga -forming bacteria, Palmer and Taft6 , and ruptured subpleural absce s, Browder;;. PATHOLOGICAL ANATOMY

In the present ca e it i impossible to arrive at a satisfactory idea of the actual pathological changes that took place. The radiological examination showed that there was air in the pleural cavity which is the essential change that takes place in spontaneous pneumothorax. Some authorities infer that the term should be made to include only those cases in which there i no cau ative lesion demonstrable. Others define the condition as including all tho e cases of pneumothorax which are not artificially induced and apply idiopathic to the class in which no cause can be found. The patient in que tion seems to belong to the idiopathic group in view of the fact that tuberculosis as a clinical entity has not been proven in his case. Complicating the condition in many cases is fluid in the pleural cavity. This may be serous, sero-purulent or purulent. The mediastinum and pericardium may be displaced to the opposite ide. These features were notably absent in the case here reviewed. Three types of pneumothorax have been described. The first or closed type, of which the patient is an example, is one in which the aperture between the pleural cavity and the pulmonary tissue within a short time seals off, leaving a closed cavity containing air. A second or open type is one in which the opening remains patent. The third and mo t serious condition is one in which there is a valvular action between the lung tissue and the pleural cavity so that the air enters the pleural cavity during inspiration and is not able to escape during expiration owing to the closure of the piece of tissue acting as a valve.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL CLINICAL FEATURES

1. Symptoms. Osler• outlines the features as follows: Pain and dyspnoea at the onset, aggravated cough with sputum, livid colour, feeble rapid pulse, sweating, respiratory distress with resultant unconsciousness and death within 24 hours. There may also be an insidious onset. Norris and Landis 2 speak of a sudden onset in 75 per cent. of the cases, with agonizing pain of stabbing or tearing character in the side, marked dyspnoea and severe shock. It is obvious that both are referring to cases where there is a complete pneumothorax, although the features of sudden agonizing pain and sudden onset are noted in the case in question. Hirschboeck 12 mentions that it occurs without marked constitutional reaction which serves as an important feature in the differential diagnosis. The fast pulse rate is referred to by Thompson 11 • The symptoms may be entirely absent since at autopsy air has been found in the plural cavity in subjects who did not have any of the above symptoms, Beale8 • 2. Signs. It is important to remember that the findings are dependent on the size and extent of t he pneumothorax. As in the present instance there may be only slight diminution in the breath sounds, slight increase in resonance and decrea ed vocal fremitus. In a more extensive case there is noticeable shifting of the viscera to the unaffected side, liver and spleen may be down, interspaces may be· obliterated or bulging, respiratory excursion may be decreased, affected side may be nyper-resonant, heart sounds may have metallic ring, succu:ssion splash may be heard and a bell-like ring when two coins are tapped together on the chest wall. 3. Diagnosis. Clinically the diagno is may be very difficult if the pneumothorax is only slight in extent. In such cases radiological examination is almost essential to make a complete diagnosis. When the process is complete t he history and phy ical findings may be sufficient to make a diagnosis, especially in a patient with active tuberculosis. 4. Differential diagnosis. (a) Emphysema. With this condition the resonance moves up and down with the respiratory excursion. History and x-ray will rule it out. (b) Massive collapse of the lung may be differentiated by the fact that the mediastinum is shifted towards the affected side. (c) Pleurisy may be r uled out by the absence of constitutional reaction, friction rub, and history. (d) Other conditions which might give rise to difficulty are large cavities, diaphragmatic or congenital hernire. 5. Prognosis. Osler• gives the mortality at 70 per cent. A patient with tuberculosis may live for a few weeks. There are cases in which the spontaneous pneumothorax seemed to have checked the tuberculosis condition and resulted in an apparent cure. With spontaneous pneumothorax of the closed type the outlook is good although

SPONTANEOUS PNEUMOTHORAX

it may be followed later by tubercula is. The patient whose condition is here reviewed, seem to have made an excellent recovery. HirschBoeck12 say that the condition may recur. This leads to t h e query as to whether the history as given by the patient of previou attacks of pleurisy may not possibly have been pontaneous pneumothorax. Palmer and Taft6 set the period of recovery at f rom two weeks to two months. TREATMENT

Osler1 advised the follow~ing :-Re t in bed, suppression of cough, avoidance of deep inspiration by strapping and, if fluid is present, leave for two weeks. If dy pnoea is extreme, as with the valvular type, thoracente i i indicated. With the formation of a pyopneumothorax drainage is instituted. Thus it is apparent that with a mild ca e the treatment is essentially that of pleurisy. With extr eme shock measures should be taken to support the patient. Later J enkinson3 advise the u e of blow-bottles to help expand the collapsed lung. SUMMARY

1. A ca e of spontaneous pneumothorax of the closed type has been reviewed. 2. The etiology, pathological anatomy, clinical features and features have been discussed with reference to current literatur e and standard texts. I wish to thank Dr. D. D. Fergu on for his kindly help in r eviewing this ca e with me, Dr. G. N. McNeill for his co-operation with the x-ray examinations, and Dr. J. W. Crane for hi able a sistance in revising the manuscript. BIBLIOGRAPHY IQsler-McCrea-"P r inciples in Practice of Medicine". 11th Edition, 1930, page 679. 2Norris and Landis-"Diagnosis of Respiratory Diseases". 4th Edition, 1929, p age 693. 3Jenkinson, E. L.-Am. J. Roentgenol, 25-237, February, 1931. ~Stoloff, E. G.-Am. J. fed. Sc., 176-657, November, 192 . "Browder, J.-Am. J. Surg. 8-415, 1929. GPalmer, J. P. and Taft, R. B.-J. A. M. A., 96-653, February 2 , 1931. ' Page, G. P.-Lancet 1-22, January 3, 1931. ~ Beale, J. R.-Brit. J. Tuber., 25-21, January, 1931. o tein, J.-Am. J. Dis. Child., 40-89, July, 1930. lOWest, S.-Lancet, 1-791, 1884. llThompson, H. E . .S.-Lancet, 2-791, October 11, 1930. t2Hirschboeck, F. J.-Ann. Int. Med., 4-705, January, 1931.

JOHN FREIND (1675-1728) During his confinement in the Tower on the charge of high trea on, Freind planned hi "History of Phy ick from the Time of Galen to t h e beginning of the Sixteenth Century"-the first history of medicine written by an Englishman.

A Study of Mental ,Disorders Occurring in Relation to Childbirth. D. O'GORMAN LYNCH, M.D., C.M.

Medical Superintendent, Ontario Hospital, Penetanguishene childbirth may be looked upon as a normal phy iological W HILE process, yet from time to time the general practitioner is confronted with patients showing definite reactions of an abnormal nature, namely the appearance of mental symptom . The diagnosis of 路a mental dfsorder during pregnancy is not always easy, e pecially when the symptoms are merely an accentuation of the ordinary longings of pregnancy, minor personality changes and emotional outbursts. Physicians expect such whims and peculiarities, knowing that most of them usually disappear a pregnancy advance or, at the late t, after the confinement. However, when such variations lead to abnormalities of speech, of conduct and behavior, then the problem become a more seriou one. The danger of uicide must never be forgotten, hence the question of institutional care has to be carefully considered. In the p ychiatric literature of earlier year it was the custom to clas ify as a definite clinical entity, insanity of pregnancy, in anity of puerperium, of lactation, etc., these names not denoting any particular type of reaction but rather a convenient means of a ociating the mental picture with the special time or period in the woman's life. In this present day, however, the generally accepted view is that there is nothing distinctive which differentiates the mental disorders of pregnancy and the peurperium from the corresponding types of p ychoses at other epochs in life. Thus we may have paranoidal or depre sive trend throughout pregnancy, maniacal or guilt reactions after childbirth, catatonic, hebephrenic, delirious or even toxic manifestations appearing. Before con idering in detail the various psychoses encountered, the question of etiology will be briefly discu ed. With regard to the causation of psycho es a ociated with childbearing, there are many factors to be considered, perhaps the mo t important being a neuropathic heredity. We see the e p ychologically unstable women break down when home and environmental condition appear the best. Hence their psychic reaction during pregnancy, when great emotional conflict and stress are such features, are not to be wondered at. Earlier mental disturbances are liable to recur at such times and persistent insomnia may be the forerunner of a profound exhau tion. Toxic factor , the exhau tion following a long and painful labor, the knowledge that the child is illegitimate, desertion or death of husband are also etiological considerations.

Interest in the problem was stimulated while at the Ontario 82

-------------------------

MENTAL D ISORDERS IN RELATION TO CHILDBIRTH

Hospitals in Whitby and Brockville. After observing a number of these patients, and following their progress, an examination was made of the clinical records at Brockville for the years 1910 to 1930 inclusive. During this period 3,923 patients were treated in the Brockville Hospital, of whom 1,921 were women. Of these there were 55 whose mental disturbance was associated with pregnancy and the puerperal state, the percentage of such psychoses to all other forms of mental disorder being 1.12 per cent., the relative occurrence among women patients alone being 2.8 per cent. AGE INCIDENCE AND NUMBER OF PREGNANCIES

The age limit among this series of 55 patients varied, the youngest being 17, the oldest 46. Approximately 40 per cent. developing a psychosis were between the ages of 26 and 30. The following table indicates the age incidence at the time patients came to hospital for treatment. Ages Ages Ages Ages Ages Ages Ages

15 21 25 31 36 41 46

to 20 to 25 to 30 to 35 to 40 to 45 years

years........ .......................................... 5 patients years.................................................. 6 patients years.................................................. 20 patients years.................................................. 11 patients years.................................................. 6 patients years ......................:........................... 5 patients and up...... ........................................ 2 patients

While mental illness associated with the birth of the first child was found in a great many instances, yet there were psychoses with the second, third, fourth, fifth and even the tenth confinement. Of this series 20 were primipara, 9 had 2 pregnancies, 6 had 3 pregnancies, 7 had 4 pregnancies, 2 had 8 pregnancies, and 1 had 10 pregnancies. In only three instances was there a history obtainable of previous attacks of mental disorder associated with former pregnancies. Of these, one patient was reported as having had attacks of depression with three previous confinements. Of the two others, each had one previous psychotic attack, patients were said to have exhibited peculiarities at former childbirths but a s they were of short duration and hospitalization did not become necessary, we can hardly regard them as being psychotic episodes. There were five single women who gave birth to illegitimate children. Two of them were depressed, one developed maniac excitement, and two showed toxic symptoms. HEREDITY

The heredity factor was prominent in our series, because 20 patients, or 36 per cent., gave a history of family mental disease. In seven patients there was a history of parental over-indulgence in alcohol. The incidence of defective heredity as might be expected was higher in the Dementia Praecox (Schizophrenia) than in the Manic, the depressed or the toxic reaction types. Neuropathic heredity was shown to be present in 14, or 61 per cent., of the 23 dementia praecox patients, in 4, or 22 per cent., of the manic depressive patients, and lowest of all in the toxic series, 13 patients, in which 2, or 13 per cent., showed an hereditary taint.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL TYPES OF P SYCHOSES ENCOUNTERED

Clinically, we can classify the psychoses into three main groups, the manic depressive group, the dementia praecox group, and what we shall call the toxic exhaustive group. This last group is now classified by the American P sychiatric Association as "psychoses with other somatic disease." There was also one case of epilepsy. The following table indicates the classification, the type of psychoses, and the number of cases. Psychosis 1. Manic Depressive Insanity

2. Dementia Praecox 3. Toxic Exhaustive Group 4. Epileptic Psychosis

Type Number Manic .............................................. 7 Excited ........................................... . Depressed ....................................... . 11-18 Hebephrenic .................................... 4 Paranoid ......................................... . 5 Catatonia ....................................... . 14-23 Exhaustion .................................. .. Delirium ........................................ .. 3 Toxic infective type ....................... . 10-13 Grand Mal .................................... .. 1- 1

ONSET AND APPEARANCE OF MENTAL SYMPTOMS

The time of appearance of mental symptoms varied considerably. Four patients showed definite mental symptoms during the latter months of pregnancy, 20 patients became psychotic within a week of the confinement, eight within two weeks, seven within two to four weeks, six within four to eight weeks, eight within two to four months, and two in whom personality changes were noted shortly after childbirth. The last two did not develop marked mental symptoms until four to six months afterwards. The majority of the toxic exhaustive psychoses developed within seven days with a sudden onset in all but two. With the manic depressive group, t he onset was sudden in eight cases and gradual in ten, the period for development of 路mental symptoms being two to five weeks after childbirth. With the 23 dementia praecox patients the onset was gradual in 17 and sudden in six patients, the symptoms appearing up to six months after childbirth. SYMPTOMATOLOGY

In reviewing the case records, the symptoms presented by the various patients were more or less constant. The manic patients showed excitement, elation or irritability and over-talkativeness. The depressions were gloomy and sad, showed outbursts of crying alternating with periods of agitation, difficulty in thinking, slowed speech and action; delusional ideas of guilt and unworthiness, and suicidal tendencies. The dementia praecox patient s showed varying degrees of mental reduction, from indifference to extreme dementia. In the paranoid types the persecutory delusions were specially marked. The husbands were looked upon with suspicion, in two cases delusions of marital infidelity were expressed and two claimed the child was not theirs. The catatonic types were given t o periods of excitement and

MENTAL DISORDERS JN RELATION TO CHILDBIRTH

destructiveness, alternating with stupor during which they were mute, negative and resistive. Habit disorders were common in the catatonic and hebephrenic patients, the hebephrenics being silly and childish and showing severe grades of dementia. Hallucinations and delusions were common to all forms of dementia praecox. The toxic exhaustive group, which was probably the most interesting, showed extreme restlessness, varying degrees of confusion, rambling incoherent conversation, fearful and fantastic delusions, changeable dream-like hallucinations especially when fever was high, signs of dehydration, etc. In these delirious types it is not uncommon to see patients showing a typical manic reaction one day and later pass into a stuporous state simulating catatonia. OUTCOME OF PATIENTS

Considering the entire group of 55 patients, 34, or 62 per cent., were discharged, improved or recovered, 9, or 16 per cent., remained unchanged or were sent to Houses of Refuge, while 12, or 22 per cent., died. The following indicate the outcome of the various psychotic patients considered in their respective groups. (a) Manic Depressive Group: Of the 11 depressed manics, seven recovered and were discharged, and four died of exhaustion. Of the seven excited manics, six recovered and were discharged, and one died of exhaustion. (b) Dementia Praecox Group: Of the 14 catatonic patients, seven were di charged as improved, three still remain in hospital, three died of pulmonary tuberculosis, and one of pneumonia. The hebephrenic patients were four in number; one improved and was discharged, one was deported to Scotland unimproved, while two still remain very demented in hospital. Of the paranoid patients, which were five in number, one improved and was di charged, two were sent to Houses of Refuge unimproved, on~ died of cerebral haemorrhage, and one died of septicemia. (c) Toxic Exhaustive Group: Of the 13 toxic exhaustive patients, nine made a complete recovery and were discharged, three died of puerperal septicemia, and one died of exhaustion. Regarding the average tay in hospital of patients who recovered or improved sufficiently to be cared for by their relatives at home, we find that the taxic exhaustive group had the shortest and the dementia praecox group the longest stay in hospital. The following table indicates the average period of hospitalization: Toxic Exhaustive Group .......................................... .. 3% months Manic Depressive, Manic........................................... . 7 months Manic Depressive, Depressed .................................. .. 11 months Dementia Praecox, ~u types .................................... .. 38 months SUMMARY

1. Of 55 patients whose mental illness was associated with childbearing, 23 were cases of Dementia Praecox, 18 of Manic Depressive

UNIVERSITY OF W ESTERN O NTARIO MEDICAL J OURNAL

Insanity, 13 of the Toxic Exhaustive type, and 1 patient was an Epileptic. 2. Forty per cent. were between the ages of 26 and 30: series, 20 patients were primipara.

Of this

3. Defective heredity was present in 36 per cent., and in 50 per cent. there was a family history of mental di ea e or alcoholism. The hereditary factor wa greate t in the Dementia Praecox patients and lowest in the Toxic Exhaustive reaction type. 4. Twenty-eight, or 52 per cent., became insane within two week of confinement. 5. Of the total series, 62 per cent. were discharged improved or recovered; 16 per cent., chronic dements, are still in hospital; and 22 per cent. have died. The highest recovery rate was in the Manic Depressive and the Toxic Exhaustive group. 6. The Toxic Exhaustive patient had the shortest and the Dementia P raecox patient the longest stay in the hospital, the mortality rate being particularly high-30 per cent.-in the former group.

A FEW POINTS WE ARE APT TO FORGET IN AN EMERGENCY Drowning.-No time hould be taken to roll the patient on a barrel. If possible, the body should be laid with the head and chest lower than

the feet. Waste no time in an effort to empty water out of him. Start resu citation at once. Electric Shock.-lf the victim is still in contact with the current, carefully free him. To remo e the electrical conductor, use a dry nonconductor such as wood, or a rope, a cloth, or rubber glove -never metal. Never gra p the conductor. If the victim's clothing is dry, grasp it and drag him away, but do not touch his bare skin. The rescuer stands on a dry board, and u es one hand or foot. If breathing has stopped, sta1路t resuscitation immediately. Gas Poisoning.-Never enter a deadly atmosphere without the protection of a mask, or in an emergency a life-line held by an assistant. A cloth over the no e and mouth is usele s. The victim hould be dragged or carried to fresh air, preferably not to cold outside air. If breathing, do not walk the patient about. If not breathing, begin resuscitation at once. In all three cases, speed is essential.

Royal College of Physicians and Surgeons of Canada DR. F. N. G. STARR, PRESIDENT

of long ago in Canada practically every doctor began life I Nasthea days general practitioner. As practice developed he began to discover that he was more intere ted in one line than in another. As soon as his purse began to show signs of bulging, he would go abroad to do some intensive po t-graduate study and practical work in his chosen specialty, returning to work as a " pecialist". In later year tudents have frequently decided during their college courses what is to be their cho en line, whether fitted or not. Upon graduating they begin their future training for. this special work by trying for a ho pital post in some special cour e. Failing this they proceed to some large clinic a onlookers for from two weeks to three months, endeavoring to learn "more and more about le and less". The question of improving the state of affair has been under consideration by the Canadian Medical A sociation for many years, culminating in the formation of the Royal College of Phy icians and Surgeons in June, 1929, when the College received a Royal Charter. It is propo ed that the standard of examination for the College shall be of the highe t and that the diploma obtained will stand for the best that is to be found in medicine, surgery and its allied branches. It is important that student should take the primary examination during their college course, when their anatomy and physiology are still fresh in their minds. Then when a few years later they have decided upon the line of work they intend to follow, they will be in a position to seek the diploma by taking the Final Examination. It is hoped that the various universities in the Dominion will arrange intensive courses of study in order to prepare their undergraduates, as well as their graduates, for these examinations.

Dr. Irving S. Cutter, dean of the Faculty of Medicine of Northwestern University, on June 7, 1931, announced at an alumni dinner t he development of neutral ga tric mucin. This development is the result of five years' research by Dr. Samuel J. Fogelson and his assistants in the department of experimental surgery. Neutral gastric mucin is obtained from gastric muco a of hogs. This preparation is found to be effective in treatment of ga tric ulcers. Dean Cutter ays in his addres : "While it is too early to make definite announcements, it seem probable that gastric mucin will play a c~nsiderable part hereafter in the management of ulcer condition." 87

UNIVERSITY OF WE TERN ONTARIO MEDICAL JOURNAL

1. When Death lurks at the door, the physician is considered as a God.

2. When danger has been overcome, the physician is looked upon as an angel.

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

3. When the patient begins to convale ce, the physician becomes a mere man.

4. When the physician asks for his fees, he is considered as Satan him elf.

-Courtetty of

ova Scotia Medical B ulletin.

Ambroise Pare (1510--1590) J. D. ROGERS, M.D.

PARE started life, humbly enough, in a little village of A MBROISE France. The year of his birth is a subject for dispute, and his early history is fragmentary, and somewhat legendary. He was surrounded from childhood by relative of medical inclinations. Indeed, his father was a barber, his brother-in-law a master barber-surgeon, and his own brother "a righteou fellow" who won great renown for exposing the frauds of beggars who hammed di ea es and deformities, to arouse public sympathy and donations. Among the various quaint traditions of his youthful days, we have the information that Pare's father put him to board with a chaplain in order that he might learn Latin. Behind the shadow of the kindly church it seems that the boy learned a little Latin, and some gardening. His determination to become a surgeon found birth with witnessing of a lithotomy. The surgeon's kill and t he general dramatic effect so impressed him, that he left at once for Paris, to study surgery under the best masters available. Here he became an apprentice to a barbersurgeon. Pare found the medical profession in Paris divided into three distinct cia ses, in the order of their importance, The Physicians, or members of the Faculte de Medicin, the Surgeons, and the Barber-Surgeons. Pare used as text-book those which had been translated into French especially for students of surgery. A a barber-surgeon's apprentice, he had to perform many menial ta ks, undoubtedly di ta teful to him. We find this pha e of his career di creetly omitted both in his own memoirs, and in the notations of hi admirer . He obtained a position in the Hotel Dieu, corresponding to modern resident surgeoncy. The Hotel Dieu was the sole public hospital in Paris. It admitted the injured and tho e ick with ordinary disea es, as well as the victims of various epidemic di eases invading Paris from time to t ime. He spent three years here, and four years in another hospital, gaining invaluable experience. As a result of his cramped financial condition, Pare, in 1531, went in the army as a military surgeon, as the only means open to him. He had not passed his barber-surgeon examinations and could not legally practice in Paris. From now on, we know much of his life and personality from his own writing . When he wa twenty-eight years of age, a volume bearing the followi ng t itle appeared: "The Manner of Treating Wounds Made by Arquebuses and other Firearms, and those by Arrows, Darts, and the Like; and also by Burns Made Especially by Gunpowder." On his first campaign Pare made the great discovery that revolutionized the treatment of gunshot wounds. He found that boiling oil was of no benefit, but actually harmful. In his own words: "That night 90

AMBROISE PARE

(1510-1590)

I could not sleep at my ea e, fearing that by lack of cauterization I would

find the wounded upon which I had not u ed the boiling oil, dead from the poi on .... I found tho e to whom I had not applied the dige tive medicament feeling little pain, their wound neither swollen nor inflamed, and having lept through the night. The others to whom I had applied the boiling oil were feverish, with much pain and swelling about their wound. Then I determined never again to burn so cruelly the poor wounded." On thi journey he met a urgeon who claimed to po sess an invaluable balm for dre sing wound made by arquebu es. As he was always eager to obtain new treatments regardles of their source, he discovered that the wonderful recipe consi ted of newborn puppies boiled in oil of lilies, mixed with earthworm prepared with oil of Venice. Having met an old woman who advi ed him to try raw onion and alt for burn , he promptly used the remedy, continuing it application in many cases. In 1541, Pare married Jeanne Mazelin and lived for many years in Paris on the left bank of the Seine, where he acquired a good deal of property. It i intere ting to note that both Rabelai and Montaigne were hi acquaintance . An amu ing narrative is given by both Montaigne in hi "E say " and Pare in his book on "Monsters". It may be aptly told in the inimitable tyle of Montaigne: "AU the inhabitants of a certaine towne have knowne and eene a woman-child until she was two and twentie years of age, and called by the name of Marie. He was, when I aw him, of good year , and had a long beard, and was as yet unmarried. He saith, that upon a time leaping, and training himself to overleap another, he wot not how, but where before he was a woman, he suddenly felt the in trument of a man to come out of him; and to this day the maidens of that towne and countrie have a song in use, by which they warn one another, when they are leaping, not be straine themsel es overmuch, or open their legs too wide, for fear they should be turned to boys, as Marie Germaine was." Returning, in 1552, from a campaign in Germany, Pare amputated an officer's leg by hi new method, u ing the ligature instead of hot irons to check the hemorrhage. Say Pare in hi book on "Wounds", "I dressed him, and God healed him." He (the officer) returned home gaily with a wooden leg, saying he got off cheaply without being miserably burned to staunch the bleeding. In hi de cription of the operation, he gives as authoritie for the use of the ligature, Hippocrates, Galen, Avicenna, Guy de Chauliac, Monsieur Hollier, Calmetheus, Celsus, Ve alius, Jean de Vigo, Lagault, Pierre de Argellata, John Andreas, and d' Alechamp. He wa criticized for refu ing to change pla ters frequently in treating an ulcer; his insistence that it wa more advisable to change the plasters but once a day, was typical of his independence of thought, as the custom of frequent changes wa inveterate and deeply rooted among contemporary physicians. His fame reached the ears of Antoine de Bourbon, later the King of Navarre, and he sent for Pare, and a ked him to go with him as

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

surgeon on an expedition he was leading into Picardy. Pare's popularity with the French army was highly unusual for a noncombatant. We find increditable incidents here and there of an otherwise admirable character. While watching the enemy pitch camp on one occasion, he requested the commi ary of the artillery to end a cannon shot amongst a group of idlers. The shot was fired, killing fifteen or sixteen. This behavior is fittingly commented on by one of hi biographers: "He lived at a time when t he Christian theology wa upreme, and much was heard of the wrath of God, but naught of the Brotherhood of Man." As a result of his excellent work in this campaign he was taken into the service of the king as one of his urgeons. In 1554, when he was fortyfour years old, he was made member of the College of Saint Come, thereby becoming a urgeon of the long robe, instead of a barbersurgeon. The surgeons of Paris were anxious to have a man of such prominence among themselves. In 1562, Pare accompanied Charles IX to the sieges of Bourges and Rouen. At the latter, the mortality among the wounded from infection was very great. It was during this siege that Pare discovered that the use of oil made from puppie , as a dressing forgunshot wounds, did not give results as good as the dre sing of the wounds with Egyptiacium, a preparation made with honey and alum. Later he used a dressing made with turpentine and brandy. While journeying through France with the entire French court on a political campaign against the Huguenots, he was bitten by a viper had an opportunity to study the plague, and learned how the inhabitants caught whales. He was per uaded at this time by Catherine de Medici to write a treatise on the plague, smallpox, and measles. He stated in this publication that bonfires of aromatic woods, such as juniper and pine, should be made in the treets to purify the air. He recommended that surgeons called to attend patients sick with the plague should first be purged and bled, and then have two issues made, one on the right arm, the other on the left leg, "As those who have open sores do not contract plague. They also hould wear a little sachet containing an aromatic powder, over the heart." His writings contain the most profound piety and he constantly speaks of death as a relief from the warfare of life. To use his own words, "Death is the fear of the rich, The desire of the poor, The joy of the wise, The fear of the wicked, End of all miseries, Commencement of the life eternal, Fortunate to the elect, Unfortunate to the reprobates."

Pare was living in Paris when the massacre of Saint Bartholomew was launched on the heads of the Protestants. Pare's religious belief

AMBROISE

PARE (1510-1590)

has been the subject of much dispute. A far as external forms of religion went, Pare was undoubtedly a Catholic, but his sympathies were with the persecuted sect. At the onset of the massacre, the king commanded Pare to stay in his chamber, saying it was not reasonable that one who was able to be of service to the whole world should thus be massacred. Pare was the single prominent Huguenot spared, and he did not even protest at the murder of his compatriots, accepting the divine right of the king. It is po ible that after the Ma sacre of Saint Bartholomew he decided that it wa wiser to become reconciled to the Catholic belief than to publicly profe s a religion which would have meant a loss of both his peace of mind and prosperity in his profession. The year 1573 marked the publication of Pare's surgical work containing his discussion on monsters, as well as a treatise on obstetrics. In the latter the innovation of artificial induction of labor was set forth. This method was employed on Pare's own daughter by Guillemeau twenty-five years later. It is curious to note Pare's deep faith in uperstitions of various types. With all his professional knowledge and remarkable good sense, we find P are firmly sub cribing to the belief that the king of France possessed the power of curing crofulous ores by the royal touch. He believed in astrology, spiritism, magic, witchcraft, and that devils sent diseases and aints cured them. He says that no one can doubt the existence of sorcerers, as he himself saw a sorcerer, who did marvelous things in the pre ence of Charles IX and his nobles. He writes of haying seen cures wrought by pells. "I have seen a hemorrhage checked by cer tain words spoken in Latin. I have seen the jaundice disappear from t he surface of the body in a s路ingle night by means of a little sachet suspended to the neck of the patient." He al o mentions having the belief that sorcerers cannot cure natural diseases, nor physicians cure the diseases caused by sorceries. Pare was a firm believer in the powerf ul effects of prenatal influence, giving many entertaining views in support of his opinions. He wrote at length on a subject which was open t o wide controversy among his contemporaries, namely, the changing of sex, stating the case of Marie Germaine, whom we have mentioned before. If his attempts at wit are a bit ponderous, we may attribute the condition to the time in which he lived. As an example, in writing of a lopecia, Pare ays, "If it is due to s~rphi lis, the patient should be rubbed (with mercurial ointment) until he enter the kingdom of Bavaria (a play on the French word 'haver', to salivate). P are's wife died in 1573, and three months later he remarried. To quote Packard in his "Life of Pare" : "By his second wife, Pare had six children, although he was ixty-four years old at the time of the marriage." We shall not indulge even in the inflection of an eyebrow, considering Packard's "although" as ample tribute. At this time he suffered a good deal from the antagonism of the Faculte de Medicin. This

UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL

body of worthies resented t he rise of the barber-surgeon and wished to have his publications banned, declaring them to be injurious to the morals of the community. This statement was based on the fact that they were written in French (and rather ungrammatical) that might be read and understood by t he laity. Contrary to the secretive methods of his contemporaries, he published all his newly acquired knowledge. He devoted a number of pamphlets to his own defense, and his general prosperity does not appear to have been affected by the ill will of his enemies. At the age of seventy he wrote a discourse on mummy and unicorn's horn. Mummy was a resinous substance supposed to be made from Egyptian mummies. Unicorn's horn was said to be derived from the animal. As a matter of fact, it was generally made from rhinoceros or elephant's t usks, and was sold for an enormous price. Pare boldly states that decomposed bodies are inconceivable as remedies, and as to unicorn's horn, he reports t hat there is no proof ~s to the existence of such an animal. He quotes Hippocrates and Galen, showing that these authorities made no use of it. His last days were spent administering to the victims of the famine resulting from the blockade of Paris by Henri IV, in which hundreds of people died daily of starvation. Pare died in Paris at the age of eighty, and was buried in the church of Saint Andre des Arts. To summarize his chief contributions to science,-besides establishing the use of emollient dressings instead of cauterization for wounds, and the use of the ligature, he was eminent as a syphilologist, he employed the speculum for examining vaginal and uterine venera! infections, and made the first detailed communications of hereditary syphilis. He also discarded the frequent dressing of ulcers, and castration in the so-called radical operation for hernia. He was the first surgeon to habitually employ trus es. He invested numerous instruments including feeding bottles for artificial nourishment. He was the first to use direct excision of the so-called loose cartilages in the joints. He practiced amputation of the leg at the point of election, and used podalic version. In concluding this glimpse into his colorful scientific and personal life, we may honestly attribute t o him the title of father of modern surgery. REFERENCE Packard.- Life and Times of Ambroise Pare. (N.Y., 1921.) Robinson, ÂĽ.-Pathfinders in Medicine. ( Pp. 99-122, N.Y., 1929.) Confessio Medici.-(Pp. 58-68, p. 97, London, 1909.) New York Times Literary Supplement.-"A Great French Surgeon." (Oct. 5, 1922.) New York Times Book Review and Magazine.-"When Boiling Oil Cured Wounds." (October 23, 1921.)

He that studies books alone will know how things ought to be; and he that studies men will know how things are.-Colton.

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Symptoms and Treatment of General Paralysis KENNETH

M. LINDSAY, M.D.

Buffalo State Hospital

i not the purpose of this paper to discuss in detail the well-known I Tcharacteristic symptoms of general paralysis; the early symptoms only will be stressed. It is in the early stage of the disea e wher e difficulty in diagnosis arises and it is early in the disease that t he best results are obtained from the present treatment. The treatment used at the Buffalo State Hospital will be outlined more or less in detail for the benefit of those who care to follow it in the treatment of their cases. More and more frequently we are receiving requests for malaria blood froll} physicians who are handling early cases without subjecting these cases to a state hospital residence. White' divides the mental symptoms of general paralysis into (1) paralytic dementia, the fundamental symptom, which is the direct result of the de truction of brain tissue and (2) paralytic psychosis which consists of various symptoms of mental disturbance engrafted upon this demented background. The early symptoms are, therefore, those of beginning dementia, manifesting themselve as gradual changes in character and failure in mental powers. The individual, heretofore always capable and diligent, now fails to continually apply himself to his work. He fails to hunt up new business. Any mental work brings fatigue. His memory is not as good as formerly. He forgets details of his business and neglects important engagement. He begins to show poor judgment and risks his whole life's savings on some worthless speculation. Too often do we hear of a man who has mortgaged his home, spent the money on hair brain schemes or debauchery unknown to his wife, and later when he is a patient in a mental hospital and he, himself, can perhaps be excused for his folly, the home is lost and his wife and children are left pennile s and destitute. The well-groomed individual now begins to neglect his per sonal appearance. He wears soiled linen or forgets his tie. His morale is apt to undergo a change. A previously sober church-going man may begin to drink to excess and to associate shamelessly with lewd women. The dementia may, however, not present itself so definitely. It may be necessary to study carefully the man's actions to bring out the earlie t symptoms which are increased restlessness, occasional fits of violent rage, and slight lapses of memory. Developing upon this demented background a r e the following five types of paralytic psychosis. The demented type shows a gradual 95

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deepening of the symptoms given above. The expansive type is marked by ideas of grandeur, psychomotor pressure, and euphoria. The agitated form which runs a rapidly fatal course shows extreme restlessness, confusion, and delusions which are rapidly changing. The depressed type is marked by depression with retardation or anxiety. The delusions take the form of hypochondriacal ideas. The paranoid type shows ideas of persecution without any great mental tension defect (i.e. defects in thinking ability and concentr ation). Cases with marked grandiose ideas are less likely to be overlooked than those showing depression of paranoid ideas. Of the physical signs the ocular-motor and tendon reflex abnormalities are the most important. The Argyll-Robertson pupil occurs early in about fifty per cent. of cases, while a sluggish reaction to light occurs in about twenty-five per cent. of cases. Berkley 2 states that even earlier than the Argyll-Robertson pupil there is a loss of consensual reaction. The pupils may show irregularities and may be myotic, mydriatic, or unequal. Fleeting ocular palsies may be present. Optic atrophy may sometimes occur, but it is more common in tabes. The deep reflexes are generally increa ed but may be dimished, lost or normal. The abdominal may be dimished or absent. The Babinski sign is occasionally present. The ataxic speech so characteristic later in the disease shows its beginnings early, if searched for carefully. At this stage occasional defects or hesitancy in single words may be noticed. Often if test phrases are combined into sentences the slurring is more apparent. The writing may be tremulous and show transposition or doubling of letters. The face will show a smoothing out of the features with fine tremors of the lips, tongue, and eye-lids. A coarser tremor of the fingers is often present. If spinal cord changes are extensive the picture is one of tabo-paresis with ab ent knee jerks, Romberg sign, and bladder disturbances. Convulsive seizures1 may be the first indication of the disease. They may resemble epileptic attacks or apoplectiform paralytic attacks. General paralysis should always be considered where epileptic attacks begin in middle life. Trauma to the head may occasionally precipitate the disease. The laboratory findings are well-known. The blood will show a positive Wassermann or Kahn reaction. A negative blood, however, will not rule out general paralysis as there are cases having extensive arsenical treatment in which the blood has become negative. The spinal fluid Wassermann is positive in practically one hundred per cent. of the cases. There is an increase of from ten to one hundred in the lymphocytes and an increase in the globulin. The colloidal gold curve is typically paretic. Following the work of Wagner Von Jauregg the treatment of general paralysis with malaria was begun at the Buffalo State Hospital

SYMPTOMS AND TREATMENT OF GENERAL PARALYSIS

in August, 1924. Since that time a total of 524 patients have been treated by this method. The benign tertian type of malaria organism has been used. The technique of inoculation is very simple. About 0.5 c. c. of warm sterile solution of two per cent. potassium citrate is drawn into a syringe. Three or four c. c's of blood is then withdrawn from a patient having malarial paroxysms. This blood is injected immediately intramuscularly or preferably into the median basilic vein of the patient to be treated. If the blood is kept reasonably warm and shaking is avoided the inoculation may be delayed for several hours. "Inoculation malaria" is not tran missable by mosquitoes 3 â&#x20AC;˘ The incubation period is from two to five days when the intravenous method is used. During the first one or two chills the temperature rarely rises above 103Â° F ., the sub equent paroxysyms are usually more severe, the temperature often reaching 106Â° F. The care during the treatment varies little from that carried out for any febrile disease. Tincture of digitalis is given where there is any special need for precaution. It has been our custom to limit fluids during the paroxysms to allow the temperature to reach it maximum. A sedative i often necessary for very agitated patients, particularly when there i difficulty in keeping the patient in bed. Increased restles ness, new mental symptoms in the form of paranoid ideas, and neuralgic pains in the extremities, are often encountered during treatment but these should not be con idered as indications to terminate the malaria. Herpes labiali frequently appear abo,!lt the eigth or ninth chill. Our patients are allowed twelve to fourteen paroxysms. Quinine sulphate, grains x, three times daily is then given for ten days. If the patient receives his first full days quinine the paroxysms usually terminate at once. Whenever the occasion arises where it is necessary to cease the treatment immediately, quinine dihydrochloride 0.65 grams is given intravenously. The patient will often show a loss in weight of ten pounds while on treatment but the increase is rapid during convale cence. One case in the past year, although inoculated three times, failed to have paroxy ms. A few others, particularly negroes and those who have had malaria therapy previously, produced only low temperatures or infrequent paroxysms which had a tendency to cease spontaneously. Many deteriorated patients, where there has been little chance of improvement, have been inoculated in order to keep the malaria strain alive. The complication most frequently noted during malaria therapy are enlarged and tender spleen and. liver with jaundice and active convulsions. Les frequently broncho-pneumonia, cardiac decompensation, and a hemorrhagic cysto-pyelitis appear. Since December, 1928, all ca es have been receiving tryparsamide intravenously. The patient is started on his first course of tryparsamide

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as soon as be has recuperated from his malaria. Three grams of tryparsamide are given once each week for twelve weeks. The patient is then allowed a rest period of from six weeks to two months and the second course is begun. These courses should be repeated frequently for three to five years. Solomon and Epstein• state that it is only the exceptional case of general paralysis in which a definite improvement of the spinal fluid could not be obtained if tryparsamide is continued long enough. A few cases have received tryparsamide before being put upon the malaria therapy. This has not affected the course of malaria in any way although it has been frequently stated that these cases do not do as well. Neither does the statement that it is dangerous to give arsenical products after malaria hold true. We have not bad any cases which have shown ill effects. Occasionally a patient shows intolerance to the drug. This is marked by fever, sweating, and nausea. In the past year we have had two cases which showed an exfoliative dermatitis, one of which was quite severe. Damage to the optic nerve occasionally occurs but the percentage is not high. The combined treatment as described above appears to give the best results. This is also the opinion of Solomon and Epstein• and of Hinsie and Blalock5 • Our statistics show that one year after treatment with malaria, twenty-six per cent. of the cases showed complet e remissions, twelve per cent. partial remissions, twenty-two per cent. improved, twenty-six per cent. did not improve, and fourteen per cent. died. The complete remissions showed no change in the serology. Three or more years after treatment 7 only seventeen per cent. were in complete remisisons. This tendency to relapse is always present when there are positive spinal fluid findings. Repeated courses of tryparsamide will tend to produce a negative serology and limit the number of relapses.

BIBLIOGRAPHY lWhite, Wm. A.-"Outlines of Psychiatry." 12th edition. Was.h ington; Nervous and Mental Disease Publishing Company, 1929. 2Berkley, H. J.-"A Treatise on Mental Diseases." New York; Appleton and Company, 1900. 3Lewis, N. D. C.-"Malarial Inoculation for General Paresis." J. Nervous and Mental Disease. 61: 349, 1925. 4Solomon, H. C. and Epstein, S. H.-Tryparsamide in Neurosyphilis." New York State. J. M. 31: 1014, 1931. 5Hinsie, L. E. and Blalock, J. &.-"Treatment of General Paralysis." American Journal Psychiatry. 11: 545, November, 1931. GLevin, H. L.-"The Results of Malaria Treatment of Paresis" with special reference to the various clinical types. New York State, J. M., May 15, 1928. 7Stanley, A. M.-"The Present Status of 181 Cases of General Paralysis, Three or More Years After Treatment with Malaria." Presented before the Central

Neurological Association. Buffalo, New York, October, 1931.

Shoulder Dislocation -- A Method of Reduction R. S. MURRAY, M. D.

Stratford , Ontario or may not have experienced difficulty in the reduction O NEof amaydislocated boulder, but by the time enough ca e have been observed, both difficulty and facility will have been encountered. The following method will reduce the trouble orne cases to a minimum. Let u take for granted a proper diagnosi ha been made. Without anae the ia, have the patient seated flat on the floor. Standing behind the patient, take a firm gra p of the wrist and lift the arm outward and upward with traction until the arm is up in a vertical position. The dislocation will now be reduced. Place your free hand in the axilla and exert an upward pressure while lowering the arm to side. This may appear to the reader too easy to be true, but it can be accompli hed without much pain and so quickly that an anaesthetic is not required. A consideration of the anatomy involved reveals the fulcrum effects of the acromion process. The withdrawal of the head of the humerus through a rent in the capsule if such exist , a relaxation of the shoulder mu cles, and no entangling in tendon , commonly mentioned as predispo ing factor preventing easy replacement, are obviated. Should failure occur without an anae thetic, one can be administered, and similar teps taken, but \vith the patient in a recumbent position. In a group of nine cases, two required anaesthesia, one being unreduced over a period of forty-eight hour , and the other, a very muscular individual, reduced readily with the first manipulation under anaesthesia. One outstanding case wa a male weighing over four hundred pounds with a fracture dislocation. The di location reduced on first trial without anaesthesia, two men being required to lift the arm. The fracture also united, no other apparatus being used than a sling for the arm. Theoretically this procedure could evoke discussion and criticism but in practice it works very sati factorily. I have never seen any record of this method in the literature. If any reader should try this method or if any one has a series of case in which this method has been used, I would be plea ed to have his impre sions. I am indebted to Dr. Dalton Smith, of Mitchell, for the first demon tration. I believe that he ha u ed this plan of reduction for many years, having had it pas ed on to him by one of his predecessors. 99

A Case of Splenic Anemia. A. I.

DANKS,

M.D.

Calgary, Alberta

introducing the subject of splenic anemia it is probably W HEN as well to recall Osler's comprehen ive definition. He speaks of the condition as: "An intoxication of unknown nature, characterized by great chronicity, primary progre sive enlargement of the spleen which cannot be correlated with any known cause, anemia of the secondary type with leukopenia, a marked tendency to haemorrhage, particularly of the stomach, and in many cases a terminal stage with cirrhosis of the liver and jaundice. Mayo states of the condition : "Put in the form of an Hibernianism, incomplete knowledge is essential to diagno i . If we know the cause of splenic anemia it i not splenic anemia". The term Banti' disea e is understood as indicating the late tages of splenic anemia with cirrhosis of the liver, a cites etc. In presenting the following case of splenic anemia the differential diagnosi of enlargements of the spleen must be kept in mind, but can only be touched upon here. Such condition a ab ce s, infarcts, cy ts (para itic or otherwise), malignant disease, the presence of infectious di ea es uch as typhoid fever, malaria, tubercula is, syphilis and certain of the tropical diseases should be kept in mind, also the enlargements present in Hodgkin's disease and the leukemia . The enlargements of the spleen in childhood and the condition of Hemolytic Icterus should not be forgotten. J. W., female, aged 50, married, seven children all living, three miscarriages. Seen fir t on December 20, 1930. Had anemia when a girl 15 years old, appendix operation in 1919, menopause three years ago. Family history negative. She complains of pain, quite evere and aching in character, over lower left ribs towards the back. She states that she last felt well on her return from a year in England in 1928, where he had gone, hoping to escape ill effects of the menopause which had just tarted. On her return to Canada she weighed 140 pounds and has been losing weight gradually until she now weighs 109 pounds. During the past year she ha become weaker and thinner. Pains started in her back nine months ago and gradually became wor e. Although not continuous at first they developed into a con tant pain. Occupations requiring bending of the back made the pain much worse. She has never been in a tropical country. She is thin and anemic, eems to tire easily and has no cough. Her appetite is fair but he cannot eat much at a time, and is con tipated. She sleeps poorly. There is no jaundice and no hi tory of epistaxis or other bleeding. Her teeth are artificial and her tonsils are small and 100

A CASE OF SPLENIC ANE~1IA

101

give no trouble. The thyroid is normal, pulse 80, temperature 97.4, and resp. 18. Blood pre ure is 80-115. The heart is enlarged to nipple line; the sounds are very soft but there are no murmurs. Lung are normal. There is a palpable mass in the left side of the abdomen, which comes about an inch to the right of the midline in the upper part, and rather more than that in the lower part. Its lower border reaches to a finger breadth above Poupart's ligament, and its upper part disappears beneath the left ribs. It is apparently fixed and does not move distinctly with respiration. On percus ion it giyes a dull note and on palpation its right border pre ents a firm, rounded edge. A distinct notch i felt in it upper portion. The liver is apparently normal in size, and there is no ascites. Bimanual examination shows normal uterus and ovaries. No mass can be felt in the pelvis. Blood count made December 22, 1930: R. B. C.-5,640,000, Hb. 67 ~c , C. I. 0.8, W. B. C.-6,400, Polys 74%, Lymphos 21 % . After a week of re t and nursing, another blood count was taken on December 30, 1930, to rule out an aleukemic phase of a Leukemia : R. B. C.-4,768,000, Hb. 65 %, C. I. 0.7, W. B. C.-4,200, Polys 70 %, Lymphos 24 7{:, large Monos 3 % . Was erman is negative. Feces show neither bilirubin nor blood. Urine shows no bile and is normal in all respects. Blood platelets total 200,000 per cu. m. m. Icterus index is 21. Fragility test i slightly increa ed, reading 50 to 34. A diagnosis of splenic anemia (Banti) in the earlier stages was made, and surgery was immediately considered, to prevent, if possible, damage to the liver. The operation seemed somewhat formidable in view of the size and immobility of the spleen, due to what eemed to be adhesions, and due to the general condition of the patient. The possibility of x-ray was considered. The likelihood of its increa ing the probable adhesions was weighed again t it action in reducing the size of the pleen, diminishing the lo s of blood to the patient and against its possible arrest of splenic function, normal or abnormal. We hoped in this way to les en shock and reaction at operation. It was decided that the pos ibility of favorable effects outweighed the possibility of any unfavorable reaction. Three treatments of deep x-ray were given by Dr. W. H. McGuffin on December 29, 30, 31, 1930. There was quite a violent reaction following the first treatment, with chills and a feeling of faintness. This pas ed off by the following morning and did not recur to the same extent in the next two treatments. The blood reaction was severe. December 31, 1930 : R. B. C.-3,936,000, W. B. C.-2,800. Two weeks later, January 14, 1931: R. B. C.-4,896,000, Hb. 59c c, , W. B. C.-3,200, Polys 56 %, Lymphos 36 % . Pain in the lower left chest and back was relieved, and patient was able to take more food. January 28, 1931: R. B. C.5,120,000, Hb. 65 f1, W. B. C. 4,000, Polys 78 %, Lymphos 22%. She was eating, sleeping and feeling better. The spleen had reduced probably one-fifth in size and was now freely movable by pressure in the left flank, and it was at least three finger breadths above

102

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Poupart's ligament. The condition was more favorable and an operation was now arranged. On February 3, 1931, the blood picture was: R. B. C.-4,512,000, W. B. C.-3,000, Hb. 60 %, Polys 60 %, Lymphos 28. % The patient went into the Calgary General Hospital on February 5, 1931. On February 7, splenectomy was done. On February 11, 路blood picture was: R. B. C.3,296,000, Hb. 62 %, W. B. C.-6,800, Polys 72 %, Lymphos 18 % . On February 16: R. B. C.-4,224,000, Hb. 80 %, W. B. C. 7,400, Polys 62 %, Lymphos 28 %, and on February 22, the day before she was discharged to her home in the ambulance: R. B. C.-4,522,000, Hb. 79 o , W. B. C.7,800, Polys 64 %, Lymphos 28 %. With regard to the operation, one of her sons, after having his blood typed, was kept in readiness as a donor, but was not used. The outer third of the left rectus was selected for the incision, which extended from the costal margin to the lower end of the mass. A quick examination revealed the absence of adhesions, but I was unable to deliver the spleen. Cutting across the rectus gave better access, but it was only after cutting between clamps for an inch or two on the upper and lower ends- of the greatly enlarged lieno-renal ligament that it was possible to deliver the spleen. While ligaturing and dividing the gastro-splenic omentum, it was noticed that the weight of the spleen, which had rolled over the outer edge of the incision, was causing one of the veins to tear. This was clamped and precaution taken. The pedicle was ligatured in three parts and these were tied together by a second ligature. We were able to exclude the tip of the tail of the pancreas. Her condition on leaving the table was good. Bronchial irritation followed the anesthetic (influenza was prevalent at the time) and gave some concern for a day or two. Except for a small amount of serum in the wound the tenth day, she made an excellent recovery, and a month after operation was allowed to walk to the next room for meals. Her general condition was satisfactory. Lab. report on March 9, 1931 :-Diffuse fibrosis of the spleen. She has been seen several times during the year since her operation. She was able to take a motor trip to Vancouver in July without untoward results, but on her return home in August outdid her strength in attempting to care for her large family, and had renewed attacks of pain in the left chest following her doing the family washing. This would subside after a day or two in bed. A careful examination, including x-ray and blood examination revealed nothing abnormal. She was advised not to do any more washing, and as a result has had no further recurrence of pain. The patient is feeling well and gaining weight. SUMMARY

While splenectomy may vary from the most formidable operation, due to adhesions and dimensions, to the comparatively simple case, the value of the x-ray in reducing the size of the mass, prior to opera-

A CASE

SPLENIC ANEMIA

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tion, is to be considered. This would seem advisable in those cases which have no definite hi tory of an inflammatory condition of the spleen and are of very large size. The pos ibility of the x-ray increasing the den ity of the adhesions and making the following operation more difficult, is in any event open to question. The advisability of operation as soon after diagnosis as pos ible hould be emphasized.

This signboard was discovered in a Cornish village, England, and is now in the possession of the Horniman Museum, London. ROGER GILES SURGIN PARISH CLARK & SKULEMASTER. GROSER & HUNDERTAKER RESPECTABLY INFORMS LADYS & GENTLEMAN THAT HE DRORS TEEF WITHOUT WATEING A MINIT. APPLIES LACHES EVERY HOUR. BLISTERS ON THE LOWEST TARMS. & VIZICKS FOR A PENNY A PEACE. HE SELLS GODFATHER'S KORDALES. KUTS KORNS. BUNYONS. DOCTORS HOSSES. CLIPS DONKIES WANCE A MUNTH & UNDERTAKES TO LUKE ARTER EVERY BODIES NAYLS BY THE EAR, JOES-HARPS, PENNY WISSELS, BRASS ANELSTICKS, FRYINP ANS & OTHER MOOZIKAL HINTRUMINTS HAT GRATELY REYDOOSED FIGERS. YOUNG LADYS & GENTLEMEN LARNES THEIR GRAMMAR AND LANGEDGE IN THE PURTIEST MANNAR. ALSO GRATE CARE TAKEN OFF THEIR MORRELS & SPELLIN. ALSO ZARM-ZINGING TAYCHING THE BASE VIAL. & OLL OTHER ZORTS OF FANCY WORKS QUADRILS POKERS WEAZELS. & ALL COUNTRY DANCES TORT AT HOME & ABROAD AT PERFEKSHUN PERFUMERY AND SNUFF IN ALL ITS BRANCHES AS TIMES I CRUEL BAD I BEGS TO TELL EE THAT I HAS JUST BEGINNED TO SELL ALL ORTS OF TASHONARY WARE. COX. HENS. VOULS. PIGS AND ALL OTHER KIND OF POULTRY. BLACKIN-BRISHES. HERRINS. COLES. SCRUBBIN-BRISHES. TRAYKEL AND GODLEY BUKE & BIBLES. MISE TRAPS BRICK DIST. WHISKER-SEED . MORREL POKKERANKERCHERS. AND ALL ZORTS OF SWATEMAITS INCLUDING TATERS, SASSAGES AND OTHER GARDENSTUFF. BAKKY ZIZARS. LAMP OYLE. TAY KITTLES AND OTHER INTOXZZIKATIN LIKKERS. A DALE OF FRUIT, HATS. ZONGS. HAREOYLE. PATTINS. BUKKITS. GRINDSTONES AND OTHER AIT ABLES. KOWN & BUNYON ZALVE AND ALL HARDWARE. I HAS LAID IN A LARGE AZZORTMENT OF TRYPE, DOGS MATE . LOLLIPOPS. GINGER BEER MATCHES & OTHER PICKLES. SUCH AS HEPSOM SALTS HOYSTERS. WINZER SOPE. ANZETRAR. OLD RAGS BORT AND ZOLD HERE AND NOWHERE ELSE. NEWLAYD HEGGS BY ME ROGER GILES ZINGING BURDES KEEPED SUCH AS HOWLS DONKIES P A YROX. LOBSTERS. CRICKETS. ALSO A STOCK OF A CELEBRATED BRAYDER. ITAYCHES GOGRAPHY RITHMETIC COWSTICKS JIMNASTICKS AND OTHER CHYNEESTRICKS. GODE SAVE THEE KING E.

1Jn Jllemoriam LIEUTENANT-COLONEL THOMAS J. MURPHY, K.C. (1855-1932)

of Colonel Murphy, I Nwetheofpassing the Medical School feel very keenly the loss of a strong and greathearted friend, who won our regard because he made it a point to get acquainted with u and took a lively personal intere t in our activities, particularly tho e of research. Not a few will alway trea ure memories of hi warm and generou commendation. The writer recalls vividly an incident illu trating this human touch : the Colonel's dutie as member of the Mothers' Allowance Board of the Provincial Goverment not infrequently took him to Toronto, ild, on one of t hese occ&sion, in the summer of 1924, he went out of his way to attend a meeting of the British Association for the Advancement of Science, for the specific purpose of hearing a paper on a new scientific in trument by a member of our Medical School taff. Many other uch example could be cited. He wa always ready to acknowledge, by an appreciative word or letter, the reprints of scientific articles ent to him. The in pirational value of such encouragement by one of the most prominent of the Board of Governors can hardly be overe timated. He himself knew the meaning of struggle, for hi pathway to success had been neither easy nor smooth. This is not the place to narrate his invaluable services given so unselfishly to the University over a period of more than three decades, by which her po ition a a Provincial and Municipal In titution was established. To no one is her debt greater. Nor can we tell of the amazing activities of thi modest and genial Irish-Canadian, born of our own sturdy pioneer stock, in so many other walks of life. He was one who loved his fellow-men, and was a man of deeply religious convictions. His life, as the preacher said at his funeral services, "was founded on religion." Colonel Murphy's home, a centre of the city's social activities radiating good-fellowship, wa pre ided over by his devoted wife. For him the lines of his poet-friend "Mack" might have been written: "That man is rich, beyond the wealth of Ophir's gold, Who has some saintly woman's seal upon his life." To her and to their children, the staff and students of the Medical School offer heart-felt sympathy. - Dr. C. C. Macklin.

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Jn jfflemoriam DR. HADLEY WILLIAMS (1864-1932)

of Dr. Hadley Williams T HEon death February 23 marked the pas ing of one of the foremost urgeons of Western Ontario. With all incerity we can say that the University of Western Ontario has lo t one of its revered and most enthusiastic upporters. Dr. William was born in Devon, England, and after receiving his early education in Buckland School there, attracted by the opportunities of a growing country, he migrated to America. He wa one of the early graduates of the University of We tern Ontario Medical School. Immediately following graduation the anatomy laboratory claimed his time and skill for several years, and it was here that he acquired the knowledge which was later to make him renowned a a surgeon. A fellow hip in the Royal College of Surgeons of London, England, marked another step in his surgical career. He wa appointed to the faculty of the Medical School in 1900, and as an instructor ranked among the highest. The fact that he was a member of the Dominion, Ontario and Briti h Medical Councils and, in the fir t named, an examiner in surgery speaks for itself. Hi as ociates and pupil mourn him with a grief and regret tinged with the admiration which is felt for the truly great. As a surgeon he saved many lives and performed feats bordering on the miraculous -as a teacher he has own seed which will continue to germinate and propagate for many years to come. His ideals have been indelibly impressed upon the mind of hi pupils.

True greatne s i mea ured in altruistic service. With this as our tandard we may rank Dr. Williams among the truly great. -W. R. Fraau, '84.

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<fbitorial Congratulations Dr. Miller! ~

INCE the last issue of this Journal a great honor has been brought

LJ to our faculty and University by the nomination of Dr. Frederick Robert Miller, M. A., M. B., (Toronto), M. D., (Munich) F. R. C. S., as a Fellow of the Royal Society. Dr. Miller has been professor of Physiology in our Medical School since 1914 and during this time has become popular with both the faculty arid students, and his newest accompli hment has brought honor and joy to all those who know him. Hi nomination come a a just reward for years spent in tudy and research. He has been an outstanding success in the field of Neuro-phy iology, and as a result his work is widely known in medical circles throughout the world. Dr. Miller has added much to our knowledge of the functions of the brain and nervous system, and his re ults and views have appeared in the leading medical publication of the world. An indication of his ability and contributions i manifest by many quotations and references to his work by other great cientists such as Sir Charles Scott Sherrington. To be elected an F. R. S. is one of the highe t distinctions a cientist can receive, and new members are carefully selected from the mo toutstanding scientists in the world. It is an honor hoped for by many, but achieved by few. The Royal Society was founded in 1662 by charter from Charles II. It has a member hip of about four hundred from all parts of t he world, chiefly from the British Empire, and include only scienti t who have made some great cont ribution to science. Each year seventeen new members are selected by the council of the society after thorough study of the candidate achievements. Be ides Dr. Miller there are ten Canadian fellows of the Royal Society, one of whom is Prof. A. B. Macallum, father of Dean A. Bruce Macallum. The staff of the University of We tern Ontario Medical Journal wishes to convey hea.rty congratulations to Dr. Miller, and may his success continue.

The Universit VOL. II

of W escern Ontario

MEDICAL JOURNAL

No. 4

Arterio ..Venous Aneurysm of the Popliteal Vessels V. A. CALLAGHAN, M.D., and C. C. Ros, M.D., F.R.C.S. (Edin.) the days of the barber urgeons, we are informed that arterioI Nvenous aneury ms due to many phlebotomies done for the various diseases, frequently occurred in the antecubital fo a. This condition is also een with relative frequency in war surgery as are ult of injuries by bullets or tab wound , but in routine civil urgery an aneurysm of this type i seldom encountered. When treatment i considered, there are many procedure , mo t of which in different part of the world have warm advocates. The rarity of the le ion together with the diversity of opinion as to the most efficient method of treatment is our ju tification for the recording of the following case of an arterio-venou aneurysm of the left popliteal fossa, the communication being between t he popliteal artery and vein .

CASE REPORT W. E., male, white, aged 18 year , wa admitted to a public ward of Victoria Ho pital on December 21, 1931, on account of two ulcerated areas in the region of the left ankle, which had been pre ent for a month. Four years ago, at the age of 14, he was hot accidentally by a playmate, a .22-calibre bullet pa sing through his leg just behind the knee. Since this accident he ha had a pul ating swelling in the popliteal fossa which has gradually increa ed in size but has not given him any pain or discomfort. On one other occa ion, two year ago, he had some smaller ulcerated area in the region of the ankle but the e healed with rest in bed. Except for this period he has been and i at the present time in good health. PHYSICAL EXAMINATION This patient was pale, and walked with the left knee slightly flexed. The re ulting limp appeared to be due to pain in the region of the ankle. Just below the external malleolus there wa a deep oval ulcer measuring 3 em. by 6 em., the edges of which were heaped up. The surrounding soft tissues were boggy, indurated and slightly 107

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inflamed, while the base wa covered with a thin, slightly purulent discharge. Below the internal malleolus there was a similar ulcer, approximately half as large. The small aphenou vein and its tributaries stood out in marked relief, the main vein in the region of the upper part of the calf of the leg being as large a a man's little finger with no varico e pouching and only slight tortuosity. Upon elevating the limb above the head this distension disappeared within a few moments. The normal hollow concave depre ion of the popliteal space wa somewhat obliterated by a diffuse swelling, the pul ation of which wa vi ible at a di tance of 10 feet, and was transmitted up along the inner a pect of the thigh for 4 or 5 inche . The scar of entrance of the bullet was found at a point 4Jh inches above the knee joint line, on a plane level with the po terior border of the femur. The scar produced by the exit of the bullet was at the level of the joint line ju t above the head of the fibula. On palpation a thrill could be felt in the popliteal fo sa. This is often de cribed in text books but is eldom demonstrable in practice or clinics. It wa discernible when the hand was placed over the patella, and also on the inner side of the thigh in the region of Hunter's canal. No distinct rna s could be detected. However, after compre ion of the femoral artery between the finger of the examiner's right hand and the patient' femur, the pul ation and thrill di appeared and with the left hand one obtained the impres ion of an indefinite soft cystic swelling. The limb was dusky in color as compared with the opposite leg but the temperature seemed about equal in both. Pul ation in the dorsali pedis artery could not be obtained. Upon auscultation a loud "buzzing" sy tolic bruit could be heard which, when the femoral artery was compre sed, al o disappeared. ROENTGENOLOGICAL EXAMINATION

Anteropo terior and lateral views of the left knee and lower third of the femur failed to show any bony ero ion, but immediately behind the femur about 2 inches above the condyles were orne calcareous deposit arranged in a ere centic manner. In an effort to determine more accurately the exact point of communication between the artery and vein, further roentgenographic pictures were taken with an opaque ureteral catheter strapped with adhesive tape to the skin between the cars of the entrance and exit of the bullet. Thse were interpreted as indicating that the point of communication wa 1 inch above the upper margin of the backward projection of the femoral condyles. TREATMENT

The patient was kept in bed with the limb elevated on pillows. Drez ings moistened with Dakin' olution were applied to the ulcers for a few day and these were then followed by dre ings of Balsam

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of Peru. It took nearly 2 months to obtain complete healing. During this time a clamp was made which compressed the femoral artery . between a circular leather pad and the femur. Daily application of the clamp for increasing periods of time developed the collateral circulation so that the limb was quite warm and of good color even after the clamp had been on for 80 minutes. It could not be tolerated longer than this due to pain at the site of pressure. To this method of prolonged short-circuiting of the blood through the collateral vessels instead of allowing it to pass through the aneurysm, we attribute much of the success of the final result. Operation was performed on February 26, 1932, under nitrous oxide anaesthesia. The patient was placed on his face, the knee flexed at an angle of 20 degress to relax the hamstring and gastrocnemius muscles. An 18-inch incision was made connecting the apex of the V formed by the hamstring muscles above with the apex of the V formed by the gastrocnemius below, the centre of the incision being opposite the middle of the popliteal space. The skin was dissected back, repainted with tincture of iodine, and towels were applied to the edges. Upon division of the popliteal fascia there projected at once through the opening a large mass of greatly distended tortuous veins. Commencing at the upper end of the wound, the posterior tibial and common peroneal nerves were found and dissected free and then retracted to either side of the wound by means of tapes. The posterior cutaneous nerve was treated in a similar manner. By means of sharp and blunt dissection the upper limits of the aneurysm were separated from the adjoining structures until the artery and vein could be clearly seen above the mass. It was particularly difficult to locate the artery as it was completely hidden by the markedly distended vein. During a similar procedure at the lower end of the aneurysmal mass one of the large veins was perforated and considerable bleeding ensued. The popliteal artery and vein below were next ligated with chromic catgut and divided between the ligatures. All apparent communicating branches were dealt with similarly including the resection of 6 inches of the small saphenous vein. Next, the popliteal artery and vein were ligated above the mass, but were not divided. When the tourniquet was removed, the aneurysm slowly filled with 路blood and pulsated slightly, apparently due to small communicating branches which were entering the sac anteriorly between the sac and the femur. It was considered unwise to resect the sac completely in order to secure these branches or to open into the sac to close off the communication between the artery and vein. Therefore, after suturing the fascia with interrupted catgut, the skin was closed with silkworm. A dressing was applied and the patient was returned to bed. ' OBSERVATIONS FOLLOWING OPERATION For four days the patient had a persistent, severe, dull, aching pain which remained fairly well localized to the popliteal space. We

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were undecided whether thi wa due to irritation produced in the nerves by the dissection or whether it was due to thrombosis occurring in the aneurysm. The aneury m wa a definite hard rna s when the first dressing was done 2 days after the operation, there being no pul ation, thrill or bruit. To each ide of the patella could be een and palpated a pulsating vessel, while in the region of the ankle there were everal smaller branches in which pul ation could be obtained. The limb remained of good color and warm throughout convalescence. There \路as no suggestion of paresis from nerve contusion, and the patient suffered little shock. The sutures were removed on the twelfth day. The only complications were 2 mall areas of superficial skin infection. The patient was fitted with a modified Thomas splint to guard against any tendency to flex the leg at the knee, and was allowed up 4 weeks after the operation. SUMMARY

In this case of arterio-venous aneurysm of the left popliteal e sels, a quadruple ligation operation was performed after preliminary compression of the femoral artery in Hunter's canal by means of a special clamp to establish a collateral circulation. Four other alternative methods of treatment were considered eriou ly: 1. Ligation of the femoral artery in Hunter's canal. This is a much impler operation to perform than the one employed. It wa not u ed, however, lest the re ulting deprivation of some of the collateral circulation might cause gangrene in the limb, and thu nece sitate an amputation. Provided the collateral circulation wa adequate, failure might have resulted due to a return flow through t he aneurysm via this collateral circulation. By ligating all but 1 or 2 small communicating branche this latter possibility was prevented. 2. Ligation of the communication by mean of a piece of fascia lata. Some writers (Nelson's Loo e-Leaf y tern) warn again t this procedure a they have found that in time the ligature gives way and the aneurysm returns. Furthermore, in our case it wa impo sible to dissect out the communication freely enough to ligate it as it was lying under the branche of the tibial nerve, supplying the ga trocnemius. It would have been necessary to sacrifice the nerves or to remove the muscle from its origin, neither of which we wi h d to do. 3. Opening the ac, with closure of the aperture in the artery by sutures. This was considered to be a more difficult operation to perform with more dangers of possible embolus formation. 4. Re ection of the sac. This could have been ea ily accompli hed but would have prolonged the operation and left a potential ource of danger because the end ligature on the femoral artery, without anything to upport it, might have been forced off by the pressure of the blood stream.

The Neurasthenic Factor in the Practice of Medicine DR.

S. M.

FISHER

London, Ontario is a scientific axiom that fundamental facts can best be T HERE expressed in simple terms. Can this golden rule be applied to the

â&#x20AC;˘

explanation of the many diverse clinical states that have been dumped together under the term of Neurasthenia? The answer, I think, is in the affirmative if we seek the explanation in the light of a complex biological reaction. Man, since the late Miocene period, has been required to adapt himself to constant changes in is habits, customs and environment. The success of this adaptation is reflected in his present state and fitness to meet the complexities of modern life. In the world today we find people with all graduations of mental, intellectual and physical equipment. In some, the constitutional or hereditary equipment admirably fits them to meet their environment and the complexities of modern life. In others, it ill adapts them for anything but a life of Institutional care. Between these two standards there are many who, by reason of their physical, their mental or their intellectual equipment, require assistance from time to time to keep them in the going. It is a fraility of human nature to attribute failure to physical causes, inherent or of environmental nature, rather than to mental or intellectual causes. So, in the daily routine of our vocation we see many nervous states, sometimes isolated but often associated with physical disease, that we designate as this or that type of Neurosis, or as Neurasthenia of this or that type, or perhaps as an anxiety state, or as a simple nervous breakdown, etc. Do these states represent but graduations of mental instability that results from a partial failure of the individual to meet successfully the realities of life and the demands of his environment? Neurasthenia as its name implies denotes "Nerve weakness", and like weakness in all things, organic and inorganic, its patent manifesta. tion depends on the factor of stress and its degree. This partial failure of the individual to adapt himself to his environment is an old story in our evolutionary history, but of late has been revamped with a new psychological binding. Unfortunately much of the terminology and many of the deductions within the scope of this binding have not in the main tended to clarify or simplify the problem of this complex nervous reaction. However, like all scientific investigation, it has added its positive and negative quota of facts to the sum total of our general knowledge. It has revealed more lucidly the influence that certain primitive instincts play in the emotional stability of our lives, and 111

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through our emotions, our physical and mental well-being. It has demonstrated the inestimable value at the root of p ycho-analysis, i. e. seeking facts from the life history of the individual that are relative to the failure of adaption. If one knows the past, one can better evaluate the present and so modify or condition the future. Notwithstanding many current theorie , it i probably a biological truth that the cerebral cortex differs only from the other ganglia and collections of gray matter of the nervous system in the complexity of its function. This complexity of function brings but an elaboration of the old story of the simple reflex arc with many superadded neuronic chains that condition the response, and determine the stability of transcortical control. The degree of trans-cortical control and stability differs widely in individuals. Some individuals inherit a characteri tically hyper ensitive and unstable nervous mechanism, irrespective of their physical and intellectual endowment. This is sometimes called the Neuropathic constitution and is characterized clinically by : (a) A lowered or subnormal receptive thre hold; all the ordinary stimuli of life, both from the outer world and from organic man himself are perceived in an excessive manner. (b) The affective and emotional reactions also exhibit an abnormal intensity. This is clearly manifested by the emotional discharges such as anger, rage, shame, distru t, likes and di like , joy, happiness, feelings of well being and depression, and al o in the sensitevene of their memory retaining mechanism. Within certain limits, that we term health, this hypersensitiveness of the nervous mechanism acts in a beneficial manner. In -individuals with the intellectual equipment we find our leaders in all walk of life, our creators in the various arts and sciences, our doers and go-getters in business, etc. However, when the environment is changed or modified, or the well-being of the individual is threatened by such factor as war, disease or economic stress, social or marital t ragedie , etc., this beneficient hyperaesthesia becomes at once excessive. Its manifestations are pathological. The excessive emotional discharges affect the routine activities of the individual, producing a feeling of uncertainity and lack of selfconfidence. The individual's well-being is threatened, and, like his primitive ancestors, he reacts with a biological mechanism or fear re pon e, well adapted to meet physical dangers, but only partially adapted and conditioned to meet the complicated problem of modern life. Many individuals seem to devine the nature of this reaction more or less instinctively and meet the situation, but many are left with a vicious circle. They lack a rational appreciation of explanation of their reactions and feelings, and t rue to type avidly seize on some abnormal somatic stimuli, feelings, or somatic condition to explain their failure in adaptation.

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Personalities are always of human interest, and a little time, patiently and sympathetically spent in the investigation of these individuals' social and economic conditions, oftentimes yields the key to the successful treatment of their condition where all else fails.

LORD LISTER BORN ON APRIL 5, 1827

"He edged the surgeon's knife with healing and drove t he devils of pyemia and gangrene out of hospital wards." Lister did more for the relief of suffering, for security of life, for prevention of anxiety, for promotion of happiness than any one man who has trod this earth.

-St. Clair Thomson.

•

Case Report of Primary Carcinoma of the Lung KEITH W. WHITTAKER,

'32

as a disease entity is rapidly increa ing in prominence C ARCINOMA and so is ju tly receiving more attention and consideration from t he medical world. Primary carcinoma of the lung i generally thought t o be a rare condition, but recent statistic tend to prove that it i not of uncommon occurrence. It presents an intere ting problem and so t he following case is reported. A. W., male, aged 48, metal polisher, wa admitted to the ho pita! complaining of cough, dy pnoea, pain in the che t and expectoration of blood-streaked sputum. He first experienced distre two years and .four months previously when he had sudden pain in the right ide of hi chest, followed immediately by haemopfy i of approximately 4 ounces. This was followed by a state of apparent good health until 1 year later when a light cough developed with expectoration, and occasional blood- h·eaked putum. He continued at work, however, f elt well and did not experience any further symptoms until 2 year and 4 month after the fir t attack when he had a further hemorrhage of one-half a dram. From that time onward the cough and expectoration increa ed; his strength diminished and there wa a pr ogre ive los of weight until his death, which took place 6 month after admittance to hospital. The physical examination of the chest revealed some impairment of re onance in both apice , with crepitant rales ascertainable posttussively in the left apex, both anteriorly and posteriorly. Marked dullne on percussion with weak to ab ent breath ounds was noted posteriorly from the angle of the capula to the ba e of the right lung. No enlargement of cervical, axillary or other gland was demon trated. Urine concentration tests on two occasions howed the presence of t ubercle bacilli. X-ray examination of chest (Figure 1) showed a den e opacity of the right base, which looked to be characteri tic of a pneumonic process, but did not fit in with the typical picture of a pleural effu ion. Serial photographs howed a progressive increa e in the right-sided opacity (Figure II), and a ociated with it an increasing cardiac displacement which ugge ted primarily an effu ion; phy ical examination, however, did not reveal any evidence of uch, and aspiration failed to locate any fluid. While in the hospital, ther e were daily exacerbation of temperature of 100° to 100.4° until within two months of death, while the pul e wa per istently over 100, and latterly the putum became bloodstreaked. In the Ia t month, r apid retrogre sion, marked loss of weight and drowsines featured the case, while large irregular glandular masses became readily palpable in the right supra-clavicular fossa . 114

CASE REPORT OF PRIMARY CARCI 1 0MA OF THE LUNG

115

At the post-mortem examination the che t showed marked emaciation, with prominent interspaces and deepened supra- and infra-clavicular fo ae. The only portion of the lung found to be collapsed was the outer part of the left upper lobe. The left lung, lower lobe, and also the right lung were covered with a fibrinou , gelatinous exudate. The con i tency of the right lung wa quite firm and the whole organ wa bound down to the pleura and the chest wall by strong adhesions.

Figure 1

The lung wa found to be practically olid from ba e to apex and was grayjsh in color, except for a caput of air-containing tis ue situated in the upper part of the upper lobe. Thi was gelatinous in structure, pinki h in color, and emitted on pre ure a yellowish purulent exudate. At the bifurcation of the trachea an increa ed thickening of the wall

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of the bronchus wa noticed, together with a definite diminution of the lumen as a consequence. The pulmonary vein wa enlarged and wa found to be filled with a crumbly-appearing rna . Microscopically, the right lung howed an exten i e, diffuse cellular growth of ti ue, which in orne locations was thrown up into orderly papillary-like tructures while el ewhere it wa quite di organized in arrangement. The predominating type of tumor cell wa flat, cuboidal

Figure 2

or large quamou , with large pigmented nuclei and faintly stained granular cytopla m. Although much modified, a similarity in the e cell to tho e of the air ve icle could be made out. An inva ion of the wall of the blood ve els wa fairly general, a also were necrotic areas throughout the tis ue. No demonstrable pathological changes resem-

CASE REPORT OF PRIMARY CARCINOMA OF THE LUNG

117

bling tuberculou infection could be ascertained at this stage. On microscopical examination of the left lung, some evidence of chronic pas ive congestion in the lower lobe was found, but no new growth or tuberculous foci were demon trated. Metastatic growths were found in the right pleural, the vi ceral and parietal pericardium, the adrenals, the left testicle, and in the lymph glands from the media tinal, diaphragmatic and bronchial regions, while a pre-cancerous change wa observed to have taken place al o in a microscopical sectionÂˇ from the pro tate. The pathological diagnosis of a primary carcinoma of the lung was made. DISCUSSION

According to Ewing1 the age of greatest incidence of primary pulmonary carcinoma i 50 to 60 years. It i rarely found to be bilateral, and as a rule it i seen more frequently in the right than in the left lung. It affect males more often than females. Although not actually demonstrated in the lung in this ca e, the chief etiological factor eem to be tuberculosi 1 â&#x20AC;˘ In the reported cases 2 chronic bronchiti and trauma need to be con idered, together with pneumoconiosis, a , for in tance, in the ca e of the celebrated German Schneeburger cancerâ&#x20AC;˘. In that ca e, exposure to ar enical du t evidently was the etiological factor in the production of many ca es of primary pulmonary carcinoma over a period of many years . Various other theories have been suggested a cau ative factors, such as influenza, the inhalation of tar from road dust, and the exhaust from internal combustion engines, but none of these have so far been pro'ven to be responsible. Histologically, three type of primary pulmonary carcinoma are recognized : 1 1. Arising from the lining epithelium of the bronchi and originating at the bifurcation of the trachea, preading upwards and downwards but rarely invading the lung extensively, and resulting in an ulcerating necrotic mass, which is liable to erode into large ve sels and cau e fatal hemorrhage. Evidence of the presence of thi type of growth was demonstrated in the above case. 2. The type arising from the bronchial mucous gland , and limited chiefly to the walls and especially to the submuco a of the bronchi and tending to produce a steno is rather than a dilatation of the lumen of the bronchi. 3. The type of growth found extensively in this ca e, which ari es from the pulmonary al eoli and may be diffu e or multiple and nodular. In the diffuse variety one whole lobe or whole lung i as a rule uniformly con olidated, re embling greatly in the gro the picture of gray hepatization found in lobar pneumonia, while microscopically there is a partial or complete filling of the air ve icles with cuboidal, cylindrical or flat cell , and frequently fairly general exten ion into the blood-

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ve sels found in the walls of the alveoli. In the nodular form, many tumor foci of miliary size are often seen in the gross specimen, while, microscopically, the air vesicles are filled with papillary projections of cylindrical cell , with often necrotic areas to be een in the centre of t he rna s. Many squamous-cell tumor of the lung have been proven to have had their origin in the bronchial muco a or the alveolar epithelium, and consequently a metaplasia must have taken place 1 • 3 • It may be as umed t herefore that the presence of squamous-cells in the sections from this case tends to prove that a metapla ia of cell from the mucous membrane of the bronchi or from the cell of the wall of the air ve icles had t aken place. The pos ibility of embryological cell-re ts should also be borne in mind. Formerly tatistic bowed that pulmonary carcinoma accounted f or approximately 1 per c nt. of a~l carcinoma, but Delafield and Prudden 2 quote Breckwoldt in aying that, owing to the extensive use of the x-ray in searching for su pected tuberculosis, many cases have been found which otherwise would have been mi ed, and consequently the percentage has risen until now it forms 5 per cent. to 10 per cent. of all carcinoma. The fairly extensive meta ta e a found is a characteristic feature of all primary pulmonary carcinomata. The treatment is palliative, a spiration being employed in cases where severe distre sis being caused by fluid collection. SUMMARY

1. A case of primary carcinoma of the lung i reported. 2. The lesion apparently was confined to the right lung, the meta tases ~!though extensive were not found in the left lung. 3. Recent statistics sugge t that primary pulmonary carcinoma is not uncommon, some estimates placing it a high as 10 per cent. of all carcinomata. 4. Primary carcinoma apparently arises from (a) bronchial mucou membrane, (b) bronchial mucous glands, and (c) alveolar epithelium. 5. As is customary with carcinomata elsewhere, the disease was practically symptomless until the end stages were reached. I wi h to thank Dr. G. . Gale and Dr. J. H. Fisher for their kind permission to report thi ca e, Dr. P. M. Andrus of Byron Sanatorium for the loan of the x-ray films, and Dr. J. W. Crane for his valuable aid and criticism in the revi ion of the manu cript. BIBLIOGRAPHY lE,,:ng, J.- Neoplastic Disea ses, 3r d ed., 1928, p. 51-859. W. B. Saunders, Phila. 2Delafield, F. and Prudden, T . M. -Te>..'t book of Pathology, 15th ed., 1931, p. 730-733. Wm. Wood Co., New York. aMacCallum, W. G.- Te>..1:book of Pathology, 4th ed., 1928, p. 1040. W. B. Saunders, Phila. •Boyd, Wm.-Pathology of Internal Diseases, 1931, p. 245-254, Lea & Febiger, Phila.

•

Treatment of Abortions A. E. MOWRY, M.D., M.Sc.

Resident in Gynecology Montreal General Hospital majority of writers describe methods of treatment of abortion T HE that are undoubtedly conservative, and give as the outstanding

reason for this con ervatism the fear of infection and the unfortunate results credited to tampering with clinically-infected ca e . The pendulum swings towards non-interference when an elevated temperature or increased pulse rate, or both, are present. Hemorrhage of a severe nature constitutes the only justification for any operative procedure. In the event of serious bleeding, packing is used, but then only in the vagina or at least partially in the cervix. Overlooking the distinction between spontaneous and induced abortions and leaving out the con ideration of threatened, missed or therapeutic abortion, I wish to consider briefly the inevitable and incomplete types. The treatment followed in the Montreal General Hospital in the service of Dr. H. M. Little may be considered radical and its main justification is summed up in a statement made recently by Dr. E. M. Blair, of Vancouver. "It is probably quite uncommon for an empty uterus to become infected. In other words it is not the uterus that becomes infected primarily, it is the content, as a general rule." The patient on admis ion is prepared by shaving the perineum and pubes and is catheterized. The vulva is painted with 2 per cent. aqueous solution of mercurochrome and sterile drapes are applied. A special abortion et is always ready for u e and from this set is obtained a bi-valve speculum. Thi is placed in po ition in the vagina and clots are removed. The anterior lip of the cervix is grasped with a single tooth tenaculum after warning the patient that some discomfort may be experienced. Placenta tissue if pre ent in the lower segment of the uterus is gra ped and removed with the ovum forceps. Plain gauze, the wider the better, up to 2 in. i saturated with acriflavine emulsion and is started through the external os with the uterine dressing forceps and is packed into the uterine cavity. Several strips are inserted if possible, the ends always being left in the vagina to avoid placing knots in the uterine body. The vagina is also packed with acriflavine gauze and the patient returned to bed. One-half c.c. of pituitary extract is given every four hours for three doses, to stimulate the uterus and thereby increa e the dilation of the cervix. When the uterine packing i started, a patient may complain of weaknes , and pallor may become marked; the blood pressure already low, tend to fall farther and yncope may result. This happens in119

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frequently but may occur in patient who have lo t a considerable amount of blood. Should it occur, the u ual " hock" treatment i carried out-morphine, intravenous injection of a gluco e olution or even tran fu sion in severe case . Tran fu sion are given routinely in patient who have had evere hemorrhage showing much loss of blood, usually on the day following the operation. The morning after the patient i admitted to the hospital and the above treatment having been carried out, she i ta ken to the operating room. Under gas-oxygen ane thesia, the gauze packing is r emoved and then with the r ight hand in the vagina, t he middle finger is inserted into the uterine cavity. With the uter us held between the abdominal and the 路vaginal hand, the placental ti ue is ea ily f r eed. Thi method not only makes it possible to tell that the uteru is empty but tends to les en trauma and prevent the accident of in trumental perf oration. Placental tissue lying free or difficult to eparat e digitally, may be removed with the ovum forceps. A combination of the finger with the ovum forceps and the dilated internal o a ures t hat nothing remain . The uteru may now be cleaned with gauze dipped in 2 2 per cent. iodine olution but no packing is in erted. T he patients make a rapid recovery and are allowed to get up on the third day. F ollowing a vaginal examination on the fourth day they are allowed to go home. During a period of six months there were 53 ca es of abortion treated after thi manner. The recoveries were uneventful except in one. Three weeks after discharge this patient returned t o t he Outdoor Department where a diagno i was made of bilateral pelvic inffiammation. It wa thought to be gonorrhoea] in origin and lapa r otomy later bowed this to be o. As is routine in ca es of t hi type, t he pus was aspirated and 10 per cent. turpentine in liquid paraffin was injected. Her recovery wa satisfactory. During thi time there was only one death from abortion on thi ervice. Here a definite hi tory of criminal interference was obtained. The u ual con ervative treatment of r epeated tran fusions with palliative mea ure wa adopted. During her illne a positive blood culture wa never obtained. Autop y r evealed thrombphlebitis of the right external iliac vein and, much to our surpri e since no uterine haemorrhage had taken place, an a cute endometritis with retained placental ti sue. It would appear t hen that if infection is at fir t limited to foetal tissue, the only "good" abortion i the complete abortion in which one has made certain that all foetal tissue has been removed. Certainly the results in the foregoing series would upport this view. At any rate, the pat ient's ho pitalization t ime i greatly reduced, permanent pelvic damage eems to be le ened and complication minimized. SUMMARY

The succe s of the method depends on the following: 1. The combination of packing with the admini t ration of

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pituitary extract makes certain of a dilated cervical canal that will admit the finger. 2. A curette, dull or sharp is not used. 3. The uterine cavity is not packed after the placenta is removed. This assures good drainage. 4. The cervix is not torn by dilators. 5. A tran fusion is routine for cases that have lost much blood. I wish to thank Dr. H. M. Little, profes or of Obstetrics and Gynecology of t he Montreal General Ho pital, for hi permission in making this report and for hi kindly interest in this study.

The Old Medical School

Cerebral Aneurysms With Sub-Arachnoid Hemorrhage L. D. WILCOX, M.D.

Interne, Royal V ictoria Hospital, Montreal into the sub-arachnoid space following t he r upture of a B LEEDING cerebral aneurysm is not an uncommon condition. It is one t hat proves rather interesting because of the ease with which it may be confused with other central disturbances. Since t he clinical picture can be recognized, and because careful treatment is oft en highly satisfactory, it has seemed worthwhile to r eport two recent cases with a short account of the usual findings. DEFINITION : ETIOLOGY

A sub-arachnoid hemorrhage due to leakage from an a neurysm is the type referred to here; blood in the sub-arachnoid space may a lso result from an intra-cerebral hemorrhage that breaks t hrough the bra in cortex or into a ventricle. Most cerebral aneurysms occur on t he circle of Willis, its tributaries, or outlets. These vessels lie free in t he subarachnoid space at the base of the brain and along its sulci, therefore, blood escaping from them will diffuse readily through this space. The etiology of cerebral aneurysms is still unsettled. Syphilis is rarely responsible, and when it is the basilars alone a re involved. The majority of them are thought to be due to (1) congenital defects, t hat may be multiple, and often associated with other developmental anomalies; (2) inflammatory changes from the lodgment of bacterial emboli in the intima or vasa vasorum, as seen in sub-acute bacterial endocarditis; and (3) arteriosclerotic degeneration. In view of these factors, it is not odd that t he condition should appear at any age. The sexes are affected about equally. SYMPTOMS-SIGNS

These are at first due t o irritation of the meninges by the blood. There is sudden intense headache, sometimes limit ed to t he side of the lesion, and often most marked over the occiput; this is accompanied by nausea and vomiting, and frequently a loss of consciousness. As the blood spreads through t he sub-arachnoid space of the posterior fossa and spinal cord, stiffness of the neck wit h pain in the back and legs develops, and the Kernig sign is usually posit ive. The intracranial pressure increases as shown by lumbar punct ure and by other findi ngs such as a raised pulse pressure, a lowered pulse rate, and frequently a choking of the optic discs, with or without retinal hemorrhages. There may be localizing signs as a result of (1) impaired circulation in 122

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the area of brain supplied by the artery on which the aneurysm is situated, either at the time of rupture or later when thrombosis has occurred; (2) the tumor effect of the aneurysm and the extravasated blood around it; or (3) the tracking of blood along the sulci onto the brain surface. Cranial ner ve palsies are quite common since the greatest damage takes pla ce about t he base; third nerve changes are the most frequent. 路 Subjective or objective bruit only appear in the pre ence of an arterio-venous aneurysm (rare). A few patients show mental disturbance such as irritability, apathy, delirium, or a r eal psychotic tate, but the e are not a a rule permanent. A feature that is rather characteristic of an aneurysm syndrome i a history of previous attacks. The e corre pond to repeated leakages from which the patient recover . Some of the patients die within a few hours from a rapidly increa ing intra-cranial pre sure if the bleeding has been excessive, but the majority of them survive the first attack. DIAGNOSIS

Because of the free communication between the sub-arachnoid space of the brain and spinal cord, the entry of blood at any point can be detected early by lumbar puncture. It is thi proceedure that e tablishes the diagnosi . In a given case, after the introduction of the needle, a water manometer is attached and a reading taken; after a sub-arachnoid hemorrhage, this is found to be elevated. It i normally between 75 and 200 mm. of water. Fluid is allowed to drop slowly into succe sive tubes marked 1, 2 and 3, and the pressure readings made after the removal of every 2 cc. (approx.). When the final pressure is about half the initial one, the needle is withdrawn. This rule has proved a safe one in a large series of cases. Cell counts are done on the three amples. Pink fluid that is due to a "bloody tap" will have a higher cell count in the first than in the third tube, while the counts in all three are the arne when the bleeding has taken place above the site of tapping. Three or four days after the on et of a sub-arachnoid hemorrhage the spinal fluid has a yellow tint if the red cell are centrifuged off, whereas if the rupture is recent or if the blood is due to a faulty tap, the fluid will always be colorless. The Van den Bergh test reveals an increase in bilirubin in yellow fluids from a breaking down of red cells. CASE REPORTS

Ca e 1.-l\fale, aged 41, laborer, no relevant family or per onal hi tory. Present condition began, while patient was at work, with severe headache, vomiting, and stiffness of the neck. These symptoms continued and he became drowsy and restless. Four days later he was admitted to the Royal Victoria Hospital. Significant findings at that time--a semi-stuporous expression, an appearance of suffering from headache, probable aphasia, equal and

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active pupils, definite choking of both optic discs, stiff neck, B.P. 125-85, deep reflexes all absent, superficial reflexes normal, positive Kernig, no control of rectum or bladder, T. 99, P. 54, urine examination neg., W.B.C. 10,000, Wassermann in blood and C.S.F. examination neg., lumbar puncture showed an initial pressure of 310 mm. of water, and the removal of 9 cc. bloody fluid reduced the pressure to 170. There were 8,000 red cells per cu. mm., and a faint yellow tinge after the cells had settled to the bottom of the tube. A diagnosis of cerebral aneurysm with rupture into the sub-arachnoid space was made. The patient was kept as quiet as possible with paraldehyde and codeine. Fluid intake was below 1000 cc. per day, a 200 cc. quantity of 25 per cent. glucose was given intravenously twice daily, and magnesium sulphate used per rectum when retained. The cerebro-spinal pressure on the sixth day of illness was only 240 mm. of water, and the next day the patient seemed so well that lumbar puncture was omitted. Coma suddenly appeared on the eighth day, breathing became tertorous, blood pressure rose to 225-100, the C.S.P. was 600, and 12 cc. of very bloody fluid were removed before the pressure fell to 25. It was felt at this time that another leak had occurred. This attack responded well to treatment and tbereafter the C.S.P. pressure remained below 400. The general condition remained satisfactory, although a slight weaknes of the right side developed. At the end of two weeks lobar pneumonia set in, and a week after this the patient died. At autopsy an extensive sub-arachnoid hemorrhage was found. A ruptured aneurysm of the right anterior cerebral artery surrounded by a large organizing clot had invaded the frontal pole very extensively, so as to form a communication with the ventricle. The sheathes of both optic nerves were distended with blood throughout their entire length. Section of the artery showed a wide muscularis defect at the angle of branching. A cavernous hemangioma of the liver was also found. Case 2.-Female, aged 22, married, personal and family history negative. Present illness: patient was about three months pregnant and for two weeks prior to admission had been vomiting in the mornings. On December 21 she vomited as usual and afterwards noted a tingling sensation over the left half of her body. This may have been the first warning of aneurysmal leakage. The next day she felt normal again. On December 26 she vomited, cried out, and was found lying on the floor in a dazed condition. She understood what was said to her and replied to questions. Her left side was paralyzed. She was very agitated, and two days later was so unmanageable that hospitalization became necessary. Significant findings on admission : a well-developed female, quite irrational and restles , moving right arm and leg aimlessly. Head and eyes deviated to the right, the neck was stiff, and there was weakness of left face, arm, and leg. Nystagmus on gaze to right or left, many sub-conjunctival hemorrhage , small but equal pupils, choked discs, and

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several large retinal hemorrhages were noted. The B.P. was 125-65. Deep reflexes on the left side were increased, abdominal reflexes absent, and the Babinski positive, T . 98, P. 84, W.B.C. 13,300, Wassermann test in blood and spinal fluid neg., and urine neg. At lumbar puncture the initial pressure was 450 mm. of water. The removal of 15 cc. of uniformly bloody fluid reduced the C.S.P. to 175; the supernatant fluid had an orange tint. A diagnosis of cerebral aneurysm with rupture was made. The patient continued to be very excited and difficult to handle. However, a rather stable pulse and blood pressure were favorable points. Treatment included paraldehyde and luminal for restlessness, with intravenous glucose when indicated, and lumbar puncture every second day. Her condition improved. The C.S.P. gradually fell, and on the twelfth hospital day it was only 170, with a faintly pink fluid. The patient remained in bed for a month, and at the end of that time felt well except for an occasional headache. The fundi were normal and slight weakness and pathological reflexes were still demonstrable on the left side when she was discharged. No interference with pregnancy was considered advisable during the period of active bleeding, since the vomiting had stopped. It was finally decided to allow the patient to go to term and then to carry out a Caesarian section. COMMENT Two fairly typical cases of sub-arachnoid hemorrhage are reported. Both patients were young adults, and both had intermittent 路 courses. Neither one showed albuminuria or glycosuria, although these findings are often mentioned. In the second case the accident may have been precipitated by vomiting; this is not unusual, and coughing or severe straining may act in the same way. Several cases developing in pregnant women have been admitted to this hospital during the past three years, in most instances with a diagnosis of eclampsia or meningitis. I wish to express my thanks to Dr. C. K. Russel, whose advice and help made the reporting of these cases possible. BIBLIOGRAPHY Andrews, M. C.-B. M. J., 1:1075-76, June 15, 1929. Beadles, C. F.-Brain 30:285, 1907. Fearnsides, E. G.-Brain 39 :224, 1916. Fitz, R.-Boston Med. Surg. Jour., 191:521, 1924. Hall, A. J.- B. M. J., 1:1025-28, June 8, 1929. Hamburger, L. P.-Am. Jour. Med. Sc., 181 :756, June, 1931. MacDonald, A. E.-Tr. Amer. Oph. Soc., 29:418, 1931. Mciver J., and Wilson, G.-J. A. M.A., 93:89-93, July 13, 1929. Schmidt, Max-Brain 53:1930. Symonds, C. P.-Quart. Jour. Med., Oct., 1924. Weber, F. P. and Bode, 0. B.-Inter. Clinics, 2:1-14, June, 1929.

Medicine in Shakespeare . 0RLO

V. DENT, '33

London, Ontario

0 not let your studies interfere with your education" was the advice I received from one of our professors in my freshman year. So let us for a few minutes digress from the practical aspects of medicine. Shakespeare was born in 1546 and died in 1616. Most of his work was done between 1588 and 1610, so medicine as related to Shakespeare is essentially the medicine of the 16th century. At the beginning of the century, Galenism and superstition were prevalent. In therapeutics and in diagnoses, purging, bleeding, and inspection of urine held prominent places. However, more modern ideas and sound thought were being introduced, and great seats of learning, such as Bologna, Padua, Ferrara, Montpelier, and Paris were established. Study of allatomy and related subjects was progressing under t he guidance of such men as Vesalius, Fallopius, Eustachius, and its artist patrons da Vinci, Angelo, Titian and Raphael. The Royal College of Physicians was beginning to show its authority, and much of the quackery and superstition was being abolished and medicine in general was being placed on a firmer basis. It is claimed that Shakespeare studied law and theology and was learned in mathematics, astronomy, and literature. We might easily believe that he was a student of medicine, but no evidence has ever been found to corroborat such a belief. Where, then, did he obtain his remarkable knowledge of medicine? Perhaps the most probable explanation is that he learned his medicine from his son-in-law, Dr. Hall, and t his is further strengthened by the fact that medical references in his work were more numerous after the wedding of his daughter Susannah to Dr. Hall. The full extent of Shakespeare's medical knowledge we do not know, because he portrays the life of others rather than his own. However, he mentions most (some perhaps under different names) of the recognized diseases of the present, as well as others which are almost forgotten now, such as chlorosis and plague. Although hundreds of references are made to medicine, surgery, obstetrics, therapeutics, anatomy, physiology, hygiene, and dietetics, we shall attempt to give only the more common, less obscure, and briefer quotations. Even with the advancement of science in the last four centuries, perhaps w~ could not much improve on the description of the physical sign of lues as given by Timon of Athens : "Consumptions sow In hollow bones of man! strike their sharp shins And mar men's spurring. Crack the lawyer's voice, 126

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That he may never more fal e title plead, Nor sound his quillets shrilly; hoar the fiamen That cold again t the quality of flesh And not belieYes him elf: down with the no e, Down with it flat; take the bridge quite away Of him that, his particular to for ee, mells from the general weal; make curled-pate ruffians bald; And let the unscarred braggart of the war Derive orne pain from you; Plague all That your activity may defeat and quell The ource of all erection. There' more gold; Do you damn other , and let thi damn you, And ditche grave you all!" Different r eferences mention other ign and symptoms, its communicable nature, and mercurial treatment of the di ea e. The following medical reference are quite elf-explanatory and for the mo t pa rt convey idea of the different di ease as we understand them today. There i , however, an element of uperstition where mention is made for letting out fever in saucers, the tar pouring down plague , and healing of crofula by the king' touch. H otspur-"Home without boot and in foul weather too! How 'scaped he ague , in the devil' name?" (P. I, King Henry IV, III and 1.) Rosalind-"-, for he eem to have the quotidian of love upon him." (A You Like It. III and 2.) Biror~r-"A fever in your blood! why then inci ion Would let her out in aucers." (Love's Labour Lost, IV and 3.) Troilus-"Even uch a pa ion doth embrace my bo om; My heart beat quicker than a feverou pul e ;" (Troilus and Cre , III and 2.) Volumniar-"Now the red pestilence (typhu fever) strike all trades in Rome And occupation peri h !" (Coriolanu IV, I.) Biror~r-"Thu pour the star down plagues for perjury." (Love's Labour Lost, V. and 2.) Adriar~r-"The air breathes upon here most sweetly. Sebastiar~r-"As if it had lung and rotten one ." (Tempest, II and 1.) Gonzalo-"There were mountaineer , dew-lapp'd like bull who e throat ha hanging on them wallets of fie h." (goitre.) (Tempe t, III and 2.) Page-"And youthful still, in your doublet and ho e, this raw rheumatic day." (Merry Wive of Wind or, III and 2.)

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Falstaff-"A man can 路no more separate age and covetiousness than he can part young limbs and leechery; but the gout galls the one, and the fox pinches the other." (pt. 2, King Henry LV, 1 and 2.) Malcol~" 'Tis called the evil: (scrofula) A most miraculous work in this good king: Which often, since my here remain in England I have seen him do. How he solicits heaven, Himself best knows; but strangely-visited people All swollen and ulcerous, pitiful to the eye, The mere despair of surgery, he cures:" (Macbeth, LV and 3.) Capulet-"Out you green sicknes Carrion! out you baggage! you tallow-face." (Romeo and Juliet, III and 5.) Bardolphr-" 'Sblood. I would my face were in your belly!" Falstaff-"God-a-mercy ! So should I be sure to be heart-burned." (Pt. I, King Henry IV, III and 3.) Agame路m non-"What grief hath set the jaundice on your cheek ?" (Trochu and Cress, I and 3.) First Servant-"Peace is a very apoplexy, lethargy; mulled, deaf, sleepy, insensible; a getter of more ba tard children than war's a destroyer of men." (Coriolanus, IV and 5.) Caliban-"The dropsy drown this fool!" (Tempe t, IV and 1.) Benvolio-"Take thou some new infection to the eye, And the rank poison of the old will die." (Romeo and Juliet, I and 2.) Desdemon~"For let our finger ache, and it indues Our other healthful members ev'n to a sense of pain." (Othello, III and 4.) Helen~"Sickness is catching ;0 were favour o, Your would I catch, fair Hermia, ere I go;" (Midsummer Night's Dream, I and 1. ) Sands-" 'Tis time to give them physic, their diseases Are grown so catching." (King Henry VIII, I and 3.) Macbethr-"The labour we delight in physics pain." (Macbeth, II and 3.) Bull-calf-"A whoreson cold, sir; a cough, sir; which I caught with ringing in the king's affair upon his coronation day, sir." (Pt. II, King Henry IV, III and 2.) Falstaff-"Sirrah, you giant, what aid the doctor to my water?" Page-"He said, sir, the water it elf was good healthy water, but for the party that owned it, he might have more di eases than he knew for." (Pt. 11, King Henry IV, I and 2.) There are many references to surgery, some of which are as follows: "We do lance diseases in our bodies." (Antony and Cleopatra, V

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and 1.) "A gaping wound i uing life blood." (:Merchant of Venice, III and 2.) " What wound did ever heal but by degrees." (Othello, III and 2.) In view of the fact that surgeons were considered much inferior to physicians, and had been and still were in some cases associated with barbers, the above references are quite just and sane and apparently beyond the general ideas of that period. Obstetrics and midwifery are often mentioned, as in the following quotations: Lear-"Thou knowe t the fir t time we smell the air, We wawl and cry:" (King Lear, IV and 6.) Costard-"Faith, unless you play the hone t Trojan, the poor wench is ca t away; She' quick; the child brag in her Belly already; 'tis yours." (Love's Labour Lost, V and 2.) Clown--"Sir, she came in great with child;" (:Mea ure for Measure, II and 1.) Therapeutic , pharmacy and toxicology were apparently well understood and many drug , such as digitalis, belladonna, hemlock, hyoscyamus, and mandragora, were known. Helenar-"You know my father left me orne prescriptions Of rare and proved effects, such as his reading And manife t experience had collected." (All's Well that Ends Well, I and 3.) Friar Lawrence"Take thou t his phial, being then in bed And thi distilled liquor drink thou off;And in this borrowed likenes of shrunk death Thou shalt remain full two and forty hours And then awake as from a pleasant sleep." (Romeo and Juliet, IV and 1.) Anatomy and physiology were often di cussed. Hamlet-"My fate cries out And wakes each petty artery in this body As hardy as the Nubian Lion's nerve." (Hamlet, I and 4.) Sir Toby-"For Andrew if he were opened and you find so much blood in his liver as will clog the foot of a flea, I'll eat the rest of the anatomy." (Twelfth Night, III and 2.) Brutus-"You are my true and honourable wife ; As dear to me as are the ruddy drops That visit my ad heart." (Julius Caesar, II and 1.) Capulet-"My child is yet a stranger in the world ; She hath not een the change of fourteen years, Let two more summers wither in their pride, Ere we may think her ripe to be a bride." (Romeo and Juliet, I and 2.)

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Hamlet-"I'll tent him to the quick; if he do blanch, I know my cour e." (Hamlet, III and 2.) The need of hygiene and dietetic wa recognized. Coriolanus-"Bid them wa h their faces And keep their teeth clean." (Coriolanu , III and 2.) Falstaff-"-, for I'll purge, and leave sack and live cleanly, as a nobleman should do." (Pt. 1, King Henry IV, V and 5.) From the references given, surely we should recognize Shakespeare as a master of medicine. Although seven phy icians are mentioned in Shakespeare, only four are named. They are Cerimon in "Pericle ," Cornelius in "Cymbeline," Caius in "Merry Wive of Windsor," and Butt in "Henry VIII." Of these, only one, Dr. Cerimon (who was perhaps patterned after Shakespeare's son-in-law, Dr. Hall, ince this play was written just after the marriage of Su annah and Dr. Hall) was recognized as a learned gentleman. Reference is made to him as Lord Cerimon, Reverend Appearer, and Master of the ecrets of Nature, etc., and the esteem in which he was held, and hi noblenes , are portrayed by the Second Gentleman in 'Pericles": "Your honor has through Ephesu pour'd forth Your charity, and hundreds call them elves Your creature , who by you have been re tored; And not your knowledge, your personal pain, but even Your purse, still open, hath built Lord Cerimon Such trong renown as time shall never." (Pericle , III and 2.) Dr. Cornelius, although showing compassion, prudence and good judgment by refusing to give the queen poi on to kill Imogen, is later rebuked by the king, and then unfeelingly t ells the iniquitous story of the disloyal queen, and how"The evils she hatched were not effected; so Despairingly died." (Cymbeline, V and 5.) Dr. Caius is portrayed a "ÂˇRidiculou French Doctor, Monsieur Mockwater," an indi creet love-maker, and a rival of the imbecile Slender. We cannot believe that Shakespeare was o unju t a to refer to the great Dr. Caiu , founder of Caiu ' College, and second pre ident of the Royal College of Physician , a the Dr. Caius of "Merry Wives of Windsor," but rather the same name wa a mere coincidence. Dr. Butt has no profes ional but a trifling and seemingly ungrateful role. If the real Dr. Butts who attended Henry VIII and was lmighted by him, and who is recorded in the Annal of the Royal College of Physicians as "Vir gravis; eximia literarum cognitione, singulari judicio, summa experientia, et prudenti consilio doctor," i represented by the Dr. Butt of Shakespeare, it is hardly just. Although the physicians of that time, as a class, were ignorant, superstitious adherents to the pa t, and did not believe their own eyes, the medicine of the plays of Shake peare was Hippocratic, modified by

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Galenism, and savoured with Paracelsus. Shakespeare was really much in advance of the medicine of his day, as shown by reference to circulation of the blood, and to treatment of insanity by means of music, rest and gentle conduct toward the patient. Notwithstanding the fact that the majority of physicians were superstitious, ignorant, and followers of Galen, there were great men as Vesalius, Fallopiu , and Eustachius. Why, then, did Shakespeare give to physicians speeches not especially characteri tically medical, and characterizations merely to complete the plot? Shakespeare, with his marvellous knowledge of medicine, had he so desired, might ea ily have glorified and lauded the physicians and surgeons of his time. Why, then, did he put words of wisdom concerning contagion, diseases, treatments, hygiene, anatomy, etc., into the mouths of such as Falstaff or Cali ban? Even though we cannot under tand Shakespeare's attitude toward the profession, we must admire him for his masterly knowledge of medicine and its related subject , and ince he was great, and be was human, we cannot censure him too severely, and for these two reasons we must believe that he was licensed to do certain things and leave certain other things undone.

J . R. Slonaker, Physiologist at Stanford University, Cal., has studied the effect of feeding different per cent . of protein in the diet on five group of Albino rats. Each of the diets contained the arne ingredients but the different per cents. of protein in groups I, II, III, IV and V, were 10, 14, 18, 22 and 26 per cent. respectively. It was found that group II, fed on t he 14 per cent. protein diet attained the greatest average maximal weight and the greatest average pontaneous activity, had the highest per cent. of fertility in both sexe , had the lea t mortality of young in nur ing, and produced the most and largest litter . The 26 per cent. protein diet was lea t efficient in producing the above effect . The length of the reproductive span from greate t to least was in the orders of groups II, I, III, IV and V. The average life pan from longest to shortest was in the orders of groups II, III, I, IV and V. It was found that the 26 per cent. protein diet in group V was best for both the mother and the growth of the young during the nursing period. A high protein diet also prevented tumour growth. Significant factors, a heredity and environment, were erased in the various determination and calculation , since all the rats were from the arne stock, and were subjected to the arne environment. Many of the re ults obtained in the experiment are applicable to man as the chemistry and physiology of nutrition in man and the rat are similar. It may be concluded that a comparatively low protein diet, consisting of animal and plant proteins in equal quantities, is es entia! for a normal healthy individuaL-Am. J . Physiol. 98-266 . Sept. 1931.

路=路Acute Nutritional Disturbances of Infancy WILMER L. DENNEY, '17

Instructor in Pediatrics, U. W. 0. Medical School Finklestein fir t published his classification of nutritional W HEN disorders in infancy he described them as ( 1) disturbed metabolic balance, (2) dy pep ia, (3) decomposition and (4) acute intestinal intoxication. Thi cia ification, based upon the clinical picture rather than on the etiological factor or factor , ha been found the most useful to date. The older practitioners possibly will be more familiar with the terms cholera infantum and cholera morbus, while the scientifically inclined will be partial to anhydremia or anhydremic intoxication. In the more torrid zone , this condition is of endemic occurrence, but in our northern latitude it exists chiefly in epidemic form during the months of August, September and October. The clinical picture takes the form at first of a moderately severe diarrhoea. l\iany of the e run on for a few days and then clear up, but those described by Finklestein as acute intestinal intoxication oon present a much more serious picture. In the e the diarrhoea teadily becomes worse, pus, blood, and mucus occurring in the frequent stools, and the temperature rapidly rising to 104掳 to 106掳. Acidosis now upervenes with rapid, pauseless respirations, acetone breath, and a gradually developing coma. At this stage the weight drops rapidly and a child, who a few days previously looked well, plump and happy, now presents an extremely different appearance. The kin is grey and wrinkled, the eyes sunken with a distant tare, the lips are parched and often of a peculiar cherry-red color, and the mouth is held partly open. The nervous symptoms and psychic disturbance are usually pronounced and often lead to confusion with meningitis. The infant is re tless, the sen orium disturbed, with an occa ional cry a~ if in pain. Before these more evere symptom develop the child appear apathetic, drow y and dopey. The face assumes a fixed expression and there is a tendency on the part of the infant to lie constantly in one position. When the child moves it does so slowly, as if too tired or weak to change its position. The condition increases rapidly in severity with stupor and coma associated with twitchings, convulsions, stabismus and other meningeal symptoms. There are few things in life presenting a more tragic and apparently inevitable course of events than this. The etiology of the condition has been cloaked in obscurity,-food, intestinal bacteria and parenteral infections in turn receiving the brunt of the blame. At present we are not in a position to state the true cause in all the cases coming under our notice, but knowledge along these lines has at lea t made some progress. *Read before the Guelph Medical Society.

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During the years 1929-30, experiments were conducted in Toronto 1 to determine insofar as was pos ible the bacterial role in the production of this condition. In all, 171 cases of diarrhoea were studied and an effort was made to i olate the offending organism in each case. As it has been said that "we need to be reminded more than we need to be educated," let me go briefly into the methods by which investigations of this nature are carried out. As soon as pos ible after the specimen of feces is collected it is tested for evidences of amoebic dysentery by direct examination of a smear. Following this, cultures of the pecimen are made on MacConkey's medium. Possible offender are recognized by the "pale" type of the colonies, and repre entative loop are picked off and sown on agar lants. In from 12 to 24 hours these are investigated and identified by their reaction to various media. If these bacteria correspond to the usual characteristics of the dysentery groups, further cro agglutination tests are performed with the serum of the patient. Historically, it is interesting to note that this method was first used by Shiga. He, after many workers attempting to throw light on these enteric problems by animal inoculations had failed to produce results, approached the problem by searching for a micro-organism in the stool of dysentery patients which would specifically agglutinate with the serum of these patients. Thus, for the postulates of Dr. Koch, a short cult was substituted. Of the 171 cases that were studied, 42 were found to be entirely negative so far as organisms of the dysentery group were concerned. This did not necessarily mean that no dysentery bacilli were involved because we know that these organi ms tend to disappear from the stool after the first few day . However, there were isolated no less than 17 different gram negative bacilli related t o the dysentery group. B. B. B. B. B. B.

Species

Number of Strains

dysenteria Sonne... .... ... ........ 14 dysenteria Flexner..... ......... 4 para-shiga (Schmitz Bac.) 17 paratyphosus aertrycke.... .. 8 muriotitis .... .. ... ... .. ... ... .. ... ... 11 asiaticus or proteus asiaticus ...... ...... ................. 8 B. morgani .... .............. ......... ..... 59 B. paracoli ..................... ...... ... 33 B. alkaligenes......... ................... 6

Species

umber of Strains

Fothergill' bacillus 11 Bacillus belonging to dysentery group similar to Sonne .............................. . 6 Proteus vu lgaris ...................... . 17 B. pyocyanus ...................... . 1 B. paradiffiuens ..................... . 20 B. diffiuens ......................... . 1 Unknown proteolytic bacilli... . 5 Unknown bacilli ..................... . 5 Of these, there were some of rather dubious qualities so far as the etiology of a severe diarrhoea was concerned. For example, we believe that while the B. morgani, B. paracoli and B. alkaligenes are capable of setting up a slight diarrhoea, they are usually found as concomitant types, i.e., types usually found in excereta where more virulent types of dysentery bacilli have previously operated. The

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B. paratyphosus aertrycke is one of the commonest causes of food poisoning and may occasionally be found in apparently normal stools. The B. dysenteria Sonne, one of the most numerous offenders in this series, appears to flourish in the more northern latitudes and has been reported in Scandinavia, Denmark, England, and America. Serum agglutination tests were carried out in most of the cases and a large number of positive results were obtained proving that the organism isolated was undoubtedly the cause of the condition. In a series of control cases suffering from conditions other than diarrhoea, some bacilli were found of the dysentery group, but with the exception of the concomitant bacilli found, all serum agglutination tests were negative. Case A.-K., aged 4 months, had a slight diarrhoea for 2 weeks. She was given protein milk but, as the condition did not improve, barley water and barley gruel were substituted. On the day that she was admitted to the Children's Memorial Hospital she appeared to be very weak and was vomiting. She went into a convulsion which persisted until her death 24 hours later. Stools while in hospital were not numerous but were green and contained a great deal of mucus. Case B.-P., aged 1 year, had a slight diarrhoea for 4 days and was treated by the mother with rice and barley water diet. When first seen at 6 a.m. the temperature was 103째, with signs of capillary bronchitis. The throat was moderately injected. At 11 a.m. she went into a convulsion which persisted until death. At 6.30 p.m. several large stools containing pus and blood were expelled. There were no evidences of acidosis-air hunger, rapid loss of weight, unconsciousness (as seen in acute intestinal intoxication) or an acetone odor to breath. A neighbor who assisted in caring for this child developed a severe streptococcic throat and was critically ill about 48 hours after this child's death. Case C.-S., aged 6 months, had diarrhoea and vomiting for 5 days and a coryza and dry cough for 12 days. She had been on a milk and water mixture. Fever was not a marked feature although the temperature was 101 o on admission. She was placed on half-strength protein milk. Twenty-four hours later she went into a prolonged convulsion and died. The temperature ranged from 102째 to 104째. At no time were there any evidences of acidosis. I believe these 3 cases present a definite syndrome : 1. Slight diarrhoea with or without fever of several days' duration. 2. Sudden onset of a profound toxemia with vomiting. 3. Convulsions and, almost inevitably, death. In none of these cases were intestinal pathogens found . From observations of other cases not quoted here, where complications such as otitis or adenitis developed and where the streptococcus was found, one may conclude that this organism may have had something to do with the condition. It has long been known that parenteral infection will cause a

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diarrhoea. Personally, we have seen as apparent primary foci the throat, middle ear, mastoid, lung, and kidney pelvi . In the brea t-fed baby the intestinal symptom are not apt to be of a severe nature but in tho e that are bottle-fed the ca e may readily progre s to the stage of acute intestinal intoxication. In no ca e of an acute gastro-intestinal upset should a general examination to rule out the po ibility of an acute focus be neglected. The ymptoms of this type of case are es entially imilar to tho e caused by enteral infection with possibly some indication as to the source. In many of the e ca es even where the diarrhoea is not of a severe type, the primary lesion appears to be masked. In many case , a swollen and injected pharynx or a bulging and inflamed ear-drum are present. Le s commonly, mastoiditis and pyelitis have been diagno ed. A few of these ca es may be quoted to advantage. Case A.-Male child, aged 7 months, was first seen 7 days after the onset of a severe diarrhoea. The temperature was 106째 and indication of acidosi were marked. The child appeared to be in extremis. There were from 20 to 30 loo e, blood- tained movement per day. He had been on barley water followed by protein milk since the onset of the condition. Both ear-drum were found to be red and bulging. Double myringotome was performed and pu obtained. No change was made in the feeding. The following day the temperature dropped to normal, the gastro-intestinal symptoms improved and an uneventful recovery took place. Case B.-A little Indian boy, 18 months of age, was brought to my office suffering from severe diarrhoea. As he promptly made a mess of my rug he was bundled to the hospital. His temperature was normal. He did not appear to be seriously ill. On examination, both ear-drums were found to be bulging. Myringotomy was performed and pus obtained. Twelve hours later his temperature ro e suddenly to 105 a nd he had a convulsion. Four hours later he died. Autopsy revealed a double rna toiditis with a great deal of bone destruction. There was al o a large cerebral infarct on the right side of the brain. Case C.-A mall girl, 3 years of age, with diarrhoea and vomiting of 4 days' duration, wa admitted to hospital with marked symptoms of acidosis. Her temperature was 103째. She appeared to be desperately ill. There was a history of a similar attack 1 year before. No focus could be found. After several intravenous injection of 10 per cent. glucose olution her condition improved. A thick stream of yellow pus wa found wending it way down the back of the pharynx. The culture of this was negative for streptococcus hemolyticu . The gastrointestinal symptoms gradually subsided. I believe this ca e to have been one of infection in the paranasal sinuses. These are undoubtedly true cases of acute intestinal intoxication due to parenteral infection . These cases have been more amenable to treatment than tho e due to enteral infections. There is a type of case de cribed by Marriott and Jeans of St.

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Louis 2 which they claim to find in astonishing abundance and which they refer to as "masked rna toiditis." In the e ca es the ear-drum may or may not be slightly injected and there may or may not be a slight drooping of the posterior wall of the exter nal auditory meatus in close proximity to the drum. Irrespective of whether or not obvious symptoms are present, the diagnosis is made by opening the rna toi d process under local anae thesia and finding pus in the mastoid cells. Dr. Jeans has made the following statement, "We are not prepared to state that infection at t hese sites con tituted the ole cause of 'Cholera infantum,' though it is a strange coincidence that since we became aware of the relationship, all the cases of this affection observed by us have had upper respiratory infection a the underlying cause." To me this appears to be most remarkable. In upport of this a sertion, case after case i quoted in which after pu has been released from the mastoid process the symptoms of acute intestinal intoxication have subsided, weight has rapidly increa ed due to the renewed ability to retain water and the case has gone on to recovery. I am sorry that I am unable to comment on this work. I have seen no ca e in my practice or hospital experience that I can place as falling within this category, possibly because I have not opened any mastoids that have appeared to be healthy. It has been suggested that some cases of diarrhoea merely accompany parenteral infections due to a lowered general resistance on the part of the patient. I have no doubt that this is true in many cases. Because so little is known regarding the role of such factors as excessive heat, spoiled milk, etc., in the production of diarrhoea, I shall not in this paper touch on these po sibilities. That they do play a part in the production of orne of these cases is undeniable. When a case of severe diarrhoea is encountered, one must first rule out any possible parent eral infection. If any upper re piratory condition is found, the appropriate treatment mu t be in tituted. Secondly, we know from the abrupt loss of weight and other signs of dehydration that the water balance has been badly disturbed. Water added to the tissues, no matter how loosely, is better than no water at all. While adding the water, we attempt to overcome the acidosis. It has been found that this i mo t readily accomplished by the administration of chemically pure gluco e. Thirdly, prolonged starvation is undoubtedly bad for these ca es and, in the absence of vomiting, food should be started within 12 hours. And finally, certain manifestations of discomfort must be attended to. In the initial stage of the treatment and in pite of much adverse critici m, I think it advi able to clean the bowel of bacteria and irritating intestinal contents by an initial purge of castor oil. The only contraindication is in the case of an extremely weak infant. In such I would be inclined to be more conservative. If much straining or abdominal pain is present, a high hot colonic irrigation may give much

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relief. All food should be stopped for 12 hour . Starvation for a longer period than this is dangerous. When vomiting is not a feature, water should be administered freely by mouth. If the infant refuses fluids, water should be given by lavage; if vomiting, the stomach may be washed with a 1 per cent. solution of sodium bicarbonate solution. In markedly dehydrated case or those di playing severe nervous or psychic disturbance a 10 per cent. glucose solution must be administered at once. One has here 3 alternative routes from which to choose. It may be given subcutaneously, intraperitoneally or intravenously. Of the 3, the subcutaneous is probably the most useful. Where aline alone is given, the intraperitoneal route may be used. In a small baby, the possibilities of intravenous medication are limited owing to the fact that only 2 veins are of any practical use. The internal saphenous vein over the internal malleolus is the one generally u ed for this purpose, although in the past the median sinus has been used extensively. This route, however, is not free from danger. In those ca es giving a history of gross dietary defects, such as prolonged milk feeding, a blood transfusion may act as a life saver. Donor's blood is given in an amount equal to 15 cc. per pound of body weight. Mter the preliminary short period of starvation, protein mill路 should be used. I am of the opinion that not even brea t milk is as efficacious in inhibiting a diarrhoea and giving nourishment where it is so badly needed. Starting with half-strength sweetened with saccharine, the mixture may be increa ed to full-strength after 24 hours. When the diarrhoea has been sufficiently checked, dextri-maltose may be added and gradually increased until from 4 to 6 tablespoons are being used. The change back to cows' milk can then be made in safety. REFERENCES 1

Marion M. Johnston, Ala Brown, and F. . Tisdale. Reported at meeting of Canadian Society for Study of Disabled Children, 1930. Jeans, P. C., and Floyd, M. L.-J. A.M. A., 87-220, 1926.

During a year the "average" American pends about $5.50 for drugs and medicines. Only a little more than a quarter of thi -about ~1.50 -goes for pre criptions ordered through a doctor or hospital. Of the annual drug bill of 715,000,000, 190,000,000 goe for prescriptions written by doctors; 360,000,000 goe for "patent" medicines (more accurately medicines secret in formula); the remainder, 165,000,000 i pent for home remedie uch as cod liver oil, bicarbonate of soda and the like. Figuring that the prescription represent sound medical advice, that the home remedie and po sibly a fifth of the "patent" medicines are u eful in medical care, the Committee e timate that Americans spend at least 300,000,000 a year for drugs and medicines which are unnece sary or u eles or both, and in some cases actually harmful. Moreover, the wasteful competition of trade-marked brands accounts for an annual outlay of $70,000,000 in advertising alone.-Potions and Pills, Reader's Digest. March, 1932.

Rami- Section D. E. ROBERTSON, M.D. Toronto, Ontario

THE surgical technique of rami-section wa

advanced by N. D. Royle, an Au tralian surgeon. He observed decerebrate pigeons and it occurred t o him to ection portion of the ympathetic nervous system t o relieve the spasticity of the lower extremities in cases of upper neuron lesions. His first rami-section was performed on a soldier whose legs were so spastic he could not walk backward or downstairs and who suffered continually with cold feet and obst inate constipation. After t he operation the spasticity of the limbs was relieved, the legs and feet became warm, and the con tipation wa relieved. Royle in company with the late J. I. Hunter op rated in many clinics in the United States but the impression wa that rami-section proved of but little benefit to spa ticity. When in Toronto, he performed the operation on a child with pa tic limbs, who had undergone tendon-lengthening operations with no benefit. After the operation the spasm relaxed, the legs became warmer, and when seen seven years later, the improvement was still more marked. The warming of the leg was due to increased blood supply brought about by division of the va o-con trictor nerves. This opened a wide field for the employment of rami-section in the treatment of certain diseases of the va cular system. Buerger's disease (thromboangeitis obliterans) is a condition in which the symptoms are due to interference with the blood supply of the affected limbs. There is severe cramp-like pain in the feet and calves which is induced by exerci e and relieved by rest. On examination, the pulse in the dorsalis pedis artery cannot be felt while the posterior tibial artery pulse may be only weakly palpable. The foot is red while in the dependent position and blanched with ischemia when the limb is elevated towards t he perpendicular while the patient is lying down. Dry gangrene may be the late re ult of trophic changes in the skin. Rami-section for the relief of pain removes constrictor nerves of vessels not yet involved in the inflammatory process. By severing the vaso-constrictors, the temperature of the foot can be raised five degrees or more because the blood supply is stabilized at its maximum and is not interfered with by changes of temperature which in the normal leg would cause a vaso-constriction. Rami-section al o is a cure for Raynaud's disease even when gangrene has already set in, and is a useful measure in other gangrenous conditions. A third important use of rami-section is associated with the large intestine. Subsequent to his first operation of t his nature, Royle reported 13 additional cases a cured of intractable constipation. Although the innervation of the bowel is not well under tood, Royle believed that Gaskell's explanation is correct-that the large bowel is supplied by 路 138

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both the sympathetic nervous y tern and the para ympathetic pelvic nerve. The pelvic nerve is concerned with peristal is, while the sympathetic nerves are de cribed an inhibitors of bowel action, and to them also is a cribed the function of controlling the pincter of the bowel. The sphincter between the pelvic colon and rectum, and the internal sphincter ani are of pecial intere t in Hir ch prung's disease, in the treatment of which rami- ection ha given marked and beneficial results. The condition is one in which there is a history, beginning soon after birth, of con tipation which i very marked and i practically not amenable to even con tant treatment. Drugs have little effects and enemata are attended with very light result . The large colon becomes overloaded and the content become toxic with the result that the patenit's health is seriou ly impaired. The abdomen i very prominent and the large loops of bowel may be readily seen and palpated. J . A. Munro Cameron attribute the anatomy of the condition to a destructive lesion of the nerve ganglia at the pelvirectal sphincter which acts as a direct ob tacle to the de cending paristaltic wave so that above it stasis of the contents takes place. In an attempt to expel the accumulated and unaccustomed burden, the wall and e pecially the circular muscle layer, hypertrophies. As a treatment aimed at the surgical cure of this condition, Sir Frederick Treves advocated and practiced the almost total extirpation of the enlarged viscus. Other have resected that portion which was most markedly enlarged. These operations were very grave proceedings and in tho e patients who survived, the results were not entirely sati factory. Dr. Royle should receive the credit for first instituting rami-section as a treatment of Hir ch prung's disease. The records of three ca e in particular of megacolon were reported, which were ucce fully treated by interference with the lumbar sympathetic trunk. Two of the e were girls of nine years of age, the third, a woman of thirty-two year . In all cases the chief ign and symptoms were typical, a hi tory, dating from infancy, of intractable constipation, and abdominal pain when the bowels emptied about every seven to ten day . The econd case had attack of nau ea and vomiting and the third case had undergone four abdominal operations (appendectomy and three bowel resection ) within the last twelve year . In all cases the abdomen wa prominent with a large palpable loaded colon. Previous to operation barium enemata demonstrated, in each ca e, an abnormally large colon, receiving without re i tance enormou amounts of enema. Roentgengram bowed a colon which almost filled the pelvis and abdomen and no haustra were to be een. The operations were performed under general anaethesia and the Royle type of incision was u ed. The trigonum lumbale was defined and pQrforated. The fingers pas ed over in front of the P oas muscle, and palpated the vertebral column, along the lateral surface of which the ympathetic trunk was felt a a fine hard cord. Royle divided the white rami communicantes and the branches which run mesially from the

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second, third and fourth enlargement; in two of the reported cases the entire lumbar cord was removed from the level of the second enlargement. In all of these cases the recoveries were uneventful and the daily movement records, which were kept for two or three months following the operation, were most satisfactory. There was no post-operative shock, and the third case stated that the double lumbar incision was not to be compared in severity to any of her previous abdominal incisions. Subsequent roentgengrams with barium enemata showed the colon to be almost down to normal size, and haustra were to be seen. Associated with the improvement in the bowel condition there was a decided rise in temperature of the leg, and the foot was palpably warmer, due to stabilized maximum blood supply. The sweat glands were also affected by the rami-section so that feet that were formerly moist and sweaty, became dry.

POST-MORTEM CAESAREAN SECTION Post-mortem caesarean section is the oldest kno ;vn obstetrical operation, dating back to 800 B.C. in the literature, and it was probably a n old operation at that date. No definite legal status has been placed upon the operation. The Roman law stated that a post-mortem caesarean section should be performed if the pregnancy was advanced 26 weeks, and as soon as life was extinct in the mother. This rule was not very rigidly adhered to following that period, on account of the low percentage of successful cases. . The church states that t his procedure should be carried out if the pregnancy is advanced more than 24 weeks in a hospital case or more than 28 weelrs in the home. In the case 'of People vs. Stahl (Mich.) 208 N.W. 685, the court quotes section 15, 224 of the compiled laws of 1915 of Michigan, and t herein states that a doctor or any other person who attends a pregnant woman and by any means destroys such a child by drugs or otherwise, except when this is done to save the life of the mother and with the advice of two physicians, is guilty of manslaughter . This indicates t hat the unborn child is a legal entity and, therefore, if an attempt to save the life thereof is not made, the doctor might be held for gross negligence and manslaughter. A. M. Campbell, M.D., F.A.C.S., and J. D. Miller, M.D., of Grand Rapids, Mich., report in the Journal of the Michigan State Medical Society, December, 1931, the case of a living child in a post-mortem caesarean section performed ten minutes after the death of the mother from cyanosis. The chances of saving the life of the child are much greater if the mother dies suddenly and violently than if death occurs from a slow generalized infection. Possibly a post-mortem caesarean section should be performed by any doctor immediately on seeing a case of death during pregnancy advanced beyond 26 weeks, even without the consent of the next-of-kin if the fetus was known t o be viable before death, even when signs of fetal life can no longer be obtained.

路.

~bitorial TANTALUS unhappy son of Zeus, doomed to an eternity of Tartarean 1 torment, know that mortal man yearns endlessly after his Utopia, and that now those self-same shades of Hade , the very authors of your misery, haunt McGill! We have just read the article, "A Di cussion of the Experiment in Medical Education at McGill," by C. R. Drew, which appeared in January's McGill Medical Undergraduate Journal. It is exceptionally well written, and we respectfully recommend it for the attention of all, including members of the faculty at Western. Our first reaction was one of admiration for a school which, recognizing that "the very essence of all growth is change," commits itself to the Spartan policy of transition, and, in the search for betterment, expo es itself to the vicissitudes and tribulations of experiment. The first of the ten items which constitute the "Statement of Purpo e" designs to elevate Medicine from the supposedly undesirable rank of Science to that exalted status which recognition as an Art would confer upon it. The ideal is doubtlessly commendable, but we should remember that not so very long ago Medicine was a trade, and not a particularly reputable one at that. Let us, then, first purge Medicine of that charlatanism which too often debases it even as a Science. .,... The teacher-student relationship is next con idered and the individuality of ancient Alexandria and Athens is desiderated. Away with ultra-didacticism and smug pedantry, tho e twin academic vampires that suck the life blood of freedom in student thought, those evil genii whose surreptitious diabolism replaces human brains with sponges! An attempt to effectively correlate the various subjects of the curriculum is announced. Even undergraduates are w,ell aware of the imperfection here discussed. The problem is a perennial teaser, and word of any progress toward its solution will be eagerly awaited. The fourth and fifth objects are concerned with the establishment of optional courses and provision of adequate time for their utilization. This was done here at Western several years ago, and erved in the majority of cases only to furnish the students with sufficient leisure to attend the matinees at the local theatres. However, in a large university, the experiment might prove uccessful. Item six deals with changes in the system of examinations which

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permit a student who has received a low mark to appear before a Board of Examiners for reclassification. An examiner, being made of common clay may, of course, in some instances, abuse his powers and not grade a candidate according to his merit or demerit. Any change, therefore, in the system, which proves a safeguard against such injustice, is naturally desirable. At intervals the students are to be subjected to progress tests a ccording to the seventh "plank" of this experimental "platform." No details of the nature of t hese tests are given and the vagueness of t his scheme is rather bewildering. Article eight proclaims that, henceforth, weakness in a single major : mbject is not to condemn a student to repetition of his year. Here, indeed, is a very "Magna Charta" ! At Western, the practice has long been to allow a man a supplemental examination in a single weak subject, or in even two, providing his general average was sufficiently high. Excelsior, McGill! The ninth aim is to convert the present five-year course into a four-year one of forty teaching weeks each. Each year is to consist of four quarters and the summer quarter is to be optional so that one may be graduated at the end of four years or of five, according to his desire. This plan seems to present advantages, but there are several questions we feel constrained to ask before commenting further. The tenth and final item calls for a senior year junior interneship "in the hospitals directly affiliated with McGill and to be recognized as official by the Medical Examining Boards of Canada and the United States." We are convinced that no license to practice medicine should be granted to a man who has not served at least one year as a junior interne in a good hospital, and predict that this will soon be officially recognized by government licensing boards. There are most certainly obvious faults in our various systems of medical education. These may be overcome in time, but yet we may not anticipate perfection. The weaknesses in human nature itself shaL ever present an insurmountable barrier to the crusader. Still there is much to accomplish before the inevitable impasse confronts us. McGill is marching forward. Vive McGill!

The University of Western Ontario Medical Journal presents in this issue the final number of Volume Two. A year ago last fall the first number of Volume One was submitted to the undergraduates and graduates of the U. W. 0. Medical School, as well as to all other medical men in Western Ontario, not as just another medical publication, but as a vehicle for their efforts at self-expression in the lore of Aesculapius. The Journal has been well received and we believe has to some extent accomplished the purpose of the men who labored hard to found it. Especially gratifying to the staff of the Journal has been the response

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of the undergraduate students to the opportunity offered in these page to publish original article . While medical paper by practitioners shall always receive, a in the past, a most incere welcome, yet we feel that the primary function of the Journal must be to encourage and develop whatever literary talents lie latent in our student body. The art of lucid writing i neither easily nor suddenly acquired; the more the tudent seek to publi h in the rather lenient undergraduate journals the better will he be equipped to write for the more exacting profes ional publication later on. There are many men now in practice who are keenly aware of their own lack of training in the the writing of medical papers during their student days. In thi connection we would like to ugge t to the junior students that the coming summer months will offer excellent opportunities to get together suitable material for an article. They will have the leisure to do the reading neces ary and the careful revision required to produce a worth-while paper. Those who expect to spend the summer in a hospital will have special advantage for this ort of work. We wish also to acknowledge our deep debt of gratitude to the first two Editors-in-chief of the Journal, to Dr. J. P. Wells, '31, for his courageous vision in initiating the Journal, and to T. S. Conover, '32, for his untiring work in establishing it. And behind the scenes there has alway been tho e unfailing ource of advice and encouragement, Dr. J. W. Crane, the godfather of every medical student at Western, and Dr. H. A. Skinner, who finally reads every manuscript. The success of the Journal during its first two years of existence fortifies us in the conviction that it has found a place of real service in the medical life of the University and of this district. Its future success is assured to the extent that it will continue to serve.

BEST WISHES TO MEDS., '32 As the end of another chool year draws near, another graduating class is doing its be t to complete the con truction of a fort of knowledge that will withstand the questionnaire of even the mo t hard-boiled examiner . Meds. '32, have reached their immediate goal-the one toward which they have been triving for at lea t the past six years. The time ha come for the unit to become divided into units. Each graduate become a force and a power omewhere. Each will as ume care and re pon ibilities in accordance with his opportunitie and his courage, and all will reflect to orne degree the teaching and ideals of a zealous and sympathetic faculty. The University of Western Ontario Medical Journal wishes the Meds. '32, a life of wholesome service and hopes that they may continue to find in the Journal a means of a ociation with their alma mater and the medical world at large. Au Revoir!

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.. A uthor's Index Page Barr, M. L.-The Psychiatry of the Greeks and Romans............................................ Boyes, J. G.-X-Ray Treatment of Herpes Zoster........................................................ Callaghan, V. A.-Arterio-Venou Aneurysm of Popliteal Vessels .......................... Campbell, Jean-Case Report of a eptic Thrombus of the Leg with Ulceration Danks, A. I.-A Case of plenic Anemia ........................................................................ Denney, W. L.-Acute I utritional Disturbances of Infancy ...................................... Dent, 0. V.-l'r1edicine in Shakespeare .............................................................................. Elgie, W . A.-Duodenal Ulcers Which Have Been Healed by Removal of a Chronic Appendix.......................................................................................................... Fisher, S. M.-The Neurasthenic Factor in the Practice of Medicine ...................... Hale, G. C.-Cardiac Pain and Its Significance.............................................................. Hill, A. C.-Dr. Moses, M. 0. H........................................... .............................................. Hughes, F. W.-Acute Anterior Poliomyelitis................................................................ Janes, R. G.-Obesity and Weight Reduction ................................................................. . LeBoldus, J. M.-Complete Heart-Block with Case Report ....................................... . Lindsay, K. IlL-Symptoms and Treatment of General Paralysis ............................. . Lynch, D. 0.-A Study of Mental Disorders Occurring in Relation to Childbirth :looney, B.-Control of Cancer and Purchase of Radium ........................................... . :forrison, W. W.-Building Resistance to Colds ......................................................... . :lowry, A. E.-Treatment of Abortions .......................................................................... Murray, R. S.-Shoulder Dislocation-A Method of Reduction ................................. . Poole, M. W.-On the History of Syphilis ..................................................................... . Riddel, A. D.-An Unusual Neuro-Pituitary Syndrome ............................................. . Robertson, D. E.-Rami-Section ....................................................................................... . Rogers, J. D.-Ambroise Pare ........................................................................................... . Ross, C. C.-Arterio-Venous Aneurysm of Popliteal Vessels ...................................... Russel, T. F.-Acute Intestinal Intoxication.................................................................... Simpson, Murray-Surgical Treatment of Pulmonary Tuberculosis........................ Skinner, H. A.-Anatomical Con iderations in Exophthalmos.................................. Starr, F . N. G.-Royal College of Physicians and Surgeons of Canada.................... Valeriote, S. L.-Congenital Atelectasis.......................................................................... \Vaite, W. I.-The Pathology of Diabetes........................................................................ Whittaker, K. W.-Ca e Report of Primary Carcinoma of the Lung ...................... Whitaker, Lorne-Therapeutic in Allergic and Related Conditions of the Respiratory Tract.......................................................................................................... Whitaker, Lorne- pontaneous Pneumothorax.............................................................. Wilcox, L. D.-Cerebral Aneurysms with Sub-Arachnoid Hemorrhage ....................

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41 16 107 14 100 132 126 38 111 71 24 6 49 63 95 82 19 12 119 99 29 56 138 90 107 53 1 35 87 45 59 114

9 76 122

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Subject Index

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. Page Abortions, Treatment of ...................................................................................................... 119 Allergic and Related Conditions of the Respiratory Tract, Therapeutics in.......... 9 Anatomical Considerations in Exophthalmos.................................................................. 35 Anemia, A Case of Splenic ................................................................................................ 100 Aneurysm of the Popliteal Vessels, Arterio-Venous ...................................................... 107 Aneurysms with Sub-Arachnoid Hemorrhage, Cerebral............................................ 122 Appendix, Duodenal Ulcers Which Have Been Healed by Removal of a Chronic 38 Arterio-Ven!)us Aneurysm of the Popliteal Vessels.................................................... 107 Atelectasis, Congenital.......................................................................................................... 45 Cancer and Purchase of Radium, Control of.................................................................. 19 Carcinoma of the Lung, Case Report of Primary .......................................................... 114 Cardiac Pain and Its Significance...................................................................................... 71 Cerebral Aneurysms with Sub-Arachnoid Hemorrhage .............................................. 122 Childbirth, A Study of Mental Disorders Occurring in Relation to.......................... 82 Colds, Building Resistance to.............................................................................................. 12 College of Physicians and Surgeons of Canada, Royal................................................ 87 Congenital Atelectasis.......................................................................................................... 45 Diabetes, The Pathology of.................................................................................................. 59 Dislocation-A Method of Reduction, Shoulder.............................................................. 99 Disturbances of Infancy, Acute Nutritional... ............................................................... 132 Duodenal Ulcers Which Have Been Healed by Removal of a Chronic Appendix.... 38 Editorial ................................................................................................................ 33, 68, 106, 140 Exophthalmos, Anatomical Considerations in.... ............................................................ 35 General Paralysis, Symptoms and Treatment of..................................... -................... 95 Heart-Block with Case Report, Complete........................................................................ 63 Hemorrhage, Cerebral Aneurysms with Sub-Arachnoid .............................................. 122 Herpes Zoster, X-Ray Treatment of.................................................................................. 16 HistoricalAmbroise Pare................................................................................................................ 90 Dr. Moses, M. 0. H......................................................................................................... 24 Medicine in Shakespeare.............................................................................................. 126 On the History of Syphilis.......................................................................................... 29 The Psychiatry of the Greeks and Romans............................................................ 41 In Memoriam .......................................... ..........................................................................104, 105 Infancy, Acute Nutritional Disturbances of.. .................................................................. 132 Intestinal Intoxication, Acute.............................................................................................. 53 Intoxication, Acute Intestinal.............................................................................................. 53 Leg with Ulceration, Case Report of a Septic Thrombus of........................................ 14 Library, Recent Accessions to the Medical School... ........................ -............................ 70 Lung, Case Report of Primary Carcinoma of the ........................................................ 114 Medicine in Shakespeare...................................................................................................... 126

145

146

SUBJECT INDEX Page

Medicine, The Neurasthenic Factor in the Practice of ................................................ 111 Mental Disorders Occurring in Relation to Childbirth, A Study of........................ 82 MiscellaneousIn Memoriam ............................................................................................................104, 105 Recent Accessions to the Medical School Library ............................................... . 70 Royal College of Physicians and Surgeons of Canada ....................................... . 87 Moses, l\'1. 0. H., Dr ............................................................... ............................................... . 24 Neuro-Pituitary Syndrome, An Unusual.. ..................................................................... . 56 Neurasthenic Factor in the Practice of Medicine ......................................... :.............. .. 111 Nutritional Disturbances of Infancy, Acute .................................................................. .. 132 Obesity and Weight Reduction ........................................................................................ .. 49 Pain and Its Significance, Cardiac ................................................................................... . 71 Paralysis, Symptoms and Treatment of General.. ......................................................... . 95 Pare, Ambroise ...................................................................................................................... . 90 Pathology of Diabetes ....................................................................................................... . 59 Pneumothorax, Spontaneous .............................................................................................. .. 76 Poliomyelitis, Acute Anterior ............................................................................................. . 6 Popliteal Vessels, Arterio-Venous Aneurysm of.. ........................................................... . 107 Practice of Medicine, The Neurasthenic Factor in .................................................... .. 111 Psychiatry of the Greeks and Romans ............................................................................ .. 41 Pulmonary Tuberculosis, Surgical Treatment of ............................................................. . 1 Radium, Control of Cancer and Purchase of ................................................................... . 19 Rami-Section ......................................................................................................................... . 138 Reduction, Shoulder Dislocation-A Method of ............................................................. . 99 Resistance to Colds, Building............................................................................................. . 12 Respiratory Tract, Therapeutics in Allergic and Related Conditions of the .......... .. 9 Royal College of Physicians and Surgeons of Canada ................................................ .. 87 Shakespeare, Medicine in................................................................................: ................... .. 126 boulder Dislocation-A Method of Reduction .............................................................. .. 99 plenic Anemia, A Case of................................................................................................ .. 100 ub-Arachnoid Hemorrhage, Cerebral Aneurysms with ............................................ .. 122 Symptoms and Treatment of General Pa ra lysis ........................................................... . 95 yndrome, An Unusual Neuro-Pituitary ......................................................................... . 56 Syphilis, On the History of ..................................... :........................................................... . 29 Therapeutics in Allergic and Related Conditions of the Respiratory Tract.. ....... . 9 Thrombus of the Leg with Ulcerations, Case Report of a ........................................... . 14 Treatment of Abortions...................................................................................................... . 119 Treatment of General Paralysis, Symptoms and ...................................................... .. 95 Treatment of Herpes Zoster, X-Ray............................................................................... . 16 Treatment of Pulmonary Tuberculosis, Surgical.. ........................................................ .. 1 1 Tuberculosis, Surgical Treatment of Pulmonary.......................................................... .. Ulceration, Case Report of a eptic Thrombus of the Leg with ............................. . 14 Ulcers Which Have Been Healed by Removal of a Chronic Appendix, Duodenal.... 38 Weight Reduction, Obesity and ....................................................................................... . 49 X-Ray Treatment of Herpes Zoster ................................................................................. . 16