History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: August, 1951 Vancouver Medical Association Aug 31, 1951

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 BULLETIN
OF If
The Vancouver Medical Association
EDITOR:
dr. j. h. MacDermot
EDITORIAL BOARD
DR. D. E. H. CLEVELAND DR. J. H. B. GRANT
DR. H. A. DesBRISAY dr- J- L- McMILLAN
Publisher and Advertising Manager
 V. E. G. MACDONALD	
VOL. XXVII AUGUST, 1951 NUMBER 11
OFFICERS 1951-52
Dr. J. C. Grimson Dr. E. C. McCoy Dr. Henry Scott
President Vice-President Past President
Dr. Gordon Btjrke Dr. D. S. Mtjnroe
Hon. Treasurer Hon. Secretary
Additional Members of Executive:
Dr. J. H. Black Dr. George Langley
TRUSTEES
Db. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Eye, Ear, Nose and Throat
Dr. B. W. Tanton Chairman Dr. John A. Irving Secretary
Paediatric
Dr. Peter Spohn Chairman Dr. John W. WmTELAW-Secretary
Orthopaedic and Traumatic Surgery
Dr. D. E. Starr Chairman Dr. A. S. McConkey Secretary
Neurology and Psychiatry
Dr. R. Whitman Chairman Dr. B. Bryson Secretary
Radiology
Dr. Andrew Turnhull Chairman Dr. W. L. Sloan Secretary
STANDING COMMITTEES
Library:
Dr. A. F. Hardyment, Chairman; Dr. J. L. Parnell, Secretary;
Dr. F. S. Hobbs, Dr. J. E. Walker, Dr. E. France Word, Dr. D. W. Moefatt
Co-ordination of Medical Meetings Committee:
Dr. J. W. Frost Chairman Dr. W. M. G. Wilson—Secretary
Summer School:
Dr. Peter Lehmann, Chairman; Dr. B. T. H. Marteinsson, Secretary;
Dr. A. C. Gardner Frost; Dr. J. H. Black; Dr. Peter Spohn:
Dr. J. A. Irving.
Medical Economics:
Dr. F. Ii. Skinner, Chairman; Dr. W. E. Sloan, Dr. G. H. Clement,
Dr. E. A. Jones, Dr. Robert Stanley, Dr. F. B. Thomson, Dr. R. Langston
Credentials:
Dr. Gordon C. Johnston, Dr. W. J. Dorrance, Dr. Henrf Scott
V.O.N. Advisory Committee
Dr. Isabel Day, Dr. D. M. Whitelaw, Dr. R. Whitman
Representative to the B.C. Medical Association: Dr. Henry Scott
Representative to the Vancouver Board of Trade: Dr. E. C. McCoy
Representative to Greater Vancouver Health League: Dr. J. A. Ganshorn VANCOUVER MEDICAL ASSOCIATION
PROGRAMME FOR THE FIFTY-THIRD ANNUAL SESSION
Founded 1898; Incorporated 1906.
REGULAR MONTHLY MEDICAL MEETINGS
FIRST TUESDAY—GENERAL MEETING—Vancouver Medical Association—T. B.
Auditorium.
Clinical Meetings, which members of the Vancouver Medical Association are invited
to attend, will be held each month as follows:
SECOND TVESDAY—SHAUGHNESSY HOSPITAL STAFF MEETING.
THIRD TUESDAY—ST. PAUL'S HOSPITAL STAFF MEETING.
FOURTH TUESDAY—VANCOUVER GENERAL HOSPITAL STAFF MEETING.
FIFTH TUESDAY—(when one occurs)—CHILDREN'S HOSPITAL STAFF MEETING.
Notice and programme of all meetings will be circularized by the Executive Office
of the Vancouver Medical Association. i^fl
VANCOUVER GENERAL HOSPITAL
Regular Weekly Fixtures in the Lecture Hall
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic,
edition, 1950.
ST. PAUL'S HOSPITAL
Regular Weekly Fixtures $§|
TUESDAY—9-10 a.m PAEDIATRIC CONFERENCE
2nd TUESDAY of each month—11 a.m .TUMOR CLINIC
WEDNESDAY—9-11 a.m . . MEDICAL CLINIC
2nd and 4th WEDNESDAY—11-12 a.m OBSTETRICS AND GYNAECOLOGY
THURSDAY—11-12 a.m PATHOLOGICAL CONFERENCE
(Specimens and Discussion)
FRIDAY—8 a.m CLINICO-PATHOLOGICAL CONFERENCE
(Alternating with Surgery)    ^Ja
ALTERNATE FRIDAYS—8 a.m ..SURGICAL CONFERENCE
FRIDAY—9 a.m DR. APPLEBY'S SURGERY CLINIC
FRIDAY—11 a.m INTERESTING FILMS $HOWN IN X-RAY DEPARTMENT
Page 262 SHAUGHNESSY HOSPITAL
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology.
Wednesday, 10:45 a.m.—General Medicine.
Wednesday, 12:30 p.m.—Pathology.
Thursday, 10:30 a.m.—Psychiatry.
Friday, 8:30 a.m.—Chest Conference.
Friday, 1:15 p.m.—Surgery.
BRITISH COLUMBIA CANCER INSTITUTE
Tuesday, 9:00 a.m. to 10:00 a.m. (weekly)—Clinical Meeting.
|    THE  BULLETIN
Publishing and Business Office — 17 - 675 Davie Street, Vancouver, B.C.
Editorial Office — 203 Medical-Dental Building, Vancouver, B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.
Closing Date for articles is the 10th of the month preceding date of issue.
Manuscripts must be typewritten, double spaced and the original copy.
Reprints must be ordered within 15 days after the appearance of the article in question, direct from the Publisher. Quotations on request.
Advertisements
Closing Date for advertisements is the 10th of the month preceding date of issue.
Advertising Rates on Request.
B.C. DIVISION, CANADIAN MEDICAL ASSOCIATION
ANNUAL MEETING
OCT. 2-3-4-5th, 1951
VANCOUVER HOTEL
Scientific papers by:
Dr. H. C. Church—Pres. Canadian Medical Association.
Dr. H. S. Polley—Mayo Clinic.
Dr. Taylor Statten—Montreal.
Dr. G. R. Brow—Montreal.
Dr. E. C. Janes—Hamilton.
Dr. J. Baker—Seattle.
Entertainment
Annual Luncheon, Wednesday, Oct. 3.
Gala Buffet Dinner Dance, Thursday, Oct. 4.
H.M.C.S. Discovery Bar.    Dal Richards and Hotel Vancouver
Orchestra.
Annual Dinner, Friday, Oct. 5.
Hotel Vancouver.    Cocktails.    Music.
Speaker: Prof. Wm. Boyd.
Golf.    Sherry-Coffee Party for Ladies.
Harbor Cruises, North Star Flights over City.
All Details in Next Issue.
Page 263 mucilose
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The elderly, the postoperative, the
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frequently are afflicted with constipation
as a result of a low-residue diet.
Mucilose—highly hydrophilic hemicellulose
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in indigestible residue, provides bland
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Trial supply will be sent to
Physicians upon request.
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Mucilose, trademark reg. U. S. & Canada
443 SANDWICH STREET WEST, WINDSOR, ONTARIO VANCOUVER HEALTH DEPARTMENT
STATISTICS — JULY,   1951
Total   population   —   estimated Z 397,140
Chinese   population  —  estimated 6,282
Other — estimated  640
June,  1951
Rate per
Number        1000 pop.
Total   deaths   (by   occurrence) 333 10.1
Chinese deaths   ; 1 20 38.2
Deaths, residents only 297 8.9
Birth Registrations — Residents and Non-residents:
(includes late registrations)
June, 1951
Male 451
Female I 425
Iti 876 26.5
Infant Mortality — resident only:
Deaths under 1 year of age	
Death rate per  1000 live births_
Stillbirths   (not included in above item) 8
CASES OF COMMUNICABLE DISEASES  REPORTED IN THE CITY
Scarlet Fever	
Diphtheria .	
Diphtheria Carriers	
Chicken Pox	
Measles	
Rubella	
Mumps	
Whooping Cough	
Typhoid Fever	
Typhoid Fever Carriers.
Undulant Fever	
Poliomyelitis	
Tuberculosis	
Erysipelas I	
Meningitis	
Infectious   Jaundice—
Salmonellosis	
Salmonellosis   Carriers.
Dysentery i	
J>ysentery   Carriers-
Tetanus 	
Syphilis	
Gonorrhoea	
Cencer   (Reportable)  Resident-
June,
1951
June,
1950
Cases
Deaths
Cases
Deaths
66
—
2
—~~
95
—
112
—
169
—
243
—
54
—
678
—
38
—
196
—
16
—
38
—
17
11
45
71
Page 264 -C CONNAUGHT >
LIVER
EXTRACT    INJECTABLE
(15 UNITS PER CC.)
Liver Extract Injectable is prepared specifically for the treatment of
pernicious anaemia. The potency of this product is expressed in units determined by responses secured in the treatment of human cases of pernicious
anaemia. Liver Extract Injectable as prepared in the Connaught Medical
Research Laboratories
—contains at least 15 micrograms of vitamin B12 per cc.
derived directly from liver and determined by the Lactobacillus leichmannii test.
—is carefully tested for potency.
—is low in \ total solids and light in colour.
—is very highly purified and therefore can usually be administered without occurrence of discomfort or local reactions.
Liver Extract Injectable (15 units per cc.) as prepared by the Connaught
Medical Research Laboratories is supplied in packages containing single 5-cc.
vials, in multiple packages containing five 5-cc. vials, and in lOcc. vials.
Liver Extract for Oral Use in powdered form is supplied in packages
containing ten vials; each vial contains extract derived from approximately
one-half pound of liver.
□
CONNAUGHT   MEDICAL   RESEARCH   LABORATORIES
University of Toronto Toronto, Canada
Established  ia 1914 for Public Service through Medical Research  aad the development
of Products for Prevention or Treatment of Disease.
DEPOT FOR BRITISH COLUMBIA
MACDDNALD'S    PRESCRIPTIONS    LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. The Editor's Page
One of the most interesting and significant items of news that appeared lately in
the press, was the announcement that the medical profession of Great Britain had
apparently won its point with the government in the matter of better terms of payment
for work done and general conditions of practice. This, as far as we can remember, is
the first time that the British Medical Profession has been able to win a major victory,
in its long struggle under the Health Insurance plans of Great Britain. We congratulate
our British colleagues most sincerely and trust that their lot, which has by no means
been an easy one, and has been made more difficult by various inequities of administration, will continue to be ameliorated.
For some forty-two years now, there has been government control in Great Britain
of medical practice, and the record is not one of which we feel that our profession can
be proud. Steadily, the conditions of medical practice in that country seem to have
"worsened", as Winston Churchill might say, and since the new Health Insurance Act
passed some years ago, they have become very bad. It .was, we are sure, a very difficult
thing for the medical profession so to organize their resistance, under conditions of a
vested interest, and against all the power of a government bent on socialization of all
national activities, that they could hope for success of any kind. The fact that they
were able to do so, shows how strong their sense of injustice and abuse must have been.
Nor are we, in this country, in any position to feel complacent about this matter.
We read in "Maclean's Magazine" an article by Blair Fraser, a well-known writer with
an ear close to the ground in all matters political. In this article he states that the
government is making a fresh attack on the subject of Health Insurance, and implies,
we seem to understand from what he says, that it won't be long now. His remarks
on Hospital Insurance are naive in the extreme—and it is hard to believe that Mr. Fraser
ever reads any newspapers published west of Toronto, or perhaps the Great Lakes.
In any case, we are not out of the woods by any means. Truly it is hard to believe
that any province (for the decision must be provincial) would want to burn its fingers
over Health Insurance, when the first stage, hospital insurance, has proved to be such
a dangerous customer to tackle. True, too, we see Australia fighting free of the present
system of Health Insurance, and its leaders seeking to return to a system more nearly
resembling free enterprise—but we have many men in positions of influence and power,
who firmly believe that a system of health insurance, where doctors will be well and
strictly disciplined and controlled, is necessary and even imperative.
As a profession, we must, as we are constantly being told, maintain our solidarity,
and maintain our principles.  How we are to do this is the big question.
From time to time suggestions crop up that we should unionize—form a guild.
We hope this will never be the case. We are not, and never can be, the sort of profession
that can unionize. For the great union weapon is the strike—and that, with us, as with
soldiers and sailors, can never be a weapon, nor is it necessary. Our experience in
British Columbia, this new development in Great Britain, the Australian situation, all
show that we can, if we stick together firmly and speak reasonably and fairly, win our
case. We, and we better than any government, know what constitutes good medical
care, and we know the evils of penny in the slot medicine. It is up to us to tell the
public our news, to tell them the truth, to- show them the dangers of poor medical
work, and the folly of thinking that they can get good medical care at bargain prices,
or at no cost at all. We should, as we can, show them the real costs of medical care,
and how much more costly it is to have a poor variety.
That is one of the things to which our new Academy of Medicine can help us,
and where it can be a centre of public education and public enlightenment. Here we
shall have in one central place, all our activities, open to view, open to access by anybody. From this centre should stem improved public relations, more open discussion,
more opportunity for both sides to come to know and understan/i each other's case,
and to appreciate each other's honesty and sincerity.
Page 265 ♦j
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Page 266 I
m
Hours During the Summer Months:
Monday to Friday f  9:00 a.m. - 5:00 p.m.
Saturday  -.- 9:00 a.m. - 1:00 p.m.
Recent Accessions: $S®
Breed, R. S.; Murray, E. G. D. and Hitchens, A. P.—Bergey's Manual of Determinative
Bacteriology, 6th edition, 1948.
Hamilton, A. and Hardy, H. L., Industrial Toxicology, 2nd edition, 1949.
Hewitt, R. M.  (editor-in-chief)—Collected Papers of the Mayo Clinic and the Mayo
Foundation, vol. 42, 1950.
Greenberg, L. A.—Antipyrine—A Critical Bibliographic Review, 1950  (gift).
Medical Clinics of North America—Symposium on Diseases of the Kidney, July, 1951.
Medical Research Council Memorandum No.  11—The Control of Cross Infection in
Hospitals, revised edition, 1951.
Recent Supplements to the Acta Medica Scandinavica:
No. 248—The  Arteriovenous  Angiomatosis  of  the  Lung  with  Hypozaemia  by  A.
Giampalmo.
No. 249—Studies on the Nicotinic and Pantothenic Acid Content in the Blood, Urine
and Feces of Man and on the Appearance of these Vitamins in Intestinal Diseases,
by J. Jouni.
No. 250—Clinical and Prognostic Aspects of Acute Coronary Occlusion by S. Ecker-
strom.
No. 251—The Effect of Digitalis, Strophanthin, and Novurit on Blood Coagulation,
by S. A. N. Pere.
No. 252—Red Cell Survival Studies in Normal and Leukaemic Subjects, by R. Berlinr
No. 253—On Treatment of Barbiturate Poisoning, by E. Nilsson.
No. 25-4—Studies in Experimental Tuberculosis, by B. Swedberg.
No. 255—The Electrocardiogram in Pulmonary Tuberculosis, by A. Bjorkman.
BOOK REVIEW
HUANG TI NEI CHING SU WEN: THE YELLOW EMPEROR'S CLASSIC OF
INTERNAL MEDICINE. Chapters 1-34 translated from the Chinese, with an introductory study by Ilza Veith, M.A., Ph.D., Baltimore:   The Williams and Wilkins Co.,
1949, pp. 253, illus. $5.50.
Many authorities consider the Nei Ching as the most important of the earliest
Chinese medical classics. It is an enormous work and Miss Veith has furnished us with
a translation of the first thirty-four chapters. It is probably the oldest book on internal
medicine extant. The time and factual existence of Huang Ti, the Yellow Emperor,
are not definitely established, but he is supposed to owe his place among the heirarchy
of Chinese deities to his authorship of this work. Probably little of the original work
actually remains, but it is generally assumed that a great part of the text existed during
the Han dynasty, and its present form—probably much of it a compilation with later
additions—is owing to its most famous commentator, Wang Ping of the Tang dynasty
in 702. It takes the form of a dialogue between Huang Ti and his minister Ch'i Po.
The introductory essay by the translator together with the three appendices, two of
them by Wang Ping, occupy over a third of the present volume, and with the translation furnish a valuable source book. Apart from this it makes fascinating reading for
• anyone whose taste draw him to the study of medical history. It even may be said
to givt good entertainment value. — D. E. H. C..J||j
Page 267 ALLERGY AND ANAPHYLAXIS*
General Principles
C. H. A. WALTON, M.Sc, M.D,, F.A.C.P.
Diseases, now known to be manifestations of allergy, or altered reactivity, have
undoubtedly existed throughout human history, but their nature and their relation to
each other has been understood only in the past forty years. The diseases themselves
are old and have been known for centuries. The allergic concept is a little more than
a generation old.
Asthma is referred to in the writings of Hippocrates but he did not distinguish
it clearly from other forms of dyspnoea. In the fourth century Aretaeus, in the time
of Galen, gave the first clear description of the asthmatic paroxysm but it was not
until the late seventeenth century that Thomas Willis and Sir John Floyer clearly distinguished bronchial asthma as a clinical entity. Characteristically, bronchial asthma
is a periodic form of difficult breathing, often with completely free intervals and with
no clinical or. pathological evidence of heart disease or of inflammatory or neoplastic
disease of the lung.  It is, in fact, periodic bronchial obstruction.
Asthma has been recognized clinically for centuries but its cause and its pathology
were not understood. In this connection, it is interesting to note the story of one Jerome
Cardan, a noted clinician of Padua, who was called to Edinburgh in 1575 to treat
a bishop who was suffering severely from asthma. Cardan wrought a miraculous cure
by advising the elimination of the bishop's feather bed. There is no doubt that this old
clinician, who was inevitably a good observer, had noted before that there was a relation between feathers and asthma. In his extensive practice he had probably observed
this relationship many times but he formed no theories or conclusions about it. He
simply applied it empirically and obtained good results in some cases.
Laennec thought that the typical asthmatic paroxysm was a neurosis, using the
word neurosis in the sense of a functional condition, and not in the sense of nervousness
that is often implied today. Laennec's idea that it was a reversible functional disturbance
of the bronchi was remarkably close to the truth but the implication that the disturbance
is mediated by the nervous system was unfortunate and probably delayed progress. As
long ago as 1819, Bostock, who was a contemporary of Bright, in England, described
a clinical syndrome, suffered by himself and a few of his patients, which was characterized by severe nasal catarrh, sometimes cough and dyspnoea, and which occured exclusively in the summertime. This disease is now known popularly as hay fever. The cause
was not recognized.   The clinical description was accurate.
In 1873, in the Pasteur era, Blackley, of London, demonstrated beyond question
that seasonal hay fever, as observed in himself and in others, was due to grass pollen,
and he demonstrated that when grass pollen was rubbed into a scratch on his skin that
an urticarial wheal resulted but that other pollens did not cause such a skin reaction.
He also demonstrated that his symptoms occurred only when there was free grass pollen
in the air. Later on, Wyman, in Massachusetts, showed that hay fever, occurring in the
United States of America, in the Autumn, was due to ragweed pollen.
These brilliant and accurate clinical observations of Blackley and Wyman demonstrated that pollen was the cause of hay fever and seasonal asthma, but the theory
received scant attention in the great bacteriological era of Pasteur. After all, why
should grass pollen, which is present in the air in England every June, give Blackley
and a few of his friends hay fever but not bother other people? Grass pollen appeared
to be innocuous, so Blackley's work and that of others was widely ignored. A few
physicians, usually victims of the disease itself, did accept the pollen thesis and elaborate
it. Dunbar, in Germany and Scheppergel, in the United States, continued to demonstrate the relationship of pollen to seasonal catarrh.
Just after the middle of the last century Hyde Salter, in the United States, showed
that asthma could be caused by animal epidermal dust. The relationship between his
observations and those published about the same time on pollen was not recognized.
First of a  series of five addresses delivered  at  the Annual  Summer  School  of the  Vancouver  Medical4
Society, May, 1951, Vancouver, B. C.
Page 268 A number of observers in the older literature noted that such entities as urticaria
and infantile eczema occurred commonly in families and often also in the same people
who suffered from^asthma and hay fever. These scattered observations attracted little
notice and it was not widely appreciated in the medical world that there was any relationship between these apparently unrelated diseases, and no adequate explanation was_
offered as to their cause. The substances which apparently caused the disease, for
example, ragweed pollen in Massachusetts, grass pollen in London, cat dander and so
on, were seemingly innocuous. They could not cause disease. They were literally
ignored, or thought to be coincidental. These diseases could not be transmitted to other
people.
It has been suggested, with some reason, that the brilliant observations of Blackley,
Wyman and others were lost sight of and excited little interest because of the great
revolution in medicine brought about by the discovery of bacteria as the causes of
disease.   Be that as it may, it is interesting that the allergic concept came about as a,
by-product of the early work in bacteriology.
In 1894, von Behring produced antitoxin for diphtheria. This remarkable substance
produced great benefits and lowered the mortality of diphtheria greatly. Yet in a number of unfortunate instances some very mysterious and frequently fatal reactions
occured following the administration of antitoxin. It is now widely known history
that the cause of these reactions was acquired sensitization of the patient to the horse
serum containing antitoxin.
It was soon found that guinea pigs, which were used for the standardization of
antitoxin could not be used a second time. In some way these animals had become
"altered" between the first and second test. This led to the development of the theory
of anaphylaxis. If a foreign material, such as horse serum, is injected into an animal
nothing happens. If, after an interval of several days, a second injection of the same
horse serum is made into the animal, very serious reactions occur, which are often lethal.
Richet advanced the hypothesis that the first injection used up the animal's protecting
antibodies so that when the second injection was made the animal had no immune bodies
left and reacted violently. For this reason he coined the term "Anaphylaxis" meaning
the removing of immunity. This theory is no longer tenable, for many reasons, but
the term anaphylaxis remains and includes all the experimental phenomena observed
in animal hypersensitivity.
Although the term is unsatisfactory, it has remained. But, in 1907 von Pirquet
suggested that another term was preferable, and he coined the term "Allergy" which
simply means altered reactivity. It described a condition without implying a cause.
Thus the term allergy, as developed by von Pirquet means the same thing as the term
anaphylaxis coined by Richet. However, allergy has come to mean, in common medical
usage, a peculiar kind of spontaneous hypersensitiveness seen chiefly in man and sometimes in animals, and it has come to mean something somewhat different from the
artificial sensitivity produced in animals and which was originally called anaphylaxis.
Anaphylaxis, then, was a phenomenon which was produced experimentally in animals. It occurred only after an animal had been passively sensitized and was specific.
Horse serum was apparently innocuous to such animals as guinea pigs on first injection.
A second injection ten days^ later caused anaphylactic shock. Something happened in
that ten days to alter the animal's reactivity. It was soon shown that after the first
injection, specific antibodies were formed which would precipitate with the specific
excitant.
About this time it was also discovered in the laboratory that if small daily injections of the antigen were made after the first sensitizing injection that anaphylaxis
would not occur.  This phenomenon was known as anti-anaphylaxis.
In 1910, Auer and Lewis showed that guinea pigs dying of anaphylactic shock,
tfied really of bronchiolar obstruction, that is from acute asthma. This observation sug^
gested to Meltzer that possibly human asthma was a disease of hypersensitivity or
anaphylaxis.
Thus an attractive theory came out of the experimental laboratory to explain the
Page 269 clinical observations of Blackley, Wyman, Bostock and others on hay fever and asthma.
The grass pollen which did not affect most people affected Blackley because he was
sensitive to it. The dander of Salter's cat was ordinarily innocuous but his lung was
sensitive or allergic to it.
While there were many similarities between human sensitivity and experimental
anaphylaxis, certain differences were soon noted. Human sensitivity was spontaneous
or constitutional; anaphylaxis was passively induced. Human sensitivity was inherited
as a dominant Mendelian character but anaphylaxis was not inherited, although it could
be passively passed to the foetus through the placenta. A major difficulty arose from
the fact that the antibodies produced in experimental anaphylaxis were demonstrated by
precipitation, but in man no such precipitable antibodies could be found. Before long,
however, Prausnitz and Kustner showed that specific reacting bodies could be passively
transferred to the skin of a non-sensitive person by injecting serum from a sensitive
person. Thus antibodies were present in human allergy but were not precipitable by
ordinary laboratory techniques.
A third term, "Atopy", should be referred to. Coca and Cooke coined the word
atopy, which means "strange disease" and intended it to include spontaneously occuring
hypersensitivity in man and in contrast to allergy, which was to include all sensitivity
phenomena as originally suggested by von Pirquet. However, generally speaking today,
the term allergy is used to denote only human hypersensitivity as seen clinically, and
anaphylaxis to denote passively and experimentally induced animal sensitivity, and also
passively induced hypersensitivity in man. This is a more limited used of the word than
von Pirquet intended, but current usage seems to settle the matter. In effect, atopy and
allergy are now used more or less synonymously, and, in fact, the only widespread use
of the word atopy is that customarily used by dermatologists who speak of atopic dermatitis. Otherwise, the terms atopy and allergy may be used interchangeably. Today,
allergy is the more common word.
In the year 1911, Noon and Freeman, in London, adopting the idea of anti-
anaphylaxis, successfully treated a patient by desensitizing him with grass pollen. They
did this by giving very small and frequent hypodermic doses of an aqueous extract of
the pollen to which he was sensitive. The effect was good and this is the first use of
what is now known as "desensitization" or perhaps, more correctly, as "hyposensitization". Noon died of tuberculosis shortly after this, but Freeman is still living and has
recently written a book "Hay Fever—A Key to the Allergic Disorders", which is
reviewed in the Canadian Medical Association Journal, May, 1951.
I have thought it useful to go into the history of the development of the theory
of anaphylaxis and allergy, not only to illustrate the rather remarkable fact that the
theories of etiology, pathology and treatment of previously misunderstood diseases
arose from experimental laboratory work on animals, but also that the conception of
hypersensitivity applies not only to sensitivity of the lung, namely asthma, but to many
other diseases involving other organs of the body. It was now possible to understand
why some clinicians had noted a relationship between urticaria, eczema, hay fever and
asthma. It was also now possible to understand why environmental factors such as
pollen, animal dust, food and so on, seemed to be casually related to diseases which did
not appear to be related pathologically. It is particularly important to recognize that
the diseases under consideration rarely came to autopsy. The severely reacting tissues'
returned to normal after the reaction subsided and usually there was no visible evidence
remaining of the violent tissue reaction which had led to such severe symptoms.
Experimental animal work has given us the key to an understanding of a group
of diseases previously not understood and not suspected of being related. It also has
given continued and invaluable facilities for further study and research.
Our knowledge of the pathology of allergic diseases has come from more frequent
autopsy studies on fatal cases, from biopsies and in particular from direct observation
on the experimental animal. From these observations we know that some of the characteristic pathological responses in allergic diseases are:
1. Increased capillary permeability with resulting loss of fluid into the tissues.
Page 270 2. Increased secretion from mucous glands and cells.
3. Eosinophilia in tissue, in the blood and secretions.
4. Smooth muscle spasm.
These are the fundamental functional pathological changes in the reacting tissue.
No matter which tissue is reacting the response is similar, with one or another of these
changes predominating. It will be readily understood that these reactions are functional
and reversible. The great difficulty in the pathological study of human allergy has been
the marked tendency of the affected tissues to return to normal after tfce allergic state
subsides. Obviously, if the reactions are long continued secondary changes may occur.
Smooth muscle spasm may lead to hypertrophy; mucous membranes may become polypoid, increased mucous secretion may be so marked and so viscid that obstruction to an
organ like a small bronchus may occur. The reaction of hypersensitivity may be so
severe that death ensues from bronchial obstruction as in the experimental guinea pig,
or from asthma in man, or from shock and falling blood pressure in the dog. In man,
death can and does occur in severe allergic reactions, usually from respiratory
obstruction.
Time does not permit an elaborate discussion of the mechanism of an allergic or
hypersensitive reaction. It must be emphasized that the hypersensitive or allergic reaction is highly specific. When a guinea pig is sensitized to horse serum it will react to a
second or shocking dose of horse serum but not to some other foreign protein. Similarly in human allergy the individual reacts specifically to definite agents. The grass
sensitive patient is not necessarily sensitive to cat dander. The serum of the grass
sensitive patient transferred intradermally to the skin of a non-sensitive person will
cause that skin to react specifically to grass pollen and no other antigen. It is thought
when the particular antigen enters the body, by whatever route, that it reacts with
antibody in the cells of the reacting tissue. The reaction of antigen and antibody
produces chemical substances which produce their effect pharmacologically.
It has been observed for many years, as long ago as 1910, by Sir Henry Dale and
Laidlaw, that when histamine is injected into an animal, the reactions are very similar
to and in fact often indistinguishable from those produced by anaphylactic shock. It
is now thought that one of the products of the allergic reaction is histamine or some
substance very like it. In addition, it is recognized that other substances are also produced and that histamine is not the only, or even the most important product of the
allergic reaction.
In the case of urticaria and hay fever, histamine appears to be the most prominent
agent produced by the allergic reaction. In asthma other substances, probably related
or similar to acetyl choline are produced. If we accept the thesis that diseases such as
asthma in man are brought about by specific sensitivity, then we must be able to demonstrate the antigen. This is possible in many instances, but not always. The possible
agents are innumerable and their recognition is therefore not easy. Earlier I mentioned
that Blackley and other clinicians had noted that if they scratched their skin with grass
pollen an urticarial wheal resulted. When unrelated pollens were scratched into their
skin nothing happened. That is, the pollen causing summer catarrh would react specifically by scratch skin test.
Now Blackley's long-neglected observations were suddenly seized upon with great
enthusiasm, and it was found that many substances which caused allergic reactions in
man and in animals would give a specific urticarial reaction when scratched or injected
into the skin. On the other hand, skin reactions were often disappointing. Without
going into the long history of this aspect of the subject, I might say that specific skin
reactions can be demonstrated in a large proportion of cases where the antigen enters
the body through the respiratory tract, that is, by inhalation, but it is very unreliable
in other instances. When pollen enters the nose or bronchi it undergoes, in effect, an
aqueous extraction. The soluble antigen is absorbed into and through the mucosa, and
if this is sensitive, causes hay fever or asthma. The absorbed antigen circulates in the
blood and any sensitive organ it reaches will also react—as for example, the skin in
atopic dermatitis. Pollen or other inhaled antigen is unchanged as it enters the body.
Page 271 On the other hand, another important route of entry for allergens is the gastrointestinal tract. In this instance, digestion materially alters the ingested substance so
that the antigen is probably a break-down product of the substance originally swallowed.
In infancy, such substances as egg and milk albumin have been shown to be absorbed
practically unchanged and the whole protein molecule is widely circulated by the gastrointestinal tract loses this property early in life. Perhaps this accounts for the common
occurrence of eczema due to milk, egg and wheat in infants. Realizing that the ingest-
ant antigen is probably a product of digestion, it is not surprising that testing the
skin with undigested antigen is often useless and indeed very misleading.
The real test of specific sensitivity is, of course, the exhibition of the suspected
antigen to the patient, preferably directly to his shock organ. For example, it is
much better to prove that the patient's hay fever is due to pollen by placing pollen
in his nose, than by indirect method of skin testing. Yet skin testing is a much
nicer procedure from the patient's point of view and is, indeed, often of the
greatest help. Skin tests then are useful for studying the possible agents for sensitivity
but are not proof of clinical sensitivity. A positive skin test simply means that there
are specific antibodies to that antigen in the dermal cells.
If you accept the thesis that a particular disease is due to allergy or specific sensitivity, you must be able to demonstrate that the specific antigen will produce the
reaction, and conversely that when the antigen is not present, that no reaction will
occur. In man, hypersensitivity is usually manifested by reactions in one organ,
although an overwhelming dose may produce general reactions. The reactive tissue
is referred to as the shock organ. This might be the skin, the nasal mucosa, the bronchi,
the gastro-intestinal tract, etc. The symptoms obviously vary with the shock organ.
Local tissue oedema may be evidenced by a hive in urticaria or by nasal obstruction in
hay fever. Smooth muscle spasm may cause intestinal cramps or perhaps dysmenorrhoea.
A very characteristic symptom of the allergic reaction is itching. In the nose this
itching is manifested as sneezing, in the lung as coughing, in the bowel perhaps as diarrhoea or crampy pain.
The outstanding clinical characteristic of allergy is its periodicity. Asthma commonly occurs in paroxysms with completely free intervals- and similarly with other
allergic manifestations. The patient who suffers from severe asthmatic dyspnoea may
be quite symptom free and without signs when he finally gets an appointment with his
doctor. Urticaria may be severe and disfiguring today and entirely absent tomorrow.
Obviously, the history of the circumstances surrounding all attacks is of the greatest
importance in making an etiological diagnosis. Skin tests may assist, but in themselves
are not the easy solution that they were once thought or hoped to be.
If one considers the possible routes of entry of an entigen into the body it will aid
in the search. Inhalation and ingestion are obvious entry routes. Injection of therapeutic substance such as liver or insulin and direct contact with the substance by the
skin are other obvious possible routes.
Blackley's grass pollen and Salter's cat dander conceivably could have been swallowed or otherwise gain entry to the body, but the most likely entry route was in the
inspired air. Such bodies must, of course, be particles which are suspended in the air.
They are air-borne.
Many types of air-borne particles, mostly innocuous, enter our respiratory tract.
Some of them are highly antigenic to allergic people. Certain large groups of cases of
hay fever, asthma and dermatitis are strictly seasonal in their incidence. This, of course,
narrows the possible field of antigens. In the growing seasons one naturally thinks of
the products of plant and fungus life such as pollen and spores which are air-borne.
These obviously vary from place to place and have fairly constant characteristics in any
one place. It is obvious that such agents, to cause harm, must enter the body in the
inspired air, that is, they must be air-borne. Only air-borne pollen and spores can reach
the patient conveniently and these can be determined by suitable botanical and air
studies. Many pollens are insect-borne and do not travel as suspended particles in the
air and are, therefore, of no importance, generally speaking, in allergy.   In Manitoba,
Page 272 in the last few. days in April, we normally expect such trees as the poplar and the elm
to pollinate. Each year these trees pollinate in the same manner. Some years greater
quantities of pollen are produced than in others, and the dates vary slightly, but are
.amazingly constant. Obviously, then, if a patient is suffering from sensitivity to the
pollen of one of these trees, he will manifest his symptoms in that particular season
and in no other season, unless he has, of course, other sensitivities. In Vancouver, the
poplar and the elm and other trees undoubtedly pollinate at a similar time and the same
rule would apply. It will be seen, therefore, that the characteristics of the air-borne
particles in any community are important if an accurate diagnosis is to be made. These
vary from community to community, and the variations account for the fact that the
patient who has symptoms in one area may be free in another, not because the climate
is different, but because the agent to which they are sensitive is not present.
If a patient who is sensitive to poplar or elm pollen has symptoms when those
trees are not pollinating, obviously there must be some other cause that should be
searched for.
There are many other examples of air-borne allergy such as the epidermal dust
from furred and feathered animals. In dealing with inhaled or suspected inhaled allergies, one must, of course, be highly suspicious of the dog, cat or horse or even the
canary. Farmers and pet lovers are therefore common victims of animal sensitivity.
Domestic dusts such as house dust, tobacco, insecticides, etc., and industrial dusts such
as grain dust, seed dust, fur dust, are obvious factors. Other environmental dusts such
as feathers, lint, etc., must be considered and are frequent causes of trouble.
Another great group of allergens is that which is swallowed, the ingestants. This
group includes food, drink and drugs. Any food may cause trouble but those which are
eaten earliest in life such as milk, egg, wheat, peas and peanuts, chocolate, etc., are
among the most common offenders. When food sensitivity involves seldom eaten foods
it is easily recognized. The person who develops hives from the ingestion of shellfish,
commonly makes his own diagnosis. The patient who has hives from such a commonly
eaten food as milk, may fail to recognize it. Skin tests are disappointing, for the reasons
referred to before. In ingestant cases they are of little or no value. Test diets are necessary and often valuable.
Injected allergens have been referred to and include such obvious therapeutic agents
as penicillin, liver, insulin and others.
At first it was generally believed that only protein could act as an antigen but we
now know that certain polysaccharides and even simple chemical substances such as
aspirin can act as allergens. It is thought that these simple substances combine in the
blood serum with globulin to form haptens which are the specific allergens.
I have referred so far only to allergens or antigens which enter the body from without, that is extrinsic agents. It seems highly probable that allergens can also originate
from within the body as products of metabolism, foci of infection, etc. These intrinsic
agents are very difficult to demonstrate convincingly and are less well understood.
If one adopted the principles of allergy and could demonstrate the offending agents
in every case the results would be most satisfactory. Indeed, in clinical practice we
can, with careful study, do this in about two-thirds of our cases. The other third are
otherwise indistinguishable, clinically, but our diagnostic resources fail to demonstrate
the specific sensitivities involved. The question has been raised, does this group represent
some mechanism other than allergy, or does it simply represent our diagnostic limitations? I think the latter is closer to the truth. We have a workable hypothesis which
answers the problem in a majority of cases but needs further elaboration. A clinician
dealing with allergic patients requires a detailed knowledge of the many invironmental
factors surrounding the patient, the botanical and mycological factors, the dusts met in
his work, the foods he eats, the drugs he takes and the drinks he drinks.
Although the allergic concept has given us an invaluable approach it is only part
of the story. We know that many allergic people are peculiary unstable psychiatrically,
some are affected by their endocrine systems, for example, during pregnancy, adolescence, etc.  Why do some people fall into the very unsatisfactory category of intrinsic
Page 273 allergy?  Does the term intrinsic allergy mean that we are too polite to say we cannot
find the cause?
Allergy is common in man and it is now recognized more frequently in animals.
Many investigators have tried to estimate the frequency of allergy although this is.
practically impossible. However, there is reason to believe that 5-10% of our population have more or less severe allergic disabilities. Perhaps as much as 2% of the population suffers from asthma of varying degrees and, of course, it is often unrecognized or
confused with some other disease. Such figures cannot be accepted uncritically, but
they do serve to emphasize the fact that allergic phenomena are very common. These
patients are too often neglected in spite of the fact that the phenomenon of hypersensitivity and its manifestations has been known for more than a generation.
At present, we must be able to recognize an allergic state and to treat its manifestations symptomatically. In many cases we can find the offending allergens and when
we do so we should attempt to separate the patient from the offending agent. If that
is impractical, perhaps we can desensitize him or otherwise protect him from his,
offenders.
There are many therapeutic measures available for the relief of symptoms due to
allergic disease. Symptomatic management is valuable but knowledge of the cause of
the disease offers much more fundamental and permanent help.
The phenomenon of hypersensitivity or allergy as we know it in man, has given
us a highly acceptible theory of the cause of certain diseases. In a large number of
properly studied cases specific causes of hypersensitivity can be demonstrated. In other
cases of the same disease where we fail to make an etiological diagnosis we cannot be
excused from the allergic concept because of our failure. There is no demonstrable
pathological difference between the allergic person in whom the etiology is known and
the allergic person in whom the etiology is not determined. It is useless to say that they
are different cases. Until other mechanisms are discovered we must assume that all of
these diseases are due to hypersensitivity and continue our effort to demonstrate a cause.
Such terms as "non-allergic asthma" seem to me to be untenable. It is true, there are
many cases in which we cannot show the allergic cause, but that simply reflects the
limitations of our diagnostic ability. Symptomatic treatment will always be necessary
and is highly useful, but etiological management is obviously desirable in all cases.
Division of Medicine,
Winnipeg Clinic,
St. Mary's & Vaughan,
Winnipeg, Man.
BRIEF SERIES OF LECTURES ON PSYCHIATRY
IN GENERAL PRACTICE
W. DONALD ROSS, M.D. (Man.), F.R.C.P. (C)
Assistant Professor of Psychiatry, University of Cincinnati
,—The Handling of Acute Psychiatric Problems in General Practice
This discussion is concerned with psychiatric emergencies in general practice, with
those situations which must be handled by the general practitioner without time to
consult a psychiatrist. I mentioned that it would be one of the discussions on treatment
and you realize that the other discussion on treatment was entirely about psychotherapy,
with nothing about other types of psychiatric treatment. The major psychiatric therapies, such as shock treatment, and the major types of psychotherapy such as hypnosis
and psychoanalysis are, of course, therapies to be administered by the specialist in psychiatry and we are not concerned with them in this course. Other physical therapies
in chronic psychiatric problems in general practice might be described, such as hormonal
and drug therapies, but there is not time in a few lectures to consider them in detail.
I think it will be more useful to you to cover a few common emergency situations,
* Presented to the Vancouver Medical Association, May 28 th - June 1st,  1951.
Page 274 such as suicidal tendencies, acute insomnia, nocturnal delirium and other organic confusions, acute alcoholic problems, acute grief, acute panic state and the apparent sudden
onset of psychosis.
SUICIDAL TENDENCIES
There is a problem here for the physician to steer a middle course between the
failure to recognize serious suicidal tendencies and get the patient to protective care, and
the opposite attitude, of being so fearful of suicidal risks that he will not carry any
responsibility for treating emotional disorders, or that he will, by his anxiety or anger at
suicidal threats, actually provoke a patient into a suicidal gesture as a way of getting attention. I want to recommend as essential reading, Chapter VI "Suicide Risks", of
Levine's book, "Psychotherapy in Medical Practice" (3). The signs of real suicidal risk
are well described there, the deepness of depression, especially from the vegetative signs
mentiond in th discussion of common emotional disorders, depressive delusions, past suicidal attempts, during the recovery from a deep depression, increased tension or agitation
with depression, unreality feelings and absence of affection for loved ones,. absence of
manifestations of hysterical personality and concealment of suicidal ideas. The risk is
greater in the early morning hours, or after return from a vacation. You are all aware of
the post-vacation depressed feelings and the Monday morning blues. In really depressed
persons these can reach suicidal proportions. The concealment of suicidal ideas leads us
over to the other group of patients with vociferous suicidal threats. Although one
cannot rely on it absolutely, the likelihood of a successful suicide attempt is less if the
patient is threatening to the doctor that he or she will commit suicide. This happens
most in hysterical dramatizing individuals, as a way of getting attention, and the doctor
may precipitate the gesture by being too concerned about the threat and not enough
concerned about the patient's basic need for psychotherapy. I recall a patient in psychotherapy who phoned her psychiatrist to say that she was going to commit suicide.
The psychiatrist, knowing the patient well, was unperturbed and told her that she
should come in at her regular appointment time to talk it over. She then phoned her
general practitioner, who said he would be right over. When he got there he found that
she had swallowed a dozen nembutal capsules after the phone call. I know of another
instance where a minister was the one who rushed over and precipitated the act. These
examples are in contrast with many instances where the" patient came to the next psychotherapy hour with no suicidal attempt because he had not provoked excessive attention by his threats. Suicides will occur, of course, even under psychiatric care, and even
in psychiatric hospitals, because psychiatrists are not omnipotent. But the risk is reduced by psychiatric supervision, and it would be fair to consider those suicides of
people who have been seeing doctors, but who have not had psychiatric consultation, as
failures in preventive medicine. I had an opportunity to review the documents of
soldiers in the Canadian Army who committed suicide. The majority of them had
been seen both by some non-psychiatric specialist, for physical complaints apparently
on a depressive basis, and also by some non-medical officer for some personal troubles,
but very few had seen a psychiatrist.
ACUTE INSOMNIA
Physicians all have their own ways of handling chronic insomnia, usually with
sedatives, and with the recognition that insomnia is a symptom of an emotional disorder requiring investigation. Even in the acute insomnia with the anxiety accompanying hospitalization, the customary use of sedatives may be the most expedient method
of handling the problem. But what about the patient who phones the doctor at night
from home because of being unable to sleep on that night? If the doctor's own sleep
has been disturbed by the call he may be particularly non-plussed as to how to handle
the situation without a punitive attitude to the patient. Yet psychological handling
of the patient may give sleep to the patient and keep the relationship with the doctor
in a state such that he can be of further help to the patient in the future. An example:
A pregnant woman who was in psychotherapy by a psychiatrist, had sprained her ankle
and had had a cast applied by a surgeon. She had taken a sedative prescribed by her
obstetrician, but being anxious and unable to sleep, phoned her psychiatrist at 1:00 a.m.
Page 275 The psychiatrist, understanding the patient, suggested that her husband prepare her
some warm milk to drink. With this "mothering" from her husband she slept like a
baby and she did not disturb the psychiatrist at night on any future occasions. The
doctor who responds with irritation at a patient's special request is more likely to find
himself provoked frequently in the future by other attempts to get him angry. The
consistently kind doctor is more likely to find his patients more loath to bother him.
Other psycho-physiological advice on such occasions include the tepid bath or reading by
a dim light instead of trying so hard to go to sleep in the dark.
NOCTURAL DELIRIUM AND ORGANIC CONFUSIONS
An exaggerated form of insomnia with organic, or toxic, cerebral disorders, such
as arteriosclerotic mental changes, is nocturnal delirium, with confusion and disorientation added to the sleeplessness. Proper psychological handling of these persons will be
better than sedation, since bromides or barbiturates further embarrass the inadequate
cerebral metabolism. Such persons may have been rational in daylight or at home but
were pushed over the threshold by anxiety in the dark or in the unfamiliar surroundings
of hospital. They are better in a room with other patients than alone, if it is not
possible to have a nurse with them constantly, and better with a light burning so that
they can orient themselves. "Mothering" with warm milk by a nurse, or by whoever is
available, is far better than adding the injury of a toxic drug to the insult of being
deserted.
If a sedative seems necessary there are far better ones for aged people or people
with brain disease than bromides or barbiturates, for example chloral hydrate, paraldehyde, or, if not contraindicated, alcohol. A sound pharmacological agent where cerebral
circulation is poor is nicotinic acid, not the amide, which has the same value as a
co-enzyme as far as impairment of cerebral oxygenation is concerned, but the acid,
with its flushing effect, in about a 50-100 mgm. dose. This produces vaso-dilation in
the brain as well as the unpleasant flushing in the skin. There is a useful drug on the
market for sedation in senile and organic states, called somnol. This combines nicotinic
acid with very small doses of apomorphine, scopolamine and two barbiturates. Its
use is described in a paper by Lehmann in the Canadian Medical Association Journal
in 1949 (1).
The vaso-dilator effect of nicotinic acid can also be used for the confusion of an
acute organic cerebral condition, such as that following a head injury, when you are
sure that all necessary neurosurgical steps have been taken. In such a case repeated
doses of 50 mgms. six times a day may accelerate clearing up of the confusions (2).
This is especially true if alcoholism preceded the head injury. Aminophylline is another
valuable vasodilator and can be given by suppository.
These organic delirious patients need special constant supervision in view of the
risk of wandering around and hurting themselves. They are always better placed on
the ground floor of a hospital, in the event that any lapse of supervision allows them
to walk out a window and they will then not have so far to fall.
ACUTE ALCOHOLIC PROBLEMS
These include pathological intoxication, delirium tremens and acute alcoholic
hallucinosis. The uncooperative alcoholic patient is certainly a strain on the physician's
equanimity, and a temptation to evade responsibility for the patient. If the physician's
calm and friendly .attitude will not soothe the savage beast, the enlistment of other
strong arms may be the kindest thing for the patient. I shall never forget one case
where the general medical officer tried to treat an acute alcoholic hallucinosis in a
barrack room, until the patient jumped out a second story window to get away from
imaginary men chasing him with water pistols. Even when the doctor shipped him
into the psychiatry ward of the hospital, which this medical officer disdained, the
doctor had not recognized the bilateral fractures of the calcanei which were sustained
in the jump. In this case the psychiatrist, who discovered the fractures, also made a
mistake. He gave intravenous pentothal in an attempt to quiet the patient, with
exactly the opposite effect. Finally, intravenous morphine did the trick, since it was the
pain of the fractures which was further exciting the patient.
Page 276 I shall not differentiate between these various acute alcoholic conditions. In all
of them what I have said about psychological handling rather than sedation in organic
disorders is applicable. Nicotinic acid is particularly valuable, plus large doses of the
rest of the vitamin B complex, in view of the usual nutritional factors in these disorders, with injection as the route of administration because of gastritis. This is a good
place to mention the sedative value of insulin, for alcoholic and other excited states.
The plan is to use a soporific dose of insulin short of a coma dose. Since alcoholics have
livers depleted of glycogen, one must go cautiously, beginning with five units and
ready to cover with intravenous glucose. One may step it up gradually and find that
perhaps 40 or 50 units are needed to maintain somnolence. A combination of vitamins,
insulin and glucose is the basis of the "Bellevue cocktail" for the treatment of D.T.'s.
I don't think there is any particular magic in the exact formula for the Bellevue
cocktail.
ACUTE GRIEF
The physician frequently encounters the problem of bereaved individuals in a
family of a patient who has died. An article by Lindemann in the American Journal
of Psychiatry in 1944 (4) is well worth reading on the symptomatology and management of acute grief. The giving of consolation and of reassurance that all possible was
done for the deceased are important parts of the physician's job, and if he is to practise
preventive psychiatry as a family physician he will continue to keep an eye on the
bereaved members to see if grief is taking a pathological form requiring more help by
him or by a pastor or social worker. One of the most difficult acute grief reactions to
handle is that of blaming the doctor for the patient's death. The doctor should realize
that this occurs as a defence against anxiety, by the relative, about his own feelings
toward the deceased. The doctor should not interpret this, nor become unduly defensive
himself, but rather take the attitude: "I understand you are upset just now, but I really
have done all I could for the patient." With understanding handling this reaction will
blow over rather than become the focus of litigation. Sedation, of course, is of great
value in the acute phase of a grief reaction. Sodium amytal is particularly useful for
this.
ACUTE PANIC STATE
We differentiated this from acute anxiety and from psychosis in our discussion of
common emotional problems. This occurs with acute internal problems or an acute
external disaster which is overwhelming. If war should bring threat to the civilian
population we may have this condition to deal with in large numbers. A firm reassuring
attitude by the doctor is important, with warm drinks and clothing, if hunger and
exposure play a part. Here heavy sedation is one of the best first aid measures, e.g.
sodium amytal in III or VI grain doses.
SUDDEN ONSET OF PSYCHOSIS
What appears to be a sudden onset of psychosis may be an acute panic state due
to internal conflicts. Chronic hospitalization may not be necessary if the individual
can be protected properly and treated, at first with sedation and later with understanding interviews. More often, the apparent sudden onset of psychosis is the sudden
recognition by the family that the patient is psychotic. They may have temporized
for some time and finally admitted that the patient is not "himself". Such is the
time to get Ithe patient to psychiatric care, before the members of the family change
their minds. If commitment to a mental hospital or referral to a psychiatrist are indicated this should be done without subterfuge. Any attempt at deception of the patient,
such as taking him for a ride in the country, or tell him he is going into a hospital
for a physical check-up, may seem the line of least resistance for the doctor at the
time but it will make things more difficult for the patient's psychiatric treatment and
for his future confidence in the doctor on recovery. Referring to a psychiatrist as
"another doctor whom you wish to see the patient in consultation" may be justified
and the psychiatrist can explain what type of doctor he is, after the patient finds that
he is not an ogre. Usually the patient has some awareness of mental illness and appreciates a complete absence of deception. If the patient will not respond to reasonable
advice ffom the doctor, and if he is a danger to himself or to others it is best to engage
Page 277 the physical force of accomplices, telling the patient at the same time that this enforced
hospitalization is in the best interests of the patient. It is important that the doctor
does not have a punitive attitude to such a patient, so that he can be guilt-free and
confident that he is using such force in the patient's own interests.
REFERENCES
(1) Lehmann,  H.:    A new  preparation  for  sedation in  organic  brain  diseases  and   senile  disturbances.
Canada Medical Association Journal 60, 157, 149.
(2) Lehmann, H.: Post-traumatic confusional state treated with massive doses of nicotinic acid. Canada
Medical Association Journal  51,  558,  1944.
(3) Levine,    M.:    Psychotherapy    in    Medical   Practice.     MacMillan.     New   York.    1949,   Chap.   VI,
Suicidal Risks.
(4) Lindemann,  E.:   Symptomatology   and Management  of  Acute  Grief.    American  Journal  Psychiatry,
101,  141, 1944.
BRIEF SERIES OF LECTURES ON PSYCHIATRY
IN GENERAL PRACTICE*
W. DONALD ROSS, M.D. (Man.), F.R.C.P. (C)
Assistant Professor of Psychiatry, University of Cincinnati
PSYCHOTHERAPY BY THE GENERAL PRACTITIONER
In this lecture we are concerned with something which .you are doing already for
your patients although you may not glorify it, or stigmatize it, whichever you prefer,
with the term psychotherapy. The aim of the lecture is not so much to give you a
new technique as to help you understand what goes on in any case between you and
your patients, and perhaps to take a little more trouble to assure that you are doing
it in a manner that is beneficial to your patients.
THE ECONOMIES OF PSYCHOTHERAPY BY THE GENERAL PRACTITIONER
When I say, "take a little more trouble," I am sure that there are some of you
who are protesting within yourselves, "But I don't have time to do psychotherapy on
my patients; they want to talk to me when I am rushed, with all sorts of emergencies
to meet, and I just can't do it." The psycho-therapeutic approach to medical practice
need not take much more time; it can save time by saving efforts which would be
wasted with those patients who require repeated examinations, or develop unnecessary
illnesses, if they do not have someone who understands them and in whom they have
confidence. Apart from the economic waste in unnecessary laboratory examinations,
which involve expense which could be better directed to compensating the physician
for his time spent with them, there is the economic waste and actual risk to health
among sick people shopping around to irregular practitioners because doctors have not
taken the trouble to understand them and give them emotional support, while keeping
the trained medical eye on them and preventing the oversight of serious physical
disease which can occur if they put their trust in a quack.
THE EMOTIONAL MEANING OF THE DOCTOR FOR THE PATIENT
Basic to having a psychotherapeutic approach in one's practice is an understanding of what the doctor means in the patient's emotional economy even if the patient
is not consciously aware of this meaning. Anyone who is sick or suffering regresses to
some extent, perhaps only unconsciously, to the emotional needs of childhood, to have
someone like a parent on whom they can be dependent and by whom they will be protected. The act of going to a doctor is an act of seeking out someone who will, like a
father, or a mother, look after them either continuously, or long enough, until, with
the restoration of health, they are able to function as an independent adult without
the special dependency on the doctor. It is not neccessary, or even advisable, for the
doctor to make the patient aware of this. It is necessary, however, for the doctor to
keep it in mind if he is not going to disappoint the patient and be a rejecting or punitive parent. It is also necessary for him to have this in mind in order to tolerate the
difficulties of what I have described as the layer of defence against anxieties in the
*Presented to the Vancouver Medical Association, May 28th - June  1st,  1951.
Page 278 patient. For this defensive layer may include rebelliousness against the doctor, complaining demandingness, or sexual feelings for the doctor. He can handle these with
equanimity only if he realizes that they need not be taken personally by him, that
they involve displacements of feelings that the patient has had for someone else on
whom he or she was dependent in the past. He can then be free to recognize the
anxieties in the patient and give the appropriate help by medical examination, by physical
treatment, by advice, or just by listening.
THE VALUE OF LISTENING
Many doctors fail to realize the full emotional value to patients of having someone
important who will listen to them. The doctor may be accustomed to doing something
whenever anything is wrong and may feel that just listening is not doing anything.
This is not so. When a person is talking out, with the one exception of compulsive
talkers who use talking as a defence, he is reorienting his feelings and becoming more
able to solve problems for himself.
This has been amply demonstrated by interviews of industrial workers. There was
a project carried out at the Western Electric Company in which employees were interviewed over a course of time while various changes were made in their working conditions in order to find out the optimum conditions for productivity and happiness. Both
productivity and morale of the workers improved continuously. Even when apparently
improved working conditions were changed back to the preexisting conditions the
workers continued to improve. It was finally concluded that the interviews in which
the workers had the opportunity to ventilate their feelings about their work was the
factor responsible for the improvement (3). This kind of experience has given rise to
the practice of employing counselors in industry who just listen to "gripes" and
encourage the employees to talk out, without giving advice or without doing anything
about it.   This has a tremendous mental hygiene value in industry.
The effect of just listening can be illustrated by a story which is told about Dr.
Helene Deutsch, a woman psychiatrist now in Boston, on the occasion of her arrival
in the United/States from Vienna. She was staying at a New York hotel and a room
clerk, having heard that she was a famous psychiatrist, asked if he could talk with her
about some marital difficulties. He spoke to her steadily for about three-quarters of an
hour, thanked her profusely, and let her go on her way. A few years later she was
visiting New York again and the same room clerk spoke to her and told her that after
that consultation with her he had been able to clear up his troubles completely. The
punch line of the story is this: that, at the time of the first visit to New York, she
spoke very little English and had hardly understood a word he had said!
THE DOCTOR DOES MORE THAN LISTEN
However, I don't want to give you the impression that that is all that psychiatrists
do! The psychiatrist has the knowledge with which he can direct the stream of talk
by the patient in a therapeutic way, and with which he can recognize when something
other than listening is indicated. Likewise the general physician, with his diagnostic
knowledge, is able to recognize when something more than listening is indicated. "Non-
directive counselors" in industry, as they are called, have been known to go on listening
to an employee while his general paresis progressed further, or while he talked himself
further into a paranoid psychosis. Hence listening by a doctor has safeguards not present
in listening by a non-medical person, even though doctors can take a leaf from the
book of the non-directive counselors. "Their book," incidentally, is one by Carl Rogers,
entitled "Counselling and Psycho-therapy" (2) and it should be read if one has difficulty in understanding how to listen without giving advice.
Hie things more than listening which the doctor does are well described in Levine's
book which I have recommended to you (1). The chapter on methods for the general
practitioner is essential reading for getting the most from our discussion today, and
the subsequent chapters on advanced methods and methods for the specialist will be
interesting to you also. Psychotherapy begins with history taking and physical examination, especially if interviewing is carried out as suggested in the first lecture, for, during
this phase, the relationship is built up between patient and doctor. It should also be
realized that all the physical methods of treatment, including medications and even
Page 279 palliative sedatives, have a psychological, as well as a physiological value to the patient.
Such medication means that the doctor-parent figure has given something to the patient
which he can take at intervals, periodically satisfying the need to be given to. This
is a better way of conceiving what goes on than the idea of "suggestion," as the
psychological effect of a prescription over and above its pharmacological action. In
fact, to rely on "suggestion" is not good psychotherapy. I would discourage the use
of inert "placebos" because of the insincerity involved. If the doctor gives a drug
with at least some beneficial pharmacological action on the patient, he feels confident
that he is giving to the patient, and this is imparted to the patient in his manner of
doing so that the patient feels the doctor's interest in him and responds to this.
What the doctor does more than listen, as far as his verbal contributions to the
patient are concerned, includes education, reassurance, and active advice. Education
may be necessary to dispel false ideas about health which are increasing the patient's
anxiety, such as the fear of the adolescent boy that masturbation causes insanity, or
the fear of the menopausal woman, or the woman after a hysterectomy, that her sex
life is over. Reassurance can be given on the various anxieties of the patient which are
out of proportion to their supposed causes. The calm unanxious attitude of the doctor
is of greater importance than the particular words he uses to reassure. On active advice,
one must be careful, and not make the mistake of assuming that a solution which
works for oneself is the best one for the patient. This is one of the commonest errors
in amateur psychotherapy. A smart handling of the seeking for advice is illustrated
by the device used by a non-directive counsellor who was asked for help by an employee
in deciding whether she should have premarital intercourse or not. The counsellor told
her to make a list of the reasons for, and the reasons against, and to come back and
talk it over. The client came back with a longer list against and said that she had
decided for herself that she wouldn't. A ticklish situation had been handled adroitly.
One must also be careful not to use the patient to talk out one's own experience. If
you ever catch yourself saying to a patient: "That reminds me of when I . . ." stop,
and think twice about it.
RELATIONSHIP TO MORE INTENSIVE PSYCHOTHERAPY
The psychotherapy which has been described includes both supportive and expressive
aspects. Some amount of expression of feelings by the patient is necessary for the doctor
to understand the patient and to give the proper support, but, by and large, psychotherapy by the general practitioner is'best aimed at supporting the patient, through
times of temporary life difficulties, or indefinitely. Cure is effected of neurotic symptoms
which have been related to a particular life difficulty, but remoulding of a neurotic
personality is not attempted. More specialized psychotherapy goes further in an expressive direction with interpretation of the sources of the difficulties in.the patient's earlier
experience and an effort to undo chronic neurotic patterns. You may feel that supporting a patient indefinitely is not in keeping with your urge to cure people, but it is as
much a part of the doctor's job as is replacement therapy in pernicious anaemia or
diabetes. As mentioned already, it is much more sound economically than having the
patient shop around wastefully, if the neurosis is not one with a reasonable hope of
cure by specialized psychotherapy, or if such is not available.
What about the time it takes to support patients emotionally? It takes about an
hour on two different occasions to make the initial assessment. Subsequent visits may
be very brief if only medication is given, or they may be 20 or 30 minutes in length,
to give the patient some unhurried opportunity to report the current state of emotional
problems. Long periods are not necessarily advisable since they may mean getting in
beyond one's depth with the patient. This time should, of course, be charged for by
the doctor at a rate equivalent to what he charges for the assessment examination, so
that no impatience about losing income because of his generosity in time enters into
the psysician's attitude to the patient. This is money well spent by the patient if the
doctor is discriminating in his allotment of time, just as is money well spent on psychotherapy by a psychiatrist if the case is properly selected. There are widespread misconceptions about psychiatrist's  fees.   Although some psychiatrists over-charge, just as
Page 280 some other doctors do, one must realize that if the psychiatrist listens to the patient
for sessions of about 50 minutes, he cannot see as many patients in a day and he must
charge accordingly. Likewise, the general practitioner can budget part of his time for
more help to a few individuals, instead of spreading himself so thin that patients with
emotional problems seek help outside of the medical profession, even when they have
physical symptoms, or worse, physical as well as emotional disease.
REFERENCES
(1) Levine, M.: Psychotherapy in Medical Practice.   MacMillan.   New York, 1949.   Chapter III. Methods
for the General Practitioner.
(2) Rogers, Carl R.: Counselling and Psychotherapy.    Houghton Mifflin.    New York, 1942.
(3) National Research Council:   Fatigue of Workers.   Its Relation to Industrial Production, pp.  56-99.
Reinhold.   New York, 1941.
URETERAL CALCULI
By DR. JOHN BALFOUR
Given before the Vancouver Medical Association Summer School—1951
(a) Symptoms
(b) Diagnosis
(c) Treatment
(d) Prognosis
Most Ureteral Calculi are secondary, having arisen in the kidney, but a few are
primary, arising in ureteroceles, ureteral diverticulum, or behind ureteral strictures.
The chemical nature of these stones has been known for years, but recent studies by
spectroscopy, x-ray refraction, and polarized light, have brought out more exactly the
structural nature. This fact has not so far, influenced the treatment.
Causes of Calculus Formation
(1) INFECTION: Ordinary pyelonephritis is an uncommon cause of calculus
formation, the two being rather uncommonly associated. The important type of urinary
tract infection, and still one of the most difficult problems encountered in urological
practise, is that caused by the urea splitting organisms such as bacillus proteus, and
aerobactor aerogenes. These organisms produce an alkaline urine by breaking down
urea to form ammonia, and calculi form in this urine with amazing rapidity, in some
cases in as little as three weeks. Changes in the pH of the urine with recurrent infections can produce different components of a calculus.
(2) SUPERSATURATION: Urine is a supersaturated solution, and the salts are
probably held in the solution by the colloids present in the urine, by the fact that the
urine is acid normally, and probably other factors. Any upset of the urinary colloids,
or a change in the pH of the urine, may cause precipitation of some of these urinary
salts. In this connection, one must not forget the well-known alkaline tide which occurs
after meals, or a false idea of the normal pH of the urine may be obtained, and efforts
made to counteract by diet and medication what is really a normal physiological condition. An excellent method of checking the pH of the urine in the office is by use of
nitrazine paper which covers quite a wide range.
(3) HYPERPARATHYROIDISM: This may be due to either hyperplasia or
tumour of the parathyroid gland. In the presence of excess parathormone the calcium
is mobilized from the bones, and the urine becomes supersaturated with calcium. This
calcium may precipitate out in either the tubules of the kidney, or in the pelvis. The
condition should be looked for in the presence of recurrent or multiple calculi, although
it is a rare cause of calculus formation. The diagnosis is established by the estimation
of the blood calcium and phosphorus.
(4) VITAMIN DEFICIENCY: Experimentally, vitamin deficiency causes kera-
tinization of the epithelium of the renal pelvis, and some of these cells may slough off
and be a nidus for stone formation.
(5) METABOLIC DISORDERS:   About 10% of stones are made up of organic
Page 281 constituents such as Cystine, Xanthine, Uric acid, or Sulpha.   The first three are due
to metabolic disorders, the last, to supersaturation of urine with the drug.
(6) STASIS: Stasis is met with in two circumstances. First — any obstructive
urinary tract conditions will cause stasis of urine behind it. Secondly — prolonged
recumbency, particularly in patients with severe bony injuries, is a precipitating factor
in the formation of a great many stones. If a patient is flat on his back in bed, urine
must drain uphill to the brim of the bony pelvis. Under these conditions, precipitation
of the supersaturated substances in the urine occurs quite readily.
(7) RANDALL PLAQUES: These are small calcified areas at the apices of the
papillae, over which the epithelium becomes ulcerated, and the calcium plaques separate
off, forming the nidus of a stone. This factor has been experimentally confirmed on
numerous occasions.,
(8) GEOGRAPHICAL DISTRIBUTION: This is a well recognized factor.
Calculus disease is extremely common amongst the people of India, for instance.
SYMPTOMS OF URETERAL CALCULI
There are four groups of symptoms which one may associate with ureteral calculi,
namely: Pain, gastro-intestinal symptoms, disturbance of bladder function, and anuria.
Pain: The pain of ureteral calculus may be of two types. The first is the acute
colic, the spasm of the ureter attempting to expel a foreign body from within its lumen.
This pain can be excruciating as anyone who has experienced it knows. It may start
in the back, or in the abdomen, and generally radiates downward, towards the scrotum
and testis of the male, or the labia and inner thigh of the female. The pain may also
radiate backwards towards the costo-vertebral angle. The lower the calculus is in the
ureter, the lower down in the abdomen the pain is felt. The patient suffering from
ureteral colic does not lie quietly in bed as in the inflammatory lesions, but rolls around,
twisting himself into various postures in an attempt at getting relief. Colic is present
in 80% of cases of ureteral calculi.
The second type of pain is of a different nature. It is a dull ache, a feeling of
fullness, or a feeling of the side being clutched in a vise. This pain is felt in the back,
in the region of the costo-vertebral angle on the affected side. This pain is due to back
pressure from obstruction of the ureter, and is caused by dilation of the ureter and
renal pelvis. It is most important to inquire about this pain in cases of ureteral colic,
because the real danger of ureteral calculi is the damage they do to the kidney behind
them, and persistent acute obstruction is extremely dangerous to a kidney. This type
of pain is almost diagnostic of obstruction, and one should not be misled if it seems
to subside and gradually disappear over a period of a few days. The obstruction may
still be present but the acute phase is over, and re-absorption of urine from the pelvis
and ureter are almost keeping pace with the excretion. The acutely obstructed kidney
does not go on and quietly atrophy, but rather undergoes the same type of hydrone-
phrotic change one sees with more chronic types of obstruction. The only difference
is that the process goes faster, and the kidney may be rendered totally useless in as little
as three weeks.
(2) GASTRO-INTESTINAL SYMPTOMS: Generalized abdominal cramps,
nausea and vomiting are present in 60% of cases of ureteral calculi. In some one sees
even a reflex ileus established which makes a differential diagnosis much more difficult.
(3) DISTURBANCE OF BLADDER FUNCTION: This is present in some 50%
of cases of ureteral calculi. It is almost invariably present if the stone is down near the
bladder, when frequent bladder spasms and almost continuous desire to void are not
uncommon.
(4) ANURIA: The sudden suppression of urine is a frightening occurrence following a ureteral colic. Fortunately, it is rare. Anuria may be due to a reflex inhibition
of a normal kidney on the other side to bilateral ureteral calculi, or to other disease
or anomaly of the urinary tract. Solitary kidney, for instance, is present in about
1^500 persons, and a calculus impacted in this ureter will cause oliguria or anuria.
Again, the other kidney may have been removed surgically, or undergone atrophy from
pyelonephritis.  Congenital hypoplasia, another not uncommon congenital anomaly, may
Page 282 be present, in which case while the person still excretes a certain amount of urine, the
urine excreted in incapable of keeping up with the body needs, and uraemia results.
DIAGNOSIS OF URETERAL CALCULI
History: The history of sharp, severe, colicky pain is usually very definite. It
starts in the back jr upper abdomen and radiates down towards the region of the
testicle or inner thigh. Muscular rigidity on the affected side may or may not be
present. Palpation of the abdomen between the spasms of colic may show an area of
quite localized tenderness overlying the calculus. The urine may be entirely negative,
and in 90% of cases will show microscopic red or white blood cells, and in 35% of
cases will show gross blood.
There is one way in which a definite diagnosis of ureteral calculus can be established, and that is by use of the x-ray. A scout film of the abdomen is very useful,
but will often miss a calculus, particularly if there is one lying over the bony structure
of the body. Intravenous pyelography is an almost certain method of making the
diagnosis. These pyelograms will show disturbed physiology on the involved side, and
if sufficient pictures are taken, and there is a considerable degree of obstruction present,
the location of the calculus can be pin-pointed by this method. Intravenous pyelography
should be used much more often in questionable emergency cases. It is a simple procedure to inject dye into a vein and take four or five x-rays. The dye should be given
quite rapidly in two to three minutes because diodrast is excreted by the renal tubules
and most of the dye is excreted the first time it passes through the kidney. These pyelograms can be taken with a portable x-ray machine if necessary. The total time consumed need not be more than forty minutes and the information obtained, if only of
a negative nature, is well worth the effort.
There is very little danger in using intravenous pyelography in these cases; but
it does no harm in acute urinary obstruction. The only real contra-indication are severe
renal disease where it is useless to inject the dye because it cannot be concentrated by
the diseased kidney, and in cases of iodine sensitivity. An intra-dermal injection or
a drop of the solution placed on the conjunctiva beforehand, will rule out iodine sensitivity. Another contra-indication is severe hepatic disease.
TREATMENT
On being confronted with a patient suffering from ureteral colic, the first consideration is relief of pain, and the only sure way of relieving pain is by use of a powerful
narcotic such as morphine or pantopon. Do not hesitate to give it intravenously, the
affect is much more rapid. Morphine gr. l/4 or Pantopon gr. 1/3, repeated if necessary in
twenty minutes, will give relief in most cases of ureteral colic. It has been stated that
in experimental animals the ureter is a neuromuscular tube with only pain and vasomotor fibers in it. Peristalsis is initiated by the presence of urine or a foreign body and
not by nerve impulses. If this experimental work is true, it would seem to indicate
that anti-spasmodics as such are of no value in treating ureteral colic.
Following control of the pain treatment of ureteral calculi must be individualized.
Ureters vary in size in different individuals, and a patent calculus which one patient
may pass easily, must be removed surgically in another. Even a small calculus may,
if left too long in one situation, cause irreparable damage to the ureter, and lead to
stricture formation and loss of the kidney. There are several points along the ureter
at which a calculus may be held up. These points represent natural narrowings of the
ureter. The first is at the uretero-pelvic junction, the second where the ureter crosses
the bifurcation of the iliac arteries, the third at the brim of the fourth where the
ovarian vessels in the female, and the vas-deferens in male, cross the ureter, and the
fifth, at the intravesical portion of the ureter. As a general rule the higher the calculus
is impacted, the more serious is the problem presented. A stone in the lower ureter, if it
does not cause ulceration and stricture formation of the wall, is less dangerous than
one impacted at the uretero-pelvic junction. In the former, the ureter takes the initial
shock of the obstruction and, dilates. In the case of the high impacted calculus the
kidney is affected immediately. A kidney with a largely intra-renal pelvis is much more
readily damaged than a kidney with an extra-renal pelvis because the pelvis will dilate
Page 283 in the latter case before damage to the kidney will occur. Occasionally a calculus will,
if left too long in one position, ulcerate through the ureter into the periureteral space
or even into the abdominal cavity, resulting in extravasation of urine.
Infection also is of extreme importance. An infected kidney, in the presence of
the ureteral calculus, is a surgical emergency. Drainage must be established as soon as
possible, and if this cannot be accomplished by passing a catheter up the ureter, then
open surgery should be instituted without delay. Delay in cases of this type inevitably
leads to loss of the kidney, if not immediately, at a future date, and may even be responsible for a septicaemia. An acute pyelonephritis may become a pyonephrosis, or terminate
in an atrophic pyelonephritis, the one renal lesion which appears definitely responsible
for hypertension in a certain percentage of cases. With the new powerful anti-biotics
to aid in control of infection, this is not as serious a problem as it used to be. Shotgun
therapy with, say, penicillin, streptomycin, and Chloromycetin is justifiable here while
waiting for culture reports, or if none are available.
All calculi in the presence of severe infection should be left for a varying period
of time to see if they will pass. While observing the patient one should make sure of
a copious fluid intake which builds up pressure behind the calculus and helps force it
down the ureter. As these, patients so often have an upset gastro-intestinal tract, are
nauseated and vomiting, this very often means intravenous fluids up to 4000 cc. per
day. Unless there has been considerable loss of fluid from vomiting, 5% glucose in
distilled water is preferable to any other solution. At this stage one may try a sympathetic block. If the ureter is a pure uro-muscular tube in which peristalsis is initiated
only by the presence of urine or foreign body there is no justification for using sympathetic block. In addition to this, patients do not like this form of treatment, they
much prefer having a spinal anesthetic, and the calculus manipulated from below. These
patients should be ambulatory, and all the urine passed should be strained in an attempt
at recovering the calculus.
If, with conservative therapy, the calculus remains fixed in the ureter there are
two other methods of treatment open. The first is manipulation, the second is open
surgery. Manipulative procedures are most valuable for a calculus impacted low down
in the urinary tract where one can hope to obtain success in between 40-50% of the
cases. Various instruments have been devised for extraction of these calculi, including
baskets, corkscrews, the use of multiple ureteral catheters, ureteral dilation with various
types of bougies, the injection of oil above a calculus, and the use of loop catheters.
This latter is probably the most universally popular method in use at the present time,
being relatively safe and fairly successful. All manipulative procedures on ureteral
calculi have their complications. Perforation of the ureter with extravasation of urine,
rupture of the ureter, loss of part of the instrument within the ureter, and engagement
of the calculus with inability to extract calculus or instrument have all occurred.
Extraction of a calculus from below should never be tried without first dilating the
ureter. Surgery is the form of treatment to which one can always turn. Calculi high
in the ureter should be approached through a loin incision. As the ureter approaches
the brim of the pelvis it is much closer to the anterior abdominal wall, and is best
approached through the muscle splitting incision. The lower end of the ureter is probably best approached through a supra-pubic incision, except for the rare case in the
female where the stone can be palpated through the vagina and a lithotomy done
through this approach. One danger of the supra-pubic incision is that with a dilated
ureter, and a round calculus, the calculus may^ slip up above the brim of the pelvis in
which case it cannot be removed through this incision. A pre-operative x-ray should
always be taken immediately before the operation, to be certain the calculus has not
changed its position since the last examination. The opening in the ureter should be
closed with sutures which do not go through the ureteral mucosa but just approximate
the musculature. Drainage should be instituted and left in situ until one is certain
there will be no further leakage of urine, or until a sinus tract is formed. Urine in
loose tissues causes an intense fibrosis, and may be responsible for ureteral stricture
formation.
Page 284 Experimental work is going on continuously in a search for solutions or combination of solutions which will dissolve renal and ureteral calculi. So far, none have
been particularly successful. Subey's "G" solution, whose base is citric acid, is probably
the most successful of those discovered so far. While this solution will dissolve the
inorganic constituents of a calculus, it does not touch the organic. Experimental work
is at present being conducted on ultrasonic waves as a means of destroying these calculi.
The single, most important thing which one can advise at present in preventing the
formation of further calculi is to have one's patient force fluids. The only really satisfactory fluid they can take in any quantity is water. A copious intake of water cuts
down on the degree of supersaturation required of the urine, and also insures the
washing out of small nuclei before they have a chance to become large calculi. Diet
is of some importance in certain conditions. The organic calculi such as cystine,
xanthine, and uric acid, can be prevented by maintaining an alkaline urine and control
of the diet. An acid ash diet is probably still of some value in treating patients with
an alkaline infection. An oxalate free diet is of no value in preventing the formation
of oxalate calculi, according to experimental work done in Germany just prior to the
last war. Ipf
PROGNOSIS
The prognosis of renal and ureteral calculi has changed greatly in the past ten
years. These calculi are more common in the male than the female. They occur in
middle age and equally on each side. Clinically, they are bi-lateral in 3%, but careful
autopsy examination will show them to be bi-lateral in close to 30%.* The advent of
the anti-biotics has cut down the recurrence rate to its present 5%. This latter figure
is a significant one. Before the advent of anti-biotics, the recurrence rate was closer to
30%, but with the elimination of infection in many cases it has been cut down to this
figure. These patients should all be followed through the years. Calculi may be silent
and may totally destroy the kidney before a patient is aware of it. Intravenous pyelography is a useful method of checking not only the function but the anatomy of the
urinary tract, and the physician can assure himself that the patient is maintaining a
copious fluid intake, the single, most important thing one can do to prevent the formation of more calculi.
Third Annual Symposium of the Washington State
Heart Association in cooperation -with Washington
State Department of Health on "Diagnosis and
Therapy of Peripheral-Vascular Disease" and "Surgical Treatment of Mitral Stenosis".
October 19th and 20th, 1951
University of Washington Medical School Auditorium
Details of the program will be forthcoming. There
will be no registration fee.
ATTENTION
On and after Monday, September 10th, 1951, the Library and offices of the
Vancouver Medical Association will be in their new quarters in the Academy of
Medicine building, 1807 West Tenth Avenue.
In order to facilitate moving the books and stacks, the Library will be closed for
approximately ten days from August 29 th, 1951, but will re-open on September
10th, 1951.
Page 285 Cortwe
VRAOOMMIC
Saline Suspension
of Cortone Acetate
(1 cc.=25 mg.) vials, 20 cc
Tablets—
Cortone Acetate
(25 mg. each) bottles, 40 tablets
Clinical studies have demonstrated that the therapeutic activity of Cortone* is
similar whether administered parenterally or orally. Dosage requirements are
approximately the same, and the two routes of administration may be used
interchangeably or additively at any time during treatment.
Although the manufacture of Cortone—probably the most intricate and
lengthy synthesis ever undertaken—has imposed unprecedented difficulties,
every effort is being made to increase production and, in the meantime, to
achieve an equitable national distribution
of this vital drug.
Among the conditions in which Cortone has
Literature on Request produced striking clinical improvement are:
Key to a New Em in Medical Science
move'
TIUOC'MAftK
ACETATE
(CORTISONE Acetate Merck)
(ll-Debydro-17-hydroxycx>rticoaterone-21-«cettte)
*CORTONE is the trade-mark
of Merck & Co. Limited
for its brand of cortisone.
RHEUMATOID ARTHRITIS and Related
Rheumatic Diseases
ACUTE RHEUMATIC FEVER
ALLERGIC DISORDERS, including Bron-
chial Asthma
INFLAMMATORY EYE DISEASES
SKIN DISORDERS, notably Atopic Derma*
this. Psoriasis, Exfoliative Dermatitis, in.
eluding cases secondary to drug reactions*
and Pemphigus
LUPUS ERYTHEMATOSUS (Early)
ADDISON'S DISEASE
MERCK & CO. Limited
Manufacturing Ch*mi$U
aONTMAl .  TORONTO .   VALLIYHHO.

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