History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1934 Vancouver Medical Association 1934

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 The BULLETIN
OFCS- »,
OF THE
\
VANCOUVER MEDI
ASSOCIATION
Vol. XI
DECEMBER,  1934
In This Issue:
SECRETORY DISTURBANCES OF THE STOMACH
ANNUAL DINNER
INFECTION: ITS SPREAD AND CONTROL
(Conclusion)  THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
"Published Monthly under the ^Auspices of the Vancouver Medical ^Association in the
Interests of the ^Medical "Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XI
DECEMBER,  1934
No.
OFFICERS   1934-193 5
Dr. A. C Frost Dr. C H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W. D. Brydone-Jack. Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L. Graham...   Chairman
Dr. J. R. Neilson       Secretary
Eye, Ear, Nose and Throat
Dr. R. Grant Lawrence  -  . Chairman
Dr. E. E. Day  —.    - —-   -        Secretary
Paediatric Section
Dr. E. D. Carder        — -Chairman
Dr. R. P. Kinsman —..Secretary
Cancer Section
Dr. A. B. Schinbein       Chairman
Dr. J. W. Thomson _.   —    Secretary
STANDING COMMITTEES
Library
Dr. W. D. Keith
Dr. C. H. Bastin
Dr. A. W. Bagnall
Dr. G. E. Kidd
Dr. W. K. Burwell
Dr. C. A. Ryan
Dinner
Dr. J. W. Thomson
Dr. F. W. Lees
Dr. W. G. Gunn
Publications
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland
Dr. Murray Baird
Credentials
Dr. R. A. Simpson
Dr. J. T. Wall
Dr. D. M. Meekison
V. O. N. Advisory Board
Dr. I. Day
Dr. H. H. Boucher
Dr. W. S. Baird
Sickness and Benevolent Fund ■
Rep.
Dr
Summer School
Dr. H. A. DesBrisay
Dr. H. R. Mustard
Dr. J. W. Thomson
Dr. C. E. Brown
Dr. J. E. "Walker
Dr. J. W. Arbuckle
Hospitals
Dr. T. H. Lennie
Dr. C. F. Covernto
Dr. H. H. Milburn
Dr. S. Paulin
to B. C. Medical Assn.
. Wallace Wilson
The President — The Trustees V
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WHY WE SAY
"Rich, Safe, Clean Milk"
1. All milk bearing the name "Associated" is
absolutely Grade A.
2. Grade A Milk is milk which in keeping quality, sweetness and flavor far exceeds the standards
prescribed and tests made by all Dominion, Provincial and Municipal authorities.
3. Special Associated Dairies tests call for the
closest of grading for flavor, temperature, acidity
and positive cleanliness, at our receiving platforms;
as well as microscopic and bacteriological tests carried out in our own laboratories under the supervision of our own bacteriologists.
4. It has taken over ten years of intensive technical supervision, on the farms and in the city, to
reach our present high standard of milk quality.
5. As a further incentive for our farmers to
maintain and improve this high quality, an extra
premium is paid for Grade A Milk. Nothing else
goes into any Associated bottle. That is why we say:
Associated Milk is Rich, Safe, Clean.
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
SERVICE phones:
Fairmont 1000    North 122     New "Westminster 144 5 VANCOUVER HEALTH DEPARTMENT
STATISTICS—OCTOBER, 1934
Total Population  (Estimated)
Japanese  Population   (Estimated)   .
Chinese Population   (Estimated) 	
HJindu Population  (Estimated) ..
Total Deaths	
Japanese Deaths	
Chinese  Deaths 	
Deaths—Residents  only....
Birth Registrations—
Male, 172; Female, 15 3.
Numbcr
175
4
5
156
325
243.71 1
7.866
8,315
251
Rate per 1,000
Population
8.5
6.0
7.1
7.5
15.7
AM
V:>i
INFANTILE MORTALITY—
Deaths under one year of age ._
Death rate—per  1,000 births  ..
Stillbirths   (not included in above).
October,
1934
11
33.8
3
October,
1933
9
35.7
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
November 1st
September, 1934 October, 1934 to 15th, 1934
Cases    Deaths Cases    Deaths Cases    Deaths
0             0                  0             0 0 0
31              1 53              0 20             0
10                  0             0 0 0
8             0 54             0 32             0
0             0                  0             0 0 0
0             0                  10 0 0
        12             0 3 8             0 18             0
11              0 20             0 6             0
0             0                  2*           0 10
0              0                   0              0 0 0
0              0                   0              0 0 0
35             7 63            10 29
0             0                  0             0 0 0
2             0                  2l            0 0 0
0              0                   0              0 0 0
0              0                   0              0 0 0
Smallpox 	
Scarlet   Fever	
Diphtheria    	
Chicken Pox	
Measles  	
Rubella ..
Mumps 	
Whooping-Cough 	
Typhoid Fever	
Undulant  Fever	
Poliomyelitis 	
Tuberculosis   	
jfBteningitis   (Epidemic)
Erysip3las   .
Encepha'itis Lethargica
Paratyphoid   .
::' Non-Resident.
S. BOWELL & SON
DISTINCTIVE  FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
in
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Page 43 ill
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■    PUBLIC HEALTH
BIOLOGICAL PRODUCTS
in
f ,m V
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid   (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum    (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
1 i
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Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C. VANCOUVER MEDICAL ASSOCIATION
Founded  1898 Incorporated  1906
Programme of the 3 7th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
1934.
October 2nd—GENERAL MEETING.
Dr. G. F. Amyot: "Infection, Its Spread and Control."
Discussion: Dr. E. D. Carder
Dr. H. A. Spohn.
October 16th—CLINICAL MEETING.
November 6th—GENERAL MEETING.
Dr. C. E. Brown: "Some Secretory Disturbances of the Stomach."
Discussion: Dr. H. A. DesBrisay.
Dr. A. Y. McNair.
November 20th—CLINICAL MEETING.
December 4th—GENERAL MEETING.
Dr. A. B. Schinbein: "Tumours of the Breast."
Discussion: Dr. J. J. Mason
Dr. B. J. Harrison
Dr. H. H. Pitts.
December 18 th—CLINICAL MEETING.
1935.
January 8th—GENERAL MEETING.
Dr. W. E. Ainley: "The Relation of the Retina to Cardio-Vascular
and Renal Disease."
Discussion: Dr. W. D. Keith
Dr. Wallace Wilson. ,
January 22nd—CLINICAL MEETING.
February 5 th—GENERAL MEETING.
Dr. Murray Blair: "Physiological Observations in Obstetrics."
Discussion: Dr. W. S. Baird.
February 19th—CLINICAL MEETING.
March 5th—GENERAL MEETING.
The Osler Lecture—Dr. Wallace Wilson.
March  19th—CLINICAL MEETING.
April 2nd—GENERAL MEETING.
Dr. F. W. Emmons: "The Surgery of the Presacral Nerve."
Discussion: Dr. J. J. Mason
Dr. F. Turnbull.
April   16th—CLINICAL MEETING.
April 23 rd—ANNUAL MEETING.
Page 44
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Odourless, tasteless valerian and strontium bromide are the basis of
Elixir Bromo-Valerianate (Gabail). NO BARBITAL. Prescribe a teaspoonful t.i.d. for hysteria, neurasthenia and other nervous affections.
ELIXIR BROMO-VALERIANATE (Gabail)
Obtainable from B. C. DRUGS LIMITED, Vancouver
GEORGIA PHARMACY, Vancouver    ::    McGlLL & ORME, Victoria.
ANGLO-FRENCH DRUG CO., MONTREAL ~mmm
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EDITOR'S PAGE
There is a school of thought which holds that history goes round in a
circle—"repeats itself" is the phrase. There is much to support this view,
especially if one regards such things as fashions; even physical fashions run
in cycles, as the immortal Mae West has shewn us.
But some of the more optimistic among us are inclined to disagree with
this view, and regard the course of history as an ascending spiral rather than
merely the circular and unending route of the ox that one sees in some
countries attached to a long pole pivoted on a central post, and, as he travels
in an everlasting circle goaded on by a small native boy astride the pole,
supplying the motive power for a sugar mill or some such primitive machine.
Our eye seems to discern signs of progress, rather than merely a return to a
phase of a cycle,—at least, in our more sanguine moments,—even if at times
we incline to the cynical or "hard-boiled" attitude of the Preacher, when
he declares that there is "nothing new under the sun."
This is, perhaps, a rather lengthy preamble to our subject: which is the
return of the general practitioner. We would perhaps not have dared, since
that is our own line of work, to broach this topic so boldly—but the attitude
of our co-editor, himself a specialist, in the editorial he wrote some three
months ago, has greatly encouraged us, and supported us in our frequently-
expressed opinion that a great many specialists, after all, are quite decent
fellows.
But, jesting apart, one sees clearly a definite swing back to what one
might call the general practitioner point of view, in the last few years, and
we cannot help saying that we feel that this is all for good. There has been,
in the last generation, let us say, an over-emphasis on specialism, and to
many of us this has seemed to be tending not towards edification. There is
no room for debate, of course, as to the need for specialists, and their value—
we simply cannot do without them, and if we have any sense, we use their
services more and more—but there is considerable room for debate as to
their number and the method by which they evolve. We ourselves have
always felt that a specialist shotdd evolve—unlike the poet, we think he is
made, and not born, a specialist. But it is quite evident that many have
disagreed with this view—and full-fledged specialists appear from universities and hospitals who have never done general practice.
Years have taught us to avoid the reactionary point of view. Not
that we agree with the mental attitude that resignedly accepts the status quo,
and says "What is, is right"—but we have come to see that nothing lasts
long or has much real staying power unless it contains a real element of
value; and it is evident that the present state of things grew out of a need,
and was evolved to meet that need. But we think that, as so often happens,
the movement went too far, and the general practitioner point of view,
that we referred to above, was, temporarily at least, lost to a great degree—
and we think this is a pity.  But we see it coming back.
Of course, the cynic may say it took the depression to rediscover the
general practitioner, and that when times are good again, he will relapse
into his usual state of decent oblivion. But we do not think so. The depression has perhaps restored to him some of what he regards as his lawful
property—but the trend back to the general practitioner began long before
the depression. Social medicine is built around him, and must always be.
The recent developments in health work, and disease prevention, are built
round him, and he is being enlisted and used, to the great profit of all con-
Page 46 ll'
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cerned, as an integral and important part of the machinery of disease prevention. This is, to us, a proof that progress is upwards rather than in a
circle. And even certain specialists are urging their own kind to think,
not as specialists, but as all-round internists. (They do not mention surgeons; we wonder why?) And our own feeling is that no specialist is quite
safe or efficient unless he thinks in general terms first.
Even in nursing we see this tendency. Dame Janet Campbell, our recent
illustrious visitor, was referring to the methods adopted in some centres,
where the same nurse does pre-school and school work, general preventive
work, and maternity work.  A general practitioner, in other words.
And this leads to the powder hidden in the jam. The general practitioner
need not preen himself on anything that he has done to bring this about.
The great advances are made, not by one side or the other, but by the joint
work of the two; and the obligation is on the general practitioner to measure
up to this new standard of confidence. It must have been his failure in
some respect, or deficiency, not necessarily culpable, that led to the evolution and even the hypertrophy of the specialist—and he must grow himself,
all-round if you like, and fill his rightful place, not merely occupy it. The
future holds great promise and opportunity for the general practitioner of
medicine—he will undoubtedly be the predominant figure for many years
to come—but this means responsibility as well as privilege, and it is for us
to meet the former, and not merely claim the latter, of these two.
Oil
NEWS AND NOTES
It is with deep regret that we record the death of Dr. F. Stainsby on
November 8th. Dr. Stainsby, while at the time of his death he was practising in West Vancouver, was well known to many of the profession on
this side of the Inlet, as he once practised here. He was greatly loved by the
West Vancouver community, as was shewn by the very large attendance
at his funeral.
Dr. E. T. W. Nash, lately interne at St. Paul's Hospital, has started
practice in Vancouver, his office being located in West Point Grey. We
wish him every possible good fortune. He began well, by winning a prize
of astronomical proportions in the Vancouver Exhibition this year, as many
of us will remember hearing.
11
|,
Almost the entire medical profession of the city visited Shaughnessy
Golf Club for a couple of hours or so on November 19th to take a postgraduate course in golf from the eminent professor of that game, Robert
Tyre Jones, better known as Bobby Jones. The weather (overhead at least)
was all that could be desired and the clinic was a very great success. The
fact that our own Davie Black sank the winning putt made the day perfect,
and our surgeon-golfer, Dr. J. Bilodeau (vide the Daily Province of recent
date) obtained a great many new wrinkles.
Dr. C. W. Prowd has returned from his trip, but, we regret to say, is
not yet very well, and is not back at work.
Dr. R. G. Wride, late of the Yukon, has moved to Princeton, where he
has taken over Dr. J. R. Naden's practice. His brother, Dr. Gordon E.
Wride, has joined him there.
Page 47 Dr. J. R. Naden, we are glad to hear, is returning to Vancouver soon,
after some time which he will spend in New York, doing postgraduate work.
Dr. W. H. Hatfield has recently returned to Vancouver from a trip of
three months through Scotland, England and France, during which he has
been studying the latest methods of prevention and control of tuberculosis.
We have received the following note from the Provincial Board of
Health Laboratories at Kelowna, which explains itself.—Ed.
"Re the article "Macro-micro Flocculation Test for Syphilis" in the
Bulletin of October, 1933: I have found that with commercial antigens
purchased by us during the past two months it is necessary to make an
adjustment in regard to the quantities of antigen and saline in order to get
clear readings, without the use of the microscope as detailed.
It was found that, if quantities of antigen and saline to given an
opacity equal to 30,000 million staphylococci were used, the test was
satisfactory and easily readable.
Mead, Johnson & Co., through their local representative, Mr. D. M.
Turner, have asked us to notify the profession that they have available for
exhibition a large number of films, dealing with a wide range of subjects—
obstetrical, surgical, pediatric and laboratory technique. These may be
shewn in offices or elsewhere to small or large groups of medical men, and
are of outstanding merit. They are at the disposal of any group of men who
may desire to view them, and a telephone message to the Vancouver Medical
Association offices, or to Mr. Turner direct, at 3449 West 26th, Bay. 4934L,
will secure a time and place of shewing. We recommend these to our
members.
:
ANNUAL DINNER
The Annual Dinner of the Vancouver Medical Association was held in
the Spanish Grill of the Hotel Vancouver on Thursday, November 22nd.
It was a conspicuous success, and Dr. J. W. Thomson and his committee are
to be congratulated on the outcome of their efforts to make it so.
Some hundred and fifty-four men sat down to dinner. Dr. Frost presided at the head table and was flanked on either side by the youth and beauty
of the Association, including Dr. R. E. McKechnie, Dr. Boyle, Dr. George
Gordon, Dr. W. D. Brydone-Jack and many others. We had many visitors,
amongst whom was noticed Dr. Sutherland of Wells, B.C., whose new
hospital was mentioned recently in the Bulletin.
The programme was good and worked without a hitch, except the one
that Wally Brewster had to take in his skirt with a couple of safety pins
procured for him by the blameless Editor of this publication, who nearly
got into a box, as he unwittingly invaded the sanctum where the very
charming young ladies who provided us with entertainment were beginning
to shed their costumes for one of their acts. It was a close thing. The
entertainment referred to was a series of dances, monologues and songs, provided by the Attree dancers. The dances and gymnastic displays were very
fascinating to watch, and revealed a very high degree of training.
Nor was there anything mean about the liquid part of the dinner. Adequate refreshment was provided, though of course the term "adequate" is
a relative one.
Page 48
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Later in the evening various stunts were put on, including an Apache
dance by HerrenDoktoren Brewster and J. E. Harrison; and a more elaborate
show in which Drs. Bilodeau and Brewster took the stellar parts of Aesculapius and Hippocrates, while Dr. Lavell Leeson took part, complete with
head-mirror, along with Dr. Hammy Boucher, who looked as if he had
been coaching the Meralomas through a rather sanguinary game with the
Regina Roughriders, and Dr. Alec Agnew, whose rendering of his role
revealed depths of Thespian ability not suspected hitherto of the placid
and even-tempered Alec. They were all very good—but if the language
used by Hippocrates on several occasions is what we may expect on arrival
in Heaven (if that is where we arrive), one can only say it is not according
to the conventional idea of Heaven at all.
Dr. Jack Wright, too, contributed a great deal to the gaiety of the
dinner by his very clever telephone conversations. Altogether, it is a matter
for congratulation that so much new talent has been unearthed amongst
the younger generation.
If one has a criticism of the dinner, it is that no music was provided.
For the first time in a great many years, our orchestra was not in evidence,
and there was no singing, which we feel to be rather a pity, as it warms
things up. Dr. Covernton, whilst he provided some entertainment unwittingly, yet did not sing Alouette, and this is a distinct loss; while Dr. Nelles
also remained silent all evening.
But the highlight of the dinner was the presentation to Dr. W. Y. Corry
of the Prince of Good Fellows (P.G.F.) degree. He was, we feel, rather
taken by surprise when his name was disclosed to the audience—but there
could be no doubt at all of the immense popularity of the choice made by
the Executive, as the loud and prolonged applause, repeated again and again,
shewed. It was felt everywhere that no man could have been chosen more
fitly, and that the recipient of the degree embodies all the qualities which
the degree is intended to recognise.
Dr. Corry responded briefly, in a witty little speech which yet shewed
how deeply he was moved by the recognition of his fellows.
Altogether, it was a very good dinner, and everyone had a very good time.
REVIEW
THE BRITISH PHARMACEUTICAL CODEX, 1934.
In these days of propaganda concerning pharmaceuticals coming daily
by mail and personal representative, it is a comfort to turn to a volume of
straight-forward description of drugs, etc., and their uses.
"To furnish information concerning the newer materia medica, consisting of substances and preparations which had not yet attained the status
of approved and established remedies included in the pharmacopoeia, as
well as giving particulars of medicinal articles, which, although in constant
demand, had ceased to receive pharmacopceial recognition," is given as the
basic reason for the publication of the British Pharmaceutical Codex of
1907 and its three subsequent editions, including the present volume. This
1934 edition is intended to provide not only a book of reference for pharmacists and medical practitioners, but also to prove a book of standards for
drugs and preparations, the fact of British Pharmacopceial recognition being
indicated when such is the case.
There are four parts.
Part I consists of monographs on chemical substances and drugs, in
Page 49 alphabetical order, giving preparations, doses, actions and uses in the manner
made familiar in our early study of materia medica.
Part II contains monographs on surgical dressings and the basic vegetable and animal fibres used in their manufacture.
Part III is the formulary, and well repays one for its perusal.
Part IV is composed of appendices containing tables, general tests,
reagents, methods of sterilisation, a pharmacological index, trade names and
proprietary substances.
The complete volume, which has a voluminous index, forms a valuable
addition to the books of reference of the library.
INFECTION: ITS SPREAD AND CONTROL
By Dr. G. F. Amyot
Read before Vancouver Medical Association, October 2, 1934
(Concluded from last month)
Before the case is even reported it should be placed under advisory isolation by the physician. That is, the sick should be separated from the well
completely. As the infection is spread in most cases by contact, if this
isolation is simply but carefully carried out, those not already infected will
escape. All articles that are soiled by the vehicle carrying the infection
should be treated in a manner to destroy the organism. Those attending the
patient, including the physician, should rigidly wash their hands immediately after contact in hot running water with soap. Not the often noticed
dip in so-called antiseptic solution for a moment and then a dry on a towel.
A surgeon, assuming the possibility of there being some pathogenic organism
present, goes through a thorough and elaborate technique of surgical asepsis.
The physician, knowing that he is actually dealing in most of his practice
with infection, forgets in his rush from place to place that there is greater
danger that he may carry to others infection that could be eliminated by a
thorough but simple medical asepsis. Our hospitals and offices are not properly supplied with suitable washing facilities to assist in this procedure, but
in spite of this drawback medical asepsis can in most cases be carried out.
The health department takes the final responsibility of quarantine and
isolation, and if this is passed to them they can relieve the physician of a
great deal of trouble. Most people, if the facts are explained to them, are
quite willing to co-operate if things are not made too rigid.
Public health has taken charge of the next method of transmission by
placing barriers in the way through regulations governing the production
and sale of milk and milk products. Pasteurization destroys the pathogenic
germs that may have gained access to the milk supply from the time it left
the cow until it reaches the dairy for distribution. This process, if properly
carried out, will make any milk safe. It does not destroy in any amount the
nutritive value of the milk.
A safe supply of water is obtained by filtration, chlorination, or other
methods. In Vancouver our supply is rather unique, as it comes from a
guarded watershed and receives no other treatment.
Sewerage systems have been provided to prevent the contamination of
water and ice supplies by sewage.
Meat and food inspection assures us of a safe food supply.
The destruction of insects, the elimination of their breeding places and
screening protect us from this method of spread of infection.
Page 50
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Is ft
' Pi We have seen the methods devised to protect us from infection by
public health and these give good results. Unfortunately they do not by
any means solve the whole question. If all cases were typical from the onset
and isolated immediately, the battle would be won, but they are not, and
we have coming into the picture the atypical case, and there are many more
of these than we are led by the text books to believe. The mild cases are
often never seen by a physician, and run at large. Patients often think that
because the case is mild it is not infectious. I have even heard medical men
say, "Oh, that is only mild; a case of scarlatina and not scarlet fever," and
do> nothing more about it. Scarlatina and scarlet fever are one and the same
thing. The case that is entirely missed by everybody also is a deadly source
of infection. Finally, the carrier, an apparently healthy person harbouring
the organisms of disease, is a definite source of infection. These cases all
miss isolation and pass all the barriers placed to stop them, and continue to
spread infection throughout a community.
How are we to stop the spread by this last group of sources? Nature
has shown the way, by demonstrating that it is in many cases possible to
develop in the body once attacked by a disease, some substance that builds
up an immunity to any further attack of that disease. Realizing this, the
immunologist has tried to get the same result without the person going
phrough the dangers and inconveniences of an attack of the disease. We
were given the first of these great discoveries by Edward Jenner. In this
century we have available toxoid to protect against diphtheria. Typhoid
vaccine demonstrated its value during the last war in a better manner than
I could tell you. There are others, not quite on a par with the three mentioned, but still very valuable. There are two ways, then, that people can
receive immunity of an active type against infection. First, to have the
disease in a very mild, unrecognised type, all the way through to the severe
type. Second, to receive some agent without the actual disease from which
they will develop an active immunity.
The use of these substances has been built up by public health and great
results have been obtained, but there is still a great deal to be accomplished.
The profession has left this work to its specialized branch of public health.
Clinics have had to be established to give this service to a public that have
shown their support all over the world. This had to be done in this manner
to establish it, but the time has come when others should be interested in
this work. I refer to the medical profession as a whole. Those of you who
had the opportunity of hearing Doctor Vaughan describe the medical participation programme he established in Detroit and in the rural areas of
Michigan will realize what can be done along public health lines by the
profession co-operating with the health departments.
Babies given toxoid or vaccinated during the last six months of the
first year are given, with practically no> reaction, a protection against two
diseases that have in the past destroyed large numbers. What better person
to give this protection than the man who brought the child into the world?
He is rightly, and should be, the family advisor in everything pertaining to
illness. But would it not be better to go one step farther and be the complete advisor to the family in everything pertaining to illness and health?
In other words, who is better suited to advise how to avoid illness and retain
health than the family physician?
Immunization is only a small part of preventive medicine, and will do
Page 51 for an example that should be expanded to include, in time, every phase of
prevention. The knowledge we have is far ahead of that now being applied.
The profession is interested, and always has been, in attempting to relieve
suffering; they are also interested in going one step further and preventing
suffering in every way possible. Periodic health examinations are certainly
approved and accepted by medicine as a great factor in finding defects and
chronic illnesses early and affording an opportunity of preventing more
serious trouble later on. They offer a means of instructing a patient along
the lines of moderation in his life so that he may reap the most fullness,
happiness and joy from his short stay on this world. Food is an important
thing in everybody's life today, and yet either receives very little attention
from practicing physicians or becomes a fad, as with a few. Commercial
firms are doing everything possible to keep diet a fad for their own selfish
gain. People want advice on these matters, and should come to their physician. The medical profession has had to carry the load of care for the indigent ever since its foundation, but the time is coming when the physician
will be adequately paid for his service. Whether these services are for the
curing of the sick or the practicing of prevention, they should be paid for.
To have a satisfactory medical participation programme established,
certain things are necessary:
First, the medical profession as a whole must be willing to co-operate
with the health departments.
Second, the practitioner must have a proper knowledge of immunization
and certain phases of preventive medicine.
Third, if he has the first two he should be able to collect for the preventive services rendered.
We must realize that no part of the public health programme now carried can be dropped until there is some other person ready, equipped and
willing to take it up and continue the work. The health department does
still have the responsibility placed on it by law to protect the public, and
can only relinquish certain phases of the work that can be successfully carried out by others.
In Detroit there are 1,100 physicians co-operating in the medical participation public health programme. The disciplining of the medical men
is done by a committee of the medical society and not by the health department. All the health department is interested in is the proper carrying out
of the programme.
Unfortunately, in Vancouver it would not be possible to pay the medical men for any services, but there is a large part of the population which
can and would pay their doctor if they were shown that he was interested
in prevention measures to the fullest extent.
I would suggest that this society appoint a committee large enough and
representative enough to draw up a programme of medical participation in
public health, to study the matter fully and to co-ordinate the available
services with the local and provincial health departments. The only plan
that will succeed is one sponsored by the vast majority of the profession.
It must have concentrated action and a complete understanding of the
whole question and it must come from the profession. They will be met
more than half way.
Page 52
i fl
•.flm I 1 ■;„
m
m
>i*i
SOME SECRETORY DISTURBANCES OF
THE   STOMACH-
Clarence E. Brown, M.D.
Vancouver, B. C.
Before discussing the question of the secretory disturbances of the
stomach it may be well to review a few of the salient points of the normal
secretory physiology of this organ. The publications of Pawlow, Carlson,
Starling, Alvarez and others have been utilized to a great extent for this
purpose.
According to Starling, histological investigations show four types of
cells in the gastric mucosa.
(1) Surface cells cover the inner surface of the mucosa and line the
ducts of the tubular gastric glands; they secrete mucus.
(2) Mucoid cells form the secreting cells of those pyloric and cardiac
glands which are placed near the two sphincters; they are also
mingled with the peptic cells lining the cardiac glands.
(3) The peptic or chief cells secrete pepsin.
(4) The oxyntic or parietal cells secrete the hydrochloric acid.   The
cytoplasm of the latter shews acid reaction during active secretion.
Much animal experimentation has been done on dogs with the Pawlow
pouch. An elongated piece is separated from the stomach of the animal
and formed into a cylinder, the orifice of which is sewed into the opening
in the abdominal wall, the other end remains connected with the stomach.
The cavity of the pouch is separated from that of the stomach by a septum
formed only of mucous membrane. [The speaker showed slides taken from
the work of Dr. Chigin showing the method of obtaining this pouch.]
An animal with a divided oesophagus and a gastric fistula eats greedily,
and although the food does not reach the stomach, within five to ten minutes there is a free flow of clear juice. This "sham feeding" establishes the
idea of a reflex nervous mechanism. This is a non-conditioned reflex. On
the other hand, if the animal is merely shown food which he desires, or
hears the preparation of food, or smells food, that is if there is any stimulation of the desire for food through any of the nerves of special sense, the
gastric juice begins to flow.  This is a conditioned reflex.
Pawlow has shown that this physical secretion is entirely abolished by
the division of both vagi, thus demonstrating the nervous mechanism of
gastric secretion.
Just as gastric secretion can be induced by pleasurable emotions, so also
can it be stopped by unpleasant or painful ones, such as fear, anger, annoyance, disgust or pain.
The juice as it is poured out by the glands always possesses the same
degree of acidity. Owing to the fact that after it is secreted it flows down
over the alkaline mucous membrane, it inevitably becomes neutralized, that
is, it has its acidity reduced. The more rapidly it is secreted the more acid
will it be. In no gastric juice does the acidity exceed the normal. Even in
animals suffering with pathological conditions, in no sample does the acidity
prove higher than normal.
The varying necessity for acid during the course of digestion is supplied
by variations in the quantity of juice and not by changes in its acidity.
Fluctuations in the acidity of the juice after it leaves the glands which
"■Presented at the meeting of the Vancouver Medical Association, November 6th, 1934.
Page 53 secrete it must be looked upon as desirable and in a normal stomach a perfectly pure juice may have its acidity reduced 2 5 per cent by neutralization
with mucus.
The first secreted portions of the gastric juice are distinguished from
the others by a stronger digestive power, that is, the strongest juice is poured
out when it is most needed. Every individual kind of food calls forth a particular activity of the digestive glands with special properties of the digestive
juices. The properties of the juice, the rate and duration of secretion and
also its quantity vary with the work to be done. The point of the maximum
outflow, as well as the whole curve of secretion, is always characteristic with
each diet. The work of the digestive glands is elastic to a high degree, also
characteristic, precise and purposive.
Comparisons are made between "bread juice," "flesh juice" and "milk
juice," etc. "Bread juice" contains four times as much ferment as "milk
juice." Not alone the digestive power, but likewise the total acidity, varied
according to the nature of the diet. The latter is, however, greatest with
flesh (0.56 per cent) and lowest with bread (0.46 per cent). The quantity
of juice poured out and the duration of its secretion are dependent upon
the kind of food. Flesh requires the most, and milk the least, gastric juice.
The hourly intensity of gland work is almost equal in the case of milk and
flesh diets, but far less with bread. The last exceeds all the others in the
time required for its digestion. The most active juice occurs with flesh in
the first hour, with bread in the second and third hour, and with milk in
the last hour of secretion. On protein in the form of bread, five times more
pepsin is poured out than on the same quantity of proteid in the form of milk.
The second phase of gastric secretion is determined by a chemical
mechanism. This may be described as the "gastrin theory." Through a
fistula in the large stomach, without attracting the dog's attention, food
is inserted into the stomach. Certain foods, such as bread and coagulated
white of egg, do not yield any juice during the first hour or more afterwards. Flesh is able to excite a secretion, but the juice appears from fifteen
to forty-five minutes after the feeding, instead of from six to ten minutes
as under normal circumstances. The amount of juice secreted as compared
to the normal feeding is much less. The quantities obtained by direct introduction of the flesh added to those of sham feeding give almost identical
results as with the normal.
Water was found to have an exciting effect on the gastric juice. Meat
broth, meat juice and solutions of meat extract proved to be constant and
active excitors of the secretory process in the stomach. Other foods, such
as starch and fat, proved to have no exciting effect. Starch in water solution had no greater effect, but rather less, than water alone. When quantities of finely divided raw flesh are introduced into the stomach of dogs
the secretion begins at the very earliest from fifteen to thirty minutes
afterwards. If one obtains the fluid digestive products from the stomach
of a dog who has eaten egg albumen and injects them into the main stomach
of a dog, a more constant and larger flow of gastric juice is obtained than
from the introduction of a like quantity of water or egg albumen.
When bread and egg albumen are eaten without appetite, or introduced
into the stomach unobserved, they lie there for a long time, just as stones
would lie, without the least appearance of digestion. When such foods are
eaten in the normal way the appetite juice is the sole initiator of the secretory process.  The psychic juice here plays the role of the igniting material
Page 54
m
M
Mil
m
V*i It
which sets the stove ablaze, and for this reason it has been called "igniting
juice" by Dr. Chigin.
Carlson (1923) states that the "gastrin theory" postulates that substances, either in the native foods or developed in the gastric digestion of
foods, act on the pyloric mucosa in such ways that a gastric secretion is
produced, this in turn is absorbed into the blood and acts on the fundic
glands via the blood. It seems highly probable, however, that the gastrins
are artefacts developed in the decomposition of the foods or in the extraction of the mucosa and do not represent physiological mechanisms. Gastrins
belong to the pharmacology, rather than to the physiology, of gastric
function.
Histamine is a general secretagogue. However, Luckhardt and others
were able to separate histamine and gastrin by chemical means, which seems
to show that they are different substances.
In man, most of our experimental work in gastric secretion has been
done in cases of gastrotomy or by means of a stomach tube.
The resting stomach usually contains from 30 to 50 cc. of fluid, consisting of gastric juice, mucus, saliva and regurgitated duodenal contents.
The hourly rate of secretion is usually 30 to 60 cc. After a good meal
500 c.c.j or more, of this juice may be secreted. Usually the range of HCl
in this juice is between 0.2-0.4 per cent. As Pawlow and others have shown,
even in man, before dilution, neutralization or regurgitation is effected, the
pure gastric juice shows a persistent HCl content up to 0.5 per cent. The
whole contents rarely, if ever, reach such a high level.
The chief digestive function of the gastric juice is dependent on the
action of the enzyme, pepsin, which is accumulated as pepsinogen. The
activation of the latter is accomplished through the HCl of the juice. The
main effect of the gastric juice is on the proteins of the food with the division
of the complex molecules. Proceeding from primary through secondary
albumoses to peptones, the breakdown never passes beyond this stage. Fat
is set free by the action of the gastric juice on the protoplasmic envelopes
and undergoes conversion into fatty acid.
There are three methods by which the acidity of the gastric juice is
altered.
(1) As we have seen in the experimental work, the gastric juice as it is
secreted flows down over the mucous membrane of the stomach and mixes
with the mucus, reducing the acidity to a considerable amount. We know
also that the pyloric glands secrete an alkaline mucus which acts as a
neutralizer.
(2) It is maintained that when the acidity reaches a certain height,
the stomach glands release a neutral sodium chloride at the expense of the
HCl and this secretion acts as a diluting fluid to the HCl of the gastric
contents.
(3) The regurgitation of the alkaline pancreatic and duodenal secretion
into the stomach is a factor in the control of acidity.
Much work has been done to prove or disprove one or all of the above
three methods of the control of acidity. It is reasonable to believe that they
all may and do take part in the process.
Whether the acid of the gastric juice is, as Cannon maintained, the
factor which controls pyloric mechanism is questionable. Others maintain
the pylorus controls the acid of the stomach.
Alvarez (1928) says that we must be careful how we speak of the
retarding action on the duodenal side as an "acid" reflex. The acid is
Page 5 5 effective, but so, also, is fat. It seems clear that if the acid is left unneutral-
ized in the duodenum, it will keep the pylorus closed for long periods of time.
Consistency of food should have much to do with the rate in which it
leaves the stomach; and, theoretically, if the carbohydrates were as difficult
to liquefy as meats they should go out as slowly as meats. Raw white of
egg, which is semi-liquid, leaves the stomach promptly like water, and not
slowly like other proteins. The main work of the stomach is to liquefy the
contents or turn them into pap, and when that is done, the material can go
into the duodenum no matter what its acidity. It appears that strong
acidification, with hydrochloric acid, of liquids or foods, will delay their
passage through the pylorus until the acid has been diluted or neutralized
to a point where it will not be so stimulating on the duodenal side. Weak
solutions of alkalies will hasten emptying. The osmotic pressure also affects
the emptying of the stomach. Isotonic solutions run out rapidly, hypertonic
ones slowly.
It is doubtful whether any chemical stimulus is needed on the gastric
side to open the pylorus. It relaxes at intervals, and if the gastric contents
are then under any pressure the liquid part is squirted out and the more
solid parts are retained. Hydrochloric acid is one of the substances which,
in strong concentration on the duodenal side, closes the pylorus. We probably have no more right to speak of an acid reflex than of a fat, a food, or
an osmotic pressure reflex. Solubility of food largely influences the rapidity
at which it leaves the stomach.
Functions of Hydrochloric Acid in Gastric Juice
(1) Activating pepsin.
(2) Slowing up the emptying time of the stomach and so leading to
better gastric digestion.
(3) Antiseptic action on the swallowed food, preventing implantation
in the lower digestive tract of infection from sinuses, teeth, tonsils and the
lungs.
(4) Pawlow has shown that in a dog with a permanent pancreatic
fistula, after 15 0 cc. of one-half per cent solution of hydrochloric acid is
introduced into the stomach, within two to three minutes the pancreatic
juice begins to secrete. This is one of the most securely established proofs
that acids have a powerful influence upon the pancreas. One can excite
the activity of the gland more by acid than by any other means. One
is justified in stating that acid is a specific excitor of the pancreatic gland.
Bayliss and Starling have shown that the -acid acting on the mucous
membrane of the duodenum and the upper jejunum converts "prosecretin"
into "secretin." This substance is absorbed into the blood stream and
results in stimulation of the pancreatic secretion.
Methods of Investigating Gastric Secretions Clinically
The fractional method of gastric analysis is a noted advance as regards
the study of gastric secretion in man, both in health and disease. The
main shortcoming of the fractional method is due to the variation in degree
of acidity of the gastric content in different regions of the stomach. (Carlson, 1923.)
Dimethyl-amino-azo-benzol, as an indicator, is sufficiently accurate for
all clinical and most research purposes.
The type of meal varies with different workers. I have used two glasses
of plain water; on occasions, a dilute alcohol meal; but as a routine, strained
Page 5 6
<(L
m oatmeal gruel has been the meal of choice. I have not used histamine
routinely. The reactions after its injection lead to caution in its routine use
in private practice. It may be used in cases where the ordinary test meal
shows anacidity in order to determine the persistence of the latter. I have
resorted to a recheck at a later date with the ordinary gruel meal rather than
resorting to histamine.
One wonders at the difference of opinion which exists as to the indications of a fractional gastric analysis. One author goes so far as to suggest
its use in all routine physical examinations, whereas others, including a
prominent gastro-enterologist, would have us believe that it has very little
place in our diagnostic equipment. I would refer you, however, to the
statistics of a large American clinic which show that 16,000 fractional
gastric analyses were done in the years 1928-1931. When one considers that
varying statistics show that achlorhydria occurs in 10 to 25 per cent of
cases with gastro-intestinal disturbance, this factor alone should indicate
its use much more generally than is the case today. The fractional meal not
only gives an indication as to the acid secreting function of the stomach,
but as well its fasting contents, its emptying time, the state of the pylorus
as indicated by the regurgitation of bile, and the presence of blood and
mucus.
Technique.—One hesitates to discuss the question of the technique of
fractional gastric analysis, but none the less, poor technique may lead to
erroneous results.  Fear and discomfort should be avoided so far as possible.
It is, therefore, advisable in preparing the patient for a gastric analysis
and the swallowing of the tube, to obtain his confidence and relieve his
apprehension. The swallowing of a small Rehf uss tube is not such a difficult
process and may be likened to the swallowing of a piece of meat or other
pieces of food that have not been well masticated. As a rule it is advisable
not to have the patient see the tube. It is warmed to body temperature and
the tip smeared with a drop of glycerine. The patient is asked to relax and
to breathe deeply in order to relax the chest and pharyngeal muscles. He is
advised to open his mouth widely and say "aah." The bulb of the tube is
passed under vision into the pharynx, avoiding the base of the tongue, and
the patient is then asked to swallow as if eating a mouthful of food. Frequently one swallow is all that is necessary, as the tube is immediately
grasped by the pharynx and passed into the oesophagus. If the patient then
keeps the mouth open and breathes deeply, the tube will usually be grasped
by the oesophagus and taken rapidly into the stomach. Muscular spasm, at
the upper or lower end of the oesophagus, may grasp the tube. A swallow of
water will usually relax such a spasm and the tube rapidly passes into the
stomach. If care is taken to observe these few details the patient has no
future dread of repeating the procedure. Patients learn to pass the tube on
themselves where repeated aspirations are necessary.
In very young patients the use of a nasal tube is preferable to the ordinary Rehf uss tube. A syringe of 50 cc or more capacity, with good
suction and a large calibre opening in the tip, is essential.
Very few illnesses contraindicate the passage of a tube; possibly advanced
cardiac disease or aneurysm of the aorta are contraindications.
There is little choice between the different test meals in use. Water, as
shown by Pawlow, is a definite stimulant to gastric secretion, and two
glasses of water are probably as effective in stimulating the secretion of the
gastric juice as oatmeal gruel, or dilutions of alcohol, or biscuits and water,
etc. Its disadvantage, I have found, after using it for a limited number of
Page 57 tests, is that it leaves the stomach a little too rapidly; and there is the possibility of the stomach emptying before a representative secretion of the
gastric juice takes place. The oatmeal gruel, which I have used almost
entirely, is somewhat slower leaving the stomach, the average emptying
time being 1 ]/4 hours. The specimens filter in a reasonable time and one
gathers some idea as to the rate at which the starch leaves the stomach.
Occult blood is not examined for, as slight bleeding may be caused by
injury from swallowing the tube. The amount of the fasting contents is
measured, the gross blood content and bile and mucus content are observed.
The practice of washing the stomach before giving the test meal has not
been considered necessary if the contents are well evacuated. The patient
swallows the test meal and specimens are extracted at fifteen-minute intervals until the stomach is emptied. The specimens are examined, after
filtering, for free HCl and total acidity, dimethyl-amino-azo-benzol and
phenophthalein being used as indicators. The regurgitation of bile, the disappearance of the starch and the presence of gross blood are noted.
In obstructive conditions of the pylorus from cedema and spasm,
or from organic scarring, or from cancerous growth, the emptying time
may be delayed unduly. If, at the end of two hours, a residue remains, it
is withdrawn and measured.
On completion of the test the tube is gradually withdrawn and usually
comes to the pharyno-cesophageal junction without any difficulty. Frequently a spasm is met with at this point, but by asking the patient to
swallow, or gag, and keeping a firm, even tug on the tube, it invariably is
released without distress or difficulty.
I would suggest that the same advice be offered to the budding gastro-
enterologist as is usually given to the genito-urinary neophyte, that is, to
pass the tube on himself. In this way a gentleness of technique and a
respect for the feelings of the patients undergoing the procedure, will be
developed.
Normal Gastric Acidity Range from Birth to Old Age
Vanzant and associates of the Mayo Clinic, in a study of over 3,000
gastric analyses done on patients with no serious diseases in the digestive
tract, attempted to arrive at a normal range. They find a steady increase
in the incidence of achlorhydria from youth to old age. At the age of 60
years 28 women in 100 failed to show free acid on repeated fractional
analysis, and similarly, 23 men in 100 were achlorhydric.
Free gastric acidity appears to increase rapidly from childhood up to the
age of 20 years when adult values are reached. About the age of puberty,
the average value for boys begins to rise considerably above that for girls.
Typical free acidity for men ranges between 45 and 50 units in the years
from 20 to 40. After this it falls off rapidly to a level of from 30 to 3 5
units in the aged. In women the mode is approximately 3 5 units throughout
adult life. It appears to fall off slightly after the age of 60 years. The
normal range of free acidity in both men and women is about 90 units. In
both sexes the combined acidity appears to vary but little from youth to
old age. Ninety per cent of the data lay between limits of 12 and 22 units
with a mode at 17 units.
As previously stated, probably there is no such condition as hyperacidity.
The- pathological change in acidity is always in the direction toward
anacidity. In pylorospasm we have a hypersecretion but never a hyperacidity.
Page 5S
tfiffl
i'lJ
■ ■ hi
'ii
Hurst maintains that the acidity curve of the gastric secretion depends
on the type of individual. He classifies them into the hypersthenic gastric
constitution, which comprises those who have a tendency toward hypersecretion, the normal, and the hyposthenic gastric constitution.
Achlorhydria.—Hurst believes that without gastritis there is no achlorhydria, but gastritis does not cause achlorhydria unless there is a predisposition to the hyposthenic gastric constitution. He gives no report on any
microscopic findings in the gastric mucous membrane which would confirm
this persistent presence of gastritis in achlorhydria.
Faber of Copenhagen, for the past thirty years, has given gastritis as
the cause of achlorhydria.
On the other hand, in regard to gastritis, Edwin F. Hirsch (1916), from
the Rush Medical College, after microscopic examination of the stomachs
of men dying in delirium tremens, noticed that the absence of changes
indicating acute or chronic inflammatory processes is striking. Except for
the presence of haemorrhage, the appearance of the stomach is unaltered in
any extent. These haemorrhages probably are anatomic manifestations of
acute toxaemia. Chronic alcoholism alone is of doubtful etiologic importance in causing chronic gastritis. We know, however, that achlorhydria is
a fairly common condition in chronic alcoholism.
Complete atrophy of the glands of the mucosa rarely obtains, achlorhydria occurring long before such serious injury results. Familial tendency
towards the development of achlorhydria is noted. I have three such cases
in my series in which both brother and sister were achlorhydric.
Baird, Campbell and Hern (1924) refer to three possible causes of
achlorhydria, namely:
(1) Normal secretion and excessive neutralization;
(2) Diminished secretion and some neutralization;
(3) Absence of secretion or true achylia.
They are of the impression that the first two may occur in healthy
subjects, but are doubtful if the third ever occurs in subjects who can really
be called normal.
Carlson believes that the possibility of achylia being congenital, and
probably hereditary, seems speculative. Permanent injury to the gastric
glands during the life of the individual through toxic agents as bacterial
toxins, alcohol, irritating food, nose and throat infections, etc., may be the
cause. He considers the most important factor in this depression of gastric
secretion is probably the cachexia of the gastric glands.
Oliver and Wilkinson seem to favour chronic gastritis as the etiological
factor, but believe the theory of constitutional origin of achlorhydria is
supported by a tendency to occur in many members of a family. The possibility of a neurogenic origin of achlorhydria is also suggested.
In the majority of cases of pernicious anaemia the achlorhydria is a
permanent condition. Achlorhydria was present in 56 per cent of pellagra
cases and also in 50 per cent of sprue cases. In subacute combined degeneration of the spinal cord, without anaemia, 100 per cent of the cases showed
gastric anacidity. Chronic pancreatitis, chronic biliary tract disease, diabetes mellitus, allergic conditions, certain skin conditions, arthritis, hyperthyroidism and numerous other conditions are associated with a varying percentage of achlorhydria.
Carcinoma of the stomach, according to Hurst, if superimposed on
peptic ulcer, may be associated with hydrochloric acid in the gastric secretion.   However, if chronic gastritis occurs in a person with a hyposthenic
Page 5 9 gastric constitution it leads to achlorhydria, and the combination of these,
with the constitutional predisposition to carcinoma, leads to carcinoma of
the stomach. This occurs in 75 per cent of cases of carcinoma of the
stomach. He reports 4 patients in whom achlorhydria was known to be
present before carcinoma developed and he found reports on at least 19
similar cases. In my series I have had only one known case of achlorhydria
which subsequently developed carcinoma of the stomach.
The microcytic type of anaemia with low colour index and associated
with achlorhydria was described by Faber in 1909. In this type of anxmia
the anti-anaemic factor of the gastric secretion is not entirely absent.
Another form of this type of anaemia is that associated with dysphagia and
achlorhydria. It is usually relieved by adequate treatment with iron and
hydrochloric acid.
Oliver and Wilkinson claim to have found approximately 24 per cent
of relatives of patients with pernicious anaemia showing the presence of
achlorhydria.
PERCENTAGE OF ACHLORHYDRIA IN GASTRIC ANALYSIS
IN VANCOUVER
f-ffli
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Vancouver General Hospital, 1933 and 1934...     827 228 27.5
St. Paul's Hospital, 1933.        103 21 20.4
Own Series           573 108 18.8
PERCENTAGE OF ACHLORHYDRIA, IN OWN SERIES, ACCORDING
TO SEX AND AGE
ft
Q
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O ^ a,
f- O
•<
^ §
'n tt,
ht
<£ "< §
ft, -< fe.
[-.&,"<
70-80 	
3
2
5
1
1
2
3 3.3
50
40
60-70 	
20
28
48
9
7
16
45
25
33.3
50-60 	
64
41
105
17
15
32
26.5
36.1
30.4
40-50	
72
66
138
10
18
28
13.8
27.4
20.3
30-40
65
88
153
3
13 i
16
4.6
14.7
10.4
20-30	
51
52
103
4
6
10
7.1
11.5
9.7
10-20	
6
9
15
	
0-10
2
..
2
_.
Unknown
1
3
4
1
3
4
100
100
100
284
289
573
45
63
108
15.8
21.8
18.8
Symptomatology of Achlorhydria.—Achlorhydria may be a symptomless condition and there is evidence that it may occur in a small number of
individuals who are seemingly in good health. It would seem, however,
that these individuals are worthy of close observation over a period of years
before one may accept achlorhydria as a normal condition. In my own
series of cases, although I have not analysed them fully, I am of the opinion
that achlorhydria is usually associated with some abnormal physical condition. One must admit, however, that this work has been done on those
who have come complaining of some physical abnormality or symptom.
Page 60
m
m EGGLESTON'S SUMMARY OF ONE HUNDRED CASES OF
ACHYLIA GASTRICA
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72; Average Age, 52.
Diagnosis
Fatigue, chronic „ ..              36
Glossitis . i    - -   9
Gastritis, chronic    .     — . —  7
Anaemia, secondary __   ....— .— .... ....   .—   16
Anemia, primary   .—        -    7
Chronic cholecystitis   .                                                                             ...       - 13
Combined lateral sclerosis     —     17
Bowel Condition No. of Cases
Normal   -      14
Constipation       —   —    75
Diarrhoea          -   -       8
Alternate constipation and diarrhoea     .—       3
Carlson believes that the explanation for the absence of symptoms associated with achlorhydria is probably to be found in some compensatory
mechanism.
As Eggleston (1931) states, diarrhoea as a symptom in cases of achlorhydria occurs far less frequently than constipation. The diarrhoea usually
is associated with colicky pains, flatulence, mild secondary anaemia, and
possibly sore tongue at intervals. There is undue fatigue and nervousness,
chronic fatigue being a prominent symptom. Flatulence, nausea, heartburn,
constipation, constipation and diarrhoea alternating, epigastric pains and
a feeling of oppression after food are symptoms which are frequently complained of. The tongue is usually coated, the breath heavy. The appetite
is usually poor. Mental depression, sleeplessness and migraine are common.
There may also be a great intolerance to cold. Dry skin and pallor may be
present. The achlorhydric individual frequently is a tired, pale, nervous
individual with an offensive breath, a coated tongue, constipated, flatulent
and miserable. Diarrhoea may be present at intervals.
Radiologic study of cases of achlorhydria exhibits frequently decided
hypermotility, the meal leaving the stomach in so short a time as one hour
and reaching the rectum in so short a time as three hours. The pylorus is
frequently seen to remain patulous and there is very little peristalsis present
in the stomach, the barium simply pouring out through the pylorus as from
a jug. After reaching the colon there is usually a stasis in the progress of
the meal.
As Eggleston states, under such conditions the digestion must be very
imperfect. In the presence of a highly putrefactive intestinal flora, it is
not impossible that irritating substances are formed which might tend to
produce a diarrhoea as a result of the colon irritation.
Treatment of Achlorhydria.—In the treatment of achlorhydria for the
past 15 years we have become accustomed to the exhibition of much larger
doses of HCl than formerly, when the dosage given in the pharmacopoeia
was 5-20 minims. Physiologists have shown that 500 cc, and upwards, of
gastric juice is secreted following each meal and a conservative estimate of
1 Yz litres during the day is accepted.
Chemically pure HCl contains, by weight, 31.79 per cent of hydrogen
chloride and 68.1 per cent, by weight, of water. Diluted hydrochloric acid
contains 10 per cent, by weight, of hydrogen chloride, that is, 3 30 grms. of
HCl, and distilled water sufficient to produce one litre.   That is, roughly,
Page 61 —i
one part of HCl, chemically pure, and two parts of distilled water. (In
Vancouver ordinary tap water may be used.)
In cases of achlorhydria this dilute HCl is prescribed ordinarily in
drachm doses, mixed with 10-12 ounces of water, sweetened as desired with
sugar, mixed with fruit juice, and taken as a beverage with each meal.
Now this amount of acid in 10 ounces of water is the equivalent of 300 cc
of 0.13 per cent HCl, or 300 cc of approximately 3 5 units in terms of
decinormal sodium hydroxide neutralizing power. Therefore, this amount,
if given during the ingestion of a meal and subsequently up to a period of
two hours following the meal, would be considerably less than the amount
of free HCl secreted in the normal stomach. As much as two drachms in
patients with the heavier meals may be given. This dilute acid should be
sipped with the meal and the balance may be taken up to one hour or more
following the meal. In this way one simulates to a degree the normal secretion of acid in the stomach. Patients carry a small vial of the dilute HCl
with them when away from home.
A small percentage of cases of achlorhydria do not tolerate hydrochloric
acid. In these cases there seems to be some benefit from the use of the juice
of citrus fruits, such as grapefruit, lemons, etc.
The effect of the acid may be slightly harmful to the teeth. In one or
two of my cases the dentist has been under the impression that decay of
the teeth has been definitely hastened. In order to prevent this effect the
fluid may be taken through a straw or glass invalid's tube and, after the acid
has been consumed, the mouth may be washed with a neutralizing solution,
such as 1 or 2 teaspoons of undiluted milk of magnesia, care being taken
not to swallow any of the alkali.
After one month's treatment the patient is advised to have a recheck of
the fractional gastric analysis. In only a small number has the stomach
resumed the secretion of the HCl.
Hurst recently advised the washing of the stomach each morning with
hydrogen peroxide, 1 drachm to a pint of water. A non-irritating diet is
advised, and in 82 per cent of Hurst's cases a return of the secretion of
HCl was observed. All nasal, throat and mouth infections are carefully
treated. Should the achlorhydria persist, dilute hydrochloric acid in 1-2
drachm doses, well diluted, and a small amount of pepsin, are given with
each meal, the first dose taken fasting before breakfast for its antiseptic
action, and the others as a beverage with lunch or dinner.
Owing to the rapid emptying of the stomach in many cases of achlorhydria and a deficiency of absorption from the intestinal tract, it has been
found advisable in the administration of dye preceding the x-ray of the
gall-bladder, to give HCl with the evening meal preceding the administration of the dye. Under these conditions we believe that the dye is more
likely to be absorbed in the upper intestinal tract and so get into the bile
passages and fewer non-functioning gall-bladders will probably be discovered.
Hypersecretion.—As previously noted (Pawlow, Carlson and others),
actual hyperacidity in the sense of a gastric juice of greater than normal
acidity' has not been demonstrated in any disease, and probably does not
exist. The pathological deviation in acidity is always in the direction toward
anacidity. But actual hypersecretion may exist, although we have no accurate measure of the total gastric secretion in normal persons in the course
of a day.  It is not less than 1500 cc and may be double that quantity.
The notion that gastric content showing 0.2 per cent HCl acidity is the
Page 62
!l M
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acidity of normal gastric juice, and that 0.4-0.5 per cent HCl is "hyperacidity," should no longer be permitted to confuse the issue. The factors
definitely known to induce hypersecretion are delayed gastric evacuation
from obstruction at the pylorus or gastric stasis due to factors that do not
at the same time depress the gastric glands.
According to Hurst, there are certain individuals with a hypersthenic
gastric constitution and it is in this group that the so-called hypersecretion
and tendency to peptic ulcer occurs.
Sagal (1933) states that high gastric acidity persisting into old age
may be considered as an indicator of longevity. Only the hardier individuals reach the eighth and ninth decade and they seem to be the ones who
have high gastric acidity.
In an experimental animal with a round ulcer in the gastric pouch,
Pawlow observed a continuous and increasing secretion, the flow finally
exceeding the normal by three to four times. The secretion was sustained
over a much longer period than would normally occur with the type of food
placed in the pouch.
Treatment of Hypersecretion.—It was found in this animal with hypersecretion that alkalies produced a marked diminution of secretion. Pawlow
claims alkalies are of value for their inhibitory effects on gastric secretion.
Others, however, claim that alkalies have a tendency to promote the
flow of juice rather than depress it. Carlson remarks in regard to alkalies:
"It would seem that we have been using gastric secretagogues to control
and depress gastric secretion. Of course, if enough of the alkalies are given,
and if they remain long enough in the stomach, direct neutralization may
more than counteract the secretagogue effects." He, however, admits that
the mechanism of the salt and alkali action on the gastric gland activity has
not been satisfactorily worked out, despite its practical importance.
Alkalies may possibly have their influence through their action on the
pylorus. That they have a favorable action in hypersecretion there is no
doubt.
At any rate, humanity has learned to relieve so-called "hypersecretion"
symptoms by the use of alkalies, such as bicarbonate of soda, calcium carbonate and salts of magnesia. This same relief is frequently accomplished
either by emptying the stomach by vomiting, or by the use of the gastric
tube. This has frequently been demonstrated in pylorospasm associated with
peptic ulcer, relief at night being obtained by aspiration of the stomach
contents at bedtime.
Pawlow recommends the use of fatty foods, or fat as an emulsion, where
an excessive activity of the gastric glands is manifested. This is suggested
by experimental evidence which shows that fat causes depression of the
gastric secretion.
Pepsin.—The peptic activity of the stomach secretion usually parallels
the acid secretion, being abundant with a high acid curve and absent or in
small amounts in anacidity. The measurement of the pepsin is probably of
little clinical value. The most satisfactory method for measuring pepsin
concentration, according to Carlson, is that of Mett, the pepsin concentration being calculated from the rate of digestion of egg white coagulated in
glass tubes.
Alvarez (1932) reports high pepsin values in persons with a nervous
temperament, and in cases with so-called "intractable" duodenal ulcer.
Patients with "tractable" ulcer, that is, in those who respond to medical
treatment, have lower pepsin values in their gastric secretion.
Page 63 Hurst recently recommended the use of pepsin along with the administration of hydrochloric acid in confirmed cases of achlorhydria.
Mucus in Gastric Juice.—Mucus is secreted in varying amounts during
the flow of gastric juice and is most in evidence at the end of the flow. All
irritants, such as 5 per cent emulsion of clove oil, absolute alcohol, a 10
per cent solution of nitrate of silver, when introduced into the stomach,
produced an enormous secretion of mucus.
Pawlow has shown that the day following this irritation a normal secretion of gastric juice may occur, without leaving a trace behind of the
previous irritation. The large quantity of mucus which is poured out dilutes
the noxious substance, or forms chemical combinations with it, and drives
it away from the stomach wall. At the same time the peptic glands remain
absolutely at rest.
Large amounts of mucus are usually found present in the fasting juice
aspirated with achlorhydria. The explanation of this is not clear. Chronic
gastritis, even if we accept it as the probable cause of the achlorhydria,
would not be severe enough to warrant the production of such large amounts
of mucus as are often obtained. The patulous pylorus, which is such a common finding in achlorhydria allows free regurgitation of the irritating pancreatic and intestinal secretions into the stomach. The mucus secretion
may be a protection against these juices.
Anti-Ancemic Factor.—According to Castle (1933), Addisonian pernicious anaemia is a deficiency disease conditioned by a lack of a specific
intrinsic factor, present in normal gastric juice and absent in cases of pernicious anaemia in relapse. In the normal individual the function of this
intrinsic factor of the gastric juice is to interact with an extrinsic factor in
the food, probably vitamin B2, to produce specific hematopoietic effects.
More recently Meulengracht has described a somewhat similar intrinsic
factor which he terms "neuropoietin," which also may be absent in the
gastric juice in pernicious anaemia, leading to development of chronic
degeneration of the posterior and lateral columns of the spinal cord. In
those cases in which "neuropoietin" alone is absent, the subacute combined
degeneration of the cord occurs without the development of Addisonian
anaemia.
These intrinsic factors are probably secreted from the pyloric and also
probably from the fundic glands.
Crohn has shown that in 600 cases of achylia following gastric subtotal
resection, no cases of Addisonian anaemia developed.
The Effect of Operative Procedures on Gastric Secretion.—Portis and
Portis (1926), using the Pawlow pouch on animals which had previously
had subtotal gastrectomy, report that the secretion from the stomach and
pouch showed no free acid from the stomach itself, with a high combined
acidity. The pouch, however, still continued to secrete its former acidity.
Peptic activity was retained in both the stomach and pouch. Roentgenologic
study of the gastric motility revealed that the stomachs emptied in about
one-half the normal time. They conclude that the essential factors following subtotal gastrectomy are the neutralization of the gastric acidity by
regurgitation and more rapid emptying of the stomach.
Following gastroenterostomy there is a tendency to a lowering of the
acidity and more rapid emptying of the stomach. Food is frequently poured
out through the new opening too rapidly. As Alvarez points out, it may
be well in these patients to begin the meal with some solid food.
Elman and Rowlette (1931), experimenting with animals, found that
Page 64 B':
'tiili
)•■,
m
when all the circular pyloric fibres were cut by a longitudinal incision down
to the submucosa, a change in the acidity was noted in that there was a more
rapid drop in the acidity and usually a quicker emptying time. They used
200 cc of 0.5 per cent hydrochloric acid as a test meal. They believe that
the stomach is rendered more accessible to regurgitation and believe that
their experiments indicate the pyloric control of gastric acidity. They
quote Einhorn as having recently relieved symptoms of duodenal ulcer in
poor surgical risks by stretching the pylorus by means of a balloon inflated
in the duodenum and pulled back through the pylorus.
In conclusion, I may say that after many years of investigation and
experimental work, both by the physiologists and the clinicians, many of
the problems of gastric secretion remain unsolved, but progress is being
made. The recent discovery of the anti-anaemic factor in gastric secretion
establishes the stomach as an important secretory organ. I do not believe
that such an important organ as the stomach, with all its special characteristic functions and its complicated histological make-up, can be of so little
value to the organism as some would have us believe.
The problem of achlorhydria has not been solved, and I believe it will
only be solved in the future by concentration of efforts both from the
physiologic and clinical viewpoint. If we accept the condition as one of no
importance our initiative will be discouraged.
The control of the pylorus is another problem which no doubt will
continue to engage serious investigators of the future. The knowledge of
its mechanism is essential for the proper understanding of many of the
problems of digestion.
BIBLIOGRAPHY
Alvarez, Walter C.: "The Mechanics of the Digestive Tract," 192 8.
Alvarez, Walter C: "Nervous Indigestion," 1930.
Anderson, David Fyfe: "Gastric Acidity in Emesis and Hyperemesis Gravidarum," Journal
of Obstetrics and Gynecology, Vol. 39, No. 3, 1932.
Baird, M. McC;  Campbell, J. M. M.; Hern, J. R. B.:  "The Importance of Estimating
Chlorides   in   the   Fractional   Test   Meal   Samples,   and   Some   Experiments   with   the
Duodenal Tube," Guy's Hospital Reports, Vol. 74, 1924, p. 23.
Bloomfield, Arthur L.: "Clinical Aspects of Gastric Secretion,'" Annals of Internal Medicine, September, 1932, p. 307.
Bolton, Charles, and Goodhart, Gordon W.: "The Variations in the Acidity of the Gastric
Juice During Secretion," The Journal of Physiology," Vol. 73, 1931.
Carlson, A.  J.:  "The  Secretion  of  Gastric Juice  in Health  and  Disease,"  Physiological
Reviews, January, 1923, Vol. 3, No. 1.
Castle, W. G.: "The Etiology of Pernicious Ana:mia and Related Macrocytic Anajmia:,"
Annals of Internal Medicine, July, 1933, Vol. 7, No. 1, p. 2-
Eggleston, Elmer L.: "Pathologic Conditions Secondary to Achlorhydria," Journal of ih:
American Medical Association, October-December, 1931, Vol. 97, p. 1216.
Elman, Robert; Rowlette, A. P.: "The Role of the Pyloric Sphincter in the Behaviour of
Gastric Acidity," Archives of Surgery, 1931, Vol. 22, p. 426.
Hirsch,  Edwin  F.:   "The  Gastric  Mucosa  in  Delirium  Tremens,"  Archives  of  Internal
Medicine, 1916, Vol. 17, p. 3 54.
Hurst, Arthur F.: "The Clinical Importance of Achlorhydria," British Medical Journal,
October  13th, 1934, p. 3849.
MacLean, Hugh; Griffiths, William J.: "The Automatic Regulation of Gastric Acidity,"
Journal of Physiology, 1928, Vol. 66, p. 3 56.
Maclagan, Noel Francis: "A Statistical Analysis of 3 89 Fractional Test Meals," The Quarterly Journal of Medicine (New Series), July, 1934, Vol. 3, No. 2, p. 321.
Oliver, T. H.; Wilkinson, John F.: "Achlorhydria," Quarterly Journal of Medicine, 1933,
Vol. 26, p. 431.
Osterberg, A. E.; Vanzant, Frances R.; Alvarez, W. C.: "The Determination of Pepsin in
the Gastric Content and its Clinical Significance in Duodenal Ulcer and Pseudo-Ulcer,"
Proceedings Staff Meetings of Mayo Clinic, 1932, Vol. 7, p. 268.
Page 65 ' ■. I'
Pawlow, J. P.: Thompson, W. H.: "The Work of the Digestive Glands," 1902.
Portis, Sidney A.; Portis, Bernard: "Effects of Subtotal Gastrectomy on Gastric Secretion,"
Journ.il of the American Medical Association, March 20th, 1926, p. 836.
Sagal, Zachary; Marks, Jerome A.; Kantor, John L.: "The Clinical Significance of Gastric
Acidity," Annals of Internal Medicine, July, 1933, Vol. 7, No. 1.
Starling: "The Principles of Human Physiology," 1930.
Vanzant, Frances R.: "The Normal Range of Gastric Acidity from Youth to Old Age,"
Archives of Internal Medicine, March, 1932, Vol. 49, No. 3, p. 345.
BRITISH   COLUMBIA   ACADEMY   OF   SCIENCES
PROGRAMME
Our attention has been directed to the following programme of the
B. C. Academy of Sciences, and we have great pleasure in publishing it.—Ed.
Speakers:
Dr. M. Y. Williams
Date Subject:
Nov. 15—The Age of the Earth
Dec.   13—The Origin of Carbon Compounds.
Jan.   11—Radium and Its Uses.
Feb.   15—Enzymes, Hormones and Vitamins.
Mar. 15—The Gene—The Unit of Heredity.
Apl. 11—The Nucleus of the Atom.
Dr. W. F. Seyer
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Dr. Henderson,
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I     Dr. G. M. Shrum
This is a new departure for the Academy. Large crowds are not anticipated, as the discussions will not be of a popular nature. The pure science
aspect will be stressed.
Three speakers on each topic will open and direct the symposia, but the
whole group will participate in the discussions.
It will also be the policy of the Executive to invite any outstanding
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Time: 8:15 p.m. Place: Room 200, Science Building, University of B. C.
ABSTRACT
THE USE OF DILAUDID IN THE PAIN OF CANCER
In the J.A.M.A. for November 10th, 1934, C. Malone Stroud of Washington University reports on the use of dilaudid in 114 patients suffering
from the intractable pain of inoperable cancer. It was given to some patients
for a period of several months, and, in every case, dilaudid proved itself an
effective anodyne. It was absorbed rapidly, and was quickly effective when
administered by mouth or hypodermic. When dilaudid was given by sup-
Page 66
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r i
pository the action was more sustained.  This was found especially useful at
night, and was frequently used in conjunction with a hypnotic.
Beginning with small yet pain relieving doses (in many cases %g grain
or less was adequate), given in simple elixir, the dose was of course increased
as the pain became more severe. Cough due to lung metastases was controlled along with pain.  In concluding, Stroud states:
1. "Dilaudid is an efficient analgesic in the control of constant pain.
It is more helpful in cancer than any other opiate I have used.
2. "In order to obtain contiuous relief of constant pain, the method of
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early-morning cereal drudgery, so that
mothers can get their deserved rest. At
the same time, all members of the family,
including the school children, are assured
of a quick nourishing breakfast.
To prepare PABLUM, simply add milk
or water of any temperature, and serve
with cream, salt and sugar. If preceded by
orange or tomato juice and followed by a
glass of milk, and a capsule of Mead's
Viosterol in Halibut Liver Oil, such a
breakfast fulfills every nutritional requirement: ProteinV FatV Carbohy-
drateV Vitamins: A, B, C, D, E, GvV
Minerals: Calcium, Phosphorus, Iron,
Copper, Etc., EtcvV CaloriesV
Pablum (Mead's Cereal pre-cooked) is a palatable cereal consist* .
ing of wheatmeal, oatmeal, cornmeal, wheat embryo, alfalfa
leaf, beef bone, brewers' yeast, and salt.
Mead Johnson & Co. of Canada, Ltd., Belleville, Ont.
Please enclose professional card when requesting Bamples of Mead Johnson products to cooperate in preventing their reaching unauthorized persons 536 13th Avenue West
Fairmont 80
Exclusive
Ambulance
FAIRMONT 80
Service jB
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St.
John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell
J. H. Cr ELLIN
W. L. Bertrand
&mt?t $c Batma Uth
Estab'ished  1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
i
WM
Published Monthly at Vancouver, B. C by ROY wrigley LTD., 300 west Pender street 

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