History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1930 Vancouver Medical Association Sep 30, 1930

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  Patient Types:
| THE MAN ON HIS FEET
Irregular and uncertain times for defecation may lead to hemmor-
hoids and more often to constipation. Cathartics aggravate the condition.
Petrolagar is very helpful in managing these cases. It brings about
normal peristalsis in a natural way. It prevents the congestion of the
hemorrhoidal veins caused by straining at stool.
Petrolagar is a mechanical emulsion of liquid petrolatum (65% by
volume) and agar-agar, deliciously flavored and pleasant to take. It has
many advantages over plain mineral oil. It mixes easily with bowel
content, supplying unabsorbable moisture with less tendency to leakage.
It does not interfere with digestion.
Petrolagar restores normal peristalsis without irritation, producing
a soft-formed normal stool consistency and real comfort to bowel movement.
Fetrol
agar
Gentlemen:—Send me copy of "HA-
Petrolagar Laboratories SS^S'ffiffi.™0™0 and
of Canada Ltd. Dr	
907 Elliott St., "Windsor, Ont. Address   	
Dept. V.M.  10. 	 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 and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abov; address.
Vol. VI.
SEPTEMBER, 1930
No.  12
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. "Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. "W. L. Pedlow
Trustees
Dr. "W. B. Burnett Dr. "W. F. Coy Dr. J. M. Pearson
Auditors:   Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr.  S.  Sievenpiper 1 Chairman
Dr. J. E.  Harrison .  Secretary
Eye, Ear, Nose and Throat
Dr.  F.  W.  Brydone-Jack   :— ,-, iChairmar-
Dr.  N. E.  McDougall  -Secretary
Pediatric Section
Dr.  C.  F.  Covernton Chairman
Dr.  G.  O.  Matthews  Secretary
STANDING COMMITTEES
Library Orchestra Summer School
£     T   „   U Dr. "W. T. Ewing
Dr. D. F. Busteed Dr. J. R. Davies Dr   r   p   KmsMAN
Dr. D. M. Meekison Dr. J. H. MacDermot Dr   W   L   Graham
Dr. W. H. Hatfield Dr. F. N. Robertson Dr' j 'Christie
Dr. C. H. Bastin Dr. J. A. Smith Dr   £ £   Brqwn
Dr. C. H. Vrooman Dr   t> l. Buttars
Dr. C. E. Brown                                    Publications
Hospitals
Dr. J. M. Pearson Dr. J. "W. Arbuckle
Dinner Dfc J. H. MacDermot Dr. J. A. Gillespie
Dr  L  H   Webster Dr- D- E- H- Cleveland Dr. "W. C. Walsh
......  Dr. F. W. Lees
Dr. E. E. Day j Credentials VQN Advisory BoarJ
r.   ^   -l, i    a Dr. W. S. Turnbull Dr. Isabel Day
Rep. to B. C. Med. Assn.   Dr a t MacLachlan . Dr. H. H. Caple
Dr. H. H. Milburn Dr. P. W. Barker Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees Phone Us
Any Hour of The Night
Before you leave to call on the patient or
after you arrive, phone us for medicine or
sick-room necessities. You'll find our all-
night service a real convenience.
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412 St. Sulpice St. EDITOR'S PAGE
Even millionaires are wrong sometimes, and the statement of one
of the most prominent of their number that "History is all bunk" is
probably the most mistaken one he ever made. The reading of history
is one of the finest mental correctives and tonics we can obtain. It restores our sense of proportion, reminds us that others have had troubles
very much like our own, and encourages us by its record of their courage and endurance. It reminds us too, that victory is not always quick
nor easy that "God does not always pay on Saturday night," and that
the only way to success is to keep on fighting.
We have been reading the editorial columns of the Upper Canada
Medical Journal of 1851. It appears that the medical profession of that
day had the same trouble with irregulars and cultists that we ourselves
have had. These men, who saw in the practice of the healing-art, only a
trade which might be lucrative, sought to "creep in by stealth and
sneak into the fold," and the profession of that day was much exercised
by the readiness of the Legislature to let them in. The arguments of
the medical writers, couched in somewhat more pedantic and Johnsonian
diction than we employ today, were exactly those that we would advance
and have advanced. They showed the lack of proof of preliminary education, or of basic scientific knowledge—they saw, as we do, that Medical
Acts should be preventive, not merely permissive, that they should
insist on the responsibility of the practitioner, not enlarge his privileges.
Finally, and we think rightly, they insisted that the duty of the medical
profession was to refuse at all times any compromise on this matter,
since only thus can we justify our claim on public confidence—and
only thus can we do our duty as guardians of the public health. To
yield to opportunism, or to bargain in any way, these men saw, was to
give away our whole position, and to derelict in our duty.
This was in Ontario, where today medical laws are perhaps the
best in the Dominion—and yet the first result of the fight was defeat.
But they fought on as must we. So the reading of this old history brings
encouragement and stimulation to us at a time when perhaps w eneed
it most.
For our battle in British Columbia is by no means won. It is virtually
certain that it will be renewed at the next Session of the Legislature.
There is talk of a Commission which will consider this question of
practice, and deal with it finally. If such a Commission were composed
of a Judge, or Judges, men trained to hear and weigh evidence impartially, we should welcome it. Not that we question in any way the
honesty or sincerity of other Commissions, but this is a matter where
sentiment or political experience should have no place and only a
judicial decision be rendered. The question at stake is not our prosperity or our privileges—we cannot see, frankly, that these are in any
way endangered—it is the safety of the public. To allow untrained
and uneducated men to practise the healing art is, as has been pithily
said, to "legalize manslaughter." It is because of our superior knowledge that we charged with the responsibility of doing all in our power
to protect the sick from the malpractice of those who would make a
trade of our profession.    We cannot compromise in this matter.    We
Page 250 should urge that a basic standard of scientific education be set up, and
that only those who can measure up to this (and it should be a high
standard) shall be allowed to treat human ailments by any method.
NEWS and NOTES
Dr. J. W. Thomson has returned to the City after a four months'
tour in Europe, and has resumed practice.
Dr. E. P. McCullagh, who is well known in Vancouver, is here on
a few weeks' holiday from Cleveland. Mrs. McCullagh, better remembered, perhaps, as Miss May Gibson of the Vancouver General Hospital,
was unfortunate enough to develop acute appendicitis and had to spend
part of her holidays in St. Paul's Hospital.
Dr. Clarence A. Ryan, an old timer in Vancouver, has returned to
the City and opened an office in the Medical Dental Building. For the
past few years Dr. Ryan has been engaged in hospital and private practice in the States and has recently been doing post-graduate work. He
intends to specialize in orthopaedics and surgery in children.
A recent distinguished visitor to the Library was Dr. Thomas Macrae
of Philadelphia. Dr. Macrae had just got off the boat after a trip to
Jasper and was passing through the City.
Dr. Isobel Day was elected President of the Federation of Medical
Women of Canada at the recent meeting in Winnipeg. Dr. Day left at
the beginning of September for a months' holiday at her home in Toronto.
She expects to visit Chicago and other Clinics on her way East.
On his way to Del Monte for a holiday Dr. Appleby dropped in at
the Coffey and Humber Clinic to learn the latest developments in their
cancer therapy, and spent a very interesting morning watching numerous
patients receive the serum.
Dr. Carl M. Eaton and Mrs. Eaton are in the City on holiday.
Dr. Eaton formerly practised in Vancouver and later at Atlin and has
been for two years taking post-graduate work in New York.
Recent addition to the Medical Register of the Province include Dr.
Hubert A. W. Brown of Toronto, and Dr. Joseph Olivier of Blairmore,
Alberta. Dr. Brown has gone into the Peace River district and is starting practice at Fort St. John. Dr. Olivier intends to practice in Creston,
B. C, where he will operate a small hospital.
Another new addition to the Register is Dr. Charles E. Davies of
Edmonton.    Dr. Davies is practising in the Standard Bank Building.
Page 251 Dr. Norbert J. Ball, formerly an Interne at St. Paul's Hospital is
now associated in practice with Drs. W. A. and C. D. Moffatt.
Dr. Ivan Beresford Thompson, who was at St. Paul's Hospital for
some months, has charge of the new Hospital of the B. C. Coast Mission
at Pender Harbour, which opened on Atigust 16th.
Dr. H. A. Spohn left at the end of August for the East. He
attended the British Medical Association meeting at Winnipeg and expects to be away for about two months.
Dr. Seldon has left for Ottawa to attend the Meeting of the
Medical Council of Canada, of which he is Vice-President, on September
3rd. Dr. J. G. McKay will also attend the meeting as one of the
representatives of the Medical Council of British Columbia.
Dr. W. T. Lockhart, Hon. Treasurer of the Association, left on
August 21st for a month's holiday in Manitoba and Saskatchewan. He
attended the British Medical Association meeting at Winnipeg.
Good progress is being made in the erection of the new Nurses'
Home of St. Paul's Hospital. It is expected to be ready for occupation
in December next and will accommodate 160 nurses. The extension of
the Hospital will be commenced as soon as the Nurses' Home is completed.
Dr. Malcolm McEachern was the recipient of a handsome silver
tea and coffee service presented by the City Council in recognition of
hsi services on the recent Hospital Survey Commission. The gift was
presented after the Dinner at the Hotel Vancouver, during the recent
Hospital Convention.
A subscription fund has been started by a Vancouver daily paper
to raise money for the purpose of sending a young man away to an
American clinic for surgical treatment. It is understood that the man,
who is a patient of a local physician, has a brain tumor and that his
only chance for recovery is an operation which no one in Vancouver is
capable of performing.
This opens up a large question which has often been brought to
the attention of various members of the medical profession in this city,
and which it is not possible to discuss at length at this time.
Nevertheless we feel that while the newspaper interested is to be
commended for the charitable impulse lying behind the action which it
is taking, we are not in agreement with the attitude of the physician in
the case. We feel that the medical profession in Vancouver can justly
lay claim to talent and ability among its members in some fields at
least, which is fully equal to that to be found elsewhere, and that in
the matter of brain surgery in particular it should not be necessary to
send a patient half way across the continent to obtain proper treatment.
Page 252 The B. C. Hospitals Association held its Annual Convention in
Vancouver last month from August 18th to August 21st. Mr. J. H.
McVety, President of the Association, and his executive are to be congratulated on a most successful meeting. Representatives attended from
all parts of the Province and in addition there were delegates from many
United States hospitals, from California to Montana.
A very pleasant feature of the Convention was the Dinner at the
Hotel Vancouver on Tuesday, August 19 th, at which Mr. McVety
presided. Various representatives of the Province and City being present. The Provincial and City Medical Associations were also represented. Mayor Malkin presented Dr. M. T. McEachern, one of the
Hospital Survey Commissioners, with a silver tea and coffee service, the
gift of the City Council, in acknowledgement of Dr. McEachern's
generosity in declining to accept any fee for hsi work as Commissioner.
Dr. McEachern responded very happily.
From our point of view perhaps the most important paper of the
meeting was read by Mr. C. Gibbons, Secretary of the Health Insurance
Commission, who saw that there was no doubt that a measure of State
Health Insurance would be recommended by the Commission. Mr. Gibbon's extensive knowledge of this subject and his clear presentation,
impressed all his hearers.
B. C. MEDICAL ASSOCIATION NEWS
The Autumn Post-graduate Tour will commence with a visit to
Fernie on September 20th. Trail will be visited on September 22nd
and Revelstoke on September 24th. From Revelstoke the party will
proceed to Harrison Hot Springs Hotel on September 26th, where the
programme will be arranged by the Fraser Valley Medical Society.
Victoria will be visited on September 29th and Nanaimo on September
30th. There will be an evening meeting in Vancouver on October 1st.
The party will leave for Prince Rupert and Prince George on October
2nd, arriving at Prince Rupert on October 4th. Prince George will be
the last place to be visited and the party will leave for the East on
October 8th. The Eastern speakers are Drs. F. Scott and R. D. Rudolph.
The two local men taking part in the tour are Drs. W. S. Turnbull and
G. O. Matthews. Mr. C. J. Fletcher will accompany the speakers on the
entire trip.
METHODS AND VALUE OF GASTRIC ANALYSIS
By Dr. William Fitch Cheney
Gastric analysis gives us information of the greatest value about
how the stomach is performing its functions. It should never be omitted
in any case where the symptoms point to gastro-intestinal disease. But
this method of investigation must not be too disagreeable, or the patient
will not tolerate it; and it must not be too complicated, or the physician
will not give it the time required for carrying it out. How then shall
it be done?
1. The oldest plan is the use of the so-called Ewald test meal.
Preceding the giving of any type of meal, the patient's fasting stomach
Page 253 contents should be withdrawn. For this purpose the ordinary Rehfuss
tube is usually most satisfactory, with a glass catheter or Luer syringe.
Then the patient is given two slices of toasted bread and a cupful (about
8 ounces) of hot water. Four extractions of stomach contents are then
made through the tube, at half hour intervals after the meal is taken.
Thus the entire test requires two hours. Naturally this procedure, like
any other we use, has both advantages and disavantages. Advantages:
The meal is a physiological stimulant to gastric function. Toast is
appetizing to most people and its taste and odor reflexly excites secretion.
Furthermore, it requires chewing and this likewise stimulates gastric
secretion. Finally, it has bulk sufficient to test the motor power of the
gastric walls in triturating it. Disadvantages: Usually the stomach
tube has to be withdrawn to permit mastication of the meal and its
proper swallowing. Protest is always excited when the tube has to be
re-introduced. The test lasts for two hours and many patients find this
an ordeal. The material obtained for analysis is thick, frequently blocks
the small Rehfuss tube and always has to be filtered before it can be
analyzed. Finally, it has been charged that the results obtained by the
Ewald meal are not reliable because of the neutralization of the free
HCl by the cereal content.
2. The Alcoholic Test Meal. By this method, after the fasting contents are withdrawn, there are poured into the stomach through
the barrel of the syringe and the Rehfuss tube 50 cc. of 7 per cent,
alcohol in distilled water. Four extractions are subsequently made at
fifteen minute intervals for analysis. This length of time is sufficient
because the stomach with this type of meal is empty in one hour.
Advantages: There is no withdrawal of the tube after fasting contents
are obtained; the test requires only one hour instead of two; clear contents are obtained and no filtration is required; the analysis is at least
as accurate as that obtained by the Ewald meal, as shown by repeated
comparisons. Disadvantages: The meal is an abnormal one, not comparable to ordinary food; it does not require mastication; it has no flavour
or savor to stimulate secretion; and it has no bulk sufficient to test
motility.
In comparing the Ewald and the alcoholic test meals, it is well
to remember that the former is old, well-tried, still generally employed,
as reliable as regards gastric secretion and more useful as an indicator
of gastric motility; but the latter is to be preferred for the ease with
which it can be performed and for the decreased discomfort it entails.
3. The Histamine Meal: Histamine is a powerful stimulant to
gastric secretion and has for some time past been used to supplement the
Ewald meal when the latter showed achlorhydria. But recently it has
been suggested for use by itself, without any other test meal preceding.
The plan is to secure the fasting stomach contents first, as usual; then
to inject hypodermically histamine hydrochloride, the dose depending on
the weight of the patient. Ordinarily it is safe to give one-tenth of a
milligram for each ten kilograms (22 lbs.) of body weight. Four extractions of the stomach contents are then made at ten minute intervals.
Advantages: By this method what is obtained is pure gastric juice,
undiluted by water and uncontaminated by food. The quantities withdrawn are entirely secretion and the quality indicates truly what the
stomach can do.    The acid values obtained by this method are all much
Page 254
;H«S8fc!S4858i»«Sg higher than by either the Ewald or the alcoholic meal and this must be
remembered in interpreting their significance. Disadvantages: Many
patients object to the use of the hypodermic needle; there is frequently a
little stinging and slight local reaction at the site of injection; flushing
of the face, pounding of the heart, fullness in the head with more or
less headache occur in many patients for about ten minutes after the
injection is given; vomiting and diarrhoea occasionally follow the use
of histamine; but it must be admitted that no severe shock or fatal outcome can be attributed to the use of histamine. Finally, no proof is
obtained by this method of the stomach's ability to respond to ordinary
normal food stimulus. Therefore under the circumstances it does not
seem wise to use histamine as a routine at present, until further experience with it has been acquired in hospital and clinic patients.
The object of all these forms of test meals is to obtain specimens of
stomach contents for exarrjination and analysis. As regards the fasting
contents, they are to be subjected to gross inspection, microscopic inspection and chemical analysis. By gross inspection we determine the
quantity, which normally varies from 25 to 50 cc; the consistence,
which ought to be fluid and slightly viscid; the color and general appearance which is grayish or opalescent, with flakes; the presence or absence
of food remnants, which ought never to be found in normal fasting
contents; the amount of mucus, which makes a glairy, sticky fluid, pouring with difficulty from one vessel to another; the presence of pus or
blood bile, which impart their characteristic colour. Microscopic examination of the sediment from fasting contents can be made direct from
the smear from filter paper or sterile gauze used in filtration, or after
staining with methylene blue. It will detect muscle or vegetable fibres
not previously evident to the naked eye; red blood cells, pus cells and
micro-organisms; Oppler-Boas bacilli that signify merely gastric stasis
from any cause or sarcinae that have the same meaning.
Chemical analysis is not done merely on fasting contents but on all
the samples removed after a test meal, after these have been filtered and
made clear. All the utensils and chemical reagents employed for these
tests are easily obtained and used. (1) To determine the total acidity,
add a few drops of a one per cent, solution of phenophthalein in alcohol
as an indicator to 0 cc of the filtrate; then run in from a burette a
decinormal solution of sodium hydrate until a magenta colour is produced;
the number of cc of the alkaline solution required to neutralize the
acidity of the filtrate as indicated by the phenophthalein, multiplied by
ten, represents the total acidity. (2) To determine the free HCl. add to
10 cc of the filtrate a few drops of a half of one per cent, solution of
dimethyl-amido-azobenzol; this gives a bright red colour at once if
free HCl is present; then again run in from a burette the decinormal
sodium hydrate solution until the color changes to a canary yellow; the
number of cc required to effect this change, multiplied by ten, gives the
amount of free HCl present. (3 ) To determine the presence of blood, dissolve a small piece of benzidin in one or two drams of glacial acetic acid;
then add an equal amount of hydrogen peroxide; a bit of the filtrate
placed in this mixture will turn it bright blue or dark blue colour if
blood is present. All of these tests can be quickly performed, without
loss of time.
Page Finally, as regards the value of gastric analysis in diagnosis, it is
at least as valuable as that of the X-ray in all diseases of the stomach
and frequently is even more reliable. In chronic gastritis, the test meal
and analysis of samples obtained practically make the diagnosis, by the
abundance of mucus found and the diminution or absence of free HCl
in the secretion. In ulcer of stomach or duodenum, approximately 80
per cent, of all cases show hypersecretion and hyperacidity. In cancer of
the stomach, it is not only the decrease or lack of acid that is characteristic, but the presence of food refuse, pus and blood that makes the
difference between a clean stomach and one diseased. Extra-gastric
disease likewise affects the stomach's functions; such as chronic cholecystitis, which in many cases is associated with achlorhydria or hypo-
secretion; and appendicitis which frequently gives rise to hypersecretion
reflexly. Pernicious anaemia rests as much for diagnosis upon complete
achlorhydria as it does on the blood picture. Occasionally chronic diarrhoeas depend upon faulty gastric secretion, also chronic skin diseases
such as eczema and urticaria paroxysmal asthma and recurring gingivitis. The list of diseases where gastric analysis aids materially in diagnosis is already large and is constantly growing larger; and it seems reasonable to predict that some day it will form a part of the routine
examination of every patient as does now urinalysis, the blood count
and the Wassermann reaction.
Delivered   before  the  Vancouver   Medical   Association   Summer   School,
June, 1930.
THE KIDNEY IN PREGNANCY
By Dr. J. E. Harrison
This paper on the kidney in pregnancy is an attempt to iron out
a few of the wrinkles in our understanding of the behaviour of the
kidney in some of its reactions to the pregnant state. While it will not
embrace a discussion of the toxaemias of pregnancy, as such, reference
must needs be made to "pregnancy toxaemia" in general, insofar as it
affects the kidney. In this connection we must remember, as a fundamental point, that the kidneys act as an eliminatory terminal only, and
any renal disturbance has to be considered as a local manifestation of a
general derangement and not as an independent idiopathic disease. Pyelitis and pyelonephritis also will not be considered in this paper. Many
attempts have been made to classify the nephropathies of pregnancy,
with resulting great confusion. Stander believes that as a rule it is
impossible to differentiate between the various types of nephritis during
pregnancy, the added strain of pregnancy on the kidneys tending to
obscure the diagnosis of any one particular form. I must say that after
reading the 101 different interpretations and classifications of 101 different writers, I heartily agree with him.
In general, however, renal disorders associated with pregnancy seem
to fall into two main groups; (1) those in which the renal disease is
entirely secondary to the toxaemia; and (2) those in which the renal
disease is the primary fault, being simply aggravated by the strain of
toxaemia of pregnancy. Under the first group we have conditions which
we have heard described variously as "albuminuria of pregnancy," "re-
Read before the Osier Society of Vancouver, February,  1939.
Page 256
«i8H'JW4rSIUtWBUl«SWiU.-. current albuminuria," pre-eclamptic toxaemia, recurrent toxaemia, hypertensive toxaemia, etc. Under the second group come acute glomerulonephritis, chronic glomerulonephritis, glomerulonephrosis, acute nephrosis (or just plain nephrosis), acute nephritis, chronic focal nephritis,
essential or benign hypertension and malignant hypertension.
Let us begin by considering this first group. There is a mild type
of toxaemia, manifesting itself usually in the eighth or ninth month of
pregnancy, and consisting of a slight elevation of blood pressure, a slight
amount of albumin in the urine and moderate swelling of the ankles.
As soon as the patient has been delivered, the symptoms disappear completely, and in a subsequent pregnancy the condition may recur or be
absent. Kellogg speaks of this as "recurrent toxaemia of pregnancy,"
and states that such a recurrence should be considered as a chronic
entity, distinct from the common kidney disease complicating pregnancy.
Von Geldern studied the subsequent history of 27 women with
toxaemia of pregnancy and found that 13 of them had one or more
normal pregnancies following the toxaemia, while 14 had recurrence. He
states that in cases of "recurrent" toxaemia, without permanent damage
to the kidney, the prognosis is difficult. Stander and Peckham (1926)
made a study of the toxaemias in repeated pregnancy in the same individual and came to the conclusion that there is a group which they call
"low reserve kidney" in which it is impossible to demonstrate any
signs, symptoms or laboratory findings suggesting nephritis. Stander
believes that many of the "recurrent toxaemias" and the simple albunin-
uria of pregnancy, as well as certain of the so-called "nephroses" of pregnancy, belong in this category. Albuminuria accompanies most of the
toxaemias of the latter half of pregnancy and therefore it appears both
illogical and confusing to attempt to designate any one type of toxaemia
as albuminuric. The term albuminuria should be reserved to denote a
laboratory finding only. It is analogous to speaking of a "hypertensive"
type of toxaemia, since most women suffering from the various late
toxaemias have an elevated blood pressure. The objection to the term
"recurrent toxaemia" is that it does not tell us whether the process is
benign or will become progressively worse with succeeding pregnancies.
Either condition may be recurrent, but it is a matter of great importance
to know whether the patient is suffering from a mild and benign
toxaemia or from a kidney condition, which, if treated inadequately,
may prove fatal in the near future. Furthermore even "eclampsia" may
be recurrent so that the use of this term may be confusing. Nephrosis
as seen in non-pregnant individuals, is a fairly definite entity and usually
signifies a degenerative change in the kidney tubules as opposed to inflammatory changes. Mussey and Keith divide the acute nephritis occurring during pregnancy into acute glomerulonephritis and acute nephrosis
and state that while the former is associated with hypertension, oedema,
oliguria, and albuminuria, the latter differs from it in the absence of
hypertension and changes in the fundi and usually in the absence of
red blood cells in the urine and in the presence of oedema. Stander has
made a clinical and laboratory study, involving fairly complete urine
and blood analyses, as well as kidney function and urea-excretion tests,
of all toxaemic patients in the Woman's Clinic of Johns Hopkins Hospital
over a period of six years, and believes it impossible to differentiate be-
Page 257 ng   during
tween   acute  glomerulonephritis   and  acute  nephrosis   occurri
pregnancy.
The term "low reserve kidney" is used to designate the mild form
of toxaemia which occurs usually during the last two months of pregnancy.    It presents the following characteristics:
1. An elevated blood pressure, which at the end of the puerperium
has dropped to a normal level. In most cases this elevation is not very
marked, rarely exceeding 159 systolic and 90 diastolic.
2. The amount of albumin in the urine is never very great, varying
before delivery between a fraction of a grain and two grains per litre,
the lower figure being the most usually observed. The albumin disappears during the puerperium and at the end of three weeks is entirely
absent or at the most .1 grains per litre.
3. The outstanding characteristic is the fact that in subsequent
pregnancies the patient's condition does not become aggravated and she
is as well as, or better than she was in the preceding pregnancy.
4. The blood chemistry as well as the urinary analysis reveals noth
ing abnormal.
Apparently the number of prgenancies through which the individual may go plays no part in the development of this entity, for it
is observed in primipara as well as in all degrees of multiparity. Moreover this type of kidney does not seem to be permanently injured by
pregnancy.
It is well known that in a healthy person, under normal conditions,
all of the glomeruli are not functioning at capacity at any one time, and
it has been estimated that there is usually a margin of safety which approaches 50%. Stander believes that in certain individuals such kidney
reserve may be greatly decreased, due either to congenital causes, or to
factors which may have lessened the number of functioning glomeruli,
without producing a chronic nephritis. We know that the strain of
pregnancy always aggravates a chronic nephritis, so that the kidneys are
less able to stand the strain of subsequent pregnancies. In this type of
kidney, however, that is not the case. The kidney reserve simply seems to
be too low to meet the extra demands of pregnancy as is manifested by
the passage of a certain amount of albumin through glomerular epithelium, and by a moderate elevation of blood pressure, and these manifestations usually disappear completely within two to three weeks after
delivery. Such kidneys appear to be quite capable of functioning adequately while the woman is not pregnant, and during pregnancy until
about the eighth month. A certain number of these cases which have
shown signs and symptoms of low reserve kidney, may go on and have
subsequently normal pregnancies, which would tend to show that the
occurrence of a mild toxaemia in a given pregnancy is not necessarily
followed by trouble in the next one and would accordingly indicate that
the kidneys had not been permanently damaged. Stander has found the
incidence of low reserve kidney to be about 35% of all pregnancy
toxaemias and about 5 % of all full term pregnancies. Doubtless jnany
of our so-called pre-eclamptic toxaemias and even some of our so-called
nephritic toxaemia cases would be more happily grouped under this
heading.
Page 258
m&rAVff wMaasai s From a study of past history, blood pressure, and urine-albumin,
presence or absence of oedema, urine and blood chemistry, eye grounds,
symptomatology and duration of pregnancy, it should usually be possible
to make a correct differential diagnosis between this type of kidney,
chronic nephritis, complicating pregnancy, and pre-eclampsia.
In contradistinction to the views of Stander oh this subject of
albuminuria, recurrent or otherwise in pregnancy, are the views of
Gibberd of Guy's Hospital in a very recent article. He believes that in
a certain number of cases, pregnancy toxaemia of this same mild type
gives rise to chronic nephritis, and has a convincing argument.
Recently several observers have shown that chronic nephritis sometime does follow pregnancy toxaemia. Caldwell and Lyle found the
incidence to be 8% after eclampsia. Gibson found definite evidence
of chronic nephritis in five out of fourteen patients who had had
eclampsia some years previously, and of twelve patients, who had suffered
from "pre-eclamptic toxaemia," chronic nephritis was found subsequently
in two. Koblanck found that 6.5% of patients had chronic nephritis
as a result of pregnancy toxaemia. Harris found that 60% of patients
who had suffered from "pre-eclamptic toxaemia" showed definite signs
of chronic nephritis one year afterwards. In none of these cases was
there any history of renal disease before the pregnancy. James Young
has recently given the incidence of chronic nephritis as 3% following
eclampsia, and 8% following albuminuria.
In a series which Gibberd published, care was taken to exclude all
cases in which there was any suspicion of pre-existing renal disease. In
the series of 37 such patients who had albuminuria with their pregnancy,
14% were found to have undoubted signs of chronic nephritis when
examined at long periods after delivery. We must admit, therefore the
possibility of chronic nephritis as a result of pregnancy toxaemia, but it
does not necessary follow, because a patient may be found to have a
chronic nephritis after a pregnancy with albuminuria, that she was
suffering from "nephritic" as opposed to "pregnancy toxaemia" during
her pregnancy.    She may have been suffering from either, or both.
The question of the frequency with which albuminuria recurs with
subsequent pregnancies is also an important one. Those cases suffering
from a definite chronic nephritis, of course, show a recurrence rate of
100%. Of the others, a summary of the findings of several authors,
show a recurrence rate of about 50%. These are patients who suffer
from pregnancy toxaemia and are apparently free from renal disease
between pregnancies.
In this connection we have four distinct clinical types.
1. Patients with chronic nephritis preceding the pregnancy. These
patients, of course, continue with signs of renal deficiency after pregnancy.    They form the "nephritic" group.
2. Patients presumably healthy before pregnancy who develop albuminuria during pregnancy, but in whom all signs and symptoms of
renal  disease  disappear  after  delivery,  and   do  not  recur   with   a  subsequent pregnancy.    In this type we know of course that no permanent .
renal damage has been done.
Page 259 3. Patients presumably healthy before pregnancy, who develop albuminuria during pregnancy, and in whom all signs and symptoms of
renal disease disappear after delivery, but. recur regularly with subsequent pregnancies.
4. Patients presumably healthy before pregnancy who develop
albuminuria during pregnancy, but in whom all the signs and symptoms of renal disease persist permanently after delivery. These are
patients who as a result of their first pregnancy toxaemia develop
chronic nephritis, and from then on fall under type 1 or the nephritic
group.
It is the third group which requires most explanation, since, although they are apparently healthy between pregnancies, yet show recurrence of albuminuria with every succeeding pregnancy. Something
more than chance must be operating in favour of recurrence, and there
must be some difference between these cases and the cases in which
subsequent pregnancies are normal. Gibberd explains these cases in this
way:
Both types are previously healthy women. They both develop albuminuria due to a pregnancy toxaemia. In the one, the secondary
renal disorder recovers completely, leaving the patient free to have a
perfectly normal pregnancy next time. In the other the renal damage
does not clear up completely, but persists in an amount insufficient to
cause symptoms until the onset of the next pregnancy. In other words,
this predisposition to albuminuria is a low grade renal insufficiency, or
an "occult nephritis" demonstrable only by the most delicate renal function test we possess and that test is pregnancy.
In support of this view Gibberd publishes a series of 47 patients,
all of whom were presumably perfectly healthy before their first attack
of alburninuria. Of these 47, signs and symptoms of chronic nephritis
persisted for a year or longer after lobour in 6 cases, that is, 13% developed chronic nephritis. Amongst these 6 cases, the average interval
from the time the albuminuria was first noted to the termination of
the pregnancy was nine weeks. Of the remaining 41 patients, none
showed any signs or symptoms of renal disease in the intervals between
successive pregnancies. They are divided into two classes; (1) In 27
patients, in whom the first albuminuric pregnancy was terminated either
spontaneously or by induction within three weeks of the time albuminuria was first noted, albuminuria recurred with the next pregnancy in
11—giving a recurrence rate of 40% for this class. (2) In 14 patients
in which the first albuminuric pregnancy was terminated either spontaneously or by induction at some time later than three weeks after albumin was first noted, albuminuria recurred with the next pregnancy
in 10 cases, giving a recurrence rate for this class of 70%.
In this series it is seen that the duration of the albuminuria with
the first abnormal pregnancy was strikingly long in those patients who
subsequently developed chronic nephritis, and the deduction is that a
prolonged toxaemia is more likely to cause permanent damage in a
previously healthy kidney than is one that lasts only for a short time.
Likewise the aetiology of the "predisposition" to recurrent albuminuria
is similar to that of frank chronic nephritis in these cases.
Page 260 We can thus regard all first attacks of albuminuria in previously
healthy patients as due to a primary toxaemia, any renal insufficiency
being purely secondary. Of ten such patients, one will suffer such marked kidney damage that she will continue to show signs and symptoms
of chronic nephritis as long as she liVes. Of the remaining nine, all of
whom are apparently healthy in the intervals between pregnancies, only
four have really recovered their kidney function completely. These four
subsequently have normal pregnancies. The • other five show a recurrence of the albuminuria fairly consistently with all subsequent pregnancies, because although their kidneys are not sufficiently damaged as
the result of their first toxaemia to show signs in the ordinary way,
yet when put to the test of pregnancy they show signs of insufficiency.
Thus we see that these patients with recurrent albuminuria are really
suffering from both "toxaemic" and "nephritic" at the same time. The
nephritic element is supplied each time by the occult nephritis which
has resulted from the first toxaemic pregnancy and the toxaemic element
is supplied every time by the strain of pregnancy.
The value of this view of the aetiology of albuminuria is that it
gives us a working basis to try to improve our results. If recurrent
albuminuria is really caused by an "occult nephritis" due to the first
toxaemic pregnancy plus the toxaemia due to the present pregnancy, it
is by paying more attention to the first toxaemia, that we may hope to
prevent occult nephritis and recurrent toxaemia.
Rest in bed and a low protein diet, plus increasing elimination will
usually prove ample treatment for these mild types of toxaemia occurring during the latter part of pregnancy. Occasionally oedema of the
ankles will disappear more rapidly after the restriction of salt. If, however, the condition becomes worse we must assume that the incidence of
chronic nephritis and of recurrent albuminuria can be favourably influenced by earlier induction of labour in the first attack of toxaemia.
Pre-eclamptic toxaemia and eclampsia also come under the heading
of pregnancy toxaemias in which the renal disturbance or damage is
purely a secondary condition. As pre-eclamptic patients usually show
the same picture as eclampsia, excepting that convulsions are absent,
and as pre-eclampsia is simply a stage in the development of eclampsia,
we will confine our attention to kidney changes in eclampsia alone for
sake of brevity. In passing, however, let me remind you that in this
stricted sense pre-eclampsia is relatively rare, not exceeding 5% of
all the toxaemias of the latter half of gestation, and according to Stander,
occurring about 14 times in every 1,000 deliveries.
In 1843, Lever demonstrated that the urine of eclamptic patients
contained albumin, and this led to the theory that kidney lesions were
always associated with eclampsia. Later Shroeder, Ingerslev and others
reported cases of eclampsia without albumin in the urine, so that the
uraemic origin of the eclamptic convulsion had to be abadoned. Autopsy
will usually reveal the presence of renal changes, but the lesions are
generally those of degeneration of the epithelium of the convoluted
tubules, according to Williams. Prutz observed kidney changes in
over 95% in a series of eclamptics who came to autopsy, but is of the
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Medical-Dental Building Vancouver opinion that the kidney lesions play a secondary part in the production
of eclampsia as they are for the most part too slight to be of great
significance. Fahr has given an excellent resume of the literature covering the kidney changes in eclampsia. In his own cases he observed renal
findings suggesting a tubulo and glomerulo-nephritis, in other words,
primary degenerative changes in the tubular epithelium and glomeruli,
as well as degenerative changes in the arterioles. He summarizes the
pathology of the kidney in eclampsia as follows: (1) Swelling of the
glomerular loops; (2) albuminous degeneration of the epithelium;
(3) degenerative changes in arterioles of inflammatory etiology; (4)
thrombotic processes in the vessels ,especially the glomerular capillaries.
(5) hemoglobin cylinders. He further differentiates between the primary inflammatory processes, such as glomerulo-nephritis in which there
is a primary inflammation of .the glomerular capillaries, and the kidney
of eclampsia—as he does not regard the latter as of an inflammatory
nature. Although most cases of eclampsia present renal changes at
autopsy, it does not seem that the kidney lesions are characteristic of
the disease, and are probably more the result than the cause of eclampsia.
Furthermore, in patients who recover, the prompt return of the urine
to normal in the majority of cases indicates that the renal changes
must be relatively slight.
Let us next consider the second of the two main groups into which
renal disorders associated with pregnancy seem to fall, namely the one
in which the renal disease is the primary fault, being simply aggravated .
by the strain of pregnancy.    Here we come upon still further confusion
in terminology, so it is probably advisable to define some of these terms.
In glomerulonephritis the lesion is primarily limited to the glomeruli, resulting in hypertension, oedema, albuminuria, oliguria, hematuria
and sometimes visual disturbances. The acute form is associated with
a sudden onset, usually with normal renal function except for decreased
excretion of salts and water, and very slight, if any, nitrogenous retention in the blood. The chronic type of glomerulonephritis differs from
the acute in that the specific gravity of the urine is low and there may
be evidence of nitrogenous retention with impaired kidney function.
Glomerulonephrosis is a term suggested by Fahr to denote degenerative lesions in the glomeruli.
Mueller used the word nephrosis to designate degenerative changes
in the kidney in contradistinction to inflammatory processes, and it now
generally signifies a primary degenerative change as opposed to arteriosclerosis. Many authors regard nephrosis as a degenerative change limited
to the tubules of the kidney. The term has also been used to denote
oedema and perhaps albuminuria without hypertension or impaired
renal function. High lipoid and low protein content ,of the blood
serum, together with normal fundi, are supposed to be associated with
nephrosis.
Acute nephritis is a vague term and does not classify the lesion,
while focal nephritis, according to Volhard, denotes slight changes in
the kidney of an inflammatory nature with albuminuria, hematuria and
casts, but without impairment of renal function, or oedema or hypertension.
Page 262 Essential hypertension is of unknown aetiology and may exist for
years without renal impairment. In the so-called malignant type of
hypertension the kidneys have become involved and a secondary nephritis
is superimposed on the original benign hypertension. Wagener and
Keith use the term malignant hypertension to denote vascular and
ratinal changes without impaired renal function.
Chronic nephritis is also subdivided into parenchymatous and inter-
stital nephritis, the former presenting three types, the large red kidney,
the large white kidney, and the secondarily contracted kidney. This
parenchymatous type is accompanied by general anasarca, headache, visual
disturbances and albuminuria. Chronic interstitial nephritis is also
known as primary contracted kidney and is usually associated with
arteriosclerosis and cardiac hypertrophy, and is characterized by polyuria,
with urine of low specific gravity, and by albuminuria.
I am sure that from a consideration of these conceptions of kidney
disease we should most likely develop some signs of kidney trouble ourselves (such as hypertension and headache, not to mention polyuria) if
we were to attempt to classify a case of renal disease in pregnancy according to these standards. The added strain of pregnancy on the kidneys
tends to obscure the diagnosis of any one particular form of nephritis, so
that at present we will content ourselves with the general diagnosis of
nephritis complicating pregnancy. The exceptions to this are, of course,
where study before onset of pregnancy has made it possible to distinguish the type, or where we have a frank acute nephritis of one sort or
another coming on during pregnancy as a sequel to an acute infection.
This type will not be discussed here.
Nephritis toxaemia, or the occurrence of pregnancy in a woman
already suffering from chronic nephritis, constitutes about 25% of all
gestation toxaemias and about 2% of all pregnancies according to
Stander. Cruickshank investigated a series of 23,630 cases admitted to
the Glasgow Royal Maternity and Woman's Hospital during a period of
ten years and found that the average incidence of nephritis was 2.84%.
The outstanding characteristics of nephritis as a complication of
gestation are as follows:
1. The last pregnancy shows more renal involvement than the one
preceding it. Usually this is shown by the fact that a rising blood
pressure and the presence of albumin in the urine are noted far earlier
than was the case in the previous pregnancy.
2. In some cases nitrogenous retention in the blood becomes quite
appreciable as is shown by a rise in the non-protein nitrogen as well as
in the urea nitrogen.
3. Oedema is quite marked in a large percentage of cases and
sometimes persists throughout the puerperium.
4. At the end of the puerperium following the last pregnancy,
the blood pressure, especially the diastolic, has not returned to normal
levels, and there is usually some albumin in the urine.
The cases in this class can probably be divided into two sub-groups,
namely, those who had developed a chronic nephritis prior to the first
Page 263
,.?..r\Tr, "   ' J ■ "t^t ^
I
pregnancy or between pregnancies from such causes as scarlet fever,
tonsillitis, infectious diseases, myocarditis or any of the conditions which
may lead to chronic nephritis, and those in which repeated pregnancies
may have played a role in the development of the nephritis, as we have
already noted. The past history of the patient will prove of value in
determining such relations.
It is highly important for the obstetrician to determine whether or
not the toxaemia falls into this group (that is, the nephritic type of
toxaemia) for his advice to the patient and the treatment of the pregnancy will be governed accordingly. When there are definite signs of
chronic nephritis, it is unwise to allow the occurrence of further pregnancies, for each subsequent pregnancy leads to an earlier break in the
kidneys and to more permanent damage to the renal tissue.
Stander, Duncan and Sisson observed in nephritis only a slightly
elevated uric acid, but a definite increase in the blood urea nitrogen
when expressed as a ratio of the non-protein nitrogen, as well as when
expressed as a ratio of the urea nitrogen percentage in the urine. The
latter ratio   B.U.N,   is approximately 16 in normal pregnancy, while it
u.n7%
rises to about 24 in nephritic toxaemia. These investigators found that
the inorganic elements were within normal limits in this type of pregnancy toxaemia. De Wesselow, in a clinical study of the toxaemias of
pregnancy, noted that a definitely raised urea content of the blood, i.e.
about 40 mgm. per 100 cc is proof that the kidney is severely damaged,
and affords an indication for the interruption of pregnancy. When there
is no increase in blood urea, this author suggests that a urea concentration test be carried out and when the result is below 2%, that pregnancy should again be interrupted. Dossena states that a differential
diagnosis between nephritis and prgenancy toxaemia as discussed in the
early part of this paper, can be made on the basis that the urea in the
blood is always increased in nephritis and never in pregnancy toxaemia.
In pregnancy toxaemia there is an increase in chlorides and consequently
water retention and oedema. Bunker and Mundell found a varying
degree of nitrogenous retention in all their cases of nephritic toxaemia.
In general, it may be said that in severe nephritis complicating
pregnancy, an elevated non-protein nitrogen urea and often a slight
increase in uric acid will be found in the blood stream, but the absence
of these abnormal findings does not exclude nephritis. The sodium
chloride content of the blood, a renal function test, the blood pressure,
the amount of albumin in the urine, the past history, and the duration
of pregnancy may all contribute in establishing the diagnosis. Usually
the finding of albuminuria in the earlier months of pregnancy means
that the patient is suffering from a chronic nephritis.
The ophthalmoscopic study of the eye grounds often aids in
differentiating nephritic toxaemia from other types. Albuminuric
retinitis is sometimes seen in nephritis complicating pregnancy, while
according to Miller it is never present in pre-eclampsia or eclampsia.
Other writers, on the contrary, believe that the theory of retinitis
gravidarum occurring only with chronic nephritis is incorrect. Fink
states that this condition is often associated with the kidney of preg-
Page 264 ■J'51.   .'  ,/—■
nancy and eclampsia.    Apparently, then, we cannot depend too much
on eye ground findings
Many authors regard capillary microscopy of value in differentiating true nephritis from other conditions. Nevermann, Hinselmann,
Heynemann and other men describe varying degrees of capillary stasis
with changes in size of the arterioles. Spasm of the walls of these small
vessels has been noted and is supposed to be due to a toxic stimulation
of the nervous supply or of the muscle of the vessel walls.
As we have noted before, the modern conception of nephritis is
that it is a systemic disease rather than one strictly limited to the
kidneys.
We have no accurate method of determining the amount of damage to the kidneys done by a pregnancy. Stander gives the immediate
maternal mortality in nephritis complicating pregnancy in his clinic
during four years as 3.3%, but believes that many women succumb to
chronic nephritis who had been a year or two previously discharged
from hospital at the end of a fairly normal puerperium.
Hussey regards nephritis as a very serious complication of pregnancy and is convinced that gestation itself exerts an injurious influence on an already existing nephritis.
Jaschke, in discussing the prognosis of kidney disease in association with cardiac disease, considers the condition very serious, and contends that labour should be induced as early as possible. It is only by
reducing the work of the kidneys and heart that the patient can be
given any chance for the future.
Very occasionally one may have to deal with cortical necrosis of
the kidney, or with a nephrectomy preceding pregnancy.
Manley and Kleinen reviewed the literature on cortical necrosis
and found only 20 cases. Most of these were in the latter half of
pregnancy, and usually associated with premature labour, and with
still-born babies. Necrosis of the cortex is considered to be intimately
connected with thrombosis of the interlobular renal vessels. Jardin and
Kennedy studied twelve cases in which suppression of urine occurred as
a complication of pregnancy. They found symmetrical necrosis of the
renal cortex in six cases. In three of them there was evidence of preexisting chronic inflammation, while in the other three the condition
was cortical necrosis. This is so rare a condition, however, that it need
hardly be considered under the nephritic complications of pregnancy.
Matthews analyzed a large series of cases of nephrectomy and pregnancy and came to the same conclusions as Schmidt, who states that a
woman with one healthy kidney does not run much greater risk, nor
does the foetus, than the woman who has two. Boreluis states that normal pregnancy can follow nephrectomy without any difficulty, provided
the remaining kidney is normal. Buchmann reports three cases of unilateral impairment of the kidney during pregnancy and suggests that
pressure from the gravid uterus affecting the right kidney more than
the left may play a part in the production of this impairment. He
considers that the diminished renal function is due to primary venous
Page 265 stasis, just as one sees in advanced heart disease, as well as to direct pressure of the uterus upon the kidneys.
From a consideration of the prognosis in nephritis complicating
pregnancy it is clear that one assumes a grave responsibility by allowing
gestation to continue in the face of an underlying nephritis.
If the nephritic condition is severe, immediate termination of pregnancy becomes imperative. In the milder types of chronic nephritis,
rest in bed and dietetic treatment occasionally allow us to carry the
patient to term without any serious harm to the mother, but such an
outcome is the exception rather than the rule. Furthermore, how can
we be sure that the underlying renal condition has not been aggravated
by the strain of the latter months of pregnancy, and the patient's life
has thereby been shortened, although this increased damage to the
kidneys may not be apparent at the time of delivery. Termination of
pregnancy, should, I think we may agree, be carried out in all cases complicated by an underlying chronic nephritis, unless marked and rapid
improvement follows the conservative treatment of rest in bed with
restricted low protein (and in some instances when there is marked
oedema, salt-free)  diet and plenty of ffuid.
Smith believes that a diet of lower protein content than is usually
employed in the treatment of chronic nephritis may be used in cases
with nitrogenous retention. He bases the amount of protein allowed in
the diet on the amount of non-protein nitrogen which the patient is
able to excrete in 24 hours. The amount of protein nitrogen in the
diet should be less than the total amount of non-protein nitrogen in
the urine in 24 hours. Peters on the other hand, argues that in patients
with albuminuria, the loss of protein must be indirectly compensated
for by increasing the protein in the diet, otherwise a drain on tissue
protein will follow. This is contrary to the usually accepted views that
high-protein diet usually leads to kidney damage.
In closing let me remind you again, that a consideration of the
patient's past history, both medical and obstetrical, the duration of the
present pregnancy, and the subjective and objective findings enables
us to form an opinion as to the severity of the nephritic condition, and
equips us with a basis for rational and successful treatment.
GASTRO-ENTEROSTOMY
British Medical Association Report
For many years medicine has seen a conflict raging between the
surgeon and the internist over the treatment of ulcers of the stomach
and duodenum. It is by no means decided, and more than ever of
late, the internist has been insisting that these conditions should be given
a thorough trial of medical treatment before surgery is called in, claiming
the while that a great many cases can be cured, and cured permanently,
without resorting to the knife.
So, to those of us who are waiting to be shewn, the recent report
of the British Medical Association on "The After-History of Gastro-
Enterostomy is of great interest. This is a most comprehensive and carefully   compiled   report,   prepared   by   Arthur   P.   Luff,   C.B.E.,   M.D.,
Page 266 "•***8£5Rr
F.R.C.P., who is apparently an internist, as he is "Physician to St. Mary's
Hospital." The full report is to be found in the December numbers of
the B. M. J. for 1929, but it is well worth while to make a brief review
of it here.
He deals with the matter under six heads—duodenal ulcer, pyloric
ulcer, perforated duodenal and pyloric ulcers, gastric ulcers, hour-glass
constriction, and perforated gastric ulcers. A very large number of cases
are studied, and the investigation of these has been remarkably thorough. The following-up of the cases, too, has been very good. Most of
them are followed over periods of four and five years—so that the results
of treatment may be regarded as valid where given.
Many of the conclusions arrived at, as to age incidence, sex, and
so on, are in complete accord with the usually-accepted teaching on
the subject—and we will not enlarge on them. It is of interest, however, to note that gastro-jejunal ulcer following gastro-enterostomy is
almost unknown in women. This unfortunate sequel, it may also be noted,
is very much more common after duodenal ulcers than pyloric, in the
ratio of three to one. An even smaller proportion occurred following
gastric ulcers.   This is a curious finding, and no explanation is attempted.
Sex Incidence
Duodenal ulcers, we find, are five times more common in men than
women, pyloric three, and gastric two—but in all the male predominance
is definite. Occupation may explain this in some degree, as we find it
commonest in men who are doing manual work, and eating hurried and
rough meals, where one would have less digestive preparation, and leisure to allow digestion to be completed. Thus perforations are commonest
in mechanics and workers of this type.
Results
The results of operatioo, if this be a posterior gastro-enterostomy,
are remarkably good, and the best results are obtained when the original
ulcer is excised or infolded. The difference in figures shewing a good
result, between this method, and the simple gastro-enterostomy alone, is
very striking. The vast majority of cases undergoing operation report
good and satisfactory results. Most of them are back at work in less
than ninety days, and over eighty per cent, are able to return to full
work. Most of them are able to return to full diet, but a ■ good many
make some slight reduction, mainly as regards protein elements in their
food. More than seventy per cent, report gain of weight, and pain and
distress seem to have disappeared.
Mortality
This is highest, of course, in cases of perforation of ulcers, in perforated duodenal ulcers it amounts to 13.6%. Half of these occurred
within seven days of operation, and this leaves a mortality in the other
cases only a little higher than that of the simple duodenal ulcer, which
is 5%, due to operation. The mortality in pyloric ulcers is only half this,
whereas in gastric ulcers unperforated, we find a mortality of 9%. In
the perforated gastric ulcer it is the highest of all, 28.6%.
Type of Operation
The  report  covers  many   types  of   operation,   but   the  net   result
corresponds fairly closely with the teaching that the posterior gastro-
Page 267 enterostomy is the operation of choice. The results of anterior
anastomosis are very poor, both as regards mortality, and end-results in
survivors. The method of making posterior anastomosis is not discussed, and it would be of interest, but the figures,show conclusively that
the ulcer should be dealt with wherever possible, at the same time as
the major part of the operation is done. The mortality is immensely
lower in every type of ulcer, and the results are better.
Cancer
In no case was carcinoma ever traced to previous duodenal or
pyloric ulcer in this series. Two cases, both of whom had suffered from
gastric ulcer some years previously, showed carcinoma, but this could
not be definitely traced to an ulcerated area. But these are suggestive,
in view of the commonly accepted opinion that gastric ulcers may be
the cause or site of cancer.
In conclusion, these results are very impressively on the side of the
surgeon, it would seem to a casual observer. Any method of treatment
that gives "quite satisfactory" results, in the patient's own words, to
over 90% of those undergoing it, that gets the patient back to full work
in over 80% of cases, within three months, that allows the same percentage to eat practically anything they want, and that frees them from
the necisity for medicine to keep them comfortable, is a very good
method of treatment, and constitutes a serious challenge to those who
try to avoid surgery. In addition, in gastric ulcers, there is probably
enough risk of carcinoma as a later danger, to make surgical removal
just a bit the safer method.
VANCOUVER HEALTH DEPARTMENT
STATISTICS,  JULY,   193 0
Total   Population    (estimated)	
Asiatic   Population    (estimated)	
Total   Deaths	
Asiatic   Deaths    . :	
Deaths—Residents   only   	
Birth   Registrations   	
Female   1S1
Male      202
INFANTILE MORTALITY—
Deaths under one year of age	
Death Rate—per  1,000 Births.:	
Stillbirths   (not   included   in  above).
  24 0,421
  9,335
Rate Per 1,000 of Population
June,
Cases
."oa -
22
Small-pox  	
Scarlet Fever	
Diphtheria       14
Chicken-pox      51
Measles        4
Mumps    21
Whooping-Cough      64
Typhoid Fever  =     2
Paratyphoid        0
Tuberculosis     .     8
Poliomyelitis         9
Meningococcus-Meningitis         1
Erysipelas        4
1930
Deaths,
0
0
0
0
0
0
2
0
0
15
0
0
0
179
18
161
383
13
33.94
12
July, 1930
Cases    Deaths
0
9
21
12
0
1
35
2
0
29
1
0
7
0
0
1
0
0
0
1
0
0
17
0
0
0
8.77
22.70
7.88
18.76
August 1
to 15, 1930
Cases    Deaths
Page 268 Ind
ex ^
Anaemia  and  Blood  Diseases : g
Annual Meeting  _ 167
Autopsy Report.    Cancer of  the Penis 97
B. C. Medical Association News 18, 63, 85, 111, 183, 210, 245
Bilodeau, J. P.    "Some Practical Points in the Late Toxaemias of Pregnancy" 86
Bladder,   Tumours  of       ...16
Boulter, W. L.    "Induction of Premature Labour"   212
Brain,    Tumours   11
Brown, C. E., Disease of the Biliary Passages 122
Burnett, W. B., Technique of Version 39
Campbell, J. E., Serological Diagnosis of Syphilis 56, 95
Canti  Film 14
Cancer   of   the   Penis 97
Carcinoma  of   Large  Bowel   232
Cheney, W. F., Diagnosis and Treatment of Peptic Ulcer  241
"      Methods of Gastric Analysis 241
Chisholm A. R., Fatal Credulity  105, 224
Cleveland,   D.   E.   H 95
Clinical Meetings 36,  50,  68,  94,  118
Coleman, R. E., Reticulocyte Count in Perniciuos Anaemia  _85
Committee  Report  re Vancouver  General  Hospital 165
Controlling  Scarlet  Fever  Outbreaks 158
Coronary  Thrombosis 130
Correspondence   . 34,  73,  96,   120
Darling, G.,  "Hypoacidity in Pulmonary Tuberculosis" .  203
Fatal   Credulity...          .        105
Gall Bladder Disease, Diagnosis and Methods of Investigation 122
Gastric    Analysis 201
Gastric Analysis, Methods and Value of 253
General  Meetings.....  - 35,  49,  70,  93,   117,   164
Genital    Prolapse     46
Glaucoma,   Early   Recognition   of 188
Goitre,  Aetiology  of 52
Graham, W. L., "Intestinal Obstruction, Post Operative" 99
Gwyn,  Norman B.,  "Anaemia  and  Blood   Diseases"  6
"     "Rheumatism"     58
Harrison,  J.  E.,  "Kidney  of Pregnancy"   256
Health   Insurance 197
Hill,   H.   W.,   "Kahns  and  Wassermanns"  ~?~7
Holden,   D.   B.,   Obituary   45
Hospital Committee Report 165
Hysterectomies   and   Myoectomies = 13 9
Induction  of  Premature Labour 212
Infant   Feeding  170
Intestinal   Obstruction,   Post   Operative.  99
Importance of Early Recognition of Glaucoma by the General Practitioner 188
Kahns   and   Wassermanns ' '
Kidney  of  Pregnancy. ^56
Laboratory Bulletins jl.^-77,  102,  157,   177,  201,  224,  247
Lennie, T.  H,  Presidential Address 168
Library Notes  94,   119,  231
Lowsley, O.  S.,  "Tumours of  the Bladder" 16
Page 269 Matheson,  J.   E., "Spinal   Fluid   Examinations" 81
"Why Do We Examine the Urine?"   103,  159
"       "Gastric   Analysis" 201
Mathews   G.   O., "Aetiology   of   Goitre" ., 52
"       "Infant   Feeding" . 170
Mason,  J.  J.,        "Genital Prolapse" 46
"Osier Lecture,"' Hysterectomies and  Myomectomies 139
Meetings:
Annual . 167
Clinical   36,  50,  68,  94,   118
General 35, 49,  70,  93,   117,   164
Special  37,  70,  93,   118,   188,  211
Menzies, A. M., "Specimens for Cellection for the Laboratory" 177
Obituary,  Dr.   D.  B.  Holden S 45
Ootmar, G. F., "Scarlet Fever Outbreaks" 158
"     "Scarlet  Fever  Experiences" 205
Osier  Society  Programme ^ 62
Osier   Lecture : 139
Paediatric Section, Scale of Charges ■. 92
Penis,  Cancer of, Autopsy  Report 97
Peptic    Ulcer 2 31
Picric Acid,  Toxic  Reaction  of 95
Pitts,  H.  H.,  "Thymus  Gland"   52
"Cancer of  the Penis,"  Autopsy  Report 97
Pregnancy,  Late  Toxaemias  of : 86
Presidential   Address ". '. ^..168
Pulmonary  Tuberculosis,  Hypoacidity   in l 203
Public Health Work in British Columbia 224
Rawlings, H. A., "Synoptical Review of X-Ray Examination of Mastoid" 220
Reticulocyte Count in Pernicious Anaemia 85
Rheumatism 5 8
Reviews:
William   Harvey,   By  Archibald   Malloch ; 6
An Introduction to the Study of Physic, By Herberden '. 6
Sachs,   Ernest,   "Brain   Tumours" ., 11
Scarlet   Fever   Experiences 2 0 5
Scarlet   Fever   Outbreaks 158
Scott-Moncreiff, W. E., "Importance of Early Recognition of Glaucoma by
General  Practitioner" 188
Specimens for Laboratory, Collection of ■ 177
Spinal   Fliud   Examinations '. 81
Strong, G. F., "Coronary Thrombosis" 130
Summer   School,   193 0 163
Synoptical Reviews of X-Ray Examination of Mastoid :. 220
Syphilis,  Serological  Diagnosis  of 56
Technique of Version : 39
Thymus   Gland j : 52
Toxoid    : 42
Urine,  Why  Do We Examine? 103,159
Vancouver  General   Hospital 71,   91,   93,   165,   118
Version . _3 9
Victoria  Medical   Society  Annual   Meeting 111
Vital Statistics . 2, 54, 65, 66, 90,  114,  138,  161, 207, 223, 246, 268
White,   Harold,   "Toxoid" .42
Wilson, G. E., "Carcinoma  of the Large Bowel" 232
Page 270  Miss R* A* Backett, r, n.
Masseuse
Rooms 503-504 Birks Building
Phone Trinity 2004
Sun Ray
with
Quartz Lamp
Cabinet Baths
and Shower
Swedish or
Weir Mitchell
Massage
Specializing in Physio-Therapy
Patients may be visited in homes
(Qualified Physicians invited to visit)
Bridging the Gap
between (tthe man on the street" and the physician in his office
By means of the most dramatic and appealing "copy" that we can devise, aided by convincing,
human-interest illustrations, the "see your doctor" message is being put before the general public in a
way that has never been attempted before.
Facts which the public should know about some of the common but perplexing affections requiring
a physician's skill for their treatment—conditions such as cancer, anemia, obesity, rheumatism—
are the subjects of current advertisements which are appearing over the signature of Parke, Davis &
Company in such magazines as the Saturday Eevning Post, the Literary Digest, Hygeia, Time, and
Collier s.
By publishing authentic, non-technical information about such diseases, and by proving how
intricate these diseases are, we are endeavoring to show people why they should go to their doctor for
consultation and treatment.
It is our sincere belief that this unique campaign of advertising, which has been running uninterruptedly for the past two years, is helping, in a measure, to bridge the gap between the man and the
woman on the street and the physician in his office.
Copies of the full-page advertisements 'which are mentioned above will be gladly
sent you if you will drop a line to our Walkerville laboratories.
PARKE,   DAVIS    &    COMPANY
WALKERVILLE, ONTARIO
MONTREAL, QUEBEC
WINNIPEG, MANITOBA n
u
^"
iicians
^here's a Club for Every
PHYSICIANS BAflHv
BETTER BABIES
Dextri-Maltose No. 1
(with 2% sodium chloride), for normal babies.
Dextri-Maltose No. 2
(plain, salt free), for salt
modificati oris by the physician. Dextri-Maltose
No.3 (with 3% potassium
bicarbonate), for constipated babies. "Dextri-
Maltose With Vitamin
B" is now available for
its appetite-and-growtb-
stimulating properties.
Samples on request.
[LMOST any player can swing around the course
with a single club, dubbing drives, lifting fairway sods and bringing home a century mark or more
for the final score. But the finished golfer needs a
club for every shot—a studied judgment of approach
or putt before the club is selected.
Similarly in artificial infant feeding. For the normal
infant, you prefer cow's milk dilutions. For the
athreptic or vomiting baby, you choose lactic acid
milk. When there is diarrhea or marasmus, you decide
upon protein milk. In certain other situations, your
judgment is evaporated milk.
Dextri-Maltose is the carbohydrate of your choice for
balancing all of the above "strokes" or formulae and
aptly may be compared with the nice balance offered
the experienced player, by matched clubs.
To each type of formula (be it fresh cow's milk,
lactic acid milk, protein milk, evaporated or powdered
milk), Dextri-Maltose figuratively and literally supplies
the nicely matched balance that gets results.
MEAD JOHNSON & CO. of CANADA, Ltd., Belleville, Ont. Rest Haven Sanitarium and Hospital
MARINE DRIVE, SIDNEY, B. C.
(Near Victoria)
(Visited by Qualified Physicians)
Rest  Haven is situated  amid  natural  beauty.    Particularly  convenient  and  desirable  for
Rest—Recuperation  and  Convalescence.
There is boating, salt water fishing, and golf.
Private room accommodation $28.00 and $35.00 weekly;
Semi-private  $21.00   and  $25.00  weekly.
Direct  patients  to   Rest   Haven  via   the   Steveston-Sidney  ferry,   MOTOR   PRINCESS.
From   Victoria   by  the   Vancouver   Island   Coach   Lines,   Ltd.,   at   the   Broughton   Street
Station.    Private car will meet boats if  desired.
FOR  RESERVATION  AND   FURTHER  INFORMATION
WRITE OR TELEPHONE MEDICAL SUPERINTENDENT OR MANAGER-
SIDNEY 95 — 61 L.
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
One Phone:
Seymour 8033
Connecting all three stores.
Brown Bros, & Co* Ltd.
VANCOUVER, B. C. »~»»~°w*T
gggS
P.
mm
 v~~«»™,-*ns
m
Fairmont 80
536 13th Avenue West
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance ABOC.at.on
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
T tt fflBM W. h. Bertrand
r. J. Campbell
J. H. Crellin
STEVENS'
SAFETY PACKAGE
STERILE GAUZE
handy, convenient, clean commodity
for the bag or the office.
Supplied in one yard, five yards and
twenty-five yard packages.
is a
B. C. STEVENS CO.
730 Richards Street
Phone Vancouver, B. C.
Seymour 698 ~H«©«!
te^eMk&T&ite
a<3*-»~
Hollywood Sanitarium
LIMITED
c&or the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference | "S. (?. offledical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver ..
Seymour 4183
Westminster 288
weae
***>    University of British Columbia Library
¥i DUE DATE
SERIALS	
Xi~*
^^m
k &
~i\<j*j * */ •»*
FORM  310S  

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