History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1949 Vancouver Medical Association Jul 31, 1949

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 I1
THE
BULLETIN
Published By
The Vancouver Medical Association
EDITOR:
dr. j. h. MacDermot
EDITORIAL BOARD
DR. D. E. H. CLEVELAND
DR. H. A. DesBRISAY
Editorial and Business Office
203  Medical-Dental Building
Vancouver, B. C.
DR. J. H. B. GRANT
DR. D. A. STEELE
Publisher and Advertising Manager
W. E. G. MACDONALD
Vol. XXV
JULY, 1949
No. 10
OFFICERS, 1949-50
Dr. W. J. Dorrance       Dr. Henry Scott Dr. Gordon C. Johnston
President Vice-President Past President
Dr. Gordon Burke Dr. W. G. Gunn
Hon. Treasurer Hon. Secretary
TRUSTEES
Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical
Dr. M. M. MAcPHERSON-Chairman Dr. W. H. S. Stockton.... Secretary
Eye, Ear, Nose and Throat
Dr. J. F. Minnes Chairman Dr. X. J. Blair Secretary
Paediatric
Dr. J. R. Davies Chairman Dr. C. J. Treffry Secretary
Orthopaedic and Traumatic Surgery
Dr. R. H. B. Reed  Chairman Dr. D. E. Starr Secretary
Neurology and Psychiatry
Dr. G. H. Gundry Chairman Dr. G. M. Kirkpatriok.—Secretary
Radiology
Dr. W. L. Sloan Secretary Dr. Andrew Turnbull Chairman
STANDING COMMITTEES
Library:
Dr. R. A. Palmer, Chairman; Dr. E. F. Word, Secretary; Dr. J. E. Walker :
Dr. S. E. C. Turvey ; Dr. A. F. Hardyment ; Dr. J. L. Parnell.
Summer School:
Dr. D. S. Munroe, Chairman; Dr. A. C. Gardner Frost, Secretary;
Dr. E. A. Campbell ; Dr. J. A. Ganshorn ; Dr. Gordon Large;
Dr. Peter Lehmann.
Medical Economics:
Dr. J. A. Ganshorn, Chairman; Dr. Paul Jackson ; Dr. W. L. Sloan ;
Dr. E. C. McCoy ; Dr. J. W. Shier ; Dr. T. R. Sarjeant ; Dr. John Frost.
Credentials:
Dr. H. A. DesBrisay ; Dr. G. A. Davidson ; Dr. Gordon C. Johnston.
Representative to B. C. Medical Association: Dr. Gordon C. Johnston.
Representative to V.O.N. Advisory Board: Dr. Isabel Day,
Representative to Cheater Vancouver Health League: Dr. L. A. Patterson.
Representative to the Board of Trustees for the Medical Care of
Social Assistance Cases: Dr. J. A. Ganshorn
■« A Significant Advance
in ANTIBIOTIC THERAPY
Note these five favorable attributes
of Dihydrostreptomycin Merck
(1) lew incidence ef vestibular disturbances
(2) Significantly less toxic
(3) less frequent allergic manifestations
(4) Highly purified
(5) Undiminished antibacterial activity against Mycobacterium, fubercufosiip
ANEW, highly purified antibiotic,
chemically distinct from streptomycin, with greatly reduced neurotoxicity, Dihydrostreptomycin
Merck is especially useful in cases requiring relatively high dosage, such as
miliary tuberculosis and tuberculous
meningitis.
It can be used interchangeably for
intramuscular therapy with Streptomycin Calcium Chloride Complex
Merck or other forms of streptomycin.
Descriptive literature is yours for the asking. \
LOW INCIDENCE
OF EIGHTH CRANIAL
NERVE DAMAGE
^^^^^^^^w?
DI«OMPTOmCl
i MmsA I
(supplied as tftfe sulfate)
- * • ■•*■■ ■•■■■
MONTREAL'
MERCK & CO. Limited ^JitM^trt^ac^iln^^AentiiA  Toronto
VALLEYFIELD VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
«P     CITY
STATISTICS — MAY, 1949
Total Population—Estimated 376,000
Chinese Population—Estimated   7,455
Hindu Population—Estimated 275
Total Deaths	
Chinese Deaths 	
Deaths, Residents Only-
Number
_    399
14
_    356
March, 1949
Rate Per
1000 Pop.
12.7
22.5
11.4
April, 1949
Rate Per
Number 1000 Pop.
351 11.2
13 20.9
310 9.9
BIRTH REGISTRATIONS—Residents and Non-Residents.
March, 1949
Male 441
Female  : . 433
874     27.9
April, 1949
378
359
737     23.5
INFANT MORTALITY—Residents Only.
Deaths Under 1 Year of Age	
Death Rate Per 1000 Live Births	
Stillbirths (Not Included in Above Items).
March, 1949
2>
36.0
9
April, 1949
17
31.3
9
CASES OFCOMMUNICABLE
DISEASES REPORTED IN THE CITY
Number    Rate Per 1,000 Population
Scarlet Fever	
Diphtheria	
Diphtheria Carriers.
Chicken Pox	
Measles ,	
Rubella	
Mumps	
Whooping Cough-
Typhoid Fever	
Undulant Fever	
Poliomyelitis	
Tuberculosis	
Erysipelas__	
Meningitis-
Infectious Jaundice	
Salmonellosis !	
Salmonellosis Carriers	
Dysentery	
Dysentery (Carriers)	
Tetanus . . ....	
Syphilis	
Gonorrhoea	
Cancer (Reportable):
Resident	
Non-Resident	
March
, 1949
April,
1949
April,
1948
Cases
Deaths
Cases
Deaths
Cases
Deaths
9
0
2
0
6
0
0
0
0
0
1
0
0
0
0
0
0
0
550
0
319
0
90
0
243
0
245
0
284
0
9
0
45
0
21
0
57
0
58
0
13
0
0
0
0
0 .
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
71
15
47
11
52
15
0
0
0
0
2
0
0
0
1
0
0
0
0
0
0
0
1
0
1
0
2
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
48
4
29
1
40
2
189
0
148
0
181
0
74
61
96
44
90
58
14
11
28
8
37
17
Page 208 p. i oz. met eie
PABLU
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economical to prepare.
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OHKBOIW *
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tmm
There is only one Pablum. It
was originated in 1932 by and
is made by Mead Johnson &
Company. "Pablum" is the
registered trademark of Mead
Johnson & Company for this
pioneer vitamin-and-mineral-
enriched precooked mixed cereal food.
PABENA
^fi^ of «tme* matt »^ "J"^
sawe ] y pre^rs!S for human use, ^"TZ. «rf
fe»* to W*M" and reduced iron. f*ben*'.jL* *»
N**"» ^ thiamine and supplies »ut"M^fB^
% , rlR8ra,s ^copper, calcium, and **Z* A
iu.7* of thorough cooking and *!#• r ^
*•»«*. it J p3,atab!ej comment » ^
economical to use.
^
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**<uutj no cook'***
■ s.«*.NA»4t "sis
Pabena was introduced by
Mead Johnson & Company in
response to numerous requests
by the medical profession.
"Pabena" is Mead Johnson's
registered trademark for this
vitamin - and - mineral - enriched
precooked oatmeal food.
,J:.iJJ>
Si
MANY   PHYS«Atp   RECOGNIZE   MEAD   JOHNSON   AND
COMPANY'S   PIONEER   IfFORT^N   THE   FIELD   OF   fNPANT
CEREALS  BY  SPECIFYING ^ABLUMV-A§D  ALSO  THE  NEy|
PABLUM-MKE   OATMEAL   CEREAL IfcNOWN   AS IpABENA"
WSm
_ _       .*„,.     i&s:	 Of all the magnificent works that have been done by that wonderful organisation,
the Canadian Red Cross, perhaps £he one that required the most courage and showed
the greatest vision, was the institution of their Blood Transfusion Service. We all
know what things were like before this was put into effect. A patient whose very life
depended on the immediate administration of blood, and others to whom its availability
meant the difference between slow, tedious recovery and a quick return to health, had to
depend on commercial donors, had to pay a high price for blood, and all too frequently
could only get it in inadequate quantities.
It was a great venture that the Red Cross undertook, and it required great faith
and courage to undertake it—when they took over the collection, processing and distribution of blood, at no cost to the patient or hospital concerned, and practically
without limit as to amount: maintaining a day and night staff, and giving a well nigh
.perfect service. What doctor is there in Vancouver today who has not benefitted by
this service, and which of us would fail to admit that this has been one of the greatest
blessings we have? Which of us could contemplate the possibility of a cessation of this
service without utter dismay?
Yet there are signs that this Red Cross Blood Service is beginning to fail, under
the strains that are put on it. It is getting ever harder to maintain the supply of blood
from voluntary donors—though it is only fair to say that taking it by and large, there
has been a truly magnificent response by the public to the campaigns for blood. But
if the service is to continue, and it must continue, it is becoming evident that something
more must be done to maintain and even increase the supply of donors.
It is just as well to be frank. We, the medical profession, have not done our share
towards attaining this end. The lay people who are running the service, who are
providing all the work and doing most of the campaigning for donors, feel very
strongly, we are told, that the medical men could and should do much more than they
are doing. In our daily practice we derive untold benefit from this Service—we could
not do without it—but with very few exceptions, we do nothing to help. We are
'taking it for granted that this blood will always be available when we want it, and that
jpthere will always be as much as we want. But things don't work that way. This blood
has been a gift from someone-—he or she does not get paid for it—and at their own
expense entirely, these public-spirited men and women give their blood. There is not
even the emotional satisfaction of knowing the individual to whom one's blood has
Been given.
We are sure that in the case of most of us, this is merely thoughtlessness: and we
believe that most of us would be only too glad to help to keep up the continuity of
flow.  What can we do about it?
Well, we could probably do more than anyone else. In some of the Eastern centres
where they do not have the Red Cross Service, the hospitals have a rule that before
any blood is given to a patient, except in dire emergency, the relatives of friends of the
patient must agree to furnish an equivalent or double quantity. We had something like
this two or three years ago, but it was voluntary.
We who are in practice, are in an unusually favourable position. We are in contact
with the relatives and friends, at a time when they would gladly do anything in their
power to help the suffering person. It is very easy at that time to point out to them
that the need for blood is great—and that if they want to help their friend or relative,
they can do so best by contributing blood to the Red Cross.   And we should see that
Page 209
ft: they appreciate the importance of "this, and that they do it. The average person is
generous, and especially when someone he or she knows is in trouble and needs help.
We believe that every one of us could do a great deal to keep this indispensable Service
going. We believe, too, that we should. If we all turn in and do what we can easily
do, the supply will increase to a point where we shall all be able to feel safe. If we
merely sit by and let the George we call the Red Cross do it all, sooner or later we are
going to have a failure—and no failure could be more tragic than this one—moreover,
it will be almost impossible to get it going again.
What we have said is no mere theorising or sentimentalising. It is the result of an
appeal from some of those who work with and for the Red Cross Blood Transfusion
Service, and they emphasize very strongly the great need that exists for help. As a
profession we can do more than anyone else to procure donors—and it is up to each one
of us to do all he can to this end. <
The medical profession of Vancouver will be greatly interested to hear that Dr.
Olive Sadler, who was formerly associated with Dr. Ethlyn Trapp in Radiology, has
recently returned to Vancouver after a two-and-a-half year's absence, and will again be
associated with Dr. Trapp in her offices on Georgia St.
Dr. Sadler has been carrying on extensive postgraduate study in various large centred
in the United States. She obtained a fellowship at the Ellis-Fischel Cancer Hospital in
Missouri, where she was working with Dr. Del Rugato for many months. She worked,
too, with Dr. S. Cantrill of Seattle, who visited Vancouver last year—and spent three
months in New York, as well as some months at St. Louis, Mo. She has been studying
the latest work in X-ray and radium therapy, including the new work on radio-active
isotopes, and Vancouver welcomes her back.
9
•
tf^.ViSf.
II
»*■»
EXCELLENT TYPIST, with Medical Record experience, desires to
work exclusively for the Medical Profession, and will be available at
all times for the typing of manuscripts, correspondence, or specialized work on Medical Records.
MISS REA W. DOW, R.N.
792 West 26th Ave. Telephone FAirmont 6369-R
REPRINTS
Reprints of papers are available. They must be ordered at the
time the paper is forwarded to The Editor for publication so that
arrangements can be made with the printer to hold the required
metal. Reprints usually come in 4, 8, and 12 page sizes with or
without a cover. Quotations can be obtained by phoning the publisher
at MArine 7729. Payment for the reprints will be the responsibility
of those ordering them.
Page 210 Vancouver  Medical   Association
President Dr. W. J. Dorrance
Vice-President  Dr.  Henry Scott
Honorary Treasurer i _.Dr. Gordon Burke
Honorary Secretary Dr. W. G. Gunn
Editor Dr. J. H. MacDermot
NASAL DISCHARGE, NASAL OBSTRUCTION
It      AND SINUSITIS §§f|   ^   jf
By P. E. IRELAND, M.D., Toronto
Read before V.M.A. Summer School—1940
I was fortunate enough to have a period of general practice before completing my
training as a specialist. I found that my medical school training was quite inadequate
to meet some of the more minor or "nuisance" symptoms which were presented to me
by my patients. Amongst these were the nasal complaints which are so common to our
climate. I try to teach our students to think in terms of symptoms and then go on to
evaluate them in the light of the diseases they may represent.  If this is not possible they
Nshould be prepared to treat or ignore them as symptoms which may not be anything more
than discomforts and not disabilities.
It is difficult in this day and age to talk to the well-read" patient who reads
assiduously in the Reader's Digest or the Medical columns of his daily newspaper what
disease he has, or should have. The psychology of medical practice has become a big
factor in the treatment of the patient, as well as in the treatment of the disease. We
must not, however, err on the side of thinking all patients belong in the category of
psycho-somatic medicine, but use the wise judgement, which is the key-word of successful practice, in separating the sheep from the goats. It was Marcus Gunn, the great
Ophthalmic Surgeon, who once said "I became a specialist because I did not think I had
sufficient acumen to become a good General Practitioner."
This abstract of my paper is necessarily rather stilted and abrupt, as I do not at any
time present a formal discussion but talk from headlines which are now given in hopes
||that they may be of some value.
I. Nasal Obstruction
Causes:
Nlr  Due to congenital shape of nose
1.   Due to bony obstruction (septum)
3. Due to swollen nasal mucosa
(a) allergy
(b) polyps
(c) adenoid mass behind
(d) infection
4. Due to new growth in nose or sinuses.
II. Important Points in Differential Diagnosis
1. Shape of nose—narrow alae, high thin bridge, etc.
2. Do they breathe through it.  Block one side at a time.   Use a .shiny tongue blade and
watch steam.
3. Will it shrink down with ephedrine—is the colour of the mucosa normal before this?
4. Can you see polypi or new growths—after shrinking? llfiii ^
Page 211.: 1
ra.
5. Is obstruction in nose itself or in nasopharynx? (adenoids, enlarged posterior ends or
tumour can be felt for if a good view of nasopharynx impossible.)
III. Common Causes of Nasal Discharge \&£
1. Normal to have some nasal and post nasal discharge.
2. Acute coryza—entitled to 2 or 3 colds a year.
3. Excessive smoking—especial for A.M. post nasal discharge.
4. Dry heating of buildings in winter.
5. Poor< air-conditioning in summer.
6. Dusts and irritating fumes of home and industry.
7. Pollens, and common antigens such as fur, feathers, etc.
8. Acute, or Chronic Sinus infections.
IV. Must Know About Discharge
1. Is it nasal or post nasal or both?
2. Where in nose can it be seen?  Middle meatus, high up anterior?
3. Is it with or without headache?
4. Is it white or purulent—does it stiffen a handkerchief?
5. Is it watery, varying with sudden change in temp.? Is it seasonable and accompanied
by itching, red eyes? Are there frequent attacks of sneezing? Have you noticed an'
irritant or food that makes it worse?
V. Treatment
1. Leave most of them alone—snoring is largely rhythmic movement of palate.
2. Submucous resection if obstruction marked or poor drainage of a sinus with resulting
symptoms.
3. Polyps should be removed.   (May recur.)
4. Adenoids should be removed.
5. Infection—see sinusitis.
6. Allergy and vasomotor rhinitis—as below.
VI. Allergy and Vasomotor Rhinitis
These are essentially the same except that specific cause can be found in the one.
History and allergy tests may give a clue to definite diagnosis.
Also Important:
a. Pale, boggy masal mucosa with blue tinge which shrinks readily.   '■ggShiM
b. Watery discharge in nose.
c. Increased eosinophilia in W.B.C. and nasal secretions.
d. Frequently nasal polypi present in nose.
VII. Allergy—Treatment
1. Elimination of irritant.
2. Specific antigen treatment where possible.
3. Ephedrine by mouth and in nose drops.
4. Antihistamine drugs—Benadryl and pyribenzamine.
5. Removal of polypi, etc., when quiescent stage reached.
VIII. Diagnosis of Acute Maxillary Sinusitis
The antrum is the most poorly drained of any sinus and may act, in the case of
failure of ciliary action, as a cesspool which stagnates and only drains by its overflow.
DC.   Signs and Symptoms—Acute Maxillary Sinusitis
1. Head cold with persisting stuffiness in nose.
2. Soreness of upper teeth—noticed in chewing.
3. Pain over eye but with no tenderness elicited over frontal sinus.
4. Tenderness over canine fossa of face.
5. Swelling in face is not associated with antrum infection.
Page 212
ft 6. Sinus dark in Transillumination.
7. X-ray will show cloudy antrum if in doubt.
8. Discharge if present is on floor of nose or in middle meatus, far back. Tends to drain
to nasopharynx.
X.   Diagnosis of Acute Frontal Sinusitis
1. Pain and tenderness over floor of frontal. Percussion of sinus is painful.
2. Periodicity of pain—begins 9.00 a.m., reaches climax 1.00 p.m., and usually
subsides in early evening.
3. Oedema of upper lid and photophobia with tendency to close eye.
4. Sinus dark on transillumination.
5. Frontal sinus may be absent and X-ray necessary to check trans-illumination.
6. Discharge streams down from front of nose high up in anterior part. Blows discharge
from front of nose.
7. Oedema—pitting type—over front face of frontal sinus usually means an osteomyelitis and is a danger sign.
8. Frontal sinusitis is most important because it is often the starting point of meningitis
or brain abscess.
XL   Treatment of Acute Sinusitis
1. Bed if possible and especially if severe, with laxative and fluids, etc.
2. Sedative and external heat.
3. Shrink yourself by cotton pledget or shrinking drops by patient.
4. Steam kettle in room.
5. Penicillin locally by drops is ineffective. Aerosol penicillin is of little use at this period.
Adequate intramuscular penicillin of great help.
6. Sinuses are never irrigated in acute stage and mostly not at all except for diagnostic
purposes.
7. Diathermy short wave—never in acute sinusitis.
8. If frontal is involved and no improvement in two to three days refer the patient as
these are the cases which get into trouble and may require surgical interference of
some sort.
XII.   Chronic Sinusitis
1.   Pain and Purulent Discharge—no single one of these gives a diagnosis of chronic
sinusitis—both are necessary.  Discharge must be purulent and may be nasal or post
nasal.  This is not true in children where pain or headache may not be present.
2^.   Examination shows discharge and its location.
£T Importance of- Transillumination, X-ray of sinuses and proof puncture to localize
whether discharge is really from sinus and which ones are involved.
Xm.   Treatment of Chronic Sinusitis
1. Conservative (a) Remove causes of obstruction to aeration of sinus (Polps, deviation
of septum.)
(b) Nasal irrigations and shrinking solutions.
(c) Diathermy may be of help.
(d) Avoiding of head colds, keeping in dry warm climate, etc.
2. Operative  (a)   Intranasal sinusotomy.   (Draining into nose at dependent floor of
antrum.)
(b)  Radical Sinusotomy—Opening of Antrums of frontal by external route.
3. Tooth Antrums
4. Fractures into Sinus
Page 213 Conclusions: ■*
1. Canadians, (and Americans), are prone to make most of the complaints of nasal
obstruction and post nasal discharge. This may be due to faulty working conditions,
excessive smoking or the other causes of nasal catarrh. The allergic factor must be
ruled out as a causative agent.
2. Acute maxillary and frontal sinusitis are a clinical entity with a definite chain of
symptoms which should be readily recognized and easily treated.
3. Chronic sinusitis is probably blamed for more headache symptoms than is justified.
Not more than 10 per cent of headeaches are due to sinusitis. It is necessary to have
a careful history and evaluation of the symptoms before a diagnosis is made.
4. The treatment of Chronic Sinusitis is that of providing an aid to nature in the proper
drainage of the sinuses.
LOWER NEPHRON NEPHROSIS
By DR. A. B. HEPLER
Read before V.M.A. Summer School
1.
The term lower nephron nephrosis has a formidable sound and suggests a condition
of academic interest only, infrequently encountered and entirely within the province of
the specialist. However you have probably treated the acute renal insufficiency to which
this clumsy term has been applied without realizing that it was a symptom of a syndrome
which follows a definite pattern both as to lesions and clinical course and which can be
caused by a wide variety of apparently unrelated conditions commonly met in your daily
practice.
It was the most frequent form of fatal kidney disorder among the military personnel
during the last war. It may develop after shock in any form, particularly postoperative
shock with hemorrhage; prolonged hypotension; crushing injuries; severe burns; the
non-obstructive type of sulfonamide poisoning; intravascular hemolytic reactions;
especially transfusions with incompatible blood; hemolysis from intravenous absorption
of the irrigating fluid during transurethral prostatic resections; dystocia and uteroplacental damage; concealed hemorrhage and eclampsia; heat stroke; blackwater fever;
alkalosis and prolonged vomiting; poisoning from a variety of agents, including carbon
tetrachloride and mushrooms. The commonest causes are postoperative shock and hemorrhage, transfusion reactions, crushing injuries, burns and sulfonamide poisoning, and it is
by no means a rare sequel of difficult obstetrics.
Therefore, because it occurs in such widely separated fields of medicine, it is important that the general practitioner and the specialist in his own particular field be
familiar with the significance of this syndrome and with its treatment. Unfortunately,
as Muirhead put it, "the management in the past has not been conducive to the proper
recovery of these patients." This has been proved by an alteration in the conventional
treatment based on a better understanding of the morphologic changes in the kidney
and the disturbed physiology and as a result of decidedly significant decrease in the mortality rate.
What is the lower nephron nephrosis? It is a type of acute renal failure, usually
initiated by varying degrees of shock following which there is a period of oliguria or
anuria for eight to ten days. It tends to be self limited and if the patient survives this-
anuric phase, there is spontaneous diuresis with complete recovery in three or four weeks.
The reversible nature of this renal failure is one of the characteristics which distinguishes
it from that in the other forms of nephritis, such as chronic glomerulonephritis, nephrosclerosis and the kidney of essential hypertension. -•'
• Parte =214 The renal lesion, which is consistent and unique, is degeneration and necrosis in the
lower segments of the tubules which are usually filled with debris and pigmented casts
of heme compounds.
This condition is, of course, not new, but it is just recently that we have recognized
that the observations which have been coming in from surgeons, physicians, obstetricians, workers in tropical medicine and urologists, are all dealing with the same thing.
It was first described in the German literature during World War I when it was found
to occur with crushing injuries to muscles. It was practically forgotten until Bywaters
and his associates in 1941, during the "London Blitz," when crush injuries were frequent, described the renal lesions and the resulting renal failure as the crush syndrome,
a term which still persists.
The lack of a more definite name contributed to delayed correlation of the findings
in other fields until Lucke, in 1946, demonstrated their similarity and used the term
lower nephron nephrosis to. describe the syndrome.
SLIDE 1
The nephron is the excretory unit of the kidney consisting, as you know, of: 1. The
glomerulus with its covering capsule constituting the renal corpuscle, or malphighian
corpuscle. 2. The first or proximal convoluted tubule. 3. the descending limb of the
loop Henle. 4. The ascending limb. 5. The second or distal convoluted tubule. The
collecting tubules are not part of the nephron but are simple excretory ducts.
The  glomerulus filters  from the  blood  a fluid which resembles  qualitatively  and
quantitatively, blood plasma without the proteins.   The tubular epithelium  reabsorbs
from this glomerular filtrate, water and certain substances of value in accordance with
the needs of the body and also secretes certain substances into the lumen of the tubules,
I the resulting fluid being urine.
The lesions in this syndrome are limited to that portion of the. nephron below the loop
j of Henle, that is the distal segments including the ascending or thick limb of the loop,
the distal convoluted tubule and also the collecting tubule.   The upper portions of the
| nephron, the glomerulus and proximal tubule are, as a rule, intact.
SLIDE 2
Miscroscopically there are three distinct characteristics:
1. Degeneration and necrosis showing a segmental or patchy distribution.
2. Debris and casts usually pigmented. The collecting tubules are rarely damaged but
contain large numbers of heme casts.
3. Edema in the interstitial tissue from cellular reaction about the damaged tubules
and from extravasation of the glomerular filtrate through them. This produces a
large, heavy, pale, wet kidney.
Regeneration begins in the tubules usually about the sixth or seventh day and progresses rapidly. After two or three months there may be no microscopic evidence of
damage.
With such consistently specific lesions, we naturally look for a single specific cause.
It has long been recognized that there is one condition which seems to be essential, namely
shock and prolonged hypotension with its resulting vasoconstriction, renal ischemia and
anoxia.
Because pigmented casts of heme compounds are so frequently found, it was at
first throught that these products of red cell and muscle disintegration, i.e. hemoglobin,
myohemoglobin, were the primary cause of the tubular degeneration and necrosis.
But it was found that substantial quantities of hemoglobin solutions can be given intravenously without producing renal insufficiency and clinically various hemoglob-
inemias have been observed for prolonged periods without any apparent kidney damage.
In animals intravenous injections of hemolyzed red cells or myohemoglobin have
little effect on the kidneys, but if the animals are first shocked or the renal vessels
temporarily constricted, we then find the typical microscopic lesion of tubular degen-
Page 215
it m
m
eration and necrosis with heme casts and anuria. Besides in those cases not associated
with intravascular hemolysis or muscle injury, pigmented casts are absent but shock
almost invariably accompanies the precipitating condition.
At the present time, the consensus is that the primary factor in the mechanism of
the production of this syndrome is renal cortical ischemia and anoxia from arterial
spasm and vasoconstriction brought about by a neurovascular defense mechanism in
shock. This concept has been supported by the work of Trueda, who has shown that
arterial spasm, whether induced by shock or various poisons, will reduce the volume of
blood reaching the kidney and may short circuit it away from the cortex into the
medullary circulation, the so-called arterial shunt. This means that those portions of
the tubules supplied by the cortical glomeruli are deprived of their blood supply and are
injured if the ischemia and anoxia is severe and prolonged.
As Haldane says: "Anoxia not only stops the machinery but wrecks the machine."
i^:?£f|l^-xJJl^ the damage and it is
these several factors acting conjointly which produce the lesions. The oliguria which
accompanies the initial shock is increased and perpetuated after the first day by the
blocking of the tubules with debris or pigmented casts and more importantly, by the
^EJ**leaJs.age of .the^glomerular filtrate through the damaged tubules into the interstitial
tissue with renal edema which increases the intrarenal pressure. This reduces secretory
pressure with further suppression and anuria.
CLINICAL COURSES
SLIDE 3
In the clinical course of the disease there is a sequence of symptoms which closely
follows the sequence of changes in the kidney and three distinct phases can be recognized. Familiarity with the average duration of each and the recognition of the transition from one to another is important because the treatment differs widely and must
be changed promptly in the different phases.
There is first the stage of onset, with reaction and shock which lasts for one to two
days. Second, the stage of renal insufficiency with oliguria and anuria, from the second
to the tenth day. Third, the stage of spontaneous diuresis, from the eighth to the
sixteenth day. The symptoms of the first stage will vary somewhat with the precipitating factor. The shock may be severe and obvious as in trauma, burns, prolonged
operations with hemorrhage, uteroplacental damage and concealed hemorrhage, incompatible transfusions or hemolysis during transurethral prostatic resections, and less
so in some of the intoxications such as sufonamide poisoning. The blood pressure
usually falls to shock levels and with hemorrhage, there is loss of blood volume. In
many instances where there is no hemorrhage, particularly in the crush cases and in
burns, there is a marked loss of plasma volume without any indication of where it goes.
The second or anuric phase starts immediately and by the second day there is
oliguria which in severe cases frequently progresses to anuria. The specific gravity of
the urine becomes fixed at a low range. There is a marked reduction in the output of
solids, including urea and sodium chloride. There is usually a large number of casts
which are pigmented in those cases associated with intravascular hemolysis. These
disappear by the third of fourth day.
With the renal shutdown there is an increase in the non protein nitrogen of the
blood so that by the third day values may reach 150 mgm, per cent. This azotemia
is associated with a rapid development of hypertension. After the first day in which
the blood pressure is usually at shock levels it rises steadily to around 150 systolic
where it may stay or show further increase. The blood serum potassium is increased and
the serum chlorides and CO2 combining power decreased with symptoms of acidosis.
There is usually very little edema unless it is the result of faulty treatment. The
patient may become irrational, develop muscle twitching, convulsions and coma which
a,« a rule are the result of cerebral edema from excessive water and salt intake.   High
Page 216 degrees of nitrogen retention are tolerated fairly well and the patient may be mentally
clear with blood values for urea as high as 200 to 300 mgm. per cent. Deaths frequently attributed to uremia in this stage are more often the result of pulmonary and
cerebral edema from attempts to overcome the anuria by excessive hydration.
Between the fifth and eighth day in this second stage one expects to find a daily
increase in the urinary output and a definite diuresis between the eighth and twelfth
day. This coincides with the beginning regeneration of the damaged tubules and constitutes the beginning of the third stage or the salt losing diuresis phase. At its height
there may be five or six liters of urine daily. This urinary supression and subsequent
diuresis generally follows a definite pattern which may vary somewhat with the
severity of the lesion and is known as the oliguria-diuresis curve.
SLIDE 4
This chart which is taken from Muirhead shows the oliguria-diuresis curve in three
patients and the values for blood urea which are represented by a curve which corresponds closely to that of the urinary output. The urine volume in cubic centimeters
is represented by the solid dark lines and the blood urea in milligrams per cent by the
lighter dotted line. In case No. 1 which was severe with anuria for six days, the peak
of the diuresis occurred on the twelfth day. In cases No. 2 and No. 3, which were less
severe and in which the patients were not anuric but had some urinary output in the
beginning, the peak of the diuresis was on the eighth day. The blood urea curve closely
folows the oliguria-diuresis curve, that is retention to high levels during the stage of
suppression and a rapid recession after the peak of the diuresis.
However this apparently favorable change in the clinical picture with the onset
of dieuresis is not without its dangers. With the beginning regeneration in the tubules,
the obstruction and renal edema subside and the patient makes urine in increasing
larger amounts. However the tubules are still damaged and have not fully recovered
their function, which is to reabsorb water and salts from the glomerular filtrate to meet
the body's needs. So what is put out is practically straight glomerular filtrate. There
is a tremendous loss of sodium chloride in the urine, as much as 40 to 50'grams a day,
as against a normal output of 16 grams, with the rapid development of dehydration,
hypochloremia, alkalosis and at times, convulsions and death. With increasing regeneration of the tubules, the kidneys regain their concentrating power and a return
to normal function is usually complete in two to three months.
PREVENTION
Before taking up the treatment, I would like to say just a few words about prevention. The most important consideration is the anticipation and prevention of shock
and hemorrhage ,which set up the kidneys for further damage by the other etiologic
factors.
As far as intravascular hemolysis is concerned, the present increased use of whole
blood transfusions has accounted for the greater number of reactions we are seeing. The
relative rate has decreased since the routine use of Rh typing. However, reactions will
continue to occur from less understood subgroup antigens and from clerical and technical errors.
Unfortunately many of them ,take place during operations when the patient is
under an anesthetic. They ar enot recognized at the time and the transfusion is continued. To obviate the danger it is suggested, that in prolonged operations in which
one or more transfusions are given, that a catheter be placed in the bladder and the
urine observed from time to time. It takes only about 40 to 60 cc. of hemolyzed blood
to produce enough hemoglobin to appear in and discolour the urine. When this is observed, the transfusion should be stopped immediately.
In the hemolysis that takes place during transurethral resections of the prostate
from absorption of the irrigating fluid, various substitutes for water that are isotonic
Page 217 have been suggested. For about two years I have been using a 2.1 per cent solution of
glycine, an amino acid, as recommended by Nesbit. Saline and glucose solutions interfere
with vision and the electrical current. Resections of very large prostates that promise
to be prolonged and bloody should be avoided and the prostate removed by some other
method. Persistent attempts to stop hemorrhage by fulguration of the venous sinuses
in the capsule usually causes more hemorrhage, prolongs the operation and results in
shock which is as important a factor in producing anuria as the amount of wash water
that gets in the circulation.
The damage to the kidneys from sulfonamide intoxication may be of three types:
a. The allergic or hypersensitivity with. glomerulonephritis, b. The obstructive from
acetylization and deposits of crystals in the tubules, in the kidney pelvis and in the
ureters, and c. The toxic and the lower nephron nephrosis.
The latter two can be avoided to some extent by avoiding massive doses. One gram
every four hours is sufficient to obtain an adequate blood level and its use should not be
unduly prolonged. Forced fluids and alkalinization of the urine are absolutely essential
when giving sulfonamides and they should never be prescribed without an equivalent
dose of sodium bicarbonate. It has been found that combinations may prove more
effective and less toxic than the use of one alone. Equal parts of sulfadiazine and sulfathiazole have been recommended or sulfadiazine and sulfamerazine, and more recently,
a combination of all three are used.
Again sulfonamides should be given with great caution in patients who have been
recently shocked because of the possibility that the kidneys are already damaged.
They are definitely contra-indicated in patients with renal insufficiency because failure
to excrete them results in dangerously high blood levels.
A distinction must be made between the oliguria and anuria of the obstructive
type, that is, the crystalluria and the toxic type or the lower nephron nephrosis.
Cystoscopy and lavage of the renal pelvis usually makes the distinction. If there is no
obstruction to ureteral catheterization and no crystals obtained in the washings, it is
assumed that it is the toxic type and is treated accordingly.
TREATMENT
Treatment of the lower nephron nephrosis, like the clinical course, is divided into
three phases. It is agreed that faulty management has been an appreciable factor in the
previously high mortality rate. This has been definitely lowered by newer concepts in
management based on the premise that this is a self limited disease, that it requires time
for regeneration and recovery of the damaged nephrons, that you can't make the kidneys
work before this recovery takes place, that injudicious attempts to do so may increase
and prolong the damage and even result in death, and that when spontaneous recovery
begins the battle isn't over, but prompt and vigorous treatment is necessary to meet
the disturbed water and electrolyte balance during the period of diuresis. Each phase
requires its own special treatment.
In the first stage, shock and hypotension are the chief features, both etiologically
and clinically, so that treatment consists in restoration of blood volume by transfusion.
This holds true even when there has been a transfusion reaction with, of course the
assurance of the complete compatibility of the blood.
The first few hours after the onset is the only time any attempt should be made
to produce a diuresis. In addition to transfusions, salt solution may be given intravenously to make up for fluid loss and to encourage renal secretion. Plasma may be
used for the same purpose. Price of Salt Lake City, in a comprehensive study of the
crush syndrome in animals, has shown that normal saline and plasma given immediately
have a decided diuretic effect and reduce the mortality rate in experimental animals.
However normal saline should not be continued beyond the first 24 hours, when the
oliguria of shock and vasoconstriction becomes the oliguria of tubular degeneration.
Here it has a decidedly opposite effect.
Page 218 Hypertonic glucose has no value in this early stage as a diuretic. It may be used
later for its caloric value. To overcome the vasoconstriction and renal ischemia, paravertebral and splanchnic block have been used and in a number of instances have been
successful in overcoming the primary oliguria.
More recently, for the same purpose, intravenous injections of procaine have been
recommended. Four mgm, per kg. or about 30 cc. of a 1 per cent solution for the
average man can be given slowly for about a 40 minute period. It has the additional
value of relieving pain and restlessness, particularly in cases of severe burns. In one
clinic it is given immediately to all children with burns, for both purposes, vasodilatation and sedation. The patient may be protected with barbiturates against a reaction.
However these methods to regulate the neurovascular mechanism are of value only in
the early primary vasoconstriction.   They are not effective in the later stages.
After 24 to 48 hours, the urinary suppression of shock and vasoconstriction becomes the suppression of tubular damage. In this stage it is important to keep in mind
that We have no means of accelerating the recovery of the tubular lesion. Attempts
to force the kidneys until this takes place spontaneously is not only futile but
dangerous. Abrupt cessation of urinary output, nitrogenous retention with impending
uremia, the anxiety of the patient and his family, all seem to constitute an imperative
call for action on the part of the attending physician.
Until recently, the temptation has rarely been resisted. It has been rather
common to give large amounts of fluids intravenously. In other words, if there is no
water flowing over the dam, the best way to start it is by pouring in more water on the
assumption that the patient is dehydrated while, in fact, the time that he is more likely
to be dehydrated is during the third stage when he is passing enormous quantities of
urine. This misconception has no doubt resulted in the death of many patients who
otherwise would have survived.
After the development of anuria, the patient retains all of his sodium. Water is also
retained to the extent of about one liter to every six or seven grams of salt and if you
pour in more water and add to his sodium by using saline solution, he become brine
soaked and water logged. This increases the interstitial edema in the kedney and prolongs the period of renal failure. Even if the tubular damage is not severe, spontaneous
diuresis may be delayed indefinitely because of the extracellular water salt overload
which make the fluid unavailable for excretion. Generalized edema follows with death
from cardiac overload and pulmonary edema. Just recently in a Seattle Hospital, a
nurse became anuric following an incompatible transfusion reaction during an operation. Under the direction of competent internists she was given 20,000 cc. of fluid
intravenously over a four day period and died promptly from pulmonary edema with a
chest full of fluid.
S In a statistical analysis of the time of death in this syndrome, it was found that
there are two peaks, the fourth to the fifth day and the eleventh to the thirteenth. The
deaths in this first period were not caused by uremia, but by pulmonary edema quite
often brought on by massive hydration. The current literature contains an increasing
number of articles stressing the overzealous administration of fluids and demonstrating
the marked reduction in the mortality rate of cases previously considered hopeless by
management aimed simply to guide the patient along to the point of spontaneous recovery.
Four points are stressed in this management:
1. A restriction of the fluid intake to just enough to replace the insensible loss
through the skin and lungs plus the urinary output. In the average case this should
be about 1000 to 1200 cc. in 24 hours, given by mouth and not intravenously unless
there is vomiting. Vomiting is not apt to be present unless the patient is overhydrated.
It has recently been shown that 1000 cc. of fluid daily in patients who are anuric
increases the blood volume more than 40 per cent and it has been recommended that
f '
Page 219 patients who are totally anuric be given no more than 500 cc. of water daily unless
vomiting, sweating, or diarrhea increase the demand.   •
2. To prevent starvation, the fluid is given in the form of a formula containing
about 1800 calories. This can be provided for by 250 cc. of medium cream, 2 eggs, 25
grams of lemon juice and 100 grams of lactose. Soft diets are encouraged early. Water
soluble vitamins should be given intravenously daily. If the patient is unable to retain
fluids or nutrition by mouth, then of course, it may be necessary to give them, intravenously, in which case 15 per -cent glucose is used for its caloric value, together with about
a half a unit of plasma daily.
3. Prevention of acidosis by moderate doses of sodium bicarbonate given by mouth
to keep the CO2 combining power of the plasma at or above fifty volumes per cent.
Excessive amounts are to be avoided but with severe acidosis, moderate doses, about four
grams per day, will not unduly increase the serum sodium concentration.
4. Digitalization at the first evidence of cardiac enlargement or pulmonary congestion and edema. In marked cardiac overload and pulmonary edema, in addition to
digitalis, venous section may give temporary relief. All diuretics should be avoided,
including the intravenous use of sodium sulphate. Finlay says, "It would be difficult to
devise a remedy more likely to induce hydremia."
Under this simple regime patients can be maintained in relatively good condition
until the kidneys open up and diuresis occurs which will be more prompt when they
are in a non-edematous state.
In very severe cases, this second or anuric phase may be unduly prolonged and the
retention of nitrogenous products become alarming. A number of measures are currently being advocated as a substitute for the kidney to get rid of these toxic products
by dialysis, and to act as holding over procedures until tubular regeneration occurs.
There are two methods of dialysis: the internal, which uses the gastrointestinal
tract or the peritoneum as a dialyzing membrane and the external, where the blood is
circulated outside the body in a dialyzing system or artificial kidney.
Early and overzealous attempts to reduce nitrogen retention are as unjustified as
excessive hydration during this second phase. These methods are complicated and not
without danger. They not only remove the non protein nitrogen, which they do
rapidly, but also the electrolytes. Carefully composed solutions must be used in the
dialysis or the body fluid and electrolyte balance is dangerously upset. They are frequently used at a time when spontaneous recovery is about to take place and are given
undue credit for the improvement. Maximum benefit from conservative treatment may
be expected up until the eighth to tenth day of anuria and intervention with mechanical
dialysis should be deferred until that time. If then there is no evidence of diuresis,
active measures may be undertaken as hold-over procedures.
Before discussing these measures briefly, something should be said about renal
decapsulation which is now receiving some attention as a method of treatment in this
stage. Its use is based on the assumption that the anuria is the result of interstitial
edema of the kidney which causes increased intrarenal pressure and that if this pressure
is relieved by splitting or stripping the capsule, secretion will begin. In evaluating
reports of favorable results from this procedure, we must again take into consideration
the natural course of the disease. No one can be sure that the decapsulation was not
done at the time urination was about to begin and that the operation was given undue
credit for the improvement. Also it may be that the added burden of a surgical procedure may delay diuresis or even be fatal.
In several instances control experiments have been reported in patients with transfusion kidneys, that is, indwelling catheters have been placed in both ureters and
decapsulation done on one side only. Shortly afterwards urine appeared simultaneously
in equal volumes on both sides and the function was actually better in the untreated
kidney than in the one operated upon.   Decapsulation has not been established as an
Page 220 effective method of treatment. However there is one circumstance in which it may be
indicated and that is when, because of overzealous hydration, there is a generalized
edema which is out of hand when the patient is first seen an drenal edema is obvious.
Under these circumstances, if it is done at all, it should be done early.
Of the internal methods of dialysis, peritoneal lavage was first used successfully by
Frank, Seligman and Fine in 1946 and there have been an increasing number of reports
with modifications of their method. They have also changed their procedure, both as to
the type of irrigation and the solution used for they found the original Tyrode solution
disturbed the water electrolyte balance. Odel and Ferris at the Mayo Clinic have
reported modifications.
It is impossible here to discuss the techniques of this procedure, which are described
in detail in the literature, except to say that it requires constant supervision to maintain
an adequate inflow and outflow. Peritonitis in some degree is inevitable and the difficulties of maintaining adequate water and electrolyte balance on both sides of the dialyzing
membrance is one of the most serious hazards.
I think we can sum up the present status of peritoneal lavage by quoting Fine,
the originator of the method. In a recent statement he said, "I am not optimistic about
peritoneal dialysis as a practical clinical method until we know more about contamination of the peritoneum. I am inclined to think that dialyzing machines will supersede
the other methods. Conservative treatment intelligently applied will often carry the
patient to recovery without the use of these methods."
A simpler method is the use of the gastrointestinal tract as a dialyzing membrane.
Marked reduction in the blood NPN can be brought about by continuous gastric lavage,
through a double nasal tube or a single tube with intermittent Wangensteen suction,
using 10 to 20 liters of water in 24 hours. However this method may upset the normal
electrolyte balance from the continuous removal of gastric hydrochloric acid with
alkalosis. Frequent estimations of the CO2 combining power have to be made and an
alkalosis avoided which will in itself aggravate the nephrosis. Continuous lavage of
the small intestine through complicated modifications of the Miller Abbott tube have
been advocated.
More encouraging results have been reported from the use of the artificial kidney.
This method consists in an arterio-venous shunt, the blood circulating through cellophane tubing that is exposed to a bath of dialyzing solutions. There are various ways
of doing this.
Kolff devised the first artificial kidney used successfully. Gordon Murray introduced
a system independently and there are an increasing number of modifications to overcome the inherent disadvantages and limitations of this method which require complicated appliances not available as yet for routine practice.
In general it can be said that if the methods of treatment as outlined are followed
in this stage, the necessity for mechanical dialysis will be greatly reduced. In one institution, study of a group of patients who were urgently referred for treatment with
the Kolff artificial kidney, showed that it was unnecessary and that diuresis and cure
occurred under conservative management.
While patience and watchful waiting are important in the second stage, prompt
and vigorous treatment may be necessary in the third or polyuric stage. When the
patient begins to make urine, he makes it in large quantities because of failure of tubular reabsorption. If water and salt are not replaced, he becomes dehydrated and develops hypochloremia with a shock-like state or convulsions. He may be lost when
the underlying renal disease is actually subsiding.
The treatment consists simply in measuring the urinary volume and the salt loss
and replacing them. The water need may reach 4000 to 5000 cc. daily, and is met
by forcing fluids by mouth and intravenous infusion. The salt loss which may reach as
high'as 30 to 40 grams a day as against a normal of 16 grams, is estimated by determining the urinary chlorides and replacing them gram for gram.
Page 221 Frequent estimation of blood chlorides for hypochloremia is complicated and expensive. The simplest method is to determine the urinary chlorides by the Fantus test
which is available to everybody. The requirements are a small test tube, a small
pipette, 20 per cent potassium chromate solution, 2.9 per cent silver nitrate and some
distilled water for rinsing the pipette. The test is performed by using 10 drops of
urine measured into a test tube. A drop of indicator (20 per cent potassium chromate
solution) is added. The silver nitrate solution is added drop by drop and the tube
shaken after each addition. The end point is a sharp color change from yellow to brown.
The number of drops of silver nitrate needed to produce the end point gives the concentration of chlorides in the urine, expressed as grams of sodium chloride per liter.
For example, 5 drops equal 5 grams of sodium chloride per liter. So knowing the
urinary volume you can accurately determine the sodium chloride output in 24 hours
and make replacements when it is in excess of normal. This salt losing diuresis may
last for about four to five days, and as tubular recovery progresses, water salt conservation takes place and the patient is allowed to regulate his own intake.
SUMMARIZATION OF THE LOWER NEPHRON NEPHROSIS
In summarization we can say that newer concepts of the underlying kidney lesions
and disturbed physiology in the acute renal failure, with oliguria and anuria caused by a
wide variety of conditions yet with exactly similar renal lesions, has led to a revision
of our management with definite reduction in the mortality rate. This departure from
the conventional treatment is based on the fact that the lower nephron nephrosis is a
self limited disease, that the damaged kidneys require time for healing and that we have
no means of hastening this regeneration or of forcing them to work until it occurs.
Because the syndrome is almost invariably associated with shock and prolonged hypotension as an etiological factor at its onset, transfusions and replacement of fluid
loss in the first 24 to 48 hours are indicated. We try to increase the blood flow to the
kidney by restoring normal circulation both in volume and pressure. As additional aids,
in overcoming the ischemia which results from the vasoconstriction set up by the
neurovascular defense mechanism, paravertebral and splanchnic block may be used,
but in this stage only.
Attempts to force the kidney to work during the anuric stage by forced hydration
may be fatal. The patient should be tided over by conservative management until
spontaneous diuresis occurs. Then we should be on the alert for water and chloride
depletion which may be excessive and has to be met at times with heroic measures.
Failure to carry out treatment based on these concepts has converted many relatively
milder into more severe forms of this disease.
FOR SALE
Examining table (oak) and stool (metal enamel).   Good condition.
906 Vancouver Block tfi
Phone MA 9445 THE LEGAL ASPECTS OF STERILIZATION
For the past five or six years the Canadian Medical Protective Association has become,
and is becoming still more, increasingly concerned over the casual attitude adopted by
doctors towards the sterilization of patients and over the consequent increase in the
number of sterilizations being done. There seems to be lacking in some doctors a full
realization of the implications, physical, mental and moral, of the operation. There seems
to be a failure to draw these considerations to the attention of patients who must be
sterilized or think they wish to be. Too few patients learn from their doctors the fact
that the operative results, in the light of present knowledge, are permanent. So far as
the Association can judge, sterilization is often done in a wholly casual, completely
thoughtless fashion, as an incidental and often unnecessary part of some other surgical
procedure, ^nost often without permission; it is being done, as well, for healthy individuals
who request it, usually for insufficient reasons of a temporary nature. There is not a
month but what the Association has to inform some enquiring doctors that they may not
accede to requests from healthy persons for sterilization, that such a procedure must be
considered illegal till shown to be otherwise. If some doctors are enquiring before doing
it there must be others who do it without enquiring. There can be little doubt that in
the future some of these surgeons will find themselves in court trying to defend themselves against charges of assault and battery. That the Association's fears have not been
baseless is shown by the fact that one member had to be defended in April, 1947, in a
suit arisnig from alleged illegal sterilization, and by the fact that another is at present
faced with threat of suit for the same reason.
The case tried in April, 1947, illustrates the trouble that may arise when sterilization
is done as part of another operation without adequate previous explanation to both the
patient and the marital partner. A patient's family doctor referred a thirty-seven year
old woman, who had had two children, to a surgeon because of an enlarging ovarian
tumour. In the preliminary discussions with the family doctor the patient said to him
"Could I be fixed so that I would not have any more children?" but no decision was
reached between man and wife, there was no discussion between them about the matter,
and the surgeon was not instructed before operation that strilization was permissible.
At operation, at which a dermoid cyst of the ovary was removed, the surgeon asked the
family doctor, "Do they want sterilization by cutting off the other tube?", and the family doctor said that was his belief. With no more knowledge of the patient's wishes than
was conveyed by that conversation the surgeon did an Irving sterilization of the remaining tube.
Within three months of the operation the husband and wife were threatening suit on
the grounds of unnecessary and unauthorized surgery, this in spite of the fact that the
patient stated to the surgeon "quite freely that she had told (her doctor) that 'she did
*not want more children' but that she 'would never have consented to a sterilization
■operation'." Shortly thereafter through a lawyer a clainTfor damages was received, on
the ground that the husband and wife "assert that the unauthorized sterilization of the
wife constitutes a trespass by you upon her person, which is actionable . . . and they
propose to commence proceedings against you in the Courts on the ground that you have
sommitted an assault and battery against the wife for which you are liable in damaees."
That point should be noted particularly. The Association's General Counsel, Mr. J. D.
Watt, K.C., drew attention to it later, "The plaintiffs in this case are suing for damages
as a result of trespass, assault and battery upon the person of the female plaintiff by the
defendants.  It is not the same as an ordinary action for malpractice. . . ."
The case came to trial in Hamilton, Ontario, before Mr. Justice Kelly and a jury.
After two and a half days of evidence and argument the action was dismissed by the
Judge on the findings of the jury. It had to be decided by the jury whether the patient's
remarks to the doctor constituted consent, expressed or implied, for the operation and
whether the husband, by his actions prior to the operation, had given his consent, implied
Page 223 or expressed, to his wife being sterilized.   The jury found that both the husband and
wife had consented to the operation.
That the Trial Judge may not have agreed wholly with the findings of the jury is
suggested by his reasons for depriving the doctors of the costs of the action. These
reasons are worth quoting because they draw attention to the wisdom and indeed
necessity, of having preoperative permission for sterilization in any case where it may
have to be done. Mr. Justice Kelly said:
"However, my main reason is the fact that (the doctor) admitted in his evidence
that he was only consulted by the female plaintiff and that he acted upon her request
(which was denied by the female plaintiff) and (the doctor) admitted that he did not
discuss the operation nor the possible sterilization of the female plaintiff with her husband.
"As the relationship between a husband and wife is not only confidential, but it is of
the most intimate nature and is attended upon with such far-reaching consequences,
I am of the opinion that anything that might be done which would interfere with such
a sacred relationship and its consequences should be undertaken only with the consent
of both parties and after discussion with the parties and advising them upon the consequences. Our laws recognize the mutual responsibility between husband and wife and
we have actions in our Courts claiming nullity of marriage based on sterility of one or
other of the life partners. It, therefore, follows that any operation performed upon a
wife which would interfere with that intimate relationship and its responsibilities and
consequences should be authorized or consented to by both spouses.
"The jury in this action found that there was a tacit consent by the husband, but
both defendants admitted in evidence that neither of them had received the husband's
consent nor had even consulted him. I am of the opinion that they were not justified
in cutting the second Fallopian tube, which was not necessary for her condition, with the
consent only of the wife, hence my decision that the defendants should be deprived of
their costs of the action."
The case cited above may serve as the introduction to a short and necessarily incomplete discussion of the legal aspects of sterilization. What is its legal status? When is
it legal, and when illegal?
In a general sense the usual rules about explanation of and permission for any
diagnostic and therapeutic procedure apply to sterilization. It is~ necessary for the
patient to know the nature and the results of the proposed treatment; it is necessary
for the patient, knowing these things, to give permission for the procedure. Because
emergencies seldom or never arise when sterilization is a life-saving measure it never need
be done without permission. If it may be necessary as a part of some operation the
possibility should be explained to the patient before the operation.
In a particular sense sterilization is legal when it is an incidental part of a medical
or surgical procedure necessary for the preservation of the life or health of the individual.
Under all other circumstances, sterilization is illegal and the doctor who does it under
any other circumstances, because he is doing an illegal act, exposes himself to the risk
that he may be sued, not for malpractice or negligfence in a professional sense, but for
common assault and battery and he may, therefore, be deprived of the protection of the
Medical Act.
Some discussion and amplification of the particular rule may be helpful. That sterilization is legal when it necessarily results from a procedure which must be done to save
life requires little comment. Malignancy of the uterus, of the testicles or penis, exsanguinating haemorrhage, acute or chronic, because of uterine fibroids, these and a
number of other conditions all require for their cure or eradication treatment which
coincidentally means sterilization. No treatment other than that involving sterilization
incidentally has any hope of success. Even under these circumstances, however, an explanation of the proposed procedure and its necessity, adapted to the individual's understanding and sufficiently clear to allow understanding, should be made to the patient
Page 224 and in some cases to the marital partner. Permission should be obtained after the
explanation and it should be written, dated, and witnessed. This may be a part of the
usual operative consent or may be a separate consent appropriately drawn.
Much more thought and care are necessary in the understanding and application of
th erule to the group where sterilization is legal because it is done for the preservation
of the health of the individual. The words "necessary for the preservation of health"
should be applied literally, always. Reasons here must always be reasons, not excuses;
they should be such that any reasonable doctor could accept them and defend them if
need arose. There should always be a consultation at which the consultant is allowed
to arrive independently at his own decision and, if he agrees, both doctors should write
their reasons and opinions. Explanations should be particularly clear and the permanence
of the resulting sterility stated emphatically. Only then should permission be sought,
from both husband and wife; if obtained it should be in writing, it should be dated,
signed, and witnessed.
Voluntary sterilization of the healthy is a wholly separate and different problem.
Excluding from the discussion those cases covered by one or two Provincial Acts allowing sterilization under specific conditions, voluntary sterilization of the healthy must be
considered wholly illegal. Under British law it is considered in the best interests of the
individual and the state for each individual to retain his or her procreative powers. Requests from healthy individuals, man or woman, for sterilization must be refused,
promptly and finally.
Too many doctors feel that signed permission protects them against any legal consequences of their act. One cannot obtain "permission" to perform an illegal act.
Therefore no "permission" may be granted for it and the signed permission or request
of the person wishing sterilization probably would not stand up in court if it were
questioned later. No "reasons" could be brought forward for having performed voluntary sterilization, no life was saved and no health preserved by it. The person whose
life was saved or health restored by an operation which incidentally resulted in sterilization may regret the sterility but cannot question the need for it or sue successfully for
damages because of it. But the person for whom neither of these things is true, if he
or she regrets it later, is likely to sue and it is very unlikely that the doctor could
defend himself successfully.
Doctors need to keep clear in their own minds the fact that patients desiring
sterilization have only excuses for getting it done, not reasons. There can be no reason
for sterilizing a man who wishes to protect his invalid wife against further pregnancies,
there may be reasons why she should be thus protected, but his sterilization is wholly
unjustifiable. How can the doctor defend himself should action be brought against him
later because the husband wants children with a second wife after his invalid wife's
death? There can be no reason for sterilizing a woman because she thinks she wishes
no more children. How can the doctor defend himself should action be brought against
fum later because the woman desirse more children, having lost her others, or having
remarried after having been widowed? A little clear thought will show the indefensibility
of the position of a doctor who has done either of these things.
To sum up: sterilization of an individual is subject to the same rules, having to do
with explanation and permission, that apply to any other medical procedure. It is legal
when a necessary part of a life-saving procedure and its necessity should be explained to
the patient, and sometimes the marital partner, and written permission should be obtained. Sterilization for the preservation of health should be preceded by careful thought,
by consultation, by written opinion of the doctors stating their reasons, by the signed
and witnessed permission of both marital partners. Voluntary sterilization of the
healthy should never be dene.
Page 225 ■
1  -;\
m
western Society for physical rehabilitation
Rehabilitation Centre, 900 West 27th Ave., Vancouver
The above is a rather lengthy title, but it is the title of one of the most important
projects that has ever been undertaken in Vancouver. It represents the culmination of
a great deal of work and effort, and the realization of a noble inspiration.
We in Vancouver will all remember the work of the Canadian School of Physical
Re-education which has been carried on by Mr. Martin Berry and has been so successful.
The quarters in which this work was done were merely temporary and quite inadequate:
but the work itself was so successful and promising that a group of business and medical
men undertook to promote a much larger centre, for the physical rehabilitation of young
people severely disabled by paralysis. The result is the present Rehabilitation Centre,
a well-equipped and well-sited building near Shaughnessy Hospital. It has been so designed that additions for a swimming pool, an additional bedroom wing, etc., can be
added as they are needed: indeed, they are now coming under construction.
This is the first centre of the kind in Canada, and Vancouver may well be proud
of it.
A short description of the history of the centre will be in order. A Board of
Directors was chosen in 1947 under the chairmanship of Dr. G. F. Strong, to whom a
great deal of the credit, to put it very conservatively, is due. Those who know Dr.
Strong will know that there would be no lack of efficiency and driving power with him
as the leader, and he had colleagues who were equally keen and devoted to the realization
of the project. Building plans were prepared, and Mr. Ross Lort, well-known Vancouver architect, was put in charge of these, and of the actual building.
The initial cost, including site, building and equipment, was put at $150,000. Ever}
cent of this has been provided by private subscription. It is hoped that later on a government grant may be obtained for maintenance. Further buildings will be added as
and when necessary. *-|p
The Kinsmen Club of Vancouver purchased the site for the building, and the furnishings for the bedroom wing. In all, a total of $200,000 has been raised, from private
citizens, business and industry. The Centre has been in operation since January 3, 1949,
and was officially opened on January 17. Its staff includes a full-time medical director,
Dr. William Thompson; a Director of Physical Therapy, Dr. George A. Greaves; physical
training instructors, especially trained for this work; training and vocational counsellors,
a matron and orderly, and necessary domestic staff. The manager is Mr. E. J. Des-
jardins, to whom I am indebted for a great deal of the information herein contained.
The work of this Centre is designed to serve:
1. Paraplegics,  both veteran  and  civilian.
2. Victims of poliomyelitis.
3. Spastic children.
4. Double-leg amputees.
5. Any orthopaedically disabled individuals who will benefit by this type of treat-
Its method and purpose are the rehabilitation of these people physically, and their
training vocationally, so that they may take their full place in industry, business, or any
vocation for which they are fitted. It neutralizes the handicap that their disability
imposes, and restores them to full, usefulness and independence. Patients from every
part of British Columbia are eligible for treatment. This treatment cannot be carried
done except at a fully equipped and scientifically designed Centre.    The plan of this
Page 226 Centre is based on the lines laid down by the Baruch Committee on Physical Medicine
in New York.
The writer of this brief sketch spent an enjoyable hour visiting the Centre and talking with Mr. Desjardins, the manager, who was most friendly and cordial. Dr. Geo.
A. Greaves, the Director of Physical Medicine, late in charge of the Physical Medicine
Department of the Vancouver General Hospital, acted as my guide and took me around.
He gave me full accounts of the work of each department. It is a beautiful building
for the purpose, full of light; comfortably, even luxuriously, furnished—and nothing
will be lacking in the way of equipment when the plans are completed. There are some
ten patients under treatment at present, but ultimately there will be thirty or more.
Twenty to thirty new cases a year are expected—but as Dr. Greaves pointed out, it is
difficult at present to assess the number in British Columbia who would benefit by this
type of treatment.    As time goes on, however, more definite statistics will be available.
It would pay every medical man to go and see this Centre for himself, and realize
what a monumental piece of work has been done here, and how far-reaching its effects
are liable to be. It provides hope and a new outlook on life for those unfairly handicapped young people whom it serves, for it is mainly designed for young people; but it
does something else besides: it salvages, for the benefit of the community, as a whole,
some of our most valuable and precious material—bodies and minds and energies which
are needed in our community, and which would otherwise be utterly wasted. Even
from an economic standpoint, it is worth while, since it makes these people self-supporting—but from the standpoint of a larger and more significant human need, that of
independence and self-support and self-respect, it is doing a far greater work. Our
congratulations and thanks must go to all who made this Centre an accomplished fact,
and we wish them continued and ever increasing success. WHAT TO DO WITH BURNED OUT FLUORESCENT TUBES
(The following note, taken from the Industrial Health Bulletin, published by the
Department of National Health and Welfare at Ottawa, is of interest and importance
to all those who work in buildings or offices where there is fluorescent lighting.
Many doctors work in such buildings, or have had fluorescent lighting installed in
their offices. Our Library has them installed. It is very important that all who work
in proximity to these lights should know the dangers that may threaten them, in case
of breakage, and should know how to handle them when burned out. We therefore
print this article in full in the Bulletin.—Ed.)
A serious health hazard has developed due to the increasing use of fluorescent lighting
in industry. The fluorescent tubes are coated on the inside with a powder containing
the element beryllium. If particles of glass carrying this powder get under the skin
the material may delay the healing of wounds and lead to chronic inflammation and
tumour-like growths.
Fluorescent tubes are made of thin glass which shatters into fine, penetrating particles when the tubes are broken. It is urged that all maintenance men, factory operators, janitors and salvage employees be made aware of the hazards of breaking fluorescent
tubes. Anyone accidentally breaking a fluorescent bulb should receive medical attention
immediately to discover whether he has been cut by the beryllium-contaminated glass.
Great care should be taken in disposing of burned out tubes. No attempt should
ever be made to salvage or reclaim the powder from the lamps as inhalation of the
powder can lead to serious lung damage. At home used tubes should not be put in the-
household incinerator or placed within reach of children. In disposing of used tubes in
industry full protective goggles should be worn and the operations carried out in such
fashion as to prevent the possibility of injury from flying glass. When a small number
of fluorescent lamps are broken the following precautions are to be taken:
(a) Break all tubes out-of-doors in a waste disposal area or in a waste container.
(b) Avoid breathing dust and vapors that may be evolved.
The following rules should be followed when disposing of large numbers of fluorescent lamps:
(a) Break lamps out-of-doors in a waste disposal area or in a ventilated hood. To
avoid unnecessary dust the breakage is best done within the waste container.
(b) The operator should be supplied with and required to wear a respirator approved
for toxic dusts.
(c) Ultimate disposal of the broken lamps should be such that the public and others
will not be unduly exposed to powders. In situations where it is necessary to break
lamps within buildings it should be done in an isolated room and in a hood so as to
minimize escape of dusts. Sufficient exhaust ventilation should be supplied to the hood
to provide an air intake of at least 125 linear feet per minute at th& breathing level. n
ew5 an
d rioted
Vancouver and Victoria were joint hosts to the Canadian Gynaecological Travel
Society. Their Annual Meeting convened in Vancouver and the concluding session was
held in Victoria.  Dr. J. B. Roberts of Victoria was one of the guest speakers.
We are happy to extend our congratulations to Dr. and Mrs. G. H. E. Green on the
occasion of their silver wedding anniversary.
Dr. E. E. Rogers has received an award of the Gold Medal of the Distinguished
Service Foundation of Optometry. The award presented in Boston recently, is for
twenty years of research in the cause of disease and toxic conditions.
Dr. W. J. Stark has returned from Los Angeles and has taken up practice in Victoria.
Dr. E. R. Hall formerly of Chemainus is now practising at Alert Bay.
Dr. J. H. Chataway has left Williams Lake to make his home in Nanaimo.
Dr. E. M. Hughes formerly of Vancouver is now practising in Duncan.
Dr. Donald S. Munroe has been named "delegate at large" to the American Heart
Association. His appointment follows the Annual Meeting of the Association recently
held at Atlantic City, N.J.
Congratulations and best wishes are extended to Dr. and Mrs. G. J. McKenzie and
Dr. and Mrs. I. S. Kaleal, on their recent marriages.
Dr. J. T. Hugill, who has recently completed a post-graduate course at the Children's Memorial Hospital in Montreal, is now on the staff of the West Coast General
Hospital at Port Alberni.
Dr. J. McLean was named a member of council of the Canadian Ophthalmologicai
Society at its Annual Meeting recently held at Jasper, Alta.
Dr. W. P. Fister is leaving Essondale to take a post-graduate course at the Neurological Institute in Montreal.
Dr. V. W. Pepper has gone to the University of Toronto for post-graduate studies
in anatomy.
Dr. G. R. Finley formerly of Cranbrook is now practising in New Westminster.
Our congratulations are extended to the following doctors and their wives on their
recent good fortune:
Dr. and Mrs. W. C. Fisher, a son.
Dr. and Mrs. Bruce MacKay, a son.
\  Dr. and Mrs. J. G. Paterson, a son.
Dr. J. D. Stevenson has gone to the Temple University Hospital in Philadelphia, Pa.,
for a residency in the Department of Radiology.
Dr. K. C. Boyce is taking post-graduate studies at Queen's University in Kingston.
Dr. A. E. Rose of Langley Prairie has left for Toronto enroute to the world conference on tuberculosis.
Dr. R. E. Simpson who has been on the staff at Shaughnessy Hospital has gone to
Toronto where he will do post-graduate work in anaesthesia at Western Hospital.
Dr. Robin Bell-Irving has left Vancouver to take up residence in Montreal, Que.
Dr. R. Gale formerly of Duncan is now practising in Victoria.
We regret to record the death of Dr. Lawrence Broe of Port Hammond. Dr. Broe
received his M.B. in Toronto and after internship in the Vancouver General Hospital set
up practice in Port Hammond, where he has been active for the past 35 years. Our
deepest sympathy is extended to Mrs. Broe and family.
Page 229 %s
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In Cardiovascular^Failure...
salt without sodium
.«» .
». •
• * *
*   ..
. .
®
Sodium restriction is an essential part of the modern
management of cardiovascular failure. But,
without seasoning, low sodium diets are difficult to
endure. Neocurtasal, completely sodium free salt,
palatably seasons all foods. Neocurtasal looks
and is used like ordinary table salt. Available
in convenient 2 oz. shakers and 8 oz. bottles.
Constituents: Potassium chloride,
ammonium chloride, potassium formate, calcium
formate, magnesium citrate and starch.
Potassium content 36%; chloride 39.3%;
calcium 0.3%; magnesium 0.2%.
Neocurtasal, trademark reg. U. S. * Canada      Write for pads of diet sheets.
WW Yonc 13. N. r.     Wmosos, Ont.
.*:«*</

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