History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1950 Vancouver Medical Association Oct 31, 1950

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 STOJRAGt   ITEM
WOODWARD
|   Wd2—
1 U.B.C. UBRARY   . ■     ;:
BB  & & MEDICAL CENTRE  BULLETIN
OF THE
VANCOUVER MEDICAL ASSOCIATION
INDEX TO VOLUME 27-1950-1951 BULLETIN OF THE VANCOUVER MEDICAL ASSOCIATION
INDEX TO VOLUME 27, 1951-52
ABDOMEN,  The Acute—L.  H.  Appleby  p£;?-| - ,Jfi^ ■■  227
ACADEMY OF MEDICINE - - 1811"  25°
ACTH—Treatment   of  Ocular  Disease—J.   F.   Minnes 1 .^£  252
ALBUMINURIA IN  CHILDREN—A.  L.  Chute....|j|l|j§i i -  17
ALLERGY AND  ANAPHYLAXIS—C.   H.   A.   Walton..... ||§L -  268
AMBULANCE SERVICE—City of Vancouver Social Service Depf  187
APPLEBY,  %.  H.—The Acute Abdomen -M- 0-  227
AUSTRALIA—National   Health  Plan—Pharmaceutical   Benefits | ..~ —~ 188
BAGNALL, A. W.—Diagnostic Criteria of Rheumatoid Arthritis and Spondylitis  119
BAGNALL, A. W.—Treatment of Marie Strumpell  Spondylitis   —-    60
BAKER,  H.—Some Recent Advances  in Pediatrics.... ......    62
BALFOUR,   J.—Ureteral   Calculi    Wh£. ~J|. -||;- --.: | I 281
BIRTH  FORMS—New,  Physician's  Notices  of     83
BLOOD   TRANSFUSION   SERVICE,   Canadian   Red   Cross—Letter { p|&  115
BOOK REVIEWS:
British Medical Bulletin  ...... §    58
Commonsense Psychiatry of Dr. Adolf Meyer—A.  Lief .' :. .    6
Diet Manual of/ Montreal General Hospital.. i .^iasfe... jj I  31
Florence   Nightingale,    1820-1910—C.   Woodham-Smith .i^I::. ..... 186
Headache and Other Head Pain—H. G. Wolff.....;i|||pL -21t§l 216
Huang Ti Nei Ching Su Wen: The Yellow Emperor's Classic of Internal Medicine—
I.   Veith *3|||||g||:----- Jf. %SSj§* HPli  267
Principles of Medical Statistics—A.  Bradford Hill ;. ...:..\.:2 ........  139
Progress in Gynecology, Vol. II, edited by J. V. Meigs and S. H. Sturgis  161
Technique of Pulmonary Resection—R. H. Overholt and L.' Langer  244
Varicose Veins—R.  R.  Foote     _  82
BRITISH   COLUMBIA   MEDICAL   RESEARCH   INSTITUTE  161
CANADIAN ARTHRITIS  AND  RHEUMATISM  SOCIETY.
CANADIAN MEDICAL ASSOCIATION—B.C. Division—
Annual   Meeting    ......  -^1
Election   Results —    ."...l~__...r
CANADIAN  RED  CROSS   BLOOD   TRANSFUSION   SERVICE—letter...
CANADIAN  RED   CROSS   SOCIETY..._..^||.,  --  ^i - ..-   32,
CANCER,  Detection of Gynaecological—D.  E. Cannell..':^^^^^^^^. ._	
CANCER,  Hormone Therapy in—J.  E.  Gregory._4?^fer— —.  .... .". 	
CANNELL,  D.  E.—Detection  of Gynaecological  Cancer ,.,...2^.	
CANNELL, D. E.—Management of the Menopause _	
CANNELL,   D.   E.—Post-Partum   Haemorrhage^:.,.......; 1	
CARE OF THE DYING—F.  Hebb l^^m^vM|i|:.. p	
CHEST  X-RAYS—Hospital   Admissions   E	
CHILD—MENTALLY DEFECTIVE, IN BRITISH COLUMBIA—A. F. Haryment	
CHUTE, A. L.—Significance of Albuminuria  in Children	
CHUTE, A. L.—Significance and Management of Hypoglycemia in Children..,.	
COLLEGE OF PHYSICIANS AND SURGEONS OF B.C.—-
Letter re  Laboratories   k .^^iSSp&i	
Results  of  Elections   -'-Sip gg| Pfel	
COMMUNICABLE  DISEASES   REPORTED   IN  CITY  OF  VANCOUVER. .... I 3,
55,  79,  104,   136,   183,  214,  242,   264]
CONSENT FORMS FOR OUT OF TOWN PATIENTS ADMITTED TO VANCOUVER
HOSPITALS'^. .......	
CRIPPLING DISEASES OF CHILDREN—Report on the Survey of;
made in the Province of British Columbia,  October,  1950	
07
DesBRISAY,  H.  A.—Osier  Lecture—Dry  Bones  of Antiquity  T63
DIABETES MELLITUS,  SOME ASPECTS OF—R. B.  Kerr ...lUlm
DOCTOR TAKES A TRIP,  THE—R. E.  McKechnie ........ | '._„:   129
DRY  BONES  OF ANTIQUITY—Osier  Lecture—H.  A.   DesBrisay ; 1  163
DYING,  THE CARE OF—F. Hebb S ..., ;. 177 EDITOR'S   PAGE  ...,.^e....-..'|££ I 4,   28,   56,   80,   105,   137,   159,   184,   215,   243,   265,   289
EDITOR,  THE—On  Writing of  Papers &. L^^^^^^Si:..—:^^^^^.        9
EYES   AND  GENERAL  PRACTICE—Meyer  Wiener 7..^ ......... _ 69,     71
EYES,   The   Care  of  Children's   Eyes—Meyer   Wiener.....^^^;:.... |§|| Hpl  -  125
ECTRASYSTOLES,   CLINICAL  SIGNIFICANCE  OF—J.   Freundlich   155
FREUNDLICH,   J.—Clinical   Significance   of  Extrasystoles
a
GENERAL    PRACTICE   AND   EYES—Meyer   Wiener.,^ ,  69,     71
GENERAL  PRACTITIONER AND  OPHTHALMOLOGIST—Meyer Wiener P§§^?®    64
GREGORY, J. E.—Hormone Therapy in Cancer ,...^L„...i£ __    39
GULF  ISLAND  IMPROVEMENT   BUREAU     217
H
HAEMORRHAGE,  POST-PARTUM—D.  E.  Cannell                          l-^Si    - 231
HARDYMENT, A. F.—The Mentally Defective Child in B.C 'M^^.-....-. 152
HEART—Clinical Significance of Extrasystoles—J.  Freundlich  155
HEBB,  F.—The Care of the Dying p| .-  177
HORMONE  THERAPY  IN CANCER—J.   E.  Gregory Jlu.-. I  39
HOSPITAL  BEDS  — Correspondence,-|=S|pL :.r'. |  105
HYPOGLYCEMIA IN CHILDREN, Significance and Management—A.  L. Chute  33
I
INFANTS—Premature, Routine Care for—P. H. Spohn   142
INTRAVENOUS THERAPY BY REGISTERED  NURSES—letter _:......;     59
KERR, R. B—Some Aspects of Diabetes Mellitus jsf; 171
E
LEUKEMIA   RESEARCH—M.   L.   Menton... .Lr|||||i;....._        8
LEWIS, H.—Tuberculosis Pleural Effusion     S.     45
LIBRARY NOTES.....^ =    --r*jl- -if—5' 30> 58-, 82, 116, 138, 160, 186, 216, 244, 267
LISTER, LORD—His Times and His Work—H. H. Murphy     86
M
McKECHNIE,  R.  E.—The Doctor  Takes a  Trip.. il| ...Jp:.-...:.  129
MEDICO-LEGAL  SOCIETY  OF B.C ...:...... ,.   ,     13
MENOPAUSE,  THE MANAGEMENT OF THE—D. E.  Cannell .;|1^,..<J|| 221
MENTALL DEFECTIVE CHILD IN B.C.—A.  F. Hardyment :....   152
MENTON,. M.   L.—Research   in   Leukemia | 1        8-
MINNES, J. F.—ACTH in the Treatment of Ocular Disease..—^;. .-.  252
MUNROE, D. S.—Diagnosis and Differential Diagnoss of Acute Pericarditis .^2*...... 234
MURPHY,   H.   H.—Lord   Lister—His   Times   and   His   Work..^.     86
IT
NEWS  AND   NOTES.
OBITUARIES
Dr. Howard Coulthard     1......— r- ....-. - - —~      51
Dr.  A.  B.   Schinbein .|| :^^m^^0fi^-——-     52
Dr.  H.  L.  Turnbull...#£-—.:^pu ....^^_.. ,-?---> -'- -      51
OCULAR DISEASE,  ACTH in  the  Treatment  of—J.  F.  Minnes  252
OPHTHALMOLOGIST AND GENERAL  PRACTITIONER—Meyer  Wiener....        64
OPHTHALMOSCOPIC EXAMINATION,  The  Importance to the Internes of a
Systematic   Routine   in   —.-.   — -— pp   §jS - -   122
OSLER LECTURE—Dry Bones  of  Antiquity—H.  A.   DesBrisay..:.^^^ ,-^Tt--Q^-A 163
PAPERS,   ON   THE   WRITING   OF—The   Editor...:^ lliip ~""    9
PEDIATRICS,   Some  Recent   Advances—H.   Baker |^ s^.,. — :fe"     62
PERICARDITIS, The Diagnosis and Differential Diagnosis of Acute—D.  S. Munroe......^ 234
POTASSIUM  ION,  Clinical  Importance  of  the—H.   S.  Robinson... . 205
PREMATURE   INFANTS-—Routine   Care   for—P.   H.   Spohn.
PRINCE   RUPERT   MEDICAL   ASSOCIATION—Annual   Meeting.
PSYCHIATRY IN  GENERAL  PRACTICE—W.  Donald  Ross -g|: 245,   274, RHEUMATIC FEVER IN CHILDREN—P. H.  Spohn ; M.. -. 14
RHEUMATIC FEVER—Diagnosis and Management—M.  Young _  43
RHEUMATOID  ARTHRITIS  AND   SPONDYLITIS,   DIAGNOSTIC   CRITERIA—
A.   W.   Bagnall .^  119
ROBERTSON,  H.  ROCKE—Surgical  Infections  255
ROBINSON,  H.   S.—The Clinical  Importance  of  the  Potassium   Ion . |  205
ROSS,   W.   DONALD—Psychiatry   in   General   Practice \ 245,    274,   278, 300
S
-Rheumatic  Fever  in  Children _jg[:     14
-Routine Care for Premature  Infants \ — '%■:: 1  142
Diagnostic Criteria of Rheumatoid Arthritis and—-A. W.  Bagnall  119
Treatment  of   Marie   Strumpell—A.   W.   Bagnall _     60
SURGICAL INFECTIONS—H.  Rocke Robertson -Slife-   -  255
SPOHN, P. H.-
SPOHN, P. H-
SPONDYDITIS,
SPONDYLITIS,
TUBERCULOSIS   PLEURAL  EFFUSION—H.   Lewis.
45
URETERAL CALCULI—J.  Balfour
281
V
VANCOUVER HEALTH  DEPARTMENT,   Cases   of  Communicable   Diseases   reported—
3,   27,   55,   79,   104,   136,   183,   214,   242,   264,   288
VANCOUVER  HOSPITALS,   Consent  Forms  for  Out-of-Town  Patients  admitted  to.——-  156
VANCOUVER  MEDICAL  ASSOCIATION
Annual Reports -2|Sf- ....«<..:^.  189
Annual   Report   Summer   School,   1950 .- '. ;...—.  .I-t::-!       7
Report re various monies held by —.:.. ..:. 117
Summer School Registration List.......i^&i—IpSE   — !§| 218
W
WALTON,  C.  H.  A.—Allergy and Anaphylaxis \ :|g 268
WIENER,  MEYER—General   Practitioner  and   Opthalmologist     64
WIENER,  MEYER—General  Practice  and  Eyes...' , 69,    71
WIENER,   MEYER—The   Care  of  Children's   Eyes   125
XYZ
YOUNG,  M.—Rheumatic  Fever—Diagnosis   and  Management |   ip-    43
X-RAYS—CHEST,   Hospital   Admissions ,-Jfc.. ,—,. -  313 T H E
BULLET!
OF
The Vancouver Medical Association
EDITOR:
DR. J. H. MacDERMOT
EDITORIAL BOARD
DR. D. E. H. CLEVELAND DR. J. H. B. GRANT
DR. H. A. DesBRISAY DR. D. A. STEELE
Publisher and Advertising Manager
W. E. G. MACDONALD
VOL. XXVII
OCTOBER, 1950
OFFICERS  1950-51
Dr. Henry Scott Dr. J. C. Grimson Dr. W. J. Dorrance
President Vice-President Past President
Dr. Gordon Burke Dr. E. C. McCoy
Hon. Treasurer Hon. Secretary
Additional Members of Executive:
Dr. J. H. Black Dr. D. S. Munroe
TRUSTEES
Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Bye, Ear, Nose and Throat
Dr. N. J. Blair. 1 Chairman Dr. B. W. Tanton Secretary
Paediatric
Dr. C. J. Trefry Chairman Dr. Peter Spohn Secretary
Orthopaedic and Traumatic Surgery
Dr. D. E. Starr. Chairman Dr. A. S. McConkey Secretary
Neurology and Psychiatry
Dr. F. E. McNair Chairman Dr. R. Whitman Secretary
Radiology
Dr. Andrew Turnbull Chairman Dr. W. L. Sloan Secretary
STANDING COMMITTEES
Library:
Dr. E. France Word, Chairman; Dr. A. F. Hardyment, Secretary;
Dr. F. S. Hobbs, Dr. J. L. Parnell, Dr. S. E. C. Turvey, Dr. J. E. Walker
Co-ordination of Medical Meetings Committee:
Dr. R. A. Stanley Chairman Dr. W. E. Austin Secretary
Summer School:
Dr. E. A. Campbell, Chairman; Dr. Gordon C. Large, Secretary;
Dr. A. C. Gardner Frost; Dr. Peter Lehmann; Dr. J. H. Black;
Dr. B. T. H. Marteinsson.
Medical Economics:
Dr. F. L. Skinner, Chairman; Dr. E. C. McCoy, Dr. T. R. Sarjeant,
Dr. W. L. Sloan, Dr. J. A. Ganshorn, Dr. E. A. Jones, Dr. G. Clement.
Credentials:
Dr. G. A. Davidson, Dr. Gordon C. Johnston, Dr. W. J. Dorrance
Special Committee—Public Relations:
Dr. Gordon C. Johnston, Chairman; Dr. J. L. Parnell, Dr. F. L. Skinner
Representative to B. C. Medical Association: Dr. W. J. Dorrance
Representative to V.O.N. Advisory Board: Dr. Isabel Day
Representative to Greater Vancouver Health League: Dr. L. A. Patterson VANCOUVER MEDICAL ASSOCIATION
PROGRAMME FOR THE FIFTY-THIRD ANNUAL SESSION
(Fall Season)
Founded 1898; Incorporated 1906.
NOVEMBER 7th—GENERAL MEETING—Speaker: Mr. L. Detwiller, Commissioner
British Columbia Hospital Insurance. Also time devoted to Medical Economics
discussion.   (TUBERCULOSIS INSTITUTE AUDITORIUM)  8:00 p.m.
NOVEMBER 22nd—WEDNESDAY—ANNUAL DINNER—COMMODORE CABARET, 7:00 p.m. K
DECEMBER 5th—GENERAL MEETING—Speaker: Dr. Sydney M. Friedman, Professor and Head of the Department of Anatomy, University of British Columbia.
Subject: "The application of Renal Function Tests to the Study of Heart Disease."
(TUBERCULOSIS INSTITUTE AUDITORIUUM), 8:00 p.m.
REGULAR MONTHLY MEDICAL  MEETINGS
FIRST TUESDAY—GENERAL MEETING—Vancouver Medical Association—T. B.
Auditorium. 'm&
Clinical Meetings, which members of the Vancouver Medical Association are invited
to attend, will be held each month as follows:
SECOND TUESDAY—SHAUGHNESSY HOSPITAL STAFF MEETING.
THIRD TUESDAY—ST. PAUL'S HOSPITAL STAFF MEETING.
FOURTH TUESDAY—VANCOUVER GENERAL HOSPITAL STAFF MEETING.
FIFTH TUESDAY—(when one occurs)—CHILDREN'S HOSPITAL STAFF MEETING.
Notice and programmme of all meetings will be circularized by the Executive Office
of the Vancouver Medical Association.
Dates of Refresher Courses and weekly fixed meetings in the various hospitals.
VANCOUVER GENERAL HOSPITAL
Refresher Courses for the General Practitioner
MEDICINE—November 15 th, 16th, 17th.
NEUROLOGY, NEUROSURGERY and PSYCHIATRY—January 15th, 16th, 17th,
1951.
SURGERY—February 12th, 13 th, 14th, 1951.
EYE, EAR, NOSE and THROAT—March 5 th, 6 th, 7th, 1951.
OBSTETRICS and GYNAECOLOGY—April 9th, 10th, 11th, 1951.
Regular Weekly Fixtures in the Lecture Hall
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic,
edition, 1950.
Page 1 ST. PAUL'S HOSPITAL
Regular Weekly Fixtures
Tuesday, 9:15 a.m.—Paediatric Ward Rounds.
Wednesday, 9:00 a.m.—Medical Ward Rounds.
Second and Fourth Wednesday's in month1—Obstetrical Clinics.
Friday, 8:00 a.m.—Surgical Clinic  (and alternate weeks)   Clinical Pathological Conference.
BRITISH COLUMBIA CANCER INSTITUTE
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology.
Wednesday, 10:45 a.m.—General Medicine.
Wednesday, 12:30 p.m.—Pathology.
Thursday, 10:30 a.m.—Psychiatry.
Friday, 8:30 a.m.—Chest Conference.
Friday, 1:15 p.m.—Surgery.
SHAUGHNESSY HOSPITAL
Tuesday, 9:00 a.m. to 10:00 a.m. (weekly)—Clinical Meeting.
B. C. Surgical Society meeting dates:
Evening meeting—Friday, November 3rd, 1950—Hotel Vancouver.
Spring meeting—March 3 0th-31st—Vancouver Hotel (open to all members of the
profession).
Medical Services Association Annual Meeting—Monday, November 20th—(S.A. M.S.
Board Room).
THE  BULLETIN
Publishing and Business Office — 17 - 675 Davie Street, Vancouver, B.C.
Editorial Office — 203 Medical-Dental Building, Vancouver, B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.
Closing Date for articles is the 10th of the month preceding date of issue.
Manuscripts must be typewritten, double spaced and the original copy.
Reprints must be ordered within 15 days after the appearance of the article in question, direct from the Publisher. Quotations on request.
Advertisements
Closing Date for advertisements is the  10th of the month preceding date of issue.
Advertising Rates on Requests Patenqigf the normal drainage exits of the
nasal accessory sinuses is of great importance m the care of upper respiratory
infections.
Neo-Synephrine hydrochloride, applied
by any of the common methods—dropper,
spray, tampon, chsplacemeni|£* constricts
the engorged mucosa surrounding the ostia,
promoting free drainage and aeration.
NEO-SYNEPHRINE® Hydrochloride
Brand of PHENYLEPHRINE HYDROCHLORIDE
^HH!^1'
SolttH>n 0.25?Kifplam or wiih aromatics)
and 1%-r-I oz. bottles.
Jelly 0.5% -~ % oz. tubes.
I NEO-SYNEPHRINE, &ademark teg. XS. S. & Canada.
L~—....     . „...—...)
Niw Youk 13, n. Y.    WtNDso*, Ont.
443 SANDWICH STREET WEST, WINDSOR, ONTARIO VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASES REPORTED IN THE
CITY
Total   population—estimated
Chinese population—estimated
Hindu  population—estimated .
Total  deaths   (by occurrence).
Chinese deaths =	
STATISTICS—JUNE, 1950
Number
Deaths,   residents  only
 385,500
____: 6,877
I 133
August,  1950
Rate per 1000 Pop.
3.60 11.2
13 22.6
329 10.2
BIRTH REGISTRATIONS-RESIDENTS AND NON-RESIDENTS:
(Includes late registrations)
Male 	
Female :	
August,  1950
470
473
943
28.7
INFANT MORTALITY—RESIDENTS ONLY:
Deaths under 1 year of age	
Death rate per 1000 live births	
Stillbirths (not included in above item)	
August,   1950
18
CASES  OF COMMUNICABLE DISEASES REPORTED  IN  THE CITY
Srarlet Fever
Augu:
Cases
      5
..     0
st, 1950
Deathes
0
0
0
0
0
0
0
0
0
0
0
0
8
0
0
0
0
0
0
0
0
0
0
'63
Augus
Cases
5
0
0
7
5
0
11
0
0
0
0
30
40
0
0
0
16
0
0
0
0
36
183
71
t, 1950
Deaths
0
Diptheria
0
Diphtheria Carriers
0
0
Chicken Pot
15
0
Measles
7
0
Rubella
6
0
Mumps
5
0
Whooping Cough
18
0
Typhoid Fever ... 	
      o
c
Typhoid Fever Carriers
o
0
Undulant  Fever
0
0
Poliomyelitis
4
,     0
Tuberculosis
■   36
8
Erysipelas
o
0
Meningitis
0
0
Infectious  Jaundice
n
0
Salmonellosis  	
Salmonellosis Carriers
	
 0
0
0
0
Dysentery
69
0
Dysentery Carriers	
Tetanus.
Syphilis
 -
      0
__     0
24
0
0
1
245
0
Cancer  (Reportable) —
Resident                    ... ^	
80
43
Page 3 PITUITARY EXTRACT (posterior lobe)
FOR USE IN OBSTETRICS, IN SURGERY AND
IN THE TREATMENT OF DIABETES INSIPIDUS
A sterile aqueous extract is prepared from the posterior lobe
of the pituitary gland, and is supplied as a solution containing
ten (10) International Units per cc.
POTENCY      ' '
Each  lot is biologically assayed  in
terms of the International standard.
. PURITY
The extract is prepared as a clear, colourless,
sterile liquid with a low content of total solids.
STABILITY
Samples  of  each   lot  are  tested  at  definite
intervals to ensure that all extract distributed
is fully potent.
PITUITARY EXTRACT (POSTERIOR LOBE) is supplied by
the Laboratories in packages of five, as well as twenty-five
1-cc. rubber-stoppered vials.
CQNNAUGHT  MEDICAL  RESEARCH  LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S    PRESCRIPTIONS    LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. The recent Golden Jubilee meeting of the B. C. Medical Association was, as we
think all must agree, one of the most successful and significant meetings that organization has ever held. In mere point of numbers, it is perhaps the largest—but that
was by no means the only, or even the main idea of its success. Both in the clinical and
in the economic fields, it must have impressed all who attended it.
The lectures were uniformly good, and were mainly designed for the benefit of the
man in general practice, though there were some special addresses, directed to special
groups. These, however, afforded ample food for thought to those whose work covers
larger and less highly specialized fields. The Programme Committee is to be congratulated on its choice of speakers.
But it was the discussions on matters of economic and business interest that shewed
something of the progress that has been made during the past fifty years, in the thinking
of the profession as a whole. Even twenty-five years ago, and we speak from personal
knowledge, it was most difficult to arouse any interest, in the minds of the great majority
of the profession, in economic matters, or to get any discussion in a general meeting. The
majority of men neither knew nor cared very much about these things. A few men, who
saw the vital importance of professional solidarity, and a better understanding by all
medical men of the problems and danger that might face us, laboured with little recognition or thanks, as it seemed to many of us then.
Today, it is a very different state of things. The average medical man is becoming
more and more aware of his responsibilities, not only to his patients, but to his. fellow-
practitioners and to the community as a whole. And the keen discussions, often acrimonious, we will admit, that kept men in their seats from nine in the morning till one or
two the next morning, and then left room for twice as long a meeting, are proof that the
concern of all of us is becoming keener and more informed; and it is good that it be so.
We can settle differences—but nobody can make anything out of indifference.
Many things have contributed to this. Perhaps the first and most effective was the
rough awakening that we received in 1934, when Health Insurance, of a type which
meant complete disaster, threatened us, and was only averted by the complete unanimity
of the profession. Then there was the sterling work done by the Canadian Medical Association, which through the years has led and guided us, wisely and well. This parent body
has worked loyally with its provincial divisions, giving due heed to their views, and
considering carefully their individual needs. In this connection, we all acknowledge the
help and benefit we have got from the general Council of the C.M.A., and especially
from its General Secretary, T. C. Routley, whose wise and cautious advice we have all
learned to value and respect.
Then, too, there is the tremendous amount of work that has been done, especially of
late years, by the various Committees on Economics, who have given so freely of their
time and energy—sacrificing a great deal of leisure and even more of working time, for
the good of us all. It is insidious, here, to mention names: especially as this would mean
a list that would far overflow our capacity. But they may feel justly that they are having
their reward, as they see the growth of intelligent interest among the profession as a
whole.
A highlight of the meeting for many men was the General Practitioners' sectional
meetings. These were excellent and we believe will do much good. But we trust and hope
that these meetings will always be held, as all medical meetings should be held, within
the framework of organized Canadian medicine. The part can never be greater or more
important than the whole and we must avoid, as we would the devil, any action that will
tend to produce rifts between different sections of the profession.  The medical profession
Page 4 needs unity more urgently than anything else. The example shown us by Great Britain
should be enough to convince us of that, where the disunity of the profession—the separation into "upper and lower" classes of medical men, gave the lever to its enemies,
which split it in two, and left it the relatively helpless thing it is today. We can settle
our differences between ourselves but as a profession we must be united.
We are all medical men first—general practitioners or specialists afterwards. Time
and patience and honest intent will settle all our problems, to the profit of all—but if we
allow ourselves to be divided up into warring groups, we shall be easy prey to those who
would gladly take advantage of the weakness that would be.the result of such divisions.
I
-   t -
•<5>
*_
HOURS:
Monday, Wednesday and Friday 9:00 a.m. - 9:30 p.m.
Tuesday and Thursday 9:00 a.m. - 5:00 p.m.
Saturday 9:00 a.m. - 1:00 p.m.
Recent Accessions—
Adler, Alfred, Problems of Neurosis, 1929 (Gift of Dr. T. W. Hill).
American Goiter Association—Transaction, 1949.
American Urological Association—Transactions, Western Section, vol. 15, 1949.
Council on Pharmacy and Chemistry, American Medical Association—New and Non-
official Remedies, 1950.
Hess, J. H. and Lundeen, E. C, The Premature Infant, 1941 (Gift of Dr. A. F.
Hardyment).
Surgical Clinics of North America—Symposium on Abdominal Surgery, Mayo Clinic
Number, 1950.
U.S. Dept. of Defense and U.S. Atomic Energy Commission—The Effects of Atomic
Weapons, 1950.
Wolff, H. G., Headache and Other Head Pain, 1948 (Gift of Dr. E. F. Christopherson).
Medical Research Council Memoranda
No. 21—List of Species maintained in the National Collection of Type Cultures, 2nd
No. 24—Sorsby, Arnold, The Causes of Blindness in England and Wales, 1950.
Medical Research Council Special Report Series
No. 267—Wood, C. A. P. and Boag, J. W., Researches on the Radiotherapy of Oral
Cancer, 1950.
No. 268—Macworth, N.B., Researches on the Measurement of Human Performance,
1950.
No. 269—Kon, S. K. and Mawson, E. H., Human Milk—Wartime Studies of Certain
Vitamins and Other Constituents, 1950.
No. 270—Perry, W. L. M., Reports on Biological Standards: IV—The Design of Toxicity Tests, 1950.
No. 271—Cheeseman, E. A., Epidemics in Schools—An Analysis of the Data collected
during the years 193 5-1939, 1950.
Page 5 Ihe following is a letter of thanks and appreciation sent to Dr. Andrew Turnbull for
continuing the gift subscriptions to the library which had previously been donated by
the late Dr. W. A. Whitelaw:
September 16th, 1950.
Dr. Andrew Turnbull,
925 West Georgia Street,
Vancouver, B. C.
Dear Doctor Turnbull:
At a recent meeting of the Library Committee our attention was drawn to the fact
that you are to continue subscribing to the library the journals "Acta Radiologica",
"American Heart Journal" and the "Journal of Thoracic Surgery" that used to be donated by the late Dr. W. A. Whitelaw.
The Committee deeply appreciates your kindness and thoughtfulness in continuing
these gift subscriptions as they are a valuable contribution to the library.
. Yours very truly,
A. F. HARDYMENT, M.D.,
Secretary Library Committee.
BOOK REVIEW
THE COMMONSENSE PSYCHIATRY OF DR. ADOLF MEYER, edited, with
Biographical Narrative, by Alfred Lief, McGraw-Hill Book Co., Inc., 1948, pp. 636
The excellently presented volume was fortunately published before Dr. Meyer's
death (in his-eighty-fourth year, on March 17th, 1950). It must have been gratifying
for him to see the book in final form. The foreword carries a pleasing picture of the)
aging doctor in informal discussion with his friend and professional biographer, Mr. Lief,
and one may glean in preview something of the essence of the basic * principles of Medicine as known and practised by Dr. Adolf Meyer, and something of the reason for the
selection of the particular fifty-two lectures and papers which largely compose this book.
Dr. Meyer characteristically urged his biographer to make the book an expression of his
own needs, and states that "The main thing is that your point of reference should always
be life itself." For those who have had the privilege of meeting Dr. Meyer, this book will
recall images of the deep well-springs of his power, the measure of which is incalcuable,
since there seems little doubt that Dr. Meyer has contributed one of the major and most
profound influences on the development of psychiatry both within and beyond America.
For those who have not previously known him, these papers give strong reflection of the
growth and greatness of the man, and the biographer has artfully correlated the papers
with the biological development, or "life chart", of their subject, under such section
headings as "Preparation in Europe", "Action in New York", "Action in Baltimore", etc.
Though written, years ago, there is still a freshness and current applicability to a
majority of these opinions. Various chapter headings, as "The Biological Approach to
Psychiatry", "Dynamic Psychology Established", "Fundamental Conceptions of Dementia Praecox", "The Criminal Insane and Medical-Legal Problems", "The Life Chart",
"Normal and Abnormal Repression", and "Freedom and Discipline", indicate the broad
scope of the book.
Repeated references to the fact of man as "an experiment in nature", "a psycho-
biological unit", or a particular "reaction-type", recall some of the favorite teaching
principles of Dr. Meyer. One could quote innumerable excerpts, for this is a very quotable book, but suffice for a few: "A mentally sick person, after all, is not the sum of the
elements of disease, but a specific functioning unit", and his observation that "The more
we teach the physician to think in terms of what is demonstrable in the case, the better
for him and the patient, and for prophylaxis, and for the formulation of further problems of investigation".
This book will serve as a pleasant and stimulating series of essays, will prove a useful
leference for all students of Psychiatry, and will give important keys for the education
ob both the medical profession and the laity. G. H. H.
Page 6 Vancouver Medical  Association
President , Dr. W. J. Dorrance
Vice-President ^_Dr.  Henry  Scott
Honorary Treasurer Dr. Gordon Burke
Honorary Secretary Dr. W. G. Gunn
Editor Dr. J. H. MacDermot
1950 ANNUAL REPORT OF THE
VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL
The twenty-eighth annual Summer School of the Vancouver Medical Association
was held May 29th to June 2nd, 1950, in the Mayfair Room of the Hotel Vancouver.
The registration this year was somewhat lower than in the past, the total being 250,
of which 209 were paid, the rest being complimentary. Of the paid registrations, 28
were out of town doctors including some U.S. visitors. The average attendance at the
Summer School in the last ten years has been 224. There was a slight deficit at this
year's Summer School, but this was offset by the fact that the year before there was quite
a large surplus.
The five guest speakers were Dr. A. L. Chute, Pediatrician, Sick Children's Hospital
and Associate Professor, Banting and Best Department of Medical Research, University
of Toronto; Dr. Howard P. Lewis, Professor of Medicine, University of Oregon Medical
School, Portland; Professor J. Chassar Moir, Nuffield Department of Obstetrics and
Gynaecology, Radcliffe Infirmary, Oxford, England; Dr. R. L. Sanders, "Associate
Professor of Clinical Surgery, University of Tennessee, Memphis, and Dr. Meyer Wiener,
Honorary Consultant in Ophthalmology, Bureau of Medicine and Surgery, United States
Navy, Coronado, California.
Each speaker delivered six lectures and in addition clinics were conducted in
Gynaecology, Surgery and Medicine at the Vancouver General, St. Paul's and Shaughnessy
Hospitals in that order. The closing lecture by Professor Moir on a non-scientific subject
"Some English Queens and their Confinements" aptly illustrated by slides, was very
thoroughly enjoyed by all in attendance.
An interesting new feature of this session was the ''Symposium on Cancer", by Dr.
S. T. Cantril, Director of the Tumor Institute, Swedish Hospital, Seattle and Dr. A. M.
Evans, Director of the British Columbia Cancer Institute, Vancouver. The symposium,
was followed by a 'Round Table Conference' on Carcinoma of the Breast, conducted by
Doctors Cantril, Evans and Sanders.
Dr. Myron M. Weaver, Dean of the Faculty of Medicine, University of British
Columbia, addressed the luncheon meeting held in 'Salon A' of the hotel. The Golf
Tournament and dinner at Burquitlam were well attended and a very enjoyable time
was reported by those participating.
At the last meeting of your Summer School Committee, the question arose as to
whether or not it would be advisable to carry on the Summer School in the future,
(1) because of the many other meetings which are being held at various times throughout
the year in Vancouver and (2) because of the opening of the Medical School with the
possibility of refresher courses being given by the University staff. Dean Weaver was
approached as to whether similar scientific meetings would be organized in connection
with the new "Medical School" but he has informed us that it will be some years before
Page 7 anything of this nature can be started and recommended that the Vancouver Medical
Association carry on with their work in this direction.
The Committee wishes to take this opportunity of extending their appreciation to
Dr. George Langley who arranged the Golf entertainment—to the Hospital authorities
and to the Chief's of Staff who supplied ijjaterial for the clinics and to Dr. A. M. Evans
for his work in arranging and participating in the Round Table Conference.
Respectfully submitted,
E. A. CAMPBELL, M.D.,
Chairman Summer School Committee.
ANNUAL MEETING PRINCE RUPERT MEDICAL ASSOCIATION
OCTOBER 11TH AND 12TH, 195D
The Annual Meeting of the Prince Rupert Medical Association, held on October
11th and 12th, 1950, was attended by a visiting team of The British Columbia Medical
Association, consisting of Dr. Stewart A. Wallace, President of The British Columbia
Medical Association, Dr. Lynn Gunn, Executive Secretary of The British Columbia
Medical Association, Dr. Peter Lehmann and Dr. D. M. Whitelaw. It was preceded by a
luncheon with the Gyro Club; and the meeting convened in the Civic Centre Building,
at 2:30 p.m. on Wednesday, October 11th, with approximately 16 medical men in
attendance, having representatives from the Queen Charlotte Islands, Terrace and
Hazelton. -
The scientific sessions were of a very high calibre, and the following papers were
presented the first day: Dr. Stewart Wallace—"Ano-rectal Conditions and Their Treatment"; Dr. Peter Lehman—"Head Injuries and Their Treatment," and "Sciatica and
Inter-vertebral Disc"; Dr. D. M. Whitelaw—"Myocardial Infraction."
f%fh'- During the day, a brief business meeting was held, at which the proposed changes
of the Constitution and By-Laws of The British Columbia Medical Association were
discussed. In this connection, a resolution was passed unanimously "That the Prince
Rupert Medical Association approve in principle the proposed changes of the Constitution
and By-Laws of The British Columbia Medical Association."
The following day, ward rounds were held in the General Hospital and two very
interesting cases were presented for discussion. Following the morning session the visitors
were entertained at a Kiwanis luncheon. In the afternoon, Dr. D. M. Whitelaw gave a
very instructive talk on "Cardiac Arrhythmia" which was illustrated by lantern slides.
The meeting was concluded by an enjoyable boat trip and dinner. The local committee
is to be congratulated for arranging a most successful meeting.
RESEARCH IN LEUKEMIA
Dr. Maud L. Menton, who has, until recently, been professor of pathology at the
University of Pittsburg and pathologist to the childrens' Hospital of Pittsburg, is
carrying out a research project at the British Columbia Medical Research Institute on a
grant from the British Columbia Branch of the Canadian Cancer Society.
On request, Dr. Menton would be glad to discuss the problems arising in the treatment of Leukemia particularly in children.
Page 8 ON THE WRITING OF PAPERS
(Notes From the Editor)
To many of the people who write articles for publication, the Editor must often
appear in the light of a rather fussy, unduly critical individual, who mutilates their
copy, corrects their English (confound his cheek!) and removes some of their most telling adjectives and phrases, for reasons known only to himself and his Creator. He
seems to enjoy doing this, his favourite colour in pencils is blue, and altogether he is
an unmitigated nuisance.
This is being written not as an apologia pro Editors, who doubtless deserve a good
deal of what you say about them, but with a hope that perhaps their side of the question may be made to appear just a little less one of simple malice and unkindness
inspired by a love of bullying, and perhaps a little more one of constructive helpfulness.
Possibly, if one understood why he does the things he feels he has to do, one might feel
more kindly towards the fellow.
Have you ever watched old Hong Ying, in his fruit and vegetable store, and noted
with what care he picks over his stock—how he washes and polishes each cabbage and
cauliflower, picking off dead leaves, removing bruised and blackened debris, and arranging everything in tempting, gleaming piles, which delight the eye, and make the mouth
water? His work here is not destructive or wasteful—it is kindly and constructive.
When he has finished, he has everything looking its best—he has increased its appeal to
the eye, has made it more saleable and attractive. In other words, he has edited the
product submitted to him, and the result is all to the good. Obvious blemishes have
been removed—the buyer knows that anything he buys will be eatable and palatable—
as far as possible, the necessity for the buyer to beware has been removed, and he may
buy with safety and confidence.
All this is the chief duty of the Editor, to make sure that the material that is offered
to him for publication will be presented in such condition that it will do the greatest
justice to the author whose work it is. To ensure this, he has one or two things at his
disposal besides a blue pencil. He has, or should have, a certain sense of literary values
—he has had experience—like Ulysses, he has suffered many evil things, (some of them
shouldn't happen to an Editor), he is dispassionate, and has no bias, such as that of
parentage, towards the article in question, so that he can look at it objectively. He is,
too, very anxious to do his best for those who have entrusted their work to him.
Believe it or not, he feels honoured that they have done so, and rejoices exceedingly when
he finds pearls of great price, as he quite often does. But, having found a pearl, he wants
to see the gem set off to the best advantage, by suitable conditions of background and
display.
One thing no Editor worth his salt will ever do, i.e. tamper with the actual material
of an article. This is not in his provinceiMfWithin the limitations of correct writing,
and some others inspired by considerations of courtesy and good taste, the author is, and
must be, complete master of his own work. Of course, every Editor has certain secret
reservations of his own, and certain pet foibles and abhorrences; but it is, no doubt,
'good for his soul's discipline to be harrowed to a certain extent, and he puts up with
these minor annoyances, for the sake of a quiet life.
So much for the Editor, who is not really the reason for writing this article at all.
Its real purpose is to make a few humble suggestions to those who may, from time to
time, submit articles for publication to this, or indeed to any other journal. To the
seasoned writer, the trained contributor, all this will be elementary stuff, and not worth
the time it takes to read it, perhaps—but very few men are trained writers, and yet
they have material and ideas and experience which are worth recording and preserving.
Them we may perhaps help a bit by emphasizing some of the rules of writing, so many
of which are violated so many times by so many writers, (to parody a famous speaker).
To begin with, we assume that the writer has something that he wishes to say, and
knows exactly what this is. It is the manner of saying it that constitutes the problem,
and is almost as important as the matter that he wishes to present.
Page 9 Consider the artist who has in his soul's eye a picture, complete in every detail, that
he wants other people to see as he sees it himself. It is not enough that he sees it clearly
in his own mind—one-half of Art is the presentation by the artist of his message in
intelligible form, so that others can receive it and profit by it. The painting must be
understood by those who see it, (we hope no modernistic artist will read this), the
music must have a meaning to those who hear it, or the artist has not brought forth
a fully-conceived and coherent creation—he has merely laid an egg.
So-with writing, which is one of the Arts, primus inter pares. Just as intricate, just
as expressive, just as creative as music, painting or sculpture, it is subject to the same
rules and restrictions, and must fulfil the same conditions.
This may seem rather elaborate for one who merely wishes to report a case of
Henoch's purpura ,or who would write an article on the use of antibiotics in industrial
surgery. But the essential thing, really, is that people should be able to read what he
has written, with ease, pleasure and profit, tuto, cito, et jucunde, as the Latin has it,
and should get from it exactly what he wants to convey. And it is surprising to
editors, how often this goal is missed, by people who really have something to say, and
just don't know how to say it, or else won't make the simple effort that is necessary to
say it clearly, simply and properly. And this applies equally to a short essay on Caesarean Section, or a complete work on pathology, or to any other writing, for the matter
of that.
Errors in writing come under two main heads, errors of omission and errors of commission. To some of us the latter, bad writing, overstuffed writing, careless errors in
grammar, spelling or syntax, errors in good taste, while more conspicuous, are yet far
less important and damaging than are the former. ,One can often remove excrescences,
re-arrange phrases, make a given spelling more conformable to that advocated by the
Shorter Oxford Dictionary, and so on—but one cannot supply a missing organ in the
progeny submitted to us, more especially if that organ be the eye, the tongue, or the
brain.    So perhaps we might begin with errors of omission.
The first has to do with a quality which, for lack of a better word, one may call
Sincerity. This does not mean Honesty, though of course that is included: it is rather
the quality which looks at things clearly and objectively, without the "wax" which
covers over defects, which is the meaning, of course, of the word "Sincere." Perhaps
this is more necessary in scientific writing than in any other. There must be no doctoring of facts, twisting of statistics, manipulation of results, or the like. It is so fatally
easy sometimes, in one's enthusiasm for a theory, to twist or stretch facts ever so little
to make them fit that theory—often it is done quite unintentionally, and without any
deliberate dishonesty at all—but it is fatal all the same. The object should be to add a
brick, no matter how small, to the edifice of knowledge and truth, not the upbuilding
of the reputation of the author, or the acquisition by him of so many credits.
Then there is Clearness; certainly the next in importance. No picture is of much
value if the, glass in front of it is obscure, and so with writing. It is not given to all
of us to write the limpid, crystal-clear prose of the Authorized Version of the Bible, or
of Robert Louis Stevenson, or of the writer of the History of the World War, who was
also the author of those marvellous speeches of the Blood, Sweat and Tears and other
collections. But within our own powers, we can emulate them in one thing, the clearness with which they wrote and spoke. Their words are windows, through which their
thought can shine clearly. They know what they want to say, they are possessed of
sincerity and intensity of purpose, and they simply say it. Probably this is rather oversimplifying things—since it was not without long practice, and strictest discipline, that
these men acquired this power. It is not without dust of conflict that one attains such
a goal.
With clearness we include Simplicity—one thing at a time, as the word implies.
Too many writers commit the grave error of trying to crowd too much into one article.
They either want to show how much they know, or are afraid, perhaps, that they may
not get another chance.    Either is a mistake.    The student at an examination is well
Page 10 advised to answer only the question asked—not to try and show that he has mastered
the whole book. The examiner gets impatient if he does, and after all, one cannot get
more than 100 per cent marks for any question. 0M.
And so with writing, or preaching, or lecturing, or indeed with painting or music.
One central idea fully developed, will convey something of value, where half a dozen,
each only half explored, confuse and bewilder, and fail to convince. Overloading the
canvas makes for confusion and vagueness, and in books and writings lack of concentration nullifies all the otherwise good work of the author.
So sincerity, clearness, simplicity, these three Muses of the Pen, must weigh each
thing we write, and approve, before we dare offer it to others.
What about errors in writing? and there are many. Some come from ignorance,
some from carelessness, some from that excess of zeal which earned for Midshipman
Easy the strictures of his Captain; some from an uninformed snobbishness, which leads a
writer sometimes to use long words which he does not fully understand, and which trip
him up.
Ignorance is, I suppose, responsible for many of our errors or phrasing, grammar,
spelling and so on, though we prefer, perhaps, to call it carelessness. Some of these
errors occur so frequently that in time one feels they will become correct usage, but at
the present time of writing they are still wrong. Every Editor, I expect, has his pet
hates. One very common one, for example, is the use of "due to," in the sense of
"because of," as for instance, "Due to the presence of adhesions, it was decided to
operate." This is not correct, as Fowler's Correct Usage will tell you—though it is one
of the commonest of grammatical errors. "Due to" means "owed to" and must refer
to something that is owed. We could say "Our decision to operate was due to the fact
that we felt adhesions were present," or "obstruction due to adhesions made us decide,"
etc., but use of the phrase "due toV in the sense of "because of" or "on account of"
is incorrect.
Then "comprise." Probably no word in the English language gets more ill-usage
than this one, and it is a pity, since it is a very good word. It means "to include," and
so we cannot say "These three books comprise a trilogy," or "the following bones
comprise the carpus." Here it is used in the sense of "constitute" or "compose," and so
incorrectly.
"Equally as good," "most extreme," "more final" crop up from time to time, and
are also incorrect. "Equally good" is right—"extreme" and "final" are superlatives in
themselves and cannot be added to or taken away from—one thing cannot be more final
than another which is already final.
"Bicep" and "forcep" occasionally, too, suggest that the writer has forgotten that
bicdps, or forceps, is the singular noun in Latin. One biceps, two biceps, unless you
want to be hopelessly pedantic, and say "Two bicipites," but the usual custom is simply
not to go that far. (We used to have the same difficulty in our mind with the word
"octopus.") Very often a patient will tell you about their appendix. "Oh. they were
taken out some years ago"; the apparently plural sound of the word having misled
them. But these are the things that give the blue pencil its exercise, and that give
the Editor a raison d'etre.   He saves your blushes from appearing at a later date.
"Collapse" in the transitive sense is also incorrect. Strictly speaking, we cannot
"collapse" a lung. The lung can collapse—but this is an intransitive verb. But we
confess that we cannot find any single word that expresses our meaning so well, and so,
in the crosstalk of medical parlance, the word is likely to persist, for convenience' sake.
"Whom the writer declared was worthy of respect" is an instance of another error
very commonly found—and requiring correction. Here "who" is correct, and is the
subject of "was," so must be in the nominative. Put commas after "whom" and
"declared," and you will readily see why.
Split infinitives are not as much of a red rag to some Editors as they are to others.
Personally we feel that they have their occasional uses, but generally they look awkward,
and are apt to be overdone.    They are always conspicuous, and that alone makes them
Page 11 objects of suspicion. But once in a while "to thoroughly understand" will sound better,
and have a better emphasis, than "to understand thoroughly," though technically, I
suppose, it is not quite correct, according to the best usage.
Some two or three years ago Dr. D. E. H. Cleveland, a member of our Publications
Board, and himself an admirable judge of correct English, prepared a succinct summary,
of a page or so in length, of the commoner errors and pitfalls into which a writer might
be led. This was published in the Bulletin, and should, we believe, be re-published from
time to time, perhaps with such addenda as Dr. Cleveland might see fit to contribute.
It is a very helpful list.
Of course, one cannot, in a short note like this, say everything that should or could
be said. But it is so.well worth while to take a little trouble with what one writes.
Words are such marvellous things and, used just right, have the effect of well-aimed
bullets. How often, listening to that great Wizard of Words, Winston Churchill, all
of a sudden one has heard him use one single word, deliberately, coldly, almost unemotionally, and the whole picture is changed—tensions are released, the atmosphere is
clearer, one breathes a fresher air. That one word, that one phrase, told you exactly
what he meant. But he didn't just happen on the word; he sought for it, and weighed
it, and tried it out in the sentence. We read of the poet, and his "aching longing for
the perfect word." Words have weight, colour, force, and it takes thought and practice to learn how to use them. It is not a matter of brevity, but of concentration and
proper placing.
The use of long words for effect is also extremely dangerous. Polysyllables are not
necessarily impressive, and especially nowadays, when few people understand them—
not as in the days of Dr. Johnson who was brought up on the Liddell and Scott Greek
Dictionary, or its equivalent of the day. His contemporaries could roar with laughter
at words like "Parallelopiped" or "Sesquipedalian," but "tain't funny, McGee" nowadays. Very few writers can make a thing of beauty out of a long word. Homer
could, and did, but we find it hard to appreciate his lines. Shakespeare had the gift of
using the longest words beautifully, and when he said "like some insubstantial pageant
faded," or "rather will this hand the multitudinous seas incarnadine," he made melody
that few could touch. But when anyone of us is writing about fractures or infections,
he would be wiser to say "eroded," or "the haemorrhage was severe."
It's obvious enough. Call a man a "perpetrator of terminological inexactitudes,"
and he won't have discovered what you mean till you're half-way down the block. But
call him "a liar," and see what happens.    It's all a matter of being clear and simple.
Another eccentricity of some of us in the editorial business is a preference for modes
of spelling in accord with the Canadian or British custom, rather than that of the United
States. For instance "center," "program," "thru," do not appeal to us. We have
no criticism, perhaps, that would hold much water, of these spellings, except that
we think they are wrong, and the only reason they are used at all, we believe, is that
we are so close to the States, and so much overshadowed by their size, and the volume of
advertising that we get from them, that our newspapers, and some of our better journals,
too, are carried away, and yield to the pressure. The word "centre" is derived from a
Greek word "kentron" while "programme" comes from a Greek word "gramma," and
the American variations are purely arbitrary. "Thru," of course, is indefensible, and
shall never soil our page proofs. The use or omission of the "u" in such words as "honour," "tumour," or the like, is a matter of taste, but personally we prefer to have it in,
though we acknowledge, in the depths of our rapidly sclerosing mind, that it is only a
matter of time before it will be a thing of the past.
Just one thing may be said here. From time to time we are fortunate enough to
receive from our good friends and esteemed colleagues in the U.S.A., papers for publication. It goas without saying that we should never dream of correcting their spelling
of these words in accordance with their preference and custom. We shall pulblish them
as they are written. This is especially important in the matter of reprints that they may
desire.
Page 12 Be very careful about any attempts at wit or humour, especially avoiding any personalities. Shun, too, as you would the devil, any jokes or witticisms that smack at all
of the dubious. There is no room for any of these in any normal scientific journal. It
is nOt prudishness that inspires this suggestion, and it is not just made up for the occasion. Occasionally we have had experiences along this line that show that such a suggestion is by no means uncalled for. Good manners and good taste, are, surely, essential
attributes of good writing.
Do not fear, finally, to give your own experience and your own opinion—and do
not give merely a digest of other people's work—even if you may think it may merit
more consideration than yours.    Remember that mouse-trap, of which Emerson spoke.
So, you see, writing for publication is really quite simple. You merely decide what
you want to say, put it clearly in simple language, and send it in, double-spaced, on one
side of the paper, and typewritten.    Thank you.
• • • •
675 West Hastings Street,
The Editor, Vancouver, B. C.
Vancouver Medical Association Journal, September 13,  1950.
Vancouver, B. C.
Dear Sir:
I have been instructed to inform you of the formation of The Medico-Legal Society
of British Columbia, which held an inaugural dinner meeting on September 7,  1950.
The Officers are:
President J. C. Thomas, M.D.
Vice-President I Walter   S.   Owen,  K.C.
Secretary A. Hugo Ray
Treasurer J. R. Naden, M.D.
The object of the Society is to be the promotion of medico-legal and scientific
knowledge in all its aspects, such object to be attained by holding meetings at which
papers will be read and discussed and by such other means as the Council shall approve.
The members of the Council are:
Medical: Legal:
Dean M. M. Weaver, M.D., Walter S. Owen, K.C.
J. C. Thomas, M.D. L. St.M. Du Moulin
T. Harmon, M.D. F. A. Sheppard
J. R. Naden, M.D. Charles W. Tysoe, K.C.
M. Digby Leigh, M.D. A. Hugo Ray
J. W. Whitelaw, M.D. R. E. Ostlund
A. Taylor Henry, M.D. John G. Gould
ill   B. J. Harrison, M.D. D. Milton Owen
Peter O., Lehmann, M.D. Sherwood Lett, K.C.
George MacKay, M.D. Dean G. F. Curtis
or his nominee.
F. J. Gilmour was elected the first member of the Society.
Yours truly,
A. Hugo Ray,
Secretary.
We understand that, when this Society is in full operation, a limited number of
applications will be open to members of the medical profession, and we presume the
legal professions, who are interested in this most important subject.
We should like to congratulate those who have been instrumental in forming this
Society, which is the second of its kind to be established in Canada. There is no doubt
that this is the right approach to the solution of many medico-legal problems, and it
will have immense educational value to the members of both the professions.—Ed.
Page 13 RHEUMATIC FEVER IN CHILDREN
P. H. SPOHN, M.D., F.R.C.P.(C)
The following is an outline of this brief discussion on some aspects of treatment,
prognosis and prophylaxis in this disease.
A. The Treatment of Acute Rheumatic Fever.
1. Value and dosage of salicylates.
2. Bed rest, indications for return to activity and special considerations in
prolonged bed rest.
B. The Prognosis in Rheumatic Fever.
1. Incidence of recurrences.
2. Longevity.
C. The Prevention of Recurrences of Rheumatic Fever.
The treatment of rheumatoid arthritis will not be discussed as it is essentially the
same as in adults.
A.   Some Aspects Concerning Treatment of Acute Rheumatic Fever.
1. The Value and Dosage of Salicylates.
The therapeutic effect of salicylates is probably limited to the antipyretic and analgesic actions of the drug and there is no definite evidence that salicylates have shortened
the course of rheumatic fever or have any permanent effect on the protean manifestations of this disease. This does not mean that salicylates are not of value in rheumatic
fever. Massive doses and parenteral administration of salicylates in children are dangerous. The proper dose of salicylates is that which produces symptomatic relief of pain and
just fails to give toxic effects. This may vary from a grain per pound of body weight
in younger children to 15 to 25 grains every two hours until toxic effects begin to appear;
the medication may then be omitted for 8 to 12 hours and the patient maintained on ,30
to 60 grains per day. This is continued until all signs of active infection have been
absent for a week or ten days. The effect of salicylates persists for about 10 days after
discontinuing and a patient should be kept in bed until the effects are over. If sodium
salicylate is used an equal or half the amount of soda bicarbonate should be given to
prevent gastric irritation. Aspirin is effective in somewhat smaller doses than sodium
salicylate. Early toxic symptoms are dizziness, tinnitus, vomiting and headache. Idiosyncrasy to salicylates is rarer in children than adults. In such cases amidopyrine or
cincophen may be used for short periods only as they are not without danger and may
cause agranulocytosis and liver damage. Amidopyrine is given in doses one fifth the
dosage of salicylates and for not longer than four days.
2. Length of bed rest Indication for return to activity; considerations in prolonged
bed rest. '}/,■-.
1. Bed rest still remains the most important form of treatment for the rheumatic
patient. The child is not allowed up until after subsidence of the active rheumatic infection; this may be weeks, mo-nths or years. It should be remembered that the danger of
chronic invalidism lies not in bed rest, but in the failure to get the child well. A few
cases run their course regardless but in the majority careful treatment is the deciding
factor. The patient should be kept in bed in most instances until clinical and laboratory
evidences of an active infection have disappeared. One should be warned about the
danger of using one specific laboratory method as an indication for return to activity.
The final decision as regards the presence or absence of active rheumatic disease rests
upon clinical evaluation of the case as a whole and a useful indication is the ability of the
child to carry on normal activity without circulatory symptoms. Salicylate therapy
should be discontinued for 10 days before a final sedimentation rate is taken. Remarks
re sedimentation rate:
(a) Usual activity—more severe sedimentation;
(b) One last return normal;
(c) May be normal and have carditis.
Page 14 2. A daily program of occupation should be arranged so bed rest does not become
boresome nor is the life of the family centered about the child and his illness. The return
to actibity must be gradual, first sitting in a chair for a short period, increasing to two
hours a day. There is then no increase for two weeks. Then he is allowed to walk a short
distance and sit up longer and then walk farther. The gradual increase in activity
requires a period of 6 to 10 weeks after the infection has subsided before the patient can
be up all day.
3. One need not mention the importance of the correct environment and adequate
diet. Schooling should not be neglected. For information concerning home instruction
and correspondence courses write Mr. T. F. Fairey, Department of Education, Parliament
Buildings, Victoria, B. C.
4. A.C.T.H. and Cortisone—These two drugs have produced dramatic results in
the treatment of Acute Rheumatic Fever. They are not yet available for general use
and it is too early to determine whether permanent benefits are obtained.
B. The Prognosis in Acute Rheumatic Fever.
1. It is important to know the course and prognosis in this disease so that the
parents, the patient and the physician have some understanding concerning the future
outlook. With this knowledge as a background a plant for living can be established. It
should be emphasized repeatedly that if the patient lives within his restrictions he may
expect, in the majority of cases, a normal life. Patients should be reassured and not
allowed to become chronic invalids.
2. Recurrences—In the majority of children the clinical course of rheumatic fever
is characterized by recurrences. The heart is involved in all cases of rheumatic fever
and fifty percent of patients suffering from an attack of rheumatic fever will eventually
develop an organic heart condition. The younger the child the more frequent the recurrences. The risk of recurrence is two to three times greater in the year following an
attack than the risk following one or two years' freedom from an attack. There is a
direct relationship between the nurrtber and the severity of recurrent attacks and the
degree of cardiac damage sustained. The average recurrence rate from 4 to 13 years
is 25%, 14 to 16 years the rate drops to 8.7% and from 17 to 25 years 3.7%. Oardiac
"failure leads to a poor prognosis and the chances of a child surviving till the second
decade of life after an attack of cardiac filure re 1 in 3. Four percent of children with
rheumatic fever die in first attack and 12% in first 5 years of the disease. It is also felt
that about 90% of patients having subacutaneous nodules will develop heart disease.
Between 20 to 40% of children with only chorea develop heart disease.
3. Longevity—The most significant statistics on longevity in children are the
studies of May Wilson who has followed 1042 rheumatic children over a 30-year period.
Eighty-nine percent of these were seen at death or at the end of the study. Some of the
significant findings from this study are:
(a) 66(feof the deaths occurred before puberty.
(b) The highest mortality occurs within the first year after onset and the chance
of death in this period is about three times as great as in most of the susequent
single years.
(c) An affected child has an 80% chance to.survive 15 years after the onset of the
disease, 75% chance to survive 20 years after onset and a 66% chance to
survive 30 years after the onset of disease.
C. The Prevention of Recurrences of Rheumatic Fever.
1. It is now agreed by most workers that in the majority of cases the initial attack
of Rheumatic Fever and subsequent relapses follow in the wake of scarlet fever and upper
respiratory infections caused by Group A Beta Hemolytic streptococci. We also know
that frequent exacerbations tend to occur in this disease and that the incidence of cardiac
damage increases with each recurrence. Because of these two facts every attempt should
be made to prevent recurrences initiated by repeated hemolytic streptococci infections.
This can be accomplished by the administration of daily doses of one of the sulphoni-
mides, a combination of the sulphonamides or by giving oral penicillin.   This regime has
Page 15 proved to be effective (preventing 5 out of every 6 recurrences) and relatively safe.
The risk of recurrences is much greater in the younger age group (25% in 4 to 13 year
group, 9% in 14 to 16 year and 4% in the 1 7to 25 year group), and is three times as
great during the first year following an attack of Rheumatic Fever. Ninety percent of
recurrences develop within 5 year period following last episode. The drug should be administered throughout the year. Sulphadiazine or Sulphamerazine are the drugs of choice
in doses of 0.25 gm. under 55 lbs., 0.5 gm. under 110 lbs., and 1.0 gm. daily in children
and adults over 110 lbs. With this dosage blood levels between 1.0 mg.% to 3.5mg.%
are usually obtained. Trulfazine, a new triple sulphonamide (Frosst) now available consisting of Sulphamethazine 0.16G., Sulphadiazine 0.16G, and Sulphamerazine 0.16G
might possibly prove to be advantageous and is given in an equivalent dose. Reactions
from repeated use of these drugs tend to occur in the first three weeks and rarely occur
after eight weeks. During the first six weeks a weekly urinalysis and W.B.C. should be
done: following this period these procedures can be done at four week intervals for three
months and then at six week intervals. A transient albuminuria may occur and is not an
indication for discontinuing the drug. Oral penicillin in doses of 100,000 units before
breakfast and supper in older children has likewise proved effective, and although fewer
toxic results have occurred and there is less tendency for resistant strains to appear than
with the sulphonamide, still it is appreciably more expensive than the sulphonamides.
These drugs should be given until puberty and for at least five years following the initial attack.
2. Intramuscular Penicillin—in the early stages of an acute upper respiratory
infection caused by the Beta Hemolytic Streptocci in a person with a history of rheumatic fever is felt to be moderately effective in preventing recurrences and warrants
usage. Sulphonimides have no effect in this stage. To be effective the penicillin must be
started as soon as infection is suspected and should be given in adequate dosag for ten
days. Every rheumatic patient should be instructed to notify his physician at the outbreak of a sore throat. If possible a culture for Hemolytic streptococcus is taken and
treatment started immediately. If the culture is positive the penicillin is continued. This
is the ideal situation, but if laboratory facilities are not available or reliable, one is justified in giving treatment to cases where a hemolytic streptococcus infection is suspected.
3. Tonsillectomy and Other Surgical Procedures—There is no conclusive evidence
that tonsillectomy is of specific value in rheumatic fever and the indications for this
procedure should not differ from those in no-rheumatic children. The same dictum
holds true for dental extractions and any other surgical procedures. It is not advisable
to perform any surgical operation until evidences of the active process has subsided.
Also because of the transient bacteriemia known to occur following tonsillectomies or
tooth extraction which may be further followed by bacterial endocarditis, it is imperative
to protect the patient with a "penicillin umbrella". Penicillin should be started 24 hours
before intervention and continued for 48 hours post operatively. Activities during this
period should be restricted.
REFERENCES—
A. Etiology of Rh. Fever—1. Waksman, B. H., Medicine 28:143, May, 1949.
2.   Swift, H. F., Annals of Int. Med. 31:715, November, 1949.
B. Laboratory and Clinical Criteria of Rheumatic Carditis in Children.
1. Taron, L. M., J. of Ped. 29:77, 1946.
C. Salicylates-—1. Hoffman W. S., et al, Amer. J. of Med., 6:433, April, 1949.
2. Coburn, A. F., Bull. Johns Hopkins, 77:1, 1945.
D. Prevention Recurrences—1.    Kuttner, A. G., Advances in Ped., Vol. 2, page 367.
2.   Hofer, J., J. of Ped., 30::135, 1949.
E. A.C.T.H. and Cortisone—1. Hench, P. et al, Proc. of Mayo Clinic, 24:277, May,
1949.
2.   Thorn, G., et al, N.E.J, of Med., 241:529, October, 1949.
F    Longevity—1.     Wilson, May, J.A.M.A., 138:794, 1948.
PETER H. SPOHN.
Page 16 THE SIGNIFICANCE OF ALBUMINURIA IN CHILDREN
By A. L. CHUTE, M.A., M.D., F.R.C.P.(C), Toronto, Ontario
* ( Read before the Summer School, 1950.)
Strictly speaking, the title should be "Proteinuria in Children" but since albuminuria has been used since time of immemorial, this designation will be continued in this
discussion.
Before describing the various forms of increased protein in the urine and the various
disease states which give rise to it, it seems advisable to review very briefly some of the
known facts regarding the physiology and anatomy of the kidney.
The kidney is composed of a great many units known as nephrons. These consist
of a glomerulus which is made up a fine network of capillaries enclosed in a globular
funnel shaped structure which continues as the proximal convoluted tubule and then
descends in a long loop in the medulla of the kidney, comes back towards the neighborhood of the glomerulus again, forms the distal convoluted tubule and then eventually
joins the collecting tubule. It is estimated that there are beween one and a half and two
million of these nephrons in each kidney. The blood enters the glomerulus through an
afferent artery or arteriole—the pressure being approximately 75 millimetres of mercury
at this time. This pressure supplies the filtration or outward pressure forcing fluid from
the capillaries into the space of Bowman's capsule. Opposing this, is the osmotic pressure
of the proteins which has a pressure of approximately 30 millimetres of mercury and
the pressure of the tissues themselves which account for about 5 millimetres of mercury.
Consequently, we have a total'of about 40 millimetres mercury pressure fluid from the
blood vessels into the glomerular space. Thanks to the brilliant work of Richards, who was
able to insert a small capillary pipette into this glomerular space and analyze the glomerular
fluid we now know that the fluid in the glomerular space is composed of an ultra filtrate
containing all the dissolved elements of the blood and a large proportion of fluid. He
was unable to determine that any protein was present. Later workers, however,
have shown that something between 10 and 20 milligrams % of protein may be present
in this filtered fluid. This is chiefly albumin since the pores in the filter are sufficiently
small to hold back most of the globulin and probably all the fibrinogen. Thanks to the
work of Smith and his pupils, ingenious chemical methods have been devised which have
enabled us to determine the renal blood flow and the total amount of filtration and the
power of the tubules to re-absorb such things as salt, sugar, etc. These investigations
demonstrate that while we form about 1000 to 1500 cc. of urine a day, the glomeruli
of the kidney actually filter about 100 times as much fluid as this. This is a weight
of fluid which is more than twice the average weight of a normal man. The function of
the tubules is to reabsorb a large amount of fluid, all the sugar and most of the salt
which is filtered, and a large part of the albumin is reabsorbed as well. If we assume
that the albumin in the filtrate is 20 mgm. % and that there are 150 litres of filtrate
formed, this would amount to something like 30 grams of albumin passed through each
day. Since the total normal amount of albumin discovered in the urine for the, whole
day is somwhere in the neighborhood of 20-30 milligrams, this large amount of protein
must have been reabsorbed by the tubules. It has also been shown that all the albumin
that appears in the urine must pass through the glomerular filter, since certain fish which
have no glomeruli are incapable of passing albumin into the urine. In diseased states,
therefore, we probably have a marked increase in filtration of albumin and globulin,
chiefly the former. The passage of these substnces into the urine may exceed the capacity
of the tubules to reabsorb these substances. On the other hand, the tubules may be
sufficiently damaged that they are incapable of reabsorbing these substances at the normal
rate. The discovery of the reabsorption of the protein by the tubules helps to explain
the reason that in the so-called "tubular nephritis" in which little glomerular damage
appears to be present, there is such a heavy albuminuria.
Having briefly reviewed the physiology of the kidney, I should like now to list the
various causes of albuminuria in children, these are:
1. Physiological causes.
2. Chemical causes.
Page 17 3. Physical causes.
4. Circulatory causes.
5. Albuminuria due to tumors.
6. Albuminuria due to infection.
7. Albuminuria due to congenital malformations.
8. Nephritis.
Under Physiological Causes for albuminuria, we have (a) prematurity, (b) newborn state, (c) orthostatic albuminuria, (d) emotional albuminuria and (e) albuminuria
due to excessive fatigue. Prematurity is a common cause for the presence of albumin
in the urine. Ewald has found that 75% of the urine passed by infants weighing less
than 3.5% killograms reacted positively in the test for albumin. Sixty-nine per cent
of new born infants tested between the 2nd and 10th day of life showed the presence of
albumin in the urine. After this period the percentage rapidly falls off so that only
about 30% give positive tests in the 3rd week of life. The presence of albuminuria at
this time probably reflects the relatively incomplete development of the kidney and in
the absence of other findings is of no clinical significance.
Orthostatic Albuminuria is a condition about which many paediatricians and general
practitioners are consulted frequently. A child may come up for an insurance examination or possibly a routine examination at school or for some athletic activity and albumin
is found in the urine. Ahe average normal 12-hour excretion of protein in the urine is
approximately 30 mgms. % for normal children. Such amounts fail to give a positive
test by the usual procedures. However, approximately 5 % of older children have demonstrable albuminuria. The incidence is equal between male and female and there is a
definite familial tendency. These children tend to be high strung, nervous types of
individuals often of a rather tall slender build. In these patients protein may vary from
a trace to as much as 8 or 10 grams per 24 hours. The condition is usually diagnosed by
obtaining two specimens of urine—one passed late in the evening just before retiring—
and the other just on arising in the morning. The early morning specimen is free of
albumin whereas the night specimen contains a fair amount. This is the reverse of that
found in people recovering from nephritis since the small amount of concentrated urine
during the night in this condition is apt to have a higher proportion of protein, than
that passed during the day when plenty of fluids are consumed. The true nephritic will
usually have some casts and perhaps some cells as well. In orthostatic proteinuria the
albumiuria can be made to appear even when the patient is lying down, if a markedly
lordotic position is assumed. The cause of the condition has not been definitely
ascertained.  The chief theories as to its etiology have been listed by Prince:
1. Increased lordosis of the lumber spine causing mechanical obstruction to the
renal circulation. 2. Decreased renal blood flow concomitant with the fall in pulse pressure
in the upright position. 3. Vasomotor instability. 4. Subnormal constitutional development. 5. Reflection of a general lowered condition—asthenia, malnutrition, lowered
vitality and resistance. 6. Imbalance of the autonomic nervous system. 7. Actual lesion
of the renal substance, very mild in character, not demonstrable by ordinary methods.
8. Focal infection in some cases. Other names which have been used to describe the
condition are benign, functional, adolescent, physiologic, intermittent and cyclic
proteinuria.
Th greatest incidence of this condition is during adolescence, when as many as 5%
of children may have this condition. By the time they have reached 20 years of age,
only 3% continue to show albuminuria and at 25 years only an occasional one shows
albuminuria. (Lee, Harvard, Frechner). It has no clinical significance, and requires no
treatment. Emotion may also be a cause of albuminuria though it must be rare in
children. Ploss, in investigating 93 5 air force officers returned from combat found 49
had albuminuria. In the same group of 935 officers, 15 minutes after a blood test was
taken for a Kahn test, 160 had albuminuria, due to the emotional stimulus. Excessive
muscular exercise or fatigue may also cause albuminuria. In 15 boys of a high school football team which was examined repeatedly only 3 of the players failed to show albuminuria
Page 18 following a game. When the season was over only one of the players continued to
eliminate protein in the urine. It has been suggested that the albuminuria due to emotional factors and that due to excessive muscular exercise may be ascribed to the action
of the adrenalin which by constricting the efferent arteriole tends to raise the effective
filtration pressure in the glomerulus allowing albumin to escape. Since all the above
causes of albuminuria are due to physiological reasons, no treatment is required.
II. The Chemical Causes for albuminuria in children are many. Some of the most
common are, mercury poisoning, lead poisoning, poisoning with oil of wintergreen,
carbon tetrachloride; all these substances tend to cause marked tubular damage and
degeneration and probably also damage to the filter allowing large amounts of albumin to
escape in the filtration fluid.
I should like to emphasize poisoning with oil of wintergreen. This substance frequently used by rheumatics smells and tastes rather pleasant, yet as little as a teaspoonful
may prove fatal to a small child. Treatment of these chemical poisonings is essentially
that of maintaining the general bodily functions, rest in bed and plenty of fluids. Sometimes correction of a metabolic acidosis with l/6th molar sodium lactate is indicated.
Since tubular regeneration recurs fairly rapidly no permanent damage appears to result
(if the child survives). If anuria develops and the child is apparently going down hill
then there is a possibility that the newer techniques employing the artificial kidney may
tide the individual over a period of time until the tubular regeneration can occur. In
poisonings with the heavy metals such as mercury and arsenic, B.A.L. has also proved very
effective.   (B.A.L.=British Anti-Lewisite.)
III. Physical Causes which may cause albuminuria in the urine are severe dehydration, which may be due to severe vomiting and diarrhoea, or to other agents such as
burns, where probably a toxic factor is also added. Treatment of these conditions is the
treatment of dehydration.
IV. The chief circulatory cause for the appearance of albuminuria in the urine is
heart failure. The poor circulation through the kidney probably leads to damage of the
glomerular filter which permits an increased amount of protein to escape. Anoxemia
itself also may be a factor in the production of albuminuria. This may be due to either
a very low haemoglobin such as is found in some of the severe anaemias, namely acute
haemolytic anaemia of the new born—or it may be due to vaso-spasm brought about by
severe injury elsewhere in the body. Treatment in these cases is to improve cardiac
action, if possible by such methods as digitalis, rest in bed, etc., and in the case of
anoxemia, to increase the haemoglobin of the blood by transfusion with whol« blood and
if due to vaso spasm following injury, the ordinary treatment for shock such as warmth,
plenty of fluids and intravenous therapy are indicated.
V. Tumours of the Kidney may also be a cause of albuminuria in the urine. In
children the only tumour of importance is Wilm's tumour. Systemic tumours such as
multiple myeloma which gives rive to Bence-Jones' protein in .the urine are rarely ever
seen in children.
VI. Infections or Febrile states, especially infections of the upper respiratory tract
in children are very prone to cause the appearance of albuminuria. The albuminuria
may be due to a number of causes undoubtedly partly due to dehydration since these
children refuse to take adequate amounts of fluid and probably also in a large part due to
the toxemia of ^infection. If the child has a blood stream infection such as a septicemia
from oseteojjsffelitis or bacterial endocarditis this may lead to a focal nephritis in the
kidney wj^ith gives rise to the presence of albuminuria. A great majority of these cases
whidgrtnow albuminuria during the course of an ordinary infection, clear up completely
once the infection is controlled. Though, occasionally the odd one may progress to a
straightforward case of nephritis.
Acute Nephritis is by all odds the most important cause of albuminuria in children.
The exact etiology of this condition is unknown. It has been thought by some to be
due to the toxic products of some bacterial infection elsewhere in the body. But since
the nephritis is often delayed by two or three weeks following such infection it has been
Page 19 suggested by others that this is some form of an allergic manifestation, or sensitization
of the individual to the bacterial toxins or products which were formed at the time of
infection.
The classification of nephritis is exceedingly complicated and controversial and has
suffered much, both at the hands of the pathologist and the clinician. I shall adopt for
the purposes of this discussion a classification used by Aldridge, since it seems to fit the
facts as we see them in children most closely.
The chief form of nephritis in children is acute post-infectious haemorrhagic glomerular nephritis. The second type, not so commonly seen is the chronic non-specific
glomerular nephritis; thirdly, pyelonephritis and finally, arteriosclerotic nephritis. I wish
to dispose of the latter right away since in children it is never seen unless possibly the
odd case showing periarteritis nodosa, lupus erythematosus or due to a Cushing's Syndrome
may be included under this category. Acute post-infectious haemorrhagic glomerular
nephritis as its name implies, usually comes on in a period following one or three weeks
after an acute upper respiratory infection. Although somewhere between 5 and 10%
of such infections may be due to skin lesions such as impetigo in children. The usual
story is that the child has been well following the infection and is about to return to
school when he begins to complain of being tired and listless. The mother may have
noticed some swelling or puffiness about the face, particularly in the mornings. The
mother or the child may have noticed that the urine is darker in color and in some cases
this may have a frankly bloody appearance. The urine is usually decreased in amount.
The patient may have some systemic sign such as headacre, nausea and vomiting. Physical examination usually reveals a small amount of pitting, oedema, although this may be
absent; there may or may not be evidence of recent infection in the upper respiratory
tract, tonsils, ears, sinuses, etc. Examination of the cardiovascular system may reveal a
slightly enlarged heart in a number of cases. In some clinics this is put as high as 50%.
During an epidemic of scarlet fever, a year ago, we had a large number of children
admitted to the Hospital who developed post-scarlatinal nephritis. In nearly every case
there was enlargement of the heart, with hypertension. It would appear that certain
types of organisms are more prone to cause cardiac toxaemia than others. Blood pressure
is frequently elevated and fundoscopic examination should always be carried out since
the presence of papilledema may be a forerunner of the severe complication of hypertensive encephalopathy.
If cardiac failure is present the liver may be enlarged and tender and there may be
evidence of dependent oedema and in severe cases pulmonary oedema may also be evident.
Examination of the urine usually reveals a large number of red blood cells, albuminuria,
and casts which may be of the cellular, granular or hyaline variety. The prognosis in
this condition is usually excellent. Approximately 85 to 90% may have complete
recovery. There may be an immediate mortality of approximately 5%. These are usually due to the initial infection which causes the nephritis or to cardiac failure due to
-toxemia or it may be due to hypertensive encephalopathy, which leads to convulsions and
death.
Uremia is a very rare cause of death from acute nephritis. The remaining 10%
apparently never make a complete recovery and go on to develop chronic nephritis.
Although the prognosis in most cases is good, it is impossible for anybody to state at any
particular time during the course of the disease whether the child will make a recovery
or not; in speaking to the parents, one should always be gurded, for one has seen the
mildest types of nephritis go on to develop chronic nephritis and death, whereas some
of the most serious complications accompanying post scarlatinal nephritis, namely:
hypertensive encephalopathy with convulsions and cardiac involvement with failure,
have been followed by complete recovery. Treatment of this disease is largely empirical
since we do not know its cause, nor are we yet aware of all the physiological and pathological conditions which re at work in the kidney during this illness. All are agreed,
however, that bed rest is essential, this is doubly so if some cardiac involvement is also
present.
Page 20 If we recall the beginning of our talk concerning physiology it will be seen that
the work of the kidney is done entirely by the tubules, which are responsible for reabsorbing water, sugar, salt. The more concentrated the fluid* within the lumen of the
tubules becomes, the greater the osmotic work of the tubules m ust be in order to remove
water and transfer it back into the blood.
For this reason, we feel that fluids should not be restricted in nephritis, but that
the children be urged to take all the fluids they can manage, unless they are suffering
from some form of cardiac failure or pulmonary oedema which, of course, then modifies
the amount of fluid which is given. The presence of peripheral edema is no contraindication to giving these children large amounts of fluid. Water is one of the best
diuratics we have and often these children will put out a large amount of urine once
adequate fluid intake has been established. We usually recommend for the average child
of 5 to 8 years of age at least a quart of fluid, and more if possible, should be consumed
withn a 24 hour period. The diet consists, in the early stages of carbohydrate only. This
is usually given in the form of different juices or sugar solutions. Carbohydrate does not
require elimination by the kidneys, it spares, if given in adequate amounts, the breakdown of body protein and supplies the caloric needs for the body. Consequently, during
the acute stages of the disease, carbohydrate is the only form of food which is given to
these patients. Since the great majority of cases develop following a streptococcal infection, even though there may be no evidence of this at the time of the onset of the
nephritis, we believe it is wise to give a course of penicillin therapy for 4 or 5 days in
order to try to eradicate any local focus, which may be present, and thereby facilitate
the healing process. A careful search is made for all forms of foci of infection and in this
regard I should like to emphasize the sinuses and teeth as a cause of infection which is
frequently overlooked. These foci of infection are usually dealt with after the acute
signs have disappeared from the urine such as the disappearance of red cells. If the child's
general condition has improved, and the blood pressure has returned to normal, the presence of albuminuria is not a contra-indication to carrying out these operative procedures
to remove the focus of infection. Again, whenever any operative procedures are undertaken, the child is given a course of penicillin starting just before the operation and
carried on for two or three days following it. The child is kept in bed for as long as
albuminuria is present and usually for a period of a week or two following this and then
allowed up gradually. If albuminuria appears in the urine when he gets up he is then
kept in bed for a further week. The average duration of the illness is usually from 6 to 8
weeks, although a number of children have gone for as long as six months to a year and
still made complete recoveries from this disease. It is important that during this part
of their treatment they should be kept free of infection and this means practically isolation, especially from other children that are prone to bring in colds and upper respiratory
infections with them. As the acute signs improve, that is disappearance of red cells from
the urine and lessening of the albuminuria, the diet is increased, milk, jelly, custards
and junkets are the first substances added to the diet and then gradually the diet is
increased to a full d'et, providing this does not cause any reappearance of red cells or an
increased albuminuria in the urine. Since these children may be on a restricted diet for a
considerable length of time, it is always wise after the first week or two to give them
some form of polyvitamin therapy, of which there are numerous preparations on the
market.
Complications of Acute Nephritis. The chief complications of acute nephritis are:
toxic myocarditis, and secondly hypertensive encephalopathy. It is doubtful whether
the acute toxic myocarditis is part of the nephritic condition—it is more likely a manifestation of the acute toxaemia which causes the nephritic condition. These children
often have enlarged hearts, gallop rhythm, rapid rate and may have signs of cardiac
failure. They usually respond well to digitalis; our usual practice is to give '/^ of a
milligram of digoxin intravenously at 4 to 6 hourly intervals for three or four doses
and then carry them on a maintenance dose of % milligram daily. Electrocardiographic
records are made to check on heart rate and signs of toxicity. Fluid and salt restriction
are also indicated as adjuncts to the treatment.   If pulmonary oedema develops, we have
Page 21 seen improvement in one or two cases by the intravenous use of two or three grains of
aminophyllin. Oxygen therapy is also of value. Most cases of cardiac failure respond
fairly promptly with such treatment. Hypertensive encephalopathy is probably the
most serious and dread complication of acute nephritis. Hypertensive encephalopathy
should be suspected in any child in whom vomiting, severe headache and drowsiness are
important signs. They should lead one to check the blood pressure, which is usually
markedly elevated and the ocular fundi which usually show some degree of papilledema.
If the blood pressure is not more than moderately elevated, 130 to 140 systolic, and
the symptoms are not severe, we are usually in the habit of giving magnesium sulphate
per os l/z ounce in 50% solution q.a.m. If the symptoms are somewhat more severe,
and especially if the blood pressure on being checked in a few hours time is rising, then
magnesium sulphate in a 10% solution is given intramuscularly. Depending upon the
size of the child 15 to 25 cc. of this solution is administered. If,, on the other hand, the
child is actually convulsing when the patient is seen or rf one feels that this condition
is apt to occur in a short time then intravenous magnesium sulphate is often a life-saving
procedure. At the Hospital for Sick Children, we use a 1 % solution, many other centers
use 2% solution of magnesium sulphate. This is given at the rate of 1 to 2 cc. per
minute. The amount that is administered depends upon the effect on the blood pressure.
It often requires between 100 to 300 cc. of this solution given over a period of about
Vz to V4 hours to return the blood pressure to normal. If the patient is seen at home or
under circumstances where intravenous magnesium sulphate is not available, convulsions
can sometimes be controlled by the use of an ether anaesthetic. Magnesium sulphate is
quite rapidly eliminated from the body and the various types of procedures which have
been indicated may have to be repeated two or three times during the 24-hour period.
Magnesium is a marked nervous depressant and in some cases of overdosage respiration
may be arrested. An ampoule of Calcium gluconate should be at hand to counteract
over-dosage.
Chronic non-specific glomerular nephritis is the next most important type of nephritis
seen in childhood. These cases appear to effect the children in the younger age groups
between 3 to 5 years of age more particularly. The first sign or symptom which brings
them to the physician is that of oedema. It is often very difficult or impossible to obtain
a history of an antecedent infection of any recent date in these patients. It is, of course,
possible that an infection occurred some months prior followed by an unobserved acute
nephritis. Besides the rrther marked generalized oedema which these patients present
there may also be a slight increase in the non-protein nitrogen; though, this is often
normal. The cholesterol is usually mrkedly elevated and in one case we saw recently
was over 1000 mgm. %. The blood pressure may be slightly elevated; though in the
majority of cases when they are seen the blood pressure appears to be around normal
value. Urinary examination revels large amounts of albumin, numerous hyaline casts
and relatively little in the way of cellular elements; though occassionally white blood
cells and the odd shower of red cells may be seen if the urine is examined frequently
enough. The treatment of these patients presents a good many problems. The chief of
these is the nursing problem, since so many of them are incapacitated by their oedema
tha they are unable to take care of their own bodily needs and frequently soil themselves
in bed. They are prone to all types of intercurrent infections, particularly of the respiratory tract, though a very important type of infection which is seen frequently is that
of cellulitis, presumably because of the tremendous oedema and lack of vitality of the
tissues; the slightest abrasion, even a slight rubbing on the sheets may cause pathogenic
organisms to gain entrance into the markedly oedematous tissues. These patients will
sometimes run a marked fever for a period of two or three days before the cellulitis
becomes sufficiently manifest to diagnose.
Peritonitis is a common complication in these children, usually pneumococcal in
type and may frequently be confused with an acute surgical condition. In the days before
chemo-therapy was available, most of these children succumbed to intercurrent infections.
Now, however, we are finding a larger and larger percentage of them surviving through
Page 22 to the chronic stage of glomerular nephritis. In the latter stages of the disease the oedema
frequently disappears but at this time the blood pressure and NPN begin to rise; there is
often a mild degree of acidosis due to the inability of the kidney to compensate for inadequate phosphate excretion.
The prognosis in this type of nephritis is not particularly good (25-50%); it
should be treated, however, energetically in the early stages, especially where there is no
evidence of rise in the NPN and when the blood pressure is normal; since a number of
these patients have been found to make complete recoveries. The main points in our
therapy consist in the restriction of salt to the barest minimum; we try and devise
a diet containing less than l/z gram of salt per day. This, of course, means the exclusion
of any forms of sodium including sodium chloride. We have found that none of the
diuretics are of any real value. A high protein diet is instituted in order to try to make
up for the marked deficit that these patients are suffering as a result of the continued loss
of large amounts of albumin in the urine. It is, however, often difficult to get the
patients to continue to take large amounts of food; much less large protein meals. We
believe that they should be kept in bed, in a separate room, away from the possible cross
infections with other children. Penicillin therapy is used whenever they are found to be
running a fever, even though the immediate cause for the infection is not apparent.
Removal of possible foci of infection in the great majority of cases appears to result
in little or no benefit, which is unlike that seen in the acute post-haemorrhagic glomerular
nephritis. We do not undertake any means of reducing the oedema by hot sweats, since
dehydration makes these children worse. We do not attempt to tap the abdominal ascites
unless this becomes so great as to interfere with respiration. This type of nephritis is
frequently referred to as the nephrotic syndrome of chronic nephritis, and by some
people more loosely as nephrosis. True nephrosis is a much rarer condition in which red
cells are never seen in the urine at any time.
Pyelonephritis, the third great cause of kidney disease in children, is in most
instances related to some congenital abnormality or defect in the urinary system. In
the very small child, especially the female infant in the diaper stage, we may have repeated
attacks of pyuria with albuminuria; these may be brought on either as a result of an
enteric infection; but are frequently associated with upper respiratory infection. Frequent
loose stools which the child has at this time lead to an ascending infection of the urinary
tract.
Such conditions are usually readily managed by the exhibition of large amounts
of fluid and sulpha drug usually in the dosage of 1 to I/2 grains per pound of body
weight per 24 hours. If the condition does not clear up readily, or if the child is subject
to repeated attacks, a systematic investigation of the genito-urinary tract is definitely
indicated. This consists in the securing of catheter specimens of urine for culture in
order to establish the presence and type of infection present. An intravenous pyelogram
and cystogram should be undertaken in order to determine whether or not any congenital
abnormality is present. These often give the correct cause for the obstruction leading to
infection, although it may be necessary to have these findings confirmed by retrograde
cystoscopic examination.
It is evident that the sooner these obstructions are relieved and the infection controlled by means of the appropriate chemo-therapy, the less likely is any permanent damage
likely to occur in the kidney. Unfortunately, there are a number of children who
apparently have relatively few symptoms and may go on to a severe chronic stage of
pyelonephritis, and do not come to a physician's attention until they are in the end
stages of their disease; marked hypertension, nitrogen retention, and uraemia. Rarely
eveen in these cases, one may find that a unilateral lesion is responsible for much of
the symptomatology. Removal of this diseased organ may bring a remarkable improvement.
If, however, the arteriosclerotic compensatory change has advanced to sufficient degree
in the contra-lateral kidney or if the process is bilateral little can be done for these
patients.
Page 23 To summarize the various causes for the appearance of albumin in the urine have
been described:
1. Physiological causes are that of prematurity; new born state, orthostatic albuminuria, emotional and effort albuminuria.
2. Albuminuria due to chemical causes, such as various poisons.
3. Albuminuria   due   to  physical   causes,   dehydration,   etc.,   circulatory   changes,
cardiac failure, shock.
4. Albuminuria due to infection.
5. True nephrities.
6. Albuminuria  which  is  due  to  congenital  malformations  which  may  lead  to
pyelonephritis.
Rarely albuminuria may be due to a neoplasm of the kidney.
BIBLIOGRAPHY
1. Wearn, J. T. & Richards, A. N.—Amer. Journ. Physiol.   71;  209,  1924.
2. Walker, A. M., & Oliver, J.—Amer. Journ. Physiol.   134: 562, 1941.
3. Smith, H. W.—Physiology of the Kidney, New York, Oxford Univ. Press 1937.
4. Smith, C. A.—The Physiology of the New Born Infant, Pg. 250, 1946.   Chas.
C. Thomas.
5.. Wolman, Irving J.—Amer. Journ. Med. Scien.   208: 767, 1944.
6. Lee, R. I.—Med. Clin. North Amer.   3:  1059, 1920.
7. Ploss—J. A. M. A. 130; 310.
8. Grulee & Eley—The Child in Health and Disease.   William & Wilkins Co.,
P. 632, Baltimore, 1948.
9. Addis—Glomerulonephritis.   McMillan Company,   1949, New York.
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